State BOPs and the politics of pharmacist workloads

Bob StoutFor the past three years, the New Hampshire Board of Pharmacy has been attempting to make changes in the workplace to protect public health and to address the numerous concerns expressed by pharmacists about unsafe practices in many work environments.

In my previous Drug Topics article [“‘Pharmacists, lobby your legislators!’ says BOP insider,” Oct. 1, 2015], I responded to Dennis Miller’s claim that state boards of pharmacy do not have the courage to address pharmacists’ working conditions because the boards are controlled by the major chains. Here’s an update.

See also: State BOPs and public safety

H.B. 141

After having a number of proposed rules rejected by the New Hampshire State Legislature three years ago - they related to lunch breaks, coupons, and adequate staffing based upon required written staffing models, authority challenged by the National Association of Chain Drug Stores (NACDS) and others - the Board of Pharmacy sought statutory changes that would give it broader authority to address various issues through rule-writing and public hearings.

We were able to garner support in the New Hampshire House of Representatives (H.B. 141, sponsored by Rep Peter Schmidt). The bill passed in the House in the spring of 2015 and was sent to the Senate for its approval.

Debate and opposition

During the committee meetings eliciting public comment, there was much debate on the merits of the bill. Speaking in opposition to the bill were NACDS and other corporate representatives.

Even though in and of itself the bill would not change anything and would simply permit the normal rule-making process to occur, representatives of the opposition stated that they were fearful of where the Board of Pharmacy would go with this authority.

Committee status, no testimony

The committee, chaired by Senator Sharon Carson, took the bill to committee status and agreed to revisit the issue at the start of the new legislative session. This occurred in early January 2016. 

At this meeting, while each senator on the committee was allowed to voice his or her opinion of the bill, the audience was not allowed to speak.

Stakeholder study committee, no agreement

The tone had changed since the hearing in May 2015. The committee was against giving the Board of Pharmacy any broad authority. It asked stakeholders to meet in an interim study committee to see whether we could reach any concessions on the issues.

These meetings have been occurring, but I do not believe everyone is negotiating in good faith. We continue to negotiate.

NABP district meeting: “Not board business”

At the fall meeting of Districts 1 and 2 of the National Association of Boards of Pharmacy (NABP) held in September 2015, I presented workflow issues as a topic during the roundtable discussions. 

To say that NABP members were less than supportive would be an understatement. Here I agree with Dennis. Many state boards of pharmacy, I believe, are strongly influenced by the chains and their representatives, and are primarily focused on the business of pharmacy and not on the practice of pharmacy. 

The overall feeling was that boards of pharmacy should not be involved in workload or working conditions, as those issues are business issues better served by the owners, and that the board’s only role is in protecting public health. 

Although I felt these issues were totally related and could not be separated, I was clearly in the minority.

2012 NABP resolution

I was surprised later to find out that in 2012 NABP passed a resolution about workload issues (Resolution 109-7-13, “Performance Metrics and Quotas in the Practice of Pharmacy”).

When I reached out to NABP to obtain any documents or policies that were developed to support this resolution, I was told that nothing had been done, but NABP would support New Hampshire when we developed some on our own.

I believe that Carmen Catizone, NABP’s executive director, is in a tough spot, recognizing these important issues but working with many board members who lobby to look the other way. 

Course correction

Facing these headwinds, we have determined that the best thing for us to do is not to try to work through NABP, but to try here in New Hampshire to accomplish meaningful change. We are working on a number of things.

First, we are seeking a legal opinion on our existing statute and what the Board of Pharmacy can do with the current law in taking steps to protect the public health.

We have been repeatedly struck down by the legislature, but we have not yet been in front of a judge to determine whether we actually do have some existing authority to institute changes.

Second, we have been working with stakeholders to institute a nonpunitive Continuous Quality Improvement program with mandatory reporting of incidents. 

Under our plan, an independent safety officer would review each incident to determine the exact root cause of the error. This would provide very useful information on what steps, if any, the Board of Pharmacy could take to improve public safety through legislation.

Here’s why we are focusing on pharmacy errors.

When we have met with pharmacists to explore what might help in the workplace, we have heard so many conflicting opinions on exactly what might help, such as RPh/tech ratios, prescription limits, staffing requirements, immunization practices, etc., that it is hard to obtain consensus on which avenue to pursue. Having statistical data on the root cause of errors might give great insight into how to proceed.

See also: Why mistakes happen

The challenges today

In summary, when it comes to the task of fighting all the business interests while trying to improve the practice of pharmacy, I believe Dennis’ comments are correct.

I became a pharmacist 40 years ago because I loved the practice of pharmacy. Unfortunately, the practice has been pushed to the back of the bus, while business interests have taken hold of the steering wheel.

Despite their claims of an ever-increasing squeeze on margins, the chains continue to grow store counts and buy other businesses. The areas of practice for which we are trying to get our pharmacists the time to do their jobs properly - immunizations, MTM, disease management - are profitable areas we need to develop.

Pharmacists first

The Board of Pharmacy is not trying to slow the progress of pharmacy, an accusation many chains have made to us in writing.

The Board is trying to get this state’s great and incredibly talented pharmacists the time they must have to truly practice pharmacy and make a difference in people’s lives.

Bob Stoutis the president of the New Hampshire Board of Pharmacy. E-mail him at rjstoutrph@comcast.net.