Clinical Governance in Medicines Management & prescribing in

hospitalswww.allaboutpharmacy.co.uk

Dr Jonathan CookeSouth Manchester University

Hospitals NHS Trust Manchester January 30th 2003

jonathan.cooke@man.ac.uk

Professional self regulation

Clinical Governance

Lifelong learning

Setting, delivering, monitoring standards

National Institute for Clinical Excellence

National Service Frameworks

Commission for Health Improvement

National Performance Framework

National Patient and User Survey

StrategicHealth

Authorities

PrimaryCare

Organisations

LocalAuthorities

NHS HospitalTrusts

NHSExecutive

RegionalOffices

key

HIP

statuary a/cservice a/c NICE

CHAI

Pharmacy in the Future – Implementing the NHS Plan

Clinical pharmacy MAU pharmacists Patients own medicines Self administration Pharmacist prescribing HSC(2000)026 Concordance

Pharmacy in the Future – Implementing the NHS Plan

Medicines Management Skill mix and Automation -

– – dispensing, aseptics, procurement

Education and Training, Manpower Research and development Electronic prescribing

Medicines Management Agenda in hospitals

Controls Assurance Standards

NHSE performance management of medicines management in NHS hospitals

Audit Commission - Audit of Medicines Management

Medicines Management Agenda in hospitals

Controls Assurance Standards

NHSE performance management of medicines management in NHS hospitals

Audit Commission - Audit of Medicines Management

The diagnostic audit

Relative change in expenditureon medicines in past 3 years

Overspend on medicines in

past 3 years

Vacancies

in pharmacy department

Throughput per staff member

Staff activity in pharmacy

department

Use of patients’ ownmedicines & self-administration

Use of original packs andmeans of prescribing

Development of joint formularybetween primary & acute care

Is there effective control overmedicines expenditure?

Is staffing adequate for theservices which should be

provided?

Is there effective use ofpharmacy staff?

Has the service introducedprocesses in line withaccepted good practice?

Are the data corroboratedby other central returns?

Key diagnostic questions

Judgement:In depth audit

work / No further audit work

In-depth audit: how it applies

DIAGNOSTIC AUDIT

Indicators of cost

Indicators of process

Indicators of staffing and workload intensity

Indicators of staff deployment

IN-DEPTH AUDIT

Surveys of user groups: nurses, doctors, consultants, managers, GPs, patients

Module 1: Management arrangements

Module 2: Financial control

Module 4: Procurement

Module 3: Policy and use

Module 5: Primary care interface

Module 6: Prescribing influence

Module 7: Risk management

A spoonful of sugarrecommendations (1)

1. The establishment of standard nation-wide definitions and categories of medication errors and ‘near-misses’ should be an early priority for the new National Patient Safety Agency.

2. Following agreement of standard definitions and categories of medication errors, base-line audits should be undertaken.

Building a Safer NHSSpecific risks targeted for

action Eliminate deaths/disability of the

maladministration of spinal inj - 2001 Reduce by 25% harmful incidences in

O/G -resulting in litigation - 2005 Reduce by 40% number of serious

errors in prescribed drugs - 2005 Reduction in suicides in MH patients

HIRSWeb form

encryption email

server

Access DB

reportsdecoding ACTION

South Manchester University Hospitals

Incident Reporting System

South ManchesterTypes of medication incidents reported %

n=320 since April 2001

0 10 20 30 40 50

Delivery error

Supply error

Prescription error

Admin. error

HIRS Medication errors %

0 10 20 30 40

Oral anticoag

Digoxin

Corticosteroids

NSAIDS

Amil/amlod

Paracetamol

Lignocaine

Penicillins

others

Insulins

Heparins

Opiates

Incident classification %

0 50

Medicine not available

Contraindicated drug

Significant underdose

Am biguous prescription

Excessive IV rate

Wrong drug prescribed

Dispensing error

Wrong m edicine given

Medicine overdose

A spoonful of sugarrecommendations (2)

3. National co-ordination of publicity posters should be considered to encourage patients to take their medicines into hospital with them

4. The DoH and the National Assembly need to work with HM Customs and Excise to equalise tax treatments between hospital and community sectors and thus remove what is becoming an obstacle to best prescribing practice

5. The DoH and the National Assembly should commission a specification for automated dispensary systems and consider the provision of earmarked funds to roll-out the introduction of these systems to all trusts

A spoonful of sugarrecommendations (3)

6. A standard national system for the coding of medicines and barcodes should be introduced across the whole of the NHS to support the development of electronic prescribing systems and automated dispensing systems

7. Earmarked funds should be made available to enable trusts to comply with the targets that are set in the NHS IM and T strategy. Central guidance on systems specification and screen layouts should be considered

8. Trusts’ medicines management framework returns should be analysed in conjunction with returns to the Audit Commission’s acute hospitals portfolio. The DoH and the National Assembly should consider using this exercise to enable the identification of Beacon Sites for medicines management.

A spoonful of sugarrecommendations (6)

13 Trust boards should use the DoH’s Medicines Management Framework in conjunction with the Audit Commission’s diagnostic to review medicines management arrangements and develop local action plans

14 Medicines formularies should be agreed that are linked to joint care arrangements, clinical guidelines and NICE guidance

15 Medicines management groups and DTCs should be made formally accountable to the trust board or to the clinical governance committee

16 Risk management arrangements should be reviewed and ‘fair blame’ and ‘near miss’ reporting systems introduced

SMUHT Medicines Management Committee

To develop and ratify the Trust policy for Medicines ManagementTo recommend and review procedures for the control, storage and administration of medicines (drugs and prescribable dressings)To receive and respond to applications for the use of new medicines from the Major Business Units

SMUHT Medicines Management Committee

To produce and maintain a Trust formularyTo ensure effective methods of promulgation of policy decisions to cliniciansTo liase with specialists and with PCOs and Area Prescribing Committees (APCs) to develop guidelines for the safe, effective and economic use of medicines To commission audits to ensure that policies and guidelines are implemented

How we deal with NICE guidance and the NSFs

NICE Technology appraisal - medicines

Clinical Governance Chairman

Medicines Management Chairman

Specialists

Medicines Management Committee

Formulary/Guidelines/PracticeHospital Care

NICE technology appraisals

46 obesity – surgery clinical audit 47 Giib/iiia inhibitors update MMC 48 haemodialysis home v hosp clinical audit 49 ultrasound for CVC clinical audit 50 imatinib CML MMC 51 depression, cognitive therapy clinical audit 52 myocardial infarction early Rx MMC 53 diabetes long acting insulin MMC 54 vinorelbine in breast CA Christie

A spoonful of sugarrecommendations (7)

17. Trust boards and senior managers should seek regular assurance that actual clinical practice reflects agreed protocols – in particular, the practice of making-up aseptic preparations on hospital wards should be stopped- CIVAs SERVICE - NPSA

18. Lead clinicians should ensure that the induction programme of all clinical staff provides adequate coverage of policies on prescribing practice, medicines administration and incident reporting. Monitoring of competencies in prescription and administration of medicines should be given high priority - Education and Training

19. Trusts should undertake reviews of pharmacy staffing levels and consider whether there are adequate resources to:(i) provide for all aspects of clinical pharmacy services;(ii) meet the demands of the NHS Plan in respect of new consultants and nurse prescribers; (iii) take patients’ medication histories; and(iv) support dispensing for discharge schemes

A spoonful of sugarrecommendations (8)

20. Arrangements should be introduced for the use of patients’ own medicines in hospital

21. Trust boards should call for a position statement on progress towards introducing self-administration of medicines and providing the necessary staff resource to maximise implementation

22. Original pack dispensing should be introduced in all appropriate areas immediately, using Department of Health guidance. Re-packaging of medicines from bulk should be stopped, wherever possible

23. The annual Service and Financial Framework round should include an assessment of future cost pressures from medicines, and a risk-sharing approach agreed between commissioners and providers

Cost pressures for 2003 and beyondinforming the LDP process

Gpiib/iiia inhibitors Taxanes Ribavarin & interferon

alpha anti TNF medicines

for Crohn’s & RA Glitazones Imatinib Insulin glargine

Syringes & minibags - EL(97)52

Antimicrobials HIV therapy LMW heparins Olizumab in asthma Tobramycin inhalation morphine syringes &

co-phenylcaine spray

% INCREASE IN OUTTURN EXPENDITURE BETWEEN 98/99 -00/01

% c

han

ge

98/9

9 -

00/0

1

South Manchester vs Teaching outside London

0

10

20

30

40

*

INTERFACE WITH PRIMARY CARES

core

(o

ut

of

27)

South Manchester vs Teaching outside London

0

5

10

15

20

25

*

The MANMED Survey Postal survey of medicines management in England MANMED (PCO) survey

– PCO prescribing priorities– high profile drugs– NSFs and NICE guidance– PCO prescribing initiatives

MANMED (NHST) Survey– NHS Trust expenditure– pharmacy IT facilities– NSFs and NICE guidance– Prescribing policies

The MANMED SurveyPattern of Response

MANMED (PCO) survey– 66% response rate (N=332)– representative of all PCOs in England

MANMED (NHST) survey– 57% response rate (N=275)– Representative of all NHSTs in England

Survey of chief pharmacists 2001

UK chief pharmacists surveyed in 2001 157/275 responses (57%) Mean trust expenditure £107m (SD £71m) Medicines expenditure £5.6m (SD £9.5m) 80% of budgets held in clinical divisions

Survey of chief pharmacists 2001IT facilities

Intranet 81% Internet 87% EDI 40% EDI invoice processing 13% Web site 37% Web formulary 21% Electronic prescribing 3% (11% partial)

DTC in 97% of hospitalsWho sits on DTC?

0102030405060708090

100

cons chief P hospP

nurse PCO GP Finman

GenMan

JunDoc

CEO patient

%

Survey of chief pharmacists 2001prescribing policies

Formulary – 78% New medicines scheme – 90% Impact on Primary Care – 94% Shared with Primary Care – 77%

Survey of chief pharmacists 2001new medicines introduction

Glitazones 79% Infliximab 70% Celecoxib 62% Linezolid 44% Esomeprazole 42% Zanamivir 34% Oxycodone 32%

Survey of chief pharmacists 2001Specific policies

28 day/OP/OP dispensing 67% 28 day/OP/1 stop dispensing 68% Reuse of Patients medicines 73% Self administration of meds 62% Nurse authorisation PGD 83% Pharmacist authorisation PGD 27%

Action on NICE guidance %ACTION PPIs Glits taxanes

Audit of practice 43 12 24 Committee set up 11 4 7 DTC submission 24 51 15 Rev of disease man guide 29 21 15 Identify indicators 10 5 8 Funding request 2 11 39 Guidance circulated 66 65 54 Directive issued 11 11 7 Formulary modified 31 44 13 No action 26 21 31

Action on NSFs %ACTION CHD Mental Health

Audit of practice vs NICE42 25 Committee set up 41 31 DTC submission 27 12 Rev of disease man guide 45 23 Identify indicators 18 8 Funding request 35 15 Guidance circulated 56 33 Directive issued 8 5 Formulary modified 20 7 No action 19 30

StrategicHealth

Authorities

PrimaryCare

Organisations

LocalAuthorities

NHS HospitalTrusts

NHSExecutive

RegionalOffices

key

HIP

statuary a/cservice a/c NICE

CHAI

Thank You

Any Questions?

MMC new medicines 2002 Medicine Approval

caspofungin limitedvoriconazole limitedzoledronic acid deferdetrusitol XL noelleste yes for GPsdovobet yesinsulin glargine yes

tiotropium yes