Hospital Pharmacist
2008;15:187-188
May 2008

Homecare medicines — managing the performance of suppliers

By Michael Butterfield, RegPharmTech

Over the past decade, the number of patients receiving medicines services at home has increased dramatically. Although homecare services are often outsourced, the need for ensuring quality of service should not be ignored by the NHS

Focus on technicians series

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At Leeds Teaching Hospitals NHS Trust (LTH), over 3,000 patients are receiving medicines in their own home that would traditionally be administered in, or collected from, a hospital.

Homecare services offer a cost-effective and convenient option for providing quality care for patients, as well as freeing up hospital beds and reducing the spread of hospital-acquired infection.

Homecare medicines services are usually contracted to third party companies, either by the hospital or the drug manufacturer. Due to the growing need for this service, the pharmacy department at LTH has recognised the need for these contracts to be performance managed.

In August 2006, I was employed as specialist technician for homecare medicines to create a framework for quality assurance in homecare medicines.

Objectives

The main aim of my role is to monitor the performance of the homecare medicine service providers and ensure poor performance is addressed. I achieve this by:

• Ensuring all homecare services are regularly reviewed

• Agreeing key performance indicators (KPIs) — measures of service quality

• Identifying risks within the homecare medicine supply chain and providing a plan for improvement

• Obtaining service feedback from patients

• Acting as a homecare expert for staff in all clinical areas

• Encouraging and promoting shared learning across all areas of homecare treatment

• Promoting standardised practice

Building the team To implement performance reviews, I had to establish a review team for each therapy area. Such review teams commonly consist of:

• Lead pharmacists

• Specialist nurses

• Pharmacy procurement staff

• Finance staff

• Clinicians

• Representatives from the homecare provider (eg, business development or customer service manager)

• Other health professionals as appropriate (eg, dieticians)

Putting a review team together was not as easy as it might seem. Many health professionals regarded review meetings as “a waste of time”, particularly when the service appeared to be problem-free. These people required considerable amounts of persuasion. Also, some professionals did not want to be heavily involved and were happy just to receive minutes of the meetings and notification of future plans.

During review meetings, the respective team scrutinises data collected from KPIs, patients and staff, and analyse any complaints or incidents.

Agreeing KPIs Effective performance management requires data relating to service quality, not just anecdotal evidence. The first contract at LTH to agree formal KPIs was the home parenteral nutrition service. These indicators were agreed by collaboration between the homecare provider and LTH staff.

The provider’s monthly performance against these indicators can be plotted on a graph to enable changes in service quality to be easily identified. For example, an increase in the number of leaking total parenteral nutrition bags may indicate a faulty batch and prompt the homecare provider to investigate further.

After two or three months of measuring KPIs, it is possible to set performance targets. These are thresholds (usually a percentage) against which KPI values are compared. For example, company X delivers 92 per cent of its products on time during January.

However, the performance target is 95 per cent for this particular KPI, so the target has not been met. The review team would then discuss why the target had not been met and what remedial action is required

Performance targets are negotiated with the homecare provider, allowing high standards to be set that are realistic and achievable.

Patient involvement

The focus of homecare service should be the patient, so it is unwise to conduct reviews without gathering patients’ opinions. I believe the best approach for achieving this is to use patient surveys.

Currently, patients are asked to rate the performance of the homecare provider. The categories of performance rating are:

• Communication
• Delivery times
• Customer service support
• Driver assistance and attitude
• Clinical waste collection

Each category is scored on a scale of 1–5 (one being poor, five being excellent). The patients are also asked to rate each category in the same way in terms of its importance to them (one being not important, five being vital). This is done because, for example, a housebound patient is likely to be less concerned about delivery times than a patient in full-time employment.

The average performance scores are calculated and compared with previous scores, and the average importance score. If the importance score for a category is greater than its performance score, then this category is targeted for improvement. The gap between the two scores dictates how urgently that aspect of service needs to be addressed.

The involvement of expert patients in the review teams is currently being considered.

Learning from feedback

Before I started my role, the performance management of homecare medicines contracts was variable. It usually involved a basic service review meeting, led by the homecare company, with no defined measures of performance. These meetings focused on the operational delivery of the service, and problems encountered, rather than measuring performance in order to improve it.

Many healthcare professionals did not respond to incidents (eg, dispensing errors) in the same way as they would if the error had been the fault of a trust employee. I do not believe that this is acceptable.

New reporting system Currently, I am creating a list of contacts so that all LTH and homecare staff know who to contact to report an incident or error. This will be supported by a policy for error reporting.

In addition to this, all incidents occurring during the provision of homecare services are recorded on a spreadsheet and cross-referenced to the company’s internal investigation. Each homecare provider has received a copy of the trust’s incident definition policies, to ensure that they are using the same terminology as the trust.

Incident reports document all communication between the relevant parties in chronological order, along with details of remedial action taken. Incidents are only “closed” after all remedial action has been carried out.

I also sit on the multidisciplinary medicines management incident review group, which meets monthly to discuss medication-related incidents. All incidents involving homecare patients are raised at these meetings.

Using the data The data collected is used by the review team, along with KPIs, to analyse the performance of a given service.

Recently, KPI data showed that there were significantly fewer patients on the homecare HIV service at one of the two hospital sites in the trust, despite both sites having similar patient numbers. Consequently, we have improved the registration process for HIV homecare by making homecare prescriptions more accessible and redesigning the prescription so that most of the information is pre-printed.

We also arranged for the homecare provider to visit the HIV clinicians to promote their service. There has since been an increase in the percentage of patients with HIV using the homecare service.

The data collected can also be used to compare the performance of different providers, which can be used when we tender for new contracts, and to share best practice.

Impact on service

Since the introduction of my post, clinical teams and homecare providers have acknowledged an improvement in the efficiency of homecare services. This has resulted in better care for patients and value for money for the NHS. Contracts are now awarded with a greater emphasis on quality and previous performance, rather than by cost or anecdotal reports.

Communication has improved due to a more holistic approach to homecare medicines. Patients are more involved and their opinions are valued. This has allowed the trust to expand its portfolio of homecare treatments and reduce the length of stay for a greater number of patients.

Industry-contracted homecare Some contracts for the supply of homecare medicines are awarded by the drug manufacturer. Even though the contract is not with LTH, we remain responsible for patient care.

Consequently, I have adopted the same approach to performance managing these contracts as with any other.

In March 2007, the homecare service for the supply of disease-modifying therapies used to treat multiple sclerosis was reviewed. A patient survey, sent out via the homecare provider, yielded a 70 per cent response rate. Using this information, a review meeting was set up between the clinical team, the homecare provider and a representative from each of the relevant drug manufacturers.

The meeting produced excellent statistics, showing a well run, highly organised service. However, deficiencies in data management systems and delivery schedules, and isolated issues concerning confidentiality were identified and have since been resolved.

The feedback from the survey was collated and shared with patients, showing the changes that had been made as a result of the meetings.

Future of my role

Establishing the performance management framework is only the beginning. As more drugs become available, the opportunities for expanding homecare services will increase. The work to set up reviews for all homecare medicines services is far from complete.

I will continue to roll out performance management for all contracts within our homecare portfolio — having prioritised services with large numbers of patients or those for whom poor performance has been an issue.

I am currently setting up an online questionnaire to send to key staff across the UK to assess how others are managing the performance of homecare medicine service providers. Ultimately, I would like to be involved with a UK-wide framework of KPIs and to promote best practice.

Conclusion

Successful changes in practices have justified the appointment of a technician to performance manage homecare services. It has also demonstrated that the work I am doing is reaping rewards for our growing population of homecare patients.

However, there is still much to do before the performance management agenda will be fully implemented, both locally and on a national scale. I believe that a national framework of performance management would allow homecare medicines services to establish themselves as a key strategy for delivering top quality healthcare in the 21st century.

ACKNOWLEDGMENT Thanks to Phil Deady and Jane Kelly, who work in the LTH pharmacy procurement team, for their help in setting up the review framework.