Section 29.5: Scheduling, Coverage, and After-Hours Protocols

29.5.1 The “Why”: Scheduling is Your Operational Pharmacokinetics

As a specialty pharmacy leader, you have now designed your organization (29.1), defined the roles (29.2), and built your team (29.3). Your final challenge is to deploy that team. This is not an administrative afterthought; it is a high-level strategic function. Your staffing schedule is your operational dosing regimen.

You are a master of pharmacokinetics (PK). You would never dose a narrow-therapeutic-index drug “once a day” if its half-life is 4 hours; you would get toxic peaks and sub-therapeutic troughs. The same principle applies perfectly to your staff. A poorly designed schedule creates toxic “peaks” of work (where 50 PAs are due and no one is available) and sub-therapeutic “troughs” of wasted labor (where 5 employees are idle). This is operational malpractice. It leads to burnout, errors, and catastrophic financial waste.

Furthermore, accreditation bodies like URAC (PHARM Core 33) and ACHC (PHARM 3-1B) have a zero-tolerance mandate: you must provide patients with 24/7/365 access to a licensed pharmacist for urgent clinical matters. This is not optional. Your after-hours protocol is not a “nice-to-have”; it is a foundational pillar of your accreditation. An auditor will test this, often by “secret shopping” your after-hours line at 2 AM on a Sunday. If you fail this test, you fail the audit.

This section is your masterclass in designing the “pharmacokinetics” of your staff. We will build:

1. Your “Steady State” Dosing Regimen: How to design an efficient, staggered business-hours schedule that matches your workflow “peaks” and “troughs.”
2. Your “STAT Dose” Protocol: How to build a robust, compliant, and “burnout-proof” after-hours on-call program.
3. Your “Contingency Plan”: How to handle “breakthrough” events like holidays, disasters, and sick calls.

This is how you move from just having a team to deploying a team with the same precision you use to dose a high-risk medication.

29.5.2 Masterclass on Business Hours Scheduling (The “Steady State”)

Your first goal is to perfectly match your staffing “dose” to your workflow “curve” during your posted hours of operation (e.g., M-F 8:30 AM – 6:00 PM). A simple “everyone works 9-5” schedule will fail, guaranteed. Why? Because your workflow is not a flat line; it’s a dynamic curve. To build a smart schedule, you must first become a “data analyst” of your own workflow.

Step 1: Map Your Workflow “PK Curve” (Data Gathering)

You must measure your “serum concentrations” of work. If you are a startup, you must *anticipate* them. If you are an existing pharmacy, you must *measure* them. Run reports from your fax queue, phone system, and dispensing software.

Masterclass Table: Typical SP Workflow Peaks & Troughs

Time Period	Workload “Serum Level”	Rationale & Predominant Tasks
Monday 8am-10am	TROUGH (New Referrals) PEAK (Follow-ups)	Providers are seeing patients, not sending referrals yet. But your queue is full of weekend faxes and “STAT” reshipments from weekend on-call issues. Tasks: Weekend triage, PCC follow-up calls.
Mon-Wed 10am-3pm	STEADY STATE	The “grind.” The core work of BVs, PAs, and clinical assessments. Workflow is steady and predictable. Tasks: All departments are at baseline.
Thursday 3pm-5pm	RISING PEAK	Providers start clearing their desks for Friday. Payers begin approving PAs submitted on Tuesday. Tasks: PA follow-ups, initial shipping coordination.
Friday 2pm-6pm	TOXIC PEAK (C-max)	This is your “Code Blue.” All providers send their last-minute referrals. All payers dump their Friday approvals. All patients call, “Will I get my medicine before the weekend?” Tasks: STAT data entry, STAT dispensing, STAT shipping.

Step 2: Designing the “Staggered” Schedule (The “Extended-Release” Regimen)

Now that you know your “PK curve,” you can see that a “9-5” dose is clinical malpractice. It leaves you “sub-therapeutic” (under-staffed) during your Friday 4-6 PM “C-max” and “supratherapeutic” (over-staffed) during your Monday 8 AM “C-min”.

The solution is a staggered, workflow-based schedule. You match your staff’s “dosing interval” to their *function*.

Masterclass Table: Sample Staggered (“Extended-Release”) Staffing Model

Department (Function)	Standard Shift	Rationale (The “Pharmacokinetics” of the Role)
Intake Department	8:00 AM – 4:30 PM	This is your “Rapid-Onset” dose. You need them to arrive *before* everyone else to clear the “morning dump” of faxes and e-portals that arrived overnight. Their “C-max” of work is 8-10 AM.
Access (PA) Department	8:30 AM – 5:00 PM	This is your “Standard Release” dose. They need to be at their desks when East Coast payers (8:30 AM EST) open. Their work is steady all day.
Clinical Department (RPh/PCC)	9:00 AM – 5:30 PM	This is your “Slightly-Delayed Release” dose. Their work *follows* Intake and Access. They also need to be available for patients who call *after* their own 9-5 job.
Dispensing/Shipping Dept.	10:00 AM – 6:30 PM	This is your “Extended-Release” dose. This is the *most important* staggered shift. Why? Their “C-max” of work begins at 3 PM, when PAs are approved and clinical calls are finished. They must be there to pack and ship all “STAT” approvals up until your FedEx/UPS cutoff (often 6:00 PM).

By implementing this simple staggered schedule, you have extended your “therapeutic coverage” from 8 hours (9-5) to 10.5 hours (8:00 AM – 6:30 PM) using the exact same number of FTEs. You’ve flattened the “PK curve” and eliminated most of your “peaks” and “troughs.” This is a sophisticated, efficient, and burnout-reducing strategy.

Step 3: Managing the “Breakthrough” (The “PRN” Plan for Absences)

Your “steady state” regimen is perfect… until your Lead Access Specialist calls out sick on a Friday. Now you have “sub-therapeutic” coverage during your “C-max.” This is a “breakthrough” event, and you must have a “PRN” plan. That plan is cross-training.

As a leader, you must operate by the “2-deep” rule: Every critical function must have at least two people who are competent to perform it. Your “critical functions” are:

• Submitting a PA
• Verifying a new prescription (RPh)
• Dispensing a prescription (Tech)
• Packing a cold-chain shipment

You must build and maintain a Cross-Training Matrix. This is an auditable document for accreditation (to prove “continuity of operations”) and your primary tool for managing daily staffing shortages.

Masterclass Table: Sample Cross-Training Competency Matrix

Employee	Role	Intake Triage	PA Submission	PCC Adherence Call	Dispense/Pack
David R.	Clinical RPh	Trained	Trained	Primary	Primary
Sarah K.	Access Specialist	Backup	Primary	–	–
Mike T.	Access Specialist	Trained	Primary	–	–
Jane L.	PCC	Backup	Trained	Primary	–
Kevin M.	Dispensing Tech	–	–	–	Primary

How to use this matrix: It’s Friday, and both Mike T. and Sarah K. (your entire Access team) call out sick. This is a “C-max” toxicity event.
Your “PRN” Dosing:

1. You (as the manager) pull up this matrix.
2. You see Jane L. is a trained “Backup” for Intake.
3. You see David R. (the RPh) and Jane L. are “Trained” on PA Submission.
4. Your Action Plan: “Jane, for today, you are off phones. You are my ‘Intake Backup.’ Please triage all new referrals. David, you and I will be the ‘Access Team’ today. Please handle all ‘STAT’ PA submissions. All non-urgent PAs will be moved to Monday.”

You have just used your cross-training “PRN” plan to manage a staffing crisis, triaging the workload and deploying your “doses” (staff) to the highest-need areas.

29.5.3 The After-Hours Protocol (The “STAT” Dosing Regimen)

This is the most critical, high-risk, and most-audited part of your staffing plan. Accreditation mandates 24/7/365 access to a pharmacist for urgent clinical needs. Failure is not an option. However, “access” does not mean “a pharmacist sitting by a phone 24/7.” That is inefficient “toxicity.”

The industry-standard, compliant, and efficient model is the “Answering Service + Triage Protocol + On-Call Pharmacist” model. This is your “STAT Dose Protocol.” Its goal is to filter 90% of non-urgent calls while providing a rapid, effective response for the 10% that are truly urgent.

Step 1: The “Filter” – The HIPAA-Compliant Answering Service

You must contract with a professional, 24/7 medical answering service that confirms they are HIPAA-compliant and will sign a Business Associate Agreement (BAA). This service is your “triage nurse.” Your job is to give them the “Triage Protocol” in the form of a script.

Masterclass Table: The Answering Service Script & Triage Logic

Operator’s Prompt / Patient’s Report	Triage Category	Answering Service Action (The Script)
Opening Greeting	Triage	“Thank you for calling ABC Specialty Pharmacy. We are currently closed. If this is a medical emergency, please hang up and dial 911. May I ask the reason for your call?”
“I have chest pain / trouble breathing / severe bleeding…”	EMERGENCY	“This is a medical emergency. Please hang up and dial 911 immediately. We cannot assist you with this.” (Operator does not take a message).
“I need a refill.” “I want to check on my PA.” “What’s my copay?” “My package didn’t arrive.”	NON-URGENT (Admin)	“Thank you. Our business hours are M-F, 8:30-6. I will take a detailed message, and a Patient Care Coordinator will return your call on the next business day.” (Operator takes message, routes to “Non-Urgent” queue).
“I missed my dose.” “I feel sick / nauseous / dizzy.” “I think I have a side effect.” “I’m out of my [Oncology] medicine.”	URGENT (Clinical)	“This is a clinical matter for the pharmacist. I will take your name, phone number, and date of birth. The on-call pharmacist will call you back within 30 minutes.” (Operator pages the on-call RPh).

This script is your most important “filter.” It correctly triages 90% of calls away from the on-call pharmacist, preventing burnout while ensuring 100% of true clinical needs are escalated. This script must be part of your formal P&P.

Step 2: The “STAT Dose” – The On-Call Pharmacist

You must create a formal, rotating schedule for your licensed pharmacists to cover the on-call pager/phone. This is a non-negotiable function of the job and must be included in the Clinical Pharmacist Job Description (from 29.2).

The On-Call Pharmacist’s “Go-Bag” (The “Protocol Kit”)

When a pharmacist is on-call, they are not just “available”; they must be “ready to practice.” You must provide them with the tools to do their job securely and effectively from anywhere.

Compensating for On-Call (The “Retention” Piece)

You are asking a professional to give up their personal time. You must compensate them fairly. Failure to do so is the #1 cause of pharmacist burnout and turnover. Your compensation model must be clear, fair, and documented.

• Model 1: The “On-Call Stipend” (Recommended):
  • What it is: A flat-rate “stipend” paid for the *act* of being on-call, regardless of call volume.
  • Example: $150 for the 7-day period (Mon-Sun). This is simple, predictable, and feels fair.
  • Best Practice: Combine this with “Call-in Pay” (below) for any *actual* calls received.
• Model 2: “Call-in Pay” (FLSA Requirement):
  • What it is: If your pharmacist is “Exempt” (salaried), this is less of a legal issue. If they are “Non-Exempt” (hourly), you must pay them for the time they work, even if it’s 10 minutes at 3 AM.
  • Best Practice: To avoid 10-minute “punch-ins,” create a “Call-in Minimum.” Any on-call employee who receives a call is guaranteed a minimum of 1 hour of pay, even if the call takes 5 minutes. This is a powerful retention tool.
• Model 3: “Comp Time” (Use Sparingly):
  • What it is: “If you get 5 calls on Saturday, you can come in 2 hours late on Monday.”
  • The Risk: This can disrupt your “Steady State” scheduling (from 29.5.2). If your RPh comes in late on Monday (a follow-up peak), you’ve solved one problem by creating another. Use this as a last resort.

29.5.4 Masterclass: The After-Hours P&P (An Auditable Tutorial)

This is the single most important document for this section. The following is a template for a “Policy and Procedure” that you can adapt. It is your formal, auditable “STAT Dosing Protocol.”

Masterclass Table 9.01-B: The On-Call Triage Matrix (An RPh Guide)

This is the “cheat sheet” for the on-call pharmacist. It guides their decision-making and ensures consistency.

Patient Report	Urgency	Clinical Assessment / Action Protocol	Documentation / Follow-Up Task
“I need a refill.” “When will my package arrive?”	NON-URGENT (Filtered by Answering Service)	N/A. Answering service should not have paged this. If they do, RPh counsels patient this is a next-business-day issue and re-trains answering service.	Document call. Create task for PCC.
“I missed my dose of [Humira, Enbrel, etc.].”	URGENT	Assess: When was it missed? Why? Action: Counsel per package insert (e.g., “Take as soon as you remember, then resume your normal schedule.”). Re-educate on adherence tools.	Document encounter. Create task for PCC to follow up on next adherence call.
“I missed my dose of [Oral Chemo, e.g., Ibrance].”	HIGH-URGENT	Assess: When was it missed? Action: Counsel per PI (e.g., “Do NOT double up. Skip the missed dose and resume your next scheduled dose.”). Escalate: Call the on-call oncologist to inform them of the missed dose, as it may affect their cycle.	Document encounter. Create task for Clinical RPh to follow up with MD office.
“I have mild nausea after my injection.”	URGENT	Assess: Is this new? What have you tried? Action: Counsel on non-pharm (ginger, small meals) and OTC (e.g., meclizine) management. Re-assure this is a common side effect.	Document encounter. Create task for Clinical RPh to assess before next fill.
“I have a fever of 101F on my [Biologic or Chemo].”	HIGH-URGENT	Assess: Any other symptoms? Action: Counsel that this is a sign of a potential severe infection (e.g., neutropenic fever). Escalate: Call the on-call provider for the patient *immediately*. Advise patient to go to the ED if instructed by MD or if symptoms worsen.	Document encounter. Create high-priority task for Clinical RPh.
“My package arrived, and it’s warm.”	URGENT (Logistical)	Assess: Was the temperature monitor (if included) activated? Action: Instruct patient to “DO NOT USE” and place in the refrigerator, marked. Empathize. Escalate: Call the on-call provider to inform them of a likely one-day therapy interruption.	Document encounter. Create high-priority task for Dispensing Team to investigate cold chain failure and reship next business day.
“I’m on my last dose and FedEx says my package is lost.”	HIGH-URGENT (Logistical)	Assess: Is this a critical, can’t-miss-a-dose med (e.g., Transplant, PAH)? Action: Empathize. Verify lost package. Escalate: Call on-call provider to explain. Resolve: Attempt to find a local 24-hr pharmacy to transfer a 1-2 day emergency supply to. (This is a last resort but may be clinically necessary).	Document encounter. Create high-priority task for all departments.

29.5.5 Handling “Black Swan” Events: Holidays & Disasters

Your “steady state” and “STAT” protocols cover 99% of situations. The final 1% are “black swan” events: planned closures (holidays) and unplanned closures (disasters). Your accreditation and your P&Ps must have a plan for both.

Protocol for Planned Closures (Holidays)

This is an adherence and logistics challenge. The #1 rule is proactive communication. You cannot let a patient be surprised that you are closed on Thanksgiving.

Protocol for Unplanned Closures (Disaster Preparedness)

This is a core requirement for accreditation (e.g., URAC PHARM Core 21). You must have a Business Continuity Plan (BCP). An auditor will ask, “Your pharmacy is in Florida, and a hurricane just destroyed your building. Your patients on oral chemo are out of meds in 3 days. What is your plan?”

Your plan must have “3 Rs”: Redundancy, Reach-Out, and Recovery.

Masterclass Table: The Disaster Recovery Plan (BCP)

“R”	Requirement	Your Action Plan (The P&P)
1. REDUNDANCY (Systems)	How do you protect your data and phones?	Data: All pharmacy software and patient profiles must be cloud-based or have a secure, off-site, HIPAA-compliant daily backup. (If your server is in the building, you’ve failed). Phones: All phone systems must be VOIP (Voice-over-IP). This allows you to instantly re-route your main pharmacy number to your cell phones or a remote team.
2. REDUNDANCY (Staff)	How does your staff keep working?	Clinical/Access: Your plan must include a “Work From Home” (WFH) protocol. Your RPhs, PCCs, and Access team (who just need a phone and computer) can log in remotely via VPN to continue managing PAs and clinical calls. Dispensing: This is the hardest part. You must have a “Backup Pharmacy Agreement”—a formal, signed contract with another specialty pharmacy (e.g., a branch in another state, or even a trusted competitor) that allows you to securely transfer prescriptions to them for *emergency dispensing* only.
3. REACH-OUT (Patient Care)	How do you care for patients in the disaster zone?	Proactive Outreach: If a known event (hurricane, blizzard) is approaching, your P&P *must* state you will run a report of all patients in the affected zip codes. Emergency Fills: You will proactively call them to ship an “emergency supply” (e.g., 7-14 days) *before* the storm hits. Evacuation Plan: You will ask them for an “evacuation address” (e.g., a relative’s home) where you can ship their next fill.
4. RECOVERY (Facility)	How do you get back up and running?

29.5.6 The Final Step: Auditing Your Own Protocols

You have a “steady state” plan and a “STAT” plan. But how do you know they *work*? As a pharmacist, you know the rule: trust, but verify. You must audit your own systems. This is the “TDM” for your protocols.