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Just in Time Compounding for Outpatient Oncology Services


November 2011 - Vol. 8 No. 11 - Page #22

Establishing 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 challenges 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 efficient 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 communication 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 information lost during shift change, communications should be automated using 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 performed within the electronic health record. This method provides an immediate feedback loop, does not rely on any single individual, and in many cases, 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 pharmacy and infusion clinic. For facilities without an electronic health record, using 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 activities; 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, laboratory 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 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 processes. 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, including orders per hour, orders by hour of operation, staffing productivity, other requirements or demands on the department, the receiving time and process, routine medication pass times on the floor, and others based on your particular practice 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 effects 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 necessary. 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 determine 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 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. Without a solid inventory management solution in place to support JIT, confidence wanes and the process breaks downs. Review your current tools whether manual 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 practitioners, 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 Philadelphia, 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 Pharmacy 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.

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