R Khan Hospital Pharmacy Decongestion Project
Kwazulu Natal Department of health

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Prior to the implementation of the project, R.K. Khan Hospital Pharmacy waiting area was extremely congested throughout the day. Being one of the busiest hospitals in the province, more than 1800 outpatients used to visit the pharmacy daily to collect medicines, with some patients arriving as early as 3am. In addition to attending to the huge volume of outpatients, pharmacy staff had to dispense medicines to + 300 ARV patients and to about 500 inpatients daily. This huge workload, coupled with a shortage of pharmacists at the time, resulted in extremely long waiting times and frustrated and agitated patients, most of whom were elderly and ill. It also led to staff becoming disillusioned as they had to work in a stressful environment for extended hours to cope with the workload. A large proportion of our patients were stabilized on chronic medicines. These patients were issued with repeat prescriptions for six months at a time. They only needed to be re-assessed by the doctor at the end of the 6 month period at which time their repeat prescription would be renewed. However they used to collect their medicines from Pharmacy every month. As these patients didn’t need to visit the doctor they used to be at pharmacy very early in the morning. Daily at 7am when pharmacy opened, there was in excess of 500 patients waiting for medicines. Our prescription intake would reach 1000 by 10am; 1400 by noon and eventually 1800 to 2000 by 16h00. Despite our best efforts, it was not uncommon to have 500 patients waiting for medicines at any one time. This led to severe congestion in the pharmacy waiting area and it was a mammoth task to get through this workload by the end of the day. Patient delays were very long and it also led to an extremely stressful environment for patients and staff. The potential for dispensing errors was also great in view of the circumstances under which staff had to dispense medicines. Pharmacy used to close after 6pm on a regular basis. Patients and staff who used public transport had difficulty getting home as there was no transport after 6pm. Some patients used to sleep over at the hospital and only leave for home the next morning. This led to ongoing complaints about our service and negative publicity in the local media which made it even more difficult for us to attract staff. At that stage we had almost half of our pharmacists’ posts vacant. In view of the long working hours and the stressful work environment, staff turnover was high. We had to therefore find ways to decongest the waiting area, to improve service delivery and reduce patient delays. We also hoped to get some assistance with dispensing of prescriptions to help reduce our long working hours. Further, we had to try and improve staff morale so that we could retain our existing staff and hopefully attract more pharmacists to our establishment.

B. Strategic Approach

 2. What was the solution?
Mr. Brian Pillay, Pharmacy Manager at R. K. Khan Hospital came up with the initiative to decongest the hospital by using facilities in the community to issue medicines to patients. He, together with Mr. Dan Maistry the Control Pharmacy Assistant, set the project in motion and it was expanded and sustained with the assistance of pharmacy staff. Pharmacy stats showed that almost 50% of patients (more than 800 per day) were stable chronic patients on repeat prescriptions who were only visiting the hospital to collect medicines. These patients arrived very early in the morning and caused a backlog as they could not be dealt with effectively. This resulted in the waiting area becoming very congested throughout the day as more patients came in to collect medicines. It was decided that if we could get the medicines for these chronic patients pre-dispensed and find alternative areas from which to issue them to patients rather than at the hospital, it would alleviate congestion significantly. That was when we decided to use community centres (temples, churches and community halls). We felt that these were suitable venues because their location was known in the community, they had adequate seating, parking and ablution facilities and they were on bus or taxi routes for easy access. In December 2007 we approached the first organization, the Sathya Sai Sudhar Mandhir, a temple in Chatsworth popularly known as the Sai ashram and we outlined our intentions to them. They agreed to allow us to use their premises weekly (Wednesday mornings). We began screening chronic patients and those living close to the ashram were requested to collect their medicines from there on specified dates. Collection times were form 07h30 and 10h00. During the same period, we sought the assistance of Esplamed Pharmacy, a chronic dispensing facility within the Department of Health for dispensing these chronic prescriptions. They agreed to assist us with pre-dispensing and packaging of medicines. On 13th February 2008 pharmacy staff issued the first batch of patients with medicines at the Sai ashram. Patients were extremely satisfied with the venue which was within walking distance from their homes thus saving them transport costs. They also saved time as medicines were pre-dispensed and could be issued to them quickly with appropriate counselling. Where previously patients, most of them elderly, had to arrive very early at the hospital and spend more than half their day waiting for medicines, they now could walk to the facility and collect their medicines quickly. It was almost a “walk-in walk out” service. Lots of positive responses were received and it spurred us on to expand the project. Once this centre was progressing well, we decided to expand following the same processes as before viz. consulting with community centres, screening patients at the hospital and referring them to the appropriate centre to collect their medicines. Within a few years of commencing the project at the Sai Ashram we had expanded to several other centres i.a. Aryan Benevolent Home; Havenside Community Hall; Montford Community Hall; Sarva Dharma Ashram; Peoples Church of God; Gospel Outreach Assembly Church; Bayview Christian Fellowship Church; Church of the Epiphany; Word of Hope Ministries and Chatsworth Child Welfare. We now had a convenient collection point in almost every area surrounding the hospital which patients could access for collection of chronic medicines instead of visiting the hospital. More than 18000 patients are currently utilizing this service and only visit the hospital every six months on their review dates. This reduced congestion very significantly and has helped to improve the image of our hospital.

 3. How did the initiative solve the problem and improve people’s lives?
The concept of utilizing community centres eg community halls, temples and churches as venues for issuing medicines to patients is a unique and innovative one. Patients stabilized on chronic medicines no longer have to wait in queues at the hospital but can collect their medicines quickly and conveniently at centres closer to their homes. Since all facilities are provided free of charge, the cost to the state is virtually nil with only minimal transport costs being incurred. The benefits however have been extremely significant since the routine monthly visits for almost 18000 patients have been reduced to just 2 visits per year. This reduces congestion and creates a less stressful environment within the hospital. It also enables staff to afford a more efficient service to patients. The result is a ‘win-win” situation for both the patients and the institution and an improved relationship with the community

C. Execution and Implementation

 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

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The pharmacy waiting area has been successfully decongested. More than 18000 patients are not visiting the hospital monthly to collect their chronic medicines but are utilizing these alternative collection points in the community. As these facilities operate from 07h30 to 10h00 daily, patient delays are significantly less than what they were at the hospital. At most facilities the average delay is about 15 to 20minutes. Staff have more time to counsel patients and to ensure that they know how to take their medicines as these venues offer a more relaxed and comfortable atmosphere. For some patients it is almost a walk-in-walk-out service. At some venues, the patients’ blood pressure and blood sugar is checked monthly despite the fact that they are on chronic medicines. This was not the case at the hospital. Also at some venues, refreshments are provided for the patients by the community organizations. There is also improved access to medicines for patients as we travel to their communities rather than them coming to the hospital. This benefits the patient as they save on time and transport costs and it benefits the institution as there is significantly reduced congestion. Patients are extremely happy with the service and complaints against pharmacy, which were previously very high, are now virtually non-existent. This has resulted in improved working conditions for staff as the work situation is not stressful as it used to be. This has enabled us to attract additional staff and this further improved our productivity and overall service delivery. Staff morale has improved significantly as the workload, although still heavy, is now under our control. By decongesting the hospital and keeping the chronic patients away we were able to re-organize and provide a better service to those acute patients that visit the hospital pharmacy. Waiting Time Surveys show that overall patient delays which were in excess of 4 hours prior to the start of 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. Prior to the project patients were leaving the hospital well after 18h00 daily. This impacted significantly on their safety as there were no taxis to transport them after 18h00 and some had to stay with relatives or at the hospital Casualty section and go home the next morning. With the smooth operation of the project work is generally completed by 5pm daily; pharmacy has to stay open until the last patient is seen at Outpatient section and very often we have to wait for these patients to get to us after 16h30 as we are up to date with dispensing. The patients thus have adequate time to get the taxis to transport them home. It has also had a significant impact on the amount of overtime worked and the cost of overtime per month. Prior to the project all staff were working until 6 o’clock daily. With the reduced congestion and better planning, there is not much dispensing to be done after 16h30. As a result, we have divided ourselves into 5 overtime groups, one for each day of the week. With staff now being required to work overtime on one day per week only as per their overtime group, they can leave at 16h30 for the rest of the week. Even on the days that they do work overtime, work is completed by 17H00. Since the implementation of the project and the positive responses that have been received from the patients, complaints against the pharmacy have reduced considerably to the point where positive responses now significantly outweigh the negative ones. Some patients who utilize the community centres actually get back to work on time in the mornings as we usually start issuing medicines well before 7h30. Previously they had to sacrifice half the working day or sometimes the whole day just to collect chronic medicines.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Yes, the project is sustainable and transferable. We have formed a “partnership” with the community based organisations and the ones that we are associated with have expressed a continued desire to assist us. We organized a workshop and lunch for them at a private venue in Chatsworth in June 2011. At this workshop with District and Provincial Health Management personnel present, we thanked the community based organisations for their assistance and presented them with certificates of appreciation for the use of their premises and for the support that they afford us and our patients. We also used the workshop to get new ideas from them on how we could improve the service and they pledged their continued support of this initiative. The partnership that we have forged with these community based organisations is long standing. These structures have been operating in the community for extended lengths of time and are well known to our patients. On winning the All Africa Public Service Innovation Award in July 2013 year which was presented to the Pharmacy Manager and the Hospital CEO in Congo Brazzaville, the hospital Board organized a lunch for the members of the community organisations and all the volunteers that assist us. At this function each facility was presented with a framed certificate of appreciation for their efforts in sustaining this partnership. Staff have been adequately trained in all aspects of the project to ensure that it is sustained. They need to ensure that all chronic patients are referred to a community based centre for collection of chronic medicines. From the inception we informed both our Hospital Management and Provincial Health Management staff of our intentions and have kept them updated on a regular basis. We have also forged a good relationship with our Transport Department who have been very helpful in providing transport for pharmacy staff and the medicines on As we have formed a strong partnership with community based organisations, we have managed to sustain the project quite easily. We have received several other offers from other community based centres to utilize their premises for our project and we are considering these. Patients are transferred daily on their review dates to these facilities by pharmacy staff. Because of the reduction in waiting time at these facilities, the improved service delivery and the reduction in transport costs for them, patients are always eager to continue collecting their medicines at these outreach facilities. Community based personnel provide refreshments for patients attending their facilities. Pharmacy personnel are also able to counsel patients more effectively on the correct use of their medicines as patients are more receptive to counseling at these relatively peaceful venues. We have also received support and help with dispensing from Esplamed Pharmacy, a chronic medicine dispensing unit within the department of health. They are currently dispensing for 3 of our facilities and also assisted with dispensing for the pilot project involving the 3 private pharmacies.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Our experience with the project was an extremely rewarding and fulfilling one. As this was a unique initiative that was not tried anywhere else, we could not count on anyone else to provide answers for us but we had to look within ourselves to find solutions to the challenges as and when they arose. It also taught us to look ahead and anticipate what can go wrong and have plans in place to deal with them. The project has taught us that although the task at hand may initially seem enormous and insurmountable, by planning carefully and working with dedication, commitment and most importantly by working diligently as a team we can achieve our goals. The key is to also take things one step at a time, set reasonable targets and once they have been achieved, one needs to extend ourselves and set higher goals. It also taught us that when a long term project is planned you cannot expect instant success and that the situation may actually get slightly worse before it starts to improve. Provided one perseveres and remain focused on the ultimate goal even when things appear difficult, the rewards will surely follow. As a result of the tremendous support we received from the community organisations, we have learnt that the goodwill that exists in the community is phenomenal and that the community organisations (churches; temples etc) really care for the communities that they serve. All we did was contact them and ask for assistance and the response that we got was overwhelming. They were even prepared to offer a whole lot more than what they were asked for. For that, we are extremely grateful and we express our gratitude to them at every opportunity. We also learnt that many people in our communities are willing to offer their services voluntarily to assist others. This is evident by the large number of volunteers (more than 50) who assist our project in one way or another and who have asked for nothing in return. They are just happy to be of service because they want to make a difference to others. Importantly, we have also learnt that we must not be afraid to think “out of the box” or to think differently from the rest to find solutions. By “daring to be different” we can actually achieve more. The project has resulted in a ‘win-win” situation for both the patients and the institution. It has also helped to improve the relationship between the hospital personnel and the community that we serve.

Contact Information

Institution Name:   Kwazulu Natal Department of health
Institution Type:   Government Department  
Contact Person:   Brian Pillay
Title:   Mr  
Telephone/ Fax:   031 4013520
Institution's / Project's Website:  
E-mail:   brianpillay03@gmail.com  
Address:   Road 336,R.K. Khan Circle
Postal Code:   4000
City:   Durban
State/Province:   KZN

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