design and control of production system of an opd pharmacy

8/14/2019 Design and Control of Production System of an OPD Pharmacy

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LAGUNA COLLEGE

SAN PABLO CITY, LAGUNA

DESIGN AND CONTROL OF THE DISPENSING PROCESS

OF A HOSPITALS OPD PHARMACY

A TERM PAPER SUBMITTED TO

DEAN BEDA L. DE PEDRO

IN PARTIAL FULFILLMENT FOR THE COURSE REQUIREMENT

OF DESIGN AND CONTROL OF A PRODUCTION SYSTEM

BY

MARIA ALENI B. VERALLO

October 19, 2013


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Abstract:

Filling of prescription is one of the pharmacists activities in every hospital in the

Philippines. However considerable delays are observed in the dispensing operation in

any particular pharmacy. These delays resulted in long queues making impatient

customers angrily leave which is definitely not good for business.

This paper focuses on the out-patient pharmacy department of a local hospital

and its dispensing process of loose solid dosage forms (i.e. tablet, capsule). The system

used to process out-patient prescription is reviewed and improved to increase the speed

of service and reduce unnecessary problems and conflicts.

This modification of the dispensing process includes changing some of the

procedures, acquiring new computer terminals, and integrating a new point-of-sale

system. Control mechanisms such as the pharmacy audit and mystery shopper audit are

also included to monitor and ensure that the customer service adheres to the quality

criteria or meets the requirement of the client or patient.


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I. Background/nature of business/product/service:

Dr. Wasfi Abbas ElTayeb defined hospital pharmacy as the department or

service in a hospital which is under the direction of a professionally competent,

legally qualified pharmacist, and from which all medications are supplied to the

nursing units and other services, where special prescriptions are filled for

patients in the hospital, where prescriptions are filled for ambulatory patients

and out-patients, where pharmaceuticals are manufactured in bulk, where

narcotic and other prescribed drugs are dispensed, where injectable

preparations should be prepared and sterilized, and where professional

supplies are often stocked and dispensed.

Hospital pharmacies usually stock a larger range of medications, including

more specialized and investigational medications (medicines that are being

studied, but have not yet been approved), than would be feasible in the

community setting. Hospital pharmacies typically provide medications for the

hospitalized patients only, and are not retail establishments.

Pharmacy operations are carried out within the healthcare system and have a

mix of both tangible and intangible characteristics. Appropriate resources are

transformed to create the pharmaceutical services which form intangible

components of the operations. These services are knowledge - based and have

high levels of customer interactions. The services accompany health

commodities which are tangible products; the logistics and supply of which are

major functions of operations management.

The focus of this work is a hospital pharmacy and its out-patient department. It

operates under the tertiary hospital type with 100 bed capacity. The out-patient


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pharmacy department operates from 6am until 10pm Mondays to Saturdays.

During Sundays it only operates from 6am until 5pm.

The main focus of this paper is the loose solid dosage form (i.e. tablets,

capsules) dispensing process which takes the longest time to finish. This can be

attributed to the numerous steps involving the repacking of these solid dosage

forms. These are acquired in bulk (packed by 30s or 100s in a bottle) and are

sold in small quantities.

A.Existing backstage processes:

a. Elements:

Materials: The out-patient pharmacy is comprised of a central

dispensary area. This is where the backstage process happens. The

dispensary area is filled with wooden cabinets for loose solid forms and

gondolas for storing vials, ampule, devices and intravenous solutions. A

biological refrigerator is also available for storing vaccines and other

medications that require refrigeration. The products are arranged by

category (i.e. vials, bottled preparation, and solid dosage forms) and in

an alphabetical order. Graduated cylinders and distilled water are also

provided to aid in reconstitution. And for loose solid dosage forms, a

counting tray is provided to facilitate rapid and sanitary counting and

transferring from the stock packages (bottles) to the dispensing pouch.

Labels are also provided to identify the contents and information legally

required to appear in the label. A cabinet is also provided for filing

prescriptions.


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Communications Technology: A telephone is also provided to facilitate

communication to doctors and other departments of the hospital.

Manpower: The pharmacist supervises all of the pharmacy operations

and assures the quality of pharmacy services provided by his staff. He

primarily does the backstage process which includes the preparation of

the medications, dispensing and packing of medications.

b. Spatial Set up and Location characteristics: The out-patient pharmacy is

located adjacent to the hospital. It is a 2 minute walk away from the in-

patient hospital pharmacy.

The central dispensary where prescription medicines are kept is located

at the back end of the pharmacy. The lighting condition is adequate for

the staff to read small product labels. The prescription medicines in

blister packs are placed in its old carton with the top of the box removed.

The medicines are arranged alphabetically. The bottled solid dosage

forms are placed in a separate cabinet. These are also arranged in

alphabetical order.

c. Procedures in relation to the back stage processes:

The procedures in relation to the back stage processes are the following:

c.1. Procurement of medication from suppliers/in-patient hospital

pharmacy

c.2. Maintenance and sanitation of the dispensary area.

d. Perceptions created by the process in the point of view of an employee

and a customer, including benefits and risks:


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According to a part time pharmacist, Theout-patient department tends

to rely heavily on the in-patient pharmacy. Their procurement happens

3-5 times a day nowadays. It slows down our operation as well as their

speed of service every time they overlook their stocks.

According to a patients relative, The speed of service is slower

compared to other pharmacies. The medications I needed were not

available that time; they have to get it from the hospital pharmacy. So I

have to wait for more than fifteen minutes. I think they were not able to

check their stock level that time. There is a high possibility that I may not

purchase my medicines here.

B.Existing front stage processes:

a. Materials:

Information technology: The out-patient pharmacy is equipped with

a computer system. The computer system serves as an inventory

system. For reasons unknown, the inventory control module is not

working. calculators are provided to facilitate computation of

medicines bought. Invoicing is also manually done. There is no cash

register machine only a make shift drawer is used for safe keeping of

cash.

Manpower: The pharmacy assistants are primarily involved in the

front stage process. They are assigned in the receiving of prescription,

preparation of the sales invoice and receiving of payment.


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b. Spatial Set-up and Location Characteristics:

The front stage processes happens on the public counter. It is around

3 yards away from the dispensary. The public counter is adjacent to

the computer/point-of-sale system. A chair near the public counter is

provided for the pharmacy assistant for comfort and to limit them

from leaving the area. It has a convenience store layout, where food

items are placed in the center aisle, where customers will walk past to

reach the public counter. The toiletries, milk products and the

beverage coolers are placed on the back end of the store, to facilitate

easy restocking. Impulse items such as cosmetics, over-the-counter

drugs, batteries and other candies can be found on one side atop the

public counter. The over-all pharmacy lighting is strong and

comfortable enough for customers and employees to read small

product labels.

c. Procedures in relation to the Front stage processes:

c.1. Maintenance and sanitation of the public counter

d. Scripts for Service Providers:

There are no scripts utilized by the pharmacists and pharmacy

assistants. They usually greet their patient/patients relativeby saying

mam/ sir? Sa kanila po?. And when the transaction is finished they

automatically thank the patient/patients relative.

If the patient/relative needs to wait they usually say sandali lang po,

kukuha lang po kami ng stock.


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e. Perceptions created by the process in the point of view of an

employee and a customer, including benefits and risks:

According to a part-time pharmacist, The process of dispensing

nowadays is getting worse. [It is] sad to say that many hospitals are

not following the good dispensing practice. They tend to dispense for

the sake of business rather than a health institution. No counseling to

the patient is being done. No cautions or directions given to the

nurses. Once the medicines are given, pharmacists are putting the full

responsibilities to the patient or to the nurses which is actually far

beyond the art of dispensing.

According to a patient, Thepharmacy assistants took ample amount

of time to finish making an invoice especially when I bought several

kinds of medicines. They still employ the tedious manual process of

invoicing or issuing of receipts.


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C. Flowchart of current processes both backstage and front stageof dispensing process (tablets):

Front Stage Back Stage

\

The receipt of the prescriptionby the pharmacy assistant

initiates the process.

The pharmacist checks prescription

legibility and availability.

The pharmacist computes the cost of the

prescription.

The pharmacist does the final accuracy

check and puts the tablets inside the

dispensing pouch.

The pharmacy assistant

prepares the sales invoice

and hands it to the patient.

The pharmacy assistantaccepts the bill from the

pharmacist.

The pharmacist prepares the medicines.

(Medicine Assembly)


processes the bill payment.


accepts the package from

the pharmacist.

Once the bill is paid, the pharmacist hands

the package to the pharmacy assistant.

The pharmacist creates the label and

affixes the label on the dispensing pouch.


hands in the package to the

patient.

Obtain items from

suppliers/hospital

in-patient pharmacy.

Maintenance and

cleaning of

dispensary and

medicine storage

area.

The pharmacist

consults physician or

nurse if needed.

The pharmacist hands the prescription to

the pharmacy assistant


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II. Problems encountered with existing design of producing this service:

a. One of the problems encountered during the production stage of operation is

discovering that the pharmacy ran out of stocks or low in inventory of a

particular medication. This is mainly because they seldom check their inventory

level.

b. There is little or no patient counseling employed. The pharmacy assistants/

pharmacist rely on the nurses to provide information to the patient or their

relative regarding the medicines purchased.

III. Re- Design of this production system:

A. Re- design of the dispensing environment:

Rationale:

As services and prescription volumes increase, more and more stock and activity needs

to be crammed into a fixed space. Increasing the size of a dispensary may not always be

feasible, and so it is essential that the available space is used in the most efficient way

possible. A poorly-planned workflow can result in confusion, fatigue, muddled processes

and increased risk of error. Re-design of workflow may involve thinking very carefully

about the flow of work as well as the general environment and ergonomic issues that will

make the dispensary a safer place for both patients and pharmacy staff.

Implications:

The implications for redesign of the work environment include the adjustments that the

staff will have to do in order to make the process a habit. Eventually by re-training the

staff will be able to adjust and maintain the workflow redesign. Workflow redesign can


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positively affect dispensing activity and allow pharmacists more time for patient

counseling. Putting up signages, for example, will facilitate patients know where to go

hand in or collect prescription, or to for advice. There will be shorter queues, less

confusion and improved communication. This will in turn put pharmacy staff under less

pressure and allow them to concentrate without interruption.

Current lay-out of the pharmacy:

1. Receipt of the prescription2. Creation of label3.

Medicine assembly4. Accuracy check (by the pharmacist)5. Preparation of Sales Invoice6. Payment Processing7. Medicine Collection

Suggested re-design of the dispensing environment:

1. Receipt of the prescription

2.

Checking of medicine inventory level/Creation of label3. Medicine assembly4. Accuracy check5. Cabinet for medicines for pick-up6. Payment processing7. Medicine collection and patient counseling


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Rationale:

According to a survey, the average time for a prescription to be filled in the

Philippines is 10-15 minutes. In the process above, an inventory system is

included and placed near the public counter. This is done to facilitate checking of

the inventory level of a particular stock item as well as easy payment processing.

Inventory checking by the pharmacist is also included after each transaction or

during off peak hours. It is very important to give patient advice and counseling.

This is done to prevent drug interactions that may affect the absorption of a

particular drug. Also, medication regimens are complicated and tend to be

confusing to some.

Implications:

Due to recent technological advances, the process of a single prescription is

reduced from 13 steps to 10 steps. In connection to this, the average patient

waiting time is also reduced from 10 minutes to 2 minutes. The frequent

inventory checking will increase the awareness of the staff in their inventory

levels. The system also prompts the staff when the inventory level is too low,

when this occurs the pharmacy staff may request the needed medicines at an

earlier time therefore reducing patient waiting time.

General script for service providers:

The general scripts provided for service providers are as follows:

Before the transaction:

Greet the customer with a smile and simply say Good day maam/sir, how may

I help you? Make eye contact and receive the prescription with a dignified

manner.

After the transaction:

Thank the customer by saying Thank you, maam/sir. It is our pleasureto serve

you.


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IV. Implementation strategies to initiate the re-design of the production

system of this pharmacy service:

Acquiring of a new point-of-sale system:

Until now, the out-patient pharmacy department runs its processes almost

entirely through a manual process. The daily sales report is written in a log book.

Invoicing is manually done tediously. With the implementation of integrated

point-of-sale, purchasing, merchandising and management information systems,

the nature of work of the pharmacy personnel will change radically. Although,

automated systems can contribute to the organizations complexity, they can also

help the organization to cope with such complexity. The speed and accuracy of

the computer, as an automated technique, seem attractive for decentralized

decision making while the top management has time for planning and

innovation. The routine, clerical activities are easily adaptable to

computerization, and procedures may be developed to handle structured

repetitive tasks. Such repetitive tasks include prescription billing, documentation

and stock control functions may be taken over by the computer. In these

situations, the work is repetitive and can be described in a clear procedure for

routine transaction processing. With this development much of the mundane,

tedious routine jobs of prescription processing may be automated while the

unstructured, non-routine and more skilled decisions can then be handled by the

pharmacists.

Acquiring a new system as well as another computer terminal near the public

counter will facilitate easy checking of the inventory level of a particular stock.

Also, this will facilitate easy processing of the payment of the customer.


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Training of Personnel:

Training session should be held in order to familiarize the staff of the process

redesign and the use of the point-of-sale system. Education and re-training the

staff and the pharmacist will enable them to advise the patient regarding his

medication efficiently.

Implementation of perpetual inventory stock card system:

Each stock will be assigned of a stock card. This stock card will be placed in the

tablets plastic boxes. Every time a tablet is dispensed, this card shall be updated

and checked against the tablets quantity on the POS. This will facilitate easy

inventory control and recall if discrepancies come up.

Implementation of Partial Refill System:

In order to minimize the encounter of having low or running out of stock, it is

advised to implement a system that allows the pharmacist to fill a part of the

prescription for the patient so they can start taking the prescribed medicine.

When new inventory arrives at the store and the rest of their prescription can be

filled, the customer can return to the pharmacy and pick up the remainder of the

medication. By implementing this system we need to ensure we always order

more immediately when we have to use the partial refill system. The following

outlines the process and benefits of this system:

Give the patient enough medication for at least five (Initial Partial Fill) days just

in case the purchaser encounter a problem when ordering inventory

Try to have the rest of the prescription filled in 1-2 days


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Once the rest of the prescription arrives, notify customer (Final Partial Fill)

Helps eliminate unhappy customers

Allows them to have at least part of their prescription rather than nothing

Reduces inconveniences for customers

V. Suggested control mechanisms to maintain the re-design of the

production system of this pharmacy service:

1. Pharmacy Audit:

A pharmacy audit is conducted on behalf of a client who usually is external to the

organization. Entities that typically request pharmacy audits include Food, Drug

and Administration, Bureau of Internal Revenue, and companies that contract

with pharmacies such as health insurances and suppliers.

The auditor who conducts the review may be either internal or external to the

program. When objectivity is an issue, the auditor typically is external to the

program being audited and reports the findings to the company who requested

the audit. Rather than view the audit as an obtrusive and potentially threatening

review, pharmacies should see the audit as a quality-control mechanism. Audit

findings and corrective actions that result assure all involved parties that a

program is operating according to established standards of practice.

Consequently, audits protect companies from potential criticism of its operations.

Audit findings can be used to defend legal claims that a company did not abide by

the terms of its contracts. And should an audit uncover a lack of clarity in a

company's contracting or operating procedures, these findings can be used to

improve the organization's performance and minimize its exposure to future

business risk. For example, an audit may reveal that a business lacks adequate

internal controls for billing, which could lead to unscrupulous employees


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engaging in fraud and abuse. It is precisely because of the benefits associated

with audits that many companies maintain internal auditing programs. As a

business expands, the audit becomes a necessary quality-control mechanism. In

fact, some executives interpret a company's first audit as a significant milestone

in the company's maturation process.

The client, not the pharmacy program, has sole right to the audit report and bears

the financial obligations for funding the audit. The following are pharmacy issues

most frequently audited:

Purchasing and dispensing of controlled substances;

Accuracy of claims including quantity, dispensing date, dispensing

intervals, and prescriber information

Product selection criteria for generic versus brand utilization;

Assuring that special inventory controls exist for government mandated

discount programs (senior citizen and persons with disability discount

program);

Accuracy of invoice preparation;

Suspicion of fraud and (drug) abuse.

Second, there is the audit plan, in which the auditor develops a methodology to

conduct the audit. The methodology must specify objective measures and

documentation that will be used to judge compliance. The auditor will develop

various "tests" to judge compliance, which may include on-site observations of

staff working. In the case of record reviews, such as verifying prescription claims,

the auditor must design appropriate sampling techniques that generate valid

findings from sample sizes. If the program utilizes computer processing, the

auditor may employ measures to test the accuracy of the computer programs

employed. An essential audit principle is that another auditor employing the

same test measures should arrive at the same findings.


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Third is the field work, which consists of the site visit and application of the

methodology. The site visit consists of record reviews and interactions with staff

through which the auditor applies the various tests of compliance. During the site

visit, the auditor has the right to access all necessary records and documents.

This includes information that is considered confidential (e.g., patient

information) or proprietary (e.g., reimbursement terms of a competitively

solicited contract). Auditors usually will explain the relevance of such

information to their work. Should a company deny an auditor's information

request, legal opinion may be sought on the matter. This, however, rarely occurs

during the audit process. Confidential information generally is reviewed on site,

and documents are rarely removed to a remote location. Also, auditors are

responsible for maintaining the confidentially of information and are accountable

for breaches of this standard. The fourth activity is the generation of findings and

the report, which is a detailed presentation of the methodology and findings of

the audit. It frequently includes recommendations for the pharmacy program.

Auditing standards require that the auditor report all findings relating to the

internal control of the audited program to the client. On occasion, the company

that was audited may receive the same information for comment and review. The

following shows the findings that require reporting under standard auditing

procedures.

Inadequate supervisory control;

Absence of appropriate separation of duties by workers;

Absence of appropriate reviews and approvals of financial transactions;

Inadequate provisions for safeguarding assets;

Failure to correct known deficiencies;

Evidence of undisclosed party transactions;

Evidence of misrepresentations to auditor;

Evidence of manipulation, falsification, or alteration of records;


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Willful wrongdoing by employees or management; and

Failure to adhere to regulatory requirements. (Expired permits and

licenses)

2. Mystery Shopper Audit:

The mystery shopper audit can be employed as quality control and evaluation

tool of pharmacy services such as patient counseling. The auditor is typically

external to the organization being audited. Through this program, the

pharmacy can be assessed thought the eyes of a customer. Mystery shopping

is an accurate, reliable and customer service standard. It and allows the client

(owners) to provide feedback to the pharmacy staff and identify areas for

improvement. A consultant (may come from Food and Drug Administration)

may work with clients to develop scenarios exploring the areas they want to

examine. After the mystery shop is conducted, clients may receive a detailed

report containing constructive feedback and tips for improvement.

design and control of production system of an opd pharmacy

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