Despite the current economy posing significant challenges to the acquisition of new technology and automation, individual US health care systems and hospitals continue to spend millions of dollars to improve the distribution, management, and safety of pharmaceuticals and pharmacy services. Directors of pharmacy are constantly pressed to provide faster, more accurate, safer, and more clinically relevant systems and processes for medication management. Given that hospitals are continuously competing for patients by promoting best practices, services, and technology, hospital pharmacies should be no different. Fortunately, we are now seeing progressive hospitals and health systems actively collaborate with pharmacy services to promote positive patient outcomes and service excellence.

In the hospital setting, pharmacy leadership is obliged to continuously develop and market clinical and distributive service innovations to hospital administrators. Therefore, a concerted effort must be made to articulate the clinical, operational, and distributive needs of the pharmacy in order to promote best practices for patient care. Aligning the pharmacy department’s goals with those of the administration is a sure way to gain support and approval for resources and technology, so it is imperative to provide sound business proposals that support the organization’s overall goals of safe and innovative patient care. Any organization’s administration is much more likely to support an endeavor that is cost efficient, improves patient care, promotes safety, and generates a tangible return on investment. The return on investment can be derived from increased revenue, decreased expenses, improved productivity, time savings, or improved public relations marketing.

Budget Development
In the process of planning for a pharmacy automation budget expense, some key questions need to be addressed:

• Will the expense improve service, operation, and patient outcomes?
  For a tangible return on investment, the product should provide an improvement to patient care, a decrease in resources needed or used, and an improvement to productivity and efficiency. Technology will not automatically fix a problem unless the user fully understands and uses the product as it is intended.

• Will the expense require additional resources and/or personnel?
  While pharmacy automation should reduce labor and resource expenses, the focus should not be on replacing people with technology, but on augmenting the workforce using technology. For example, implementation of automated dispensing cabinets (ADCs) should never be sold on the premise that doing so will reduce the number of employees needed to distribute medications. While ADCs can help streamline the manual process of medication delivery, they also introduce new functions that must be attended to, such as filling the individual units and monitoring user activities, and performing routine maintenance and quality assurance checks. In this example, the ADC improves the efficiency and accuracy of medication delivery, provides safety and security of the medications, and reduces total inventory needed on hand. This in itself reduces expenses, inventory costs, and labor time. So, this decrease in labor time doesn’t necessarily translate into a reduction in workforce, rather it allows the existing workforce to take on other functions that also improve efficiency.

• Will the expense require input from other disciplines?
  The pharmacy department cannot operate in a vacuum. Pharmacy automation may appear only to affect the pharmacy operations and staff, but in reality, other disciplines are almost always involved. For example, a seemingly benign action such as changing the process by which medications are packaged and labeled would involve alterations to label sizes, fonts, relevant information, data placement, and formats that may impact other healthcare practitioners’ understanding and practices. It is important to consider all potentially affected disciplines and ask for input during the proposal process.

• Will the expense need to be paid at once or are installment payments available?
  The method of payment may be key to administrative approval. A large, one-time payment may be hard to justify and be too financially taxing for a health system, whereas installments could ease the burden. Determine whether payments can be made through a lease agreement directly with the company, or if a capital lease program through a financial institution is possible. Companies that are more flexible and accommodating with payment methods are more likely to win bids and contracts.

• Will the expense create potential risk factors for the organization that could negatively impact credit ratings or cash flow?
  If the expense will clearly create a significant risk for the institution in these areas, it is likely the proposal will fail. Pharmacy leadership needs to have an understanding of their organization’s fiscal abilities and work closely with the finance department to develop an economically viable proposal.

Planning for Acquisition and Implementation
Planning for the implementation of pharmacy automation tends to be a fallible process, but performing some key steps will assist you in selecting the right automation and help ensure the success of the process improvement you seek. These steps include but are not limited to:

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A SWOT Analysis
SWOT stands for strengths, weakness, opportunities, and threats. As part of a strategic plan, a SWOT analysis can help put into focus the needs and risks facing your department or organization. The purpose of a SWOT analysis is to clarify the mission, goals, positive attributes, and areas of growth needed to be successful.

Mapping the Process
Though the solution may appear obvious, it is still key to review the process you are trying to improve, as unexpected challenges and issues could prove detrimental. Creating a process flow map enables you to capture all the pieces of the process ahead of time, and an assigned group of stakeholders, directly and indirectly involved with the process to be improved, should meet and map out the flow diagram. The workflow map should include key decision points and should clearly define all steps in the process (see Figure 1).

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Failure Mode Effect Analysis
A FMEA is a powerful tool that can be used to determine all possible failure points identified in the process flow map. The stakeholder group should meet to discuss all possible failure points that may occur during the process and apply a FMEA, which will result in a ranking of potential failures from greatest to least risk. Scores are based on the likelihood of a process error occurring, ease of error discovery, and severity of error outcome. The risk scale will make a designation from 1 to 10 with 1 indicating the least impact and 10 the greatest. Keep in mind, the FMEA process also can be quite useful to evaluate a product after implementation to maintain optimal usage (See Table 2).

Proposal
Once a suitable pharmacy automation solution has been identified, a preliminary meeting with the facility’s administrator or decision-making body is necessary. This preliminary, informal meeting can help to relay the concern and vision without committing the administrator to make an immediate decision. This also creates an opportunity to obtain information and explore questions and issues you may not have thought of. The point of such meetings is to open lines of communication, promote dialogue, and gain a willingness, from all parties, to explore a process improvement that will incur an expense. Once an understanding has been reached, the acquisition proposal can be crafted. The proposal needs to address the following information:

• Identify the manufacturer or company responsible for delivering the product. List the contact numbers and names of individuals involved with the sale and purchase.
• If it is a product replacement, review the life cycle of the old equipment and specify the reasons for replacement.
• Include the repair history and total costs related to the old equipment. This will help administrators understand the expense and liability of defective, dated, and/or broken equipment.
• Specify the stated or typical life cycle of the new product.
• Note the cost and availability of a maintenance/service contract.
• Identify and list the cost impact on patient volume and procedures.
• Detail labor expenses, savings, or changes that will occur as a result of the new technology implementation.
• Explain how the new technology will:
  • Improve patient clinical pharmacy interventions and services
  • Improve the medication administration and delivery process
  • Increase medication safety, security, and/or accountability
  • Increase charge capture
  • Increase inventory turns and revenue stream

Automation Implementation
Once the proposal and budget have been approved, creating an implementation schedule is the next step. This schedule should include the vendor’s input with a full explanation and forecast of necessary resources, expected delivery time, and total expenses provided. When the preliminary implementation schedule has been established, reconvene all affected stakeholders and vendor representatives to discuss, in detail, the elements and resources needed to initiate the implementation process. The implementation process should intricately detail the expected timeline, including checkpoints and progression events, and list the responsible parties. As with any complex forecast, be sure to include some flexibility in the schedule to allow for unforeseen circumstances, failures, and setbacks. The final go-live implementation schedule should be sent to all stakeholders with timelines and goals clearly delineated, and regular updates also should be sent to the group throughout, especially if there are schedule or process changes. Employing group calendars, scheduling software, and weekly update sessions are excellent ways to keep everyone informed and on schedule. The other advantage to frequent update sessions is that they create opportunities to flush out problems and address them quickly so as not to impede the implementation.

The implementation should not hinge on a single project manager, rather it should have layers of empowered decision makers who can act on various issues without having to stop the entire process. It should be understood that even the best laid plans are likely to change during the process. Remember to focus on the final, intended results of the implementation, and not the exact path it took to get there. The real measure of a successful implementation is the manner in which the group is able to transition to alternate plans and strategies to get the job done.

Conclusion
While it is often easy to imagine the benefits of new technology to your pharmacy practice, it can be more difficult to imagine the best route by which to justify, acquire, and manage that technology. Managing the acquisition and implementation of automation requires constructive communication, teamwork, commitment, research, planning, and perseverance. An organization committed to best practices, safety, and patient care will dedicate the resources, finances, and time necessary to achieve its automation goals, which ultimately should be in line with its overall goal of efficent, safe, and beneficial patient care.

Mitch G. Sobel, RPh, MAS, is the corporate director of pharmacy Services for the St. Joseph’s Healthcare System in Paterson, NJ. He is also past-president of the New Jersey Society of Health-Systems Pharmacists (NJSHP) and is an American Society of Health-System Pharmacists Regional Delegate for NJSHP.