Effective Communications With

1
Effective Communications With The C-Suite
A Financial Dialogue
2
Program Objectives

• A brief overview of the make-up and key
  attributes of the C-Suite
• Describes the current priorities for the C-Suite
  in order to understand them as an audience
• Outlines an approach to the C-Suite including
  speaking their language
• Uses a case discussion to address a C-Suite issue

3
C-Suite Composition
Data on File. Baxter Healthcare from CEO
interviews conducted and PCAB Surveys.
4
Global Healthcare Trends

• 2008 Health Costs Projected 2.4 trillion and
  growing
• US population is ageing
• Increase in multiple chronic illnesses and
  ability to treat them
• Increasing medication use
• Healthcare reform
• Access to care
• Cost of care
• Comparative Effectiveness
• Shared information
• Unfunded mandates

Source Centers for Medicare and Medicaid
Services1
5
Impact of Current National Economic Crisis on
Hospital Finances

• Hospital operating margins continue to be
  bombarded
• Reductions in elective healthcare spending
• Increasing interest rates on variable-rate debt
• Increasing bad debt associated with unemployment
  and lost healthcare benefits
• Steadily increasing supply costs
• Debt markets are stressed
• Cash reserves are stretched making the bond
  market unattractive
• Reductions in charitable donations
• Reductions in investment income
• Impact of Healthcare Reform on financial margin
• Unfunded mandates (USP797, REMS, etc.)
• Required quality reporting
• Required informatics development
• CMS rules

AHA. (March 2009). Rapid Response Survey, The
Economic Crisis Ongoing Monitoring of Impact on
Hospitals.
6
Hospital Margins

• Percent of Hospitals with a Negative Total
  Margin, 2009 Calendar Year to Date Versus Same
  Period Last Year

Percent
Negative total margin experienced in 1Q 08
Negative total margin expected for 1Q 09
Source AHA (March 2009) Rapid Response Survey.
The Economic Crisis. Ongoing Monitoring of Impact
on Hospitals.
7
Top 5 Priorities of Healthcare CEOs
Priority Percent Selected
Quality/Patient Safety 69
Physician Recruitment/Retention 43
Reimbursement 29
Consumer Satisfaction 25
Construction/Capital Improvements 25
What are the opportunities for pharmacy? Should
we be proactive or reactive?
Adapted from HealthLeaders Media Industry Survey
2009. HealthLeaders Media survey.. Available
at http//www.healthleadersmedia.com/pdf/
survey_project/2008-2009/CEO_final.pdf. Accessed
July 10, 2009.
8
9 in 10 HospitalsHave Made Cutbacks
Percent of Hospitals Making Changes in Response
to Economic Concerns since September 2008
AHA. (March 2009). Rapid Response Survey, The
Economic Crisis Ongoing Monitoring of Impact on
Hospitals.
9
Healthcares Perfect Storm
We need a balance of better safety, quality of
care, and financial responsibility. Pharmacy is
ESSENTIAL
10
How is Pharmacy Seen by the C-Suite

• Ancillary support service
• Drug cost focus
• Clinical impact undervalued
• Managed as a commodity
• Isolated from strategic decision making
• Unaware of the opportunities in pharmacy

11
Example of Pharmacy Cost Mix
Pharmacy is different from other cost
centers, so we need to educate as to why this
isnt bad.
Data on file. Clarian Health Partners.
12
Communicating Pharmacy Issues to the C-Suite

• To establish the pharmacy as a positive
  contributor to the challenges
• To create the perception that the pharmacy is
  material to the organizations efforts in terms
  of
• Financial management
• Patient safety
• Clinical care
• Regulatory compliance

13
You are the Most Qualified Personto Relay this
Information

• Pharmacy is the leader in medication safety
• COO Pharmacy is the only position that fully
  understands both the clinical and financial
  aspect of the healthcare business.
• Leverage expert stature/training
• Have implemented / areimplementing system-wide
  medication safety initiatives
• Valued and trusted member of institution

Lacaria K, Balen RM, Frighetto L, Lau TTY,
Naumann TL, Jewesson PJ. Perceptions of the
Professional Pharmacy Services in a Major
Canadian Hospital A Comparison of Stakeholder
Groups. Longwoods Review. 20042(1). Nurses
Shine, Bankers Slump in Ethics Rating, Press
Release from the 2008 Gallup Honesty and Ethics
Poll, Available at http//www.gallup.com/poll/112
264/Nurses-Shine-While-Bankers-Slump-Ethics-Rating
s.aspx. Accessed on June 11, 2009.
14
C-Suite Expectations for Pharmacy

• Manage drug use and cost by controlling
  prescribers
• Distribution of products and information across
  all points of care utilizing emerging technology
• Clear and defined role for pharmacy expertise to
  be available at the point of care
• Redefinition of the basic systems and services to
  meet the changing organizational model
• Creative and innovative solutions that align with
  organizational goals and direction
• Balancing act that requires collaboration and
  new skills

15
Six Key Questions From the C-Suite

1. Are we buying drugs at the best possible
   advantage?
2. Are sound business principles and practices being
   applied to all pharmacy operations? (i.e., Is
   the pharmacy business being approached as the
   large business enterprise it has become?)
3. Are patient billing and revenue processes for
   pharmacy sound and routinely monitored?
4. Are pharmacy resources, including drugs, supplies
   and manpower, properly controlled and managed?
5. Are patient outcomes and medication safety
   concerns properly balanced with financial
   considerations in the pharmacy department?
6. Are all pharmacy entrepreneurial opportunities
   identified, explored, and pursued when
   appropriate?

16
Value of Clinical Services
In one study, decline in ADE for ICU patients
with clinical pharmacists on rounds(Preventable
ADEs per 1,000 patient days)
66 decline
Baseline
9-Month Follow-up
Source. Leape LL et al. JAMA 1999282267-270
17
Clinical Pharmacist Impact
Source Boyko et al. Am J Health-Syst Pharm.
1997541591-1595.
18
On the Same Page . Speaking the
Same Language.

• COO, CFO, CEO Comments
• If you dont report, do you really care?
• If you provide information that wasnt
  requested, it can make a big impression.
• What do they read ?
• What can pharmacy provide ?
• What keeps them up at night ?
• Can pharmacy insight allay their fears?
• What do they need ?
• We probably have the right prescription for their
  diagnosis !

19
Have A Good Measurement System

• Accurately Measure Current Status of Performance
  (where are we at now)
• Measurement System Provides the breakdown of
  Opportunities (what do we need to do to hit
  target)
• Able to explain variations (is the change due to
  volume, intensity LOS, price increase

20
Dashboards are Expected

• Definition A visual method for displaying and
  sharing Key Performance Indicators (KPI).
• Application
• Usually 4 10 KPIs with thresholds, targets, and
  alarms
• Identify trends
• Cost and workload ratios (drug cost / Pt D FTEs
  per AdjPD)
• Performance (response time patient wait times)

21
Flex Budget

• Definition
• A budget that adjusts or flexes for changes in
  the volume of activity, usually associated with
  admissions or adjusted patient days. A static
  budget remains at one amount regardless of the
  volume of activity.
• Application
• Hospitals will often provide a flex budget and a
  static budget comparison (variance) as a method
  to explain actual financial performance on the
  monthly operating statement.
• Variance helps explain staffing and workload
  trends, and the use of overtime.

22
Adjusted Patient Day (AdjPD)

• Definition
• The AHA formula is Total Hospital Revenue
• 
  Inpatient Revenue
• A Metric used to normalize data and account for
  all services provided from the hospital by using
  IP Day
• Application
• AdjPD is used as a denominator for staffing or
  flex budget ratios.
• Caution
• For high OP volume institutions, the ratio is
  highly skewed.
• AHA reports national average as 1.35 (Moffitt
  Cancer Center is 3.42)
• OP volume is usually subject to greater
  fluctuation than the IP volume. It is difficult
  for disproportionately high OP volumes to compare
  data to national surveys.

23
Case Mix Index (CMI) My Patients are Sicker
Than Your Patients !

• Definition
• Ave RW / Pt Sum of RWs for all Providers
• Number of Patients
• Relative Weight is usually defined by patient
  cost, and is a relative indicator for average
  patient acuity based on level of service provided
  to your patients vs. national average for a
  specific DRG. CMS posts average CMI for each
  DRG.
• Application
• Determine if higher patient acuity is causing an
  increase in Cost / PtD, or Drug Units / PtD
  compared to historical levels, or national
  benchmarks.
• Compare specialty hospitals to general hospitals
  for a specific DRG. (Moffitt Cancer Center CMI
  2.17)
• Assess the need for staffing level adjustments
  assuming higher average acuity justifies more
  resources.

24
Variance

• Definition The difference between actual and
  anticipated numbers.
• Application
• Identify economic trends by comparing actual cost
  or revenue to budgeted or flexed budget.
• Required reports for variance gt 5 is common.
• Caution
• Be sure to compare the current metric with the
  YTD average, and the same month the previous
  year.
• Determine if Accounting Dept engaged in an
  accrual process where money was shifted to a
  different month. Pharmacy may own the numbers,
  but other people touch them.

25
Days in A/R(How Long we Wait for our Money)

• Definition
• Total Accounts
  Receivable Balance
• Average daily
  billings
• Application
• A standard metric that many hospitals use to
  assess the effectiveness of their patient
  accounting programs to collect billed revenue.
• Ideally, most hospitals try to keep A/R Days gt
  60, and keep Operating Cash On Hand greater than
  A/R Days.

26
Operating Days Cash On Hand (COH)

• Definition
• Total Liquid
  Assets
• Ave. Daily Operating
  Costs
• Application
• Gauge the operating capital available, and if the
  institution must borrow money.

27
Gross Charges and Revenueaka Top Line

• Definition
• Full dollar amount of all goods and services
  billed to patients.
• Patient charges are determined by a formula that
  must be consistently applied across all like
  charges.
• The charges are listed in a service or charge
  master file.
• Application
• Shows the amount of patient charges at full list
  price before any discounts or adjustments are
  applied.
• Caution
• If the billing formula is changed, the Cost to
  Charge Ratio (CCR) will also change and affect
  historical comparisons.

28
Net Revenueaka Adjusted Revenue

• Definition
• (gross charges) (contractual adjustments
  discounts) net revenue
• The amount the organization expects to collect.
• Application
• Pharmacy varies by service element.
• Retail we expect 100 of contracted gross revenue
• Outpatients 50 - 70 of gross charges
• Inpatients 25 - 35 of gross charges.
• Caution
• Hospitals may apply an average hospital
  collection rate to the pharmacy.
• If you have access to pharmacy specific
  collection, through a detailed collection report,
  it should be used.

29
Write-OffsBad Debts and Contractual Allowance

• Definition
• What the hospital expected to collect, but was
  unsuccessful.
• Bad debt where the payer defaults and may be
  turned over to collection agencies
• The amount anticipated, minus what the hospital
  accepted, following non-contractual negotiation
  with the payer.
• Application
• Important that write-offs for high cost drugs do
  not occur without pharmacy consultation. This is
  a good opportunity to identify candidates for
  Patient Assistance Programs (safety nets).
• It is possible to work with the Managed Care
  Director to develop outlier provisions in payer
  contracts.

30
Cost to Charge Ratio (CCR)

• Definition Direct Cost
• Billed Charges
• Applications
• Monitor the relationship between gross revenue
  and direct costs to determine if mark up
  formula requires adjustment.
• A low CCR can be caused by excessive charges or
  lower costs. The lower the CCR, the larger the
  profit margin. Used by payers as a comparative
  benchmark between organizations.
• A benchmarking source is the Am. Hosp. Directory
  www.ahd.com
• Caution
• CCR refers to gross charges, so it doesnt
  reflect net margin.
• Changes in markup formulas can alter this ratio,
  and should be factored into historical
  comparisons.

• Cost () Charge () Ratio
  Margin ()
• 100 0.40
  60
• 55 100 0.55
  45

31
Direct vs Non-Direct Cost

• Definition
• Direct costs have a high statistical correlation
  to a specific charge (eg. drug acquisition cost)
• Indirect costs are proportionately averaged
  across all charges (eg. utilities, management
  costs)
• Application
• Justify total cost to deliver a specific drug,
  and provide arguments for appropriate
  reimbursement. (eg. ASP 4 will not cover real
  costs of doing business)
• Caution
• There is disagreement over direct vs. indirect
  costs for drug prep, drug administration, and
  monitoring.

32
Payer Mix

• Definition Breakdown of each payer category by
  of business volume and contracted (anticipated)
  collection rate.
• Application Determine changes in net revenue
  based on a change in the payer mix volume, or
  contractual agreement. Adjust budget
  accordingly.
• Payer Mix categories for IP and OP are
• Medicare
• Medicare HMO
• Medicaid
• Medicaid HMO
• HMO/PPO
• Commercial
• Self Pay

33
Medicare Cost ReportWhy Billed Revenue is
Important Under DRGs

• Definition
• Large financial report that a hospital provides
  to Medicare on an annual basis. The report
  contains data on total gross charges, gross and
  net revenues, expenses, patient visits, and payer
  mix.
• The report is broken down by service.
• Application
• Used for a variety of financial functions such as
  establishing the DSH Adjustment Percentage,
  Residency Reimbursement Rate, CMS DRG modifier,
  and CMS Regional Wage and Salary modifier.

34
Drug Inventory Turns

• Definition
• (Total Annual Purchases) (Change
  in Inventory Value)
• Current
  Inventory Value
• Application
• Used to measure how long an average item sits on
  the shelf. Inventory is a significant
  investment, and can result in lost investment
  interest, or the need to borrow operating cash if
  not optimally managed.
• The national average is generally reported as 12
  15 turns for general hospitals, and 20 22 for
  specialty hospitals.
• Caution
• Excessively high inventory turns might indicate
  that too much labor is consumed, or there are
  high rates of stock outage that result in short
  purchases off contract, and at a higher rate.

35
Drug Dose vs Billing Dose

• Definition
• CMS defines the billing dose for HCPCS coded
  drugs, which is the dose that must be used for
  billing.
• Application
• Ondansetron is billed at 1mg increments,
  therefore a 12 mg dose appears as 12 doses on a
  dose volume report.
• Clotting factors are billed in 1u increments, and
  Tx doses can be 100,000s.
• This can significantly affect workload data.

36
Full Time Equivalent (FTE)

• Definition by Government Accountability Office
  (GAO)
• The number of total hours worked divided by the
  maximum number of compensable hours in a work
  year as defined by law.
• If the work year is defined as 2,080 hours, then
  one worker occupying a paid full time job 1.0
  FTE. An employee working for 1,040 hours would
  be 0.5 FTE.
• Application
• Used by hospitals to budget and monitor staffing
  levels.
• Caution
• Does not consider overtime and incentive plans
  (pool hours), so the monthly FTE report might
  understate the actual workload. This could
  affect productivity reports, or justification for
  additional support.

37
Relative Value Unit (RVU)

• Definition
• The average direct and indirect resource cost to
  provide a service, measured in time or money.
• Application
• Measures resources required in productivity
  analysis.
• If the average time to produce and dispense a
  single IVPB solution is 3 minutes, then one
  man-hour is required per 20 IVPBs.
• If the average total labor cost required for
  pharmacy to manage an SCU patient throughout a 24
  hour day is 90, then 20 SCU patients per day
  will require 1,800 in pharmacy salary expense.

38
Fixed vs Variable Work

• Definition
• Variable work is directly correlated with a base
  unit that fluctuates, such as patient days or
  admissions.
• Fixed work is required regardless of the patient
  volume, such as IV hood maintenance, teaching
  students, and attending meetings.
• Application
• Determine the total amount of work required for
  the entire workforce. This will determine the
  total number of FTEs that are required.

39
Flaws With Traditional Metrics

• Percentage of Net Revenue Revenue (contracts,
  Net reimbursements, etc) is beyond control of MM,
  as are the regional differences in reimbursement.

Avg 2007 Medicare Reimb by region for MSDRG 470
40
CMI Normalization Doesnt Work
MS-DRG Description 2009 Case Weight National Avg Supply Cost
484 Major Joint Limb Reattachment Procedures of Upper Extremity without CC/MCC 1.744 5,929
199 Pneumothorax w MCC 1.744 1,457

36 Carotid Artery Stent Px w/o CC/MCC 1.57 5,027
58 Multiple Sclerosis Cerebellar Ataxia w MCC 1.57 1,266
Same case weight different supply cost!
40
41
Revenue and Margins

• Gross Revenue Per
• Patient Day
• Variables Include Acuity and Therapy Innovation
• Adjusted Pt D
• Better denominator than IP day
• Separate OP visits if OP business is very large
• Admission
• AdjPD and CMI is essential
• Product Line
• Determine Ave CMI for each product line

42
Alternative Financial ActivitiesWhere Are They
Reported?

• Patient Assistance Programs
• Document as Write-off avoidance with impact on
  Drug Expense
• Co-Pay Collection
• Impact on OP Revenue
• Investigational Drug Service
• Direct Revenue
• Drug Cost Offset using Commercial drug
  equivalent cost
• Impact of Alternative Revenue / FTE
• Separate productivity monitor for these employees

43
Projecting Drug Use and Cost What is the
emerging New World Order ?

• Current Model
• Physician choice / experience
• Population studies / generalized outcomes
• Payer formularies
• Future Model
• Evidence based treatment guidelines and compendia
• Genomic based personalized therapy
• Drivers
• Clinical and Informatics technology
• Economic demands from purchasers
• Health Capital is real and must be measured and
  supported
• Flat world economics
• International supply / trials competition
• Tele-medicine and international therapy
  vacations
• Future drug cost, and drug reimbursement will be
  determined based on value more than it is today.
  
• Who defines value ?
• Does it include outcomes ?

44
Data Tools and ResourcesHospital Information
Systems

• Data Mining Tools
• Pharmacy, Hospital, Lab, Billing Systems
• E-MAR (Power Chart) and Reports (Power Vision)
• Integrated system (Pandora, Pyxis Connect)
• Peripheral system (Sentry, billing system
• Financial database
• Payer mix
• Contractual discount rate
• Primary billed diagnosis
• Drug usage
• Patient database
• Census
• Adjusted Patient Days
• CMI
• Payer Mix

45
Data Tools and ResourcesHospital Information
Systems

• Financial database
• Payer mix
• Contractual discount rate
• Primary billed diagnosis
• Drug usage
• Patient database
• Census
• Adjusted Patient Days
• CMI
• Payer Mix

46
GPO and Wholesale Database

• Purchasing history by
• Account
• Product line
• Web base access
• Canned and custom report capability
• Multiple business metrics can be designed
• External regional or national comparison
• Internal comparison

47
Pitfalls to Avoid

• Failure to establish clear accountability,
  structure, and leadership for pharmacy as a
  unique business and clinical department
• Adopting standard benchmarks and shrinking to
  greatness cost monitors/cost cutting strategies
  without considering pharmacy scope of services,
  patient types and related drug costs
• Failure to recognize the ongoing communication
  with the C suite is essential to maintain an
  understanding of pharmacys role and
  responsibilities

48
Pitfalls to Avoid

• Over commitment of resources to technology
  advances and projects without adequate planning
  support
• Failure to assure the basics of pharmacy
  dispensing and distribution are done well as
  pharmacy expands into clinical and other areas
  and programs
• Establishing clinical initiatives and cost
  controls within the pharmacy team without
  building adequate credibility and support with
  medical staff

49
Conclusion

• Take time to understand C-Suite needs and
  expectations
• Create maximum pharmacy value
• Be cognizant of and work to continuously improve
  your pharmacy
• Be able to effectively answer the 6 key questions

50
Always be Prepared

• In preparing for battle, I have always
• found that plans are useless, but
• planning is essential.
• Gen. Dwight D Eisenhower

51
Health - Econ Sources

• www.managedcaredigest.com
• www.modernhealthcare.com
• www.cms.gov/statistics/nhe (Nat. Healthcare
  Economy)
• www.bis.gov (U.S. Bureau of Labor Statistics)
• www.bea.gov (Bureau of Economic Analysis)
• www.aha.org (American Hospital Association)
• www.citigroup.com (Private Sector)
• www.imshealth.com (National Drug Sales)

52
Example of Approach to CEO Based on Their 1
PrioritySupporting your Decision
53
Safety Remains a Major Problem
1. Institute of Medicine To Err Is Human
Building a Safer Health System. Available at
http//www.iom.edu/Object.File/Master/4/117/ToErr
-8pager.pdf. Accessed July 14, 2009. 2. Institute
for Healthcare Improvement. Available at
http//www.ihi.org/IHI/Programs/Campaign/Campaign.
htm?TabId6. Accessed July 14,
2009. 3. HealthGrades. Available at
http//www.healthgrades.com/media/dms/pdf/PatientS
afetyInAmericanHospitalsStudy2009.pdf. Accessed
July 14, 2009.
54
Building Your Case Safety and Parenteral
Medications

• Patient safety is the 1 priority of hospital
  CEOs, yet medication errors are common
• Errors involving parenteral medications can have
  a major financial impact on hospitals
• Institutions should consider using the most
  ready-to-administer form available to decrease
  medication errors related to compounding

55
5 Parenteral Drug Delivery Systems

• Pharmacy compounded
• Non-pharmacy compounded at point of care
• Outsourced ready to use
• Manufacturer point of care activated
• Manufacturer ready to use

56
Parenteral Drug Delivery SystemsSafety Summit
Ranking
Product Type Applicability Ease of use Regulatory compliance Cost Safety Implementation TOTAL
Pharmacy compounded 6.7 3.7 3.5 3.8 4.2 3.6 25.5
Non-pharmacy compounded at point of care 5.8 3.6 1.8 4.9 1.8 2.6 20.5
Outsourced ready to use 5.4 5.5 5.2 3.4 4.5 4.9 28.9
Manufacturer point-of-care activated 3.6 4.9 6.0 4.1 4.6 4.7 27.9
Manufacturer ready to use 4.0 6.2 6.5 4.0 6.0 6.0 32.7
Based on a 7-point Likert scale
Adapted from Sanborn MD, et al. Second Consensus
Development Conference on the Safety of
Intravenous Drug Delivery Systems2008. Am J
Health-Syst Pharm. 200966185-192.
57
Ready-to-use Products are Recommended by

• The Joint Commission

To reduce compounding and labeling errors, the
hospital uses only oral unit dose products,
pre-filled syringes, or pre-mixed infusion bags
when these types of products are available.
The Joint Commission Accreditation Program
Hospital. National Patient Safety Goals. The
Joint Commission Web site. Available at
http//www.jointcommission.org/NR/rdonlyres/31666E
86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf.
Accessed July 10, 2009.
58
Ready-to-use Products are Recommended by

• A 2008 multidisciplinary panel representing
  medicine, nursing, pharmacy, and governmental and
  patient safety organizations

Dispense IV medications and admixtures in
ready-to-administer form.
ASHP. Proceedings of a summit on preventing
patient harm and death from i.v. medication
errors. Am J Health-Syst Pharm. 20086523672379.
59
Hospitals That Provide The Best Quality Also
Fare Better Financially
Outcome Top 100 Hospitals Peer Hospitals Difference
Patient-Safety Index 0.85 0.99 14.1
Average Length of Stay 4.93 d 5.48 10.3
Expense per Adjusted Discharge 4,775 5,503 13.2
Top 100 Hospitals National Benchmarks for
Success by Thomson Healthcare
Wilson L. Modern Healthcare. 20083826,28-30
60
A Major National Survey The C-Suite GetsHow Do
You Compare? How Do You Respond?(75th
Community Group, 75th University Group)
Case 1 Response to National Survey / Data
Base

• Staffing Measures
• RPh per 100 beds (9.6, 13.1)
• Non-pharmacists per 100 beds (10.5, 11.6)
• Administrative staff per 100 beds (1.1, 1.4)
• Ambulatory Services
• Prescriptions per budgeted manhour (3.9, 4.4)
• Drug cost per prescription (56.80, 64.70)

61
A Major National Survey How Do You Compare? How
Do You Respond?(75th Community Group, 75th
University Group)

• Cost Measures
• Salary cost per FTE (74,000, 71,000)
• Salary cost per admission (273, 377)
• Doses per patient day (30, 28)
• Drug cost per dose (4.63, 7.47)
• Drug cost per admission (615, 963)
• Drug cost per patient day (124, 154)
• Inventory turns annually (14.5, 14.0)
• Pharmacy total cost per admission (1182, 2291)
• Hospital total cost per admission (21,159,
  30,382)
• Pharmacy cost as a of hospital cost (6.4, 8.2)

62
Case 2 Drug Cost Alarm

• Drug costs are rising at your institution when
  compared to the previous year average (up 8),
  and the same month the previous year (up 9).
• Is this good or bad ?
• What are the first metrics that you will evaluate
  to provide your COO and CFO with an explanation
  and possible strategy?

63
Case 3 Staffing Ratio Tanks

• Your FTE / Admission ratio has increased and your
  boss asks for a detailed explanation and
  recommendations for corrections.
• What metrics to you use to determine if your
  current staffing levels are appropriate?
• What are some ways you could change the metric to
  give a more realistic monitor for the future?

64
Case 4 Reported Medication Errors are Rising

• The documented medication errors are rising
  rapidly, and you just hired 2 new pharmacists.
  Your boss is concerned that your new hires are
  incompetent.
• What are the likely explanations?
• What metrics can you use to prove this might be a
  good thing?