Improving Time and Cost Effectiveness of Homecare services for Disease Modifying Therapy (DMT) in MS

St George’s Hospital (SGH), contains a neurology department which is a regional tertiary centre serving a population of 3 million people across South-West London, Surrey and Sussex.

The MS service offers a full range of disease modifying therapies. All of the self-injectables and oral treatments are provided through pharmacy homecare, this is to save 20% Value Added Tax (VAT). Presently all homecare MS prescriptions are clinically screened by two band 7 and two band 8 pharmacists.

Lean Six Sigma was identified as a method to review the MS homecare prescription process. Lean Six Sigma is a method that relies on a collaborative team effort to improve performance by systematically removing waste.^[1]

A meeting was held with stakeholders using an outside facilitator to understand the overall homecare process, this involved

• Mapping the steps (stapling) in the process
• Identified duplication and extra processing
• Creating a swim lane (Figure 1 on poster)

To characterise the DMT homecare workload an audit was started in October 2019

• Recorded data (time taken to screen prescription, DMT prescribed, number of urgent prescriptions, number of uncompleted Blueteq forms, number of prescriptions delayed beyond 24 hours, number of deviations from protocol, time taken to resolve problems, origin of prescription (hub or spoke hospital)
• Calculated time spent screening prescriptions: total time, average time, range.
• Identified staff grades of pharmacists screening prescriptions (figure 2 in poster)
• Generated some different cost models in pharmacy homecare. (see poster-cost models)

Service development

• Repeat prescriptions for patients receiving glatiramer acetate to be 6-monthly instead of 3-monthly. To be evaluated with a view to extending 6-monthly repeats to interferon prescriptions
• Technician (Band 5) to be trained to screen glatiramer acetate prescriptions-with possible rollout to all injectables
• Consider band 6 pharmacists to have a screening role
• In the case of low lymphocyte count, the MS coordinator to be contacted as point of first call for information on action agreed by MS Nurse/Consultant
• TB screening and other “grey areas” of DMT protocols – Neurology lead pharmacist to review, identify and resolve.
• Lead neurology pharmacist to schedule meeting with MS coordinator to understand blood monitoring card system currently in use
• Use one database instead of the 2 parallel databases currently in use
• To appoint Blueteq technician

Conclusions

• Many DMT prescriptions can be screened quickly (63 prescriptions screened in 1-3 minutes)
• The prescriptions taking 15 minutes or longer to screen, (18 prescriptions) took 7 hours 59 minutes, this is roughly half of all the total screening time. Future work needs to reduce this perhaps more timely triaging with the MS coordinator and using the blood monitoring card system
• Current model “top heavy” in higher grade pharmacists screening DMT prescriptions
• Potential time saving of >6 hours of pharmacist band 8a time comparing current with future model
• Pharmacist band 7 screening time in the proposed model would be time neutral as would be supported by band 6 pharmacist and band 5 pharmacy technician
• The results from the service development and audit results will direct changes to pharmacy homecare that will need to be re-audited in the future

• (1) Summers, Donna C.S (2011). Lean Six Sigma: Process Improvement Tools and Techniques. One Lake St, Upper Saddle River, New Jersey: Prentice Hall. ISBN 978-0-13-512510-6.