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by Patricia Houghton

Names such as the "Zip Scripts," "Paper Pushers" and "Stock Squad" are more likely to evoke images of company softball teams than money- and life-saving hospital initiatives. However, at Grand Rapids, Michigan-based Metro Health Hospital, a member hospital of VHA Inc., that's exactly what these groups achieve. These teams are based on the lean manufacturing philosophy made famous by the Toyota Production System.

How can a program designed to improve automobile manufacturing apply to running a hospital pharmacy, or to patient safety? Peter Haverkamp, RPh, director of pharmacy services at Metro, has successfully applied lean manufacturing strategies to health care, as his department's production demonstrates.

A fresh start
Lean is a performance tool for business improvement that initially took root in manufacturing industries. Its goal is to enhance quality, reduce cost, speed delivery and maximize human resources. It does so by first exposing nonvalue-added steps in processes from the customer's perspective. Lean makes continuous improvement possible by providing the tools organizations need to remove nonvalue-added process steps. Empowering staff members builds the enthusiasm necessary to motivate them to eliminate waste on a daily basis. This empowerment is a key component of any lean initiative.

Before lean, Metro's inpatient pharmacy service was a busy place, as are most hospital pharmacies. The staff worked hard to meet the almost-constant needs of patients, nurses and physicians by responding to medication orders and phone calls while rushing to make deliveries on time. It was a place where interruption was the norm, so much so that the staff became concerned about the potential negative effects this hectic environment might have on patient safety.

During the second quarter of 2005, Haverkamp and a small group of frontline pharmacy staff members enrolled in one of Metro's new, intensive, three-day lean process-improvement workshops. This training, created in conjunction with Bruce McLenithan of Tolt Consulting, used an industry-proven methodology to dramatically improve quality, safety and operational efficiency. By the end of the workshop, the team realized that the pharmacy's overall design did little to enhance its ability to safely deliver medications to patients.

The Metro pharmacy started with a modest goal of reducing the lead time for getting the first dose of a medication to a patient. The lead time was measured from the time an order arrived at the pharmacy to its delivery on the appropriate hospital floor. The pharmacy found, however, that once it started the lean process, the results far surpassed this initial goal.

Improving efficiency
Using lean, the Metro pharmacy carefully laid out all the process steps involved in getting the first dose of the correct medication to the right patient. The pharmacy found that it had a 14-stage process with some unnecessary steps, resulting in a total lead time of 166 minutes. During the initial program, lean teams worked to dissect the value-added from nonvalue-added process steps in the hope of reducing lead time.

In lean terminology, a nonvalue-added activity is one that takes time, resources or space without adding to the value of the service itself. For example, to a user (in this case, a nurse or patient who needs to get medication quickly), the fact that the technician must look for medication all over the pharmacy is irrelevant, and thus, it's a nonvalue-added step in the process. A value-added step, on the other hand, transforms or shapes services or information to meet the customer's requirements.

Pharmacy challenges
Metro's pharmacy faced several challenges. First, it had a serious inventory duplication problem. Medications were stored in four locations (fast-mover section, unit-dose cart fill, bulk storage and injectables), as is common in many hospitals. Certain medications were located in all four areas, which meant that staff had to refill multiple areas and had to search in more than one location for medications. They had 2,741 medication storage bins, 857 of which were duplicates. Thus, the team determined that 31 percent of this duplicated inventory was unnecessary.

During the evaluation process, the pharmacy calculated that it took technicians an average of 1.5 minutes to locate a product. That might not seem like a long time, but for a pharmacy operating around-the-clock and delivering more than 100,000 doses a month, time wasted in searching was costly to the organization. "A key part of our lean initiative was laying out the process and looking at which pieces had the greatest effects on time and safety," says Haverkamp. "Our primary goal was to reduce the time it took to deliver a medication to a patient. The inventory issues actually came up secondarily but resulted in significant time and money savings."

In fact, technicians were spending 77.4 percent of their time locating products; when a pharmacist needed a technician for clinical activities, the technician was usually off searching for a drug. The staff was so used to the status quo that it didn't realize how much time it spent searching for medications.

Another major problem centered on the system the pharmacy had in place for labeling and bagging medications for patient delivery. When pharmacists needed to fill orders, the information arrived electronically, and the appropriate labels were printed out on a single printer. However, multiple orders went to the printer simultaneously, and the labels were printed according to when they arrived, not according to patient. At the printer, which was inconveniently located, a technician separated labels by patient, peeling them off the strip and placing them on bags for the appropriate patients. Then technicians filled the bags with medication according to which labels were on the bags. This created confusion and led to medication errors resulting from labels printing simultaneously and technicians occasionally placing labels on the wrong bag.

Smaller problems, like locating the label printer far from the medications, amplified major problems, such as product duplications and an inefficient label-handling system. Likewise, there was a confusing categorization system. Although medications were supposed to be stored alphabetically by generic name, the alphabetizing system was inconsistent. For example, a multi-vitamin might be under "V" or "M," or even "T" for its trade name, Theragran. Similarly, vitamin C might be under "C" or "V," or under "A" for ascorbic acid.

The lean teams outlined several nonvalue-added steps in the process, only one of which was out of the pharmacy's control (i.e., the time it took to transport the ordered medication, once filled, to the appropriate floor). However, other nonvalue-added steps in the process were controllable and included:

The pharmacist retrieving the medication order from the queue

Labels accumulating on the printer

Travel time to retrieve a label from the printer

Technicians splitting labels by patient name

Locating product

Checked product sitting on counter

Moving the medication to a delivery basket

Moving the medication again to a delivery cart


At Metro, implementation of the lean program in the pharmacy involved closely following the Toyota Production System model. After meeting with leadership as well as an outside lean consultant, the pharmacy formed a team that set immediate 30-day and 90-day goals during a three-day process. During the three days, team members weren't involved in their normal work duties.

On day one, teams underwent training about lean concepts, tools and processes. A lean leader worked with each team to determine and finalize the scope of the project and its objectives. Day two involved dissecting the problem by gathering data, developing process charts, examining issues and inefficiencies, brainstorming and generating solutions. On day three, teams began the implementation process by developing communication plans, documenting steps, fine-tuning, and presenting solutions to area supervisors and lean leaders.

The teams also made lists of items to accomplish during the following 30 days, complete with names of responsible individuals and specific goal dates for each item. The team followed a similar process for 90-day goals. After completing the initial three-day program, teams began implementing the steps to meet the goals for the pharmacy department.

"Some quality-improvement initiatives are complicated and time-intensive, but implementing lean isn't complicated," says Haverkamp. "It's so straightforward, and the staff sees that early on in the process. There are immediate results, and three days isn't a lot of time to wait to see some real changes initiated."

Resistance to change
Nonetheless, it should come as no surprise that one of the main challenges to implementing lean ideas was resistance to change by staff. Regardless of the level of renovation a department or process might need, pulling individuals out of their comfort zones can be unpleasant. Similarly, when individuals operate the same way for a protracted period, the problems within the system become part of the everyday fabric.

Although reorganization didn't require the loss of jobs or the change of job titles for pharmacy staff, it did require significant changes to job descriptions, processes and physical locations. The need to rearrange the department meant added costs such as furniture purchases, which the pharmacy balanced against a projected inventory reduction of $50,000. The actual reduction ended up being more than triple that figure.

Still, the most challenging step was to convince the staff that the pharmacy indeed could improve. "Health care by its nature is very task-oriented, so many of the individuals working in health care also are task-oriented," notes Haverkamp. "It's hard to move beyond a trusted step-by-step process in health care, even an inefficient one."

However, presenting the step-by-step process to the staff gave them the opportunity to move beyond the process and look at it from the outside. By doing so, lean team leaders were able to help the staff see the potential benefits of the redesign. At Metro, everyone involved had an equal vote. Metro management believes that an all-inclusive approach improves staff buy-in more than a top-down approach.

The primary metrics monitored at Metro were medication error rates and cost reduction. The pharmacy streamlined the four medication areas into one centralized medication storage area. By doing so, the pharmacy reduced the number of unnecessary drug reorders as well as the time-intensive process of locating medications. By addressing its inventory problems, Metro reduced annual drug inventory costs by $153,000 the first year, and is now at pre-2001 inventory levels.

To solve labeling and location issues, the pharmacy first made sure that each bag had only one patient, one label and one medication. This one-product-per-bag-per-patient system smoothed out the filling process and decreased the chance of a medication error. Then the teams moved the printer to a more convenient location, nearer to the actual medication filling and setup area. By taking these simple steps, the pharmacy eliminated the labeling and bagging errors that were occurring at the printer and shortened the time it took a technician to retrieve a medication order.

Standardization was a key component of the redesign, especially with the process flow as it moved through the department. For example, after a technician filled a medication order, a pharmacist needed to check that the medication and dose were correct, and then place it in to-go status so that the appropriate party could pick up or deliver it. However, there were no specific locations within the pharmacy that differentiated which medications needed checking from those already checked, so filled orders sometimes would remain unchecked and to-go orders would sit unnecessarily.

As a part of the standardization process, the pharmacy implemented two new counters: a "check" counter and a "to-go" counter. They put in a simple color system in which red indicated the check counter and green indicated the to-go counter. They decreased the number of distractions by implementing a "safe zone" where a pharmacist could check medications without being disturbed. This easy fix reduced interruptions and decreased error rates significantly. Product no longer sits on the counter without a pharmacist knowing it's there, nor are there redundant steps between the delivery baskets and delivery carts. After the checkpoint, the medication automatically goes in the "to-go" area delivery bin.

Addressing the alphabetization problem also was simply a matter of standardization. By devising and agreeing upon a uniform system for categorizing medications, pharmacists and pharmacy technicians no longer face confusion or the need to search the alphabet--and thus the pharmacy--for a particular medication or vitamin. For example, all vitamins are now under "V." Likewise, standardized categorization simplified training and reduced numerous exceptions to the rule facing pharmacy trainees.

Overall, the pharmacy at Metro realized a 33-percent reduction in time to get medications to patients, and reduced the number of process steps from 14 to nine simply by removing nonvalue-added steps. Patients have experienced a 40-percent reduction in pharmacy-related medication errors, and the severity of those errors has decreased. In fact, since the implementation of lean, there have been no pharmacy-generated medication errors resulting in harm to patients.

Lean spreads beyond the pharmacy
Metro found that lean could go beyond patient-care areas and span the entire organization. For example, lean principles are applicable to environmental services, janitorial services and even administrative staff. "We have yet to see a situation in this organization for which lean hasn't worked," says Haverkamp. In fact, Metro currently has 432 individuals trained in lean (99 of those are on more than one team) and 90 projects completed. While the "Zip Scripts" handled the pharmacy initiative, the "Paper Pushers" are currently working to develop a standard forms-approval process and the "Stock Squad" is tackling inventory processes at neighborhood treatment centers. Metro is also building a new hospital and is using lean widely prior to moving into the new facility.

The future: lean Six Sigma in health care
Since 1999, VHA Inc., a national hospital alliance, has been helping hospitals explore and implement lean Six Sigma techniques for health care performance improvement to help them reduce costs as well as improve operational effectiveness and stakeholder satisfaction in supply-chain management, clinical, operational and financial areas. Most organizations focus on lean first and then implement Six Sigma, which can help identify and prevent process defects by reducing the number of standard deviations from a predetermined goal of near perfection for a given parameter. The union of lean manufacturing practices and Six Sigma methodologies has a proven record of accomplishment for generating the lowest-cost and highest-quality product on time.

Although pharmacies such as Metro's are using lean to fill drug orders in a timely fashion, lean Six Sigma principles can address multiple hospital needs. For example, these principles can improve:

Throughput in the emergency room

Throughput in the admissions department

Diagnostic testing turnaround time

Clinical-information management

Nursing efficiency

Start times and turnaround times in the operating room

Discharge processes

Standardization of clinical practices

Streamlining forms in pre-admission and admission processes

Co-pay collection and financial management


Baptist Health Medical Center in Little Rock, Arkansas, reduced the time it takes to move patients to an inpatient bed from the emergency department from 155 minutes to 55 minutes while simultaneously improving patient wait times. In catheterization labs, hospitals can use both lean and Six Sigma techniques to determine appropriate skill levels and ensure that they have the right equipment in place. For example, teams at Eastern Maine Medical Center in Bangor, Maine, improved on-time starts in the operating room by 83 percent, improved catheter laboratory charge capture and increased revenue.

When hospital administrators review their strategic and operational plans, it's worthwhile to consider using lean and Six Sigma tools and methodologies to implement change. Using such methodologies, hospital administrators can achieve their organizational goals quicker, and increased staff input and commitment can lead to dramatic clinical, operational and financial improvement. Although these proven methodologies stem from other industries, they're equally applicable to health care and can help hospitals accomplish many of their goals. Both lean and Six Sigma are newer endeavors for the health care industry, but when implemented, they're achieving dramatic results.

About the author
Patricia Houghton, RN, MHA, MBA, currently provides the direction and support for VHA consulting services for the New England and northeast region of the United States. She is also responsible for managing and facilitating rapid-improvement projects; clinical, financial and operational process-improvement engagements; and is a national product line leader for lean and Six Sigma methodologies. Houghton has more than 35 years of experience in the health care industry, and has more than 30 years as an experienced nursing leader and quality improvement lean/Six Sigma consultant. She received her master's degree in hospital administration from St. Joseph's College in North Wyndham, Maine, and a master's degree in business administration from St. John Fisher College. She is a registered nurse and a Six Sigma Black Belt.