Pharmacy management : essentials for

all practice settings Fifth Edition Leticia

R. Moczygemba (Editor)
Visit to download the full and correct content document:
https://textbookfull.com/product/pharmacy-management-essentials-for-all-practice-set
tings-fifth-edition-leticia-r-moczygemba-editor/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Manual for pharmacy technicians Fifth Edition. Edition

Bonnie S. Bachenheimer (Editor)

https://textbookfull.com/product/manual-for-pharmacy-technicians-
fifth-edition-edition-bonnie-s-bachenheimer-editor/

Java All in One For Dummies Fifth Edition Doug Lowe

https://textbookfull.com/product/java-all-in-one-for-dummies-
fifth-edition-doug-lowe/

Essentials for nursing practice Ninth Edition Hall

https://textbookfull.com/product/essentials-for-nursing-practice-
ninth-edition-hall/

Essentials of managing stress Fifth Edition Seaward

https://textbookfull.com/product/essentials-of-managing-stress-
fifth-edition-seaward/
Remington The Science and Practice of Pharmacy
Remington The Science and Practiice of Pharmacy 23rd
Edition Adeboye Adejare

https://textbookfull.com/product/remington-the-science-and-
practice-of-pharmacy-remington-the-science-and-practiice-of-
pharmacy-23rd-edition-adeboye-adejare/

School social work : national perspectives on practice

in schools 1st Edition Leticia Villarreal Sosa

https://textbookfull.com/product/school-social-work-national-
perspectives-on-practice-in-schools-1st-edition-leticia-
villarreal-sosa/

Service Management: Theory and Practice John R. Bryson

https://textbookfull.com/product/service-management-theory-and-
practice-john-r-bryson/

Pharmacy Technician Certification Review and Practice

Exam 4th Edition Barbara Lacher

https://textbookfull.com/product/pharmacy-technician-
certification-review-and-practice-exam-4th-edition-barbara-
lacher/

Coulson and Richardson’s Chemical Engineering, Fourth

Edition: Volume 3A: Chemical and Biochemical Reactors
and Reaction Engineering R. Ravi

https://textbookfull.com/product/coulson-and-richardsons-
chemical-engineering-fourth-edition-volume-3a-chemical-and-
biochemical-reactors-and-reaction-engineering-r-ravi/
PHARMACY MANAGEMENT
ESSENTIALS FOR
ALL PRACTICE SETTINGS
 Notice
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors and the publisher of this wor1<: have checked with sources believed
to be reliable in their efforts to provide information that is complete and generally
in accord with the standards accepted at the time of publication. However, in
view of the possibility of human error or changes in medical sciences, neither
the authors nor the publisher nor any other party who has been involved in the
preparation or publication of this work warrants that the information contained
herein is in every respect accurate or complete, and they disclaim all responsibil-
ity for any errors or omissions or for the results obtained from use of the informa-
tion contained in this wor1<:. Readers are encouraged to confirm the information
contained herein with other sources. For example and in particular, readers are
advised to check the product information sheet included in the package of each
drug they plan to administer to be certain that the information contained in this
work is accurate and that changes have not been made in the recommended
dose or in the contraindications for administration. This reoommendatiOn is of
particular importance in connection with new or infrequently used drugs.
PHARMACY MANAGEMENT
ESSENTIALS FOR
ALL PRACTICE SETTINGS
FIFTH EDITION

David P. Zganick, PhD, FAPhA Ldicia R. Moczygemba, PbannD, PhD

Professor Associate Profussor
Sc:hoolofPhannacy Health Outcomes Division
Bouve College of Health Sciences The University ofTeus College of Pharmacy
Northeastem University .Associate Director
Boston, Massachusetts Tew Center for Health Outcomes .Research.
and Education
Greg L. AI.ton, PharmD
Professor and Associate Dean
South Univcnity Savannah Campus Shane P. Deuelle, RPb, PbD, FAPhA
Savmnah, Georgia Professor, College of Pharmacy
Touro Univenity California
Vallejo, California

New York ChiQ&O San Francisoo Ad=. London Madrid Mexico City
Milan New Dclh.i Singapore Sydney Toronto
Copyright© 2020 by McGraw Hill Education. All rights reserved. Except as permitted under the United States Copyright Act of
1976, no part ofthis publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval
system, without the prior written permission of the publisher.

ISBN: 978-1-26-045639-4
MHID: 1-26-045639-0

The material in this eBook also appears in the print version of this title: ISBN: 978-1-26-045638-7,
MHID: 1-26-045638-2.

eBook conversion by codeMantra

Version 1.0

All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every occurrence of a trade-
marked name, we use names in an editorial fashion only, and to the benefit of the trademark owner, with no intention ofinfringe-
ment of the trademark. Where such designations appear in this book, they have been printed with initial caps.

McGraw-Hill Education eBooks are available at special quantity discounts to use as premiums and sales promotions or for use in
corporate training programs. To contact a representative, please visit the Contact Us page at www.mhprofessional.com.

TERMS OF USE

This is a copyrighted work and McGraw-Hill Education and its licensors reserve all rights in and to the work. Use of this work
is subject to these terms. Except as permitted under the Copyright Act of 1976 and the rightto store and retrieve one copy of the
work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit,
distribute, disseminate, sell, publish or sublicense the work or any part ofit without McGraw-Hill Education's prior consent. You
may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to
use the work may be terminated if you fail to comply with these terms.

THE WORK IS PROVIDED "AS IS." McGRAW-HILL EDUCATION AND ITS LICENSORS MAKE NO GUARANTEES
OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE OBTAINED
FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED THROUGH THE WORK VIA
HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY WARRANTY, EXPRESS OR IMPLIED, INCLUD-
ING BUT NOT LIMITED TO IMPLIED WARRANTIES OF MERCHANTABILTIY OR FITNESS FOR A PARTICULAR
PURPOSE. McGraw-Hill Education and its licensors do not warrant or guarantee that the functions contained in the work will
meet your requirements or that its operation will be uninterrupted or error free. Neither McGraw-Hill Education nor its licensors
shall be liable to you or anyone else for any inaccuracy, error or omission, regardless of cause, in the work or for any damages
resulting therefrom. McGraw-Hill Education has no responsibility for the content of any information accessed through the work.
Under no circumstances shall McGraw-Hill Education and/or its licensors be liable for any indirect, incidental, special, punitive,
consequential or similar damages that result from the use of or inability to use the work, even if any of them has been advised of
the possibility of such damages. This limitation of liability shall apply to any claim or cause whatsoever whether such claim or
cause arises in contract, tort or otherwise.
DEDICATION

To Michelle, Seamus, Zoe, and Fiona (D.P.Z.)

To Travis and Ashton (L.R.M.)
To June (G.L.A.)
and
To Deborah and Brittney (S.P.D.)
CONTENTS

Contributors I ix
Preface I xiii
Acknowledgmcnts I xvii

I. WHY STUDY MANAGEMENT IN PHARMACY SCHOOL? 1

Chapter 1 The "Management" in Medication Therapy Management 3
Chapter 2 Management Functions 21
Chapter 3 Leadership in Pharmacy Practice 35
Chapter4 Ethical Decision-Making, Problem-Solving, and Ddegating Authority 55
Chapter 5 Creating and Managing Value 75

II. MANAGING OPERATIONS 89

Chapter6 Strategic Planning in Pharmacy Operations 91
Chapter? Business Planning for Pharmacy Programs 109
Chapter 8 Operations Management 127
Chapter 9 Managing Technology that Supports the Medication Use Process 141
Chapter 10 Ensuring Quality in Pharmacy Operations 161
Chapter 11 Risk Management in Contemporary Pharmacy Practice 187
Chapter 12 Preventing and Managing Medication Errors: The Pharmacist's Role 205
Chapter 13 Compliance with Regulations and Regulatory Bodies 233

III. MANAGING PEOPLE 253

Chapter 14 Managing Yourself for Success 255
Chapter 15 Negotiation Skills 275
Chapter 16 Organizational Structure and Behavior 293
Chapter 17 Human Resources Management Functions 325
Chapter 18 The Basics of Employment Law and Workplace Safety 347
Chapter 19 Pharmacy Technicians 367
Chapter 20 Performance Appraisal Systems 391

IV. MANAGING MONEY 415

Chapter 21 Financial Reports 417
Chapter 22 Budgeting 437
Chapter 23 Third-Party Payer Considerations 455
vii
viii CONTENTS

v. MANAGING TRADITIONAL GOODS AND SERVICES 481

Chapter 24 Marketing Fundamentals 483
Chapter 25 Marketing Applications 513
Chapter 26 Customer Service 535
Chapter 27 Supply Chain Management 557
Chapter 28 Merchandising 585

VI. MANAGING VALUE-ADDED SERVICES 607

Chapter 29 Value-Added Services as a Component of Enhancing Pharmacists'
Roles in Public Health 609
Chapter 30 Implementing Value-Added Pharmacist Services 625

VII. MANAGEMENT APPLICATIONS IN SPECIFIC

PHARMACY PRACTICE SETTINGS 655
Chapter 31 Entrepreneurship and Innovation 657
Chapter 32 Applications in Independent Community Pharmacy 671

Index I 695
CONTRIBUTORS

Jennifer L. Adams, PhannD, &ID

Clinical Associate Professor and Associate Dean fur Academic .Affitlrs, College of Pharmacy, Idaho State University,
Sam and Aline Skaggs Health Science Center, Meridian, Idaho

Greg L Alston, PhannD

Professor and Associate Dean, South University Savannah Campus, Savannah, Georgia
Chief Value Officer, Pharmacist Success Academy

Mitch Hamett, PhannD, MS

Associate Professor, Touro University California, Vallejo, California

John P. Bentley, PhD

Professor and Chair, Department of Pharmacy Administration, School of Pharmacy, University of Mississippi,
University, Mississippi

Steve Boone
Pharmacy Insurance Practice Leader, Heffernan Insurance Brokers, Chesterfield, Missouri

Peter T. Bulatao, PharmD, MS, MMAS, BCPS, BCACP

Associate Professor, Pharmacy Practice, South University Savannah Campus, Savannah, Georgia

Leigh Ann Bynum, PhD

Associate Professor, Pharmaceutical Sciences, Belmont University College of Pharmacy, Nashville, Tennessee

I.amen M. Caldas, PharmD, BCACP

Assistant Professor, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia

PatrickJ. Campbell, PharmD

Director of Measurement Outcomes Research, Pharmacy Quality Alliance, Alexandria, Virginia

Antoinette B. Coe, PharmD, PhD

Assistant Professor, University of Michigan College of Pharmacy, Ann Arbor, Michigan

Edward Cohen, PhannD

Executive Vice President, Pharmacy Advocacy, Michael JHennessy Associates, Inc., Plainsboro, New Jersey

Michael R. Cohen, RPh, MS, Sc:D

Founder and President, Institute for Safe Medication Practices, Huntington Valley, Pennsylvania

ix
x CONTRIBUTORS

Shane P. Desselle, RPh, PhD, FAPhA

Professor, College of Pharmacy, Touro University California, and President, Applied Pharmacy Solutions,
Vallejo, California

Andrew J. Donnelly, Pha.nnD, MBA

Director, Pharmacy Services, University of Illinois Hospital and Health Sciences System, Clinical Professor
of Pharmacy Practice and Associate Dean for Clinical AfFairs, University of Illinois at Chicago, College of
Pharmacy, Chicago, Illinois

Brent I. Fox, PhD, Pha.nnD

Associate Professor, Department of Health Outcomes Research and Policy, Harrison School of Pharmacy,
Auburn University, Auburn, Alabama

PerryL Fri
Executive Vice President of Industry Relations, Membership and Education, Healthcare Distribution Alliance
(HOA} and Chief Operating Officer, HOA Research Foundation, Alexandria, Virginia

Eric Fromhart, PhannD

Co-founder and President, Secure340B.oom, Philadelphia, Pennsylvania

Caroline M. Gaither, PhD

Professor, Department of Pharmaceutical Care and Health Systems, Senior Associate Dean, Professional
Education Division, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota

David Gettman, MBA, PhD

Professor, D'Youville College School of Pharmacy, Buffalo, New York

Matthew Grissinger, RPh, FISMP, FASCP

Director, Error Reporting Programs, Institute for Safe Medication Practices, Huntington Valley, Pennsylvania

Dana P. Hammer, RPh, PhD

Faculty Lead for Student Professional Development, Skaggs School of Pharmacy and Pharmaceutical Sciences,
University of Colorado, Denver, Colorado

Karl M. HC5S, PharmD, APh, CTII, FCPhA, AFfM RCPS (Glasg)

Associate Professor of Pharmacy Practice, Director, Community Pharmacy Practice Innovations,
Department of Pharmacy Practice, Chapman University School of Pharmacy, Harry and Diane Rinker
Health Science Campus, Irvine, California

Susan E. Higgins, MBA

Independent Management and Strategy Consulting Serving the Health Care Industry
 CONTRIBUTORS xi

Kenneth C. Hohmeier, PharmD

Associate Professor of Clinical Pharmacy and Translational Science, Director of Community Affairs,
University ofTennessee Health Science Center College of Pharmacy, Memphis, Tennessee

Erin R. Holmes, PhD, PharmD

Associate Professor, University of Mississippi School of Pharmacy, Oxford, Mississippi

Jan M. Keresztes, PhannD, F.ASHP

Senior Educator, Pharmacy, Talent First PBC, Orland Park, Illinois

Michael L Manolakis, PhD

Vice President, National Pharmacy Practice Group, Aon Consulting, Charlotte, North Carolina

Ema Mesic, MPH

Manager, Retail and Pharmacy Projects, Walgreens, Deerfield, Illinois

Leticia R. Moaygemba, PhannD, PhD

Associate Professor and Associate Director, Texas Center for Health Outcomes Research and Education,
Health Outcomes Division, The University of Texas College of Pharmacy, Austin, Texas

Rashid Mosavin, PhD

Dean and Professor, College of Pharmacy and Health Sciences, Texas Southern University

Md L Nelson, PhannD
Director of Research and Academic Affairs, Pharmacy Quality Alliance, Alexandria, Virginia

Jacob T. Painter, PharmD, MBA, PhD

Associate Professor, Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical
Sciences, Little Rock, Arkansas

Evan T. Robinson, PhD

Dean and Professor, College of Pharmacy and Health Sciences, Creighton University, Omaha, Nebraska

Meagan Rosenthal, PhD

Assistant Professor, Department of Pharmacy Administration, University of Mississippi School of Pharmacy,
Oxford, Mississippi

Thad Schumacher, PhannD

Pharmacist and Owner, Fitchburg Family Pharmacy, Fitchburg, Wisconsin

Glen T. Schumock, PhannD, MBA, PhD

Dean and Professor, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
xii CONTRIBUTORS

Mark H. Siska, BS Phann, MBAfTM

Chief Pharmacy Informatics Officer, Mayo Clinic, Rochester, Minnesota

Todd D. Sorenson, PharmD, FAPhA, FCCP

Professor and Associate Head, Department of Pharmaceutical Care and Health Systems, College of Pharmacy,
University of Minnesota, Minneapolis, Minnesota

Rachel Sullivan
Project Manager, HDA Research Foundation, Alexandria, Virginia

Benjamin S. Teeter, PhD

Assistant Professor, University of Arkansas for Medical Sciences, Little Rock, Arkansas

Kyle M. Turner, PharmD, BCACP

Assistant Clinical Professor, University of Utah College of Pharmacy, Salt Lake City, Utah

Benjamin Y. Urick, PhannD, PhD

Research Assistant Professor, Center for Medication Optimization, Eshelman School of Pharmacy, University of
North Carolina, Chapel Hill, North Carolina

Julie M. Unnie, PhD

Associate Professor, University oflowa College of Pharmacy, Iowa City, Iowa

Terri L Warholak, PhD, RPh

Professor and Assistant Dean of Academic Affairs and Assessment, University ofArizona College of Pharmacy,
Tucson, Arizona

Wdliam Wynn, PharmD

Assistant Professor, Experiential Education Coordinator, and Director of lnterprofessional Education,
South University Columbia Campus, Columbia, South Carolina

David P. z.gamck, PhD, FAPhA

Professor, School of Pharmacy, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
PREFACE

• WHY DID WE CREATE THIS TEXTBOOK?

Pharmacy remains a very exciting profession; in fact, more opponunities are available for pharmacists, pharmacy
students, and educators than ever before. The roles of pharmacists in interprofessional health care teams continue
to evolve, as does their recognition by payers and policy makers. Pharmacists continue to transform the delivery
of their services to accentuate the critical nature of publlc health and proactive health care. But with new oppor-
tunities also come challenges, including the challenge of how to manage the personal and professional resources
necessary to succeed in today's ever-changing environment.
Educators must not only keep up with changes in pharmacy practice, but also anticipate and prepare our
students for opponunities and contingencies that will arise throughout their professional careers. In our efforts to
best prepare students, pharmacy management educators have increasingly had to gather teaching materials from
a variety of textbooks, journals, and other educational resources. This is due to the fact that many resources only
focus on a specific management function (marketing, personnel, accounting, and finance) or a specific practice
setting (independent pharmacies, hospital pharmacies). We believed that there would be value in a comprehen-
sive pharmacy management textbook that covered many content areas and gathered a variety of resources into
one text. We also aimed to develop a text that uses "evidence-based management"; that is, material derived from
the best and most contemporary primary literature, but that which at the same time focuses on the appllcation
of knowledge into skills that pharmacists will use every day.

• NEW CONTENT IN THIS EDITION!

In planning for a fifth edition of this text, we sought input from faculty who teach pharmacy management, as
well as from pharmacy students and pharmacists who apply management principles in their daily practice. We
llstened carefully to users also while scanning the latest advances in teaching strategies to produce the fifth edi-
tion. Of course, we also considered the many changes in pharmacy practice, management, and health systems
reform that have occurred during the past few years.

• Every chapter has been updated to reflect the fluid nature of its respective management topic.
• New trends in the management literature are reflected in each of the chapters, including management trends
within and beyond pharmacy.
• Some chapters have been revised substantially and with new authors to provide users of the text with the most
relevant information. Examples include the following:
• Sustaining medication therapy management services through implementation science as well as other mod-
els of care delivery, such as continuous medication monitoring (CoMM).
• Leveraging leadership skills into practice by guiding change management, establishing a culture of employee
self-motivation, extracting the most from your resources and infrastructure, all while advocating for your
profession and the patients you serve.
• Broadening our views of how pharmacists manage the supply chain, particularly to ensure that they can
access safe and effective medications and other resources that are needed by their patients.
xiii
xiv PREFACE

• Maintaining compliance with laws, rules, and regulations which impact a pharmacy manager's ability to
care for patients and manage their practice.
• Developing new ways of organizing and managing our time for our own success and the success of others,
particularly given the challenges and opportunities provided by social media and other forms of technology.
We have also added new chapters commensurate with contemporary pharmacy practice in anticipation of
continually evolving models of care. These include:
• Ethical Decision Making, Problem Solving, and Delegating Authority, where pharmacists utilize appropriate
judgment processes when faced with decisions of how to optimize care in the face of budgetary constraints
and preferences of various stakeholders in the medication use process.
• Negotiation Skills, a skill needed through various components of practice, ranging from encouraging treatment
adherence from patients, to requesting a change from the prescriber in a patient's medication regimen, to
adjudicating a fair contract with a third-party payer for the services renders to covered enrolees.
• Pharmacy Technicians, the persons to whom pharmacists are increasingly delegating more responsibility and
greater numbers of tasks that pharmacists used to perform so that they can now spend more time in direct
patient care activities.

• NEW FEATURES IN THIS EDITION!

Management education encompasses a broad constellation of knowledge, skills, abilities, and attitudes required
to become an effective leader. It is difficult for instructors to possess the breadth of experience across all aspects
of pharmacy management to intuitively design structured lesson plans to effectively educate their students. With
that in mind, the editors of the fifth edition have developed tools to assist instructors with teaching the concepts
covered in this book. Instructors who adopt the textbook will have full access to these resources which include:
(1) PowerPoint~ slides that cover the core content of each chapter; (2) lesson plans built on the Understanding
by Design model developed by Jay McTighe and Grant Wiggins. These plans guide the course leader through the
three stages oflesson design: (1) focusing on the big ideas within the content; (2) crafting fair, valid, and reliable
assessments of the desired results; and (3) creating an effective and engaging learning unit.

• WHAT WILL THE READER FIND IN THIS TEXTBOOK?

This textbook is organized to reflect all of the major management functions performed by pharmacists in any
practice setting. The book is divided into sections representing each function, and is further divided into chapters
that detail the various components of each function.
Our experience as educators has taught us that students are the most effective learners when they are "ready"
to learn. Many students selected pharmacy as a major in part from the desire to help people, but also due to
their fascination and intrigue with how such small amounts of various medicinal substances have such profound
effects on the body. Many of these students also believe that they only need to learn about management after they
graduate, and then only if they take on a managerial or administrative position at their pharmacy. The first sec-
tion of this book makes the case that management skills are imponant for all people and pharmacists, regardless
of their position or practice setting. In an environment of increasingly scarce resources and higher accountability,
we also help the reader to understand and create the value proposition for themselves, their services, and their
 PREFACE xv

organization. After establishing the need for management in both our personal and professional lives, the next
four sections describe the management functions and resources that are common to all pharmacy practice set.-
rings (operations, people, money, traditional pharmacy goods and services). Chapters within each section focus
on important aspects of each function or resource.
As pharmacy practice moves from a product orientation to a patient orientation, there are unique challenges
that arise in managing the value-added services that pharmacists are devdoping to meet patient needs in medic~
tion therapy management. A section of this book is dedicated to the planning, implementation, and reimburse-
ment of these new patient care services offered by pharmacists.
Several chapters are dedicated to describing the risks inherent in pharmacy practice and the impact that
laws, regulations, and medication errors have on pharmacy management. The final section describes how man-
agement functions are applied by entrepreneurs and intrapreneurs in settings ranging from independently owned
community pharmacies to those devdoping new goods, services, and ideas in any setting to meet needs related
to medications and their use.

• HOW EACH CHAPTER IS ORGANIZED?

Each chapter is divided into several sections to facilitate the reader's understanding and application of the mate-
rial. Chapters begin with a list of learning objectives that outline the major topics to be addressed. A brief sce-
nario is used to describe how a pharmacy student or pharmacist may need or apply the information described
in this book in their daily lives or practice. Questions at the start of each chapter provide direction and assist the
reader in understanding what they can expect to learn.
The text of each chapter provides comprehensive coverage of the content and theory underlying the major
concepts. References to the management and pharmacy literature are commonly used to provide readers with
links to additional background information. Explanations and applications are also used to hdp readers better
understand the need to master and apply each concept. Questions at the end of each chapter encourage readers
to think about what they have just learned and apply these concepts in new ways.

• WHAT WE HOPE YOU WILL GAIN FROM THIS BOOK?

If you are a pharmacy student, we hope that using this book will help you gain an appreciation for the roles of
management in pharmacy practice, regardless of your future position or practice setting. This book will also
provide you with a variety of management theories and cools that you can apply in your daily life.
We realize that many pharmacists have not had much management coursework in their formal education
or professional training. We hope that this book serves as a valuable guide to pharmacists who may require some
assistance in dealing with matters they did not anticipate when embarking on their careers. For those pharmacists
with formal management education and experience, we hope that this book serves as a valuable reference or as a
source of new ideas that can be applied in daily practice.
For educators, this book has been designed as a comprehensive pharmacy management textbook. As a
whole, it is meant to be used in survey courses that cover many areas of pharmacy management. The section
format also allows the book to be used in courses that focus on specific pharmacy management functions or top-
ics. The sections and content of each chapter are meant not only to provide valuable information that is easy for
students to understand but also to stimulate further discussion and motivate students to learn more on their own.
xvi PREFACE

• WE WOULD LIKE TO HEAR FROM YOU!

The creators of each chapter have put a great deal of time and effort into getting their final outputs ready for
consumers, but it rarely can be considered a "finished product." Textbooks are "works in progress" that can always
be improved. The best way to improve these products is to seek input from our users. As you use this book,
we would like to learn what you like about it, what could be improved, and what topics or features you would
like to see included in the future. Please feel free to share your thoughts at any time by contacting us through
pharmacy@mcgraw-hillcom. We plan to improve this book over future editions by listening to your feedback and
continuing to reflect changes in the management sciences and pharmacy practice.

For Ancillaries, please go to the Pharmacy tab at:

https://www.mhprofessional.com/desselle5e
ACKNOWLEDGMENTS

We would like to thank the colleagues who have played provided an environment that makes this type of
an important role in our development throughout our endeavor possible. We would also like to thank all of
undergraduate, professional, and graduate studies, as the students we have taught who have inspired us to
well as at our institutions. In addition, as our careers continue to strive to become better educators.
have advanced, we also have come to know many We would like to thank everyone at McGraw-
great academicians in other disciplines and other Hill Education and, in particular, our editor, Michael
leaders in pharmacy who have greatly influenced our Weitz, for working with us to improve this compre-
careers and provided keen guidance. We have learned hensive pharmacy management textbook.
so much from all these people and feel fortunate that Finally, we would like to acknowledge the efforts
they have been willing to share their knowledge and of each of our chapter authors. We chose our authors
experience with us. not only because of their expertise but also because
Thanks must also go to all the faculty, staff, and of their dedication to teaching and the professional
administrators at Northeastern University, University development of pharmacy students and pharmacists.
of Texas College of Pharmacy, South University There is no way in which we could have completed
Savannah Campus, and Touro University who have this textbook without their efforts.

xvil
SECTION I

WHY STUDY MANAGEMENT IN

PHARMACY SCHOOL?
THE "MANAGEMENT" IN
MEDICATION THERAPY
MANAGEMENT
Shane P. Desselk, Leticia. R Moczygemba, DaviJ P. Zgarriclt, and Grtg L. Alston

bout the.Auihon: Dr. Desselle is a professor of Social, Behavioral, and Admin.istrative

A Pharmacy at Touro University California College of Pharmacy. His rcsean:h program

focuses on optimizing mles fur pharmacy technicians, development of mentorship
programs, and in promoting healthy organizational cultures and citizenship bchaviors in pro-
fessional settin~. He is a Fulbright Specialist Scholar having completed a project to develop
a Center of Assessment for the University of Pristina in Kosovo. Dr. Desselle is a Founding
Editor-in-Chiefof the international peer-reviewed journal, Research in Social and Administra-
ti~ Pharmacy with graduate students and collaborations worldwide on various projects such
as medication safety and medication adherence issues with informal cazegivers. Dr. Desselle
also is a primary author for the Pharmacy Management Tips of the Week on .AccessPharmacy
that accompany this te:lttbook.
Dr. Moczygemba is an associate professor and associate director of the Texas Center
for Health Outcomes Research and Education at The University ofTaas College of Pharmacy.
Her reseuch program focuses on working with communities and health S}'3tems to mitigate
health disparities by developing patient-ccntered interventions to optimize medication-related
health outcomes. She has worked to advance the health care of homeless individuals, older
adults, and those living in rural areas through. the development, implementation, and evalu-
ation of care models that integrate pharmacists with health care team&. She teaches in the
health care systems course in the Doctor of Pharmacy (PharmD) program and is engaged. in
interprofe&sional education initiatives with a focw on quality improvement and patient safety.
Dr. Zganick is a professor in the School of Pharmacy at North.eastern Univenity's Bouve
College of Health Sciences. He received a BS degree in pharmacy from the University of
Wisconsin and a MS and PhD in pharmaceutical administration from the Ohio State Univer-
sity. He has practice experience in both independent and chain community pharmacy settin~.
He has taught courses in pharmacy management, business planning for professional services,.
and drug literature evaluation. His scholarly interests include pharmacist workforce research,
pharmacy management and operations, pharmacy education, and the development of post·
graduate programs.
Dr. Alston is Associate Dean and professor, Savannah Campus, South University School
of Pharmacy. He has over 30 years of experience in community pharmacy management, both
3
4 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

as a chain pharmacy administrator and an independ- and The Ten Things A New Manager Must Get /Ught
ent pharmacy owner. He earned a Doctor of Phar- From the Start, and Own Your ~lue- The Real Future
macy degree from the University of the Pacific and ofPharmacy Practice. His passion lies in teaching the
has published three best-selling management books, next generation of pharmacists how to create value for
The Bossho/e Effect-Managing People Simplified the stakeholders they serve.

• LEARNING OBJECTIVES
After completing this chapter, readers should be able to
1. Identify changes in the roles of pharmacists since the early 1900s.
2. Describe how pharmacy practitioners and educators viewed the need for man-
agement skills as the roles of pharmacists evolved.
3. Identify principal domains of pharmacy care.
4. Describe how management skills and functions fit within the context of provid-
ing medication therapy management services.
5. Identify myths surrounding the practice of pharmacy and health care as a business.
6. Evaluate the need for a management perspective to better serve patients and
improve outcomes to drug therapy.
7. List the managerial sciences and describe their use as tools to assist pharmacists
in practice.

• SCENARIO students having already completed the course, she is

concerned. "What do I have to take this course for?
Stephanie Chen has just completed the first 2 years of I did not come to pharmacy school for this. I'm very
a PharmD curriculum. Despite many long hours of good at science. If I liked this kind of stuff, I would
hard work and a few anxious moments preparing for have majored in business. How is this going to help
examinations, she has been pleased with her educa- me to become a better pharmacist?" she asks hersd£
tional experience. She perceives that as she continues After some thought, she comes to realize that, at
progressing through the curriculum, the upcoming worst, taking this course will not be the end of the
courses will be more integrated and directly appli- world, and even better, it simply might be a mod-
cable to pharmacy practice. She is especially excited erate intrusion in her Monday-Wednesday-Friday
about taking courses in pharmacology and therapeu- routine. She begins to focus on other issues, such as
tics so that she can "really learn about how to be a her part-time job at Middletown South Pharmacy.
pharmacist." As she glances down at her schedule and Lately, she has been dreading each day she goes to
sees that she is enrolled in a required course in phar- work there. The staff consistently seems rushed
macy management, her enthusiasm becomes some- and impatient. There always seems to be conflict
what tempered. She immediately consults with fellow among the employees, and as soon as one fire has
students on what they have heard about the course, been put out, another larger one begins to burn. She
and they tell her that the course is about "finance, regrets her decision to quit her job at Middletown
accounting, personnel management, and market- North Pharmacy 3 months ago, even though it took
ing." Despite some positive comments provided by 20 minutes longer to get there. Things always
 The "Management" in Medication Therapy Management 5

seemed to run smoothly at Middletown North. and empathic and seek personal reward and self-
Mary even noticed that the patients at Middletown actualization through the helping of others (Meyer-
North seemed happier and healthier than those at Juncol., 2015, Pohontsch et al., 2018; Warshawski et
Middletown South. al., 2018). Finally, many pharmacy students also con-
sider the relatively high salaries of their chosen profes-
sion prior to choosing a college major and a career
• CHAPTER QUESTIONS pathway. While few fields guarantee graduates a job,
and certainly not one with entry-level salaries in the
1. How have pharmacists' roles in delivering goods
six figures, pharmacy srudents take comfort in know-
and services evolved over the past few decades?
ing that employment in their profession will provide
What roles and functions do pharmacists perform
them with a generous and steady stream of income.
today?
It comes as no surprise that pharmacists and pharmacy
2. What is the significance of management within
students have been shown to be risk-averse individuals
the context of the profession's movement toward
who do not deal with uncertainties particularly well
the provision of direct patient-care services such as
(Latif, 2000; Leung et al., 2018). This further explains
medication therapy management? Why has its sig-
their gravitation toward science-oriented courses that
nificance typically been overlooked by pharmacists
offer straightforward solutions to problems.
and pharmacy students?
Unbeknown to many pharmacy students is that
3. What are some of the myths surrounding the con-
the actual practice ofpharmacy does not present a suc-
fluence of business practices and the provision of
cession of problems that can be resolved in such a lin-
patient care by pharmacists?
ear manner. While the sequential processes involved
4. What evidence exists that a business perspective is
in community pharmacy practice have remained the
critical to provide effective pharmacy services to
same-patients present with prescriptions, pharmacy
patients?
personnel fill them, and the necessary counseling
5. What are the managerial sciences, and how can
is offered or provided by the pharmacist-a careful
pharmacists use them effectively?
introspection reveals that the profession has under-
gone a rapid, head-turning transformation over just
• INTRODUCTION the past few decades. Pharmacists now are increas-
ingly involved with providing direct patient-care ser-
The preceding scenario, though perhaps overly sim- vices in addition to dispensing medications, and are
plistic, captures the feelings of many students who taking greater responsibility for patients' outcomes
select pharmacy as a major. They generally are inter- arising from drug therapy. Pharmacists have become
ested in science, have a desire to help people in need, more integrated into health care delivery teams that
and prefer a career offering long-term financial secu- coordinate patient care through the implementation
rity. Given that the pharmacy curriculum consists of of evidence-based guidelines and treatment algo-
courses that apply knowledge from physics, chem- rithms. This has been even further accelerated by
istry, anatomy, physiology, and therapeutics, most recent changes in states' pharmacist scope of practice
pharmacy students achieved success in science and regulations, collaborative practice agreements, reim-
math courses throughout their pre-pharmacy studies bursement incentives from payers, and the reorganiza-
(Keshishian et al., 2010). Second, students select- tion of health care delivery into medical home models
ing pharmacy as a major typically are attracted to and accountable care organizations (George et al.,
health care fields and may have contemplated nursing, 2018; Isasi & Krofah, 2015; McConaha et al., 2015).
medicine, or other health professions. Research has For students to better understand the way that
demonstrated that people in health care are caring pharmacy is practiced today, time should be devoted
6 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

to understanding the major forces that have shaped Pharmacy was, at best, a "marginal" profession.
the profession. This chapter begins with a brief his- Most practitioners entered the occupation through
tory of the evolution of pharmacy practice in the 20th apprenticeships rather than formal education. The
century. This history, coupled with a snapshot of con- pharmacist's principal job function was described
temporary pharmacy practice, will make it clear that as the "daily handling and preparing of remedies in
the past and current pharmacy practice models are as common use" (Sonnedecker, 1963, p. 204). Phar-
much about management as they are about clinical macists, or "apothecaries," were often engaged in the
pharmacy practice. The chapter proceeds by pointing wholesale manufacture and distribution of medici-
out myths about the exclusivity of the pharmacy busi- nal products. Pharmacists' roles during this time
ness and patient outcomes and by providing evidence were considerably different than they are today. In
that what is best for the operation of a pharmacy busi- the early 20th century, pharmacists' primary roles
ness is often also best for the patients and other stake- were to procure raw ingredients and extemporane-
holders that it serves. The chapter concludes with a ously compound them into drug products for con-
brief discwsion of the managerial sciences-tools sumer use. While pharmacists had yet to achieve
that every practitioner will find weful at one point or recognition as health care professionals, they often
another regardless of the practice setting. This chapter had considerable autonomy in their practice. There
and all other succeeding chapters we an evidence-based was no dear distinction between "prescription" and
approach to discuss pharmacy management, relying "nonprescription" drugs. Although physicians were
on recent literature and research findings to describe engaged in the process of writing prescriptions,
and explain what is happening in practice today. pharmacists were not precluded from dispensing
Students are encouraged to explore readings of inter- preparations without a physician's order. Consum-
est among the references cited throughout the text. ers commonly relied on their pharmacists' advice
on minor ailments, and often entrusted the nick-
name of "doc" to their neighborhood pharmacist
• A BRIEF HISTORICAL (Hepler, 1987).
OVERVIEW OF PHARMACY Pharmacists had little choice but to have sharp
PRACTICE bwiness acumen to survive. Since few of the products
they dispensed were prefabricated by manufacturers,
There have been several noteworthy efforts to describe pharmacists had to be adept at managing inventories
the evolution of pharmacy practice. Some have of bulk chemicals and supplies wed in compound-
described the process within the context of "waves," ing the preparations they dispensed. They also had to
or shifts, in educational and indwtrial forces (Hepler, have a keen sense of how to manage time and people
1987), another through identifying stages of profes- to accomplish a series of complex tasks throughout the
sional identity (Hepler & Strand, 1990), and still workday.
another through describing activation of pharmacists' A series of studies commissioned by the US gov-
setvices as stewards of public health in a medical care ernment in the early 1900s produced what became
system increasingly challenging for patients to navi- known as the "Flexner reports" in 1915. These reports
gate (Blanchard et al., 2017). While these approaches were critical for health care professionals and their edu-
appear quite different, their descriptions of the princi- cation, including pharmacists. The reports questioned
pal drivers of change closely mirror one another. the validity and necessity of pharmacists as health
care professionals. Shortly thereafter, the American
Pharmacy in the Early Twentieth Century Association of Colleges of Pharmacy (AACP) com-
Pharmacy in the United States began in the 20th missioned a study directed by W. W. Charters that
century much like it existed in the latter 1800s. ultimately served as the basis for requiring a 4-year
 The "Management" in Medication Therapy Management 7

baccalaureate degree program for all colleges of phar- and content driven. A fifth year of education was
macy (Hepler, 1987). These and other forces led to added to the 4-year baccalaureate degree by colleges
dramatic changes in pharmacy in the coming years. and schools of pharmacy during the late 1940s and
early 1950s following the AACP Committee on Cur-
Pharmacy in the Middle of the riculum report entitled, "The Pharmaceutical Cur-
Twentieth Century riculum" (Hepler, 1987). It was during this time
The 1940s through the 1960s often have been referred that pharmacology, pharmaceutics, and medicinal
to as the "era of expansion" in health care (Smyrl, chemistry matured as disciplines and became the
2014). The Flexner reports paved the way for a more core of pharmacy education. Pharmacy students were
scientifically sound, empirically based allopathic required to memorize an abundance of information
branch of medicine to become the basis by which about the physical and chemical nature of drug prod-
health care was practiced and organized. The federal ucts and dosage forms. Courses in the business aspects
government invested significant funds to expand the of pharmacy took a secondary role, whereas education
quantity and quality of health care services. The in patient care (e.g., communications, therapeutics)
Hospital Survey and Construction (Hill-Burton} Act was for all intents and purposes nonexistent.
of 1946 provided considerable funding for the reno- With the APhA Code of Ethics suggesting that
vation and expansion of existing hospitals and the pharmacists not discuss drug therapies with patients,
construction of new ones, primarily in underserved the profession lost sight of the need for pharmacists
inner city and rural areas (Torrens, 1993). to communicate effectively with patients and other
Ironically, pharmacists began to see their roles health care professionals. As the number of hospital
diminish during this era of expansion in health care. and chain pharmacies expanded, resulting in pharma-
Among the factors responsible for this decline were cists being more likdy to be an employee than a busi-
advances in technology and in the pharmaceutical sci- ness owner, the importance of practice management
ences, coupled with societal demands that drug prod- skills was not stressed in schools of pharmacy. Ironi-
ucts become uniform in their composition. These cally, studies such as the "Dichter report" commis-
brought about the mass production of prefabricated sioned by the APhA revealed that consumers regarded
drug products in tablet, capsule, syrup, and dixir dos- pharmacists more as merchants than as health care
age forms, thus significantly reducing the need for professionals (Maine & Penna, 1996).
pharmacists to compound prescription orders. The
passage of the Durham-Humphrey amendment to
the Food, Drug, and Cosmetic Act in 1951 created a Pharmacy in the Latter Part of the
prescription, or "legend," category of drugs. Pharma- Twentieth Century
cists did not have the ability to dispense these drugs The era ofexpansion slowed in the 1970s when society
without an order from a licensed prescriber. Finally, began to question the value obtained from the larger
pharmacy's own "Code of Ethics" promulgated by the amount of resources being allocated toward health
American Pharmaceutical Association (APhA) stated care. Congress passed the Health Maintenance Act of
that pharmacists were not to discuss the therapeutic 1973, which helped to pave the way for health main-
effects or composition of a prescription with a patient tenance organizations (HMOs) to become an integral
(Buerki & Vottero, 1994, p. 93). This combination of player in the ddivery of health care services. Govern-
forces relegated the role of the pharmacist largely to a ments, rather than the private sector, took the lead
dispenser of pre-prepared drug products. in attempting to curb costs when they implemented
The response of schools and colleges of pharmacy a prospective payment system of reimbursement for
to these diminishing professional roles was the crea- Medicare hospitalizations based on categories of
tion of curricula that were more technical, scientific, diagnosis-related groups (Pink, 1991).
8 WHY STUDY MANAGEMENT IN PHARMACY SCHOOL?

In 1975 the Millis Commission's report, Pharma- pharmacists willing and knowledgeable enough to
cists for the Future: The &port ofthe Study Commission provide patient-oriented clinical services face signifi-
on Pharmacy (Millis, 1975), suggested that pharma- cant barriers when practicing in a community phar-
cists were inadequately prepared in systems analysis macy environment (Blalock et al., 2013; Kennelty
and management skills and had particular deficien- et al., 2015; Schommer & Gaither, 2014). In addi-
cies in communicating with patients, physicians, and tion, the growth of mail order services in the outpa-
other health care professionals. A subsequent report tient pharmacy setting virtually excludes face-to-face
suggested incorporating more of the behavioral and consultation with patients. Mail order pharmacy has
social sciences into pharmacy curricula and encour- become a significant channel for the distribution of
aged faculty participation and research into real prob- pharmaceuticals and is used by the Veterans Admin-
lems inherent in pharmacy practice (Millis, 1976). istration system and many pharmacy benefits managers.
Prior to these reports, the American Society of Many brick-and-mortar pharmacy operations now
Hospital Pharmacists had published Mirror to Hospital have a significant mail order component to their
Pharmacy stating that pharmacy had lost its purpose, business as well. While providing consumers with a
falling short of producing health care professionals convenient way to obtain drug products, this form
capable of engendering change and noting that frw- of commerce has the potential to further remove the
tration and dissatisfaction among practitioners were pharmacist from patients and others who could ben-
beginning to affect students (Hepler, 1987, p. 371). efit from their clinical services. Moreover, this trend
The clinical pharmacy movement evolved in the has continued; at the time of writing this chapter,
1970s to capture the essence of the drug use control the massive e-retailer Amazon had begun its foray
concept forwarded by Brodie (1967) and promoted into the prescription drug market initially through
the pharmacist's role as therapeutic advisor. The clini- the purchase of a company (PillPack) that delivers
cal pharmacy movement brought about changes in medication to patients through the mail in packag-
pharmacy education and practice. After being intro- ing aimed to improve patient adherence (LaVito &
duced in 1948, the 6-year PharmD degree became the Hirsch, 2018). With Amazon's advantages in supply
only entry-level degree offered by a small number of chain and operational cost-savings (see Chapter 27),
colleges of pharmacy as early as the late 1960s and this could provide for a momentous disruption in the
early 1970s. The additional year of study was devoted prescription drug market. However, as described fur-
mostly to therapeutics or "disease-oriented courses" ther in this chapter and in many places throughout
and experiential education. The PharmD degree the text, sometimes challenges such as this can end up
became the entry-level degree into the profession in being a boon to practice and with the proper manage-
the early 2000s, with colleges of pharmacy phasing ment and leadership can be among a number of phe-
out their baccalaureate programs. nomena that could result in a greater opportunity for
These trends toward a more clinical practice pharmacists to become more highly involved in direct
approach may at first glance appear to be an ill- patient-care activities.
conceived response given recent changes in health
care delivery. These changes placed a heightened
concern over spiraling costs and have resulted in the • PHARMACEUTICAL
deinstitutionalization of patients and the standardiza- CARE AND MEDICATION
tion of care using tools such as protocols, treatment THERAPY MANAGEMENT AS
algorithms, and disease-based therapeutic guidelines. MANAGEMENT MOVEMENTS
Adoption of a clinical practice approach may also
appear to fly in the face of changes in the organiza- With these changes in mind, adopting pharmaceuti-
tion of the pharmacy workforce and current mar- cal care as a practice philosophy in the 1990s would
ket for pharmaceuticals. Studies have suggested that have appeared "a day late and a dollar short" for both
 The "Management" in Medication Therapy Management 9

the profession and the patients it serves. And indeed, "domains" in which these standards could be classified
that might have been the case had the concept of (Desselle & Rappaport, 1995). These practice domains
pharmaceutical care been entirely clinical in nature. can be found in Table 1-1. Figuring prominently into
The originators of the concept fervently stressed that this classification was the "risk management" domain,
pharmaceutical care was not simply a list of clini- which included activities related to documentation,
cally oriented activities to perform for each and every drug review, triage, and dosage calculations. However,
patient but was, in fact, a new mission and way of the contributions of the managerial sciences do not
thinking that takes advantage of pharmacists' accessi- stop there. The remaining four domains connote sig-
bility and the frequency to which they are engaged by nificant involvement by pharmacists into managerial
patients-a way of thinking that engenders the phar- processes. Two of the domains ("services marketing"
macist to take responsibility for managing a patient's and "business management") are named specifically
drug therapy to resolve current problems and prevent after managerial functions.
future problems related to their medications.
It has been argued that the focus on preventing
and resolving medication-related problems is simply From Pharmaceutical Care to Medication
an extension of risk management (Heringa et al., 2016 Therapy Management and Other Paradigms
see also Chapter 11). Risks are an inherent part of While the pharmaceutical care movement made an
any business activity, including the provision of phar- indelible mark on the profession, its use in the mod-
macy services. Common risks to a business include ern lexicon describing pharmacists' services is fad-
fire, natural disasters, theft, economic downturns, ing. It has been replaced with terminology that more
and employee turnover, as well as the fact that there accurately reflects pharmacists' growing roles in the
is no guarantee that consumers will accept or adopt provision of public health services and reorganization
any good or service that the business offers. The prac- of care into medical homes. In recognizing the mor-
tice of pharmacy involves additional risks, specifically bidity and mortality resulting from medication errors
the risk that patients will suffer untoward events as as a public health problem, the profession embraced
a result of their drug therapy or from errors in the the concept of medication therapy management
medication dispensing process. These events are sig- (MTM). MTM represents a comprehensive and pro~
nificant because they may result in significant harm active approach to hdp patients maximize the ben-
and even death to a patient. They can also harm phar- efits from drug therapy and includes services aimed
macists and their businesses. Risk management sug- to facilitate or improve patient adherence to drug
gests that risk cannot be avoided entirely, but rather therapy, educate entire populations of persons, con-
it should be assessed, measured, and reduced to some duct wellness programs, and become more intimately
feasible extent (Flyvbjerg, 2006). involved in disease management and monitoring. The
The idea that pharmaceutical care should be MTM movement has been strengthened by language
viewed strictly as a clinical movement was called into in the Medicare Prescription Drug. Improvement
question (Wilkin, 1999). Evidence that pharmaceuti- and Modernization Act (MMA) of 2003 (Public Law
cal care existed in part as a management movement Number 108-173, 2010), which mandates payment
was provided in a study that sought to identify stand- for MTM services and proffers pharmacists as viable
ards of practice for providing pharmaceutical care health professionals that may offer such services. The
(Desselle, 1997). A nationwide panel ofexperts identi- place of MTM in health care delivery was advanced
fied 52 standards of pharmacy practice, only to have a even further in the Patient Protection and Affordable
statewide sample of pharmacists judge many of them Care Act, which established pilots for integrated care
as unfeasible to implement in everyday practice. Of delivery, comprehensive medication review for Medi-
the practice standards that were judged to be feasible, care beneficiaries, and grants specifically for MTM
the researchers constructed a system of "factors" or programs (Public Law Number 111-148, 2010). As
Another random document with
no related content on Scribd:
Niagara work for the people at almost twice the efficiency ever
obtained from its waters before.
Let us see just what this means. An ordinary pail holds about
one cubic foot of water. Suppose, as we stand on the brink of the
gorge, I hand you pails full of water, and that you let them fall, one
every second, to the river below. If the force of this fall could be
applied to a machine as efficiently as flowing water, each pailful
would generate electricity to the amount of thirty horse-power, or an
amount about equal to the energy of a five-passenger touring car
when run at full speed. Imagine twenty thousand such pailfuls being
fed into the penstocks every time your watch ticks, and you will then
understand what the six hundred thousand horse-power capacity of
this station means.
Step with me into the electric elevator that goes down the face of
the cliff to the power house. At the bottom we find the offices of the
engineers and experts in charge. There is, also, a restaurant for the
workers. One huge room is filled with the switches and recorders
which keep these men constantly informed of conditions in all parts
of the plant and enable them to control every detail. We descend still
farther to the lower levels, where are the giant waterwheels and
generators. We prowl around in vast subterranean chambers and
gaze at one of the sixty-thousand-horse-power generators. There is
no visible motion and almost no sound, yet it is producing enough
power to move at high speed a procession of two thousand motor
cars, or to drive two Majesties or Leviathans across the ocean.
The generators are of the vertical type. They are mounted above
the waterwheels, each nine feet in diameter, which keep them
turning at the highest permissible speed. The wheels are encased in
steel, and we can see nothing but their outer shell. A muffled roar is
the only sign of the mighty force they are creating. It is difficult to
realize that such tremendous energy can be completely tamed and
working in harness, and we shiver as we wonder what would happen
if one of these mechanical Titans should suddenly break loose.
Each generator is a huge affair, as tall as a four-story house, and
a rope eighty feet long would hardly reach around it. Its largest
portion weighs more than three hundred tons. It reminds us
somewhat of a merry-go-round, only in this case the whirling portion
is all inside, and turning so fast that it seems to be standing still. It is
so big that it would take thirty men, standing close together, to
encircle it, and it is making one hundred and eighty-seven and one
half revolutions a minute. We look through a little window in the
bearing case and see a miniature lake of two hundred gallons of
frothing oil that furnishes lubrication. So much heat is developed in
the operation of the generator that cold air must be fed to it. In warm
weather, it requires thirteen hundred and eighty thousand pounds of
air every two hours and a half, or exactly as much as the total weight
of the generator itself. In winter the air warmed by the generators is
utilized for heating the power station.
On the trip down to Niagara Falls from Toronto I had an
opportunity to see something of what cheap power has done for
southwestern Ontario. I passed through Hamilton, a place of more
than one hundred thousand inhabitants, with plants operated by
Niagara. Here are a large number of American branch factories
using electric current that costs them less than fifteen dollars per
horse-power per year. As in London, Windsor, Brantford, Kitchener,
and other towns, the manufacturing establishments of Hamilton are
increasing in number and size, and the people say that one of the
chief reasons for their prosperity is the “Hydro” power system. In
riding over the country I was struck with the well-cultivated farms and
the attractive homes. I passed through the heart of the Niagara fruit
district, which yields rich crops of grapes, apples, peaches, and other
fruits. Most of the farmers now have electricity to help them with their
outdoor work and lighten the labours of their wives as well.
One of the engineers I talked with has given me a new
appreciation of what development of water-power means to Canada.
He tells me that each thousand horse-power developed brings an
ultimate investment of eighteen hundred and sixty thousand dollars,
which provides work for twenty-two hundred persons and pays them
wages amounting to five hundred seventy-one thousand dollars a
year. The cost of building and operating the power station itself
represents only thirteen per cent. of all this; it is the application of the
new energy in shops, mines, and mills that is responsible for the bulk
of the investment. A new power development attracts industries;
these in turn attract workers and their families; the latter bring in their
train the tradesmen and the professional people needed to serve
them. In this way new towns come into being, and old ones start to
grow. Water-power is sometimes called “white coal.” It should be
called “white magic.”
 Canada is one of the richest countries in the world
in its water-power. Engineers calculate that every
thousand electric horse-power developed from her
waterfalls eventually provides employment for more
than two thousand people.
 Since their discovery in 1903, the Cobalt mines
have yielded silver bullion worth more than
$200,000,000. These huge piles of tailings were
formerly thrown away as waste. They are now being
worked over again at a profit.
 CHAPTER XVI
THE SILVER MINES OF NORTHERN ONTARIO

Take up your map of North America and draw a line from Buffalo
to the lowest part of Hudson Bay. Divide it in half, and the middle
point will just about strike Cobalt, the centre of the world’s richest
silver deposits. I have come here via North Bay from Toronto, more
than three hundred miles to the south, and am now clicking my
typewriter over ground that has produced upward of one million
dollars an acre in silver-bearing ore. For a long time it has turned out
a ton of silver bullion every twenty-four hours.
There are said to be only two real silver-mining districts in the
world. One is at Guanajuato, Mexico, where the veins are of
enormous extent but yield a low grade of ore. The other is here at
Cobalt, where the deposits, though comparatively small, are almost
pure silver. In practically all the other great silver districts the metal is
a by-product. The Anaconda mine in Montana and the Coeur d’Alene
in Idaho are both famous silver producers, but in the former it is a by-
product of copper, and in the latter, of lead.
Twenty years ago, when I visited Cobalt shortly after the
discovery of its underground wealth, I rode all day on the Ontario
government railway through woods as wild as any on the North
American continent. The road wound its way in and out among
lakes, sloughs, and swamps. The country was covered with pine and
hardwood, and so cut up by water that one could have gone almost
all over it in a canoe. Even along the railroad it was so swampy and
boggy that the telegraph poles had to be propped up. Outside the
swamps it was so rocky that deep holes could not be made, and in
such places great piles of rock were built up about the poles to
support them.
 Some of the country was covered with bogs known as muskeg.
This is a bottomless swamp under a thin coating of vegetation,
through which one sinks down as though in a quicksand, and, if not
speedily rescued, is liable to drown. Hunters in travelling over it have
to jump from root to root, making their way by means of the trees
that grow here and there. There is said to be still much of this
muskeg in the region of Hudson Bay and almost everywhere
throughout this northland. Much of it has been drained, leaving a
land somewhat like that of northwestern Ohio, which was once
known as the Black Swamp.
Reaching Cobalt, I had to rely on the miners for living
accommodations. Log cabins and frame buildings were going up in
every direction and a three-story hotel was being started, but many
of the people were still living in tents or in shacks covered with tar
felt. Even the banks hastily established to take care of the rapidly
growing wealth of the settlement were in tents, and the bankers slept
at night beside their safes with a gun always within reach. Streets
were yet to be built, and the wooden and canvas structures of the
town straggled along roads winding this way and that through the
stumps. In the centre of the settlement was a beautiful little lake that
one could cross in a canoe in a few minutes, and the mining
properties extended back into the woods in every direction.
To-day, although still possessing many of the characteristics of
the typical mining camp, Cobalt is a busy little city of six or seven
thousand inhabitants. The tar shacks and tents have been replaced
by modern buildings—banks, churches, stores, and homes—many
of them erected since the big fire in 1912. There are good schools,
including a school of mines, and the muddy roads have long since
given way to sidewalks and streets. Even the lake has gone, its
waters having been pumped away to allow mining operations, and
where it once rippled peacefully some of the richest veins in the
district are now being worked. Kerr Lake, a short distance from the
town, has also been drained to allow safer underground workings.
The place reminds one of the mines of the Bay of Nagasaki, Japan,
where coal has been taken out of fifty miles of tunnels under the
Pacific Ocean. I have visited those tunnels, and have also ridden by
electric car through the coal mines under the ocean off the coast of
south Chile.
The discovery of silver at Cobalt marked the first finding in the
Dominion of any precious metal in important quantities between the
Atlantic Ocean and the Rocky Mountains. Two railway contractors,
employed in the building of the line northward from the town of North
Bay, were idly tossing pebbles into the lake when they found some
that they believed to be lead. An analysis showed almost pure silver.
Shortly afterward a French blacksmith named La Rose stubbed his
toe upon a piece of rock where the railway route had been blasted
out, and upon picking it up saw the white metal shining out of the
blue stone. He conferred with his friends and sent it down to Toronto
to be assayed. The report was that it was very rich in silver. La Rose
thereupon filed a mining claim, selling the first half of his property to
the Timmins corporation for five hundred dollars. Later he disposed
of the balance to the same parties, receiving for it twenty-seven
thousand dollars, which seemed a fortune to him. It was also a
fortune to the purchasers, who took out more than a million dollars’
worth of pure silver.
Owing to the general tendency of the people to doubt the
existence of precious metals in large quantities in Ontario, and the
efforts of those who had made the “strike” to keep their discoveries
secret, it was more than two years before excitement over the find
reached a climax, and work on a large scale was begun. Since then
these mines have produced nearly fourteen thousand tons of silver
bullion, worth more than two hundred million dollars. Think what this
means! Loaded into cars of thirty-five tons, the total output would fill
sixteen trains of twenty-five cars to the train! Made into ten-cent
pieces and laid side by side, it would make a band of solid silver
twice around the world at the Equator! Manufactured into teaspoons,
it would furnish one for every person in the United States, England,
and France, with many to spare!
The height of the silver production at Cobalt was reached in
1911, when thirty-one million ounces of the metal was refined. Since
then the yield has declined, but mining engineers say that the district
will produce silver in commercial quantities for another half century.
Eight mines are still each shipping a quarter million ounces or more
of silver a year, and one of them, the Nipissing, is producing annually
an average of four million ounces. Its huge mills, where the ore is
crushed and the silver taken out, can be seen across the lake bed
from the railway station, with gigantic overhead conveyors carrying
the rock from the mine to the mill. Silver is now being extracted in
paying quantities from what was once considered waste ore, and the
tailings previously dumped into the lakes have been treated in the
mills, yielding a net profit of three dollars’ worth of silver a ton. In the
meantime, the original three-mile radius of the silver-producing area
has been extended twenty miles to the southeast and sixty miles to
the northwest.
The entire Cobalt region seems to be one vast rock covered with
a thin skin of earth. I have visited the chief silver regions of the world,
but nowhere have I seen the metal cropping out on top of the ground
as it does here at Cobalt. The veins run for hundreds of feet across
the country, and often show up on the surface. I saw one mine where
the earth had been stripped off to the width of a narrow pavement for
a distance of a thousand feet. The rock underneath, which had been
ground smooth by glaciers, looked when cleaned much like a
flagged sidewalk. Winding through it was a vein of almost pure silver,
so rich that I could see the metal shine as though the rock were
plated. I walked over this silver street for hundreds of feet, scouring
the precious metal with my shoes as I did so. These veins are not
regular in width nor do they run evenly throughout. Here and there
branches jut out from the main one like the veins of a leaf, and the
ore has everywhere penetrated into the adjoining rocks.
For a long time the work here was more like stone quarrying
than mining. The country about is cut up by long trenches from ten to
twenty feet deep and five or more feet in width, which have been
blasted out of the rock to get the ore. The sides of the hills are now
quarried where the silver breaks out, and the veins are followed
down into the ground for long distances. One mining company has
sunk a shaft to a depth of four hundred and fifty feet, and has
excavated about thirty-seven miles of tunnels. So far, no one knows
how deep the veins go. The geologists say that the silver will lessen
in extent as it descends, and it is claimed that this has been the case
with many of the mines.
The discovery in 1923 of the largest silver nugget ever found
renewed interest in the Cobalt deposits, and has led to the reopening
of several old mines with profitable results. This gigantic find, which
tipped the scales at more than two thousand pounds, was about
ninety per cent. pure silver, and was valued at twenty thousand
dollars. The discovery was made by Anson Clement, a carpenter, in
the Gillies Timber Limit about five miles from Cobalt, and a team of
horses with a block and tackle was needed to haul the giant nugget
out of the ground. Nuggets of silver eighty and ninety per cent. pure
and weighing three and four hundred pounds each are not
uncommon, and I have seen chunks of silver ore the size of a paving
brick that I could not lift. Indeed, much of the ore reminds one of the
rich copper nuggets that are found in the Lake Superior region.
Recently a vein of almost pure silver, which in one place was
between four and five feet in width, was uncovered in the Keeley
Mine, eighteen miles from Cobalt.
Before the discovery of the Cobalt deposits, British Columbia led
in the production of silver in Canada, and still has an output about
one third that of Ontario. Silver is mined also in Quebec and Yukon
Territory, a new silver district of promise having been discovered at
Keno Hill in the Yukon. Three thousand tons of ore has been taken
from one of the Keno Hill mines in one season. This has to be
carried on dog sleds and wagons forty-five miles to the Stewart River
and then sent down the Stewart and the Yukon to the Pacific, where
it goes by ocean steamer to the nearest smelter. Only an unusually
high grade of ore can be handled profitably with so long a freight
haul before smelting.
The Cobalt mines produce not only silver, but also four fifths of
the world’s supply of cobalt. Cobalt and silver are frequently found
together, but nowhere in such quantities as here. Cobalt is a mineral
somewhat like nickel in its properties, and is also used instead of
nickel for plating steel. It is used to make paints and pigments, and is
often known commercially as cobalt blue. Silicate of cobalt furnishes
the colour for all the finest blue china. Practically the entire Canadian
output, most of which is smelted at plants in southern Ontario, is
exported to England and the United States.
The cobalt can be plainly seen in the ore when the rock is
exposed to the weather. It is of a steel-gray colour tinged with rose-
pink, and where it occurs in the form of a powder it looks exactly like
rouge. When heated it turns a beautiful blue. Arsenic and other
elements are often found mixed with the cobalt-silver ore, and the
region has deposits of nickel, copper, and lead.
A hundred miles to the north of Cobalt is the Porcupine gold
district. The gold output ranks first in value among the metals
produced in Canada, and four fifths of all that is mined in the
Dominion comes from the Porcupine and Kirkland Lake districts of
Northern Ontario. The Hollinger mine in the Porcupine area is the
largest gold mine in North America and one of the richest in the
world. It began operations in 1910, and within ten years after it was
opened had produced almost a hundred million dollars’ worth of
gold, and had paid dividends of thirteen millions. The Hollinger shaft
goes down into the earth fifteen hundred feet or more and there are
about thirty miles of underground tunnels.
There is no telling what minerals may not be discovered in this
section of Ontario, which seems to be a part of the great mineral belt
that extends from Lake Superior northward toward Hudson Bay.
There is iron on the Canadian side of Lake Superior, and some of
our richest mines of iron and copper are found on the western and
southern shores of that lake. Petroleum, natural gas, and salt are
produced in the peninsular region of the province between lakes
Huron, Erie, and Ontario to the amount of more than three million
dollars’ worth a year. About a hundred miles from Cobalt lies
Sudbury, which has the richest nickel deposits of the whole world,
and prospectors say that there are minerals all the way north to
James Bay, which juts down into Canada at the lower end of Hudson
Bay.
 The silver deposits around Cobalt crop out on top
of the ground in veins of almost pure metal hundreds
of feet long. Millions of dollars’ worth have been
mined without any underground workings.
 The prospector in northern Ontario, the richest
mineral region in Canada, safeguards his claim by
erecting “discovery posts” bearing his name, number
of his mining license, and date of his find.
 CHAPTER XVII
NICKEL FOR ALL THE WORLD

Canada has a nickel mine out of which has been taken so much
ore that if it were put all together the pile would be larger than the
National Capital at Washington. About ten million tons have already
been dug from it and there are still millions left. Indeed, it is
apparently inexhaustible. It is known as the Creighton, and is
situated about eight miles from Sudbury in the province of Ontario
not far north of Georgian Bay. The International Nickel Company of
Canada, Ltd., which owns it, is the largest nickel producer in the
world, and supplies most of that metal used in the United States.
There are only two places so far discovered where nickel exists
in large quantities. One is in the little island of New Caledonia off the
eastern shore of Australia on the opposite side of the globe. About
ten per cent. of the total world production comes from there. The
other is here in Canada, in a region that yields eight times as much
as New Caledonia. A small amount of nickel is obtained also by the
electrolytic method in the refining of copper and other ores.
The ore near Sudbury is a combination of nickel, copper,
sulphur, and iron. It is found in mighty beds or pockets going down
no one knows how deep. On one side of the deposit is granite and
on the other a black formation known as diorite.
At first the ore was quarried rather than mined, and a huge pit
was formed that looks like a volcanic crater. It reminds me of the
Bromo volcano, which I visited in the mountains of eastern Java.
Later a shaft was sunk, and the vast body of nickel I have mentioned
has been taken out by running tunnels into the ore at different levels.
The lowest level of the shaft is now fourteen hundred feet below the
earth’s surface. There hundreds of workmen are drilling and blasting.
They load the ore on cars, which carry it to an underground storage
chamber, where the large pieces are crushed. It is then hoisted to
the top of the shaft house, a structure as high as a fourteen-story
building. After descending through rock crushers and screens, it is
ready for smelting.
Through the kindness of one of the officials of the International
Nickel Company, I have been able to go through its smelters at
Copper Cliff, which cover many acres. The country about is as arid
as the desert of Sahara. Before the mines were discovered, it was a
green forest and one may still see here and there charred stumps
standing out upon the barren landscape. In the town itself there is
not a green leaf, a blade of grass, a bush, or a flower to be seen at
any time of the year. It makes me think of the nitrate fields about
Iquique in northern Chile, where all is sand and rock and there is no
fresh water for hundreds of miles. All this is due to the sulphur that
comes from the ore. It so fills the air about Copper Cliff that no
vegetation will grow.
After being crushed and screened the ore is roasted. Hundreds
of tons of it are piled upon beds of cord wood and the fine ore dust is
spread over the top. A fire is started and burns day after day for a
period of two months or more. This drives out fifteen or twenty per
cent. of the sulphur, which rises in a smoke of a light yellow colour.
The smoke is almost pure sulphur. It smells like burnt matches and it
fills the air about the furnace to such an extent that the men use
rubber nose caps to protect their lungs from the fumes. These caps
are for all the world like the nipples on babies’ nursing bottles, save
that they are as big as your fist, and each has a sponge inside it
soaked with carbonate of ammonia. This counteracts the effect of
the sulphur and makes it possible for the men to work. I had one of
these nipples over my nose when I went through the works, but
nevertheless my lungs became filled with sulphur. I coughed until the
tears rolled down my cheeks, and as I did so I thought if some of our
preachers could get such a taste of brimstone their word pictures of
the lower regions would be more realistic.
 One might suppose that the miners would be injured by these
sulphur fumes. They are, on the contrary, as healthy as any people
in the world. The children have rosy cheeks and the men are more
rugged in appearance than those about Pittsburgh, or Anaconda,
Montana.
Even after the roasting there is still about seven per cent. of
sulphur left. Most of this is removed in the smelting, which reduces
the ore to a crude metal known as matte. Matte is the form in which
the nickel is sent to the refineries.
Formerly most of the refining was done in the United States or
Europe, but during the World War the International Nickel Company
built a refinery at Port Colborne, Ontario, and most of the Sudbury
ore is now refined there. A large quantity goes also to Huntington,
West Virginia, for making what is known as monel metal, an alloy of
nickel and copper that possesses great strength, does not corrode
easily, and is impervious to electrical currents. It is used in hotel
kitchen equipment, in dyeing and pickling vats, and in many kinds of
electrical apparatus.
The mineral deposits of Sudbury were discovered by the
Canadian Pacific Railway, which was responsible also for the finding
of silver at Cobalt. However, no attention was paid to the nickel in the
ore, which for years was considered valuable only for the copper it
contained. Part of the ore was sent to New Jersey for smelting and
refining, and part to Wales. The reduction works at New Jersey
looked upon the nickel as of no account and let it run off with the
slag, while the Wales smelters paid only for the copper and kept the
nickel as a private rake-off. Later the mine owners discovered that
the nickel was far more valuable than the copper, and since then
nickel has been the principal source of profit.
Although the largest, the Creighton is by no means the only
nickel mine here. The British American Nickel Company owns and
operates the Murray mine, where nickel was first found in Canada. It
formerly belonged to the Vivians of Wales. This company has a large
smelting plant at Nickelton, not far from Sudbury, and a refinery at
Deschennes, near Ottawa. A half dozen mines are owned by the
Mond Nickel Company, which ships practically all its matte to
Clydach, Wales, for refining. The copper in this matte is recovered as
copper sulphate, which is exported largely to Italy and other grape-
growing countries for spraying the vines. The matte exported by the
Mond Company is shipped in oaken casks, which are refilled in
Wales with the copper sulphate and sent to Italy. The Italian
peasants insist on the chemical being received in such containers,
not only to keep the sulphate crystals unbroken, but also because
after emptying, they saw the casks in two and use them as
washtubs.
The production of nickel reached its height in 1918, when five
thousand tons of ore a day were mined. This was due to the many
uses of the metal in the World War. After the Armistice, the nickel
market was so over-stocked that a severe slump in prices occurred,
and the nickel production fell from forty-six thousand tons in 1918 to
eight thousand tons in 1922. There were large quantities of the metal
in all the belligerent countries, and these had to be absorbed before
the Canadian industry could return to normal. The end of 1922 found
a more active demand, and this was followed by an increase in
production and sales.
During my stay at Copper Cliff I have had a talk about nickel and
its uses with one of the metallurgists of the International Nickel
Company. This man has been working successfully in nickel for thirty
years or more, and he knows as much about the metal, perhaps, as
any one in the country. Among the first discoverers of nickel, says
he, were the German miners of old, who found this metal in their
copper ore. Its hardness and the difficulty they experienced in
smelting it led them to associate it with “Old Nick”—hence its name.
This hardness is one of the most valuable characteristics in its
present-day uses.
“Most of the nickel goes into nickel-steel,” said the metallurgist,
“although it enters also into many other manufactures. The value of
nickel-steel is due to the fact that it combines exceeding toughness
with great strength. Copper wire has great toughness. A steel needle
or pen-knife has great strength. But it is only nickel-steel that has
both toughness and strength. This makes it the best metal we know
for armour plate. A battleship with a hull covered with steel or iron
would be shattered to pieces if it were hit by one of the modern
shells. If the armour plate is made of nickel-steel, the largest
projectile makes only a dimple, such as you would in a pat of butter
by sticking your finger into it. This property of toughness is added to
the steel by putting in three and one half per cent. of nickel during
the process of manufacturing. All the big warships of to-day have a
belt of nickel-steel armour plate about eighteen inches thick. Nickel
is also alloyed with copper for making army field kitchens and bullet
casings.”
Nickel-steel rails are used largely where there are curves at the
bottom of steep grades. When a heavily loaded freight train strikes
such a curve, the only things that hold it on the track are the flanges
of the wheels and the heads of the rails. In winter the rails are apt to
become brittle, and when a heavy train, rushing down hill, strikes
them they sometimes break and there is a wreck. The Horseshoe
Curve of the Pennsylvania Railroad, for instance, is made of nickel-
steel rails.
The metal is employed also in bridge building. It is going into
many of our large apartment houses and other tall buildings. It is fifty
per cent. stronger than ordinary steel and the result is that less metal
can be used, or with an equal weight the building can have double
the strength. Nickel-steel does not expand or contract as much as
common steel, and for this reason it is made into clock pendulums,
which must be of the same length the year round in order to keep the
right time. As nickel does not rust in air or water, and resists the
action of many acids, it is much used in plating other metals. It is in
demand for cooking utensils, household articles, and plumbing
equipment, as well as for automobile parts. Practically all the nickel
contained in our five-cent pieces is from the Canadian mines. They
are only one quarter nickel, however, the remainder being copper.
Indeed, there is but a fraction of a cent’s worth of nickel in a five-cent
piece. A few countries, however, use pure nickel for their coinage.
Do you know that nickel-steel and meteorites have practically the
same composition? Indeed, the process for making nickel-steel was
suggested by a meteor found in Greenland. This meteor was an
immense mass that had fallen from the skies ages ago and was
venerated by the Greenlanders as a god. The natives were wont to
hammer splinters from it and make them into spear heads and
hammer heads, accompanying their work by prayers to the god.
Explorers found that such spear heads were harder and finer than
any others. An Englishman named Riley heard of these discoveries,
and they gave him the idea that ended in the new metal.
 CHAPTER XVIII
SAULT STE. MARIE AND THE CLAY BELT

I am at the “Soo,” where Lake Superior, the world’s largest body

of fresh water, has been harnessed and is being made to work with a
force of sixty thousand horses all pulling at once. The St. Mary’s
River, through which Lake Superior empties into Lake Huron, has a
fall of about twenty-two feet in one mile, and power plants have been
installed which are generating electricity for industries on both the
American and Canadian sides of the river.
A large number of the industrial plants here belong to Americans.
The main buildings of these works look like mediæval castles rather
than modern factories. They are equal in beauty to any of the ruins
of the Rhine or the Danube. Indeed, they remind me of the mighty
forts of Delhi, the capital of India. They are made of a rich red and
white sandstone, with crenellated walls, and, notwithstanding their
beauty, are said to have been built at a remarkably low cost. The
blocks of sandstone were taken out of the canal dug for the power
plant.