Director of Pharmacy
On behalf of the Pharmacy Automation Team
Conwy & Denbighshire NHS Trust
The publication of A Spoonful of Sugar(1) by the Audit Commission and a presentation to the Health Minister for Wales by the Welsh Chief Pharmacists’ committee has firmly put automation on the political agenda in Wales. A further study evaluating automation illustrated the release of staff from the dispensing process as a consequence of automation.(2) A further publication suggested that, at a national level, these “savings” in personnel may be sufficient to address the chronic problem of staff vacancies.(3) These findings established the desire for testing out automation in Welsh hospitals.
Funding and health policy
Funding and health policy are managed differently in Wales and in England, with the Welsh Assembly being responsible for policy development. The introduction of automation was finally confirmed with the publication of the Welsh pharmacy strategy Remedies for Success(4) placing this issue at the forefront of development, with a three-stage implementation for secondary care planned.
Funding for a first-wave implementation was announced in January 2003, with three hospitals being part of the pilot study: Carmarthen Hospital and Llandough Hospital in South Wales and Conwy and Denbigh (C&D) Hospital in North Wales. A specification was drawn up and the tender issued during the spring of 2003, with the contract going to ARX (Rowa system).
Automation implementation at C&D Hospital
This article details the processes and benefits demonstrated at C&D Hospital, which was the largest of the three implementations. This implementation included hardware and software for the filling of ward stock boxes, as well as its use within the dispensary setting. Medicines are supplied following two routes. The first route is a named inpatient, or original pack supply, which is stored at the side of a patient’s bed, utilised throughout their stay and then taken home with them if appropriate. Secondly, medicines that need to be available at ward level for use in an emergency or to initiate administration while the pharmacy department is closed are kept as stock items at ward level. These are routinely supplied weekly to wards according to a standard stocklist. The automation of this routine supply function has not been reported to date and was the area of the project that, it was hoped, would deliver benefits over and above those reported elsewhere.(3)
As with all projects of this size, and particularly those involving technology, the management of the change process was of paramount importance. A key feature is helping staff to adapt to the technology and implementing new ways of working. This was especially important with this project, as we were looking to redeploy staff to other tasks following implementation. Thus, ensuring that there were other tasks available for them following implementation formed a large part of the project. The main area of focus with any staff time freed from the dispensary was at ward level, where reduction in medication error has been demonstrated.(5) Within the distribution service, benefits were uncertain, and planning revolved around increasing the level of ward stock control offered.
Three cabinets, each with its own picking head, were installed, so that peaks of activity could be managed. This allowed the replenishment of stocks within the robot during normal working hours. Initial working with the robot demonstrated that we needed to change the way we worked, so that the workflow could be smoothed out during the day. Problems experienced due to poor workflow were highlighted by data from the robot, which allowed us to revise our workflow patterns, reducing the problems of peaks in activity.
The installation of a robot at C&D Hospital required a redesign of all dispensing and distribution processes to ensure that the benefits would be realised. Within the dispensary, a change to workstation-based dispensing was planned and implemented. This released approximately 30–35% of the dispensing staff to work at ward level. These benefits were realised on day one, with further time-releasing developments expected in the next few months (namely the completion of training and the introduction of automatic labelling). Dispensing errors, which were a major problem at C&D Hospital, have been dramatically reduced by the changes introduced (see Figure 1).
Benefits within the distribution service have exceeded expectation, with 30–40% of staff time being freed up, in addition to increased space and improved working conditions.
A further 17 wards/departments are now benefiting from routine top-up, with another eight areas currently in development. Extending top-up frees more time, as the improved management of stocks is generating fewer emergencies! Coupled with these benefits, stock control has improved markedly, with fewer errors being seen (and less time wasted trying to locate missing items). Picking errors have also been reduced (see Figure 2).
Stock hold has been reduced, as the main dispensary and stores stocks have now been amalgamated, with an overall stock hold saving of approximately 20%. However, this is under constant review as a reduction in stock can lead to an inability to fill orders. So far, “stock-outs” have also been reduced. Internal movement of stock between the stores and dispensary has also been reduced, with a reduction of 4,000 orders per month.
Automation has now been live at C&D Hospital for four months, during which time the benefits detailed above have been achieved. The project still has some way to run:
- A bidirectional interface between the pharmacy stock control system and the robot has just been installed to further improve stock control.
- Controlled drugs are being put into the robot.
- Receipt of drugs will be managed via the robot and not manually entered via the pharmacy stock control system.
- Packs will be automatically labelled as part of the picking process.
Further work to evaluate the system is underway, with measurements looking at distribution error rates, dispensary capacity and turnaround times to be remeasured in the next few months as the revised processes are finalised. As the developments above are installed, they will also be evaluated.
Automation is more than just installing a robot: it involves a complete redesign of services to ensure that benefits are realised and, more importantly, collaborative working with all staff to ensure that cultural changes are addressed.
Thanks must go to all staff within the department who worked hard to get the system up and running. Particular thanks must also go to the project team who managed to stay cheerful despite their workload!
- Audit Commission: A spoonful of sugar – medicines management in NHS hospitals. London: Audit Commission; 2001.
- Slee A, Farrar K, Hughes D. Implementing an automated dispensing system. Pharm J 2002:268;437-8.
- Farrar K, Slee A, Yates M. On auto-pilot. Health Serv J 2002;112:26-8.
- Remedies for success – a strategy for pharmacy in Wales. A consultation document. Cardiff: Welsh Assembly Government; 2002.
- Lewis M. Introducing a medicines management service led by a pharmacy technician. Pharm J 2003;10:487-90.