ENTRY – 01
Hospital Pharmacy Management
DHPM/2017/20 Submission Date : 18/07/2018
PORTFOLIO ENTRY – 01:- Unit 2 & 3 of Module I
Select list of cardiovascular drugs in your annual institutional drug estimate and apply “VEN” analysis to categorize them.
To be able to demonstrate essential medicine concept and rational use of medicine to provide an efficient service as a technical expert in pharmacy.
To gain competency in using limited resources/allocation of an organization in a manner of getting maximum benefits.
Introduction to portfolio entry 01
This portfolio entry, the first entry out of six entries is reflecting on how the selection of the list of cardiovascular drugs in annual drug estimate in Gampaha District and the categorization of those drugs according to the VEN analysis has been done.
According to the definition by Oxford Dictionaries, estimate means an approximate calculation or judgment of the value, number, quantity or extent of something. When it comes to the medicines, the annual institutional drug estimate is the document which includes the estimation of the quantities of each drug required for the following year for a particular institution. Hence, a drug estimate should be processed once a year at the institutional, regional and provincial level.
Mainly, the purpose of processing an annual drug estimate is managing the consumption of medicines with minimizing wastage, pilferage and shortages. Drug management is the process which ensures the drugs are maintained in proper qualities and are made available for the patients when needed. The most vital activity in the drug management is the estimation of drug requirements. However, management of drugs is a collective responsibility as many officers are involved at different levels.
An efficient drug estimate leads the way for a continuous flow of medicines which helps to contribute a proper service to the patients.
Through a properly analyzed estimate, patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time and the lowest cost to them and their community; it is called as ‘rational use of drugs’.
Essential medicines are those that satisfy the priority health care needs of the population. They are selected with drug regard to public health relevance, evidence on efficacy and safety and comparative cost effectiveness.
The selection of essential medicines is one of the core principles of a national drug policy as it helps to set priorities for all aspects of the pharmaceutical system. This can be identified as ‘The concept of essential medicines’.
Essential medicines are always highlighted in health care institutions because of their importance and common use.
The branch of economics that uses cost-benefit, cost-effectiveness, cost-minimization, cost-of-illness and cost-utility analyses to compare pharmaceutical products and treatment strategies; is the given definition for pharmaco-economics. It is an aid to make a better decision when preparing the annual estimate.
To fulfill those needs and cover those situations, the annual estimation should be well planed and also analyzed. So, we use several systems to analyze drugs. This can be happened under their mode of action, meaning the specific way in which the body responds to a drug and chemical structure. In another word, it can be identified as drug categorization.
VEN analysis is one of the main analyses, which we use in categorizing drugs.
VEN analysis is the methodology which can be used to prioritize drugs according to the need.
It was clearly recognized that preparing drug estimates with the help of VEN analysis is a lot easier and more efficient than just preparing the estimates.
This portfolio entry is based on five questions and Kolb’s reflective learning cycle.
Five questions which reflect the whole portfolio are shown below.
What is the learning event?
What did I learn?
What more do I have to learn?
How am I going to learn?
Evidence for learning?
There are four main components (stages) of Kolb’s cycle.
01. What is the learning event?
Selecting the list of cardiovascular drugs in annual drug estimate of Gampaha District and categorizing them according to the VEN analysis is the learning event.
A well planed annual estimate always keeps a continuous accrual of drugs and other pharmaceuticals throughout the year. It collaborates that patients are always treated well.
Over estimation leads to excess stocks which causes drug wastage and pilferage. Under estimation causes shortages. In government health sector in Sri Lanka, annual estimation for each institution prepares in last quarter of the year, exactly in September or October.
As a pharmacist in drug stores at District General Hospital, Gampaha nearly ten years, I could experience preparing the annual estimation from institutional level. After that, as the divisional pharmacist of Gampaha district nearly eight years, I was able to prepare the annual estimation from regional level.
In the past, pharmacists prepared estimates by filling a booklet which includes printed forms and sent those estimates to the Regional Director of Health Services Office. At that time, the VEN analysis was done by the pharmacists in each institution. But, nowadays when the MSD send us the format of the estimate to fill it according to the requirements from institutional level, the VEN analysis has been already applied. Then the divisional pharmacist created the consolidated estimates using those estimates and sent it to the MSD. Currently, the institutions directly send their forecasted monthly requirements to MSD through MSD website. Then, this consolidated estimate is sent to the Divisional Pharmacist by MSD for the corrections and approval. Then the final consolidated estimate is uploaded to the MSMIS system by MSD.
Previously, each institution was given an allocation for estimation. This was done according to five institutional levels, from level 1 to level 5. Level 5 institutions were given the highest value of allocation. When we were analyzing drugs according to their priority and the amount of use, we had to manage that given allocation. But, according to my past experiences, the annual estimate could not be prepared successfully within that financial allocation.
After being the divisional pharmacist in Gampaha, I could work with level 1 to level 4 institutions. Level 5 stands for teaching and general hospitals.
Since 2014 allocation limits were removed and we are carry on a desirable amount of estimation.
Many a time, I experienced that drugs went out of stock and expire before its use. Absence of or lack of sufficient drugs in drug stores lead to poor health care delivery and bad reputation. Thus, I understood the need for planning, designing and organizing the healthcare institution in a manner that results in efficient clinical and administrative services becomes all more pertinent in this situation.
The ultimate aim of this learning event is to gain the ability of categorizing the cardiovascular drugs in the estimate in to three groups such as vital, essential and non-essential, according to the VEN analysis. The Kolb’s Experiential Learning Cycle will be applied for this learning event in the following manner.
When I was preparing the annual estimate, a major problem which has been encountered is how to maintain stocks of drugs without facing problematic situations. The above problem was experienced clearly everywhere and that can be interpreted as facing the first stage of Kolb’s Experiential Learning Cycle which is the “Concrete Experience” stage, where a new experience is encountered.
When further reviewing this experience, which leads to the Kolb’s Experiential Learning Cycle’s second stage, it was recognized that a wrong estimate can lead to major disastrous situations such as no vital drugs in stocks when needed and other issues like over budgetary situations where the actual cost of drugs exceeds the allocated budget and drug wastage due to expiration and hence the wastage of money allocated by the government for drugs. Of course, someone cannot prepare an estimate which is 100% accurate, which doesn’t give the sense to the word ‘estimate’.
Still someone can give a try to prepare a decently accurate estimate by using the techniques to get the prediction values’ accuracy high.
So, the challenge is to prepare the drug estimates in such a way that those estimates can give the maximum benefit with minimal wastage. Kolb’s Experiential Learning Cycle’s third stage is ‘Abstract Conceptualization’, which means learning from the experience and this stage is met when finding the ways to avoid the above-mentioned problems. In this stage, the necessary knowledge will be gained to evaluate each of the drug items in the list as vital, essential or non-essential and the cardiovascular drug list will be categorized accordingly. A comparison of those results with the existing island wide and worldwide categorizations also will be done.
The final stage of Kolb’s Experiential Learning Cycle which is the ‘Active experimentation’ stage will be the stage where the VEN categorization will be put into practical mode in preparing estimates and get the results. The annual drug estimate was previously prepared by calculating the monthly consumption of the drugs. Here, the annual drug estimate will be created by using VEN analysis, while giving more priority to the vital drugs in the drug list.
With this process, I tried to minimize the complexity which arises while the process of preparing the annual estimate.
02. What did I learn?
As mentioned previously, a good estimate avoids many mishaps and erroneous situations. It was clearly identified about the importance of a good estimate and the positive impact of VEN analysis over a good estimate was also recognized.
I realized that VEN analysis is a good tool when preparing annual estimates because VEN analysis sets up priorities for purchasing medicines and keeping stock.
As I learned, VEN analysis can be described as following.
This analysis sets the priorities for selection, procurement and use according to the potential health impact of every drug. VEN analysis assigns each drug on the essential medicines list to one of the following three categories.
V – Vital Drugs are potentially lifesaving and crucial for providing basic health services. Should be available always.
E – Essential Drugs are effective against less severe but nevertheless significant forms of illness but are not absolutely vital for providing basic health care.
N – Non-essential drugs are used for minor illnesses are of questionable efficacy or have a comparatively high cost for a marginal therapeutic advantage.
According to the above categorization, it can be concluded that in the annual estimation process, particular attention should be paid to V and E drugs. Whenever there is a shortage of funds, V and E drugs will be the last to be eliminated from the list.
The VEN classification may directly affect the following scenarios.
Ordering drug quantities
Maintaining safety stocks
Assignment of staff
Rather than just preparing estimates, applying VEN analysis is always good since it gives a vision on how the drugs get prioritized according to their health impact and essentialness. I learned all these things in the third stage of the Kolb’s Experimental Learning Cycle which is called as ‘Abstract Conceptualization’ when I was viewing the deep analysis of the experience I had gained. This deep analysis of the experience was done in the second stage of the Kolb’s Experimental Learning Cycle, which is ‘Reflective Observation’ stage. Applying VEN analysis when preparing the drug estimates was the solution for the problem of creating estimates with a decent accuracy.
In order to categorize the cardiovascular drugs according to the VEN analysis, I learned about the details of cardiovascular drugs such as indications, cautions, contra-indications, side effects, dose and patient information for the drugs which are in the annual institutional drug estimate.
According to the above guidelines, using the VEN analysis, I categorized cardiovascular drugs to gain competency in using limited resources.
Sometimes, the given VEN analysis by the MSD did not match for our demand in Gampaha district. Hence, I changed the category of some items in VEN analysis according to the criteria given below.
Characteristics of Drug or Target condition Vital Essential Non-essential
Occurrence of target condition Persons affected
(% of population) Over 5% 1-5% Less than 1%
(number per day at average health center) Over 5% 1-5% Less than 1%
Severity of target condition Life-threatening Yes Occasionally Rarely
Disabling Yes Occasionally Rarely
Therapeutic effect of drug Prevents serious disease Yes No No
Cures serious disease Yes Yes No
Treats minor, self-limiting condition No Possibly Yes
Symptoms and conditions Has proven efficacy Always Usually May or may not
Has unproven efficacy Never Rarely May or may not
Moreover, I learnt that there are many more drug analyses that can be taken part in the medical industry. ABC analysis is another analysis that is used frequently.
ABC analysis helps in identifying the items that require the greater attention for control. In this,
Group A: – 10% items consume about 70% of budget.
Group B: – Next 20% inventory items take away 20% of financial resources.
Group C: – The remaining 70% items account for just 10% of the budget.
After learning above analyses, I could clearly understand a combination of ABC and VEN analysis (ABC – VEN matrix) can be gainfully employed to involve a meaningful control over the material supplies.
Category I:- includes all V and E items such as AV,BV,CV and AE
Category II:- includes E and B groups such as BE and CE
Category III:- includes the desirable and cheaper group of items such as CN
In these sub categories, the first alphabet denotes its place in the ABC analysis, while the second alphabet stands for its place in the VEN analysis.
Following steps can be undertaken to do ABC-VEN analysis of the drug indent.
Step 1 :- calculating the Annual Drug Expenditure (ADE) incurred on each item.
Step 2 :- analyzing drugs using ABC analysis .For this, the annual expenditure of individual items should be arranged in descending order. The cumulative cost of all the items should be then calculated. The cumulative percentage of expenditure and the cumulative percentage of number of items should be calculated. This list should be then subdivided into three categories; A,B and C, based on the cumulative cost percentage of 80%, 15% and 05%, respectively.
Step 3 :- Analyzing drugs using VEN analysis.
Step 4 :- Finally, a matrix should be formulated by combining the ABC and VEN analysis to evolve a management system, which can be used for prioritization. From the result of the combination, the above three categories can be classified.
It is crystal clear that ABC and VEN analysis identifies the drugs requiring stringent control for optimal use of funds and elimination of out of stock situations in hospitals. When preparing the annual estimate, I paid my keen attention for Essential medicine concept, managing rational use of drugs and applying pharmaco-economics to gain a better and well-prepared estimate.
01.What more do I have to learn?
There’s a lot more which I have to learn.
I intend to research and learn further about more analyses.
Anatomical Therapeutic Chemical Classification System which is also known as ATC Classification System (The ATC Classification system is used for the classification of active ingredients of drugs according to the organ or system on which they act and their therapeutic pharmacological and chemical properties) should also be considered.
It will help me to prepare a more realistic estimate in the future.
How am I going to learn?
I paid my attention so far because of the training program for Diploma in Hospital Pharmacy Management 2017 which includes the training sessions related to the above topic. I’m going to get the maximum benefits from these sessions.
Secondly, I will discuss the related topics with my colleagues. Ideas through experiences are always very precious to seek the most meaningful and efficient answer for each and every question regarding to the drug managing systems.
There are plenty of websites which has information on how to categorize drugs according to VEN and many more analyses. Those websites can be used to gain the knowledge regarding the above topic.
There are already existing categorizations in the internet. First, I am planning to categorize the drug items according to VEN analysis using my knowledge and then I am planning to compare my categorization with the existing categorizations.
04. Evidence for learning
Annual estimate of year 2007 issued by MSD is attached herewith. Previously, the pharmacist had to apply VEN analysis for all drugs which are included in the estimate. (annex 01)
Nowadays MSD apply VEN analysis for all drugs which are included in their estimate, but some are different from our actual needs. Forecasted yearly requirements of some drug items of our district estimate are so high. We have to apply E category instead of N category for these items. Forecasted yearly requirement 2018 of Gampaha district, VEN categorization applied by MSD and deviation for the cardiovascular drugs of Gampaha District have been attached with annex 02.
As the divisional pharmacist, I arrange the awareness programs for all the officers who prepare the annual estimates to their institutions every year. At the current year meeting “Awareness Program for Drug Estimation 2019”, I expect to proceed PowerPoint presentation about preparing the annual estimate 2019 using VEN analysis and ABC analysis and how to obtain maximum benefits with minimum wastage. The soft copy of my PowerPoint presentation is attached herewith. (annex 03)
British National Formulary – 54
Manual on Management of Drugs – Second Revision – 2008
National List of Essential Medicines – Sri Lanka – 2013 – 2014 Fifth Revision