Issue 11 • July 2012
Applying Toyota Production System Techniques to Medication Delivery
by Terry Newell and Cynthia Seaver; Process Engineers, Spectrum Healthcare
Spectrum Health is the largest not-for-profit health care system in West Michigan with nine hospitals, 190 service sites and 1,938 licensed beds system wide. We have the largest children's hospital in West Michigan, Helen DeVos Children's Hospital, and the largest adult open heart program in the state. We are the largest regional provider of cancer care and have one of the top joint replacement programs in the nation. Our service area covers all of Michigan with 600,000 Priority Health plan members and more than 12,000 employers through Priority Health.
At two Spectrum Health hospitals (700 beds), located in Grand Rapids, Michigan, a 24-hour medication cart-fill exchange process for inpatient medication deliveries had been in place for more than 15 years. The complexity and volume of patients had significantly changed during that period, and the medication delivery system needed to be redesigned to account for new technologies and nursing expectations.
A multidisciplinary project team began its work by developing a process map of the medication delivery system’s current state. Starting with the end customer (i.e. bedside nurses) and working backwards through the process, the team examined each customer-supplier connection. They documented all “wastes” in the process and compared them against an Ideal State.
A pharmacy IV bag delivery simulation utilizing LEGO® products was designed to illustrate the benefits of transitioning from a scheduled, manual, cart-fill batch push system to a single-piece pull system. Using this simulation process, the team was able to see how disconnected local activities behaved in the existing environment and how they would behave in a pull system.
The next step was for the project team members to go to “Gemba,” a Japanese word for the place where all activities are actually taking place. Pharmacy team members went to nursing units so they could understand the issues nurses faced with the existing medication delivery system and nursing representatives went to the inpatient pharmacy to understand how hard those personnel were working to ensure that correct medications were delivered to their units. In the end everyone reached the same conclusion: “Everybody is working so hard. The problem must be something else!”
The team then constructed a completely new medication delivery system based on the pull system concepts of TPS. They started with the customer – a unit nurse – retrieving a medication for a patient and worked backwards to the pharmacy. Historical usage data on medications administered on units in the hospital was used to determine that a high percentage of medications were needed with a high level of frequency, and a low percentage of medications were needed infrequently. With this information, the project team chose to set up a Kanban “A” system (store) for the majority of medication orders and a Kanban “B” system (flow line) for the remaining orders.
The new Kanban “A” system utilizes an automated dispensing cabinet ADC to store the majority of medications used every day on the unit, without assigning them specifically to a patient until needed. Once the inventory drops below a specified minimum level, the item is replenished in the ADC. The quantity of inventory stored is established at a level to ensure that there are no stock-outs on the nursing unit while waiting for replenishment. For the remainder of the medications, a secure individual patient-specific storage box is utilized.
A Kanban “B” system is used to assure timely delivery of patient-specific medications. In this process, physician orders for infrequently used patient-specific medications are sent directly to the inpatient pharmacy for processing in an orderly First In, First Out (FIFO) method. The system also includes a process to expedite medications for urgent needs, which bypasses the FIFO rules.
Results: Nursing satisfaction increased by more than 25% with the new process, nursing time hunting for medications was reported to have been reduced by 2.5 hours/day in each unit. In an average to medium to large size hospital with 20 units or more this would be more than 18,000 nursing hours per year – equivalent to approximately 10 full time nurses. 75% of all needed medications are available on demand in the unit and the pharmacy now fills specific patient medication to the units 8–10 hours sooner than before and the pharmacy technicians are now filling the ADC’s on the units instead of delivering carts. Pharmacy was able to reallocate 5 hours of technician time per day to other work. Medication returns have decreased by more than 30% and as high as 60% on some units. Reduced returns have generated several benefits, including (a) decreased nursing processing time, (b) decreased pharmacy technician processing time, and (c) reduced medication waste.
In addition to the improvements listed above, other post-implementation benefits have included increased financial accountability, improved patient safety, decreased tube system utilization and increased patient and staff satisfaction.
by Steve Newlon
5S remains the unsung hero in lean and while perhaps the simplest concept, it remains one of the most difficult to truly achieve. As a quick background:
1st S: Sort, remove what you don't need
2nd S: Set in Order, put items where you need them to create flow and enable standard work
3rd S: Shine, return the workplace to like new conditions
4th S: Standardize, also called Standardize Clean up. Regularly do the 1st 3Ss.
5th S: Sustain, maintain and improve the first 4 S's
As a system, 5S is highly effective. It is designed to create/enable a high performing workplace while instilling discipline into the workforce. As a point tool, however, it will have immediate, un-sustained results. 5S as a system means you put in place a number of components that all work together to support the area's 5S effort.
Components of the 5S system include:
Clear Management Direction: Often 5S itself tends to be the vision or purpose, but it's not; creating a culture of improvement is the purpose. Embarking on 5S is like a journey across the ocean, and people want to know the destination. A simple, clear vision is best, but it needs to point to the direction and be shared with all staff associates.
There's a strong connection that exists between a successful 5S program and training. Informal training is common. Typically, the most effective method is a lecture along with some learning by doing. Give your 5S training serious attention. Give managers and staff the training they deserve; interesting, informative, and on-going training.
Training materials: Supporting your training program you can have in-house slides, books, and/or consultant created materials and DVDs. "5 Pillars of the Visual Workplace" by Hiroyuki Hirano is an excellent book and considered one of the authoritative sources on 5S.
Management Standard Work: Management needs to support the initial 5S efforts and they need to continue to support areas post implementation. A common and effective piece of management standard work is regular auditing. Management’s commitment to do this on-going auditing and problem-solving is even more important that management agreeing to support a kaizen event.
Checklists: Shine often results in clean schedules, another important piece. Standardize involves shift or daily checklists that the teams create and identify people responsible for doing at set intervals. Checklists can be short, but they need to be effective and done consistently. Management audits help to ensure this; this is one example of the components working together as a system.
Reward and Recognition: A cleaner area is a reward, but you need to develop more as R&R drives behavior. Ask the staff, brainstorm ideas and focus heavily on recognition for this component of your 5S system.
Scheduling: Often not seen as part of the 5S system directly, but another critical component. Incorporating 5S into the staff's schedule, allotting appropriate time, shows its importance and ensures completion of other system components such as audits and checklists.
Briefings: Your standard work on how and when you present 5S results should be developed and followed serving as another 5S system component. Determine how you will capture results and maintain; before and after pictures speak volumes.
Supply and Resupply Process: Various types of tapes for bordering, a label machine that can print 18mm labels and a host of other items that are neatly maintained and available will help your teams keep moving.
Facilitation Guide: 5S provides us a fresh approach of learning by doing. Guiding teams through the 5S is best done if standardized. A facilitator's guide, along with experience, is an invaluable component.
A 5S journey is fun, rewarding and fruitful. There's a difference, though, between doing 5S and building a 5S system that ensures successful deployment and sustainment. Identify the components you want, divide up the work, and build your 5S system today!
Developing the Workforce -Training opportunities in the next 90 days
There are two upcoming training and developmental opportunities for the healthcare sector that will be available this fall; both will be delivered as public workshops. Workshop prices are set to deliver maximum value for your training dollars.
21 September 2012 – Evidence-Based Patient Care Re-Design sponsored by Mackenzie Health (formerly York Central Hospital) in Richmond Hill.
This one day workshop was designed to demonstrate how “lean” design approaches were used to create a new model of evidence-based care utilizing an optimal mix of regulated and non-regulated healthcare professionals in an inpatient setting. The design leads to enhanced patient and staff satisfaction, improved patient safety and patient care, and an optimization of resources.
The workshop is available on a first come, first serve basis with a cap of ~50 participants.
17-18 October 2012 - Lean Facilitator's Workshop sponsored by Peterborough Regional Health Centre in Peterborough, ON.
This 2 day workshop is designed to develop the skills of individuals in preparing, planning, and sustaining lean quality improvement. Key topics include having an understanding of roles and responsibilities on the improvement team, following a structured approach to preparing and selecting the right measures, and having the right team engaged. The technical process of improvement is briefly covered followed by soft skill techniques used to get the best out of the improvement team. Strategies to sustain the improvement close out the workshop.
The session will also be filled on a first come-first serve basis and be limited to ~30 participants. Note: this first workshop sold-out.