BSc MSc PhD FRPharmS FCPP(Hon)
You will not get a new product into the NHS unless it fits the quality, innovation, productivity and prevention (QIPP) agenda”, was the stark message from Ron Pate (pharmaceutical adviser, secondary care, Department of Medicines Management, University of Keele). The essence of the QIPP programme is improvements in performance and outcomes through changes in culture, philosophy and processes, he explained.
Robotics fits well with QIPP because it represents an innovation and can clearly improve quality – in reduced patient waiting times for dispensed items, in more timely deliveries to wards and in redeployment of pharmacy staff for near-patient activities. Productivity is improved through space-saving, reductions in stock-holding and shortened dispensing times. In addition, it can prevent undesirable outcomes by reducing dispensing errors and avoiding loss of prescription income out-of-hours.
The QIPP programme is complemented by the ‘commissioning for quality and innovation’ (CQUIN) programme. Mr Pate suggested that commissioners should specify appropriate indicators. Examples for dispensing services could include the percentage of patients waiting for more than 20 minutes in the pharmacy for their medicines and the percentage of product selection errors before and after automation.
Automated guided vehicles (AGVs) are now in use in Forth Valley Hospital for routine transport of surgical supplies, linen, waste, patient food and other materials, Ian Mullen (Chairman, Forth Valley Health Board) told the audience. One of the reasons for implementing such a system was that it allowed skilled staff to spend more time on direct patient care. For example, it had been shown that previously a staff nurse was interrupted 21 times per hour and spent less than 50% of her time on direct patient care. Another important consideration was safety – “in the past clinical waste was handled on average by five people with significant consequences”, said Mr Mullen.
The battery-powered vehicles are controlled by a central PC and are equipped with an array of sensors that allow them to move safely through the service corridors. They can be requested by nurses using PDAs or touchscreens, but the overall coordination is handled by the central host PC. When a vehicle arrives at a ward it notifies the host PC.
At present the AGVs are not used for medicines although the possibility of using them for ward boxes and intravenous fluids is under consideration, said Jann Davison (lead pharmacist for acute care and quality, NHS Forth Valley). However, the working systems of whole new hospital had been planned with e- health solutions in mind. For example the prescribing and patient management system at ward level also includes medicines reconciliation and drug history elements, she said. In addition electronic care plans and discharge summaries can be with at patient’s GP within six hours of discharge. All staff are equipped with hand held devices to ensure smooth running of the system.
The pharmacy is equipped with an ARX robotic dispensing system incorporating an out-of-hours chute that can be operated remotely. The dispensary is effectively ‘paperless’ as all prescriptions are electronic. A ward tracking system enables wards to keep track of prescriptions and eliminates the need for ‘chasing’ phone calls. Full e-drug histories and medicines reconciliation can be achieved for 80–90% of patients within 24 hours of admission, seven days a week, said Ms Davison. Further improvements included a £500,000 reduction in stockholding and more efficient use of space. Discharge prescription turn-round times have been reduced by 50%, consequently ambulance can be ordered earlier. In addition, the number of items dispensed at discharge has fallen by 20% as a result of efficient medicines reconciliation at the beginning of patients’ hospital stays.
Ms Davison concluded that one of the most critical factors for success in the new hospital was the change in culture.
More than 100 Omnicell Smart Store cabinets have been installed in Guy’s and St Thomas’ NHS Foundation Trust and some 10,000 users have been trained. Don Mandeman (chief pharmacy technician, ward automation, Guy’s and St Thomas’ NHS Foundation trust) explained how the scheme operates. Smart Store cabinets hold medical and surgical sundries and stock medicines such as intravenous fluids. Users log into the cabinets by means of a fingerprint, flashing lights lead them to the location of the item required and a correct pick can be confirmed using a bar-code reader. The cabinets can be configured to generate top-up orders and send them to the pharmacy automatically. Pharmacy staff are responsible for picking, delivering and putting away of the orders. They are also responsible for training end users and for identifying and re-educating poor users to ensure that the system works smoothly.
The implementation process was meticulously planned in close collaboration with the ward staff and the project did not go live until 80% of nurses were trained. One objective of the scheme was to reduce inventory costs by £25,400 – a 20% reduction. So far, a reduction in inventory costs of £16,000 has been achieved and they are on course to meet the target, said Mr Mandeman. The next phase of the project will include the installation of cabinets in theatres and in Evelina Children’s Hospital (part of the Guy’s and St Thomas’ group).
Using an Omnicell cabinet as an electronic controlled drug (CD) cabinet and using an electronic controlled drugs register (eCDR) could save about 6.25 hours per week in the pharmacy at Kings College Hospital Pharmacy, according to Nigel Brinklow (deputy director of pharmacy, Kings College Hospital NHS Foundation Trust). The times taken to process CDs were recorded for two, two-day periods. During one period an eCDR was used and during the other a paper-bound CDR was used. The use of the eCDR had a marked impact on the time taken to process CDs. The chief technician with responsibility for CDs had handled one third of all transactions and there was a risk that others could use the system so infrequently that they could forget their passwords, he explained. Overall there was a high level of satisfaction with the eCDR and in April 2010 and the department switched to routine use of the eCDR. Mr Brinklow felt that the time savings reported are only the tip of the iceberg and that there are many opportunities for further time saving. One significant improvement would be if the system were to allow more than one user to have access at once, he suggested. Another useful development would be to integrate the required identity checks of the person collecting the CDs (for outpatient and discharge medicines) with webcam photos or signatures.
Linking LEAN principles to a pharmacy refit enabled the pharmacy department at the University Hospital of North Staffordshire to increase efficiency and improve staff morale. Susan Thomson (clinical director of pharmacy) and Heather Fowler (project manager, pharmacy department, University Hospital of North Staffordshire) described the key steps in the process. Replacement of the pharmacy computer system and the introduction of automated dispensing were just two of five transformation work streams undertaken. A robot was required to process 90,000 items per month for ward boxes and 26,000 dispensary times per month. In addition, it had to be operator-friendly and transferable, as a new pharmacy is to be built in 2012. A RoboPharma robot was selected and the dispensary workflow was remodelled. The robot is filled manually by a full-time band 3 technician. Automated filling of ward boxes resulted in a saving of two ATO posts. It has also become more efficient and transport runs are no longer missed. In the dispensary, the number of dispensing terminals was increased from eight to 12, to avoid staff having to queue to use them. Overall, there have been reductions in stockholding, turn-round time for discharge, and staff overtime. A calmer working environment has been created and staff morale has improved.
The PharmaTrust point-of-care dispensing kiosk could be a way of providing a dispensing and advice service out-of-hours, according to Peter Ellis (PharmaTrust Ltd). Such kiosks have been in use in Ontario, Canada for three years and PharmaTrust is currently recruiting trial sites in the UK.