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MARIA ALENI B. VERALLO October 19, 2013


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.


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

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:


The out-patient pharmacy is comprised of a central This is where the backstage process happens. The

dispensary area.

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.

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 inpatient 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:

According to a part time pharmacist, The out-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.

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 relative by 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.

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, The pharmacy 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.

C. Flowchart of current processes both backstage and front stage of dispensing process (tablets):
Front Stage The receipt of the prescription by the pharmacy assistant initiates the process. Back Stage The pharmacist checks prescription legibility and availability. The pharmacist consults physician or nurse if needed.

The pharmacist computes the cost of the prescription.

The pharmacy assistant accepts the bill from the pharmacist.

The pharmacist hands the prescription to the pharmacy assistant

The pharmacy assistant prepares the sales invoice and hands it to the patient.

The pharmacist creates the label and affixes the label on the dispensing pouch.

The pharmacist prepares the medicines. (Medicine Assembly)

Obtain items from suppliers/hospital in-patient pharmacy.

The pharmacy assistant processes the bill payment. .

The pharmacist does the final accuracy check and puts the tablets inside the dispensing pouch.

Maintenance and cleaning of dispensary and medicine storage area.

The pharmacy assistant accepts the package from the pharmacist.

Once the bill is paid, the pharmacist hands the package to the pharmacy assistant.

The pharmacy assistant hands in the package to the \ patient.

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:


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

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. 2. 3. 4. 5. 6. 7.

Receipt of the prescription Creation of label Medicine assembly Accuracy check (by the pharmacist) Preparation of Sales Invoice Payment Processing Medicine Collection

Suggested re-design of the dispensing environment:

1. 2. 3. 4. 5. 6. 7.

Receipt of the prescription Checking of medicine inventory level/Creation of label Medicine assembly Accuracy check Cabinet for medicines for pick-up Payment processing Medicine collection and patient counseling

B. Re-design of the process of dispensing solid dosage forms (tablets) :

Front Stage Back Stage

The receipt of the prescription by the pharmacy assistant initiates the process.

The pharmacy assistant checks for prescription availability in the POS and computes the cost of the prescription.

. The pharmacy assistant gives the prescription and the billing statement to the pharmacist.

The pharmacist checks prescription legality and legibility.

The pharmacist consults the physician or nurse if needed.

The pharmacy assistant prints the sales invoice and hands it to the client/patient.

The pharmacist prepares the medicines. (Medicine Assembly)

The purchaser obtains the medicines from the suppliers.

The pharmacy assistant processes the bill payment.

The pharmacist creates the label and affixes the label on the dispensing pouch. The pharmacist does the final accuracy check and puts the medicines inside the dispensing pouch.
The pharmacist maintains the POS and customer records and inventory.

Once the bill is paid, the pharmacist hands the package to patient and performs patient counseling and consultation.

Before returning the tablet containers, the pharmacist checks the actual inventory level of the medicines dispensed against the POS inventory level.

If the inventory level is low, the then writes the needed medicines in the emergency procurement form.

The pharmacy assistant maintains the sanitation of dispensary and medicine storage area.

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 pleasure to serve you.

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.

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

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

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.

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;

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.