(Management Case Study) Sharp Objectives — Planning for Successful Sterile Compounding Renovations via a Centralized Dispensing Model

Purpose: Sterile compounding renovation planning is a complex process that requires focused effort, strategic considerations, and continued process improvement efforts. The purpose of this case study is to describe the methods utilized by a multi-hospital system to provide minimal disruption in the provision of patient medications while ensuring sterile compounding compliance, optimizing workflow and leveraging current staff amid a technician shortage, to maximize productivity.

Methods: A workgroup consisting of pharmacy operations leadership, pharmacy procurement, pharmacy informatics and dedicated sterile compounding pharmacists was developed to include representation from multiple affected facilities. Assessment strategies included review of historical usage data per facility, determination of consistent batch print/fill times based upon patient population/physician practice and valuation of qualified staff. Product batch compounding records were standardized to a single electronic documentation platform and inventory levels were established. A shared electronic health record allowed batches for the renovation facility to print at the site designated as the “central fill” location. Courier services were set for specific times each day to accommodate for preparation/verification time for the products and allowed ample buffer for delivery between facilities.

Results: Implementation of centralized sterile services occurred several months prior to the start of the sterile renovation project to allow for optimization of processes. The renovation facility standardized batch fill qualify times to mirror the central fill facility to allow for consistency in practice. Staff at the central fill facility were educated on product differences due to facility practice and automation capacity. Dedicated sterile pharmacists at each facility gradually worked through batch items that should only be prepped at the “home” facility due to hazardous nature, limited stability, or medication inventory. As both facilities are 340b eligible, a reporting system was developed to ensure inventory of medication was appropriately ordered and designated by the dispensing facility. The pharmacy procurement team managed all inventory needs to allow frontline staff to focus on accurate product preparation and verification.

Conclusion: Printing patient specific batch labels at a single facility allowed for centralization of a considerable volume of sterile product needs. Movement of batch product three times daily provided an effective method to accomplish a successful cleanroom downtime and allowed for valuable insight into the journey of development of a centralized sterile compounding services for a multi-site health system.