If you ever go to visit the nearest big box, chain pharmacy, you’ll see a dozen patients in line, but only 2-4 people behind the counter.
Mind you, the pharmacy team isn’t just counting pills and putting labels on bottles.
We have up to 6 phone lines and a drive-through line, all of which are usually ringing.
We have a hundred prescriptions that are being called in, faxed, and e-prescribed, all within the last hour.
Insurance rejections delaying therapy for a sick, elderly patient.
Threat of regulatory bodies coming in at any moment to fine and/or suspend licenses.
Risk of litigation due to negligence or dispensing errors.
One look at the pharmacy personnel’s faces will show you that we are stressed out of our minds and unhappy to be caught in the middle of everyone’s problems.
What’s The Cause Of These Symptoms?
But it’s not our disposition that causes this burden, it’s the environment we work in.
The Retail Pharmacy workplace is actually an affliction, yet no one knows what causes it.
We’ve come to accept this beast of burden we call under-staffing.
We’re quick to diagnose, and want an equally quick prescription for it.
But what’s the real patho-physiology of the business operations underneath the symptoms we see at the pharmacy counter?
The most common phrase you’ll hear is how understaffed the store is.
There’s a thousand overdue prescriptions, tons of flu shots to give, hundreds of calls to make, and overdue operational tasks.
Everyone feels they need an extra 7 hands to do all the work.
We’re all spinning plates on sticks in this pony show we call Retail Pharmacy.
The First Diagnosis
Lack of adequate help.
The quickest prescription to solve all ailments is to spend more on tech hours.
There’s lines and lines of patients waiting for prescriptions, but only 1 technician and 1 pharmacist doing work behind the pharmacy counter?
What is going on?
While many times the answer to this common scenario is more help, we’re only seeing superficial symptoms of this pharmacy.
If a patient goes to the physician and says, “I’m hurting, Doc. I’m sick every week, and I need medicine.”
We scorn the practitioner who scans the patient for less then 1 minute and prescribes a Z-Pak.
How confident are we that this solution actually solves the problem?
With only a superficial, possibly incorrect diagnosis, there is a good chance the underlying problem will persist.
Same goes for the pharmacy.
Don’t get me wrong.
I truly believe that if a fast food restaurant like Chick Fil-A can operate profitably with more than a dozen employees per location to serve their customers, a big box chain pharmacy should be able to pay for human resources to protect their brand, employees, and patients.
But what if the pharmacy has a true disease?
Couldn’t we manage the symptoms more effectively and find other solutions?
Many times, the diagnosis gets swept under the rug, and we want that quick fix prescription.
Asking for more tech hours for weeks, months on end.
We all know how well that solution works.
So why not take a different approach for once?
Start by examining the underpinnings of pharmacy operations.
Here’s 9 most common afflictions that cause a pharmacy to operate like a hellish nightmare.
1) High Volume Pharmacies Filling Inappropriate Medicine
Hundreds of times a day, the pharmacist has to triage and resolve DUR’s (drug utilization reviews).
These can be hard-stop medication interactions or simply duplicate therapy notifications.
But halfway through the shift, the downtrodden pharmacist experiences what we call verification fatigue.
We see the alerts, but don’t have the mental bandwidth to disposition with 100% alertness.
We’ll check the prescription for accuracy and contraindications.
But we’ll overlook the patient’s history and refuse to question if the prescription is still active or needs to be filled.
Insurance companies allow early refills sometimes up to 3 weeks early.
But there’s no alert that stops the pharmacy from filling a prescription the doctor just sent, even if it’s 3 weeks early.
That’s what the pharmacist is for.
But 9 times out of 10, the team will type this prescription, fill it, and verify it, only for it to sit in the waiting bin for two weeks.
On a similar note, outdated therapy sometimes remains active in a patient’s profile.
High-dollar prescriptions that will never be picked up get filled.
Irrelevant OTC “prescriptions” make it through because the pharmacy team is just following the motions of an assembly line.
And here’s the kicker: these irrelevantly filled prescriptions get removed from inventory, consuming time and manual labor.
Sometimes, the pharmacy team has to make outreach phone calls to remind the patient to pick up.
This is a value-added service, but only for legitimate prescriptions that patients needs.
After the 5-10 minutes it takes to type, fill, and verify this unneeded prescription, we spend even more time and energy calling patients about it (average of 2-3 times)
Then we spend even more time returning it.
Multiply this by a hundred times a day, and you can begin to see how unproductive work enslaves the pharmacy team.
2) Processing And Editing Prescriptions, But Not Actually Selling Medicine
In some pharmacies, we experience the whips and chains of micromanagement so hard, we’ve been conditioned to follow the computer like mindless automatons.
We’ve been written up and verbally abused by upper management to “meet the promise times” and “never go orange” on the computer screen.
We’ve been conditioned to fear designating any prescription as a “Waiter” because we’ll never be able to get it out before it dings our score card.
In the queue of several hundred prescriptions, the onslaught of overdue prescriptions creeps up relentlessly with each passing minute.
Burdened by the expectations from upper management, we feel a phantom-like trauma from the last store visit.
So some stores came up with a solution, a way to cheat the system.
They edit the prescription promise times.
Instead of spending their precious time verifying for accuracy and making interventions, this anxious pharmacist manipulates the queue for self-preservation.
At the expense of service and productivity.
It will literally take up 20-30 seconds (depending on computer response time) to edit a prescription.
Combined with obsessive compulsive disorder and poor operational management, a good hour can be spent on this pointless activity.
But it happens every day, all across the nation.
Running away from the true problems due to poor leadership.
Teams producing absolutely nothing tangible for the business but satisfaction to the ego, and preventing a whipping from upper management.
3) Delaying Prescriptions By Assigning Inaccurate Wait Times
In a similar fashion, the overrun pharmacy team begins to resent patients that want to wait for their prescriptions.
Pages upon pages of overdue prescriptions loom over them, and they can’t fathom putting someone ahead of the hundreds of people currently in the queue.
So the technicians will inflate the promise times to the patients.
“The earliest we can have this ready is 2 hours,” or “it will be ready tomorrow.”
But the underlying problem of poor operational management is still there.
The assigned times in the queue are all inaccurate.
A 2 hour promise times gets slotted behind the prescription that is already 2 days overdue.
The technician just successfully buried this patient who wants to wait in the minutiae of lost prescriptions.
The net effect?
When that patient comes back expecting the prescription to be done, they complain, cause a scene, and consume more time and energy from the pharmacist.
And then the pharmacy team decides then and there that this patient is worthy enough to be made into a “Waiter” and expedites the prescription.
Adding more insult to whatever injury they are experiencing in this new day.
Delaying a waiter by promising a false completion time unsuspectingly adds more work and further buries the poor pharmacy.
4) Missing Opportunities To Up-Sell And Convert Traffic To Dollars
A phenomenon that we all experience in retail are the endless lines of patients at the pharmacy counter.
I’ve personally witnessed lines with fifteen to twenty people in it.
With all the business happening at this particular store, you’d think there were enough human resources to serve them all?
But no one can predict true real-time customer demand.
Not you, not me, not corporate, not even the pharmacy gods themselves.
Any business is given a budget to make a certain amount of profit.
But pharmacy teams think that more foot traffic equals more payroll.
“Corporate should know that we’re so busy, and we deserve more hours.”
More patients equals more payroll.
In reality, more pharmacy sales equals more payroll.
Some technicians think that ringing out patients as quickly as possible is efficient and effective.
They skip the prompts, they ignore the loyalty cards, they refuse to recommend vaccines.
But all those buttons on the screen, the loyalty program, and healthcare services are what make money for the pharmacy.
It’s what increases margin and keeps the lights on.
Money is what funds our payroll budget and gets us more hours.
Multiply this opportunity cost by a few hundred times, 7 days a week, and the end result is a negative compound effect that obliterates the bottom line.
Say goodbye to payroll (what’s left of it).
5) Improperly Billing Prescriptions
Breaking news: pharmacy reimbursements are declining.
Yet, some pharmacies don’t care to calculate prescription day supply 100% accurately.
Sometimes, the technicians don’t know how to calculate.
Many times, they’re too lazy or too busy and simply enter 30 days for everything.
Maybe the pharmacist has bigger fish to fry than non-clinical day supply calculations.
What some pharmacists overlook is the concept of over billing.
What happens if a prescription is billed incorrectly?
Nine times out of ten, any insurance plan will accept an input of 30 day supply during adjudication.
Then the insurance company refuses to pay for incorrectly billed medicine; it’s in within their contractual rights.
For the sake of efficiency, the most notorious culprit of over-billing are insulin packages.
Until Walgreens was recently sued for improper insulin billing, the average pharmacist would refuse to break an insulin box.
But those packages sometimes last longer than 30 days.
And insurance companies love reasons to withhold payment.
Third party plans literally have teams of people who analyze prescription claims for erroneously billed medications.
They all huddle together in large teams, creating quotas of how to take money back from unsuspecting pharmacies.
It’s too bad we aren’t budgeted to lose tons of money on prescription claims.
Not only does a third party audit require time and energy to dispute; it can result in lost profit, further diminishing our already abysmal reimbursement rates.
Another strike against the bottom line.
6) Inventory Mismanagement
Inventory is the number one most expensive asset a pharmacy has.
Literally, millions of dollars sits on the pharmacy shelf, making zero profit unless it moves to the patient.
The most common disease: incorrect balance on hands create false orders or delays medication shipments.
Pharmacies usually have protocols around auditing prescription inventory.
Whether it’s counting random medicine or using an inventory management system, ensuring correct counts is vital to reducing unnecessary expenses.
Ordering excess inventory increases costs exponentially.
But being out of stock is equally detrimental.
Opportunity costs are harder to measure, but losing a patient one time who desperately needs medication in the moment usually results in distrust and possible losing them for good.
Equally harmful to the workplace morale is the mental, emotional damage the rightfully irate patient will cause when they show up needing medicine for their afflicted family member.
Miscommunication surrounding inventory and customers’ expectations also creates a tidal wave of patient problems and escalations at the pharmacy counter.
Relentless calls of frustration, disappointment, and emotional disruption plague the pharmacy day after day.
All the while, the pharmacy continues to suffer from unproductive, unprofitable activity.
Causing frequent returns of excess inventory to try and recuperate money spent.
What seems like small mistakes easily compound, especially when multiple workers continue to make them day by day.
Even something as simple as ordering incorrect brands or medicine that isn’t covered by insurance (failure to pre-adjudicate before ordering) ties up company dollars on the shelves, resulting in higher costs and lower bottom line profits.
If the Pharmacy Manager is wondering why they don’t have enough payroll or flexibility to overspend, inventory can either be the culprit or a gold mine.
7) Not Enough Autofill/App Utilization/Text messaging
Are phones ringing off the hook non-stop?
Do the same patients call every day, sometimes multiple times per day?
We all have the patients that need more personalized service and “hand holding,” but a large number of needy patients signals an opportunity for automation.
Automatic refills and text messaging services are the simplest programs a pharmacy can offer, but are the most important.
If you serve 25,000 patients, a benchmark like only 50% auto-fill/text enrollment means that over 400 different patients can call you on any given day due to request something simple like filling medicine or checking if it’s ready.
Most big chain pharmacies are open 14 hours, which comes out to about 28 calls per hour. Even more if your pharmacy is open less.
We seem to underestimate the importance of these programs until they get taken away.
I have personally seen a pharmacy have to re-enroll all their patients in auto-fill, text messaging, and apps.
The phone calls never end, and you don’t realize how many patients you truly serve until each one personally calls you at the pharmacy wanting something.
This is why automating service is so crucial.
The real goal for auto-fill/text enrollment should be closer to 90%.
Enrolling patients in mobile app is trickier, but well worth the time and investment.
What takes 5 minutes to explain and teach, saves countless hours for the lifespan of that patient at your pharmacy.
If a machine can do something for you and a patient, let it.
Leave the human resources for only human interactions.
Leave the pharmacist alone for only pharmacist duties.
Automation of services is inevitable, and it’s the only way we can survive in this super lean future of community pharmacy.
8) Having One Pharmacy All-Star
Who is the go-to person when there’s a problem?
Who is the fastest producer, the best typer, or the best with insurance?
Many times, a pharmacy team will specialize in their own niche of skills.
While efficient during crisis, this strategy builds a house of cards.
Especially if the pharmacist is the most skilled person.
The pharmacist should not be the best producer, typer, or problem-solver.
This creates highly co-dependent technicians and team members.
In this case, teams are doing “work,” but the truly important workload never gets completed.
Because everyone is dependent on one another, the pharmacist will eventually have to break attention from pharmacist duties to assume other responsibilities technicians can easily do.
Everyone has limited mental and physical bandwidth.
The bottleneck is usually the pharmacist.
Of course, we have to play a role on the team and pitch in.
But if any one person is doing more than 80% of any given activity, that is a recipe for failure.
Bottlenecks in workflow, paralyzed workers, multiple people hovering around a screen or patient trying to solve the same problem.
The production queue and the onslaught of patients tied to them will soon come to destroy us while we’re standing around doing one thing at a time.
9) Using Pharmacy Students As Substitute Employees
Lastly, the most widespread disease in retail pharmacies today is a double edged sword.
With all of us feeling the stress of under-staffing, we praise the pharmacy gods when we receive a student.
An extra body, someone who can help lift the burdens we face daily.
But this is a deathly trap.
Here’s what really happens.
Because the pharmacist is too stressed and mentally warped to serve effectively as a preceptor, they throw the new student to the techs.
Or worse, they throw them straight to production duties or the wolves at pick up.
Not only does this severely limit their growth and development, it teaches technicians to rely on students instead of increasing their bandwidth or creating new ways to solve problems or increase productivity.
The pharmacy student’s role in the pharmacy should be pharmacist apprentice.
They should be taught to take over pharmacist duties and roles, not become an assembly line expert.
Pharmacy technician students should shadow techs and learn operational roles and responsibilities.
But even then, building a system and culture where students are needed in workflow creates a different expectation for the employees.
Employees get used to a slower productivity and build different habits for delivering results.
They expect another person to maintain productivity instead of utilizing the systems and best practices.
They reject any automation enhancements, new programs, or company protocols to retain the older traditional workflow standards that require more people.
But every year, we see opposing moves from corporate in the form of lower payroll budgets.
It’s not right, but it’s reality.
And another real fact: the intern being used as a production machine serves only as a band-aid.
What happens when they leave their rotation?
Despair and frustration all over again combined with a fixed mindset.
And virtually no attention to the root causes of the operational deficiencies.
The Final Diagnosis
Retail Pharmacy is chaotic, unforgiving, and downright brutal to work in.
We are all spinning plates on sticks and feeling the stress of adding more with each new patient that arrives to the counter.
But we don’t make money just working and thinking hard.
We may feel like it, but we’re not hamsters on wheels.
We have to get a return on investment to successfully run a pharmacy business.
If the pharmacy managers and their teams can’t see what’s truly making money behavior and what isn’t, they are more susceptible to operational disease.
Processed prescriptions can justify the tech hours needed.
But prescriptions sold is more accurate of a measure to determine what we will be held accountable to.
Foot traffic needs to convert to bottom line dollars.
Properly communicating with patients is also key to preventing crisis at the counter.
Inventory needs to move accurately and profitably.
Billing prescription claims need extra special attention to prevent the pharmacy from bleeding money.
Teams need to use systems to manage patients and their medicine.
Weakest links on the team need to be cross-trained and developed to be independently awesome.
Students should be challenged with demonstrating leadership, creating systems, and making everlasting changes at the pharmacy.
We need the awareness and the foresight to diagnose the problems instead of just reacting to them.
Only then will we be able to change our circumstances, positively influence our profession, and effectively care for our patients.
The life of our profession is in your hands.
What will you do now that you have learned about theses diseases in Retail Pharmacy?
-Mr. Corporate Pharmacist