Walgreens comments 18VAC110-20-113 Pharmacy working conditions, Part 2

Dear Executive Director Juran and respected Board members,

On behalf of all pharmacies owned and operated by Walgreen Co. in the state of Virginia, we thank you for the opportunity to comment on 18VAC110-20-113 Pharmacy working conditions. Walgreens appreciates the Board’s time and effort related to addressing working conditions and consideration of public comments on these rules.

We fully recognize that the pharmacy working environment can be challenging, and the Board is attempting to support pharmacists and pharmacy technicians. Walgreens is also aligned with the need to support our pharmacy team members.  We believe a shared partnership between the pharmacy permit holder and pharmacy staff is necessary to ensure safe working conditions.  Safety is a top priority and pharmacies must be able to continue to provide critical patient care services.

Walgreens would like to highlight the following four concerns with 18VAC110-20-113:

1. Unintended consequences of unilateral authority on enforcement.
2. Quotas vs. Metrics
3. Unintended consequences as a result of pharmacists ceasing patient care services.
4. Effective communication between permit holders and PICs regarding staffing concerns.

1. Unintended consequences of unilateral authority on enforcement

• Walgreens believes that pharmacy permit holders and pharmacists should have a discussion or protocol on how to arrive at a decision rather than unilateral decision-making on either side, which could put the health, safety, and welfare of patients at risk.

• We believe that shifting responsibility unilaterally to solely the permit holder is not an effective nor sustainable model to ensure that all responsible parties, including the PIC and pharmacist on duty, are working in collaboration to ensure safe working conditions are met.  

To illustrate this point, below are two real-world examples where shifting responsibility unilaterally to the permit holder may lead to a disconnect between the permit holder and PIC. The successful hiring and training of technicians work optimally when both the PIC and permit holder work together.       

Example #1: If the hiring manager is also the PIC of the pharmacy, does the PIC have any portion of the responsibility for appropriate hiring, scheduling, and staffing?

Example #2: The PIC is ultimately responsible for training the pharmacy staff consistent with the requirements set forth in VA Statute 54.1-3321. Does the PIC hold any responsibility as well to ensure technicians are “sufficiently trained” within these rules?

To be clear, these examples are not to shift all of the responsibility to the PIC, but to demonstrate there should be a shared responsibility for both hiring and training of technicians. 

• Walgreens believes that the responsibility of ensuring a safe working environment should not rest solely upon the permit holder, but rather the permit holder, in partnership with the PIC and pharmacist on duty should share the responsibility of ensuring a safe working environment for their patients and staff.  

Walgreens recommends the following amendment to 18VAC110-20-113(A) and 18VAC110-20-113(B)(1) & (4):

1. A pharmacy permit holder shall protect the health, safety, and welfare of patients by consulting with the PIC or pharmacist on duty and other pharmacy staff to ensure patient care services are safely provided in compliance with applicable standards of patient care. A permit holder's decisions shall not override the control of the PIC or other pharmacist on duty shall work in collaboration with the PIC or other pharmacist on duty regarding appropriate working environments for all pharmacy personnel necessary to protect the health, safety, and welfare of patients.

B. To provide a safe working environment in a pharmacy, a permit holder shall, at a minimum:

1. Along with the PIC, ensure sufficient personnel are scheduled to work at all times in order to prevent fatigue, distraction, or other conditions that interfere with a pharmacist's ability to practice with reasonable competence and safety. Staffing levels shall not be solely based on prescription volume, but shall consider any other requirements of pharmacy staff during working hours;

4.  Along with the PIC, ensure staff are sufficiently trained to safely and adequately perform their assigned duties, ensure staff demonstrate competency, and ensure that pharmacy technician trainees work closely with pharmacists and pharmacy technicians with sufficient experience as determined by the PIC.

2. Quotas vs. Metrics

• Walgreens agrees with the concept of a prohibition on the use of quotas.
  • Walgreens has previously removed the use of metrics from performance evaluations prior to the adoption of the Board’s working condition rules.
• There is a significant concern with the utilization of metrics or other data in pharmacies and how an inspector or the Board may decide to interpret this utilization.
• Walgreens believes the onus should be on individual permit holders to manage the utilization of metrics effectively and responsibly.
• Many current reimbursement models and specialty accreditation (i.e. URAC (Utilization Review Accreditation Commission)) standards rely on the use of metrics to assist in measuring adherence, utilization, patient impact, quality measures, etc.
• As this information is captured and shared back to pharmacy teams, the concern is the perception that these are seen as quotas, when in fact they are simply providing data.
• Walgreens therefore recommends that the Board issue guidance surrounding the proper use of metrics and improper utilization of quotas, as utilization of metrics can be open to individual interpretation.

Walgreens therefore recommends that the Board issue guidance surrounding the proper use of metrics and improper utilization of quotas, as utilization of metrics can be open to individual interpretation.

Walgreens also respectfully requests the Board define pharmacy quotas and metrics within their rule, using the following suggested definitions:

                Quotas: A measure that is tied to negative consequences for the individual failing to achieve

                Metrics: A measure that is utilized to improve patient care or outcomes 

3. Unintended consequences as a result of Pharmacists ceasing patient care services.

• Walgreens fully supports efforts to protect both pharmacy staff and patients, and the ability for pharmacists and pharmacy technicians to safely provide patient care services.
• Walgreens believes that pharmacists are already empowered to make decisions to ensure the safe operation of a pharmacy while they are on duty, and any additional language is unnecessary.
• However, Walgreens has significant concerns with the scope and unintended consequences that could significantly reduce access to critically needed patient care services that could arise as a result of the current rules going into effect.

Here are just a few examples that highlight the unintended consequences of shutting down patient care services:

• Patients depend on their pharmacist to provide critically needed medications, immunizations, and patient care consultations in order to maintain or improve their health.
  • Elimination of patient care services, such as immunizations, can ultimately lead to decreased vaccine access to patients. 
  • Most patients rely on their pharmacy for immunization services.
  • If a patient seeking a vaccination is turned away by their pharmacy, there is a significant possibility that they will go without being vaccinated.
• According to the 2021 APhA/NASPA National Pharmacy Workplace Survey, the following stressors were identified by respondents as being likely to contribute to a medication error or near miss.
  • Patient expectations or demands (81%)
  • Harassment/Bullying from patients/customers (72%)
• As the Board’s working conditions rules are written, they have the potential to exacerbate the very conditions that they are attempting to solve.

Walgreens urges the Board that there should be no unilateral decision-making and that pharmacists and pharmacy permit holders should be working together to determine how best to address reducing any services due to safety reasons.

Walgreens recommends the following amendment to 18VAC110-20-113(C)

C. A pharmacy permit holder shall not override the control of the pharmacist on duty regarding all aspects of the practice of pharmacy, including a pharmacist's decision not to administer vaccines when one pharmacist is on duty and, in the pharmacist's professional judgment, vaccines cannot be administered safely. Prior to the discontinuation of any patient care services by a pharmacist, the pharmacist must first communicate their concerns to their immediate supervisor or permit holder in order to seek a solution. A pharmacist must not impede a patient’s access to care and must provide the patient an alternative pathway to seek services if the pharmacist’s decision is not to provide any patient care service.

4.  Effective communication between permit holders and PICs regarding staffing concerns.

• Walgreens agrees that pharmacy personnel should be able to share their concerns and provide the permit holder the opportunity to support their pharmacy personnel.
• Walgreens also believes that the permit holder should have the ability to address these concerns by the PIC or pharmacist on duty, prior to any reports directly to the Board.
• Walgreens has concerns with the 48-hour documentation timeframe within the rule. If the communication were to occur over a holiday, weekend, or when the pharmacy may be closed may create a hardship for permit holders to submit documentation within the required timeframe.
  • Walgreens respectfully asks that the 18VAC110-20-113(E)(3) be amended to include that the documentation or corrective steps must be submitted within 72 hours, to account for these possibilities.
• Walgreens also asks that the Board amend the completion of the staffing form to permit alternative formats, such as an electronic format considering the many advantages an electronic format can provide.

Walgreens recommends the following amendments to 18VAC110-20-113(D)(1) &(2) and 18VAC110-20-113(E)(3):

4. Staffing requests or concerns shall be communicated by the PIC or pharmacist on duty to the permit holder using a form developed by the board or an alternative format, such as an electronic method.

3. 1. Executed staffing forms shall be provided to the immediate supervisor of the PIC or pharmacist on duty, with one copy maintained in the pharmacy for three years, and produced for inspection by the board.
   2. The PIC or pharmacist on duty shall communicate their concerns directly to their immediate supervisor or permit holder. If these concerns go unresolved or need immediate escalation, they may report directly to the Board. may report any staffing issues directly to the board if the PIC or pharmacist on duty believes the situation warrants immediate board review.
   3. Under no circumstances shall a good faith report of staffing concerns by the PIC, pharmacist on duty, or notification of such issues by pharmacy personnel to the PIC or pharmacist on duty result in workplace discipline against the reporting staff member.

E.  Permit holders shall review completed staffing reports and shall:

3. Document any corrective action taken, steps taken toward corrective action as of the time of inspection, or justification for inaction, which documentation shall be maintained on-site or produced for inspection by the board within 4872 hours of request; and

Walgreens appreciates the Board’s efforts to address workplace conditions and respectfully asks that the Board consider the recommendations and amendments that have been provided above.  

Sincerely, 

Jeenu Philip, 

Director, Pharmacy Affairs