The pharmacy department at NMC Specialty Hospital implemented a Lean process improvement study to address long wait times. Key issues included patients leaving without filling prescriptions due to waits of over 15 minutes for cash patients and over 27 minutes for insurance patients. The team mapped processes, measured times, identified root causes like staff allocation and insurance approval delays, and implemented solutions. These included changing from 4 to 6 counters, modifying the medication delivery process, and improving the patient environment. As a result, wait times were reduced to under 8 minutes for cash patients and under 15 minutes for insurance patients. Patient satisfaction also increased while over $2 million in additional revenue was gained during the study period.

1. BREAKTHROUGH PROCESS
IMPROVEMENT STUDY
NMC SPECIALTY HOSPITAL, DUBAI
A ‘prescription’ for improving the patient
experience by “Leaning” the Pharmacy
JUNE‐OCTOBER, 2011
QUALITY TEAM

2. INTRODUCTION
NMC Specialty Hospital, Dubai is one of the
prominent hospitals of choice in Dubai. It provides a
comprehensive range of healthcare services supported by
experienced medical professionals.
With around 620 employees, this 100- bedded
Multispecialty hospital, located at the Border of Dubai and
Sharjah, serves in a demographically strategic location for
Emiratis and expat population. The hospital strives to make
every patient’s experience welcoming and comfortable.

3. D M A I C
PROJECT CHARTER
A. The Business Case:
The opportunity cost lost due to the
dissatisfied customers is 22% of the total business
generated by the pharmacy .This loss of business
is due to dissatisfied customers who are leaving
the pharmacy without fulfilling their prescriptions
because of a long waiting time.
Since the Organization’s Mission
and Vision is for providing World Class care to
patients, it became necessary to study the issue in
detail.

4. D M A I C
B. The Problem Statement
Patients are leaving the pharmacy without
fulfilling their prescriptions because they find
the waiting time and the experience to be
unsatisfactory resulting in loss of revenue.

5. D M A I C
PROJECT INITIATIVE
With continuous flow of patient complaints and
dissatisfied customers, loss of revenue from medication sales
when the patient left the pharmacy, dissatisfied employees
due to patient arguments due to long waiting time in
outpatient pharmacy, various initiatives were taken by the
management to improve the pharmacy patient waiting time
but were not successful in reducing the long waiting time.
Later it was decided by the management that the
pharmacy project would be taken as six sigma project that
would improve bottom lines as well as patient satisfaction.

6. D M A I C
PROCESS MAPPING

7. D M A I C

8. D M A I C

9. D M A I C
INDICATORS

10. D M A I C
Goal statement
1.Reduce the waiting time and also the inconsistency of
processing time for the same kind of customers served:
Cash Patient -360 seconds
Credit Patient-720 seconds
2. Retention of lost business to the tune of about AED 9.5
million per annum.
3.Increase patient satisfaction about 85%

11. D M A I C
Teams Involved
• Dr Abraham-Vice President - Quality and Standards.
• Dr Ajit Kumar-Medical Director.
• Dr Jaskaran Singh –Medical Administrator.
• Dr Reshma Karmar-Quality Coordinator.
• Dr Samar-PRO.
• Mr Sarvana-Head of Accounts Department.
• Dr Eman-Insurance Department.
• Mr Shivaji Shetty-Head of Pharmacy (NMC Group).
• Mr Praveen-Head Pharmacy.
• Ms Binu-Head of cashiers.
• Ms Mercy Augustine-Nursing Director.
• Nursing Supervisors.

12. D M A I C
Stakeholders model
PHARMACIST
SECURITY DOCTORS
PHARMACY
PATIENTS NURSES
SUPPLIERS CASHIERS

13. D M A I C
Project Timelines
Activity Date-set time Actual completion time
Start 23/06/2011 25/06/2011
Define 27/06/2011 28/06/2011
Measure 1/06/2011-7/06/2011 1/06/2011-7/06/2011
Analyze 15/06/2011-20/06/2011 21/06/2011-22/06/2011
Improve 23/06/2011 30/06/2011
Control 1/10/2011 1/10/2011
Closure and handover 7/10/2011 7/10/2011

14. D M A I C
Quick win opportunities
We found out that the staff allocation was unsuitable to handle the patients flow.
Number of staffs working in OPD hours 0900H to 1300H and 1700H-2100H and non
working hours (1300H to 1500H ) were not appropriate.
Action taken : staff re-allocation was done as per the patients flow.
Pre study Re-Allocation
10 9
9 8
8 7
7 6
1 st day 1 st day
Axis Title
Axis Title
6
2nd day 5 2nd day
5
4
4 3rdday 3rdday
3 3
4th day 4th day
2 2
5th day 5th day
1 1
0 6th day 0 6th day

15. D M A I C
Measure Phase
• Time Measurement: Measurement using Time sheets was done in seconds.
Data collection was done for a week from Wednesday to Tuesday for 24 hours.
This gave a complete idea as to what are the busy hours and which days can be
considered as busy days.
• System generated data had only 3 variables : Arrival time, Token called time
and Billing Time.
• Preparing time, Approval time and Counseling Time was manually entered by
the pharmacist and cashier. Billing time was again cross checked on random
basis with the bills generated time and was found accurate.
The intention for collecting this data was to get a fair idea as to
what is the time taken for each step process.

16. D M A I C
Measure Phase(contd.)
The process flow was divided into 6 steps:
Arrival time: Patient entry time.
Preparing time: Placement of the prescription on the pharmacy
tray, to medication preparation and its placement on the
Pharmacy Table.
Approval time: Insurance Company called time to approval
received time from respective insurance company.
Counseling time: Token called time to medication bills received
by patient time which includes counseling of the patient .
Billing Time: Bills received by patient time to receipt received
from cashier time.
Exit-when the patient leaves the pharmacy

17. D M A I C
Measure Phase (contd.)
No of prescription prescribed from out patient department- Prescriptions sent
from outpatient department were compared with the number of prescription
present in pharmacy.
The rationale behind this was to know the total number of patients
the pharmacy was not able to serve.
Efficiency of the counters: This was done with the number of prescription being
billed by each counter. This helped in knowing work load on each counter and its
distribution.
Staff distribution: This was collected using the staff rota being assigned on those
days of data collection. This was to used to know whether the staff distribution was
accurate corresponding to the patient flow.
Voice of customer: This data was collected using the survey forms which was
already implemented in the hospital to measure the patient satisfaction in
pharmacy.

18. D M A I C
Measurement system limitations
All the processes used in the OPD pharmacy are not system-
based as this is a time-based study. The start point is the
patient entry into the pharmacy & the exit is when the patient
receives the medications and exits.
The constraints are that the team worked with an improper
recording system. That is, computer generated system time
were not available for all times. Manual entry had to be done
at several steps in the process.
Not all patients data was collected due to time constraints.

19. D M A I C
Measurement reliability
Measurements sheets were given at different counters and
staff entered data only for the time recording assigned to
them. They were not able to see the other timings recorded in
the process. At the end of the day the data was collected
from different counters and compilation was done of all
variables .
Manual measurements were compared with system
generated variables.
Billing time was again cross-checked on random basis with
the bills generated time and was found accurate.

20. D M A I C
Process Capability
Increase in number of counters.
Seating area inside the pharmacy close to the
token system.
Re-training of pharmacist, cashiers.
Information to regular patients on change in
process.

21. D M A I C
DPMO
Pre study
DPMO for Cash Patients - 825553
DPMO for Insurance Patients - 764568
Post -Study
DPMO for Cash Patients - 427807
DPMO for Insurance Patients - 496434

22. D M A I C
Problem statement
An average of around 482 patients per day were
consulted by OPD clinics and prescription served. Out of these 302
were insurance patients and 180 were cash patients. Around 97 patients
left the pharmacy without availing any pharmacy services. The loss of
revenue per patient was estimated AED 179 per day resulting in an
estimated loss of revenue to the tune of AED 9.5 million per annum.
One of the main reason for patients leaving the
pharmacy was a long patient waiting time. We also determined the
average time spent by the patients in the pharmacy for being served for
each category of customer. An average of around 667 seconds for cash
patients and 1634 seconds for insurance patients were utilized by the
pharmacist to dispense the medications.

23. D M A I C

24. D M A I C
Validation of root cause
To create the diagram, the team started with the problem statement , and asked
“Why?” a total of five times.
•Why Long preparing time for cash and insurance patient’s ?
•Why Cash counter was not free?
•Why Delay in insurance approvals?
•Why Delay in counselling time?
•Why Long waiting time.?
Validation: Root Cause analysis was validated by Gemba investigation

25. PARETO CHART DEPICTING TIME INTERVALS
FOR CASH PATIENT

26. PARETO CHART DEPICTING TIME INTERVAL FOR
INSURANCE PATIENTS

27. Pareto chart interpretation
The Pareto analysis depicts that 80% of time is
contributed by the waiting time and counselling
time in both cash and insurance patients.
Since the counselling time may not be easy to
decrease the team decided to work on other steps
in the process .

28. D M A I C
Solution criteria set by the team
• To speed up the process of medication
delivery
• To retain patients leaving the pharmacy
• To improve patient satisfaction

29. Solution selection process
Solution Advantage Disadvantage Scoring Total Ranking
Change in No installation 5 25 1
process of charges
medication
delivery
Decreased 5
Deployment
time
Decreased 5
training time
No involvement 5
of doctors
No manpower 5
wastage

30. D M A I C
Solution Advantage Disadvantage scoring Total Ranking
Increase in More number of patients 5 20 2
Number of can be served
counters
Less installation charges 5
as available space been
used
Convenient for the 5
pharmacist for dispensing
Convenient for the patient 5

31. Solution Advantage Disadvantage Scoring Total Ranking
Increase in Reduces Increased 5–5=0 0 3
Number of Medication salary
pharmacist delivery expense
time
Increased Manpower 5–5=0
number of wastage as
patients can per the
be served allocation of
the counters.

32. D M A I C
Solution Advantage Disadvantage Scoring Total Ranking
Electronic 1.Ensures Quick error free 1.Large 5–5=0
prescriptions prescriptions installation -10 4
expense .
2.Patients are retained as 2.Increased 5 – 5= 0
prescriptions are not deployment
handed over to the time
patients
3.Increased -5 = -5
training Time
4.Involvement -5 =- 5
of Doctors

33. D M A I C
Ranking method
The Advantages and Disadvantages were scored +5 and -5
respectively and the total was considered for the ranking.
The ranks are mentioned below
Change in process of medication delivery= 25(Rank 1)
Increase in number of counter= 20(Rank 2)
Increase in Number of pharmacist= 0 (Rank 3)
Electronic prescription = -10 (Rank 4)
Rank 1 and rank 2 were considered for the solution.

34. D M A I C
Solution Details
The major area for improvement and changes as per the study was
Change in the design of counter from 4 counters to 6 counters.
Change in the whole process of medication delivery were one
staff is involved in dispensing of medication.
Change in the environment of the pharmacy. Patient had no
more to wait outside. Instead they were made to sit inside
pharmacy and view the process.

35. Change in process of medication Delivery
D M A I C

36. MISTAKE PROOFING
The token slip mentions “cash” or “credit”. This is to
provide a check in preventing error in dispensing the wrong
token.
The dispensing pharmacist as well as the patient counter
checks to ensure that the right token is dispensed.
Cash prescriptions, insurance prescriptions which require
approvals and insurance prescriptions which does not
require approvals are handled exclusively by separate
counters.
Seating of the patient inside eliminates the lag time from
when the patient is summoned to when the patient appears
at the counter.

37. PRE-STUDY PHARMACY
STRUCTURE

38. PRE-STUDY PHARMACY
STRUCTURE

39. POST STUDY PHARMACY
STRUCTURE

40. D M A I C
Benefits generated
Benefits Target Pre-study Post study
Dispensing Time Reduce of the Total time 667 seconds 449 seconds
for cash patient to 360 seconds
Dispensing Time Reduce of the total time 1634 seconds 864 seconds
for Credit patient to 720 seconds
Average of 2.2 million has been gained within the
confines of study period. This has accomplished the
strategic profitability and patient satisfaction.

41. D M A I C
TIME MEASUREMENT
BEFORE-AFTER STUDY
Cash Patients Preparing Counseling Time Waiting Billing Time Total Time
Time Time
Time estimation before 117 145 327 86 667
Time estimation after 108 127 177 54 499
TIME ESTIMATION FOR CASH PATIENT BEFORE
AFTER
800
700
600
500
400
300
200
100
0
PREPARING TIME COUNSELLING TIME BILLING TIME WAITING TIME TOTAL WAITING TIME

42. D M A I C
Before –After Time study
Insurance Preparing Approval Counseling Billing Waiting Total
patients Time Time Time Time Time Time
Time Estimation 112 356 145 93 1222 1634
Before
Time Estimation 157 236 193 62 460 864
After
TIME ESTIMATION FOR INSURANCE PATIENTS BEFORE
AFTER
1250
1050
850
650
450
250
50
PREPARING TIME APPROVAL TIME COUNSELLING TIME BILLING TIME WAITING TIME TOTAL WAITING TIME

43. D M A I C
Patient Satisfaction
Patient Satisfaction
80%
70%
60%
50%
40%
30%
20%
10%
0%
Before study After study
Patient Satisfaction

44. D M A I C
CONTROLS PUT IN PLACE TO ENSURE
THAT THE GAINS ARE LOCKED :
• Physical structure of pharmacy counters.
• Periodic inspection of the process by the Administrator.
• The Team developed a control plan for regularly and
consistently measuring the buying time and taking timely
corrective action in case the data indicated negative trends or
points in the control chart that suddenly appeared outside the
control limits, signifying sudden process shifts due to
assignable causes.

45. D M A I C
Roles of stake holders
Overall Guidance
Vice President Quality and Standards
Medical Administrator Guidance
Training of staff, analysis, collection
Quality Department of data.
In collection of data, dispensing of
Pharmacist Medication as per the new process
Collection of prescriptions
Nurses
Maintenance Responsible for change in the
Structure of pharmacy

46. LEARNINGS
Improvement in process efficiency lead
to shortened throughput time resulting in
improved patient satisfaction and
recovery of lost revenue

47. Horizontal deployment
Similar changes are being implemented in
sister hospitals of NMC healthcare

48. Team recognization
The Team was recognized with an
appreciation certificate

49. An Excellent Example
A prescription for Improving Healthcare by “Leaning”
the Pharmacy is a excellent example because of the
following benefits
Increase in Patient satisfaction from 58% to
75%
Decrease in time taken to dispense medications
• Cash patients-667 seconds to 449 seconds.
• Insurance Patients-1634 seconds to 864 seconds.
Recovery of business loss to 2.2 million within
the period of project.