Team Leader: SSN Anbukkarasi D/O Sakadevan Naidu, Team Co Leader : Dr Moosa Aminath Shiwaza Team Member: Dr Shera Chaterji, Ms Chua Liwei, Mr Ron Ang Yee Loon, SSN Yeo Chek Cheng, SSN Ng Ah Mui, SSN Lee Yuet Lai.

Reduce PRINT (Prescription Re – print In Nurse Clinician Service TCU appointment)

Aim : The aim of the project is to explore ways to reduce the

occurrence of missing NCS prescriptions and re-printing of these prescriptions again by physicians.

In Singhealth Polyclinics, Nurse Clinician Service(NCS) is an appointment nurse –based service offered to patients with well controlled chronic medical conditions. Trained nurse clinicians attend to these patients and they endorse the prescription that had already been prescribed by the physician at the previous visit. (Workflow as shown in Figure : 1.)

The aim of this project is to explore ways to reduce the occurrence of missing NCS prescriptions and the re-printing of these prescriptions again by physicians. The aim of this project is to explore ways to reduce the occurrence of missing NCS prescriptions and the re-printing of these prescriptions again by physicians. The aim of this project is to explore ways to reduce the occurrence of missing NCS prescriptions and the re-printing of these prescriptions again by physicians.

The team formed consisted of 4 nurses, 2 doctors, 1 administration staff and

1 pharmacist.

With the implementation of the new workflow, the incidence of missing NCS prescriptions have been significantly reduced resulting in time and manpower savings, as well as a reduction in the frequency of interruptions to the physician.

Patient

Patient to see doctor for chronic medical condition(s) and receive prescription. Submit the prescription to pharmacy and arrange appointment at appointment

counter for next visit to see NCS nurse.

Doctor

NCS eligibility checked and prescription issued as per physician's preference for duration of either 24 weeks or 32 weeks. Post consult slip ticked on NCS column and passed to patient to make next appointment.

Pharmacy

To collect the prescription and check on ‘By protocol-supply half first then the rest after review’. To supply the medication to patient and original prescription to place in the NCS slot at pharmacy.

Nurse

Collect the NCS prescription and check the next date and file in the NCS prescription files according to date and month.

MRO

Admin

As per post consult slip next appointment made for NCS review.

Team feedback and brainstorm session

Cause and Effect using Ishikawa Diagram

As shown in Figure. 3: Three main key factors were identified during the feedback session.

1.Pharmacy staff wrongly placed the NCS prescription into

the stack for storage instead of the one to be returned to the NCS room.

2.The NCS prescription was filed wrongly by the nurse at NCS room

3. Patient was given doctor’s appointment instead of NCS due to being wrongly ticked in appointment (post- consult) slip by doctor or mistakenly wrong service given by the appointment staff.

Pharmacy •To separate ‘NCS prescription by protocol’ from the non NCS prescription.

ISHIKAWA DIAGRAM

Missing NCS

Prescription

PATIENT

DOCTOR

PHARMACYSYSTEM

MRO NURSES

Tick wrong TCU date in post consult slip

Did not indicate in the Prescription by "PROTOCOL"

Dr never order NCS review in Clin Doc and advise to remain OLD NCS Appt

Tick wrong service in post consult slip

Font & shape

small

Gap between the check

box too close

inconsistency in Post Consult Slip

Originalprescription given to patient for partial collection

Prescription filedin to the common pool.

Forward NCS appointment given by NCS during NCS visit date

collect partial medication and did not bringoriginal presciption

Nurse unable to locate presciption from NCS folder

prescription

fi led under different service or date

nurse

unaware how to locate the presreption

Nurse return the prescription to phamarcy if no nurse service appointment made

patient did not make

NCS appt

MRO given dr appointment

instead of NCS

appointmentgiven for wrong service

appointmentgiven for wrong date

MRO given

appointment for di fferent service or date

nurse put

prescriptionunder wrong service or date

patient madeappointment via call center/online

Nurses •On the job training {OJT)

to file NCS prescriptions accordingly at

NCS files.

Doctor •Reminded to tick on the correct box for NCS

appointment.

Senior Admin Staff

Conduct training for their staff to enter appointment correctly

Pharmacy Nurse Doctor Senior

admin Staff

•Continuous monitoring

pharmacy staff to place the

NCS prescriptions at NCS

slots for Nurses to collect

every morning.

•- On going

• Continuous OJT to

place the NCS prescription at NCS files according to date and month by nurse after collection

of NCS prescription

every morning from pharmacy

•– On going

•Continuous OJT for ticking the NCS column correctly.

•– on going.

•Continuous reminder to enter appointment correctly and to keep constant info on ‘remarks’ information if patient not keen for NCS appointment.

• – On going

The multi-disciplinary stakeholders analyze the factor contribute and identified the potential cause the problem; a resultant of cause –effect Ishikawa diagram (as shown in Figure 2).

After brainstorming on the main factors identified, team members agreed on 4 interventions as shown in figure 4.

Figure: 4

Figure. 3:

Intangible Benefits Better care and safe care for patient. Manpower saving in time and enhance for more focus on treatment care. Less disruptions in service quality to patient.

We would like to thank :

Adviser : Dr Hwang Siew Wai.( Director Bukit Merah Polyclinic)., NM Tan Joo See .,NC Zuhaidah Amir.

In a two weeks survey performed in June 2017, it was found that, out of an average daily NCS attendance of 22 patients, 18 of the prescriptions were missing, requiring resources of manpower and time to re-print the lost prescription.

Figure:5

49%

45% 47%

49%

45%

0.81% 0.84% 0.51% 0.31% 0.40%

0%

10%

20%

30%

40%

50%

60%

Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

Percentage reprint NCS prescription

After intervention a three months survey done and the result shown a positive outcome and supported by our stakeholders and core team members.

Intervention Starting point

Figure 2

Final and completion of Intervention

Sustainability period