Download R2 Pharmacy Wait Time Reduction

PROJECT NAME: R2 Pharmacy Wait Time Reduction
Institution: MD Anderson Cancer Center
Primary Author: Kim Chau
Secondary Author: Linda Ju
Project Category: Efficiency
Overview:
1) Location where the work was completed:
The work was completed in the Rose 2 (R2) Retail Pharmacy at MD Anderson
Cancer Center. Rose 2 was the first retail pharmacy in the institution and remains
the busiest with an annual volume in excess of 162,000 dispensed prescriptions.
2) Reason the change was needed:
Qualitative survey data from patients, nurses, and physicians indicate
dissatisfaction with excessive wait times in the R2 Retail Pharmacy.
3) Faculty/staff/patient groups were involved:
A team comprised of Division of Pharmacy staff was assembled including: The
Retail Pharmacy Manager, 2 Charge Pharmacists, 1 Staff Pharmacist, 2 Pharmacy
Technicians, 2 Pharmacy Informatics Staff members, and a CS&E Project Mentor.
4) Alignment to organizational goals:
Based on the institution’s published Strategic Vision 2010-2015, the project closely
aligns with Patient Care strategy 1.5 which states, “we will enhance productivity,
access and efficiency by strengthening our infrastructure and support systems”
(p. 3).
Aim Statement (max points 150):
Reduce average wait times in the R2 Retail Pharmacy by 15% by June 20, 2012.
Measures of Success: How did you measure the impact of your proposed
change?
1) Baseline time data was collected for two weeks. The data included time
measurements (to the minute) for six major milestones in the prescription
dispensing process including: 1) Physical arrival of prescription until entry into the
Pharmacy Information System, 2) Entry to matching the prescription with the
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label, 3) label matching until placed on fill table, 4) fill table to pharmacist fill and
verify, 5) fill and verify to batching to shelf, and 6) batching to shelf until physically
delivering the prescription to the shelf for patient pick-up.
2) A series of agreed upon interventions were implemented. (see:
Interventions section below)
3) Post-intervention time data was collected for two weeks. The data
elements and methodology were identical to those used in the baseline data
collection (described above).
Use of Quality Tools (max points 250): What quality tools did you use to
identify and monitor progress and solve the problem?
1) Process Maps – processes were documented for prescription pre-screening,
insurance processing, routine prescriptions, and for investigational drug
prescriptions.
2) Value Stream Map – A value stream map was produced based on the baseline
data to determine what steps in the process were most time intensive.
3) Cause and Effect Analysis – A cause and effect analysis was performed
which resulted in identification of approximately 90 perceived causes for wait
times.
4) Intervention Brain-Storming and Ranking – The approximately 90 identified
causes were discussed in numerous intervention brain-storming sessions with the
team. Upon completion of the brain-storming sessions a total of 118 interventions
were identified to address wait time.
The solutions were then ranked based on two criteria. The first criterion was the
perceived impact of the intervention with a value of 1 assigned for “high impact”
interventions and a value of 9 representing those interventions considered “low
impact.” The second criterion was the perceived ease of implementation for each
intervention. For this ranking, a score of 1 was assigned for interventions
considered “Very Easy” to implement versus a value of 9 for those considered
“Very Difficult” to implement.
5) Interventions – Based on a summation of the composite scores for perceived
impact and ease of implementation described above, the team chose to focus on
interventions with a composite rank of 6 or less. In other words, the team chose to
implement those interventions the team considered “High Impact” and “Easy to
Implement.”
Interventions (max points 150 includes points for innovation):
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1) Overall improvement plan
After interventions were ranked, they were also categorized. The intervention
categories included: Standard Operating Procedures (SOPs), Education and
Training, Visual Controls, Personnel, and IT/Telecomm. The large team was
segmented into smaller teams to address each of the intervention categories and
began meeting weekly.
The team decided that the interventions would be communicated to the staff and
implemented immediately. Implementations were executed predominately during
the months of March, April, and May 2012.
2) Implementation of proposed changes:
As each team assigned to the various categories performed implementations, the
implementation dates were reported to the larger team. Furthermore, any
obstacles to the interventions were discussed with the entire team and mitigated
whenever possible. The various implementations occurred over a 3-month period.
3) Those involved in implementing the change:
The charge pharmacists, staff pharmacist, and pharmacy technicians involved in
the project were primarily responsible for implementing the changes. Since the
team members who developed the changes are the staff responsible for the
changes, communicating such changes to their colleagues was quite expedient.
4) Communication of the changes to all key stakeholders:
The Pharmacy Manager and Charge Pharmacists communicated changes to
pharmacy staff during the routine monthly staff meetings. The Charge
Pharmacists involved in the project conducted informal meetings with the Retail
Pharmacy Manager. Furthermore, every 2 to 3 months a formal meeting was
conducted with the Retail Pharmacy Manager which included a high-level project
status update and discussions of the various implementations.
5) High-Level Timeline for the Project including changes:
November 2 - 15, 2011 - Baseline Data Collection (10 weekdays)
December 2011 - Cause and Effect Analysis
January - February 2012 - Intervention Brainstorming and Ranking
Implementations:
March - May 2012 (ongoing) - Standard Operating Procedures (SOPs)
May 2012 (ongoing) -- Education and Training
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March - April, 2012 (ongoing) -- Visual Controls
March - May, 2012 -- Personnel
March - April, 2012 -- IT/Telecomm
June 4 - 15, 2012 -- Post implementation data collection (10 weekdays)
6) Especially innovative features:
Several LEAN concepts were implemented and include:
1) Moving work to the people NOT people to the work – prior to the project,
each pharmacist rotated to various stations within the pharmacy based on the type
of prescription being dispensed. An intervention was completed which designated
a permanent “work cell” for each pharmacist. Subsequently, the work was moved
to each pharmacist enabling the pharmacist to optimize their “work cell” based on
their unique needs.
2) Load Balancing – it was discovered that certain categories of dispensed
medications were lower in volume than others. Therefore, an intervention was
completed to “balance” the various categories of prescriptions among the
pharmacists. In addition, pharmacy staff (pharmacists and technicians) were
performing tasks which were clerical in nature. These duties were reassigned to
administrative assistants within the pharmacy.
3) Visual Controls – A number of visual controls were implemented to assist the
pharmacy staff to easily identify prescriptions requiring intervention from insurance
reimbursement representatives. Such visual controls helped pharmacy staff to
quickly and appropriately identify and prioritize prescriptions.
Results (max points 250):
1) Results
Wait times for all prescriptions in the R2 Pharmacy decreased from an average of
90.51 minutes to 73.08 minutes, a reduction of 19.25%. This decrease exceeded
the goal of 15% by 4.25%.
See tables, figures and diagrams on following pages.
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2) Cause and Effect (Fishbone or Ishikawa) Diagram
3) Comparison Table by Category (Note: green indicates favorable change,
red indicates unfavorable change)
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4) Baseline and Post-Intervention Value Stream Map
5a) Baseline Control Chart
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5b) Post Implementation Control Chart
6) Box and Whisker Chart by ALL and Category (Baseline v. Phase 1)
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Revenue Enhancement /Cost Avoidance / Generalizability (max
points 200):
1) Revenue enhancement /cost avoidance:
Reducing wait time is a cost avoidance that is difficult to define. With the process
improvement interventions there was an increase in pharmacist productivity
without increasing resource expenditure. Before implementation, pharmacist
productivity was 8.5 prescriptions per hour. After the interventions were
implemented productivity increased to 10 prescriptions per hour, representing an
18% increase in efficiency.
2) Implementation in other sites (see: Conclusion and Next Steps section)
Conclusions and Next Steps:
1) Conclusions drawn from project
Affecting pharmacy wait times in a hospital based high-volume pharmacy is quite
difficult. Many causes contribute to wait times. However, it is important to utilize
various performance improvement tools to help identify and target areas for
improvement. For example, utilizing a Value Stream Map (VSM) early in the
project helped to determine which process steps consumed the most time. Once
these process steps were identified, they could be targeted.
Cause and effect analysis was crucial in identifying the myriad of causes of wait
time in the R2 Retail Pharmacy. After the causes were analyzed and potential
interventions brain-stormed, the number of proposed interventions was also quite
large (118 total). Therefore, ranking the solutions proved quite helpful allowing the
team to target interventions considered most impactful while at the same time easy
to implement.
2) Recommendations for future work
Future work recommendations include: 1) Extending the Standard Operating
Procedures and Best Practices to the other two retail pharmacies on Rose 10 and
in the Ambulatory Clinic Building, and 2) Create an operations manual for the retail
pharmacies to standardize operating procedures and best practices across all
retail pharmacies.
3) Project alignment with organizational goals
Based on the institution’s published Strategic Vision 2010-2015, the project closely
aligns with Patient Care strategy 1.5 which states, “we will enhance productivity,
access and efficiency by strengthening our infrastructure and support systems”
(p. 3).
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4) Plans to move ahead
The team will continue to implement the identified interventions until the end of the
calendar year in order to achieve a total 30% reduction in R2 Retail Pharmacy wait
times. Once the identified interventions are completed and all SOPs and best
practices are documented, these interventions will be extended to the other two
retail pharmacies within the institution.
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