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

 

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 there are additional actions in addition to the working conditions regulations that can be taken by the Board to improve workplace conditions.   

 

In 2022, members of the NABP Work Group on Workplace Safety, Well-Being, and Working Conditions convened, and issued the following 5 recommendations to support a healthy work environment[1]:

 

1. NABP collaborates with stakeholders to:

1. identify new practice models that support pharmacists’ ability to provide patient care services; and 

b. identify/set meaningful standards for staffing to include but not be limited to:

i. lunch breaks/shift lengths;

ii. well-being;

iii. clinical functions;

iv. use of automation technology; and

v. use of pharmacy technicians.

2. NABP reviews the Model Act to identify model act language that can create barriers to care and suggest edits to submit to the Committee on Law Enforcement/Legislation. 

3. NABP encourages industry stakeholders to amplify current messaging to educate patients about pharmacy operations to manage expectations. 

4. NABP encourages boards of pharmacy to consider pathways to innovation such as automation and central fill, reimagine new delivery models that support pharmacists’ ability to provide patient care services and address staffing shortages. 

5. NABP encourages boards of pharmacy to review and revise regulations to utilize pharmacy technicians to augment the role of the pharmacist and to identify current pharmacist-only duties that could be safely and competently performed by non-pharmacist personnel.

 

While we acknowledge the Board has taken great strides to require pharmacy permit holders to address working conditions, we respectfully ask the Board to examine ways it can improve workplace conditions.

 

Based on feedback we have received from Virginia licensed pharmacists and pharmacy technicians working in our pharmacies, below are five ways the Board can implement changes to provide relief to pharmacies:

1. Elimination of the 4:1 technician ratio
2. Elimination of the 2-year experience requirement to become a PIC
3. Modification of the Board’s current enforcement approach
4. Consider the use of other support/ancillary personnel in the pharmacy
5. Amend remote verification standards

 

1. Elimination of the 4:1 technician ratio
   • Walgreens supports the empowerment of pharmacists to determine what staffing and optimal workflow models meet their patients’ needs given the specific volume and patient care requirements at their pharmacy.
   • However, Walgreens believes that the term “ensure sufficient personnel” is not only ambiguous but may not be possible for PICs and pharmacists on duty to attain, given the current technician-to-pharmacist ratio of 4:1.
   • The current 4:1 technician-to-pharmacist ratio creates a significant barrier to the pharmacists on duty in ensuring sufficient personnel is present in a pharmacy.
   • We believe the Board has ample evidence to move forward with the elimination of the technician ratio in Virginia: 
     • There is no evidence to support any particular ratio, and no reports or studies show that ratios improve patient safety.
     • 24 states and the District of Columbia have opted not to place limits on the number of technicians a pharmacist can oversee.
     • Notably, the Department of Veterans Affairs (VA) has never had a pharmacy technician ratio and there has been no negative impact on patient safety.
     • NABP has consistently reiterated that it does not support technician ratios.
   • Pharmacists should not have to fear regulatory enforcement if they determine the need to use more than four pharmacy technicians.

 

Walgreens recommends an amendment to 110-20-110 that would allow a pharmacist's professional judgment to determine the appropriate amount of pharmacy support.

 

2. Elimination of the 2-year experience requirement to become a PIC.
   • This would allow qualified pharmacists, who may not have the current experience requirement, to become a PIC sooner.
   • Our pharmacists are telling us that the 2-year experience requirement is an unnecessary barrier in identifying qualified candidates, particularly in remote areas.
   • A 2-year requirement does not make an individual qualified to become a PIC.  A PIC candidate with less than 2 years' experience may have previous leadership experience or lengthy experience in other roles that may make them a better candidate.  Two years is an arbitrary number and creates unnecessary hurdles. 
   • By eliminating this requirement, pharmacies can be staffed with the most qualified candidates.   

 

Walgreens recommends that the Board eliminate or reduce the 2-year experience requirement to become a PIC in the state of Virginia.

 

3. Modification of the Board’s current inspection approach 

3. 1. Unannounced annual inspections
      1. Our pharmacies want to be prepared for inspections and be respectful of the time of the inspectors in their pharmacies.
      2. A complete Board inspection can take a considerable amount of the pharmacy staff's time by removing them from workflow to be present during inspections. As a result, this can increase the workload placed on the staff when they return to workflow thereby adding to the stress levels.

 

Walgreens asks the Board to modify its current inspection approach to focus on measures that impact patient safety. This will help reduce any unnecessary and burdensome tasks being placed on pharmacy staff.  Walgreens respectfully requests that if the Board does not want to amend and reduce the intensity of its inspections, an alternative approach could be to provide advance notice of the inspection to allow for the pharmacy an opportunity to provide an additional staff member available to assist the inspector and not remove a pharmacy team member from the workflow.

 

3. Consider the use of other support/ancillary personnel in the pharmacy.

• The minimum requirements to obtain a pharmacy technician registration include completing an accredited training program and obtaining national certification.

• These minimum requirements have led to a shortage of qualified and registered pharmacy technicians in Virginia. 

• There are tasks within the pharmacy department that can be completed by non-registered or individuals with significantly less training, such as inventory tasks. 

• Such an individual can check for outdates, complete pharmacy returns, put up inventory, and other inventory-related functions without being involved directly in the dispensing process. 

• The addition of support/ancillary personnel can help alleviate the non-technical workload of a pharmacist or pharmacy technician, freeing them up to further provide patient care services.

• We applaud the high standards being set in Virginia for pharmacy technicians and the pathway for a career. The downside risk is that the candidate pool is reduced due to the mandatory completion of an accredited program and passing of a national exam.  This leads to applicant openings that cannot be filled resulting in shifts not getting covered in the pharmacy and added stress to pharmacists working without the necessary support. 

 

Walgreens recommends the Board introduce a support/ancillary personnel category that would enable utilization of such persons without significant training and certification barriers. 

 

3. Amend Remote Verification Standards

 

• 37 states allow for remote processing without the need for individual state licensure.  This is an established standard of practice that we believe Virginia pharmacies can benefit from.

• The NABP Model Act does not recommend individual state licensure to provide remote processing services.

• The Board should consider if a prescription error were to occur, what is the likelihood of a revocation or severe disciplinary action for a data entry/DUR error?  If the board utilizes a just culture approach, data entry errors are human errors that should not be treated in a punitive manner.  

• The Board should weigh the risk of accountability for pharmacists vs. the benefit of the support these pharmacists can provide. We believe the benefit in this case far outweighs the minimal risk. 

• Currently, Walgreens provides remote processing services to 37 states which permit pharmacists to provide remote processing services across state lines without in-state licensure requirements if they are performing work for a licensed facility of that state.  Remote processing can alleviate some of the workload for pharmacists.  At this time, Walgreens is unable to support Virginia pharmacies with the use of pharmacist remote processing due to the licensure requirements. 

• The Board could consider using such entities as NABP Verify as an alternative solution if it chooses to hold some level of individual accountability. 

• Walgreens believes that if a pharmacist is duly licensed within the state that they reside in and employed by a licensed Virginia facility, they should be able to perform remote verification work for any Virginia-licensed facility. 

 

Walgreens recommends the following amendments to 18-110-20-276(B)(3) and 18-110-20-276(F) Central or remote processing to include:

B. A pharmacy may outsource certain prescription processing functions as described in subsection A to another pharmacy in Virginia or a registered non-resident pharmacy under the following conditions:

1. The pharmacies shall either have the same owner or have a written contract describing the scope of services to be provided and the responsibilities and accountabilities of each pharmacy in compliance with all federal and state laws and regulations related to the practice of pharmacy;

2. Any central or remote pharmacy shall comply with Virginia law and regulation with respect to requirements for supervision of pharmacy technicians and the duties which are restricted to pharmacists and pharmacy technicians. Pharmacy technicians at the remote pharmacy shall either be registered in Virginia or possess credentials substantially equivalent to those required for a technician registered in Virginia;

3. A pharmacist licensed in Virginia or duly licensed within the state that they reside and employed by a Virginia licensed facility, whether at the remote pharmacy or the dispensing pharmacy, shall perform a check for accuracy on all processing done by the remote processor; and

4. The pharmacies shall share a common electronic file or have technology, which allows sufficient information necessary to process a non-dispensing function.

 

F. Nothing in this section shall prohibit an individual employed by a Virginia licensed facility and licensed as a pharmacist in Virginia or duly licensed within the state that they reside from accessing the employer pharmacy's database from a remote location for the purpose of performing certain prescription processing functions as described in subsection A, provided the pharmacy establishes controls to protect the privacy and security of confidential records.

 

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

 

Sincerely, 

Jeenu Philip, 

Director, Pharmacy Affairs