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Recommendation  to  Saint  John’s  Health  Center  Pharmacy  Department  

Kawin  Thoncompeeravas  

CSUCI  Business  530  

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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  

   

 

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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.  

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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.  

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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

14000 Q

uant

ity U

D

Drugs

The top most frequently UD items (May 2010 to October 2010)

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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.    

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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  

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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.    

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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  

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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  

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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  

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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  

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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  

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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  

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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  

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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  

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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  

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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  

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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