Carolyn Heinze

Ms. Heinze is a freelance writer based in Vancouver, British Columbia.

Few would disagree that pharmacists want the prescriptions they are filling to be used properly. With the pressures associated with the nation’s health care costs on the rise and the emphasis on medication therapy management, the profession is playing a larger role in counseling patients not only to take their medicine, but to do so according to the instructions—and if they are not being followed, to play a part in finding out why. Another element is safety: what physicians prescribe&mdash;or even what patients buy over-thecounter&mdash;can be harmful if misused, or in the worst cases, abused.

According to Richard Logan, PharmD, a pharmacist at L&S Pharmacy in Charleston, Missouri, and a police officer with the Mississippi County Sheriff’s Department, prescription abuse cannot be linked to one specific socioeconomic demographic. “The problem of prescription drug abuse covers all ages, sexes, and race—it makes no difference,” he said. “It is a universal problem, and because of that, there are no hard and fast rules to pick out the person that is the abuser.”

This means that the medical community must be on the lookout at all times, starting with an emphasis on the relationship between the patient and those providing their health care. “Pharmacists are charged by education, training, and oath to ensure the safe and sane use of drug products in our patients,” Logan said. “When a patient sees a physician, the physician has a duty of care that he must fulfill.”

In order to prescribe opioids and controlled substances, he adds, there must be a true physician—patient relationship. “If every step in the patient care process has not been undertaken by anyone in the chain, it is our duty to not fill that prescription and, depending on the circumstances, proceed from there.”

A number of signs hint at prescription abuse: requests for early refills, patients who seem to be overly knowledgeable about the drugs they are taking, and an insistence on becoming extremely familiar with the pharmacist are good indicators. Some patients will try to alter prescriptions outright, noted Lauren S. Schlesselman, PharmD, assistant clinical professor of pharmacy practice at the University of Connecticut at Storrs. “There might be a mark from a different pen: the doctor might have written a prescription for 80 tablets, and there is a “1” that was written in an ink that wasn’t quite the same color,” she illustrated. Another method is pharmacy-hopping: a patient fills a prescription at one pharmacy one day, and then tries to do the same at another outlet the next. These individuals often request to pay for the order in cash, rather than having it run through the insurance system.

Schlesselman notes that some patients will go so far as to attempt to strong-arm the pharmacist into filling a prescription that does not mandate refills. Others may insist that only one narcotic works—which may be true in some instances, she admits, but not always. Then there are the most obvious signs of abuse, such as track marks, pinpoint eyes, and slurred speech.

In many pharmacies, technicians are charged with receiving prescriptions and entering them into the computer; then, either the pharmacist or technician will fill the order, and the pharmacist will double-check it before handing it over to the patient. No matter the workflow process, when a prescription for a narcotic comes in, it warrants some attention. “Even when the technicians are entering the prescriptions into the system, they can look at the profile and see how often this patient is filling prescriptions for abusable substances,” Schlesselman said.

Although pharmacy staff should receive the training necessary to identify prescription abuse, Kristen Binaso, media advisor and director of corporate alliances at the American Pharmacists Association in Washington, DC, underlines that the buck stops with the pharmacist. “Ultimately, when that prescription is given to the patient, it is the pharmacist’s responsibility to counsel that patient,” she said. “The pharmacist needs to be out there so that they can say to the patient, ‘I am going to go over some important things about this medicine.’” Despite the increasing demand on the pharmacist’s schedule, it is too important not to make the time for this, she maintains. “When it comes to someone’s risk and benefits, we shouldn’t be too busy.”

When suspicion is aroused surrounding a specific prescription, the first step is to contact the prescribing doctor. Oftentimes, it is discovered that the physician is not aware that the patient has been receiving prescriptions for controlled substances from practitioners—and even if that is not the case, the pharmacist should put in a call anyway. “I still want to call and find out what is going on,” Schlesselman said. “The pharmacist should be in the loop about what is going on with the patient’s care, and the doctor may be able to say, ‘this person has a lot of pain from this injury or this type of chronic disease.’” The physician may not know what is going on either, however. “They may not realize that the patient is going to one doctor for a controlled substance for cough, and they are going to them for pain.”

What happens next varies, depending on the circumstances. Some pharmacists will simply refuse to fill the prescription, write “void” across it, and hand it back to the patient with an explanation as to why the order was refused, whereas others will contact the police. Regardless, it is necessary to work with other health care providers in the community. “You need to keep those lines of communication open and not be afraid to bring it up,” Binaso said. “Not everyone is going to be open to it, but if they choose to act on that information—and you would hope that they would&mdash;that is their choice. The fact is that my role, as a health care provider, was to take it up with them.”

In April 2008, the National Community Pharmacists Association (NCPA) launched the “Protect Your Pharmacy Now!” initiative to help its members deal with the issue of pharmacy crime, including prescription abuse. John Norton, public relations manager at the NCPA, notes that this spring, the association added a prescription disposal program as well. “[It] helps members set up programs that will keep their patients from keeping expired and unused drugs in their cabinets that can be abused, and avoid simply flushing them down the toilet where they can contaminate our drinking water,” he explained.

As the FDA investigates pain medications, Binaso believes that the discussion on risk management programs will move to the forefront. These initiatives may involve a patient registry or contracts between medical practitioners and their patients that spell out how medications should be used and that require, under signature, patient compliance.

“Part of the discussion is covering what kind of pilot programs should be run, because they do not think that the patient understands the risk and benefits, and there is a lot of concern about abuse,” she said. “It is a matter of seeing what is really out there—and I think that is what the FDA is trying to do right now&mdash;and then coming up with some pilot programs that can be tested to see if they work.”

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Prescribed Measures: Identifying and Preventing Prescription Abuse

With the continued focus onpromoting patient adherenceto reduce overallhealth care costs, pharmacists areunder increasing pressure to findways to deliver health care educationat the same time that prescriptionvolumes are on the rise.

The standard answer to this is thedistribution of printed materials, deliveredwhen the patient receives theprescription or refill. While this offersvalue, it is not as effective as it couldbe if accompanied by a face-to-facecounseling session, argues Bill G.Felkey, BA, MS, professor emeritus ofhealthcare informatics in the PharmacyCare Systems department at AuburnUniversity in Auburn, Alabama. "Wehave research to show that the printedinformation does not create adherenceto the same level as a combinationof both oral and printed information,"he says. "The majority of pharmacistsright now also are not very happy withthe printed information because it contains,mostly, bad news."

Another issue is the amount of inaccurateinformation that patients canaccess. Numerous Web sites, and evenrespected mainstream news outlets,are guilty of publishing data that iseither out of context, too hastily summarizedto be of use, or just plainwrong. The upside, Felkey says, is thatafter a while, patients tend to give upconducting their own research. "TheInternet is not too great a threat tothe pharmacy because people becomeoverwhelmed when they are trying tonavigate through the ocean of informationthat is out there," he says. "Whatthey need, they quickly realize, is somebodyto help sort through which informationapplies to them, what is themost important thing they should takeaway, and how they should use theinformation."

Felkey notes that patients fail in followingtheir treatment recommendationsfor several reasons: (1) they donot know what to do; (2) how to do it;or worse, (3) they are not motivatedto abide by the suggested practices."The toughest of those 3 is motivation,"Felkey says. "What predicts thegreatest extent of how a patient willattempt to change their behavior toget the benefits of their prescriptionmedicine, or to do other treatments,or instituting lifestyle changes, is therelationship between the pharmacistand the patient."

Bill Ladwig, vice president of professionalservices at Lewis Drug inSioux Falls, South Dakota, labels thisrelationship as "paramount." He notes,however, that the biggest challenge hispractice faces is getting patients to takethe time to ask questions. "People areso rushed that they do not oftentimesstop and ask the questions that are so important for their own health," hesays. "We are trying to make peoplerealize that they need to take the timeto ask the questions and to slow theprocess down a bit."

At Leesburg Pharmacy in Leesburg,Virginia, pharmacists step up their contactwith patients by holding certainprescriptions back so that when thepatient comes to pick up the medicine,he or she must speak with the pharmacistfirst. "During the filling process,if it is identified that there is someneed to speak with the patient, wehold it in an area that we call 'specialhandling' to make sure that we dospeak with the patient," explains CheriGarvin, Leesburg's executive vice presidentand chief executive officer. "If itis something that we know has a lot ofside effects, or if there is a potential fora drug interaction that we want to discusswith the patient, we hold it behindthe counter with the pharmacist untilthe patient comes."

Lewis Drug attempts to change theirpatients' behavior—and therefore motivatethem to interact with the pharmacist—through the media, and recentlyran a campaign entitled "Just Ask."The spots featured several differentpharmacists delivering a few lines, theoverlaying message being, "Just ask—even if you are late. Just ask—even ifthe kids are crying." Ladwig says, "Weare trying to reestablish the thoughtprocess. Pharmacists are accessible;we need to make ourselves accessiblefor this purpose." He adds that pharmacistsshould seize any opportunity theyhave to make contact with the patient,be that through counseling sessions oreven other activities, such as speakingengagements at local schools.

Ladwig declares that this meansmore than simply giving patients theopportunity to ask questions. "The 'doyou have any questions for the pharmacist?'method is not a very successfulmodel," he says. "You need to actuallystop and talk to the person to say, 'thisis what this is for.'"

In the past, some pharmacists worriedthat they would experience reticencefrom other members of themedical community when they presentedthemselves as another source ofcounseling in the bigger picture. Thishas decreased, largely because doctorsare pressed for time. "Because of ourmanaged care stresses, physicians arespending less and less time with theirpatients," Felkey says. "It's not a turfissue about who should be doing theeducation. Physicians are increasinglyrelying on pharmacists to do a greateramount of education—especially aboutanything related to the drug product."

Pharmacists, too, face time constraints,and will continue to do soas their distribution loads increase."Because of the decreased reimbursementfor the prescription, you have toincrease your volume in order to makethe same money as you did last year,"Felkey says. This competes with theemphasis on the importance of providinghealth education, which is underlinedwhen aspiring pharmacists enrollin school. "We are trying to make ourstudents realize that pharmacy's futureis based on how valuable they are consideredin the health care system asprofessionals who can produce desiredoutcomes in patients, and that has gotto start with their educational role."

Garvin agrees that time is an issueto everyone—physicians, patients, andpharmacists—and she hopes that in thefuture, a larger number of insurancecarriers will recognize the benefits ofservices like medication therapy management(MTM), opening the door forreimbursement for these counselingsessions. "If you step out from behindthe counter to counsel somebody, ormaybe they have asked for a recommendationon an OTC medication, itis not like all of the other work goesaway," she says. "There is always thatpressure; the longer you spend talkingto them, the more your pile of workbuilds up in the pharmacy area. Timeconstraints are real." So, too, are staffingissues: pharmacies cannot simplyhave an extra pharmacist on hand in theevent that an MTM case may—or maynot—walk through the door. "If everyonecould see that we will be paid forthese services, I think we would have alot more of the profession on board."

Ladwig says that while robotics andautomation have helped with timemanagement, right now the way toprovide health care education is byrelying on assisting personnel. "The biggestaspect of pharmacy is the contactwith the patient," he says. "Successfulpharmacists realize the importance offilling prescriptions, but you still haveto make that patient contact."

For health education to be successful, the relationship between the pharmacist and the patient is paramount.

Getting Customers Literate: Your Role in Health Care

Undeniably, for anyone in retailthese days, it is touch andgo&#8212;although consumers arestill spending, they are demandingthat their dollars go further. Impulsebuys are no longer so impulsive, andlarge purchases have, in many cases,been put on hold. Among the retailestablishments out there, pharmaciesare arguably in an enviable position&#8212;whether the economy is strong orweak, individuals still need their medicine,which drives traffic through thefront end of the store.

Still, pharmacies are not entirelyrecession-proof, requiring owners to bewise in their front-end retail strategies.Although the temptation may be to cutback and batten down the hatches forthe rough ride ahead, the risk is thatif the store appears too sparse, theowner may be projecting an image thatis detrimental to the pharmacy's overallwell-being.

"The front end of your store is lessthan 10% of your business, but it is 90%of your image," says Gabe Trahan, anindependent consultant and director ofretail services at Burlington Drug inGeorgia, Vermont. "Independent pharmacieshave got to control their inventoryin a better way."

He argues that carrying 1 or 2 unitsof each item sends the message that theproduct is so expensive that even thepharmacy itself cannot afford to stockit. "I fear that, in this economy, theindependents and even the chains aregoing to cut back on inventory, whichmakes it look like you are almost outof business." If your front end is poorlystocked, he challenges, why would customersbelieve that the situation is anybetter behind the prescription counter?

For independent pharmacies, theitems that are often the most difficultto move are the "B" of HBA (healthand beauty aids): oral hygiene, skincare, deodorant, and hair care products,which see considerable markdownsin the big boxes. Trahan argues thatindependent pharmacies should reducetheir prices in line with what the largerchains are offering in an effort to keepthe customer in the store.

"You are never going to get rich sellingHBA, but if you are just a little highon the stuff that you do not sell muchof, you are telling your customer: ?Getyour prescription filled here, but go andget your toothpaste somewhere else,'"he says. Chances are, the retailer thatis selling toothpaste at a lower priceprobably fills prescriptions as well."Someday, that person is going to be sobusy that they are going to see what thecompetition can do on a prescription."

Trahan advises pharmacies to assesstheir least successful departments and,on the price-sensitive items (such astoothpaste and hair care), reduce theprice&#8212;even if this means cutting intoyour margin. "You are not selling it anyway&#8212;you are chasing people to otherpeople's stores," he says. "This is a lossleader that actually keeps people in yourstore." Instead of adding departmentssuch as photo developing or expandinggift departments that have little todo with health care, he urges pharmaciesto be more strategic on pricing theproductsthey carry already&#8212;and haveknowledge about. "The front end maynot be a big part of your business, butit is a big part of your image. If the frontend is slightly higher-priced than moststores, then it is going to be tough torecruit a new Rx customer, becausethey are going to think you are expensive,regardless of whether or not thereis a third-party payer."

If you believe that expansion in someareas is necessary, examine what yourcustomers' needs are: plenty of potentialexists to develop comprehensivedepartments dedicated to diseases suchas diabetes, arthritis, and bone density."Instead of being a supplier, pharmacieshave to become a partner to their customers,"Trahan says. "Our clients arelooking for more than just getting theirprescriptions filled. If you say to them,?let us be a partner with you and yourdoctor,' it will be a big attraction."

Medicine Shoppe International isendeavoring to do this by maintaininga solid focus on patient care. The company'sspecialty centers concentrate onspecific disease states, such as diabetes,as well as home health care. "We are tryingto make disease state managementmore prominent in our stores," explainsMark Kenkel, Medicine Shoppe's directorof OTC, adding that these are someways in which the organization can differentiateitself from the larger chains."We understand who our patients areand what the age of the general populationthat comes into our store is.Demographics play a big part of it; weneed to offer these specialty care itemsthat are going to differentiate us fromthe big boxes."

Another way that pharmacies aredifferentiating themselves is by establishingin-store clinics to drive trafficthrough the store&#8212;an effort that MaryKate Scott, principal at Scott & Co Inc,a consulting firm based in Marina DelRey, California, says is very much in alliancewith the current economy. "If youthink about the rising health care costsand increasing interest of consumers intheir own health care, it is no surprisethat the consumer likes and prefers theretail clinic," she says.

Although the construction of an in-storeclinic may seem like a considerableinvestment&#8212;especially in a downeconomy&#8212;independent retailers havethe option of outsourcing the service toa retail clinic operator or a health careprovider, such as a hospital system."If you are an independent pharmacyowner with 1 or 2 stores, it is probablypretty challenging to set this up on yourown," says Scott. "You will probablysee greater success by working with apartner&#8212;whether that is a retail clinicoperator or a hospital." She adds, however,depending on the organization,it is possible for an independent drugstoreowner to set one up and staff it.Regardless of which business modelpharmacies adopt, it is important toassess why the store would benefitfrom a clinic&#8212;would it increase visitsfrom regular customers or attract newones?

Scott argues that a large chance existsthat the store would benefit from a clinic.Developments such as consumer-drivenhealth care, flexible spending accounts,and higher deductibles on health insuranceplans have consumers taking morecontrol over their health and wellnessexpenditures. "They are taking a muchmore active role in how they think aboutspending money on prescriptions, onOTC products, and how they managevisits to health care professionals," Scottsays. In doing this, individuals are turningto their pharmacies for advice onwhat health care options are most effective,both in terms of patient outcomeand cost.

"That is why we have seen genericprescriptions go up, flexible spendingaccounts being used, and retail clinicsbeing used," Scott says. "The consumeris saying, ?Help me figure out when Ireally need to buy the brand prescription,the generic prescription, or whenthere is an OTC product that could giveme self-diagnosis, or help me understandwhen I can use a retail clinic so that I canget a great service at a fair price.'"

In an industry where pretty muchevery retail establishment sells the sameproducts, pharmacies should concentrateon service&#8212;the factor that setsthem apart from the competition. Notonly does this differentiate one storefrom another, Scott says, but it alsostrengthens the organization's relationshipwith its consumers. "You get stronger,deeper customer relationships whenyou combine service with product."

In today's economy, pharmacies must consider growth strategies and avenues to drive traffic into their stores and increase revenues.

The Showroom Floor: Front-End Retail Strategies for Today's Economic Climate

With disease management initiatives like the Asheville Project, the American Pharmacists Association (APhA) Foundation Patient Self-Management Program and its complementary Diabetes 10-City Challenge, pharmacy has helped to show that when patients take their medicine, overall health care costs decrease significantly. Adherence leads to healthier lifestyles, fewer sick days, and a more productive workforce.

Major players in the pharmaceutical industry are also beginning to step up their efforts in this area, notes Daniel Garrett, RPh, MS, formerly senior director of medical adherence programs at the APhA Foundation and now executive director of the American Health Care Foundation. "Pharma's strategy is to improve awareness that adherence leads to lower overall health care costs," he said, citing GlaxoSmithKline's support for the Diabetes 10-City Challenge. Insurance carriers and pharmacy benefit managers, too, are starting to warm up to the idea that adherence is actually a cost-effective measure. "It wasn't too long ago that one of the reasons we had rising copays was because people were alarmed about how much money they were spending on medication," Garrett said. "Now we are starting to see some programs that promote adherence." He cites North Carolina Blue Cross/Blue Shield as an example of a carrier that has decreased its copays for medications targeting certain conditions, such as diabetes. Humana and others are also striving to promote awareness that adherence, in fact, does make a difference.

Pharmacists' proximity to the patient, however, puts the bulk of adherence promotion on their shoulders. Whereas certain programs like the Asheville Project offer reimbursement for counseling services, "right now, pharmacists do not get reimbursed for taking the time to sit down with people routinely," Garrett said. "When programs have been put in place and pharmacists have been paid for that time, we see dramatic improvements in adherence-not only in taking medications, but also in relation to lifestyle changes-and it contributes significantly to the bottom line."

Garrett argues that adherence promotion offers a significant opportunity for pharmacists to increase sales, and, thus, profitability. "If we know that 50% of people with chronic conditions aren't taking their medicine as prescribed, if they have efforts to improve adherence they have the opportunity to double sales," he said. "The business incentive is there, because they do make money when they fill prescriptions."

The sticking point is the issue of time: pharmacists are already fulfilling demanding workloads, and many wonder where they will find the hours to provide the patient counseling that adherence programs demand. To get around this, some are turning to technology as a way of expediting the prescription- filling process, freeing up time that would have otherwise been spent on filling orders manually.

"The key here is to free pharmacists' time up from one component of their work-it may be related to dispensing- and move that time over to the cognitive or counseling part of their work," said Michael Murray, PharmD, MPH, professor and chair of pharmaceutical outcomes and policy at the School of Pharmacy, University of North Carolina at Chapel Hill.

Pharmacists also can employ software to set up automated refill systems, suggests Stacey Swartz, PharmD, director of management and educational affairs at the National Community Pharmacists Association. "This can result in stable prescription volume and more manageable workflow," she noted. Additionally, some pharmacies have implemented antibiotic callback lists, which enable pharmacists or technicians to track those who have recently claimed a prescription for antibiotics. Swartz said that this serves as a marketing tool because, "patients know their pharmacist cares about them and can encourage good compliance with antibiotic regimens, which patients may be tempted to stop early."

Those active in the promotion of adherence emphasize that the most crucial element is the relationships that patients share with their caregivers. "What we have learned in Asheville and at the sites around the country with the patient selfmanagement program and the Diabetes 10-City Challenge is that it's really a personal relationship with a care provider that encourages patients to take their medicine," Garrett said. "You can put up billboards, you can have Internet Web sites, and you can send people mailings, but what really works is when there is a personal relationship."

Murray points out that each patient is different, requiring pharmacists to tailor their counseling accordingly. "There is the patient who is the busy person, for example, who wants to get in and get out without much counseling. How does a pharmacist handle that, when they really need to spend more than a few minutes with the patient, and neither one of you has the time?" It may require scheduling a follow-up call to go over adherence instructions or some other way of communicating this information, he adds.

Bruce Berger, PhD, professor and head of pharmacy care systems at Auburn University in Auburn, Alabama, argues that patient counseling leads to results only when the case is assessed thoroughly. "We are in an age where we think that just giving information is enough," he said. "We load patients up with things like: here's how to take this drug, here is what it is, it's for your diabetes, take it once a day, and then we think we've done our job. My retort to that is: if information were enough, nobody would smoke."

Berger applies a motivational approach, based on methodologies taught at Auburn's Motivational Interviewing Training Institute. The philosophy is simple: unless caregivers understand why a patient is not taking his or her medicine, there is little they can do to change this behavior. "If you've got a person in front of you who is not taking their medicine, and you start telling them why they need to, they're going to tell you why they won't," he said. "Even if they present a prescription, it doesn't mean that they are ready to do anything. We have patients who come into the pharmacy, and we never assess how ready they are to do any of this. What do they see as the benefits of doing it? What is going to get in their way of being able to do this?" Assuring a patient that their doctor would not prescribe an ineffective medication, Berger says, is not enough.

The following Web sites can provide more information on patient adherence programs:

American Pharmacists Association Foundation

Auburn University Motivational Training Institute

National Community Pharmacists Association (NCPA)

University of North Carolina, School of Pharmacy

Any health care provider who strives to improve adherence-especially for chronic, asymptomatic illnesses-must assess the patient's understanding of that condition, explain how the treatment works, and discern how confident the patient really is in the treatment itself, Berger underlines, adding that this requires regular follow-up. "Case management is doing this," he said. "If we don't do this, we are not going to be able to significantly change outcomes. Ultimately, if pharmacy cannot show that the use of medicine reduces total cost of care, we're not going to get paid for it."

Better medication adherence means healthier patients and lower health care costs; pharmacists are at the front lines of this movement.

Promoting Adherence Benefits More Than Just the Patient

Ms. Heinze is a freelance writer based in Vancouver, British Columbia

Reputed for its adoption of innovative technology and procedures, the Children?s Hospital of Philadelphia (CHOP) provides both inpatient and outpatient services for children and adolescents. The facility boasts a division of hematology, as well asa clinical oncology program that is recognized as one of the largest in the United States.

Like the rest of the hospital and research center, CHOP?s pharmacy practice aims for innovation through the application of a number of progressive principles, surprisingly, gleaned from automotive manufacturing. Director of Pharmacy Winson Soo-Hoo explains that over the past 2 years, the facility has incorporated the values of ?lean thinking,? a Japanese philosophy made famous by Toyota.

The basic principle behind lean thinking is that by focusing on all things that provide value to the customer, an organization can implement an effective workflow that, when streamlined, eliminates waste. ?As you are processing orders, there is a whole host of waste, such as transportation, making too much, and not having inventory at the time that you need it,? Soo-Hoo observed. ?All of these things keep the employees or the pharmacist from doing the job that they are supposed to be doing.?

This is especially challenging in CHOP?s pharmacy practice, where pharmacist training lasts up to 6 months. ?There is a lot that we have to teach the staff that they may not get from pharmacy school,? Soo-Hoo explained. ?Pediatrics, for mostpharmacy graduates, is a 1-week introduction.? CHOP?s pharmacy training program encompasses extensive testing and simulation modules, which Soo-Hoo recognizes is not the norm in many hospitals.

With their emphasis on workflow, lean principles embrace the notion of standardization, which, Soo-Hoo notes, greatly improves training. ?If you have a week?s worth of training, and you have 4 people training the same person, you are really not training them because you are not getting reinforcement,? he said. Standardization, he adds, is not only the basisof good training, but of continual  improvement as well. ?If everybody is not doing things in a standardized way, there is no way to identify what the root cause is, and there is no way to develop a solution that addresses the problem, because everybody is doing something different.?

To properly incorporate lean principles in an organization, employeesmust have ownership of the workflow process. In this way, not only are they contributing to the development of the practice; they are also accountable for the changes that they make. ?When they are engaged, they hold each other accountable to those solutions, and you get better compliance to the solutions that are implemented,? Soo-Hoo said. ?Also, because we are giving them feedback on what the outcome is, we are giving them the chance to grow.?

This helps with both recruitment and retention, because as the overall workflow is improved upon, employees know both where they stand in terms of performance and why any modifications are being made in the first place. ?If you have standardized work?if everybody knows and participates in these processes?they can explain to the employees why we are doing  things a certain way,? Soo-Hoo said. It is a better approach to training. He adds, ?Instead of someone saying, ?I do not really know why they are doing it this way, but this is the way that we have always done it,? employees are told, up front, ?these are the reasons why we are doing things this way.??

As CHOP continues to integrate new systems into its pharmacy, Soo-Hoo and his team are constantly evaluating how workflow and technology can complement each other for optimum performance. ?When you integrate automation, there needs to be a merging of your workflow into this technology,? he said. ?It is not about adding the technology; it is about how you rearrange your work to complement the technology or vice versa.? Has CHOP arrived at the perfect solution, then? ?No, but I think we are working towards it.?

For more information on CHOP, please visit 

Children's Hospital Applies Lean Thinking to Pharmacy Practice

With America?s collectivepocketbook undercontinued strain, massmerchandisers offeringpharmacy services are respondingby offering low-cost prescriptions incombination with in-store clinics toappeal to budget-conscious individualswho do not have a lot of time on theirhands.

Wal-Mart Pharmacists Make a Difference in Patients? Lives

For Wal-Mart, part of this effortinvolves its offer of $4 generic drugs,explains spokesperson Christi DavisGallagher. ?Our commitment to providingaffordable, accessible solutionsto America?s health care challenges isimportant. We will continue to focuson finding solutions to the toughesthealth and wellness dilemmas ourcustomers may be facing,? she said.One way the organization is achievingthis is by leveraging technologyto drive efficiencies. ?Just as our $4prescription program has saved ourcustomers more than $1 billion sofar, we know through technology,innovation, and collaboration, thereare other ways we can do our part tooffer solutions to these issues.?

At the pharmacist level, Gallaghernotes, Wal-Mart promotes the involvementof pharmacists as part ofthe overall health care solution. ?AtWal-Mart, we want to be a placewhere our pharmacists feel like theyare truly making a difference in thelives of their customers by offeringaffordable health care solutions like$4 prescriptions,? she said. ?Helpingour customers save money so theycan live better, healthier lives is Wal-Mart?s mission and top priority, andit is something our pharmacists areproud of.? She adds that this is onereason why the company is able tonot only attract, but also to retain, itspharmacy personnel.

Growth and Development Possibilities with Target

Last May, Target announced pricereductions on OTC and prescriptiondrugs, including $4 or less on OTCs,$4 prescriptions, and 90-day suppliesof prescription drugs for $10. JoshuaThomas, spokesperson for TargetCorp in Minneapolis, Minnesota,underlines that it is often the company?spharmacists who act as the?face? of the organization. ?They arethe primary contact for the peoplewho travel into that store,? he said.?They are answering health-relatedquestions, and they are looked at asexperts in their department.?

Internally, Thomas explains thatTarget aims to foster a culture thatencourages growth and advancement.?There is a continuous focus on development,and how you can grow inyour role and with the company,?he said. ?It is possible to start out inpharmacy as an intern, and moveup to being a lead pharmacist andeven beyond that. From a career perspective,Target opens the door to awide variety of business areas that youmight not otherwise be exposed to.?

Thomas points out that Target?sheavy focus on design is applied toits pharmaceutical practice throughClearRx, the company?s bottlingsystem that combines esthetics withpracticality to ensure that customers?or, as they are referred to atTarget, 

?remain well informedabout how to take their medications.?At Target, design is fashionable andfunctional. You do not necessarily directly apply those concepts to thepharmacy,? he said. ?If you see whatwe have done with our ClearRx system,it has brought something newto the industry that had not beentouched for more than 50 years. Itwas about simplifying, clarifying, andenhancing the safety of our guests.?

The bottles?a considerable stepaway from the traditional brown pillcontainers that patients have beenaccustomed to for decades?featureclear, easy-to-read labels, color-codedrings that fasten around the neckof the container to distinguish onefamily member?s prescriptions fromanother?s, a flat face and back forconsultation at a glance, a liquid dispenserfor measuring quantities, anda free magnifier for those who havetrouble reading the fine print. ?It is abottle that looks great, and Target isknown for creating merchandise thatis esthetically pleasing,? Thomas said.?Taking it a step forward, we believethat design should be smart, and thatit should make peoples? lives better,and, in this case, easier. With ClearRx,it is a communications vehicle so thatour guests understand the prescriptionsthat they are taking, and canavoid the danger of possibly takingthe wrong medication or taking thewrong dose of medication.? Targetalso offers free flavoring for thosewho do not like the taste of theirmedicine.

At the store level, Target recentlyconducted some physical modificationsthat saw the pharmacy areasbeing moved from the back or centerof its stores to the front. ?What wehave learned, based on speaking withour guests, is that it would be moreconvenient if that pharmacy counterwas right at the front of the store,?Thomas said, adding that this enablescustomers to drop off their prescriptions,do their shopping, and recovertheir filled order on their way out.?Our guest is time-starved, and isalways looking to cut corners when itcomes to working against the clock.We have found that a small step likethis can have a huge impact on thecustomer?s experience.?

In-store Clinics a Health Care Destination

Another way that mass merchandisershave addressed the time-starvedconsumer/patient is by adding clinicalservices to their rosters. Wal-Mart?s in-store clinics were rolled outin 2005, and Gallagher notes that thepremise behind them is to providelow-cost care in a convenient setting.?We know that our customersspend time in our stores already, andmeeting their nonemergency medicalneeds in that same store is convenientfor them,? she said. ?Doing soat Wal-Mart prices makes the experienceeven better.? Wal-Mart clinicsaffordably price acute (Get Well) andpreventive (Stay Well) services fora number of common conditions,including sore throats, sinus infections,upper respiratory infections,earaches, bladder infections, insectbites and stings, cholesterol screening,blood sugar testing, vaccinations,drug screening, and routine physicals.

Target first began experimentingwith in-store clinics in Minnesotaand Maryland in 2003, through itspartnership with MinuteClinic. ?Wehad a great relationship with Minute-Clinic, and the idea was to test the instoreclinic environment to see if thiswas a service that our guests wantedand would use,? Thomas recounted.?We found that they did, and wewanted to find a way to make thatexperience uniquely Target.?

In 2006, this came to fruition withthe launch of the Target clinic format.The organization currently has25 locations spread out over Minnesotaand Maryland. Services includetreatments for minor illnesses (suchas allergies, colds, coughs, bronchitis,earaches, flu, mononucleosis, sorethroats, and sinus infections); minorinjuries (bruises, insect bites or stings,minor burns, splinter removal, stitchremoval, and wound checks); skintreatments (acne, athlete?s foot, coldsores, eczema, impetigo, poison ivy orpoison oak, rash, ringworm, shingles,skin infections); vaccinations; andwellness testing and screening (suchas blood pressure checks, pregnancytesting, camp and sports physicals,cholesterol screening, and smokingcessation).

?Pharmacy plays a key role in ourcontinued store growth, because itallows us to provide an environmentfor our guests that is marked byconvenience and excellent customerservice,? Thomas said. ?It plays a keyrole in delivering the in-store experiencethat we have established.?