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1 Title of Presentation Thinking About Tech-Check-Tech? Gayle Mayer, RPh, BPharm Director of Pharmacy, Spencer Hospital Faculty & Co Program Coordinator, Pharmacy Technician Diploma Program at Iowa Lakes Community College 1

2 Faculty Disclosure Gayle Mayer reports no actual or potential conflicts of interest associated with this presentation. Gayle Mayer indicated off-label use of medication will not be discussed during this presentation. Learning Objectives Upon completion of this activity pharmacists and technicians will be able to: State the need in the profession for a technician-managed distribution process Describe the opportunities for pharmacists to provide clinical services Review current regulations that govern Tech-Check-Tech (TCT) programs Review the principles of ASHP s New Practice Model Initiative and IPA s New Practice Model Task Force Illustrate the case to pharmacy staff, upper management, and the Board of Pharmacy 2

3 THE TIME IS NOW Today s medication-use systems rely heavily on pharmacy technicians. The ability of pharmacists to focus their attention on the safe and effective use of drugs, biologicals, vaccines, and contrast media depends on the availability of technicians who have been appropriately trained and credentialed and possess necessary skill sets regarding drug preparation and distribution PTCB CREST Summit, Feb 17-18, 2011 Henri Manasse, Jr., EVP & CEO, ASHP and Thomas Menighan, EVP & CEO APhA PTCB CREST Summit, Feb 17-18, 2011 Why Expand the Roles of Pharmacy Technicians? Pharmacists desire an environment where they can practice at the top of their skills. Technicians want to perform at the top of their current skills and wish to expand their activities in support of delivering pharmaceutical care and services. This requires commitment from all levels: technicians, pharmacists and administration. Standardized education, training and quality improvement should be present. All these elements must be ongoing. 3

4 What We Can Do To Expand Roles of Pharmacy Technicians via Tech-Check-Tech Review current national initiatives Outline examples of state programs Illustrate a specific site example List the benefits for patients, pharmacists and technicians About Pharmacy Technicians Map of states that regulate pharmacy technicians (2) 355,300 pharmacy technicians in the US (3) Requirements for practicing as a pharmacy technician vary from state to state, but according to NABP s 2011 Survey of Pharmacy Law, over 80% of jurisdictions license, register, or require certification of technicians (4) 4

5 PTCB* TCT Summary (14) 17 states currently allow Tech-Check-Tech (TCT) in some form Mixture of 4 factors Education Training/Competency Automation Trust TCT has successfully been part of pharmacy practice in the federal sector for many years *Pharmacy Technician Certification Board Current Technician Initiatives: Tech-Check-Tech & More National: ASHP: PPMI 2010 (8) : Section of Inpatient Care Practitioners / Section Advisory Group / Pharmacy Support Persons PTCB: C.R.E.S.T. Summit 2011 (7) NABP: Task Force (6) States: Three examples will be discussed ASHP/American Society of Health-System Pharmacists PPMI/Pharmacy Practice Model Initiative NABP/National Association of Boards of Pharmacy 5

6 ASHP s PPMI ASHP PPMI 2/1/2011 D. Advancing the Use of Pharmacy Technicians Beliefs and Assumptions D1. Pharmacy technicians who have appropriate education, training, and credentials could be used much more extensively to free pharmacists from drug distribution activities. D2. Assigning medication distribution tasks to pharmacy technicians would make it possible to redeploy pharmacists time to drug therapy management activities. D3. The following tasks can be assigned to pharmacy technicians who have appropriate education and training Technician Tasks Outlined in PPMI Although the PPMI outlines several tasks in section D3 that technicians might perform, this is the one we will focus on today: D3c. Checking dispensing by other technicians (i.e., Tech Check Tech ) (Of note, successful implementation of Tech-Check-Tech is a great step to adding more technician tasks.) 6

7 ASHP Other Groups & Initiatives SICP (Section of Inpatient Care Practitioners) SAG (Section Advisory Group) Pharmacy Support Persons (PSP) Toolkits Practice Spotlights Technician Resource Center ASHP is currently drafting: Statement on the Role of the Pharmacy Technician not available to share yet SAG on Pharmacy Technicians and Support Services (PTSS) Charge ( ) (13) To assist the Section of Inpatient Care Practitioners (SICP) by: Addressing the education, training, certification, and development of core competencies for Pharmacy Technicians Promoting the advanced role of Pharmacy Support Persons (PSP) within the profession of pharmacy Identifying means for PSP to exercise safe medication practices Integrating the recommendations of the PPMI into the duties of Pharmacy Technicians Enhancing communication regarding the role of Pharmacy Technicians 7

8 PTCB s C.R.E.S.T Summit February 17-17, 2011, Palm Beach, Florida Consumer Awareness Resources Education State Policy Testing PTCB's Board of Governors and Certification Council are considering the recommendations on testing and education requirements. Of the seven recommendations, all but one specify a deadline of The recommendation about ASHP-accredited training programs is the exception. Its deadline is C.R.E.S.T. Summit Survey Potential increased roles in Health-System Pharmacy: Medication safety positions and/or quality management Tech-Check-Tech Purchasing / Inventory Control Holding leadership and/or supervisory roles Participating in medication reconciliation 8

9 C.R.E.S.T. Summit Survey Potential increased roles in Community Pharmacy: Medication safety positions and/or quality management Holding leadership and/or supervisory roles Pharmacy administrative support Maintaining and/or optimizing technology Tech-Check-Tech NABP: Technicians and Boards of Pharmacy Requirements for practicing as a pharmacy technician vary from state to state, but according to NABP s 2013 Survey of Pharmacy Law, over 80% of jurisdictions license, register, or certify technicians, and at least two states are currently working on legislation for doing so. As technician training grows and technicians increase their presence in the pharmacy, regulation of their practice will become more standardized. The NABP Task Force on Pharmacy Technician Education and Training Programs recommended that by 2015, state boards of pharmacy require all certified pharmacy technicians to complete an accredited education and training program. Currently, over one-third of jurisdictions have continuing education requirements that technicians must meet in order to maintain their license, certification, or registration, and with CPE Monitor pharmacy technicians will be equipped to track and monitor their status. (6) 9

10 NABP: Resolutions & Task Force Reports Has 3 resolutions: 2008, 2009, 2010 on technician education, training and standardization of such Has published two task force reports on pharmacy education and training programs in 2008/9 and 2009/10 All are available on their website Technician Education & Training Currently there are no national standards for education or training States set their own standards Not all states require certification ASHP may accredit programs; it is currently voluntary Programs may be found at community colleges, vocational/technical schools, on-line and employer based Two national certification exams: PTCB Pharmacy Technician Certification Board ExCPT Institute for the Certification of Pharmacy Technicians (ICPT) part of the National Healthcareer Association (NHA) 10

11 Technician Advancement in Wisconsin (16) Variance from Wisconsin's Pharmacy Examining Board - pharmacies submit a variance under Wisconsin law with recommended program elements 7 pharmacies with TCT through end of 2013 PSW (Pharmacy Society of Wisconsin): Tech Check Tech toolkit (12) including: Overview of steps to obtain variance from Wisconsin Board Program elements Policy & procedure templates based on Wisconsin Programs Tools for implementing a TCT program Training, Exam and Skills Evaluation tools Quality Assurance guidance Technician Advancement in South Dakota The SD Board of Pharmacy approved the first TCT program at Rapid City Regional Hospital on Facility licensed for 414; however full at 330 Pharmacy staff of 60 for inpatient services Approved via variance process through the Board of Pharmacy The facility presented a variance request with a PowerPoint presentation The program will be reviewed by the Board in 1 year The program has been under development for the last 3 years Designed for inpatient or long term care settings Barcoding and additional check by another health care staff member needed (e.g. RN) Pharmacy technician undergoes specialized training Written exam, training packet, demonstrations, practice & evaluations On going quality assurance audits Site coordinator and PIC responsible for maintaining documentation and assuring program requirements are met 11

12 Technician Advancement in Iowa Health-System/Institutionalized Settings Current Board of Pharmacy (BOP) rules on TCT (IAC 657 Ch. 40) Requires site specific approval from Iowa Board of Pharmacy 5 pharmacies with Board approval through 2013 Community/Non-Traditional Settings Current BOP rules on pilot projects (IAC ) Iowa Pharmacy Association s (IPA) New Practice Model Initiative: community pilot programs 9,10 IPA s HSLB (Health System Liaison Board) 11 Advancing the Practice of Pharmacy in Iowa: Developing a Plan for Action Collaborative Education Institute (CEI) Continuing professional development Technician training modules Iowa Board of Pharmacy: Tech-Check-Tech Rules Highlights Tech utilization & authorized checking functions Checking technician participation & training Responsible Individual / Staffing Pharmacist review of Orders Additional drug check prior to administration Records Evaluation of program and technicians Reassignment of pharmacist hours to clinical services Board of Pharmacy approval must be obtained no less than 90 days before implementing TCT 657 Chapter 40, "Tech Check Tech" Iowa Administrative Code 12

13 Iowa Records Highlights 1. Name of the certified pharmacy technician 2. Date site specific training completed 3. Date authorized to participate in TCT and tasks authorized to perform 4. Date authorized to check the work of other CPhT and date advanced training was completed 5. Dates and results of all competency evaluations 6. Date and reasons for any suspension or revocation of TCT authorization 7. Date and reasons for any disciplinary action taken in connection with duties relating to TCT Spencer Hospital Care You Trust, From People You Know 13

14 One Hospital s Journey: Spencer Hospital Sharing Our Steps and Lessons An Acute Care Facility in NW Iowa Inpatient Mental Health (15 beds) Intensive Care Unit (6 beds + 5 Step Down beds) Emergency Department Two Dialysis Units (one on campus & one in Spirit Lake, Iowa) Radiation Oncology & Medical Oncology 5 days/week Obstetrics (8 beds) Surgery Center & Same Day Services Ambulance Service Two family practice clinics located in Sioux Rapids and Milford, Iowa A central pharmacy and a pharmacy located in the Abben Cancer Center wing Preliminary Activities & Support 1. The pharmacists have shared input on developing this proposal and will continue to be engaged in training and support of the technicians. The pharmacists have increased their clinical opportunities. 2. The technicians have actively embraced this opportunity to further their careers and become more actively involved in serving patients as a member of the SH Pharmacy team. They have received increased responsibility and rewards. 3. Administration has supported initiatives to maximize the use of existing staff to increase pharmacy services to patients, nurses, and medical staff with the most effective use of payroll dollars and quality service to our patients. 14

15 Implement Suggest the Idea Get Preliminary Admin Approval Present to State Board of Pharmacy for site approval Get the support of the staff pharmacists Develop program to receive Admin Approval Get the support of the technicians Pharmacy Initiative with Administrative Support TOGETHER at Spencer Hospital: working towards a new practice model that goes beyond just Tech-Check-Tech. These additional technician duties permitted the creation of a new job description / career ladder accompanied with a higher pay scale. Today we are focusing on just the TCT responsibilities of the certified technicians. 15

16 SH Pharmacy Overview Open weekdays on weekends and holidays Remote coverage to provide 24/7/365 coverage Staff pharmacist on call after hours for issues not handled by remote services Two physical pharmacies Central pharmacy (new 2008, staffed 365 days per year) Oncology pharmacy (new 2010, staffed 5 days/week) 797 sterile compounding suites in each pharmacy Central 3 rooms (Anteroom + BSC Clean room + Laminar Clean room) Light & buzzer system to summon pharmacists for checking Oncology 2 rooms (Anteroom + Clean Room/2 BSC) Hands free intercom and a camera in the larger hood for checking & communication McKesson Paragon operating system with Bar Code Med Administration and Computerized Physician Order Entry OmniCell Automated Medication Dispensing Cabinets SH Pharmacy Staffing & Services 4 pharmacists weekdays: Central, Clinical, Closing, and Oncology Therapeutic Dosing and Monitoring Diabetic & Anti-Coagulation Programs, Nutrition Support & Anti-Microbial Stewardship Weekly teaching in Cardio/Pulmonary Rehab and Mental Health 4-5 technicians weekdays: Team workflow using a checklist Techs billing/charging in specialty areas Sterile (Central & Oncology) and non sterile compounding Repackaging med into Unit Dose Bar Code Filling, Checking, and Delivering Medications (AMDS & other) Ordering & stocking, inventory control (not CII) Medication Reconciliation Support Weekends are staffed with 1 pharmacist and 2 technicians 16

17 Pharmacy layouts conducive to: Direct technician supervision Direct observation of work flow Questions from techs & dialogue with techs Follow-up from pharmacists About a 1:1 Pharmacist/Tech Staff Ratio in both pharmacies Experienced Pharmacists & Technicians Pharmacists average 20 years+ and techs average about 8 years Remote coverage to make us 24/7/365 Technology: Why Spencer Hospital?? Automated Medication Dispensing System/Omnicell CPOE (Computerized Prescriber Order Entry) BCMA (Bar Code Medication Administration) Spencer Hospital Overview Phase One Prior to Go Live Didactic Education Hands on Evaluations (Filler and Checker) Individual Technician Approval for Program Followed with Continual and Ongoing Monitoring Daily Monitoring Biweekly Summaries Rolling 12 Week Averages Retraining or suspension if needed 17

18 Tech Utilization & Authorized Checking Functions Authorized per TCT: Each pharmacy will define the scope of the Checking Technician on their specific site application for the Board of Pharmacy approval. This will not be the same for all pharmacies your proposal to the Board of Pharmacy will be specific for your site. SH Advanced Pharmacy Technicians An active PARTNER in delivery of pharmaceutical services to our patients, prescribers, and other healthcare professionals. The pharmacy technician is partnering with a pharmacist, prescriber or nurse to provide support in patient care. The pharmacists must be a resource for the technicians in supporting both the program initiation and the ongoing education and quality initiatives. Following the Iowa BOP rules: designing, submitting and receiving approval on a business plan allowed us to redesign our practice model and expand goals and services of our pharmacy department with existing staff. 18

19 SH Clinical Services Expansion Routine daily therapeutic Dosing and Monitoring expanded Nearly 20% increase in pharmacy interventions Diabetic monitoring expanded and Education participation added Anti-Coagulation Program added Nutrition Support Program added Anti-Microbial Stewardship Program added Weekly teaching in Cardio/Pulmonary Rehab added Weekly teaching in Mental Health added Added a full time oncologist in 2013 & went to 5 days/week service Pharmacy support (Advanced Techs) on Medication Reconciliation Unexpected nursing accuracy increase on Med Rec with pharmacy review/support We found techs can also support allergy and immunization review What we have learned Iowa BOP requires 90 days advance notice (and approval) before you can implement a tech check tech program; this period was very intense with training and evaluation. Because we were the first approval in the state, we proceeded carefully! When starting from scratch no techs trained in TCT, and everyone has to do every step, every lesson - it did take a long time we needed the entire 90 days to implement. Adding new techs to the existing program is much easier! Having other departments understand what we are doing is valuable we discovered people didn t really know what we did to start with. Technician checking rates are excellent, but filling rates increased dramatically when techs began checking each other. 19

20 Why We Benefited Technician workflow improved we had not considered the time they spent waiting for a pharmacist to check. Now techs check each other resulting in a more efficient process. Pharmacists have less interruptions and can focus on clinical work. Expanding TCT to Advanced Tech (with sterile oncology compounding, med reconciliation support, allergy review and immunization verification) further benefited the pharmacy department workflow efficiencies and allowed us to add and expand clinical services. Expanded clinical services may show increased revenue opportunities OR show decreased expenses on current care Job satisfaction has increased for pharmacists and technicians. Trust and teamwork is needed to establish an Advanced Tech Program, but is worth the time invested. Potential Dilemmas How to schedule: Appropriate staff for TCT at all times Staff TCT just at peak times Pharmacists will still check: Dependant on TCT staffing Items not covered by TCT How do you train and integrate new staff? How to encourage staff not engaged in the addition of a TCT program Continual support of quality: Quality monitoring Quality improvement 20

21 Quality Improvement (QI) Staff buy-in of a robust QI program for TCT Staff education of the importance of QI Staff sharing of QI opportunities Staff sharing of QI lessons learned Ask Yourself Do we have the support of pharmacists, technicians and administration for a TCT program? 2. Do we have pharmacy layouts conducive to supervision & communication in a TCT program? 3. Do we have appropriate staffing to consider TCT? 4. Do we have trust within our staff to support TCT? 5. Do we have experienced staff with a commitment to ongoing learning to succeed with a TCT program? 6. Do we have the technology to support and enhance a TCT program (safety features, redundancies)? 7. Are we committed to expanding our clinical services with the redistribution of pharmacy hours in conjunction with a TCT program? 8. Does our state allow TCT in my practice setting? 21

22 Yes! We Want TCT The Collaborative Education Institute has available a complete TCT curriculum Contact Us The Collaborative Education Institute P.O. Box Des Moines, IA phone fax csmith@gotocei.org Post-Assessment Questions 1. Which of the following would NOT be a quality review of a Tech Check Tech program? a) Periodic review and pharmacist check of the checking technician b) Review of all errors identified by the pharmacist OR the checking technician c) Review of errors identified following release by checking technician. d) Review of errors identified in inventory stocking 22

23 Post-Assessment Questions 2. A Tech Check Tech program, with technician managed distribution, would NOT show: a) Increased pharmacist clinical hours, shifted from distributive tasks b) Pharmacist hours redirected to patient care activities c) A decrease in total pharmacist hours by using technicians to check distribution of medications d) An increased error rate in filling and checking by technicians Post-Assessment Questions 3. True or False. It is not necessary or helpful to have administrative approval of tech check tech programs. 23

24 Post-Assessment Questions 4. True or False. There is national direction from pharmacy organizations to support expanding the role of technicians in the pharmacy. Post-Assessment Questions 5. A Tech check Tech program requires continuous evaluation containing all the following elements except: a) Excessive overall error rate b) Number of end user/medication administration errors c) Retraining procedures based on individual or program error rates d) Identification of benchmarks and sentinel events 24

25 Post-Assessment Questions 6. Elements recommended to participate in a certified pharmacy technician Tech check Tech (TCT) program might include: national certification, state registration or licensure, prior experience, site specific training and?. a) Mandatory associate degree b) Evaluation of prior education c) Additional 10 hours of advanced CEU every 2 years d) Specialized training - currently either site specific and/or nationally accredited Post-Assessment Questions 7. True or False. There is currently a national standard for Tech Check Tech (TCT) programs, that if met, allow techs to participate in TCT at pharmacies in all states. 25

26 Post-Assessment Questions 8. Implementing a Tech Check Tech (TCT) program in a pharmacy requires: a) Support from administration and management b) Buy in from the certified pharmacy technicians c) Encouragement and ongoing support from the pharmacists d) Additional didactic training and ongoing evaluation for the participating technicians, including an expanded job description. e) All of the above Post-Assessment Questions 9. Which of the following groups has published information and support of TCT? a) ASHP b) PTCB c) NABP d) All of the above 26

27 Post-Assessment Questions 10. Benefits of a TCT program may include: a) More time for pharmacists to expand clinical activities b) Improved work flow c) Increased job satisfaction and teamwork d) All of the above Questions I would be happy to share my original TCT packet submitted to the Iowa Board of Pharmacy and was approved in November 2011 or answer any specific questions at a later date. Please contact me at gmayer@spencerhospital.org 27

28 References 1. United States Department of Labor. Bureau of Labor Statistics. Occupational Outlook Handbook: Pharmacy Technicians and Pharmacy Aides. Accessed March 5, Pharmacy Technician Certification Board 3. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, Edition, Pharmacy Technicians, on the Internet at (visited January 27, 2014) National Association of Boards of Pharmacy %20No%20CE%20Code.pptx David Bobb, PTCB, Iowa BOP November