The Consequences of Working Differently

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The Consequences of Working Differently
City Hospitals Sunderland Foundation NHS Trust
NHS

• Where we started from ?
• What are the Principles and Philosophies ?
• What we implemented going forward ?
• The consequences of those changes ?
• Do they deliver ?

Managing Medicines - Enhancing Patient Care
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History
Slow, Error Prone, Expensive
Prescribe
Purchase
Supply
Dispense
Store
Manipulate
Supply
Manufacture
Administer
Pharmacy
Monitor
THE CURRENT MEDICATION MANANGEMENT PROCESS
Discharge
Record
Communicate
Patient / Ward
Primary Care
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SLOW and delayed
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Awaits collection
Phase 1 - Mean Duration 1.2 hours
Phase 2 - Mean Duration 1.6 hours
Porter Collects
Phase 3 - Mean Duration 1.2 hours
Phase 4 - Mean Duration 1.3 hours
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The Patient Perspective
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ERRORS
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When you are in deep, deep trouble, say
nothing and try to look like you know what
youre doing!
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The Philosophies
City Hospitals Sunderland Foundation NHS Trust
NHS

• We want to be Leading Edge not Bleeding Edge.
• We will practice centralised decentralisation.
• What they want is what they say but what they
  need is what they pay !
• Work is like a st sandwich Cant Disguise
  with bread
• We are advocates of better utilisation of
  medicines not controllers or policemen of the
  process.
• The journeys end may never be reached and we are
  in a yacht at the mercy of prevailing winds and
  tides.

Managing Medicines - Enhancing Patient Care
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MEDICINES MANAGEMENT
City Hospitals Sunderland Foundation NHS Trust
NHS

• Remove Errors E.g. Validating History
• Review Medication Re-utilise PODs
• Original Pack Dispensing for Discharge
• Attend Ward Rounds
• Counsel and Reminder Card
• Pharmacist /Technician Managed Discharge Process
• Improved Discharge Summary to GP
• Service to all Medical, COTE, Surgery and TO (25
  wards) Net Investment (transfer) of 350k

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CHS PICTURE
City Hospitals Sunderland Foundation NHS Trust
NHS

• Reduced Errors
• Quicker Discharge
• Prevention of Duplication of Supply
• Dispensing for Discharge
• Utilised Patients Drugs during Inpatient Stay
• Eliminated use of taxis

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CHS PICTURE
City Hospitals Sunderland Foundation NHS Trust
NHS

• Problem Solving /Formulary Management
• Recruitment Retention
• Patient Satisfaction High
• Cover the costs of the scheme ?
• 1 of 14 PWC FFF08 Workstreams
• Current Establishment
• 45 pharmacist
• 65 technical staff

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PHARMACY PROFILE
City Hospitals Sunderland Foundation NHS Trust
NHS

• MM Inpatient Service
• - 25 inpatient wards
• Full E.P.M.A System
• - all inpatient wards

• Robotic System (Agreed for 2 Dispensaries)

Managing Medicines - Enhancing Patient Care
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Principles
City Hospitals Sunderland NHS Trust
NHS

• COMPUTERS
• Reliable and make continuous rapid consistent but
  simple decisions
• PEOPLE
• Careless and make inconsistent, relatively slow
  but complex decisions
• RULES BASED PROTOCOLS YES/NO

Managing Medicines is a complex decision process
that has yes but rather than yes/no decisions
Managing Medicines - Enhancing Patient Care
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CHANGES IN PRACTICE ?
Less correcting doctors mistakes More preventing
mistakes More useful information Targeting
Prioritisation Multiple Access to prescriptions
at all times Accurate Audit Trails Access to a
wider picture from remote locations (e.g.
Dispensary, Home?) Decision Constraint vs
Decision Support
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WHAT DOES IT DELIVER ?
City Hospitals Sunderland NHS Trust
NHS

• Removes Ward Pharmacy
• Illegibility and Misinterpretation removed ?
• Correct Formulation Route Restrictions?
• Area and Prescriber Restrictions ?
• Accurate Transfer to Discharge ?
• Status of the Order ?

Managing Medicines - Enhancing Patient Care
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WHAT DOES IT DELIVER ?
City Hospitals Sunderland NHS Trust
NHS

• Dose Checking Automatic Directions ?
• Allergy, Duplication and Interaction Checking
• Rules Based Prescribing E.g Automatic Stops
• Additional Information ?
• Protocol Prescribing order sets
• Formulary Control - (got worse ?)

Managing Medicines - Enhancing Patient Care
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City Hospitals Sunderland NHS Trust
NHS

• Mrs IB 79 years old orthopaedic patient

• Ward sister noted raised potassium levels
• led to check against prescription

• Patient prescribed Permitabs 1 daily

Potassium Permanganate administered orally for
at least 4 out of last 5 days
Managing Medicines - Enhancing Patient Care
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Staffing Consequences?
City Hospitals Sunderland Foundation NHS Trust
NHS

• Heavily dependant on Pharmacists (turnover)
• Front Load Training Programme
• Band 7 Postgraduate Diploma
• New Roles
• Band 3 Checking Dispensers
• Pharmacist Prescribers
• Technician Free Dispensaries
• No role for Band 4
• Gap Clinical Dispensing Staff
• New source of errors?
• 365 day extended out-of-hours working
• Deskill other professions
• Reduced staff during weekdays
• External Factors
• PSG001

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Drug Form
?
History
Drug Dose
?
Decision Support
Prescribe
Drug Need
?
?
?
Purchase
Supply
Dispense
?
?
Store
Manipulate
?
?
Supply
Manufacture
Administer
Pharmacy
?
Monitor

• Automation ? of systems will allow
• Greater Freeing of Resources
• Near 100 efficiency of patient care

Counsel
?
?
Record
Communicate
Patient / Ward
Primary Care
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When you fly check the landing zone !!