Avera taps Sectyr LicenseTrak for compliance trifecta

Sioux Falls, S.D.-based Avera Health serves patients across South Dakota, Iowa, Minnesota, Nebraska, and North Dakota through its 37 hospitals, 215 clinics, 40 senior living facilities and more. The integrated health system cares for nearly one million patients across 72,000 square miles. As the health ministry of the Benedictine Sisters of Yankton, S.D., and the Presentation Sisters of Aberdeen, S.D., Avera encourages its 20,000 employees to live by the Gospel values of compassion, hospitality, and stewardship. Although Avera’s tagline is “moving health forward,” Avera Pharmacies, part of Avera McKennan Hospital & University Health Center, found moving forward with license renewals arduous.

Struggling to track licensing, accreditations, and incidents

With spreadsheets, paper checklists and manual tabulations, the pharmacy tracked critical license renewals largely by hand. The pharmacy’s compliance coordinator felt the system would eventually fail in some way. In 2019, one of Avera’s directors attended an industry conference where she met a peer from another health system using Sectyr’s SectyrHub LicenseTrak^® compliance software to manage the very thing Avera was struggling with.

“One reason we pursued LicenseTrak was because our person managing license renewals felt something might fall through the cracks, maintaining our licenses is too important to have a lapse,” says Christine Burg, PharmD, MSHSA, pharmacy compliance coordinator for Avera Pharmacies.

For example, South Dakota has a naloxone standing order allowing trained pharmacists to initiate and dispense the naloxone opioid antagonist. Pharmacists must complete CE to be eligible. Once Avera implemented SectyrHub LicenseTrak, Burg tapped the software to store the naloxone certifications and other licenses. The dashboard in LicenseTrak has colored options of what is past due and pending, which Burg says is a quick reference for license renewals that she relies on heavily. Through the initial demonstration of the software, Burg and her colleagues also learned that LicenseTrak could also be used to manage incident reports and accreditation tasks.

“We have a URAC accreditation, ACHC accreditation for our specialty pharmacy, and we’re working on ACHC for our retail pharmacy,” says Jeff Berning, business analyst for Specialty Pharmacy at Avera McKennan Hospital & University Health Center. “LicenseTrak is unique among software solutions because it tracks licenses, accreditations, and incidents; we needed this.”

According to Burg, incident tracking was of particular interest to her colleague Berning. Avera’s target for accuracy is 99.95 percent, says Berning, and the organization allows only a few errors per quarter. Errors, for example, might be dispensing an incorrect quantity of drug; providing a patient with an injectable drug, but dispensing only one of two boxes containing an injectable pen; or incorrectly dosing a drug (i.e., providing a pen versus a syringe). Any of these incidents require reporting to improve patient care and maintain accreditations.

Before implementing SectyrHub LicenseTrak, Berning says he had no efficient way to pull information about incidents and centrally store them. For instance, the steps required to report on an incident included collecting and extracting data from a lot of PDFs. Prior to SectyrHub LicenseTrak, Berning recalls extracting incident data once per quarter. Once Avera turned the new system on, Berning began pulling data every month. The data also feeds a compliance log detailing all reported events, which Avera stores in SectyrHub LicenseTrak. That information, in turn, helps Avera maintain its accreditations with URAC and ACHC.

“With SectyrHub LicenseTrak, we have data at the ready on dispensing and distribution accuracy,” notes Burg. “We add anecdotes about dispensing and distribution to report to URAC; having the ability to gather all the details for an incident, along with summarizing that information easily, has helped immensely.

“As we kept growing, we couldn’t keep doing this manually; with a system like SectyrHub LicenseTrak, we can focus on other critical areas competing for our time,” says Burg.