Pharmacy Service Improvement

Background

UK Learning NHS Trust provides emergency and non-emergency services to East Surrey, North-East West Sussex and South Croydon. East Surrey Hospital, Redhill has 697 beds, and there are a range of outpatient, diagnostic and planned services at The Earlswood Centre, Caterham Dene Hospital and Oxted Health Centre in Surrey, and at Crawley Hospital and Horsham in West Sussex. In total there are circa 3,500 staff, with an annual budget of £300m. The trust needed to reduce overall costs, as they had overspent by £20,000,000.

Due to difficulty hiring and retaining professional staff, there were several vacancies remaining unfilled. This led a very high locum spend and reliance on bank staff to meet daily requirements.

The pharmacy was performing poorly against trust expectations and commitments, with consistently high levels of patients being discharged without their medication. This was leading to very high costs to deliver the medication via whatever means were available to the trust.

Morale in the dispensary was very low. Staff had improvement suggestions but were unable to implement their ideas due to crossover between departments such as portering and facilities.

A budget was made available to redesign the department if required, and the trust was willing to make any changes that it felt necessary. Value for money and clear business case evidence would be deciding factors.

Challenges

This Pharmacy department had been confronted with numerous issues relating to the timely expedition of take-out medication for patients who had been discharged.

Staff were finding it difficult to process the prescriptions after the ward rounds, as they were arriving in bulk, late in the afternoon, and up to 700 Prescriptions were processed each day. On many occasions, the medication would be delivered to the wards after the patient had been discharged. This was leading to significant amounts of medication being disposed of or being stored onwards.

Pharmacists did not take part in ward rounds and were consistently paged to screen drug charts at regular intervals, stopping them from carrying out their role effectively. Medication to take out [TTO’s] were not being delivered in a timely manner, leading to an extended length of stay for patients who should have been discharged.

The wait times in the Pharmacy varied widely. We discovered that this was because the pharmacy did not operate any kind of ‘first in, first out’ processing – the next prescription processed was the one on the top of the pile. This lead to very long delays for the prescriptions at the bottom of the pile.

No tracking of prescriptions was in place, no one knew if the specific prescription was in process or at what stage. This led to a lot of firefighting and searching when a prescription was being chased.

Solutions

We reviewed the Pharmacies establishment and identified any staffing requirements and levels of competency required to dispense in line with the volume required.

A process mapping activity was undertaken with professional staff in order to identify areas where improvement opportunities existed.

In the Pharmacy dispensary, we identified the blockers to meeting the 2-hour turnaround required by the trust to meet the required objectives. A review of the working practice needed to be undertaken in order to identify areas for improvement. Once we discovered there was no first-come, first-served system, we implemented this system. This vastly improved wait times. Additionally, short interval control was implemented within the pharmacy in order to manage variation in demand across the day.

In response to the issues with medication being delivered to the ward after the patient had already left, a Plan, Do, Check, Act confirmation system was implemented in order to confirm if the patient was present to receive drugs before departure, and storage of medications on the ward was no longer allowed.

Impact on Performance