Clinical Governance in Medicines Management

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Clinical Governance in Medicines Management
prescribing in hospitals

• www.allaboutpharmacy.co.uk
• Dr Jonathan CookeSouth Manchester University
  Hospitals NHS Trust Manchester January 30th
  2003
• jonathan.cooke_at_man.ac.uk

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Setting, delivering, monitoring standards
National Institute for Clinical
Excellence National Service Frameworks
Professional self regulation
Clinical Governance
Lifelong learning
Commission for Health Improvement National
Performance Framework National Patient and User
Survey
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key
NHS Executive
statuary a/c
NICE CHAI
service a/c
Regional Offices
HIP
Strategic Health Authorities
Local Authorities
NHS Hospital Trusts
Primary Care Organisations
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Pharmacy in the Future Implementing the NHS Plan

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

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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

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Medicines Management Agenda in hospitals

• Controls Assurance Standards
• NHSE performance management of medicines
  management in NHS hospitals
• Audit Commission - Audit of Medicines Management

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Medicines Management Agenda in hospitals

• Controls Assurance Standards
• NHSE performance management of medicines
  management in NHS hospitals
• Audit Commission - Audit of Medicines Management

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The diagnostic audit
Key diagnostic questions
Relative change in expenditure
on medicines in past 3 years
Is there effective control over
Overspend on medicines in
medicines expenditure?
past 3 years
Vacancies
in pharmacy department
Is staffing adequate for the
Are the data corroborated
services which should be
by other central returns?
Throughput per staff member
provided?
Staff activity in pharmacy
Is there effective use of
department
pharmacy staff?
Judgement In depth audit work / No further audit
work
Use of patients own
medicines self-administration
Use of original packs and means of prescribing
Has the service introduced
processes in line with
Development of joint formulary between primary
acute care
accepted good practice?
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In-depth audit how it applies
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A spoonful of sugarrecommendations (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.
• Following agreement of standard definitions and
  categories of medication errors, base-line audits
  should be undertaken.

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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

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South Manchester University Hospitals
HIRS Web form
email
encryption
server
Incident Reporting System
Access DB
reports
decoding
ACTION
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A spoonful of sugarrecommendations (2)

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

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A spoonful of sugarrecommendations (3)

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

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A spoonful of sugarrecommendations (6)

• Trust boards should use the DoHs Medicines
  Management Framework in conjunction with the
  Audit Commissions diagnostic to review medicines
  management arrangements and develop local action
  plans
• Medicines formularies should be agreed that are
  linked to joint care arrangements, clinical
  guidelines and NICE guidance
• Medicines management groups and DTCs should be
  made formally accountable to the trust board or
  to the clinical governance committee
• Risk management arrangements should be reviewed
  and fair blame and near miss reporting
  systems introduced

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SMUHT Medicines Management Committee

• To develop and ratify the Trust policy for
  Medicines Management
• To 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

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SMUHT Medicines Management Committee

• To produce and maintain a Trust formulary
• To ensure effective methods of promulgation of
  policy decisions to clinicians
• To 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

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How we deal with NICE guidance and the NSFs
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NICE Technology appraisal - medicines
Clinical Governance Chairman
Medicines Management Chairman
Specialists
Medicines Management Committee
Formulary/Guidelines/Practice
Hospital Care
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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

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A spoonful of sugarrecommendations (7)

• 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
• 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
• 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

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A spoonful of sugarrecommendations (8)

• Arrangements should be introduced for the use of
  patients own medicines in hospital
• 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
• 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
• 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

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Cost pressures for 2003 and beyondinforming the
LDP process

• Gpiib/iiia inhibitors
• Taxanes
• Ribavarin interferon alpha
• anti TNF medicines for Crohns 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

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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

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The MANMED SurveyPattern of Response

• MANMED (PCO) survey
• 66 response rate (N332)
• representative of all PCOs in England
• MANMED (NHST) survey
• 57 response rate (N275)
• Representative of all NHSTs in England

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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

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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)

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DTC in 97 of hospitalsWho sits on DTC?

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Survey of chief pharmacists 2001prescribing
policies

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

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Survey of chief pharmacists 2001new medicines
introduction

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

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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

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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

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Action on NSFs

• ACTION CHD Mental Health
• Audit of practice vs NICE 42 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

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key
NHS Executive
statuary a/c
NICE CHAI
service a/c
Regional Offices
HIP
Strategic Health Authorities
Local Authorities
NHS Hospital Trusts
Primary Care Organisations
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Thank You Any Questions?
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MMC new medicines 2002

• Medicine Approvalcaspofungin limitedvorico
  nazole limitedzoledronic acid deferdetrusitol
  XL noelleste yes for GPsdovobet yesinsulin
  glargine yes
• tiotropium yes

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