Challenges and Lessons Amid the COVID-19 Pandemic at One College of Pharmacy

Continuity of Operations

The University of Oklahoma has always had some form of a disaster recovery plan, but it was not until the fall of 2014 that the university created the emergency operations plan (EOP) that provided for a more integrated plan among all the different colleges, units, and divisions. A key component of the EOP is the Continuity of Operations Plan (COOP). The OU College of Pharmacy took this responsibility to heart and converted our plan into the COOP. The EOP takes into consideration as many scenarios of disruption as possible and is built around short-term disruptions (1-2 days), medium-term disruptions (1-2 weeks), and long-term disruptions (30 days or longer). While the COOP did not address all of the unique challenges presented by COVID-19, it helped us respond to an unprecedented long-term disruption for which no one was fully prepared.

Essential vs Nonessential Personnel

Because the college has several areas of operation, we had to modify our operations differently for each area. For the entire college, we identified individuals who were essential vs those who were nonessential. The one thing that became clearer during this pandemic is that some individuals who might be considered non-essential in a short disruption became essential (at least part of the time) in the long term. For example, the college could have gone a few days without having checks deposited or invoices paid, but these jobs became more critical as time passed so we had to adjust employees’ schedules to ensure these tasks were completed.

The other variable that we had planned for was the need for essential employees to be able to work from home, so we already had most of those employees set up to do that. Where we had to adjust our plan was when the need arose for nonessential employees to work from home as well. We made provisions for these employees to come in once or twice a week to drop off files and pick up invoices and other deliverables. They then finished those processes at home by logging into our systems using remote access software. Nonessential employees who could not work from home (eg, they did not have internet access) were instructed by central administration to use administrative leave during this time. While this applied to only a small percent of people in the college, we still had to account and track those expenses by adding a new field in our payroll system labelled “COVID-19 Leave.”

A Spring Break Week to Remember

On March 17, 2020, we decided that for at least two weeks following spring break, the didactic program would be delivered via distance learning. Given that the school previously had a satellite campus, we already had most of the technical components in place and many faculty and staff members were familiar with the process. We did have to pivot quickly on testing procedures. On March 19, our Associate Dean for Academic Affairs collaborated with a manager in the campus Academic Technology unit to provide a one-hour crash course for faculty and staff members on maintaining the integrity of and procedures for students testing off campus using Respondus Monitor (Redmond, WA) with a webcam and microphone for remote proctoring. To maintain social distancing, faculty and staff members assembled in five separate rooms throughout the college building, used the college’s integrated technology system to communicate, and had no more than 10 individuals in one space. The campus uses the Desire2Learn (Kitchener, Ontario, Canada) learning management system. We have two staff members who coordinate all aspects of the Respondus Monitor program, including setting parameters, inputting items, proctoring, and troubleshooting all technical problems, who were critical to the success of the change in testing procedures. These staff members now also review any flagged student videos after the examinations and follow up with students who have excessive or major flags. There have been very few flags to date. However, one student would frequently swear when she began a test. This was reported to the Associate Dean for Students Affairs who reminded the student that she was being recorded and to cease the behavior. Several procedures were put in place to ensure academic integrity such as having students hold their college ID in front of the camera, having each student’s microphone and camera turned on throughout the examination, and not allowing students to wear a hat or have extraneous materials nearby. Some faculty members also felt we should not allow reverse navigation (ie, the ability for a student to return to an earlier question in the examination), display only one question at a time, and place a time limit on completing individual items.

After spring break ended and several rounds of tests were conducted under these conditions, class presidents reported to the academic affairs and student affairs associate deans that the students felt disrespected and that it seemed faculty members almost had an expectation that they would cheat. The administrative team made the decision to alter the testing environment such that reverse navigation would be allowed, all test items would be displayed, and individual items would not be timed. That is, returning to conditions similar to those students had experienced sitting in a lecture hall on campus, albeit with remote proctoring. The students were very grateful and there was much less stress and tension regarding testing.

On March 20, a telework policy was disseminated to the college from the dean’s office. This went out the window, so to speak, when the following week the University of Oklahoma Health Sciences Center (OUHSC) sent out shelter-at-home orders and guidelines for telecommuting through April 15, which was subsequently extended through May 8, for nonessential personnel. On May 11, employees were encouraged to continue telecommuting through June 30 if possible, but faculty and staff members were allowed the flexibility to work from their office on campus if necessary.

By March 25, the college determined that the didactic curriculum would be delivered via distance learning for the remainder of the semester. The experiential portion of the curriculum required extensive adjustments, which were handled by our Associate Dean for Professional Programs and recently appointed Director of Experiential Education. We adjusted internal APPE requirements from two ambulatory care rotations to one and, with approval of the college’s curriculum committee, we allowed students to complete a maximum of four vs two non-patient care rotations and still meet ACPE standards. We created an Essential Knowledge and Skills APPE elective for all fourth-year students who had met their core patient care APPE requirements. This was instrumental to ensuring these students met graduation requirements.

Service Units

The college also operates the Oklahoma Center for Poison and Drug Information (OCPDI),¹ Pharmacy Management Consultants (a pharmacy benefit administrator for the state Medicaid system),² a nuclear pharmacy,³ and four community pharmacies⁴ on our health sciences campus. Each operation is essential. For example, the OCPDI is required by the state to take calls 24 hours a day as citizens, hospitals, physicians, daycare workers, and others use this service at night as well as during the day. The OCPDI was able to quickly make arrangements to provide services remotely, thereby allowing most OCPDI employees to take calls and record them to the system from home. These steps were critical to continuing these operations. Although calls specific to COVID-19 increased, of greater concern was the increase in calls about children getting into cleaning supplies (bleach cases were up 13% and disinfectants up 46%) and people inappropriately mixing cleaning products (71% higher than the previous year), likely resulting from most families staying at home during the crisis.

Our PMC operations are critical for the continuity of pharmacy benefits for the state Medicaid population. With specific performance metrics built into the agreement, our clinical pharmacists and staff members have been able to continue providing the services remotely. Prior authorization services and drug utilization review (DUR) services are important components of this agreement and obtaining prior authorizations ensure patients get their medications in a timely manner. We still have a few employees coming into the office to work (eg, new employees, call center employees who lack high-speed internet access), with all practicing social distancing while there.

The pharmacies managed by the college are located within clinics or in hospitals and are essential to ensuring that patients have easy access to medicines. Consequently, we have maintained the same operating hours and continue to serve the patients who are seen in clinics or discharged from the hospital. When possible, we deliver medications to the bedside upon discharge to ensure that patients go home with the medications they need and thus limit their exposure by not having to go to a commercial pharmacy. These are the pharmacists and technicians on the front line of health care, and they did not balk about providing these services. We have modified pharmacy operations where we can to improve safety, such as by installing glass partitions, wearing masks and gloves, limiting the number of patients in the pharmacy at any given time, and sanitizing the space continuously. Initially, we had difficulty in acquiring the preferred N95 masks for the pharmacy staff to wear. Upon our initial attempt to obtain some through normal distribution channels, we were first told the masks were on backorder and later told that the order had been cancelled. Our hospital partner provided us with some surgical masks (especially important for our staff members who were delivering medicine to patients’ bedsides). When those ran out, they provided us with cloth masks until we were able to get another supply of surgical masks. We had some gloves and other supplies left over from our annual flu clinics and diverted them to the pharmacies as needed. Finally, our nuclear pharmacy was able to compound hand sanitizer to distribute as needed, and even acquired 95% alcohol from a local liquor store when the supply chain for industrial alcohol was interrupted.

Our nuclear pharmacy typically spends its day preparing approximately 400 doses of radiopharmaceutical medicines for patients at 25 area hospitals and clinics. With elective and non-emergent procedures cancelled or postponed, we saw as much as a 40% drop in the number of doses ordered. As procedures have begun to increase again, dose preparation has also started to increase.

Another disruption of services involved the inability to acquire some drugs, especially in our specialty pharmacy. Antiviral drugs for HIV patients became difficult to purchase as some treatments entered the conversation as a possible solution to help fight COVID-19. When we began to see there might be supply issues, we were able to place a marginally larger than usual order so that we would be able to at least stay slightly ahead of demand as our wholesaler began to limit orders. While this took cash out of our reserves in the short term, it allowed us to meet the needs of our patients until we reduce our inventory at the appropriate time that will also replenish the cash back into reserves.

Financial Implications

While the funding for OCPDI and PMC for FY2020 was not decreased, we are monitoring how state funding might be cut, which could eventually affect these operations. The clinic pharmacies are already operating on thin margins and when clinics started postponing patient visits, the number of prescriptions filled was adversely affected. During the four-week period starting March 23, 2020, we saw an average 25% decrease in business across our pharmacies, with the largest impact on our nuclear pharmacy business, which saw a 40% decrease in business. Overall, our specialty pharmacy has only been down 10%, which has kept us in better financial shape than expected, considering what the potential impact was.

The advantage of having diverse operations helps when called upon from partner colleges and services. For example, the University of Oklahoma expanded a testing site for COVID-19 to the OU-Tulsa campus, 90 miles northeast of Oklahoma City. However, they needed to get the samples to the testing laboratory on our OKC campus. We were able to divert one of our nuclear pharmacy delivery drivers to the Tulsa testing site to pick up samples and deliver them to OKC and to deliver testing kits from OKC to Tulsa when needed. This helped offset costs for a pharmacy that was seeing declining business during this time while also meeting a need for campus services.

While we do not anticipate additional budget cuts for this fiscal year, we have been processing multiple scenarios for our next fiscal year as we prepare our budgets. The information has been changing depending on variables such as decreases in student enrollment, impacts on pharmacy operations, ability to continue research, and market impact on our endowment accounts. During these times, it is important to have adequate reserves. Fortunately, the college has always made this a priority to ensure operations continue during unexpected downturns in the economy that have negative effects on financial resources. Dipping into reserves may go hand in hand with cutting some expenses, such as delaying hires or delaying projects where possible. While we have not had to consider furloughs or layoffs yet, the news stories of other institutions and even our undergraduate campus having to make these decisions have led us to believe this may be asked of each college if adequate reserves and funding are not available.^5,6

Impact on Development

Fundraising for the College of Pharmacy at the University of Oklahoma Health Sciences Campus has historically required unique approaches. As funds appropriated by the state of Oklahoma have steadily decreased, we have also experienced a decrease in applicants. Therefore, private donations have never been more necessary to meet the demands of providing a first-rate education to students and attracting the most qualified applicants.

Relationships with alumni, local businesses, and friends of the college are vital to securing this type of philanthropy. This requires ongoing stewardship with known donors as well as a constant search for possible new gifts. As the state of Oklahoma has a modest population of people and businesses, keeping them engaged with the college is vital. The current environment has produced a double blow to this effort. The COVID-19 virus has put this state, as well as the entire country, in a standstill as we abide by the necessary shelter-in-place orders. Face-to-face meetings are not possible. Additionally, Oklahoma is experiencing an implosion of oil prices never before seen in its history. As a state that is dependent on the oil and gas industry, the full effect of this crippling downturn has yet to be determined.

Communication with donors, which is vital in securing private funding through donations, has required different techniques. One such effort has been to communicate with each prospect by phone, written note, or email. Reaching out in this manner and checking in with them and inquiring on their well-being during this trying time has been met positively. Taking a careful approach so as not to appear to be taking advantage of the pandemic but genuinely “touching base” with each donor to see how they are doing has kept communications open.

There is no question that our donor base is anxious about both COVID-19 health concerns as well as the local and state economy. Therefore, in addition to focusing on current giving, we have also encouraged planned giving. A gift included in a donor’s estate plan allows for the donor to support the college without putting pressure on their immediate financial needs. These future gifts are a vital part of the total picture of private funding and are needed now more than ever in order to maintain the mission of the college.

Faculty Searches

We had an unusually high number of faculty searches underway in recent months, with three each in the clinical sciences and basic sciences. From December 2019 through the second week of March 2020, we hosted campus visits, led tours, conducted interviews, held seminars, and provided meals for prospective candidates. We had one more interview for an ambulatory care position scheduled for March 16, 2020, the first day of Spring Break. We first verified with the candidate that she was able to travel, then compressed the schedule for her visit and instituted social distancing throughout the interview. Two previous interviewees declined our offers for employment because they were unwilling to relocate given the unfolding situation with COVID-19. Despite these obstacles, we have been able to fill five of the six positions. For the remaining open position in pharmaceutics, interviews with candidates were conducted via Zoom (San Jose, CA) in mid-May.

Going forward, we will institute a policy of conducting an initial interview via Skype (Palo Alto, CA) or Zoom before any campus visits are scheduled. Communication concerns, lack of chemistry/collegiality, and teaching prowess should be assessed before spending time and money on a candidate who will probably not be a match for the position. We also plan to set a limit on the number of candidates invited to visit the campus and only pursue interviews with the next tier of candidates if necessary. For several of the searches, vetting the candidates took us so long that several had received multiple offers or had already accepted an offer by the time we were prepared to make an offer.

The Administrative Team

The administrative team for the college developed a covenant about 10 years ago. It has gone through several revisions. This relational covenant reflects our shared expectations, experiences, and aspirations and is how we wish to be treated in our interactions with one another and as a whole. Our goal is to be open enough to allow for constructive conversations even in light of inevitable conflict, and do so with humor, humility, and compassion. In order to be the most effective team possible and strive for excellence in support of the tripartite mission, we are responsible for and will commit to and model: adaptability, trust, effective communication, leadership, diversity, accountability, and mutual respect.

We are blessed to have highly capable and productive members. There are numerous quotes about the whole being greater than the sum of its parts and other concepts of synergy. Typically, this involves working toward common goals. However, in this crisis, these have taken a back seat to getting through a day, a week, to the end of the semester. Now we are planning for fall semester 2020. More than likely, didactic delivery will be primarily online with laboratory sessions conducted in smaller groups than usual in order to maintain social distancing.