self-monitoring instrument to improve the efficiency of drug management in hospital pharmacy...

SELF-MONITORING INSTRUMENT TO IMPROVE THE SELF-MONITORING INSTRUMENT TO IMPROVE THE EFFICIENCY OF DRUG MANAGEMENT IN HOSPITAL EFFICIENCY OF DRUG MANAGEMENT IN HOSPITAL PHARMACYPHARMACY

Pudjaningsih DPudjaningsih D1 1 & Santoso B & Santoso B 22

11 PKU Muhammadiyah Hospital, YogyakartaPKU Muhammadiyah Hospital, Yogyakarta22 Departement Clinical Pharmacology, Faculty of Medicine,Gadjah Departement Clinical Pharmacology, Faculty of Medicine,Gadjah

Mada Univercity, YogyakartaMada Univercity, Yogyakarta

ABSTRACTABSTRACT

Problem StatementProblem Statement: The operational budget of hospital pharmacy service is relatively high, : The operational budget of hospital pharmacy service is relatively high, representing approximately 40%-60% of hospital’s total budget. In order to ensure appropriate use of representing approximately 40%-60% of hospital’s total budget. In order to ensure appropriate use of these funds, appropriate drug management must be monitored and enforced. Drug management these funds, appropriate drug management must be monitored and enforced. Drug management consists of selection and quantification, procurement, and storage and distribution, each of which must consists of selection and quantification, procurement, and storage and distribution, each of which must be assessed for efficiency. The instrument used must be valid, specific, and sensitive. be assessed for efficiency. The instrument used must be valid, specific, and sensitive.

ObjectiveObjective : : to develop the efficiency indicators for use in rapid-assessment of hospital drug to develop the efficiency indicators for use in rapid-assessment of hospital drug management.management.

DesignDesign: The study consisted of two steps. The first step was the development of indicators, involving 50 : The study consisted of two steps. The first step was the development of indicators, involving 50 drug managers. The final draft of the indicators was then field-tested in 6 hospitals. This abstract drug managers. The final draft of the indicators was then field-tested in 6 hospitals. This abstract described the results of the field-tested. described the results of the field-tested.

Setting and populationSetting and population: Fifty pharmacists working as drug managers in 50 hospitals in 5 provinces : Fifty pharmacists working as drug managers in 50 hospitals in 5 provinces were involved during the development of the indicators. The finals draft of the indicators instrument was were involved during the development of the indicators. The finals draft of the indicators instrument was then field-tested in 6 hospitals in Yogyakarta province.then field-tested in 6 hospitals in Yogyakarta province.

Intervention:Intervention: The literature was searched for potential indicators, resulting in Draft I. A workshop The literature was searched for potential indicators, resulting in Draft I. A workshop involving 12 hospital managers was conducting to evaluate Draft I and nominate specific indicators to involving 12 hospital managers was conducting to evaluate Draft I and nominate specific indicators to adapt for use in hospital, producing Draft II. .The draft II was then further developed, and 50 drug adapt for use in hospital, producing Draft II. .The draft II was then further developed, and 50 drug hospital managers were invited for comments; the result of this step was the Draft III (final draft). The hospital managers were invited for comments; the result of this step was the Draft III (final draft). The final draft consisted of three indicators for the selection stage, three indicators for procurement stage, final draft consisted of three indicators for the selection stage, three indicators for procurement stage, four indicators for storage stage, and six indicators for distribution stage. This finals draft of indicators four indicators for storage stage, and six indicators for distribution stage. This finals draft of indicators was then field-tested in rapid self-assessments conducted at six hospitals.was then field-tested in rapid self-assessments conducted at six hospitals.

ResultResult:: The results showed that rapid self-assessment was feasible in one day when all of the needed The results showed that rapid self-assessment was feasible in one day when all of the needed information was available. level of drug management and information management varied among the information was available. level of drug management and information management varied among the six hospitals. Rapid self-assessment in private hospitals are faster than those public hospitals because six hospitals. Rapid self-assessment in private hospitals are faster than those public hospitals because the private hospitals could more easily access the information needed. The indicator instrument was the private hospitals could more easily access the information needed. The indicator instrument was able to detect that any serious problems and to determine the quality of drug management. able to detect that any serious problems and to determine the quality of drug management. Respondents found the instrument easy to use, if provided all information needed was available. Two Respondents found the instrument easy to use, if provided all information needed was available. Two indicators in the procurement stage were considered not sensitive, whereas, the other indicators were indicators in the procurement stage were considered not sensitive, whereas, the other indicators were proven valid, sensitive and specific.proven valid, sensitive and specific.

ConclusionConclusion: Appropriate hospital drug management depends on access to complete information. This : Appropriate hospital drug management depends on access to complete information. This instrument is considered useful in detecting problems and measuring the quality of drug management . instrument is considered useful in detecting problems and measuring the quality of drug management . Continuous improvement can be achieved if the indicators are used regularly.Continuous improvement can be achieved if the indicators are used regularly.

Funding SourceFunding Source:: PKU Muhammadiyah Hospital, Yogyakarta, Indonesia. PKU Muhammadiyah Hospital, Yogyakarta, Indonesia.

Background & SettingBackground & Setting

The operational budget of hospital pharmacy service is The operational budget of hospital pharmacy service is relatively high, approximately 40%-60% of hospital relatively high, approximately 40%-60% of hospital budgetbudget

To ensure the efficient use of these funds, appropriate To ensure the efficient use of these funds, appropriate drug management must be monitored and enforced.drug management must be monitored and enforced.

Drug management consists of drug selection and Drug management consists of drug selection and quantification, procurement, storage, and distributionquantification, procurement, storage, and distribution

The quality of drug management must be assessed for The quality of drug management must be assessed for efficiency by using instruments or indicatorsefficiency by using instruments or indicators

The indicators must be valid, specific, and sensitive to The indicators must be valid, specific, and sensitive to minor changes minor changes

Setting and Population: Setting and Population: Development of indicators: 50 drug managers Development of indicators: 50 drug managers

from 50 hospitals in 5 provinces from 50 hospitals in 5 provinces Field-test: 3 private and 3 public hospitals in Field-test: 3 private and 3 public hospitals in

Yogyakarta, Indonesia.Yogyakarta, Indonesia.

Study ObjectiveStudy Objective

To develop and field-test the To develop and field-test the efficiency of indicators in selection, efficiency of indicators in selection, procurement, storage and procurement, storage and distribution stages in hospital drug distribution stages in hospital drug management management

Draft IDraft IReviewed Reviewed

by 12 by 12 Hospitals Hospitals ManagersManagers

Literature Literature ReviewedReviewed

Workshop Workshop Involving Involving

50 50 Hospital Hospital

Drug Drug ManagersManagers

Draft II -Draft II -NominatNominat

ededIndicatorIndicator

Set of Set of Indicators Indicators

IIII

Set of Set of Indicators IIndicators I

RecommRecommended ended

IndicatorIndicatorss

Field-test Field-test in in Six Six

HospitalsHospitals

Output: Output: Final Final

IndicatorsIndicators

STEP ISTEP I

STEP IISTEP II

Methods

The Final Set of IndicatorsThe Final Set of Indicators

Stage of Stage of drug drug

managememanagementnt

NoNo IndicatorIndicator Standard ValueStandard Value

SelectionSelection 11 Availability of drug budgetAvailability of drug budget 100 %100 %

22 Ratio of planning and consumptionRatio of planning and consumption 1:11:1

33 Average percentage of drug consumed Average percentage of drug consumed 100 %100 %

ProcuremeProcurementnt 11 Average procurement frequency Average procurement frequency Depends on optimal balance between space and Depends on optimal balance between space and

quantityquantity

22 Frequency of incomplete drug orderFrequency of incomplete drug order 00

33 Frequency of delayed hospital drug payment Frequency of delayed hospital drug payment 00

StorageStorage 11 Conformity of records to phisical checks on drug Conformity of records to phisical checks on drug quantityquantity 11

22 Turn over ratioTurn over ratio 8 - 12 x8 - 12 x

33 Percentage of drugs placed in shelf properlyPercentage of drugs placed in shelf properly 100 %100 %

44 Percentage of damaged and expired drugPercentage of damaged and expired drug 0 %0 %

DistributioDistributionn

11 Percentage of generic drug usePercentage of generic drug use >80 %>80 %

22 Percentage of outpatient complaintsPercentage of outpatient complaints 0 %0 %

33 Percentage of doctors complaintsPercentage of doctors complaints 0 %0 %

44 Time to fill prescriptionTime to fill prescription <30 minutes<30 minutes

55 Percentage of prescription which are not filledPercentage of prescription which are not filled 0 %0 %

66 Percentage of non-formulary drugsPercentage of non-formulary drugs 0 %0 %

IndicatorsIndicators UnitUnit CalculationCalculation

Availability of drug budgetAvailability of drug budget %% Available budget at a time divided by the total fund needed for drugs in one year x 100%Available budget at a time divided by the total fund needed for drugs in one year x 100%

Ratio of planning and Ratio of planning and consumptionconsumption ratioratio Total drug items planned in the beginning of the year : total drug items used at the end of Total drug items planned in the beginning of the year : total drug items used at the end of

the yearthe year

Average percentage of drug Average percentage of drug consumed consumed %% Randomly select 10 drug items, calculate the percentage of the quantity consumed over Randomly select 10 drug items, calculate the percentage of the quantity consumed over

quantity planned for each item, calculate the averagequantity planned for each item, calculate the average

Average procurement Average procurement frequency frequency xx Randomly select 10 drug items, calculate the frequency of purchase during the last 1 year Randomly select 10 drug items, calculate the frequency of purchase during the last 1 year

for each item, calcukate the averagefor each item, calcukate the average

Frequency of incomplete drug Frequency of incomplete drug orderorder

x/x/monthmonth

Take all drug order forms in the last 1 month, identity the number of mistakes in writing the Take all drug order forms in the last 1 month, identity the number of mistakes in writing the ordersorders

Frequency of delayed hospital Frequency of delayed hospital drug payment drug payment x/yearx/year Calculate the number of invoices during the last 1 year, check with the due date of Calculate the number of invoices during the last 1 year, check with the due date of

payment, calculate how many are overdue in the respective yearpayment, calculate how many are overdue in the respective year

Conformity of records with Conformity of records with phisical checks on drug phisical checks on drug quantityquantity

%% Randomly select 10 drug items at the time of visit, check the record with the physical Randomly select 10 drug items at the time of visit, check the record with the physical quantity, calculate how many items of the 10 are incorrect, x 100%quantity, calculate how many items of the 10 are incorrect, x 100%

Turn over ratioTurn over ratio xx The total value (Rp) of drug income in the last 1 year divide by the total value (Rp) of drugs The total value (Rp) of drug income in the last 1 year divide by the total value (Rp) of drugs on stock at the end of the yearon stock at the end of the year

Percentage of drugs placed in Percentage of drugs placed in shelf properlyshelf properly %%

Randomly select 10 drug items, check the order of purchase, check the placement of the Randomly select 10 drug items, check the order of purchase, check the placement of the drugs. The first in (or the first expired) must be in the front rows. Calculate the number of drugs. The first in (or the first expired) must be in the front rows. Calculate the number of items placed incorrectly, divide by 10, x 100%items placed incorrectly, divide by 10, x 100%

Percentage of damaged and Percentage of damaged and expired drugexpired drug %% Calculate the value of damaged and expired drug s (Rp), divided by the total value (Rp) of Calculate the value of damaged and expired drug s (Rp), divided by the total value (Rp) of

drugs in stock, x 100 %drugs in stock, x 100 %

Percentage of generic drug usePercentage of generic drug use %% Calculate the number of R/ in generic in the last 1 month, divided by the total R/ in the Calculate the number of R/ in generic in the last 1 month, divided by the total R/ in the respective month, x 100%respective month, x 100%

Percentage of outpatient Percentage of outpatient complaintscomplaints %% Interview 30 out-patient exits, calculate the percentage of patients who are not satisfied Interview 30 out-patient exits, calculate the percentage of patients who are not satisfied

with the pharmaceutical serviceswith the pharmaceutical services

Percentage of doctors Percentage of doctors complaintscomplaints %% Interview 10 doctors on the day of visit, calculate the percentage of doctors who are not Interview 10 doctors on the day of visit, calculate the percentage of doctors who are not

satisfied with the pharmaceutical servicessatisfied with the pharmaceutical services

Time to fill prescriptionTime to fill prescription minutminuteses

Randomly select 20 out patients in the pharmacy service area, calculate the average time Randomly select 20 out patients in the pharmacy service area, calculate the average time spent to get the prescription readyspent to get the prescription ready

Percentage of prescription Percentage of prescription which are not filledwhich are not filled %% Calculate the number of prescription filled during the last 10 days, divided by the total Calculate the number of prescription filled during the last 10 days, divided by the total

number of prescriptions written during the same period, x 100%number of prescriptions written during the same period, x 100%

Percentage of non-formulary Percentage of non-formulary drugsdrugs %% Observe all prescription during the last 10 days, calculate the number of R/ which is not Observe all prescription during the last 10 days, calculate the number of R/ which is not

from the hospital formulary, divided by the total R/ of the same period, x 100%from the hospital formulary, divided by the total R/ of the same period, x 100%

Calculation

Result: field-test of indicators in 6 HospitalsResult: field-test of indicators in 6 Hospitals

NoNo IndicatorIndicator Private Private HospitaHospita

l 1l 1

Private Private HospitaHospita

l 2l 2

Private Private Hospital Hospital

33

Public Public Hospital Hospital

44


55


6611 Availability of drug Availability of drug

budgetbudget 100 % 100 % 100 %100 % 100 % 100 % 39 %39 % N/AN/A 73 %73 %

22 Ratio of planning and Ratio of planning and consumptionconsumption 1 : 1.11 : 1.1 1:1.11:1.1 1 : 1.1 1 : 1.1 1 : 1.41 : 1.4 N/AN/A N/AN/A

33 Average percentage of Average percentage of drug consumed drug consumed 16 % 16 % 4 %4 % 26 %26 % 280 %280 % N/AN/A N/AN/A

Selection

NoNo IndicatorIndicator Private Private HospitaHospita

l 1l 1

Private Private HospitaHospita

l 2l 2

Private Private Hospital Hospital

33


44


55


661.1. Average procurement Average procurement

frequency frequency 1 – 2 X 1 – 2 X 3 - 4 X3 - 4 X 1 X1 X N/AN/A 1 X 1 X 4 X4 X

22 Frequency of incomplete Frequency of incomplete drug orderdrug order 9 X 9 X 1 X1 X 9 X9 X N/AN/A 2 X2 X N/AN/A

33 Frequency of delayed Frequency of delayed hospital drug payment hospital drug payment 25 X 25 X N/AN/A N/AN/A 10 X10 X N/AN/A N/AN/A

Procurement

Result: field-test of indicators in 6 Hospitals Result: field-test of indicators in 6 Hospitals (continued)(continued)

NoNo IndicatorIndicatorPrivate Private Hospital Hospital 11

Private Private Hospital Hospital 22

Private Private HospitaHospital 3l 3

Public Public HospitHospital 4al 4

Public Public HospitHospital 5al 5

Public Public HospitaHospital 6l 6

11Conformity of records with Conformity of records with phisical checks on drug phisical checks on drug quantityquantity

100 % 100 % 100 % 100 % 100 % 100 % N/AN/A 100%100% 100 %100 %

22 Turn over ratioTurn over ratio 11 X 11 X 23 X 23 X 12 X 12 X 4 X4 X 7 X7 X N/AN/A

33 Percentage of drugs placed in Percentage of drugs placed in shelf properlyshelf properly 100 % 100 % 100 % 100 % 100 % 100 % N/AN/A 10 %10 % 20 %20 %

44 Percentage of damaged and Percentage of damaged and expired drugexpired drug 0.2 % 0.2 % 0.05 % 0.05 % 0.06 % 0.06 % 0.75 %0.75 % 0.24 %0.24 % 0 %0 %

StorageStorage

NNoo

IndicatorIndicatorPrivate Private Hospital Hospital 11





Public Public Hospital Hospital 66

11 Percentage of generic Percentage of generic drug usedrug use 17 % 17 % 3 % 3 % 16 % 16 % 68 %68 % 57 %57 % 60 %60 %

22 Percentage of outpatient Percentage of outpatient complaintscomplaints 3 % 3 % 5 % 5 % 0 % 0 % 0 %0 % 0 %0 % 0 %0 %

33 Percentage of doctors Percentage of doctors complaintscomplaints 3 % 3 % 50 % 50 % 10 % 10 % 28 %28 % 0 %0 % 40 %40 %

44 Time to fill prescriptionTime to fill prescription 30 ‘30 ‘ 24 ‘24 ‘ 18 ‘18 ‘ 42 ‘42 ‘ 16 ‘16 ‘ 10 ‘10 ‘

55Percentage of Percentage of prescription which are prescription which are not filled innot filled in

22 % 22 % 24 % 24 % 0 % 0 % 27 %27 % 1 %1 % 2 %2 %

66 Percentage of non-Percentage of non-formulary drugsformulary drugs 0 % 0 % 0.4 % 0.4 % 0 % 0 % 8.2 %8.2 % 0 %0 % 6.6 %6.6 %

Result: field-test of indicators in 6 Hospitals Result: field-test of indicators in 6 Hospitals (continued)(continued)

DistributionDistribution

Qualitative FindingsQualitative Findings

The rapid self-assessment was able to be conducted The rapid self-assessment was able to be conducted in one day if all information needed was availablein one day if all information needed was available

Rapid self-assessment in private hospitals are faster Rapid self-assessment in private hospitals are faster than thay in public hospitals, because in private than thay in public hospitals, because in private hospitals the information was more instantly hospitals the information was more instantly availableavailable

The indicators were able to detect serious problems The indicators were able to detect serious problems in drug managementin drug management

Respondents found the instrument easy to use, Respondents found the instrument easy to use, provided that all information needed was availableprovided that all information needed was available

DiscussionsDiscussions

The final indicators showed its validity, sensitivity, and The final indicators showed its validity, sensitivity, and specificity:specificity:

Valid to measure the quality of drug managementValid to measure the quality of drug management Sensitive to determine any problem, either in the Sensitive to determine any problem, either in the

process or outcomeprocess or outcome Specific to detect if there is a problem Specific to detect if there is a problem

The indicators are easy to use for:The indicators are easy to use for: Determining problems in drug managementDetermining problems in drug management Motivating hospitals to improve the management Motivating hospitals to improve the management

information systeminformation system

This instrument is considered useful in detecting problems and This instrument is considered useful in detecting problems and measuring the quality of drug management, and is able to measuring the quality of drug management, and is able to show the difference among hospitals show the difference among hospitals

Regular use of this set of indicators will be useful in improving Regular use of this set of indicators will be useful in improving the quality of drug management the quality of drug management

Although none of the hospitals showed a good quality of drug Although none of the hospitals showed a good quality of drug management, the private hospitals showed a slightly better management, the private hospitals showed a slightly better drug management than the three public hospitalsdrug management than the three public hospitals

ConclusionsConclusions

self-monitoring instrument to improve the efficiency of drug management in hospital pharmacy...

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