process innovation for pharmacists technicians …1 process innovation for pharmacists &...

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Process Innovation for Pharmacists & Technicians

Randy Martin, Pharm.D.

Metroplex Society of Health‐System Pharmacists Annual Seminar

Saturday, January 16, 2016

Learning Objectives

• Compare and contrast common process improvement methodologies

• Discuss and apply tools used to define processes

• Discuss and apply tools used to identify and eliminate the eight types of waste

• Discuss the importance of collecting and analyzing the voice of the customer (VOC)

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Before we get started…

Is NOT a bad word!

The word:

Methodologies

Program Six Sigma Lean Theory of Constraints

Theory Reduce variation Remove waste Manage constraints

Application • Define• Measure• Analyze• Improve• Control

• Identify value• Value stream• Flow• Pull • Perfection

• Identify constraint• Exploit constraint• Subordinate processes• Elevate constraint• Repeat cycle

Focus Problem Flow System constraints

Theory of Constraints

• Identify– The constraint (weakest link or bottleneck) is identified

– Long queues, big batches

• Exploit– Process is improved to maximum capacity

• Subordinate– Speeds of subordinate processes are paced to the constraint

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Theory of Constraints

• Elevate

– Major changes and resource investment considered

• Repeat

– Where is the new constraint?

Lean Six Sigma combines process velocity (Lean) with Defect elimination and variation reduction (Six Sigma)

Effectiveness

Six Sigma is a process improvement method that uses data and facts to produce bottom line measurable results through reduction in process variation

Six Sigma is also a standardized method of measurement that provides organizations proven world-class measurement of process effectiveness. An organization that acquires a Six Sigma level the performance virtually eliminates errors in its processes.

Finally, Six Sigma is a management philosophy that strives for ever increasing levels of perfection across all public and private sector industries.

2001601208040

LSL USL

130120110100908070

LSL USL

Six Sigma Tools & Techniques

Processing For Six Sigma

DMAICDesign For Six Sigma

DMADV

Six Sigma

• Define

– Who are the customers?

– What are their needs?

– What are their problems?

• Measure

– Key characteristics categorized

– Measurement system verified

– Collect data

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Six Sigma

• Analyze– Identify the fundamental causes of the problem

– Identify the most important caused of the problem• 80/20 rule

• Improve– Solutions are developed

– Changes are made

– Measure results of the changes

• Control– Sustain improvement through monitoring

Six Sigma

Define

Measure

AnalyzeImprove

Control

Lean is not new but is based on more than two centuries of continuous improvement philosophy!

1955

Shigeo Shingo Begins working

with Toyota

1960 1969 1974 1980 1984 1995 2002

Shingo DevelopsMistake ProofingBased on Jidoka

Shingo DevelopsSingle Minute

Exchange of Dies

Toyota reveals to the worldIt’s Just In Time

Production System

Goldratt“The Goal”

Lean / Six Sigma

Movement

MotorolaSix Sigma

Movement Begins

James WomackLean thinking

1911 1920 1924 1926 1940 1949 1951

Frederick TaylorScientific

Management

Ford – River RougeEconomies of Scale

Walter ShewhartBell Telephone Ops.

w/ Joe Juran &W. Edwards Deming

Ohno Starts Work on TPS

Joe Juran“Quality Control

Handbook”

Focke-Wulf inventsTakt Time concept

Deming lecturesPDCA in Japan

1902

Sakichi ToyodaLoom w/ Jidoka

1885

The GilbraithsMotion Study

1883

Frederick TaylorTime Study

1776

Adam SmithDivision of Labor

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Lean (AKA: Toyota Production System)

• Identify Value

– Value is defined by the customer (internal and external)

• Identify the Value Stream

– Activities that contribute to the value are identified

– Are non‐value added activities necessary or can they be minimized?


• Improve Flow– “Flow” is the uninterrupted movement of the service or product to the customer

– In general, the following are all bad for flow:• Queues

• Batches

• Transportation

• Allow Customer Pull– The product or service is provided ONLY when the customer needs it

A value stream is all the actions (both value-added and non value-added) currently required to bring a process through the patient and

information flows

A Value Stream

Information

INFORMATION FLOW

PATIENT FLOW

CU

ST

OM

ER

VA

LU

E

Treatment Service DischargeAdmissions Finance

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• Strive for Perfection

– Repeat, Control, and Spread

• Lean Assumptions:

– People value the visual effect of flow

– Waste is the main restriction to profitability

– Many small improvements in rapid succession are more beneficial than analytical study

If/Then of the 3 Theories

• For TOC: “If we focus on constraints, then throughput volume will improve.”

• Six Sigma: “If we focus on reducing variation, then we will have more uniform process output.”

• Lean: “If we focus on waste removal, then flow time will improve.”

Lean Six Sigma combines process velocity (Lean) with Defect elimination and variation reduction (Six Sigma)

Effectiveness

Six Sigma is a process improvement method that uses data and facts to produce bottom line measurable results through reduction in process variation

Six Sigma is also a standardized method of measurement that provides organizations proven world-class measurement of process effectiveness. An organization that acquires a Six Sigma level the performance virtually eliminates errors in its processes.

Finally, Six Sigma is a management philosophy that strives for ever increasing levels of perfection across all public and private sector industries.

2001601208040

LSL USL

130120110100908070

LSL USL

Six Sigma Tools & Techniques

Processing For Six Sigma

DMAICDesign For Six Sigma

DMADV

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Performance

ImmediateProblems

ProductionFocus

Process Stability

Process Improvement

Operational Excellence

Stages of Evolution

1 2 3 4 5

Six Sigma

Design For LeanSix Sigma

Lean

Journey of Process Excellence

DEFINING THE PROCESS

SIPOC

Suppliers

Pharmacy Techs

Wholesaler

Inputs

Bulk Medication

Repackaging Supplies

Prepack Record

Process

Medication Repackaging

Outputs

Unit dose medication

Prepack Record

Customers

Pharmacists

Nurses

Patients

Pharmacy Techs

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TEAM EXERCISE…

Lets make a SIPOC

• ADS Refill

• Sterile Compound Preparation

• Receiving Purchase Order

• Making the Perfect Grilled Cheese Sandwich

There are at least 3 versions(usually)

How you would like it to be ...

How you think it is... How it really is...

Describe the process by following the current path of the data or material

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Process MappingTake Home Labeling

START

Pharmacist verifies Take Home Order

Label Prints

Technician Pulls Medication

Is the Med OTC?

Y

N

Technician Fills Out Label & Rx

Record

Pharmacist Checks and Labels

Med

STOP

Pharmacist Discards Rx Record

Pharmacist Files Rx Record

Technician Sends Med

Lets make a Process Map

• ADS Refill

• Sterile Compound Preparation

• Receiving Purchase Order

• Making the Perfect Grilled Cheese Sandwich

The Eight Wastes“Muda”

Transportation

Inventory

Motion

Waiting

Overproduction

Over‐processing

Defects

Skills

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TECH CHECK TECHIdentifying and Remedying Waste…

Tube

Station

Tech Work Station Pharmacist Work Station

Tech Work Station

Check Station

Lab

RFG Check Station

CarouselTable

Office

Spaghetti Chart

Time Chart ‐ADS Batch Refill Time (min), Before TCT

Date Waiting to Pull

Time to Pull Batch

Time Waiting for Check

Time to Check Time Waiting to Deliver

6/9/2014 32 50 73 22 22

6/10/2014 5 37 80 25 5

6/11/2014 6 30 72 27 5

6/13/2014 0 25 65 25 30

6/16/2014 18 72 86 35 25

6/17/2014 0 43 93 27 45

6/19/2014 0 40 65 25 25

6/23/2014 0 81 75 30 15

6/24/2014 0 45 112 36 40

6/25/2014 25 43 83 25 80

7/3/2014 105 82 102 45 158

Average 17.36 49.81 82.36 29.27 40.91

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Time Chart ‐ADS Batch Refill Time (min), After TCT

Date Waiting to Pull

Time to Pull Batch

Time Waiting for Check

Time to Check

9/9/2014 15 35 10 10

9/11/2014 10 30 5 15

9/12/2014 10 35 5 15

9/16/2014 0 35 5 10

9/17/2014 5 30 5 10

9/18/2014 2 30 5 10

9/19/2014 10 25 5 15

Average 7.43 31.43 5.83 11.67

Project Benefit

0

20

40

60

80

100

120

140

160

180

Before TCT After TCT

Time (minutes)

Time to check

Time waiting for check

Time to pull

Recap

• What tools did we use?

• What kinds of waste did we eliminate?

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STERILE PRODUCTS AREAIdentifying and Eliminating Waste

One‐Piece Flow

2 SPL Batches per Day

5 SPL Batches per Day

Effect of lean process improvement techniques on a university hospital inpatient pharmacy.HINTZEN, BARBARA; KNOER, SCOTT; VAN DYKE, CHRISTIE; MILAVITZ, BRIANAmerican Journal of Health‐System Pharmacy. 66(22):2042‐2047, November 15, 2009.

Expired or Unusable Drug

What kind of waste is this?


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Number of Missing Doses

What kind of waste is

this?


Number of Compounding Errors

What kind of waste is this?


What is 5S?

• Sift

• Sort

• Sweep

• Standardize

• Sustain

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5S the Sterile Product Area

Before After


Recap

• What tools did we use?

• What kinds of waste did we eliminate?

THE CUSTOMER

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Why is the customer so important?

• They define value

• We need their buy in – they must AT LEAST feel involved!

• The customer PULLS process improvement

Going Back to Our SIPOC…

Suppliers

Pharmacy Techs

Wholesaler

Inputs

Bulk Medication

Repackaging Supplies

Prepack Record

Process

Medication Repackaging

Outputs

Unit dose medication

Prepack Record

Customers

Pharmacists

Nurses

Patients

Pharmacy Techs

Identify your customers and stakeholders

What value does the customer get

from the process?

What are the customers needs?

Improving Anesthesia Charging

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A New SIPOC

Suppliers

Anesthesia

Providers

Pharmacy Techs

Inputs

ADS Machines

Med Removal

ADS Refill

Process

Anesthesia ADS

Charging Process

Outputs

Patient Charges

Customers

Pharmacy Techs

Billing Personnel

Anesthesia Providers

Voice of the Customer

What is the largest barrier to remembering to charge the patient?

“ADS System Runs Slow at Times”

“Education earlier alerting us of this

problem”

“Commonly used drugs are in

different drawers” “Lack of automation

between EMR and ADS”

“Time”

“Time, Patient Safety”

“Forgetting to click the screen”

“Patient care”

“Personally, I don’t see any barriers. The process is

simple.”

OtherTimeTechnology

Affinity Diagram

“ADS System Runs Slow at Times”

“Education earlier alerting us of this

problem”

“Commonly used drugs are in

different drawers”

“Lack of automation

between EMR and ADS”

“Time”

“Time, Patient Safety”

“Forgetting to click the screen”

“Patient care”

“Personally, I don’t see any barriers. The process is

simple.”

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Root Cause Analysis Tools

• 5 Whys

– Why are anesthesia charges being missed?

• Fishbone (Ishikawa) diagram

– What factors are in play?

QUESTIONS

Next Steps

• There are SO MANY other tools to be great Lean Six Sigma practitioners!

• Ask your supervisor if you can get Lean Six Sigma certified!

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NOW LETS GET THE VOICE OF THE CUSTOMER…

process innovation for pharmacists technicians …1 process innovation for pharmacists &...

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