(UDD)

DIFFICULT TO IMPLEMENT?
Case study in three public
hospitals

Naswir1 & Sri Suryawati2

INRUD—Padang, Indonesia
Department of Clinical Pharmacology, Faculty of
Medicine, Gadjah Mada University, Yogyakarta.
ABSTRACT
Problem Statement: Unit-dose dispensing (UDD) is a system of drug distribution in hospitals
that aims to increase efficiency, cost-containment, and the quality of drug delivery. Many
studies at the national and international level have shown that this system provides
advantages to the quality of service, to the patients and also to the hospitals. Yet at the time
the study was undertaken, there were no hospitals in Indonesia that were using the system
comprehensively. It was suspected that some inhibiting factors were behind this, which need
to be identified and resolved.
Objective: To find obstacles and opportunities for successfully implementing UDD.
Design: Case study
Setting and population: Three public hospitals in Indonesia which have already implemented
UDD for at least 3 years in a particular ward.
Outcome measures: Qualitative data obtained from observation, in-depth interview, and
questionnaire with hospital directors, head of pharmacy departments, health providers, and
patients.
Results: The main inhibiting factors included the lack of facilities in the ward, incapability of
staff responsible for drug distribution in the ward, and the most important, the lack of political
will from the hospital management. The lack of facilities in the ward included inavailability of
equipments for UDD implementation, assigned room for UDD activities, etc. The lack of
incapability of staff included insufficient knowledge about UDD concept among health
providers, and communication problem between provider and patient, or among providers.
The lack of political will from the hospital management mainly due to the conflicts of interest
between making profit and promoting efficient use of medicines, which are not yet solved
properly.
Conclusions: Although UDD has been proven useful, it is still very difficult to implement.
Political will of the hospital managers, with a strong support from the director is the key factor
of UDD implementation. To achieve this, the concept of UDD should be understood, by the
hospital managers. To anticipate conflicts of interest, managerial intervention, such as
improving the mechanism of incentive – desincentive, is also very much needed.
INTRODUCTION
What is Unit Dose Dispensing (UDD)?
 Drugs distribution system for inpatients in hospitals
 Drugs which are packed in single dose and single package.
 Drugs which are given in one unit or one time using.
 Drugs which are available to use in 24 hours.

Advantages (ASHP,1986):
 A reduction in the incidence of medication errors.
 A decrease in the total cost of medication related activities.
 A more efficient usage of pharmacy and nursing personal, allowing
for more direct patient care involvement by pharmacist and nurses.
 Improved overall drug control and drug use monitoring.
 More accurate patient billings for drugs.
 The elimination or minimization of drug credits.
 Greater control by the pharmacist over pharmacy work load pattern
and staff scheduling.
 A reduction in the size of drug inventories located in patient care
areas.
 Greater adaptability to computerized and automated procedures.
INDONESIA EXPERIENCE

 Successful pilot studies:

 To reduce the cost of medication for patient (Irmawati,
1993).
 To increase efficiency of drug management (Sujarwoto,
1997).
 To eliminate medication error (Widayati, 1998).
 To reduce the time for UDD preparation (Budiarti,
2000).

 Despite success in small-scale pilot studies,

no hospital in Indonesia is nowadays
implements UDD in hospital scale.
Objective

To find obstacles and

opportunities to
institutionalize the
UDD implementation.
Design
 Case study in three public hospitals
Identifying underlying factors of UDD
implementation

Management function (inputs, process,

outputs)
Of UDD implementation

OPPORTUNITIES OBSTACLES

Evaluation and
recommendation

How to implement UDD hospital-wide

collection
 Types of data: qualitative, covering input,
process, output
 Method of data collection: observation, in-
depth interview, questionnaire.
 Data sources:
 documents of drugs management in
hospitals
 employees including hospital director, head
of pharmacy installation, health providers
 patients
 Data collector: staffs of drug distribution,
pharmacist, nurses, pharmacist technicians
Characteristics of
hospitals
Hospital A
 Type A Hospital, located in Surabaya, East Java Province
 Teaching hospital with 1150 patient beds.
 Bed Occupation Rate (BOR) ± 65%.
 Has 19 specialist and 14 sub specialist Departments.
 Has implemented UDD in a part of Pediatric Ward (74 beds) since 1988.

Hospital B
 Type B Hospital, located in Padang, West Sumatera Province
 Teaching hospital with 650 patient beds.
 Bed Occupation Rate (BOR) ± 70,56%.
 Has 17 specialist and 6 sub-specialist Departments.
 Has implemented UDD in a part of VIP Ward (90 beds) since
1980.
Hospital C
 Type C Hospital, located in Brebes, Central
Java Province
 District Hospital with 213 patient beds.
 Bed Occupation Rate (BOR) ± 62,41%.
 Has 5 specialist Departments
 Has implemented UDD in one Ward since
FINDINGS: HOSPITAL A
Facilities
 Equipments to support UDD are not enough. To serve 74 beds, 5
trolleys are available
 Inadequate room for UDD preparation
 In parallel with UDD, patients also receive medications from other
sources
Staffing
 3 pharmacists, 4 pharmacy technicians and 1 non-medical staff
 In continuous education about UDD concepts among health
providers
 Poor communication between provider-patient and providers-
providers
Managerial supports
 No enforcement for UDD implementation
 No explicit budget allocation for UDD implementation
 Imbalance incentive-disincentive system, resulting in serious
conflict of financial interest
FINDING: HOSPITAL B
Facilities
 Inadequate equipments to support UDD. To serve 90 beds, 12
small trolleys are available
 Inadequate room for UDD preparation
 In parallel with UDD, patients also receive medications from other
sources
Staffing
 3 pharmacists, 13 pharmacy technicians
 Routine education about UDD concepts among health providers
(twice a year)
 Poor communication between providers-providers, due to
frequent absence of the doctors

Managerial supports
 Enforcement for UDD implementation in a form of written Director
Instruction
 Inadequate budget allocation for UDD implementation
 Conflict of financial interest still exists
FINDINGS: HOSPITAL C
Facilities
 Lack of equipments to support UDD. No medicine trolley,
inadequate drug packaging
 No room for UDD preparation
 A private drug outlet exists in the Ward

Staffing
 1 pharmacists, 1 pharmacy technicians
 Education about UDD concepts was addressed to few health
providers
 Poor communication between providers-patients

Managerial supports
 Enforcement for UDD implementation in a form of written
Director Instruction
 No budget allocation for UDD implementation
 Imbalance incentive-disincentive system, resulting in serious
conflict of financial interest
Conclusions
Facilities
These three hospitals do not provide adequate equipments
and rooms for UDD implementation. Lack of this support
indicates that UDD implementation is not a priority.
Staffing
Most hospitals have inadequate number of pharmacists and
pharmacy technicians to support UDD implementation, and
the concepts of UDD does not disseminated thoroughly to all
providers. Again, lack of this support indicates that UDD
implementation is not a priority.
Managerial support
In most hospitals, there is practically no political supports
from the hospital managers. Unwillingness to implement UDD
is mostly due to serious conflict of financial interest.
Recommendatio
ns
 Efforts should be sought to improve the
understanding of hospital managers on the
importance of good dispensing practices
without sacrificing the hospital income.
 Better balance between incentive and
disincentive should be promoted by hospital
managers to eliminate the conflict of financial
interest.
 Improving rational use of medicine should be
supported by improving the work environment
Thank You