Virginia Regulatory Town Hall
Department of Health Professions
Board of Pharmacy
Regulations Governing the Practice of Pharmacy [18 VAC 110 ‑ 20]
Action Pharmacy working conditions
Stage Emergency/NOIRA
Comment Period Ended on 11/22/2023
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10/25/23  9:23 am
Commenter: Zachary May

This is a good start, but needs to go further

The regulations, as proposed, are a good first step towards improving working conditions.  However, even though these have already been in place as emergency regulations, there has been zero response from any of the large corporations to actually implement changes to improve the working conditions thus far.   For example, one large chain still allows pharmacists a lunch break, but because the pharmacy remains open while the pharmacist is on lunch, the pharmacist is still required to address mandatory counseling blocks (such as generic "90 day refill" blocks).  If their 30 minute lunch break turns into a 5 minute lunch break, so be it.  Likewise, another large chain does close for lunch, but at a set time.  Regardless of if the pharmacist is helping patients or not after 1:30, the pharmacist is required to return promptly at 2:00.  If the pharmacist is administering immunizations, or is counseling a patient, and doesn't get to actually leave the pharmacy until 1:45, they still have to be back at 2:00.  The technicians, on the other hand, are guaranteed a protected 30 minutes, whether they leave at 1:30, 1:45, or later.  I have had a permit holder point blank state that "you have 30 minutes to eat somewhere in your 11 hour shift.  Figure it out".

Large corporations will, quite simply, look at the proposed regulations and will pull out the policy manual that says "we already meet these regs".  Because they do.  Any pharmacist that challenges the corporate budget or corporate direction will not be termed or demoted because they challenged the actual work conditions, they'll be punished for "poor customer service".   As an example, Walgreens very publicly announced that they "will no longer hold pharmacy teams accountable to performance metrics".  That's true.  They don't.  Prior to my leaving the company they changed their performance evaluations to only focus on "leadership qualities".  However, these "leadership qualities" are then tied more deeply to "did you're pharmacy meet goal script growth?  Immunizations? MTM?"  No?  Then you must have poor leadership.  It's easy for the board to put in regulation "Avoid the introduction of...quotas...", and it's just as easy for a corporation to hide those quotas behind the vague umbrella of "effective leadership skills".

My pharmacy did over 800 prescriptions in the span of 3 days with 1 pharmacist and 2 technicians.  I went to the bathroom two times in 10 hours on the first day, one time the second day, and was unable to the third day because while I had 2 technicians, they were both acting as cashiers for the majority of that time.  So 1 pharmacist entered scripts, reviewed them accuracy, filled a good chunk of those scripts, and verified for product correctness.  In addition, about 25%-30% of those required mandatory patient counseling after checkout (dictated by the corporate software).  This is after the emergency regulations were published.  We did several dozen immunizations, and received constant pressure from our management to also complete additional MTM claims because "we were over 100 active claims".  I could, very easily, have told my management "I'm sorry, but the volume we are attempting to fill with only 2 certified technicians is unsafe and we are unable to accommodate any additional services right now".  However, I still need my job.  I absolutely guarantee I would receive a very strong warning, if not lose my position.  I could lodge a formal complaint, but it wouldn't do any good, the company would replace me with another pharmacist less vocal and say "I have poor customer service skills and am not respective of my patients needs".

No, without concrete minimums in writing that are black and white corporations will continue to use and abuse pharmacists.  We're "highly compensated individuals" and as such, according to the corporations, deserve every bit of what they want to dish out.  The Board needs to step up to protect both the patients and the pharmacists.  Pharmacist walk-outs (of which I did not participate) only hurt the patients.  They get publicity, but that's it.  When CVS is posting over $320 billion in revenue for 2022, I seriously doubt 22 pharmacies closing for a few days because of a walkout will truly make an impact.  At the end of the day, corporate pharmacy boards are ruled by non-pharmacists that will do everything to keep shareholders happy and profits as high as possible.  I fully intend to exit pharmacy well before my retirement age, if possible.  I have many friends that have exited retail completely, and in some cases pharmacy completely.  What happens when retail pharmacies can't be staffed, not because of COVID, but because the pharmacists are not there to staff them?  Pharmacy deserts.  Mail order.  I think everyone can agree its inconvenient for a patient to drive 30 to 40 minutes to find a pharmacy in rural areas.  But Virginia is in large part rural.  Nobody likes mail order.  There's a reason mail order market share has never gotten above single digits since its conception.

Any regulatory movement should address working conditions in black and white.

  • Pharmacists are people too.  A six hour shift should mandate a 30 minute lunch break and one fifteen minute break for every 4 hours worked.  Both should be uninterrupted.  Pharmacists and techs are in a high-stress, high-risk environment.  Research shows that even small breaks from workflow and the job can reduce stress, fatigue, and ultimately errors.  The regulations should specifically state breaks must be uninterrupted and must allow the full defined break period.
  • Pharmacy staffing regulations should define absolute minimums required to safely operate a pharmacy, and these minimums should take into account the services provided by a pharmacy.  From a safety perspective, no pharmacist should ever be required to work alone except in an emergency; 1 certified technician should always be present with the pharmacist.
    • It is unreasonable to dispense 400 prescriptions and expect scheduled immunizations, walk-in immunizations, and MTM to be completed by 1 pharmacist in a shift.  This is in addition to everything else required to keep a pharmacy running that does not involve direct patient care.  To put that into perspective, on an average with zero other expectations, I am spending approximately 1 minute and 20 seconds on a prescription.  That includes entering the script, filling the script, and reviewing it for accuracy and safety.  Given that filling a script is ~30-45 seconds of that and entry is ~20 additional seconds, a single pharmacist in a 9.5 hour shift filling 400 prescriptions is only spending about 10-20 seconds per script actually reviewing it for accuracy and safety.  10-20 seconds to perform a DUR check against the patient profile and make sure the script was actually entered correctly.  And that assumes zero other responsibilities.  In reality, we're looking at probably 5 seconds or less.  How is this safe?  But that is the corporate expectation.  That or stay after business close to get it done.  Again, I know personally of pharmacists that have stayed 4-5 hours after the close of business just to fill prescriptions, worked a 14 hour day, and repeated it again and again because that is the corporate expectation.  Again, I believe defining a reasonable minimum of 1 pharmacist for every 200-250 prescriptions dispensed would improve that patient safety margin.  Additionally, defining technician minimums as at least 1 technician hour for every 10-11 prescriptions entered (not sold, entered) would help ensure that pharmacists are not the sole point of contact on a script from entry to dispensing and again, improve that patient safety margin.
  • A popular tool over the last few years has been the introduction of appointment-based vaccinations and clinical services.  That's fine, but its again an unreasonable expectation to have an appointment scheduled for an immunization and expect the pharmacist to drop everything they are doing for that appointment.  In the setting of appointment-based clinical services, a pharmacist dedicated to that service should be scheduled outside of the pharmacist dedicated to dispensing prescriptions.  I can recall a recent conversation with my district manager wherein I had turned away several vaccine appointments because I was the sole pharmacist on duty and, between the walk-in vaccines and the volume of the business at the time, I was unable to accommodate those additional services.  Because one of the patient's had complained, I was in no uncertain terms told that I was to take appointments first, ahead of anything else going on in the pharmacy, and that in no circumstances could I ever turn away a shot on the basis of how busy the pharmacy was.
  • Another popular tool has been the introduction of "net promoter scores (NPS)".  Or, how "happy" your customers/patients are based on a 5-point scale.  Technically, since a pharmacist cannot be terminated over failing to meet metrics, the NPS score is where its at now if you want to get rid of a pharmacy manager or pharmacist.  Regulations should encompass NPS scores as invalid for performance evaluations.  We've all had the experience of a survey at a business; healthcare is no place for these surveys.  The people that answer them are either very pleased with the business, or angry and want to make a point.  While there can be learning moments from these survey responses, corporate management also holds them over pharmacist's heads.  Anytime we have a neutral (3/5) response, we have to call and find out what we can do better.  99% of the time its "fill my prescription faster" or "hire more help so I don't have to wait in line as long".  On average our pharmacy will have the prescription done in 10 minutes or less, or, in the name of customer service, will fill it while they stand there in less than a minute.  We, as pharmacists, cannot objectively approach a patient when we are held to survey results.  Pharmacists naturally want to help people; that being said the answer we give is not always what the patient wants to hear.  That does not mean its the wrong answer, but it also should not lead to me having to deal with my district manager to explain why the patient was upset that I didn't comply with their demands.  There have been multiple attempts at evaluating the effects of patient satisfaction surveys on healthcare outcomes; the results are a mixed bag.  In some cases it appears patients satisfied with their care are more adherent and have improved outcomes, while in other studies it appears that tying satisfaction surveys to performance results in worse outcomes.  In either case, like production quotas and quality metrics, pharmacists and pharmacy teams should not be held to NPS scores as performance measures.

Ultimately, legislatively the issue with DIR fees and PBMs needs to be addressed, as in my own personal opinion PBMs are the root of the problem.  Pharmacy is the only business, to my knowledge, where we sell a product or service for less than its value, and have no guarantee to ever get paid for the full value of that product or service.

I believe the regulations as proposed are a good first step, but they don't go far enough.  Simply because, by their interpretation, corporations can truthfully say "we meet these regulations" and continue pushing pharmacy teams to the breaking point at the expense of patient safety.  The regulations to address working conditions should be clear, black-and-white standards much like the physical standards of pharmacies, that do not leave any room for interpretation.  In summary:

  • Break periods should be clearly defined, with clearly stated requirements for breaks with regards to shift lengths, break length, and number of breaks
  • Regulations should establish staffing minimums to safely operate a pharmacy that a clear and unambiguous and address the prescription volume that warrants multiple pharmacists, as well as clearly state staffing levels required for clinical services in addition to dispensing.  Regulations should also clearly state that no pharmacist should be required to work alone without at least 1 certified technician at all times.
  • Pharmacies that offer appointment-based clinical services in addition to traditional dispensing should staff an additional pharmacist during those hours that appointment-based services are available, whose sole responsibility is to provide care for those patients to allow the dispensing pharmacist to focus on safely dispensing medication.
  • Regulations should clearly state that production quotas and metrics in addition to patient satisfaction surveys shall not be introduced to the pharmacy for the purpose of pharmacist or technician performance evaluation.
CommentID: 220446