Osama Tabbara, R.Ph., BCNSP, EMBASenior Director, Department of Pharmacy ServicesCleveland Clinic Abu Dhabi, UAE

Disclosure InformationEstablishing a World Class Pharmacy: The Cleveland Clinic Abu Dhabi ExperienceOsama Tabbara

I have no financial relationship to disclose

&

I will not discuss off label use and/or investigational use in my presentation.

Learning Objectives

• At the completion of this activity, you will be able to:

• Be aware of various initiatives used in Cleveland Clinic Abu Dhabi when establishing the pharmacy services.

• Describe the space, design, workflows, and manpower needed for to establish world class pharmacy.

• Identify the technologies used to enhance medication safety and quality

Day #1: March 2015

• 360-bed facility

• Five centers of excellence:

• Heart and vascular medicine

• Neurological medicine

• Digestive diseases

• Ophthalmology

• Respiratory and critical care

• 170 Physicians

• 78 Pharmacy Caregivers

• 1700 Nurses

"Placing patients first is our highest priority.

Patients are the reason we exist and the reason

we come to work each day."Delos M. Cosgrove, M.D.

Chief Executive Officer and President

Cleveland Clinic Health System

جميعاومن أحياها فكأنما أحيا الناس

And whoever saves one - it is as if he had saved mankind entirely

Al-Maaida, Aya 32

Cleveland Clinic Abu Dhabi Department of Pharmacy Services

• Our Mission:

• To provide safe and optimal medication therapy through compassionate, patient-centered care of the highest quality.

• Our Vision:

• To be a world class leader in Pharmacy care.

• Our Values:• “Patient First” care through Cleveland Clinic Abu Dhabi

shared values of Quality, Compassion, Integrity, Teamwork, Service, Innovation and Stewardship

• S = Sincerity

• T = Trust / Transparency

•A = Accountability

•R = Respect

We are Committed to STAR

cy

• Design the medication use system based on highest technologies

• Patient-centered pharmacist practice model / PPMI*

• Spread the culture of medication safety at regional level

• To lead the transformation of Pharmacy landscape in the gulf region and beyond

*Pharmacy Practice Model Initiative

Major Programmatic Goals

CCAD Pharmacy

• Granted HiMSS Stage 6 License• Stage 7 Enabled

• Only 5% of USA hospitals are HiMSS stage 7

One in Canada

3 hospitals in Asia

3 hospitals in Europe

The Road Ahead

2015

2016

2017 Ramp up and research

Persistent Forward Progress

Commitments to Safe Startup Operation

•Research & Innovation

• IV Remote Verification

•PGY-2 Residency

•Out-patient Robotics

• Introducing IV Robotics

•PGY-1 Residency

•ACPE providers

•Activation of Satellite Pharmacies

•1,000 Scheduled Visits

•100 Inpatient Census11

The People & The Facility

Initial Team

IV Room

Ambulatory Pharmacy

In-Patient Pharmacy

IV Room

Size in m square Size in ft Square

Out-Patient Pharmacy 520 m2 5,597 ft2

In-Patient Pharmacy 1,060 m2 11,410 ft2

4 Satellites Pharmacies 246 m2 2,648 ft2

TOTAL 1,826 m2 19,655 ft2

Pharmacy Surface Area

Quality & Transformational Caregivers

• We hire non-traditional Caregivers• Committed to the mission of the department

• Our ABC for recruitment• A: Attitude

• B: Background

• C: Communication

Recruitment Criteria

• No Nepotism (Wasta)

• “If you meet the criteria, you have the right to sit for an interview”

• Start the interview with disclosure and intention of fairness

• STAR interviews

• Source references

• It took us 4 years to recruit 68 caregivers

• Interview to on-boarding: 9-15 months per Caregiver

CCAD Pharmacy Manpower & Demography41 Pharmacists, 27 Technicians, 2 Analysts,

8 Distribution Agents

Male/Female1:1

62% Pharm.D.31% at least PGY-1

30% with Master36% with Board

60% USA trained40% MEA trained

CHALLENGES

Strategic Issues and Challenges

19

What make most pharmacy leaders awake at night?

• Maintaining employee engagement

• What is happening in the IV Room

• The turn-around time in the out-patient pharmacy

• Stock shortages

• How to prevent medication errors

• The Internal Factors:• Vision • People (No inheritance)• Name/benchmark• Location• Package• Technologies

• The External Factors:• Regulations• Logistics• Regional political & economical instability

Internal versus External Factors

Pharmacy Forecast 2013-2017, ASHP Foundation Report, 2012

The Future of Hospital Pharmacy Practice

Pharmacy Forecast 2013-2017, ASHP Foundation Report, 2012

The Future of Hospital Pharmacy Practice

Facts

• Pharmacists lose skills when not

performing patient-centered activities:

Drug information

Kinetics

Rounds

Ambulatory Clinics

The Gulf Experience from the USA• 5% increase per year in out-patient

pharmacy orders

• 2.5% increase per year in in-patient hospital drug orders.

The Gulf Experience

The Future

• System improvement through advanced informatics and automation should be the focus of every pharmacy leader

• Leverage the IT talents of Pharmacists

Challenges & Lessons Learned

• Integration between Middle Eastern and Western experiences takes one year

• Strong Operational staff are as important as strong Clinical People

• Low turnover retards career growth!

• Maintaining Male: Female at 1:1 is very difficult

• Challenges in recruiting local operational Pharmacists• Shift demands

Pharmacy Administration

Manpower Design

28

In-Patient FTEs Benchmarks

Pharmacists per

100 beds

Technicians per

100 beds

100-199 beds 11.7 9.7

200-299 beds 12.1 10.6

300-399 beds 12.1 10.8

400-599 beds 11.1 9.6

> 600 beds 11.5 10

Am J Health-Syst Pharm, Vol 72, July1, 2015

FTEs* BenchmarkPharmacists

per 100 beds

Technicians

per 100 beds

ASHP** Survey

(300-399 beds)12.1 10.8

Cleveland Clinic

Main Campus

1300 beds

9.5 10

3 Saudi Hospitals

(1800 beds)13 9

Cleveland Clinic

Abu Dhabi

(120 beds start up)

11.6 13.3

* FTEs: Full Time Equivalents

**American Society of Hospital Pharmacists

In-patient Pharmacy Cleveland Clinic Abu Dhabi FTE* Model

• First 100 beds:• 14 Pharmacy Technicians

• 12 Pharmacists

• FTEs per 100 functioning beds above 100• 10 Pharmacists

• 10 Technicians

• FTEs per each Satellite Pharmacy • 1-2 Pharmacists and 1-2 Technicians

*Full Time Equivalents

Order Processing per Pharmacist

• 150 to 300 order verifications per Pharmacist per 8-hour shift

• Prescriptions filled per In-Pharmacist:• 110 per day = 13 /hour

UHC list serve, 7 USA hospitals, 2015

IT* Manpower Design

1. C. A. Pedersen et al., Am J Health-Syst Pharm-Vol , 26 May 15,2009

* IT: Information technology

**ASHP: American Society of Hospital Pharmacists

Number of FTEs

ASHP** Survey 1 IT pharmacist + 1 IT technician per

100 beds1

Cleveland Clinic Health System, Ohio 29 IT pharmacy staff

Cleveland Clinic Abu Dhabi 3 IT pharmacists + 4 IT analysts

Inpatient Pharmacy Services

In-Patient Pharmacy

34

The Medication Use Process in the In-Patient

•

Robotic Packager

Selection & Procurement

Automated Storage Cabinets

Medication Tracking/Monitoring/Documentation

Medication Administration

Computerized Prescriber Order Entry

Dispensing

Knowledge Portal

Wasting Controlled

Medication

• 97.1% of USA hospitals ADMs

• 100% of hospitals (>300 beds) use ADMs

Am J Health-Syst Pharm, Vol 72, July1, 2015

Automated Dispensing Machines (ADMs)

In-Patient Carousel

37

Carousels

• 21.1% of USA hospitals use carousels

• 40.7% of hospitals (>300 beds) use carousels

Am J Health-Syst Pharm, Vol 72, July1, 2015

18%

21%

17%

17%

18%

18%

19%

19%

20%

20%

21%

21%

22%

2011 2014

Pyxis to Bed Ratio

•1 Pyxis per 9-11 beds in CCAD* compared to 1 Pyxis per 16-18 beds in North American hospitals

*Cleveland Clinic Abu Dhabi

Challenges

• It takes at least 6 months for nurse to accept ADMs

• It takes one year for physicians to digest the concept of Pyxis Anesthesia stations.

Inpatient Dispensing TAT*

41

10 minutes with ADMs** compared to

50 minutes with traditional dispensing

*TAT: Turn-Around Time

** ADMs: Automated Devices Machines

BARCODING

Barcoding

• Rate of all potential dispensing errors decreased by 86-97% (P<0.001)

• For inventory purposes (Pharmogistics, out-patient inventory)

• Assure safety in loading/selecting drugs in Pyxis

• For medication tracking (Medboard)

• e-MAR purposes, Infusion pumps, BCMA*.

Eric G. Poon et al., Annals of internal med 2006, 145 (6) 426-34

*Bar Code Medication Administration

Barcode Medication Administration Scanning

Challenges with Barcoding

Lack of regional NDC*

Difficulties in barcoding

Large Volume Parenterals

Multiple Dose Vials

* National Drug Code

• ChallengesInterface problems

Frequent Shortages

Downtimes

Packaging Robots

Sterile Preparation Center

PMS: Particulate Monitoring System

Benchmarks in Clean Rooms

• 65% of USA hospitals have USP 797 compliant clean rooms

• 93.5% of USA hospitals (> 600 beds) are compliant

Am J Health-Syst Pharm, Vol 72, July1, 2015

Automated PN Compounding

• 60% of USA hospitals (> 600 beds) use PN Automated Compounding

Am J Health-Syst Pharm, Vol 72, July1, 2015

Medication Tracking System

Ambulatory Pharmacy Services

52

Ambulatory Pharmacy Services

Medication Dispensing to Clinics, Emergency, Discharge

Retail OTC* Sales

Patient Counseling & Education

24/7

Services

* OTC: Over The Counter

Manpower Design

• We are 18 Pharmacists and 13 technicians

• 2 Pharmacists + 1 Technician safely process, fill, dispense and counsel 30-35 patients per hour

• More counseling stations, more pharmacists

• Prescriptions filled per Out-Patient Pharmacist: (UHC list serve, 7 USA hospitals, 2015)

• 87 Rx per shift = 11 / hour

November 2013: “Still Long way to go”!

Facts

• 8 x increase in number of out-patient deaths due to errors compared to 2 x increase in hospital deaths

• From the Institute of Medicine (IoM), 2010

• Single MER event in the out-patient pharmacy is capable of generating enormous negative publicity

Ambulatory Pharmacy: Activation Challenges

• IT integrations between systems

• Ambulatory Pharmacy technologies are more complex than in-patient pharmacy

• Forecasting of needed medications in a multispecialty hospital

• Compliance in ordering formulary compared to non-formulary medications!

Pharmacotherapy Services

Pharmacotherapy Services

• Highly trained

• Board certified with ≥ 1 residency training

• 3 Senior Pharmacotherapy Specialists

• 3 Pharmacotherapy Specialists

Fully integrated with the in-patient team

Scope of Pharmacotherapy Services

• Patient care rounds and consult services• Heart, ICU, ID, Medicine, ED

• Parenteral Nutrition

• Therapeutic drug monitoring

• Formulary management

• Ambulatory anticoagulation management

• 16.8% of USA hospitals have Anticoagulation Clinic

• 54.3% of hospitals (>600 beds) have Anticoagulation Clinic

Am J Health-Syst Pharm, Vol 72, July1, 2015

11%

16%17%

0%

5%

10%

15%

20%

2012 2103 2014

Pharmacy-Based Anticoagulation Clinic

Pharmacy-Based Future Ambulatory Care Clinics

Anticoagulation

Medication Therapy Management

Diabetes Clinic

Hypertension & Lipid Control Clinic

Pain Management Clinic

Travel & Vaccination Clinics

Smoking Cessation Clinic

Narcotics Management

Controlled & Narcotics Service

63

Controlled Medications: Restriction Levels

Controlled Medication Restriction

Level

Narcotic Medications

#37

Controlled Drug Class A (CDA)

#73

Controlled Drug Class B (CDB)

#56

C-II Safe

Challenges

*HAAD: Health Authority of Abu Dhabi

*MOH: Ministry of Health

***CCAD: Cleveland Clinic Abu Dhabi

• HAAD*/MOH** regulations don’t consider automation & informatics to manage controlled meds

• Culturally diverse Clinical Caregivers at CCAD*** who are not used to UAE regulations

• e.g. Saving Empty Ampoules/ Vials

Overcoming Challenges

• Partner with regulators and existing providers

• HAAD approval to automate controlled medications management

• Intensive plan for Caregivers training & education

Use of Pyxis Far exceeds Regulator’s Requirement

Retrieval requires a witness & documentationDual sign-off in Pyxis with blind count

Controlled medication wastageDual sign-off in Pyxis

Smart Sinks for Controlled Meds Waste

Offering more comfort to regulators

Securing & safe preventing any diversion

Avoiding pollution compared to other methods

Continuous Improvement: Management of Broken Ampoules

0

2

4

6

8

10

12

April May June July

BrokenAmpoules (#)

Reduce number of

ampoules in patient care

units

Supporting the fragile

ampoules by padding the

pockets

Mats were placed beneath

each Pyxis

Camera over each Pyxis

to protect caregivers

• Before

AfterBefore

EMPLOYEE ENGAGEMENT

Satisfaction: “the contentment one feels when one has

fulfilled a desire, need, or expectation.”

Employee satisfaction is related to the organization

Engagement: “employee is involved in, enthusiastic

about, and committed to his or her work.”

Engagement is driven by the local work group environment

Satisfaction versus Engagement

Employee Engagements

• Allows for strong culture of learning and growth

• Develop subject matter experts & future leaders• Amina Al-Hammadi- MBA

• Rami Ismail - Anticoagulation Therapy Management Program

• Osama Abu Tabar - Public Healthcare Quality examination

• Lisa Brennan - Geriatric Certification Exam

• Khalid Abdel Dayem - 4 EPIC Willow certifications

• Lana Hussein - EPIC Willow Certification

• Omar Chehab - EPIC Willow Certification

• Ziad Sadiq - EPIC Willow Certification

• Ahmad Chaker - EPIC Willow Certification

• 3 caregivers completing MBA, MHA and EMHA

Employee Engagement Models

•Gallup Q12•Hewitt's Engagement Model

•Towers Watson

•CIPD Model

Gallup-Q12

Basic Needs

Individual Contribution

Teamwork

Growth

Q12. Opportunities to learn and grow

Q11. Progress in last six months

Q10. I have a best friend at work

Q9. Coworkers committed to quality

Q8. Mission/Purpose of company

Q7. At work, my opinions seem to count

Q6. Someone encourages my development

Q5. Supervisor/Someone at work cares

Q4. Recognition last seven days

Q3. Do what I do best every day

Q2. I have materials and equipment

Q1. I know what is expected of me at work

Our Pharmacy Gallup Grand Mean

4.05

4.89 4.83

4.29

Grand Mean 2012 Grand Mean 2013 Grand Mean 2014 Grand Mean 2015

Engaged

Caregivers

Engaged

Patients

1. Increased retention 2. Less Sick Calls 3. Productivity 4. Profitability 5. Improvements in safety 6. Customer Engagement

Why is Caregivers’ Engagement Important?

Engagement’s Business Outcome

Patient Experience / TOP BOX

From Our Culture: Daily Huddles

• A time that is never missed

• Fun AM ice breaker

• Transparent open forum

1. Become genuinely interested in other people

2. SMILE, SMILE, SMILE

3. Remember a person’s name

4. Be a good listener

5. Talk in terms of other person’s interest

6. Make the other person feels important

How to Win Friends and Influence People?

From the Book by Dale Carnegie

6 Ways to Make People Like You

Advice to the leaders

Be popular: smile, laugh, and have fun!

Open door

Let others teach you

Solutions found only through brainstorming

Watch yourself: Be a role model

Early sensing lack of engagement

Focus on Strengths Culture

Mohammad A. Siddiqui, PharmD.,MBA | Manager, Inpatient Pharmacy | Department of Pharmacy Services

Cleveland Clinic Abu Dhabi | P.O. Box 112412 | United Arab Emirates | Mobile No. 971-052-699-7757

Office No. +971 2 501 9999 Ext. 40934| Office fax No. +971 2 4108223. Email: siddiqm2@ccaduae.ae

My top 5 strengths are: Developer, Responsibility, Empathy, Connectedness, Relator

Reference: “The Strengths Finder”

Pharmacy Mentorship Program

Build Self awareness

Develop Skills

Improve Performance

Grow Professionally

Your performance as a leader

• Spend half of your time developing leaders

“You do less and they do more while everyone is happier”

Excellence Awards

Happy Team

Thank You!