Thursday, May 22, 2014

'Kanbans' improve processes for Pharmacy

Continuous quality improvement is all about finding ways to do our daily work better – creating efficiencies that add up to improved departmental performance.

In the Pharmacy department at Cox South, you can see an obvious sign of one of those improvements: large red tags hanging among the medications on the wall.

Those tags, known as “kanbans” in the parlance of process improvement, provide a quick visual cue that alerts staff that a medication needs to be reordered. Kanban is a Japanese word translated roughly as “signboard.” The use of signs as signals is a key part of Toyota’s manufacturing efforts, which serve as the basis of process improvement in a variety of fields.

Over the past several months, the kanbans have helped manage the flow of medication out of inventory and into use.

“In the past, we knew we had some issues with inventory management,” says Jennifer Reeves, operations director for CoxHealth’s Pharmacy department. “Sometimes there was excess product on the shelf, other times we would run low.”

Now, the kanban project has helped dial in the optimal amount of medication to have on hand. In addition to reminding staff members that a medication needs to be restocked, the cards have made that process faster and easier. Reeves says the kanban process has replaced educated guesswork with a data-backed system.

Improving processes
Inside the pharmacy, a large wall is stocked floor to ceiling with pegs filled with pharmaceuticals. Previously, a technician would walk along 20-30 feet of wall space and review the items on the pegs to determine what needed to be reordered and what needed to be repackaged. That staff member had a good sense of how quickly medications were used and they knew roughly when the pegs needed to be restocked.

“Each day, a technician was spending an hour just reviewing what was on the wall and figuring out what they would be cueing up for their work that day,” Reeves says.

To reduce that time and make sure there would always be the right amount of product on hand, Reeves and the team delved into the data of medication usage. They looked at a 120-day timeframe (60 summer days and 60 winter days) to measure the actual usage. From there, they created a “safety stock level” – the minimum amount of each medication they want to have on hand.

How it works
The kanban cards are placed on each peg, in front of the safety stock. The cards have reorder numbers and barcodes that can be scanned to reorder. The cards also include details about the kind of package a medication needs – paper, light sensitive, etc. – so the techs can sort their workflow by the type of packaging.

When a staff member gets to a kanban card, the card is placed on a separate board. At the end of the day, a tech can scan all the cards for ordering overnight. The next day when the medication arrives, that becomes the day’s workflow.

“What used to be a one-hour process is now a 10-minute process,” Reeves says. The technicians are freed up for other responsibilities, so other staff get to go out on patient floors. “Without hiring any new staff members, we’ve been able to increase our services to the nursing staff.”

Reeves says that since wholesalers deliver medications five days a week, it’s just as efficient to have multiple, small orders rather than having the pharmacy overstocked.

“We have to use all of our available space to the best of our ability and extra stock takes up extra space,” Reeves says.

Data-driven performance
Monitoring the data has been key to adjusting the days-on-hand supply in the Pharmacy. The team started with seven days on hand and they have been adjusting down as they go.

The biggest question Reeves hears when people learn of the project is, “How do you keep from running out?” She’s quick to point out that the days on hand amounts also account for variability in patients and include some extra as a cushion in case of emergency.

“We can also get most medications from another location within the system, or here in the city,” she says, noting that patients are never at risk of being unable to access medication. Reducing days on hand just makes sense when you have access to reliable data and frequent deliveries, Reeves says.

“Our controlled substances used to have 17 days on hand, for example, but there’s no need for that when we can get anything the next day. You don’t have 17 days of bread on hand at home.”

Strategy expands 
The kanban system has been in place in the pharmacy since last fall and it’s being introduced to a wider variety of medication storage areas. Staff members and leaders have also been working to spread the usage of kanbans. Ashley Digiovanni, technical supervisor, recently implemented a kanban system in the bins where liquid medications are prepared. The bins where the medications are prepared now have “critical low” cards that remind all technicians of the supply level.

Jennifer Reeves says the kanban process is continuing to expand: Kanbans will soon be in place in the IV room and staff members are evaluating usage numbers for the injectable section. Reeves expects to have kanbans used in nearly every area within the pharmacy by the end of the year.