Performance Metrics and Perceived Impact on Safety, Errors and Job Satisfaction Among California Community and Outpatient Pharmacists

Performance measures, or metrics, are frequently used in pharmacy settings to ensure that pharmacies are meeting specific outcomes that align with company objectives as well as to evaluate the quality of pharmacies and assess pharmacist care and services provided.^1–3  The Pharmacy Quality Alliance (PQA), a national organization focused on quality to improve medication safety, adherence and appropriate use, created five of the 12 Medicare Part D Star Rating measures.⁴  The Centers for Medicare and Medicaid Services (CMS) uses measures to assess Medicare Part D Star Ratings. Pharmacies can impact prescription drug plans’ overall Star Ratings through pharmacy-based measures such as medication adherence, management of chronic conditions and comprehensive medication reviews.^1,2,5,6  Pharmacies that perform well in key metrics are designated as preferred in-network for drug plans, and some drug plans further incentivize meeting Star Ratings metrics with bonus payments made to top performing pharmacies.¹  Pharmacists working in community and outpatient pharmacy settings may also have company-based metrics where they are encouraged to meet quotas such as patient wait times or prescription filling counts.

Despite the financial incentives for pharmacies, there have been recent reports of the negative impact of pharmacy-based metrics on pharmacists. In a 2020 New York Times article, pharmacists expressed their concerns to state regulatory boards stating they practiced in an environment where they are “racing to meet corporate performance metrics” and putting patient safety at risk.⁷  A 2021 NBC News segment described pharmacists as “health care professionals on the breaking point,” expressing concerns of not having enough resources and fearing fatal errors were made.⁸  Though the pressures of meeting metrics and understaffing in pharmacies are not new, these reports highlight that pharmacists are overworked and overwhelmed, and these conditions have been further exacerbated by the COVID-19 pandemic.⁸ 

Pharmacists’ concerns about errors are valid, as prescription dispensing errors are problematic with an estimated 51.5 million errors occurring annually in the United States.⁹  Specific to the community pharmacy setting, one systematic review concluded the overall dispensing error rate estimated at 0.015 with a range of 0.00003% to 55%.¹⁰  In the United Kingdom and Saudi Arabia, major factors for pharmacists’ self-reported errors have included high-dispensing volumes and high workload.^11,12 

A robust assessment of the impact of pharmacy metrics on pharmacy error rates and patient safety has not yet been published. Additionally, few studies have explored the impact of work-based performance metrics on pharmacists. Pharmacists working in stores with metrics were more likely to feel like they do not have time to do their job and have reported increased overall job stress due to insufficient time to complete tasks related to metrics.^13,14  This study investigated if, and which metrics were being used in community and outpatient pharmacies, as well as applicable targets for metrics. Additionally, the study assessed if pharmacists perceived that metrics may impact patient safety, pharmacy error rates, adequacy of time to complete tasks, conduciveness of their work setting to patient care and safety, and job satisfaction.

This was a descriptive, cross-sectional survey of licensed California pharmacists working in community or outpatient pharmacy settings including retail/chain, grocery, mass merchandiser, compounding, independent, long-term care, or hospital/clinic outpatient pharmacies in California.

Respondents were excluded if they were retired, out of the workforce, or worked in an inpatient pharmacy. An anonymous online survey platform, Qualtrics, was used to administer the survey from June 2019 to September 2019. The survey was distributed through the California Pharmacists Association (CPhA) email listserv in a weekly newsletter and posted on the organization’s website homepage for the duration of the survey period. Additionally, three printed surveys were delivered with prepaid postage and preaddressed envelopes to pharmacists at 80 pharmacy practice settings. The pharmacists could complete the survey and then mail it back. If the pharmacists chose to complete the survey later, a reminder telephone call was made two, four and six weeks after survey drop-off as a reminder to complete the survey. To maintain pharmacist and pharmacy anonymity, the envelopes were addressed to one study investigator and remained sealed until all in-person completed surveys were collected.

Respondents were asked to indicate their pharmacy practice settings and if metrics were used. If metrics were used, participants were asked to provide information on which metrics were in place and what targets or goals there were for each metric. The survey also queried on pharmacists’ perceptions of the following statements: 1) metrics affect patient safety (Likert scale 1 = very likely to improve patient safety; 2 = likely to improve patient safety; 3 = neutral; 4 = likely to worsen patient safety; and 5 = very likely to worsen patient safety); 2) metrics affect the number of pharmacy errors (Likert scale 1 = very likely to reduce pharmacy errors; 2 = likely to reduce pharmacy errors; 3 = neutral; 4 = likely to lead to pharmacy errors; and 5 = very likely to lead to pharmacy errors); 3) satisfaction with amount of time to do job (Likert scale 1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; and 5 = strongly disagree; and 4) employer provides a work environment that is conducive to providing safe and effective patient care (Likert scale 1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; and 5 = strongly disagree). Lastly, participants were asked to rate their overall job satisfaction measured on a scale where 0 = completely dissatisfied to 10 = completely satisfied.

The pharmacy settings were grouped into four categories to facilitate statistical comparison. The categories included 1) retail/chain pharmacies (24-hour and non-24-hour), 2) grocery/mass merchandiser pharmacies, 3) compounding/independent pharmacies and 4) health system outpatient/long-term care pharmacies. Statistical analyses were conducted with STATA/SE 16 with p < 0.05. Median values of ordinal data were used to compare pharmacists’ perceptions of the impact of metrics. Kruskal-Wallis tests were used to determine preliminary differences among pharmacists in the four specified pharmacy setting categories. Post-hoc analyses using a systematic series of Wilcoxon rank-sum comparisons between each possible pair of pharmacy settings were done to identify which specific practice settings differed. Data for job satisfaction from each pharmacy setting were aggregated and summarized using medians and 25th and 75th percentiles. The University of California San Diego Human Research Protections Program determined this study to be exempt from review.

A total of 79 pharmacists responded to the survey. Of these, three were excluded from analysis; one was a retired pharmacist, and two worked at inpatient health systems for which outpatient care was unable to be verified (n = 76). Of the more than 5,000 pharmacists potentially reached via the CPhA weekly listserv newsletter, 21 responses were received, and 58 pharmacists responded out of the 240 paper surveys dropped off at pharmacies.

Most pharmacists (71%) reported that their worksite used metrics (Table 1). Of the 21 retail respondents, 20 indicated the presence of metrics at their job site and one indicated being unsure. Retail pharmacists were more likely to report the use of metrics than independent and compounding pharmacists, who indicated metrics were not used. Fifteen respondents were unsure if metrics were utilized at their pharmacy and were excluded from further analyses (n = 64).

Table 2 displays the most common metrics reported. Top metrics reported included daily number of prescriptions filled (68.5% with an average target of 301 prescriptions/day), minutes from receiving to dispensing prescriptions (42.6% with an average targeted time of 18 minutes) and average patient wait time (44.4% with an average targeted time of 17 minutes). The least reported metric was assessment of patient vitals with only one pharmacist reporting this as a metric used in their pharmacy.

Comparisons of pharmacists’ perceptions of the impact of metrics on patient safety and prescription error rates did not differ significantly by practice setting (Table 3). However, grocery/mass merchandiser pharmacists reported less satisfaction with time allotted to do their job (p = 0.037) and compounding/independent pharmacists were more likely to feel that their worksite was conducive to providing safe and effective patient care (p < 0.001).

Post-hoc individual pairwise comparisons were made between pharmacy settings (data not shown). Pharmacists practicing in retail/chain settings (24-hour and non-24-hour) did not differ significantly in their satisfaction with time to complete tasks than their counterparts in any other practice setting. However, pharmacists from retail/chain settings did report a significantly lower level of perceiving that their workplace was conducive to patient safety than compounding/independent pharmacies (p < 0.001) and this trended toward significance when compared to hospital/long-term care pharmacies (p = 0.095). Pharmacists practicing in grocery/mass merchandiser stores were less likely to be satisfied with the time they had to complete tasks than those at compounding/independent pharmacies (p = 0.007) or those at health system/long-term care pharmacies (p = 0.026). Similarly, grocery/mass merchandiser pharmacists also reported feeling a lower level of workplace conduciveness to patient safety than compounding/independent pharmacists (p < 0.001) or hospital/long-term care pharmacists (p = 0.027). Finally, pharmacists from compounding/independent pharmacies reported a lower level of workplace conduciveness to patient safety than hospital/long-term care pharmacies (p = 0.026).

Job satisfaction was significantly lower in pharmacists working in pharmacies with metrics (n = 54) with a median score of 8 (7–9) compared to pharmacies without metrics (n = 10) with a median score of 9 (8–10) (p = 0.01). These findings did not change when retail/chain and outpatient clinic/hospital respondents (all reported metrics present) were excluded from analyses.

This study aimed to provide a descriptive analysis of metrics used in the workplace, quantify targets for measures where possible, and assess pharmacists’ perceptions of the impact of these measures. This study is novel in that respondents represented a variety of community and outpatient pharmacists describing the metrics used at their pharmacy settings and their perceptions of the impact of such metrics. Most pharmacists working across a broad range of community and outpatient pharmacies reported the presence of metrics at their workplace, except for independent and compounding pharmacies. It has been reported that pharmacists who left large retail/chain pharmacies to work in independent pharmacies have improved working conditions and a decreased prevalence of performance metrics.^7,8 

The comparisons among pharmacy settings offer valuable preliminary insight into where pharmacists may be feeling the most pressure to meet company metrics with potentially negative impacts. Specifically, pharmacists working in settings associated with a higher likelihood to employ metrics, including retail/chain, mass merchandiser, and grocery pharmacies were more likely to report a lack of adequate time to complete tasks and/or work environments less conducive to providing safe and effective patient care. Our findings are in alignment with Tsao et al. that included 58% chain pharmacists and 19% independent pharmacists.¹³  Pharmacists working in chain pharmacies required to meet monthly metrics (including quantity of medication reviews, immunizations, and prescriptions filled) reported a significant negative impact on working conditions and perceived patient safety.¹³  Additionally, Munger et al. found that chain pharmacy pharmacists were significantly more likely to report feeling that their company sets unrealistic target measures without enough time to perform patient consultation duties.¹⁴  Similarly, participants in a recent qualitative analysis noted that metrics deterred them from providing meaningful patient care and were concerned about potentially harmful mistakes due to working conditions.¹⁵ 

Our study did not specifically ask which tasks retail pharmacists felt were overlooked due to metrics. However, findings from the 2019 National Pharmacist Workforce Study, of which half of respondents worked in community pharmacy settings, illustrated that pharmacists reported their most stressful job aspects included having so much work to do that everything cannot be done well and concerns that a patient would be harmed by a medication error.¹⁶  Indeed, several studies have demonstrated that high workload in the community pharmacy setting increases the likelihood of dispensing errors.^17–19  It may be surmised that some company-driven performance measures may actually be decreasing the quality of care provided by pharmacists, which is the opposite of the intent of PQA. At the very least, there may be an incongruence between the top metrics reported by pharmacists at their work sites and the quality metrics that PQA aims to ensure.

Our findings that job satisfaction was significantly lower in pharmacy settings where metrics are used shed new light on the impact on pharmacists. Factors contributing to decreased job satisfaction could include longer shift hours, increased pressure and demands, and lack of adequate pharmacy staff. Of note, our data were collected prior to the COVID-19 pandemic. The pandemic further exacerbated the already stressful work environment in community and outpatient pharmacies due to becoming an essential access point for COVID-19 vaccination and testing services, while having to cope with increased prescription volume, staff shortages, and social distancing protocols.^20,21  This noted increase in workload demands further follow-up analyses to determine if metrics were changed or adjusted during this time.

The study was severely limited by a low response rate (< 1% via listserv distribution and 41.4% for in-person surveys) and in particular, a low number of participants from independent and compounding pharmacies. A national report found that 28.9% of pharmacies in the nation are independent pharmacies (which included compounding pharmacies), resembling the 24% of respondents observed in this study.²²  Though the demographics of this study resemble other studies, the overall low number of participants may have resulted in the inability to detect significant differences between settings, particularly pertaining to impact of metrics on patient safety. Additionally, our findings are only generalizable to California pharmacists where state law does allow for Advanced Pharmacy Practice licensure, which may increase the tasks that pharmacists are responsible for completing. Furthermore, the in-person surveys were a convenience sample of pharmacies since the investigators only distributed surveys to regions within traveling distance. There was potential responder bias as those who were able to complete the survey may be representative of a cohort that felt there was enough time in their workdays to complete this survey. Future research should include a national survey to expand generalization, avoid convenience sample biases, and compare pharmacy metrics with job satisfaction and burnout in community and outpatient pharmacy settings versus inpatient pharmacy settings.

Finally, while our study did assess for job satisfaction, it did not measure burnout in our respondents. According to the American Pharmacists Association, one significant contributing cause of pharmacist burnout includes unrealistic performance metrics that reward volume rather than value.²³  Pharmacist burnout is a looming concern and has become more prevalent and likely exacerbated by the COVID-19 pandemic. The unprecedented and unique challenges of the pandemic increased the responsibilities and strain on pharmacy personnel, only furthering the likelihood of decreased job satisfaction and increased burnout in the aftermath.^20,21 

Some movement has been generated as policymakers have begun to address the high-pressure demands of pharmacy-based metrics. California passed SB 362 in September 2021, which prohibits chain community pharmacies from establishing quotas for pharmacist or pharmacy technician duties, including fixed numbers or formulas such as prescriptions filled, services and programs rendered to patients, and revenue obtained.²⁴  This legislative change is promising for the future of community and outpatient pharmacies and as more data becomes available, the potential role that measures play in pharmacist job satisfaction and burnout may be elucidated.

Most outpatient and community pharmacists reported use of performance metrics at their work site. Respondents working in retail settings and grocery/mass merchandiser settings were more likely to report less satisfaction with time to complete their tasks and grocery/mass merchandizer pharmacists felt their worksite was less conducive to effective and safe patient care. The presence of metrics negatively impacted overall job satisfaction across all settings. The role of metrics should be further explored in a larger population of community and outpatient pharmacists.