SELF-MONITORING INSTRUMENT TO IMPROVE THE EFFICIENCY OF DRUG MANAGEMENT IN HOSPITAL PHARMACY Pudjaningsih D 1 & Santoso B 2 1 PKU Muhammadiyah Hospital, Yogyakarta 2 Departement Clinical Pharmacology, Faculty of Medicine,Gadjah Mada Univercity, Yogyakarta

ABSTRACT  Problem Statement: The operational budget of hospital pharmacy service is relatively high, representing approximately 40%-60% of hospital’s total budget. In order to ensure appropriate use of these funds, appropriate drug management must be monitored and enforced. Drug management consists of selection and quantification, procurement, and storage and distribution, each of which must be assessed for efficiency. The instrument used must be valid, specific, and sensitive.  Objective : to develop the efficiency indicators for use in rapid-assessment of hospital drug management.  Design: The study consisted of two steps. The first step was the development of indicators, involving 50 drug managers. The final draft of the indicators was then field-tested in 6 hospitals. This abstract described the results of the field-tested.  Setting and population: Fifty pharmacists working as drug managers in 50 hospitals in 5 provinces were involved during the development of the indicators. The finals draft of the indicators instrument was then field-tested in 6 hospitals in Yogyakarta province.  Intervention: The literature was searched for potential indicators, resulting in Draft I. A workshop involving 12 hospital managers was conducting to evaluate Draft I and nominate specific indicators to adapt for use in hospital, producing Draft II..The draft II was then further developed, and 50 drug hospital managers were invited for comments; the result of this step was the Draft III (final draft). The final draft consisted of three indicators for the selection stage, three indicators for procurement stage, four indicators for storage stage, and six indicators for distribution stage. This finals draft of indicators was then field-tested in rapid self-assessments conducted at six hospitals.  Result: The results showed that rapid self-assessment was feasible in one day when all of the needed information was available. level of drug management and information management varied among the six hospitals. Rapid self- assessment in private hospitals are faster than those public hospitals because the private hospitals could more easily access the information needed. The indicator instrument was able to detect that any serious problems and to determine the quality of drug management. Respondents found the instrument easy to use, if provided all information needed was available. Two indicators in the procurement stage were considered not sensitive, whereas, the other indicators were proven valid, sensitive and specific.  Conclusion: Appropriate hospital drug management depends on access to complete information. This instrument is considered useful in detecting problems and measuring the quality of drug management. Continuous improvement can be achieved if the indicators are used regularly.  Funding Source: PKU Muhammadiyah Hospital, Yogyakarta, Indonesia.

Background & Setting  The operational budget of hospital pharmacy service is relatively high, approximately 40%-60% of hospital budget  To ensure the efficient use of these funds, appropriate drug management must be monitored and enforced.  Drug management consists of drug selection and quantification, procurement, storage, and distribution  The quality of drug management must be assessed for efficiency by using instruments or indicators  The indicators must be valid, specific, and sensitive to minor changes  Setting and Population:  Development of indicators: 50 drug managers from 50 hospitals in 5 provinces  Field-test: 3 private and 3 public hospitals in Yogyakarta, Indonesia.

Study Objective  To develop and field-test the efficiency of indicators in selection, procurement, storage and distribution stages in hospital drug management

Draft I Reviewed by 12 Hospitals Managers Literature Reviewed Workshop Involving 50 Hospital Drug Managers Draft II - Nominated Indicator Set of Indicators II Set of Indicators I Recomme nded Indicators Field-test in Six Hospitals Output: Final Indicators STEP I STEP II Methods

The Final Set of Indicators Stage of drug managemen t NoIndicator Standard Value Selection1 Availability of drug budget 100 % 2 Ratio of planning and consumption 1:1 3 Average percentage of drug consumed 100 % Procurement1 Average procurement frequency Depends on optimal balance between space and quantity 2 Frequency of incomplete drug order 0 3 Frequency of delayed hospital drug payment 0 Storage1 Conformity of records to phisical checks on drug quantity 1 2 Turn over ratio x 3 Percentage of drugs placed in shelf properly 100 % 4 Percentage of damaged and expired drug 0 % Distribution1 Percentage of generic drug use >80 % 2 Percentage of outpatient complaints 0 % 3 Percentage of doctors complaints 0 % 4 Time to fill prescription <30 minutes 5 Percentage of prescription which are not filled 0 % 6 Percentage of non-formulary drugs 0 %

IndicatorsUnitCalculation Availability of drug budget % Available budget at a time divided by the total fund needed for drugs in one year x 100% Ratio of planning and consumption ratio Total drug items planned in the beginning of the year : total drug items used at the end of the year Average percentage of drug consumed % Randomly select 10 drug items, calculate the percentage of the quantity consumed over quantity planned for each item, calculate the average Average procurement frequency x Randomly select 10 drug items, calculate the frequency of purchase during the last 1 year for each item, calcukate the average Frequency of incomplete drug order x/mont h Take all drug order forms in the last 1 month, identity the number of mistakes in writing the orders Frequency of delayed hospital drug payment x/year Calculate the number of invoices during the last 1 year, check with the due date of payment, calculate how many are overdue in the respective year Conformity of records with phisical checks on drug quantity % Randomly select 10 drug items at the time of visit, check the record with the physical quantity, calculate how many items of the 10 are incorrect, x 100% Turn over ratio x The total value (Rp) of drug income in the last 1 year divide by the total value (Rp) of drugs on stock at the end of the year Percentage of drugs placed in shelf properly % Randomly select 10 drug items, check the order of purchase, check the placement of the drugs. The first in (or the first expired) must be in the front rows. Calculate the number of items placed incorrectly, divide by 10, x 100% Percentage of damaged and expired drug % Calculate the value of damaged and expired drug s (Rp), divided by the total value (Rp) of drugs in stock, x 100 % Percentage of generic drug use % Calculate the number of R/ in generic in the last 1 month, divided by the total R/ in the respective month, x 100% Percentage of outpatient complaints % Interview 30 out-patient exits, calculate the percentage of patients who are not satisfied with the pharmaceutical services Percentage of doctors complaints % Interview 10 doctors on the day of visit, calculate the percentage of doctors who are not satisfied with the pharmaceutical services Time to fill prescription minute s Randomly select 20 out patients in the pharmacy service area, calculate the average time spent to get the prescription ready Percentage of prescription which are not filled % Calculate the number of prescription filled during the last 10 days, divided by the total number of prescriptions written during the same period, x 100% Percentage of non-formulary drugs % Observe all prescription during the last 10 days, calculate the number of R/ which is not from the hospital formulary, divided by the total R/ of the same period, x 100% Calculation

Result: field-test of indicators in 6 Hospitals NoIndicator Private Hospital 1 Private Hospital 2 Private Hospital 3 Public Hospital 4 Public Hospital 4 Public Hospital 5 Public Hospital 6 1 Availability of drug budget 100 % 39 % N/A 73 % 2 Ratio of planning and consumption 1 : 1.1 1:1.1 1 : 1.4 N/AN/A 3 Average percentage of drug consumed 16 % 4 % 26 % 280 % N/A N/A N/A SelectionNoIndicator Private Hospital 1 Private Hospital 2 Private Hospital 3 Public Hospital 4 Public Hospital 4 Public Hospital 5 Public Hospital 6 1. Average procurement frequency 1 – 2 X X X 1 X N/A 4 X 2 Frequency of incomplete drug order 9 X 1 X 1 X 9 X N/A 2 X N/A 3 Frequency of delayed hospital drug payment 25 X N/AN/A 10 X N/AN/A Procurement

Result: field-test of indicators in 6 Hospitals (continued) NoIndicator Private Hospital 1 Private Hospital 2 Private Hospital 3 Public Hospital 4 Public Hospita l 5 Public Hospital 6 1 Conformity of records with phisical checks on drug quantity 100 % N/A100% 2 Turn over ratio 11 X 23 X 12 X 4 X 7 X N/A 3 Percentage of drugs placed in shelf properly 100 % N/A 10 % 20 % 4 Percentage of damaged and expired drug 0.2 % 0.05 % 0.06 % 0.75 % 0.24 % 0 % Storage

NoIndicator Private Hospital 1 Private Hospital 2 Private Hospital 3 Private Hospital 3 Public Hospital 4 Public Hospital 5 Public Hospital 6 1 Percentage of generic drug use 17 % 3 % 16 % 68 % 57 % 60 % 2 Percentage of outpatient complaints 3 % 5 % 0 % 3 Percentage of doctors complaints 3 % 50 % 10 % 28 % 0 % 40 % 4 Time to fill prescription 30 ‘ 24 ‘ 18 ‘ 42 ‘ 16 ‘ 10 ‘ 5 Percentage of prescription which are not filled in 22 % 24 % 0 % 27 % 1 % 2 % 6 Percentage of non- formulary drugs 0 % 0.4 % 0 % 8.2 % 0 % 6.6 % Result: field-test of indicators in 6 Hospitals (continued) Distribution

Qualitative Findings  The rapid self-assessment was able to be conducted in one day if all information needed was available  Rapid self-assessment in private hospitals are faster than thay in public hospitals, because in private hospitals the information was more instantly available  The indicators were able to detect serious problems in drug management  Respondents found the instrument easy to use, provided that all information needed was available

Discussions  The final indicators showed its validity, sensitivity, and specificity:  Valid to measure the quality of drug management  Sensitive to determine any problem, either in the process or outcome  Specific to detect if there is a problem  The indicators are easy to use for:  Determining problems in drug management  Motivating hospitals to improve the management information system

 This instrument is considered useful in detecting problems and measuring the quality of drug management, and is able to show the difference among hospitals  Regular use of this set of indicators will be useful in improving the quality of drug management  Although none of the hospitals showed a good quality of drug management, the private hospitals showed a slightly better drug management than the three public hospitals Conclusions