TOPIC NAME

A COMPARATIVE STUDY OF IN-HOUSE PHARMACY AND

RETAIL PHARMACY

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 Executive Summary

It is purely focused on the comparison of customer satisfaction and psychology on the in-
house pharmacy and retail pharmacy. It specifies the systematic understanding of knowledge and
a critical awareness of current problems or new insights at the forefront of your discipline.

It gives a brief view on the present scenario of the in- house pharmacies and retail
pharmacies which specifies the customer mindset and preferences on the medicines about the
services provided by both the pharmacies in order to satisfy their customers and patients, which
results in the comparative state of the pharmacy growth and development.

This project report gives a detailed study about both in-house pharmacy and retail
pharmacy in the prospect of customer psychology , preferences, services provided to them , medical
guidance and their convenience and satisfaction in terms of pharmaceutical support. It gives an
insight about the customer preferences over in-house pharmacies and retail pharmacies on the
service provided by them.

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 ABSTRACT

In-house pharmacies are pharmacies usually found within the premises of a hospital.
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. Retail pharmacy
technicians have many duties besides filling prescriptions. They spend much of their time
interacting with patients when prescriptions are dropped off or picked up. They operate the cash
register to sell prescriptions as well as other items sold in the store. They process insurance
claims for the patient, which often involves being on the phone with insurance representatives.
They also stock shelves, keep inventory records, clean the pharmacy, and file paperwork. They
may even be asked to work in other areas of the store when needed. In some jurisdictions,
governments and the public look to community pharmacies to provide expanded primary health
care services, including care plans with follow-up. Care planning services, covered by the
Compensation Plan in Alberta, Canada, require pharmacists to assess an eligible patient’s health
history, medication history, and drug-related problems to establish goals of treatment,
interventions, and monitoring plan. Follow-up assessments are also covered by the
Compensation Plan. A comparative case study method facilitated an in-depth investigation of
care planning services provided by four community pharmacy sites. Data from 77 interviews, 61
site-specific documents, and 94 h of observation collected over 20 months were analyzed using
an iterative constant comparative approach. Using a sociomaterial theoretical framework, the
perceived value of care planning services was examined through an investigation of the
relationships and interactions between people and information. Patients perceived the value of
care planning as related to waiting time to access care and co-creating individualized plans.
Physicians and other health care professionals valued collaboration, information sharing, and
different perspectives on patient care. Pharmacists valued collaboration with patients and other
health care professionals, which renewed their sense of responsibility, increased satisfaction, and
gave meaning to their role.

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 TABLE OF CONTENT

PARTICULARS PAGE NUMBER

INTRODUCTION 5–8

LITERATURE REVIEW 9 – 13

COMPANY PROFILE 14 - 23

RESEARCH METHODOLOGY 24 – 39

DATA ANALYSIS 40 – 55

FINDING, SUGGESTIONS AND 56 – 58

RECOMMENDATION

LIMITATION 59

CONCLUSION 60

REFERENCES 61 – 66

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 INTRODUCTION

About in-house pharmacies:

In-house pharmacies are pharmacies usually found within the premises of a hospital.
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.

They typically do not provide prescription service to the public. Some hospitals do
have retail pharmacies within them (see illustration), which sell over-the counter as well as
prescription medications to the public, but these are not the actual hospital pharmacy.
In-house pharmacies provide a huge quantity of medications per day which is allocated to the
wards and to intensive care unit according to medication Schedule. Larger hospitals use
automated transport systems for dispatch of medications.

About retail pharmacies:

A retail pharmacy is the place where most pharmacists practice the profession of
pharmacy. It is the community pharmacy where the dichotomy of the profession exists—health
professionals who are also retailers.

In most countries, the dispensary is subject to pharmacy legislation; with

requirements for storage conditions, compulsory texts, equipment, etc., specified in legislation.
Where it was once the case that pharmacists stayed within the dispensary
compounding/dispensing medications, there has been an increasing trend towards the use of
trained pharmacy technicians while the pharmacist spends more time communicating with
patients. Pharmacy technicians are now more dependent upon automation to assist them in their
new role dealing with patients' prescriptions and patient safety issues.
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 Pharmacies are typically required to have a pharmacist on-duty at all times when
open. It is also often a requirement that the owner of a pharmacy must be a registered
pharmacist, although this is not the case in all jurisdictions, such that many retailers now include
a pharmacy as a department of their store.

Likewise, many pharmacies are now rather grocery store-like in their design. In
addition to medicines and prescriptions, many now sell a diverse arrangement of additional items
such as cosmetics, shampoo, office supplies, confections, snack foods, durable medical
equipment, greeting cards, and provide photo processing services.

In-house pharmacy versus retail pharmacy:

Retail pharmacy technicians have many duties besides filling prescriptions. They
spend much of their time interacting with patients when prescriptions are dropped off or picked
up. They operate the cash register to sell prescriptions as well as other items sold in the store.
They process insurance claims for the patient, which often involves being on the phone with
insurance representatives. They also stock shelves, keep inventory records, clean the pharmacy,
and file paperwork. They may even be asked to work in other areas of the store when needed.

In-house pharmacy technician does not deal with patients or process insurance
claims. They spend more time filling prescriptions than any other duty. The process of filling
prescriptions in a hospital is very different than in a retail pharmacy. In a retail pharmacy, the
technician may fill up to 200 prescriptions in a day. Each prescription will be anywhere from a 7
– 90 day supply of medication that the patient will administer to themselves at home. In a
Hospital pharmacy, the pharmacy technician may fill over 1000 individual doses of medications
which are given to nurses to be administered to patients.

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Objectives of the Study:

 It would provide holistic medical care including general care in various general, medical
surgical specialties, and in selected super specialties which are not available or grossly in
adequate in this region

 It will act as a secondary level as well as a selected tertiary level referral center for the
poor pollution of this region at a affordable cost

 To create a center of excellence for providing patient care and educational facilities of
high order.
 To provide training in para medical and allied fields
 Patient care, educational training and research facilities will be complementary to
SGPGIMS.
 The medical institute, with public service hospital will cater both to the poor patient who
are unable to pay and to the population that has the capacity to pay on user changes at no
profit no loss basis.
 The institute is registered under the society registration act 21, 1860 and the registration
NO. is 1982 2006-07 dated 4th Nov 2006.
 It is established as an autonomous, independent satellite center under the act of state
assembly similar to SGPGIMS. On 3rd june 2006, Govt. declare the Institute to be an
independent Society
 The regular OPD services started on 01.10.2010. out of 18 department 16 department
became functional in which at least one faculty member is working in each department.

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 The scope of pharmacy practice research is huge, which is a reflection of the fact that, in
order to promote safe and appropriate use of medicines, pharmacists have to take many issues in
account. New directions in the health policy, changing needs and expectations of the population,
the structural, economic, social and cultural contexts of health care and the aspirations of the
pharmacy for the greater role in its delivery all provide the background and frameworks for the
conception and execution of the pharmacy practice research. The research conducted under the
umbrella of ‗Pharmacy Practice‘ is important to patients, healthcare organizations, government
and the profession. Participation in the original research is also seen as a fundamental component
in a student‘s education. Conducting a research report should be seen as an opportunity to not
only develops personal skills but also to take the original piece of work that has the potential to
influence services of the future.

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 LITERATURE REVIEW

History of pharmacies:

The history of pharmacy as an independent science dates back to the first

third of the 19th century. Before then, pharmacy evolved from antiquity as part of
medicine.

Sumerian cuneiform tablets record prescriptions for medicine. Ancient

Egyptian pharmacological knowledge was recorded in various papyri such as the Ebers
papyrus of 1550 BC, and the Edwin smith papyrus of the 16th century BC.

In Ancient Greece, according to Edward Kremers and Glenn Sonnedecker,

"before, during and after the time of Hippocrates there was a group of experts in medicinal
plants. Probably the most important representative of these rhizotomoi was Diocles of
carystus (4th century BC). He is considered to be the source for all Greek
pharmacotherapeutic treatises between the time of Theophrastus and Dioscorides." The
Greek physician pedanius discords is famous for writing a five volume book in his native
Greek ("Peri hules iatrikes") in the 1st century AD. The Latin translation De material
medica (Concerning medical substances) was used a basis for many medieval texts, and
was built upon by many Middle Eastern scientists during the Islamic golden age. The title
coined the term material medica. There is a stone sign for a pharmacy with a tripod, a
mortar, and a pestle opposite one for a doctor in the Arcadian Way in Ephesus near
Kusadasi in turkey.

The earliest known Chinese manual on material medica is the Shennong

Bencao Jing (The Divine Farmer's Herb-Root Classic), dating back to the 1st century AD.
It was compiled during the Han dynasty and was attributed to the mythical Shennong.

Earlier literature included lists of prescriptions for specific ailments, exemplified by

a manuscript "Recipes for 52 Ailments", found in the Mawangdui, sealed in 168 BC. Further
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details on Chinese pharmacy can be found in the pharmacy in china article.

The earliest known compilation of medicinal substances in Indian traditional

medicine dates to the 3rd or 4th century AD (attributed to sushruta, who is recorded as a
physician of the 6th century BC).

In Japan, at the end of the Asuka period (538-710) and the early Nara period
(710-794), the men who fulfilled roles similar to those of modern pharmacists were highly
respected. The place of pharmacists in society was expressly defined in the Taiho code
(701) and re-stated in the Yoro code (718). Ranked positions in the pre-Heian Imperial
court were established; and this organizational structure remained largely intact until the
Meiji restoration (1868). In this highly stable hierarchy, the pharmacists—and even
pharmacist Assistants—were assigned status superior to all others in health-related fields
such as physicians and acupuncturists.

Pharmacy public health policy context Community pharmacists already make a

significant contribution to public health through their day-to-day activities. These include
the provision of information and advice, facilitating self-care, the care and support of drug
users, visits to the homes of housebound people and advice on smoking cessation and
emergency hormonal contraception. Community pharmacy is in a unique position to
deliver the pubic health agenda. Comprising around 12,000 dedicated premises,
pharmacists provide a highly accessible, informal network of ‘drop in’ access points for
medicines and advice on health and well-being, making them a significant component of
the public health workforce.

Community pharmacy is unusual in that it straddles both public and private sectors.
Community pharmacists are independent contractors to the health service, giving advice
and dispensing medicines for the NHS. But they also have to survive as small businesses in
local communities or as major retailers in the high street. The dual health and commercial
role occupied by pharmacy offers a unique opportunity to target activities towards healthy

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people, as well as those with health problems. Pharmacy users’ experiences are often more
‘consumer’ orientated than ‘patient’ orientated. The Government’s focus on public health
is considerable and is primarily directed at developing the capacity within the public health
workforce and reducing inequalities in health. Often the potential contribution that
pharmacists can make to achieve these stated aims is omitted. However, in recent years, a
number of key policy documents have outlined the areas in which the public health role of
pharmacists should be developed further. For example, the Health Committee Inquiry into
Public Health recommended that ‘the Government takes steps for community pharmacists
to play a more active role in public health’.

The Government strategy document for outlining the future direction of pharmacy,
Pharmacy in the Future, recognised that the skills and expertise of the pharmacist could be
further utilised. According to the strategy this could be achieved through pharmacy
becoming more integrated with the NHS, through working more flexibly as part of a
multidisciplinary healthcare team and through playing a greater role in supporting self-
care. Tackling Health Inequalities: A Programme for Action highlights the importance of
community settings and services in addressing health inequalities, including community
pharmacies. A Programme for Action goes on to state that community pharmacists have a
vital role to play in improving the public’s health by giving advice, specifically on how to
quit smoking, offering exercise on prescription, identifying patients at risk of heart disease
and providing services for substance users.

A Vision for Pharmacy in the New NHS, recognises the untapped contribution that
pharmacists can make to the public health agenda. The Vision made a commitment to
develop a pharmaceutical public health strategy for England by 2005, integrating pharmacy
with the wider public health agenda and workforce. The Vision also reflected the public
health contribution that community pharmacy makes in the new pharmacy contract. The
contract for community pharmacy in England is essential to delivering public health
services in community pharmacy. Under the new contractual framework, essential services,
provided by all community pharmacies will include the promotion of healthy lifestyles and
the promotion of self-care.

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 The inclusion of public health in the essential service element recognises the
importance of public health and the contribution that can be made by pharmacy. While the
Department of Health for England provides overarching policies to tackle UK wide public
health issues, Northern Ireland, Scotland and Wales have each developed their own set of
priorities based on the particular needs of their regional communities.

The Scottish Executive’s vision for improving the public’s health, is to reduce
inequalities, social exclusion and poverty. Reducing the differences in opportunity and
experience is at the heart of work to improve Scotland’s health, as is the belief that
improving living and working conditions, and influencing lifestyle, will lead to better
health. All parts of the Scottish NHS are expected to contribute to this agenda by working
together in the community to improve health and reduce health inequalities.

Pharmacy for Health: The Way Forward for Pharmaceutical Public Health in
Scotland, recognises the often untapped potential contribution which pharmacy can make
to improving the public’s health and the need to engage all pharmacists in the public health
agenda, utilising their skills and experiences to the full. The National Assembly for Wales
has as its set of guiding principles, ‘act now for the future’, ‘reduce poverty and achieve
equality’. The aim is to improve the health and well-being of people in Wales and to
reduce inequalities in health.

Improving quality and effectiveness of healthcare and promoting interagency

working, underpins this strategy. In Northern Ireland there is a multidisciplinary approach,
that recognises that social, economic, physical, cultural and environmental factors largely
determine health and well being. The strategy is to take action to tackle the factors that
adversely affect health and increase health inequalities. Making it Better - A Strategy for
Pharmacy in the Community recognises that pharmacy plays an important role within the
health services and community as a whole due to the accessibility of pharmacy, and
therefore in a prime position to deliver services that improve the public’s health.

The strategy aims to build on traditional roles within pharmacy, to use pharmacists’
skills to the fullest and make pharmacy an integral part of the health and social care team.

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Overall, the message is clear throughout Great Britain: pharmacy makes an important
contribution to improving the public’s health and reducing health inequalities, due to the
skills and experience of the pharmacy workforce and location and accessibility of
pharmacies.

All four countries are now recognising this untapped resource and the need to
engage all pharmacists in the public health agenda. In the future, pharmacists will become
more recognised as public health practitioners, utilising their skills and experiences to the
full and becoming more integrated with the NHS and wider public health workforce. Our
Reports 1 and 2 of the Evidence Base Review clearly demonstrated the potential of
community pharmacists to improve the public’s health. The diagram below represents
pictorially the evidence summary of where community pharmacy contributes to improving
the public’s health.

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 COMPANY PROFILE

On 9 September 2004, in a Government of Uttar Pradesh cabinet meeting held under the
chairmanship of Shri Mulayam Singh yadav, the then chief minister of Uttar Pradesh took the
decision to improve the medical facilities at Dr. RML Hospital. This would involve the addition
of specialized and super specialized medical departments. A detailed project report (DPR) was
prepared but not fully implemented. The State cabinets meet of August 23, 2005 under the
leadership of shri Mulayam Singh yadav resolved to establish Dr.RMLIMS as a super specialty
medical institute having PG medical education, research and front line tertiary patient care as
guiding force. It was conceptualized initially as a satellite center of SGPGI, know to make
available the super specialty medical care within the precincts of the city. However, the State
cabinet in its meeting on May 30, 2006 took a decision to establish Dr.RMLIMS as an
independent Medical Institute of excellence and its bylaws were worked out which envisaged
with a preamble that it will work on the analogous pattern of SGPGI in every respect. A
memorandum of understanding was worked out to implement the decision of the cabinet and the
Institute was registered under the Societies Registration Act 21, 1860 bearing the Registration
No. 1982, 2006–07, dated 4 November 2006. Thus, Dr. Ram Manohar Lohia Institute of
Medical Sciences came into being as an autonomous Medical Institute of U.P GOVERNMENT,
established on the line of Sanjay Gandhi postgraduate institute of technology. On 3 June 2006,
Govt. declared the Institute to be an independent society.

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 Infrastructure:
 Academic facilities:

 Lecture rooms- Available in admin block, planned in new academic blocks.

 Demo rooms- Available in admin block and hospital building.
 Common rooms- Available in admin blocks.
 Labs- Available
 Auditoriums- Available
 Library- Books available- 4158 , Journals(Indian + Foreign)- 58, Seating capacity- 50,
Librarian- Dr.P.P Rawat, Working hours- 9am - 5pm, also open on Sundays and holidays
from 9am - 2pm.
 Computer center-Available

 Residential facilities- Hostels, cafeterias and mess ( Under construction – 83 single rooms
for PGs and 26 double rooms for PGs )

 Recreation facilities- Indoor and outdoor (Badminton, gym and playground in new
academic block )

 Medical facilities for students and staff- Available at general and super specialty hospital
in campus.

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Services provided by the hospital:

1. Pathology: The Department of Pathology at RMLIMS has been planned as a complete

state of art investigation service and academic department. The Department of Pathology
was started in January 2011. The department has facilities for high end investigations not
available at most government hospitals in the state as well as the complete range of
routine tests. The department is focused to act as a cost effective referral service for the
benefit of residents of Uttar Pradesh and to avoid diagnostic difficulties for poor patients.

The Departments Pathology has been upgraded to ―State Referral Centre for Lab
Investigations (SRCLI)‖ as per Government Order No. 519/ 71- 2- 13- R M-9/ 2012
Dated 9 April 2013. The aim of the referral centre is to provide high end investigations at
low cost in government sector, with quality assurance and short turnaround time. Taking
care of our enrolled population in the best manner possible will enable the ―State
Referral Center For Lab Investigations‖ (SRCLI) at the Institute to meet the requirements
for efficient, effective, patient-centric health care.

Services Rendered:

 A wide range of laboratory investigations are available. The number and scope of
investigations was expanded.
 List of Investigations available at pathology department:

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 2. Radio diagnosis: The department of Radio diagnosis of Dr.RMLIMS was started in
March 2009. The department has state-of-the-art latest equipments consisting of digital
X-Ray machines, high end ultrasound equipments, computerized
mammography, BMD, Digital Fluoroscopy, MDCT and 3Tesla

MRI. High quality diagnostic work including imaging of heart & vessels is being
done in the department on all seven days of the week including holidays. Emergency services are
provided by the department upto 9pm for X-Rays, CT & MRI. Portable machines are available
for bed side X-Rays of the patients. Interventional procedures such as drainage, biopsy, PTBD &
PCN etc. are being done in the department. In near future the department will be acquiring C-
ARM & DSA for advanced interventional work. Efforts are also being made for acquiring Breast
Tomography machine. This will help in very early detection of breast cancer.

Facilities:

a. BMD
b. Computerized Radiography
c. Digital Radiography
d. DRF
e. MDCT- 64 Slice with PIGA arm
f. Mammography
g. MRI -3 Tesla
h. Portable X-Ray machines – 2 in number
i. Ultrasound- 3 in no.

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 3. Microbiology: The Department of Microbiology was inaugurated by Mr. Manjit Singh,
Principal Secretary, Medical Education on 9th October 2011.The department is located at
sixth floor, hospital building, Dr RMLIMS. The department had initially started
serological services in 2011, which gradually expanded to conventional as well as
automated state of art microbiological facilities.

Projected scope of activities:

 Bacteriology division:

a) Bacteriology lab has facilities for isolation and identification of various

pathogenic microbes and determining their antimicrobial susceptibility by conventional as well
as automated methods. It has automated continuous monitoring system of blood culture for
growth of aerobic bacteria and fungi. Automated culture method for anaerobic bacteria is also
available.

 Serology/Immunology division:

a) Serology lab has latex agglutination tests for ASO titers, CRP and Rheumatoid
factor. It also has serologis for syphilis, enteric fever, and leptospirosis. Procalcitonin
quantitative testing by VIDAS automated analyzer is also available as sepsis marker
measurement.

b) Immunology lab has ELISA testing for complete profile of Hepatitis A, B, C, and
E by manual as well as automated method. All markers of Hepatitis B are available i.e. HBe,
HBc, HBs. HIV testing is done according to NACO guidelines. Complete TORCH profile is also
present. Rapid testing for dengue Ag and Ab is also available.

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  Mycobateriology division (Tuberculosis laboratory):

Mycobateriology lab has state of art facilities. Conventional and Automated Culture
(MGIT 320) is done for pulmonary as well as extra pulmonary samples. Culture is identified by
tubercular from non tubercular mycobacterium. First /Second line anti-mycobacterium
susceptibility testing by MGIT automated method is done. LPA molecular testing for
identification of MDR patients is done in pulmonary samples. Real-time PCR for Tuberculosis is
done in any samples (except blood-not recommended)

 Mycology division:

Routine culture and identification of fungi and automated identification and

susceptibility testing of yeasts is available. Latex agglutination test for Cryptococcus neoformans
is done regularly.

 Parasitological division:

Identification of blood and enteric parasites is available. Rapid test for antigen
detection of Malaria and Microfilaria and ELISA for cysticercosis and Echinococcus spp are also
available. Automated Immunoassay analyzerBOD IncubatorsBiosafety Cabinet.

4. Anesthesiology: The department is providing specialized anesthesia care for

Neurosurgery, Urology, Onco-surgery, Plastic surgery, Gastro surgery and Interventional
Radiological Procedures. Four operation theatres function daily and all are equipped with
High-end Anesthesia Workstations (DRAGER Primus) with Ventilators, pulse ox meters,

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 hemodynamic monitoring systems and invasive monitoring facility. Post- operative pain
relief with continuous epidural or intravenous analgesia Pain Clinic is providing
following facilities for intractable chronic pain:

Chronic pain relief services for cancer pain patients with neurolytic blocks under
fluoroscopic guidance. Ozone Discectomy for low back pain patients under fluoroscopic
guidance. Epidural steroid injections for low back pain patients under fluoroscopic guidance.

 Equipments Available: ICU Ventilator ABG Machine

Department of Physical Medicine and Rehabilitation (PM&R): PM&R is a large

interdisciplinary team of doctors, nurses, occupational therapists, physiotherapists, speech
therapists, social workers, psychologist, prosthetists and orthotists. This team works together in
maximizing the health and functional abilities of people with disabilities. The department
provides outpatient and inpatient services for persons with physical/ neurological impairments
due to conditions such as:

a. Spinal Cord Injury

b. Brain Injury due to trauma and other causes Stroke
c. Developmental disorders such as cerebral palsy, spinal dysraphism
d. Amputations of the extremities
e. Rheumatologic conditions
f. Hemophilia
g. Neuromuscular disorders
h. Chronic pain

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Facilities:

a. Galvanic /Faradic Stimulation

b. Ultrasonic Therapy
c. Short wave Diathermy
d. TENS
e. Lumbar Traction
f. Cervical Traction
g. Hand exercises
h. Neurological Rehabilitation
i. Cardiac Rehabilitation
j. Surgical Rehabilitation

5. Dietetics: With advancement in the field of nutrition sciences, the daily needs of human
health and disease are now well established. The department of dietetics in hospital
formulates the most appropriate nutritional therapy for each patient. Patient are
being provided with nutrition education and hygienically prepared
high quality food services.

Objectives:

The main objectives of department of Dietetics are to provide:

 Clinical Services –Daily ward rounds are taken by the dietician and diet is prescribed and
implemented in consultation with the doctors. Individual diet counseling along with diet
chart is provided to indoor as well as outdoor patients

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 Meal Services-Meal services are provided to general as well as private wards patients. In
general ward tea and breakfast services are decentralized and Lunch and dinner are
centralized, whereas all meal services are centralized in private wards. The cost for
general diet is Rs.42/- per day and Rs.150/-per day for private ward patients.

 Training-The department of dietetics undertakes training of dietetics interns. Duration of

internship is 3 months. Eligibility- PG diploma in dietetics &nutrition Or M.Sc (Food &
Nutrition).

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 RESEARCH METHODOLOGY

Research is a common parlance which refers to search for knowledge. It is a procedure of

logical and systematic application of the fundamentals of science to the general and overall
questions of a study and scientific technique, which provide precise tools, specific procedures
and technical rather philosophical means for getting and ordering the data prior to their logical
analysis and manipulating different types of research design is available depending upon the
nature of research project, availability of manpower and circumstances.

According to D. Slesinger and M. Stephenson research may be defined as, The

manipulation of things, concepts and symbols for the purpose of generalizing to extend , correct
or verify knowledge, whether that knowledge aids in the construction of theory or in the practice
of an art‖. Thus it is original contribution to the existing stock of knowledge of making for its
advancement. The research methodology adopted for eliciting the data required for the study was
survey method. It is the overall pattern or framework of the project that will dictate as to what
information is to be collected, from which sources and by what procedure.

DATA COLLECTION: The information needed to further proceed in the project had been
collected through primary data and secondary data.

DATA SOURCE: There were two types of data sources used in

this research. These were:

 PRIMARY DATA: Primary data is the data collected for the first time from the source
and never had been used earlier. The data can be collected through interviews,
observations and questionnaires. In this project, an appropriate questionnaire was
designed which was filled by the customers of retail pharmacies and patients of Dr. Ram
manohar lohia institute of medical sciences to know their opinion on the services of in-
house pharmacy and retail pharmacy.

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SECONDARY DATA: Secondary data is the data collected from already been use or published
information like journals, diaries, books, etc. In this research project, secondary source used
were various journals and websites of various hospital pharmacies and retail pharmacies.

Various internet sites and blogs have been used to collect information about the
company. The Respondents are various customers of retail pharmacies and patients of the
hospital.

RESEARCH DESIGN:

A research design is the arrangement of conditions for collection and analysis of data
in a manner that aims to combine relevance to the purpose with economy in procedure, In fact,
the research design is the conceptual structure within which research is conducted. This research
was descriptive in nature.

DESCRIPTIVE RESEARCH:

The research undertaken was a descriptive research as it was concerned with specific
predictions, with narration of facts and characteristics concerning comparative study on in-house
pharmacy and retail pharmacy with special reference to Dr, Ram manohar lohia institute of
medical sciences.

SAMPLING DESIGN:

The following factors have been decided within the scope of sample design:

 Theoretical: It covered all the individuals who are the patients of Dr, Ram manohar lohia

25
 institute of medical sciences and customers of retail pharmacies.

 Accessible: It covered all the individuals who are the patients of Dr, Ram manohar lohia
institute of medical sciences and the customers of retail pharmacies who are within our
reach.

SAMPLE SIZE:

A sample of minimum respondents will be selected from various areas. An effort was
made to select respondents evenly. The survey will be carried out on 50 respondents.

SAMPLE TECHNIQUE:

For the purpose of research convenient sampling technique was used.

UNIVERSE OF STUDY:

Universe of the study means all the persons who are the patients of Dr. Ram
manohar lohia institute of medical sciences and the customers of the retail pharmacies.

TOOLS OF PRESENTATION:

It means what all tools are used to present the data in a meaningful way so that it
becomes easily understandable. In this research tables and graphs were used for presenting the
data.

STATISTICAL TOOLS TO BE USED:

A structured questionnaire is used to collect the data and the data will be analyzed
with the help of percentage table, respective graph, bar graph and pie charts.

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Descriptive statistics: Used to describe data like graphical display, cross-tabs or summary
statistics.

 Correlation: Used in market research to determine if different measure is related.

 Clustering: Used to group similar types of people together (segment the market) and then
profile the groups (define target segments).
 Regression: Model relationships between variables and predictive modeling or to understand
casual relationships.

The pharmacy should be easily located & identified by the public. Exterior of the
pharmacy should be maintained neat and clean. The façade should be clearly marked with the
word “PHARMACY” written in English as well as in the local language(s) of the area. As far as
possible, the pharmacy should be conveniently assessable to people using prams or wheel chairs
etc. pharmaceutical services and products should be served from an area which is separate from
the other activities/services and products. This facilitates the integrity & quality of products, and
minimizes the risk of dispensing errors.

The Pharmacist should be directly & easily accessible to public for information,
counseling, etc. Purpose:
(i) Patients may feel hesitant or uncomfortable to speak out his/her illness /about
his medicine to a pharmacist when he feels he could be overheard by others.
(ii) If the problem/query of the patient needs alone time (10 minutes or more), it
needs a place where a patient can sit at ease.
(iii) Demonstration of certain instruments,/diagnostic kits/self-usable devices (for
e.g. Training the patient on making an insulin injection, or demonstrating
with the help of charts or video would be better done in a secluded and
related place.

27
 The pharmacy environment should be clean with minimum dust and should be
maintained clean as per pharmacist cleaning schedules and SOPs. It should be free from rodents
and pests/ insects and pest control measures should be taken from time to time. The pharmacy
should have a constant supply of energy especially for the refrigerator(s). There should
preferably be a provision for drinking water to facilitate drug administration to the patients and
for use of the staff. The pharmacy should have a comfortable environment for ease/comfort of
clients and personnel. The pharmacy should have:

(i) Sufficient pace for clients to stand comfortably at the dispensing counter and
if possible for some to sit comfortably while they wait.
(ii) Space for patient information displays, including for information leaflets/
material.
(iii) A separate enclosure described as “counselling Area” for patient counselling,
storage of reference resources (e.g. books, internet access etc.) is a
fundamental requirement. Counselling area should be a place where patients
can talk freely with the pharmacist. It should be away from the area
otherwise normally accessed by the patients and should preferably be an
enclosure with a door which can be closed for further confidentiality. It
should be well lighted with comfortable seating for the Pharmacist and the
patient/attendant.
(iv) A compounding pharmacy should also have sufficient additional space for
making extemporaneous preparations, besides the necessary equipment for
doing so.
(v) Separate waste collection baskets/boxes should be available for the staff and
for the clients.

28
The products storage area should be protected from exposure to excessive light and heat.
Ambient temperature in the pharmacy should be maintained within the stipulated range to
prevent deterioration of various medicines stored at room temperature conditions.

Furniture and fixtures

The pharmacy should have neat, well placed shelves with provision for storage of medicines and
other items in a neat manner, protected from dust, moisture, excessive light. Adequate provisions
should be available for storing various medicines at prescribed temperature conditions. The
counseling area should be furnished with:

(i) A table.
(ii) Chair for the Pharmacist and a couple of patients
(iii) Cabinet for storing patient medication records (PMRs)

Equipment

The pharmacy should be equipped with refrigerated storage facilities (validated from time to
time) and should be available for products requiring storage at cold temperature. The counseling
area should be equipped with:

(i) Reference material

(ii) Demonstration charts, kits and other demonstration material.
(iii) Patient information leaflets (PILs) (iv)Some basic instruments for e.g.
Sphygmomanometer, glucometer, Snellens chart, stethoscope, etc.
(iv) Weight and height scale

The pharmacy should preferably be equipped with computers and appropriate software that can

1. Manage inventory

2. Manage invoicing

3. Generate timely warning for expiring medicines

29
4. Archive patient medication records

The computer should also be equipped to give demonstrations to the patients and other relevant
purposes. Compounding section of the pharmacy should be equipped as prescribed under
Schedule N to the Drugs and Cosmetics Rules. Other equipment, as necessary for operations,
should also be available.

Personnel

The Community Pharmacy should be managed under the overall supervision of a chief
pharmacist, who will have the final responsibility for all the professional activities and
operations. All staff members including newly recruited staff should be trained as per the staff
training policy of the pharmacy. All activities in the Pharmacy should be carried out as per well
documented guidelines and procedures, which should have been framed by the management in
consultation with the Chief Pharmacist.

Each staff member should have clearly allotted responsibilities, which must be
performed according to documented standard operating procedures. All personnel in the
pharmacy must, at all times, wear a neat apron/ coat. All Pharmacists should additionally wear a
badge prominently displaying their name and the word “Pharmacist”. Additionally, a recent
photograph, qualification certificate and the State Pharmacy Council Registration Certificate
may be displayed in clear view of the clients entering the pharmacy. Due to regular exposure to
patients some of whom may be carriers of contagious diseases all pharmacy personnel should
wear medically examined and adequately immunized periodically and their health data should be
archived.

Pharmacists working in the pharmacy should:

1. Hold at least a Diploma in Pharmacy and preferably a degree in Pharmacy.
2. Be registered as a pharmacist with the Pharmacy council of the state in which he/she
is practicing.
3. Have undergone adequate practical training in a community pharmacy.
4. Undergo in house training as per the organisation’s staff training policy.

30
 5. Have communication skills & capabilities to give adequate and proper advice to the
clients on the appropriate use of medicines, illness, etc. so as to achieve optimal patient
compliance.

Each Pharmacist working in the pharmacy must be competent enough to:

(i) Play a professional role to assess prescriptions.

(ii) Advise the patients on appropriate selection and use of OTC medicines.
(iii) Advise patients on appropriate use of prescribed medicines.
(iv) Check & advice on drug-drug and drug-food interactions.
(v) Be alert for adverse drug reactions.
(vi) Comprehend the client’s condition or illness and provide advice on proper use of
medication and diet.
(vii) Assess the patient’s condition and decide when to refer him/her to the doctor.
(viii) Perform the role of a health care provider and a counsellor.

Systems

The pharmacy should have well defined and documented systems for each operation carried out
in the pharmacy.

Quality Policy

It is a general declaration of the intent of the pharmacy about the level of quality of service and
products offered to the public. Quality goals emanate from the stated quality policy and they are
the targets, which are set and which can be in a stipulated period of time. Different quality goals
need to be set in the various operational areas of the pharmacy. It is the responsibility of the
Chief Pharmacist to formulate a Quality Policy and set and achieve Quality Goals along with the
management and other staff. The pharmacy should have a quality manual, which should state, in
detail, the necessary steps to be carried out for fulfillment of the desired quality goals. The
manual should also enlist the details of the activities, routines, distribution of responsibilities,
31
work procedures and instructions that are necessary for achieving the quality goals in day-to-day
operations in the pharmacy.

The Quality Manual should be accessible to the staff of the pharmacy for their easy reference.
All the activities mentioned in the Quality Manual should be well documented, and it shall be the
final responsibility of the Chief Pharmacist to ensure that the pharmacy quality goals are in
consonance with the quality policy of the pharmacy. The Chief Pharmacist should ensure that the
quality policy and quality goals are understood, implemented and maintained throughout the
operations in the pharmacy. Timely audits should be conducted to check the extent to which the
pharmacy meets its quality goals and the outcomes should be documented for a review to further
improve the process.

Service Policy

Service policy is a statement of the nature of services provided in the pharmacy and the standards
laid down for the provision of those services. The pharmacy should have a well-documented
service policy based on its client servicing goals. Service policy statement should include issues
like home delivery of products, the nature and level of attention to be given to clients of Various
kinds (e.g. elderly clients, regular clients, etc.). The service manual should state, in detail, the
necessary steps to be carried out for providing each service offered in the pharmacy. Promptness
of service, service time and pharmacy operation schedule, etc. form an important part of the
service policy. The manual should also enlist the details of the activities, routines, distribution of
responsibilities, work procedures and instructions that are necessary for provision of the services
in day to day operations of the pharmacy.

Staff Training Policy

A well-conceived and implemented staff training policy has the potential to determine the future
of the pharmacy in the community in which it operates. Availability of adequate reference
32
resources (books, current periodicals, software, etc.) in the pharmacy is the fundamental
requirement of the training process.

Training policy should encompass the needs evolving out of service policy of the
pharmacy. The policy should prescribe the content & frequency of the training and the training
resources. Training policy should ensure that all personnel in the pharmacy are kept abreast of
the developments in their fields. Upgrading communication and inter-personal skills should form
the core of the training policy so that pharmacy personnel can operate in tandem with other
healthcare providers on one end and are able to form professional bonds with the clients on the
other. Efforts should be made to involve professional representatives of pharmaceutical
companies in the trading process. The policy should prescribe the minimum continuing
education levels to be attained by each staff member so that the ultimate goal of pharmacy-
provision of Pharmaceutical Care – is achieved. All pharmacy personnel should be aware of
Quality Policy of the pharmacy, and should be conscious about their role of delivering health
care to the clients. They should be trained & made aware of minimal personal hygiene levels, as
well as the level of hygiene to be maintained in storage and handling of medicines.

Special emphasis should be laid on training

(i) Pharmacists: in communication & counselling skills, handling of

prescriptions & clients, continuing education in illnesses & drugs, latest
developments in the field of medicine and pharmacy and general health
matters, on “when to refer” to a doctor.
(ii) Pharmacy assistants: in communication skills, salesmanship, handling of
prescriptions, dispensing of drugs, procurement & storage of drugs, and
“when to refer” to a Pharmacist for counselling.

33
Procedures for imparting education/training should be well documented, and carried out as per a
predetermined schedule. Training process should be well documented and reviewed periodically.
Pharmacists should be encouraged to keep their knowledge up-to –date through scientific
literature, textbooks, journal and periodicals, workshops, etc. Networking with pharmacists in
other pharmacies should be encouraged. Management and the Chief Pharmacist shall be
responsible to continuously train the human resources available in the pharmacy to ensure
maximum benefits to the community.

Complaints policy

The pharmacy should have a complaints policy which should be reviewed from time to time. All
complaints-oral or written- must be immediately addressed by the pharmacist, and suitable action
be taken to amend the situation. The complaint, its nature, the erring person’s name and the
action taken must be documented in a complaint register. The event should be reviewed and
evaluated to find the underlying cause(s). Appropriate steps should be taken to amend the
operating procedures or other guidelines so as to prevent the recurrence of the same or similar
events.

Drug Recall Policy

The Pharmacist should have a well-documented recall policy:

(i) The pharmacy should proactively participate in any state wide or nationwide
recall process for any substandard drug. All such records should be initiated
upon receiving authentic information and alarms to do so. The initiation,
progress and completion of recall should be well documented. Adequate
vigilance must be maintained to look out for recall alarms from regulatory
sources as well as from pharmaceutical companies.
(ii) In case of any suspicion, the pharmacist should take immediate steps to stop
the sale of drug and notify the relevant parties.
(iii) If the pharmacist has a suspicion or a reason to believe that short comings
34
 have occurred in the process of delivery of medicines from the pharmacy,
immediate effective measures should be initiated to minimise the risk of
damage or danger to the patient(s).

Audit Policy

Audits are conducted to check whether the Quality Management Systems are functioning
properly, and as per guidelines set forth in the Quality Manual, to see whether the desired
objectives of the pharmacy are being achieved. By a Quality Audit, the Chief Pharmacist can
evaluate the different routine processes and the quality systems in the pharmacy, and check
whether the systems are functioning as per requirements. This is achieved by frequent internal
audit and a periodic external audit. Based on the audit reports, steps should be initiated to make
necessary improvements. The internal audit can be conducted by the chief pharmacist along with
the senior staff or members of the management team. The staff deployed for internal audit should
be adequately trained for the purpose. Audit may be carried out once in six months, or more
frequently. An external audit must be done at least once a year by external auditors, who are
competent to do so and are appointed by the management. All audit procedures should be
suitably documented. The audit report should be used to analyze the weaknesses and defects in
the system so that rectifications are initiated.

Documentation system

Documentation is one of the core activities for achieving and maintaining quality. The overall
responsibility for documentation rests with the chief pharmacist. All necessary statutory
documents (for e.g. regulatory licenses, registrations, permissions, etc.) for operating a pharmacy
must be adequately maintained and should be displayed if required under the law. In all cases
they should be easily accessible whenever required. All operational documents, for e.g., purchase
invoices, sales invoices, and other r statutory documents should be maintained and archived as
prescribed by the law. There should also be adequate control and maintenance of documents that
form a part of the pharmacist’s quality system. Some of the necessary documents include:

(i) Protocols

35
 (ii) Standard Working Procedures
(iii) Operation instructions
(iv) Quality Manual
(v) Cleaning and maintenance processes and records
(vi) Complaint records
(vii) Audit records (internal and external)
(viii) Policy documents
(ix) Personal details

In addition, the documents required for the pharmaceutical care process should also be
adequately maintained and stored. These documents include:

(i) Patients’ health profile

(ii) Patients’ medication records
(iii) Records of counselling follow-ups, etc.

Process guidelines

The pharmacy should develop and maintain a safe, effective operational and socio-economically
acceptable operation system. As far as possible, the chief pharmacist should ensure that
medicines and other health care products are readily available in the pharmacy in sufficient
quantities. The operational system should be socioeconomically effective so that the
pharmacists’ financial interests are maintained while providing optimal health and cost benefits
to the clients.

Procurement and inventory management

The pharmacist should ensure that the source of supply of medicines and other items meet the
standards laid down in the law. Where no regulatory standards have been prescribed the chief
pharmacist has the additional responsibility to protect the interest of clients and the pharmacy
from being cheated by substandard supplies. The chief pharmacist should satisfy himself about
the reliability and adequacy of the matches deployed by the vendor’s chain to ensure that all
products have been handled in appropriate storage and transit conditions. Details of the vendors

36
(for e.g. their addresses, contact numbers, names and addresses of their management persons,
technical persons and administrative staff, copies of various licenses held by them should be
maintained).

A written communication regarding the list of authorized representatives of the vendors and their
specimen signatures should be maintained and archived. Responsible designated person(s) from
the pharmacy should visit the vendor’s premises from time to time for conducting audit of their
premises and systems to the extent they are likely to affect the quality of the products. Errors
made by the vendors should be brought to the notice as soon as possible and get rectified. All
errors made by the vendors, nature of errors, repetition of the same errors, method and time
frame of rectification should be documented and reviewed periodically to prevent their
recurrence

The chief pharmacist may consider informing the regulatory authorities in case there are
reasons to believe deliberate, dubious activities by the vendors(s). It is important to store
products manufactured by reputed companies. The pharmacist should maintain a ‘products list’
where all items ‘approved’ by the pharmacy for stocking are described. This will discourage the
non-approved and low quality medicine vendor, who may otherwise try to sell drugs, which may
not be of standard quality and/or those which do not have a proven safety profile.

This list may be reviewed and updated as often as necessary. Any new items added to
the inventory must be first included in the list after a professional review by the chief pharmacist.
Where the pharmacy operations are managed using computers the item must first be entered into
the database and then ordered for procurement. Ideally, the product lists also specify the location
of that product in the pharmacy. Adequate cost – effective purchasing methods should be
followed which ensures adequate inventories leading to optimal financial gain for the pharmacy.
In-house benchmarks for various categories of products should be set for minimum-remaining -
shelf –life at the time of procurement. All products received from vendors should be tallied
against their invoice and checked for correctness of quality, price, batch number and expiry date.
Any anomalies should be brought to the notice of the supplier /s and suitable rectification got
done. All such rectification should be documented and got authenticated by an authorized

37
representative of the vendor. The purchase records/invoices should be maintained as stipulated
under the law.

Storage management

A products coming into the pharmacy should initially be quarantined, preferably in the separate
area, before they are checked for correctness of quality, batch number, expiry, integrity, etc. after
necessary, checks, they should be transferred to their respective storage location. All drugs
should be stored at stipulated temperature areas, protected from excessive light, dust, and
humidity. Temperature at various areas should be recorded at predetermined periodicity and
daily records should be preserved for a period of 2 years. They may be correlated with the
subsequent years’ corresponding data to improve arrangements for maintenance of temperatures.
The medicines and shelves should be maintained clean and dust free at all times by following
cleaning schedules and SOPs. Prescription drugs should be maintained be kept in such a manner
that they are out of reach of clients. All the drugs that are to be stored in a ‘cold’ temperature
should be kept in the refrigerator unless the ambient temperature in the area is cold enough. Drug
and dosage form that special care while dispensing (e.g. drugs specified under the schedule X,
Narcotic drug and Psychotropic Substances Act and some other CNS drug etc.) should be kept
under lock and key. The key for this should be available only with the Pharmacist in-charge at
the time. Records of purchase and sales of such medicines should be kept as per legal
requirement.

Shelves should be checked at a predetermined periodicity to ensure removal of drugs whose

expiry date is approaching. In-house threshold period should be set and followed foe such
retrieval of drugs from the shelves. The near expiry products should be stored separately and
disposed of either by returning to the respective vendors or by expending their dispensing.
Drugs, which have already expired, should be stored separately in a locked shelf. Bearing the
label “Expired Goods Not For Sale”. Care should be taken that such goods do not reach the client
in any case. Expired drugs should be returned to the supplier or destroyed as per in-house
procedure at the earliest.

38
Drug Information Services Division

 Provide drug information on drugs and drug therapy to doctors, nurses, medical
and nursing students and the house staff.
 Maintain the drug information center.
 Prepare the hospital's pharmacy newsletter.
 Maintain literature files.

Purchasing and Inventory Control Division

 Maintain drug inventory control.

 Purchase all drugs.
 Receive, store and distribute drugs.
 Interview medical service representatives.

39
 DATA ANALYSIS

The data analysis is the process of inspecting, cleansing, transforming and modeling data
with the goal of discovering a useful information, suggesting conclusions and supportive
decision making.

Here are some of the questions which are asked to the consumers and patients of the in-
house pharmacies and retail pharmacies in order to analyze their effectiveness, efficiency and
usefulness of the pharmacies for its user regarding its services and benefits. When designing a
retail pharmacy program at an organization with a PSP, a key consideration is the level of
participation in the retail pharmacy program. For example, providers may choose to develop
outpatient pharmacy services including retail operations, home infusion services, and specialty
pharmacy programs, among others.

These pharmacy services may be patient centric or employee-centric, and can involve a
full or partial partnership with an existing third party commercial pharmacy chain. An
independent closed-door retail pharmacy can be on-site, mail order, or a combination of the two.
While prescription capture volumes may vary depending on whether the provider opts for retail
or specialty pharmacy, there are financial incentives related to all approaches. Insights and
analytics Throughout the health care value chain there are three key transaction points that drive
the total cost of drug delivery:

• Acquisition cost—the cost for the pharmacy to purchase the drug from a distributor or
manufacturer

• Insurance/Health Plan Payment—Health plan (PSP or otherwise) pre-defined payment

to the pharmacy to cover a portion of the drug cost

• Patient co-pay—the patient’s remaining financial responsibility By utilizing an in-house

(either on-site or mail order) retail pharmacy, a health system can achieve cost savings on each
driver:

40
 • Decrease acquisition cost by leveraging existing distribution and manufacturer contracts
and reducing/ eliminating any third-party commercial pharmacy markups

• Retain income when patients fill prescriptions, since the PSP insurance payment to the
pharmacy for the cost of the prescription is kept within the same health system and parent
company

• Provide financial benefit to patients and the community through improved access and
reduced copays for each drug

In summary, the overall cost of a prescription can be lowered by leveraging an in-house

retail pharmacy in more ways than one. Figure outlines the specific price levers that can be
reduced through this mechanism by displaying two different scenarios: the first when a drug is
procured from a third-party commercial pharmacy, and the second when a drug is procured from
an in-house retail pharmacy.

In the scenario involving the in-house retail pharmacy, the total prescription cost is
approximately 25% lower than the cost in a third-party commercial pharmacy transaction. As
illustrated in Figure 1, the total cost of a prescription drops from $200 to $250 (for $50 in
savings) when utilizing an in-house retail pharmacy. In this scenario, if the health system is able
to reduce the co-pay ($10 vs. $20) when utilizing the in-house pharmacy, lower the insurance
payment from the PSP to the pharmacy (all within the same system) and negotiate for better
acquisition costs ($137 vs. $150), the health system can drive a significant discount on overall
prescription procurement costs.

41
 Figure: Total cost of prescription

Through the Health Resources and Services Administration (HRSA) 340B Drug Pricing
Program, drug manufacturers are required to provide outpatient drugs to eligible health care
organizations or covered entities at significantly reduced prices. If health systems qualify for
340B (with carefully controlled processes and appropriate systems to meet HRSA’s patient
eligibility criteria), providers can acquire drugs at a discount as compared to third-party
commercial pharmacies and can capture additional savings by shifting plan members to in-house
pharmacies.

As illustrated in Figure, a 340B eligible provider’s cost of procuring a drug is displayed

in two different scenarios: the first when a drug is procured from a third-party commercial
pharmacy, and the second when a drug is procured from an in-house retail pharmacy. By
leveraging an in-house pharmacy, providers can leverage 340B regulations to drive down the
drug’s acquisition cost and the overall prescription cost. In a 340B eligible scenario, the in-house

42
retail pharmacy prescription cost is approximately 50% lower than the same cost in a third-party
commercial pharmacy transaction.

Figure: Total cost of a prescription— 340B eligible provider

On-site retail pharmacies can also enable robust transformation of the patient (customer)
health care journey, increase patient satisfaction, and drive better qualitative outcomes:

• Filling prescriptions on-site can be more convenient for patients who seek a more
efficient discharge process rather than filling prescriptions at an off-site location, thereby
streamlining a patient’s health care pathway and improving overall experience.

• By re-structuring patient co-pays, health systems can reduce cost barriers and improve
access to drugs.

• By having transparency for when prescriptions are filled, physicians and care managers
have the potential to improve medication adherence by implementing medication therapy
management programs, which in turn can positively impact outcomes and reduce readmissions3.

43
 • As a result of direct access to a patients’ electronic health record, an in-sourced
pharmacy enhances health care data integration. As evidenced by successful Pharmacy Benefit
Managers at health systems such as Lifespan in Rhode Island4 and the Cleveland Clinic5, a
patient’s entire medical team operates based off the same set of medical information and
streamlines communication across the care continuum.

Key considerations

Provider executives looking to in-source retail pharmacy should consider:

• Are space and resources available?

• How do we currently track prescriptions paid to third party commercial pharmacies?
• Can we quantify the opportunity by drug and plan member?
• Can existing technology be optimized to support new volume?
• How should we establish and implement a targeted co-pay structure?
• Are there contracting opportunities for better pricing to further reduce acquisition cost?
• How can data and analytics be assimilated to continue identifying areas of opportunity?
• How can data and analytics drive predictive modeling in areas outside of pharmacy?

Patients are being forced to buy

high-priced drugs and medical
devices from hospital pharmacies.
With hospitals increasingly
operating as for-profi t businesses,
44
these pharmacies are an
important revenue source for
hospitals. In essence, the in-house
pharmacy is a spatial monopoly
within the premises of the
hospital with the patients obliged
to buy f rom it at prices dictated by
the management.

P atients are being forced to buy

high-priced drugs, medical devi-

ce s, e tc, from hospital phar mac ies
(Nagarajan 2016; Shrivastav 2015). This
is because patients are in a relatively
weaker position compared to
hospitals.
45
There are two main reasons for this:
fi rst, for decisions regarding their health,
patients are dependent on hospital-
employed doctors; and second, some-
times patients are brought in a life-and-
death situation to hospitals and require
immediate access to drugs and medical
devices. In addition, the nearest—and
sometimes the only—drugstore availa-
ble to patients is the in-house hospital
pharmacy. Due to these factors, hospital
pharmacies have a spatial monopoly on
drugs and medical devices (Centad 2010).
Moreover, hospitals can not only over-
charge and force patients to buy prod-
ucts at their pharmacies, but can also
negotiate with drug and medical device
manufacturers to get lower purchasing
prices. This is because hospitals buy
these products in bulk, which in turn
46
gives them more bargaining power. The
competition bet ween sellers to woo
these bulk buyers also works in the
hospital’s favour.
In this article, we fi rst explore over-
charging at hospital pharmacies and
then examine the methods they use to
get lower purchasing prices from manu-
facturers. We conclude with an exami-
nation of the ethical implications of
such practices.
Higher Selling Prices
Since these pharmacies enjoy a spatial
monopoly, setting a price higher than
that charged in outside stores becomes
very easy. There have been many situa-
tions where this phenomenon has been
recorded.
For example, a case wa s brought against
Fortis Escorts Hospital, Jaipur, in the
47
District Forum for forcing a patient to
buy overpriced drugs from the hospital
pharmacy. The case was then taken
to the state commission, Rajasthan (Gai
2016). The patient had been admitted
to the intensive care unit (ICU) of the
hospital. She had to be given fi ve injec-
tions, each of which cost `18,990 in the
hospital pharmacy. But the same injec-
tion was available at a price 30%–40%
lower in other shops outside the hospi-
tal. However, the hospital
f o r ced the
patient to buy them from the hospital
pharmacy. The District Forum fi ned the
hospital `2 lakh (Gai 2016).
Similar complaints of overcharging
patients have been fi led in the case of
medical devices too. In a complaint
regarding cardiac stents, the patient
48
stated that they were
forced to buy
the stent from the hospital itself, though
the hospital price for the stent was
`95,000, whereas it was available at
`27,000 from the distributor (Bedi
2016). Requests to
either reduce the
price or to allow the patient to buy
from the distributor were rejected by
the hospital. Hospitals fi nd it particu-
larly easy to overcharge for medical
devices, since they are the only ones
who use these devices, which gives them
a monopolistic position (Bedi 2016). Both
the above cases clearly show how hospi-
tals use their position to overcharge
helpless patients and force them to buy
overpriced drugs.
Another complaint of overcharging
49
was registered against Max Hospital,
Delhi (Nagarajan 2016). The complain-
ant had bought an “Emerald” brand dis-
posable syringe from the hospital phar-
macy for `19.5. Disposable sy ringes from
the same brand were available at `10
from other shops against the printed
maximum retail price (MRP) of `11.5.
The syringe available in the hospital
pharmacy had `19.5 printed on it as
its
MRP (Nagarajan 2016). The
Competition
Commission of India (CCI) has recom-
mended further investigation. The com-
plaint pointed to a possible collusion or
an agreement between the hospital and
the (drug) manufacturer, who printed
the higher MRP o n t h e s y r i n g e .
Such
50
kinds of agreements were also alleged in
the cardiac stents case, between distri-
butors and hospitals.
Patients are being forced to buy
high-priced drugs and medical
devices from hospital pharmacies.
With hospitals increasingly
operating as for-profi t businesses,
these pharmacies are an
important revenue source for
hospitals. In essence, the in-house
pharmacy is a spatial monopoly
within the premises of the
hospital with the patients obliged
to buy f rom it at prices dictated by
the management.

51
P atients are being forced to buy

high-priced drugs, medical devi-

ce s, e tc, from hospital phar mac ies
(Nagarajan 2016; Shrivastav 2015). This
is because patients are in a relatively
weaker position compared to
hospitals.
There are two main reasons for this:
fi rst, for decisions regarding their health,
patients are dependent on hospital-
employed doctors; and second, some-
times patients are brought in a life-and-
death situation to hospitals and require
immediate access to drugs and medical
devices. In addition, the nearest—and
sometimes the only—drugstore availa-
ble to patients is the in-house hospital
52
pharmacy. Due to these factors, hospital
pharmacies have a spatial monopoly on
drugs and medical devices (Centad 2010).
Moreover, hospitals can not only over-
charge and force patients to buy prod-
ucts at their pharmacies, but can also
negotiate with drug and medical device
manufacturers to get lower purchasing
prices. This is because hospitals buy
these products in bulk, which in turn
gives them more bargaining power. The
competition bet ween sellers to woo
these bulk buyers also works in the
hospital’s favour.
In this article, we fi rst explore over-
charging at hospital pharmacies and
then examine the methods they use to
get lower purchasing prices from manu-
facturers. We conclude with an exami-
nation of the ethical implications of
53
such practices.
Higher Selling Prices
Since these pharmacies enjoy a spatial
monopoly, setting a price higher than
that charged in outside stores becomes
very easy. There have been many situa-
tions where this phenomenon has been
recorded.
For example, a case wa s brought against
Fortis Escorts Hospital, Jaipur, in the
District Forum for forcing a patient to
buy overpriced drugs from the hospital
pharmacy. The case was then taken
to the state commission, Rajasthan (Gai
2016). The patient had been admitted
to the intensive care unit (ICU) of the
hospital. She had to be given fi ve injec-
tions, each of which cost `18,990 in the
hospital pharmacy. But the same injec-
tion was available at a price 30%–40%
54
lower in other shops outside the hospi-
tal. However, the hospital
f o r ced the
patient to buy them from the hospital
pharmacy. The District Forum fi ned the
hospital `2 lakh (Gai 2016).
Similar complaints of overcharging
patients have been fi led in the case of
medical devices too. In a complaint
regarding cardiac stents, the patient
stated that they were
forced to buy
the stent from the hospital itself, though
the hospital price for the stent was
`95,000, whereas it was available at
`27,000 from the distributor (Bedi
2016). Requests to
either reduce the
price or to allow the patient to buy
from the distributor were rejected by
55
the hospital. Hospitals fi nd it particu-
larly easy to overcharge for medical
devices, since they are the only ones
who use these devices, which gives them
a monopolistic position (Bedi 2016). Both
the above cases clearly show how hospi-
tals use their position to overcharge
helpless patients and force them to buy
overpriced drugs.
Another complaint of overcharging
was registered against Max Hospital,
Delhi (Nagarajan 2016). The complain-
ant had bought an “Emerald” brand dis-
posable syringe from the hospital phar-
macy for `19.5. Disposable sy ringes from
the same brand were available at `10
from other shops against the printed
maximum retail price (MRP) of `11.5.
The syringe available in the hospital

56
pharmacy had `19.5 printed on it as
its
MRP (Nagarajan 2016). The
Competition
Commission of India (CCI) has recom-
mended further investigation. The com-
plaint pointed to a possible collusion or
an agreement between the hospital and
the (drug) manufacturer, who printed
the higher MRP o n t h e s y r i n g e .
Such
kinds of agreements were also alleged in
the cardiac stents case, between distri-
butors and hospitals.
Patients are being forced
to buy
high-priced drugs and
medical 57
devices from hospital
pharmacies.
With hospitals
increasingly
operating as for-profi t
businesses,
these pharmacies are an
important revenue
source for
hospitals. In essence, the
in-house
58
pharmacy is a spatial
monopoly
within the premises of
the
hospital with the
patients obliged
to buy f rom it at prices
dictated by
the management.
Patients are being forced
to buy
59
high-priced drugs and
medical
devices from hospital
pharmacies.
With hospitals
increasingly
operating as for-profi t
businesses,
these pharmacies are an
important revenue
source for
60
hospitals. In essence, the
in-house
pharmacy is a spatial
monopoly
within the premises of
the
hospital with the
patients obliged
to buy f rom it at prices
dictated by
the management.
Patients are being forced to buy high-priced drugs and medical devices from hospital
pharmacies. With hospitals increasingly operating as for-profi t businesses, these pharmacies are
an important revenue source for hospitals. In essence, the in-house pharmacy is a spatial
61
monopoly within the premises of the hospital with the patients obliged to buy from it at prices
dictated by the management.

62
The data which is collected are represented in the form of a pie chart that clearly signifies the
response of the consumers and patients about the different aspects of the pharmacies and its
services.

63
Analysis regarding in-house pharmacies:

Patients are being forced to buy high-priced drugs, medical devices, etc, from
hospital pharmacies (Nagarajan 2016; Shrivastav 2015). This is because patients are in a
relatively weaker position compared to hospitals. There are two main reasons for this: first,
for decisions regarding their health, patients are dependent on hospital employed doctors;
and second, sometimes patients are brought in a life-anddeath situation to hospitals and
require immediate access to drugs and medical devices. In addition, the nearest—and
sometimes the only—drugstore available to patients is the in-house hospital pharmacy.

Due to these factors, hospital pharmacies have a spatial monopoly on drugs and
medical devices (Centad 2010). Moreover, hospitals can not only overcharge and force
patients to buy products at their pharmacies, but can also negotiate with drug and medical
device manufacturers to get lower purchasing prices. This is because hospitals buy these
products in bulk, which in turn gives them more bargaining power. The competition
between sellers to woo these bulk buyers also works in the hospital’s favour. In this article,
we fi rst explore overcharging at hospital pharmacies and then examine the methods they

64
use to get lower purchasing prices from manufacturers. We conclude with an examination
of the ethical implications of such practices.

Higher Selling Prices

Since these pharmacies enjoy a spatial monopoly, setting a price higher than that
charged in outside stores becomes very easy. There have been many situations where this
phenomenon has been recorded. For example, a case was brought against Fortis Escorts
Hospital, Jaipur, in the District Forum for forcing a patient to buy overpriced drugs from
the hospital pharmacy. The case was then taken to the state commission, Rajasthan (Gai
2016). The patient had been admitted to the intensive care unit (ICU) of the hospital. She
had to be given fi ve injections, each of which cost `18,990 in the hospital pharmacy. But
the same injection was available at a price 30%–40% lower in other shops outside the
hospital. However, the hospital for ced the patient to buy them from the hospital pharmacy.
The District Forum fi ned the hospital `2 lakh (Gai 2016). Similar complaints of
overcharging patients have been fi led in the case of medical devices too.

65
 In a complaint regarding cardiac stents, the patient stated that they were forced to
buy the stent from the hospital itself, though the hospital price for the stent was `95,000,
whereas it was available at `27,000 from the distributor (Bedi 2016). Requests to either
reduce the price or to allow the patient to buy from the distributor were rejected by the
hospital. Hospitals fi nd it particularly easy to overcharge for medical devices, since they
are the only ones who use these devices, which gives them a monopolistic position (Bedi
2016). Both the above cases clearly show how hospitals use their position to overcharge
helpless patients and force them to buy overpriced drugs.

Another complaint of overcharging was registered against Max Hospital, Delhi

(Nagarajan 2016). The complainant had bought an “Emerald” brand disposable syringe
from the hospital pharmacy for `19.5. Disposable syringes from the same brand were
available at `10 from other shops against the printed maximum retail price (MRP) of `11.5.
The syringe available in the hospital pharmacy had `19.5 printed on it as its MRP
(Nagarajan 2016). The Competition Commission of India (CCI) has recommended further
investigation. The complaint pointed to a possible collusion or an agreement between the

66
hospital and the (drug) manufacturer, who printed the higher MRP on the syringe. Such
kinds of agreements were also alleged in the cardiac stents case, between distributors and
hospitals

Lower Purchasing Prices

As mentioned above, the hospital’s ability to buy in bulk and the competition
between sellers to woo these big buyers, works in the hospital’s favour. Hospitals often use
these factors to their advantage during the tendering process. This process of acquiring
drugs through tenders has been followed under the “Delhi Model” in Delhi.1 In the “Delhi
Model,”2 drugs are procured for multiple hospitals and health centres through a central
agency. A study by Roy Chaudhury et al (2005) found that drug procurement costs under
the Delhi Model were lower than the corresponding costs from government retail outlets
(Super Bazar, henceforth SB). The average difference in procurement costs between the
Delhi Model and SB was 248%, with the minimum being 135% (for ranitidine 150 mg
injection) and the maximum being 728% (for diazapem injection).

67
 This example, though not linked with private hospitals (and their pharmacies),
illustrates the power of institutional buyers (especially hospital chains, if buying centrally)
to negotiate and get lower prices for drugs and medical devices. Similarly, individual
hospitals also have this bargaining power, but to a lesser degree, and this is reflected in the
prices they pay. Roy Chaudhury et al (2005) also list the procurement costs of drugs when
purchased through open tenders (OT) by individual government hospitals.

Based on the author’s calculations, procurements costs in the case of OTs were on
an average 72% lower than the costs incurred while procuring from SB, which was 248%
lesser than the costs incurred under the Delhi Model. Compared to drugs, in the case of
medical devices, hospitals have more bargaining power as they are the only users and
sellers. They use their monopolistic position to get lower prices, which is reflected in the
differences in the prices offered by hospitals and distributors. Like in the complaint
regarding cardiac stents, the difference between distributor (`27,000) and hospital prices
(`95,000) was `68,000 (Bedi 2016), which is more than 250% of what the distributor
offered to the patient. In fact, hospitals’ margins in stents can go up to 654% while
distributors’ margins go up by 200% only (Nagarajan 2017). The biggest jump in stent
prices seems to happen at the hospital level.

68
 Hospital Pharmacies as Retail House

From the previous sections, it is possible to conclude that hospitals get drugs
and medical devices at a lower price from manufacturers (as shown in the Delhi Model and
stent cases) and then sell them at a high price to patients (as shown in complaints by
patients to consumer forums, etc). This in turn gives them big margins. This seems to be
becoming an additional stream of revenue for hospitals. A Centad report on the Indian
pharmaceutical industry also reiterated this conclusion (2010: 70). The pharmacy
department is said to contribute more than 30% to hospital revenues with profit margins
going up to 25%–30% for drugs3 and medical devices (Shukla 2009). In essence, these
pharmacies have transformed into in-house retail for hospitals.

69
 However, this retail pharmacy behaves more like a house located inside an
airport or a multiplex. The complaint regarding syringes being sold at the hospital at the
higher MRP printed on them parallels a similar situation where water bottles are sold in
airports or multiplexes by shops on the premises at higher MRPs (Niyogi 2014). Here,
hospitals can be compared to the airport or multiplex; hospital pharmacies the shops on
their premises; the drugs and medical devices can be compared to the things being sold in
those shops (water bottles, etc); and the patients can be compared to the passengers or
customers visiting the airport or multiplex.

Here, patients, like passengers, become a captive audience. This transformation

not only reduces patients to passengers or customers, but also removes all the urgency
associated with the life-anddeath situation of a patient. This urgent situation rather
becomes a characteristic of the helpless customer, which is to be ultimately exploited by
the seller. It also reduces the importance of life-saving drugs and medical devices to mere
products being sold in any retail shop. In addition, the decision to purchase is made by the
doctor, who in turn is also a hospital employee. So, hospitals not only have a retail shop,
but also have several purchase decision-makers on their payroll.

70
 It has also been reported that many hospitals maintain a tight control over their
employees, with corporates and big hospitals taking the lead (IMS 2014). Prescription
tracking, penalising doctors for non-compliance (IMS 2014), and instructing nurses to
refuse products bought from outside pharmacies (Shrivastav 2015) are some of the tools
used by these hospitals to control staff. Here, doctors and medical staff act like the
retailer’s employed (and controlled) salesforce recommending use of the retailer’s products
only.

Goal of pharmacy

Just as any organization must have long-range goals toward which its daily
activities are directed, so must a profession, its members, and their representative societies.

For example the American Society of Hospital Pharmacists, in its Constitution and
Bylaws, sets forth the following objectives:

1. To provide the benefits of a qualified hospital pharmacist to patients and health

care institutions, to the allied health professions, and to the profession of pharmacy.

71
 2. To assist in providing an adequate supply of such qualified hospital pharmacists.

3. To assure a high quality of professional practice through the establishment and

maintenance of standards of professional ethics, education, and attainments and through
the promotion of economic welfare.

4. To promote research in hospital pharmacy practices and in the pharmaceutical

sciences in general.

5. To disseminate pharmaceutical knowledge by providing for interchange of information

among hospital pharmacists and with members of allied specialties and professions.

More broadly, the Society's primary purpose is the advancement of rational, patient-oriented
drug therapy in hospitals and other organized health care settings.

To the preceding can be added the following objectives:

1. To expand and strengthen institutional pharmacists' abilities to:

 Effectively manage an organized pharmaceutical service.

 Develop and provide clinical services.
 Conduct and participate in clinical and pharmaceutical research
 Conduct and participate in educational programs for health practitioners, students, and
the public.

2. To increase the knowledge and understanding of contemporary institutional pharmacy

practice by the public, government, pharmaceutical industry, and other health care
professionals.

72
3. To promote compensation and benefits commensurate with pharmacists responsibilities
and contributions to patient care.

4. To help provide an adequate supply of qualified supportive personnel for institutional

pharmacy services.

5. To help ensure that health care reimbursement and payment systems do not inhibit the
implementation of innovative pharmaceutical services or adversely reflect on institutional
pharmacy practice.

6. To assist in the development and advancement of the pharmacy profession. The

foregoing serves as a collective statement of goals of the Society and its constituency.
Transforming these goals into realities will require the dedicated efforts of all
institutional pharmacists, both as individuals and as members of the Society

73
 FINDINGS, SUGGESTIONS AND RECOMMENDATIONS

The findings for the data interpreted are as follows:

 Not every retail pharmacy provides the customers with professional services.

 Not all the retail pharmacies provide information about the new medicines because many
pharmacists mainly focus on selling the medicines instead of making the customers aware about
its benefits and side effects too.

 There are many pharmacies that are doing home delivery of the medicines in order to make their
sales high and also for consumer convenience.

 More number of retail pharmacies are very clean and hygienic but there are also some of the
pharmacies mainly in rural areas which are not up to the mark.

 Retail pharmacies are somewhat lack in the availability of in-stock medicines as per the needs of
the consumers.

 Services experienced by the patients in the hospital pharmacies or in-house pharmacies are not
appropriate, as in government and public hospitals it is average but in private hospitals it is good.

 The cleanliness of the in-house pharmacies is very good but in pharmacies located in remote
areas it is average.

74
 In-house pharmacies which have their own members for serving the patients had a good response
by their patients but the hospitals having lack of staff results in poor service to the patients
regarding any information about the medicines or its dosage.

 In in-house pharmacies the staff members comparatively provides good services as compared to
the retail services due to more number of staff in the hospitals, which saves the time of the
patients and chances for delay is also very less.

 The patients of the in-house pharmacies are more liable to get satisfied as compared to the retail
pharmacies.

The Suggestions and Recommendations are as follows:

To deliver high-quality patient-centered care, hospital and pharmacy leaders

need to maximize the efficiency of their pharmacy operations in support of overall hospital
initiatives and goals.

 Pharmacy staff must be involved in supporting critical strategic mandates:

Such as reduction of unnecessary readmissions and extension of the continuum

of care. Specific areas of focus include integration of pharmacists into care transitions,
improvement of post- discharge medication adherence, and provision of clinical pharmacy
services in ambulatory care environments.

75
  Pharmacists and technicians need to practice at the top of their licenses and/or
certifications:

To provide the greatest possible value. Efficiency will not be optimized if

pharmacists perform tasks that could be accomplished by technicians or if technicians spend time
on work that could be automated.

 Pharmacies need to adopt appropriate levels of automation: So that staff can focus on
the highest-priority clinical initiatives.

Some of the recommendations for the pharmacists are as follows:

 Make use of time.

 Strategically position the products.

 Be proactive.

 Use pharmacist‘s knowledge.

 Create a most recommended display.

 Use resources from partners.

76
 LIMITATIONS

Some of the limitations are as follows:

The major limitation of qualitative research is that fewer people are studied. These
are several consequences; for example, the results are unlikely to be representative of a particular
population making it impossible to generalize. This means that the results can be difficult to
directly compare or generalize to other people/patient types; other settings or other findings.
Because the results are often unique to the relatively few people included in the study.

Qualitative research is totally dependent on the skills of the researcher, particularly

when conducting individual interviews, focus groups and observations. There is always the
danger that the research can easily influenced by the researcher‘s personal biases idiosyncrasies.

With regard to resources qualitative studies are time- consuming and labor intensive-
in terms of both data collection and data analysis.

Critics say that qualitative research has lower credibility with many administrators
and policy makers, who often prefer statistics, tables and percentages.

77
 CONCLUSION

The retail as well as in-house pharmacies is very different from each other. As they
are having more number of dissimilarities based on their servicer, behavior and customer or
patient relationship.

Through this study we come to know about the different functions and aspects of the
pharmacies both in-house and retail. It shows how both the pharmacies are beneficial for the
patients in different ways regarding the convenience of them. It also renders about the services
provided by the pharmacies to the consumers. How they are useful for them and in what aspect
they are better than each other.

It also complies about the customer satisfaction for the medicines, about the behavior
of the staff of pharmacies and their relationship with their customers.

78
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