CHPPC Module 32, Section 1.5: Capturing Wins for Stewardship
MODULE 32: FORMULARY, NON-FORMULARY & THERAPEUTIC INTERCHANGE—WITHOUT FRICTION

Section 32.5: Capturing Wins for Stewardship & Budget Impact

Making your value visible: The art and science of documenting your clinical and economic impact.

SECTION 32.5

Capturing Wins for Stewardship & Budget Impact

If you don’t document it, it didn’t happen: Proving your worth in the language of data.

32.5.1 The “Why”: From Invisible Cost Center to Visible Value Generator

In the traditional hospital model, the pharmacy department is often viewed through a single, unflattering lens: as a massive cost center. The drug budget is one of the largest line items in any hospital’s operating expenses, and from an administrative perspective, the pharmacy’s primary role is to control that cost. This view, while fiscally understandable, is profoundly incomplete. It completely misses the enormous value that pharmacists generate every single day. Every therapeutic interchange, every IV-to-PO conversion, every renal dose adjustment, every prevented adverse drug event is not just a clinical action—it is an act of value creation. It improves patient outcomes, shortens length of stay, prevents costly complications, and promotes the responsible use of resources.

The problem is that this value is almost entirely invisible. The cost of the drugs you dispense is meticulously tracked down to the penny. The value of the interventions you make is often ephemeral, existing only in a brief conversation or a note in a chart, and then vanishing into the ether. The single greatest challenge and opportunity for the modern pharmacy department is to make this invisible value visible. This is accomplished through the systematic, rigorous, and consistent documentation of your clinical interventions. The old adage, “If it wasn’t documented, it didn’t happen,” is not just a legal maxim; it is a professional and economic imperative.

This section is a masterclass in the art and science of capturing your wins. We will move beyond the clinical action itself and focus on the crucial final step: recording your impact in a quantifiable, reportable, and persuasive way. You will learn that documenting an intervention is not “extra work” that comes after your “real work”; it is part of the real work. It is the final step that transforms a single clinical act into a data point, and those data points, when aggregated, tell a powerful story. They tell the story of a pharmacy department that is not just a cost center, but a powerful engine of clinical quality, patient safety, and financial stewardship. Mastering this skill is essential for your personal career growth, for the advancement of your department, and for the continued recognition of pharmacy as an indispensable pillar of patient care.

Retail Pharmacist Analogy: The “Coupon Savings” on the Receipt

Think about a modern grocery store or retail pharmacy receipt. At the very bottom, there is often a line that says, “You saved $12.58 today with your loyalty card!” Why do they do that? It’s a brilliant piece of business psychology.

Without that line, your experience is purely one of cost: “I just spent $85 on groceries.” With that line, the experience is reframed around value: “Wow, I spent $85, but I got a great deal and saved over $12!” The store has successfully made their value visible at the point of transaction. They have documented their “win.”

Now, imagine your pharmacy’s Director of Pharmacy has her annual budget meeting with the hospital’s Chief Financial Officer (CFO).

  • Scenario A (No Documentation): The CFO looks at a spreadsheet and says, “Your drug expenses were up 8% last year. You are a massive cost center. I need you to find ways to cut your budget.”
  • Scenario B (With Documentation): The Director of Pharmacy comes to the meeting with her own report. She says, “Yes, our drug expenses were up 8% due to a few new, expensive oncology drugs. However, I want to show you this. My team of clinical pharmacists documented 15,000 therapeutic interventions last year. Those interventions resulted in a direct, documented cost avoidance of $2.1 million. We are not a cost center; we are one of the most effective cost-saving departments in this hospital. In fact, our data shows we need to hire another clinical pharmacist for the ICU, where we could capture an additional $300,000 in annual savings.”

Every time you document a therapeutic interchange, you are adding a data point to that second report. You are printing the “You Saved…” line on pharmacy’s receipt. You are changing the narrative from cost to value.

32.5.2 The Anatomy of a “Win”: What, How, and Why to Document

Effective documentation requires a standardized approach. You need to capture the same key pieces of information for every intervention so that the data can be aggregated and analyzed meaningfully. Most modern EHRs (like Epic and Cerner) have built-in “Intervention” or “Clinical Documentation” tools designed specifically for this purpose. Your first step is to master the tool your institution uses. While the specific clicks may vary, the core data fields are universal.

Masterclass Table: The Essential Fields of an Intervention Note
Data Field What to Capture Example & “Street Smarts”
Problem/Reason for Intervention What was the issue you identified? This is the “why” of your action. The EHR tool will have a picklist of standardized problems. Example: “Non-formulary agent ordered.”
Street Smarts: Always pick the most specific reason possible. “Dose too high” is better than “Incorrect Dose.” Precision here makes the data much cleaner.
Recommendation/Action Taken What did you do about it? This is the “what” of your action. Again, use the standardized picklist. Example: “Changed to formulary alternative per protocol.”
Street Smarts: Be sure to capture the outcome. If the provider accepted your recommendation, great. If they rejected it, you must document that as well. “Provider rejected recommendation; wishes to continue non-formulary agent.” This is also important data.
Drug(s) Involved The specific medications related to the intervention. Most tools allow you to link directly to the order. Example: Changed From: Esomeprazole 40mg IV. Changed To: Pantoprazole 40mg IV.
Street Smarts: This is critical for cost analysis. Without the specific drugs, you cannot calculate the financial impact. Be meticulous here.
Cost Impact / Cost Avoidance ($) The financial impact of your intervention. This is the most powerful field and the one most often neglected. Example: “$85.00”
Street Smarts: Your EHR or a departmental tool should help you calculate this. The basic formula is: (Cost of Original Therapy – Cost of New Therapy) x Duration. Even if your system doesn’t auto-calculate, you should learn the costs of your top 10-20 interchanges and enter it manually. This is your value statement.
Clinical Impact / Stewardship The non-financial benefit of your intervention. This captures your impact on patient safety and quality of care. Example Picklist: “Adverse Drug Event Prevented,” “Antimicrobial Stewardship,” “IV to PO Conversion.”
Street Smarts: This is where you capture the “softer” but critically important wins. An IV-to-PO switch saves money, but its biggest impact is reducing the risk of a central line infection and facilitating earlier discharge. Choose the best descriptor.
Free-Text Comments A brief, objective narrative of the situation, if needed. Example: “Patient on clopidogrel. Switched from non-formulary esomeprazole to formulary pantoprazole to avoid CYP2C19 interaction and align with hospital protocol. Change made per automatic therapeutic interchange policy. Notified RN via EHR note.”
Street Smarts: Keep it short, professional, and to the point. State the facts. This is not the place for subjective opinions. Justify your action and confirm you closed the communication loop.

32.5.3 Calculating Your Impact: The Art of the Cost-Avoidance Calculation

Documenting a cost impact can feel intimidating, but it is based on a simple and defensible formula. The term “cost savings” is often a misnomer; you didn’t literally save money that was already spent. The more accurate and professional term is cost avoidance—you have prevented the hospital from spending more than was necessary to achieve the same or better clinical outcome. The calculation for a simple therapeutic interchange is straightforward.

The Core Cost-Avoidance Formula

$Cost , Avoidance = (Cost_{Original , Drug} – Cost_{New , Drug}) times Duration , of , Therapy$

Key Definitions:

  • Cost: This should be the actual acquisition cost (AAC) of the drug for the hospital, which is the price the pharmacy actually pays the wholesaler. Your institution will have a standard formula, often based on Wholesale Acquisition Cost (WAC) minus a contracted discount. For your daily work, a simplified cost file is often available.
  • Duration of Therapy: This is an estimate. For an antibiotic, you might use the planned course of therapy (e.g., 7 days). For a maintenance medication like a PPI, you might use the patient’s average length of stay for that diagnosis (e.g., 4 days). Your department should have a standardized list of durations to use for consistency.
Worked Example: The Classic PPI Swap
  • Order: Esomeprazole 40mg IV daily.
  • Intervention: Changed to Pantoprazole 40mg IV daily.
  • Cost Data:
    • Cost of Esomeprazole 40mg vial: $90
    • Cost of Pantoprazole 40mg vial: $5
  • Assumed Duration: 4 days (Average Length of Stay)

Calculation:

$Cost , Avoidance = ($90/day – $5/day) times 4 , days$

$Cost , Avoidance = ($85/day) times 4 , days = $340$

By spending 60 seconds making a simple, evidence-based swap and another 30 seconds documenting it, you have just generated $340 in value for the institution. Now, multiply that by the number of similar swaps you and your colleagues make every single day. This is how you demonstrate a multi-million dollar impact.

32.5.4 Beyond the Dollar Sign: Capturing Clinical and Stewardship Wins

While cost avoidance is the easiest metric to understand, it is not the most important. Your clinical impact on patient safety and quality of care is your true value, but it can be harder to quantify. This is where using the standardized “Clinical Impact” fields in your documentation tool becomes critical. These allow you to categorize the non-financial benefits of your actions.

Masterclass Table: Documenting Your Clinical Value
Intervention Type The “Win” You Are Capturing Documentation Example
IV to PO Conversion Reduced risk of CLABSI (Central Line-Associated Bloodstream Infection), reduced nursing time, facilitated earlier discharge, significant cost savings on drug and supplies. Problem: “IV route inappropriate – patient on oral diet.”
Action: “Changed to oral equivalent.”
Drugs: From: Levetiracetam 500mg IV q12h. To: Levetiracetam 500mg PO q12h.
Cost Avoidance: (Calculate based on drug/supply cost difference).
Clinical Impact: “IV to PO Conversion.”
Antimicrobial De-escalation Improved antimicrobial stewardship, reduced risk of C. difficile, reduced selective pressure for resistant organisms, often significant cost savings. Problem: “Spectrum of coverage too broad.”
Action: “Recommended narrowing of antimicrobial therapy.”
Drugs: From: Vancomycin/Piperacillin-Tazobactam. To: Cefazolin.
Cost Avoidance: (Calculate).
Clinical Impact: “Antimicrobial Stewardship.”
Comment: “Final cultures resulted as MSSA. Per discussion with ID and primary team, de-escalated to cefazolin.”
Preventing an Adverse Drug Event (ADE) This is the pinnacle of pharmacist value—preventing harm before it happens. This includes catching drug interactions, incorrect doses, or contraindicated medications. Problem: “Significant Drug Interaction.”
Action: “Discontinued/changed offending agent.”
Drugs: Discontinue: Sertraline. Continue: Linezolid.
Cost Avoidance: (Often $0, but the value is immense).
Clinical Impact: “Adverse Drug Event Prevented.”
Comment: “Patient on linezolid. New order for sertraline placed. Called provider to recommend holding sertraline due to high risk of serotonin syndrome. Provider agreed.”

32.5.5 From Data to Action: What Happens to Your Documentation?

The final step in this process is understanding how your individual data points are aggregated and used to drive institutional change. Your meticulous documentation fuels the engine of quality improvement and demonstrates the pharmacy’s return on investment (ROI).

  • Departmental Dashboards: Your pharmacy leadership will use this data to create monthly or quarterly reports. These dashboards might track total cost avoidance, the number of interventions per pharmacist, the most common drug classes requiring intervention, or the prescribers who most frequently order non-formulary agents.
  • Targeted Education: If the data shows that one particular medical service is responsible for 80% of the non-formulary PPI orders, this is not a reason for punishment. It is an opportunity. A clinical coordinator or manager can now approach the chief of that service with objective data and offer a targeted educational session for their team.
  • P&T Committee Decisions: Your data provides the real-world evidence the P&T committee needs to make informed decisions. If you document dozens of cases where a non-formulary drug was required because the formulary agent failed, you have just built the case for adding that drug to the formulary.
  • Justifying Your Job: Ultimately, this aggregated data is the most powerful tool your director has to justify the expansion of clinical pharmacy services. When they can go to hospital administration and prove that every dollar invested in a clinical pharmacist’s salary returns three dollars in documented cost avoidance and quality improvements, they can make a compelling case for hiring more staff, expanding your role, and investing in new pharmacy programs. Your daily documentation is a direct investment in your own professional future and the future of your department.