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Laurence A Goldberg
HPE Editorial Consultant
Automation is the only way to satisfy all the demands on hospital pharmacy services, according to Jacqueline Surugue (President of the European Association of Hospital Pharmacists, EAHP). Demands for “front office” and direct patient care services are increasing, but the back office jobs still have to be performed, she explained. Automation will bring additional benefits, including faster and more reliable dispensing, fewer dispensing errors and liberation of staff time,which could then be used for added-value tasks. Above all, automation is likely to increase patient safety, she stated.
A survey of professional practice in 634 hospitals throughout Europe conducted by the EAHP in 2000 showed that computerised dispensing of unit doses was available in 2.4%, computerised stock-picking in 1.5%, installation of robots in 0.1% and integrated computerised systems in 3.6%. A further survey has been conducted in 2005 and the results will be published shortly.
Planned automation in France
Pharmacy services in a children’s hospital in Dallas provided the inspiration for changes planned at a hospital in Marseille, according to Jean-Pierre Reynier (Professor and Head Pharmacist, Assistance Publique des Hôpitaux de Marseille, France). Automated processes have been implemented over a 10-year period in a stepwise fashion as a way of ensuring that pharmacists are available to care for patients 24 hours per day. In 1997, when the Dallas project started, the medication error rate was 280 per million doses dispensed. In the first year, the installation of a robot that dispensed unit doses halved the error rate (140 per million doses). The introduction of pharmacists to all wards in 2002 reduced the error rate to 80 per million doses. Finally, the installation of a robot for intravenous doses, and the introduction of barcoding for intravenous doses, brought the error rate down to 54 per million doses issued.
A project starting in 2006 will enable pharmacists in Marseille to re-engineer the pharmacy services to four hospitals comprising approximately 4,000 beds. In the current system, medicines are distributed from a regional store by the pharmacy service, and nurses dispense medicines from the large stocks that are held on hospital wards. In the new system, suppliers will deliver directly to the wards and medicines will be stored in “intelligent cupboards”. A fully integrated system should be operational by 2010, he predicted.
An automated unit-dose system was in operation at a hospital in Toulouse for a number of years, but it did not meet the requirements of the hospital system, according to Jean Calop (Professor of Clinical Pharmacy, University of Grenoble, France). A better system would be automated dispensing for all medicines, including sterile products, with secure, automated cabinets on wards, he suggested. This would allow pharmacists to spend more time on wards educating patients about their treatments and
offering advice to healthcare professionals.
Good management is the root of everything, and understanding of human psychology is a critical element of management, explained Virginie Saurel (Journalist and Communications Consultant, France). If members of your staff do not behave as you wish then you should consider a new style of management, said Ms Saurel. Originally, all management was directive, but in the mid-1980s participative management was developed in America. The latest development was management by coaching – an approach that relies strongly on partnership with colleagues and thrives in an atmosphere of trust. The coach-manager sits down with individuals and helps them to find solutions to their problems. The manager who can combine all three styles can achieve prodigious innovations.
The other key element of good management is to have an understanding of the different qualities and aptitudes of individuals and how to create situations in which they work best. A model of thinking styles can help to characterise how individuals think and make judgements (see Figure 1). This, in turn, can be used to work out how to communicate with individuals and identify the tasks for which they are best suited.
A four-quadrant model in which the horizontal axis represents left-brain and right-brain thinking and the vertical axis goes from cerebral to limbic thinking has been proposed. Those who fall in the blue quadrant (cerebral left-brain thinking dominates) tend to be seen as cynical, cold and factual. They are suited to tasks such as purchasing, pricing strategy, marketing performance, organisation of meetings, merchandising and budgeting. Those in the green quadrant (limbic left-brain thinking) are typically seen as being tidy and well ordered. They are suited to tasks such as reception, planning and numerous back-office administrative tasks. Those in the red quadrant (limbic right-brain thinking) are seen as being aesthetic. They are particularly suited to tasks that draw on their interpersonal skills, such as commercial negotiating, involvement in sales and the provision of advice and qualitative merchandising. Those in the yellow quadrant (cerebral right-brain thinking) are forward-looking, imaginative innovators who see the big picture rather than the detail. They are particularly suited to creative tasks such as strategic planning, marketing, monitoring critical developments in the marketplace and organising events.
Understanding the dominant quadrants for individual members of a team can help a manager to work effectively with them, explained Ms Saurel. For example, “blue” thinkers perform well if objectives are specified and authority is delegated to them, whereas “green” thinkers prefer to have reassurance, defined protocols and a clear explanation of plans. “Red” thinkers, on the other hand, thrive on empathy and recognition, and “yellow” thinkers benefit from encouragement to use their initiative because this is their natural strength. Research has shown that most people have two dominant thinking styles. Overall, pharmacists tend to be strong in the blue and green quadrants and are moderately well represented in the red quadrant, but the profession would benefit from more “yellow” (cerebral, right-brain) thinkers.
Automation in UK hospitals
In UK hospitals, the impact of automated dispensing has been very significant, according to Derek Swanson (Deputy Director of Pharmacy, Royal Liverpool and Broadgreen Hospital, UK). The benefits have included faster, more accurate dispensing, improved stock management and a quieter dispensary. Other real but intangible benefits have been improved morale and recruitment, he added.
The first automated dispensing systems were installed in UK hospitals in 2000, and there are already more than 50 hospitals with such systems. Another 30 hospitals are planning to implement automated systems in the near future. The reasons for automation included an increasing volume of work (dispensing more than 1,000 items per day in Mr Swanson’s hospital), the need to make better use of space and a desire to improve the speed and accuracy of dispensing, he said.
Pharmacists in the UK now have mainly clinical roles and routinely undertake medication history reviews, provision of prescribing advice and medicines management. In some cases they are also involved in prescribing. Pharmacists are supported by highly trained technicians and other staff, such as purchasing officers and trained dispensers, who ensure that the back-office functions run smoothly. The overall effect of these developments has been to make better use of the time and expertise available, which, in turn, has led to improvements in the quality of care, as many problems are prevented instead of having to be fixed after the event.
Individual patient-medicine cabinets have revolutionised the handling of medicines at ward level in a hospital in Northern Ireland. Michael Scott (Chief Pharmacist, Antrim Area Hospital, UK) described how an integrated medicines management project has been set up in which ward teams, each comprising a pharmacist and a technician, provide a comprehensive medicines management service from admission to discharge. The scheme has been rigorously evaluated by means of a randomised controlled trial. The results showed that numerous benefits have flowed from the scheme, including decreased length of stay, reduced readmission rate, reduced wastage of medicines, better use of junior doctor and nurse time, improved accuracy of medication records, rationalisation of therapy, improved compliance, fewer medication administration errors and discharge prescription errors, reduced expenditure on medicines and improved communication with primary care.
A critical element of the project was better management of medicines on wards. This involved the use of individual bedside medicine cabinets. Antrim Area Hospital has chosen cabinets made by Bristol Maid that incorporate a large lockable drawer for medicines. The drawer is controlled by a transponder device that can be carried on a key fob or wristband. The device also records the history of use and can be programmed to give “lockout” periods – for example, from 8pm until 8am. The use of the cabinets on one surgical ward, together with original pack dispensing, has reduced the number of missed doses to zero and shortened the time taken for medicines rounds by 30%.
In the Wirral Hospitals, automated dispensing systems based on Rowa SpeedCase robots have enabled technicians to leave the dispensary to take on ward-based roles in which they control all aspects of medicines supply. Ann Winsper (Chief Technician, Wirral Hospitals NHS Trust, UK) explained that the amount of reworking has fallen dramatically as they have been able to eliminate problems such as re-ordering of items that have already been supplied. She predicted that, in future, hospital wards will become the pharmacy technician’s first home and the dispensary will have a skeleton staff. Pharmacy assistants (ATOs) are now being trained to dispense medicines, as this is a task that they can handle once dispensing robots are in place.