Why hospital selling? For many representatives, hospital selling offers several advantages.

For one thing, on many days hospital sales provide opportunities for onestop selling. With planning and foresight, you can park your car in the morning, deliver scheduled individual presentations to a half-dozen or more physicians, attend a lecture related to your product's disease state, and spend some quality time with the director of pharmacy, a nursing supervisor or other key staff members all in one day, and you haven't burned an ounce of gas! The "business" of Consider, too, that hospital visits provide you with opportunities to hospital selling connect with new and "no-see" physicians. This is because some doctors who are difficult to see in the office environment may be more approachable in the institutional setting. If you promote a specialty product an injectable oncology medication, for example you may have substantial opportunities to interact with key thought leaders, especially if you call on large academic hospitals or specialty (for example, cancer) centers. Also, experience in the hospital sector can be an education in and of itself, providing you with broader exposure to diagnostic procedures, treatment options, outcomes, provider opinions, and patient concerns related to the diseases and conditions for which your products are indicated. The bottom line is that you will discover countless opportunities to learn about patient care while enhancing awareness of your company and its products and driving product spillover from the hospital to Additional opportunities other settings, including physician offices, outpatient clinics, longterm care facilities and home healthcare. Before the first visit Let's start at the beginning. When you are ready to make your first visit to a hospital, keep in mind that sales success begins with in-depth profiling. If you have not yet called on a particular hospital, learn all you can about the facility so that you can speak credibly with your audience. This means that you need to know about hospital ownership (independent or chain; private, non-profit or government); whether or not the hospital is part of an integrated system; the business potential for your company's therapeutic categories; formulary structure and management; and so on.

Formularies in integrated systems

Your key sources of information include hospital Web sites, annual reports, local media, interviews with office-based referring physicians and your own company's internal resources, such as an institutional account manager. Then, when you are ready for your first visit, it is strongly recommended that you schedule a 10or 15-minute orientation meeting with the hospital's pharmacy director. If you are taking over for another sales representative, it will be important for you to accompany and observe this representative on a number of calls. Getting Started Starting off on the right foot is essential to ensure that you will be welcome in the hospital on subsequent visits. Violations of ethics or protocol on the first visit can shut you out of a hospital's business forever. With that in mind, follow these basic suggestions the first time around (and, in most cases, every time thereafter):

Park in the designated visitors area (not in "15-minute parking" or a designated patient's lot) and use the main entrance. Check in at the visitor's desk. This may be the designated check-in point for vendor representatives, but you may be directed to hospital security, the purchasing office or the pharmacy. Sign in and obtain a visitor badge if necessary. Visit the pharmacy first (where you already may have scheduled an appointment). The pharmacy director will provide you with sales representative protocol where you can go, whom you can see, types of authorized literature, CME policies, designated hours and so on. On subsequent visits, you may be required to visit the pharmacy first, depending upon local rules. If you promote a product that is utilized primarily in a specific department (surgery, oncology/hematology, cardiology), then make it your second stop, especially if that department has a dedicated pharmacy. Always follow the rules. Observe sales representative policies regarding physician access. Carefully note if you require appointments, if there are off-limits areas and if you need to check in with department administrative assistants. Also, take care that you are familiar with and follow HIPAA rules regarding patient privacy patient care areas are off limits in today's environment.

Hospital formularies Hospitals, like managed care organizations, develop formularies to encourage appropriate product use, promote quality care and help manage costs. The hospital's P&T committee evaluates and selects products considered most useful in patient care and assigns them to the formulary, making them routinely available for treatment. Some hospitals may have a formulary booklet and allow you to take or at least view a copy. If there is a formulary, you need to be familiar with your product's status on the formulary, as well as with guidelines or protocols that relate to its utilization.

If the product is not on formulary, ask about the formulary approval process. Here is a general outline of the formulary submission process in hospitals:

First, if the product is not on formulary, physicians still may be allowed to write for it under certain conditions. So identify doctors who may be already prescribing the medication. They may be willing to sponsor or advocate the product. Usually the sales representative must secure a sponsor either ask an influential or senior member of the pharmacy staff how to do this. The sponsor usually a physician may be required to fill out a request form and you may be asked to support it by preparing a dossier. Follow the dossier instructions to the letter. After the initial submission, the pharmacy and the P&T chairperson will make a preliminary decision on whether or not to submit the request to the full committee. If the request goes forward, the full committee will receive information about the product prior to the meeting at which the decision will be made. The sales representative may be required to provide information packets for distribution to committee members. In some cases, the sales representative may be allowed to present to committee members. Typically, time allotted for these presentations is strictly limited and the representative must limit content to information requested by the committee. The committee meets and listens to pharmacy staff as well as to committee members who have clinical experience with the product. The committee then votes to grant or deny approval.

If the committee votes affirmatively, it is important for the representative to contact and thank product sponsors; confirm that the pharmacy notifies appropriate departments (for example, via the hospital's drug bulletin); and proceed with sales calls per hospital policy. If the committee's vote is negative, it is important to call or visit the pharmacy director and find out why. Then ask if trial use is permitted (and by whom), check on future prospects and plan accordingly. Integrated systems In many parts of the country, hospitals are components of integrated healthcare systems. Typically, the system will operate:

A "flagship" academic hospital. The flagship hospital is usually in a major metropolitan center. This hospital may manage the formulary and set pharmacy policy for other hospitals in the system. (In some systems, this is not an issue that you need to identify during profiling.) Satellite hospitals. These are community hospitals and specialized hospitals in the surrounding service area. Specialized hospitals focus on a specific disease (for example, a cancer hospital, such as Memorial Sloan-Kettering Cancer Center in New York City) or patient type (such as the numerous children's hospitals throughout the country). Clinics and physician group practices. Most integrated systems are tied in with a network of primary care and specialty clinics, as well as primary care and specialty group practices. (You can identify these affiliated organizations on the system's Web site.)

You may be able to spot product opportunities at several points in the system, but target the flagship hospital first, which is very often a teaching hospital. Chances are, this is where you are most likely to find key product-influencers, and this hospital may be the source for diseasespecific protocols used throughout the system. It is essential that you understand how the system is networked because it will be easier for you to "follow the script." In other words, if a patient is started on your company's product at one point in the system (such as the flagship institution or the inpatient mental health facility), you will want help to ensure that the patient stays on the product when he or she is referred to satellite hospitals or clinics, or back to a personal physician in the community. If your product is indicated in a chronic disease or condition, one of your objectives is to maintain the business along the entire continuum of care. Therefore, in an integrated system always ask where patients are referred to and for follow-up and aftercare. General hospital selling tips Beyond first-visit and formulary basics, here are some general hospital selling tips:

Develop call plans and objectives. Just as with any office call, you must be prepared with call-plan objectives. You should have electronic profiling and call-history forms available for access. Review them before every call and keep them up to date. Map out your visits. Know the hospital layout and learn the most efficient ways to get from one department to another. If hospitals are clustered in a downtown area, park your car once and cover several hospitals in the same day. Monitor opportunities in teaching hospitals. Teachings hospitals are usually "trendsetters." Utilization here has a spillover effect in other hospitals, so your sales team should plan strategies accordingly. Schedule calls according to hospital rules. Most hospitals today require appointments with pharmacy personnel, physicians and even nurses. Schedule calls well in advance and when appropriate, provide an agenda and materials ahead of time. Perform "hall calls" when you get the chance. If you spot a targeted physician, nurse or pharmacist, strike up a conversation and deliver a product message. (Use tact here. It is essential that you observe hospital policy and respect physicians' time. Sales representative access is generally far stricter today than it was just a few years ago.) Use support materials (sales aids, clinical studies, etc.). Have your detail bag organized and make sure that key items are accessible. Have them ready you never know whom you'll meet in a hospital. Find the source of power. Is it the pharmacy or specialty medical staff? Identify and cultivate key physicians in targeted departments. Over time, they will prove to be effective advocates for your product. Communicate with nursing staff, early and often. Hospital nurses interact with patients on a daily basis, are familiar with therapeutic regimens, and are well-versed in efficacy and safety trends. Talk with nurse educators about current issues and look for CME opportunities that benefit the nursing staff.

Don't forget fellows and residents. Physicians in training are your customers of the future. Their preferences often follow them into the general medical community. Know product reimbursement. Be familiar with the billing codes that relate to the administration of your product in the hospital. Be prepared to explain codes and reimbursement to hospital staff when necessary. Follow up and follow through. Your post-call analysis is your next pre-call plan. Make every hospital call productive.

Conclusion Use these principles as starting points for your hospital selling experience. The hospital setting allows for many promotional activities outside of direct selling that provide excellent ways to enhance exposure in the hospital while supporting the hospital's mission. Take advantage of these opportunities, follow the rules, and utilization of your products will follow.