Why Are We Here?

1. Why Are We Here? John Lowe Associate Chief Consultant PBM

2. Objectives • Discuss findings of internal and external reviews • Review VA’s response and action plan to reviews • Provide training to staff and supervisors on the front line • Establish network of co-workers

3. Internal and External Reviews • Office of Inspector General Combined Assessment Program (OIG CAP) • Government Accountability Office (GAO) • Joint Commission (JC) • System-wide Ongoing Assessment & Review Strategy (SOARS) • Drug Enforcement Agency (DEA)

4. Reviews of Pharmacy Inventory • OIG Audit of Pharmacy Inventory 2000 • OIG Audit OF VA CMOP Inventory Management 2002 • GAO Review of Pharmacy Inventory 2004 • OIG Audit of VA CMOP Inventory Accountability 2009 • OIG Audit of VHA’s Management of Non-Controlled Drugs 2009

5. OIG Audit of Pharmacy Inventory 2000 • Findings (from sample of 4 facilities): • Inventories reduced compared to previous system under supply depot system • Inventories at all 4 centers exceeded 10 day supply • None of the facilities had determined stock levels or reorder points based on use • None of the facilities conducted physical inventories • End of year purchases contributed to excess stock

6. OIG Audit of Pharmacy Inventory 2000 • Recommendations • VHA issue guidance for inventory reduction • VHA monitor progress in reducing inventories • Provide staff training for inventory management • Discourage using end of year funds for large purchases of stock

7. OIG Audit of VA CMOP Inventory Management 2002 • Findings • Supply on hand exceeded benchmarks for 59.9% of items in inventory • CMOP did not effectively monitor stock levels or management item demand • Maintained “cushions” of excess stock • Inventory included items with little or no demand • Estimated $28.8 million in excess inventory

8. OIG Audit of VA CMOP Inventory Management 2002 • Recommendations • Require CMOPs to eliminate excess inventory and use automated information to manage inventory • Improve CMOP automated inventory management and control reports • Develop minimum demand for adding new items • Train CMOP staff on inventory management techniques and use of automation

9. OIG Audit of VA CMOP Inventory Management 2002 • Recommendations • Ensure CMOPs implement internal controls and security requirements for controlled substances • Monitor CMOP progress in reducing inventories and improving inventory control

10. GAO Review of Pharmacy Inventory 2004 • Focused on drugs for return • Findings (6 medical centers): • 5 of 6 did not inventory drugs for return • No analytical review of credits • Returned drugs stored in unsecured open bins in 4 of 6 facilities • VA uses an honor system, relying on contractors • VA not aware of company requirements regarding returns (exp dates, etc) • Pharmacy staff claimed not cost effective to monitor (without data to support claim)

11. GAO Review of Pharmacy Inventory 2004 • VA Response to GAO • Facilities will maintain a list of drugs held for credit (VISTA Patch PSA*3*51) • Non-controlled drugs for return will be secured • Facilities will periodically test to see if credits received is correct • Network PBM will monitor facility returns • Data will be analyzed for trends • National directive will be published

12. OIG Audit of VA CMOP Inventory Accountability 2009 • Findings: • Inadequate wall to wall inventories • Inadequate tracking of dispensing by software • Significant differences between actual and projected on hand inventory • Inadequate control of inventory balance adjustments • Lack of control for drugs held for return • Inadequate separation of duties over critical system functions • Inadequate Econolink system access controls (everyone used same password)

13. OIG Audit of VA CMOP Inventory Accountability 2009 • VHA Response • Wall to wall inventories completed quarterly • Each CMOP Director certified compliance with policy for returned drugs • Developed a statement of work to rewrite software to ensure complete tracking of inventory • Developed management policy to review inventory adjustments monthly • Established procedures to restrict one person from ordering, receiving and adjusting inventory • Generic password for Econolink was disabled

14. OIG Audit of VHA Management of Non-Controlled Drugs 2009 • Findings (Review of 31 facilities): • Drug dispensing not accurately and consistently recorded (transfer and returns to stock) • State home dispensing • Automatic replenishment/ward stock • Label reprint function used inappropriately to dispense drugs • Drugs returned to stock not accurately captured • Lack of policy to monitor high risk non-controlled drugs • Wall to wall inventory data not used to improve accountability

15. OIG Audit of VHA Management of Non-Controlled Drugs 2009 • VHA Response • VHA will identify high risk drugs to monitor • PBM will re-emphasize the importance of tracking all dispensing activity and survey results • PBM will remind staff that drugs that leave pharmacy cannot be returned to stock • Inventory balances must be adjusted for drugs that don’t leave pharmacy and are returned to stock • Access to label reprint will be limited • PBM will develop standardized electronic formats for inventory and hold managers accountable for accuracy

16. SOARS Program • Provide assessment and educational consultation to VA facilities • Support a continuous readiness culture • Help provide quality health services • Assist medical centers with meeting standards of care • Identify and share strong practices

17. SOARS Program • Site visit to each facility every 3 years • ~250 trained SOARS consultants • Training films completed for SPD, Mental Health and Pharmacy • Strong focus on pharmacy and medication management

18. SOARS Trends ReportInventory Related Findings • Based on 136 reviews • Identification, management and security of high cost, look alike-sound alike, high risk and other sensitive drugs (40 sites, 29%) • Pre-labeling, accurate labeling, segregation and security of drugs throughout organization (63 sites, 45%) • Management of controlled substance inventories (13 sites, 9%)

19. Annual Inventory Results

20. In Summary • Inventory management opportunities cited in numerous internal and external reviews • Reviews identified a lack of training for staff involved in inventory management and drug accountability • Need to improve management of dollars involved in inventory as a tax payer funded organization • Reduce opportunity for theft and diversion • Improve services to veterans

21. Questions

22. Welcome! PBM Drug Accountability Conference