PROVIDING E-APPOINTMENT SYSTEM TO STAKEHOLDERS FOR LICENSING APPLICATIONS AND GUIDANCE
ORGANIZATION OF MEDICINES - VALIDATION OF APPLICATIONS & MARKETING AUTHORIZATION DIVISION (DDYEP)
Greece

The Problem

The National Organization for Medicines of Greece (EOF) was established in 1983, and is a public entity of the Ministry of Health and Social Solidarity. EOF’s mission is to ensure public health and safety with regard to the following products marketed in Greece: medicinal products for human and veterinary use, medicated animal foods and food additives, foodstuffs for particular nutritional use, food supplements, biocides, medical devices, and cosmetics.

The Validation of Applications & Marketing Authorization Division (DDYEP) is the Organization’s first-stop in assessing the quality, efficacy and safety of pharmaceutical products and authorizing their sale in Greece. Prior to their submission for scientific assessment, all applications are physically accepted and reviewed for completeness and quality by the Division’s Assessors. The validation process often required multiple visits from the interested parties (Pharmaceutical Companies), both for the purpose of documentation review and delivery of guidance through which to meet National and European regulatory requirements. Applicants are located both in Attica (Athens) as well as the provinces of Greece.

The time required to review an application and to grant a marketing authorization is critical both to Pharmaceutical Companies, and the citizens for which the pharmaceutical product is intended. Delays in the review process imply a lost market opportunity for the Pharmaceutical Company and unavailable medicinal products for the citizen / patient. Further, regulatory requirements mandate timeframes in which applications are to be assessed and a decision relative to market authorization rendered. Time allocated for the purpose of application documentation review needs to be balanced with time spend for scientific assessment in order to ensure the safety, quality and efficacy of the pharmaceutical product, as well as the timely execution of the review process.

Prior to the implementation of the e-appointment system, Pharmaceutical Companies telephoned DDYEP’s Administrative Control Sector’s personnel to arrange for visits. Appointments were scheduled and tracked with the use of personal calendars. This “manual scheduling system” provided little evidence relative to the processes’ objectivity, transparency, and effectiveness, an issue often raised by the Pharmaceutical Companies. Further, the manual scheduling system proved to be cumbersome for Pharmaceutical Companies, given that a scheduled visit required multiple attempts to arrange (one to five calls) and that the duration of the visit was not standardized. Fifty percent (50%) of the time, the scheduled visit was not on the day or time originally requested by the Pharmaceutical Companies’ representative. Finally, the Division’s personnel utilized in excess of twenty percent (20%) of their time answering telephone calls concerning scheduled visits, a time which was lost from the total time spend in the validation process. This time was neither documented nor measured.

The driving force behind the development and implementation of the “e-appointment system” within DDYEP was to cope with the increasing pressure on existing resource, to meet the challenges of orienting its approaches to be more customer-focused, to seek out and make use of available technologies, to maximize efficiency, to promote transparency and equity and to continuously improve on existing systems, while preparing for future challenges.

Solution and Key Benefits

 What is the initiative about? (the solution)
In its continual effort to stream-line administrative processes and reduce administrative burden, DDYEP has implemented an on-line e-appointment system.

The e-appointment system offers the opportunity to each Pharmaceutical Company to schedule appointments with DDYEP’s Assessors through a friendly application available on the Organization’s web side.

Each applicant, using a user specific password (issued by EOF’s IT Division on the Pharmaceutical Company’s request) can enter the e-appointment system, choose the desired day and time for the appointment, and specify the nature of the application/visit (approval, variation, renewal of pharmaceutical products’ Marketing Authorization).

Assessors are identified with the use of code numbers in the system and only at the time of the visit are the applicants informed of the name of the Assessor who will handle their case.

Appointments are available on 8, 15, or 30 minute intervals, depending of the nature of the application. These time frames were established having considered the expected number of each type of application per year and the time required by the Assessor to effectively validate the documentation of each application.

During the e- appointment process, the free (available) days and times for each type of application validation are displayed. The Pharmaceutical Company’s representative selects his/her desired (available) time slot. The names of other Pharmaceutical Companies who have already scheduled visits are not shown to ensure protection of confidential information.

In order to provide services to as many Pharmaceutical Companies as possible per day, and after analyzing existing system capability statistics, a maximum of three appointments per applicant (per day) was established.

When the applicant arranges his/her appointment, an e-mail message is automatically sent confirming that the appointment has been accepted by the system. The applicant may modify or cancel his/her appointment until the noon of the previous day of the scheduled visit. Finally, if no cancellation occurs, DDYEP confirms each appointment via an e-mail message automatically send by the system to the applicant.

In its current version, the e-appointment system ensures to Pharmaceutical Companies the following:
- efficient time management as appointments are scheduled quickly and efficiently,
- flexibility relative to the day and time of the scheduled visits, as the time of the appointment is subject primarily to their preference,
- substantial reduction of repeat visits to the Organization for the same application,
- reduction in awaiting time prior to the visit (elimination of queuing), and,
- equality and transparency.

Process indicators, both qualitative as well as quantitative and a formal satisfaction survey are used to monitor the system’s performance. Through ongoing assessment of process results, opportunities for improvement are identified and corrective actions are implemented to address them.

Ultimately, the key benefits resulting from the implementation of the e-appointment system are realized by the citizens / patients who use the products marketed by the Pharmaceutical Companies. Efficient application processing, including timely documentation review and thorough scientific product assessment ensure timely access to effective, safe, and quality medicines.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
There has been increased recognition that public agencies have to improve and modernize their services through the implementation of quality management tools and techniques in order to satisfy the needs of their stakeholders. EOF’s stakeholders are: Physicians associations, Pharmacists associations, Veterinary associations, Hospitals and other public health care institutions, Trade associations, Patient associations, Social Security and Reimbursement Institutions, and the general public.

DDYEP has embraced the concept of quality, and has assumed a proactive strategy towards meeting its stockholder’s needs. The first step towards this was to develop a documented Quality Management System consistent with the requirements of the International Standard ISO 9001.

In addition, DDYEP has adapted the Common Assessment Framework (CAF) as an integral part of this strategy. Through the implementation of the CAF, the Division was able to perform a comprehensive diagnosis of its organizational performance and to identify strengths and improvement opportunities.

In the context of its pursuit for continuous improvement within the Division’s core processes, the Internet application for the scheduling of meetings with DDYEP’s personnel for the purpose of administrative assessment / validation and guidance has been developed. The necessity for this application rose through stakeholder feedback, satisfaction questionnaires, evaluation of complaints, outcomes of internal inspections, and employee suggestions.

The need for the development of the e-appointment system was analyzed in the context of a structured review conducted by the Division’s Quality Team (lead by the Division’s Director) in an effort to assess the Division’s adequacy and effectiveness and to secure transparency. The system’s development and deployment was supervised by the Division’s Director and managed by a working group comprised of Division personnel, representing the various functions.

An initial feasibility study was conducted which lead to a project proposal that was presented for approval to the Organization’s Management Board. The feasibility study included the strategic and operational objectives of the initiative, cost considerations and an implementation time-line.

Following Management Board approval, a number of meetings were held between the Division’s Director and Associations representing Pharmaceutical Companies’ interests, in which specific requirements were identified and prioritized. Division personnel provided functional information relevant to the system’s development, and contributed positive ideas which led to a user-friendly application.

Prior to the system’s deployment, a multi-day conference was organized and attended by stakeholders (i.e. Pharmaceutical Companies’ Registration / Regulatory Affairs Managers) and Division personnel. The objective of the conference was to introduce the system, to provide training on the use of the system, and to collect feedback relevant to system effectiveness in addressing their needs.

Following the system’s deployment, Pharmaceutical Companies’ perception relating to the system’s effectiveness was captured through the use of structured questionnaires which were then analysed by the Quality Management Team as part of its formal system review. A number of system improvements were identified and incorporated in subsequent upgrades.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
Through the implementation of the e-appointment system the Division aspired to cope with the increasing pressure on existing resource; to meet the challenges of orienting its approaches to be more customer-focused; to consolidate individual effort and embrace a team based approach within its policy boundaries; and to continuously improve on existing systems by making use of available technologies, while preparing for future challenges.

The initiative’s strategic objectives were formulated by the Division’s Quality Team (lead by the Division’s Director) and endorsed by the Organization’s Management Board. These were:
- to increase process transparency by directly involving Pharmaceutical Companies in the formulation of the visit schedule,
- to ensure fair treatment of all Pharmaceutical Companies, independent of their Organization’s size, influence, and market share,
- to provide services which meet Pharmaceutical Companies’ needs rather than to arrange services based on Division capabilities,
- to create an environment of common purpose and cooperation between the Division and the Pharmaceutical Companies,
- to develop a standardized process, which can be monitored, measured, analysed and continuously improved, and finally,
- to prepare both the Pharmaceutical Companies and DDYEP’s personnel for future Division developments, which will include e-systems for every process of the Division.

The system’s operational objectives were the following:
- to increase the Division’s operational effectiveness by controlling the amount and quality of time spend with each Pharmaceutical Company,
- to control the variance between the time spend with each Pharmaceutical Company, ensuring that all receive the services they require,
- to eliminate idle time between Pharmaceutical Companies visits,
- to ensure effective long term scheduling of Division staffing.

During the system’s design process, stakeholder input was solicited and captured through planned meetings with a number of Associations, representing Pharmaceutical Companies interests.

A number of access mechanisms were developed to allow customers to seek assistance, voice complaints, get information, and communicate with the Division relative to the e-appointment system. The mechanisms were designed to reflect the preferences of stakeholders relative to the specific “means of access” that they wished. Resolving complaints effectively and efficiently has helped the Division improve satisfaction and build positive relationships with its stakeholders.

Through the use of a satisfaction surveys the Division has been able to accurately capture stakeholder satisfaction relative to the performance of the e-appointment system and to introduce corrective actions where deemed necessary. The Division’s customer satisfaction survey processes are evaluated annually to improve the survey questions and survey response rate.

There is an Annual Management review where the relevant process owners present performance issues to the Division’s Management. A strategy and/or action plan is developed and incorporated into the Division’s Objectives to ensure that performance issues are addressed.

Through ongoing internal/external assessments and audits, observations are identified and corrective action plans put in place to address them. On a quarterly basis, the Division publishes a report that summarizes this information and the progress made in closing any outstanding items. Annually, this information is consolidated and reported to the Organization’s Management Board and relevant stakeholders.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Following the Organization’s Management Board approval for the implementation of the e-appointment system, a five-member team was formulated, and an external vendor was contracted to assist in the development of the required software application. All requirements were considered early in the system’s development process, through planned meetings with Division personnel and a number of Associations, representing Pharmaceutical Companies’ interests.

Stakeholder needs mainly focused on scheduling appointments quickly and easily, on their desired day and time, on accomplishing their job if possible in only one visit with the Division’s personnel, and on receiving guidance during the appointment or in any other time.

The Division went to great lengths to ensure that all pertinent process, customer, regulatory, and other requirements were discovered early in the process. Missing or conflicting requirements were identified and resolved before they negatively affected the system’s development.

The system was developed in a total of six months. The actions and timeline of the e-appointment system’s development were:

- Feasibility study (30 days)
- Management Board approval (15 days)
- Vendor selection/ contract (15 days)
- System requirements definition/ development (30 days)
- Division employee training (15 days)
- User (applicant/ Pharmaceutical Companies’ personnel) information & training(15 days)
- System development (pilot phase) (45 days)
- Corrective Actions (15 days)
- System deployment (permanent phase) & Continues improvement (ongoing)

At the end of each development phase the team conducted a lessons learned analysis to identify opportunities to improve the development process.

The results of each step in the development process as well as decisions taken were documented in a design process workbook. Key activities were assessed systematically to ensure that they conformed to the objectives of the initiative.

Prior to the system’s implementation, standard operating procedures were documented and incorporated into the Division’s Quality Management System. Further, a user-friendly work instruction describing the system’s operation was developed and disseminated through the Organization’s official web page.

Formal training was instrumental in ensuring that Division personnel were aware of the relevance and importance of their performance relative to achieving the Division’s objectives.

After the system’s pilot phase, corrective actions were introduced (as warranted) by accessing system results. Specific indicators provide data and information on the performance of both Pharmaceutical Companies’ participation and DDYEP’s personnel. Corrective Actions included redefining key performance indicators and measurement parameters.

Following the system’s official deployment, improvements were implemented, including the Pharmaceutical Companies registry (user specific access codes). The above was implemented in preparation for the automation of licensing issuance process.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The market authorization review process involves a number of successive stages, which must be successfully completed in order for a medicinal product to be licensed so that it can be marketed in Greece. An ineffective application documentation review process typically will cause delays on the part of the Organization, and/or need for subsequent documentation submission and revision, on the part of the Pharmaceutical Company (licensee). The development of the on-line scheduling system required an alignment between the Division’s processes affected by the system’s implementation and the Organization’s existing application review procedures.

The Division documented standard operating procedures for the processes and sub-processes involved in the on-line scheduling system. This documentation allowed these processes to be understood in detail. The Division’s on-line scheduling process documentation also includes “connections” or “linkages” to other processes, so that the interaction of the elements of these processes can be understood and controlled.

Procedures include responsibility matrixes defining the level of involvement of all participants throughout the different phases of the application review (validation) process. Further, these procedures define the different phases, the actions in each phase and the tasks in each action in the review process. Finally, the relevant timeframes associated with each specific action are defined, as well as specific mechanisms relating to process quality control and assurance.

The Division’s on-line scheduling system needed to replace the existing (manual) system in a relatively short period of time so as to proactively control the anticipated “resistance to change”. It was believed that the use of the e-appointment system in conjunction with (rather than instead of) the manual system would have an adverse affect on the system’s effectiveness and thus on the initiative’s strategic objectives.

The technical competence of both Division personnel as well as that of the applicants was essential to the systems successful deployment. Formal education and training ensured that the required competence was achieved and that any shortcomings addressed. Feed- back collected during the training sessions were communicated to the system’s development team. Corrective actions on the system’s modules were implemented and their impact on the system’s effectiveness verified.

A number of circulars (formal communications on part of the Organization) were drafted and made available through the Organization’s web page. In addition to ensuring that applicants were made aware of the Division’s policies pertaining to the e-appointment system, the circulars were intended to provide the necessary information on required actions on the part of the applicants prior to system use.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
Following the Organization’s Management Board approval for the implementation of e-appointment system, a five-member team was formulated (led by the Division’s Director) for the purpose of overseeing the system’s development and deployment. This team devoted the time required for the system’s development and deployment ensuring the uninterrupted execution of their scheduled (regular) responsibilities.

All requirements were considered early in the system’s development process, through planned meetings with Division personnel and a number of Associations, representing Pharmaceutical Companies’ interests, hence controlling unanticipated cost, both in time as well as in capital.

The software application for the e-appointment system was developed in cooperation with an external vendor, which the Organization contracted for that purpose. System requirements (deliverables) were defined and agreed within the existing technical capacity of the Organization’s Industrial Technology Division. A detailed action plan was formulated identifying development stages, responsibilities, time-lines, quality considerations and reviews.

Planned training of DDYEP’s Administrative Control Section Assessors ensured the competence of all Division personnel. Prior to the System’s implementation a single Assessor (with one substitute) was responsible for each kind of application, i.e. either approval or variation or renewal of pharmaceutical products.

Following the training, and before the e-appointment system implementation, each Division Assessor was able to handle all types of applications and provide guidance on any relevant issue. This action ensured the system’s integrity, given that a Pharmaceutical Company at the time of scheduling the appointment does not know the Assessor who is going to validate the application. The effectiveness of the training of DDYEP’s personnel was enhanced though the use of detailed case studies.

Prior to the system’s deployment, a multi-day conference was organized by DDYEP and attended by stakeholders (i.e. Pharmaceutical Companies registration managers) and Division personnel. The objective of the conference was to introduce the system, to provide training on the use of the system, and to collect feedback relevant to system. This conference was held in EOF’s facilities, hence controlling financial burden on the Organization.

Following the system’s deployment, Pharmaceutical Companies’ perception relating to the system’s effectiveness was captured through the use of structured questionnaires and analysed by the Quality Management Team as part of its formal system review. A number of system improvements were identified and incorporated in subsequent upgrades.

The development cost of the e-appointment system relative to the design of the software application was less than 20,000 euros. The system was designed so that it could be deployed using the Organization’s existing hardware, and managed (maintained) by the Organization’s existing personnel.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
Through the use of the e-appointment system non-value adding activities pertaining to Pharmaceutical Companies visits has been minimised. Processes requiring bureaucratic procedures can be redefined with the use of innovative approaches. Making use of technology to augment traditional procedures will result in an increase in the effectiveness of existing systems and resources, including human resources.

This application would be of value in an environment where highly skilled professionals are burdened with bureaucracy, which adds little value to the outcome of the process.

Any size organization could benefit from the use of an e-appointment system given that the implementation of the system is effectively communicated and deployed.

The initiative’s explicit objectives have been to streamline the communication process between DDYEP and its stakeholders in a manner which embraces integrity, efficiency, and transparency. The project’s implicit objectives have been to better utilize the existing personnel so as to achieve higher productivity levels, thus allowing more time for thorough reviews and the delivery of beneficial consultation services. DDYEP’s performance in relation with these objectives (as monitored through key process indicators as well as satisfaction measurements) demonstrates an increase in productivity with a parallel increase in customer satisfaction.

The primary goal of the Division is to ensure that safe and effective pharmaceutical products reach the citizen-patient promptly. The e-appointment system is instrumental in streamlining the processes through which this goal is realized.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
An effective health care system requires the implementation of strategic initiatives intended to ensure public health protection, provide equal access for all citizens / patients to safe, efficient and cost-effective medication, improve patients’ quality of life, ensure budgetary stability, promote efficient use of resources, and support domestic production of medicines.

DDYEP’s main objective is to promote a balance between the cumbersome processes intended to ensure the quality, safety, and efficacy of pharmaceutical products, and the timely access to medicinal products and therapies for citizens-patients, so important in improving health and quality of life. The e-appointment system was successful in reducing non-value-adding activity in the Division’s application validation procedures, and in cultivating a climate of trust and common purpose between the Division and its stakeholders.

The implementation of the e-appointment system has had a positive impact on the Division’s ability to effectively cope with the increasing requirements of application documentation review. The direct involvement of the applicant in the scheduling process has resulted in a well-structured relationship between the Pharmaceutical Companies and the Division, the assurance of transparency in the validation scheduling process, and a means through which to collect valuable data on applicant visits. Specifically:
 the utilization of technological innovations to improve traditional processes has been successful in achieving the desired results,
 the direct involvement of Pharmaceutical Companies in the Division’s scheduling process has had a positive impact on the effectiveness and efficiency of the Division’s validation activities,
 the systematic capture of stakeholder requirements leads to initiatives aligned with expressed and implied needs and encourages results achieved through a common approach and co-operation,
 the increased transparency of the validation scheduling process has proactively addressed Pharmaceutical Companies’ grievances, and has resulted in cultivating a spirit of common purpose,
 analysis of visitation scheduling statistics allows for better staffing decisions, hence providing better services which meet Pharmaceutical Companies’ needs,
 process control obtained through systematic analysis expedites the required workload and makes better use of limited resources.

Contact Information

Institution Name:   ORGANIZATION OF MEDICINES - VALIDATION OF APPLICATIONS & MARKETING AUTHORIZATION DIVISION (DDYEP)
Institution Type:   Public Organization  
Contact Person:   AGGELIKI KOUTSOUKI
Title:   DIRECTOR OF DDYEP  
Telephone/ Fax:   +30 210 6507208
Institution's / Project's Website:   +30 210 6547004
E-mail:   koutsoukil@eof.gr  
Address:   284 MESOGEION AVENUE
Postal Code:   15562
City:   ATHENS
State/Province:  
Country:   Greece

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