TY - JOUR
AU - Tyler, Linda, S
AB - Abstract Purpose A pharmacy services call center (PSCC) was implemented to centralize pharmacy phone calls and reduce interruptions of dispensing activities in 7 community pharmacies of an academic health center. An evaluation was conducted to define, quantify, and compare the numbers and types of phone interruptions before and 3 months after PSCC implementation. Methods Through structured, direct observation of pharmacy staff, the numbers and types of “breaks in task” (BIT) due to phone interruptions and other distractions were identified. A standardized data collection tool formatted on tablet computers was used by trained observers to document BIT for 3-hour time blocks on 5 consecutive business days (2 days of pharmacist observation and 3 days of technician observation, for a total of 10 observation days per pharmacy). Results Over 5,000 prescriptions were processed during 414 hours of observation (13.3 prescriptions per observation hour). Overall, BIT due to phone interruptions totaled 2.2 BIT per observation hour, with those interruptions reduced by 46.4% overall after PSCC implementation (by 30.0% in 4 small pharmacies and by 57.5% in 3 large pharmacies). Technicians were more likely than pharmacists to be interrupted by phone vs nonphone BIT (eg, distraction by another technician, pharmacist, or patient). Comparison of phone vs nonphone BIT suggested an overall 46.0% reduction in phone BIT in all pharmacies (reductions of 42.4% and 45.0% in large and small pharmacies, respectively). Conclusion PSCC implementation noticeably decreased the amount of phone interruptions and distractions for employees. call centers, human factors, interruptions, medication errors, pharmaceutical services KEY POINTS Operations changes intended to reduce interruptions to prescription filling can be estimated through employee observation methods. Multiple operations statistics should be used to evaluate the impact of interruptions on employee productivity. Reduced phone call interruptions may lead to improved productivity and reconsideration of employee responsibilities. Interruptions and distractions are a well-known problem in healthcare1,2 and have been associated with higher prescription dispensing error rates in ambulatory pharmacies.3-6 Flynn et al3 defined an interruption as the “cessation of productive activity before the current prescription-filling task was completed for any externally imposed, observable or audible reason.” An interruption can also be thought of as a “break-in-task,” 1 or something that requires attention and necessitates cessation of a primary task. A distraction, on the other hand, may be defined as some stimulus that briefly requires the attention of the worker but does not result in switching to the interrupting task.3 In truth, interruptions and distractions in pharmacies are many, and they can be expected to affect workflow and lessen employee perception of their workplace as a positive experience. While nurse7 and physician1,2 healthcare processes have been studied in detail, less is known about the impact of interruptions and distractions in pharmacies. The effects of interruptions and distractions are well documented in the aviation industry, and nurse investigators have evaluated adapted “sterile cockpit” techniques,8,9 “no interruption zones,” and nurses wearing “no interruption vests” 10 during medication handling. However, according a systematic review by Raban et al11 of medication administration process changes designed to reduce interruptions, evidence that process changes to reduce interruptions reduced errors was weak. In addition, Persoon et al2 observed the effect of operating room distractions on physicians during common endourological procedures and found a median of 20 distracting events per procedure, or 1 distracting event every 1.8 minutes on average. Chisholm et al1 evaluated emergency department staff interruptions (brief attention needed but no task switching) and “breaks in task” (BIT), defined as interruptions lasting longer than 10 seconds and requiring task switching, with similar results (a mean [SD] of 30.9 [9.7] interruptions per 1.5 hours and 20.7 [6.3] BIT). Although Berg12 has questioned whether all interruptions should be considered as leading to negative consequences, interruptions may not be helpful to worker productivity or positive patient outcomes if errors are made during complex processes. The Brixey Model of Interruption13 proposes that interrupted individuals can handle interruptions in a variety of ways. Accordingly, if a worker is involved with a primary task that involves a stepwise requirement to assure successful primary task completion, interruptions or distractions may result in an interruption phase during which the worker takes time (however little) to decide whether to accept the interruption or not. If accepted, the worker would deal with the interruption and then resume the primary task after completing review of tasks completed prior to the interruption (again taking time to reorganize, however little). For example, if a pharmacist’s primary task was processing a prescription, certain steps would need to be completed in a particular order. If that pharmacist was interrupted by a phone call, a quick decision would be made to accept the interruption (take the call) or not (decline the call). If the call was declined, then the pharmacist would resume the dispensing task at hand. If the call was accepted, then the primary dispensing task would be interrupted. Once the interruption task was complete, the pharmacist would presumably resume the primary dispensing task, requiring him or her to remember and reorganize thoughts around the primary dispensing task. Although multitasking can take place with simple tasks or automated tasks (eg, gear shifting in a manual transmission car), the ability to multitask during complex tasks, especially during medication dispensing processes performed by pharmacists and technicians, likely increases errors. Unfortunately, multiple and often competing demands are regularly placed on pharmacists and technicians while they are preparing medications for dispensing. Phone calls from patients, insurance companies, and healthcare providers can introduce significant interruptions and distractions into the dispensing process. A 2003 United States Pharmacopeial Convention newsletter proposed 5 suggestions for minimizing distractions, one of which stated, “. . . place phones away from those selected healthcare workers who are actively preparing, dispensing, or administering medications.” 6 Alternatively, the design and implementation of a centralized call center may remove phone-related distractions and interruptions in community pharmacies that are part of larger healthcare systems, thereby improving critical safety task performance and employee prescription preparation efficiency. However, there is little published evidence on the types and frequency of interruptions and distractions observed in community pharmacy settings. As part of a larger effort to improve patient experiences and working conditions for community pharmacy staff, University of Utah Health (UUH) Pharmacy Services implemented a pharmacy services call center (PSCC) in October 2014 to answer simple and repetitive calls (ie, those regarding prescription readiness and refill status) for 7 of 14 UUH community pharmacies.14 Interactive voice response (IVR) phone systems rerouted calls (based on IVR selection) to the PSCC, which was staffed by pharmacists and technicians. In essence, the PSCC was expected to decrease the number of phone interruptions and distractions for community-based pharmacy staff, leading to improved productivity, including additional pharmacist clinical activities. The primary objective of the study described here was to define, identify, and quantify through direct observation the numbers and types of pharmacist and technician interruptions and distractions (defined as BIT) relative to the number of prescriptions dispensed during specified periods before and during the 3 months after PSCC implementation. Methods A detailed description of pre- and postimplementation characteristics of each of the 7 pharmacies (staff full-time equivalent [FTEs], number of prescriptions dispensed, and phone call volume) appeared elsewhere.15 PSCC operations started in October 2014; FTE and prescription dispensing estimates were calculated for fiscal year (FY) 2015 (July 2014 through June 2015). Data for phone call volume per pharmacy were available only on a calendar year basis. Observations were conducted before PSCC implementation in 2014. Since pharmacies were added in a stepwise fashion as PSCC staff were added, postimplementation observations occurred throughout FY15 and FY16 after the first 90 days since implementation had passed for each of the 7 pharmacies. Direct observation procedures were modeled after published reports from Persoon et al,2 on physician interruptions during surgeries, on and work/workflow evaluations of intensive care unit (ICU) physicians16,17 and ICU nurses.18 A national expert in evaluation of distractions and interruptions of workflow in healthcare (a member of the author team for this article) provided additional input. Data collection was accomplished using a standardized data collection tool running on Pocket Observer Software (Noldus Information Technology, Wageningen, Netherlands) that was implemented on tablet computers. The software was selected because it allowed for use of tablets for detailed data collection, with downloading to secure electronic storage immediately post data collection. Categories of work defined for the electronic data collection tool were developed by initially observing and talking with community pharmacy staff (Appendix A; definitions of work categories in Appendix B). A 4-hour pilot observation was conducted to adapt the tool for interrupting tasks that were not originally identified, as well as to fine-tune the tool to accurately document BIT type and quantity during prescription filling. Revisions to the tool were also made by speaking with pharmacists and technicians whose primary job in participating pharmacies was to dispense prescriptions. Pharmacists and technicians scheduled for 5 weekdays (Monday through Friday) of data collection were invited to participate based on scheduling logistics in order to minimize observation of the same employee multiple times. Employee participation was voluntary with the option to refuse participation without retribution. All pharmacy residents and technicians who conducted data collection underwent standardized training, which included an introduction to the project, orientation to the electronic data collection tablet (slide presentation available upon request), and training in the different observation categories. A practice observation was conducted by each data collector to minimize personal or subjective differences between observers. Trained observers then observed pharmacists and technicians during normal business hours for two 3-hour time blocks per day (0900-1200 and 1400–1700) for 5 business days per pharmacy both before and after PSCC implementation (10 days in total). As Mondays and Fridays were busier days in the pharmacies, pharmacists were observed for 2 days (Monday and Thursday), and technicians were observed for 3 days (Tuesday, Wednesday, and Friday), to gather a minimum of 12 observed pharmacist hours per pharmacy and 18 observed technician hours per pharmacy. Although more observation days would have been optimal, a decision was made not to put an observer into constricted space for any more time than necessary. All other evaluations (described elsewhere19) were also scheduled for only 5 business days (Monday through Friday) so that data collection for 4 of 5 non–survey-based evaluative methods could be accomplished in 4 weeks. To estimate the number of interrupted prescriptions in process and filled during an observation period by each observed employee, a report from the community pharmacy’s dispensing software on how many prescriptions each employee “touched” during the observation time frame was generated by an information technology support pharmacist. Calculation of the number of BIT per prescription during each observation period was then estimated via use of a “prescriptions touched” denominator. Observation results were analyzed in aggregate at the health system level (n = 7 pharmacies), and by pharmacy group (small or large) based on whether a pharmacy was considered small (<10 FTEs, n = 4) or large (>10 FTEs, n = 3). Baseline pharmacy characteristics (observation hours and numbers of prescriptions touched per observation hour) were analyzed by pharmacy size and employee type using simple summaries. Work category summaries (Appendix A) were analyzed as a ratio of dispensing to nondispensing activities (ie, all other work activities staff may perform while simultaneously trying to dispense a prescription; Appendix B). Finally, ratio comparisons were also completed for phone vs nonphone BIT per prescription touched during each observation period. Statistical analyses were performed using Microsoft Excel 2013 (Microsoft Corporation, Redmond, WA). As part of a larger evaluation of the PSCC’s impact on community pharmacies published elsewhere,15 the project was approved by the University of Utah institutional review board. Results Site characteristics. As described in detail elsewhere,15 during FY 2015 (FY15) and FY16, community pharmacy hours were expanded to accommodate longer community clinic hours, and the staff was increased to accommodate this change (a net of 527 prescriptions per FTE per month in both FY15 and FY16). However, due to PSCC diversion of repetitive calls, the overall total number of phone calls per month decreased 15.5% (from 15,357 in calendar year 2014 to 13,291 in calendar year 2015). Additionally, the average number of phone calls per FTE per month in all pharmacies decreased 24.5% (from 193 in FY15 to 155 in FY16, an overall net reduction of 38 calls) due to the additional pharmacy-specific FTEs to accommodate prescription workload increases.15 Analyses of observations, then, focused on whether BIT types and quantities were also reduced after PSCC implementation. A total of 414 observation hours (210 hours before and 204 hours after PSCC implementation) were completed at the health system level (n = 7 pharmacies; Table 1). For pharmacists, 162 observation hours were completed by observers (84 and 78 hours before and after implementation, respectively), with 252 hours (126 hours in both periods) completed for technicians. For small pharmacies (n = 4), 234 observation hours were completed (90 pharmacist observation hours and 144 technician observation hours, or 93.7% and 100% of the respective observation goals), although one 3-hour post–PSCC implementation pharmacist observation period was missed in 2 different pharmacies due to short staffing. For large pharmacies (n = 3), 180 observation hours were completed (72 and 108 pharmacist and technician observation hours, respectively, both at 100% of goal). Table 1. Observational Data Collected Before and After Call Center Implementation, Overall and by Pharmacy Size and Employee Type . Observation Hours . Rx Touched . Phone BIT . Rx Touched per Hour . Change After PSCC Implemented . Phone BIT per Hour . Change After PSCC Implemented . Phone BIT per Rx Touched . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 414 5,511 910 13.3 2.2 0.17 Summary PRE 210 3,217 597 15.3 2.8 0.19  Pharmacists 84 1,991 161 23.7 1.9 0.08  Technicians 126 1,226 436 9.7 3.5 0.36 Summary POST 204 2,294 313 11.2 –26.8% 1.5 –46.4% 0.14 –26.3%  Pharmacists 78 1,268 109 16.3 1.4 0.09  Technicians 126 1,026 204 8.1 1.6 0.20 Small Pharmacies (<10 FTEs) Summary PRE 120 1,259 236 10.5 2.0 0.19  Pharmacists 48 801 73 16.7 1.5 0.09  Technicians 72 458 163 6.4 2.3 0.36 Summary POST 114 899 159 7.9 –24.8% 1.4 –30.0% 0.18 –5.3%  Pharmacists 42 485 51 11.5 1.2 0.11  Technicians 72 414 108 5.8 1.5 0.26 Large Pharmacies (>10 FTEs) Summary PRE 90 1,958 361 21.8 4.0 0.18  Pharmacists 36 1,190 88 33.1 2.4 0.07  Technicians 54 768 273 14.2 5.1 0.36 Summary POST 90 1,395 154 15.5 –28.9% 1.7 –57.5% 0.11 –38.9%  Pharmacists 36 783 58 21.8 1.6 0.07  Technicians 54 612 96 11.3 1.8 0.16 . Observation Hours . Rx Touched . Phone BIT . Rx Touched per Hour . Change After PSCC Implemented . Phone BIT per Hour . Change After PSCC Implemented . Phone BIT per Rx Touched . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 414 5,511 910 13.3 2.2 0.17 Summary PRE 210 3,217 597 15.3 2.8 0.19  Pharmacists 84 1,991 161 23.7 1.9 0.08  Technicians 126 1,226 436 9.7 3.5 0.36 Summary POST 204 2,294 313 11.2 –26.8% 1.5 –46.4% 0.14 –26.3%  Pharmacists 78 1,268 109 16.3 1.4 0.09  Technicians 126 1,026 204 8.1 1.6 0.20 Small Pharmacies (<10 FTEs) Summary PRE 120 1,259 236 10.5 2.0 0.19  Pharmacists 48 801 73 16.7 1.5 0.09  Technicians 72 458 163 6.4 2.3 0.36 Summary POST 114 899 159 7.9 –24.8% 1.4 –30.0% 0.18 –5.3%  Pharmacists 42 485 51 11.5 1.2 0.11  Technicians 72 414 108 5.8 1.5 0.26 Large Pharmacies (>10 FTEs) Summary PRE 90 1,958 361 21.8 4.0 0.18  Pharmacists 36 1,190 88 33.1 2.4 0.07  Technicians 54 768 273 14.2 5.1 0.36 Summary POST 90 1,395 154 15.5 –28.9% 1.7 –57.5% 0.11 –38.9%  Pharmacists 36 783 58 21.8 1.6 0.07  Technicians 54 612 96 11.3 1.8 0.16 Abbreviations: FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab Table 1. Observational Data Collected Before and After Call Center Implementation, Overall and by Pharmacy Size and Employee Type . Observation Hours . Rx Touched . Phone BIT . Rx Touched per Hour . Change After PSCC Implemented . Phone BIT per Hour . Change After PSCC Implemented . Phone BIT per Rx Touched . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 414 5,511 910 13.3 2.2 0.17 Summary PRE 210 3,217 597 15.3 2.8 0.19  Pharmacists 84 1,991 161 23.7 1.9 0.08  Technicians 126 1,226 436 9.7 3.5 0.36 Summary POST 204 2,294 313 11.2 –26.8% 1.5 –46.4% 0.14 –26.3%  Pharmacists 78 1,268 109 16.3 1.4 0.09  Technicians 126 1,026 204 8.1 1.6 0.20 Small Pharmacies (<10 FTEs) Summary PRE 120 1,259 236 10.5 2.0 0.19  Pharmacists 48 801 73 16.7 1.5 0.09  Technicians 72 458 163 6.4 2.3 0.36 Summary POST 114 899 159 7.9 –24.8% 1.4 –30.0% 0.18 –5.3%  Pharmacists 42 485 51 11.5 1.2 0.11  Technicians 72 414 108 5.8 1.5 0.26 Large Pharmacies (>10 FTEs) Summary PRE 90 1,958 361 21.8 4.0 0.18  Pharmacists 36 1,190 88 33.1 2.4 0.07  Technicians 54 768 273 14.2 5.1 0.36 Summary POST 90 1,395 154 15.5 –28.9% 1.7 –57.5% 0.11 –38.9%  Pharmacists 36 783 58 21.8 1.6 0.07  Technicians 54 612 96 11.3 1.8 0.16 . Observation Hours . Rx Touched . Phone BIT . Rx Touched per Hour . Change After PSCC Implemented . Phone BIT per Hour . Change After PSCC Implemented . Phone BIT per Rx Touched . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 414 5,511 910 13.3 2.2 0.17 Summary PRE 210 3,217 597 15.3 2.8 0.19  Pharmacists 84 1,991 161 23.7 1.9 0.08  Technicians 126 1,226 436 9.7 3.5 0.36 Summary POST 204 2,294 313 11.2 –26.8% 1.5 –46.4% 0.14 –26.3%  Pharmacists 78 1,268 109 16.3 1.4 0.09  Technicians 126 1,026 204 8.1 1.6 0.20 Small Pharmacies (<10 FTEs) Summary PRE 120 1,259 236 10.5 2.0 0.19  Pharmacists 48 801 73 16.7 1.5 0.09  Technicians 72 458 163 6.4 2.3 0.36 Summary POST 114 899 159 7.9 –24.8% 1.4 –30.0% 0.18 –5.3%  Pharmacists 42 485 51 11.5 1.2 0.11  Technicians 72 414 108 5.8 1.5 0.26 Large Pharmacies (>10 FTEs) Summary PRE 90 1,958 361 21.8 4.0 0.18  Pharmacists 36 1,190 88 33.1 2.4 0.07  Technicians 54 768 273 14.2 5.1 0.36 Summary POST 90 1,395 154 15.5 –28.9% 1.7 –57.5% 0.11 –38.9%  Pharmacists 36 783 58 21.8 1.6 0.07  Technicians 54 612 96 11.3 1.8 0.16 Abbreviations: FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab The number of prescriptions touched during each observation periods was also calculated as described above. At the health system level, 5,511 prescriptions were touched during the 2 observation periods combined (3,217 before and 2,294 after PSCC implementation). Per observation hour across all pharmacies (n = 7), an average of 13.3 prescriptions were touched (15.3 before and 11.2 after PSCC implementation). The numbers of prescriptions touched per observation hour in large pharmacies were double the numbers in small pharmacies (21.8 vs 10.5 before PSCC implementation and 15.5 vs 7.9 after implementation). In all pharmacies, the number of prescriptions touched per observation hour decreased after PSCC implementation (an overall decrease of 26.8%, with decreases of 24.8% and 28.9% in small and large pharmacies, respectively), possibly due to less prescriptions processed during the hours of observation in the postimplementation weeks of data collection. Finally, the number of observed BIT due to phone interruptions totaled 910 (597 observations before and 313 observations after PSCC implementation). This represented a ratio of 2.2 phone BIT per observation hour (2.8 and 1.5 per hour before and after PSCC implementation, respectively) at the health system level. Thus, phone interruptions appeared to be reduced by 46.4% overall due to PSCC implementation (by 30.0% on average in small pharmacies and by 57.5% in large pharmacies). This also resulted in an overall 26.3% reduction in phone BIT per prescription touched, with reductions of 5.3% in small pharmacies and 38.9% in large pharmacies. Work categories and BIT sources. A count of observed work tasks (Appendix A) simultaneously completed while filling prescriptions is listed in Table 2. Work tasks were summed into nondispensing (covering/directing workflow, patient consult, inventory management, personal conversations, vaccinations, and other) and dispensing categories to create a pre- and postimplementation ratio comparison. At the health system level, an overall 6.3% reduction was observed in nondispensing tasks (reductions of 13.0% in small pharmacies and 1.7% in large pharmacies). Technicians experienced the most change in nondispensing tasks relative to dispensing tasks, perhaps due to increased staffing and reduced overall prescription volume per employee, as described above. Although not a measure of phone call impact, this change may represent the extent to which staff multitasked while filling prescriptions. Table 2. Observational Data on Dispensing and Nondispensing Tasks, Overall and by Pharmacy Size and Employee Type . Dispensing Tasks . Nondispensing Tasks . Ratio of Nondispensing to Dispensing Tasks . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 1,801 1,104 0.61 Summary PRE 925 586 0.63  Pharmacists 408 220 0.54  Technicians 517 366 0.71 Summary POST 876 518 0.59 –6.3%  Pharmacists 371 210 0.57 5.6%  Technicians 505 308 0.61 –14.1% Small Pharmacies (<10 FTEs) Summary PRE 410 284 0.69  Pharmacists 172 106 0.62  Technicians 238 178 0.75 Summary POST 520 313 0.60 –13.0%  Pharmacists 198 126 0.64 3.2%  Technicians 322 187 0.58 –22.7% Large Pharmacies (>10 FTEs) Summary PRE 515 302 0.59  Pharmacists 236 114 0.48  Technicians 279 188 0.67 Summary POST 356 205 0.58 –1.7%  Pharmacists 173 84 0.49 2.1%  Technicians 183 121 0.66 –1.5% . Dispensing Tasks . Nondispensing Tasks . Ratio of Nondispensing to Dispensing Tasks . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 1,801 1,104 0.61 Summary PRE 925 586 0.63  Pharmacists 408 220 0.54  Technicians 517 366 0.71 Summary POST 876 518 0.59 –6.3%  Pharmacists 371 210 0.57 5.6%  Technicians 505 308 0.61 –14.1% Small Pharmacies (<10 FTEs) Summary PRE 410 284 0.69  Pharmacists 172 106 0.62  Technicians 238 178 0.75 Summary POST 520 313 0.60 –13.0%  Pharmacists 198 126 0.64 3.2%  Technicians 322 187 0.58 –22.7% Large Pharmacies (>10 FTEs) Summary PRE 515 302 0.59  Pharmacists 236 114 0.48  Technicians 279 188 0.67 Summary POST 356 205 0.58 –1.7%  Pharmacists 173 84 0.49 2.1%  Technicians 183 121 0.66 –1.5% Abbreviations: FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab Table 2. Observational Data on Dispensing and Nondispensing Tasks, Overall and by Pharmacy Size and Employee Type . Dispensing Tasks . Nondispensing Tasks . Ratio of Nondispensing to Dispensing Tasks . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 1,801 1,104 0.61 Summary PRE 925 586 0.63  Pharmacists 408 220 0.54  Technicians 517 366 0.71 Summary POST 876 518 0.59 –6.3%  Pharmacists 371 210 0.57 5.6%  Technicians 505 308 0.61 –14.1% Small Pharmacies (<10 FTEs) Summary PRE 410 284 0.69  Pharmacists 172 106 0.62  Technicians 238 178 0.75 Summary POST 520 313 0.60 –13.0%  Pharmacists 198 126 0.64 3.2%  Technicians 322 187 0.58 –22.7% Large Pharmacies (>10 FTEs) Summary PRE 515 302 0.59  Pharmacists 236 114 0.48  Technicians 279 188 0.67 Summary POST 356 205 0.58 –1.7%  Pharmacists 173 84 0.49 2.1%  Technicians 183 121 0.66 –1.5% . Dispensing Tasks . Nondispensing Tasks . Ratio of Nondispensing to Dispensing Tasks . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 1,801 1,104 0.61 Summary PRE 925 586 0.63  Pharmacists 408 220 0.54  Technicians 517 366 0.71 Summary POST 876 518 0.59 –6.3%  Pharmacists 371 210 0.57 5.6%  Technicians 505 308 0.61 –14.1% Small Pharmacies (<10 FTEs) Summary PRE 410 284 0.69  Pharmacists 172 106 0.62  Technicians 238 178 0.75 Summary POST 520 313 0.60 –13.0%  Pharmacists 198 126 0.64 3.2%  Technicians 322 187 0.58 –22.7% Large Pharmacies (>10 FTEs) Summary PRE 515 302 0.59  Pharmacists 236 114 0.48  Technicians 279 188 0.67 Summary POST 356 205 0.58 –1.7%  Pharmacists 173 84 0.49 2.1%  Technicians 183 121 0.66 –1.5% Abbreviations: FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab Similar to the work categories comparisons, counts of sources of BIT during prescription filling are listed in Table 3. BIT were summed into phone BIT and nonphone BIT (the latter were categorized by source: technician, pharmacist/other staff, patient, personal, count change) to allow a ratio comparison. It was assumed that interruptions would always occur, and a comparison of phone and nonphone BIT allowed for identification of nonphone BIT that might replace phone BIT with a reduction in phone calls. At the health-system pharmacy level, there was an overall 46.0% reduction (with reductions of 45.0% in small pharmacies and 42.4% in large pharmacies) in phone calls as a source of BIT relative to other sources. Regardless of employee type, reductions in phone BIT corroborate the fiscal analysis data described previously15 (ie, an average decrease in the number of phone calls per FTE per month of a 24.5%, or 38 calls). Table 3. Observational Data on Breaks in Task, Overall and by Pharmacy Size and Employee Type Location . Phone BIT . Nonphone BIT . Ratio of Phone BIT to Nonphone BIT . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 910 2,357 0.39 Summary PRE 597 1,195 0.50 Pharmacists 161 488 0.33 Technicians 436 707 0.62 Summary POST 313 1,162 0.27 –46.0% Pharmacists 109 507 0.21 –36.4% Technicians 204 655 0.31 –50.0% Small Pharmacies (<10 FTEs) Summary PRE 236 588 0.40 Pharmacists 73 244 0.30 Technicians 163 344 0.47 Summary POST 159 715 0.22 –45.0% Pharmacists 51 321 0.16 –46.7% Technicians 108 394 0.27 –42.6% Large Pharmacies (>10 FTEs) Summary PRE 361 607 0.59 Pharmacists 88 244 0.36 Technicians 273 363 0.75 Summary POST 154 447 0.34 –42.4% Pharmacists 58 186 0.31 –13.9% Technicians 96 261 0.37 –50.7% Location . Phone BIT . Nonphone BIT . Ratio of Phone BIT to Nonphone BIT . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 910 2,357 0.39 Summary PRE 597 1,195 0.50 Pharmacists 161 488 0.33 Technicians 436 707 0.62 Summary POST 313 1,162 0.27 –46.0% Pharmacists 109 507 0.21 –36.4% Technicians 204 655 0.31 –50.0% Small Pharmacies (<10 FTEs) Summary PRE 236 588 0.40 Pharmacists 73 244 0.30 Technicians 163 344 0.47 Summary POST 159 715 0.22 –45.0% Pharmacists 51 321 0.16 –46.7% Technicians 108 394 0.27 –42.6% Large Pharmacies (>10 FTEs) Summary PRE 361 607 0.59 Pharmacists 88 244 0.36 Technicians 273 363 0.75 Summary POST 154 447 0.34 –42.4% Pharmacists 58 186 0.31 –13.9% Technicians 96 261 0.37 –50.7% Abbreviations: BIT, breaks in task; FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab Table 3. Observational Data on Breaks in Task, Overall and by Pharmacy Size and Employee Type Location . Phone BIT . Nonphone BIT . Ratio of Phone BIT to Nonphone BIT . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 910 2,357 0.39 Summary PRE 597 1,195 0.50 Pharmacists 161 488 0.33 Technicians 436 707 0.62 Summary POST 313 1,162 0.27 –46.0% Pharmacists 109 507 0.21 –36.4% Technicians 204 655 0.31 –50.0% Small Pharmacies (<10 FTEs) Summary PRE 236 588 0.40 Pharmacists 73 244 0.30 Technicians 163 344 0.47 Summary POST 159 715 0.22 –45.0% Pharmacists 51 321 0.16 –46.7% Technicians 108 394 0.27 –42.6% Large Pharmacies (>10 FTEs) Summary PRE 361 607 0.59 Pharmacists 88 244 0.36 Technicians 273 363 0.75 Summary POST 154 447 0.34 –42.4% Pharmacists 58 186 0.31 –13.9% Technicians 96 261 0.37 –50.7% Location . Phone BIT . Nonphone BIT . Ratio of Phone BIT to Nonphone BIT . Change After PSCC Implemented . All Evaluated Pharmacies Overall (7 pharmacies) 910 2,357 0.39 Summary PRE 597 1,195 0.50 Pharmacists 161 488 0.33 Technicians 436 707 0.62 Summary POST 313 1,162 0.27 –46.0% Pharmacists 109 507 0.21 –36.4% Technicians 204 655 0.31 –50.0% Small Pharmacies (<10 FTEs) Summary PRE 236 588 0.40 Pharmacists 73 244 0.30 Technicians 163 344 0.47 Summary POST 159 715 0.22 –45.0% Pharmacists 51 321 0.16 –46.7% Technicians 108 394 0.27 –42.6% Large Pharmacies (>10 FTEs) Summary PRE 361 607 0.59 Pharmacists 88 244 0.36 Technicians 273 363 0.75 Summary POST 154 447 0.34 –42.4% Pharmacists 58 186 0.31 –13.9% Technicians 96 261 0.37 –50.7% Abbreviations: BIT, breaks in task; FTE, full-time equivalent; POST, postimplementation; PRE, preimplementation; PSCC, pharmacy services call center. aAll data are counts (n) unless indicated otherwise. Open in new tab Discussion Use of observation as a method of data collection and documentation of pharmacy staff multitasking while filling prescriptions enabled investigators to better understand the impact of a centralized call center on prescription filling activities. Although the number of prescriptions touched per observation hour decreased at all levels (Table 1), this may have been due to either increased staffing levels to accommodate expanded service hours or more efficient use of time due to less phone calls, allowing staff to more efficiently fill prescriptions. On average, the number of prescriptions filled per FTE per month remained the same, at 527.15 Both the number of phone BIT per observation hour and the number of phone BIT per prescription touched were measurably reduced, although predominantly in the larger pharmacies. In addition, because the number of prescriptions touched per observation hour was nearly twice as high in large vs small pharmacies, the desired reduction of phone calls as interruptions to dispensing should have helped staff focus on desired dispensing tasks. Relative to dispensing and nondispensing work categories, the goal of a pharmacy is to dispense and provide direct patient care through counseling, vaccinations, etc. Therefore, any reduction in nondispensing tasks (ie, multitasking across multiple activities) should improve staff focus on dispensing (Table 2). Technicians were the primary beneficiary of nondispensing task reductions, although both pharmacists and technicians were observed to spend more effort either covering or directing workflow. After PSCC implementation, pharmacists were interrupted more by nonphone activities, especially “other” tasks such as coordinating prior authorizations or inventory management, that caused many interruptions categorized as “other.” One goal of the PSCC was to replace time spent on phone calls with other clinically focused activities (especially for pharmacists), although the evaluation described here was not intended to ascertain whether that occurred. As an example, providing vaccinations is a time- and space-dependent activity, especially administration of flu shots prior to flu season, and this evaluation was not designed to specifically capture data for that time of year. Implementing the PSCC substantially reduced phone interruptions for technicians (Table 3), with an overall 46.0% reduction in phone BIT for all employees after PSCC implementation. For technicians specifically, a 50.0% reduction was seen at the health system level, while a 42.6% reduction was seen in the small pharmacies and a 50.7 % reduction was seen in the large pharmacies. Technicians were largely responsible for answering phones in our pharmacies, so reduced phone workload allowed technicians to focus on other tasks. Additionally, since BIT may require individuals to completely stop what they are doing, switch to another activity, and then switch back to the prior activity, BIT demand a larger focus on changing work environments to prevent task switching due to BIT to the extent possible. Finally, larger pharmacies with multiple technicians may be better able to triage workload by moving staff to areas of need. Smaller pharmacies with 1 or 2 technicians and 1 pharmacist are thus less able to move limited staff to cover workload increases, even temporarily. Among nonphone BIT sources, technicians and patients were observed as the largest source of BIT interruptions for pharmacists, again corroborating what is seen in practice. Technicians often direct workflow, especially between pharmacists and patients, which allows the pharmacist to focus more directly on completing dispensing and counseling activities in a timely manner. Raimbault et al5 showed that conversation was the largest interruption, affecting about 26% of pharmacists and 29% of pharmacy technicians. For our evaluation, professional conversation was categorized as “directing workflow,” so any similarities are unknown. Interestingly, personal sources of interruption (personal conversations, personal phone calls, or bathroom breaks) increased after PSCC implementation. This finding could be due to the Hawthorne effect wearing off or indicate that more time was available for personal use, especially time dedicated to two 15-minute breaks and one 30-minute break during an 8.5-hour shift. Anthony et al10 showed a 40.9% decrease in interruptions after implementation of a “no interruption zone.” Such an approach would be nearly impossible to implement in a community pharmacy, and our results indicate a significant decrease in phone BIT for technicians. Persoon et al2 demonstrated that approximately 20 distractions occurred per operating room procedure. That finding was consistent with results of our study, as there was nearly 1 phone BIT for every 5 prescriptions touched (Table 1). Again, since BIT require changing focus and then refocusing on the prior task, any workplace changes that can reduce BIT interruptions should contribute to improved staff perceptions of pharmacy safety, implying fewer filling errors. Therefore, the impact of interruption rate decreases on filling errors would be a topic for further study. Several limitations should be considered when interpreting the results of our evaluation. As previously described, an observation data collection period of 5 weekdays was used to prevent additional crowding of small community pharmacy workspaces. Five business days in each pharmacy should have allowed for enough observations to gain an accurate picture of pharmacy operations. However, it was challenging to observe without contributing another source of interruptions or distractions. More days of data collection would have contributed to a more definitive evaluation of PSCC impact on each pharmacy. Subjective differences between observers could have caused observer bias. Training of observers and a practice observation session were conducted to overcome observer bias and encourage observers to code observations consistently. Observers from outside the health system or professional observers were not used or considered, largely due to a need for flexibility in scheduling observation days and a sense of urgency to schedule evaluative methods in a timely manner before and after the stepwise addition of 7 pharmacies to PSCC operations. There were also discrepancies in timing of observations and in the number of observations at each pharmacy. Initially, observation periods were scheduled to avoid lunch hour or break periods. In reality, pharmacy employees often schedule breaks when workload lulls occur. For example, some observation periods were disrupted by lunch breaks for the staff member being observed or by a staff member being late for work or leaving early. In these cases, observers “stopped the clock” on a 3-hour observation period and restarted when the employee returned to the work station. As noted earlier, the goal of 3-hour observation blocks was largely successful; missing observation hours were also noted and reflected in the final analysis. Conclusion Implementation of a central call center serving community pharmacies in an integrated health system decreased the amount of phone interruptions and distractions for employees. This approach may allow more time for other patient care activities and make for a more efficient work environment. Disclosures Dr. Tyler currently serves on the ASHP Board of Directors as 2020-2021 ASHP president-elect. The other authors have declared no potential conflicts of interest. Appendix Appendix A—Template for collection of data by direct observation Date: . . Pharmacy: . . Time Observation Began: . . Observed Pharmacist: . . Time Observation Ended: . . Observed Technician: . . . . Observer: . . Task . Source . New Task . Response . Dispensing Phone Covering workflow void Dual‐tasking Covering workflow void Technician Directing workflow Task switching Directing workflow Pharmacist Patient consult Ignoring interrupt Patient consult Patient Inventory management Other Inventory management Personal Personal conversation Personal conversation Other staff Personal phone (text/call) Personal phone (text/call) Professional conversation Vaccination Vaccination Count change Count change Other Other Date: . . Pharmacy: . . Time Observation Began: . . Observed Pharmacist: . . Time Observation Ended: . . Observed Technician: . . . . Observer: . . Task . Source . New Task . Response . Dispensing Phone Covering workflow void Dual‐tasking Covering workflow void Technician Directing workflow Task switching Directing workflow Pharmacist Patient consult Ignoring interrupt Patient consult Patient Inventory management Other Inventory management Personal Personal conversation Personal conversation Other staff Personal phone (text/call) Personal phone (text/call) Professional conversation Vaccination Vaccination Count change Count change Other Other Open in new tab Appendix A—Template for collection of data by direct observation Date: . . Pharmacy: . . Time Observation Began: . . Observed Pharmacist: . . Time Observation Ended: . . Observed Technician: . . . . Observer: . . Task . Source . New Task . Response . Dispensing Phone Covering workflow void Dual‐tasking Covering workflow void Technician Directing workflow Task switching Directing workflow Pharmacist Patient consult Ignoring interrupt Patient consult Patient Inventory management Other Inventory management Personal Personal conversation Personal conversation Other staff Personal phone (text/call) Personal phone (text/call) Professional conversation Vaccination Vaccination Count change Count change Other Other Date: . . Pharmacy: . . Time Observation Began: . . Observed Pharmacist: . . Time Observation Ended: . . Observed Technician: . . . . Observer: . . Task . Source . New Task . Response . Dispensing Phone Covering workflow void Dual‐tasking Covering workflow void Technician Directing workflow Task switching Directing workflow Pharmacist Patient consult Ignoring interrupt Patient consult Patient Inventory management Other Inventory management Personal Personal conversation Personal conversation Other staff Personal phone (text/call) Personal phone (text/call) Professional conversation Vaccination Vaccination Count change Count change Other Other Open in new tab Appendix B—Definitions of observed pharmacist and pharmacy technician tasks Task . Definition . Dispensing Data entry, filling, verifying; normal duties to fill a prescription Covering workflow void Someone is not where he/she is scheduled to be working, or one area is backed up and therefore observed person covers; cashier line is long, so the observed person jumps in to help; technician is in the bathroom, so observed person answers the phone, etc. Directing workflow Directing a technician or pharmacist to do something; observed pharmacist realizes the line is long and therefore stops what he/she is doing to direct a tech to help out Patient consult A patient comes to the counter or calls asking about a medication, etc.; observed pharmacist must stop what he/she is doing to counsel Inventory management Refilling the printer, pulling more medications from stock, refilling or fixing the robot Personal conversation Non–work-related conversation Personal phone (text/call) Non–work-related text or phone call Vaccination Patient vaccination Count change Pharmacist double counting of technician change when taking prescription or other payment Sources of breaks in task Responses Phone, technician, pharmacist, phone, patient, personal, other staff Dual‐Task Resume both initial and secondary task; answer the phone while dispensing prescription Task‐Switching Switch to new task; stop dispensing a prescription in order to answer phone Ignoring interrupt Continue primary task (dispensing prescription) and ignore answering the phone Task . Definition . Dispensing Data entry, filling, verifying; normal duties to fill a prescription Covering workflow void Someone is not where he/she is scheduled to be working, or one area is backed up and therefore observed person covers; cashier line is long, so the observed person jumps in to help; technician is in the bathroom, so observed person answers the phone, etc. Directing workflow Directing a technician or pharmacist to do something; observed pharmacist realizes the line is long and therefore stops what he/she is doing to direct a tech to help out Patient consult A patient comes to the counter or calls asking about a medication, etc.; observed pharmacist must stop what he/she is doing to counsel Inventory management Refilling the printer, pulling more medications from stock, refilling or fixing the robot Personal conversation Non–work-related conversation Personal phone (text/call) Non–work-related text or phone call Vaccination Patient vaccination Count change Pharmacist double counting of technician change when taking prescription or other payment Sources of breaks in task Responses Phone, technician, pharmacist, phone, patient, personal, other staff Dual‐Task Resume both initial and secondary task; answer the phone while dispensing prescription Task‐Switching Switch to new task; stop dispensing a prescription in order to answer phone Ignoring interrupt Continue primary task (dispensing prescription) and ignore answering the phone Open in new tab Appendix B—Definitions of observed pharmacist and pharmacy technician tasks Task . Definition . Dispensing Data entry, filling, verifying; normal duties to fill a prescription Covering workflow void Someone is not where he/she is scheduled to be working, or one area is backed up and therefore observed person covers; cashier line is long, so the observed person jumps in to help; technician is in the bathroom, so observed person answers the phone, etc. Directing workflow Directing a technician or pharmacist to do something; observed pharmacist realizes the line is long and therefore stops what he/she is doing to direct a tech to help out Patient consult A patient comes to the counter or calls asking about a medication, etc.; observed pharmacist must stop what he/she is doing to counsel Inventory management Refilling the printer, pulling more medications from stock, refilling or fixing the robot Personal conversation Non–work-related conversation Personal phone (text/call) Non–work-related text or phone call Vaccination Patient vaccination Count change Pharmacist double counting of technician change when taking prescription or other payment Sources of breaks in task Responses Phone, technician, pharmacist, phone, patient, personal, other staff Dual‐Task Resume both initial and secondary task; answer the phone while dispensing prescription Task‐Switching Switch to new task; stop dispensing a prescription in order to answer phone Ignoring interrupt Continue primary task (dispensing prescription) and ignore answering the phone Task . Definition . Dispensing Data entry, filling, verifying; normal duties to fill a prescription Covering workflow void Someone is not where he/she is scheduled to be working, or one area is backed up and therefore observed person covers; cashier line is long, so the observed person jumps in to help; technician is in the bathroom, so observed person answers the phone, etc. Directing workflow Directing a technician or pharmacist to do something; observed pharmacist realizes the line is long and therefore stops what he/she is doing to direct a tech to help out Patient consult A patient comes to the counter or calls asking about a medication, etc.; observed pharmacist must stop what he/she is doing to counsel Inventory management Refilling the printer, pulling more medications from stock, refilling or fixing the robot Personal conversation Non–work-related conversation Personal phone (text/call) Non–work-related text or phone call Vaccination Patient vaccination Count change Pharmacist double counting of technician change when taking prescription or other payment Sources of breaks in task Responses Phone, technician, pharmacist, phone, patient, personal, other staff Dual‐Task Resume both initial and secondary task; answer the phone while dispensing prescription Task‐Switching Switch to new task; stop dispensing a prescription in order to answer phone Ignoring interrupt Continue primary task (dispensing prescription) and ignore answering the phone Open in new tab References 1. 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TI - Reduction of phone interruptions post implementation of a central call center in community pharmacies of an academic health system
JF - American Journal of Health-System Pharmacy
DO - 10.1093/ajhp/zxaa363
DA - 2021-01-05
UR - https://www.deepdyve.com/lp/oxford-university-press/reduction-of-phone-interruptions-post-implementation-of-a-central-call-sgCJ01TdMm
SP - 113
EP - 121
VL - 78
IS - 2
DP - DeepDyve
ER -