The Transformation of a Pharmacy Department: A 10-Year Journey to Preeminence in Pharmacy Practice

Dennis K. Helling, Pharm.D., FCCP, FASHP, Kent M. Nelson, Pharm.D., BCPS, Jairo E. Ramirez, R.Ph., Tammy L. Humphries, Pharm.D., BCPS

Kaiser Permanente Colorado Region

Aurora, Colorado

Prior to 1992, the Kaiser Permanente Colorado Region Pharmacy Department was primarily product-focused and expectations for developing other pharmacy services were minimal. The services provided by four Clinical Pharmacy staff were also very limited. Consequently, there was a lack of support from physicians because the Medical Group wanted more from a pharmacy department than basic prescription dispensing. Operations/Support Pharmacy Services and Clinical Pharmacy staff worked independently. The lack of coordination and communication between the two groups further compounded problems with the Medical Group and resulted in inconsistent pharmaceutical care. Changes were required to build a progressive pharmacy department.

Strategic plans were developed to revise the Pharmacy Department. Emphasis was placed upon integration between Clinical Pharmacy Services and Operations/Support Pharmacy Services. Although the department would consist of two services and the roles of pharmacy personnel would be differentiated, the Pharmacy Department would function as one unit. The expertise resulting from differentiated roles and specialized functions would be utilized to collaborate with the Medical Group to provide excellent patient care. Changes in hiring practices were implemented. Employees were sought that had strong communication skills and shared the common vision of developing a progressive pharmacy department. Additionally, a physician joined the pharmacy team as the Medical Director of Pharmacy Utilization and Therapeutics to ensure increased collaboration with the Medical Group.

Plans were implemented to expand Clinical Pharmacy Services. Clinical Pharmacy staff include clinical pharmacy specialists and clinical pharmacists. In addition to a Doctor of Pharmacy (PharmD) degree and residency training, board certification within the first three years of employment is required for clinical pharmacy specialists. Areas that presented challenges to the Medical Group were identified as opportunities fro clinical pharmacy expansion. Areas of expansion included the Primary Care Clinical Pharmacy Services team, Centralized Clinical Pharmacy services and Specialty Clinical Pharmacy Services. The projected cost savings that would result justified the expansion.

The value of having Primary Care Clinical Pharmacy Services (PCCPS) staff in each medical office working alongside physicians and other health care providers was recognized, and the staff was increased to accommodate this model. Centralized Clinical Pharmacy Services were developed to manage large populations of patients and assist the Medical Group. The Clinical Pharmacy Anticoagulation Service (CPAS) was established in 1996, and is currently one of the largest anticoagulation services in the nation, managing greater than 5,600 patients. The Clinical Pharmacy Call Center (CPCC) was also created in 1996 to help nurses in a regional Call Center answer medication-related questions. The CPCC team currently answers approximately 1000 telephone calls daily.

In 1998, a physician in the Prevention Department asked for help in managing the cholesterol of patients with coronary artery disease (CAD), and the Clinical Pharmacy Cardiac Risk Service (CPCRS) was developed. The CPCRS team now cares for the entire Colorado Region CAD patient population, approximately 8,300 patients. The Clinical Pharmacy International Travel Clinic (CPITC) had already been established prior to 1992, but was expanded and provides approximately 9,500 travel consults annually.

Changes were also made in the Specialty Clinical Pharmacy Services (SCPS). The roles of the Drug Information and Infectious Diseases Clinical Pharmacy Specialists were redefined. New positions were created in Mental Health, Oncology, Cardiology/Heart Failure, Long Term Care, Asthma, Diabetes, Nephrology, and Managed Care. The Oncology Clinical Pharmacy Specialist and the Oncology Staff Pharmacists coordinated to develop the Clinical Pharmacy Growth Factor Service (CPGFS).

Significant modifications were made in the Operations/Support Pharmacy Services as well. Patient satisfaction surveys specific to the medical office pharmacies were developed to identify areas that required additional focus. Medical office pharmacies were also remodeled to make it easier for pharmacy staff to address patients’ needs and facilitate patient counseling. Mandatory patient counseling on all new prescriptions was implemented in 1995. In order to free pharmacists’ time for patient care activities, the Pharmacy Automated Refill Center (PARC) was established in 1999. PARC utilizes bar codes, radio frequency transmitters, and drug imaging to process approximately 40% of the total prescription volume and ensure prescriptions are filled accurately. Pharmacists perform clinical screening and provide final checks on prescriptions filled through PARC.

The use of automation to fill prescriptions supported the development of an innovative Desk Top Medicine (DTM) Service in the medical office pharmacies. The DTM Service assists the Medical Group with refill requests on chronic, predefined medications. Protocols were developed that allow staff pharmacists to order relevant laboratory tests and make recommendations regarding test results. The Pharmacy Information Technology Service and the Quality Leadership Team created programs that targeted patient safety initiatives.

Visionary leadership and implementation of the above initiatives transformed the department from a retail pharmacy outlet into an innovative leader in pharmacy practice. In 1992, the entire department consisted of 175 staff members, and the annual operating budget was $10 million. Currently, the Pharmacy Department has approximately 550 employees comprised of 150 staff pharmacists, 125 clinical pharmacy staff, 75 pharmacists in supervision/management, and 200 technicians/administrative support staff. The 2002 annual operating budget is $150 million. Recent patient satisfaction surveys indicate over 90% of patients are satisfied with the service they receive in the medical office pharmacies.

Positive economic and clinical outcomes have been realized. The efforts of the PCCPS team have resulted in substantial savings as they cost avoid over $5 million annually compared to other health plans. The CPITC, CPCC, and CPGFS teams have also demonstrated significant cost savings. CPAS has saved 25 lives annually since its inception in 1996 due to reduced bleeding complications and other adverse events. Furthermore, according the National Committee for Quality Assurance (NCQA), CPCRS leads national rankings for NCQA-accredited health plans in the cholesterol screening and cholesterol control of patients with CAD. These positive clinical and economic outcomes have resulted in numerous publications and several awards for the Pharmacy Department.

Integration between Clinical Pharmacy Services and Operations/Support Pharmacy Services, along with collaboration with the Medical Group, has resulted in unprecedented success for the Kaiser Permanente Colorado Region Pharmacy Department. During its 10-year journey to preeminence, the Pharmacy Department has become recognized role model in pharmacy practice.