Hospitals and health systems face a number of operational and clinical challenges brought on by the COVID-19 pandemic, from surge preparation and operationalizing emerging therapies to a lack of treatment strategies and managing shortages in personal protective equipment (PPE). There is the further challenge of ensuring employee safety while maintaining patient care. Many institutions have transitioned eligible employees to teleworking whenever possible, and for staff who were unable to telework due to the nature of their role, various strategies have been utilized to implement social distancing requirements, conserve PPE, and ensure an operational medication use process.
Despite these efforts, staffing shortages have continued to threaten operational ability. Pharmacy departments are responsible for ensuring the functionality of drug distribution, which is largely impacted by staffing shortages and operational changes such as surge unit expansions.1 This task becomes increasingly difficult in tandem with rising rates of COVID-positive staff and COVID-related absences.2,3 There is a clear need for a plan to address these issues not just during the current pandemic, but during all emergencies that may lead to such shortages. To preserve pharmacy functionality in the face of these challenges, the UNC Health Triangle West Region Department of Pharmacy has developed a staffing needs assessment and a cross-training plan to address pharmacy workflow with identified staffing gaps during COVID-19 and other such situations that result in staff shortages.
UNC Health is a 12-hospital, not-for-profit integrated health system with the UNC Medical Center (UNCMC) serving as the flagship academic medical center for the system. The UNC Health Department of Pharmacy is divided into 4 regions with the Triangle West region encompassing a 900-bed academic medical center (UNCMC), an 86-bed acute care hospital, a 25-bed critical access hospital, an inpatient/outpatient mental health center, and 4 off-site infusion centers. The pharmacy department at UNCMC consists of over 450 FTEs and services over 900 acute care beds, and both onsite and offsite outpatient clinics and infusion centers. There are six distinct inpatient pharmacies within UNCMC: Central Inpatient Pharmacy (CIP), Sterile Products Area (SPA, located within CIP), Pediatric Satellite Pharmacy, Cancer Hospital Infusion Pharmacy (CHIP), Operating Room Satellite Pharmacy, Investigational Drug Services (IDS) Satellite, and Neurosciences IDS Satellite.
COVID-related absences within UNC Health Triangle West are triaged and managed through local Occupational Health Services. Beginning in December 2020, UNC Health implemented numerous tactics to minimize employee-to-employee disease spread, including mask wearing, eye protection, and physical distancing. Given these precautions, if an employee tests positive for COVID-19, the coworkers of that employee are typically not required to quarantine unless there was a breach in PPE use. However, as rates of community spread increase, the risk of outside exposures for UNC Health employees also increases. Quarantine requirements addressing COVID-19 exposures from community spread were designed by the Occupational Health Services (OHS) and include a 10-day quarantine if an employee tests positive or an up to 24-day quarantine if a household contact tests positive. While necessary, these quarantines have a serious impact on staffing.
Initial Needs Assessment
To better understand the potential impact of COVID-related absences on staffing levels, pharmacy leaders determined a staffing needs assessment was necessary to ensure staff coverage for specific operational areas as well as the specific skillsets needed within each of the operational areas. This assessment of staffing needs was then broken into three phases, which were used to measure staffing requirements needed for possible severe vacancies.
Pharmacy area leaders were tasked to determine the minimal number of staff required to maintain the core distributional functions of each operational area. Additionally, each area identified the specific skills necessary for the operations in their respective area via a survey (eg, experience with hazardous sterile compounding) and then leveraged that data to identify both the operational areas and the specific skillsets that required additional training for backup staff. The results showed the skillsets requiring additional staff training were non-hazardous sterile compounding (CSP) and hazardous (HD) sterile compounding due to their critical nature. Two operational areas were identified as requiring back-up due to the unique tasks required in these locations.
The next step was to calculate the actual number of staff that must undergo training in order to meet the identified needs. Using the lowest number of staff required to maintain operations, the department calculated the impact of vacancy rates of 7%, 15%, and 30%. Vacancy rates at UNCMC for pharmacists and technicians at the time were 7-15%. A vacancy rate of 30% was estimated as the worst possible impact from the COVID-19 pandemic. Example calculations for applying these vacancy rates to determine minimum staffing needs are detailed in TABLE 1. The FTE requirements calculated from the vacancy rates were then compared to the numbers of staff currently trained in the specific skillsets to identify the actual need (see TABLE 2).
A majority of the operational areas in the department had similar tasks, allowing for a small buffer in moving staff between areas. However, the option of sharing staff between operational areas would be quickly exhausted. Therefore, pharmacy leadership realized having a reserve of technicians available for specific tasks would be necessary. As such, the department aimed to have 25% of staff on reserve at all times to serve as an extended buffer of support. Example calculations for determining how many staff would be required to absorb the identified vacancy rates and provide a 25% reserve of trained individuals are provided in TABLE 3.
Utilizing the data calculated in phase 2 of the evaluation, the team focused on identifying which operational areas had allowable vacancies that could send technicians for additional training. The allowable vacancy was calculated using this formula:
Technician Cross-Training Plan
Following the three assessment phases, the department set out to create a cross-training plan to build a reserve of staff trained within a skillset. The data demonstrated that the number of staff trained in sterile compounding was at the greatest risk during a 30% vacancy, followed closely by HD compounding, while there were enough staff trained in the other identified skill sets to withstand severe vacancies. Thus, the focus of cross-training shifted to training additional technicians in CSP and HD compounding.
A 2-week training period was established to provide technicians the minimum competency needed in a specific skillset. A cross-training checklist and training schedule were designed to facilitate the 2-week training period in a timely manner (see TABLES 4 and 5).
During the needs assessment, allowable vacancy rates were calculated by operational area and ranged from 0-100% (see TABLE 6). Areas with higher allowable vacancy rates include the Informatics Team, Investigational Drug Services, Chatham, and CHIP. Areas with any allowable vacancies were asked to provide team members who did not have any CSP or HD training to be cross-trained. The allowable vacancy rates were higher in some areas due to their flexibility to collapse existing workflows in favor of prioritizing COVID-19 cross-training efforts.
From here, an 8-week training plan was developed to minimize the impact to various areas by operating within the allowable vacancy rates. The 8-week training plan was designed to train multiple staff in different skillsets over four separate 2-week periods. The training plan would provide an additional 10 individuals trained in CSP compounding, an additional five people trained in HD compounding, and six individuals trained in the largest operational area, the centralized inpatient pharmacy. A majority of the trained individuals were from CIP, and it was determined that there would be a need for additional cross-training in CIP to support the potential of these staff members being reprioritized in the event of increased absences.
After implementation, the pharmacy was successful in training eight additional people on CSP preparation, five additional people on HD compounding, and three additional people in CIP operations. The cross-training efforts were modified for operational need on an every 2-week basis as allowable vacancy rates changed for areas providing technicians for training.
The staffing assessment and cross-training plan closed identified training gaps, provided resources for specific technician skillsets in the event of critical need, and broadened opportunities for technician staff. Recognizing that the traditional training period for some of the more advanced skillsets spans over multiple months, the technicians trained through this program would only be called upon after initial backup and down staffing plans were exhausted. To support ongoing cross-training, area leaders are encouraged to create educational resources for individuals called into action. Utilizing this approach to cross-training could benefit other departments of pharmacy looking to support potential resource gaps. While this needs assessment and training were developed to address the COVID-19 pandemic, it is beneficial to have this plan in place should another emergency situation arise.
Conor Myers, PharmD, MS, BCPS, is a second-year health system pharmacy administration and leadership resident at University of North Carolina Medical Center (UNCMC). He earned his doctor of pharmacy degree from the University of South Carolina and his MS degree with an emphasis in health-system pharmacy administration from the UNC Eshelman School of Pharmacy.
Elissa King, PharmD, MS, BCPS, is the clinical manager of pharmacy for infusion services at UNCMC. She earned her doctor of pharmacy degree from the University of Maryland School of Pharmacy and her MS degree with an emphasis in health-system pharmacy administration from the UNC Eshelman School of Pharmacy while completing a 2-year health system pharmacy administration residency at UNC Health.
Nathan E. Barnes, PharmD, MHA, is the clinical manager for oncology pharmacy operations at UNCMC. He received his bachelor of science and doctor of pharmacy degrees from the University of North Carolina Eshelman School of Pharmacy in Chapel Hill and is currently pursuing a Master’s of Healthcare Administration from the University of North Carolina Gillings School of Global Public Health.
Samuel M. Eberwein, PharmD, MS, BCPS, BCSCP, is the clinical manager of pharmacy for the sterile products area, perioperative services, and special formulations at the University of North Carolina (UNC) Medical Center. He earned his doctor of pharmacy from Campbell University and his MS with an emphasis in health-system pharmacy administration from the UNC Eshelman School of Pharmacy while completing his 2-year health-system pharmacy administration residency at UNC Hospitals.
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