RCPharm benchmarking metrics for acute hospitals

= processing efficiency of the pharmacy – lower figure is good, but if too low then will increase transactional costs and risk of stock outs i.e. needs to be balanced against other metrics.

Note: use the NPPSC* definition: include all stock-holding locations for which the chief pharmacist/director of pharmacy is accountable (satellite dispensaries, aseptic units etc.). Exclude outsourced out-patient dispensaries and ‘stand-alone’ production and pre-packing units etc. Include VAT.

*NPPSC = National Pharmacy Procurement Specialists Committee

Calculation = 365/stock turn figure (see below).

Stock turn figure = (Annual Hospital Medicines Expenditure minus any expenditure unrelated to/not directly handled by hospital pharmacy (e.g. outsourced out-patients, inventory delivered directly to/held on wards, clinics etc), annual homecare expenditure, FP(10) costs) ÷ (year-end pharmacy store stock holding figure).

The figure for this metric would generally be expected to be a range and hospitals will want to compare with similar peers.

= effectiveness of pharmacy procurement system in minimising physical store involvement – lower figure is good, but if too low then will increase transactional costs and risk of stock outs i.e. needs to be balanced against other metrics.

Calculation = 365/stock turn figure (see below).

Stock turn figure = (Annual Hospital Medicines Expenditure) ÷ (year-end pharmacy stock holding figure).

Used as a comparator to metric 1. Offers two stock holding options as metrics – each would have its own target defined. Ideally metric 1 is low and metric 2 relatively lower. The greater the relative difference the more effective the system as most stock bypasses a physical pharmacy store.

= processing efficiency of the pharmacy procurement system – high figure is good.

E-trading of orders is the process whereby orders are sent directly from the purchaser’s computer system to the supplier’s computer system by electronic means. No paper is involved in these transactions, which take place electronically and without manual transcription. This excludes faxing or emailing of orders from the numerator. 

Calculation = (number of orders sent electronically) ÷ (total number of orders created in the same time period) – expressed as a percentage.

Note: it is the number of orders and not the value of orders.

This calculation should be done for (a) all orders sent including homecare and (b) all orders excluding homecare.

It is recognised that a metric that looks at the number of lines ordered, rather than the number of orders, would be more useful, whilst at present it is not possible to measure this easily organisations should be working toward this.

= processing efficiency of the pharmacy procurement system – high figure is good.

E-trading of invoices is the process whereby invoices are sent directly from the supplier’s computer system to the purchaser’s computer system by electronic means. No paper is involved in these transactions, which take place electronically and without manual transcription. This excludes faxing or emailing of invoices from the numerator. It is expected that a PEPPOL-compliant eCommerce system is used.

Calculation = number of invoices processed electronically/total number of invoices processed in the same time period – expressed as a percentage.

Note: it is the number of invoices and not the value of invoices.

It is recognised that a metric that looks at the number of lines ordered, rather than the number of orders, would be more useful, whilst at present it is not possible to measure this easily organisations should be working toward this.

This calculation should be done for (a) all invoices processed including homecare and (b) all invoices excluding homecare.

= an indicator of ambition of pharmacy service to be core clinical; modified denominator accounts for pharmacists who are not eligible to access prescribing training; larger figure better.

Calculation = (number of pharmacists qualified as prescribers) ÷ (total number of pharmacists in service who have been registered a minimum of three years) – expressed as a percentage.

Note: this is calculated per head-count as oppose WTE.

= an indicator of how well developed a pharmacy service is in terms of being core-clinical.

Calculation = (number of pharmacists qualified as prescribers who routinely prescribe as part of their clinical role) ÷ (total number of pharmacists in service who are qualified to prescribe) – expressed as a percentage. 

It is accepted that the term ‘routinely’ can be open to interpretation plus it is not easy to put a general value to this. However, the principle is that prescribing is part of the pharmacist’s routine clinical practice i.e. the pharmacist will typically prescribe when working in their clinical role; compared with prescribing only occasionally or rarely, which would not be routine.

= indicator of extent of pharmacy medicines optimisation practice that is targeted at admission.

Calculation = (number of patients admitted, electively AND non-electively, who have their medicines reconciled by a member of the pharmacy team within 24 hours of the time of admission) ÷ (total number of patients within sample). Sampled monthly as per medicines safety thermometer (100% of patients; admissions during previous 24 hours; last Wednesday of the month). Expressed as a percentage.

The metric uses the National Institute for Heath and Clinical Excellence (NICE) definition of medicines reconciliation.

For this definition, medicines reconciliation is considered complete once the changes have been communicated to the prescriber. However, the longer-term aspiration is to amend the definition so that medicines reconciliation is complete only when discrepancies are corrected.

Admission is considered to be from the time the decision is taken to admit (not from the day after admission).

This metric is a measurement of the extent of pharmacy team medicines reconciliation, it is recognised that in some organisations other clinical staff may also undertake medicines reconciliation. Where this happens pharmacy should have a programme of training and competency assessment in place to oversee the medicines reconciliation process.

A useful comparison can be made against metric 11; however, to enable this, data should be collected such that it can be broken down between elective and non-elective admissions.

= an important indicator of overall quality of medicines use within an organisation. Lower value better.

It is accepted that this metric reflects many things including:

The robustness of the medicines management system within a complex organisation to deal with variation (e.g. how medicines are managed when patients are transferred).

Quality and responsiveness of medicines supply system pertaining to inpatient care.

Nurse/doctor awareness of the importance of administration of critical medicines and related behaviours (e.g. willingness of nurses to source medicines if not available; timing of doctors’ prescribing in relation to ward routines).

Calculation = number of patients with an omitted dose of a critical medicine (as defined by medicines safety thermometer) ÷ (total number of patients within same sample from metric 8).

Note: the numerator should exclude omissions due to patient refusal or valid clinical reason for omission – this is different to medicines safety thermometer (but efforts are underway to standardise). Expressed as a percentage.

= crude estimate of resource utilisation between clinical and other.  Definition of ‘clinical’ is anything pertaining to an individual patient, but excluding operational activities, details outlined below.

Calculation = (A) ÷ (A plus B).  Exclude C.  Present as a percentage.

‘A’ = estimate of overall staff time deployed as a sum of all clinical activities i.e. those provided for individual patients on wards, in outpatient clinics, care homes and in domiciliary patient-facing clinical roles (e.g. counselling, drug history taking, medicines reconciliation, organising transfer of care, shared decision-making, prescribing, clinical validation, participation in ward rounds and multidisciplinary team working, medicines administration).

Note: facilitating ‘near patient’ medicines use at ward level including dispensing, use of patients’ own medicines etc. is inextricably linked to a technician’s clinical role and should be included in an estimate for A.  However, satellite dispensaries on or near wards are simply dispensaries and are not clinical.  Any dispensing/supply undertaken by a pharmacist at ward level should be excluded from estimates.

‘A’ should also include an estimate of resources that are contained within departments that provide clinical services for individual patients, as defined (e.g. medicines information i.e. query answering for specific patients; clinical validation undertaken in providing an aseptic dispensing service).

‘B’ = estimate of overall staff time deployed as a sum of all operational activities including: stock management, dispensing (including staff time working in satellite dispensaries on or near wards, but excluding ‘near patient’ dispensing/supply undertaken by technicians as described), procurement, aseptic dispensing, production, formulary support, administration, quality control, topping up, medicines information (excluding the estimate of individual patient directed resource in ‘A’ as described above).  

‘C’ = resources deployed as chief pharmacist (or equivalent), medicines safety officer (or equivalent), clinical informatics (or equivalent), controlled drug accountable officer, quality assurance, audit, practice research, quality improvement and teaching time i.e. C ≠ A or B.  These resources should not be included in the calculation.

There is no justification for precise measurement of this metric at a service level – there are too many confounding factors to make detailed benchmarking worthwhile. However, this is a useful (albeit crude) estimate of resource utilisation as an indicator of scale of clinical orientation of service.  Staff time is used as the currency as it is easier to understand/work with when compared to financial resource deployment.

Note: in future it will be important to tease out different roles and the resources dedicated to each (e.g. clearly not cost effective to use an AfC band 8b (pharmacist) when an AfC band 5 (technician) could do the same job e.g. drug history taking).

= not all clinical activity is essential seven days per week.  Using an assumption that emergency care, all non-elective admissions, present a constant demand for clinical pharmacy, then medicines reconciliation at the point of admission can be used as a single proxy measure of appropriate deployment of clinical pharmacy resources across a seven-day time period.

Calculation = (number of patients admitted non-electively, who have their medicines reconciled by a member of the pharmacy team within 24 hours of the time of admission) ÷ (total number of patients within that sample).  As per metric 8 i.e. 100% of patients, but identified as non-elective; admitted in the previous 24 hours; sampled on a Monday morning). Expressed as a percentage.

A useful comparison can be made against metric 8. 

= use of standard formulations and doses for ‘commonly used chemotherapy’ medicines to enable aseptic capacity to be focused on activity that does require local production i.e. complex, high cost and/or clinical trial medicines.  Assumption is that high volume ‘outsourced’ chemotherapy will provide better value for money and free up valuable local aseptic dispensing capacity.  A high figure is good, but a very high figure may be inappropriate.

Calculation = (number of pre-assembled/ready-made injectable chemotherapy items dispensed as sourced) ÷ (number of pre-assembled/ready-made injectable chemotherapy items dispensed as sourced + number of injectable chemotherapy items locally produced and dispensed).  Expressed as a percentage.

‘Commonly used chemotherapy’ includes all chemotherapy that can be prepared in a pharmacy aseptic unit and is included in the national chemotherapy dataset (SACT data submission).

Chemotherapy refers to any systemic anti-cancer therapy, this includes monoclonal antibodies/targeted therapies, intravenous, subcutaneous, intrathecal and oral chemotherapy as well as topical treatments for bladder cancer; hormonal treatment is excluded. NHS standard contract for cancer: chemotherapy (adult) – service specifications. NHS England.

Large aseptic manufacturing units should add internal batch prepared products to their figures for pre-assembled/ready-made).

Further background information can be found in Guidance on managing the sourcing and supply of ready to administer chemotherapy doses for the NHS: A ‘how to’ guide (Edition 1A).

= sourcing and supply of ready-made standard formulations or, if adult parenteral nutrition bags are supplied to wards as separate components, this removes work from aseptic units and thereby creates capacity for complex, high cost and/or clinical trial medicines.

Calculation = (number of ready-made standard bags sourced and/or number of parenteral bags supplied to wards without any manipulation) ÷ (total number of parenteral bags supplied in total). Expressed as a percentage.  Calculate performance for adults and paediatrics separately to aid benchmarking comparisons being made.

Variation in performance will obviously be partially explained by level of clinical complexity within organisations i.e. tertiary/specialist centres may have a lower percentage performance.  Therefore, important to benchmark between similar organisations.

The mixing of individual components at ward level is not being advocated.  A safe system to enable individual components being administered separately is obviously required.

= indicator of the extent to which an organisation complies with national guidance on the safe handling of high strength intravenous potassium salt solutions.

Calculation = (number of mmols of high strength potassium issued by pharmacy as ready-to-administer infusions) / (number of mmols of potassium issued as ampoules + number of mmols of high strength* potassium salt solutions issued by pharmacy as ready-to-administer infusions).

Note: include all intravenous potassium-containing solutions (e.g. potassium chloride, potassium acid phosphate).

*High strength applies to concentrations greater than 80mmol/L. Expressed as a percentage.

The metric represents the proportion of intravenous potassium solutions issued as ready-to-administer infusions (%). The higher the metric value the greater the level of compliance. Data from pharmacy department stock control systems should be used. 

Centres providing services to paediatrics/neonates may have a lower % performance than those with only with adult patients.

= effectiveness of pharmaceutical quality system; takes account of activity. Lower figure is good.

Calculation =  number of Datix (or equivalent) and/or in-house (‘near miss’) reports per month ÷ number of aseptic workstation sessions*.

*A workstation session is defined as a grade A workstation (laminar air flow cabinet or isolator; two gloves represent one station) in use on any morning or afternoon (or part thereof).

(E.g. an aseptic unit with one negative pressure two glove isolator in use for five mornings and five afternoons would have ten workstation sessions per week and 40 per month (assuming a 20 working day month).

Datix reports (or equivalent) and/or local in-house ‘near miss’ reports should both be used as Datix reports (or equivalent) are not always used to record in-process ‘near miss’ errors.  The number of errors occurring in production will be higher than the number of actual errors leaving the unit and therefore is a much more useful benchmarking metric.

= a simple high level measure of ‘preparedness for discharge’ which can potentially demonstrate the effectiveness of the whole system of supply of medicines from the perspective of patient flow.  Patients ‘not ready’ for discharge otherwise have to wait for pharmacy to dispense their medicines from a discharge order/prescription as a step which happens late in the process. This metric is meaningful to patients as it helps prevent avoidable delays in discharge.

A = those patients sampled who do not need any medicines dispensed by pharmacy at the point a decision is made to discharge from hospital.

B = total number of patients sampled.

Calculation = (A) ÷ (B).  Present as a percentage.

In the absence of any easier way to measure this, use a simple sequential count of patients, large enough to be representative (e.g. 100).  Measure (a) non-elective patients admitted and/or (b) elective surgical patients, as performance may differ between the two groups, and this approach also allows improvement efforts to be differentiated.

If collected continuously/frequently, then this data can be used to help drive improvement.  It can of course be collected less frequently as a means of providing assurance of performance.

It is acknowledged that multiple factors impact performance with this high level metric (e.g. use of patients own medicines, extent of discharge planning, system of supply used e.g. dispensing for discharge, use of ward stocked over-labelled packs, impact of clinical pharmacy at ward level etc).

However, lower % performance should prompt further inquiry/action as it would indicate a potential opportunity to improve patient flow.  Higher % of patients not requiring a supply of medicines from pharmacy at discharge will reduce delay at patient discharge due to medicines supply.

Higher % of patients not requiring supply of medicines from pharmacy at discharge is more likely achievable in elective surgical patients than other groups due to the greater opportunity to pre plan treatment (e.g. using standardised treatment regimes, positively impacting in pre-admission settings on use of patients’ own medicines etc.).

It is acknowledged that other metrics are necessary to aid further detailed improvement work, some of which are very system-specific and therefore difficult to measure and benchmark.

= a simple high level measure of timeliness of TTO processes on the day of a patient’s discharge when a supply by pharmacy needs to be made on the day of discharge. It includes the whole process from writing the TTO to the time the patient is ‘discharge ready’ from a medicines perspective. This can demonstrate the effectiveness of the whole system of supply of medicines from the perspective of patient flow.  This metric is meaningful to patients as it helps determine a component of their experience at the point of discharge and can be a source of complaints.

The median time of day that patients requiring a supply of medicines from pharmacy on the day of hospital discharge receive them. This includes supplies made by pharmacy staff from any location in addition to a dispensary and includes near-patient supplies from the ward stocks, use of over-labelled medicines, satellites, trollies etc.

In the absence of any easier way to measure this, use a simple sequential count of patients, large enough to be representative (e.g. 100).  Measure (a) non-elective patients admitted and/or (b) elective surgical patients, as performance may differ between the two groups.

This data does not need to be collected continuously but will be more useful if it is and this should be an ambition. This measure can be used as a means of measuring improvement and benchmarking internally and externally.

It is acknowledged that multiple factors impact performance with this high-level metric (e.g. time of decision to discharge, time of TTO writing, extent of discharge planning, impact of clinical pharmacy at ward level etc).  However, a later median time should prompt further inquiry/action, as it would indicate a potential opportunity to improve patient flow. An earlier time helps to improve early patient flow and increase the likelihood of discharges to care homes etc. Other ward processes will need to be considered when improving this metric.

An earlier median time of medicines supply at the time of discharge is more likely achievable in elective surgical patients than other groups due to the greater opportunity to pre-plan treatment (e.g. using standardised treatment regimes, positively impacting pre-admission settings on use of patients’ own medicines etc.).

It is accepted that other metrics are necessary to aid further detailed improvement work, some of which are very system-specific and therefore difficult to measure and benchmark.

= marker of efficiency in clinical validation process.  Low figure is positive (zero is optimal).

A = number of prescriptions received by the dispensing pharmacy within the reporting period with incorrect or no clinical pharmacist validation by the referring centre.

B = total number of prescriptions (new and repeat) received by the homecare provider and placed on the system during the same reporting period. For clarity, a prescription is one prescription form, regardless of how many instalments or items are on that prescription.

Calculation = A ÷ B.  Present as a percentage.

This is a requirement of the RCPharm Professional Standards for Medicines Homecare Services.

A higher number indicates a potential safety risk within the referring centre pharmacy team.

= marker of efficiency in the ordering and invoicing process.  Low figure is positive (zero is optimal).

A = number of prescriptions received without a purchase order number.

B = total number of prescriptions received during the same reporting period.

Calculation = (A) ÷ (B).  Present as a percentage.

Note: A and B can be drawn from the National Medicines Homecare standard dataset.

This metric is included in the standard National Medicines Homecare standard dataset, hyperlink below, (as KPI K4) and is reported routinely (each month) by all homecare providers to all hospitals for all homecare medicines services.

Provides assurance for compliance with good financial governance in clinical medicines homecare as recommended within Hackett Report (2011).  Also marker for compliance with clinical referring centres standing financial instructions.