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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, ••, pp. ••–••
A waste walk through clinical pharmacy: how do the ‘seven wastes’ of Lean techniques apply to the practice of clinical pharmacists Christopher F. Greena,c, Victoria Crawfordb, Gaynor Bresnenc and Philip H. Rowec a
Countess of Chester Hospital NHS Foundation Trust, bBlackpool Teaching Hospitals NHS Foundation Trust and cSchool of Pharmacy and Biomolecular
Sciences, Liverpool John Moores University, Liverpool, UK
Keywords hospital; pharmacy service Correspondence Dr Christopher F. Green, Pharmacy Department, Martindale House, Countess of Chester Hospital NHS Foundation Trust, Liverpool Rd, Chester, Cheshire CH2 1UL, UK. E-mail: [email protected] Received May 29, 2013 Accepted February 4, 2014 doi: 10.1111/ijpp.12106 Work carried out at: Countess of Chester Hospital NHS Foundation Trust (COCH). Ethics approval: Approval was obtained from the local Research and Development office at COCH and also from the Liverpool John Moores University Research Ethics Committee.
Abstract Aims and objectives This study used a ‘Lean’ technique, the ‘waste walk’ to evaluate the activities of clinical pharmacists with reference to the seven wastes described in ‘Lean’ including ‘defects’, ‘unnecessary motion’, ‘overproduction’, ‘transport of products or material’, ‘unnecessary waiting’, ‘unnecessary inventory’ and ‘inappropriate processing’. The objectives of the study were to categorise the activities of wardbased clinical pharmacists into waste and non-waste, provide detail around what constitutes waste activity and quantify the proportion of time attributed to each category. Setting This study was carried out in a district general hospital in the North West of England. Method Staff were observed using work-sampling techniques, to categorise activity into waste and non-waste, with waste activities being allocated to each of the seven wastes described earlier and subdivided into recurrent themes. Key findings Twenty different pharmacists were observed for 1 h on two separate occasions. Of 1440 observations, 342 (23.8%) were categorised as waste with‘defects’ and ‘unnecessary motion’ accounting for the largest proportions of waste activity. Conclusion Observation of clinical pharmacists’ activities has identified that a significant proportion of their time could be categorised as ‘waste’. There are practical steps that could be implemented in order to ensure their time is used as productively as possible. Given the challenges facing the UK National Health Service, the adoption of ‘Lean’ techniques provides an opportunity to improve quality and productivity while reducing costs.
Introduction As part of the Quality, Innovation, Prevention & Productivity (QIPP) challenge, acute hospitals are coming under increasing pressure to reduce costs, be more efficient and increase quality of the care they provide for patients.[1] To meet this challenge, many hospitals are using Lean methodology to improve the efficiency and reliability of their services.[2,3] These techniques have significantly improved the efficiency and quality of working practices in many industries, perhaps most famously within the Toyota car manufacturing business. The Lean Enterprise Institute defines Lean production as: ‘A business system for organising and managing product development, operations, suppliers, and customer relations that requires less human effort, less space, © 2014 Royal Pharmaceutical Society
less capital, and less time to make products with fewer defects to precise customer (patient) desires, compared with the previous system.’[4] In a clinical setting, key elements of ‘Lean’ are described as ‘minimising or eliminating delays, repeated encounters, errors and inappropriate procedures’.[5] In a clinical Lean system, ‘the primary goal is meeting patient needs, including high quality and prompt access to care, with the right staffing levels’. Unsurprisingly, there is a view that an individual’s treatment regime is not as simple as, nor can it be compared with a manufacturing process;[5] however, there are many elements of the provision of patient care which are potentially hampered by inefficient processes. International Journal of Pharmacy Practice 2014, ••, pp. ••–••
2
At the Countess of Chester Hospital UK National Health Service (NHS) Foundation Trust Hospital (COCH), a working partnership with Unipart Expert Practices has generated significant improvements in the hospital’s performance and generated significant cost savings.[6] Similarly, it has been reported that the Royal Bolton Hospital has saved millions of pounds by applying Lean techniques to practice.[7] The Unipart programme has included the introduction of a number of Lean techniques including the concept of the ‘seven wastes’[8] and the ‘waste walk’ where nominated assessors follow a work process, making observations of opportunities that arise to remove elements of the process that do not add value. The principles around the seven wastes relate originally to those defined by Toyota, which have since been adapted and in the broader clinical setting can be described as follows:[9] 1 Defects: readmissions, repeating tests that were not done correctly in the first place, dispensing errors. 2 Unnecessary motion: unnecessary movement of hospital staff or equipment. 3 Overproduction: unnecessary investigations and tests. 4 Transport of products or material: borrowing equipment from different wards, not having sufficient stock and portering. 5 Unnecessary waiting: waiting for patients to arrive in theatres, waiting for notes, results or medication 6 Unnecessary inventory: excess stock or numbers of patients on waiting lists. 7 Inappropriate processing: duplication of any work, repeating tasks, asking the same questions. While application of Lean techniques to the delivery of pharmacy services does not figure prominently in the literature, the studies that have been described or reported on tend to have been focussed on process around dispensing or sterile production, rather than in a patient contact or clinical setting.[2,10,11] This article describes the application of an adaptation of the waste walk technique to work carried out by ward-based clinical pharmacists using work-time sampling methods.
Aim The aim of the study was to utilise the waste walk technique as described earlier to evaluate the activities of ward-based clinical pharmacists and identify those that could be described as ‘waste’.
Objectives The objectives of the study were to categorise the activities of ward-based clinical pharmacists into waste and non-waste, provide detail around what constitutes waste activity and quantify the proportion of time attributed to each category. © 2014 Royal Pharmaceutical Society
A waste walk through clinical pharmacy
Method Setting The COCH provides medical services to almost half a million patients per year. Observations took place in spring 2012, over a 5-week period and including a variety of wards across the Trust. Approval was obtained from the local research and development office at COCH and also from the Liverpool John Moores University Research Ethics Committee. All pharmacists undergoing observation gave informed consent prior to the work-time sampling exercise. A prospective analysis of pharmacists carrying out clinical pharmacy activity was undertaken using work-sampling techniques,[12] that is, documentation of random observations of work activities. The observed activity at a random moment in time is recorded rather than the actual time spent in performing each task with the premise that the number of occurrences of a particular activity will be directly related to the proportion of time carrying them out.[13] Using this technique, the numbers of actual observations spent on different activities are recorded and then calculated as a percentage of total time. A literature search was performed to identify similar research on analysis of nursing time and these studies, predominately from the United States and covering a variety of ward areas, were used to guide the sampling strategy for this article although varying approaches were identified.[12,13] Following statistical advice, and based on previous work we have carried out using this technique, a series of 1-h observation periods were planned, during which 36 random electronic bleeps per hour were generated by a pre-programmed pager (Random Reminder, Divilbiss Electronics, Fredericktown, OH, USA). The researcher followed one clinical pharmacist on their ward visit for 1 h on two separate occasions. All clinical pharmacists working at the Trust during the study period were studied in this manner. The duties of a clinical pharmacist vary depending on their particular workload but share a common core activity set. This includes performing medicine reconciliation on admission, monitoring the effects of medicines as patients progress throughout their hospital stay, providing advice on drug selection and dosing, monitoring laboratory data, supporting antibiotic stewardship and safety agendas, and ensuring that the discharge prescription is correct. At each bleep, the researcher documented the activity of the pharmacist at that time. Where the pharmacist was performing more than one function at a time, the primary activity was recorded.[13] For example a pharmacist making an entry in a patient’s medical record while simultaneously teaching a trainee pharmacist would have ‘Documenting in patients records’ documented. At the end of each ward round, International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Christopher F. Green et al.
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each activity that could be described as waste was placed into the appropriate category. The researcher decided what could be categorised as waste following an assessment of the task the pharmacist was carrying out.
Results Twenty different pharmacists were observed for 1 h on two separate occasions, giving a total of 40-h observations, each with 36 bleeps giving a total of 1440 observations. Of these, 342 (23.8%) were categorised as waste which are described in Table 1. ‘Defects’ (95 observations, 6.4%) and ‘unnecessary motion’ (90 observations, 6.25%) were the most frequently occurring categories of waste. There were no incidents of waste associated with ‘unnecessary inventory’, ‘transport of products and material’ and ‘overproduction’.
Discussion The results indicate that almost one quarter of pharmacists’ activity is lost on inefficient or ‘unproductive’ activity. The description of pharmacists’ activities as waste may be questioned because the pharmacist’s contribution to patient-care
Table 1
centres around the safe and effective use of medicines, and part of that role inevitably centres on identifying and correcting errors. However, this study was designed to dispassionately scrutinise the activities of pharmacists from a Lean perspective and as such, describing activities carried out by pharmacists as waste refers entirely to the philosophy of ‘Lean’ and does not dismiss or diminish the importance of the pharmacist’s role. From a patient-care perspective, performing tasks correctly at the first opportunity is not only more efficient but also safer and more likely to result in positive outcomes.
Strengths and limitations of this work All 20 pharmacists actively engaged in ward-based clinical duties were observed, giving a representative sample of activity across the team of pharmacists and across a range of clinical settings including medical, surgical and high dependency wards. This work was carried out at one site and observed one model of clinical pharmacy practice. Multi-centre research is required to assess the extrapolation of the results to other units and may identify more efficient models of practice which could be used to identify best practice.
Waste categories observed during the study and common examples
Type of waste
Number of ‘waste’ observations (n = 1140)
Defect
95 (6.4%)
Unnecessary motion
90 (6.25%)
Unnecessary processing
82 (5.7%)
Unnecessary waiting
Overproduction Transport of products and material Unnecessary inventory Total
© 2014 Royal Pharmaceutical Society
75 (5.2%)
Most common examples of waste
Frequency
Correcting errors: e.g. dose, formulation, dosage regimen. Adding instructions to drugs chart Adding review dates for antibiotics Stopping doses Documenting allergies Other Walking to or from the ward Looking for notes/drug charts Moving to computer Moving to retrieve stationery Other Repeating work – writing the same information in patients notes and on the computer Writing in the doctor’s job book Looking for documentation of allergies and medical history Documenting in patients notes to say what was added/missed Repeating errors spotted earlier on and still not been dealt with. Other For computer to load/log on/log off Waiting to talk to other members of staff Waiting for computer access
40 (11.7%) 20 (5.8%) 11 (3.2%) 5 (1.5%) 5 (1.5%) 14 (4.1%) 32 (9.4%) 22 (6.4%) 12 (3.5%) 6 (1.8%) 18 (5.3%) 19 (5.6%) 11 (3.2%) 11 (3.2%) 11 (3.2%) 9 (2.6%) 21 (6.1%) 49 (14.3%) 23 (6.7%) 3 (0.9%)
0 0 0 342 (23.8%)
International Journal of Pharmacy Practice 2014, ••, pp. ••–••
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The method of using an observational study was chosen so that a true representation of the activity of the pharmacist could be taken without bias, but it is limited by the fact that the observer can only take one observation at one place at a time. Furthermore,in many observational studies,it is reported that the Hawthorne effect,that is,the pressure felt upon an individual who is being watched, can consequently influence the way in which they work and subsequently affect the results.[14] It is also possible that the sampling method may have not accurately captured the activities being observed; however, the likelihood of this was minimised by setting the random bleep at its most frequent setting, and obtaining 40 h’ worth of observations. Categorisation of activities into waste or non-waste activities was carried out by the researcher in tandem with the pharmacist being observed. Use of a panel to review observations was considered but deemed impractical since collecting adequate data for 1440 observations would have rendered the observation method impossible to administer. Secondly, the view was taken that categorisation of activities was clearly and objectively defined around the seven waste categories. For example walking down a corridor, waiting for a computer to become available, correcting an error on a prescription or completing an incomplete prescription are, in our view, clear examples of waste. By contrast, activities such as taking a medication history, counselling a patient, reviewing laboratory results and suggesting potential improvements to a prescription are clearly those that are contributing to the patients care, and have not arisen as a result of mistakes or deficiencies elsewhere in the process. Pharmacists were observed on their wards for 1 h at a time during the observation periods to allow for observer fatigue and to minimise intrusion on the working environment for clinical pharmacists working with patients in an acute care setting. In reality, pharmacists may spend a longer or shorter periods of time on their ward depending on their schedules and thus behave somewhat differently during these extended or shortened time periods.
Defects The majority of activity relating to ‘defects’ was described predominately as correcting or clarifying inpatient and discharge prescriptions. Ensuring that medicines are safely and accurately prescribed is largely the raison d’être for clinical pharmacy services. In this study 11.7% of the documented wastes were correcting errors that the prescribers had made and a further 5.8% were adding missing or supporting information to the prescription. It might be argued therefore that it is inaccurate to describe this activity as waste and more accurate to describe it as an essential part of patient care. However, if prescriptions were accurately written at the first attempt, this activity would be unnecessary and it therefore meets the criteria to be defined as waste. In combination, cor© 2014 Royal Pharmaceutical Society
A waste walk through clinical pharmacy
recting errors was by far the most prevalent form of waste, and the Trust, indeed the NHS, needs to examine strategies to tackle this further and improve the quality of prescribing on a ‘right first time’ basis. The unacceptably high incidence of prescribing errors has been highlighted in the recent EQUIP study and the recommendations of the report need to progressed.[15] The implementation of electronic prescribing is an opportunity to reduce prescription errors, particularly those related to missing or incomplete information. However, the EQUIP study also identifies an unacceptably high prescribing error rate in hospitals with electronic prescribing, and this should not be seen as a panacea to the problem.
Unnecessary motion The majority of activity in this category was recorded largely while walking to or from the ward but also walking to locate or access patients’ notes or a computer. A potential method of reducing at least some of the waste generated by travel to and from wards is to base pharmacists on wards, rather than centrally in a pharmacy department and to provide them with portable, handheld computer devices. Other strategies to reduce unnecessary motion would be to increase or introduce the use of air-tube delivery systems and electronic ordering, rather than paper-based ordering systems. Electronic prescribing has been implemented at the hospital and the results suggest that there is an efficiency gain of pharmacists’ time, since they no longer have to look for prescription charts. However, this requires further investigation since the additional time required to access and log on to computers may well negate this benefit.
Unnecessary waiting The predominant waste in this category was waiting for a computer to log on and off, as opposed to waiting to access a computer for use, and this accounted for a significant proportion of the time categorised as waste (14.3%). The impact of this could be mitigated by investment in more capable and increased numbers of computers, and utilising software solutions that negate the requirement to manually log in and out of desktop or laptop computers. Less technical solutions are also available, for example ensuring that computers are all serviced and in working order, and that those requiring charging are doing so when not in use. Waiting to talk to other members of staff is also potentially avoidable in instances where these conversations are required to query an issue that has occurred in error and, thus, a reduction in errors would reduce the need to have these conversations; the extent of this was not measured as part of the study. In practice, it could be counterproductive if not dangerous to engender a view that talking to colleagues was a waste since staff and patients are an essential resource for pharmacists to obtain important inforInternational Journal of Pharmacy Practice 2014, ••, pp. ••–••
Christopher F. Green et al.
mation. Notes or entries in the patient’s record are frequently left by pharmacists to avoid waiting, but anecdotally, these are often lost, ignored or not actioned accordingly, and direct interaction with those concerned is a more robust method of addressing clinical problems.
Inappropriate processing This category of waste in the context of this study was largely related to repeated actions, for example repeatedly accessing the same patient’s notes during the same ward round or the same patient’s blood results. Anecdotally, these wastes appeared to be more commonly observed in instances where pharmacists were unfamiliar to that particular ward and unfamiliar with the history of each patient. Documentation of allergy status was also observed on 11 occasions as this should have been carried out by the doctor admitting the patient into the hospital, but was not. The allergy status may have been written in the notes; however, it was not documented on the prescription in the appropriate place, meaning the pharmacist then had to requestion the patient and document it accordingly. Following this study and the introduction of electronic prescribing, the input of allergy data has become a mandatory field, reducing the likelihood that, other than confirming details with the patient, pharmacists would have to carry out this task in future. In terms of duplicate documentation, pharmacists make contemporaneous notes in the patient’s medical record for medical staff to read and acknowledge, but may also document the same information in the electronic pharmaceutical care plan so that it is accessible remotely, for example in the dispensary or where pharmacists are on call. Again, a strategy to resolve this using a shared electronic record could generate efficiencies.
Overproduction, transport of products or material and unnecessary inventory These waste categories were not recorded as being observed during the study and this may be related to nuances of applying an industrial model to a clinical setting and, more specifically, to a model of clinical pharmacy practice. Wards should be arranged so that equipment used by all staff should be central to their working practices, for example printers, computers, pneumatic tube transport system and the storage system of notes should all be located in the middle of the ward in order to reduce excess motion.
Comparison to other studies using Lean in the pharmacy setting Although the use of the ‘waste walk’ with regard to clinical practice has been referred to in the literature,[16] observational data with the descriptive detail provided in this study were © 2014 Royal Pharmaceutical Society
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not identified in any other study, and as a result, it is not possible to directly compare this work with that of others. However, there are a number of reports in the literature of the application of Lean to pharmacy settings which have resulted in positive outcomes for service delivery. Vercaeren et al. described the application of Lean thinking to the patient pathway for non-elective cardiac surgery using a process mapping exercise to identify waste.[17] Opportunities to reduce waste were identified including ensuring that medicines are transferred with the patient avoiding the need to wait for resupply and the availability of medicines at the point of discharge. The Royal Bolton Hospital is one of the more prominent Trusts in the UK that have implemented a number of Lean initiatives.[2] The article gives a good description of the seven wastes and examples of their manifestation within the pharmacy setting, but as an overview rather than in detail. Two papers are published based on work at the Taunton and Somerset Hospital with regard to chemotherapy and dispensary services.[11,18] Methods described include the use of process mapping, failure modes and effects analysis and the ‘Plan, Do, Study, Act’ cycle. As a result, a number of waste activities were identified including process complexity, irrational prioritisation, duplication, batching and avoidable interruptions.
Conclusion The ‘waste walk’ has been a useful exercise and has focussed our attention on improving the efficiency of clinical pharmacy activity at our Trust. According to the observation research, 23.75% of pharmacist’s time is wasted because of inefficient work activities. The use of the term ‘waste’ may be contentious given that some of the activities, for example correcting prescription errors, are key patient safety activities. However, prescribing correctly at the first opportunity would prevent a number of unnecessary activities. The introduction of electronic solutions, particularly around prescribing and contemporaneous medical records, could generate efficiencies in pharmacists’ time; however, the accessibly and functionality of these solutions must be carefully designed to avoid the introduction of alternate forms of waste. This is the first study of its kind, examining the role of clinical pharmacists and their activities from a ‘Lean’ perspective, and it has identified that there are a number of opportunities to implement practical solutions which would allow pharmacists to become more efficient with their time and improve patient safety and quality of care.
Declarations Conflict of interests The Author(s) declare(s) that they have no conflicts of interest to disclose. International Journal of Pharmacy Practice 2014, ••, pp. ••–••
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A waste walk through clinical pharmacy
Funding
Authors’ contributions
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
All authors made contributions to the conception and design of the study, VC was responsible for the acquisition of data, or VC, CG and PR were responsible for the analysis and interpretation of data, CG was responsible for the drafting of the article and all authors were responsible for the final approval of the version to be published. All Authors state that they had complete access to the study data that support the publication.
Acknowledgements We would like to thank all the pharmacists at COCH for their agreeing to take part in, and their assistance with this study.
References 1. Department of Health. Quality, Innovation, Productivity and Prevention (QIPP). 2014. http://www.evidence .nhs.uk/qipp (accessed 21 April 2013). 2. Smith B. Using the Lean approach to transform pharmacy services in an acute trust. Pharm J 2009; 282: 457– 461. 3. Young T et al. Using industrial processes to improve patient care. BMJ 2004; 328: 162–164. 4. Ott S et al, ed. ‘Becoming Lean’ Inside Stories of U.S Manufacture. New York: Productivity Press, 2004. 5. Hyatt J. Keen to be lean. CFO Magazine. 2009 December issue. http://www.cfo .com/article.cfm/14457598?f=single page (accessed 22 January 2012). 6. Unipart Expert Practices. Case study: the countess of Chester NHS Foundation Trust. http://www.unipart consulting.com/images/CaseStudy PDFs/chester%20of%20chester%20 -%20overview.pdf (accessed 5 February 2013). 7. News item. Hospital’s £8m savings are influenced by car industry. http://
© 2014 Royal Pharmaceutical Society
8.
9.
10.
11.
www.boltonft.nhs.uk/wp-content/ uploads/2012/12/bics_benefits _realisation2010.pdf (accessed 14 March 2014). NHS Institute for Innovation and Improvement. Lean – seven wastes. 2008. http://www.institute.nhs.uk/ quality_and_service_improvement _tools/quality_and_service _improvement_tools/lean_-_7_wastes .html (accessed 5 February 2013). The Institute of Operations Management. Lean techniques adopted by Bolton hospital. 2011 http://www .iomnet.org.uk/News/Public-Sector/ August-2011/Lean-techniques -adopted-by-Bolton-hospital800699901.aspx (accessed 5 February 2013). Jenkins A, Eckel SF. Analyzing methods for improved management of workflow in an outpatient pharmacy setting. Am J Health Syst Pharm 2012; 69: 966– 971. Beard J, Wood D. Application of lean principles can reduce inpatient prescription dispensing times. Pharm J. 2010; 284: 369–371.
12. Urden L, Roode J. Work sampling: a decision making tool for determining resources and work redesign. J Nurs Adm 1997; 27: 34–41. 13. Pelletier D, Duffield C. Work sampling: valuable methodology to define nursing practice patterns. Nurs Health Sci 2003; 5: 31–38. 14. Gale EAM. The Hawthorne studies – a fable for our times? QJM 2004; 97: 439– 449. 15. General Medical Council. The EQUIP study. 2009. http://www.gmc-uk.org/ about/research/research _commissioned_4.asp (accessed 25 June 2012). 16. Stuenkel K, Faulkner T. A community hospital’s journey into Lean Six Sigma. Front Healthc Manag 2009; 26: 5–13. 17. Vercaeren S et al. Can a little bit of Toyota benefit your pharmacy team. Pharm Manag 2010; 26: 9–15. 18. Beard J, Dunn J. Applying Lean principles to improve hospital chemotherapy services. Pharm J 2012; 289: 1–5.
International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2014, ••, pp. ••–••
A waste walk through clinical pharmacy: how do the ‘seven wastes’ of Lean techniques apply to the practice of clinical pharmacists Christopher F. Greena,c, Victoria Crawfordb, Gaynor Bresnenc and Philip H. Rowec a
Countess of Chester Hospital NHS Foundation Trust, bBlackpool Teaching Hospitals NHS Foundation Trust and cSchool of Pharmacy and Biomolecular
Sciences, Liverpool John Moores University, Liverpool, UK
Keywords hospital; pharmacy service Correspondence Dr Christopher F. Green, Pharmacy Department, Martindale House, Countess of Chester Hospital NHS Foundation Trust, Liverpool Rd, Chester, Cheshire CH2 1UL, UK. E-mail: [email protected] Received May 29, 2013 Accepted February 4, 2014 doi: 10.1111/ijpp.12106 Work carried out at: Countess of Chester Hospital NHS Foundation Trust (COCH). Ethics approval: Approval was obtained from the local Research and Development office at COCH and also from the Liverpool John Moores University Research Ethics Committee.
Abstract Aims and objectives This study used a ‘Lean’ technique, the ‘waste walk’ to evaluate the activities of clinical pharmacists with reference to the seven wastes described in ‘Lean’ including ‘defects’, ‘unnecessary motion’, ‘overproduction’, ‘transport of products or material’, ‘unnecessary waiting’, ‘unnecessary inventory’ and ‘inappropriate processing’. The objectives of the study were to categorise the activities of wardbased clinical pharmacists into waste and non-waste, provide detail around what constitutes waste activity and quantify the proportion of time attributed to each category. Setting This study was carried out in a district general hospital in the North West of England. Method Staff were observed using work-sampling techniques, to categorise activity into waste and non-waste, with waste activities being allocated to each of the seven wastes described earlier and subdivided into recurrent themes. Key findings Twenty different pharmacists were observed for 1 h on two separate occasions. Of 1440 observations, 342 (23.8%) were categorised as waste with‘defects’ and ‘unnecessary motion’ accounting for the largest proportions of waste activity. Conclusion Observation of clinical pharmacists’ activities has identified that a significant proportion of their time could be categorised as ‘waste’. There are practical steps that could be implemented in order to ensure their time is used as productively as possible. Given the challenges facing the UK National Health Service, the adoption of ‘Lean’ techniques provides an opportunity to improve quality and productivity while reducing costs.
Introduction As part of the Quality, Innovation, Prevention & Productivity (QIPP) challenge, acute hospitals are coming under increasing pressure to reduce costs, be more efficient and increase quality of the care they provide for patients.[1] To meet this challenge, many hospitals are using Lean methodology to improve the efficiency and reliability of their services.[2,3] These techniques have significantly improved the efficiency and quality of working practices in many industries, perhaps most famously within the Toyota car manufacturing business. The Lean Enterprise Institute defines Lean production as: ‘A business system for organising and managing product development, operations, suppliers, and customer relations that requires less human effort, less space, © 2014 Royal Pharmaceutical Society
less capital, and less time to make products with fewer defects to precise customer (patient) desires, compared with the previous system.’[4] In a clinical setting, key elements of ‘Lean’ are described as ‘minimising or eliminating delays, repeated encounters, errors and inappropriate procedures’.[5] In a clinical Lean system, ‘the primary goal is meeting patient needs, including high quality and prompt access to care, with the right staffing levels’. Unsurprisingly, there is a view that an individual’s treatment regime is not as simple as, nor can it be compared with a manufacturing process;[5] however, there are many elements of the provision of patient care which are potentially hampered by inefficient processes. International Journal of Pharmacy Practice 2014, ••, pp. ••–••
2
At the Countess of Chester Hospital UK National Health Service (NHS) Foundation Trust Hospital (COCH), a working partnership with Unipart Expert Practices has generated significant improvements in the hospital’s performance and generated significant cost savings.[6] Similarly, it has been reported that the Royal Bolton Hospital has saved millions of pounds by applying Lean techniques to practice.[7] The Unipart programme has included the introduction of a number of Lean techniques including the concept of the ‘seven wastes’[8] and the ‘waste walk’ where nominated assessors follow a work process, making observations of opportunities that arise to remove elements of the process that do not add value. The principles around the seven wastes relate originally to those defined by Toyota, which have since been adapted and in the broader clinical setting can be described as follows:[9] 1 Defects: readmissions, repeating tests that were not done correctly in the first place, dispensing errors. 2 Unnecessary motion: unnecessary movement of hospital staff or equipment. 3 Overproduction: unnecessary investigations and tests. 4 Transport of products or material: borrowing equipment from different wards, not having sufficient stock and portering. 5 Unnecessary waiting: waiting for patients to arrive in theatres, waiting for notes, results or medication 6 Unnecessary inventory: excess stock or numbers of patients on waiting lists. 7 Inappropriate processing: duplication of any work, repeating tasks, asking the same questions. While application of Lean techniques to the delivery of pharmacy services does not figure prominently in the literature, the studies that have been described or reported on tend to have been focussed on process around dispensing or sterile production, rather than in a patient contact or clinical setting.[2,10,11] This article describes the application of an adaptation of the waste walk technique to work carried out by ward-based clinical pharmacists using work-time sampling methods.
Aim The aim of the study was to utilise the waste walk technique as described earlier to evaluate the activities of ward-based clinical pharmacists and identify those that could be described as ‘waste’.
Objectives The objectives of the study were to categorise the activities of ward-based clinical pharmacists into waste and non-waste, provide detail around what constitutes waste activity and quantify the proportion of time attributed to each category. © 2014 Royal Pharmaceutical Society
A waste walk through clinical pharmacy
Method Setting The COCH provides medical services to almost half a million patients per year. Observations took place in spring 2012, over a 5-week period and including a variety of wards across the Trust. Approval was obtained from the local research and development office at COCH and also from the Liverpool John Moores University Research Ethics Committee. All pharmacists undergoing observation gave informed consent prior to the work-time sampling exercise. A prospective analysis of pharmacists carrying out clinical pharmacy activity was undertaken using work-sampling techniques,[12] that is, documentation of random observations of work activities. The observed activity at a random moment in time is recorded rather than the actual time spent in performing each task with the premise that the number of occurrences of a particular activity will be directly related to the proportion of time carrying them out.[13] Using this technique, the numbers of actual observations spent on different activities are recorded and then calculated as a percentage of total time. A literature search was performed to identify similar research on analysis of nursing time and these studies, predominately from the United States and covering a variety of ward areas, were used to guide the sampling strategy for this article although varying approaches were identified.[12,13] Following statistical advice, and based on previous work we have carried out using this technique, a series of 1-h observation periods were planned, during which 36 random electronic bleeps per hour were generated by a pre-programmed pager (Random Reminder, Divilbiss Electronics, Fredericktown, OH, USA). The researcher followed one clinical pharmacist on their ward visit for 1 h on two separate occasions. All clinical pharmacists working at the Trust during the study period were studied in this manner. The duties of a clinical pharmacist vary depending on their particular workload but share a common core activity set. This includes performing medicine reconciliation on admission, monitoring the effects of medicines as patients progress throughout their hospital stay, providing advice on drug selection and dosing, monitoring laboratory data, supporting antibiotic stewardship and safety agendas, and ensuring that the discharge prescription is correct. At each bleep, the researcher documented the activity of the pharmacist at that time. Where the pharmacist was performing more than one function at a time, the primary activity was recorded.[13] For example a pharmacist making an entry in a patient’s medical record while simultaneously teaching a trainee pharmacist would have ‘Documenting in patients records’ documented. At the end of each ward round, International Journal of Pharmacy Practice 2014, ••, pp. ••–••
Christopher F. Green et al.
3
each activity that could be described as waste was placed into the appropriate category. The researcher decided what could be categorised as waste following an assessment of the task the pharmacist was carrying out.
Results Twenty different pharmacists were observed for 1 h on two separate occasions, giving a total of 40-h observations, each with 36 bleeps giving a total of 1440 observations. Of these, 342 (23.8%) were categorised as waste which are described in Table 1. ‘Defects’ (95 observations, 6.4%) and ‘unnecessary motion’ (90 observations, 6.25%) were the most frequently occurring categories of waste. There were no incidents of waste associated with ‘unnecessary inventory’, ‘transport of products and material’ and ‘overproduction’.
Discussion The results indicate that almost one quarter of pharmacists’ activity is lost on inefficient or ‘unproductive’ activity. The description of pharmacists’ activities as waste may be questioned because the pharmacist’s contribution to patient-care
Table 1
centres around the safe and effective use of medicines, and part of that role inevitably centres on identifying and correcting errors. However, this study was designed to dispassionately scrutinise the activities of pharmacists from a Lean perspective and as such, describing activities carried out by pharmacists as waste refers entirely to the philosophy of ‘Lean’ and does not dismiss or diminish the importance of the pharmacist’s role. From a patient-care perspective, performing tasks correctly at the first opportunity is not only more efficient but also safer and more likely to result in positive outcomes.
Strengths and limitations of this work All 20 pharmacists actively engaged in ward-based clinical duties were observed, giving a representative sample of activity across the team of pharmacists and across a range of clinical settings including medical, surgical and high dependency wards. This work was carried out at one site and observed one model of clinical pharmacy practice. Multi-centre research is required to assess the extrapolation of the results to other units and may identify more efficient models of practice which could be used to identify best practice.
Waste categories observed during the study and common examples
Type of waste
Number of ‘waste’ observations (n = 1140)
Defect
95 (6.4%)
Unnecessary motion
90 (6.25%)
Unnecessary processing
82 (5.7%)
Unnecessary waiting
Overproduction Transport of products and material Unnecessary inventory Total
© 2014 Royal Pharmaceutical Society
75 (5.2%)
Most common examples of waste
Frequency
Correcting errors: e.g. dose, formulation, dosage regimen. Adding instructions to drugs chart Adding review dates for antibiotics Stopping doses Documenting allergies Other Walking to or from the ward Looking for notes/drug charts Moving to computer Moving to retrieve stationery Other Repeating work – writing the same information in patients notes and on the computer Writing in the doctor’s job book Looking for documentation of allergies and medical history Documenting in patients notes to say what was added/missed Repeating errors spotted earlier on and still not been dealt with. Other For computer to load/log on/log off Waiting to talk to other members of staff Waiting for computer access
40 (11.7%) 20 (5.8%) 11 (3.2%) 5 (1.5%) 5 (1.5%) 14 (4.1%) 32 (9.4%) 22 (6.4%) 12 (3.5%) 6 (1.8%) 18 (5.3%) 19 (5.6%) 11 (3.2%) 11 (3.2%) 11 (3.2%) 9 (2.6%) 21 (6.1%) 49 (14.3%) 23 (6.7%) 3 (0.9%)
0 0 0 342 (23.8%)
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The method of using an observational study was chosen so that a true representation of the activity of the pharmacist could be taken without bias, but it is limited by the fact that the observer can only take one observation at one place at a time. Furthermore,in many observational studies,it is reported that the Hawthorne effect,that is,the pressure felt upon an individual who is being watched, can consequently influence the way in which they work and subsequently affect the results.[14] It is also possible that the sampling method may have not accurately captured the activities being observed; however, the likelihood of this was minimised by setting the random bleep at its most frequent setting, and obtaining 40 h’ worth of observations. Categorisation of activities into waste or non-waste activities was carried out by the researcher in tandem with the pharmacist being observed. Use of a panel to review observations was considered but deemed impractical since collecting adequate data for 1440 observations would have rendered the observation method impossible to administer. Secondly, the view was taken that categorisation of activities was clearly and objectively defined around the seven waste categories. For example walking down a corridor, waiting for a computer to become available, correcting an error on a prescription or completing an incomplete prescription are, in our view, clear examples of waste. By contrast, activities such as taking a medication history, counselling a patient, reviewing laboratory results and suggesting potential improvements to a prescription are clearly those that are contributing to the patients care, and have not arisen as a result of mistakes or deficiencies elsewhere in the process. Pharmacists were observed on their wards for 1 h at a time during the observation periods to allow for observer fatigue and to minimise intrusion on the working environment for clinical pharmacists working with patients in an acute care setting. In reality, pharmacists may spend a longer or shorter periods of time on their ward depending on their schedules and thus behave somewhat differently during these extended or shortened time periods.
Defects The majority of activity relating to ‘defects’ was described predominately as correcting or clarifying inpatient and discharge prescriptions. Ensuring that medicines are safely and accurately prescribed is largely the raison d’être for clinical pharmacy services. In this study 11.7% of the documented wastes were correcting errors that the prescribers had made and a further 5.8% were adding missing or supporting information to the prescription. It might be argued therefore that it is inaccurate to describe this activity as waste and more accurate to describe it as an essential part of patient care. However, if prescriptions were accurately written at the first attempt, this activity would be unnecessary and it therefore meets the criteria to be defined as waste. In combination, cor© 2014 Royal Pharmaceutical Society
A waste walk through clinical pharmacy
recting errors was by far the most prevalent form of waste, and the Trust, indeed the NHS, needs to examine strategies to tackle this further and improve the quality of prescribing on a ‘right first time’ basis. The unacceptably high incidence of prescribing errors has been highlighted in the recent EQUIP study and the recommendations of the report need to progressed.[15] The implementation of electronic prescribing is an opportunity to reduce prescription errors, particularly those related to missing or incomplete information. However, the EQUIP study also identifies an unacceptably high prescribing error rate in hospitals with electronic prescribing, and this should not be seen as a panacea to the problem.
Unnecessary motion The majority of activity in this category was recorded largely while walking to or from the ward but also walking to locate or access patients’ notes or a computer. A potential method of reducing at least some of the waste generated by travel to and from wards is to base pharmacists on wards, rather than centrally in a pharmacy department and to provide them with portable, handheld computer devices. Other strategies to reduce unnecessary motion would be to increase or introduce the use of air-tube delivery systems and electronic ordering, rather than paper-based ordering systems. Electronic prescribing has been implemented at the hospital and the results suggest that there is an efficiency gain of pharmacists’ time, since they no longer have to look for prescription charts. However, this requires further investigation since the additional time required to access and log on to computers may well negate this benefit.
Unnecessary waiting The predominant waste in this category was waiting for a computer to log on and off, as opposed to waiting to access a computer for use, and this accounted for a significant proportion of the time categorised as waste (14.3%). The impact of this could be mitigated by investment in more capable and increased numbers of computers, and utilising software solutions that negate the requirement to manually log in and out of desktop or laptop computers. Less technical solutions are also available, for example ensuring that computers are all serviced and in working order, and that those requiring charging are doing so when not in use. Waiting to talk to other members of staff is also potentially avoidable in instances where these conversations are required to query an issue that has occurred in error and, thus, a reduction in errors would reduce the need to have these conversations; the extent of this was not measured as part of the study. In practice, it could be counterproductive if not dangerous to engender a view that talking to colleagues was a waste since staff and patients are an essential resource for pharmacists to obtain important inforInternational Journal of Pharmacy Practice 2014, ••, pp. ••–••
Christopher F. Green et al.
mation. Notes or entries in the patient’s record are frequently left by pharmacists to avoid waiting, but anecdotally, these are often lost, ignored or not actioned accordingly, and direct interaction with those concerned is a more robust method of addressing clinical problems.
Inappropriate processing This category of waste in the context of this study was largely related to repeated actions, for example repeatedly accessing the same patient’s notes during the same ward round or the same patient’s blood results. Anecdotally, these wastes appeared to be more commonly observed in instances where pharmacists were unfamiliar to that particular ward and unfamiliar with the history of each patient. Documentation of allergy status was also observed on 11 occasions as this should have been carried out by the doctor admitting the patient into the hospital, but was not. The allergy status may have been written in the notes; however, it was not documented on the prescription in the appropriate place, meaning the pharmacist then had to requestion the patient and document it accordingly. Following this study and the introduction of electronic prescribing, the input of allergy data has become a mandatory field, reducing the likelihood that, other than confirming details with the patient, pharmacists would have to carry out this task in future. In terms of duplicate documentation, pharmacists make contemporaneous notes in the patient’s medical record for medical staff to read and acknowledge, but may also document the same information in the electronic pharmaceutical care plan so that it is accessible remotely, for example in the dispensary or where pharmacists are on call. Again, a strategy to resolve this using a shared electronic record could generate efficiencies.
Overproduction, transport of products or material and unnecessary inventory These waste categories were not recorded as being observed during the study and this may be related to nuances of applying an industrial model to a clinical setting and, more specifically, to a model of clinical pharmacy practice. Wards should be arranged so that equipment used by all staff should be central to their working practices, for example printers, computers, pneumatic tube transport system and the storage system of notes should all be located in the middle of the ward in order to reduce excess motion.
Comparison to other studies using Lean in the pharmacy setting Although the use of the ‘waste walk’ with regard to clinical practice has been referred to in the literature,[16] observational data with the descriptive detail provided in this study were © 2014 Royal Pharmaceutical Society
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not identified in any other study, and as a result, it is not possible to directly compare this work with that of others. However, there are a number of reports in the literature of the application of Lean to pharmacy settings which have resulted in positive outcomes for service delivery. Vercaeren et al. described the application of Lean thinking to the patient pathway for non-elective cardiac surgery using a process mapping exercise to identify waste.[17] Opportunities to reduce waste were identified including ensuring that medicines are transferred with the patient avoiding the need to wait for resupply and the availability of medicines at the point of discharge. The Royal Bolton Hospital is one of the more prominent Trusts in the UK that have implemented a number of Lean initiatives.[2] The article gives a good description of the seven wastes and examples of their manifestation within the pharmacy setting, but as an overview rather than in detail. Two papers are published based on work at the Taunton and Somerset Hospital with regard to chemotherapy and dispensary services.[11,18] Methods described include the use of process mapping, failure modes and effects analysis and the ‘Plan, Do, Study, Act’ cycle. As a result, a number of waste activities were identified including process complexity, irrational prioritisation, duplication, batching and avoidable interruptions.
Conclusion The ‘waste walk’ has been a useful exercise and has focussed our attention on improving the efficiency of clinical pharmacy activity at our Trust. According to the observation research, 23.75% of pharmacist’s time is wasted because of inefficient work activities. The use of the term ‘waste’ may be contentious given that some of the activities, for example correcting prescription errors, are key patient safety activities. However, prescribing correctly at the first opportunity would prevent a number of unnecessary activities. The introduction of electronic solutions, particularly around prescribing and contemporaneous medical records, could generate efficiencies in pharmacists’ time; however, the accessibly and functionality of these solutions must be carefully designed to avoid the introduction of alternate forms of waste. This is the first study of its kind, examining the role of clinical pharmacists and their activities from a ‘Lean’ perspective, and it has identified that there are a number of opportunities to implement practical solutions which would allow pharmacists to become more efficient with their time and improve patient safety and quality of care.
Declarations Conflict of interests The Author(s) declare(s) that they have no conflicts of interest to disclose. International Journal of Pharmacy Practice 2014, ••, pp. ••–••
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A waste walk through clinical pharmacy
Funding
Authors’ contributions
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
All authors made contributions to the conception and design of the study, VC was responsible for the acquisition of data, or VC, CG and PR were responsible for the analysis and interpretation of data, CG was responsible for the drafting of the article and all authors were responsible for the final approval of the version to be published. All Authors state that they had complete access to the study data that support the publication.
Acknowledgements We would like to thank all the pharmacists at COCH for their agreeing to take part in, and their assistance with this study.
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