Drug shortages are a serious problem for hospitals throughout the world, with the potential to create serious adverse events for patients. They’re more common than most people think. Having a system in place to manage these shortages is critical to ensuring patient safety.
Global health care provider UPMC, headquartered in Pittsburgh, Pennsylvania, has created a multi-pronged approach to managing drug shortages. It does this by focusing on teamwork and market analysis to predict where shortages might occur and prepare contingencies to protect patients. The team at UPMC conducted an analysis of the drugs they use and found that one out of every three items in their wholesaler catalog had some kind of supply issue, whether it was a short-dated product, available for partial allocations, or completely unavailable. When they examined only the products they used regularly – a smaller subset of the catalog – up to 50 percent of the items they needed had experienced supply issues.
This is especially true of generic items, says Jessica Daley, Vice President of HC Pharmacy & Supply Chain Commercial Services at UPMC. “We have issues with the old generic items, staples of patient care, that we really can’t do without. For example, running out of IV fluids, or saline in a bag, can cripple your operations and put patient care in jeopardy due to all of the downstream dependencies that you have to change to manage that [shortage],” she says. “They’re the things we take for granted and use every day in every facility, but they don’t offer a big profit margin for suppliers. We have to work very hard to make sure we have these products on our shelves all of the time.”
UPMC knew that it needed a way to respond quickly to drug shortages, but it wanted to go further by creating a system that could predict and prepare for shortages of the drugs that are most critical to patient care. When looking for a roadmap forward, UPMC felt that it was closely aligned with the Patient Safety Movement Foundation’s (PSMF) Actionable Patient Safety Solutions Drug Shortages challenge.
“We’ve done a lot of work around drug shortages, so we looked to see if PSMF’s commitment aligned with our vision and contained other things we could learn from and implement,” says Amy Lukanski, Quality Manager, System Implementation and Sustainability at the Wolff Center at UPMC. “Because of our history with PSMF, we know they’re committed to reducing harm and we are, too.”
One of the first steps UPMC took to develop the system was to build “failure to supply” and “safety stock” clauses into some of its supplier contracts to penalize suppliers for shortages, as well as ensure that suppliers kept extra stock on hand specifically for UPMC. The health system also expanded its supplier networks, finding some new companies that helped to meet demand when other suppliers could not. UPMC is lucky, says Daley, because it also has space to warehouse drugs, meaning that extra stock can be kept on hand.
“We can weather the storm because we can warehouse stock,” Daley says, “but we aren’t immune to shortages that can impact patient care.” For this reason, UPMC also created multiple teams to focus on managing and responding to drug shortages quickly. A team of data analysts scans the market and reports the supply status of all 10,000+ pharmacy items each day. Once a week, a team of buyers, contract managers, warehouse staff, and pharmacists troubleshoot new and ongoing shortages, providing action-oriented direction to end-users and clinicians. When the impact of a potential shortage grows and threatens to significantly impact patient care, a larger team is engaged.
The UPMC Team
Beginning with the Chief Quality Officer and the Chief Supply Chain Officer, UPMC formed an executive steering committee made up of quality and safety analysts, pharmacists, inventory specialists, central purchasing, warehousing, nurses, physicians, information technology, and emergency response staff.
The team meets weekly during critical shortages to examine the status of the market and determine if any steps need to be taken to protect supply and patient care. When necessary, the executive committee coordinates clinicians to propose adapted drug use recommendations, including changes to dosing regimens, order sets, or the use of alternate products.
The diversity of the team, representing departments from across the system, is important to ensure patient safety, Daley says. It is critical to get all clinician leaders engaged in understanding supply status. For example, if a shortage means that staff must change dosing regimens or limit the use of a drug for a certain population, it could be very difficult to get clinicians across departments to agree to make those changes unless they can see the shortage as a system-wide challenge. Having a multi-disciplinary team also opens lines of communication and allows for greater transparency when making difficult decisions such as prioritizing drug flow to the highest-need patients. “Every patient is important so it’s hard to prioritize when you don’t have enough product to go around,” says Daley. “Having the right protocols and processes in place is critical.”
Leadership on Board
Perhaps more important is having senior leadership on board. “Whether it’s creating more space for inventory, or providing the right people with the time to strategize, executive commitment and support to work through solutions has made this process much easier,” Daley says. “Because we have an executive committee that supports us, we’ve had a lot of success in getting alignment. The committee can advocate for the changes that need to be made.”
Once the protocols were in place, UPMC turned to the challenge of supporting its plan from a technology perspective. The leadership team felt strongly that being able to predict shortages rather than just react to them would be a game-changer.
“Generally, hospitals don’t get enough up-front information or advance warning of a shortage,” Daley says. “So, we wanted to find a way to watch market trends, analyze data and look for patterns.”
This led UPMC to develop a system that uses augmented intelligence and machine learning to analyze market trends over time and predict when a shortage might occur. The system scans national, regional, and local demand signals to provide recommendations on inventory levels for items routinely impacted by shortages and provides early warnings. This allows clinicians and pharmacists to act early to conserve supply, prepare alternative therapies, and train impacted healthcare providers so that patient care continues safely.
One of the many benefits of the system is that it allows the supply team to monitor more products than they could previously. In the past, UPMC has tracked supplies of the most critical drugs for its patients, but the number of products it could follow was relatively small. “If you ask doctors [what drugs are most important], they’ll say all of them, but manually we can’t track every critical data element that may indicate impending supply challenges,” Daley says. The new system mines upstream supply chain data, looks at the supply history of each product, examines any issues that make shortages likely, and uses algorithms to inform inventory management practices and create buffer supplies of drugs.
UPMC decided to build the tool in-house because of a lack of available solutions in the market, and the need for specialized data management expertise. Once the tool has been fully released and tested, it is expected to be made available to other hospital systems.
When asked how the new protocol and systems have impacted patient care, Daley says that the improved levels of transparency and communication have been appreciated by both individual staff and the overall hospital system. “We have certainly become more efficient,” she says. “The technology solution allows us to really expand our capabilities, and the executive steering committee allows us to get together and support rapid decision making. For example, when Hurricane Maria hit, we assembled the team, and, within a couple of weeks of the hurricane, we had new clinical treatment plans in place and had sequestered supplies. In the past, that would have taken much longer. Now we can move fast to protect our patients.”