Size matters—but not for clinical services

Though larger hospitals reported better efficiency

Further proof of the importance of clinical services to hospital pharmacist care comes in research from the University of Illinois that found that clinical services remain essentially the same no matter how big a hospital is, even when there are differences based on hospital size on a number of workload and productivity measures.

The research has implications for staff recruiting and retention because the results offer an understanding of the quality of care provided in smaller hospitals. While there has been a common assumption among pharmacists that larger hospitals are a more attractive place to work because they provide a greater variety of clinical pharmacy services, this research shows that smaller hospitals dedicate a proportionately equal amount of time and provide the same types of clinical services as do larger hospitals.

One goal of the study was to come up with comparative statistics pharmacy administrators could use to look at their hospital's efficiency when compared to other facilities of similar size. Another goal was to provide data policymakers could use in better determining staffing and resource needs.

Lead researcher Glen Schumock, PharmD, MBA, FCCP, director of the University of Illinois at Chicago's Center for Pharmacoeconomic Research, says little is known about how hospitals, which the American Hospital Association says range from six beds to more than 2,000 beds, differ with respect to pharmacy efficiency or scope of services by hospital size. The data were collected from a 50-item web-based survey sent to pharmacy directors at Consorta, Inc., member hospitals, a group purchasing organization that at the time comprised 60% of the nonprofit Catholic hospitals in the United States. Responses were received from 110 (45.5%) of the 242 surveyed organizations.

Schumock divided the respondents this way: Hospitals with fewer than 100 staffed beds were placed in the small hospital group, those with 100-300 staffed beds were considered medium hospitals, and those with more than 300 beds were placed in the large hospital category. The analysis covered 31 small hospitals, 48 medium hospitals, and 31 large hospitals.

Respondents were asked to give the number of budgeted full-time equivalents (FTEs) for various positions within the pharmacy. Just about every hospital showed a budgeted position for a pharmacy director. Positions of clinical coordinator were related to hospital size. The number of FTEs considered clinical pharmacists was significantly smaller in small hospitals than in medium and large hospitals. But the difference between medium and large hospitals was not statistically significant. Schumock says this trend was not observed for the number of staff pharmacists, which was significantly different for all three groups, as were the numbers of FTEs in the positions of pharmacy buyer, technician, and secretary or administrative assistant.

Productive and paid hours weekly

Respondents were asked to report the total number of productive and paid hours per week for the entire pharmacy department. The three groups differed significantly for both values. Compared with small hospitals, medium hospitals had approximately four times more productive hours and large hospitals had approximately nine times more productive hours. For paid hours, medium hospitals had approximately four times more than small hospitals, and large hospitals had approximately eight times more than small hospitals.

Total staff time was also categorized by type of activity (drug dispensing, clinical, managerial, and other). There were significant differences in the allocation of staff time for drug-dispensing activities between small hospitals and medium and large hospitals (but not between medium and large).

Interestingly, the three groups did not differ significantly in the percentage of time allotted for clinical activities.

However, time spent on managerial activities was significantly different, with small hospitals spending the most time on managerial activities in contrast to medium and large hospitals. The remainder of staff time dedicated to all other activities was similar among the groups and included billing, secretarial and administrative assistant, and quality assurance activities among others.

Pharmacy dispensing workload was measured by the sum of the total doses administered, processed, billed, or dispensed per year. There was a significant difference among the three groups for number of doses.

Inpatient working hours

Schumock asked respondents about the total weekly hours of operation of the inpatient pharmacy and reports those hours of operation differed significantly among all three groups. The larger the hospital, he says, the more time the pharmacy is in operation.

Participants were given a list of common clinical pharmacy services and were asked to indicate which services their facility provided and to identify any other clinical services not listed.

There were no significant differences among the three groups in terms of the percentage of hospitals providing a specific service except for drug therapy monitoring, IV to PO switch programs, in-service education, and rounds with physicians

Pharmacy workload and productivity were assessed for each group of hospitals by a series of calculated ratios. Small and large hospitals differed significantly with respect to number of FTEs per 1,000 patient days and FTEs per 100 occupied beds. Small hospitals also differed significantly from medium and large hospitals with respect to number of FTEs per 1,000 adjusted patient days and FTEs per 1,000 pharmacy adjusted patient days

All three groups were significantly different in terms of the number of FTEs per 1,000 case-mix index (CMI)-adjusted patient days, while there were no significant differences among the groups in the ratios of FTEs per 1,000 doses dispensed per year, FTEs per 1,000 admissions, and productive hours per paid hours.

Calculated ratios for each size group

Pharmacy and hospital cost efficiencies were assessed for each hospital size group through a series of calculated ratios. There were no significant differences among the groups for any of the calculated ratios; however, there were noticeable trends within the ratios for each hospital size.

Generally, costs and hospital size are inversely related. Schumock says this was most evident for pharmacy personnel expenditures per occupied bed and per admission, pharmaceutical expenditures per admission, total pharmacy expenditures per admission, and total hospital expenditures per admission.

A direct relationship between costs and hospital size was observed for pharmaceutical expenditures per occupied bed and total hospital expenditures per occupied bed. Total pharmacy expenditures per occupied bed decreased between small and medium hospitals ($30,080.23 and $28,056.68, respectively) and increased between medium and large hospitals ($30,726.83).

Schumock says he expected that many of the variables the researchers asked about would differ based on hospital size. But they found it interesting and potentially significant, he says, that small hospitals appeared to dedicate a proportionately equal amount of effort to clinical activities as do medium and large hospitals, with the overall percentage of staff time being the same for all three groups.

Further, they say, the scope of clinical activities provided in small hospitals was not greatly different from that provided by medium or large hospitals, with just a few services being provided more often in larger hospitals.

Larger facilities more efficient

The data do show, however, that as the size of the hospital increases, pharmacy departments become more efficient. In terms of productivity, larger hospitals had fewer FTEs per 1,000 adjusted patient days, fewer FTEs per 1,000 pharmacy adjusted patient days, and fewer FTEs per 1,000 CMI-adjusted patient days. Larger hospitals also had lower values for FTEs per 1,000 patient days and FTEs per 100 occupied beds.

These findings are not particularly surprising, according to Schumock and his colleagues, and are supported by data from the 2005 ASHP national survey of pharmacy practice in hospital settings.

In terms of costs, pharmacy and hospital expenditures per occupied bed and per admission generally decrease as hospital size increases.

One would expect that there are certain economies of scale with respect to staffing and costs that occur when the volume of work and patient population increase, the researchers say.