Tech Check Technician (TCT)

Primary  Intended Outcome(s):

1. Creating an advanced role for certified pharmacy technicians, who have appropriate additional edu- cation and training, where they can be used more extensively to free pharmacists from drug distribu- tions activities.
2. Pharmacists’ time should be redirected to addition- al clinical and cognitive functions, including drug therapy management activities.

PPMI Recommendation or ASHP Strategic Plan Association:

• Supporting facility wide medication reconciliation including obtaining and documenting patients’ medication information for nursing verification and for pharmacists’ review.
• Including review of medication allergies (that re- quire pharmacist, physician or nurse follow up) dur- ing the patient interview for medication reconcilia- tion.
• Checking dispensing by other technicians (i.e., “tech-check-tech”).
• Compounding routine sterile preparations in con- formance with well-documented procedures, edu- cation and evaluation.
• Compounding sterile oncology preparations in con- formance with documented procedures, educa- tion, and evaluation.
• Supporting pharmacist clinical monitoring by assist- ing in gathering and maintaining specific patient data.
• Inspecting and replenishing medication storage devices.
• Contributing to aspects of quality improvement programs regarding the advanced technician func- tions, including Tech Check Tech and Medication Reconciliation.

Site Description:

Spencer Hospital is a licensed 99 bed acute care facility in northwest Iowa. Spencer Hospital has over 500 em- ployees.  Services include:

• Two - twenty bed Medical/Surgical floors, OB, Same Day Services, Ambulance, ED
• A sixteen bed inpatient Mental Health unit
• A six bed Intensive Care unit with an additional five step down beds
• Two Dialysis units (one on campus, and one o ff site)
• Radiation Oncology and Medical Oncology units on campus, both o ffering services 5 days/week
• Emergency Department with over 9,000 visits an- nually
• Surgery Center
• Two family practice clinics o ff site

Pharmacy department staffng consists of a Pharmacist Director, 6 sta ff pharmacists, and 7 certified pharmacy technicians: representing about 11.5 FTE. Two pharma- cies are sta ffed and both have complete USP 797 suites for sterile compounding. The central pharmacy is open from 0700 to 1800 on week days and from 0700 to 1530 weekends and holidays. The oncology pharmacy is open Monday – Friday 0800 to 1700. Remote pharmacy services are used to provide pharmacy services 24 hours/day. There is a sta ff pharmacist on call during the remote coverage hours.

Pharmacy FTE allocation:

• pharmacist director (1 FTE)
• 6 sta ff pharmacists (approximately 5 FTE)
• 7 certified pharmacy technicians (approximately

6.5 FTE)

Weekday pharmacist staffng:

• Central Opening pharmacist
• Floor or Clinical pharmacist
• Oncology pharmacist
• Central Closing pharmacist

5 technicians are sta ffed each weekday, duties include:

• Automated Medication Dispensing System (AMDS) pulling orders, checking orders, filling ma- chines
• Oncology sterile compounding & cleaning
• Central sterile compounding & cleaning
• Medication Reconciliation Support to nursing and pharmacy
• Ordering, inventory management, stocking filling Clinic Orders
• Filling Orders for Anesthesia, Surgery, Same Day Services, Dialysis Units
• Filling cart exchange/pass thru medications process for 2 units

Weekend and Holiday staffng is performed by one pharmacist and two technicians. Overlapped relief cov- erage is provided for the beginning and end of each day to allow the sta ff pharmacist time to perform clini- cal interventions.

Advanced Role Description:

Spencer Hospital advanced technicians are involved in TCT, Medication Reconciliation support and sterile on- cology compounding. Spencer Hospital technicians al- so are gaining expanded roles in documenting clinical monitoring statistics and checking medication storage areas. This case study will focus on the TCT duties and is an extension of technician filling, and should be re- garded as the same skill set but with additional respon- sibility.

Factors to consider when implementing TCT would in-clude:

• A large enough staff (pharmacists and certified tech- nicians) to provide team flexibility.
• An engaged staff, including administration, with a desire to move ahead in the new pharmacy practice models that support advanced roles for certified pharmacy technicians, including TCT implementation and Medication Reconciliation support.
• Often the physical layout of the pharmacy can add to the success of a TCT program. A pharmacy with an open layout is conducive to active communication and oversight.
• Facilities with Bar Code Med Administration and simi- lar technologies have an extra layer of safety and opportunity.
• A facility which offers a wide scope of services pro- vides the opportunity for expanded clinical pharma- cy services, supported by expanded technician activi- ties.

How to Start:

The initial approach at this hospital began with discus- sion among pharmacists regarding their thoughts to- wards developing an advanced technician program with TCT. Overall technician competencies were dis- cussed (technicians averaged 8 years experience) along with the pharmacists’ commitment to be in- volved in further training, educating, and supporting the technicians in the hospital. Input and ideas were shared on the potential for pharmacists to increase clinical services. Administration was encouraged by the attitude of the pharmacy staff and supported the po- tential TCT program.  TCT was viewed as a “win/win” for the pharmacists and technicians both!

The next step included visiting with the technicians, sharing the direction national pharmacy groups (Pharmacy Technician Certification Board and Ameri- can Society of Health-System Pharmacists) (2, 3, 4) were taking on technician services, including TCT, and review of the TCT rules proposed by the state. (5) The entire group of technicians actively embraced the po- tential of TCT to further their careers by taking on more responsibility and to be more actively involved in serving our patients as members of the hospital phar- macy team. Discussion of a potential career ladder was held– which included conversations about other in- creased roles such as pharmacy technician supported medication reconciliation and allergy reviews with pa- tient admissions.

After giving an overview of both state and national di- rection on increased roles for pharmacy technicians, a specific plan for the hospital TCT proposal was shared with administration. The initial reaction was positive, and after further discussion the decision was made to move forward with a site specific TCT proposal to the Iowa Board of Pharmacy. An effective use of payroll dollars that would increase patient, nursing and physi- cian satisfaction via increased pharmacy clinical ser- vices was recognized by administration if TCT was im- plemented.

A checklist of questions can include:

• Are pharmacists ready to share responsibility on checking with the certified technicians?
• Are your current fill rates excellent?
• Are technicians ready to step up to more responsi- bility?
• Do your technicians support each other and work as a team?
• Does administration understand what impact phar- maceutical care has on patient outcomes?
• Do your physicians support the value in increased clinical pharmacy services?

Regulatory and/or Legal Requirements:

Spencer Hospital was the first TCT program approved in Iowa, a state that allows technicians to check other technicians with site specific approval by the Board of Pharmacy. Pharmacies in other states will need to fol- low their state rules and regulations, or advocate for implementation of additional levels of technician re- sponsibilities. The Board of Pharmacy required reports be submitted from our project .  (See Supporting  Documents)

Revenue & Expense Parameters (abbreviated financials):

Staffng levels or hours of operation were not changed, rather work was redistributed. An additional pay scale was implemented for the advanced certified techni- cian job description.

Training and/or education requirements:

Technicians moving to the Advanced Certified Phar- macy Technician position from a Certified Pharmacy Technician position were required to complete extra didactic training and evaluations.

Didactic training started with four lessons and accom- panying quizzes that were prepared on site and deliv- ered via a hospital on line training system. Technicians read the lessons and took the quizzes at their own pace. The four lessons consisted of:

• Math Review
• Dosage Forms and Routes of Administration
• Prevention, Identification, and Classification of Med Errors
• TCT Program Rules Review

Technicians read three articles from “Pharmacy Techni- cians Letter” and took three short quizzes (created on site) via the hospital system on the content of each:

• “Look-Alike, Sound Alike Medications”
• “Medical Errors”
• “How to respond to Medical Errors”

State specific rules required education on the “prevention, identification, and classification of medi- cation errors.” The other lessons were deemed appro- priate and necessary by the hospital.

The “Filler Technician Competency Evaluation” con- sisted of:

• Basic hospital technician orientation
• 7 specialized and advanced lessons for TCT
• Filling evaluations @100% in 7 different areas (2 to 10 batches/area)
• Sign off and date that the technician may fill in the TCT program

The “Checker Technician Competency Evaluation” re- quires completion of the above, plus an equal number of batches checked @ 100% accuracy.

Limited references for a target rate of errors are availa- ble - the most common target was 99.8% accuracy for checking. (1,2,3,4,5,) 100% was used for evaluating because of small batch sizes in some areas: 99.8% represents just 2 errors per 500 doses; many batches are not that large. Selection of 99.8% is the ongoing filling AND checking accuracy target rate; the ongoing rates are cumulative and represent all the doses per period, not just a spe- cific batch.

Outcome Measures:

To monitor quality for TCT, a “Technician QA Daily Monitoring Sheet” was developed. This form only takes a few seconds to record which technician filled and which technician checked in defined areas and if any errors occurred. This document also allows capture of dose counts on medications that are not processed through regular pharmacy software (clinics, etc.).

All the following errors are recorded:

• Wrong drug, dosage form or strength
• Wrong count or paperwork
• Wrong patient, unit or AMDS
• Outdated medications

If any filling or checking error occurs, a pharmacist must re-verify and discuss the error with the techni- cians involved. This discussion is documented to evalu- ate and prevent any future occurrence. To monitor TCT, spreadsheets are used to record the data in each bi-weekly period and to summarize over time. Marked improvement in filling rates occurred even during the monitoring period while merely gathering information for the TCT proposal. Improvement in filling rates has continued after implementation of TCT.

Checking rates have been nearly perfect, with very few misses. Only one checking error left pharmacy control (a bar code issue which was immediately resolved). Six errors in nearly two years of the program were docu- mented as checking errors but were actually corrected at an additional checkpoint (bar code while restocking the AMDS) and did not actually leave pharmacy con- trol.

• records of individual fill rates to evaluate any ex- cessive error rate
• records of individual check rates to evaluate any excessive error rate
• plans for suspension, retraining and reinstatement as needed.

TCT is evaluated on an overall department basis for total filling and checking accuracy, while individual technician data is compared to identify any need for suspension or retraining.  The overall fill and check rates are calculated using total doses, it was not practi- cal to determine how many doses each individual tech- nician “touched.” Technicians rotate through daily job assignments equally, therefore individual error rates are compared using an “hours worked” formula to identify any technician needing retraining or suspen- sion from TCT.

Lessons Learned:

What are some rewards received from implementing TCT?

• Pharmacist satisfaction – more time to work at the top of their skill level
• Technician satisfaction –expanded skills, responsi- bilities and pay
• Increased teamwork and respect within the depart- ment
• Smoother workflows- less interruptions for phar- macists
• Effcient workflows- less waiting by technicians for pharmacists
• Increased accuracy in filling and increased patient safety

Future

• How can individual pharmacies be encouraged to advance the roles of technicians?
• Can states without advanced roles for techs be en- couraged?
• How can we build a career ladder for technicians?
• How can incentives be established for additional technician responsibilities?
• What other roles for advanced technicians can we develop?

Technicians can share with the pharmacists the desire to move into new and advanced roles. Being knowl- edgeable, demonstrating professionalism, working ac- curately and sharing a desire for more responsibility will help encourage the implementation of advanced roles at your pharmacy.

Supporting Documents:

• Advanced Technician Job Description
• 2nd  quarter 2013 TCT Report to Iowa BOP
• 4th  quarter 2012 TCT Report to Iowa BOP
• Didactic Training Modules
• Checker Technician Competency Evaluation
• Daily Technician QA Form

References:

• Adams AJ, Martin SJ, Stolpe SF. “Tech-check-tech”: A review of the evidence on its safety and benefits. Am J Health Syst Pharm. 2011;24:1824–1833.
• www.ichpnet.org/news/display_news.php?article=121
• www.google.com/url?q=http://www.oregon.gov/Pharmacy/Imports/Rules/March12/855- 041_TCVP.pdf&sa=U&ei=WpVYUOT2BMq5ywHX8Y HIDA&ved=0CBsQFjAD&usg=AFQjCNGrKzmnRM7C 0nNI4xQPVbLtoDe9P
• www.ajhp.org/content/68/19/1824
• www.ajhp.org/content/68/19/1820?related-urls=yes&legid=ajhp;68/19/1820