Medicine Supply Management in ILembe District, KZN...31 Primary Health Care(PHC) Clinics 662 413...
Transcript of Medicine Supply Management in ILembe District, KZN...31 Primary Health Care(PHC) Clinics 662 413...
Improving Medicine Supply Management in ILembe District,
KZN
HST Conference 4 May 2016
Lindiwe Mthiyane Ndwedwe CHC Sushila Reddy Stanger Hospital Ashina Rajkumar Sundumbili CHC Renal Govender Umphumulo Hospital Nhlakanipho Thela Montebello Hospital Sbonelo Mbatha Untunjambili Hospital Vani Naidoo District Office
Outline of Presentation
1 • Background
2 • Situation Prior to the Intervention
3 • Stakeholder Analysis and Engagement
4 • Challenge Model
5 • Monitoring and Evaluation Plan
6 • Key Interventions
7 • Results & Discussion
8 • Way Forward
9 • Acknowledgements
Background: ILembe 2014
1 Regional, 3 District Hospitals
2 Community Health Centre’s (CHC)
31 Primary Health Care(PHC) Clinics
662 413 Population
Background 2014 contd.
Sub District • Designated supervisory pharmacists in each sub-district (Khethimpilo)
PHC Support
• 6 institutional pharmacies with delegated support personnel to attached PHC clinics - Post Basic Pharmacy Assistant (PA) and supervising pharmacist
• Regular support visits to PHC clinics • Working relationships improving between PA /
Pharmacist and Operational Managers at PHC
• Pharmacists are actively involved at sub-district PHC meetings
Situation Prior to Intervention
End of June 2014
Lack of awareness of expired stock within the district
Expired stock was under reported and not adequately addressed
Quarterly & Monthly Performance reports consistently reflected high expired medicines with no specific interventions to eliminate the problem
Fruitless pharmacy expenditure continued
Weekly
There were weekly stock out reports despite concurrent expiring stock reports
Patients repeatedly sent home without the full quota of their medicines
Challenge Addressed
INCREASE STAFF AWARENESS
IMPROVE MEDICINE SUPPLY MANAGEMENT & MEDICINES AVAILABILITY
REDUCE FRUITLESS EXPENDITURE
• In 2014 the rand value of expired stock was very high every month although % expired stock was within provincial norm <1% of medicines expenditure
• Non commitment of staff members to improve stock management by reducing the expired stock
Situation at end of June 2014 as per District Quarterly Performance Report (Qtr. 1 of 2014-2015)
***Only closed stock was reported
Expired stock as a % of medicines expenditure at Hospitals and CHC
0.18 %
Expired stock as a % of medicines expenditure at PHC clinics
0.29%
Provincial Target <1 %
ROOT CAUSE ANALYSIS DIAGRAM
POLICIES
PEOPLE ENVIRONMENT
Policies • Non adherence to Public Finance
Management Act(PFMA) • Medicine Supply Management
(MSM) SOP’s not implemented • Incorrect disposal of
Pharmaceuticals • Deviation from the Essential
Medicine Lists
Processes and Procedures • Monthly stock takes & expiry checks not done
correctly/ regularly • Procurement process- incorrect quantities
ordered ; expiry dates not checked on receipt • No implementation plans are made when
changes to policy/ protocols; no District PTC • No feedback to staff on expiry checks
People • Attitude • Skills • Honesty
Environment • Decisions taken to meet targets and deadlines.
Pressure to phase in new items with poor planning.
• Patients prioritized – more time spent dispensing than checking and monitoring stock
Expired stock accounted for 0.18% of medicine
expenditure at hospitals and CHC
Expired stock accounted for 0.29% of medicine
expenditure at PHC clinics
PROCESSES & PROCEDURES
Stakeholder Analysis
Pharmacy Managers &
Pharmacy Staff
Doctors and Nurses
Senior Management
Patients
Institutional and District PTC
Stakeholder Analysis Stakeholder Role How Engaged?
Pharmacists and Pharmacist Assistants
• Check expiry dates on receipt of stock • Conduct expiry checks in wards ,
consulting rooms • Comply with MSM policies • Provide support to PHC
• Regular departmental meetings
• Feedback reports on progress
Doctors • Adherence to STG • Co-operation when changes in STG
• District and institutional PTC Internal correspondence
Members of PTC ( district and institutional)
• Medicine utilisation reviews • Implementing plan for the phasing in of
new items • Adherence to STG
• Monthly PTC meetings / quarterly District PTC
Stakeholder Analysis Cont.
Stakeholder Role How engaged?
Patients • Correct use of medicines
• Inform pharmacy staff when medicine is in excess at home
• One on one counselling • Health education
sessions
Institutional Senior Management
• Support the project
MISSION
To provide pharmaceutical services based on principles of rational drug use ; cost-effective quality care to all
stakeholders in ILembe
Re-order levels not maintained at facilities
Expiry checks not done when receiving stock
from depot/ supplier
Policies not implemented ( PFMA; EML, MSM)
Expiry checks done but not actioned
Staff attitude- commitment vs compliance
No planning for phasing in of new items
No District PTC
Review re-order levels quarterly
Implement & monitor 6 MSM SOP’s
Monthly Distribution plan for excess &
short dated stock in the district
Regular feedback to staff
Performance Management
Commenced with District PTC
Phasing in plans via PTC
Current Situation
Expired stock accounted for 0.18% of medicine expenditure at hospitals and CHC
Expired stock accounted for 0.29% of medicine expenditure at PHC clinics
VISION
Quality pharmaceutical services for a happy healthy ILembe
Measurable Result
Reduce expired stock ( open and closed) from 0.18% at hospitals/CHC & from 0.29% at PHC clinics, to < 0.1% of the ILembe District quarterly medicines expenditure , by the end of June 2015.
Root Causes
Priority Actions
M&E Plan Measurable Result : Reduce expired stock ( open and closed) from 0.18% at hospitals/CHC & from 0.29% at PHC clinics, to < 0.1% of the ILembe District quarterly medicines expenditure , by the end of June 2015.
Indicator/s Definition Data Source (from which
source?)
Data Collection Method (how?)
Frequency of data
collection (how often?)
% expired medicine
Value of expired stock in ILembe district per quarter/ Total medicines expenditure per quarter for ILembe district
Board of survey from Plankmed; Open stock costing; PPSD expenditure reports report
Captured daily at point of discovery ; during stock takes
Daily At month end
Rand Value of expired medicines
Rand Value of expired stock ( open and closed) per quarter for ILembe
Board of survey from Plankmed; Open stock costing
Captured daily at point of discovery ; during stock takes
Daily
M&E Plan contd. Measurable Result : Reduce expired stock ( open and closed) from 0.18% at hospitals/CHC & from 0.29% at PHC clinics, to < 0.1% of the ILembe District quarterly medicines expenditure , by the end of June 2015.
Indicator/s Definition Data Source (from which
source?)
Data Collection Method (how?)
Frequency of data
collection (how often?)
Rand Value of Relocated stock (short dated)
Rand value of short dated with < 6 months expiry that has been relocated to another facility
Time Expiry sheets; requisition from facility
Costing of requisition
Monthly
Rand Value of Relocated stock (excess stock)
Rand Value of excess stock that has good expiry but cannot be used up timeously by the facility and has been relocated to another facility
High Stock report from Plankmed; requisition from facility
Costing of requisition
Monthly
Key Interventions
1. Identify areas where medicines are expiring
2. Monitor Programme needs
3. Encouraged Honest reporting of expired stock to detect the extent of the problem within the district
4. Proper documentation of expired medicines.
1. Regular monitoring of both open and closed stock.
2. Monitor phasing out of old stock when STG changes
3. Reinforced health care worker pledge to patients & need for accountability for expired medicines.
4. Records of both open and closed stock
4.
INTERVENTIONS METHODS
Key Interventions
M & E
1. High stock reports & expiry checks done monthly
2. Improved monthly & quarterly pharmacy reports
CLINICAL STAFF/PERSONNEL
1.Engaged with stakeholders (nursing; pharmacy; doctors; district PTC)
2. Rational prescribing in accordance with EML
(changing prescribing trends)
BUDGET IMPACT
1.Relocated stock, reduce fruitless expenditure
(sub-districtdistrict KZN)
PROCEDURES
1. Re-order levels adjusted
2. Changed costing of expired stock (include both open and closed stock)
Monitoring of Closed and Open Stock
Examples of Phasing Out Plans
Item to be phased out Item to be phased in Plan
Cefixime no longer in STI guidelines –PHC EML 2014
Ceftriaxone Use all existing stock of cefixime Redistribute excess to other institutions in district
Doxycycline no longer on STI Guidelines ( PHC EML 2014)
Azithromycin Relocate existing stock of doxycycline to hospital and CHC in district
Gliclazide 80mg tablets ( PHC EML 2014)
Glimepiride tablets Newly diagnosed out patients to be prioritised. Reserve stock of gliclazide for chronics whilst awareness and education increases.
Engaging with nurses at PHC
Patient Counselling & Education
Results /Findings
HOSPITALS & CHC - Rand Value of Expired Stock & % Expired Stock ( Qtr1 and Qtr2 of 2014-2015)
Institution
Quarter 1 Quarter 2
Expired stock
Value(R)
Total Medicine
Expenditure
% of Expired
stock
Expired Stock
Value(R)
Total medicine expenditure
% Expired
stock
Ndwedwe CHC
R 0 R2 539 089 0% R365 R3 277 441 0.01%
Montebello Hospital
R0 R1 768 544 0% R0 R3 341 558 0.61%
Sundumbili CHC
R9 165 R3 396 234 0.27% R1 210 R6 470 894 0.02%
Stanger Hospital
R1 046 R 10 039 587 0.01% R0 R19 787 294 0%
Umphumulo Hospital
R10 414 R 2 382 568 0.44% R0 R2 630 874 0%
Untunjambili Hospital
R 17 691 R1 234 216 1.43% R6 597 R2 857 148 0.36%
ILembe District
R 38 316 R21 360 238 0.18% R28 494 R38 385 209 0.07%
HOSPITALS & CHC - Rand Value of Expired Stock & % Expired Stock ( Qtr3 and Qtr4 of 2014-2015)
Institution
Quarter 3 Quarter 4
Expired stock
value(R)
Total Medicine Expenditure
% of expired
stock
Expired stock
value(R)
Total medicine expenditure
% Expired
stock
Ndwedwe CHC
R2 791 R2 603 065 0.17% R10 393 R1 630 964 0.64%
Montebello Hospital
R12 367 R 1930 712 0.64% R7 394 R2 614 675 0.28%
Sundumbili CHC
R6 903 R6 857 212 0.08% R2 550 R8 188 635 0.03%
Stanger Hospital
R7 189 R13 759 854 0.05% R2 935 R15 659 676 0.02%
Umphumulo Hospital
R681 R3 302 302 0.02% R2 662 R5 400 448 0.05%
Untunjambili Hospital
R5 430 R1 844 835 0.32% R2 476 R1 705 875 0.15%
ILembe District
R35 361 R30 297 980 0.12% R28 410 R35 200 273 0.1%
HOSPITALS & CHC - Rand Value of Expired Stock & % Expired Stock ( Qtr1 of 2015-2016)
Institution Quarter 1
Expired stock value(R)
Total medicine expenditure
% of expired stock
Ndwedwe CHC R 10 603 R3 507 743 0.3%
Montebello Hospital R 10 591 R 3 245 899 0.33%
Sundumbili CHC R4 680 R 6 262 336 0.07%
Stanger Hospital R4 250 R13 845 249 0.03%
Umphumulo Hospital R2 167 R 2 136 473 0.1%
Untunjambili Hospital
R15 916 R 1 586 074 1%
ILembe District R 48 207 R30 583 774 0.16%
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
Pe
rce
nta
ge E
xpir
ed
Sto
ck
Institutions
QTR1
QTR2
QTR3
QTR4
QTR1 (2015-2016)
HOSPITALS & CHC - % Expired Stock ( Qtr1 of 2014-2015 to Qtr 1 of 2015-2016)
R 0
R 10 000
R 20 000
R 30 000
R 40 000
R 50 000
R 60 000
QTR1
QTR2
QTR3
QTR4
QTR1 (2015-2016)
HOSPITALS & CHC - Rand Value of Expired Stock ( Qtr1 of 2014-2015 to Qtr 1 of 2015-2016)
Institutions
Ran
d V
alu
e o
f Ex
pir
ed
Sto
ck
PHC - Rand Value of Expired Stock & % Expired Stock (Qtr1 and Qtr2 of 2014-2015)
Institution Quarter 1 Quarter 2
Expired stock
value(R)
Total Medicine Expenditure
% of expired
stock
Expired stock
value(R)
Total medicine expenditure
% Expired
stock
Ndwedwe CHC(3)
R 0 R368 239 0% R0 R281 625 0.%
Montebello Hospital (3)
R0 R823 652 0% R8741 R425 760 2.05%
Sundumbili CHC (7)
R11 592 R1 667 256 0.7% R17 161 R1 228 044 1.4%
Stanger Hospital (9)
R6125 R 5 309 722 0.12% R6 145 R4 498 642 0.14%
Umphumulo Hospital (7)
R269 R 1 190 171 0.02% R0 R644 246 0%
Untunjambili Hospital (2)
R 9743 R311 156 3.13% R4 382 R173 867 2.52%
ILembe District (31)
R 27 729 R9 670 196 0.29% R36 429 R7 252 184 0.5%
PHC - Rand Value of Expired Stock & % Expired Stock (Qtr3 and Qtr4 of 2014-2015)
Institution Quarter 3 Quarter 4
Expired stock
value(R)
Total Medicine Expenditure
% of expired
stock
Expired stock
value(R)
Total medicine expenditure
% Expired
stock
Ndwedwe CHC(3)
R0 R371 061 0% R0 R328 473 0%
Montebello Hospital (3)
R23 779 R693 036 3.4% R4 330 R 440 355 0.9%
Sundumbili CHC (7)
R 5 625 R1 483 339 0.3% R 1 761 R 1 408 521 0.13%
Stanger Hospital (9)
R 839 R 6 660 773 0.01% R21 325 R 4 703 996 0.45%
Umphumulo Hospital (7)
R2 005 R728 053 0.23% R3 105 R1 179 527 0.26%
Untunjambili Hospital (2)
R 2 189 R 182 732 1.2% R 14 364 R 269 412 12.9%
ILembe District (31)
R 34 437 R 10 118 994 0.34% R44 885 R 8 330 284 0.54%
PHC - Rand Value of Expired Stock & % Expired Stock ( Qtr1 of 2015-2016)
Institution Quarter 1
Expired stock value(R)
Total medicine expenditure
% of expired stock
Ndwedwe CHC R 2 357 R 979 214 0.24%
Montebello Hospital R 12 146 R 468 474 2.6%
Sundumbili CHC R 1 744 R 3 410 081 0.05%
Stanger Hospital R 6 114 R 4 530 628 0.13%
Umphumulo Hospital R 1 852 R 1 478 152 0.13%
Untunjambili Hospital R 3 945 R 185 390 2.13%
ILembe District R 28 158 R 11 051 932 0.25%
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
Pe
rce
nta
ge E
xpir
ed
Sto
ck
( n)= no of PHC clinics attached to mother institution
QTR1
QTR2
QTR3
QTR4
QTR1 (2015-2016)
Institutions
PHC - % Expired Stock ( Qtr1 of 2014-2015 to Qtr 1 of 2015-2016)
R 0
R 5 000
R 10 000
R 15 000
R 20 000
R 25 000
R 30 000
R 35 000
R 40 000 QTR1
QTR2
QTR3
QTR4
QTR1 (2015-2016)
n= number of PHC clinics attached to mother institution
PHC - Rand Value of Expired Stock ( Qtr1 of 2014-2015 to Qtr 1 of 2015-2016)
Institutions
Ran
d V
alu
e o
f Ex
pir
ed
Sto
ck
Rand Value of Excess Stock & Short Dated Stock Relocated (2014-2015)
INSTITUTION & PHC CLINICS
VALUE OF EXCESS STOCK (Rands)
VALUE OF SHORT DATED STOCK (Rands)
TOTAL VALUE OF STOCK RELOCATED ( Rands)
Stanger + 9 PHC R56 489 R46 158 R102 647 Sundumbili + 7 PHC R58 144 R32 37 R90 511 Ndwedwe CHC + 3 PHC R19 493 R893 R20 386 Montebello + 3 PHC R17 977 R16 580 R34 557 Umphumulo + 7 PHC R6 546 R16 853 R23 399 Untunjambili + 2 PHC R408 916 R71 260 R480 176
ILEMBE R567 565 R184 111 R751 676
Best Practices
Best Practices • Select excess or short dated items for district focus
• Circulate excess/ short dated lists before PPSD orders are due
• Plan and manage phasing in of new items due to STG changes
• Encourage honest reporting to give true reflection of challenges.
Limitations Challenge Impact
Transport – Insufficient Vehicles due to combined trips with other health care workers to PHC
Some trips to clinics have to be cancelled if no vehicles available ; little or no pharmacy support or reduced time spent at PHC
Lack of Full time PAs at Clinics Roving PAs have limited time for adequate stock monitoring.
No Electronic System to monitor expiry dates (Plankmed does not contain expiry date trackers)
Short dated stock has to be identified manually ( time consuming and less effective as electronic)
Board of Survey Committees not sustained at clinics and all institutions
Non compliance with regulation for destruction and disposal of expired stock (PFMA)
Lack of commitment of Stakeholders MSM policies not fully implemented
Progress in ILembe
Before 2012
2012-2013
2013-2014
2014-2015 2015-2016
PHC reported nil, all hospitals/CHC not reporting
PA’s visiting clinics; PHC values for expired stock still added on to hospital values
reporting improving; awareness increasing
MSM Training , SOPs, Project commences; start to identify what items expiring and why; open or closed stock
Now we know: • Where ? • What ? • Why ? • Open or closed ? • What class ? • EML/non EML ? • Excess vs short
dated ?
Scaling up interventions within the district
• Closer monitoring is still required in clinics
• Monthly reports (Pharmacy Managers District Pharmacy Manager)
• Regular feedback to stakeholders
• Improve participation of nurses
Sustaining the project
Phased implementation of
MSM policies; STG/EML changes
and consistent monitoring thereof
Policy must be institutionalized and awareness
campaigns broadened
Design interventions to
target therapeutic classes with high
expiries
Ongoing communication with relevant stakeholders with regards to rational medicines prescribing,
and medicines management
Roll out project to other districts
Acknowledgements
• Provincial Pharmaceutical Services
• MSH / SIAPS
• Institutional Senior Management
• District & Institutional PTC members
• Operational Managers & PHC Supervisors
• Pharmacy & Nursing Staff
• Fellow Pharmaceutical Leadership & Development Programme (PLDP) participants and colleagues
Acknowledgements • This project was carried out as part of the
Pharmaceutical Leadership Development Program (PLDP) facilitated by the USAID funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS)
• This presentation is in memory of our team member and Pharmacy Manager, Mr. N. Thela who passed away tragically on 17 April 2016
Inspiration
Thank You