Jennifer Goldsmith
Director of Administration, Division of Global Health Equity
3 November 2016
Read more about Samahel’s work and collaboration with BWH in Pharmacy Today.
Although I have visited the Hôpital Universitaire Mirebalais (HUM) in Haiti before, my latest trip there marked the first time I received a behind-the-scenes look at its pharmacy. The impact that access to prescription drugs has on the lives of the hospital’s patients cannot be understated and it is made possible by the significant effort put into organizing medications and treatments, which is key to the pharmacy’s efficiency. Inventory management and supply chain are highly specialized operations distinct from the biochemical side of pharmacy work.
I was in the Mirebalais pharmacy in my role as fellowship director for the Walton Global Health Administration Fellowship, which was established in 2014 in BWH’s Division of Global Health Equity. Several generous BWH donors envisioned a program that would build on the existing bonds between BWH, Partners In Health (PIH) and PIH’s Haiti-based organization Zanmi LaSante (ZL). Through the fellowship, ZL administration and leadership would build skills to match the needs of a new 300-bed teaching hospital that was built in the aftermath of the devastating 2010 earthquake. To date, six fellows have participated in the program; among them is Samahel Joseph, director of Pharmacies at HUM.
The Miebalais hospital provides remarkable care in a setting that shows great respect for the patients and their families. This is of course the same approach we take at BWH. HUM is a beautiful open-air structure with communication, signage and clinical care at a standard not always found in settings limited in resources. There, I was struck by the calm pervading the hospital – despite the activity of many, many patients who arrive each day. I was conscious of how much trust exists between patients and providers. And I noticed some familiar technical systems, as well as some more manual approaches to tasks long since automated at BWH and throughout U.S. hospitals and health systems.
As a part of the fellowship, each participant develops an improvement project. Samahel’s concept was to dramatically improve “bedside unit dose control “ of medication, that is how medications that are prescribed are administered at the bedside. At Mirebalais, there is no unit-based Pyxis machine, so prescription orders are delivered at the bedside from mini-pharmacies on the nursing units. Upkeep of these pharmacies is a challenge. There is neither time nor space for efficient inventory management. It’s difficult to keep the pharmacies stocked with needed drugs and to keep them organized, given competing demands. Often, if a drug is not easily found on one unit, another unit shares its inventory. While this helpful in the short term, it further complicates inventory management and can lead to pilferage, as well as less-than-optimal patient care.
As a baseline for Samahel’s improvement pilot, he measured doses that were missed or filled with substitutes as high as 72 percent. This could have been due to inability to access a drug on the unit or that the entire institution’s stock was depleted. No matter the cause of these errors, the results are the same: compromised patient care.
Through a collaborative, multidisciplinary process, Samahel came up with the following improvement. He developed a simple paper form on which all meds for a patient in a given bed would be recorded for a 24-hour period. The unit nurse would collect these papers, and they would be delivered to the central pharmacy. There, a pharmacist would review and then fill prescriptions in small, numbered and color-coded tray. These trays are stocked with the exact prescriptions written. Two review and safety check-off processes were undertaken, one in the pharmacy and another when the worksheets and trays were returned to the nursing unit. Where the mini-pharmacy once sat, often in disarray, now trays are organized and prepared for easy distribution.
While Samahel was in Boston during the fellowship last spring, he worked extensively with BWHC Chief Pharmacy Officer William Churchill, MS, RPh, FMSHP, and John Fanikos, RPh, MBA, executive director of BWH Pharmacy Services. They generously offered their time and that of their team, allowing Samahel to shadow BWH staff and observe our systems to understand what works well here. He was also able to evaluate the balance between technology-driven solutions that may not be accessible in Haiti and the principles behind them that he could replicate with his own pharmacy team.
The results are compelling. The missed dose rate dropped initially from 72 percent to 38 percent and more recently to 5 percent. Samahel believes this 5 percent is a true reflection of available inventory of medications. In fact, stock availability seems to have increased by 50 percent. This is a measure both of actual stock and inventory management that allows access to what’s in the hospital – centrally, rather than diffused in small pharmacies. This clarification also allows the pharmacy to focus on true inventory concerns rather than those that were obscured by the past processes.
According to Samahel, the unit-dose pharmacy model improved storage, distribution and inventory management centrally and locally. In addition, it improved patient pharmaceutical documentation and team collaboration.
Recently, Samahel received approval for hospital-wide scale-up of his pilot. My own experience was really visceral. Observing at Mirebalais this summer, I could see the local inventories on units that had not yet migrated to the new model. Despite their best efforts, the units’ approach to dispensing medication seemed chaotic. There’s no mystery why. Nurses on these units wear many hats. The labor model looks quite different than at BWH or other U.S. hospitals, and given the choice of meeting critical patient care needs or organizing a local pharmacy, any nurse would choose patient care. In this new model, the nurse doesn’t need to choose at all. Seeing the efficiency of the trays in the central pharmacy and the straightforward approach of intuitive tracking sheets was a wake-up call on back-to-basics care. We can use remarkable technology, but in the absence of those options, patients are not condemned to poor care. My colleagues in Haiti are creative and efficient.
While the fellowship was intended to strengthen administrative skills among my Haitian colleagues, time and again their resourcefulness in the face of limited resources has reminded me how we too can focus on concepts like quality and efficiency rather than relying solely on technology and often higher-cost solutions.