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Ars Pharmaceutica, 44:1; 81-108, 2003

81TOTAL QUALITY MANAGEMENT IN THE PHARMACY: "EVALUATION OF THE QUALITY PLAN". (PART 2)

Administracin y Gestin de la Calidad Totalen la Farmacia Oficinal: "Evaluacin preliminardel plan desarrollado". (Parte 2)

Total Quality Management in the Pharmacy: "Evaluation of the Quality

Plan". (Part 2)

OVIEDO S1, ANTONELLO A2, Y DI PAULI NA3

1 y 3 BioANALITICA, Servicios Biofarmacuticos de Consultora en Gestin y Calidad. Caseros 3253 CP 5003.

CORDOBA- Repblica Argentina.2 FARMACIA ANTONELLO-VILCA , CORDOBA - Repblica Argentina.

3 FARMACIA GREMIAL, Gremio de Expendedores de Diarios y Revistas de la Provincia de Crdoba.

RESUMEN

Hablar de calidad presupone que es oportuno y posible la verificacin de las caractersticas o atributos que son

propios de un objeto o entidad. Cuando planteamos la Calidad en un servicio de farmacia estamos diciendo que este

cumple plenamente con las expectativas de quin se asiste por l.

En este reporte acercamos los resultados preliminares de la primera etapa de aplicacin del Plan de Calidad y su

impacto en el crecimiento del servicio farmacutico.Del anlisis de los resultados obtenidos se desprende que para el xito definitivo del plan, es de suma importancia

la consolidacin de la relacin Farmacutico Paciente/usuario como elemento central del proceso de atencin

farmacutica dentro de un concepto de calidad total.

Por otra parte, el anlisis de los resultados contables (no expuestos en este trabajo) ponen de manifiesto el logro

de la eficiencia en el manejo de los recursos financieros y en la contencin de costos, como consecuencia del plan de

gestin y el planeamiento de los procesos estratgicos del servicio.

En resumen, desde la aplicacin del plan de calidad, se produjo un incremento de las ganancias, como consecuencia

directa de la reduccin de costos relacionados con acciones de no calidad (mala atencin al paciente, falta de

informacin, elevado nmero de devoluciones de medicamentos por vencimiento, etc.) y por un aumento de la

productividad asociada a la dispensa del medicamento y a las buenas prcticas de atencin farmacutica.

Finalmente podemos decir que nuestra hiptesis se cumple y que el desarrollo de la calidad y su bsqueda estn

unidos al desarrollo y crecimiento profesional en un marco tico y de servicio.

PALABRAS CLAVES: Atencin Farmacutica. Gerenciamiento de la Calidad Total (TQM). Administracin Farmacutica.Aseguramiento de la Calidad.

ABSTRACT

To speak of quality pre-supposes that it is both appropriate and possible to verify the distinguishing elements or

attributes that are characteristic of an object or entity. The consideration of Quality in pharmaceutical services, implies

that the service provided fully fulfils the expectations of those using the service.

In this report the preliminary results of the first stages of the application of the Quality Scheme and its impact on the

growth of pharmaceutical service are considered.

From the results obtained it became apparent that a successful outcome of the scheme depends upon the consolidation

of the pharmacist - patient/client relationship. This factor was found to be of prime importance and was considered as

a central element in the process of pharmaceutical care, within the concept of total quality.

On the other hand, the analysis of the results of the bookkeeping records (not given in this report), shows that as a

consequence of the management scheme and the planning of the strategic processes of the service, greater efficiency in

the management of financial resources and a restriction on costs had been achieved.


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OVIEDO S, ANTONELLO A, DI PAULI NA

INTRODUCCIN

Hablar de calidad presupone que es oportunoy posible la verificacin de las caractersticas oatributos que son propios de un objeto o entidad.En el caso de los servicios la calidad se expresaen el grado de satisfaccin del destinatario delmismo. Es decir que cuando planteamos la Ca-lidad en un servicio de salud estamos diciendo

que este cumple plenamente con las expectativasde quin se asiste por l y las condiciones que dedicho servicio se esperan son las adecuadas1.

La Farmacia como profesin destinada a pro-curar mejores estndares de salud de los indivi-duos y sus comunidades, constituye un serviciocuyo objetivo es garantizar un bien esencial. Eneste sentido hemos sostenido que la AtencinFarmacutica como expresin de la relacin delFarmacutico con el Paciente es el resmen aca-bado del servicio que presta una Oficina de Far-

macia.En esta idea involucramos a todo el procesode funcionamiento de la Farmacia al conceptode Atencin Farmacutica2.

Podemos, as, definir a la Oficina de Farma-cia como una Empresa de Servicios de Salud ycomo tal afectada por las leyes del mercado ycon la responsabilidad de velar por un bien esen-cial como la salud.

En nuestro reporte anterior3 marcbamos quedentro de este contexto, la situacin socioecon-

mica del pas y de la regin planteaba la nece-sidad de cambios estructurales en las formas degerenciamiento de una Oficina de Farmacia, demanera de responder con calidad a la demandade los pacientes. Tambin adelantbamos que estopresupona el desafo de conciliar los interesesde la gestin econmica con los de prestar unservicio de salud.

Esta reingeniera farmacutica se estructurodentro de la filosofa de la calidad total y seplante el desarrollo de un Plan de Gestin deCalidad Total (GTC o en ingls Total QualityManagement, TQM) como la herramienta ade-cuada para tal transformacin4.

INTRODUCTION

To speak of quality pre-supposes that it isboth opportune and possible to verify the distin-guishing elements or attributes that are characte-ristic of an object or entity. In the case of servi-ces, quality is expressed in terms of degree ofcustomer satisfaction. That is to say that the qualityof a health service may be considered as the

complete fulfilment of customer expectations withregard to both the service and the conditions inwhich they are provided1.

Pharmacy, as a profession dedicated to achie-ving a higher degree of individual and commu-nity health, constitutes a service whose objecti-ves are to guarantee an essential asset. In thissense we have maintained that PharmaceuticalCare, as an expression of the relationship bet-ween pharmacist and patient, is the sum of thefinished service provided by a Community Phar-

macy.All the processes involved in the running ofa pharmacy are therefore, to be included in theconcept of Pharmaceutical Care.

The Community Pharmacy may be defined asa Health Service Enterprise, which is as such,affected by market laws. On the other hand it isa business which has the responsibility of safe-guarding the essential asset of health.

In our previous work3 we highlighted thatwithin this context, the social-economic situa-

tion of the country and the region has made struc-tural changes in the management of CommunityPharmacy necessary, in order to respond to thedemands of patients, with a quality service. Itwas also pointed out that this pre-supposed thechallenge of reconciling the interests of econo-mic management with the provision of a healthservice.

This re-engineering of pharmaceutical servi-ces has been structured within the philosophy oftotal quality and the idea of developing a TotalQuality Management scheme (TQM) was devi-sed as a tool for achieving transformation4.

In summary, the application of the quality scheme produced an increase in profits, as a direct consequence of the

reduction of costs related to non-quality activities (poor attention given to the patient, lack of information, high number

of returned expired drugs, etc.) and an increase in productivity associated with drug dispensing and good pharmaceutical

attention practices.

Finally, it may be stated that our hypothesis was correct and that the development of quality and its pursuance go hand

in hand with the development and professional advancement within the ethical framework of the provision of a service.

KEY WORDS: Pharmaceutical Care. Total Quality Management (TQM). Pharmaceutical Administration. Quality assurance.


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El objetivo planteado en aquel momento fueintroducir el Plan de Calidad en una Oficina deFarmacia y a partir de su desarrollo generar elcambio gerencial. El desempeo del sistemadesarrollado se evalu en un corto y mediano

plazo empleando los indicadores que se definie-ron oportunamente.En este reporte acercamos los resultados pre-

liminares de la primera etapa de aplicacin delPlan de Calidad y su impacto en el crecimientodel servicio farmacutico.

El Proceso de Introduccin del Plan de GTC o

TQM

Como primer punto del desarrollo del Plan deGestin de Calidad se defini la misin de laoficina de farmacia y los objetivos de la mismacomo centro de salud, adoptando los lineamien-tos que provee la Organizacin Mundial de laSalud y adecundonos a los requisitos legalesde la regin y del pas (figura 1).

The objective considered at that time was tointroduce a Quality Scheme into a communitypharmacy, and throughout its stages of applica-tion generate a change in management practices.This application of the system was evaluated in

short and medium term time periods, using theindicators that were appropriately defined.In this report the preliminary results of the

first stages of the application of the Quality Schemeand its impact on the growth of pharmaceuticalservice are considered.

The Process of Introduction of the TQM Scheme

As the first point of implementation of the

Quality Management Scheme, the mission of thecommunity pharmacy, and its objectives as a healthcentre were defined, adopting the guidelines setforth by the World Health Organisation, andadapting them to the legal requirements of theregion and the country (figure 1).

FIGURA 1. Esquema del Plan desarrollado para implementacin de la Gestin en Calidad en la oficina de farmacia.

FIGURE 1. Outline of the Scheme developed for the implementation of quality managementin the community pharmacy.

D E F I N I C I O N D E

R E S P O N S A B I L I D A D E S

Q u e e l e m e n t o

d e l a n o r m a

c o r r e s p o n d e a

c a d a s e c t o r

A N E X O 1

A n l is i s d e

P r o c e s o s

( D e s c r i p c i n )

P L A N D E L

P R O Y E C T O

C o m p a r a ci n c o n

e l E s ta d o d e

R e f e r e n c i a

A U T O E V A L U A C I O N

C R O N O G R A M A

D E I M P L E M E N TA C I O N

D E L P L A N D E

C A L I D A D

D E S A R R O L L O D E

L A M A T R I Z

D E

C O R R E L A C I O N

P R E S E N T A C I O N

D E L A

P R O P U E S T A

A D E C U A C I O N Y

T R A N S F E R E N C I A

A L A

E M P R E S A

IS O 9 0 0 2 / G P P / G D P

E L E C C IO N D E L

M O D E L O

D e c l a r a c i n d e P r i n c i p i o s

(O b j e t iv o s - M o t i v o s )


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Se defini los objetivos del Plan de Calidad,planteando como objetivo general: La imple-mentacin de un sistema de gestin de calidad,certificable por terceras partes y que satisfagalos requisitos de las normativas presentes, pero

que se desarrolle con la previsin de la evolu-cin de las normativas nacionales e internacio-nales, que permita la insercin del mismo en unproceso de administracin estratgica iniciado porla organizacin y que incluya en su desempeolos conceptos y objetivos de la atencin farma-cutica.

Los objetivos particulares se definieron como: Establecimiento y oficializacin de las de-finiciones estratgicas. Introduccin del sistema de calidad como

elemento bsico del plan estratgico de la ofi-cina de farmacia. Objetivos especficos de un moderno sis-tema de gestin y aseguramiento de la cali-dad de los procesos operaciones que se eje-cutan en el acto de atencin farmacutica. Utilizacin de recursos internos y exter-nos en condiciones que permitan la mximaeconoma y el mayor beneficio alcanzable porla oficina de farmacia en el proceso de desa-rrollo e implantacin del proceso.

La modalidad de ejecucin del plan de cali-dad const de dos etapas o partes:

Planificacin e implementacin del Plan Consolidacin y Mejora permanente delPlan.

La primera accin a tomar fue capacitar atodo el personal de la Oficina de Farmacia en elconocimiento sobre fundamentos de calidad yherramientas de aplicacin. Simultneamente seaplicaron en la organizacin de la Farmacia tc-

nicas de orden, limpieza y control como lasconocidas 5 S.

Se determin un flujograma de proceso (figu-ra 2) donde se definieron cuales eran los ncleosprincipales de la actividad, sus cuellos de botellay los puntos de control. Esto permiti a su vezdefinir los indicadores de mejora que posterior-mente se emplearon para evaluar el desempeodel funcionamiento de la farmacia y de su plande calidad.

The objectives of the Quality Scheme weredefined from a general point of view as: Theimplementation of a system of quality manage-ment, which could be certified by third partiesand could satisfy the requirements of current

regulations, which at the same time could allowfor possible changes in national and internatio-nal regulations, and the insertion of such chan-ges, in a process of strategic administration ini-tiated by the organisation, and simultaneously,include the concepts and objectives of pharma-ceutical care.

The particular objectives were defined as: The establishment and official recognitionof strategic definitions. The introduction of the quality system as

a basic element of the community pharmacysstrategic plan. Specific objectives concerned with a mo-dern system of management and the guaran-tee of quality in processes involved in the onthe spot execution of pharmaceutical care. The use of internal and external resourcesthat permit maximum economy and the achie-vement of the highest degree of profitabilitythat can be attained by a community pharma-cy while introducing and developing the pro-cess.

The execution of the quality plan consisted oftwo stages or parts:

Planning and implementation of the Sche-me. Consolidation and Improvement of the Sche-me.

The first step to be carried out was to train allthe personnel in the Community Pharmacy inawareness of the principles of quality and the

tools involved in their application. Simultaneously,techniques in order, cleanliness and control knownas 5 S were imposed.

Flow charts of the process were devised, wherethe main nuclei of activities, bottle necks andcontrol points were defined. This, at the sametime, allowed the indicators of improvement, thatwere subsequently applied, to be defined in or-der to be able to evaluate the running of thepharmacy and the effect of the quality schemeintroduced.


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85ADMINISTRACIN Y GESTIN DE LA CALIDAD TOTAL EN LA FARMACIA OFICINAL: ...

FIGURA 2. Flujograma de proceso de la oficina de farmacia.

Pacientesolicita el

medicamento

Paciente

Mdico

Con-

trol

Particular

Con-trol

Annamesis

Revisin

de Receta

Obra

Social

STOCK

Con-trol

Empaque

Alternativa

(mono droga)

Reposicinde

Droguera

Recepcin

Fichade

Farmacov

CAJASeguimientodelpaciente

FIGURE 2. Flowchart of processes in the community pharmacy.

Patientrequestsmedicine

Patient

Doctor

Con-trol

Particular

Con-trol

Anamnesis

Revisionof prescrip-

tionPrivatehealth

STOCK

Con-trol Packaging

Alternative(mono drug)

Replace-ment ofstock

Reception

Rec.of

drug

TILLPatientMonitoring


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Nivel 1:Manual dela Calidad

Nivel 2:Manuales

deProcesos

Nivel 3: Procedimientos Operativos Estndares (SOPs)

FIGURA 3. Esquema de la pirmide de documentacinadoptada.

Determinados los indicadores crticos de xi-to de la empresa, se agruparon de acuerdo a cuatrodimensiones, Capacitacin, Procesos, Pacientes/Clientes, Finanzas. La dimensin capacitacin seevalu a travs de los siguientes indicadores:

Capacitacin a empleados, Capacitacin geren-cial y mandos medios y sistemas de informa-cin. La dimensin procesos incluy: calidad total,costos, desarrollo y tecnologa. La dimensinpacientes/clientes se evalu a travs de la varia-ble Mercadeo o Marketing y el ndice de percep-cin del paciente usuario sobre la calidad delservicio de salud y finalmente la financiera seevalu a travs de la situacin actual de la empresarespecto a los resultados y situacin financiera.

Documentacin de la Calidad

Definida la misin, los objetivos, las polti-cas y el proceso de la Farmacia, se inicio laetapa de documentacin, elaborando documen-tos de nivel 1 (Manual de la Calidad) y nivel 3(Procedimientos Operativos Estndares o POSs),no se redactaron documentos de nivel 2 (PlanesGenerales), estos se integraron dentro del Ma-nual de la Calidad y los POSs (figura 3).

Once the critical indicators of business suc-cess were determined, they were categorised intofour different aspects; Training, Processes, Pa-tients/Clients and Finances. The training aspectwas evaluated in accordance with the following

indicators: Employee training, management andmiddle management training and informationsystems. The process aspect included: Total qua-lity, costs, development and technology. Thepatient/client aspect was evaluated through themarketing factor and an index of the patientsquality perception of the health service providedwas designed. Finally, the financial aspect wasevaluated in the light of the results obtained andthe companies current financial situation.

Documentation of Quality

Once the mission statement, the objectives,policies and processes of the pharmacy had beendefined, the documentation stage was initiated.Document level 1 (Quality Manual) and level 3(Standard Operating Procedures or SOPs) wereproduced. Documents for level 2 (General Plans)were not produced separately as they were inclu-ded within the Quality Manual and the SOPs(figure 3).

Level 1:Qualitymanual

Level 2:Process

manuals

Level 3: Standard Operating Procedures (SOPs)

FIGURE III. Outline of the pyramid of documentationadopted.


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En el Manual de la Calidad se incluyo elManual de la Organizacin, los Planes de Ase-guramiento de la Calidad, Validacin de Equi-pos de Ensayos, software y hardware, Manual deBuenas Prcticas de Dispensacin, Validacin del

Proceso de Atencin Farmacutica, Manual deDispensacin, Manual de Registro de Datos eHistorias Clnico-Farmacolgicas de los Pacien-tes, Plan de Capacitacin Permanente.

Es decir con los documentos de nivel uno quedadescripta la revisin apropiada y la comprobacindel proceso que determina la seguridad y calidadde los medicamentos dispensados, como del ser-vicio de atencin al paciente, monitoreo y segui-miento del medicamento una vez dispensado.

Los Procedimientos Operativos (POSs) se

desarrollaron siguiendo un criterio prctico y segeneraron documentos que definieran las opera-ciones necesarias para realizar el acto de aten-cin y dispensacin correctamente. A grandeslneas podemos mencionar que los POSs abar-caron las siguientes operaciones:

1. Traduccin e interpretacin de la receta; esteprocedimiento contempla la revisin del perfilde droga suministrada, estado de salud delpaciente y la relacin de interacciones conel medicamento prescrito. La revisin de lacorrecta redaccin de la receta y su conteni-do (droga, dosificacin, y posologa).

2. Registro y evaluacin de la Dispensa deNarcticos y Medicamentos de Venta BajoReceta Archivada.

3. Registro y Control de Stock de Medica-mentos.

4. Procedimientos de Cuidados al Paciente.5. Procedimiento de registro de la atencin al

paciente, indicando la confeccin de su his-toria clnica y farmacolgica.

6. Procedimiento de Tratamiento de medica-mentos vencidos.

7. Procedimiento de Reposicin y Distribu-cin de los Medicamentos.

8. Procedimiento de registro y procesamientode quejas de los pacientes: Se investiganlas quejas recibidas y se documentan. Tam-bin se documenta el resultado de la inves-tigacin de las causas de las mismas y lasacciones correctivas asociadas. Se supervi-sa las acciones correctivas para verificar

su efectividad en un ciclo de mejora con-tinua.

The Quality Manual included; the OrganisationManual, Quality Guarantee Schemes, Validationof Testing Equipment, software and hardware,the Good Drug Dispensation Practices Manual,Validation of Pharmaceutical Care Processes, the

Dispensation Manual, the Manual of Data Re-cords and Clinical-Pharmacological Backgroundsof the Patients and the Permanent Training Scheme.

That is to say, that in the documents at levelone, the appropriate revision and checking of theprocess determining the safety and quality of thedrugs dispensed are described, as well as theservice of attention given to the patient and themonitoring of the dispensed drug.

The Operating Procedures (SOPs) were de-veloped by following a practical criterion and

documents were produced to define the neces-sary operations in order to carry out attentionand dispensation services correctly. Generallyspeaking it could be stated that the SOPs cove-red the following operations:

1. The translation and interpretation of theprescription; this procedure contemplates theprofile of the drug supplied, the patients stateof health and the possible interactions withthe drug prescribed. The revision of the correctdrafting of the prescription and its contents(drug, dosage and dosage schedules).

2. Registering and evaluation of the Dispen-sation of Narcotics and Drugs Sold UnderFiled Prescriptions.

3. Registering and Stock Control of Drugs.4. Patient Care Procedures.5. Registering procedures of attention given

to patients, showing the drafting of clinicaland pharmacological backgrounds.

6. Procedures and Treatment of expired drugs.7. Replacement Procedures and Distribution

of Drugs.8. Registry procedures and processing of pa-

tient complaints: The complaints are inves-tigated and documented. The results of thecomplaint investigation are documented to-gether with their causes and their associa-ted corrective courses of action. The co-rrective course of action are supervised inorder to verify their effectiveness in a cycleof continual improvement.

9. The establishment of procedures for the

care and monitoring of Diabetic and Hy-pertensive patients.


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9. Procedimientos para cuidado y control depacientes Diabticos e Hipertensos.

10. Procedimientos para cuidado y limpiezade reas de consulta.

Siendo estas tan slo una muestra, ya quesera material para otro reporte el anlisis deta-llado de las caractersticas y definicin de losprocedimientos operativos adecuados para laoficina de farmacia.

Los procedimientos operativos generaron or-den y sistematizacin de las actividades en laOficina de Farmacia, tambin permitieron acce-der a la informacin requerida de forma ms rpiday con los registros se realiz en seguimientoestadstico del funcionamiento de la Farmacia y

su plan de calidad, en algunas tareas especficascomo ser el control de glucosa en pacientes dia-bticos o de presin arterial en hipertensos, comoas tambin en otras actividades tales como laconsulta de pacientes sobre el correcto empleo delos medicamentos se inici la implementacin deun control estadstico de estos procesos lo quepermiti determinar los lmites de calidad y losestndares requeridos para esta primer etapa.

Evaluacin del desempeo del Plan de Calidad

Transcurrido un ao desde la implementacindel plan se realiz un estudio evaluativo de sudesempeo y para ello nos valimos de los indi-cadores mencionados prrafos arriba.

Las variables de percepcin se las caracteriza travs de una escala ordinal de tres niveles.

Se ponderaron las variables y se construy unalgoritmo matemtico, con el cual se elabor unorden de mritos que permiti clasificar a losresultados en cuatro grupos: Excelente, Bueno,

Regular y Malo, (E 90%; B 89-40%; R 39-10%y M 9%).

El puntaje mximo otorgado a la dimensincapacitacin fue de 500 puntos, a la dimensinprocesos 600 puntos, a las dimensiones clientesy financiera 100 puntos, cada una respectivamente.

Un puntaje igual o superior al 80% en cadadimensin fue calificado como excelente, unpuntaje entre el 40 y el 79% en cada dimensincomo bueno, un puntaje menor al 39% comoregular y un puntaje menor al 10% en cada di-

mensin se lo calific como malo.La percepcin de la calidad desde la perspec-

10. Procedures for the care and cleaning ofconsultation areas.

The above points only represent a generaloutline, given that such procedures in themsel-

ves would provide the subject matter for anotherreport giving a detailed analysis of the characte-ristics and definition of appropriate communitypharmacy operative procedures.

Operative procedures generate order and sys-tematisation of Community Pharmaceutical acti-vities. Additionally, they permit fast access toany required information and with the recordsproduced a statistical following of the functio-ning of the Pharmacy and its quality scheme couldbe made. In some specific areas of care such as

the control of glucose in diabetic patients, in thedetermination of arterial pressure in hypertensi-ve patients, or patient counselling with regard tothe correct use of drugs, a statistical control wasimplemented, in order to establish the parame-ters of quality and standards required during thisfirst stage.

Evaluation of the objectives of the Quality Scheme

One year after the initial implementation ofthe scheme, a study to evaluate the objectivesusing the previously mentioned indicators wascarried out.

The variable of perception were characterisedby means of a three levelled ordinal scale.

The variables were considered and a mathe-matical algorithm was produced with which anorder of merits could be established in order toclassify the results into four grades: Excellent,Good, Fair and Bad (E 90%; G 89-40%; F 39-10% & B 9%).

The maximum possible grading in the trai-ning aspect was established at 500 points, forthe procedural aspect at 600 points, and for theclient and financial aspects at 100 points eachrespectively.

A score of 80% and above in each aspect wasregarded as excellent, between 40% and 79% asgood, 39% or lower as fair and a score of 10%or less as bad.

The perception of quality of pharmaceuticalcare from the patients perspective was evaluated

from the information obtained from a surveyconducted on 2938 clients, that had attended the


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tiva de los pacientes usuarios del servio de aten-cin farmacutica, se evalu a partir de los datosobtenidos de una encuesta efectuada a 2938 usua-rios que asistieron a la oficina de farmacia enlos tres meses posteriores a la implementacin

del plan de calidad.La evaluacin evolutiva de las fortalezas ydebilidades del servicio se realiz considerandolas ventajas operativas, respecto de las demsfarmacias de la zona, obtenidas desde la imple-mentacin del plan de calidad. Se estableci unamatriz F.O.D.A (fortalezas, oportunidades, debi-lidades y amenazas), evalu los datos con unagrfica de PARETO y se emple una matriz degravedad, urgencia, tendencia (GUT) para ela-borar un plan de accin para la mejora conti-

nua5

.Para los agrupamientos, el anlisis estadsticode los datos, tablas de contingencia y anlisis noparamtricos, se emple el software MicrosoftExcel Versin 97.

Los resultados obtenidos

La percepcin de fortalezas y debilidades dela Oficina de Farmacia con relacin a la compe-tencia se representa en la comparacin de venta-

jas operativas que se detallan en la tabla 1, don-de se observa que como consecuencia deldesarrollo del plan de calidad se afianz las for-talezas y se inici un proceso de mejora muyevidente en las debilidades. El promedio de for-talezas, estndar o normal y debilidades previo ala implementacin del plan de calidad se ubicen 16,18%, 44,13% y 39,69% respectivamente.Estos porcentajes demostraron que si bien lapercepcin estaba mayoritariamente en una nor-mal, las debilidades superaban con amplitud a

las fortalezas y marcaban una tendencia negati-va para el desarrollo de la organizacin, este hechodeterminaba que se estaban perdiendo oportuni-dades y que se acrecentaban las amenazas parael futuro de la farmacia. Desde la aplicacin delplan la percepcin evolucion favorablementepresentando un promedio porcentual de 38,72%para las fortalezas, 48,02% para la normal y13,25% para las debilidades. Se puede decir quese revirti la tendencia de amenazas y que lafarmacia transita un camino de mejoras.

community pharmacy, during the first threemonths, following the implementation of thequality scheme.

The evolutionary evaluation of the strengthsand weaknesses of the service were carried out

considering the operative advantages gained af-ter the implementation of the quality scheme incomparison with other pharmacies in the area.An S.O.W.T. (strengths, opportunities, weaknes-ses and threats) matrix was established, and thedata were evaluated by means of a PARETO graph.Furthermore, a severity, urgency, and tendency(SUT) matrix was used to produce a plan for acourse of action so as to achieve continual im-provement5.

For the groupings, statistical analysis of the data,

contingency tables and non-parametric analysis, thesoftware Microsoft Excel Version 97 was used.

The results obtained

The perception of strengths and weaknessesof the community pharmacy with respect to thecompetition is represented by the comparison ofoperative advantages shown in table 1. As aconsequence of the development of the qualityscheme, a consolidation of strengths can be seento occur, while the weaknesses are evidentlyaffected after the initiation of the process ofimprovement. Average values for strengths, stan-dard or normal and weaknesses prior to the im-plementation of the quality scheme were esta-blished at 16.18%, 44.13% & 39.69% respectively.These percentages demonstrate that while theperception of quality was mostly considered asnormal, weaknesses greatly surpassed strengths,indicating consequently, a negative tendency inthe development of the organisation. Such a

finding indicates that the company was missingout on opportunities, and that the future of theenterprise was under growing threat. After theimplementation of the scheme, perception ofquality evolved favourable presenting averagepercentages of 38.72% for strengths, 48.02% fornormal and 13.25% for weaknesses. Moreover,it may be stated that the tendency towards sus-ceptibility to threats was reversed and the phar-macy was being directed along a path towardsimprovement.


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90



Pre Plan d e Calidad

Atributo Fuerte Normal Dbil Total

Gestin 11.00% 40.70% 48.30% 100.00%

Planificacin 10.80% 44.30% 44.90% 100.00%

Costos 29.80% 45.10% 25.10% 100.00%

Logstica 6.50% 46.60% 46.90% 100.00%

Ventas 12.00% 49.00% 39.00% 100.00%

Distribucin 6.20% 47.90% 45.90% 100.00%

Calidad Total 2.60% 43.90% 53.50% 100.00%

Tecnologa 36.70% 41.90% 21.40% 100.00%

Mantenimiento

Correctivo

15.00% 28.30% 56.70% 100.00%

Desarrollo 42.90% 41.50% 15.60% 100.00%

Capacitacin 2.50% 44.60% 52.90% 100.00%

Informacin 18.20% 55.80% 26.00% 100.00%ISP* SD SD SD SD

Con Plan d e Calidad

Atributo Fuerte Normal Dbil Total

Gestin 45.60% 45.90% 8.50% 100.00%

Planificacin 40.80% 47.30% 11.90% 100.00%

Costos 39.90% 53.10% 7.00% 100.00%

Logstica 21.50% 47.90% 30.60% 100.00%

Ventas 31.50% 51.90% 16.60% 100.00%

Distribucin 41.50% 45.90% 12.60% 100.00%

Calidad Total 45.80% 44.50% 9.70% 100.00%

Tecnologa 40.90% 44.50% 14.60% 100.00%Mantenimiento

Correctivo

35.90% 47.50% 16.60% 100.00%

Desarrollo 45.50% 44.90% 9.60% 100.00%

Capacitacin 35.90% 44.60% 19.50% 100.00%

Informacin 30.70% 55.80% 13.50% 100.00%

ISP* 47.90% 50.50% 1.60% 100.00%

TABLA 1. Percepcin de fortalezas y debilidades previas y posteriores a la implementacin del plande gestin y calidad.

* Indice de Insatisfaccin del Cliente.


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La tabla 2 y el grfico 1 muestran el agrupa-miento de las dimensiones analizadas y sus indi-cadores, en funcin del valor obtenido a travsdel algoritmo de calificacin. En el anlisis delos porcentajes de las cuatro dimensiones (grfi-co 1) se observa el crecimiento obtenido desdeque se inici el plan de calidad, el punto msevidente se demuestra en la dimensin pacien-tes-usuarios.

Table 2 and graph 1 show the grouping of theaspects analysed along with their respective in-dicators, based on the values obtained by meansof the grading algorithm. In the analysis of thepercentages of the four aspects (graph 1), growthobtained since the initiation of the quality sche-me may be observed. The most evident effectswere apparent in the patient-client aspect.

Pre-Quality scheme

Attribute Strong Normal Weak Total

Management 11.00% 40.70% 48.30% 100.00%

Planning 10.80% 44.30% 44.90% 100.00%

Costs 29.80% 45.10% 25.10% 100.00%

Logistics 6.50% 46.60% 46.90% 100.00%

Sales 12.00% 49.00% 39.00% 100.00%

Distribution 6.20% 47.90% 45.90% 100.00%

Total quality 2.60% 43.90% 53.50% 100.00%

Technology 36.70% 41.90% 21.40% 100.00%

Corrective

maintenance

15.00% 28.30% 56.70% 100.00%

Development 42.90% 41.50% 15.60% 100.00%

Training 2.50% 44.60% 52.90% 100.00%

Information 18.20% 55.80% 26.00% 100.00%

ISP* N/A N/A N/A N/A

Subsequen t to Quality scheme

Attribute Strong Normal Weak Total

Management 45.60% 45.90% 8.50% 100.00%

Planning 40.80% 47.30% 11.90% 100.00%

Costs 39.90% 53.10% 7.00% 100.00%

Logistics 21.50% 47.90% 30.60% 100.00%

Sales 31.50% 51.90% 16.60% 100.00%

Distribution 41.50% 45.90% 12.60% 100.00%

Total quality 45.80% 44.50% 9.70% 100.00%

Technology 40.90% 44.50% 14.60% 100.00%Corrective

maintenance

35.90% 47.50% 16.60% 100.00%

Development 45.50% 44.90% 9.60% 100.00%

Training 35.90% 44.60% 19.50% 100.00%

Information 30.70% 55.80% 13.50% 100.00%

ISP* 47.90% 50.50% 1.60% 100.00%

* Index of Client Dissatisfaction.

TABLE 1. Perception of strengths and weaknesses prior to and subsequent to the implementationof the quality management scheme.


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92



GRFICO I. Agrupamiento de las Dimensiones Analizadas.

A)Pre Plan de Q

0%

43%36.6%

43.75%

Capacitacin

Procesos

Pacientes

Financiera

Plan de Q

78.67%

67.5%

53%87%

Capacitacin

Procesos

Pacientes

Financiera

B)

DIMENSIONES Pre Plan Q Plan Q

Indicador Puntos % Puntos %

Cap. Empl. 150 30 395 79

Cap. Gern. 200 40 435 87

Capacitacin

Sist. Inf. 200 40 475 95

Calidad Total 150 25 450 75

Costos 300 50 550 91.67

Desarrollos 275 45.83 430 71.66

Procesos

Tecnologa 325 54.17 460 76.67

Marketing SD 0 65 65Pacientes/

Clientes Ind.Perc.Pac. SD 0 70 70

Financiera Contable 43 43 5 3 53

TABLA 2. Distribucin de los indicadores en funcin de los puntajes obtenidos.

ASPECTS Pre-Q Scheme Q Scheme

Indicator Points % Points %

Training Empl. 150 30 395 79

Training

Management

200 40 435 87

Training

Syst. Inf. 200 40 475 95

Total quality 150 25 450 75

Costs 300 50 550 91.67

Development 275 45.83 430 71.66

Processes

Technology 325 54.17 460 76.67

Marketing N/A 0 65 65Patients/

Clients Index of

perception

Patient.

N/A 0 70 70

Financial Accounts 43 43 53 5 3

TABLE 2. Distribution of the indicators based on the points obtained.


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Pre Q Scheme

43.75%

36.6%43%

0%

Training

Processes

Patients

Finances

Q Scheme

87%53%

67.5%

78.67%

TrainingProcesses

Patients

Finances

GRAPH 1. Groupings of the aspects analysed.

A) B)

Al evaluar individualmente los indicadores decada dimensin (grfico 2) se observ que eldesarrollo y aplicacin del plan de calidad influ-yo en mayor medida en aquellos que tienen re-lacin con la gestin y con la atencin al pacien-te, a priori no se evala detenidamente la influenciadel mismo sobre las finanzas, aunque se observauna mejora en las mismas, fundamentalmenteprovocada por un incremento de las ventas (fi-gura 4), una mejora en la logstica de la farma-cia que represent una disminucin en la devo-lucin de medicamentos vencidos o scrap (figura5) y un incremento de la fidelidad de los pacien-tes usuarios del servicio a partir de la mejorade la atencin farmacutica (grfico 3).

On evaluating the indicators of each aspect(graph 2), the application and development ofthe quality scheme was seen to exert the mostinfluence in areas related to management andpatient attention. The influence of the schemeon the financial aspect was not immediatelyevaluated. However, an improvement was detec-ted due to an increase in sales (figure 4), and animprovement in pharmaceutical logistics in theform of a decrease in the return of expired drugs(figure 5), and an increase patient/client fidelitybrought about by an improvement in pharmaceu-tical care (graph 3).

30%40% 40%

0

10

20

30

40

%

Capacitacin Pre Plan Q

Cap. Empl.

Cap. Gern.

Sist. Inf.

25%

50% 45.83% 54.17%

0

10

20

30

40

50

60

%

Procesos Pre Plan Q

Calidad Total

Costos

Desarrollos

Tecnologa

43%

0

10

20

30

40

50

%

Finanzas Pre P lan Q

Contable

0% 0%

0

0.2

0.4

0.6

0.8

1

%

Pacientes /clientes Pre Plan Q

Marketing

Ind.Perc.Pac.

GRFICO 2 A

GRFICO 2. Evaluacin individual por indicador y por dimensin, comparacin pre y post aplicacin

del plan de gestin y calidad.


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94



GRFICO 2 B

30%40% 40%

0

20

40

%

Training Pre Q Scheme

Train. Empl.

Train. Man.

Syst. Inf.

25%

50% 45.83% 54.17%

0

20

40

60

%

Processes Pre-Q Scheme

Total Quality

Costs

Development

Technology

GRAPH 2. Individual evaluation per indicator and per aspect, pre and post application comparisonof the management and quality scheme.

GRAPH 2 A

43%

0

10

20

30

40

50

%

Finances Pre-Q Scheme

Accounts

0% 0%

0

0,5

1

%

Patients /clientes Pre-Q Scheme

Marketing

Ind.Perc.Pat.

79% 87%95%

0

20

40

60

80

100

%

Capacitacin Plan Q

Cap. Empl.

Cap. Gern.

Sist. Inf.

75%92%

72% 77%

0

20

40

60

80

100

%

Procesos Plan Q

Calidad Total

Costos

Desarrollos

Tecnologa

53%

0

20

40

60

%

Finanzas Plan Q

Contable

65%70%

62

64

66

68

70

%

Pacientes /clientes Plan Q

Marketing

Ind.Perc.Pac.


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FIGURA 4. EVOLUCION DE RESULTADOS OPERA-TIVOS: Evolucin Ventas, Gastos,y relacin Utilidad neta/Venta (Margen de Beneficios)

-1

-0,5

0

0,5

1

1,5

2

2,5

3

3,5

4 8 12 16 20 24 30

Vtas x $ 50.000

Gast. Tot. $ 10.000

Margen Beneficios/100

Meses de Impl. elPlan de Q.

Graph 2 B

79% 87% 95%

0

20

40

60

80

100

%

Training Q Scheme

Cap. Empl.

Cap. Gern.

Sist. Inf.

75% 92% 72%77%

0

20

40

60

80

100

%

Processes Q Scheme

Calidad Total

Costos

Desarrollos

Tecnologa

53%

0

20

40

60

%

Finances Q Scheme

Accounts

65%

70%

62

64

66

68

70

%

Patients /clients Q Scheme

Marketing

Ind.Perc.Pat

Total Quality

Costs

Development

Technology

Marketing

Ind.Perc.Pat.

-1

-0,5

0

0,5

1

1,5

2

2,5

3

3,5

4 8 12 16 20 24 30

Sales x $ 50.000

Tot. Expense $ 10.000

Profit M argin/100

Months of Impl.of Q.Scheme

FIGURE 4. EVOLUTION OF RESULTS OF OPERATIONS:Sales, Expenses, and Net profit/sales (Profit Margin)


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96



0%

10%

20%

30%

40%

50%

60%

70%

COS CPP CSP

Buen Trato

Est Conforme con la Atencin Farm.

Est conforme con el tratamiento

Sigue control de Diabetes

Se cur

Servicio Barato

Tiempos de espera largos

Hay medicamentos

Servicio eficiente

Sirven los conse jos

GRFICO 3. Motivos por los cuales el paciente elige y vuelve al Servicio de Farmacia. (COS = Obra Social,CPP= Medicina Prepaga, CSP= Servicio Pblicos de Salud)

FIGURE 5. INDICATORS OF QUALITY OFMANAGEMENT. Evolution of the percentage of

rejected Drugs for defects or exceeded expiry date(Capability of suppliers to supply quality products/

reduction of scrap).

0

1

2

3

4

5

6

7

8

9

4 8 12 16 24 30

% Medic. reject./

Total Medic.

Months of Impl.

of Q.Scheme

FIGURA 5. INDICADORES DE CALIDAD DE LAGESTION. Evolucin del % de Medicamentos

rechazados por defectos o vencimiento (Capacidadde calidad de los proveedores/ reduccin de scrap).

0

1

2

3

4

5

6

7

8

9

4 8 12 16 24 30

% Med. rechaz./ Total

Medic.

Meses de Impl. elPlan de Q.


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GRAPH 3. Motives for which the patient chooses and returns to the pharmaceutical service. (Pr.HS = Private HealthSchemes, PPM = Prepaid Medicine, Pu.HS = Public Health Service)

0%

10%

20%

30%

40%

50%

60%

70%

Pr.HS PPM Pu.HS

Good treatment

Content with pharmceutical care

Agrees with treatment

Follows diabetic control

Was cured

Cheap Service

Long waiting times

Supply of medicines

Efficient service

Useful advice

Con relacin a la percepcin de los pacientes usuarios respecto a la calidad del servicio deatencin los resultados demostraron que fue buenaen un 78,95 de los casos, fue regular en un 16,5%y mala en un 4,55 %. Del anlisis del juicio delos usuarios con relacin a los positivo y nega-tivo de la atencin en la oficina de farmacia sedetermina la importancia que adquiere la dimen-sin procesos (45.6%), sobre todo en lo relacio-nado con la atencin, el trato personal, las accio-nes de dispensacin, consulta e informacinrecibida durante la entrevista con el profesionalfarmacutico. Los aspectos relacionados con lafacilidad de acceso al servicio farmacutico, comotiempo de espera, facilidad de obtencin delmedicamento solicitado, costo del servicio far-

macutico, significaron un 29.7% de la aprecia-cin de los pacientes. En lo que respecta a las

With regard to patient/client perception of thequality of the attention received, the results de-monstrated that 78.95% perceived this aspect asgood, 16.5% as fair and 4.55% as bad. From theanalysis of client perception of positive and ne-gative elements in attention received in the com-munity pharmacy, it was found that the procedu-ral aspect became a matter of importance (45.6%).This was apparent above all in the areas of at-tention, personal treatment, drug dispensation,consultation and information received during theinterview with pharmaceutical staff. Aspects re-lated to accessibility to the pharmaceutical ser-vice, such as waiting time, ease with which therequested drug could be obtained, cost of thepharmaceutical service, produced a 29.7% level

of patient appreciation. With regard to facilitiesand technological equipment, staff training re-


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98



instalaciones y equipamiento tecnolgico delservicio, capacitacin del personal representaronel 12.2% y finalmente la percepcin de mejoraen su estado de salud como consecuencia de laatencin recibida y del buen empleo de los me-

dicamentos represent el 12,5% (grfico 4). Enel grfico 5 se observan los principales motivosde percepcin de la calidad por parte de lospacientes, mientras que en el grfico 6 se defi-nen los motivos por los que juzga al serviciofarmacutico como da mala calidad.

presented 12.2% and finally, the perception ofimprovement in health brought about by the carereceived and the appropriate use of medicinesrepresented 12.5% (graph 4). In graph 5, thepatients main reasons for evaluating the quality

of the service are presented, while graph 6 defi-nes their reasons for judging the service as beingof poor quality.

Accesibilidad Instalaciones Proceso Resultado29.7% 12.2% 45.6% 12.5% .

Econmica Suficiencia Contenido de Cambios(precio de materiales la atencin endel servicio) (Disp/seguim.) salud

Organizacional Organizacin Relacin Efecto(tiempos de horarios, inter- dede espera) citas, fichas personal medicamentos

COS CPP CSPBuena 39,3% 78,1% 89,5%Mala 60,7% 21,9% 10,5%Total 100% 100% 100%

b) Diferencia de la Percepcin de la Calidad de la Atencin segn las caractersticas de la consulta:

GRFICO 4.

a) Dominio conceptual de la Calidad de la Atencin: principales elementos representativosde la perspectiva del Usuario.

GRAPH 4.

a) Conceptual Dominion of Quality of Care: Principle Elements Representative of the Clients Perspective.

b) Differences in the Perception of Quality of Care in accordance with the Characteristics of the Consultation

Accesibility Facilities Process Results29.7% 12.2% 45.6% 12.5% .

Economic Suficiency Contents of Changes(price of materials care inof service) (Disp/monitor.) health

Organizational Organization Interpersonal Effect(waiting times) timetables, relationship of

app., records medicines

COS CPP CSPGood 39.3% 78.1% 89.5%

Bad 60.7% 21.9% 10.5%Total 100% 100% 100%


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GRFICO 5. Principales motivos de percepcin de la calidad segn el Paciente. (COS = Obra Social,CPP= Medicina Prepaga, CSP= Servicio Pblicos de Salud)

0%

10%

20%

30%

40%

50%

60%

70%

COS CPP CSP TODOS

Buen Trato personal

Preparacin Tca delPersonal

Resultados Positivosen su salud

Bajo Costo del

Servicio

GRAPH 5. Main reasons for perceiving Quality according to the Patient. (Pr.HS = Private Health Schemes,PPM = Prepaid Medicine, Pu.HS = Public Health Service)

0%

10%

20%

30%

40%

50%

60%

70%

Pr.HS PPM Pu.HS All

Good personaltreatment

Personnel Tech.Skills

Positive results inhealth

Low Cost of Service


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100



0%

5%

10%

15%

20%

25%

30%

COS CPP CSP TODOS

Tiempo de Espera

Mal Trato Personal

Resultados Positivosen su salud

Alto Costo de la

Atencin

GRFICO 6. Principales motivos de percepcin de la mala calidad segn el Paciente. (COS = Obra Social,CPP= Medicina Prepaga, CSP= Servicio Pblicos de Salud)

GRAPH 6. Main reasons for perceiving Quality according to the Patient. (Pr.HS = Private Health Schemes,PPM = Prepaid Medicine, Pu.HS = Public Health Service)

0%

5%

10%

15%

20%

25%

30%

Pr.HS PPM Pu.HS ALL

Waiting time

Poor Personaltreatment

Positive results inhealth

High Cost ofAttention


21/28



The improvement produced by the qualityscheme, in the process of pharmaceutical care,was seen to be reflected in patient response andwas manifest in an increase in sales, broughtabout by an increase in the index of client satis-

faction and by a decline in the costs of non-quality related elements of the service (figure 6& 7).

La mejora introducida por el plan de calidaden el proceso de atencin farmacutica, se vioreflejada en la respuesta de los pacientes que seexpresa en un incremento de las ventas comoconsecuencia del incremento del ndice de satis-

faccin de los usuarios y de la merma de loscostos de la no calidad (figuras 6 y 7).

$1000

$500

*

$ 100

$ 10Bajo - 0 POP 1 POP2 POP3 Alto- 100

Costos ResultantesCostos ControlablesCostos Resultantes ms Costos del ClienteCostos de Insatisfaccin del Cliente

* Costos del Cliente

Curva Resultante 1Curva Resultante 2

Curva Resultante 3POP: Punto Operativo Optimo

FIGURA VI. Relacin entre los costos, el punto ptimo operativo (POP) y el ndice de satisfaccindel paciente/cliente.

FIGURE VI. Relationship between costs, optimal operative point (OOP) and the index of patient/client satisfaction.

$1000

$500

*

$ 100

$ 10

Low - 0 OOP 1 OOP 2 OOP 3 High-100

Resulting CostsControllable CostsCosts Considered higher by the Client* Costs of Client Dissatisfaction

Cost to the ClientResulting Curve 1Resulting Curve 2

Resulting Curve 3OOP: Optimal Operating point


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102



FIGURE VII. Variation in Patients Satisfaction index after the implementation of the quality scheme.

X1 X2

SASTIFACTION

C2 $ 1500

C2 $ 100

High

COST

Low

DISSASTIFACTION

Low DEGREE OF QUALITY OF PRODUCT Optimal

X1:Initial Operative Level, X2: Final Operative Level. Client, C1: Cost of Initial Dissat.,C2: New Cost of Dissat. Var. of Cost Dissat. Var. of Client's Request

Index of Satisfaction New Index of Satisfaction

X1 X2

SASTIFACCION

C2 $ 150

C1 $ 115

Alto

COSTO

BajoINSASTIFACCION

Bajo GRADO DE CALIDAD DEL PRODUCTO Optimo

X1:Nivel Operativo Inicial, X2: Nivel Operativo+ Insast. Clte, C1: Costo Insast. Inicial,C2: Nuevo costo de Insast. Var. Costo Insast, Var. Requer. del Cliente

Indice de Satifaccin Nuevo Indice de Sastifaccin

FIGURA VII. Variacin del ndice de Satisfaccin del paciente desde la implementacin del plan de calidad.


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Beneficios obtenidos con la Implementacin del

Plan de Calidad

Los beneficios obtenidos con la implementa-cin del plan presentan una estrecha vincula-

cin con la relacin entre la farmacia y sus pro-veedores y principalmente con el proceso deatencin farmacutica, tal como se puede apre-ciar a continuacin.

Proveedores, Laboratorios y Drogueras Ma-yoristas:

* Eliminacin de riesgos de recibir medica-mentos, cosmticos y accesorios de farmaciadefectuosos o cuyo origen sea desconocido o decalidad poco probable.

* Seguimiento peridico en el cumplimiento

del proveedor a travs de indicadores como n-dice de calidad tcnica, de entrega de pedidos,de existencias, de respuesta, de asistencia tcni-ca y profesional.

* Reaseguro de un sistema de reclamos y de-voluciones rpido y efectivo por parte de la dro-guera o laboratorio.

* Costos de devolucin de medicamentos enmal estado o vencidos menores debido a una mayorcalidad y confianza entre las partes.

Procesos de Atencin y Dispensacin:* Medicin del ndice de satisfaccin de los

pacientes usuarios a partir de una mejor atencindispensada por personal entrenado y capacitado.

* Tratamientos estadsticos de los datos in-formados a travs de grficas de control en tiemporeal, histogramas, capacidad de proceso (Cp, Cpk),ndices de calidad y movimientos diarios quepermiten elaborar planes de accin y contingen-cia en un proceso de mejora continua.

* Mayor control de la documentacin y delos datos relacionados a la calidad junto a todosaquellos documentos de procedencia externa (or-

denes de consulta por obras sociales, recetasarchivadas, etc.) revisados y aprobados.

* Disposicin de Procedimientos operativos einstructivos de trabajo en los lugares donde serealizan las operaciones crticas del proceso deatencin farmacutica.

* Registro, tratamiento y evaluacin econ-mica de las no conformidades, con el objeto deminimizarlas.

* La orientacin de todas las actividades dela farmacia a establecer soluciones permanentes

a problemas repetitivos, con el fin de lograr ungrado ptimo de eficiencia y calidad en la pres-

Benefits obtained from the implementation of the

Quality Scheme

The benefits obtained from the implementa-tion of the scheme, as stated below, are closely

linked to the relationship between the pharmacyand its suppliers, and principally with the pro-cess of pharmaceutical care.

Suppliers, Laboratories and drug whole-salers:

* Elimination of the risk of receiving defec-tive drugs, cosmetics and pharmaceutical acces-sories, or products of unknown origin, or pro-ducts of little proven quality.

* Periodic following of the suppliers fulfil-ment of such elements as technical quality, de-

livery of orders, stocks, response, and technicaland professional assistance.* The reassurance of a fast and effective sys-

tem provided by the drug wholesaler or labora-tory, for dealing with complaints and products tobe returned.

* Lower costs associated with the return ofexpired medicines or drugs in poor condition,due to higher quality of the product supplied anda higher level of trust between both parties.

Attention and Dispensation Processes:* Measurement of an index of patient/client

satisfaction by means of improved attention gi-ven by trained staff.

* Statistical treatment of the collected datathrough control graphs in real time, histograms,process capacity (Cp, Cpk), quality indexes, anddaily movements that allow action and contin-gency plans to be produced in a process of con-tinual improvement.

* Greater control of documentation and ofdata related to quality, together with all revisedand approved external documents (requests for

consultation by charitable organisations, filed pres-criptions, etc,).

* Availability of operative procedures andworking instructions in the workplace, whereimportant functions in the pharmaceutical careprocess are carried out.

* Registration, treatment and economic eva-luation of non-conforming factors, with the aimof lessening their effects.

* The orientation of all activities carried outin the pharmacy towards the establishment of

solutions to repetitive problems, with the aim ofachieving an optimal level of efficiency and quality


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104



tacin del servicio de salud y en la economa dela organizacin.

* Control y disminucin del depsito de me-dicamentos de escasa dispensacin y de medica-mentos vencidos.

* Documentacin y seguimiento clnico far-macolgico de los pacientes, favoreciendo unacorrecta dispensacin de los medicamentos, sobretodo en aquellos de tratamientos prolongados.

DISCUSIN

Este trabajo es uno de los primeros que serealiza en Argentina y que recaba informacinespecfica y detallada sobre un plan de gestin

de Oficinas de Farmacia, cuyo concepto originales dejar de hacer nfasis en las ventas y en elmercadeo, si no que adopta un criterio ms com-pleto y se enfoca la atencin en la calidad delservicio de salud y en la importancia de unaadecuada y eficiente Atencin Farmacutica,asumida desde la perspectiva de los pacientes usuarios del mismo.

En la primera parte de nuestro trabajo3 se plan-teaba el diagnstico sobre el desempeo de lafarmacia oficinal enmarcado en el contexto de laArgentina del MERCOSUR y describamos lainfluencia que el mercado impona en el desa-rrollo de la actividad farmacutica. Como plande accin para hacer frente exitosamente a lasituacin planteada se propuso realizar una rein-geniera de la gestin del acto profesional demanera de plantear el ejercicio farmacutico comoun servicio de salud redituable econmicamentey de excelencia.

Nuestra reingeniera se bas en el diseo yaplicacin de un plan de calidad total que integrael concepto de Atencin Farmacutica y reafirma

la actividad farmacutica como el valor profesio-nal que asegura el empleo seguro, adecuado yracional del medicamento, siendo el eje del servi-cio la relacin paciente farmacutico y no elproducto dispensado. El objetivo de tal reingenie-ra respondi a cumplir con los requisitos del decretoPEN (Poder Ejecutivo Nacional) N1269/92 y dela resolucin del Ministerio de Salud de la Na-cin N 432/92 con relacin a la implementacinde Sistemas de Calidad en Servicios de Salud y aobtener un sistema de Gestin acorde con dicho

servicio y que permita lograr eficazmente con losobjetivos de la empresa5-7.

in the provision of the health service and in theeconomic performance of the organisation.

* Control and reduction in the storage of drugsthat are rarely dispensed and expired medicines.

* Documentation and clinical and pharmaco-

logical monitoring of patients favouring a co-rrect dispensation of drugs, above all in the caseof prolonged treatments.

DISCUSSION

This work is one of the first of its kind to becarried out in Argentina and has gathered speci-fic and detailed information on a managementscheme in community pharmacies. The original

concept of the work has been to reduce empha-sis on sales and marketing and to adopt a morecomplete overall view that additionally focusesupon the quality of the service provided, as wellas on the importance of achieving a high degreeof efficiency and appropriateness in pharmaceu-tical care, from the users perspective.

In the first part of our work3, a diagnosis ofthe work carried out by the community pharma-cy was considered within the framework ofArgentinas situation in MERCOSUR and the

influence exerted by market forces on the per-formance of pharmaceutical activities were des-cribed. As a plan of action designed to success-fully confront the situation that was discussed, aprocess of re-engineering in the management ofprofessional activities was proposed. The viewwas taken that the pharmacists professionalactivity should be considered as both a healthservice of excellence, as well as an economica-lly profitable enterprise.

Our re-engineering was based on the designand application of a total quality scheme that

integrated the concept of Pharmaceutical Careand reaffirmed the pharmaceutical activity as aprofessional value that assures the safe, appro-priate and rational use of drugs. The fundamen-tal consideration in the provision of the servicewas to put more emphasis on the patient-phar-macist relationship rather than on the dispensedproduct itself. The objective of the re-enginee-ring process was to respond and comply with therequisites of governmental decree N1269/92 andto the Ministry of Healths resolution N 432/

92, regarding the implementation of QualitySystems in Health care services and also to ob-


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tain a system of management that could efficien-tly achieve the objectives of the company5-7.

This report outlines the preliminary results ofthe first stage of application of the managementand quality system that was developed. From the

results obtained it became apparent that a succe-ssful outcome of the scheme depends upon theconsolidation of the pharmacist - patient/clientrelationship. This factor was found to be of pri-me importance and was considered as a centralelement in the process of pharmaceutical care,within the concept of total quality. It was disco-vered that by using simple language, stripped oftechnical terms and professional fillers, takingexamples from day to day life and by taking intoaccount the social-cultural characteristics of tho-

se demanding the service, that an effective sys-tem of communication could be established. Anattitude of trust and respect could be built up,resulting in the consolidation of the patients asloyal users of the service. This favoured the per-ception of the quality that patients/clients had ofthe service (graph 5), and allowed us to ascer-tain what factors were to be associated with alack of quality in pharmaceutical care (graph 6).Furthermore, a greater compliance with medicalprescriptions was achieved in accordance withthe Pharmacists instructions.

Another important observation was the factthat the processes and results obtained were eva-luated simultaneously, enabling us to comparethe resulting conclusions and to discover mis-takes in the implementation of the scheme du-ring this stage. The result was a constant impro-vement in structural organisation and animprovement in management. A priori this hasallowed us to be sure that our hypothesis wasnot mistaken and that quality management is anappropriate strategy in the management of a com-

munity pharmacy.With regard to the global evaluation of the

performance of the management and quality sche-me, in contrast with the patient/clients ownperception, it was apparent that more defects inmanagement performance were perceived fromwithin the community pharmacy itself than tho-se perceived by the patients/clients (graph 8).That is to say, that the level of self-imposeddemands were set at a higher standard than thepre-determined ones. In principle, this can be

considered as having a positive effect on therunning of the business, given that throughout

En este reporte acercamos los resultados pre-liminares de la primera etapa de aplicacin delsistema de gestin y calidad desarrollado. Delanlisis de los resultados obtenidos se desprendeque para el xito definitivo del plan, es de suma

importancia la consolidacin de la relacin Far-macutico Paciente/usuario como elementocentral del proceso de atencin farmacutica dentrode un concepto de calidad total. Se descubrique empleando un lenguaje sencillo, despojadode tecnicismos y muletillas profesionales, tomandoejemplos de la vida cotidiana y segn las carac-tersticas socio culturales de los asistentes alservicio se permiti elaborar un sistema de co-municacin efectivo y en contrapartida receptaruna actitud de confianza y respeto de los pacien-

tes que se fueron consolidando como usuariosfieles del servicio. Esto favoreci a la percep-cin de calidad que los pacientes usuarios tie-nen del servicio (grfico 5), nos permiti cono-cer que motivos se relacionaban con una falta decalidad en la atencin farmacutica (grfico 6) yen un mejor cumplimiento con las prescripcio-nes mdicas, en conjunto con las indicacionesdel Farmacutico.

Otra observacin importante consiste en elhecho de que se evalu los procesos y los resul-tados obtenidos simultneamente, lo que permi-ti comparar las conclusiones resultantes y des-cubrir las fallas en el desempeo del plan duranteesta etapa, el resultado fue una constante mejoraen la estructura organizacional y un mejor des-empeo en la gestin. Esto a priori nos permiteasegurar que nuestra hiptesis no era errnea yque el gerenciamiento de la calidad es una buenaestrategia de gestin para la oficina de farmacia.

En cuanto a la evaluacin global del desem-peo del plan de gestin y calidad cuando secontrasto la percepcin propia con la de los pa-

cientes usuarios se pudo observar que la ima-gen de la gestin de la oficina de farmacia quese tena hacia adentro planteaba ms defectos quelos que los pacientes usuarios perciban (grfico8). Es decir que el nivel de exigencia autoimpues-to super los estndares predeterminados, esto enprincipio es positivo ya que en esta etapa de con-solidacin del plan de gestin de la calidad esimportante que la organizacin se plantee exigen-cias superiores a las de la meta, pero paulatina-mente esta conducta tiene que disminuir para no

afectar en un futuro el desempeo, despliegue ydesarrollo dinmico de la oficina de farmacia.


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106



GRAPH 7. Global evolution of the performance of the management and quality scheme. Comparisonof perception within the pharmacy with that perceived by patients.

According to company According to Patients

100 50 0 0 50 100

30 20 10 0 0 10 20 30

Global Quality(Exc+VG)

PROCESSESDelivery

Salesattention

Patientattention

Publicity

the consolidation stage of the scheme, it is im-portant that the organisation sets its sights onhigher goals than those that have already beenpre-established. However, such an attitude shouldtend to gradually diminish throughout the pas-

sing of time, so as not to affect the future per-formance, deployment and dynamic developmentof the pharmacy.

Segn la Empresa Segn los Pacientes

100 50 0 0 50 100

30 20 10 0 0 10 20 30

Calidad Global(Exc+MB)

PROCESOSEntregas

Atencin deVentas

Atencin alPaciente

Publicidad

GRFICO 7. Evolucin global del desempeo del plan de gestin y calidad. Confrontacin de la percepcinde la Farmacia con la de los pacientes.


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En nuestro plan las acciones de calidad con-forman un sistema interrelacionado en el queconfluyen conceptos de gestin de calidad apli-cados en el mbito industrial y de servicios, re-gulaciones nacionales y regionales de salud,

conceptos de atencin farmacutica y estndaresde calidad para servicios de farmacia7,8 esto per-miti tener procesos centralizados conviviendocon otros descentralizados, actividades y siste-mas que funcionan por control y otros por mo-tivacin, funciones que detectan fallas y otraseminentemente de educacin sanitaria, sistemaspara prever riesgos y potenciar oportunidades.Esto fue posible a la ya mencionada interaccinpositiva entre el profesional y sus pacientes usuarios y a la implementacin de un adecuado

sistema de capacitacin y informacin. Esto ge-ner una diferencia cualitativa que a la luz delos resultados signific una ventaja comparativaen el desempeo econmico de la farmacia.

Por otra parte, el anlisis de los resultadoscontables (no expuestos en este trabajo) ponende manifiesto el logro de la eficiencia en el manejode los recursos financieros y en la contencin decostos, como consecuencia del plan de gestin yel planeamiento de los procesos estratgicos delservicio. La optimizacin de la informacingenerada y su organizacin sistematizada, favo-reci su empleo; en especial con aquella relacio-nada con la identificacin de montos econmi-cos de insumos tales como medicamentos odescartables.

En resumen, desde la aplicacin del plan decalidad, se produjo un incremento de las ganan-cias, como consecuencia directa de la reduccinde costos relacionados con acciones de no cali-dad (mala atencin al paciente, falta de informa-cin, elevado nmero de devoluciones de medi-camentos por vencimiento, etc.) y por un aumento

de la productividad asociada a la dispensa delmedicamento y a la buenas prcticas de atencinfarmacutica.

En el marco conceptual, el modelo de calidadaplicado a este servicio ha mostrado su utilidaden varios aspectos de las polticas fijadas. Indu-dablemente que con este plan slo estamos ini-ciando un camino que se ir fortaleciendo en lamedida que se avance en la consolidacin de lacultura organizacional y en la motivacin de losprofesionales en el servicio de atencin de sa-

lud. Slo de esta manera la Gestin de la Cali-dad Total ser una respuesta a los problemas que

In this quality scheme, the course of actiontaken conforms with an interrelated system, inwhich the concepts of quality managementapplied within the scope of industry and servi-ces, national and regional health regulations, phar-

maceutical care concepts and quality standardsin pharmaceutical services converge7, 8. It haspermitted centralised processes to coexist withother decentralised ones, activities and systemsthat function through control and others thatfunction through motivation, systems that anti-cipate risks and promote opportunities. Such asituation has been made possible due to the al-ready mentioned positive interaction betweenstaff and their clients and the implementationof an appropriate system of training and infor-

mation. This generated a qualitative differencethat in the light of the results has produced acomparative advantage in the pharmacys eco-nomic performance.

On the other hand, the analysis of the resultsof the bookkeeping records (not given in thisreport), shows that, as a consequence of themanagement scheme and the planning of thestrategic processes of the service, greater effi-ciency in the management of financial resourcesand a restriction on costs had been achieved. Theoptimisation of the information generated andits systematic organisation has favoured its use.This is especially true of aspects concerning theidentification of total cost of consumables suchas medicines or rejected products.

In summary, the application of the qualityscheme produced an increase in profits, as adirect consequence of the reduction of costsrelated to non-quality activities (poor attentiongiven to the patient, lack of information, highnumber of returned expired drugs, etc.) and anincrease in productivity associated with drug

dispensing and good pharmaceutical attentionpractices.

Within this conceptual framework, the modelfor quality applied to this service has demonstra-ted the usefulness of a number of the policy aspectsmentioned. Undoubtedly, although the scheme isat an early stage of development, the processwill be strengthened as it tends towards beco-ming more consolidated within organisationalframeworks and becomes a motivational factoramong health care service staff. Only in this way

will Total Quality Management provide the res-ponse to the problems facing community phar-


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108 OVIEDO S, ANTONELLO A, DI PAULI NA

enfrenta la oficina de farmacia en el contextosocial antes mencionado.

Como idea final se puede decir que el desa-rrollo de la calidad y su bsqueda estn unidosal desarrollo y crecimiento profesional en un marco

tico y de servicio.Slo esta conviccin ha de permitir que todoesfuerzo de construccin y seguimiento de lacalidad tenga xito real.

macies, in the social context that have alreadybeen mentioned.

Finally, it may be stated that the developmentof quality and its pursuance go hand in handwith development and professional advancement

within the ethical framework of the provision ofa service.It is only with this conviction that the effort

to construct and follow a quality system willachieve real success.

BIBLIOGRAFA / BIBLIOGRAPHY

1. Donabedian, A., Prioridades para el progreso de la evaluacin y Monitotero de la Calidad de la Atencin. Salud Pblicade Mxico, 1993; 135 (1): edicin on.line www.insp.mx/salud

2. Peretta, M. Y Filinger, E., Principios que Rigen la Atencin Farmacutica. Acta Farm. Bonaerense 1998; 17 (1): 59-71.

3. Oviedo, S. Y Antonello A., Administracin y Gestin de la Calidad Total en la Farmacia Oficinal: TQM una Alternativapara Competir. Atencin Farmacutica/ European Journal of Clinical Pharmacy 2000 (in press).

4. Brooks, J.M., Sorofman, B., Doucette, W. Varying health care provider objectives and cost-shifting: the case of retailpharmacy in the US. Health Economics 1999; 8 (2): 137-150.

5. Lafaye, H.E, Las Herramientas de la Calidad, Edit. Letras de Crdoba. Crdoba, Repblica Argentina; 1997.6. El Papel del Farmacutico en el Sistema de Salud.- Buenas Prcticas de Farmacia: Normas de Calidad de Servicio

Farmacuticos. Informe OMS, Tokio Septiembre de 1993. OPS/HSS/HSE 95.01, WHO Pharm./94.569, OPS/HSS/94.49.

7. International Pharmaceutical Federation. Standards for Quality of Pharmacy Services. 1999; www.fip.org8. Federacin Internacional de Farmacia. Declaracin de la FIP sobre normas Profesionales: La Atencin Farmacutica

1998; www.fip.org\docs\statem\pharm-care1998\p-care19998-spanish.

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