1. 1
Recommendation
to
Saint
John’s
Health
Center
Pharmacy
Department
Kawin
Thoncompeeravas
CSUCI
Business
530

2. 2
Table
of
Contents
Cover
Page
1
Table
of
Contents
2
Background
3
Lean
Initiatives
4
Issues
6
Recommendations
for
Facility
&
Infrastructure
Improvement
11
Recommendations
to
Address
Pharmacist
Bottleneck
15
Recommendations
to
Reduce
Technician
Productivity
Waste
16
Innovative
initiatives
17
Conclusion
18
References
19
Appendix
20

3. 3
Background
Saint
John’s
Health
Center
Pharmacy
Department
consists
of
a
minimum
of
seven
pharmacists
and
eight
technicians
working
on
a
daily
basis
to
dispense
medication
and
consultation
24/7
in
a
safe
and
precise
manner.
The
process
begins
with
physician
orders
that
are
either
tubed
or
faxed
down
to
the
pharmacy
located
in
the
basement,
where
pharmacists
enter
the
order
and
verify
the
final
medications
before
sending
them
out
to
the
various
units.
The
pharmacy
technician’s
role
is
to
assist
the
pharmacists
in
the
preparation,
dispensing
and
compounding
of
both
oral
and
intravenous
medications.
Together
as
a
department,
the
team
works
diligently
to
get
the
medications
to
the
nurses
so
that
they
can
administer
medications
safely
and
effectively.
In
addition
to
the
main
Pharmacy,
there
are
unit-­‐based
pharmacists
that
work
in
the
Oncology,
Med-­‐Surgical,
Orthopedics,
and
ICU,
NICU
who
perform
clinical
evaluations
from
satellite
locations.
While
the
orders
go
to
pharmacists
on
specific
floors,
the
central
pharmacy
remains
the
central
hub
for
dispensing
all
of
the
medications
out
to
the
hospital.
An
additional
specialized
pharmacist
is
solely
responsible
for
clinical
pain
evaluations
of
Patient
Controlled
Analgesia
patients
including
terminally
ill
patients
and
palliative
care
patients
to
ensure
proper
management
of
symptoms
and
comfort
care.
Another
niche
pharmacist
oversees
the
Operating
Room
pharmacy
satellite
and
provides
medications
to
preoperative,
surgical
and
post-­‐anesthesia
care
departments.

4. 4
The
technicians
are
responsible
for
triaging
phone
calls,
filling
cart/cassette,
Omnicell
(Decentralized
Automated
Drug
Dispensing
System
[ATM])
restock,
oral
solid
medication
packaging,
medication
delivery
to
the
units
and
intravenous
admixtures.
Intravenous
admixtures
such
as
large
volumes,
chemotherapeutics,
total
parenteral
nutrition,
and
syringes
have
to
be
aseptically
prepared
in
a
sterile
environment.
Lean
Initiatives
A
lean
project
initiative
implemented
by
the
OR
pharmacy
involved
a
medication
used
in
surgery
called
Lymphazurin,
a
blue
dye
used
as
a
diagnostic
tool
in
lymphatic
mapping.
Over
a
three-­‐month
period,
the
OR
pharmacy
collected
data
on
159
patients
using
By
altering
the
past
practice
of
giving
whole
vials
and
implementing
a
new
practice
of
drawing
specific
dosages
aseptically,
waste
of
partial
vials
was
eliminated
and
dosing
errors
were
minimized.
The
initiative
helped
improve
patient
care
and
reduced
costs
within
the
OR
setting.

5. 5
Another
project
that
was
recently
completed
concerns
the
unit
dose
packaging
of
individual
oral
solid
medication
over
a
six-­‐month
period
of
May
through
October
2010.
Through
the
use
of
Pareto
analysis,
it
was
determined
that
the
nine
most
frequently
packaged
medications
account
for
47%
of
all
total
drugs
packaged.
The
department
then
decided
on
outsourcing
these
nine
drugs
to
AIDAPAK
that
will
charge
six
cents
for
each
tablet
or
capsule
packaged
for
excluding
the
delivery
and
drug
costs.
Labor
costs
alone
for
packaging
approximately
seven
thousand
oral
solids
over
a
six-­‐month
period
equal
to
$474.60
or
the
equivalent
of
31.64
productive
hours
of
a
technician
with
an
hourly
wage
of
$15.
1555 1302 893 753 510 484 433 403 365
7551
10.9%
20.1%
26.3%
31.6%
35.2%
38.6% 41.6% 44.4% 47.0%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
0
2000
4000
6000
8000
10000
12000
14000QuantityUD
Drugs
The top most frequently UD items
(May 2010 to October 2010)

6. 6
Careful
analysis
of
the
cost
benefit
of
this
decision
would
reveal
that
there
is
a
better
solution.
Considering
that
the
average
technician
can
unit
dose
300
oral
solids
within
an
hour,
it
would
be
more
cost
effective
to
do
this
initiative
in-­‐house
for
three
shifts
totaling
24
hours,
providing
cost
savings
of
$125,
and
more
productivity
of
the
unit
dosing
machine
the
pharmacy
already
owns.
Though
a
step
in
the
right
direction,
these
lean
processes
must
be
well
thought
out
with
substantial
data
and
information
to
make
informed
decisions.
More
lean
processes
need
to
be
initiated,
as
there
are
many
issues
and
complacency
with
the
status
quo
will
only
result
in
a
bloated
department
unable
to
adapt
to
the
storm
of
changes
that
loom
ahead.
Issues
There
are
several
major
issue
areas
in
the
pharmacy
department
that
can
be
substantiated
through
data
gathering
using
job
tours,
wok
sampling,
flow
charts
and
organizational
charts.
Using
an
initial
relationship
diagram
to
document
the
amount
of
paths
required
to
accomplishing
an
action,
it
is
obvious
that
the
facility
layout
and
infrastructure
is
not
effective
or
efficient.
This
data
would
be
better
visualized
using
a
spaghetti
diagram.
The
pharmacy
does
not
follow
a
functional
assembly
line
concept
that
is
characteristic
in
manufacturing
plants
or
the
common
sense
that
is
found
in
hotels.
Second,
when
you
see
technicians
waiting
for
verification
of
medication
preparations,
it
is
apparent
that
pharmacists
represent
a
source
of
bottleneck
within
the
workflow
of
the
pharmacy.
Finally,
the
department
does
not
effectively
use
its
technicians’
time
and
work
processes.

7. 7
The
first
major
issue
is
the
facility
layout
of
the
main
pharmacy
and
the
infrastructure
of
the
hospital
as
a
whole
since
it
does
not
smoothly
transition
from
a
process
layout
to
a
physical
one.
The
dominant
flow
patterns
of
a
basic
action
often
cross
its
own
path
multiple
times.
An
example
is
filling
a
medication,
getting
it
checked,
and
tubing
it
to
the
unit
results
in
many
wasted
steps
due
to
the
obstacles
of
inflexible
built
in
furniture.
Furthermore,
areas
with
similar
purposes
such
as
storage
are
separated
in
various
locations
throughout
the
pharmacy
making
it
a
logistical
maze.
The
infrastructure
servicescape
that
the
pharmacy
operates
in
is
in
disarray.
Systems
that
could
be
automated
such
as
narcotic
storage,
where
accountability
and
tracking
is
a
major
issue
with
not
only
JCAHO
but
also
with
the
DEA
department,
is
still
being
tracked
using
paper
inventory
cards
that
are
easily
lost
and
often
not
recorded
on.
This
paper
tracking
is
also
true
of
the
medical
records
of
patients.
Another
action
that
can
be
automated
is
the
printing
of
discontinued
medication
lists
and
restocks
lists
at
a
specific
time
during
the
day
that
would
solve
the
mistake
of
a
technician
forgetting
to
run
them.
In
addition,
department
phone
extension
codes
and
the
pneumatic
tube
system
codes
do
not
follow
a
logical
order.
Communication
is
inhibited
by
nonsensical
extensions
randomly
coded
not
providing
a
hint
or
clue
to
the
destination
of
the
tube
or
phone
call.
An
example
is
illustrated
within
the
same
Medical
Surgical
floor
and
unit
where
the
tube
stations
have
two
numbers
designating
higher
numbered
patient
rooms
with
14
and
designating
lower
numbered
rooms
with
22.
This
is
then
compared
to
the
ICU
floor
above
it
where
the
lower
numbered
rooms
are
designated
23
but
the
higher
numbered
rooms
are
designated
9.
These
issues
lengthen
the
learning
curve

8. 8
for
an
individual.
In
addition,
the
centralized
hub
nature
creates
confusion.
Orders
come
from
every
unit
through
the
tubes
where
the
tubing
system
is
inherently
prone
to
miss
delivery
(human
error)
or
pneumatic
tubing
station
itself
is
prone
to
malfunction
and
failure.
Additionally,
there
is
massive
miss
communication
between
the
pharmacy
and
the
two
emergency
departments
ED1
and
ED2.
Though
they
are
relatively
close,
they
do
often
do
not
notify
the
pharmacy
which
department
the
patient
is
admitted
in.
Situations
like
this
result
in
higher
call
volumes
asking
the
status
of
the
orders
and
miss
delivery
of
the
medication
in
question.
The
second
significant
issue
is
that
a
major
source
of
bottlenecks
occurs
with
pharmacists.
Pharmacists
are
needed
for
front-­‐end
processes
such
as
order
entry
and
also
tail
end
processes
such
as
checks
and
verification
of
medication
and
the
dispensing
of
narcotics.
In
addition,
high
demand
of
pharmacist’s
attention
is
spent
on
discontinuing
and
re-­‐entering
transfer
orders
that
will
remain
active
constituting
a
huge
amount
of
wastage
of
work
functions.
Not
provided
essential
information
such
as
patient
height,
weight
and
allergies
is
a
major
obstacle
in
the
pharmacists’
completion
of
their
task
of
order
entry.
Another
major
obstacle
to
order
entry
is
when
the
patient
is
not
admitted
into
the
unit
and
the
order
set
must
be
placed
on
hold
until
the
patient
is
registered.
Furthermore,
despite
the
same
peak
volumes
that
occur
during
the
daytime,
fewer
pharmacists
are
staffed
during
evening
shifts
that
often
lead
to
overtime
for
these
pharmacists
as
they
struggle
to
bring
the
workload
to
a
manageable
level
for
the
lone
midnight
pharmacist.

9. 9
Finally,
a
large
amount
of
productive
work
hours
of
technicians
is
wasted
throughout
the
workday.
During
the
morning
shifts,
a
full
24
hour
IV
list
is
printed
that
would
then
need
to
be
separated
by
hand
for
the
evening
IV
technician.
Not
only
is
this
time
consuming,
it
provides
multiple
opportunities
for
these
labels
to
be
lost
throughout
the
day.
It
is
also
highly
inefficient
that
the
person
producing
these
IV’s
have
to
travel
across
the
pharmacy
in
order
to
get
the
materials
they
need
to
finish
their
IV
batch.
When
the
evening
IV
technician
comes
in,
the
individual
would
then
have
to
manually
verify
the
status
of
each
IV
label.
This
is
precious
time
that
the
technician
can
use
to
be
fulfilling
other
duties
such
as
the
preparation
of
emergency
carts
and
transport
boxes.
This
system
of
a
24
hour
batch
for
both
large
volumes
and
piggyback
IV’s
creates
multiple
points
of
extra
action
worksteps.
Approximately
half
of
the
items
prepared
the
previous
morning
are
returned
to
the
pharmacy
unused
and
will
have
to
be
wasted.
These
medications
that
are
delivered
account
not
just
for
one
wasted
action
process.
They
propagate
the
downstream
workflow
actions
that
must
be
taken
to
ensure
proper
crediting
of
the
patient’s
billing
but
also
of
the
assurance
that
patient
confidentiality
is
protected
as
well
as
the
proper
disposal
of
the
medication.
Disposal
of
these
medications
are
then
charged
based
on
weight
that
is
a
large
cost
that
the
department
can
largely
avoid.
It
can
be
observed
that
once
a
particular
batch
is
done,
the
IV
technician
is
then
free
to
help
triage
the
barrage
of
phone
calls
that
occur
during
peak
hours.
The
morning
shift
technicians
have
a
lot
of
wasted
work
steps
scheduled
into
their
routine.
The
cassette/cart
fill
technician
arrives
at
6
am
to
fill
medication
lists
for
the
various
units
and
finishes
everything
by
the
latest
9
am.
The
remainder
of
the
shift
is
then

10. 10
spent
updating
and
removing
medications
that
are
newly
ordered
or
discontinued
even
though
these
medications
will
not
be
used
until
the
day
after.
Another
major
source
of
wasted
work
hours
is
the
separation
of
deliveries
by
the
types
of
medication
prepared.
Deliveries
occur
in
the
following
schedule:
Omnicell
restocking
at
8
am,
12pm,
5pm
and
9pm,
large
volumes
at
9am,
piggybacks
at
11
am,
oral
medications
for
the
next
day
at
2
pm,
TPN
delivery
at
8
pm.
Each
delivery
for
the
hospital
accounts
for
half
an
hour
of
walking
time.
Total
amount
of
walking
time
that
accounted
for
deliveries
would
then
equal
four
hours
of
technician
work
time,
that
can
be
broken
down
to
about
$60
a
day.
It
is
largely
because
of
these
multiple
deliveries
that
a
total
of
four
technicians
are
required
to
work
the
morning
shift.
On
the
other
hand,
the
night
shift
IV
technician
only
has
to
complete
the
remainder
of
the
24
hour
IV
list
that
was
printed
a
full
8
hours
previous
and
the
TPNs
due
that
night.
This
technician
is
then
available
for
approximately
over
four
hours
to
accomplish
other
duties,
which
are
not
defined
and
thus
are
not
completed.
Although
when
it
the
pharmacy
is
busy,
it
may
seem
like
technicians
are
under
staffed,
the
actual
reality
is
that
technicians
are
being
under
utilized.
In
addition,
the
delivery
technician
for
the
entire
shift
only
has
two
specific
goals
to
accomplish:
making
a
delivery
of
IV’s
and
doing
an
omnicell
restock
at
9pm
with
the
rest
of
the
shift
wasted.
Furthermore,
an
hour
is
too
large
of
an
overlap
for
the
scheduling
of
the
morning
shift
and
evening
shifts
of
technicians
with
limited
work
action
steps.
Finally,
redundancy
of
several
work
steps
account
for
a
lot
of
wasted
effort
and
energy.
The
remaking,
rechecking,
and
resending
of
medication
is
the
result
of
over
half
the
phone
calls.
The
remainders
of
the
phone
calls
are
requests
for
tubes

11. 11
resulting
in
large
distance
to
walk
to
fill
the
request.
Finally,
the
incompatibility
of
operating
room
billing
system
and
the
record
system
requires
a
technician
to
bill
electronically
what
was
electronically
recorded
and
printed
from
another
system.
This
accounts
for
12.5%
of
the
OR
technician’s
productive
work
hours.
Recommendations
for
Facility
&
Infrastructure
Improvement
When
preliminary
decisions
were
being
made
for
the
pharmacy
lay
out,
plans
should
have
been
made
for
short-­‐term
and
long-­‐term
changes:
Utilizing
modular
systems
enables
workstations
to
be
tailored
to
the
current
work
process,
yet
adaptable
to
future
changes
because
the
pharmacy
doesn't
operate
in
a
vacuum,
its
processes
need
to
be
designed
to
interrelate
with
the
hospital's
clinical
practices,
as
well
as
its
equipment
and
facility
management
systems.
Inevitably,
processes
will
change
within
the
pharmacy
or
throughout
the
hospital,
and
the
system
needs
to
be
able
to
adapt.
One
such
instance
is
the
impact
of
barcoding
on
systems
and
spaces
that
is
driven
by
new
regulation
to
verify
the
“Five
Rights”
(right
patient,
right
drug,
right
dose,
right
method,
right
time)
at
various
checkpoints
in
the
process
creates
a
closed-­‐loop
system
so
medication
errors
don't
reach
the
patient.
As
a
result,
the
pharmacist
can
focus
on
the
critical
task
of
order
entry
instead
of
being
interrupted
to
perform
repeated
checks.
Another
instance
where
regulation
will
effect
pharmacy
practices
is
The
HITECH
Act,
part
of
the
2009
economic
stimulus
package
(ARRA)
that
will
penalize
doctors
and
medical
institutions
that
do
not
adopt
an
HER
(electronic
health
record)
by
2015
1%
of
Medicare
payments,
increasing
to
3%
over
3
years.
Thus,
incorporating
the
criteria
dictated
by
regulations
early
in
the
design

12. 12
planning
process
can
prevent
changes
to
meet
these
laws
that
will
impede
workflow
and
detract
from
the
overall
design.
The
appropriate
solutions
integrated
into
the
workflow
and
environment
can
minimize
the
risk
of
contamination,
protect
patients'
personal
health
information,
and
ensure
the
responsible
disposal
of
pharmacy
waste.
The
repetitive
nature
of
the
work,
the
physical
demands
of
the
environment,
and
the
fear
of
making
a
mistake
contribute
to
the
state
of
chronic
stress
that
can
be
experienced
by
pharmacy
staff.
The
design
of
the
pharmacy
process
and
environment
needs
to
mitigate
the
physical
and
emotional
burdens
on
the
staff.
Internal
and
external
stressors
may
diminish
cognitive
abilities,
leading
to
a
decrease
in
job
performance,
which
in
turn
may
lead
to
error.
Pharmacists
entering
orders
should
be
shielded
from
surrounding
noise
and
interruptions,
while
maintaining
a
sightline
to
the
order
fill
and
check
areas.
Currently,
pharmacists
have
their
back
to
these
areas
and
are
constantly
bombarded
with
phone
calls
and
the
sharp
impact
of
pneumatic
tubes.
Multiple
channels
of
incoming
and
outgoing
orders,
via
computers,
faxes,
pneumatic
tubes,
robots
and
couriers,
lead
to
the
potential
for
unbalanced
workloads
and
delays
in
priority
cases.
The
elimination
of
redundancies
and
gaps
can
promote
efficient
handoffs
and
distribution
of
medication
throughout
the
hospital.
This
can
be
done
in
several
ways.
The
most
cost
effective
way
is
to
initiate
a
fax
to
email
system
that
would
sort
out
orders
by
the
department
the
orders
originated
from.
This
method
also
provides
order
tracking
and
the
shared
nature
of
emails
can
be
accessed
simultaneously
by
several
pharmacists
to
share
the
workload.
It
eliminates
the
need
for
the
pharmacist
to
be

13. 13
by
a
tube
station
or
a
fax
machine
in
order
to
receive
orders.
This
method
can
also
be
applied
to
missing
medication
requests.
Another
method
is
to
adopt
a
Computerized
Physician
Order
Entry
System
that
will
eliminate
the
need
for
pharmacist
order
entry
as
well
as
the
need
for
time
wasteful
clarification
calls.
These
steps
are
ways
to
promote
efficient
handoffs.
Most
pharmacies
operate
at
maximum
capacity,
a
state
worsened
by
the
fragmented
nature
of
the
system.
To
relieve
this
fragmented
nature
it
is
necessary
to
arrange
materials
and
equipment
concentrically
around
the
production
point
in
their
order
of
use.
Although
pharmacy
isn't
manufacturing
work,
Lean
strategies
can
be
applied
to
minimize
waste
of
time,
waste
of
motion,
and
waste
of
storage
space.
New
roles
like
the
“waterspider”
can
be
used
to
improve
flow.
In
manufacturing,
waterspiders
are
responsible
for
ensuring
a
steady
stream
of
parts
is
supplied
to
the
people
assembling
the
product.
They
need
to
be
skilled
and
knowledgeable
to
be
able
to
anticipate
the
needs
of
the
line
to
maintain
standard
work
and
keep
the
process
moving.
In
pharmacy
work,
this
role
will
be
required
to
be
trained
cross
functionally
and
can
be
used
to
eliminate
bottlenecks.
Several
experiments
have
been
conducted
where
a
technician
prepare
the
drugs
and
solutions
necessary
for
the
IV
technician
cutting
IV
preparation
time
in
half
from
approximately
four
hours
to
two
hours.
The
investment
cost
was
found
to
be
miniscule
as
it
only
requires
between
30
to
40
minutes
for
the
waterspider
to
prepare
the
batch.
To
fully
utilize
a
waterstrider
in
the
workflow
process
it
is
necessary
that
they
be
in
communication
with
all
the
different
areas
they
will
be
assisting.
In
SJHC’s

14. 14
case,
it
will
take
drastic
measures
to
move
the
bolted
furnishing
and
equipment
to
optimum
placement
but
small
steps
can
be
taken
now
to
take
advantage
of
the
waterstrider
role.
Observing
the
current
facility
layout,
the
oral
solid
medication
should
be
moved
to
where
the
workstations
are
and
these
workstations
should
be
next
to
the
fax
machine
and
tube
stations
to
efficiently
receive
and
send
orders.
This
has
the
benefit
to
the
tail
end
process
in
medicine
verification
and
delivery.
The
intensive
work
would
be
to
move
the
main
IV
preparation
area
to
the
narcotic
storage
room
and
the
chemotherapy
hood
be
moved
to
the
adjoining
room
beside
the
new
IV
room.
Bulk
storage
and
medicine
storage
can
then
be
moved
into
the
vacated
IV
room
where
it
will
now
establish
a
linear
flow
of
materials
from
the
innermost
area
of
the
pharmacy
to
the
exit.
In
addition,
this
move
will
minimize
space
wastage
and
will
minimize
the
amount
of
walking
needed
to
complete
an
action.
Narcotics
should
be
placed
into
an
Omnicell
in
order
to
remove
paper
tracking
while
increasing
accountability
and
tracking.
This
will
minimize
errors
and
discrepancies
that
occur
around
narcotics.
Printers
should
be
moved
to
the
corner
workstation
where
it
is
central
to
all
functions
of
the
fill
and
drug
preparations
area.
Though
materials
may
not
be
as
easily
accessible
to
the
IV
technician,
the
new
role
of
Waterspider
will
improve
efficiency
by
providing
a
steady
stream
of
meds
to
be
processed
by
the
IV
technician.
In
another
scenario,
if
the
waterspider
is
working
solo,
it
will
provide
that
technician
the
ability
to
observe
multiple
streams
of
orders
simultaneously.
Infrastructure
solutions
that
will
have
resounding
effects
throughout
the
hospital
is
the
standardization
of
communication,
record
keeping
and
billing.
Phone

15. 15
extension
codes
and
pneumatic
tube
station
codes
need
to
be
obvious
to
any
individual
without
consulting
a
directory.
It
is
recommended
that
the
hospital
adopt
a
service
scape
best
represented
by
the
hotel
industry.
The
pneumatic
tube
code
should
thus
represent
the
floor
(1,2,3,4)
in
the
ten
positions
and
the
location
on
that
floor
(0-­‐9)
in
the
one
position.
The
phone
extension
improvement
will
be
a
system
that
will
allow
one
to
dial
the
room
number
as
a
four
digit
extension
that
will
automatically
connect
to
the
nurse
in
charge
of
the
patient
in
that
room.
This
will
remove
unnecessary
hold
calls
and
will
keep
the
process
moving.
Finally,
the
most
effective
implementation
is
initiating
electronic
health
records
that
can
be
securely
accessed
from
anywhere.
This
will
provide
greater
options
for
pharmacist
staffing,
as
it
will
allow
home
sourcing
to
occur.
This
means
pharmacists
will
not
have
to
commute
to
do
their
job
in
either
entering
orders
or
the
verification
of
orders
entered
by
physicians.
Furthermore,
compatible
billing
and
electronic
medical
records
systems
will
allow
for
better
data
collection
and
thus
better
lean
processes.
Recommendations
to
Address
Pharmacist
Bottleneck
There
are
several
options
to
solve
the
pharmacist
bottleneck.
One
method
is
to
share
pharmacist
responsibilities
with
technicians.
There
are
two
very
important
ways
this
can
happen.
Assuming
order
entry
is
still
a
pharmacy
duty,
then
having
technicians
perform
order
entry
would
be
the
most
cost
effective
method
to
reduce
the
workload
on
pharmacists.
Of
course,
verification
of
these
orders
must
be
performed
but
with
well-­‐trained
technician
staff,
it
becomes
a
reliable
method
of
maximizing
order
entry
potential.
Another
method
to
relieve
pharmacists
of
heavy

16. 16
workload
is
to
initiate
a
Tech-­‐check-­‐Tech
system
specifically
for
cassete/cart
fill,
omnicell
restocks,
and
missing
medication
requests.
This
will
require
an
extensive
training
as
well
as
a
quality
assurance
system
such
as
a
random
audit
check
by
pharmacists.
The
most
ovious
way
to
alleviate
the
pharmacist
bottleneck
is
just
to
schedule
more
pharmacists
during
peak
hours.
This
is
especially
necessary
with
the
evening
and
weekend
scheduling
during
heavy
emergency
department
admissions.
Recommendations
to
Reduce
Technician
Productivity
Waste
The
first
recommendation
to
reduce
technician
productivity
waste
is
to
initiate
multiple
IV
batches
separated
by
due
time.
This
will
guarantee
that
discontinued
medications
will
not
appear
in
the
batch
as
well
as
minimize
waste
especially
the
time
and
monetary
cost
spent
in
delivering,
searching
for
expired
unused
medications,
crediting
and
disposing
of
medications.
Another
source
of
time
wasted
is
the
time
spent
in
the
mixing
of
custom
TPNs.
Premade
standardized
TPNs
should
be
made
available
for
the
physician
and
dietician
to
select.
By
switching
to
standard
TPN’s,
the
department
will
be
able
to
reduce
its
inventory
in
70%
dextrose
and
Freamine
that
are
used
only
in
the
mixing
of
TPNs.
Another
important
recommendation
is
moving
the
cart
fill
shift
to
midnight,
when
medication
changes
and
orders
are
minimized
and
it
will
free
up
time
for
a
technician
to
do
other
responsibilities
such
as
a
main
nightly
omnicell
restock,
medication
packaging,
IV
preparation,
cassette
exchange
as
well
as
crash
cart
preparation.
This
is
beneficial
because
there
are
minimal
patient
discharges
and

17. 17
transfers
through
out
the
night.
This
technician
will
also
be
able
to
make
deliveries
as
well
as
prepare
any
stat
medication
for
the
midnight
pharmacist.
Finally,
deliveries
to
the
units
should
be
minimized
and
changed
to
deliver
only
those
medications
that
are
due.
Also
included
in
these
deliveries
should
be
any
critically
low
items
to
the
omnicells
as
well
as
supplies
to
replenish
the
floor
stock.
This
will
require
a
large
grid
cart
that
will
be
able
to
hold
large
volumes,
piggybacks,
the
omnicell
batch
and
floor
stock
all
in
one
delivery.
To
maximize
the
usage
of
the
omnicell
further,
inventory
within
these
automatic
dispensers
should
be
increased
further
to
reduce
the
cassette
fill
as
much
as
possible.
Additionally
to
reduce
restocking
errors,
omnicell
restocks
should
automatically
round
numbers
up
to
the
nearest
ten,
increasing
the
efficiency
of
the
technician
and
the
restock.
Though
making
the
department
more
effective
generally
means
increasing
the
responsibilities
of
the
technicians,
there
is
a
certain
duty
that
should
be
removed
from
the
pharmacy
department’s
unwritten
obligation.
The
most
frequent
call
to
the
pharmacy
are
requests
for
tubes.
These
calls
not
only
distract
pharmacists
attempting
to
enter
orders,
but
it
prevents
the
more
important
calls
from
being
answered
and
triaged.
Thus
to
reduce
potential
medical
errors,
another
department,
perhaps
central
supply,
should
be
responsible
for
the
collection
of
excess
tubes
and
the
dispersal
of
the
surplus
to
the
various
floors.
Innovative
Initiatives
Patient
confidentiality
is
major
concern
that
is
regulated
by
HIPAA.
It
is
this
issue
that
the
department
has
to
contend
with
in
the
disposal
or
the
recycling
of

18. 18
medications.
An
innovative
solution
to
this
problem
would
the
printing
of
patient
identification
information
with
ink
that
will
fade
within
a
certain
time
frame
while
the
drug
description
may
be
printed
using
permanent
laser.
This
will
then
reliably
bypass
the
HIPAA
drug
disposal
issue.
Another
innovative
solution
that
will
offer
effective
communication
between
physicians,
nurses,
and
pharmacists,
is
the
adoption
of
a
in-­‐hospital
twitter
like
update
system
that
may
reduce
the
large
volumes
of
phone
calls.
Other
potential
lean
projects
may
be
the
acquisition
of
a
robotic
automated
cassette
fill
machine
and
an
inventory
control
carousel.
However,
due
to
the
high
costs
of
such
equipment,
it
is
unlikely
that
they
will
be
adopted.
Conclusion
The
most
crucial
issue
of
facility
layout
and
infrastructure
must
be
solved
to
give
personnel
the
ability
to
smoothly
transition
from
one
work
process
to
another.
Renovation
of
the
pharmacy
is
necessary
to
facilitate
workflow
and
increase
efficiency
and
cut
wasteful
movements.
It
is
important
for
an
inpatient
pharmacy
department
that
is
striving
to
be
lean
but
have
not
yet
taken
steps
to
automate
their
processes
to
retain
flexible
qualities.
Most
importantly,
the
department
needs
to
support
critical
thinking
and
apply
lean
principles
throughout
the
pharmacy
system.
The
lean
process
must
not
be
an
isolated
event,
and
must
be
continually
applied
to
the
processes
and
workflow
of
the
entire
pharmacy
department.
Future
consideration
of
changes
should
keep
in
mind
that
while
automation
drives
the
design,
not
building
in
the
surrounding
furniture
allows
the
space
to
be
adapted
to
future
changes
in
technology.
Solving
the
pharmacist
bottleneck
will
require
a

19. 19
highly
adaptive
and
flexible
staff
to
enable
the
department
to
fluidly
shift
resources
around
as
needed
to
meet
the
demand
of
the
various
units.
Eliminating
waste
will
likely
involve
lots
of
changes,
however,
the
ability
to
effectively
reduce
staff
within
a
given
day
is
increased
with
cross
functional
abilities
of
a
waterspider.
Applying
lean
techniques
in
Saint
John’s
Health
Center
inpatient
pharmacy
will
not
only
improve
workflow
and
reduce
waste,
but
also
achieve
substantial
cost
savings.
References
1. Jacobs,
Robert;
Chase,
Richard;
Aquilano,
Nicholas:
Operations
&
Supply
Management,
2009,
12th
edition
McGraw
Hill
2. T.
Elgourt,
T.
Fan,
Personal
Communication,
March
18,
2011
3. http://en.wikipedia.org/wiki/Electronic_health_record#United_States
4. Bhosle,
M.,
BPharm,
and
Sansgiry,
S.,
PhD
Computerized
Physician
Order
Entry
Systems:
Is
the
Pharmacist's
Role
Justified?
J
Am
Med
Inform
Assoc.
2004
Mar
5. Fendrick,
S.,
Kotzen,
M.,
Gandhi,
T.,
Keller,
A.
Process-­‐driven
design:
Virtua
Health
planning
a
greenfield
campus,
Issue
Date:
June
2007
6. Kelly,
C.
Redman,
M.
Rx
for
pharmacy
spaces:
A
user-­‐centered
approach
Issue
Date:
November
2009,
Posted
On:
11/1/2009