WQD2011 - Breakthrough Process Improvement - NMC - A ‘prescription’ for improving the patient experience by “Leaning” the Pharmacy

BREAKTHROUGH PROCESS IMPROVEMENT STUDY

NMC SPECIALTY HOSPITAL, DUBAIA ‘prescription’ for improving the patient experience by “Leaning” the Pharmacy

JUNE‐OCTOBER, 2011QUALITY TEAM

INTRODUCTION

NMC Specialty Hospital, Dubai is one of the prominent hospitals of choice in Dubai. It provides a comprehensive range of healthcare services supported by experienced medical professionals.

With around 620 employees, this 100- bedded Multispecialty hospital, located at the Border of Dubai and Sharjah, serves in a demographically strategic location for Emiratis and expat population. The hospital strives to make every patient’s experience welcoming and comfortable.

PROJECT CHARTER

A. The Business Case:

The opportunity cost lost due to the dissatisfied customers is 22% of the total business generated by the pharmacy .This loss of business is due to dissatisfied customers who are leaving the pharmacy without fulfilling their prescriptions because of a long waiting time.

Since the Organization’s Mission and Vision is for providing World Class care to patients, it became necessary to study the issue in detail.

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B. The Problem StatementPatients are leaving the pharmacy without fulfilling their prescriptions because they find the waiting time and the experience to be unsatisfactory resulting in loss of revenue.

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PROJECT INITIATIVE

With continuous flow of patient complaints and dissatisfied customers, loss of revenue from medication sales when the patient left the pharmacy, dissatisfied employees due to patient arguments due to long waiting time in outpatient pharmacy, various initiatives were taken by the management to improve the pharmacy patient waiting time but were not successful in reducing the long waiting time.

Later it was decided by the management that the pharmacy project would be taken as six sigma project that would improve bottom lines as well as patient satisfaction.

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PROCESS MAPPINGD M A I C

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INDICATORS

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Goal statement

1.Reduce the waiting time and also the inconsistency of processing time for the same kind of customers served:

Cash Patient -360 secondsCredit Patient-720 seconds

2. Retention of lost business to the tune of about AED 9.5 million per annum.

3.Increase patient satisfaction about 85%

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Teams Involved

• Dr Abraham-Vice President - Quality and Standards.• Dr Ajit Kumar-Medical Director.• Dr Jaskaran Singh –Medical Administrator.• Dr Reshma Karmar-Quality Coordinator.• Dr Samar-PRO.• Mr Sarvana-Head of Accounts Department.• Dr Eman-Insurance Department.• Mr Shivaji Shetty-Head of Pharmacy (NMC Group).• Mr Praveen-Head Pharmacy.• Ms Binu-Head of cashiers.• Ms Mercy Augustine-Nursing Director.• Nursing Supervisors.

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Stakeholders model

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PHARMACY

PHARMACIST

DOCTORS

NURSES

CASHIERSSUPPLIERS

PATIENTS

SECURITY

Project Timelines

Activity Date-set time Actual completion time

Start 23/06/2011 25/06/2011

Define 27/06/2011 28/06/2011

Measure 1/06/2011-7/06/2011 1/06/2011-7/06/2011

Analyze 15/06/2011-20/06/2011 21/06/2011-22/06/2011

Improve 23/06/2011 30/06/2011

Control 1/10/2011 1/10/2011

Closure and handover 7/10/2011 7/10/2011

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Quick win opportunities

We found out that the staff allocation was unsuitable to handle the patients flow. Number of staffs working in OPD hours 0900H to 1300H and 1700H-2100H and non working hours (1300H to 1500H ) were not appropriate.

Action taken : staff re-allocation was done as per the patients flow.

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Measure Phase

• Time Measurement: Measurement using Time sheets was done in seconds. Data collection was done for a week from Wednesday to Tuesday for 24 hours. This gave a complete idea as to what are the busy hours and which days can be considered as busy days.

• System generated data had only 3 variables : Arrival time, Token called time and Billing Time.

• Preparing time, Approval time and Counseling Time was manually entered by the pharmacist and cashier. Billing time was again cross checked on random basis with the bills generated time and was found accurate.

The intention for collecting this data was to get a fair idea as to what is the time taken for each step process.

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Measure Phase(contd.)

The process flow was divided into 6 steps:Arrival time: Patient entry time.Preparing time: Placement of the prescription on the pharmacy tray, to medication preparation and its placement on the Pharmacy Table.Approval time: Insurance Company called time to approval received time from respective insurance company.Counseling time: Token called time to medication bills received by patient time which includes counseling of the patient .Billing Time: Bills received by patient time to receipt received from cashier time. Exit-when the patient leaves the pharmacy

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No of prescription prescribed from out patient department- Prescriptions sent from outpatient department were compared with the number of prescription present in pharmacy.

The rationale behind this was to know the total number of patients the pharmacy was not able to serve.Efficiency of the counters: This was done with the number of prescription being billed by each counter. This helped in knowing work load on each counter and its distribution.Staff distribution: This was collected using the staff rota being assigned on those days of data collection. This was to used to know whether the staff distribution was accurate corresponding to the patient flow.Voice of customer: This data was collected using the survey forms which was already implemented in the hospital to measure the patient satisfaction in pharmacy.

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Measure Phase (contd.)

Measurement system limitations

All the processes used in the OPD pharmacy are not system-based as this is a time-based study. The start point is the patient entry into the pharmacy & the exit is when the patient receives the medications and exits.The constraints are that the team worked with an improper recording system. That is, computer generated system time were not available for all times. Manual entry had to be done at several steps in the process.Not all patients data was collected due to time constraints.

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Measurement reliability

Measurements sheets were given at different counters and staff entered data only for the time recording assigned to them. They were not able to see the other timings recorded in the process. At the end of the day the data was collected from different counters and compilation was done of all variables .Manual measurements were compared with system generated variables.Billing time was again cross-checked on random basis with the bills generated time and was found accurate.

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Process Capability

Increase in number of counters.Seating area inside the pharmacy close to the token system.Re-training of pharmacist, cashiers.Information to regular patients on change in process.

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DPMO

Pre study

DPMO for Cash Patients - 825553

DPMO for Insurance Patients - 764568

Post -Study

DPMO for Cash Patients - 427807

DPMO for Insurance Patients - 496434

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Problem statement

An average of around 482 patients per day were consulted by OPD clinics and prescription served. Out of these 302 were insurance patients and 180 were cash patients. Around 97 patients left the pharmacy without availing any pharmacy services. The loss of revenue per patient was estimated AED 179 per day resulting in an estimated loss of revenue to the tune of AED 9.5 million per annum.

One of the main reason for patients leaving the pharmacy was a long patient waiting time. We also determined the average time spent by the patients in the pharmacy for being served for each category of customer. An average of around 667 seconds for cash patients and 1634 seconds for insurance patients were utilized by the pharmacist to dispense the medications.

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Validation of root cause

To create the diagram, the team started with the problem statement , and asked “Why?” a total of five times. •Why Long preparing time for cash and insurance patient’s ?•Why Cash counter was not free?•Why Delay in insurance approvals?•Why Delay in counselling time?•Why Long waiting time.?

Validation: Root Cause analysis was validated by Gemba investigation

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PARETO CHART DEPICTING TIME INTERVALS FOR CASH PATIENT

PARETO CHART DEPICTING TIME INTERVAL FOR INSURANCE PATIENTS

Pareto chart interpretation

The Pareto analysis depicts that 80% of time is contributed by the waiting time and counselling time in both cash and insurance patients.

Since the counselling time may not be easy to decrease the team decided to work on other steps in the process .

Solution criteria set by the team

• To speed up the process of medication delivery

• To retain patients leaving the pharmacy• To improve patient satisfaction

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Solution Advantage Disadvantage Scoring Total Ranking

Change inprocess of medication delivery

No installation charges

5 25 1

Decreased Deployment time

5

Decreased training time

5

No involvement of doctors

5

No manpower wastage

5

Solution selection process

Solution Advantage Disadvantage scoring Total Ranking

Increase in Number of counters

More number of patientscan be served

5 20 2

Less installation chargesas available space been used

5

Convenient for the pharmacist for dispensing

5

Convenient for the patient 5

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Solution Advantage Disadvantage Scoring Total Ranking

Increase in Number of pharmacist

Reduces Medicationdelivery time

Increasedsalary expense

5 – 5 = 0 0 3

Increasednumber of patients can be served

Manpowerwastage as per the allocation of the counters.

5 – 5 = 0

Solution Advantage Disadvantage Scoring Total Ranking

Electronic prescriptions

1.Ensures Quick error free prescriptions

1.Large installationexpense .

5 – 5 = 0-10 4

2.Patients are retained as prescriptions are not handed over to the patients

2.Increaseddeployment time

5 – 5= 0

3.Increased training Time

-5 = -5

4.Involvement of Doctors

-5 =- 5

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Ranking method

The Advantages and Disadvantages were scored +5 and -5 respectively and the total was considered for the ranking.

The ranks are mentioned below

Change in process of medication delivery= 25(Rank 1)Increase in number of counter= 20(Rank 2)Increase in Number of pharmacist= 0 (Rank 3)Electronic prescription = -10 (Rank 4)Rank 1 and rank 2 were considered for the solution.

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The major area for improvement and changes as per the study was

Change in the design of counter from 4 counters to 6 counters.Change in the whole process of medication delivery were one staff is involved in dispensing of medication.Change in the environment of the pharmacy. Patient had no more to wait outside. Instead they were made to sit inside pharmacy and view the process.

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Solution Details

Change in process of medication Delivery

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MISTAKE PROOFING

The token slip mentions “cash” or “credit”. This is to provide a check in preventing error in dispensing the wrong token.The dispensing pharmacist as well as the patient counter checks to ensure that the right token is dispensed.Cash prescriptions, insurance prescriptions which require approvals and insurance prescriptions which does not require approvals are handled exclusively by separate counters.Seating of the patient inside eliminates the lag time from when the patient is summoned to when the patient appears at the counter.

PRE-STUDY PHARMACY STRUCTURE

PRE-STUDY PHARMACY STRUCTURE

POST STUDY PHARMACY STRUCTURE

Benefits generated

Average of 2.2 million has been gained within the confines of study period. This has accomplished the strategic profitability and patient satisfaction.

Benefits Target Pre-study Post study

Dispensing Time for cash patient

Reduce of the Total time to 360 seconds

667 seconds 449 seconds

Dispensing Time for Credit patient

Reduce of the total time to 720 seconds

1634 seconds 864 seconds

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TIME MEASUREMENT BEFORE-AFTER STUDY

Cash Patients Preparing Time

Counseling Time WaitingTime

Billing Time Total Time

Time estimation before 117 145 327 86 667

Time estimation after 108 127 177 54 499

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PREPARING TIME COUNSELLING TIME BILLING TIME WAITING TIME TOTAL WAITING TIME

TIME ESTIMATION FOR CASH PATIENT BEFORE

AFTER

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Before –After Time study

Insurance patients

Preparing Time

Approval Time

Counseling Time

BillingTime

WaitingTime

Total Time

Time Estimation Before

112 356 145 93 1222 1634

Time Estimation After

157 236 193 62 460 864

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PREPARING TIME APPROVAL TIME COUNSELLING TIME BILLING TIME WAITING TIME TOTAL WAITING TIME

TIME ESTIMATION FOR INSURANCE PATIENTS BEFORE

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Patient SatisfactionD M A I C

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Before study After study

Patient Satisfaction

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CONTROLS PUT IN PLACE TO ENSURE

THAT THE GAINS ARE LOCKED :

• Physical structure of pharmacy counters.

• Periodic inspection of the process by the Administrator.

• The Team developed a control plan for regularly and consistently measuring the buying time and taking timely corrective action in case the data indicated negative trends or points in the control chart that suddenly appeared outside the control limits, signifying sudden process shifts due to assignable causes.

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Roles of stake holders

Medical Administrator Guidance

PharmacistIn collection of data, dispensing ofMedication as per the new process

Nurses Collection of prescriptions

Maintenance Responsible for change in theStructure of pharmacy

Quality DepartmentTraining of staff, analysis, collection

of data.

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Vice President Quality and Standards Overall Guidance

LEARNINGS

Improvement in process efficiency lead to shortened throughput time resulting in

improved patient satisfaction and recovery of lost revenue

Horizontal deployment

Similar changes are being implemented in sister hospitals of NMC healthcare

Team recognization

The Team was recognized with an appreciation certificate

A prescription for Improving Healthcare by “Leaning” the Pharmacy is a excellent example because of the following benefits

Increase in Patient satisfaction from 58% to 75%Decrease in time taken to dispense medications • Cash patients-667 seconds to 449 seconds.• Insurance Patients-1634 seconds to 864 seconds.

Recovery of business loss to 2.2 million within the period of project.

An Excellent Example