| 4. In which ways is the initiative creative and innovative?
To ease congestion at the hospital, our strategy was to utilize community centres (temples, churches and community halls) as venues to issue chronic medicines to patients.
In December 2007 we informed a member of the Hospital Board of our strategy and requested assistance to source venues in the community. He organized for us to meet representatives of the the Sathya Sai Sudhar Mandhir, a Sai ashram in Moorton, Chatsworth. We outlined our intentions and they were willing to allow us to use their facility weekly on Wednesday mornings.
Also in December 2007, we contacted the District Pharmacy Manager who was able to persuade Esplamed Pharmacy, a chronic dispensing facility within the Department of Health to assist us with pre-dispensing as our workload was too heavy for us to cope.
With the first venue and assistance with pre-dispensing sorted out, we had to screen chronic patients, check their addresses and we had to convince those that lived close to the ashram to utilize the new venue to collect their medicines.
We prepared control sheets to record patients’ names and hospital reference numbers and sent these control sheets with the prescriptions to Esplamed Pharmacy in advance so that they had adequate time to dispense and package them.
Transport had to be arranged for transporting the scripts to Esplamed, for collection of the pre-dispensed medicines and for us to transport the medicines to the ashram on clinic days.
On 13th February 2008 the first batch of patients collected their medicines at the Sai ashram. Issuing of medicines took place from 07h30 to 10h00. The ashram arranged for volunteers to help direct and seat patients in an orderly manner so that they could be attended to systematically. A retired nursing sister from the community was present to perform blood pressure and blood sugar tests. Patients were offered refreshments during their short visit. These gestures were very well received by all.
Patients were given a 4week return date for the next medicine collection and they were eager to return because they were treated excellently.
At the hospital more patients were encouraged to use the new venue and with time more patients had accepted.
With this venue progressing well, the Hospital Board member then suggested another venue for us, the Aryan Benevolent Home (ABH), an old age home situated in Arena Park.
The same process followed as with the ashram and on Tuesday 8th April 2008, dispensing at ABH commenced with a nurse on site to assist with BP and blood sugar monitoring.
With 2 sites in operation and more than 1200 patients a month utilizing the service there was a lot of positive interest generated within the community. We began to receive requests from church leaders to utilize their churches so that we could improve our service in their communities. We also approached private pharmacies for assistance and the municipality for the use of community halls.
In a systematic and well co-ordinated way, we then spread the project to include several other venues in and around Chatsworth. These included Gateway Clinic; Medina Pharmacy; Montford Pharmacy; Chatsworth Pharmacy; Havenside Community Hall; Montford Community Hall; Sarva Dharma Ashram; Peoples Church of God; Express Pharmacy; Gospel Outreach Asembly; Bayview Christian Fellowship; Church of the Epiphany; Word of Hope Ministries; and Chatsworth Child Welfare.
By April 2012 there were more than 750 patients per day utilizing the service and congestion at the hospital was significantly reduced. We were then able to organize ourselves and provide a more improved service to those patients that did attend the hospital.
| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The project involves a unique partnership between R. K. Khan Hospital and the following:
a) The community organisations who provide the temples and churches for us to use,
b) The municipality who provide us the use of the community halls and
c) The 3 private pharmacies who were part of the pilot project.
Those that formed an integral part of the project were:
- Pharmacy Manager Mr. Brian Pillay who came up with the idea.
- Control Pharmacy Assistant Mr. Dan Maistry helped Mr. Pillay with co-ordinating the project
- The entire pharmacy team helps regularly to ensure that all deadlines are met even if it means working after hours, on weekends and on public holidays to keep ahead of schedule.
- The members and volunteers from the 16 community centres are also an integral part of the project – they continue to provide their venues on a daily basis and also provide invaluable assistance to us at each venue. Without their continued assistance it would be impossible to sustain the project.
- Mr. Gona Moopanar - Member of the Hospital Board, who sourced the 2 venues for us that started the programme
- Reverend Cyril Pillay, Chairperson of the Hospital Board who provided his church for us to use and provides valuable support to the project
- Mrs. Bongi Mkhize the District Pharmacy Manager, who helped to get Esplamed Pharmacy to assist us,
- Esplamed Pharmacy Staff who help with pre-dispensing for 3 sites.
- Our hospital Transport division who assist with deliveries
- Our CEO Dr. PS Subban and Hospital Management staff who supported our initiative
- Mr. Peter Avery and members of the Central Chronic Medicine Dispensing Unit Committee who helped support our project and facilitated the pilot project with the 3 private pharmacies.
| 6. How was the strategy implemented and what resources were mobilized?
We had to source venues in the community which could be used as dispensing points from which patients could collect their medicines. As mentioned, with assistance from a member of the Hospital Board we managed to source the first 2 venues in the community viz Sai Ashram and ABH for issuing medicines.
Since then we had progressed to sourcing a total of 16 different venues 14 of which are still being utilized.
All the venues are provided free of charge for us to use so there is no cost to the state. The only minor costs incurred have been transport costs to and from the different centres.
Assistance with dispensing for 3 of our venues was provided by pharmacists at Esplamed Pharmacy which is a part of the Department of Health.
The 3 private pharmacies assisted with issuing pre-dispensed medicines to patients as part of a pilot project between the hospital, the Department of Health and the pharmacies. As this was a pilot project which lasted for a period of up to 2 years, no additional costs were incurred.
Volunteers at the different venues help to sustain the project. These are mostly retired members who want to give something back to the community. No remuneration is required for their efforts and their assistance is provided voluntarily.
In June 2011, the Department of Health sourced funding from a private organization to fund a lunch and a workshop for the 55 volunteers who assist in the different venues as a token of appreciation for the sterling work that they do in assisting our staff at the outreach centres. At this function the volunteers were also provided with certificates of appreciation.
In July 2013 when our hospital won the All Africa Public Service Innovation Award in the category “Innovative Partnerships in Service Delivery” the Chairman of the Hospital Board orgainsed a lunch for all the project volunteers at his church, The Peoples Church of God in Chatsworth together with certain hospital staff members. Here again the community organisations were thanked for their continued support and certificates of appreciation were provided by our hospital to each volunteer that assists with the project. The function was well received and the volunteers as well as the community organisations involved in the project pledged their continued support.
Routine dispensing of the prescriptions for the different venues is performed by pharmacy staff who sometimes work after hours to ensure that the project is ahead of schedule at all times.
| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
a) Significant decongestion of the pharmacy waiting area - More than 18000 patients are not visiting the hospital monthly to collect their chronic medicines but are utilizing 13 alternative community facilities
FACILITY No. OF PATIENTS REFERRED PER WEEK
Peoples Church of God 300 (Monday)
Word of Hope Ministries 100 (Monday)
Aryan Benevolent Home 100 (Tuesday)
Child Welfare Chatsworth 350 (Tuesday)
Sathya Sai Clinic 200 (Wednesday)
Church of the Epiphany 200 (Wednesday)
Havenside Hall 200 (Thursday)
Bayview Christian Fellowship 250 (Thursday)
Montford Hall 500 (Friday)
Gospel Outreach Assembly 300 Friday)
Sarva Dharma Ashram 50
Gateway Clinic 150 daily
Express Clinic 300 daily
b) Significant improvement in service delivery and patient waiting times
At most community facilities the delay is about 15 minutes which was a tremendous improvement in waiting time. By decongesting the hospital we were able to re-organize and provide a better service to those acute patients that visit the hospital. Waiting Time Surveys show that overall patient delays which were in excess of 4 hours prior to the project have reduced significantly. The average delay in our outpatient area is about an hour with the maximum delay being in the region of 2 hours.
c) Improved access to medicines
There is improved access to medicines for patients as we travel to their community rather than them coming to the hospital. This benefits the patient as they save on time and transport costs
d) Improved working conditions, reduced overtime and improved staff morale
The project has resulted in improved working conditions for staff as the work situation is not stressful as before. This enabled us to attract pharmacists which further improved our productivity and overall service delivery.
Prior to the project staff had to work until after 6pm daily. With the smooth operation of the project work is now generally completed by 5:00pm.
e) Improved publicity in the media
Patients are extremely happy with the service and complaints against pharmacy, which were previously high, are now virtually non-existent.
Prior to the project there was negative publicity about the pharmacy and the hospital in the local media. With the introduction of the project patients responses were very positive.
We also engaged the local press in a positive way by getting them to publish articles to notify patients of the new clinic sites that were in operation.
| 8. What were the most successful outputs and why was the initiative effective?
When the project started in February 2008, and with the introduction of each new facility, it was the co-ordinators of the project, Pharmacy Manager Mr. Pillay and the Control Pharmacy Assistant Mr. Maistry, who visited each site and set it up for dispensing. They also were the ones to initiate the dispensing at each site. Only when the teething problems were sorted out and the new clinic was operating smoothly and with positive reviews from the patients, did they hand it over to other trained staff and they began planning for the next site.
A comprehensive Standard Operating Procedure was also drafted when the first clinic was initiated to assist all personnel involved in the project. The SOP outlines each person’s roles and responsibilities in order to ensure that the project progresses smoothly with little or no inconvenience to the patient.
Staff were also enlightened on the project and those that were due to take over dispensing sites were given hands on training on all the procedures that needed to be followed.
Mr. Pillay and Mr. Maistry visit the clinics on an ongoing basis to monitor the progress, to evaluate the project and to engage with patients and volunteers. Any suggestions or input from patients and volunteers that could assist with improving the project are welcomed and incorporated.
Any transgressions from procedure are brought to the attention of the staff concerned and they are counselled regularly to ensure that the project continues to work as intended.
We also meet regularly with and request weekly feedback from the personnel attending the clinics to ascertain whether there are any challenges that need attention. We also request input from them as to how the service can be improved.
We do adhoc inspections on the different stages of the project from the time the patient is transferred to the clinics to the time they receive their medicines to ensure that there are no flaws in the system.
If for some reason a patient who has been transferred to a facility does not receive his medicines as scheduled, we investigate the error thoroughly to ensure that the problem does not recur.
| 9. What were the main obstacles encountered and how were they overcome?
The challenges experienced were as follows:
i) Initially, some patients expressed reluctance to be transferred to the any other facility but wanted to continue collecting medicines at the hospital. Some felt that their medicines may not be sent to the clinics or that they may not get all their medicines at the clinic. We had to constantly explain to them the benefits of the outreach centres and assure them that all their medicines will be issued and on time.
ii) Patients defaulting and not collecting medicines on their scheduled dates. Patients who default are counseled on adhering to their scheduled dates. “Defaulter” stickers are placed on their prescriptions to alert us and the prescriber to the fact that the patient has defaulted.
iii) Excessive number of patients scheduled at facilities. During public holidays, the service is not operational. Patients are therefore given collection dates for the week before or after the holiday. Hence more patients than usual turn up at facilities. To prevent this from recurring, we try and get alternate days in the week if there is a public holiday and we monitor referral stats to assist with planning.
iv) Venues (community halls) being double booked on some days due to community halls being used for pension payouts. To prevent this, we obtain a schedule from the municipal office listing the pension payout dates for the year to assist with planning and prevent a recurrence.
v) Transport to and from clinics – sometimes there is no hospital vehicle available to transport staff to the clinics. Staff use their own vehicles as and when the need arises
vi) Initial shortage of trained personnel – the training process had to be ongoing so that adequate staff have the knowledge of the operation