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Panelists of Clinically Integrated Supply Chains and GHDonline staff

Clinically Integrated Supply Chains

Posted: 12 Oct, 2015   Recommendations: 22   Replies: 64

When a supply chain system is functioning well, it is a hospital’s silent partner: drugs and supplies are manufactured, purchased, transported, shipped through customs, unloaded, inspected, and stored in an efficient and reliable manner. It is only when a supply chain system breaks down - for example, when a necessary antibiotic is stocked out or expired - that health care providers usually take notice. Unfortunately, poorly performing supply chains are all too common, especially in low and middle income countries. Many organizations in these countries have supply chain systems that rely too heavily on existing staff who may not have the time, motivation, or formal training to complete core supply chain operations. Some argue that clinicians should take an active role in the decision-making related to their organization’s supply chain practices.

To discuss strategies for building clinically integrated supply chains, GHDonline is pleased to welcome the following panelists for this Expert Panel, hosted from October 19th - 23rd:

• Oluwaseun Ayanniyi, CSCP, MS, B.Pharm - Quantification Advisor, SCMS project at Partnership for Supply Chain Management (PFSCM)
• Yasmin Chandani, MPH - Project Director, inSupply at John Snow, Inc
• Jesse Greenspan, MSPH - Planning Manager for Haiti at Partners In Health
• Scott Kellerman, MD, MPH - Clinical Advisor, Partnership for Supply Chain Management
• Andrew MacCalla, MA - Director, International Programs & Emergency Response and Prep at Direct Relief
• Luis Martinez Juarez, MD, MPH - Director of Operations for Mexico at Partners In Health


During our week-long discussion, panelists will address the following questions:

1. How can a healthcare organization involve clinicians in the supply chain operation without overburdening them?
2. How does your organization bridge the gaps (technical, communication, etc) between clinicians and supply chain experts?
3. How does your organization help clinicians balance supply chain responsibilities alongside their primary responsibility of providing quality patient care? How can you persuade reluctant clinicians to become engaged in supply chain management operations?
4. What training, systems, and standard operating procedures has your organization adopted to ensure that clinicians become effective members of the supply chain operation?
5. What are some of the key benefits of a clinically-integrated supply chain? What evaluations have you implemented regarding the impact of clinically-integrated supply chains?

We look forward to a rich discussion next week – please join the conversation and share your questions or comments!

Replies

 

Fisseha Eshete Replied at 9:39 AM, 12 Oct 2015

Thank you this is very important topic for discussion,am happy for this as
this is the part of quality health services improvement

Usman Raza Replied at 9:47 AM, 12 Oct 2015

This is a very relevant topic for LMIC. We frequently come across supply
chain weaknesses in our field projects involving medicines as well as other
commodities. Looking forward to this interesting discussion.

Amado Alejandro Baez Replied at 9:48 AM, 12 Oct 2015

Very important topic. We will have our Santo Domingo Health Cluster www.
clustersaludsd.org actively participate in this important discussion

AB

Maimunat Alex-Adeomi Replied at 11:07 AM, 12 Oct 2015

Great topic.

Sukumar Cvhakrabortty Replied at 3:45 PM, 12 Oct 2015

It's very much important for a Hospital to develop a supply chain system to run all activities smoothly. Until the well supply chain system get functioning , no good result may be expected. So, it's a very important issue to develop the system. In a hospital, many things are involved to play a good supply chain system. If we think, why there is not good supply chain system, we have to verify how is the management system as well . How is data base system, how is the inventory system, how the data base generate report and who are responsible to check the day to day activities. Normally, it's a common practice in a pharmacy to minimum stock level, maximum stock level, reorder level, how the expiry items are checked. So, until the management system is developed and accountability system is developed, supply chain system will not work properly. But it is very much important issue for a hospital to develop the supply chain system.
In some cases , Our experience go that there are many many items in a hospital and if we want to develop a strong supply chain system, everything will be modern computerized in place of manual system,development of daily monitoring system and make accountable the persons for negligence of performance. If we can remove all irregularities , it's possible to develop strong supply chain system.

Sukumar.

John Elianu Replied at 3:44 AM, 13 Oct 2015

very important topic. I hope to learn and share a lot.
Issues of stock outs are affecting provision of quality health care
Thank you.

Luis Azpurua Replied at 8:58 AM, 13 Oct 2015

This is an important topic.

For us the supply chain system is the Hospital's "back office". Usually not visible for the clinicians who are in the Hospital's "front office" working with patients and utilizing medicines, medical consumables and so on in order to treat the patient. Most of the time they don't worry how these items that they use are there when they need it.

My question is very basic: what would be the clinician's role in the supply chain system decision-making?

Jeannette Guarner Replied at 10:24 AM, 13 Oct 2015

How can clinicians help?
They should advocate to their hospital administration/ governments to have the services they need to take care of their patients. The advocacy should include reagents for laboratory and radiological tests, medications, vaccinations, etc. I would say that hospital administration and governments tend to listen more to those taking care of patients (clinicians) and patients, than to the few of us that work in any of the testing arenas or pharmacy.

Edward Krisiunas Replied at 4:15 PM, 13 Oct 2015

Good afternoon all..

I have been involved in one component of supply chain management that is
not often discussed..waste disposal. I have been involved in looking at
disposal of pharmaceuticals ( expired/unused/damaged) as well as donated
supplies in a number of countries such as Haiti, Namibia, Tanzania and
Ethiopia. I am headed to Ethiopia in December to further work with FMHACA
that deals with the pharmaceutical management. I have done this through
SCMS along with other groups. Waste management remains a challenging issue
in low to middle income countries. There are some creative ways of
ensuring pharmaceuticals are not wasted but tackling the issue before it
becomes an issue is the obvious solution - which this group will be
discussing....implementation is the more difficult task.

Look forward to the feedback...

Elizabeth Glaser Replied at 6:04 PM, 13 Oct 2015

Edward glad of your participation. I appreciated your past contributions to the discussion in the Ebola response community on waste and sharps disposal, the hidden side of supply chain management.

Elizabeth

Justin Miranda Replied at 11:19 PM, 13 Oct 2015

In preparation for next week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address next week. Looking forward to a great discussion!

Justin

Attached resources:

AUSTIN GUMBO Replied at 1:39 AM, 14 Oct 2015

This is a welcome topic and I can't wait to learn best practices across the world.

Ade Yahya Replied at 3:44 AM, 14 Oct 2015

This is a great topic. I this that an effective integrated supply
chain will involve clinicians and the different staff member and
especially people working in IT. A system that is used in retail could
be developed where every time the clinician uses an items it will
automatically generate a shortage and then ordering. But with this my
best guess is that clinicians will raise the issue of time.

Judith Thermidor Replied at 8:00 AM, 14 Oct 2015

All my compliments for this powerful topic. An adequate health care supply chain management is the starting point to combat disparities and inequalities in healthcare system.
Thanks for raising this topic, I can't wait to participate.
Judith

Kurt Figueroa Replied at 4:07 PM, 14 Oct 2015

This is a very important topic, i am well pleased with the invitation.

It is true, an efficient way is important, also communication and a proper
IT program, i understand it is quite difficult to address a well
functioning supply chain in rural areas due to environmental situations,
road blockages and so on, but still, there are ways to get the supplies and
the reports on time and also in urban areas sometimes turns difficult due
to providers issues or missinformation.

I will be more than glad to listen and attend to all your expert
recommendations and learn about more efficient ways to improve.

It has a lot of benefits within.

Regards from Mexico City

A/Prof. Terry HANNAN Replied at 4:39 PM, 14 Oct 2015

I am going to try and post some ideas that I hope are not totally naive and are based on my experiences as a clinician-physician. These thoughts are stimulated by the introduction of HIT into the discussion.
The demand for and use of resources are driven by "the demands of care". It is therefore necessary to "capture the data of resource utilisation during patient care". It is then the requirements for resource supply and demand can be more clearly determined. For example the number of blood counts ordered or MDRTB tests or medication doses required can begin to be formulated and done do in advance over time because the "monitoring of supplies" occurs in association with real-time use in the delivery of care.
Please inform me if this is too simplistic an idea or approach. It was this model we used in Kenya in the early stages of the MMRS project that led to ampath.

Ashley Canchola Replied at 9:47 AM, 16 Oct 2015

Looking forward to the discussion!

Elizabeth Glaser Replied at 10:25 AM, 16 Oct 2015

Terry,
As someone who also has only a passing knowledge about supply chain, I think it is an iterative process.
HIT can both improve ordering and tracking, allowing us to better plan services,and helping us find the gaps or bottle necks in the process after the fact.

Elizabeth

Sandeep Saluja Replied at 11:16 AM, 16 Oct 2015

I have been associated with low resource and very remote areas.Often one has to make trips to the cities to procure supplies and that too often substandard.I wonder if it would not be a good idea to have online stores run by reputed organisations for supplies needed by medical establishments in such areas?All such supplies should be available at one site.To restrict unwarranted rush,only approved organisations may be permitted to purchase from such sites.
Of course,it would then be important for the sites to have delivery mechanisms for such areas.

Patrick Jouissance Replied at 11:39 AM, 16 Oct 2015

Thanks to GHDonline for the invitation to participate to this pertinent topic discussion.
Fruitful comments will certainly emerge from our group.

John Mhango Replied at 11:43 AM, 16 Oct 2015

Thank you very much. Looking forward to interact with fellow clinicians on this topic.

Gueilledana PAUL Replied at 12:18 PM, 16 Oct 2015

Thank you for this topic discussion. I will be happy to share some ideas.

Gueilledana

Hannah Faal Replied at 12:48 PM, 17 Oct 2015

In question 3. it is rightly pointed out that the clinicians primary
responsibility is the provision of quality patient care. The supply chain
system discussion seems to cover from manufacture to storage. In the LMIC
there could be many more slips between the stage of the clinicians
presription up to the patients ingestion/application/utilisation. To
ensure quality patient care, the clinicians should be concerned with the
stages beyond storage.

Manufactures in their packaging, labelling, information documentation of
drugs and other pharmaceuticals have largely responded to the health
system, health workers and the legal requirements stipulated largely by the
developed countries.

At the end of the supply chain are the patients and their carers. In the
developed countries, because the literacy level is high, it is presumed
that the packaging, labelling and instructions are fully patient
responsive. I do not know how or if any checks are done to ensure that the
packaging, labelling or instructions are ALL patients responsive/friendly
who are the the consumers at the end of the supply chain.
Universal health coverage will mean reaching the invisible in the
population; the illiterate, poor, non health educated, far removed from the
health worker and health services who will be given drugs and at best a
busy health worker's instructions. In most of the remote locations it will
be the corner patent drug store. All the patients and carers go with the
drug and maybe a package and figure out how to use the item when they get
home. In typical homes, drugs get shared get used in others who seem to
have a similar problem.
Recently a tragedy occurred in West Africa when an umbilical chord
dressing medication/drops/ointment were dispensed in dropper and tubes
identical to eye drop bottles and ointment were The mothers used the item
for the umbilical chord and since it also looked like eye drops,they used
the drops on eyes which looked infected/red. The drug was used for eyes
of babies and children with disastrous consequences, the corneas were
destroyed, The babies and children went blind.
The parents were illiterate, poor and were from very rural villages. They
could not read whatever was on the packet, bottle nor information paper.
The tragedy is worse because a prevention strategy in otherwise healthy
children ended in a lifetime disability.
This example addresses the level of literacy. I have watched persons with
various forms of disability especially visual impairment struggle to see
the very fine print in poor contrast on packages, bottles of drugs.

Until the drug manufacturers see that the end of the supply chain is the
patient and carer, especially the illiterate, un reached and poor and do
the required market research which ensures that the packaging, labeling and
instructions employ communication methods relevant to that crucial
component of the market, be it visual pictorial info-graphic, we will not
have applied the spirit and intent of UHC.

The clinicians should also look at this section of the supply chain. The
policy makers and drug regulatory bodies should put the framework in place
to test and monitor.
In summary
The discussion this week should discuss the supply chain to the end of the
chain;the patient and the carer.
The clinicians' primary responsibility is quality patient care and that by
implication must include this extension of the supply chain.
Equity demands that the packaging, labeling, information and especially the
instructions should look at the communication methods which respond to ALL
especially the invisible - the illiterate, the poor in our remote rural
areas and urban slums. This is entirely possible as it has been used by
marketers on other products.
The clinicians should drive this change.
Hannah Faal
Main interest is in international eye health, health systems and community
health.

Yustina Tizeba Replied at 2:42 PM, 17 Oct 2015

thanks for the very important discussion

Luis Martinez Panelist Replied at 12:46 AM, 19 Oct 2015

Any organization has something in common, and this is regardless if it is governmental or not governmental, privet or public, big or small, profit or non-profit, etc; and this common thing is that all of them have a value chain, which according to Michel Porter, it is the set of activities and actions that a given organization needs to perform in order to deliver a given value product or service. In other words, any value chain is constituted by all the members of the organization with all the actions that all the members and stakeholders need to perform in order to offer a given product or service.

I mention this because in my perspective the supply chain is one of the most important components in any value chain because it is what moves any product or service from the supplier to the final costumer; however, the important thing here is that all the members of the value chain that have participation in the creation and delivery of the [health] product or service are equally important to any other member of this chain because its absence jeopardize the delivery and/or the quality of this given product or service; therefore, if any member of the value chain has the same value in all the process, then its presence in the supply chain is equally important because at the end of the day, a functional supply chain is what could cover in an efficient way all the necessities of all the members that are working to deliver the final product or service.

The understanding of these premises is really important because the answer to the question “how can a health organization involve clinicians in the supply chain operation overburdening them” have the same answer for clinicians and for any other member of the in the value chain, and the answer is by limiting and standarazing the participation of the clinicians and any other member to just develop the work that they need to do in the design, planning and analysis of the supply chain and the value chain.

Usually, clinicians have other activities in the value chain, and must of the time they are the most important actors that have interaction with the patient [client]; therefore, their perspective become essential in the design of the most adequate supply chain, but the answer is the same, even that their participation is essential, this participation needs to be well identified and limited in the same process of design and development of the supply chain. In other words, if the design and revision of the supply chain protect the participation and time of all their members then it would be very difficult that they could be overburden; and this action is really important not only for the dupply chain but also for the rest of the processes.

What do you think?

Yasmin Chandani Panelist Replied at 8:35 AM, 19 Oct 2015

Thank you for a very lively discussion. First and foremost, based on our experience working in resource limited settings as well as learnings from my clinical colleagues who have worked in hospital settings in urban, high resource environments, its important that as much as possible routine supply chain tasks should be handled by dedicated supply chain staff and not clinicians and this is true for developing and developed settings. This serves the dual purpose of ensuring that supply chain staff have the knowledge and skills to perform their tasks and the supply chain runs smoothly, and leaves clinicians free to play the valuable role of serving clients.

However, clinicians do play an important role in supply chains. Tasks that are important for them to be involved in include
1) designing supply chains,
2) drug quantification and forecasting - planning
3) they should be trained in how and why the supply chain works as it does (even if they don’t have a routine role in the supply chain) so that they are appropriate advocates and champions for the supply chain
4) they should know how they can access health products easily in the case of an emergency or a stock out i.e. they should know who to contact,
5) they also should have the ability to provide feedback on the supply chain procedures and opportunities to provide ideas on how it could be improved.

Do you think there are other key tasks we should add to this list?
In my Australia pharmacist experience nurses were typically the ones that end up interacting with the supply chain the most and they rarely had any training and often had no real inclination towards supply chain tasks. It was best to have supply chain dedicated staff and not pharmacists doing supply chain. We always tried to routinize supply chain procedures as much as possible but also be adjusting our processes to try and make it easier for the clinical staff - serving the customer and to stop their grumbling. In hospital you always had dedicated pharmacy technicians who would be responsible for supplying the wards and they would have routine supply procedures, plus there would be various ways nurses could “order” emergency supplies, e.g. writing it on a notepad, paging the pharmacist etc.

Yasmin Chandani Panelist Replied at 8:39 AM, 19 Oct 2015

Related to my previous post, I just want to add that while routine supply chain tasks should be handled by dedicated supply chain staff, the nurses (and possibly other clinicians) will always have a role when the supply chain breaks down at the patient level. A nurse at a renowned university hospital in the U.S. describes her role as the “gatekeeper”, “problem solver”, “buffer” for her patients to advocate for and ensure the quality of care they receive. Even with highly sophisticated, electronic ordering and dispensing systems, glitches can and do happen (e.g. the drawer in the medication carousel won’t open) or when there are stockouts (there was a national stockout of normal saline for IV infusion), it’s the nurses who make the emergency calls, run down to the pharmacy, borrow from other wards or patients etc. This will not change. Thus the importance of them knowing how the supply chain works and where to access products.

In higher resource settings, nurses contribute to forecasting hospital drug needs by completing risk management assessments of their patients. This patient profile data is then used in an algorithm to determine upcoming drug needs (e.g. during flu season). Nurses also provide feedback on drug effectiveness and side effects in their patients which is used to inform drug selection decisions by physicians and hospital procurement units. Again this may not always translate to low resource settings where a standard list for the entire country is used, which is why involving clinicians in supply chain design is important.

Luis Azpurua Replied at 9:06 AM, 19 Oct 2015

Yasmin, excellent post.

I would add the role of clinicians in assessing the quality of the products they are consuming. Nowaday in our country (Venezuela) it is very frequent to have consumable and medicine shortages. So we have to to implement the "B" or "C" plan in order to get it and don't stop healthcare delivery.

Oftentimes we find in the market a consumable brand that we have not tested/used to replace the shortage. In this situation the clinician's opinion / approval is imperative in order to acquire it.

Kabba Joiner Replied at 9:26 AM, 19 Oct 2015

Can't agree with you more. Nurses DO have a critical role to play in the supply chain, even in resource challanged settings. This has been my experience in Liberia, with limitted medical manpower.

Oluwaseun Ayanniyi Panelist Replied at 10:11 AM, 19 Oct 2015

Thanks for everyone for a great discussion so far.

In addition to what Yasmin has stated, an additional area where clinicians play a major role especially in limited resources settings is data collection. Logistics data is required when making supply chain decisions and data will needed to be collected by Nurses, Pharmacists, community health workers, laboratory scientists etc at point of care where these commodities are dispensed or used. The data collection process can be cumbersome due to the multiple forms that may need to be completed. Involving clinicians in the supply chain design process will help streamline data collection.

Clinicians should interface regularly with the supply chain experts to obtain information on the performance of the supply chain and how it impacts patient care. This strategy has been particularly helpful in HIV/AIDS programs where the changes in treatment guidelines have impacted the supply chain. Involving both clinicians and supply chain specialists in the decision making process during the quantification process or strategic planning on when to phase out an existing regimen or introduce a new regimen will help ensure that existing stocks are depleted in a timely manner while adequate stocks of the medicines for the newly introduced regimens are available.

Scott Kellerman Panelist Replied at 10:45 AM, 19 Oct 2015

Fascinating discussion. I think Yasmin hit on the points I've been thinking of. While clinicians certainly do have a role in SC, the expectation of how big that role might be is a point of disagreement in the posts I've read so far. Having designed HIV programming and worked in many less resourced settings, i can say that the doctors and nurses are generally quite absorbed with day to day patient care and all that entails. To expect those folks to expand their role beyond certain critical areas may not be realistic or fair. HR issues are a constant concern and I worry about overburdening further already overburdened staff.
So certainly clinicians need to be aware of and consultants for which regimens are most used (regardless of disease), and shifting guidelines to inform procurement. They need to provide critical inputs as to inventory, to minimize stockouts, expiry, etc. Too often, the "back of the house" admin, procurement, etc. is divorced from those actually delivering hands on patient care, and I think there is room to improve this communication, but am equally concerned about putting further responsibility on clinicians. Thoughts?

A/Prof. Terry HANNAN Replied at 11:06 AM, 19 Oct 2015

Scott, a wonderful posting. You highlight the first of the requirements described by Mamlin and Biondich for the success of eHealth systems. COLLABORATION
DESIGN GOALS FOR COMPLEX E-HEALTH SYSTEMS
[Taken from OpenMRS]
COLLABORATION:
SCALABILITY / SUSTAINABILITY:
FLEXIBILITY:
RAPID FORM DESIGN:
USE OF STANDARDS:
SUPPORT HIGH QUALITY RESEARCH:
WEB-BASED AND SUPPORT INTERMITTENT CONNECTIVITY:
LOW COST: preferably free/open source
CLINICALLY USEFUL: feedback to providers and caregivers is critical. If the system is NOT CLINICALLY USEFUL it will not be used.

AMPATH Medical Record System (AMRS): Collaborating Toward An EMR for Developing Countries Burke W. Mamlin, M.D. and Paul G. Biondich, M.D., M.S. Regenstrief Institute, Inc. and Indiana University School of Medicine, Indianapolis, IN

Hannah Faal Replied at 12:28 PM, 19 Oct 2015

Mine is not a direct reply to Terry's but a posting which I think was sent to the wrong address copied below.
We do need to delineate where the supply chain begins and ends; it needs must be taken beyond storage and up to the patient and family/carers. My comment is on such an extension.
In question 3. it is rightly pointed out that the clinicians primary responsibility is the provision of quality patient care. The supply chain system discussion seems to cover from manufacture to storage. In the LMIC there could be many more slips between the stage of the clinicians prescription up to the patients ingestion/application/utilisation. To ensure quality patient care, the clinicians should be concerned with the stages beyond storage.

Manufactures in their packaging, labeling, information documentation of drugs and other pharmaceuticals have largely responded to the health system, health workers and the legal requirements as stipulated largely in the developed countries.

At the end of the supply chain are the patients and their carers. In the developed countries, because the literacy level is high, it is presumed that the packaging, labeling and instructions are fully patient responsive. I do not know how or if any checks are done to ensure that the packaging, labelling or instructions are responsive/friendly to pateints and carers who are the the consumers at the end of the supply chain.
Universal health coverage will mean reaching the invisible in the population; the illiterate, poor, non health educated, far removed from the health worker and health services who will be given drugs and at best a busy health worker's instructions. In most of the remote locations supply will be from the corner patent drug store. Patients and carers go home with the drug and maybe in its package and figure out how to use the item when they get home. In typical homes, drugs get shared and get used by others who seem to have a similar problem.
Recently a tragedy occurred in West Africa when an umbilical chord dressing medication/drops/ointment dispensed in dropper and tubes identical to eye drop bottles and ointment were used by mothers/carers on the eyes of babies and children which looked infected/red. The consequence? corneas were destroyed, The babies and children went blind.
The parents were illiterate, poor and were from very rural villages. They could not read whatever was on the packet, bottle nor information paper.
The tragedy is worse because a prevention strategy in otherwise healthy children ended in a lifetime disability.
This example addresses just the level of literacy. I have watched persons with various forms of disability especially visual impairment struggle to see the very fine print in poor contrast on packages, bottles of drugs.

Until the drug manufacturers, policy makers, regulatory bodies and clinicians see that the end of the supply chain is the patient and carer, especially the illiterate, un reached and poor and do the required market research which ensures that the packaging, labeling and instructions employ communication methods relevant to that crucial component of the market, be such methods visual pictorial info-graphic, we will not have applied the spirit and intent of UHC.


In summary
The discussion this week should discuss the supply chain to the end of the chain;the patient and the carer.
The clinicians' primary responsibility is quality patient care and that by implication must include this extension of the supply chain.
Equity demands that the packaging, labeling, information and especially the instructions should look at the communication methods which respond to ALL especially the invisible - the illiterate, the poor in our remote rural areas and urban slums. This is entirely possible as it has been used by marketers on other products.
CLINICIANS SHOULD DRIVE THE CHANGE.
Hannah Faal

Yudha Saputra Replied at 1:01 PM, 19 Oct 2015

Thank you Rebecca and GHDOnline for the invitation. It’s an honor to join this fruitful and lively discussion.

Personally I do still lack of knowledge in field of supply chain. What I understand so far is how can we provide every necessity of healthcare service (medicine, medical tools, systems, etc. ) in time with low cost, high quality, and sustain. In my practice, we were not just delivering medicine to patient, but also to clinic and other healthcare professional who practice in professional. We selecting the medicine from distributor and sub-distributor of pharmaceutical then store it in our warehouse. Not mention to naive, we make differences about pricing. If it’s for patient who middle up (not use health insurances card or not provide proof of people which income under national standard salary), we make it higher. If it’s for physicians or other healthcare professionals and patient with low income, we make it lower. We do need to give the best medicine as we can so they can reach expected clinical outcomes, meanwhile our business can keep running to the peak. To help grow our business, we try to innovate like selling some primary, secondary, and thirdly necessity of society such as diaper, cotton bud, and other stuff like in mini market. This kind of thing we done because we try as best as possible not give patient too high standard of price of medicine.

In the mean time, price of medicine depends of several thing I only now until today is currency value of USD and rate of slow or fast moving of medicine. Active ingredients of medicine, even we have our resources, we don’t have the machine to produce it, thus that we import it from other country. While dollar weakening, our national value currency is significantly goes up, and automatically affected in price of goods and service. Even it’s just a few percentage, it’s sure become a quite burden for clinicians when their patient ask them how much does the medicine cost. Rate of slow moving medicine make that medicine become expensive, because not many demand but high supply. Storing medicine it’s really depends on expired time, temperature level, and quality of medicine itself. If it’s fast moving, the stock of warehouse will always be refreshed, rather than the slow one. Slow and fast also depends of what kind of illness is spreading. If it’s flu season then it’s flu encounter medicine with some of immunomodulator agent, but if it’s season where Herpes spreading everywhere, anti-virus is fast moving.

One that become my concern, I’m not sure if it’s correlated in this discussion or not, is the over-use of antibiotic. I’m currently join online course that taught about social entrepreneurship. I’m interested in how can we address this over-use issue, with approach of health technology and social business. If about this discussion, will this discussion could lead to answering how to controlling over-use issue of antibiotic, with supply chain management approach perhaps?

In my narrow experience in pharmaceutical intership session, supply chain is about how to get things done quicker and better. Need critical analysis, business mindset, and strategy to harmonizing both internal and external sector who play role key of this system. It’s more on management skill and instinct of how to solve complex things in simple way. Let’s consider supply chain is a team in hospital. In my personal opinion, they need to learn supply chain strategy, effective planning, and grow their business instinct. If it’s like ordering flu medicine while summer season coming, I can’t imagine how purchasing department will stay calm considering all of those boxes of medicine is approaching it’s expired date.

I hope this discussion can enrich us with positive knowledge and could help us to improve our quality of delivering care. Let the fun begin!

Regards,

Yudha
Pharmacist
Indonesia

A/Prof. Terry HANNAN Replied at 1:46 PM, 19 Oct 2015

Yudha, your comment "One that become my concern, I’m not sure if it’s correlated in this discussion or not, is the over-use of antibiotic" on the Integrated Supply Chain does fit into this discussion because the 'supply' is dependent upon the 'demand/use' of the antibiotics.
The demand/use element of this 'chain' is driven more by individiual physician preferences rather than scientific knowledge. This is a well documented phenomenon in publications relating to unsupported/inadequately supported Clinical Decision Making [CDM] and the wide variations in health care costs and quality [see John Wennberg].
Here is some data where CDM is adequately supported that I believe is relevant to your points and this discussion in general.

Computerized Clinical Decision Support
REAL TIME CLINICAL DATA TO IMPROVE COSTS/QUALITY/OUTCOMES/RESEARCH

Overall antibiotic use: decreased 22.8%
Mortality rates: decreased from 3.65% to 2.65%
Antibiotic-associated ADE: decreased 30%
Antibiotic resistance: remained STABLE
Appropriately timed preoperative a/biotics: 40% to 99.1%
Antibiotic costs per treated patient: decreased $122.66 to $51.90
Acquisition costs for antibiotics: fell 24.8% to 12.9%
($987,547) to ($612,500)

Our Case-Mix index which measures patient acuity levels INCREASED during this period, meaning we were treating sicker and sicker patients while better utilizing the delivery of antibiotics.


Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15

Jesse Greenspan Panelist Replied at 5:38 PM, 19 Oct 2015

Hello everyone. I am excited to participate in this conversation and just wanted to briefly introduce myself and then provide some thoughts on question 1 below. I have been working on supply chain management with Partners In Health (PIH) for over five years. From 2008-2010, I was providing support to our programs in Haiti, Malawi, Rwanda, and Lesotho, including purchasing and handling shipping logistics. After the earthquake in Haiti in 2010, my job became focused on the relief effort and coordinating the high volume of in-kind donations that PIH received during that time. From 2012-2014, I moved to Haiti to roll out a supply chain management system, OpenBoxes and worked closely with the clinical and pharmacy teams to improve our ordering accuracy and implement new processes. I am now based in our Boston office and continue to focus on supply chain optimization in Haiti.

In response to question 1, I think it is always a balance of adding work to the clinical team but at the same time being reliant on this team to ensure that we are ordering the correct products and the correct quantities. Some systems that we have put in place that I think are mutually beneficial to the supply chain and clinical teams are:

1. Formulary committee—This committee has been essential during the opening of our new tertiary care hospital in Haiti. As we add new services, we depend on this committee, made up of doctors, nurses, and pharmacists, to tell the supply chain team what additional products are needed, including the estimated quantity based on expected patient volume. Implicit in the goals of this committee is also to maintain our formulary for Haiti. A formulary has proven to be an essential tool for successful supply chain management because it takes the mystery of knowing exactly which items are to be kept in stock at all times versus products that are discontinued or purchased for specific cases.

2. Stock lists—These are lists of products that each facility, and ward within that facility, need to operate on a daily basis. The list also includes a maximum quantity needed for the replenishment period. Having the maximum quantity helps us avoid having peaks and valleys in demand that can throw off forecasting down the road. The clinical team is essential in building these stock lists based upon their knowledge of patient needs.

3. Requisition system based on stock lists—A key part of our requisitions that is captured in our supply chain management software, OpenBoxes, is recording a need even if we are not able to fulfill that need due to a stock out or low stock. This allows us to include unfulfilled need in our forecast so that we are not always playing catch-up and have a more realistic picture of true demand.

Looking forward to hearing if others have implemented similar processes and the experiences they have had.

Jesse Greenspan Panelist Replied at 5:40 PM, 19 Oct 2015

In response to Luis Azpurua's comment about quality, I think this is an excellent point. We rely on the clinical team to provide feedback if a product procured is not of adequate quality. People who work in procurement can then note that this is not a preferred product, so that it is not purchased in the future. This is an area where clinical knowledge is absolutely essential to making correct purchasing decisions.

Maimunat Alex-Adeomi Replied at 6:48 PM, 19 Oct 2015

Hello Jesse,

At Sanford International clinics, Ghana. We used these same 3 systems you mentioned above after we were having several stock outs and wastageof non-fast moving supplies.

It is still a work in progress but has greatly improved availability and quality of supplies.

Maimunat

Andrew MacCalla Panelist Replied at 11:17 PM, 19 Oct 2015

Hi All,
Very sorry to be coming late to this panel as a panelist but I'm excited to be a part of it and provide a brief intro about my background. I'm currently Director of International Programs and Emergency Response for Direct Relief. Direct Relief’s mission is to improve the health and lives of people affected by poverty or emergency situations by mobilizing and providing essential medical resources needed for their care. We receive donations from over 100 medical manufacturers, as well as procure and manufacture our own items, and provide them to hospitals, clinics, healthcare networks, non-profit pharmacies, and Ministries of Health in 75 countries as well as to Community Health Centers in all 50 US States. In all, we ship out an equivalent of a 20 foot ocean container every day with that greatly increasing during emergencies. We use SAP to run our inventory systems which handles over 18,000 SKUs, along with a CRM interface for the donors and recipients to order. We can talk about this in tomorrow's discussion.

I was the Warehouse Manager and then Operations Manager at our headquarters in Santa Barbara, CA before stepping into my current role. I spent two years in Haiti after the 2010 earthquake as the coordinator of Direct Relief’s response – the largest humanitarian effort since the organization was founded in 1948 – managing the supply and distribution of over $150 million worth of medical materials from our Port au Prince warehouse in five years. More recently, I was on the ground responding to Hurricane Sandy in New York, the tornadoes in Oklahoma, flooding in Colorado, Typhoon Haiyan in the Philippines, the Ebola crisis in Sierra Leone and Liberia, and the Syrian refugee crisis in Jordan.

Very happy to be a part of the discussion and learn more about all of this.

Judith Thermidor Replied at 12:01 AM, 20 Oct 2015

Greettings
it's an essential topic.
If we consider the lack of infrastructure is a blockage in low- income countries for the quality and availability of healthcare system. I am convinced the nonexistence of training supply chains is the collapse of any healthcare operation in poor settings. Making reference to some basic points to tackle any hindrance for health inequalities and disparities system.
• So the first step, it’s fundamental for all clinicians getting access to a formal training in supply chains management (it’s essential: courses, seminar, intensive program, fellowship, online course, to establish the relationship between clinicians and supply chain responsibilities). From my point of view, it will be the best way for clinicians to become engaged in supply chain.
• Possessing training in supply chain will guarantee that clinicians in low resources setting will become effective to strengthen the disproportion of healthcare policies. Considering the supply chain management refers primary to the information by compiling data. That information collected represents the backboned for a concrete distribution of goods and services.
• After establishing a solid junction between clinicians and supply chains, they are will capable to design and implement information system to enhance clinical outcomes and secondly to optimize the finances.
• In resume, supply chain management is indispensable for global health to face disparities and inequalities in healthcare system.

Akintunde Orunmuyi Replied at 2:17 AM, 20 Oct 2015

Greetings,
I am a Nuclear medicine specialist working in the first Nuclear Medicine Centre in Nigeria. To deliver a seamless service, we rely on overseas suppliers from France, Turkey and South Africa. We order cold kits and radionuclides fortnightly.
Developing a reliable supply chain is pivotal to the desired private sector participation/investment that will lead to the expansion of Nuclear Medicine services for Nigeria's 160 million residents.
One major problem we face is the delay at customs with clearing our supplies. Patients bear the brunt of this delay. In one instance, a radioactive iodine capsule had decayed nearly 50%! This happens frequently (20-30% of the time) As a young specialist, I'm interested in finding a permanent solution to ‎this problem. I wrote up a motivation/business proposal to two providers to set up a logistics solution for Nigeria. One responded. The company will be visiting Nigeria in November. I've been sent QC forms to draft a template, agreement forms, e.t.c. I started it now I don't know where to go from here. ‎What relationships do you have in place to minimize delays with customs in your experience? What structure do you have in your local operations to distribute safely your relief materials ‎What resources can help further develop basic knowledge in supply chain development Would you recommend a course in SAP? Thanks.
Akin

Gani Alabi Replied at 11:52 AM, 20 Oct 2015

Dear All,
My apologies for joining this interesting discussion late.
Even though I am a physician by training and practice, am also very experienced in Procurement Supply Management having been a Global Drug Facility TB/PSM Consultant for over ten years.

The sub-optimal participation and or performance of health staff (excluding pharmacy personnel to some extent) can be traced first and foremost to the MAJOR defect in the design and implementation of health staff pre-service training institutions' curricula as it concerns Procurement and Supply Management (PSM). More often than not, health staff, except pharmacy personnel, learn a lot about drugs and their uses but very LITTLE about how and what are involved when the drugs move from the manufacturing house to the clinics or wards where they are delivered to the patients. In other words, by the time the physicians, clinicians, nurses, health assistants are graduating from the pre-service training institutions,, they are deficient to varying degrees on issues relating to PSM such as forecasting, quantification, procurement and value chain management( and more importantly to their roles in PSM in general.

The second contributory factor is that many health staff hardly know their roles and responsibilities in PSM because orientation and or training on PSM at service delivery level is often heavily biased towards pharmacy / store staff with little or no involvement of other health staff. The result is that the staff interdependent & interdisciplinary nature of PSM is lost because most concerned do not understand what and how to do. For example, It is not uncommon for a surgeon to complain among stock-outs of surgical materials. But ask the surgeon, whether the procurement/logistics/admin officers know his needs for the surgical unit, the answer is likely to be "NO" because the surgeon, physicians/clinicians and other key health staff are hardly involved in forecasting, quantification, etc of drugs and supplies mangement.

The third factor relate to supervision (checking whether staff know what/how to do and are competent, provision of support, mentoring of staff), monitoring of PSM activities (Drug storage, supply, use, adverse events, reports etc) and evaluation of PSM plan. Take a look at the checklist for district health office, health facility supervision & monitoring, how much of it contains critical information on PSM planning, implementation, supervision, M&E?

The forth factor is the slow or lack of application of information technology to facilitate effectiveness and efficiency of our PSM. I must admit that this factor may be limited by funding availability.

It is my candid opinion therefore that the first three CRITICAL factors (pre-service training, service-level training, Supervision, M&E) must be ADDRESSED before we can realize a value supply chain of our dream at all levels. When we have acceptable value supply chain, we then can proceed to IT applications to improve effectiveness & efficiency of our PSM operations at all levels.

Luis Martinez Panelist Replied at 8:49 PM, 20 Oct 2015

How does your organization bridge the gaps (technical, communication, etc) between clinicians and supply chain experts?

In Compañeros en Salud (CES), also known as Partners in health Mexico , almost all the staff are clinicians doing different roles, from coordinating the different programs we have (all of them related to health) like the community health works program, right to health program and even positions in the direction of the organization, to the physicians that are working in the rural communities giving free clinical attention. In other words, clinicians are highly related to the supply chain; therefore, the answer and the perspective that I could share here is totally different than others.
To answer this question, in CES all the members have participation in the design and analysis of the supply chain (directly and indirectly) because all the activities depends on this chain. In our environment, every clinician that works in the communities manage a supervisor (who is also a physician) and both the supervisor and the physician in the field works with the clinical director and the director of operation to analyze very week the different technical and supply gaps with the aim to cover all the necessities in the operation. CES is working with the government with the aim to enhance the health system and the infrastructure that already exist, so we work in the government clinics and we support this work with the medicines and equipment that the physicians need in the field in order to offer the best possible practice, and most important, with the aim to offer 100% of the treatments that patients need. Actually, we manage near to 100% of adherence to the clinic and more than 90% of adherence to treatment in important chronic diseases like diabetes, depression and hypertension.

We work in global health, and because we are dealing with important geographic barriers, the risk of having gaps in the value chain is really high; for this reason, we have every week meetings with the supervisors of all the programs with the aim to review the necessities for every particular program; in other words, our model is based in having the most regular analysis and feedback of every necessity with the aim to offer in a constant way the best version of our services.

In retrospective I should mention that a key element in the success of this program is the emphasis in the constant and periodic analysis of all the process with the aim to avoid these gaps and with the aim to adapt the different strategies to the different problems that could emerge in real time.

Oluwaseun Ayanniyi Panelist Replied at 9:43 PM, 20 Oct 2015

On the SCMS project, we engage with clinicians during quantification exercises for medicines and laboratory commodities. They provide input into the assumption building process which is a key com

Oluwaseun Ayanniyi Panelist Replied at 10:20 PM, 20 Oct 2015

On the SCMS project, we engage with clinicians during quantification exercises. Since they directly interact with the patients and provide the services and medicines to patients, they provide useful inputs around selection and use of commodities during the assumption building exercise.

During the process of phasing out some medicines such as Stavudine fixed dose combinations, information on stock availability was shared with clinicians so that patient switch to a different regimen was carried out in a measured way to avoid having large quantities of unused commodities left to expire.

Om G Replied at 7:48 AM, 21 Oct 2015

Jesse,

Thanks for those valuable insights and for your work.
How are you using analytics and forecasting?

Luis Martinez Panelist Replied at 9:05 AM, 21 Oct 2015

3. How does your organization help clinicians balance supply chain responsibilities alongside their primary responsibility of providing quality patient care? How can you persuade reluctant clinicians to become engaged in supply chain management operations?

As I mentioned in question 2, in Compañeros en Salud (CES) also known as Partners in Health Mexico, most of the staff are physicians working in strategic positions in the organization leading the different programs that are offered in the communities (community health workers, medical referrals to 2dn and 3erd level, mental health, maternal health and primary health care attention), and in this effort, all the team understand their strategic role in the value chain. In order to answer this question, let’s just focus in the clinicians that works in the communities as health care providers; in this context, they understand that the only way to provide the best possible health care in poor and marginalized communities is by having all the resources that they need to detect, diagnose and treat every single medical case. This understanding is enough to have their commitment in the design and analysis process in the supply chain.

In base of this understanding and commitment, every clinician have continuous contact with a supervisor, who works directly with the director of operations and the clinical director with the aim to provide and solve in real time the different resources that the clinicians need in the communities. This analysis and feedback is constant every week, and in every interaction, the detection and analysis of these necessities are well standardized with the aim no only to understand their necessities in real time but also with the aim to always analyze the same variables and the same necessities. Of course this process needs to be adapted to the necessities of the operation, but the “recipe” is the same: create an instrument that could measure necessities in real time with the aim to be solved as soon as possible. When clinicians and the rest of the members of the organization understand this necessity and this operational potential then they understand their responsibilities in the creation of these instruments and in the analysis of the supply chain and the rest of the processes in the value chain.

Justin Miranda Replied at 9:39 AM, 21 Oct 2015

Thanks Luis -

A few follow up questions ...

How does CES standardize "necessities"? I assume necessities include medications, supplies, and equipment. Are there other necessities (e.g. processes) that are reviewed on a weekly basis?

Could you also provide a concrete example of this "feedback loop" mechanism in practice. For example maybe illustrate an case where the weekly review showed an anomaly and CES needed to take action to rectify the situation? Or describe how your team dealt with a supply chain emergency that occurred during the course of normal activities.

Jesse Greenspan Panelist Replied at 10:21 AM, 21 Oct 2015

Oluwaseun, it would be great to hear about the specific exercises you use to engage clinicians in quantification.

Jesse Greenspan Panelist Replied at 10:41 AM, 21 Oct 2015

In response to question 3, I think that looking at prescribing practices is a natural point of focus for clinicians that also has a large impact on the supply chain. By using appropriate prescribing practices, the clinicians are automatically engaging in supply chain operations. The supply chain team at PIH has been talking a lot about the importance of a good “demand signal” recently. This demand signal is what trickles down the supply chain and informs our forecasting. The origination of the demand signal is the prescriptions that clinicians give to patients. It is therefore important to ensure that these prescriptions are correct and that they follow the treatment regimens ascribed to by the organization. For example, if the organization has chosen first line antibiotics because of the clinical effectiveness and lower cost, but clinicians are prescribing a second line antibiotic instead, the demand signal will tell the supply chain team to order more of this more expensive second-line drug. To correct this demand signal, we need to make sure that clinicians are familiar with the regimens adopted by the organization (i.e. training). But the supply chain team has a large responsibility in making sure this system works as well. For example, if there have been a lot of stock out of the first-line drug, then the regimen cannot be used appropriately—clinicians will continue to provide the best care they can to patients in an environment of scarcity. We must ensure that from both sides (clinical and supply chain) that we are facilitating the use of agreed-upon regimens and recognizing this important feedback loop.

Yasmin Chandani Panelist Replied at 12:50 PM, 21 Oct 2015

Thanks for this really vibrant discussion. I wanted to comment on two threads. First related to our question for day 2 - namely how to bridge the gaps between clinicians and supply chain experts.

One example of where we have included clinicians into supply chain problem solving, communication and performance improvement in a way that doesn’t overburden them but allows them to be involved is in our work around setting up quality improvement teams for supply chain improvement. JSI has set up QITs for a variety of purposes and in a growing number of countries - but specifically for supply chain in Malawi and Rwanda for improving outcomes for community health supply chains. These teams were multi level teams in that they included participants from districts, health facilities and community health workers (CHWs) and we set up teams around a common goal, using structured approaches and tools for using data to prioritize bottlenecks, problem solve, action plan and monitor progress and results. In Malawi, we included program coordinators, health center medical assistants, CHWs and we had pharmacists, drug store in charges. They were very successful for their purpose and even went beyond the supply chain scope and helped members of the team raise and address a broader range of issues. I think it was a good example of bridging the gap and for helping to foster collaboration and coordination between clinicians and supply chain staff around a variety of issues and bringing the focus on serving clients/customers effectively.

In other countries we see logistics management units set up, and these logistics/supply chain staff (who play important roles in quantification, forecasting, performance management etc) are dedicated to particular programs. They focus on FP, MCH, HIV issues in particular and help bridge the gap by reaching out to program managers to discuss changes in trends or needs for that particular program.

Finally, automating information systems using technology such as eLMIS, mHealth systems for logistics which have user-centered dashboards can also bridge the gap since it enables program managers to view stock outs and other metrics that might affect how patients are treated.

Gani Alabi Replied at 12:56 PM, 21 Oct 2015

On concerning how to encourage & motivate physicians and clinicians in PSM work, first thing to do in my opinion is to include relevant Procurement Supply Chain Management tasks in the job description of every physician and clinician so that their tasks in this endeveavour are considered important and essential. The clinicians also need to be orientated on these PSM tasks. Value supply chain management is a team work with the Pharmacy staff providing the lead. It is important for every health facility manager/In charge to know this and to solicit the cooperation of all staff concerned.

The next step is to have a PSM committee with a pharmacy staff providing the lead in the committee. This committee Terms of Reference may be included in the Health Facility management team in small health centre or big hospital set up to avoid proliferation of committees. And as illustrated by Luis Martinez of PIH the mechanisms for all aspects of PSM can be developed, implemented, monitored and evaluated by the committee. As a former PIH/APZU Malawi Medical Director , I can attest to the fact that we practise this in Neno district of Malawi and in other PIH supported countries worldwide and it works well.

Another example that I know very well and have been involved with for three decades is the Tuberculosis Control Program where medical personnel are orientated on their roles and responsibilities supply chain management of TB drugs and supplies. The system is simple. The nurse, clinician or health worker taking care of the patients completes the treatment card for his/her patient on every clinic day. At the end of every quarter (three-month treatment), the amount of drug dispensed/used by all patients are collated (consumption/use report). Quantification for the next quarter is done based on the number of patients treated for the quarter just ended. Ordering is then calculated by determining the closing stock, taking into consideration the consumption report and the quantification plus the buffer stipulated by the national TB program. The district program manager does this for each & all health facilities in the district, working with the facility personnel. This is process is repeated at regional level for all districts in the region and same by the National Program Manager at the central level for the regions in the country as applicable. Forecasting is done in a similar way using, patient load per year (case finding report), consumption report / ordering request and the trend in case notification. Many countries like Nigeria, Ethiopia, and recently Malawi have integrated or are integrating TB drug/supply chain management into their Logistics / Supplies Chain Management.

The key to staff performance in this regard is regular supportive supervision and mentoring where needed. We should remember that performance is directly related to skill and the willingness to work. Skill can be achieved through training and willingness through motivation. Integrated value supply chain is multidisciplinary and therefore health need to work as a team and as said earlier on, the pharmacy staff is the lead for PSM. I like to differ from the earlier comment of Yasmin in this regard.

Finally, Physicians and clinicians need to be reminded of their tasks in PSM through orientation, dialogue, motivation and reprimand where necessary.

Yasmin Chandani Panelist Replied at 1:03 PM, 21 Oct 2015

Coming to question 3 - I'd like to offer a comment on the second half of the question which hasn't received much discussion - namely "How can you persuade reluctant clinicians to become engaged in supply chain management operations?" In my experience people generally (not only clinicians but also policy makers in Ministries of Health, donors etc) are mainly willing to focus on supply chain as part of an overarching goal about providing services, improving health outcomes or achieving performance targets. So I think the key as Jesse has alluded to above is to include clinicians in aspects of SCM where they can clearly understand the impact or relationship their involvement will have with whatever it is they really care about. For example, when Zambia was first starting out with its National ART program, their targets for patient treatment were too high given all the training that needed to happen of providers and the time lag needed to see the effect of HIV testing etc on people seeking treatment. It was also a time where there was absolutely no previous data available to do forecasting because all HIV programs were new. If we had gone with procuring ARV drugs based on the program manager's targets, the country would have wasted a lot of resources and seen a lot of expiries of drugs, which would have possibly become a political issue. So instead we used an "informed assumption" based approach to forecasting that relied exclusively on clinicians with experience in HIV treatment helping us to build our model. While it wasn't something they initially were excited about, we used the lure of what they did care about - namely increasing numbers of patients receiving good quality HIV care and treatment - as a way to get their involvement. And as they started participating they realized how much it helped their assumptions and plans for treatment in that it helped them further refine their prescribing protocols and identify greater training needs. In the end they became our biggest champions for advocating and supporting the development of supply chain processes and procedures for all levels of the system. So finding a need they have that supply chain can help address and trying to build supply chain champions among the group of clinicians is how we have approached this.

Christopher Mindiera Replied at 1:36 PM, 21 Oct 2015

Gani
Good contribution

A/Prof. Terry HANNAN Replied at 1:51 PM, 21 Oct 2015

I love this discussion it is interesting and understandable.
Re Gani's posting "The system is simple. The nurse, clinician or health worker taking care of the patients completes the treatment card for his/her patient on every clinic day. At the end of every quarter (three-month treatment), the amount of drug dispensed/used by all patients are collated (consumption/use report). Quantification for the next quarter is done based on the number of patients treated for the quarter just ended. Ordering is then calculated by determining the closing stock, taking into consideration the consumption report and the quantification plus the buffer stipulated by the national TB program."
There are several aspects highlighted in Gani's text.
1. The information 'flow' is described succintly by Gani
2. The continuing requirment for paper plus e-tools (it is an evolution)
3. Simple e-tools can be designed to manage this flow
4. The system design should / must capture the provision of services (drug dispended/used/+other) and this design generates as a "byproduct in real time" the data required for the supply chain management (see Mosoriot Medical Record System / AMPATH development and their results.
5. The philosophy and core principles described in 4. were formulated in the later 1980s in systems such as the Johns Hopkins Oncology System, Regenstrief, Beth Israel Deaconess, Brighams and Womens Hospital and LDS in Utah.
6. The technologies required are now affordable (mHealth) and as prior postings have documented EVERYONE in the chain needs to be involved.

Elizabeth Glaser Replied at 2:20 PM, 21 Oct 2015

Do you provide support for clinicians to participate and/or continue in the face of a system that may have poor infrastructure (poor access during wet season) or a high frequency of stocks outs.
Both issues can be very demoralizing.
What kind of problem solving do you employ to cope with porblems and at what levels ?

Jesse Greenspan Panelist Replied at 5:52 PM, 22 Oct 2015

In response to both question 4 and Om G’s question on Oct 21, PIH has recently started using a new software tool called GMDH Shell to help us with forecasting. This software takes consumption information, lead time information, inventory information, and quantity on order information directly out of OpenBoxes (our supply chain management software system) and uses that to inform the forecast, and then a suggested order quantity for each product.

Just last week we piloted a new process called S&OP (adapted from the private sector’s “sales and operations planning”) in Haiti in which we invited clinicians and pharmacists to come to a meeting to look at the data and the GMDH forecast. During the meeting, the clinical team can decide to “override” the statistical GMDH forecast based on new program openings, if they think the previous consumption was too low, if they want to change a prescribing practice, etc.

This is a brand new process, but we hope that it will be a useful forum for engaging the clinical team in a way that has a direct impact on supply chain and patient care. Hopefully seeing this impact will also improve attendance at the meeting. I think even for organizations that do not have a tool like GMDH, this exercise can still be done—a meeting to provide clinicians the opportunity to update the forecast and make suggestions for products that have caused problems in the past, i.e. repeated stock outs. As this process is new, your feedback would be most welcome!

Andrew MacCalla Panelist Replied at 6:31 PM, 22 Oct 2015

I wanted to briefly touch on Q2 since there wasn't a lot of talk on it and yet it's where Direct Relief is mostly involved. As I mentioned, we use an SAP database to inventory and track over 18,000 skus of materials. These are offered out to providers, clinicians, pharmacists, etc through a online portal where they log in, view what is available by product category (broken down by generic name, lot, expiry, manufacturer, size, strength, unit) and then ordered through the system. The order is then packed and shipped to the destination and we generate all the relevant shipping documents needed for import including: commercial invoice, letter of humanitarian aid, letter of donation, and itemized packing list containing 18 attributes for each material. The recipient then manages bringing the shipment through customs into their facility and that process (to an earlier point raised) can be quite challenging and the rules can vary country by country and even broker by broker. Typically, we send the materials directly to the end user facility (rather than a centralized depot) so that we can track where they end up and better account for adverse events, diversion, recalls, etc. From there, the products are managed by the facility, who have a variety of different inventory management systems from paper and pen to Access to Open Boxes.

From our perspective, we'd like to understand better what is working well as a inventory and requisition system for the healthcare facility and if there is a system that could be used in a variety of different settings (which have all types of connectivity, access, internet, electricity challenges) that could possibly be rolled out on a larger scale.

Luis Martinez Panelist Replied at 7:05 PM, 22 Oct 2015

4. What training, systems, and standard operating procedures has your organization adopted to ensure that clinicians become effective members of the supply chain operation?

Working in a NGO level, must of the processes are focused in specific implementations in the field. As I mentioned in previous questions, Compañeros en Salud (CES), also known as Partners in Health Mexico manage specific programs in 10 poor and marginalized communities in Chiapas (Mexico) which are: first health care attention, community health workers, medical referrals to 2nd and 3er level, mental health and maternal health. Even that the different clinics are operated by clinicians, all the projects are coordinated by physicians that previously worked in the field. (for more information please visit www.companerosensalud.mx)

As I mentioned in previous questions, CES manage specific but important health programs which require the most effective supply chain to be functional and to deliver the best possible quality in all the implementations. This supply chain is not a new model and was not designed by an expert; on the contrary, the peculiarity of this supply chain is that it is the adaption of continue and well standardized reviews every 3 months. In other words, what we are doing is receive the feedback of all the members that have participation in the supply chain with the aim to modify and adapt the different processes of the chain. As Jannie Naidoo mention not only for health management but also for health promotion strategies: every program needs to be designed with the particular purpose to be evaluated every given time with the only objective to adapt any process to what is really necessary; and in this process, clinicians are one of the most important elements that help us to review this chain.

An NGO manage different processes than clinics or hospitals; however, I believe that in this matter, all the members of the supply chain must be considered to design and review the complete chain in a standardized way.

What do you thing?

Oluwaseun Ayanniyi Panelist Replied at 10:48 PM, 22 Oct 2015

4. What training, systems, and standard operating procedures has your organization adopted to ensure that clinicians become effective members of the supply chain operation?

Pre-service training (PST) for supply chain management has been implemented in a number of countries to develop local capacity. Supply chain management wasn't taught to health workers during their academic training which resulted in clinicians who were not skilled in managing supply chains at health facilities. While in-service training is conducted to build the skills of those already in the workforce, the gap in the training curricula needed to be bridged which led to the introduction of the pre-service training. Pre-service training introduces the principles and practices of supply chain management for health commodities to pharmacy, pharmacy technician, nursing and bio-medical students while they are still in school. The USAID|DELIVER and SCMS projects in conjunction with local academic institutions in a number of countries developed and integrated the curricula for supply chain management into the academic programs thus equipping future health workers with the skills necessary to manage a supply chain. The pre-service training model is considered to be sustainable and cost-effective.

Randy Mungwira Replied at 3:00 AM, 23 Oct 2015

Interesting discussion with regards to your line of work Fina...happy
reading

R

Yasmin Chandani Panelist Replied at 8:00 AM, 23 Oct 2015

Today's question is "What are some of the key benefits of a clinically integrated supply chain? What evaluations have you implemented regarding the impact of clinically integrated supply chains?" I wanted to share some thoughts about this and link the answer to this question to Q2 and Q4. In Malawi to help community health workers better access essential medicines and serve customers, we worked with the ministry of health to design and implement an mHealth system for supply chains (called cStock) and quality improvement teams to help foster a change in culture around improved use of data for performance improvement and to refresh and improve skills in basic supply chain tasks. During our evaluation our biggest piece of learning was that technology alone comes with some process improvements but didn't change outcomes; but adding the team component that was built around better collaboration, communication, capacity building significantly improved outcomes - with much better reporting rates, reporting completeness, lead times and stockout rates. So there in our experience there is huge value in finding a way to implement clinically integrated supply chains (and supply chains that are integrated in themselves). I think its about finding the balance that allows clinicians to perform their core functions while strengthening the supply chain and improving performance.

Attached resource:

Luis Martinez Panelist Replied at 6:15 PM, 23 Oct 2015

5. What are some of the key benefits of a clinically-integrated supply chain? What evaluations have you implemented regarding the impact of clinically-integrated supply chains?

In case of Compañeros en Salud (CES) clinicians are always integrated to the supply chain becasue almost all the staff are physicians . The question "What are some of the key benefits of a clinically-integrated supply chain?" has the same answer to the benefits of having all the actors of the value chain in the supplay chain, becasue the presence of all the actors is the only way that could let you know the real necesities in the different processes of the value chain. In managment and in every supply chain, all these processes must be adapted to real necesities almost in real time, therefore, the best benefit is having real time feedback and information from all the actors in order to complete a given process in an efective way with high quality standards.

As mentioned in prevous questions, not only the processes related th the suply chain should be evalauted with a given frecuency, on the contrary, all the processes require of these types of evaluations in order to always adapt the desing and the processes to what should be done in every branch of the value chain.

I understand that the NGO perspective is different in comparison with hospitals of ohter healthcare serivies, but in my perspective, all the examples could follow the same strategy:

1) desing the supply chain in base of the services that you need to offer

2) consider in the dessing and analysis processes all the actors that have participation in the value chain

3) review in a given frequency all the processes in order to change and adapt the strategies to what it is really necesary

what do you think?

Justin Miranda Replied at 10:08 AM, 24 Oct 2015

Thank you to everyone that contributed and followed along the discussion this week. We'll officially end the panel on Monday, so feel free to continue the discussion over the weekend.

Best,

Justin

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