Kindly read the article entitled: “Pharmacy and Therapeutics Committee Preparedness Plan for COVID-19” by Abu Esba, Al Harbi, Alrushidan, & Al- Abdulkarim, (2020) from Global Journal on Quality and Safety in Healthcare. It can be accessed through: https://doi.org/10.36401/JQSH-20-9 5 Learning assessment will be served as your assignment and quiz and will be given via schoology at the end of the week after our virtual consultation. Lean Assessment Activities UNIT 5 -Week (7) - THE HOSPITAL FORMULARY Intended Learning Outcomes (ILO) At the end of the unit, you are expected to: 1. Describe the hospital formulary, its content & organization. 2. Determine how the hospital formulary is updated and revised. 3, State the importance of formulary in hospital. Introduction Nowadays, there are many ways to optimize and manage medications in various healthcare settings. The key to medication management in the health system environment is the formulary system. In fact, Vazquez~ Mourelle et al., (2019) mentioned that Hospital drugs formularies are lists of drugs drawn up to optimize inpatient care and ensure clinically appropriate, safe and cost-effective access and are a common tool for rational drug use in developed countries. This unit will focus on the content and organization of hospital formulary. Italso deals with the role of pharmacists in updating and revising the hospital formulary system. Please proceed immediately to the “Unlocking of Difficulties” in order to understand the terms used in the Lecture notes. Unlocking of Difficulties To attend the following intended learning outcomes the lesson of the course, you need to fully understand the following essential knowledge that will be laid down in the succeeding pages. Please note that you are not 13limited to exclusively refer to these resources. Thus, you are expected to utilize other books, research articles and other resources such as e-journals and various pharmacy mobile applications. Key Terms: = FORMULARY- A list of medicines approved for use in the health care system by authorized prescribers. * FORMULARY SYSTEM- The system of periodically evaluating and selecting medicines for the formulary, maintaining the formulary, and providing information in a suitable manual or list. " FORMULARY RESTRICTION- The act of limiting the use of specific formulary to specific physicians based on areas of expertise, patient disease state, or location. Lecture Notes Hello future Pharmacist! In relation to our previous topic, let's discuss the content and importance of hospital formulary. |. THE FORMULARY * A formulary is a continually updated list of medications and related information, representing the clinical judgment of physicians, pharmacists, and other experts in the diagnosis, prophylaxis, or treatment of disease and promotion of health. * A formulary includes, but is not limited to, a list of medications and medication-associated products or devices, medication-use policies, important ancillary drug information, decision-support tools, and organizational guidelines. FORMULARY SYSTEM= Formulary systems are used in many different settings, including hospitals, acute care facilities, home care settings, and long-term-care facilities, as well as by payers such as Medicare, Medicaid, insurance companies, and managed care organizations. = is the ongoing process through which a health care organization establishes policies regarding the use of drugs, therapies, and drug-related products and identifies those that are most medically appropriate and cost-effective to best serve the health interests of a given patient population USP-NF > isa combination of two compendia, the United States Pharmacopeia (USP) and the National Formulary (NF). It contains standards for medicines, dosage forms, drug substances, excipients, biologics, compounded preparations, medical devices, dietary supplements, and other therapeutics. Figure 1: The USP-NF (Book Depository, 2020) PNDF > The Philippine National Drug Formulary is an integral component of the Philippine Medicines Policy which aims to make quality essential drugs available, accessible, efficacious, safe and affordable. The PNDF (Volume 1) is the Essential Medicines List (EDL}for the Philippines prepared by the National Formulary Committee (NFC) in consultation with experts and specialists from organized professional medical societies, medical academe and the pharmaceutical industry. vFigure 2: PNDF (DOH Philippines, 2020) PNE > Philippine National Formulary is the latest edition of formulary in the Philippines. > It contains the list of essential medicines that can be procured by the government. > Italso serves as the basis for Philhealth reimbursement for both public and private health facilities. wu bm Ce pC os Figure 3: PNF (DOH-Philippines, 2020) I. FORMULARY MANAGEMENT = Decisions on the management of a formulary system should be founded on the evidence-based clinical, ethical, legal, social, Philosophical, quality-of-life, safety, and economic factors that result in optimal patient care. = Only the following proponents can apply medicines for inclusion in the PNF: ‘A. Pharmacy and Therapeutics Committee (PTC) of both public and private hospitals B, Professional medical societies recognized by the Philippine Medical Association (PMA) C. Patient groups D. National Health Programs (DOH Offices, Philhealth) E. Formulary Executive CouncilF, National Antibiotic Guidelines Committee * Applications for inclusion shall only be accepted within the month of January of each year. * ~The proponent shall completely accomplish the PNF form for inclusion, which shall be signed by the: A. PTC Chair for hospitals B. President for professional medical societies and patient organization C. Head of Office for National Health Programs + The six critical process identified by the Joint Commission on medication-use system to ensure optimal patient outcome: SELECTION AND PROCUREMENT, STORAGE, ORDERING AND TRANSCRIBING, PREPARING AND DISPENSING, ADMINISTRATION, AND MONITORING SP rerr Il, Factors to Consider in Formulating a Formulary: > Aformulary list should be limited to conserve resources > It is not necessary to stock all medicines listed in the Philippine National Drug Formulary (PNDF). Generic duplication should be eliminated. > Medicines should be selected based on diseases and conditions treated at the health facility > Medicines of choice should be selected comparing efficacy, safety, toxicity, pharmacokinetic properties, bioequivalence, pharmaceutical and therapeutic equivalence. > Cost effectiveness should be a primary consideration > Once medicines of choice are selected, they form the basis for standard treatment guidelines and for therapeutic substitution > Second line alternatives to medicines of choice may be included when necessary. > The hospital formulary should correspond with the current edition of the PNDF and to the approved standard treatment guidelines. IL CONTENTS OF FORMULAR' = Title page = Names and Titles of the members of the PTC * Table of Contents * Information on hospital policies and procedures concerning drugs/medicines:> Objectives & operation of the formulary system Hospital policies governing the prescribing, dispensing, and administration of drug products standard including drug administration times. Pharmacy operating procedures Information on using formulary Pharmacologic category of medicines Brief description of the PTC, including its members, responsibilities and operation. Policies on pharmaceutical company representatives Procedures on reporting adverse drug events and medication errors. = Drug Product List = Information to be included in each entry may vary. At a minimum, each entry must include the following: > Generic name of the basic drug entity or product/combination products. > Dosage forms, strengths, packaging, and sizes stocked at the Pharmacy > Formulation (active ingredients) of a combined product. vvYY v vv = Formulary Entries may be arranged as follows: > Alphabetically, by generic name > Alphabetically, within therapeutic class » Acombination of two systems in which the bulk of the drugs/medicines are contained alphabetically in a general section which is supplemented by several special sections such as ophthalmic /otic drugs, and various dosage forms = Drug listing indices may be by generic name of drug items or by therapeutic/pharmacologic index. = Appendices: Rules for Calculating Pediatric doses > Schedule of Standard administration > Forms of addition to/ deletion from formulary and others. = Pharmacologic/Therapeutic Index * Special Information that may be included which are not readily available in other sources such as: > List of hospital-approved abbreviations > Table of Sodium content of antacids > List of the contents of emergency cart/boxes/cabinets Dosage guides for patients with impaired renal functions ¥v 18Metric conversion scales and tables Examples of request for deletion/inclusion and prescription form. Provisions of the Generics Act on prescribing and dispensing especially erroneous, violative and impossible prescriptions. > Table of drug interactions > Poison antidote charts vv v RESTRICTED MEDICINES: Restricted medicines include those products that fill a particular need by a specialty within the health system. These medicines need to be defined by the PTC to limit their use. Some examples of restricted medicines and their applicability include: * Certain antibiotics for infectious diseases (e.g., ceftriaxone) * Antipsychotic medicines for use by mental health professionals (e.g., use of risperidone can be restricted to psychiatrists). * Antineoplastic products for use by physicians with specialized knowledge of these medicines. SAMPLE CONTENT OF PHILIPPINE NATIONAL FORMULARY ‘ABBREVIATIONS AND SYSTEM OF MEASUREMENTS. . + Mecienal plant produc estore wit) BFAD Use wt arene sauton in doses exceeding 20 mg per day, contandented in seue corenary events Specie penis, dagrostc precision, or special auiprent recuied for proper ise @ = United incaons or nartow spectrum faci a) = Dangerous Orug Fregaraons to be presesbea and ‘aspenced vvough the DOH Ofc! Presarzton Form (Yellow Fe. On one (3) dangerous rg Dreparston shat’ be pfoccrbed in one sige preconpton frm. Paral fing towed. STRICTLY NORERUL e + To be prescribed using Persnatzed Pression 'ssund by the presernng physician wih te S2 conse # Inckated theren. Only one (2) a beparaton shat be prescrbed in ene. single Dresenpton frm. Parl fing ellwed, STRICTLY NORERLL 02) + Drug Preparations containing Contotea Chemicals 1 be asperced and prescribed though 8 Personalized Prescription Esued by a presi piyselan with Uwe 82 foenee #, emeng otters Frdested therein Oniy one (1) Su preperation ‘hal be preserbes in one angle sreseipton fom. Paria rg alowed. STRICTLY NO REF. UUst8 meacines requang in vo eequvalence o= uta cram tneadermal icin = imvamuseutarinacion = Inetion| Intrnatara Uns Fees" ERS even en i o WS tere tte tea | gen = ane cede (nce Covet OR, we. Bema Saad toe St Forestry ea «tenes Nero On pea = Pecan Py raeromng nt htt nd fesinto aton FL eae ries prstin of Dargo Seg heptane slneter bones Patan yoonaey one C Sacomene ein won ttn MUSuRoNOT torte oa), isoa ‘Quanies of 1 gram or more sould be writen as 1g ee, ‘Quansies of ess nan 3 gram shows be wetter in igre, eg, 500 me, PtOS e ‘Quan las than 4 mlgrm shold be wtann mcogranys, #4, 100 ‘mierogranvs net 0.4 me. ‘When decimate am uravoiati, 8 reroute be writen eto decimal ait where tere is no Rue, 0 0.8 mL ot 5 mL. “he term miter (mt) shoukd be used and not cutie entmetars oc Focus Questions Guide questions for Unit 5 discussions: 1. How do formularies influence medication use within institutions? 2. How can pharmacists take a leadership role in the formulary management?Related Readings In order to appreciate the above discussion, kindly Read the 8"" Edition of Philippine National Formulary through: http://caro.doh.gov.ph/wp- content/uploads/2018/04/PNF-8th-edition. pdf EO Learning assessment will be served as your assignment and quiz and will be given via schoology at the end of the week after our virtual consultation. Learning / Assessment Acti UNIT 6 -Week (8-9): PHARMACY MANAGEMENT AND CONTROL Intended Learning Outcomes (ILO) At the end of the unit, you are expected to: (a (0) 4 1. Describe the concept of pharmacy management. 2. Determine the Recognizing the applications of Financial Management in Hospital Pharmacy. 3. Describe the process of purchasing and inventory control in hospital pharmacy. Introduction Basically, Pharmacists manage stock levels, budget and manage the finances of a pharmacy and ensure access to safe, effective, and affordable drugs. Moreover, Kruger et al., (2019) mentioned that effective management of a pharmacy requires much more than what a pharmacist normally performs, namely dispensing drugs and consulting patients. It requires skills to effectively manage staff, keep track of inventory, and adhere to various licensing formalities, as well as provide documentation regarding finances and facilities. This unit will focus on the management of pharmacy which include financial management and inventory control. Please proceed immediately to the “Unlocking of Difficulties” to understand the terms that you will encounter in the succeeding part.Unlocking of Difficulties To attend the following intended learning outcomes for the first lesson of the course, you need to fully understand the following essential knowledge that will be laid down in the succeeding pages. Please note that, you are not limited to exclusively refer to these resources. Thus, you are expected to utilize other books, research articles and other resources such as e-journals and various pharmacy mobile applications. Key Terms: = INVENTORY- refers to the total stock kept on hand at any storage point to protect against uncertainty, permit bulk purchasing, minimize waiting time, increase transportation efficiency, and buffer against seasonal fluctuations, "INVENTORY COTROL- is a method of supply management that aims to provide sufficient stocks of drugs at the lowest costs possible. = FIRST IN FIRST OUT (FIFO)- is a method of inventory management in which the first products received is the first products issued. = PHARMACOECONOMICS—the description and analysis of the cost of pharmaceutical therapy to health care systems. = COST—the total resources consumed in producing a good or service = PRICE—the amount of money required to purchase an item. = MEDICINE EFFECTIVENESS—the effects of a medicine when used in real-life situations. = MEDICINE EFFICACY—the effects of a medicine under clinical trial conditions. Lecture Notes © D since the Pharmacists manage the hospital Pharmacy. It is important to understand the role of pharmacist in inventory control and financial management in the hospital pharmacy. 2|. FINANCIAL MANAGEMENT "DIRECT COSTS OF A MEDICINE: Acquisition cost Transportation cost Supply management cost (i.e., storage facility cost) Cost of supplies and equipment to administer medicines, such as syringes and needles > Personnel costs to prepare and administer such as physicians, pharmacists, and nurses > Other direct costs (e.g., ADRs, hospital room charges, laboratory fees) > Nonmedical cost (e.g. p vvVY nt travel expenses) = INDIRECT COSTS OF A MEDICINE > Cost of illness to the patient > Lost time from work > Time required to care for somebody = INTANGIBLE COSTS > Costs associated with pain and suffering usually incorporated into utilities assigned to health states which reflect quality of life. * COST MINIMIZATION ANALYSIS (CMA) > Is the simplest pharmacoeconomic tools > Applied when comparing two drugs of equal efficacy and equal tolerability. > It compares the cost of therapies that achieve the same outcome. = COST MINIMIZATION ANALYSIS (CMA) PROCESS > Obtain acquisition price for each medicine and calculate the price for the course of treatment to be compared—dose per day, number of days of treatment. Calculate pharmacy, nursing, and physician costs associated with the use of each medicine. Calculate equipment cost associated with each medicine, Calculate laboratory cost associated with each medicine. Calculate cost of any other significant factor. Calculate and compare total medicine costs for each medicine. vov v vv= COST EFFECTIVE ANALYSIS (CEA) > A form of economic analysis that compares the relative expenditure (costs) and outcomes (effects) of two or more courses of actions. > Used to compare two or more medicines which are not therapeutically equivalent. » Effectiveness of therapy according to predetermined therapeutic measure. = COST EFFECTIVE ANALYSIS (CEA) STEPS > Define objectives—which medicine regimen is preferred to achieve the desired clinical outcome? v List the different options (medicines and other treatments) to achieve the desired clinical outcome. > Identify and measure for each option: (1) cost and (2) clinical outcome. > Calculate the incremental cost-effectiveness ratio. > Perform sensitivity analyses. Adjust cost of variables and re-analyze to confirm or refute results. Incremental Cost-Effectiveness Ratio (Net costs treatment A — Net costs treatment B) (Net effects treatment A— Net effects treatment B) = Additional cost per additional benefit = COST-UTILITY ANALYSIS (CUA) > a type of cost-effectiveness analysis in which the desired clinical outcome or benefit is measured in utilities, for example, in quality-adjusted life years (QALYs) and isa adjusted life years (DALYs). = COST-BENEFIT ANALYSIS (CBA) > a comparison of the costs and benefits of an intervention by translating the health benefits into a monetary value, so that both the costs and benefits are measured in the same monetary unit.= SENSITIVITY TESTING > Used to measure how different assumptions made in a particular cost analysis will affect the conclusions. > Change the assumptions concerning the cost of different variables, and repeat the cost-analysis study to see if the results supporting the original conclusion change. = DISCOUNTING > Used in cost evaluations to account for a future cost of a benefit from the medicine (or intervention) > Method to account for effects of the medicine (or intervention) over prolonged periods of time (because of the effects of inflation) > The discount rate must be tied to the economics of the country where the medicine or intervention would be provided Il. INVENTORY CONTROL + INVENTORY MANAGEMENT > Is the heart of drug supply system > It is described as an itemized list of goods with its estimated worth. Monthly inventory report of stocks is regularly submitted to the accounting section. v = PURPOSES OF INVENTORY 1. OPERATIONAL - To ensure the adequate supply of drugs conform to the requirements of the hospital turn-over at a reasonable rate without carrying excess quantities. 2. FINANCIAL -To optimize the inventory investment at a given time, reduced the cost of handling, storage, issuance, interest, and at the same time avoid losses from deterioration, expired drugs, pilferages and fluctuating prices. INVENTORY CLASSIFICATION ¥ Raw material inventories Y In process inventories Y Finished goods inventories Y Indirect inventories= INVENTORY CONTROL METHODS > ABC (Always Better Control) analysis of very common items with large inventory items are stocked > VED (Vital Essential Desirable) - utility of material useful in controlling and maintaining > FSN (Fastmoving slowmoving Nonmoving) > Setting off various level (max or min) > Buffering stock (SOS- Seasonal off seasonal)-unexpected demands and helpful in emergency condition > Modern computerization of inventory control TYPES OF INVENTORY BEING USED IN THE HOSPITAL PHARMAC' 1. PHYSICAL INVENTORY > The quantity of inventory on hand is determined through actual count of items as contrasted with accepting the values shown in records. (Bin and Stock records). > The best way to ensure that accuracy is maintained is through “cycle counting” or to continually count available drug products. > Drugs/medicines received on the day of the inventory or shortly thereafter shall not be counted and clearly marked “Post inventory”. 2. PERPETUAL INVENTORY > Isa system where information on inventory and availability is updated ina continuous basis. > This type keeps inventory at its current balance throughout the year. > Itmay be facilitated through a manual system of visible index cards or by means of an electronic data system > The use of any of these systems would provide a hospital with a record of all inventory items, a maintenance balance in quantity and monetary value. Il. BUDGETING = BUDGET > isa short-range plan for future operations » Provides a means to monitor the hospital financial activities > Forecast of the income and expenditure that the policies be implemented.PLAN Define the purpose of the unit (objective) Establish policies for its operation Project the hospital growth Reasonable Through the conscientious efforts of all personnel Attainable Not be interpreted as tool to restrict initiative to the effect of changing condition VVVVVVY DIVISION OF A BUDGET: 1. Income or revenue accounts 2. Expense accounts 3. Capital and equipment request INCOME ACCOUNT ® Total income must be calculated for the proper implementation of budget > Maintains daily,weekly, monthly and annual cost Value of the prescriptions and requisitions processed > Income in hospital pharmacy-limited to the sale of drugs to inpatients, ambulatory patients and department of the hospital (deductions-from purchase accounts) ~ Statistics to accurately predict the activities of pharmacy: ¥ Total number of prescription ¥ Total number of service ¥ Prescription volume per hour v Per day average cost of medication Y Average salary cost per prescription EXPENSE ACCOUNT/ EXPENDITURE > guide to meet its particular needs > This are the allocation of the FOUR GENERAL CATEGORIES in the hospital: 1. Administration and General 2. Professional care of the patient 3. Out-patient and emergency 4. Other expenses ADMINISTRATIVE AND GENERAL > Expenditures related to the day-to-day operations of a business. » pertains to operation expenses > Includes rent, utilities, insurance and managerial salaries.= PROFESSIONAL CARE OF PATIENTS Includes: Salaries and wages Supplies and expense Drugs and pharmaceuticals Purchased services Expenditures on overtime positions Miscellaneous supplies and expense KASS = OTHERS: EQUIPMENT AND CONSTRUCTION BUDGET > Funding of physical plant and equipment > Immediate arrangement of new model equipment's » Actual cash should be budgeted = PARAMETERS IN THE IMPLEMENTATION OF BUDGET: 1. Requirement of different department Actual fund position Utility of particular budget Cost of products Quantity of products yaens IV. PURCHASING & PROCUREMENT * PURCHASING > To establish standard and specifications for all drugs, chemicals, diagnostic agents and other preparations used in patients and pharmaceutical equipment. > With the P and TC-set up adequate specification for the purchase of quality pharmaceutical. > Use of competitive bidding * PHARMACY PROCUREMENT PRACTICE > Also known as Sourcing > Complete process of obtaining goods and services from preparation and processing of a requisition through to receipt and approval of the invoice for payment. > It involves: Purchase Planning Standards Determination Specifications Development Supplier Research and Selection Value Analysis Financing Price Negotiation Making the purchase Supply contract administration War nuewne10. Inventory control and stores 11. Disposals and other related functions. NINE PRINCIPLES OF PHARMACY PROCUREMENT: 1- Transparency 2-Cost Containment 3—Technical Capability 4 Operational Principles of Good Pharmaceutical Procurement 5 — Purchasing for Safety 6 - Ensuring Appropriate Selection 7 -Timely, Accurate and Assessable Information 8 — Ensuring Quality Products 9 — Proper Budgeting and Financing Figure 1: Pharmaceutical Supply Chain (Pinterest, 2020) = DUTIES OF A PURCHASING AGENT Y Issues purchase order Maintain purchase records Follow-up on delayed orders Initiate competitive bidding procedures v v v ¥ Obtain quotations from specified sources = PURCHASING PROCEDURES vv ¥ By direct purchase from the manufacturer By direct purchase from a wholesaler By bid from either manufacturer or wholesaler By purchase from local retail pharmacy (emergency Purchase only) By contract purchase arrangement with the manufacturer By a contract purchase through a corporation= 3 WAYS IN WHICH MERCHANDISE MAY BE PURCHASED AT A. DISCOUNT OR SAVINGS: 4s 2. 3. Volume contracts Deals Discounts = CONTROL ON PURCHASE: > Placing a limitation on the PO > LOW TURNOVER indicates: Y Duplication of stock Y Large purchase of slow moving items Y Dead inventory > HIGH TURNOVER: Y Due to small volume purchasing which is indicative of a failure to take advantage of maximum quantity discounts. = Other ways of purchasing a drug is through a consignment system. V. PRICING OF DRUGS = COMPONENTS OF DRUG PRICING 1 NOV aeD Direct personnel cost Drug costs Other direct supply cost Fixed overhead cost Direct cost Revenue deduction Profit margin Focus Questions Guide questions for Unit 6 discussions: 1. What are the roles of pharmacists in financial management of hospital pharmacy? 2. What are the challenges encountered by the pharmacists in Inventory control? 30