1. 22 ■ November 2011 ■ www.pppmag.com
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PHARMACY
&Purchasing Products
Outpatient Pharmacy By Joseph W. Coyne, RPh
E
stablishing just in time (JIT) compounding to support outpatient
oncology services is critically important in the effort to eliminate
waste. In addition to increasing cost control over these expensive
agents, this approach allows for the preservation of an increasingly
limited supply of potentially life saving medications in this time of
escalating drug shortages. Of course an additional benefit is the maximization
of staff efficiency for both the pharmacy and infusion departments.
Changing pharmacy’s traditionally scheduled workflow to the more flexible
JIT compounding model can be difficult to achieve given the inherent challeng-
es in communication, scheduling, and the clinical complexity of oncology care.
These challenges along with the need for a unique mix of patience and efficiency
make JIT compounding difficult for some to achieve as it differs from traditional
hospital practice of a more scheduled workflow.
Queue Management
Pharmacy commonly employs the first in, first out approach, and while effi-
cient in many settings, this method is less so in outpatient oncology practice
and can lead to treatment delays. Moving toward JIT requires efficient queue
management, which in turn relies on the establishment of strong communi-
cation pathways. Communication between the pharmacy and the infusion
center, the IV room, and the clinical pharmacists must be timely, clear, and
accurate. To avoid the common challenges of distracted message takers or in-
formation lost during shift change, communications should be automated us-
ing one of the many evolving electronic forms. One approach is secure health
messaging via the electronic health record, and while effective, issues can arise
with this hybrid of email and instant messaging when messages are sent to a
specific individual. In the event that person is unavailable, those messages may
sit dormant. Another choice is a facility board, which is an electronic version
of the dry erase board that updates in real time when certain actions are per-
formed within the electronic health record. This method provides an immedi-
ate feedback loop, does not rely on any single individual, and in many cases,
Just inTime Compounding
for Outpatient Oncology Services
updates are triggered by actions performed within the health record, such as
admissions and appointment cancellations or changes. Each facility board can
be completely customized to meet the differing data display needs of the phar-
macy and infusion clinic. For facilities without an electronic health record, us-
ing an old fashion dry erase board strategically placed within the pharmacy
may be a good choice, as the process will transition well into an electronic
facility board down the road. Regardless of your chosen tool, it is vital that it is
updated regularly and serves as the source of truth for all compounding activi-
ties; otherwise inconsistency develops, leaving staff without a single source of
information to drive their activities. As with any significant process change,
staff buy-in will be intrinsic to a successful implementation, so solicit input
from staff on the data content, layout, etc. Our staff requested that the board
include patient location, prescribing physician, medication ordered, labora-
tory data, and scheduling information.
With an organized queue, it is easier to determine time saving steps. Not only
do we prioritize compounds based on time of administration, but at peak times,
we also prioritize the compounding of the first drug in the patient’s regimen and
once the initial medication compounding is complete, return to the sequence
of the other drugs in the regimen. This allows patient treatment to begin while
buying time for the pharmacy IV room. Hood space is a limited resource in the
IV room as are appropriately trained pharmacy technicians, and even the most
efficient operations will hit a critical point with regards to these resources if
this technique is not employed at times. This process cannot be implemented
Photo courtesy of Chemocato LLC
It is important that inventory levels
adjust based on issues such as
seasonal fluctuations, chair capacity,
and the addition of new practitioners.
As both hood space and appropriately trained technicians are commonly
in short supply, increasing efficiency is always a worthwhile effort.
PhotocourtesyofBaxaCorporation

2. www.pppmag.com ■ November 2011 ■ 23
in a vacuum, however, so before beginning a change of this magnitude, engage
nursing leadership as there will be some changes required in their workflow to
achieve maximum efficiency.
Workflow Management
To build an efficient workflow, you must be willing to examine all current pro-
cesses. Maintaining a procedure simply because that is the way it has always been
done all but assures inefficiency. There are numerous metrics to be reviewed, in-
cluding orders per hour, orders by hour of operation, staffing productivity, other
requirements or demands on the department, the receiving time and process, rou-
tine medication pass times on the floor, and others based on your particular prac-
tice setting. Consider bringing in an outside facilitator to force a fresh perspective
and examine all processes for potential improvements. For example, can the time
the wholesaler order is received be changed to allow for processing during non-
peak patient demand time? Does TPN really need to be prepared at the same time
everyday or can it be moved to minimize traffic and flow in the IV room during
peak infusion center demand? Can staff training and new employee orientation
be scheduled to minimize workflow stress—are early mornings, evenings or even
weekends a good time to train new staff?
In addition to gathering data, consider any upstream and downstream ef-
fects from a process change. Be sure to have representation from all disciplines
that could be affected by the change. If your organization uses Lean Six Sigma
processes, this might be a great Kazan activity, A3, or Green Belt project.
Managing Staff
Just as workflow is analyzed, a thorough review of your staffing model is neces-
sary. Consider the rationale behind established staffing levels. Has the model
been reviewed against the most appropriate metrics or is it simply the way it has
always been done? Strategically assess the resources at your disposal to deter-
mine the most appropriate deployment. As distribution efficiencies are realized,
consider moving staff to clinical positions whenever possible. While few of us
are excited by change, open communication and the presentation of objective
data will lead staff to ultimately embrace new processes they believe will impact
their job satisfaction as well as improve patient care. Be sure to roll out any staff
To increase technology acceptance, request
staff input when determining data content.
changes in conjunction with the human resources department, as these changes
may effect employment status, benefit eligibility, overtime opportunities, or take
home pay. The objective is to minimize the impact on employees and hold flat or
decrease payroll while improving service levels.
Managing Inventory
Unless your organization has endless resources to keep excess products on
hand, inventory management is a key component of JIT compounding. With-
out a solid inventory management solution in place to support JIT, confidence
wanes and the process breaks downs. Review your current tools whether man-
ual or electronic. Are minimum and maximum levels dynamic? Too often these
levels, once established, remain static. It is important that levels adjust based
on issues such as seasonal fluctuations, chair capacity, addition of new prac-
titioners, etc. We use an electronic inventory management system from our
carousel vendor.
Future of Workflow Management
There are several workflow management solutions available on the market,
which provide automation for the compounding workflow. However, to realize
efficiencies, it is key to first develop solid processes, otherwise you run the risk of
automating inefficient processes. ■
Joseph W. Coyne, RPh, currently serves as the vice president of
pharmacy services for Cancer Treatment Centers of America, which
operates a network of cancer treatment hospitals and facilities in
the United States. The company has hospital locations in Philadel-
phia, Pennsylvania; Tulsa, Oklahoma; Seattle, Washington; Zion, Illinois; and
Goodyear, Arizona. Cancer Treatment Centers of America, Inc. was founded
in 1988 and is based in Schaumburg, Illinois.
Joe obtained his BS in pharmacy from the Philadelphia College of Phar-
macy and Science, where he is currently an adjunct senior clinical professor
with the department of pharmacy practice. He serves as a co-diplomat to
Temple University’s School of Pharmacy for the Academy of Managed Care
Pharmacy, and is a member of ASHP, HOPA, and ISOPP.
WHERE TO FIND
COMPOUNDING
IV Workflow Management
Supplier
Baxa Corporation
Chemocato LLC
Envision Telepharmacy
Health Robotics
ScriptPro
.com
PhotocourtesyofBaxaCorporation