WHY IS UNIT DOSE DISPENSING WHY IS UNIT DOSE DISPENSING (UDD) (UDD) DIFFICULT TO IMPLEMENT?DIFFICULT TO IMPLEMENT?Case study in three public Case study in three public hospitalshospitals

NaswirNaswir11 & Sri Suryawati & Sri Suryawati22

INRUD—Padang, IndonesiaINRUD—Padang, IndonesiaDepartment of Clinical Pharmacology, Faculty of Department of Clinical Pharmacology, Faculty of

Medicine, Gadjah Mada University, Yogyakarta.Medicine, Gadjah Mada University, Yogyakarta.

Problem Statement: Unit-dose dispensing (UDD) is a system of drug distribution in hospitals that aims to increase efficiency, cost-containment, and the quality of drug delivery. Many studies at the national and international level have shown that this system provides advantages to the quality of service, to the patients and also to the hospitals. Yet at the time the study was undertaken, there were no hospitals in Indonesia that were using the system comprehensively. It was suspected that some inhibiting factors were behind this, which need to be identified and resolved.Objective: To find obstacles and opportunities for successfully implementing UDD.Design: Case study Setting and population: Three public hospitals in Indonesia which have already implemented UDD for at least 3 years in a particular ward.Outcome measures: Qualitative data obtained from observation, in-depth interview, and questionnaire with hospital directors, head of pharmacy departments, health providers, and patients. Results: The main inhibiting factors included the lack of facilities in the ward, incapability of staff responsible for drug distribution in the ward, and the most important, the lack of political will from the hospital management. The lack of facilities in the ward included inavailability of equipments for UDD implementation, assigned room for UDD activities, etc. The lack of incapability of staff included insufficient knowledge about UDD concept among health providers, and communication problem between provider and patient, or among providers. The lack of political will from the hospital management mainly due to the conflicts of interest between making profit and promoting efficient use of medicines, which are not yet solved properly.Conclusions: Although UDD has been proven useful, it is still very difficult to implement. Political will of the hospital managers, with a strong support from the director is the key factor of UDD implementation. To achieve this, the concept of UDD should be understood, by the hospital managers. To anticipate conflicts of interest, managerial intervention, such as improving the mechanism of incentive – desincentive, is also very much needed. Funding Source: self-funded

ABSTRACTABSTRACT

INTRODUCTIONINTRODUCTIONWhat is Unit Dose Dispensing (UDD)?What is Unit Dose Dispensing (UDD)? Drugs distribution system for inpatients in hospitalsDrugs distribution system for inpatients in hospitals Drugs which are packed in single dose and single package.Drugs which are packed in single dose and single package. Drugs which are given in one unit or one time using.Drugs which are given in one unit or one time using. Drugs which are available to use in 24 hours.Drugs which are available to use in 24 hours.

Advantages (ASHP,1986):Advantages (ASHP,1986): A reduction in the incidence of medication errors.A reduction in the incidence of medication errors. A decrease in the total cost of medication related activities.A decrease in the total cost of medication related activities. A more efficient usage of pharmacy and nursing personal, A more efficient usage of pharmacy and nursing personal,

allowing for more direct patient care involvement by pharmacist allowing for more direct patient care involvement by pharmacist and nurses.and nurses.

Improved overall drug control and drug use monitoring.Improved overall drug control and drug use monitoring. More accurate patient billings for drugs.More accurate patient billings for drugs. The elimination or minimization of drug credits.The elimination or minimization of drug credits. Greater control by the pharmacist over pharmacy work load Greater control by the pharmacist over pharmacy work load

pattern and staff scheduling.pattern and staff scheduling. A reduction in the size of drug inventories located in patient care A reduction in the size of drug inventories located in patient care

areas.areas. Greater adaptability to computerized and automated procedures.Greater adaptability to computerized and automated procedures.

Successful pilot studies:Successful pilot studies: To reduce the cost of medication for patient (Irmawati, To reduce the cost of medication for patient (Irmawati,

1993).1993). To increase efficiency of drug management (Sujarwoto, To increase efficiency of drug management (Sujarwoto,

1997).1997). To eliminate medication error (Widayati, 1998).To eliminate medication error (Widayati, 1998). To reduce the time for UDD preparation (Budiarti, To reduce the time for UDD preparation (Budiarti,

2000).2000).

Despite success in small-scale pilot studies, Despite success in small-scale pilot studies, no hospital in Indonesia is nowadays no hospital in Indonesia is nowadays implements UDD in hospital scale.implements UDD in hospital scale.

INDONESIA EXPERIENCEINDONESIA EXPERIENCE

To find obstacles and To find obstacles and opportunities to opportunities to institutionalize the institutionalize the UDD implementation.UDD implementation.

ObjectiveObjective

DesignDesignIdentifying underlying factors of UDD

implementation

Management function (inputs, process, outputs)Of UDD implementation

OPPORTUNITIES OBSTACLES

Evaluation and recommendation

How to implement UDD hospital-wide

Case study in three public hospitalsCase study in three public hospitals

Data Data collectioncollection Types of data: qualitative, covering input, Types of data: qualitative, covering input,

process, outputprocess, output Method of data collection: observation, in-depth Method of data collection: observation, in-depth

interview, questionnaire.interview, questionnaire. Data sources: Data sources:

documents of drugs management in documents of drugs management in hospitalshospitals

employees including hospital director, head employees including hospital director, head of pharmacy installation, health providersof pharmacy installation, health providers

patientspatients Data collector: staffs of drug distribution, Data collector: staffs of drug distribution,

pharmacist, nurses, pharmacist technicianspharmacist, nurses, pharmacist technicians

Characteristics of Characteristics of hospitalshospitalsHospital AHospital A Type A Hospital, located in Surabaya, East Java ProvinceType A Hospital, located in Surabaya, East Java Province Teaching hospital with 1150 patient beds.Teaching hospital with 1150 patient beds. Bed Occupation Rate (BOR) Bed Occupation Rate (BOR) ± 65%± 65%.. Has 19 specialist and 14 sub specialist Departments.Has 19 specialist and 14 sub specialist Departments. Has implemented UDD in a part of Pediatric Ward (74 beds) since 1988.Has implemented UDD in a part of Pediatric Ward (74 beds) since 1988.

Hospital B Hospital B Type B Hospital, located in Padang, West Sumatera Type B Hospital, located in Padang, West Sumatera

ProvinceProvince Teaching hospital with 650 patient beds.Teaching hospital with 650 patient beds. Bed Occupation Rate (BOR) Bed Occupation Rate (BOR) ± 70,56%.± 70,56%. Has 17 specialist and 6 sub-specialist Departments.Has 17 specialist and 6 sub-specialist Departments. Has implemented UDD in a part of VIP Ward (90 beds) since Has implemented UDD in a part of VIP Ward (90 beds) since

1980.1980.Hospital CHospital C Type C Hospital, located in Brebes, Central Type C Hospital, located in Brebes, Central

Java ProvinceJava Province District Hospital with 213 patient beds.District Hospital with 213 patient beds. Bed Occupation Rate (BOR) ± 62,41%.Bed Occupation Rate (BOR) ± 62,41%. Has 5 specialist DepartmentsHas 5 specialist Departments Has implemented UDD in one Ward since Has implemented UDD in one Ward since

1995.1995.

FINDINGS: HOSPITAL AFINDINGS: HOSPITAL A FacilitiesFacilities

Equipments to support UDD are not enough. To serve 74 beds, 5 Equipments to support UDD are not enough. To serve 74 beds, 5 trolleys are availabletrolleys are available

Inadequate room for UDD preparationInadequate room for UDD preparation In parallel with UDD, patients also receive medications from In parallel with UDD, patients also receive medications from

other sourcesother sources

StaffingStaffing 3 pharmacists, 4 pharmacy technicians and 1 non-medical staff3 pharmacists, 4 pharmacy technicians and 1 non-medical staff In continuous education about UDD concepts among health In continuous education about UDD concepts among health

providers providers Poor communication between provider-patient and providers-Poor communication between provider-patient and providers-

providersproviders

Managerial supportsManagerial supports No enforcement for UDD implementationNo enforcement for UDD implementation No explicit budget allocation for UDD implementationNo explicit budget allocation for UDD implementation Imbalance incentive-disincentive system, resulting in serious Imbalance incentive-disincentive system, resulting in serious

conflict of financial interestconflict of financial interest

FINDING: HOSPITAL BFINDING: HOSPITAL BFacilitiesFacilities Inadequate equipments to support UDD. To serve 90 beds, 12 Inadequate equipments to support UDD. To serve 90 beds, 12

small trolleys are availablesmall trolleys are available Inadequate room for UDD preparation Inadequate room for UDD preparation In parallel with UDD, patients also receive medications from In parallel with UDD, patients also receive medications from

other sourcesother sources

StaffingStaffing 3 pharmacists, 13 pharmacy technicians 3 pharmacists, 13 pharmacy technicians Routine education about UDD concepts among health providers Routine education about UDD concepts among health providers

(twice a year)(twice a year) Poor communication between providers-providers, due to Poor communication between providers-providers, due to

frequent absence of the doctorsfrequent absence of the doctors

Managerial supportsManagerial supports Enforcement for UDD implementation in a form of written Enforcement for UDD implementation in a form of written

Director InstructionDirector Instruction Inadequate budget allocation for UDD implementationInadequate budget allocation for UDD implementation Conflict of financial interest still existsConflict of financial interest still exists

FINDINGS: HOSPITAL CFINDINGS: HOSPITAL CFacilitiesFacilities

Lack of equipments to support UDD. No medicine trolley, Lack of equipments to support UDD. No medicine trolley, inadequate drug packaginginadequate drug packaging

No room for UDD preparation No room for UDD preparation A private drug outlet exists in the WardA private drug outlet exists in the Ward

StaffingStaffing 1 pharmacists, 1 pharmacy technicians 1 pharmacists, 1 pharmacy technicians Education about UDD concepts was addressed to few health Education about UDD concepts was addressed to few health

providers providers Poor communication between providers-patientsPoor communication between providers-patients

Managerial supportsManagerial supports Enforcement for UDD implementation in a form of written Enforcement for UDD implementation in a form of written

Director InstructionDirector Instruction No budget allocation for UDD implementationNo budget allocation for UDD implementation Imbalance incentive-disincentive system, resulting in serious Imbalance incentive-disincentive system, resulting in serious

conflict of financial interestconflict of financial interest

ConclusionsConclusionsFacilitiesFacilitiesThese three hospitals do not provide adequate equipments These three hospitals do not provide adequate equipments and rooms for UDD implementation. Lack of this support and rooms for UDD implementation. Lack of this support indicates that UDD implementation is not a priority.indicates that UDD implementation is not a priority.

Staffing Staffing Most hospitals have inadequate number of pharmacists and Most hospitals have inadequate number of pharmacists and pharmacy technicians to support UDD implementation, and pharmacy technicians to support UDD implementation, and the concepts of UDD does not disseminated thoroughly to all the concepts of UDD does not disseminated thoroughly to all providers. Again, lack of this support indicates that UDD providers. Again, lack of this support indicates that UDD implementation is not a priority.implementation is not a priority.

Managerial supportManagerial supportIn most hospitals, there is practically no political supports In most hospitals, there is practically no political supports from the hospital managers. Unwillingness to implement from the hospital managers. Unwillingness to implement UDD is mostly due to serious conflict of financial interest.UDD is mostly due to serious conflict of financial interest.

RecommendatioRecommendationsns

Efforts should be sought to improve the Efforts should be sought to improve the understanding of hospital managers on the understanding of hospital managers on the importance of good dispensing practices importance of good dispensing practices without sacrificing the hospital income.without sacrificing the hospital income.

Better balance between incentive and Better balance between incentive and disincentive should be promoted by hospital disincentive should be promoted by hospital managers to eliminate the conflict of managers to eliminate the conflict of financial interest.financial interest.

Improving rational use of medicine should be Improving rational use of medicine should be supported by improving the work supported by improving the work environmentenvironment

Thank YouThank You