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Examine the perianal and anal region, and perform digital anorectal examination. Look for lesions, masses, condylomata, and other abnormalities. In women, also examine the vulva, vagina, and cervix. Simple anoscopic examination with the naked-eye may not reveal any abnormality because dysplastic tissue tends to be flat and difficult to differentiate from normal anal tissue; application of 3% acetic acid is required see below. ACE Inhibitors Of the nine drugs in this key drug type in the renin-angiotensin aldosterone system inhibitors class, the six generics are covered by at least 13 of the 14 plans and at costsharing amounts of or less. The brand options in this group are much less likely to be covered and are more expensive when they are covered. Cardioselective Beta Blockers Most of the drugs in the cardioselective beta blockers key drug type in the larger class of beta blockers are available in generic form, and most are inexpensive drugs. The one exception is Toprol XL, a commonly prescribed extended-release version of Metoprolol. As a key drug type, the CMS guidelines require that at least one drug be covered. Several of the drugs in this group are among the most commonly prescribed drugs used by Medicare beneficiaries. Because most of these drugs are generics, it is not surprising that four of the six drugs in this group are covered by all plans and at similar cost to the beneficiary. Toprol XL, the only brand in this group and one of the top 10 most commonly prescribed brand drugs, is typically several dollars more expensive than the others. But given its relatively low list price, users often pay close to full price for this drug. Four plans chose to leave one or two of the products in this group off their formularies. Enrollees in these plans who chose to remain with these products would pay considerably more as a result. The standard benefit offered by Humana Standard and Prescription Pathway Bronze means that the cost of these beta blockers rises and falls with the underlying costs of the drug. Thus, users of Toprol XL, Metoprolol, or Atenolol would save by joining these plans, but users of Acebutolol would face somewhat higher costs. MINNESOTA BOARD OF PHARMACY - 755 Meeting, June 10 & 11, 2003 Page 5 seconded that those programs recommended for approval by the Continuing Education Advisory Task Force be so approved and that those programs for which the Continuing Education Advisory Task Force recommended denial of approval be denied. The motion passed. The Board next addressed the report of the Examination Committee. Mr. Holmstrom presented the Board with scores for candidates for licensure by reciprocity. After a review of the performance of the candidates for licensure by reciprocity, Mr. Tom Dickson moved and Ms. Carol Peterson seconded that, having passed the Multistate Pharmacy Jurisprudence Examination required of candidates for licensure by reciprocity, the following candidates be granted such licensure based on their current license to practice in the state listed with their name: CERTIFICATE # 8310 8311 8312 The motion passed. Mr. Holmstrom next presented a report from the Internship Committee. No formal action on this report was required. Mr. Holmstrom next presented to the Board the report of the Variance Committee. In addition to the report of the committee, individuals proposing two different variance proposals requested an opportunity to make a presentation directly to the Board. The first of those proposals involved a proposal from Mendota Healthcare relating to RedPharm Pharmacy and the InstyMeds Automated Drug Dispensing Unit. Ms. Linda Kobilarcsik and Mr. Ken Rosenblum personally appeared before the Board to discuss the proposal. The proposal put forward by Ms. Kobilarcsik was that RedPharm Pharmacy be able to use the InstyMeds Automated Medication Dispensing System at a remote location as part of a telepharmacy-dispensing program with RedPharm Pharmacy being the host site. Of particular concern to the Board, however, was that the proposal did not include direct pharmacist-patient communication, unless the patient initiated a phone call to the pharmacy. After a lengthy discussion of the proposal with Ms. Kobilarcsik, Mr. Vern Kassekert moved and Ms. Carol Peterson seconded that the proposal be tabled until the July 23rd meeting when the Board members who are absent from this meeting can consider the proposal and provide their input. The motion passed. NAME Renee Lynn Burgess Stephanie Anne Thompson Lance Leonard Swearingen Sarina Bee Lee Brian Joseph Redig Christopher J. Sedlmajer Edward J. Berki STATE OF ORIGINAL LICENSURE MT AR WI.

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Without challenging experiences for committee members. Looking back, we can see the value of attending to some common principles related to managing change. Realize That Shared Decision Making Takes Time Arriving at decisions through consensus may require more time in the planning phase of the practice change. Arriving at decisions by command may take less time in the beginning, but implementation and integration of the practice change may suffer because of poor acceptance. Seven PCUs were represented on the committee. When a practice issue or proposal for practice change was brought to the PCU committee for consideration, preliminary discussion about the issue or change occurred in the committee meeting. After the PCU committee meeting, each member was expected to communicate the proposal for practice changes or issue to his or her own unit committee and then return to the PCU committee with feedback from the unit. At a subsequent meeting, PCU members discussed the various units' comments and concerns and attempted to arrive at a consensus about how to address the issue or whether to adopt the practice change and how to implement the change. If the issue or practice change was complex, or needed more research, revisions to the proposal would be required, and the cycle would be repeated. Some practice changes endorsed by the PCU committee required review by department or institutional committees. The time frame to endorse and plan for some practice changes spanned months, but consensus was gained, department and institutional considerations were addressed, and the implementation of the changes was successful. Engage in Multidisciplinary Collaboration None of the practice changes just described involved nurses only. In each instance, physicians' collaboration and endorsement was important. Proposals for practice changes were discussed with each unit's physician director and, as appropriate, with physician practice committees. This step allowed committee members to learn the physicians' perspective on proposed changes and proactively address questions and concerns. Formal written endorsement by established physician groups promoted acceptance by the larger physician group as the changes were implemented. In the instance of developing drug infusion guidelines, the pharmacist also was critical in providing the evidence on which decisions were made and in bringing those decisions to the larger group of pharmacists serving the PCUs. Successful implementation of the ST-segment monitoring could not have been achieved without collaboration with the monitoring technician supervisor and staff. Explore the Upstream and Downstream Effect of Changes While Planning for the Change Examine the number of departments that will be influenced by the change. Staff from the emergency department, postanesthesia care unit, and ICU needed to know about specific admission and discharge guidelines for patients admitted to the PCU. ICU personnel were informed about the details of the intravenous infusion guidelines so that they could plan for transfers into and out of the ICU. We found that the ability of PCUs to take on patients receiving some drug infusions affected the census and flow of patients in the ICUs. Development of the new PCU documentation form affected multiple users of the form. Users included anyone documenting or reviewing information on the form. Multiple departments, such as dietary, respiratory therapy, pharmacy, and nursing in general, and ICU units, unit secretaries, and physicians required information about the new documentation form. Be Prepared to Devote a Substantial Amount of Resources to Solidify the Practice Change A single educational intervention before implementation of the practice change was not adequate to ensure that the practice change would be adopted and implemented by staff. After the initial implementation date, staff members had frequent questions and concerns and needed further coaching and mentoring to integrate the change into their practice. We addressed this need by having resources such as staff nurse champions for the change, nursing education specialists, and clinical nurse specialists available to reinforce information and answer questions. We created reminders via pocket cards and posters on the units and posted a PowerPoint presentation on the PCU Web site. Prompt feedback of staff performance was provided through concurrent chart audits and acitretin.

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