Sunday, March 18, 2012

Progress in managing the national injectable drug shortage

Yay for Saskatoon Health Region (SHR) Pharmacists! As I mentioned last time, SHR (along with the rest of the country) is dealing with a shortage of injectable medications.  Pharmacists have the task of managing our region's supply.  Right on schedule (March 13), they created a table of suggested alternative medications to address the shortage of injectable medications.  (Even though I advocated for this in my last post, don't give me any credit, because they were already in the process of creating the table before the idea occurred to me.)

The table has been circulated, posted on the SHR network, and has already been updated.  They also have a plan to track use of injectable medications that are in very short supply and have conversations with physicians using those medications to make sure that alternative administration routes are used as soon as appropriate.

This situation made me think of the Model for Improvement, a widely-used technique for process improvement.

The Model for Improvement has us ask ourselves 3 fundamental questions whenever we want to improve something:

What are we trying to accomplish?

How will we know a change is an improvement?

What changes can we make that will result in an improvement?
 In the case of the med shortage, the answer to the first question is obvious: We're trying to conserve the supply of injectable medications.  At least, that's how it looks from an operational point of view.  Our real aim is may be something like:

We will ensure that patients receive appropriate care and access to necessary medication.  We will do this through careful management of the injectable drug supply and by use of alternative medications and administration routes.

SHR Pharmacists have already given answers to the third question: What changes can we make that will result in an improvement?  They have notified all clinical staff of the shortage and have asked that we consider changes to practice that will conserve medications that may be in short supply.  Further, they've helped us achieve that goal with the alternative medication table mentioned above.  They will have individual conversations with practitioners, if there seem to be opportunities to appropriately change clinical practices.

It's the second Model for Improvement question I'd like to consider further: How will we know a change is an improvement?  This is about measurement.  Or, more accurately, measurement to enable change.

Pharmacists will be tracking use and supplies of injectable medication.  But, as they are not the ones using the medication, that information will have limited use if it's only in their hands.  Clinicians understand the importance of this initiative to appropriately use medication to preserve supply.  We can do a better job if we get feedback on our performance.

Show us whether we (individually, by department, or hospital ward) have made helpful changes to our practice.  Compare rates of use of injectable to non-injectable meds before and after this change initiative.   Have the reminders/exhortations from Pharmacy made a difference?  If so, plot these rates over time so we know whether helpful changes are sustained.  If not, then we need a different strategy.

Take advantage of positive deviation in practice.  Find out which departments/wards are making the changes more successfully and explore how they've achieved that.

Show clinicians that there actually is room for improvement.  I suspect that many docs had the same thought as me when I received the notification about changing prescribing behaviour: I'm already optimally using these medications.  This change doesn't apply to me!

What is the gap between current and desired prescribing behaviour?  If the gap is wide, then let's work to narrow it.  If not, then efforts to change clinician behaviour are a waste of time and we should pursue other change ideas.

Specific feedback will keep clinicians' attention on this important issue.  Without it, emailed updates will become background noise.  


  1. Kishore, I'd really like to see how they've structured the table; it might spark some ideas for other provinces and other projects. Is there a link to the table you could provide that would let "outsiders" see how it looks?

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