The most effective way of gaining support is through a dynamic DTC that can formulate policy and guidelines with consensus of all parties and that is seen to be sensitive to comments.
STEP 1 Organizing the committee and selecting members
Opinions vary regarding the optimal size and composition of the committee. Smaller committees may be appropriate for smaller hospitals; larger ones may be useful in big hospitals with wider work perspectives. Fewer members may allow consensus agreements to be reached more easily. More members can provide greater expertise, reduce the workload for individual members, and increase the ease of implementation of decisions. All committees should have sufficient members to represent all stakeholders, including the major clinical departments, the administration and the pharmacy.
Members should be selected with reference to their positions and responsibilities and they should have defined terms of reference. In most hospitals, the membership includes:
• a representative clinician from each major specialty, including surgery, obstetrics and gynaecology, internal medicine, paediatrics, infectious diseases, and general practice (to represent the community)
• a clinical pharmacologist, if available
• a nurse, usually the senior infection control nurse, or sometimes the matron
• a pharmacist (usually the chief or deputy chief pharmacist), or a pharmacy technician where there is no pharmacist
• an administrator, representing the hospital administration and finance department
• a clinical microbiologist, or a laboratory technician where there is no microbiologist
• a member of the hospital records department.
Other members may also be included for their particular expertise, for example a drug information specialist, quality assurance specialist or consumer group representative. In Australia consumer representatives have included a retired judge, a psychiatric patient, a member of a pensioners’ association and a volunteer hospital worker. However, with regard to consumer representatives, “beware the politician with a hidden agenda”.
A dedicated and committed chairperson and secretary are critical to the success and efficiency of a DTC. In most hospitals, a senior medical doctor, ideally well-known and respected, is appointed as the chair and the chief pharmacist as the secretary. The chair and secretary should be allotted sufficient time for their DTC functions, and this should be included in their job descriptions and terms of reference. The allotted time should be sufficient to cover all DTC meetings and other work in relation to the meetings. Nonmember specialists can be invited during discussions of important issues. In large hospitals, various subcommittees can be established to address particular issues, for example antibiotic use, adverse drug reactions, medication errors and drug use evaluation/audit. All hospitals should have an infection control committee; if such a committee does not exist, the DTC should establish it. Where other committees exist, the DTC should liaise and coordinate with them in order to avoid duplication of activities.
STEP 2 Determine the objectives and functions of the committee
It is not possible for a DTC to do everything. The first thing a DTC should do is to agree its terms of reference, which specify the DTC’s place in the organizational structure of the hospital, its goals, objectives, scope of authority, functions and responsibilities. The most important objectives and roles have already been described in chapter 1. Once basic functions, such as a formulary system, are implemented, the DTC can move on to other activities. Annex 2.2 shows the terms of reference of the DTC in a Zimbabwean hospital. Sometimes the initial functions of the DTC, during the time of organization, depend on the prevailing clinical and pharmaceutical management problems that must be immediately addressed. This is a good way of getting the support of the management and the agreement of medical personnel. Figure 2.1 shows how the different possible functions of a DTC interrelate. The DTC is responsible for maintaining standards. In order to do this, the DTC must define standards, assess performance, diagnose why performance is poor and introduce measures to improve it.
Figure 2.1 The DTC’s cycle of activities and function
STEP 3 Determining how the committee will operate
• Regular meetings of the DTC, at least quarterly and preferably monthly, are important. The schedule may vary depending on needs. Special meetings can be convened when necessary. The length of meetings should be limited, as clinician members of the committee are unlikely to attend or to stay throughout if the meetings are too long.
• Regular attendance of members at committee meetings is often a problem. As a solution, some institutions make it a part of the requirements for reappointment. Other institutions provide some monetary incentives, or serve food or refreshment at meetings.
• The agenda, supplementary materials and minutes of the previous meeting should be prepared by the secretary and distributed to the members for review in sufficient time before the meeting. These documents should be kept as permanent records of the hospital and should be circulated to chairpersons/directors of all clinical departments.
• All DTC recommendations should be disseminated to the medical staff and other concerned parties and authorities in the hospital. Regular hospital activities such as grand ward rounds and clinical discussions can be used as venues to discuss recommendations and to educate the health staff on the proposed policies for implementation.
• All DTC operating guidelines, policies and decisions should be documented. This documentation should include the decisions on actions to be taken if the decisions, guidelines or policies are not followed. Relevant documentation must be made available to interested parties such as staff members and drug companies. Members of the committee should be responsible for disseminating the resolutions of the DTC.
• Liaison of the DTC with other hospital committees and regional or national committees is important, for two reasons:
- to harmonize related activities (for example, surveillance of antimicrobial resistance (AMR) and antimicrobial use)
- to share information concerning common activities (for example, monitoring of adverse drug reactions and educational strategies such as continuing medical education).
STEP 4 Seeking a mandate
Only with a mandate from the most senior authority in the hospital is a DTC credible and sustainable. The mandate of a DTC should specify:
• its roles and functions
• its place in the organizational structure
• its membership
• its scope and lines of authority.
The strongest mandate a DTC can have is that issued by the government, as in Zimbabwe (see annex 2.3). In some industrialized countries, hospitals are required to have DTCs in order to be accredited by professional societies and universities as training institutions. In other countries patients can only get reimbursement for treatment from hospitals that are accredited by the insurance companies and such accreditation may require functioning DTCs.
STEP 5 Identifying budgetary sources
The DTC must be able to identify budget resources to support its own activities (such as meetings or incentives for its members) and those activities it recommends for implementation (for example, educational programmes, development of standard treatment protocols, drug utilization review and supervision). Budgeted staff time should also be reflected in their job descriptions. Usually the budget requirement is not substantial and can be justified to the hospital administration on the basis of drug cost savings that can be realized through the DTC activities. The DTC should be able to demonstrate its own cost-effectiveness when requesting a regular budget allocation from the hospital management. To this end, the DTC should prepare an annual action plan with corresponding budget requirements. It is more convincing to present budgetary requirements together with past or potential future cost savings.
STEP 6 Forming subcommittees to address specific issues
Often there are specific areas which need a great deal of extra work and expertise that the DTC cannot provide or give time to, for example, the use of antimicrobials. Many DTCs have dealt with this issue by forming a subcommittee to work in the specified field on behalf of the DTC and report back. See chapter 8 on antimicrobials and injections.
BOX 2.1 INDICATORS TO ASSESS DTC PERFORMANCE AND IMPACT
• Is there a DTC document that indicates its terms of reference, including its goals, objectives, functions and membership?
• Is the DTC in the organizational chart of the hospital?
• Is a budget allotted to DTC functions?
• Does the DTC have established criteria and authority concerning drug selection?
- How many medicines are there in the hospital formulary?
- Are there documented criteria for addition to and deletion from the list and requests for the use of non-formulary medicines?
- What percentage of prescribed medicines belong to the hospital formulary?
• Has the DTC been active in the development and implementation of STGs?
- Has the hospital developed/adopted its own STGs?
- Have drug utilization studies been performed to assess adherence to STGs?
• Has the DTC organized educational activities about medicines?
- Have there been any organized training and lectures for health-care staff?
- Is there an established library accessible to staff?
- Is there continuing medical education?
- Is there a drug information service available to staff?
• Have any intervention studies to improve medicine use been undertaken?
• Has the DTC been involved in drug budget allocation?
- Was the DTC consulted during drug budget allocation?
- Was DTC clearance needed prior to drug budget approval?
• Has the DTC developed a policy for controlling the access of drug representatives and promotional literature to hospital staff?
STEP 7 Assessment of the DTC’s performance
Self-assessment and evaluation of the DTC are very important if performance and impact are to be improved. The organizational development and performance of the DTC should be monitored continuously and documented, especially if the DTC expects the hospital management to provide continuing funds. Some indicators that can be used in DTC self-assessment are shown in box 2.1. These indicators are considered to be core parameters that should be used. However, the DTC can develop other indicators and measures that will suit its purpose. Most important is for the indicators to be used in evaluating the impact of the DTC. In this way, the DTC may see if it is achieving its goals and objectives and justify the continued support of the hospital management.