Pharmacy within HCA is viewed as simply as this: 1. Drugs cost a lot of money. 2. Pharmacists are in the best position to enforce the formulary. 3. If we have just enough pharmacists in the hospital to make sure really expensive drugs are not being used, we have great pharmacy services.
Attempting to grow and expand services at the facility level is simply not allowed. Decisions in this regard are driven from the corporate office and are generally extremely short sighted. The onus placed on facility-level pharmacy is to do more with less. When the case is made that additional staff is needed, the answer is always "no." Small hospitals especially find themselves woefully under staffed; so much so that patient safety is compromised. The argument that deploying an adequate number of pharmacists to perform clinical work will improve patient outcomes thereby reducing total costs of care (which is well substantiated by evidence) is given no merit. The consistent theme that ideas originating from frontline staff are given no consideration is consistent throughout the company.
Formulary decisions are also made based on short-sighted decision making. The basis of nearly all decisions is reduction of direct drug expenditures. No consideration is given to patient outcomes or evaluation of costs from a broader perspective. Certain medications are essentially banned from use due to their cost, regardless of whether their use would result in the best outcome for the patient. Whether a pharmacy department is managing their supply expense well is evaluated based on drug expense per adjusted patient day; a metric that in no way reflects whether drug purchases are appropriate for the patients receiving the drug. The metric is used simply because it gives the best estimate of income for the company. Thus, if expenditures per unit of income are minimized, a favorable profit margin can be ensured.
In my time with the company, I have seen many decisions made that most would consider to be morally reprehensible. If you raise your concerns, you are considered to be a troublemaker. Individuals who simply keep their mouths shut and do what their told are held in high regard. This is especially true if you suck up to the right people.
Administrators and other leaders will preach about ideals such as accountability and integrity; yet fail to exhibit these characteristics themselves. One would dare not share this observation, however; lest you be considered a problem employee. This is a prominent concept within HCA in general: a lot of talk and very little (if any) action.
Finally, physician bullying is overlooked. Despite its detriment to patient safety, the fact that happy physicians make the company money is enough to convince administrators that there is no sense in addressing physician behavioral issues. The prospect of losing a physician's business is simply not worth the risk.
With so many health systems developing increasingly innovative ways to deploy pharmacists to ensure patients are making the best use of the medications they are receiving, I cannot fathom a reason one would want to work for this company. That is, unless you prefer to be a complacent "yes man" in an extremely bureacratic environment.
