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MODULE 29: YOUR WORKFORCE DEVELOPMENT PLAYBOOK
Section 29.3: Recruiting, Onboarding, and Retention
Building and Keeping Your A-Team: Your “Talent Adherence Program”
SECTION 29.3
Recruiting, Onboarding, and Retention
Applying your clinical adherence skills to build a high-performing team.
29.3.1 The “Why”: The True Cost of a “Non-Adherent” Employee
As a pharmacist, you are a master of adherence. You know that the total cost of a non-adherent patient is not just the price of the wasted medication. It’s the catastrophic downstream cost of a hospital admission, an emergency department visit, a failed therapy, and a permanent loss of clinical progress. The same principle applies with 100% accuracy to your staff. Employee turnover, or organizational non-adherence, is not just an “HR problem”—it is a catastrophic financial, operational, and clinical risk to your specialty pharmacy.
In a traditional business, the cost of losing an employee is estimated to be between 50% and 200% of their annual salary. In a high-stakes, licensed, and accredited specialty pharmacy, this cost is exponentially higher. You must learn to articulate this cost in terms your CFO and leadership will understand. This is not a “soft” cost; it is a hard, quantifiable loss.
Masterclass Table: Calculating the True Cost of Turnover (A Deep Dive)
Let’s analyze the true cost of losing one (1.0) Access Specialist (PA Tech) who earns $55,000/year.
| Cost Category | Description of “Downstream Costs” | Conservative Cost Estimate |
|---|---|---|
| 1. Separation Costs | The immediate administrative costs of processing the employee’s exit, paying out unused PTO, COBRA administration, etc. | $1,500 |
| 2. Recruitment Costs | The cost to find a replacement: Posting on job boards (LinkedIn, Indeed), internal HR/Manager time spent screening resumes (20+ hours), and interviewing (10+ hours). | $4,000 |
| 3. Training & Onboarding Costs | The cost of the new hire’s first 90 days. This includes the manager’s training time, the “buddy” or preceptor’s lost productivity, and the new hire’s salary while they are not yet productive. | $15,000 |
| 4. Lost Productivity Costs | The cost of the vacancy. For 6-8 weeks, that PA Specialist’s workload doesn’t disappear. It’s either (a) not done, or (b) dumped on the rest of the team, causing burnout and errors. | $10,000 |
| 5. The “Specialty Pharmacy” Risk (The Big One) | The new, untrained specialist makes errors. They submit PAs with the wrong code. They fail to find financial aid.
|
$50,000+ (Highly variable) |
| Total Cost to Replace 1 Tech: | This is the real number. | $80,500+ |
That $55,000 employee just cost you $80,500 to replace. This is a 146% turnover cost. This is financial malpractice. The entire purpose of this section is to teach you how to avoid this unforced error. You must think of your workforce strategy not as a “soft skill” but as a primary financial and clinical risk management program. You are building a “Talent Adherence Program,” and this section is your clinical guideline.
Pharmacist Analogy: Your “Talent Adherence Program”
You are already an expert at this. You just need to change the “drug” and the “patient.” Your new “patient” is your employee. Your new “drug” is their job. Your new “therapeutic goal” is a high-performing, long-term team member. Your “adherence program” has three phases:
Phase 1: Recruiting = The “Patient Identification & Sourcing”
This is your pre-screening and sourcing. You wouldn’t start a $50,000/month drug on a misdiagnosed patient. You don’t just “find a person”; you find the right person. This involves:
- Sourcing: You don’t get limited-distribution drugs from any wholesaler. You don’t find specialty talent on Craigslist. You must go to the right channels.
- Screening: This is your “diagnostic.” You must confirm the “diagnosis” (their skill) with a “lab test” (a case-study interview), not just “patient-reported symptoms” (their resume).
Phase 2: Onboarding = The “Initial Assessment & First-Dose Training”
This is the most critical phase. You would never mail a biologic to a patient’s home without a first-dose counseling session and injection training. Why would you treat a new $55,000 employee with less care? A bad “first-dose experience” (onboarding) leads to immediate non-adherence (turnover). This phase includes:
- Assessment: 30-60-90 day check-ins to assess their “tolerance” and understanding.
- Training: Using your Competency Framework (from 29.2) as your formal “Injection Training Checklist.”
Phase 3: Retention = The “Long-Term Adherence Management”
Your job isn’t done after the first fill. The real work is keeping the patient adherent for life. This is your retention strategy.
- Managing Side Effects: The #1 “side effect” of a job is burnout. You must actively monitor for it (with “Stay Interviews”) and manage its cause (workload, using your FTE models).
- Proving Value: You remind the patient why they are on this therapy. This is your recognition program and supportive culture.
- Setting Therapeutic Goals: You and the patient agree on a goal (e.g., “remission”). This is your Career Ladder, which gives the employee a reason to stay adherent.
29.3.2 Part 1: Recruiting – Sourcing Your “A-Team”
In the specialty pharmacy market, you are in a war for talent. Hospitals, PBMs, other SPs, and even manufacturers are all fighting for the same small pool of experienced pharmacists and technicians. You cannot simply “post a job” and hope. You must hunt. This requires a multi-channel sourcing strategy.
Your Job Description (from 29.2) is your *internal* document. Your Job Posting is your *external* marketing advertisement. It must be compelling. It must sell the mission, not just the tasks.
Tutorial: Writing “The Magnetic Job Posting”
A bad job post is a “cut-and-paste” of your JD. A great job post tells a story. Here is a before-and-after.
BAD POST (The “Task List”):
“Seeking PA Specialist. Will be responsible for PA submissions, BVs, and patient calls. Must have 2 years experience. Competitive pay.”
This is boring. It will attract uninspired candidates who just want a paycheck.
GOOD POST (The “Mission Statement”):
Title: Reimbursement Specialist (Patient Access Advocate)
About Us: At ABC Specialty, we believe that no patient should ever have to choose between their health and their finances. Our Access Team are the “financial engineers” and “patient advocates” who make that mission a reality.
The Role: We are looking for a passionate, investigative, and relentless problem-solver to join our Access Team. This is not a “call center” job. You are a financial detective. You will be responsible for navigating the complex world of insurance to secure coverage for life-saving medications. Your “wins” are not just “approved PAs”—they are patients getting the therapy they need to fight their disease.
What You’ll Do:
- Be a “forensic accountant” for patient benefits, performing deep-dive BVs to find coverage.
- Be a “legal advocate” for patients, building and submitting rock-solid clinical cases for prior authorizations.
- Be a “treasure hunter” for funding, connecting your patients with millions of dollars in copay and foundation grants.
- You hate taking “no” for an answer and see a “denial” as the start of a fight, not the end.
- You are meticulously organized and love the feeling of checking a complex case off your list.
- You are empathetic and can talk to a nervous patient with the same confidence you use to talk to an insurance rep.
This post sells the mission. It will attract a totally different, and far better, candidate.
Sourcing Channel 1: The “Compounded” Internal Pipeline (Your Best Source)
Your single best, most reliable, and most cost-effective source of talent is already in your organization. The star pharmacy technician at your community or retail pharmacy is your next Access Specialist or Patient Care Coordinator. The only thing separating them from that role is opportunity and training.
Why this is the #1 Strategy:
- Known Quantity: You already know their work ethic, their reliability, and their attitude. You are eliminating 90% of the hiring risk.
- Cultural Fit: They are already “adherent” to your company culture.
- Loyalty & Retention: You are not just giving them a *job*; you are giving them a *career*. The loyalty you earn from this is immeasurable. They will stay with you for years.
- Cost: The cost is a 3-month training program, not an $80,000 turnover event.
How to Build It: Create a formal “Specialty Pharmacy Trainee” program. Announce it to your retail/community staff. Take your best CPhT, give them a small raise, and put them into your 90-Day Onboarding Program (see 29.3.3) for an Access Specialist role. You have just “compounded” your own A-Team player.
Sourcing Channel 2: The “Limited Distribution” Networks
You must go where the specialists are. Posting on Indeed is a “shotgun” approach; you need a “rifle.”
- Clinical Pharmacists:
- ASHP (American Society of Health-System Pharmacists): Their career center is the #1 place for hospital and clinical RPhs.
- ACCP (American College of Clinical Pharmacy): For more specialized, residency-trained candidates.
- AMCP (Academy of Managed Care Pharmacy): Excellent for pharmacists with payer/PA experience.
- NCODA (National Community Oncology Dispensing Association): The *best* place to find an experienced Oral Oncology pharmacist.
- Technicians/Specialists:
- NPTA (National Pharmacy Technician Association): A hub for career-oriented CPhTs.
- Local Technical Colleges: Connect with the Program Director for the “Pharmacy Technician” program. Offer to come and give a “guest lecture” on specialty pharmacy. You become the employer of choice before they even graduate.
Sourcing Channel 3: The “University Formulary” (APPE Rotations)
This is your long-term strategy. You must establish yourself as a rotation site for local pharmacy schools. An APPE (Advanced Pharmacy Practice Experience) rotation is a 6-week job interview where *you get paid* (in the form of a student’s labor) to evaluate them.
You assign the student a project (e.g., “Analyze the new 2026 Medicare Part D guidelines”) and have them shadow each department for a week. At the end, you know *exactly* who the stars are. You make them an offer contingent on graduation. You have just secured your “Class of 2027” pharmacist two years in advance, for free.
The Interview Process: Your “Clinical Trial”
Your interview process must be a structured assessment, not an unstructured “chat.” You are testing for the competencies in your framework (from 29.2).
Tutorial: The Case-Study Interview (The “Diagnostic Test”)
Never hire a “knowledge worker” without seeing their work. The case study is the single best predictor of on-the-job success. It replaces “Tell me about yourself” with “Show me what you can do.”
Case Study for an Access Specialist:
The Prompt: “Here is a printout of a fictional patient profile and a PA denial. The patient is ‘Jane Smith,’ the drug is ‘Skyrizi,’ and the insurance is ‘Aethem.’ The denial reason is ‘Insufficient clinical information provided.’ You have 10 minutes to review this. Then, I want you to walk me through your exact next 5 steps. What are you looking for, who are you calling, and what are you saying?”
What You’re Listening For:
- Bad Answer: “I’d call the insurance and ask them to approve it.”
- Good Answer: “First, I’d read the denial, which is too vague. So, I’d call the payer’s Pharmacy Services line—not the main member line—to get the specific clinical criteria. I’d ask them to fax me the criteria form.”
- Great Answer: “A ‘vague denial’ usually means the provider just sent the script. I’d immediately go to the Skyrizi PA form on CoverMyMeds, which I know requires a ‘tried and failed’ on Humira or Cosentyx. I would then call the provider’s office—specifically the MA, not the front desk—and say, ‘I’m working on the Skyrizi PA. I need the chart notes from the last 6 months showing the patient’s trial and failure of Humira.’ While I wait, I’d check the patient’s profile to see if we can get a manufacturer ‘bridge’ started…”
You’ve just learned everything you need to know. The “Great Answer” candidate is hired on the spot.
Case Study for a Clinical Pharmacist:
The Prompt: “Here is a new referral for ‘Patient John Doe.’ He is starting Ibrance (palbociclib) for HR+ metastatic breast cancer. His profile also lists ‘Warfarin,’ ‘Fluconazole,’ and ‘Lisinopril.’ This is all the information you have. What are your top 3 clinical priorities, in order, before this drug can be dispensed?”
What You’re Listening For:
- Bad Answer: “I’d check the dose and counsel him.”
- Great Answer: “Priority 1 is the catastrophic drug interaction. Ibrance is a CYP3A4 substrate, and fluconazole is a strong inhibitor, which can cause severe neutropenia. This needs an immediate call to the oncologist. Priority 2 is the warfarin; Ibrance can also increase its effect. I need a baseline INR and a plan for more frequent monitoring. Priority 3 is a baseline lab check. Ibrance requires a baseline CBC with ANC > 1,000 *before* dispensing the first dose. I would hold this script, call the oncologist, and resolve all three of these DTPs before even starting the counseling call.”
29.3.3 Part 2: Onboarding – The 90-Day “First-Dose” Program
You’ve “sourced” your drug and “diagnosed” your candidate. Now comes the “first dose.” A study by the Wynhurst Group found that 22% of all staff turnover occurs within the first 45 days. Why? A terrible, disorganized, and overwhelming onboarding process. This is the definition of “first-dose non-adherence.” It is a 100% preventable failure.
Your Competency Framework (from 29.2) is the spine of your onboarding plan. The goal of onboarding is not to “be nice”; it is to systematically train and document the sign-off of every single competency for that role. This creates a confident employee and an audit-proof training file.
The 90-Day Onboarding Plan: A “Tutorial-in-a-Box”
You must have a formal, written plan for every new hire. Handing them this plan on Day 1 is the most important thing you can do. It shows you are organized, you have a plan for their success, and you are taking their career seriously.
Phase 1: Week 1 – Culture, Compliance, and Core Systems
Goal: Acclimate the employee. Overwhelm them with support, not work.
- Day 1: HR paperwork, systems logins, welcome lunch with the team. Manager gives them the 90-Day Plan. Assign their “Buddy” (cultural guide) and “Preceptor” (technical trainer).
- Day 2-3: “Compliance Boot Camp.” This is all the “boring” stuff. Do it first.
- HIPAA / HITECH Training (with quiz).
- OSHA / Safety Training (Handwashing, etc.).
- Employee Handbook Review (with signature).
- Error Reporting & QMP Training.
- Day 4-5: “Systems Boot Camp.” Supervised, “sandbox” training on the core software.
- Pharmacy Dispensing System (e.g., CPR+, QS/1). Inbound Fax Queue / Triage Software.
- Phone System.
- PA Portal Logins (CMM, Surescripts).
Phase 2: Weeks 2-4 – The “Shadowing & Supervised Practice” Phase
Goal: Connect the training to the real work, using the Competency Framework as a checklist.
- Shadowing (Weeks 2-3): The new hire (NH) sits “plugged in” with their Preceptor. The Preceptor does 100% of the work. The NH’s job is to listen, watch, and ask questions. The Preceptor “narrates” their work: “Okay, I’m opening a new PA denial. I see the code… so I’m going to call the provider now…”
- Supervised Practice (Week 4): The roles reverse. The NH now “drives” the keyboard. The Preceptor sits plugged in. The NH performs the task (e.g., a BV call), and the Preceptor is there to stop them *before* they make a mistake. The Preceptor reviews and signs off on 100% of their work before it’s finalized.
Phase 3: Weeks 5-12 – The “Competency Validation” Phase
Goal: Gradually transition the NH to an independent, productive team member. This is the “washout” period.
- Weeks 5-8 (“On a Leash”): The NH works their own *limited* queue. The Preceptor/Manager performs a 100% audit of all their work at the end of each day. Errors are corrected in real-time, which is the most effective training.
- Weeks 9-12 (“Independent”): The NH is now working a full queue. The Manager moves to a 25% random audit.
- Week 12 (The 90-Day Review): The Manager and NH sit down with the Competency Framework Checklist. They go through every single item.
- Manager: “Okay, Competency 3.2, ‘Submits an accurate PA.’ I’ve audited 50 of your PAs. You have a 98% accuracy rate. I am signing you off as ‘Competent.'”
- Manager: “Competency 4.1, ‘Manages Appeals.’ We’ve only had one complex appeal, so I’m marking this as ‘Needs Further Development.’ We will focus on this in the next quarter.”
The 90-Day Review is an Auditable, Legal Document
The 90-Day Review is not a “chat.” It is the final step of your initial training program. The signed Competency Checklist is the legal and compliance document that proves this employee is trained and competent to perform their job. This document is the thing an auditor will ask for. It also serves as the final step of a probationary period. If the employee cannot be signed off on their “Essential Functions” after 90 days of structured training, you have a clear, objective, and defensible case for termination.
The “Buddy” vs. “Preceptor” System
This is a simple but highly effective tactic. A new hire has two types of questions: technical (“How do I…?”) and cultural (“Who do I…?” or “Is it normal for…?”). You should assign two different people to answer them.
- The Preceptor (Technical): This is a senior, high-performing team member in the same role. Their job is to train on the “hard skills” of the Competency Framework. This is a formal, recognized role (and should come with a small bonus or recognition).
- The Buddy (Cultural): This is a peer, often in a different department. Their job is to be the “safe” person. They take the NH to lunch, show them where the coffee is, and answer the “stupid questions” the NH might be afraid to ask their manager (e.g., “What’s the *real* dress code?”). This builds an immediate social bridge and accelerates their sense of belonging.
29.3.4 Part 3: Retention – Your Long-Term “Talent Adherence Program”
You have “sourced” your talent and “onboarded” them. They’ve had their “first dose” and are stable. Your job is now to ensure they stay “adherent” to the “therapy” (the job). As you know from your clinical practice, adherence is not a “one and done” activity. It is a proactive, continuous process of engagement, monitoring, and barrier-removal.
Your goal is to become an “employer of choice.” This doesn’t mean “pays the most.” It means “is the best place to work.” This is built on a foundation of managing the #1 “side effect” of any job: Burnout. Your retention strategy is your burnout management program.
Retention Component 1: Career Ladders (The “Therapeutic Goal”)
This is the single most important, non-financial retention tool you have. People will tolerate a high-stress job if they see a future in it. They will leave a low-stress job if it’s a dead end. A career ladder is a formal, transparent document that shows your team *how to get promoted*. It is the “therapeutic goal” they are working toward. It gamifies their career and gives them a clear “why.”
Tutorial: Building a Career Ladder for Your Access Team
This framework can be applied to your PCCs, Dispensing Techs, or any other non-pharmacist role. It creates growth, recognizes mastery, and justifies pay increases.
| Level | Title | Competencies & Responsibilities | “Promotion Requirement” |
|---|---|---|---|
| Level 1 | Access Specialist I |
|
(This is the hiring-in level). |
| Level 2 | Access Specialist II |
|
1. 18+ months in Level 1 role. 2. “Exceeds” rating on last review. 3. Demonstrated mastery of all Level 2 competencies. |
| Level 3 | Senior Access Specialist |
|
1. 24+ months in Level 2 role. 2. “Exceeds” rating. 3. Manager recommendation. |
| Level 4 | Access Team Lead |
|
(Internal promotion by manager only). |
This ladder is now your *entire* retention and performance plan. It is transparent, fair, and objective. It stops “favoritism” and clearly shows your A-Team how to advance. You have just cured “dead-end job” syndrome.
Retention Component 2: Recognition (The “Positive Reinforcement”)
Your team is doing incredibly hard, stressful work that is invisible to the patient. If the only time they hear from management is when they make a mistake, they will burn out and leave. Recognition is the “positive reinforcement” that proves their work matters.
- Formal, Metric-Based Recognition:
- “PA Superstar” Award: The specialist with the highest first-pass approval rate this quarter.
- “Access Champion” Award: The specialist who secured the most in foundation funding for patients.
- “Adherence All-Star” Award: The PCC with the highest PDC rate for their patient panel.
- “Good Catch” Award: For any employee who spots a major error (e.g., a dosing error, a compliance risk) and reports it. This is critical for building a “no-blame” safety culture.
- Informal, High-Impact Recognition:
- Pass on a Compliment: When a provider’s office emails, “Thank you, Jane was a lifesaver,” forward that email to Jane and CC your own boss. This 2-minute act is more powerful than a $100 bonus.
- “The Wow Story”: Start every team meeting with one “Wow Story” from the past week. “I want to recognize Bill. He spent 2 hours on the phone with a PBM, got a 3-level appeal approved, and got a patient their oncology drug in 24 hours. That is our mission. Thank you, Bill.”
Retention Component 3: Culture & Support (Managing the “Side Effect” of Burnout)
Burnout is the primary “adverse event” of your “job therapy.” It is caused by three things: 1) Feeling overwhelmed (workload), 2) Feeling powerless (no control), and 3) Feeling unappreciated (no recognition). Your culture must be designed to fight these three things.
Tutorial: The “Stay Interview” (Your Proactive Adherence Check)
Do not wait for the exit interview to learn why your best employee is leaving. By then, it’s too late. A “Stay Interview” is a proactive, 1-on-1 meeting you have with your high-performing, “at-risk-of-leaving” employees before they are unhappy. It is your “adherence check-in.”
The Script (Manager to a top-performing PCC):
“Hi Sarah, I’d like to schedule 30 minutes for a ‘Stay Interview.’ You are not in trouble—in fact, it’s the opposite. You are one of our most valuable team members, and I want to make sure we are doing everything we can to keep you challenged and happy here. I have 4 questions I’d like to discuss:”
- “What do you look forward to when you come to work each day?” (Identifies their ‘motivator’)
- “What is the most frustrating or demotivating part of your job?” (Identifies their ‘barrier’ or ‘side effect’)
- “If you had a magic wand, what is the one thing you would change about your role or our team?” (Identifies opportunities)
- “What would make you ‘discontinue therapy’ and look for a job somewhere else?” (IdentExample: “If my workload doubled again” or “If I didn’t see a path for growth”)
The answers to these four questions are your retention playbook. The employee in question #4 just told you, “I’m burning out, and I want a promotion.” You can now act. You can use your FTE model (from 29.1) to get them help, and you can show them the Career Ladder (from 29.3.4) to give them a goal. You have just prevented a “non-adherence” event.
Retention Component 4: Compensation & Benefits (The “Copay Assistance”)
You cannot have a great culture and pay 30% below market. Money isn’t the reason people stay, but it’s a huge reason people leave. Your compensation must be fair, transparent, and competitive.
- Benchmark Annually: Don’t guess. Use professional salary surveys (from ASHP, NPTA, or a service like Salary.com) to benchmark your pay *for your region* and *for your industry*. “Pharmacy Technician” is not the right benchmark. “Specialty Pharmacy PA Specialist” is.
- Tie Bonuses to Metrics (The P4P Model): Your retention plan should be a “Pay for Performance” model, just like your payer contracts.
- Team Bonus: If the *entire pharmacy* hits its goals (e.g., >95% TTT, >90% PDC, 0.00% dispensing error rate), everyone gets a $1,000 bonus. This aligns everyone to the same goal.
- Individual Bonus: Tie it to the Career Ladder. When a PCC I gets promoted to PCC II, it comes with a 5% raise and a $500 “Mastery” bonus. This reinforces the value of growth.
