Comparison on Human Resource Requirement between Manual and Automated Dispensing Systems

Transcription

1 VALUE IN HEALTH REGIONAL ISSUES 12C (2017) Available online at journal homepage: Comparison on Human Resource Requirement between Manual and Automated Dispensing Systems Prapaporn Noparatayaporn, BSc (Pharm) 1,2, Rungpetch Sakulbumrungsil, PhD 1, *, Tanita Thaweethamcharoen, PhD 2, Wunwisa Sangseenil, BSc (Pharm) 2 1 Social and Administrative Pharmacy International Graduate Program, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand; 2 Department of Pharmacy, Siriraj Hospital, Mahidol University, Bangkok, Thailand ABSTRACT Objective: This study was conducted to compare human resource requirement among manual, automated, and modified automated dispensing systems. Methods: Data were collected from the pharmacy department at the 2100-bed university hospital (Siriraj Hospital, Bangkok, Thailand). Data regarding the duration of the medication distribution process were collected by using self-reported forms for 1 month. The data on the automated dispensing machine (ADM) system were obtained from 1 piloted inpatient ward, whereas those on the manual system were the average of other wards. Data on dispensing, returned unused medication, and stock management processes under the traditional manual system and the ADM system were from actual activities, whereas the modified ADM system was modeled. The fulltime equivalent of each model was estimated for comparison. Results: The result showed that the manual system required FTEs of pharmacists and FTEs of pharmacy technicians. By adding pharmacist roles on screening and verification under the ADM system, the ADM system required FTEs of pharmacists. Replacing counting and filling medication functions by ADM has decreased the number of pharmacy technicians to FTEs. After the modified ADM system canceled the return unused medication process, FTEs requirement for pharmacists and pharmacy technicians decreased to and FTEs, respectively. Conclusions: The ADM system decreased the workload of pharmacy technicians, whereas it required more time from pharmacists. However, the increased workload of pharmacists was associated with more comprehensive patient care functions, which resulted from the redesigned work process. Keywords: automated dispensing machine, automated dispensing system, ADM, dispensing system, full-time equivalent, human resource management, medication distribution system, returned medication system, stock management, workload. & 2017 Published by Elsevier Inc. on behalf of International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Drug distribution is the major responsibility of the pharmacy service and an essential part of the patient care process and has a significant impact on treatment outcomes. The work process of medication distribution in the pharmacy unit is composed of multiple steps and involves a large number of personnel, and this increases the risk of medication errors and adverse events. Automated dispensing machines (ADMs) are widely used in many countries, such as the United States and Canada, and in some private hospitals in Thailand [1 3]. The expected benefits of implementation of ADMs in the dispensing process include more efficient use of human resources and improvement in the quality of the medication distribution process [4]. Previous studies have revealed that ADMs reduced the dispensing time of pharmacists [5 7]. With less time spent in dispensing, pharmacists would have more time to provide more cognitive services, such as patient care related activities. However, Klein et al. found that the working time of pharmacists was not affected significantly whether or not ADMs were used [8]. Alvarez et al. reported that the workload in the pharmacy department increased after the ADM system was implemented [9]. The reduced time may not be the only interesting factor in implementing the ADM system, but the quality of pharmacy services should also be taken into account. At the 2100-bed university hospital (Siriraj Hospital, Bangkok, Thailand), a pharmacy-based (centralized) ADM (Yuyama YS-TR- 406FDS-II) was implemented in the pharmacy department. An ADM contains 406 medication cassettes and a designated tray for more specialized medications. Each cassette is calibrated for each medication to optimize dispensing accuracy. Radiofrequency identification (RFID) chips and the barcode system are used to recognize the cassette position in the ADM. Medications are removed from manufacturers original packaging before being placed in the cassette. The unit dose dispensed pack contains all prescribed medications accompanied by information for each The authors have indicated that they have no conflicts of interest with regard to the content of this article. * Address Correspondence to: Sakulbumrungsil Rungpetch, Social and Administrative Pharmacy International Graduate Program, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand. rungpetch.c@chula.ac.th; rungpetch.c@gmail.com $36.00 see front matter & 2017 Published by Elsevier Inc. on behalf of International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

2 108 VALUE IN HEALTH REGIONAL ISSUES 12C (2017) Fig. 1 Work process in the manual, automated dispensing machine (ADM), and modified ADM systems. a,b Common steps in the, Pharmacist;, pharmacy technician. administration. The ADM fills the medications in unit dose packs at the rate of up to 1 pack per second. To reduce contamination, the ADM is cleaned every day, and cleaning of the whole machine is scheduled to occur every 3 months. The ADM system was implemented and piloted in February 2012 for dispensing medications to 1 inpatient medical ward. The work process and the roles of pharmacists and pharmacy technicians were modified and adjusted after implementation of the ADM With the use of ADMs, the dispensing process required additional tasks that increased the involvement of pharmacists. The ADM system is planned to be implement in all 110 wards. However, the number and model of ADMs needs to be considered for full implementation. Thus, this study aims to compare human resource requirements among manual, automated, and modified automated dispensing systems. Methods We performed the research at the 2,100-bed university hospital. Data were collected from the pharmacy department. Data on the duration of the medication distribution process for both the manual and the ADM systems were collected during the month of October 2012, 8 months after implementation. The data on the ADM system were obtained from 1 piloted inpatient ward, whereas those on the manual system were the average of other wards. The duration for each work process was self-reported by pharmacists () and pharmacy technicians () using recording forms. Expert opinion was obtained in some processes for which data were not available. The dispensing and returned unused medication processes in the manual, ADM, and modified Total time spent ðhr=yearþ ADM systems are shown in Figure 1. Working time per FTE ðhr=man=yearþ Full-time equivalents of both pharmacists and pharmacy technicians were estimated for comparison. FTE was defined as the number of personnel required for each work process. The human resource requirement of all systems was extrapolated to cover all 110 hospital wards for the purpose of comparison. The FTE of the hospital was calculated by using a formula based on 7 hours per day and 230 days per year. One FTE was equal to hours per week.

3 VALUE IN HEALTH REGIONAL ISSUES 12C (2017) Medication Distribution System Manual Dispensing System (Manual system) The manual system was composed of 3 major functions: dispensing, returned unused medication, and stock management. The dispensing process (Fig. 1) started with prescription screening by a pharmacist, followed by a pharmacy technician recording the medication order, labeling a zip-locked bag, and matching it with the prescription. Next, the pharmacy technician counted the medications and put them in the prepared bag, and a pharmacist conducted the final check for accuracy before dispensing the medication to an inpatient ward. The returned unused medications were managed by a pharmacy technician, and this included checking the unused medications returned from a ward, recording the information, checking the invoice of the returned unused medications, and placing returned unused medications back into the inventory. For stock management, the manual system covered the steps of placing medications on shelves and checking inventory every day. Automated Dispensing System (ADM system) The ADM system was also composed of the same 3 major functions. For dispensing process (Fig. 1), a prescription was first screened by a pharmacist and then recorded by a pharmacy technician. The same pharmacist verified the prescription and transferred data onto the ADM for preparation. The ADM filled the medications in unit dose packages, and a label was automatically printed and placed on each unit dose package. A pharmacy technician cut the strip-packaged medication prepared by the ADM for each patient, matched it with the prescription, and checked for the consistency of the dispensed unit dose. The pharmacist conducted the final check before the unit dose medicines were delivered to the inpatient ward. When unused medications were returned from a ward, recording and checking the invoice of returned unused medications were managed by a pharmacy technician. The ADM system required a pharmacist to monitor the filling of medication into the machine, whereas in the manual system, a pharmacy technician was responsible for these tasks. The ADM program could facilitate stock management by identifying the quantity and expiration date of the medication, and thus no checking of inventory was required in the ADM Modified Automated Dispensing System (Modified ADM system) To increase the efficiency of the ADM system for workload reduction, the ADM system was modified and designed to cover 2 functions, including dispensing and stock management (Fig. 1). Return of unused medications was not allowed. For the dispensing process, the final checking of the medication for accuracy before delivering it to the inpatient ward was conducted by a pharmacy technician with no involvement of the pharmacist. With regard to stock management, filling of medications into the ADM was managed by a pharmacy technician, who was solely responsible for this step. Results All systems dispensed medications for 1 day, and the estimated number of dispensed prescriptions and returned prescriptions per year were 1,637,277 and 137,090, respectively. The work process and time spent by pharmacists and pharmacy technicians in the manual and ADM systems are shown in Table 1. The manual system required FTEs of pharmacists and FTEs of pharmacy technicians, whereas the ADM system required FTEs of pharmacists and FTEs of pharmacy technicians. In the dispensing process, the ADM system needed more pharmacists for the screening, verification, and checking steps, whereas the pharmacy technician s FTEs decreased in the steps of labeling and preparation. The screening step, in which the pharmacist reviewed the appropriate use of medications, required FTEs for the ADM system and FTEs for the manual The screening process for the ADM system was designed such that the pharmacist had to conduct more intensive prescription review. The physician s order would be checked in comparison with the patient s drug profile and the data entered by using the electronic patient drug profile feature in the ADM The verification step was not required in the manual system, whereas pharmacist FTEs were needed before the data were transferred onto the ADM and served as a double-checking process to avoid drug interaction and drug duplication. Placing of the label on the bag by a pharmacy technician in the manual system was now performed by the machine in the ADM Matching and checking for the accuracy of the dispensed unit dose by a pharmacy technician was still needed in the ADM The FTEs of pharmacy technicians in the steps of labeling, matching, and checking for accuracy were reduced from to in the ADM With the use of the ADM to prepare medications, FTEs of pharmacy technicians in the manual system could be replaced. Checking for item accuracy of unit dose dispensed packages prepared by the ADM would require more time than that of items dispensed in the manual The FTEs in this process increased from in the manual system to in the ADM The returned unused medication process in the ADM system required 8.47 pharmacist FTEs, which were not required in the manual In stock management, pharmacy technician FTEs were needed compared with 4.08 FTEs for filling the shelf in the manual In the ADM system, not only was a pharmacy technician involved, a pharmacist also monitored the filling process to ensure that there would be no misfilling. This required 0.38 pharmacist FTEs. Since the ADM program could automatically provide the quantity and expiration date of the inventory in the ADM, it thus eliminated 1.36 FTEs of pharmacists and 4.53 FTEs of pharmacy technicians required in the manual The modified ADM system was designed to increase the efficiency of the ADM The modified ADM system could shorten the dispensing process and reduce human resource requirement. FTE requirements for pharmacists and pharmacy technicians are shown in Table 1. The ADM system required FTEs of pharmacists and FTEs of pharmacy technicians, whereas the modified ADM reduced pharmacist FTEs to and pharmacy technician FTEs to Dispensed medications that were prepared by the ADM did not require a pharmacist for final checking, since the machine could be calibrated for accurate dispensing. Another major change to comply with good pharmacy practice standard was that the modified ADM system did not allow any dispensed medication to be returned to the The human resource requirement was thus reduced by 8.47 FTEs of pharmacists and 3.86 FTEs of pharmacy technicians. In stock management in the modified ADM system, a pharmacy technician was assigned to conduct both checking of medications and filling them into the ADM; a total of FTEs of pharmacy technicians was therefore required.

4 110 VALUE IN HEALTH REGIONAL ISSUES 12C (2017) Table 1 Work process and time spent by pharmacist and pharmacy technician in manual, ADM, and modified ADM systems. Work process Manual system ADM system Modified ADM system Dispensing process Screen * Record Verify Label Simultaneous with medication preparation step by ADM Match Simultaneous with checking for consistency Simultaneous with medication preparation step by ADM Simultaneous with checking for consistency Prepare Check for consistency Final check Total FTEs in dispensing process Returned unused medication process Check returned medication Record Check invoice Place returned medication on shelf Total FTEs in returned unused medication process Stock management Fill shelf 4.08 Fill ADM Check inventory Total FTEs in stock management Total FTEs in all processes , pharmacy technician;, pharmacist. * Common steps in the Common steps in the Not applicable. Discussion Total times spent by pharmacists and pharmacy technicians in the manual, ADM, and modified ADM systems are shown in Table 1. The work process of the ADM system mostly imitated the manual system, but with requirement of pharmacist manpower increased from FTEs to FTEs. However, number of pharmacy technicians decreased from FTEs to FTEs. The study showed that the medication distribution system should be changed when a different system was implemented to maximize the benefit from the ADM By adapting the work process of the ADM system, the modified ADM system could shorten dispensing process and reduce the human resource requirement. However, the modified ADM system required more pharmacists but fewer pharmacy technicians compared with the manual The addition of pharmacist FTEs into the system could improve the quality of patient care. Moreover, we expect that continuous work process of the ADM system can reduce the turnaround time in the dispensing process compared with the manual As indicated by the unpublished data from the piloted ward, administration time and probability of administration error by nurses were decreased. The reduced work process of checking [5,7], which decreased pharmacist s time, helped avoid medication errors [10],. However, Klein et al. showed that the pharmacist s workload did not differ even though the work process increased in the ADM system [8]. In this study, the ADM system required more pharmacists for screening and verification. With regard to the pharmacy technician s time, Wise et al. found that pharmacy technicians spent more time in the step of filling medications into the ADM [5]. Nevertheless, in the study by Schwarz and Brodowy, reduced time in the preparation step decreased the overall workload [7]. In this study, pharmacy technicians time in the preparation step decreased but more time was consumed for filling medications into the ADM. The results from previous studies on the working time of pharmacists and pharmacy technicians were quite different, depending on the study design, model of ADM, and work process. The piloted ward in this study was a medical ward, which had the most number of medications compared with other wards where physicians prescribed fewer medications (e.g., surgical and maternity wards). The human resource requirement can vary, depending on the number and types of medication dispensed. This study did not take into account the time spent on medication items that could not be dispensed by the ADM. Policy recommendation, the ADM system is effective and should be promoted and implemented. The ADM system needed more pharmacists, whereas it required fewer pharmacy technicians. Human resource management should therefore be planned accordingly, and effective training for personnel involved in ADM implementation, such as pharmacists, pharmacy technicians, and nurses, should be considered. To increase efficiency of the

5 VALUE IN HEALTH REGIONAL ISSUES 12C (2017) medication distribution system within the hospital, work process should be redesigned to gain the most benefits from the ADM Conclusions The ADM system decreased the workload of pharmacy technicians, whereas it required more of pharmacists time. The higher level of involvement of pharmacists in the work process and the computerized ADM system together can directly increase the efficiency of the medication distribution system and indirectly improve the quality of patient care in the hospital. The modified ADM system was thus redesigned to shorten the dispensing process and reduce human resource requirements. Acknowledgment This study was successfully conducted through the cooperation of all staff members in the pharmacy unit, who provided information regarding their routine jobs and work processes; their cooperation during the period of data collection and suggestions are highly appreciated. The authors have no other financial relationships to disclose. REFERENCES [1] Canadian Agency for Drugs and Technologies in Health (CADTH). Technologies to reduce errors in dispensing and administration of medication in hospitals: clinical and economic analyses. CADTH Technol Overv 2010;1:e0116. [2] Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration Am J Health Syst Pharm 2012;69: [3] Plodkratoke WKT, Sakulbumrungsil R, Reungjarearnrung K. Cost saving and cost avoidance of the pharmacy automation Thai J Hosp Pharm 2010;20: [4] ASHP guidelines on the safe use of automated dispensing devices. Am J Health Syst Pharm 2010;67: [5] Wise LC, Bostrom J, Crosier JA, White S, Caldwell R. Cost-benefit analysis of an automated medication Nurs Econ 1996;14: [6] Guerrero RM, Nickman NA, Jorgenson JA. Work activities before and after implementation of an automated dispensing Am J Health Syst Pharm 1996;53: [7] Schwarz HO, Brodowy BA. Implementation and evaluation of an automated dispensing Am J Health Syst Pharm 1995;52: [8] Klein EG, Santora JA, Pascale PM, Kitrenos JG. Medication cart-filling time, accuracy, and cost with an automated dispensing Am J Hosp Pharm 1994;51: [9] Alvarez Rubio L, Martin Conde JA, Alberdi Leniz A, et al. Assessing an automated dispensation system in the emergency department of a level III-hospital. Farm Hosp 2003;27:72 7. [10] Ray MD, Aldrich LT, Lew PJ. Experience with an automated point-of-use unit-dose drug distribution Hosp Pharm 1995;30:18, 20-3,