illiam Clifford Roberts, MD (hereafter, WCR): This is August 18, 1998, and I am speaking with Ms. Keenan-Milligan in her office at Baylor University Medical Center (BUMC). Ms. Keenan-Milligan, thank you for taking the time to talk with me today. I understand that you came to BUMC in February 1998. I have heard good things about you. Could you speak a bit about your background? Where you were born? Where you grew up? Where you went to school?

Marilyn Keenan-Milligan, MS, RPh (hereafter, MKM): I have been at BUMC just over 6 months now. I transferred from Baylor Medical Center at Irving where I had been the director of Pharmacy for 14 years. Before that, I trained at the University of Pittsburgh Medical Center and graduated from the University of Pittsburgh School of Pharmacy. Subsequent to coming to Texas, I obtained a master of science in Health Care Administration from Texas Woman’s University. I was born in Pittsburgh, Pennsylvania, and lived all over the world while I was growing up but ended up back in Pittsburgh before going to college.

WCR: When did you come to Texas?

MKM: I had been a supervisor in the University of Pittsburgh Medical Center for about 8 years and was looking to relocate to a warmer climate. A position came up at the Texoma Medical Center in Denison, Texas. I sent in my resume, and the next thing I knew, they flew me to Denison for an interview. I assumed the job there, but it did not work out to be the job I was looking for, so I left in less than a year and moved to Dallas. Denison was a little too rural for me. At that time there were no management positions open in Dallas, so I assumed a position to develop the Intensive Care Unit Pharmacy at Children’s Medical Center. I was there for 6 to 9 months when a position opened at Irving. I came to Irving as the assistant director of Pharmacy, and within 6 months the director left. I ended up being the director at Irving for 14 years. (Two or 3 years ago, of course, Irving merged with Baylor.) When I was offered the directorship of the Pharmacy Department at BUMC, I made the move because I thought it was a step forward in my career.

WCR: When you were at Baylor Medical Center at Irving, how many pharmacists were in your department?

MKM: I had a staff of about 40; 15 to 20 were pharmacists and the rest were support staff.

WCR: How many beds are at Baylor Medical Center at Irving?

MKM: It is licensed for 288 and operates about 240. It runs a census of about 75%.

WCR: Here at BUMC you are the director of how many people?

MKM: About 170.

WCR: Of those 170, how many are pharmacists?

MKM: Sixty to 70.

WCR: You have 3 shifts of pharmacists during the 24 hours?

MKM: Yes.

WCR: How does that break down? Obviously, most of them must be here during daylight hours, or how does it actually work?

MKM: We have 2 sides of the pharmacy operation. One is the clinical side of patient care, and the other is the operation or support part of patient care. The operation side is a 24-hour service, 7 days a week. We staff the main pharmacy and intravenous lab 24 hours a day. Our clinical staff is deployed to the floors during normal work hours, from about 7:00 AM to 6:00 PM, 7 days a week. We have various service lines. We have service lines in cardiovascular medicine, critical care, oncology, bone marrow, women’s and children’s health, and general medicine. The clinical pharmacists cover those various areas based on their expertise. Most of the medication support comes from the operational side, and most of the clinical and cognitive support comes from the clinical side.

WCR: You have divided the Department of Pharmacy into how many different service lines?

MKM: There are about 5 to 6 service lines, and in addition to these we have satellite pharmacies where we staff minipharmacies. We have minipharmacies in the operating rooms in both Roberts and Truett hospitals, and in the bone marrow unit.

WCR: So this is a big operation?

MKM: Our departmental expense budget per year is $20,000,000. Although revenue does not count much anymore, our charges end up being about $100,000,000 a year. It is really like running a little corporation.

WCR: Your charges are $100,000,000 annually, but you don’t receive anywhere near that?

MKM: Correct, only a fraction of that.

WCR: The Department of Pharmacy is one of the biggest expense items of this hospital or indeed any hospital. Is that correct?

MKM: Right.

WCR: Your department and the operating room and anesthesia are the biggest expenses of the hospital?

MKM: Yes.

WCR: It seems that the responsibilities of the Pharmacy Department are getting far more complex than they used to be. In the past, of course, there was an open formulary; today, it looks like most hospitals, including this hospital, are trying to limit the number of drugs on the formulary so you can decrease your expenses without decreasing quality. Is that the double purpose or is it just one purpose?

MKM: The primary purpose is to decrease costs while maintaining or improving quality. It is called the “formulary-decision process.”

WCR: The primary purpose of the Pharmacy and Therapeutics (P and T) Committee of any hospital in the past was to get drugs that had been approved by the Food and Drug Administration on the hospital formulary. In the past that was sort of an automatic process. Is that correct?

MKM: Yes. Before costs became an issue in health care, it was very much a wide-open process with the exception of the Veterans Administration hospitals. Whenever new drugs came on the market, it was almost automatic that they would then be “added to the formulary.” Until relatively recently we did not really call it a formulary. We called it whatever drugs were “stocked in the pharmacy.”

WCR: When BUMC was a completely open formulary, how many drugs did you have in house?

MKM: We probably had 7000 to 8000 line items.

WCR: If you take those particular line items and each drug has, let’s say, 2 or 3 doses, what does that add up to?

MKM: All dosage forms, including oral, injectable, suppository, and topical are considered “line items.”

WCR: So, you are dealing not with 7000 to 8000 different agents, but with a lesser number of agents that may have various dose formulations.

MKM: There may be 3000 to 4000 drugs that make up 7000 line items.

WCR: So, 3000 to 4000 drugs with the various dosages and the different ways of administration all add up to 7000 to 8000 line items.

MKM: Yes.

WCR: Now, BUMC, via the P and T committee of the hospital, is attempting to reduce the number of those drugs from 3000 to 4000 down to a couple of thousand?

MKM: Yes, to end up with a total line item count of about 3500.

WCR: Thirty-five hundred rather than 7000?

MKM: Right.

WCR: The P and T committee is a committee consisting entirely of physicians?

MKM: No. It is a multidisciplinary committee with representatives from key hospital departments such as Pharmacy, Nutritional Support, Nursing, and different subspecialties of the medical staff.

WCR: Who votes in that committee?

MKM: The physicians are the only voting members with the exception of me.

WCR: You are the only nonphysician who can vote?

MKM: That is correct.

WCR: How often does the committee meet?

MKM: It meets every other month. There are 5 subcommittees that meet monthly, and they feed their recommendations into the main P and T committee.

WCR: So, the P and T committee, in actuality, has had its head turned on itself in the past year or so because of its being transformed from simply recommending approval of new drugs that had been Food and Drug Administration approved to actually determining which drugs in a particular class get on the formulary in this hospital?

MKM: Right. We went from a rubber-stamping type of mentality to an analytical decision-making process.

WCR: The physicians who are the voters on that committee surely are not experts in all these various classes of drugs? How many physician members are on the committee?

MKM: Probably 12 or 15.

WCR: How many other members have input but can’t vote other than you?

MKM: Maybe 4 or 5.

WCR: So, the committee not only determines which new Food and Drug Administration–approved drugs get on the formulary, but which drugs in each particular class get on the formulary or stay on the formulary?

MKM: That is correct. One of the subcommittees of the P and T committee is the Drug Usage Evaluation (DUE) subcommittee. That is the subcommittee that does all of the research on the drug classes and makes recommendations to the P and T committee for additions to or deletions from the formulary. The way that subcommittee works depends on the type of drug class the members are looking at. They will do an unbiased, nonproprietary search of all available literature. They will start to compile some results and then, depending on the drug class, will send those to the chiefs of service for those different sections. If it happens to be a cardiology drug, they will get cardiologists’ input on a semifinal list of drugs. The list passes back and forth between the specialists and the subcommittee for a while, and then, once all the consensus is made, it comes to the P and T committee for its recommendation. The P and T committee is not a decision-making body; it simply makes recommendations to the Medical Executive Board.

WCR: So, the Medical Executive Board actually makes the final decision whether a particular drug stays on the formulary or is eliminated and whether a particular drug comes on the formulary for the first time?

MKM: That is correct.

WCR: The people who actually analyze these various classes of drugs and present those recommendations to the P and T committee are pharmacists in your department?

MKM: Right. Most of them are doctors of pharmacy or clinical pharmacists. Some of them are clinical specialists who have years of residency training and practical work experience. They do the literature searches, compile the drug class review, and then bring it to the DUE subcommittee for initial discussion.

WCR: Who makes up the DUE subcommittee?

MKM: A small group of physicians, pharmacists, and nurses.

WCR: The physician members of that committee are members of the P and T committee?

MKM: The chairman of the subcommittee also is the assistant chairman of the P and T committee, but the other physicians, for the most part, do not also sit on the P and T committee. It is a cross-section of physicians.

WCR: You have 13 to 15 physicians on the P and T committee and about 5 subcommittees. How many members are on those subcommittees?

MKM: The subcommittees are each composed of about 5 physicians.

WCR: And you have 5 subcommittees that meet once a month?

MKM: Yes.

WCR: Your pharmacy people are the ones who actually do the research on these drugs, and it is your people who are really making recommendations to the DUE subcommittee, which in turn makes recommendations to the P and T committee?

MKM: Yes, and from those meetings it goes to the Medical Executive Committee for final approval.

WCR: The Medical Executive Committee must surely rubber-stamp the recommendations?

MKM: It sends things back when the members don’t agree. They do read the minutes of the P and T committee and take their job seriously as to whether they will approve things.

WCR: You and the members of your department who are on these DUE subcommittees and who write up the analyses of drugs must be under enormous pressure from pharmaceutical companies and physicians and others to get this or that drug on the formulary.

MKM: Probably the most pressure comes from the pharmaceutical companies. We don’t allow the drug companies a lot of access to the people doing the research. We don’t allow any literature to be submitted from a drug company! We want to make sure it is as unbiased as possible. We go to Medline and Grateful Med and other databases to do our analyses on comparative drug studies and efficacy outcomes.

WCR: You have published several of these analyses in the BUMC Proceedings, and they have been very good. Suppose I come into BUMC taking a particular drug, and I am here for 5 days and the drug I am taking is not on BUMC’s formulary. What happens?

MKM: These are procedural issues that we are attempting to work in the formulary package. Some options being considered for chronic medications in stable patients are having the pharmacist contact the patient’s physician to promote a change, obtaining the drug on a nonformulary basis, or allowing the patient to take his/her own medication brought from home. This kicks in a whole different process of ensuring that what is in the bottle from the patient’s home is indeed the drug that it is labeled to be. The pharmacist’s input in the identification process of that medication is still needed. Those are details we are still working out. That is why the formulary has not been totally rolled out yet. We have these detailed procedures to be worked out, and we strive for consensus with the medical staff.

WCR: In the past, if I was taking 3 drugs on the outside and came into the hospital, I would not be able to take the medicine that I had brought in from the outside while I was in the hospital?

MKM: Yes. We used to discourage that process. We could not assure that the drugs had been stored correctly or that they were still within a good expiration date. For a variety of reasons it was best that the institutional pharmacy supply those medications. These are probably still valid things to look at. Now, we have to weigh that against the following: do we get a bottle of 100 pills, use only 5 of them, and never use the rest? Patients are much more knowledgeable now about the drugs they are taking. If you try to switch them from a pink pill to a blue pill, they question the nurse and the physician, and it sets up a whole new realm of concern.

WCR: You are reconsidering the idea of patients taking the drugs that they brought to the hospital while they are in the hospital?

MKM: Yes, that is true.

WCR: That must decrease the income that the Pharmacy Department would make. If 20% of the patients coming into BUMC brought their own medicines in with them and took those medicines, the income of the BUMC Pharmacy Department would diminish?

MKM: We mostly find that that is not real income anyway. It is a write-off against per diem charges. Everything is so discounted now that we really don’t think it is going to have a big impact on the bottom line of the organization.

WCR: Let me put another scenario in front of you. Let’s say I am in the hospital and taking a drug on your formulary, but after discharge I learn that the drug on your formulary is not on my managed care plan. What do I do then?

MKM: Generally, an intervention is done at the retail pharmacy level. Because there is on-line adjudication of prescriptions, a pharmacist pulling up your name also pulls up the name of your carrier. Typing in the prescription with a particular drug not covered under your plan will light up a warning. You, as the patient, can demand that you want that prescribed drug, but you must pay for it yourself. Or, the pharmacist can contact the physician and recommend a change to whatever your managed care plan does cover. This type of service is what we are also balancing by having an in-house formulary different from other managed care formularies. It is difficult for the physician to keep track of what is on what plan. They can’t do it.

WCR: It must be discouraging to some pharmaceutical companies who spend $300,000,000 to develop a drug and then are unable to get it on the hospital’s formulary. The new drugs are developed by the pharmaceutical companies. Physicians are not developing new drugs. You are not developing new drugs in your department. So, the pharmaceutical companies have to have some profit to continually come up with new drugs. How do you handle that?

MKM: Whenever we are making a formulary decision, the first thing we look at is the efficacy and safety profile of the drug. If we agree that there are 2 or more drugs that meet the same criteria with the same outcome, then we put them up for bid. We open up the opportunity for the pharmaceutical companies to give the best pricing available for their product, assuming we could shift the market share of their competitor’s product totally to their product or to at least a significant amount of that market share. What most pharmaceutical companies are interested in right now is the highest percentage of market share in whatever therapeutic class of drug they have.

WCR: Let’s take antihistamines. In the days of an open formulary, maybe 11 antihistamines were available in your pharmacy department, and now you want to limit that number to 2. If you limit it to 2, the manufacturers of those 2 drugs will give you a huge discount at the end of the year, if you use a certain amount of their product during that period.

MKM: The discount will vary. They are not all huge. Sometimes we make formulary decisions that actually end up costing us some money because it is the best drug to use and there is no manufacturer willing to come to the table and negotiate better pricing. Usually, however, there are opportunities to save money. We looked at one antibiotic class called the fluoroquinolones and looked at all the drug entities available in that class of drugs. One manufacturer came to the table after we had done all of our literature search to show that their drug was as good as any out there, and that company offered us a significant price savings. It meant that if we were able to convert 80% of the market share to their drug, we would save about $150,000 per year. Sometimes the savings can be significant, but sometimes we are just talking about nickels and dimes.

WCR: The problem really is that managed care, insurance companies, and the government are putting a squeeze on the hospitals. Since the Pharmacy Department is such a big spender in the hospital, the hospital is looking for ways to save money, particularly in the areas that spend the most money.

MKM: Your leverage points. Pharmacy is a big leverage point.

WCR: There are some who argue the best way to save money is to have an open formulary. How do you respond to that?

MKM: I think that history has shown that if you can control your formulary and you make good decisions, the manufacturers will come to the table and will negotiate pricing. As long as there is a free market and they are competing on the best sales job they can do or on their marketing campaign, they are not willing to negotiate price at all. They are going to get the best price they can.

WCR: The Pharmacy Department at BUMC is spending $20,000,000 a year. You want to get that cost down to what?

MKM: We don’t know what the whole potential is because for so long there has never been a formulary at BUMC. We don’t know how receptive the manufacturers are going to be to price negotiations. I think they are sitting back waiting to see how successful we are in rolling out our first group of drugs. The more successful we are, the more willing they will be to talk. I am sure that there are at least a couple of million dollars in potential savings.

WCR: You have to balance that with physicians and patients not being able to get the drugs they want. Is $2,000,000 worth it from a public relations standpoint?

MKM: The administration has to answer that question. Pharmacy is here to gather the information and give the medical staff the ability to make an informed decision. Whether or not this is a doable project comes from the highest levels of the administration.

WCR: Baylor University Medical Center is just one cog in the big wheel of the Baylor Health Care System. Also, this is a tertiary hospital in many respects. Potentially, the decisions made at this hospital can have a great impact on Baylor’s other hospitals. When you make a decision as to which drug is going to be on the formulary here at BUMC, are you at the same time determining the formulary at these other Baylor hospitals?

MKM: Yes, we have an integrated pharmacy group in place to make those kinds of decisions and role them out. In fact, most of the community medical centers have been successful in implementing a formulary. Baylor University Medical Center is the only campus that does not have a closed formulary in the whole Baylor Health Care System.

WCR: Why is that?

MKM: Part of it is because the previous pharmacy administration did not consider a closed formulary a high priority. They did not agree with the concept, and I don’t know the reasons for that. Probably they just did not feel it was a battle worth fighting. Another obstacle is the sheer size of this organization. To get communication to all the levels of the medical staff is difficult. It is much easier to get consensus when working with a medical staff of 200 to 300, which is my experience in a mid-sized hospital, versus a medical staff of 1000 physicians.

WCR: You jumped into a fire by coming here?

MKM: Yes, but I knew that.

WCR: You think this fire is going to burn how long?

MKM: It depends on the support of the medical staff and how well we can educate them about the process by which decisions are made. The process is a medical staff–driven one, not a pharmacy-driven one. The success also depends on administrative support. This can’t just be the Pharmacy out there alone doing this. It has to be the administration educating the physicians that this is an important thing for BUMC to do for long-term survival. I believe that if we are successful, we will definitely be able to move market share and see significant savings. This is a very powerful organization, very well respected by drug manufacturers, and we have a lot of leverage. We just have not used that leverage before.

WCR: Let me ask you a bit about the P and T committee. You mentioned that it consists primarily of physicians, although there are nonphysicians on the committee, but you are the only nonphysician with a vote?

MKM: Yes.

WCR: It seems that the names of the physicians on that committee are somewhat secretive. I gather the reason is that the physicians would otherwise be flooded with visits from pharmaceutical representatives pleading their cases.

MKM: That is true. I don’t know why it is so secretive. It could just be another symptom of a lack of communication within the organization. The physician members are appointed through the medical staff process, just like any other committee. I don’t think there is any conscious attempt to make it secret other than maybe keeping it secret from the drug companies.

WCR: Does the Pharmacy Department ever take grants, restricted or unrestricted, from pharmaceutical companies?

MKM: Yes, we do.

WCR: How does that come about?

MKM: A manufacturer may come and say that they have the opportunity to make available to us a couple of thousand dollars as an unrestricted educational grant with no promise on our part to buy their drug, to use their drug, or to persuade physician or pharmacy practice.

WCR: Let’s say you have 2 drugs you are evaluating and you think one of them certainly deserves to be on the formulary and you want to limit it to 1. If one of those companies gives you an unrestricted grant, aren’t you a little more liable to put that drug on the formulary rather than the other one which does not give you an unrestricted grant?

MKM: No. That would not be factored into the equation at all. We would expect more income from a decrease of the acquisition price than from an unrestricted grant. If they both came to the table, all other things being equal, it drops down to a price issue. We never factor in that this company is going to give us $5000 and this company is not going to give us any grant. We would not do it, and it has not happened.

WCR: What do you use these unrestricted grants for in your department?

MKM: To pay for educational programs mostly.

WCR: That you have in-house or at other sites?

MKM: The grants allow somebody to go to a seminar in their specialty or to buy a new piece of equipment, such as a personal computer.

WCR: What has been the biggest surprise for you since you came to BUMC?

MKM: How difficult the formulary implementation process is. Understanding the complexity of this organization and the many layers through which you have to work, not only to get a decision made, but also to have it implemented.

WCR: It takes a while?

MKM: It takes a long time.

WCR: You had a limited formulary at Irving?

MKM: Yes, we did.

WCR: You were able to convert that from an open formulary to a limited one in a reasonable period of time?

MKM: When I got there 14 years ago that was the first thing I did. We had a closed formulary there for nearly all of the 14 years I was there. To be honest with you, it was a day-to-day struggle to keep it closed. There were always oddball medications that patients are on when they come in. We had a fairly logical process where we would reexamine each drug class every 2 years. We were always trying to stay on top of what was already out there. When new drugs became available, we did a formulary analysis as to whether to place the new drug on formulary. We looked at the whole class again in 2 years.

WCR: I gather that one reason BUMC was quite interested in you was because you had already converted an open formulary into a closed formulary.

MKM: I don’t know if that was the case, but, nevertheless, it is a different scenario here.

WCR: You mean it is more difficult to get the process moving and keep it moving at BUMC than it was in Irving?

MKM: I think once it is put in place and physicians get used to it, it will go much more smoothly. The whole thing of bringing it to life is full of problems and obstacles.

WCR: Closing the formulary has been your biggest challenge since you have been at BUMC?

MKM: Absolutely.

WCR: Do you think it will stay your biggest challenge for a while?

MKM: Other than getting ready for the year 2000 and making sure that none of our computer systems blow up. That is the only other really major challenge.

WCR: How many computers do you have in your department?

MKM: We have about 100 to 150 personal computers. Because we have terminals on the nursing units on the floors, we support at least 8 to 10 different databases.

WCR: What do you mean by “databases”?

MKM: We have a database that controls our clinical information, the patient profile, and the actual dispensing of medications. We have a database that controls all the compounding for total parenteral nutrition. We have a database that controls where labels route within the manufacturing process. We have a database that controls the machines that dispense the drugs, both on the floor and in the central pharmacy. There are 8 or 9 separate databases.

WCR: How many pharmacists do you have on the floors during the daylight hours?

MKM: About 10 or 15 throughout the day.

WCR: They are consulting with physicians a lot of that time?

MKM: Because there is not standard rounding time for physicians here, it is catch-as-catch-can. If you are looking for a physician, you either beep him/her or leave a note. The pharmacists also consult with the nurses. We are trying to do kinetic dosing and renal dose adjustments based on patients’ creatinine levels. There are a variety of activities that the pharmacists do on the hospital’s floors.

WCR: You have worked with drugs for a long time. What is your view about how much the average physician knows about drugs?

MKM: I think most are fairly knowledgeable within the scope of their practice. In other words, if they are a subspecialist they know the drugs they use every day very well. When they get out of the box of drugs they use daily, the assistance of pharmacists is helpful in choosing drug regimens and dosages. The pharmacists’ knowledge of drug interactions is helpful. Things are so complex now that nobody can keep all these different complications and contraindications in his/her mind. The computer systems help us support that kind of information.

WCR: Did you make the right decision for yourself to come to BUMC?

MKM: Yes. I would like to see BUMC physicians give the pharmacists an opportunity to show what value they can add to the physicians’ practices. We are not looking to try to manage their patients or their practices, but there are some services and cognitive type things that we can provide. I hope the medical staff will be open-minded to at least give it a try. I enjoy working here. I have enjoyed every person I have come in contact with, and it has been a pleasure so far. Six months have gone by fast.

WCR: You mentioned earlier that you would show me around your department.

MKM: Yes. We try to use as much bar code technology as possible to decrease the potential for medication errors because we dispense 6 million doses of medication in this pharmacy each year.

WCR: That includes both pills and injections?

MKM: Yes.

WCR: Six million. Wow! How many errors are made a year?

MKM: We don’t exactly know right now. It is <0.001%. Medication errors, however, are traditionally underreported because of the punitive process that usually goes along with errors. We think we know only the tip of the iceberg. Much goes unreported.

WCR: It is usually the wrong drug or the wrong dose?

MKM: Usually it is the wrong drug.

WCR: What happens in here? (tour of area)

MKM: This is our education center. We are doing a lot of personal computer–based training where people can work in a quiet area. All of their references can be obtained in here. A lot of our references are on-line on the Web. In our receiving area, we transmit electronically to our vendors who send the medication. Then we scan the bar codes and enter them into our inventory. We keep on the shelf at any 1 time about $1,500,000 worth of drugs. We have a lot of medicines coming through here every day. Controls are a big issue. We have to make sure that what we ordered is what we received.

WCR: Your operation is very much at the mercy of computers?

MKM: Yes. We would like to be even more at their mercy. We need more sophisticated computers than we now have. What we would like to see is the whole bar coding technology taken to the point of care of the patients so that a drug is monitored from the time it is delivered to the Pharmacy Department to the time it is administered to the patient.

WCR: What happens in this area?

MKM: This is where we process all orders. The nurse faxes the orders down, we verify the medications, make sure there are no complications or drug interactions, and then release the drug to what is called a “verified status.”

WCR: “Verified status” means what?

MKM: That the pharmacist has reviewed it and everything is okay, that there will be no complications to the patient.

These are called REMstar units, and they are interfaced with the order processing that is ongoing on the floors. As new orders are entered, these shelves will rotate around and stop on the needed shelf. Then the bin lights up. The employee picks the quantity based on information provided by the carousel. She has a label instructing her to put 1 in the bag. She scans it, and if she scans the wrong thing, it beeps at her and tells her she has done the wrong thing. Then it goes to the next order.

WCR: Thus, it is difficult to make a medication error?

MKM: Yes.

WCR: Good, that makes me feel better. What happens here?

MKM: These are outpatient prescriptions for transplant patients. Now, most outpatient traditional prescription filling is sent to a local pharmacy.

WCR: Why is that?

MKM: Part of it has to do with the contracts we have signed. We have signed contracts that say we get the best pricing if we only use the product for our patients in-house. A person cannot walk off the street and get a prescription filled in our hospital pharmacy. The manufacturers will not allow that because it is considered a violation of the contract.

WCR: What happens in this area?

MKM: These are all of our controlled substances. Every narcotic we possess is in here. Another database system manages the controlled substances. The system is a good tracking mechanism because, obviously, controlled substances have the highest potential for diversion. We need to meet a lot of legal and safety requirements that relate to handling controlled substances. All of this is controlled by computers.

WCR: You seem to be pretty compact here. Do you have enough space?

MKM: We have plenty of space.

WCR: I’ll bet you are the only departmental chair at BUMC who would make a statement like that.

MKM: We just got a whole new pharmacy, so I cannot complain.

WCR: All this is new as of when?

MKM: We moved in July 1998. We lived through the renovation. We worked here while it was being rebuilt, which was difficult.

WCR: What happens in here?

MKM: This is our conference room where we have meetings and in-services.

WCR: Do you have meetings every day?

MKM: We have conferences about once a week. Staff meetings are once a month. We have to go to an even bigger room for staff meetings because we can’t all fit in here.

WCR: Do the pharmacy people from other Baylor hospitals come in for the meeting?

MKM: No.

WCR: You have no control over the pharmacy departments at the other Baylor hospitals?

MKM: I have no management oversight, but we work very well together in a consolidated group to try to address issues and make decisions as a system rather than as individual hospitals.

WCR: Do you hope that drugs on formulary at BUMC will be those on formulary for the entire system?

MKM: Yes. It would obviously give us more leverage if we could implement things as a system instead of at just 1 hospital, although there is such volume here that we could do it by ourselves and still drive the market share for the other Baylor hospitals. It would be nice to have the whole Baylor Health Care System reap the benefits of our efforts.

WCR: Ms. Keenan-Milligan, on behalf of BUMC Proceedings readers, thank you for the opportunity to “pick your brain” and for your openness in discussing the operations and goals of your Pharmacy Department.

MKM: Thank you.