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MSHP Annual Meeting 2017LEAN in Pharmacy:Empowering Your Team to Problem SolveMelissa Ortega, PharmD, MSDirector, Inpatient Pharmacy OperationsNeil Gilchrist, PharmD, MBA, BCPSManager, Pharmacy OperationsTufts Medical Center, BostonUMass Memorial Medical Center, WorcesterObjectives:List the common tools of Leanmethodology used to evaluate waste andimprove efficiency Define steps to create a Lean culture inyour pharmacy team Apply Lean concepts to problem-solvingand how this can be used in yourpharmacy department

MSHP Annual Meeting 2017Mass. Board of Pharmacy Policy *New* POLICY No. 2016-03: An Introduction andGuide to the Practice and Implementation of LeanConcepts in a Pharmacy Setting “Sterile compounding, complex non-sterile compounding, andinstitutional sterile compounding pharmacies shall ensure theiremployees are trained in lean concepts before renewing theirpharmacy license. See M.G.L. c. 112, §§ 39G(a)(6), 39H(a)(6), and39I(a)(7).”Mass. Board of Pharmacy Policy Effective December 31st, 2017 Pharmacist Manager of Record shall attestthat their employees have been trained inLean concepts per recently approved policy pharmacy/alerts/policy-2016-03.pdf

MSHP Annual Meeting 2017Mass. Board of Pharmacy Policy Individualized to each particular pharmacypractice settingLean training should provide an understandingof:1. The definition of Lean concepts2. The concepts of waste and value3. The benefits of Lean in pharmacy4. The basic Lean principles and their use to improvepharmacy processes5. The use of the “5S” toolsWhat is Lean? A process improvement methodologyfocused on eliminating waste in processwhile increasing value for the customer

MSHP Annual Meeting 2017Development of Lean Thinking Term "lean" was created to describeToyota's business during the 1980s by aresearch team headed by Jim Womack,Ph.D.Evolution of Lean ThinkingLiker J. The Toyota Way- 14 Management principles form theWorld’s Greatest Manufacturer. New York, NY: McGraw-Hill; 2004.Joosten T., Bongers I., and Janssen R. Application of Lean Thinkingto Healthcare: Issues and Observations. Int J Qual Health care.2009 Oct 21; 21(5):341-347.

MSHP Annual Meeting 2017Lean Consumption4 Fundamental RulesAll activities should be highly standardizedand specific Direct connection must occur betweencustomer ad supplier Products and services follow a simple,predetermined path Improvement efforts follow a scientificprocess Spear S, Bowen HK. Decoding the DNA of the Toyota Production System.Harv Bus Rev, 1999;77:96-108.

MSHP Annual Meeting 2017Lean in HealthcareSimilarities to manufacturing, reliant onmultiple complex processes Many processes and lots of waste Operating requirements continue toexpand faster than operating budgets 20-30% of Healthcare spending is waste Overtreatment of patients, failure to coordinatecare, administrative complexities, etc.Going Lean In HealthCare. Innovation Series 2005. Institute for HealthCare ImprovementWhite oingLeaninHealthCareWhitePaper-3.pdf.Accessed Feb 2017.McManus. Application of Lean in Healthcare Processes; A Complex System Perspective.Lean in Health Care. Lean Academy Healthcare. March 2012. Accessed February 2017.Impact of LeanIndustry AveragesDirect Labor/Productivity ImprovedCost Reduced45-75%25-55%Throughput/Flow IncreasedQuality/Safety (Defect) ReducedInventory ReducedSpace ReducedLead Time Reduced60-90%50-90%60-90%35-50%50-90%Going Lean In HealthCare. Innovation Series 2005. Institute forHealthCare Improvement White oingLeaninHealthCareWhitePaper-3.pdf. Accessed Feb 2017.

MSHP Annual Meeting 2017Lean in Pharmacy Turnaround time for all chemotherapy preparationsdecreased from 60 to 44 minutes Increasing the frequency of sterile product batches from 2to 5 batches per day reduced rework and waste by 64% Using lean principles to improve outpatient adult infusion clinicchemo prep (Lamm M, AJHP 2015)Use of lean production to reduce waste in sterile compounding(Davis J, Hospital Pharmacy 2009)Cost saving of 289,256 due to waste reduction &improvements in workflow Effect of lean process improvement techniques on a universityhospital inpatient pharmacy (Hintzen B, AJHP 2009)Lean: Operational Principles1. Define ValueDefine from the standpoint of the patient and customer2. Identify the value streamSomething “flows”Identify all steps in the processEliminate waste3. Improve FlowIdentify value added steps4. Establish PullProvide service only when needed5. Strive for ExcellenceCreate valueProduce a consistent result each timeRooney S, Rooney J. Lean glossary. Qual Prog. 2005;38:41–7.Womack J, Jones D. Lean Thinking. New York, NY: Simon & Schuster;2003.

MSHP Annual Meeting 2017Value Determined by the "end" customer, in thecase of healthcare, by the patient No unnecessary delays in access to care,particularly no "scheduled waiting"Accurate, consistent and satisfying outcomesFlexible attention to need, change andexpectationsValue-Added Activity Transforms patient, material, information, decisions, or risks AND the customer wants it AND it’s done the right the first timeNeeded Activity No value is created Cannot be eliminated based on current state of process,technology, or policyNon-Value Added Activity (waste) Consumes resources but adds no value Process continues when activity removedAdapted from: McManus. Application of Lean in Healthcare Processes; AComplex System Perspective. Lean in Health Care. Lean AcademyHealthcare. March 2012. Accessed February 2017.

MSHP Annual Meeting 2017Waste Non-value adding activities Mura: Unbalanced workflowMuri: Overburdening people or equipmentMuda: Process steps that do not add valueLean in Pharmacy: 8 WastesDefects Overproduction Waiting Transportation Inventory Motion Lack of standardization Non-utilized talent

MSHP Annual Meeting 2017Identify the Value Stream Process Maps Document the movement patterns (spaghettidiagrams)or workflows throughout a process An organized visualization ofall the interrelated activitiesValue Stream Mapping Identify and eliminate the non-value addedactivities in each process stepSpaghetti DiagramPowerful visual tool for seeingunnecessary movementSource: Ortega, M. Master’s Project: Workflow optimization andredesign for a new oncology clinic pharmacy area at an academicmedical center. The University of Wisconsin Hospitals and Clinics.Department of Pharmacy, 2012.

MSHP Annual Meeting 2017Value Stream MappingProcess: Medication Stream(Chemo Prep)Sort: Value- Added Activities(by Role)Source: Ortega, M. Master’s Project: Workflow optimization andredesign for a new oncology clinic pharmacy area at an academicmedical center. The University of Wisconsin Hospitals and Clinics.Department of Pharmacy, 2012.Value Stream Map Equation Increase % Value and reduce % Waste Increase ThroughputLower CostImprove QualityAdapted from: McManus. Application of Lean in Healthcare Processes; AComplex System Perspective. Lean in Health Care. Lean AcademyHealthcare. March 2012. Accessed February 2017.

MSHP Annual Meeting 2017Customer Pull in PharmacyBatch refilling versus critical low refilling Can we control our work? Source: Umass. Department of Pharmacy Process ImprovementProject: A3 Batch Refilling versus Critical Low Refilling. September2013Leveling WorkloadBatch refilling of control substances toautomatic dispensing cabinets Single-piece workflow based on stock low Source: Umass. Department of Pharmacy Process ImprovementProject: A3 Batch Refilling versus Critical Low Refilling. September2013

MSHP Annual Meeting 2017Lean Tools: Problem SolvePDCA / PDSA Ishikawa (Cause-and-Effect) Diagram 5 Whys PDSA cyclesUseful tool when you when you understandwhy something is happening Develop a plan Test the plan (Do) Review the result (Study) Where many fail Act upon the results

MSHP Annual Meeting 2017PDSA cycles Plan Review ADCsDo Remove devicesStudy Impact on serviceAct No action needed27Source: Umass. Department of Pharmacy Process ImprovementProject: A3 Pyxis Optimization. June 2014.Ishikawa (Fishbone) DiagramIncorrect InventoryRestock incorrectlyIncrease UtilizationMin/Max Set-upUser DependentCounted incorrectlyPatient SpecificUtilization of alternative agentsPractice ChangesCurrent Communication Tools:New entityNew strengthBlastCensus ChangedContract ChangedDrug Shortages ListsEmailsMeetingsProduct DiscontinuationWord of MouthAllocated ProductFDA RecallsRaw Material ShortageRotation of InventoryStock OutsCritical Shortage 2 weeksLong Term Back OrderShort Term Back OrderShortagesSupply ChainSource: Tufts Medical Center. Department of Pharmacy: DrugSelection Committee.Expired Medications

MSHP Annual Meeting 2017Lean Tools: Control Strategies To insure long term sustainability ofprocess improvement and spread adoption 5SStandardized WorkAudit Tools5S Methodology Five step methodology aimed at creatingand maintaining an organized visualworkplace This system aids in organizing , cleaning ,developing , and sustaining a productivework environment

MSHP Annual Meeting 20175S – IV Storage Area Sort Set in Order Shine Standardize SustainSource: Umass. Department of Pharmacy Process ImprovementProject: 5S IV Storage Area. March 20145S – Pediatric Vaccine FridgeAre your work areas organized? How do we sustain? Source: Umass. Department of Pharmacy Process ImprovementProject: 5S Pediatric Vaccine Refrigerator. November 2014.

MSHP Annual Meeting 2017Standardized Work Documenteddescription ofmethods, materials,tools, & processingtimes RecipesChecklistsTemplatesSource: Tufts Medical Center. Master Formulation Record.ExerciseStandardized Work

MSHP Annual Meeting 2017Standard Work ExerciseTake 2 minutes and draw a football Share your drawing with the person next toyou Does it look the same or is their variation?What contributes to your drawings lookingdifferent? Skillset, memory, application, etcStandard Work ExerciseTake 2 minutes and draw a football Draw 2 lines from the left to right Use the red dots on the paper to drawDraw 5 laces on the football Draw two lines at each of ball Use the green dots on the paper todraw

MSHP Annual Meeting 2017Standard WorkDo your team members know what to do ateach workstation? Do you observe variation in the work beingdone at different workstations? Where does standard work supplementwhat exists in policies and procedures? Application to cross training Source: Umass. Department of Pharmacy Standard Work. ADC vsCII Safe Comparison Standard Work.

MSHP Annual Meeting 2017Lean Tools: Test Concepts Small tests of change offer quicksimulations of change concepts Waste Walk/GembaKaizen EventLean Culture Requires cultural change of continuousimprovementPDSAA PDSA PS DA PS D Emphasis on customer satisfaction, aclean, safe, and orderly environment aswell as teamwork, cooperation in problemsolving, and employee empowerment

MSHP Annual Meeting 2017Idea Board SystemsCreate opportunities for staff to share theirideas that leaders may not see Elimination of integrilin drips in from eachcath room to central cath hall eliminated 42,000 in wasteper year and 90%of waste eliminated Idea Board CardsEveryone can identify a problem Train staff at all levels to think about rootcauses 5 WhysEngage employee ideas Utilize PDSA cycles

MSHP Annual Meeting 2017How to make LEAN successful inyour teamA team that utilizes LEAN methodologyeffectively embraces the culture oftransparency The culture must be opento new ideas and acceptthe question WHY? Key PointsLean is a set of principles not just tools,and the application of these principles canimprove pharmacy processes Tools of Lean can help you understandyour systems, problem solve, improveefficiency, and add value The strive for excellence requires strongleadership and persistence over time

MSHP Annual Meeting 2017 Lean in Healthcare Similarities to manufacturing, reliant on multiple complex processes Many processes and lots of waste Operating requirements continue to expand faster than operating budgets 20-30% of Healthcare spending is waste Overtreatment of patients, fail