Lean Fills Prescription for Change at Hospital Pharmacy

The process improvement journey at Jordan Hospital took a large step forward last year when the organization was introduced to Lean Six Sigma concepts as part of a departmental optimization effort for its internal pharmacy. Jordan Hospital is an acute care, 150-bed, not-for-profit community hospital, serving 12 towns in Plymouth and Barnstable counties in Massachusetts, USA.

Jordan Hospital’s pharmacy is currently undergoing several major changes to improve operations, reduce costs and better serve the needs of customers via the application of Lean principles. The pharmacy, led by John Leone, director of pharmacy, is following Lean’s primary tenets to reduce the time the supplier takes to deliver a customer’s order, and to eliminate wastes (and costs) throughout the system.

The objective for the hospital, according to Russ Averna, leader of the hospital’s Lean program and the vice president of human resources, is to apply Lean principles to improve operations, reduce costs, and better serve the needs of customers. Many other industries, including those that are service related, have adopted Lean approaches to increase their effectiveness and efficiency.

To optimize the transformation to using Lean, the hospital worked with consultants to introduce the change management tools to a broad audience of people from different areas of the hospital. The objective was to identify potential problems surrounding upcoming changes and create actionable plans to mitigate concerns and foster facility-wide acceptance.

Building Consensus for Change

A project team focused on increasing the clinical role of pharmacists to create a new vision of the “pharmacist of the future.” Another team worked on enhancing the communication of all changes within the pharmacy, and planning to optimize the future integration of the oncology pharmacy staff with the oncology department to further improve patient care and reduce drug delivery turnaround time.

In addition to these consensus-building events, the leadership also challenged the pharmacy team to improve the current performance inside its own walls where there were opportunities for improvement, specifically looking at the first-dose process and IV/chemo preparation.

The first step was to understand the current state of the process. This included the development of a value stream map (Figure 1) to identify where there was waste in the process. The value stream map highlighted non-value-added steps, including significant wait times during which medication was not being processed (waiting on quality checks or delivery runs) as well as extensive travel distances for the technicians who had to fetch some medications from outside the immediate work area.

In addition to opportunities to reduce the overall product lead-time by improving the cycle time, travel distance and flow patterns, there was an issue of physical space constraints. This was relevant because space in the pharmacy was extremely tight and congested, with people running into each other while filling patient orders.

Figure 1: Value Stream Map

Rapid Results with Kaizen

The next step was to prepare for a Kaizen improvement activity. Kaizen is a Japanese word that means change for the better, or more commonly, continuous improvement. A Kaizen is a hands-on burst of improvement activity in the actual workspace that occurs during a relatively short period of time – usually three or four days.

A team, which was comprised of those who perform the activities every day, brainstormed improvement approaches, and then tested them on the actual production or service line (referred to as “trystorming”). This method results in rapid recognition of which solutions will work and which will not. The Kaizen team also created plans to sustain the gains once improvements were made, and developed reports to leadership on its actions.

In preparation, management set clear goals for the Kaizen team. The goals focused on creating a standard work environment and implementing an improved replenishment system using Kanban, a Japanese word meaning “sign board” or “signal.” Pharmacy Director John Leone said, “Despite the fact that our environment will change a lot over the next 12 months, there are many areas where we need to improve the process to optimize future changes. We assembled a great team, and we had every expectation they could achieve the targets.”

The first activity was a half-day training session to familiarize the team and attending executives with the Lean process improvement method and the Lean tools that would be used during the week. After the training was completed, the Kaizen began. The initial activity centered on a 5S of the pharmacy (sort, set in order, shine, standardize and sustain). This included evaluating the purpose and value of all supplies and activities in the work areas. This step alone cleared a significant amount of “clutter” from the area, improving visual control and eliminating several safety hazards. The 5S activity freed up an entire rack where medication that was no longer used was being stored.

Figure 2: Pharmacy Area Before and After 5S Activity

Creating and Sustaining Change

The team then split up and focused on the “bug juice” preparation process and on the IV preparation process and replenishment of this area. As soon as the teams agreed on how to approach the individual problem, they went ahead and dove into the “trystorm” phase where they implemented their ideas. The bug juice team quickly identified and implemented a visual aid and a standard process that would increase communication and reduce the amount of “waste” produced due to communication and replenishment issues with the operating room team.

The IV prep team implemented a two-bin replenishment system close to the point where the medications were used. The two-bin system prevents overstocking of material, provides a mechanism to assure first-in-first-out inventory management and supports a much more just-in-time-driven replenishment.

In addition, the workspace for frozen IV preparation was moved from a congested area to a new location in the space that was recovered through the 5S activity. In the newly created space, workers could focus on the delivery quality of this task without being interrupted. The original IV area had no clear organization of inventory near by. The new IV area had point-of-use equipment and frequently used inventory visible.

Figure 3: The Original IV Area and the New IV Area

The benefits for this 3.5-day project included a reduction of approximately 51 miles per year in travel distance for the technicians, a cycle time reduction of about 102 hours per year, plus additional space created in the tight area.

Figure 4: Filling IV Label – Before and After

Also, the “bug juice” improvements will reduce the waste of medication, which, before, was calculated to about $50,000 per year. Additionally, several safety issues were resolved on the spot, making the environment a safer place to work in. The group then created a 30-day follow-up plan to fully implement those changes that could not be completed within the Kaizen event week to assure that full benefits could be calculated and sustained.

The success of the project was credited to the make-up and performance of team members, the support given to the team, the constructive feedback given to the rapid changes, and the methods used to ensure that changes are communicated effectively. “We really emphasized the people side during Kaizen and the other activities. Change is difficult, but making sure we gave every opportunity to participate was key to the positive results we achieved,” Vice President Averna noted

Additional factors included thorough preparation, clear objectives, management support, a can-do and creative mindset, continuous communication with all affected areas, standardization of the improvements, and routine monitoring and tracking of improvements following implementation.