Mathematicians like to talk about the “Golden Ratio.” It occurs when two numbers, divided by the larger are in the same proportion as the larger is to the smaller. Oh, never mind. You can read about it here later. But the phrase the “golden ratio” came to my mind as there has been talk about the best ratio of pharmacists to technicians in a retail pharmacy lately. The hubbub has been stirred up by a recent move in the Florida legislature to increase the current ratio from 1:3 to 1:6. The bill passed through the House with a crushing 101 to 16 vote. The senate is due to vote on it soon.
I’m a retail pharmacist at heart. I’ve done, and I do, other things. But there is more of the community setting, prescription dispensing, phone ringing, patient counseling blood flowing through my veins than anything else. I’ve worked in pharmacies from California to Connecticut. I’m licensed in 4 New England states. I’ve done independent and chain. I’ve managed, staffed and floated. The point is, I kinda know retail. And strangely, I like it.
But for all this I can’t seem to get all worked up about things like “pharmacist to technician” ratios. To me, like my age, it’s only a number. Read on for a little and let me try to explain.
For those not otherwise familiar with this issue, it has to do with the number of technicians a pharmacist is allowed to supervise at a single time. The thinking is this: 1 pharmacist can only watch and check the work of so many techs. In theory, the number of techs could so outnumber the pharmacist that she/he couldn’t really expect to safely keep up. So, for example, some states limit the ratio to 1:3 (1 pharmacist and no more than 3 technicians). In this case, if the pharmacy needs MORE help, they must hire another pharmacist before hiring any more techs.
However, there is a problem when we start to get all worked up about the ratio rules. How do you determine what, precisely, is the “right” ratio to help ensure patient safety? Is the prescription process handled with greater care when there are 2 technicians helping me, or 3, or 12? If I were to ask you “pick a number – how many techs do you want to be in the store helping you today” what would you say? Do more errors happen when I have 1 tech, 2 techs or 10 techs?
The problem becomes apparent. The ratio isn’t the issue. Ratios by themselves, in fact, are meaningless. They have no intrinsic power to increase or decrease the effectiveness, efficiency or safety of the filling process. And this is why there is no consensus across the country. Each state makes up its own rules. They do so, I suppose, because they like rules and like arguing about rules. But the rules, in this case, mean nothing. And maybe this is why about 30% of the states have no imposed ratio rules at all.
You see, if I’m told I have to fill 500 prescriptions today, and I’m asked “how many techs” I want…my answer is going to vary based on a LOT of different things. I can tell you I want more than 2. I probably don’t need 10. But exactly how many I need is really hard to say…because of the other factors involved.
Anyone who has worked retail pharmacy for a while recognizes that there are other factors than ratios that really determine how safely and effectively the pharmacy department will run. For example:
Tech Quality – How good is the technician at entering prescriptions, managing general patient questions and handling insurance claims? This is huge. Give me two well-trained and capable techs over 4 who lack the appropriate training and experience any day!
Pharmacist Quality – Can I say that? Will I be flooded with hate mail? I don’t think so. Folks, lets face it, not every pharmacist is cut out for retail. Most are not insane enough. It can be (depending on the store and circumstances) overwhelming. You have to be able to multi-task and keep your head about you. You don’t get to sit in a comfortable office. You don’t stroll along the aisles or hide in a basement. You are on the front line. And patient lives are in your hands. You are handling billing issues, patient questions about EVERYTHING under the sun, and making sure Mrs. Smith knows where to put the Canasa suppository.
Store Systems & Policies – 500 scripts filled at Pharmacy A may be a very different thing than 500 scripts filled at Pharmacy B. Layouts are sometimes terribly designed. Software can be outdated and irritating. Certain store policies about “who” is allowed to touch certain Rx bottles, staple the bag, where the pill goes when you find it on the floor…etc., can be designed to cripple the process of filling prescriptions. These have nothing to do with state laws. They are simply “rules” which may or may not have a BIG impact of the filling process and safety.
Prescription/Staffing Metrics - Maybe most significant for a safe and effective prescription filling process are the staffing policies of the pharmacy. Most major pharmacy retail chains determine staffing based upon prescription volume. You get “so many” pharmacist hours and “so many” technician hours per “so many” prescriptions per week. These ratios are FAR more significant, in my opinion, than simple R.Ph to Tech ratios dictated by the state.
Customer & Prescription Characteristics – Patients in certain areas may (rightly so) need more time from their pharmacist. If your pharmacy sees a lot of hospital discharges, you may need to spend more time with patients. If you are right across the street from a pain clinic and fill 100 Schedule II prescriptions a day, you will need more time for each one. If you do more compounding, that will take longer.
AN ALTERNATIVE THOUGHT
Rather than getting all worked up about ratios, I think our energy would be better spent making sure our help is well trained, that our systems are conducive to an efficient process and that we are documenting issues that are contributing to unsafe conditions.
But even more importantly, pharmacists and technicians will have a far greater influence on safety when we begin to take more control of our careers. We do this when we begin to truly practice pharmaceutical care and our patients come to expect and seek out our services and advice. There are many ways to do this. There are many opportunities before us. I just can’t get all caught up in the Golden Ratio rigmarole. It’s just a number, and it’s not made of gold. We can debate it until the cows come home, but we’ll never arrive at perfection. As René Descartes once said “perfect numbers like perfect men are very rare.”
Oh, and in case my opening line about the Golden Ratio has made you curious, you might enjoy the following book: