waste not; want not - pharmacyadvisor.com · usmp/mg1/14-0227 6/14 lean based on toyota production...

Waste Not; Want NotUtilizing Lean Concepts to Reduce IV Waste

USMP/MG1/14-0227 6/14

Utilizing Lean Concepts to Reduce IV Waste

Frank M. McCloy, R.Ph.

Sterile Products Supervisor

East Jefferson General Hospital

Metairie, Louisiana

Donna Carbajal, RN, RRT, MBA

Supervisor, Clinical Excellence

USMP/MG1/14-0227 6/14

We Welcome Your Questions

� You can submit questions throughout the webinar

using the form on your screen.

� If you experience any technical issues during the

webinar, please use the help button shown on your

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� Download a PDF handout of the presentation on the

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to join today’s webinar.

2

USMP/MG1/14-0227 6/14

Disclosure

� The content of this presentation was created by the

presenters and does not necessarily reflect the views

of Baxter Healthcare Corporation.

� Our speakers have accepted an honorarium from

Baxter for this presentation.

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USMP/MG1/14-0227 6/14

About Our Speaker

Frank M. McCloy, R.Ph.

� Frank McCloy is the Sterile Products Supervisor at East Jefferson General Hospital

(EJGH), a 435-bed hospital in Metairie, Louisiana.

� At EJGH, he is responsible for a $7.8 million sterile products budget. He is also in

charge of the MD Anderson chemotherapy inpatient/outpatient pharmacy and

USP 797 IV compliance.

� He has 20+ years of hospital pharmacy management experience.

� He has a record of accomplishment in operations management, inventory

management, clinical program development, emergency preparedness, Joint

Commission standards, USP 797 implementation, quality improvement methods,

staff development and team building, pharmacy turnarounds/start-ups, project

management, and cost control.

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USMP/MG1/14-0227 6/14

About Our Speaker

Donna Carbajal, RN, RRT, MBA

� Donna Carbajal is the Supervisor of Clinical Excellence and the Quality and

Organizational Effectiveness Specialist at East Jefferson General Hospital (EJGH) in

Metairie, Louisiana.

� At EJGH, her responsibilities include accountability for organizational wide

direction and facilitation of performance assessment, reassessment, development

and implementation of the Quality/Performance Improvement program in

accordance with all regulatory requirements.

� She is involved in a number of quality and organizational activities at EJGH,

including: FMEA, RCA, and performance improvement facilitation; JCAHO, CMS,

and DHH preparation, survey facilitation, & remediation; patient and system

tracers for regulatory compliance; peer review & medical staff committee support;

incident review & sentinel event determination; and leadership, medical staff,

board quality & lean performance improvement presentations and

action plans.

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USMP/MG1/14-0227 6/14

Panelists

Frank McCloy and Donna Carbajal will be joined during the question and

answer session by their colleagues on the EJGH LEAN Management Team:

Charlotte Williams, CPT

Certified Pharmacy Technician


Metairie, Louisiana

Hai M. Nguyen, PharmD

Dept. of Pharmacy


Metairie, Louisiana

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USMP/MG1/14-0227 6/14

Objectives

� Enhance IV room productivity and reduce IV waste

while improving medication delivery to the nursing

units.

� Demonstrate strategies resulting in a significant

decrease in medication requests.

� Identify changes in the IV drug delivery preparation

and delivery process that resulted in IV drug cost

savings.

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USMP/MG1/14-0227 6/14

If you keep on doing what you have

always done,

You will keep on getting what you’ve

always got.

-Anonymous

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USMP/MG1/14-0227 6/14

� Things you should know about Lean:

• Automation shouldn’t be the first answer

• Lean takes a systems approach

• Lean is team based

• Lean is a system for the absolute elimination of waste1

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Lean

1. Thun J, et al. Int J Prod Res. 2010;48:7089-7106.

USMP/MG1/14-0227 6/14

Lean

� Based on Toyota Production System2

� Identification and elimination of WASTE in a process2

� Got its name from MIT (James Womack)3

� Improves Quality, Cost, Delivery, Safety, Morale2

� Increases process capacity2

� Reduces defects2

� Results in a stable, reliable, repeatable, predictable process2

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2. Hintzen BL, et al. Am J Health-Sys Pharm. 2009;66:2042-2047.

3. Lean People. Lean Enterprise Institute. www.lean.org

USMP/MG1/14-0227 6/14

Lean

� Lean focuses on:

• Reducing the 7 wastes1

• Improving process flow2

• Increasing process speed2

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USMP/MG1/14-0227 6/14

Lean

� Lean is about fixing the SYSTEM and transforming the CULTURE

� Lean is about FLOW

� Lean is about people, not just about improvement tools

� Lean is about YOUR expectations, what YOU are willing to tolerate

in terms of Quality, Cost, Delivery, Safety, Morale

� Processes rarely get better on their own

� Successful processes have rules, standards, and absolutes

� To solve a problem you have to admit you have one

� Problems need to be quantitatively defined and their corrective

action quantitatively tracked

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USMP/MG1/14-0227 6/14

Lean: Key Elements

� Standard work2

• The process of delivering care

o Automation with a human touch

o Make problems obvious

o Immediate problem resolution

� User friendly

• Provide the patient or staff what is needed, when it’s needed, in

the quantity needed, on time, every time, 24/7/365

� Unobstructed throughput4

• Eliminating process constraints to increase throughput

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2. Hintzen BL, et al. Am J Health-Sys Pharm. 2009;66:2042-2047

4. Oakley J. Quality. 2008;47:58-61.

USMP/MG1/14-0227 6/14

A Lean Organization

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Standard Work User-Friendliness Unobstructed Throughput


5. Huttmeir A, et al. Int J Production Economics. 2009;118:501-507.

6. Tamura T, et al. Int J Production Res. 2011;49:4299-4315 .

USMP/MG1/14-0227 6/14

A Lean Organization

15

Jidoka6

Making

Problems

Obvious

Standard Work User-Friendliness Unobstructed Throughput




USMP/MG1/14-0227 6/14

A Lean Organization

16

Jidoka6

Making

Problems

Obvious

Standard Work User-Friendliness

Kaizen2

Continuous

Improvement

Unobstructed Throughput




USMP/MG1/14-0227 6/14

A Lean Organization

17

Jidoka6

Making

Problems

Obvious


Kaizen2

Continuous

Improvement

Respect2

For

People





USMP/MG1/14-0227 6/14

A Lean Organization

18

Jidoka6

Making

Problems

Obvious


Kaizen2

Continuous

Improvement

Heijunka5

Just in Time

Respect2

For

People




6. Tamura T, et al. Int J Production Res. 2011;49:4299-4315 .Pharmacy Advisor is a trademark of Baxter International Inc.

USMP/MG1/14-0227 6/14

A Lean Organization

19

Jidoka6

Making

Problems

Obvious

Value Stream Focus


Kaizen2

Continuous

Improvement

Heijunka5

Just in Time

Respect2

For

People





USMP/MG1/14-0227 6/14

A Lean Organization

20

Jidoka6

Making

Problems

Obvious

Value Stream Focus

Lean Organization


Kaizen2

Continuous

Improvement

Heijunka5

Just in Time

Respect2

For

People





USMP/MG1/14-0227 6/14

Respect for People

� Foster a culture that enhances individual creativity

and teamwork, while honoring mutual trust and

respect between staff and management

� Acknowledge staff are the experts

� Include staff in Lean events

� Teach all staff to solve problems

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USMP/MG1/14-0227 6/14


22

4. Oakley J. Quality 2008;47:58-61.

ED ORInpatient

Unit

USMP/MG1/14-0227 6/14


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ED ORInpatient

UnitWaste Waste


USMP/MG1/14-0227 6/14


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ED ORInpatient

Unit


USMP/MG1/14-0227 6/14


25

ED

OR

Inp

atie

nt

Un

it


USMP/MG1/14-0227 6/1426

Continuous Flow



USMP/MG1/14-0227 6/14

Waste (Muda)2

� Waste is any activity that:

• The customer isn’t willing to pay for

• Doesn’t positively change the form, fit, or function of the

product or service (Value Added)

� Remember:

• If you don’t have time to do it right, when will you have

time to do it over?

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USMP/MG1/14-0227 6/1428


USMP/MG1/14-0227 6/14

The Lean Process

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Step 1

Identify Customer Value

USMP/MG1/14-0227 6/14

The Lean Process

30

Step 1


Step 2

Map the Process

(Value Stream or

Process Map)

USMP/MG1/14-0227 6/14

The Lean Process

31

Step 1


Step 2

Map the Process

(Value Stream or

Process Map)

Step 3

Determine capacity & customer demand

USMP/MG1/14-0227 6/14

The Lean Process

32

Step 1


Step 2

Map the Process

(Value Stream or

Process Map)

Step 3


Step 4Identify & Eliminate

Waste

USMP/MG1/14-0227 6/14

The Lean Process

33

Step 1


Step 2

Map the Process

(Value Stream or

Process Map)

Step 3



Waste

Step 5

Adjust flow to customer demand

Eliminate disruption and abnormalities

USMP/MG1/14-0227 6/14

The Lean Process

34

Step 1


Step 2

Map the Process

(Value Stream or

Process Map)

Step 3



Waste

Step 5

Adjust flow to customer demand

Eliminate disruption and abnormalities

Step 6

Improve flow

and continuously

improve

Lean Organization

USMP/MG1/14-0227 6/1435

Pharmacy Kaizen

USMP/MG1/14-0227 6/14

Sense of Urgency

� Pharmacy costs as a percentage of hospital

expenditures increasing

� Waste reduction and financial stewardship of

pharmacy resources a priority

� Pharmacy leadership in a position to optimize

medication management by reducing non-value

added process steps thereby positively impacting the

hospital’s budget

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USMP/MG1/14-0227 6/14

Problem Statement

� A month-long study

estimated annual IV

waste costs at $750,000

� Opportunities related to:

• rework

• over processing

• batching

• lack of standard work

• unnecessary motion

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USMP/MG1/14-0227 6/14

Key Issues Identified

� Piggybacks and large volume batched in 12hr time frames

� 400 drugs/month wasted

� Expired NS and D5W 50 and 100 ml bags wasted due to lack of

use prior to expiration date when stocked in each nursing

units’ Pyxis dispensing cabinet

� Lack of point of care medication preparation resulting in

waste due to expired piggybacks not utilized within

established timeframe

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USMP/MG1/14-0227 6/14

Key Issues Identified

� Over 200 medication requests a day from nursing due to lack

of standard work related to communication and IV delivery to

nursing units

� Lack of standardized location for delivery and pick up of

medications on nursing unit leading to duplication of IV remix

� Pharmacists are frustrated with multiple medication requests

from nursing

� Nurses are frustrated with delayed medication delivery

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USMP/MG1/14-0227 6/14

Goals/Desired Outcomes

� Enhance IV room productivity

� Reduce IV waste while improving medication delivery to the

nursing units

� Metrics:

• Decrease medication requests by 25%

• Decrease IV waste by 30%

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USMP/MG1/14-0227 6/14

The Team

� 4 Nurses from high usage units

� 2 Pharmacists

� 2 Pharmacy technicians

� Lean facilitator

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USMP/MG1/14-0227 6/14

Project Preparation

� Team preparation for the project

• Team reviewed the medication request process from MD order

through delivery to nurse

• Representatives from four high volume medication request nursing

units and four pharmacy representatives were selected to participate

on team

• Facilitator conducted a 2-hr JIT education session on Lean for team

members on day 1 of the Kaizen

• Kaizen was conducted in 8-hr day intervals over 2 wks for a total of 40

hours (3 days the 1st week; 2 days the 2nd week)

• Established goals for the team

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USMP/MG1/14-0227 6/14

Current State Medication Process

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USMP/MG1/14-0227 6/14

Current State Supporting Documentation

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IV Waste for 1 week Pharmacy Tech Steps

560 steps in 40 min. observation

USMP/MG1/14-0227 6/14

Current State Supporting Documentation

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Gemba & Time Observation

USMP/MG1/14-0227 6/14

Future State Medication Process

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USMP/MG1/14-0227 6/14

Developing the Future State

After conducting a walk

through and time

observation study of

Pharmacy Tech filling

medications, the team

used brainstorming to

develop desired future

state.

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USMP/MG1/14-0227 6/14

Future State Supporting Documentation

� Established a timeline for implementing

recommendations and assignment/accountability for

each action item

� Gantt chart of action items with responsible party

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USMP/MG1/14-0227 6/14

Expected Results

� Decrease medication requests by 25%

� Decrease IV waste by 30%

� Decrease return medications and associated

labor by 30%

� Improve medication storage

� Improve timeliness of medication delivery

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USMP/MG1/14-0227 6/14

Sustainment

� Pharmacy will monitor:

• IV waste

• Medication Requests

� Nursing will monitor

• Compliance with medication storage, intake, and return

• Duplicate medication requests

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USMP/MG1/14-0227 6/14

Reflection

� Project reflection

• Pharmacy and Nursing staff now appreciate the process steps

required to complete a medication request.

• Having Pharmacy and Nursing view each other’s processes

allowed collaboration to make changes for the better.

• Pharmacy and Nursing now have understanding of Lean

concepts and recognize waste in their processes.

� Self-reflection

• Collection of more baseline data prior to the meeting would

have benefitted the team’s productivity.

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USMP/MG1/14-0227 6/14

Project Summary: A3

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Background Recommentations

Current Situation

Implementation Plan

Analysis

Follow Up

Goal Results Report

Med requests delayed and/or duplicated

Why? System built to sort orders/requests by order time

Why? No sorting of new orders versus medication requests

Why? Allows duplicate med. requests.

Why? Pharmacist works queue for both new orders and medication requests by ordered time

Why? Pharmacist may not recognize med. request duplicated

IV waste high

Why? Orders changed after IV mixed

Why? IV batches are every 12hours

1) Post list of meds requiring med requests, longer mix times, and shorter expiration dates by nursing unit pyxis

2) Standardize nursing unit medication bins (one in and one out bin) located in pyxis room (exception: ICU central location but multiple

bins set up)

3) Paint 30 tube system cannisters blue to alert nursing to return to Pharm immediately

4) Implement hourly Main Pharm Tech rounding of IV Meds needing to be tubed to prevent delay

5) Implement IV Pharm Tech coordination w ith Main Pharm Tech to deliver NICU p.o. meds w hen NICU IV meds are delivered.

6) Implement sorting box in IV Med room to allow Pharm to track pending requests by time due.

7) Create tube system dow ntime code f or Pharmacy to alert Charge Nurses of 2 hr rounding implemented

8) Purchase Cardizem connector to allow nurses to mix medication on unit (reduce med. request and expired meds.)

9) Reposition 2E scanner closer to unit secretary w orkstation

10) Purchase IV piggyback (D5W, N/S 50 &100cc bags) to individually w rapped and move to nursing unit stock. Set up Par levels.

11) Decrease IV bulk and piggyback batch runs from 12 hr to 2 hour intervals to reduce IV w aste.

12) Create medication request queue for Pharm. Techs to expedite response to nsg med. req.

13) Install w ireless phones for Pharmacy Techs

14) Meet w ith Nsg Directors to agree on secure non-emergent bulk meds storage (locked bedside table draw )

15) Educate Nsg and Pharmacy on changes (use education flyer, EGG, unit meetings)

1) Round on nursing units & Pharmacy to review impact and compliance with changes.

2) Collect established metrics (below) to assess impact of changes and long term gains.

A 2009 week long study revealed we are wasting $750,000 in duplicate/expired/wasted IV medications. In addition, approx. 600 medication

requests per day are processed by the Pharmacists. Many requests are duplicates which creates delays leading to frustration for both the

nursing and pharmacy.

% CompDec Jan FebDescription#

3115 147 2821 4 15

75%Pasqua / ITMed. Req. Queue for Pharm Tech7

25%Pasqua/Nsg DirMeet /w Nsg re: locked bedside table 2.15.116

25%Scanlon / ITReposition 2E Scanner 2.15.115

25%McCloy/RadtkeIV Piggybacks as Nsg Floor Stock 2.4.114

100%PasquaCadizem connector 1.20.113

75%McCloy/TorresReduce IV batches to 2 hr intervals 2.15.112

100%RauschWireless phones for Pharm Tech 12.10.101

Who

Pharm Tech560 steps in 40 min. observation

IV Waste for 1 week

Standard work observation

Establishing standard work for nsg station meds in / out

Visual Signals: Blue tubes identifies Pharmacy tubes to be returned to Pharm

immediately to expedite delivery of meds to

nurses

USMP/MG1/14-0227 6/14

Improvements

� 400 most commonly used

drugs relocated closer to the

pharmacy technician

• Reduced steps and improved

fill time

� Batches reduced from 12 to

3 hours for all piggybacks

and LVPs

• Created more nimble

response to changes in orders

and patient discharges

• Resulted in reduced IV waste

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560 steps in 40 minutes

USMP/MG1/14-0227 6/14

Improvements

� Quick connect device placed on nursing units’ supply

cart (Diltiazem, Vancomycin 1 g and Azithromycin) for

small IV infusions

• Rework reduction for pharmacists by eliminating the

duplicate requests from nursing to fill an order already

processed

• Nursing administration delays reduced due to minimization

of searching for a piggyback or requesting again from

pharmacy

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USMP/MG1/14-0227 6/14

Improvements

� NS and D5W 50 & 100 ml bags stocked on nursing

supply cart as individually wrapped bags

• Added longer shelf life reducing waste due to expiration

of unwrapped bags prior to use

� Medication request queue created for

Pharmacy Tech

• Reduced redundant requests leading to potential

duplication by Pharmacist

• Allowed quicker response to nursing request

• Reduced workload for pharmacist

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USMP/MG1/14-0227 6/14

Improvements

� Standardized pharmacy delivery and pick up

locations on nursing units

• Allowed quicker identification of delivered drugs

• Reduced duplicate medication requests

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USMP/MG1/14-0227 6/14

Improvements

� Thirty tubes from tube

system painted blue

• Visual cue

• Enhanced prompt return

to Pharmacy

57

Visual Signals: Blue tube identifies

Pharmacy tubes to be returned to

Pharmacy immediately to expedite delivery

of meds to nurses.

USMP/MG1/14-0227 6/14

Improvements Continued Post Kaizen

� To reduce IV bags and tubing waste, a new process

was established for nurses to push IV ABX instead of

using an IV pump.

� Sterile water needed as a nursing unit stock supply

for IV medication dilution.

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USMP/MG1/14-0227 6/14

Kanban & Push vs Pull1

59

� Kanban literally means

“visual card”

� Kanban is a card,

labeled container,

computer order, or

other device used to

signal that more

products are needed

� It creates a pull rather

than a push system

� It uses Just in Time

ordering to minimize

stock outs

1. Thun J, et al. Int J Prod Res. 2010;48:7089-7106

USMP/MG1/14-0227 6/14

Current State

� Using IV piggyback and

IV pump sets to deliver

antibiotics in IV

piggyback bags

� Wasting IV piggyback

antibiotics due to delay

in administration or

delay in getting d/c to

pharmacy

60

Waste

USMP/MG1/14-0227 6/14

Future State

� RNs now pushing IV

medications, when

appropriate, eliminating

wasted IV bags and tubing.

� Sterile water now stocked on

each nurses station in a

Kanban system to prevent

stock outs. Nurses put

Kanban card in pharmacy

return box for restocking.

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USMP/MG1/14-0227 6/14

Two Bin Kanban

� Two bin Kanban

• Calculate par levels, reorder quantity, & reorder time

• Stock enough supplies to meet demand

� Standard Work

• Pull supplies from top bin first

• When top bin empty, replace with bottom bin

• Place Kanban card in Pharmacy return box

• Pharmacy tech picks up Kanban card & restocks

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USMP/MG1/14-0227 6/14

Responsibility

63

Action Due Date % Complete Person

Restocking

Kanban

Daily 100% Pharm.

Tech

Monitoring

Compliance

Biweekly 100% Pharm IV

Supervisor

USMP/MG1/14-0227 6/14

Results

� March 2011:

• 71% reduction in medication requests and a 41% reduction

in IV waste were realized

� Since then:

• IV waste decreased from $62,500/month to $4000/month,

a savings of $58,500/month

• Mainly attributed to the reduction in IV batches from

twelve to three hours

• Utilization of quick connect adaptors allowing nurses

access to medications using just in time philosophy

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USMP/MG1/14-0227 6/14

Results

� The shared understanding of the process between

pharmacy and nursing has led to:

• Improved communication

• Teamwork as departmental silos are broken down to

improve the medication process flow

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USMP/MG1/14-0227 6/14

Results

� Annualized 2011 IV waste

• $48,000/year

• 94% improvement when compared to the 2008 IV waste of

$750,000/year:

Annual savings of $702,000

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USMP/MG1/14-0227 6/14

We Welcome Your Questions

� You can submit questions throughout the webinar

using the form on your screen

� If you experience any technical issues during the

webinar, please use the help button shown on your

screen

� The views and opinions expressed during the

question and answer session are those of the

individual presenters and should not be attributed to

Baxter

67

USMP/MG1/14-0227 6/14

References

1. Thun J, Druke M, Grubner A. Empowering Kanban through TPS-principles–an

empirical analysis of the Toyota Production System. Int J Prod Res. 2010;48:7089-

7106.

2. Hintzen BL, Knoer SJ, Van Dyke CJ, Milavitz BS. Effect of lean process improvement

techniques on a university hospital inpatient pharmacy. Am J Health-Sys Pharm.

2009;66:2042-2047.

3. Lean people. Lean Enterprise Institute. Available at:

www.lean.org/WhoWeAre/LeanPerson.cfm?LeanPersonId=1. Accessed May 15,

2012.

4. Oakley J. Increasing throughput with lean concepts. Quality. 2008;47:58-61.

5. Huttmeir A, de Treville S, van Ackere A, Monnier L, Prenninger J. Trading off between

heijunka and just-in-sequence. Int J Production Economics. 2009;118:501-507.

6. Tamura T, Okumura T, Singh Dhakar T, Ohno K. Optimal production sequencing

problem to minimise line stoppage time in a mixed-model assembly

line. Int J Prod Res. 2011;49:4299-4315.

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waste not; want not - pharmacyadvisor.com · usmp/mg1/14-0227 6/14 lean based on toyota production...

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