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With increasing operation costs, patient safety awareness, and a shortage of trained personnel, it is becoming increasingly important for hospital pharmacy management to make good operational decisions. In the case of hospital inpatient pharmacies, making decisions about staffing and work flow is difficult due to the complexity of the systems used and the variation in the orders to be filled. Pharmacy turnaround time is a crucial metric for patient safety and caregivers’ satisfaction. Pharmacy management is under constant demand to reduce turnaround time. In order to help The Methodist Hospital Pharmacy Management make decisions about work flow, a team was created to analyze the impact of an alternate work process. The team examined the impact of the process and work flow changes on the amount of time medication orders take to be processed. The goal is to help the pharmacy management team find the best process and workflow to get medications to the patients as quickly as possible. Systems Thinking and Kaizen are used as tools to achieve that goal by using pharmacy staff effectively and make the process more efficient.
The pharmacy division’s initial goals for 2006-07 were to increase patient safety by improving turnaround time (TAT) by 25% for the preparation, dispensing, and delivery process for first dose medication orders. Improved TAT means that the patient receives medication when he or she needs it without delay, thus ensuring optimal, timely, and safe administration of the medication. The goals changed after the data were analyzed by lean team using the value-stream map. Systems Thinking (thinking transformation) and Kaizen (continuous improvement) were the principle means which demonstrated marked improvement.
Six pharmacists and four technicians were selected as a “Lean Team”. A systems thinking & Kaizen workshop, using a group model-building approach, was held for three days. A facilitator introduced the qualitative system dynamics approach, which would be used for finding a way to make sense of the complex relationships and work flow.
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Understanding Systems Thinking
To understand systems thinking as it is known today, it is necessary to go back several decades and view some of its evolution. General systems theory was introduced in the 1940's by Ludwig von Berttalanffy (Cummings, 1980), but has been vastly expanded since its inception. It developed as a response to rapid technological complexities that confronted engineering and science. It was a radical departure from traditional science which dealt with cause and effect explanations. Systems thinking viewed an organization and its respective environment as a complex whole of interrelating, interdependent parts. It stressed the relationships and the processes that make up the organizational context, rather than the separate entities or the sum of the parts (Cummings, 1980).
It is interesting to note that there are several ways to classify systems. Peter Checkland's classification system (Richardson, 1991) described the purposeful activity of human beings as human activity systems. This classification includes organizations, industrial activity, and political systems and is the one which is of most interest to managers and employees. These kinds of systems are referred to as soft systems and are usually described by language rather than mathematics. Such systems include several basic concepts. Because it is a system of purposeful activities there will be goals, objectives, or purposes. Connectivity will exist as systems imply interrelatedness. Organizational systems must also have some way to measure performance and make decisions, but these processes have control mechanisms which act within certain boundaries or areas of responsibility. If the systems’ objectives are to be met, resources must be available. Finally, a human activity system will be a part of a systems hierarchy. It will be a subsystem within a greater system, or it will be a larger system incorporating smaller subsystems within itself (Wilson, 1984).
Systems Thinking means that even while analyzing separate parts of a process the relationships among them are still kept in mind. It also means that the system’s processes are considered more likely to be the case of problems than are individuals (Buccini, 1993).
Thinking can be defined as having a conscious (sic, self-aware) mind, to some extent of reasoning, remembering experiences, and making rational decisions. Thinking involves volition. Many biologic systems have free will: ants, lions, fish, but only humans think with purposes beyond survival. Thinking humans can create things never seen before, and humans can kill for purposes other than survival.
Change for improved performance means changing the system. Any intervention in a system which does not alter people's thinking will produce no change. This is why quality improvement training often fails to improve performance over the long term. It's not just a matter of learning new tools--the everyday practical matters of workflow and systems design must be dealt with. Once people have a better understanding of how work gets done, their behaviors will change. Altering the system means taking out things that limit or damage current performance. This means that barriers may need to be removed, control mechanisms revised, and processes refined. Improvement actions must be aimed at putting in place the right "system conditions" to ensure that performance is managed from a strong base of workflow understanding.
The application of systems thinking forces planners and strategists to focus on processes, interactions and causes of poor outcomes, rather than individual players, isolated components of a system or interim results. 'When only the superficial symptoms of complex problems are addressed, the underlying problem typically remains unsolved, and even can be exacerbated if the solution feeds into a vicious cycle such as providing food as direct aid, which relieves starvation but perpetuates the problem of population growth in inhospitable climates' (Edmondson, 1996 quoting Senge, 1990). Managed care in the USA and the British National Health Service were touted as answers to national healthcare ills, but each has both exacerbated the old problems and created new ones.
Any attempt to solve a problem or improve an outcome needs to deal with both, system and process. Recognizing that we operate within systems requires a different type of thinking to be fully effective. Thinking that fully explores the complexity of the cause and effect relationship between the constituent processes and the behavior of the people that enact them. Systems Thinking is the key capability for describing and understanding problems to optimize outcome.
KAIZEN, a tool for systems improvement
KAIZEN is a Japanese word meaning gradual and orderly, continuous improvement. The KAIZEN business strategy involves everyone in an organization working together to make improvements 'without large capital investments'.
KAIZEN is a culture of sustained continuous improvement focusing on eliminating waste in all systems and processes of an organization. The KAIZEN strategy begins and ends with people. With KAIZEN, an involved leadership guides people to continuously improve their ability to meet expectations of high quality, low cost, and on-time delivery.
Kaizen Event is any action whose output is intended to be an improvement to an existing process. Kaizen Events are commonly referred to as a tool that:
1) Gathers operators, managers, and owners of a process in one place
2) Maps the existing process (using a deployment flowchart, in most cases)
3) Improves on the existing process
4) Solicits buy-in from all parties related to the process
The true intent of a Kaizen Event is to hold small events attended by the owners and operators of a process to make improvements to that process which are within the scope of the process participants (Six Sigma website).
Lean Team is ready to go
The initial step in the pharmacy was to map the current-state value stream. The key tovalue-stream mapping is actually observing the process and measuring the cycle times of steps in the process (figure1).
The team then had mini-kaizen events to evaluate the current state, identify clouds (problems, barriers, waste time), develop the future state, and plans the action steps (figure 2).
The Lean-Team identified three areas for immediate improvement: Create a call center, redesign the work stations to have all pharmacists in one place, and get a terminal PC located close to the refrigerated items to reduce walking distance and time waste. The management team approved the proposal and allocated the necessary budget for improvement.
In general, the non-value-added steps in the process were identified by the value-stream map and observation. Many of these steps were walking, waiting, interruptions, and motion caused by lack of communication and information. The team was able to eliminate the waste through process redesign, using the concepts of lean with a focus on one-piece flow. The process redesign was part of a physical renovation within the pharmacy, planned before lean was implemented. This allowed design changes on the basis of the future ideal state. Other areas of waste were eliminated through the use of technology. A new computer terminal was created to generate labels for refrigerated items, which removed steps, duplication, and rework by the technicians and pharmacists.
A call-center was created and all incoming calls to pharmacy were received by trained technicians. Directing calls to the center reduced interruption and minimized time waste answering calls which did not need a pharmacist intervention. Reallocating pharmacists to work in a separate area minimized interruption and reduced turn-around time required for order verification.
There has been a reduction in first dose order processing time. TAT decreased from an average of 61 minutes to 47, a 23% improvement. One of the most significant outcomes is the change in the staff’s viewpoint. The success of lean training has been seen in many areas. Managers and staff now think of their processes in terms of lean and ask, “How can we improve?” It has changed the way staff members think about what they do and how it affects patients and customers. The culture is beginning to change to one in which staff members are empowered to make decisions about how they do their work. They are using the lean/scientific problem-solving methodology to find the answers needed to make these decisions. Staff members at all levels are able to recognize waste in their work, and they are taking the initiative to make the necessary changes to remove waste.
Using a combination of Systems Thinking and Six Kaizen, hospital pharmacies would see measurable improvement in turnaround time. The Methodist Hospital pharmacy was able to reduce its TAT from 61 minutes to 47 minutes. While Systems Thinking is a way to rethink The Entire Operation, Kaizen is an effective tool to Eliminate Waste to Optimize Value.
The pharmacy management is using the results from these Kaizen events to help justify changing the pharmacy operational policy. Since the results are based on changes in some areas, the effect of the changes may not be exact when applied to other areas, but the direction and relative magnitude can be used to compare the effects of possible changes. As changes are made the process will be further verified, and if other options need to be explored the process can be modified to explore further changes.
Buccini, E.P. (July 1993) Improving the quality of care. New England Journal of Medicine, 335, 1060-1063.
Cummings,T.G. (Ed.). (1980). Systems theory of organizational development. New York: Wiley.
Edmondson AC. 1996. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error. Journal of Applied Behavioral Science 32(1): 5-28.
Richardson, G. P. (1991). Feedback thought in social science and systems theory. Philadelphia: University of Pennsylvania Press.
Senge PM. 1990. The Fifth Discipline -The Art and Practice of the Learning Organization. Currency Doubleday: New York.
Six Sigma: http://healthcare.isixsigma.com/dictionary/Kaizen_Event-411.htm
Wilson, B. (1984). Systems: Concepts, Methodologies, and Applications. New York: Wiley.