QCC Activity

Reducing the unconsumed prescribed

diabetic pill waste
By MINI HEART Group
Out Patient Department
Thailand Tobacco Monopoly Hospital
1
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Institutional Introduction

2
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1.General Information
1.1 MINI HEART Members
Team Head

Miss Sarinpas Siritanapirom Miss Mutita Paichayon Miss Pramualrat Boonnau Miss Surapa Pattanasin
Secretary
Education : Bachelor Degree in Nursing
Average Age : 47 years old
Average of employment duration : 20 years old
QCC experience : 1 Topic
MissJumnearn Sastravisut
Miss Nonkluk Kaewna

Group Slogan: Together we can

Group Adviser

Group Symbol*
Mr.Sutham Setthawong
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1.2 Institutional Responsibilities and Missions
To provide medical services, health promotion and awareness
Working procedures consist of 6 steps:
6.Giving advice –
dispense medicine
1. History
by a pharmacist
interview/screening

2.Symptom and sign 5.Consultation –

evaluation Discharging

3.Recording 4.Seeing the doctor,

receiving a medical
checkup and treatment,
make a prescription
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2. Problem Investigation
The Table shows the 12 rank orders of the information of risks, institutional indicators and problematic phenomena in the
management process which gained the most frequency and caused the highest worth of damage as a result of following 6
procedural steps enforced for 12-month period from September 2015 – August 2016
Procedures Problems
Step1. 1.assigning to a wrong clinic
Patient interview and triage 2.slow triage process
3.interview a wrong patient
Step2. 4.A patient’s symptom got worse while waiting for the
Symptom evaluation and measuring the vital sign checkup
Step3. 5.incomplete patient information
Interview recording / follow up the result from the 6.incomplete medical results
laboratory / x-ray
Step4. Seeing the doctor/medical treatments & dispensation 7. a mismatch between a patient and the patient’s card
Step5. 8.make an error of appointment information
Giving advice/health education/discharging 9.unable to track the postponement of an appointment
10.Invalid patient information

Step6. 11.A mismatch between a patient’s name and medicine

Giving advice and dispense medicine by a pharmacist sticker
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The chart shows the frequency of an issue [time(s)/a year]

issues
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Evaluate the negative outcomes and worth of damage of issues
worth(baht)

Pareto chart showing the value of the losses

Problem

3 issues that cause the highest loss (worth of 93%damage) are

selected and taken into account
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3. Issue Selection
Issue1. patients return leftover pills Waste
869,500 baht/a year
Outcome: destroy the leftover
pills by burning

Issue2. unable to track the

postponement of appointments
Waste
Outcome: waste time and expenses
200,653 baht/a year

Issue3. patients’ symptom got

worse while receiving medical services Waste
Outcome: waste time/expenses for
care and treatment
173,900 baht/a year
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Topics Frequ Cost of Risks Possibiliti Scores
Issues ency loss/year toward es to
Selection Table(RPN) /year patients solve the
issues

1.Leftover
medicine
4 4 2 3 96
Criteria for issue selection returned
by patients

Scores Freque Loss of

ncy cost
[Time(s (Baht/a
) /a year)
Dangers
toward
patients
Possibilities to
solve the issues 1
year] 2.unable to
track the
2 1 3 3 18
1 0-125 0-137500 cause risk but A request for the
not affect the approval from the postpone
ment of
2
patients executives
the
2 126-250 137501- cause risk but A need for appointme
not harmful assistance from nt
275000
the committee

3 251-375 275000- cause risk and difficult remedy

3.Patients’
symptom
1 1 4 4 16
412500 danger, need
monitoring
because it is
related to other
got worse
while
3
organizations receiving
the
4 376-500 412501- cause risk and simple remedy
checkup
550000 need treatment within the
organization
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The information collected before the remedy: 1-year from October, 2015 – September, 2016
Rating the loss of leftover medication returned by the patients is shown on the chart.
100%
96%
88%
73%

The Pareto chart classifies the waste of leftover pills

Leftover
medications

Diabetic medicine is the

leftover medicine which are
returned most by the
patients (up to73%)

The topic of issue is the rate of the waste of diabetic medicine from the high-rated unused medication.
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The topic of the activity is Reducing the unconsumed
prescribed diabetic pill waste
Motivation
Institutional level

National level Impacts Motivation

*Thailand has prescribed medicine to the patients
excessively.
* Expense for the medicine cost over one hundred
billion, which is finalized as 42% of all the health
expenses of the country.
* Thailand is ranked to be the country that has a
high consumption of medication in the world and
has continuous increase of medical expense every
year.
* The survey shows that the patients had leftover
medicine at home with the average rate of 300-
400%/one patient)
1.Cost The cost of waste is 645,860 baht/a year
2.Delivery Waste 7,200 minutes/a year to solve the problem
3.Frequency The high frequency of 480 times/a year, which
equals 36,048 tablets.
4.Morale Officials were positive about sharing help in
saving resources in the organization.
5.Quality Improve the quality of medical care in terms of
providing medication.
6.Environment Reduce the global warming by decreasing the
energy for burning the leftover medicine
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4.The Current Survey The process in relation to problems
Patient come to the hospital owing to the appointment

meet the doctor, receive medical treatment and

make a prescription

bring the prescription sheet to the nurse, checked and

pick up the medicine

The pharmacist gives advice and provide medicine

for the patients

The patients return the unused diabetic medicine

and a large number will be sent out for burning.
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The Check sheet shows the cost of waste of the returned diabetic pills for 6 months
retrospectively. The data was collected from April-September 2559, supervised มุทติ า ไพชยนต์
The CHECK SHEET shows the unused medicine A retrospective 6-month information of the cost of

in September 2559 the waste of returned diabetic pills

date Diabetes /time(s) Number of cost calculated from the expense of diabetic medicine
of returning tablets
1 //////// 8 83 during that month
2 ////////////////////// 22 164
3
4 Month The cost of the waste The cost of all diabetic Percentage
5 ///////////////////////23 186
6 ///// 5 66 of diabetic medicine/a medicine / a month
7 ///////////////// 17 163
8 /////// 7 91 month
9 ///////////////////// 21 214
10
11
12 //////////////// 16 Apr. 109,720 731,466
13 ///////// 9
136
104
15%
14 ///////////// 13 126
15 ////// 6 75
May 124,956 1,041,300
16
17
//////////// 12 135 12%
18
19 /////////////// 15 186
June 114,608 818,628
20
21
///
///////////////////
3
20
54
185
14%
22 ///////////////////// 24 215
23 ///////// 9 98 July 112,008 861,600
24 13%
25

26 //////////////// 16 168
Aug. 134,628 897,520
27
28
//////////
////////////////
10
18
96
182
15%
29 ////////// 12 141
30 /////////////// 15 136 Sep. 156,208 976,300 16%
รวม 3004 156,208baht
 The chart shows the percentage of the waste of returned diabetic pills from 14
%The waste April-September 2559

mouth

The mean of the rate of the waste of diabetic medicine from the last 6 months
equals 14%
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5. Target and plan
5.1 Setting the target
The target is to reduce the rate of the waste of diabetic medicine to 7 %

% of Loss value

Reasons
The policy was enforced to reduce all current expenses to be at least 5% that equals (14-5)=9%
But the group set the rate of the average waste from 6 months as the target
and reduced 50% which equals 7%
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5.2 procedural plan The time limitation was 3 months
Started from September - November 2559, all meetings totaled 16 rounds which spent 2-3 Hours / a round
Sep.-15 Oct-15 Nov-15 Dec.-15
Activity Process Jan-16 Feb-16 Person in charge
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
1.Searching issues Plan
Group member
and topic Do
Plan
2.Determining target Group member
Do
3.Surverying the Plan
Group member
P current situation Do
Plan
4.Searching causes Group member
Do
Plan
5.Finding solutions Group member
Do
Plan
D 6.Evaluating Group member
Do
Plan
C 7. Setting standards Group member
Do
Plan Sarinpas
8.Following up
Do Nongluk
A 9.Conclusion and Plan
Determine next Group member
Do
project
 6.Finding causes: Analyze the causes of issues by means of the Pareto chart 17
Excessive prescription
4. The doctor asked to people
stop taking medicine Not following the procedure
Change the
treatment Pharmacists made Nurses made a Patients returned the
Drug allergy/not respond to
a mistake mistake. medicine
the treatment

Blood result improves 6.Pharmacists not 7.Nurses not check the number to match the appointment date
check the leftover
The prescription order not fit the medicine
amount of the appointment period Staff not check
excessive leftover medicine over the
amount of appointment period
Reduce / stop taking medicine at will
The patient not aware
Lack knowledge
2. No record for unused medicine about medication
Afraid of using
Symptom
No informing medicine
improves
Patients not take 1.Patients lack knowledge about medicine
Not return unused drug to enough medicine
the doctor
Prescription system from the
computer Patients have much unused drug
Not deduct the Lack knowledge
unused drug Computer about medication The rate of the
Amount of system not
unused drug inform
Insufficient educating waste of diabetic
drug from the
2. No system to record for 3.No system to help alert
Personal unused
unused medicine about unused drug
educating medication was
The doctor Pursue an appointment 5.No instructional high.
not aware period / excessive media and education Patients misused
prescription medicine

methods devices
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The causes consist of 7 issues

1. Patients lack knowledge about the use of medication

2. No system to record the number of unconsumed pills
3. No system to help alert about unconsumed medicine
4. The doctor ask to stop taking medicine
5. No instructional media/information about the use of medicine
6. Pharmacists do not check if the patient have the leftover pills.
7. Nurses do not arrange the number of pills to match the amount of
the appointment period.
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Proving the real causes of issues by following the 3 principles: real work/real place/ real situation

Causes Real work Real place Real situation result of proof

1.Patients Information given by the Received the The result shows… Misusing the
lack the patients, amounts to checkup in front medicine
knowledge N=300 samples in of the medical Reducing the consumption at will, True
of using Sep.,10-14, 2559 examination room which caused much increase of
medicine -by doing an interview before meeting leftover medicine and returned to the
-making a random check the doctor for the hospital
for the use of medicine medical treatment
and record

2.No The survey shows that.. In front of the -Every treatment would get a
system to There is no record about medical particular amount of medicine that fit
record the the leftover medicine of examination room the amount of the appointment period True
number of the patients and no -No leftover medicine for the next
leftover medicine was returned examination
medicine for an examination. - Get new medicine

Causes Real work
3.No system -The survey shows that the
to help alert computer program that the
about the doctor used to make a
leftover prescription, did not show the treatment/prescripti information was not alerted by the
medicine information of the leftover
medicine of the patients
4.The doctor - The survey shows that the
asked to stop doctor gave a different type
taking the of medicine when the
medicine patients showed the sign of
drug allergy or when the
symptom improves or blood
sugar decreases.
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Real place Real situation Result of the
proof
The computer -The doctor made a prescription for the
through which the patients without knowing that the patients True
medical still had unused medicine because the
on were processed program in computer.
is the SSB system -The patients kept getting new medicine
which caused the increase of leftover
medicine.
In the medical - The doctor made a new prescription
examination room and reduced the amount of medication True
but did not request the return of the old
medication or made a deduction in the
prescription sheet.
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Causes Real work Real place Real situation Result of the
proof
5. No From the survey about - Medical -No instructional media, video or
instructional instructional media used examination room educational board for the use of True
media to
in Outpatient department and nearby medicine
educate patients
about the use of - There was only a random private
medication teaching.

6. The From the random survey In front of the

pharmacists did and examination of the pharmacy’s
not check the pharmacists’ drug counter Not true
unused drug. dispensation - The pharmacy
. N=300 samples for outpatients The pharmacists checked the leftover drug and educated
Sep 10-14, 59 patients about the use of drug every times
OP-PHA-08 is the method to make a drug dispensation for
the outpatients
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Causes Real work Real place Real situation Result of proof

7. Nurses did From the random The nurse station
not arrange survey and the in front of the Not true
the amount of examination of outpatient’s
medicine to fit nurses’ working medical
the amount of performance and examination room
appointment making an after meeting the
period. appointment letter doctor The patients found that every nurse examined and
N=300 samples gave advice about the use of medicine following
Sep.10-1459 the discharge principles (OP-NUR.OPD-04 ).

There are 5 real causes Controllable Uncontrollable

1. Patients lack knowledge about drug application. 
2. No system to record the amount of unused medicine 
3. The doctor asked to stop taking medicine 
4. No system to help alert about the unused drug 
5. No instructional media to educate patients about the use of medicine 
4 causes can be controllable and resolved
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7. Resolution
7.1 Finding the solution is processed and evaluated through HOW HOW Chart as follows
1. Patients lack knowledge about drug application.

Possibility to solve

Solve immediately

Not breaking the rules

Expected result
Real
2. No system to record the number of remaining pills

Total scores
causes

Ranks
3. No system to help alert about the number of remaining pills
4. No instructional media to educate patients about the pill consumption

HOW1 HOW2 HOW3 HOW4

diabetic medication
How to reduce the rate of the waste of leftover

Educate about the Daily public Produce media 4.1create board and
video 4 5 3 6 18 3
use of medicine relation
Private teaching
Cause1and4 4.2 wire broadcasting 4 4 3 5 16 4

Improve the saving

system by typing in
4.3 create a program
Written-form record
Produce the computer to record the amount
system to
record the And save in the
And draw a notice
of leftover drug which
computer
amount of
leftover drug
mark in the
computer
links to the doctor, 5 6 6 6 23 1
hospital and
Casue2 pharmacy
For the doctor to The pharmacists can
reduce the amount track the drug
of drug prescription reduction prescribed
by the doctor.
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Real 1. Patients lack knowledge about drug application.

Not beaking the rule

Possibility to solve
causes

Solve immediately
Expected result
2. No system to record the amount of the leftover medication

Total scores

Ranks
3. No system to help alert about the leftover medication
4. No instructional media to educate patients about the use of medicine

HOW1 HOW2 HOW3 HOW4

leftover diabetic medication
How to reduce the rate of the waste of

Set up the - Include the 4.4 include the

system that can system that alerts system in the
about the amount computer that alerts
Create a system
to help alert
create and send
an alert message of leftover about the amount of 5 6 6 6 23
1
about the to the doctor by medicine the leftover medicine
amount of typing - The SSB program - This information
leftover will create an alert will be delivered
medicine message that
through the SSB
identifies the
Improve the program to the whole
amount and the
Cause3 appointment date when the
hospital departments
form that drug is used up
provides 4.5 Set up the
written alert By typing in the system to put alert
message for computer in the appointment 5 6 5 6 22 2
patients card

Two solutions were approved, which are 4.3 and 4.4

 Solution 4.3 Designing the program to record the amount of the leftover medication in the 25
computer and 4.4 Adding the alert system for the leftover medication in the computer
Why-สาเหตุ What-แนวทางแก้ไข How-วิธีแก้ไข When-ระยะเวลา Who-ผูร้ บั ผิดชอบ
2.No system to Create the system 4.3.1 Design the recording form for the Oct 5-7, 59 group work
record the leftover to record the unused drug in the computer
medication amount of the
leftover medication

4.3.2 examine the unused drug of the Started Oct.10, มุทิตา

The result is the communication to thepatients
doctorandandmake a record in
pharmacy the the
about 59 นงค์ลกั ษณ์
computer
amount of the leftover medicines so that program
the drug reduction can be
determined conveniently and quickly.
4.3.3 the amount of unused drug will Improvement1 Group work
be shown in the doctor’s computer in the Oct. 3-7, 59

medical examination room.
Improvement2
The doctor then prescribes less amount
of medicine Oct. 21-26, 59
The doctor affirms the medication is
leftover.

4.3.4 The affirmation mark will be Started Oct.10, ศริณภัสร์

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Why-สาเหตุ What-แนวทางแก้ไข How-วิธแี ก้ไข Whenระยะเวลา Whoผูร้ บั ผิดชอบ
3. No system to Organize the system Add the alert system to remind about Oct. 10-15, 59 Group work
help alert about for the alert of the the amount of the leftover drug in the
the amount of leftover medicine SSB program of the hospital
the leftover
medicine
Message-the patient used to get the
medication Glucophage(Metformin)850mg. Tab.
The leftover drug is equal 180 tablets.
Available period is Feb. 7-May8, 2560.

When the doctor prescribes this medication

set while the old set is still unused, the
message will alert immediately.

The result is that the information is delivered to the doctor and pharmacists accurately
and quickly and able to reduce the amount of the prescription and other expenses.
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7.2 The process of resolution
7.2.1.Organize the recording system to track the amount of the Remaining pills

Design the
recording form

check and save

it in the
computer

Create the computer

system to help remind
the number of the
remaining pills
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7.2.2.Create the alert system to remind the amount of the leftover medicine in the computer

Improve the SSB program to add the alert system to remind the amount of the leftover medicine

The patient used to get Glucophage(Metformin)850mg. Tab.

The remaining pills are 180 tablets.
Available period is Feb.7-May8, 2560

The system will alert about the amount of the leftover medicine.
If the same type of medication is prescribed, the doctor will reduce the
amount of it.
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8.The result of process after solving the problem % of Loss value
The graph compares the percentage of the waste of the diabetic medicine before and
after doing the activity.

Better than
Target 3%

The outcome is 3% more satisfactory than the target.

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The graph compares the difference of the waste between
before and after the improvement
%of the waste
BEFORE AFTER

Mouth
9. Standardization 31
Standard1. Recording system for the leftover diabetic pills ( WI-NUR.OPD-04 No.15 ), started in Nov. 29, 2016
1.The patients count the remaining pills and write the number
on the envelop and bring it to the doctor.
2.The officials check and save the amount of medicine in
the leftover medication record form in the computer system
before the patients meet the doctor.
3.The doctor reduces the dispensation by deducting from the amount
of the leftover medicine of the patients that identities in the alert
message.

4.The nurses review about the amount of the medicine according to the
doctor’s statement to fit the next appointment and encourage the patients
to use up the old set of medication before receiving the new set.
The patients will be alerted to bring the leftover medicine to the doctor
which is also alerted in the appointment card. 31
Standard 2. The alert system to remind the amount of the leftover pills of the patients in the computer 32

( WI-NUR.OPD-04 No.16 ) started in Nov. 29, 2016

The alert system to The alert message will The red message including The information
inform the amount of show up in the doctor’s identification of the drug will be delivered
computers in the medical expiration will show up to remind to the pharmacy.
the leftover medicine in
examination room. the doctor if the old set of the
the hospital computers medication is still leftover.

32
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10.Summarizing and Follow-up
10.1Summarizing 1. The waste of the leftover diabetic pills is reduced to 4%
Direct impact which is 3% more satisfactory than the Target.
2.The expense from the waste of the leftover medicine is reduced to
1,223,184 baht/a year

Better than
target 3%
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Indirect impact
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10.2 Follow-up and Evaluation
%Of loss value

The comparison chart monitoring and follow up

Found that the percentage is Still lower than the control limit

Control Limit

mouth
 12.Topics for the future activity 36
According to 1-year retrospective statistics and events from March 2015 to Feb 2016, the serious
issues that caused the highest cost of waste were taken into consideration.
Possibility to
Frequency/ Cost of waste intensene
causes solve the scores Impacts Motivation
a year / a year ss
issues
1. Unable to track the 2 1 3 3 18
postponement of an 1.Cost Reduce the cost of waste from
appointment protectable illnesses
2. Symptom got 1 1 4 4 16
worse while waiting 2.Delivery Employees get 100% chance to
for the checkup
The next activity receive a medical checkup
3. Postpartum-period 1 3is the 2increasing
4 of 24annual health checkups for
mother with the the tobacco factory’s employees
breastfeeding 3.Frequency once/ a year
 6 months
4. A small number of 4 4 3 3 72 4.Morale Be proud
staff engaged in the
annual medical 1
checkup 5.Quality Improve the quality of the medical
5.Patients couldn’t 2 2 2 4 32 check up activity
engage in the medical
service at all clinics
as expected
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