Service Improvement In A Hospital Pharmacygsblibrary.uct.ac.za/researchreports/2009/Maharaj.pdf ·...

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CASE STUDY: SERVICE IMPROVEMENT IN A HOSPITAL PHARMACY

CASE STUDY: SERVICE IMPROVEMENT IN A HOSPITAL

PHARMACY

A Thesis

presented to

The Graduate School of Business

University of Cape Town

in partial fulfilment

of the requirements for the

Masters of Business Administration Degree

by

Vanita Maharaj

December 2009

Supervisor: Professor Norman Faull

Co-supervisor: Ralph Hamann

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PREFACE

This thesis is not confidential. It may be used freely by the Graduate School of Business. The

names of the respondents and organization in this Case Study have been changed in order to

ensure confidentiality.

I would like to thank all the management and pharmacy staff that provided me with their time

and input in explaining the situation within the Outpatient Pharmacy Department (OPD). I

appreciated the openness from all the pharmacy personnel. I would also like to acknowledge

the help that the process analyst gave me. Without any of their assistance I would not have

accomplished what I set out to do.

I would like to thank the ethics board at the hospital for allowing me to conduct my

interviews at the hospital. Their staff‘s promptness is much appreciated.

I would like to acknowledge the valuable guidance of Ralph Hamann. He has helped me with

understanding how the message of this research should be portrayed.

Finally, I would like to thank my supervisor Norman Faull who helped me in times when

situations didn‘t work out, and guided me in understanding the importance of the message

that I needed to bring across in this case study.

This case allowed me, as a healthcare professional, to experience how lean could be adapted

in settings that might have been regarded as impossible by others.

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PLAGIARISM DECLARATION

I understand that plagiarism in wrong. It entails using another‘s work and pretending

that it is one‘s own work.

I certify that this thesis is all my own work.

I will not allow anyone to copy this thesis with the intention of passing it off as their

own work.

I have used the conventional method of citation and referencing. All quotes, and

literature used have been referenced.

Name of Student: Vanita Maharaj

Signature of student:

Date: 10 Dec. 09

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ABSTRACT

This case study describes the challenges faced in a service environment with regard to lean

implementation and sustainability. It focuses around the Outpatients Pharmacy Department

(OPD) within a public hospital. It aims to provide insight to the importance of change

management in creating a lean environment and culture. Various models from literature were

used as a guideline to determine whether the change process was acceptable. The results

showed that the initial implementation was successful and produced positive results in the

work operations. However, after a series of events within the pharmacy the lean project

started to deteriorate, putting a strain on the processes as well as the staff.

KEYWORDS: Change management, creating lean cultures, lean

implementation, lean sustainability, lean implementation

challenges, lean in public service environment, enablers and

inhibitors.

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CONTENTS

LIST OF TABLES .................................................... 9

LIST OF FIGURES ................................................... 9

1. INTRODUCTION ............................................. 11

1.1 CASE THEME AND PURPOSE ....................................... 11

1.1.1 CONTEXTUAL BACKGROUND ...........................................11

1.1.2 PURPOSE OF THE RESEARCH ...........................................16

1.1.3 SIGNIFICANCE OF THE RESEARCH ..................................17

1.2 LEARNING OBJECTIVES .............................................. 18

1.3 RESEARCH ASSUMPTIONS AND ETHICS .................... 20

2. LITERATURE REVIEW ................................... 21

2.1 LEAN IN HOSPITALS ........................................... 21

2.2 LEAN THINKING ........................................................... 23

2.3 CHANGE MANAGEMENT .............................................. 26

2.3.1MODELS FOR CHANGE .......................................................27

2.3.2MANAGERS .........................................................................30

2.4 CREATING A LEAN CULTURE .................................... 33

2.4.1 LEAN MANAGEMENT SYSTEM ..........................................34

2.4.2 FOCUSING ON THE STAFF ................................................37

2.5 THE CHANGE AGENT (CA) ......................................... 37

2.5.1CHARACTERISTICS OF A CA ..............................................38

2.5.2LEADERSHIP ROLES/STEPS ...............................................38

2.6 ATTITUDES TOWARDS CHANGE ................................ 41

2.6.1 INHIBITORS .......................................................................41

2.6.2 ENABLERS .........................................................................43

2.6.3 ENABLING EMPLOYEES-OVERCOMING RESISTANCE .....44

2.7 LEAN TOOLS/CONCEPTS ........................................... 46

2.7.1 CELLULAR FLOW ...............................................................46

2.7.2 VALUE STREAM MAPPING ................................................47

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2.7.3 PLAN-DO-STUDY-ACT (PDSA) CYCLE & A3 TOOL .............48

2.7.4 5S, FISHBONE ....................................................................50

2.8 SUSTAINABILITY ....................................................... 52

2.9 CONCLUSION ............................................................. 53

3. CASE METHODOLOGY .................................. 55

3.1 SAMPLING .................................................................... 55

3.2 DATA COLLECTION METHODS .................................... 57

3.3 DATA ANALYSIS METHODS ......................................... 59

3.4 RESEARCH INSTRUMENTS ........................................ 60

3.5 A TEACHING CASE METHODOLOGY......................... 59

4. CASE STUDY: SERVICE IMPROVEMENT IN A

HOSPITAL PHARMACY ........................................ 62

1. ORGANIZATIONAL BACKGROUND ................................ 63

2. OUTPATIENTS PHARMACY DEPARTMENT – OPD .... 64

2.1 THE DISPENSING PROCESS ................................................ 64

2.2. THE DRAWBACKS ............................................................ 66 2.3 THE NEED FOR CHANGE ................................................................67

3. INTRODUCING LEAN ...................................................... 68

3.1 PHARMACY MANAGEMENT ..................................................69

3.2 THE PROGRESSION ..............................................................69

3.3 THE FACILITATOR’S AIM ......................................................71

4. A CHANGE HAS COME .................................................... 72

4.1 THE OUTCOMES ...................................................................73

5. STAFF ROTATION .......................................................... 75

5.1 LEAN FOLLOWING A ROTATION ..........................................75

5.2 FACILITATORS REALIZATION ..............................................77

6. GOING FORWARD ........................................................... 78

EXHIBIT 1: PROCESS FLOW- THE DISPENSING PROCESS ............ 80

EXHIBIT 2: TIMELINE OF EVENTS ............................................ 81

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EXHIBIT 3: PATIENTS COMMENTS ........................................... 81

EXHIBIT 4: A3 TOOL FOR OPD (4/6/8). .................................. 82

EXHIBIT 5: PROCESS FLOW- THE BUDDY SYSTEM ..................... 83

EXHIBIT 6: VALUE STREAM MAP WITH LEAN ............................ 84

EXHIBIT 7: PATIENTS COMMENTS AFTER LEAN ......................... 85

5. TEACHING NOTES ........................................... 86

5.1 CASE SUMMARY .......................................................... 86

5.2 LEARNING OBJECTIVES ............................................ 87

5.3 CASE PREPARATION .................................................. 88

5.4 DISCUSSION SESSION ............................................... 88

5.5 ASSIGNMENT QUESTIONS & ANSWERS .................... 89

QUESTION 1: WHAT ENABLED AND INHIBITED EMPLOYEES TO ADOPT THE LEAN

PROJECT? IN YOUR ANSWER, MENTION HOW THE VALUE STREAM MAP HELPED.

.............................................................................................................89

QUESTION 2: WHAT ARE THE TRAITS OF THE CHANGE AGENT THAT EITHER

PROMOTED OR INHIBITED THE LEAN TRANSFORMATION THROUGH THE CASE

STORY? ..................................................................................................92

QUESTION 3: HOW SHOULD MANAGEMENT HANDLE THE SUSTAINABILITY OF LEAN

PRINCIPLES? WAS IT BENEFICIAL THAT THE LEAN PROJECT CREATED AN

“EMERGENCY MODE”? ...............................................................................94

QUESTION 4: CONSTRUCT A FISHBONE DIAGRAM TO ILLUSTRATE HOW THE

PROBLEM OF THE INCREASED WAITING PERIOD, AFTER LEAN IMPLEMENTATION,

HAD OCCURRED. .......................................................................................96

5.6 TIME ALLOCATION ..................................................... 97

REFERENCES ....................................................... 98

INTERVIEW LOG BOOK ...................................... 102

INTERVIEW 1: VARNI –HEAD PHARMACIST- 26 OCTOBER 2009 ......................... 103

INTERVIEW 2:VARNISHREE NAICKER-HEAD PHARMACIST-30TH OCTOBER 2009 ....... 106

INTERVIEW 3-LELITHA-PHARMACIST- USE TO BE THE MANAGER IN OPD DURING LEAN-3RD

NOVEMBER 2009................................................................ 109

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INTERVIEW 4-PATRICIA-PHARMACIST-OPD PHARMACY MANAGER AT CURRENT-3RD

NOVEMBER 2009................................................................ 113

INTERVIEW 5-NISHA-LOCUM PHARMACIST-3RD NOVEMBER 2009 ...................... 117

INTERVIEW 6-AKEELA-ASSISTANT MANAGER-OPD-NEW EMPLOYEE-3RD NOVEMBER .. 120

INTERVIEW 7 -NARIMA- PHARMACIST ASSISTANT- 15 YEARS- SHE HERE WAS BEFORE AND

AFTER LEAN-3RD NOVEMBER 2009 .............................................. 122

INTERVIEW 8-IRENA-CHIEF OPERATIONAL PHARMACIST-SECOND IN CHARGE-9 NOVEMBER

................................................................................. 127

INTERVIEW 9-DR ZAMEER BREY-FACILITATOR & CHANGE AGENT-9 NOVEMBER 2009 130

INTERVIEW 10-FEROSA- OPD MANAGER DURING THE ROTATION- INTERVIEW 12

NOVEMBER 2009................................................................ 138

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LIST OF TABLES

Table 1. Lean thinking principles within a hospital setting. ....................................... 17

Table 2. Factors aiding the deterioration of service to patients .................................. 22

Table 3. Ten ways to: “Getting Lean Right” .............................................................. 24

Table 4. Approaches to Lean implementation ............................................................ 32

Table 5. Attributes of different cultures in mass and Lean production ....................... 33

Table 6. Differences in habits and practices between batch and Lean cultures ............ 34

Table 7. Leader Standard work for Team leaders and supervisors ............................. 35

Table 8. Three tiers of daily meetings ........................................................................ 36

Table 9. Dimensions of leadership .............................................................................. 39

Table 10. Steps required for adoption of Lean thinking .............................................. 40

Table 11. Different factors contributing change ......................................................... 41

Table 12. Ways in which presence of resistance can be restricted. .............................. 44

Table 13. Ways in which resistance can be dealt with. ................................................ 45

Table 14. Components of A3 tool .............................................................................. 50

Table 15. Processes for acting on sustainability .......................................................... 52

Table 16. Categories of change and improvement...................................................... 53

Table 17. Linkages between literature and the research area ..................................... 54

Table 18. Composition of a teaching case ................................................................... 60

Table 19. Steps in preparation ................................................................................... 88

Table 20. Dimensions of leadership ............................................................................ 93

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Table 21. Interviews ................................................................................................ 102

LIST OF FIGURES

Figure 1. Transforming Healthcare Organizations, adapted from Golden (2006). ....... 28

Figure 2. The Generic Framework for the Management of Change towards a Lean

Enterprise, adapted from Smeds (1994). .................................................................... 29

Figure 3 The Role of Temporal Shifts in Facilitating Organizational Change, adapted

from Staudenmayer et al. (2002). ............................................................................... 29

Figure 4. Management hierarchies in a traditional company and a Lean company,

adapted from Found & Harvey (2007). ...................................................................... 31

Figure 5. Classification of Climate dimensions, adapted from Bouckenoogehe et al.

(2009). ....................................................................................................................... 43

Figure 6. Cellular Working: no delays between steps ................................................. 47

Figure 7. Value-stream mapping, adapted from Rother & Shook (2003), cited by Zak

(2008) ........................................................................................................................ 48

Figure 8. Model for improvement adapted from the Institution for Healthcare

Improvement. ........................................................................................................... 49

Figure 9. The hierarchy within the pharmacy division ............................................... 56

Figure 10. Cycle times against takt times ................................................................... 91

Figure 11. Cycle times after ECSS against takt time ................................................... 91

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1. INTRODUCTION

1.1 CASE THEME AND PURPOSE

1.1.1 CONTEXTUAL BACKGROUND

The concept of Lean is associated with applying practices at each step in a process which

generates ―quality‖. The Toyota Production System (TPS)1, developed by the automobile

manufacturer Toyota, has been the founder of the Lean management philosophy and

practices. The objectives of TPS includes delivering the results smoothly, while removing

any inconsistencies and most importantly, eliminating waste. Lean principles have been

predominantly applied within the manufacturing environment, which then showed use in the

service industries over the last twenty years.

Health care services have been the latest addition to utilize Lean principles (Corbett, 2007).

The hospital institution that will be the domain for this research is a Tertiary Academic2

hospital that forms part of the Public Health sector within South Africa. It is a large,

government-funded, teaching hospital situated in Cape Town, South Africa. The hospital has

an annual budget that exceeds R1 billion and employs more than 3500 personnel. The

hospital has developed a number of hubs of expertise in fields such as neurosurgery,

haematology, cardiology and transplant medicine. The pharmacy within the hospital setting is

the area in which medicine originates and is distributed to the other sectors (Intensive care

units/ICU‘s, Wards, Patients) in the hospital. Within this tertiary institution there are five

different types of pharmacy departments, namely:

The inpatients’ pharmacy department that supplies medication to cater to patients that

have been hospitalized and for those who are being discharged from the hospital.

1 Obtained from, http://en.wikipedia.org/wiki/Toyota_Production_System. [Accessed August 23, 2009]

2 A tertiary hospital, tertiary referral centre or tertiary care centre is a term without a formal definition

which in the United States generally refers to:

a major hospital that usually has a full complement of services including paediatrics, general

medicine, various branches of surgery and psychiatry or

A specialty hospital dedicated to specific sub specialty care (paediatrics centres, oncology centres,

psychiatric hospitals). Patients will often be referred from smaller hospitals to a tertiary hospital

for major operations, consultations with sub specialists and when sophisticated intensive care

facilities are required.

Obtained from, http://en.wikipedia.org/wiki/Tertiary_referral_hospital. [Accessed, August 24, 2009]

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The outpatients’ pharmacy department that supplies medication to day patients. Day

patients include those individuals who approach the hospital‘s clinicians (doctors)

with aliments that do not require them to be hospitalized.

The bulk pharmacy which operates as the storage facility of medication.

The chemotherapy pharmacy that focus on drugs used for treating cancer patients.

The sterile unit that deals with Total Parental Nutrition (TPN), which are nutritional

formulae administered intravenously (through the vein) to patients.

The activities that the pharmacy performs, with regard to medicine distribution within the

hospital are:

Daily supply of medication to ward stocks

Daily dispensing of medication to new and current inpatients

Compounding medication

Dispensing of emergency medication

Ordering medication.

Pharmacies have a different set of time and flow requirements. Speed and response to

demands are important for process requirements within a pharmacy. In this study, emphasis

will be placed on the busiest pharmacy hub – the Outpatient Pharmacy department (OPD) –

within the hospital. They have a daily influx of 500 folders on average. These folders contain

the doctor‘s scripts that have a list of medication that needs to be dispensed to the patients.

Unfortunately OPD had been experiencing an ongoing problem of the patients waiting 4

hours on average for their medication. Before democracy in 1994, South Africa‘s health care

system was characterised by fragmentation. The health sector focused mainly on hospitals as

the forum for healthcare to be delivered; thereby no attention was given to delivering primary

healthcare3 to the majority of the people in need. Individuals who lived in rural areas had no

access to clinics when in pursuit of healthcare treatment, and therefore had to travel long

distances to the hospitals. Progressively over time the health sector has changed to

3 "Primary Health Care is essential health care based on practical, scientifically sound and socially

acceptable methods and technology, made universally accessible to individuals and families in the

community through their full participation and at a cost that the community and the country can afford

to maintain at every stage of their development in the spirit of self-reliance and self-determination"

(Alma Ata Declaration on Primary Health Care, WHO-UNICEF, 1978)

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accommodate those who were previously disadvantaged with relation to accessibility of

healthcare. With regard to new legislation, in recent years, it has been passed to4:

Provide affordable drugs and promote generic medication;

Prevent discrimination against individuals who are ―high risk‖ with regard to health or

age, by regulating the medical schemes;

Legalise abortion and in both public and private health facilities;

Increase awareness about health risks of tobacco.

With people having this expectation of better healthcare, the increased waiting time was not

suitable for the sickly patients that waited for their medication, especially those who had

travelled far. As a result, quality of care – the aim of any healthcare facility – was

deteriorating.

The problem also affected the functionality of the staff within the OPD. Staff were highly

stressed and overworked. They could not meet the demands of the influx of folders.

According to Graban (2008), delay in medication orders may stem from work overload and

understaffing. This was seen in the OPD, which caused problems when there were

insufficient staff levels to attend to the patients promptly. This in turn caused an increased

waiting time for the patients. If work was not level-loaded, this resulted in delays during

different peak levels.

The country faces difficulties in retaining the healthcare professionals (doctors, pharmacists,

nurses, etc.) in South Africa, thereby affecting the delivery of services by health institutions.

The reasons for emigrating are broad, and range from, insufficient staff levels, weak

infrastructure, inadequate resources and supplies, or unfavourable remuneration. In a

Memorandum to all Department of Health Professionals5 (2009), the Deputy Director

General of the National Department of Health of South Africa, Dr Percy Mahlathi stated that

reasons for health professionals leaving have been focused around questions of their salaries

and working conditions under which they perform health care services. Many medical staff

believe that their working conditions have progressively deteriorated, and therefore a cycle

has been created: frustrated staff leave for prospects of a better life elsewhere, placing the

staff that are left behind in a worse crisis. The primary reason the public health sector has not

4Facts and Information in this paragraph was received from

http://www.southafrica.info/about/health/923086.htm. [ Accessed August 21,2009] 5 Obtained from, http://www.doh.gov.za/docs/pr/2009/pr0526.html. [Accessed August 29, 2009]

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disintegrated yet is that its employees remain loyal and are often committed to extending their

services far beyond their contractual requirements, responsibilities, and remuneration. The

outcomes of previous as well as current strikes have given healthcare professionals the

impression that empty promises from the Government have resulted in an unprecedented

event in South Africa: the withdrawal of services by healthcare professionals until their

demands have been met. Countermeasures have been implemented to address the ―brain

drain‖ situation. These countermeasures have manifested in the form an Occupational

Specific Remuneration and Career Progression Dispensation (OSD) for health professionals

which have the objectives to6:

―Enhance recruitment and retention of critical skills and competencies required in

health service delivery.

Provide clear salary and career progression measures based on competence and

performance.

Recognise outstanding performance through comprehensive occupation specific

performance measurement tools rather than following the generalised ‗one size fits

all‘ approach.

Reward additional skills and professional competencies that translate to good clinical

performance.

Support personal development towards specialisation because this is critical for the

maintenance of high standards of care.

Create transparency in salary determination by keeping special remunerative

allowances to a minimum‖.

Hospital management was not willing to supply resources to acquire more staff. They decided

to utilize a process analyst to attend to the problem that OPD was facing. Graban (2008)

describes Lean in hospitals as an approach to deviate employees and physicians‘ attention

away from unnecessary ‗roadblocks‘ through elimination of such obstacles, therefore

allowing them to focus primarily on patient care. Lean can also facilitate in providing long-

term benefits to hospitals, such as reducing costs and allowing for growth and expansion of

the organization. ‗Silos‘ that may exist between different departments within the hospitals

can be eliminated through the process of Lean implementation, thereby allowing a more

effective, and supportive environment for executing health care to patients.

6 Obtained from, http://www.doh.gov.za/docs/pr/2009/pr0526.html. [Accessed August 29,2009]

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With the application of Lean principles, such as Value Stream Mapping, A3-Tool, and PDSA

cycle, the waiting time was reduced to 55 minutes. However, receiving support from all the

staff was a problem. Some staff were supporters while others were resistors. According to

Graban (2008) Lean concepts can cause ―dramatic improvement by looking at our processes

in a new way, engaging our own employees to identify waste and develop their own

solutions‖. Increasing resources in a hospital will not eliminate the problems. Increasing hard

work will not guarantee problem resolution. It is the processes that need to be changed, which

could ultimately lead to a decrease in work load because outcomes are improved for all. That

is why it is imperative to focus on facilitating the staff to bring about change.

Although success showed, no documentation was done in response to interventions that were

implemented. This impacted OPD negatively when a staff rotation had occurred. A new

management team entered OPD. Because of the lack of documentation and no proper

communication between the old and new management team, the new team shifted the focus

of the OPD from a Lean environment to a HR-related environment. Staff needs were the main

focus. This caused the waiting period for patients to increase, as processes were changed and

not adhered to. There was no sustainability of the processes.

At present, the Department of Health has established a Draft Program of Action7 for the

period of April 2009 – March 2010 that incorporates aspects and actions aimed at:

Improving the Quality of health services;

Improving the management within the healthcare system through: developing an

accountability framework for the public and private sector ;developing a decentralized

operational model that includes new governance arrangements (approved by the

National Health Council); and strengthening the health-specific management capacity

for programs and facilities, especially hospitals; and

Revitalization of infrastructure :through implementation of refurbishment and

preventative maintenance of all health facilities that are instructed to use 3 – 5% of

budget to implement change; as well as through strengthening provincial departments

of health capacity to deliver and maintain health infrastructure for primary and

secondary health facilities.

7 Draft Program of Action: Health, for April 2009 – March 2010. Received by Dr Zameer Brey.

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Although not much is known about the exact processes that will be implemented by the

Department of Health with regard to service improvement, it is important to realise what

other ―non-monetary‖ options are available. Options like Lean.

1.1.2 PURPOSE OF THE RESEARCH

There is a paucity of literature on how to implement Lean principles within a hospital, with

particular focus on the people element of change and improvement. This ‗change

management‘ forms the foundation to assist the traits that individuals might have that either

allow them to accept or reject change within their work setting. This study will focus on

investigating how individuals within the Pharmacy setting can implement Lean to benefit

both the staff and the patients , which will also relate to how management its approaching the

sustainability issue within these settings. Sustainability is important as it will promote the

concept of Lean processes in hospitals, demonstrating their effectiveness through practicality

that emits excellent results. This in turn will provide other departments (In-patients

pharmacy, or bulk store pharmacy) within the hospital setting to adapt the processes, thereby

not having any prejudice that might hinder the implementation of Lean principles. It is

important to keep in mind that the hospital previously had a patient waiting time at the

Outpatients Pharmacy Department of approximately 4 hours on average. Through initiation

and implementation of Lean principles, the waiting time had dropped to 55 minutes on

average. Understanding the factors that contribute to staff adopting these principles is of

importance, as this suggests the sample group be regarded as successful to the rest of the

population (remaining pharmacies within the hospital) who could then adapt these principles

for themselves, causing a ‗chain reaction‘. Describing and investigating how waiting time

was reduced will also be focused upon.

The purpose of this research is focused on illustrating the importance of change management

within a hospital pharmacy which has been newly introduced to Lean principles. Focus is

also placed on illustrating how these principles can disappear if individuals do not adhere to

it. The importance of proper change management also influences the employee‘s ability to

either inhibit or enable change. This illustration will be used within the context of a Teaching

Case Study. This will give a ground to effectively identify and describe aspects that are

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imperative for proper implementation and sustainability of Lean, as well as the benefits of

these principles.

1.1.3 SIGNIFICANCE OF THE RESEARCH

Operating problems arise in the forms of poor designs, production bottlenecks, poor worker

performance and methods, product quality and delivery (Coughlan & Coghlan, 2002). These

problems tend to lead to negative results that accumulate rapidly if not taken care of, which

causes the healthcare professionals to deviate from their primary focus – which is attending to

patients – and attend to dealing with unnecessary problems.

Graban (2008) identifies that according to the Lean Enterprise Institute, hospitals should have

the following ‗Lean thinking principles‘8:

Table 1. Lean thinking principles within a hospital setting.

Principle Lean Hospitals Must:

Value Specify value from the standpoint for the end customer (patient)

Value Stream Identify all the value-added steps across department boundaries (the value

stream), eliminating steps that do not create value.

Flow Keep the process flowing smoothly by eliminating causes of delay, such as

batches and quality problems

Pull Avoid pushing work onto the next process or department; let work and supplies

be pulled, as needed.

Perfection Pursue perfection through continuous improvement

The contents within the table above describe principles that would aid to quality, process

flow, service, and people development within the hospital. The significance of the research

will provide readers with a view on how important change management is in an environment

that is converting to Lean. According to Zak (2008), without a determined leader and

effective leadership, a conversion of an organisation would not meet the expected outcomes.

The awareness of individual‘s enablers and inhibitors that contribute to the adaptation of

Lean principles is important to sustain or maintain the processes. This can cause better

control and management of the processes within the pharmacy in response to excess

8 Adapted from Lean Enterprise Institute, “Principles of Lean”,

http://www.Lean.org/WhatsLean/Principles.cfm [accessed August 25, 2009]

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workload, as well as decrease the overall waiting time for patients who require their

medication. The teaching case would be useful to healthcare practitioners who have a main

focus on patient care, and the need to develop better working conditions for staff.

I as a qualified pharmacist will be provided with the advantage of clearly identifying and

understanding processes within the pharmacy that have potential for improvement, and

therefore documenting and describing the aspects of the change in the form of a Teaching

Case Study.

1.2 LEARNING OBJECTIVES

The Teaching Case Study consists of three scenarios that focus on Lean implementation, and

sustainability within a Public Healthcare facility, which in this case is the Outpatient

Pharmacy Department (OPD).

The first scenario describes the situation before the initial Lean intervention. During this

phase the dispensing process is introduced, along with its related problems. The aim for this

section of the Teaching Case Study is to allow students to develop proposed ideas on what

the Pharmacy manager should do.

The second part introduces the implementation of Lean, and indicates the steps that were

taken to implement Lean, showing the positives and negatives. This section is aimed at

providing the student with ideas of what they would identify as missing steps in the process.

The final part describes how performance deteriorated, and the reasons behind the increase in

waiting time. Students are required to take into consideration the issue of the staff rotation,

lack of documentation and proper communication, before establishing proposed solutions to

what the Pharmacy Manger should do next.

The research study is also sought to answer the following questions:

1. What are the enablers and inhibitors to Lean implementation in an outpatient

pharmacy?

2. What are the traits of a Lean facilitator that either promote or inhibit Lean

principles?

3. What are the roles of management in relation to sustainability of Lean

principles?

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4. Determine the root cause of the increased waiting time using Lean tools.

Change management plays a central role in the Teaching Case Study, especially the approach

that management took to achieve team buy-in. With regard to the first three questions above,

students must realise the importance of a change agent, and the characteristics that change

agents should demonstrate to provide a successful Lean transformation in an organization.

With students being aware of factors that influence employees to resist change they must

understand how to determine ways to overcome resistance and enable them to take on

change.

Although the emphasis is placed on Change management in this Teaching Case Study,

students must be aware of the importance of the Lean tools. This is where the last question

shows importance. They must be able to develop a “root-cause analysis” from this case to

determine why the deterioration happened and how it hindered the current situation.

Understanding the Value Stream Maps before and after Lean implementation is important as

it will allow them to see the benefits of the Lean implementation.

Limitations of the research study consist of:

Not adopting any quantitative research methods, analysis or designs.

The scope of the study will be limited to only the Outpatient Pharmacy Department

and not the remainder of the pharmacy departments. Only individuals who played

important roles during the Lean transition will be regarded as part of the sample.

Not much documentation was available because personnel failed to document most of

the Lean interventions.

This study will only describe and investigate the reasons why Lean process has shown

improvement in the pharmacy and cannot at this stage provide insights to results that

may have stemmed from sustainability management practices regarding Lean.

Coding which will be used as qualitative data analysis is inherently subjective. More

than one coder will not be employed for consensus on subjectivity relating to the data.

Therefore, as the researcher, I will be the sole coder.

Possible prejudices and/or biases of the researcher need to be taken into consideration

as well.

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1.3 RESEARCH ASSUMPTIONS AND ETHICS

Research assumptions would include:

The demanding nature of a hospital setting will occupy the personnel that would be

essential in providing the necessary information and authorization for carrying out the

research. Therefore availability of the respondent‘s time is an important factor in data

gathering.

Access to personnel and information should not be a problem, but awareness relating

confidentiality of information should be factored into the study.

The research was conducted with the utmost consideration of the privacy of patients and

staff. There was no insinuation of negativities regarding current practices within the hospital

settings. The research will be focused around describing past and current practices, while

avoiding criticism.

Permission was granted by the University of Cape Town Research Ethics Committee with

regard to carrying out the research. A proposal of the research was submitted to the

Committee and I was granted approval for conducting the research for a year, up to 7

November 2010.

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2. LITERATURE REVIEW

2.1 LEAN IN HOSPITALS

―Healthcare organizations are the most complex form of human organization we have ever

attempted to manage‖, is a statement by Peter Ducker (1993) that describes how the

incompatible interest, time, and perspectives of the varying stakeholders contributes the

complexity of a healthcare organization. On top of that is the challenge of these stakeholders

to attend to the increasing demand for healthcare, without a continuous influx of financial

support handed to them.

The Toyota Production System (TPS), the origin of Lean, has been used for efficient design

and management of large-scale operations. Over recent years, TPS has been adopted in

different industries and is regarded as the ‗dominant manufacturing paradigm‘ (Sobek &

Jimmerson, 2003). According to Barlow (2008), Lean principles have been adapted on a

continuous basis within health organizations because of their successfulness within other

industries. If Lean is adhered to it can ―improve clinical service and supply chain

management‖ within the hospital. This is what is needed in order to accommodate the

growing needs‘ of the country, especially in the public sector. Barlow (2008) also states that

Lean principles are a ―highly disciplined approach‖ that focuses mainly on ―waste and

inefficiencies in the supply chain‖. This approach could however be difficult to adhere to

especially in a setting where staff turnover and staff rotation is high.

Wysocki (2004) expresses how Toyota‘s production techniques can be applied in hospital

settings:

“Flow – in the Toyota factory this approach focuses on smooth flow of goods, or

products, while in the hospital setting it emphasizes the rapid flow of patients.

Root-Cause Analysis – Error which are examined immediately and countermeasures

are implemented in order to avoid repetition.

Value Stream Mapping – Work diagram that depicts work processes with the intention

to eliminate non-value adding steps that affect the patient.

Kaizen – a Japanese term for continuous improvement that involves constant small

steps to improve efficiency.‖

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If these techniques were used in a Pharmacy environment it would be ideal to have a flow of

patients who enter and exit the pharmacy within a reasonable time period. Applying

continuous improvement and reviewing of a pharmacy‘s processes are also ideal as this can

accommodate increases in patients. King et al. (2006) identifies a key concept on Lean

principles, which states that the initial commencement of Lean principles should not be

focused on an immediate solution, but rather the ―development of a detailed understanding of

how a complex process is‖. This ties into one of the techniques mentioned above, which

suggests that in order to pin-point the waste and achieve a better understanding of the

situation, a detailed Value-Stream Map is required.

The table below describes factors which aid in the deterioration of service that could be

offered to patients. These factors need to be addressed, especially in a health care setting, in

which the priority should be the patients and not the inability to assist them.

Table 2. Factors aiding the deterioration of service to patients

Toyota has identified Eight Types of ―Waste‖ 9(Graban, 2008). This is applicable to the

research:

Waste in Healthcare according to Zak (2008):

Waste of waiting Waiting

Waste of Human Potential Barriers to flow (unproductive sequence

of steps & delay between steps)

Waste of Inventory Handoffs (cause delay and isolate

responsibility and knowledge)

Waste of Transportation Unnecessary movement

Waste of motion Inflexible process ( inability to switch to

another product or service quickly)

Inappropriate focus (organizational needs

versus customer needs)

The ‗wastes‘ mentioned above inhibit the employees‘ primary duties as healthcare

professionals, which is to take care of patients needs. This is because there are plenty of

unnecessary problems, like inventory build-up or administrative work that needs to be done.

This takes away from the value that they could add.

9 Defects, Overproduction, Transportation, Waiting, Inventory, Motion, Over processing, and Human

Potential

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2.2 LEAN THINKING

Muda is regarded as anything that creates waste-resources that add no value. This is the

primary concept underlying Lean thinking (Zak, 2008). The rationale behind eliminating

waste is that an organisation may carry on providing more value, with its current resources.

Rather than have specialized employees performing repetitive tasks, Lean advocates the use

of a cross-functional team made up of ―workers who can perform interrelated task‖ which

increases productivity levels, increases worker satisfaction, decreases waste, and accelerates

staff contribution (Zak, 2008). This is a good way to describe how the pharmacist and their

assistants should work within a pressurized setting. Because pharmacies are busy, it will

work better if a team is created to distribute the work evenly.

The ―Five Steps of Lean‖ are imperative in implementing Lean principles and thinking into a

hospital (Zak, 2008). These steps include:

1. Specify value: The patient‘s perspective determines the value. Patients should be

given information to help them understand their options and encourage them to be

responsible for their health.

2. Identify the Value stream: Track the steps that are used to deliver a service or

product. Identify the value-adding and non-value-adding steps. As mentioned

previously, the value stream is beneficial in determining waste.

3. Flow: Producing a product/service from beginning to end, without interruptions, or

waste. This ensures that work flows smoothly, increasing flexibility and decreasing

unnecessary motion. Flow is regarded as horizontal, while batch-and-queue10

is

vertical. This vertical arrangement requires activities to be grouped according to type

or functions and handled by individual departments. However, this often produces

bottlenecks, as the different departments wait for the change over to the next step.

Therefore Lean promotes a more horizontal flow of products, which requires

dedicated product teams which would have the work evenly distributed, therefore

maintaining the balance. It is important to:

Focus on the service

10

At any given time dealing with a large quantity of material or products which start to pile up and form

queues.

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Eliminate old ways of doing things

Re-evaluate work practices and equipment that might help eliminate

bottlenecks

4. Pull: Accommodates changes in customer demand, Provides the service and products

when it is needed. This follows the ‗Just in Time (JIT)‘ concept of producing and

delivering the right items at the right time in the right amounts.

5. Perfection: Improvement process is never-ending. More waste will be made visible

and therefore staff begin to eliminate the waste, in turn, perfecting the processes.

The steps mentioned above is a good guideline to apply within a pharmacy hospital setting.

With regard to horizontal flow is preferred in a setting where a pair or team of pharmacy

professionals work together to complete tasks. Work is therefore evened out and not placed

on a single individual. The JIT concept also relates to how medication within a pharmacy is

dispensed – only when needed. These steps give a good indication of how Lean thinking can

be applied within a hospital setting.

Even though health professionals might be hesitant towards new ways of thinking, there are

ways that can make it easier to accepting principles that differ from their norm. The table

below describes the ten ways Flinchbaugh (2005) suggests to ―Getting Lean right‖. This is

seen in Column ―A‖ and ―B‖. In Column ―C‖ Flinchbaugh‘s suggestions are compared to

what other literature has to say. Column ―D‖ indicates where in this Literature review the

related topics can be found:

Table 3. Ten ways to: “Getting Lean Right”

A. THE

WAYS

B. DEFINITION C. COMMENTS D. DISCUSSION

TO FOLLOW

1. Rome

wasn‘t built in

a day.

Here he states that Lean is a

process that will require one to

two years to build the necessary

momentum. Even though there

might be rapid short term results,

it is normal for process

improvements to decline back to

where it began. However, the

most profitable returns would

manifest through a two-to-five

year plan.

I agree that this thinking will

manifest within a hospital,

because a Lean culture slowly

develops from daily practices of

discipline, and continuous use

of Lean tools. This becomes the

new ―habits‖. (Mann, 2005)

2.4 CREATING A

LEAN CULTURE

2. This is not

a part-time

job.

A dedicated leader or team is

required who understands the

scope of the project.

Leaders must recognize the

need for change, and create

conditions in which a new set of

reinforcing beliefs and rules can

2.3

CHANGE

MANAGE-MENT

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give the desired results.(Zak,

2008)

3. Lean is

more than just

tools.

“Lean is not born from what you

see; it is born from how you

think‖. The entire way of thinking

should be embedded in every

person in the organization.

―Improvement requires change,

and in a health care setting this

often translates to the fact that

people must change‖ (Zak,

2008).

Teaching individuals about the

importance of visual controls

will benefit their development

of Lean thinking. (Man. 2005)

2.4 CREATING A

LEAN CULTURE

2.5 CHANGE

AGENT

2.7 LEAN TOOLS

4. Lean is a

journey that

never ends.

A company cannot declare

themselves to have achieved Lean

status, because there are always

gaps that exist between the

current and ideal state. Lean is an

ongoing process that requires

constant implementation.

A Lean management system

―sustains and extends the gains

from implementing Lean

production‖. Having discipline

and daily practices, as well as

tools to create and preserve an

intensive focus on process

comprises a Lean management

system. It is the ―process focus‖

that aids the sustainability of

Lean processes. (Man, 2005)

2.8 SUSTAIN-

ABILITY

5. Be

prepared for

resistance.

“When change is proposed,

people often feel threatened‖.

Help people understand why,

what, and how.

This can apply to hospital

settings as well, because staff

members can resist change if

they feel that: leadership is

weak or conflicting in support

of its stated goals; if the goals

do not benefit employees; and if

not empowerment exists. (Zak,

2008)

It is therefore important to assist

employees in understanding.

2.6 ATTITUDES

TOWARDS

CHANGE

6. Leaders,

not managers,

are required.

“Leadership is moving people

toward the ideal state‖.

Leadership is a prerequisite to

Lean transformation.

This is true for every institute,

because without a determined

leader and effective leadership,

a conversion of an organisation

would not meet the expected

outcomes. (Zak, 2008)

2.3 CHANGE

MANAGE-MENT

2.5 CHANGE

AGENT

7. Be

prepared for

the

investment.

Individuals need time to

learn/gain new skills. Therefore,

financial investment in training

programs should be considered.

This is a problem in government

hospitals because they do not

have a high influx of financial

resources.

(See 1. Introduction:

Contextual

Background)

8. Lean is not

just about the

shop floor.

―Attack every corner of the

business — from accounting to

human resources to

manufacturing‖.

A Lean culture can be

developed through a practicing

a Lean management system.

(Mann, 2005)

2.4 CREATING A

LEAN CULTURE

9. There is no

recipe, but

there is a

roadmap.

There is no single recipe to Lean

success, as every company has

different problems or constraints

and will adopt different

approaches. There is however,

guidelines that allow you to be

aware of your position, and the

effectiveness of your processes.

Different models of change can

be utilized. 2.3 CHANGE

MANAGE-MENT

10. Don‘t

copy the

Every company is unique and

should not be used as a

I disagree, because even though

companies are different, their

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answers benchmark for another

success of Lean should resonate

within their organizations.

2.3 CHANGE MANAGEMENT

Many sources propose that at least half of all change efforts fail to meet the expected

objectives (Choi and Behling, 1997). Staudenmayer et al. (2002) believes that an organisation

adopts a change as soon as a problem has surfaced. These ‗rhythm-changing‘ events cause

shifts that allow individuals to promote organisational change. The shifts have four outcomes:

1. Trigger: The shift acts as a way to allow individuals to shift their thinking to that of

reassessment, reflection, and thinking about possibilities to the future.

2. Acts as a resource: Individuals disengage from their daily routine and take time to

think about procedures rationally, and reflect and reassess upon them.

3. Coordinating Mechanism: Instead of individuals focusing on their own tasks, it

brings them to a level where they are all synchronized with their work and are

executing it as a team.

4. Symbolic of Organization’s need: Managers taking the time-out to reprioritize the

needs of the organization and thereby showing commitment to change.

Managers should be aware of these shifts and help direct it in a way that would cause a

positive change to their company.

With the unexpected events that could occur when dealing with a change initiative, it seems

that healthcare managers have additional challenges because: they deal with contrasting

views from the stakeholders; they have different missions to try and abide to, such as

providing primary healthcare, while still being an employer, and remaining solvent;

physicians and nurses value their independence and their decision influences the hospital‘s

expenditures; and they have a lack of information to try and manage change processes

(Golden, 2006).

Parks (2002) quotes leadership principles, developed by author John Kotter, which allow for

a successful change management strategy. This can change the organizational culture to a

Lean culture. These principles include:

1. Establishing a sense of urgency by identifying opportunities for improvement and

crisis.

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2. Creating the Guiding Coalition by gathering the right people to lead the change

initiative.

3. Developing a Vision by formulating strategies to achieve the vision and leading the

change.

4. Communicating the Change Vision by constantly informing the employees about the

vision, strategy and purpose of the change initiative and what is expected from

everyone.

5. Empowering Broad-based Action by eradicating any obstacles that might hinder the

change initiative and encouraging the team to deviate from the traditional ideas.

6. Generating Short Term wins by showing visible improvement in the processes and

acknowledging the people who achieved it.

7. Consolidating Gains and producing more change by allowing change to happen on a

bigger scale, affecting other departments, and finding the people who can

accommodate these requests and changes.

8. Anchoring New approaches in Culture by improving and encouraging better

management and leadership skills.

With regard to change management, Kotter‘s list gives a clear instruction that communication

is imperative in providing functionality between the employees that will ultimately produce

the necessary basis to implement Lean processes. Communicating the information accurately

amongst the organisation will allow support for a Lean initiative. Another important principle

will be showing positive short-term results that will allow people to believe that the concept

works, and in turn create a network of support through informing others in different

departments about Lean. Multifunctional workers or those who rotate between

job/departments often have to be provided with additional attention when implementing

Lean.

2.3.1 MODELS FOR CHANGE

When individuals are asked to make a broad change to improve performance, this means that

there needs to be a culture change. When an organization has a set of rules and beliefs that

give them the results they expect, those beliefs are known to be reinforced (Zak, 2008).

With regard to the illustration below, in beginning a transformation it is important to

determine the performance gap (Stage 1). The desired state describes the journey of the

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process. Once you have supporters of change, the organizations readiness (Stage 2) is then

assessed according to who will be affected, what work will be affected, and if the

organization requires additional changes to get to the goal. A change agent is important in

this stage. Their qualities should include: personal conviction and motivation; self-

confidence; broad range of perspectives; influential; connected; and skilled. Stage 3

reinforces some of Kotter‘s thinking with regard to change.

Figure 1. Transforming Healthcare Organizations, adapted from Golden (2006).

Stage 1 Stage 2 Stage 4 Stage 3

-Situation Analysis (past

and present)

-Top management

support

-Key player/ stakeholder

analysis

-Change leader selection

-Communicate need for

change

-Show benefit to

employees

-Build coalition

-Monitor and re-evaluate

-Recognize/reward

-Support

-Showcase success

-Fine-tune systems

Determine

desired end

state

Assess Readiness

for change

Broaden support

Organizational Redesign

Reinforce and

sustain change

-Goals& tasks

-Structures

-People/HRM

-Rewards

-Cultures and Values

-Information and decision support

-Goals-New

behaviours

-Organisation

architecture

-Systems

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The following framework adapted from Smeds (1994) indicates that a change movement

starts from a vision with a strategy that guides the smaller projects.

Figure 2. The Generic Framework for the Management of Change towards a Lean Enterprise,

adapted from Smeds (1994).

The first two diagrams illustrated how change can be initiated, implemented and sustained.

The diagram below describes how events can help influence individuals to take action on the

problem, by changing their ―experience of time‖. This can be beneficial in Stage 3 of

Golden‘s (2006) model for change, and the first two steps of Smeds (1994) model.

Figure 3 The Role of Temporal Shifts in Facilitating Organizational Change, adapted from

Staudenmayer et al. (2002).

Rhythm-

changing

event

Temporal Shift

Involved changes in actors‘

experience of time in terms of:

Sense of time

pressure

Perceived discretion

over time

Perceived tension

among competing

time demands

Time Horizons

considered

Sense of ―found time‖

Facilitates organizational

change

By finding new ways to

use time, people are able

to take time around pre-

existing problems

By adopting new ways

of thinking about and

using time, people

develop new approaches

to their work

Serve as:

Trigger for

action

Resource of

time and

attention

Coordinating

mechanism

Symbol of

need for

change

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Even though a change initiative might take place, it is important to identify whether or not the

change is actually taking place. Ashburner et al. (1996) have identified five factors that

indicate whether or not transformatory change is taking place within an organization. These

factors include:

―the existence of multiple and interrelated changes across the system as a whole‖,

which describes how an organization has been frequently exposed to new changes;

―the creation of new organizational forms at a collective level‖ which represents a

significant ― breakpoint‖ in organisational life in which long standing and

conventional rules or relationships have been broken up and new ones negotiated;

―the creation of roles at an individual level‖ which has their roles and responsibilities

revised;

―formation of new leadership groups‖; and

―The creation of a new culture, organization meaning, and ideology‖.

2.3.2 MANAGERS

“Changes must be sold to senior management first, through strong leadership and effective

communication, before it can be accepted” (Sheridan, 1996).

Graban (2008) believes that Lean is an ongoing journey that requires an engaged workforce

that would be able to adhere to continuous process improvement. According to Graban

(2008), a manager‘s role should be to:

ensure each person takes the initiative to solve problems and improve their job; and

ensure each person‘s job in aligned with the needs of the patient.

A manager can also improve the success of a ‗change‘ effort within an organization by

approaching a number of strategies; however, no matter how good those strategies followed

through, it is always important to have a monitoring process of the implementation that

would deal with unexpected occurrences.

According to Found & Harvey (2007), the evolution of leadership theories have progressed

from being a role of focusing on the task at hand, to being more ‗dispersed‘ within the

organization. At present, leaders should be able to adapt their roles and qualities within all

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departments of an organization, thereby developing more leaders within different

departments to carry out responsibilities.

Figure 4. Management hierarchies in a traditional company and a Lean company, adapted

from Found & Harvey (2007).

The diagram above is similar to how Womack & Jones (1996) describe how a Top-down

leadership approach (Traditional Company) is converted to a bottom-up (Lean Company)

initiative. Initially when a change is being introduced into the organization, it will take a top-

down approach where senior management will directly demonstrate to the employees the

need for change, therefore actively guiding them. This approach changes as time goes by,

when each employee takes responsibility for checking their work, becomes multi-skilled, and

participates in redesign through improvement activities. This approach relinquishes senior

management influences or constant interferences, and advocates a more supportive role from

senior management. In order to allow the bottom-up initiatives to take place, it is important to

divert the employees from adhering to the traditional way of processes in which strict

directions and commands are all that is given to them. These processes are key to a ―self-

sustaining organization‖. It is also important for senior management to change their

behaviour and thinking if they are only familiar with traditional ways of managing.

With regard to operations management, there should be important elements that a manager

can practice on a daily routine. Baker et al. (2009) describe that these main elements should

include:

Grasp the situation: Plan, Do, Check, Adjust-problem solving, and countermeasures.

Visual management processes: Used if you cannot grasp the situation immediately.

The visuals will tell a story, whether there is a plan, if it is being followed, and if not

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why. This provides information for a root cause analysis. Then get a plan to get back

on track.

Clear alignment of goals, roles, and responsibilities.

Appropriate management time frames

Structured problem solving

Fitzgerald et al. (2003) describe ways in which top management could use for effective

implementation of change. Motwani (2003) suggests approaches to Lean implementation that

will allow a successful change in a company. These suggestions are listed in the table below.

Here is how they relate:

Table 4. Approaches to Lean implementation

Fitzgerald et al. (2003) Motwani (2003)

“acknowledge that the managerial process

requires a facilitative approach;

-Team leaders/supervisors should be trained

upfront so that they become experts in Lean.

They should be sent to seminars in order to

familiarize themselves and accept Lean.

-5S lays the foundation for other processes to

begin

“ building collaborative relationships”, which

should be nurtured on a constant basis to form

a trust relationship;

Senior management support is important. Middle-

managers should feel empowered.

“actively using opinion leaders from within

primary care” as change leaders to guide

process improvements;

ensuring that change targets are aligned with

the values of the professionals involved;

-Maximising value-added activities by

identifying what the customer would pay for

-Apply best practices

Establishing good informal relations while

allowing open debate without too much

interference from hierarchy; and

“Using data and evidence to influence”. -Mapping the processes to determine where

improvements should be made.

-Visual controls to be used as a communication

device

Kotter‘s list and Fitzgerald et al. (2003) suggestions have a commonality that focuses around

communication, building relationships, having a supportive environment, and results. These

factors seem to constitute a ―guideline‖ to change management and transformatory success.

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However, Mann (2005) has opposing views with Motwani (2003). He states that it is more

beneficial to provide the newly introduced Lean staff with standard work processes as

opposed to sending them to Lean training. Training might give buy-in but cannot guarantee a

culture change. Lean is more about ―what you do than about what you know‖. Therefore,

being practical and taking a ‗doing‘ approach, before a more ‗knowing training approach‘

would aid in supporting the processes and the mentality that comes along with it (Mann,

2005).

2.4 CREATING A LEAN CULTURE

According to Mann (2005) the Lean journey consists of a majority of internal work. This

internal work entails: imposing a disciplined approach to the processes you are now

conducting; the increased focus on the processes at hand; and trusting the outcomes resulting

from trusting the processes. Without this internal work the outcome of Lean implementation

will consist of individuals who fall back into their old habits. Without a Lean management

system in place that supports the new changes, it is easy for the system to fall back into the

old ways. It might be used as workarounds just to get them out of a potential situation. To try

and implement Lean again becomes an up-hill battle. Managers should change from the

―habitual focus on results to quite a different and less obvious focus on process and all it

entails‖.

The following table adapted from Mann (2005) shows the attributes of different cultures in

mass and Lean production:

Table 5. Attributes of different cultures in mass and Lean production

Cultural Attribute Mass Production Culture Lean Production Culture

Process Improvement Made by technical

project teams

Changes must be

specifically

―chartered‖

No changes

between ― official‖

projects

Routinely initiated by anybody, including

operators

Regular, structured vehicles encourage

everyone from the floor on up to suggest

improvements and perhaps get involved in

implementation.

Improvement goes on more or less all the

time, continuously

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2.4.1 LEAN MANAGEMENT SYSTEM

A Lean management system is important to reinforcing discipline, especially around people.

People require a different kind of maintenance and attention, as they are more prone to

introducing bad habits in the system that might deviate from the original system (Mann.

2005).

The following table lists some differences in habits and practices between batch and Lean

cultures (Mann, 2005):

Table 6. Differences in habits and practices between batch and Lean cultures

Mass Production: Personally focused work

practices

Lean Production: Process Focused work

Practices

Independent Interdependent, closely linked

Self-paced work and breaks Process-paced work, time as a discipline

―We do whatever it takes to get the job done; I know

whom I can rely on at crunch time‖

There‘s a defined process for pretty much everything;

follow the process

―I define my own methods‖ Methods are standardized

Results are the focus, do whatever it takes Process focus is the path to consistent results

―Improvement is someone else‘s job; it‘s not my

responsibility‖

Improvement is the job of everyone

Managed by the pay or bonus Managed by performance to expectations

There is a relationship between documentation and habits. In a newly arranged Lean

environment, you would see team leaders or managers running around and being more hands

on. There is no focus on documenting any interventions or changes of the processes because

they are focusing on making the process run smoothly. When it is implemented and the

targets are reached, paperwork would be done but no preference is given to filing and keeping

things in order. This is normally seen in a conventional production culture. (Mann, 2005)

According to Mann (2005), the Lean management system contains four principal elements:

1. Leader standard work-this provides a structure that helps a leader change their focus

from results to a combination of process plus results. This is done by ―translating the

focus on process‖ into defined expectations for the ―leader‘s own specific job

performance‖. This is seen as the most difficult conversion for a leader from a batch-

and –queue background into Lean thinking. Lean standard work is also process-

dependent and not person-dependent. This means that when new management team

enters a Lean facility, they do not conduct their staff and processes according to their

different management skills, but rather apply their management skill to mandatory,

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well-defined processes in which the core tasks and routines are clearly called out. This

is the standard that is expected from leaders. The benefits from this approach is:

a. Continuity of basic practices

b. Raises the game of the existing leadership staff, or highlight those that are

unable to make the transition-determining the ―gaps‖ of leadership qualities

that need to be developed.

The Leader Standard work that exists for Team leaders and supervisors are:

Table 7. Leader Standard work for Team leaders and supervisors

Team Leaders Supervisors Accounts for 80% of their day- being on the

production floor paying attention to their

processes

Accounts for 50% of their day. Most tasks are

repeated daily or weekly.

Discretionary time to respond to abnormalities,

work on daily improvement tasks, and perform

periodic tasks such as training operators

They get the shift started and staff appropriately

Reviewing yesterday‘s production-tracking

documents to understand and take any further

required actions to follow up misses or other

issues.

Reviewing team leaders‘ task assignments due

that day and making new assignments.

2. Visual controls- that allow processes to be made visible within the organisation. This

aids in more focus on the process as well as comparing the actual and expected

performance. Visuals are an essential enabler for ―disciplined focus on and adherence

to Lean processes‖. This aids the sustainability of Lean. However, it is important to

have disciplined follow-up with these visuals, otherwise they become futile. The

benefits of doing the follow-ups and becoming aware of the visuals include:

a. Increase involvement of operators in observing, analysing, and improving the

processes in which they work every day.

b. Increase focus on process and accountability

c. Provide the foundation for a greater level of employee involvement-which is

essential for a Lean environment.

The overall importance of the visual controls is to understand and see the purpose of

having them there. It is important that leaders make it their standard work to ensure

that visual controls are put in place, and are also followed-up on.

3. Daily accountability process- used to ―reinforce the Lean management system‘s

focus on process and through it, to identify and implement opportunities for

improvement‖. In a Lean world, focus in placed on improving and maintaining

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process, as well as doing follow-ups in order to understand the problems of yesterday

and eradicate them.

There are 3 tiers of daily meetings required for a daily accountability process

includes:

Table 8. Three tiers of daily meetings

Tier Description Consist of:

First Happens at the start of a

shift; is the production team

leader meeting briefly with

the team members

Daily/ today‘s activities; team leader updates

yesterday‘s performance; reviews today‘s

plans and any issues of note; on designated

days specific topics might receive special

attention like- 5s audit results, status of ideas

suggested.

―Pull‖ communication used- meetings are

determined by the expressed needs from the

staff/employees/floor. Employees must play

an active role in discussions and feel free to

raise their concerns

Second Consists of the supervisor

meeting with their team

leaders and any dedicated

support group

representatives

Led by the supervisor and focuses on running

the business and improving the business.

Team leaders bring the production-tracking

charts and post them on the information

board. The board can also consist of previous

week top three problems, their extent, and

actions used to resolve them.

Has same agenda as Tier One

Reflect on production-charts: describe what

happened, actions taken, and if they need

support from the third tier.

Improving the business involving a visual

task-assignment board giving responsibilities

to team leaders.

Third Meeting is with the value

stream manager or

equivalent meeting with

their supervisors or any

dedicated support group

representatives or staff

members

Daily performance data are added to trend

charts covering safety, quality, delivery, and

cost aspects.

Manager reviews the days staffing situation

and yesterday‘s performance measures. They

scrutinize the performance tracking charts.

They then review items still pending and

assignments due today

4. Leadership discipline

Measuring process improvement is more effective when done on a daily basis, as the

immediate feedback facilitates root cause problem solving and the avoidance of problems

from occurring. Daily stand-up meetings use a standardized work approach so that the same

agenda is talked about each day/shift. Meetings are conducted for 5-10minutes per day.

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Problems and suggestions are captured on a whiteboard (Graban, 2008). Standardised

improvement questions according to Baker et al. (2009) are:

1. Eliminate: How can we eliminate this activity/connection/process?

2. Combine: How can we combine this activity/connection/process with another

without adding any waste?

3. Sequence: Is this the best sequence of activities/connections?

4. Simplify: How can we simplify this activity/connection/process?

These steps can be used in the third principle of Mann‘s (2005) Lean management system

steps. Asking these questions in the ―Daily accountability process‖ can aid in maintaining and

improving processes.

2.4.2 FOCUSING ON THE STAFF

It is very difficult in a hospital environment, especially state hospitals, to reward individuals

with bonuses. Therefore, other means of appraisal for a job-well-done are necessary. It is

important to get staff buy-in with Lean implementation, and allow them to own their

suggestions, in order to feel empowered by their performance to their expectations (as the

table in 2.4 describes the different aspects between Mass and Lean production). Supervisors

should go out of their way to be positive about suggestions. Even if the suggestions are

irrelevant, their responses should be aligned with asking questions. (Graban, 2008)

Having rotation within an organisation lessens the stress that individuals are faced with, as

well as provides a multi-skilled workforce, and allows for different perspectives on

improvement suggestions. However, this means rotation is applied to all, and there is a

chance that not everyone will succeed at each job. (Mann, 2005)

2.5 THE CHANGE AGENT (CA)

Changing a culture to a Lean system starts with a top-level leader/s, called change agents,

who take the responsibility to launch a kaikaku campaign, which is a radical improvement or

change in an organization. This may result in dramatic outcomes within a short period of

time, but only with the support of the staff members that would sustain and improve each

major step.

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2.5.1 CHARACTERISTICS OF A CA

Bahri (2009) quotes James Womack, a founder of the Lean Enterprise institute, who states

that by focusing on Purpose, Process and People, helps an individual become a better Lean

leader:

Purpose:

o This first responsibility of a Lean leader is to create distinct and motivating

purpose that guides the direction of the practices as well as the behaviour of

everyone involved. Therefore, defining the value, according to the

patient/customer, and using it to guide the Lean process, and apply correct

action for improvement. The other set of values that can be prescribed are

organizational values, the rules that everyone follows when making decisions.

o Put the Customer first.

o Focus on reliability and responsiveness as this is what drives a customer‘s

perception of quality service.

Process:

o First standardize, then improve: Continuously document changes

o Build a problem solving culture- Using the Plan, Do, Study, Act (PDSA) cycle

in daily practice.

o Cross-train staff to meet the needs of the patients

o Create a learning environment safe for experimentation

People:

o Respect people‘s time, knowledge, experience, and personal lives

o Create a open relationship

o Gain trust by providing proof

o Build consensus rather than attempting to control the situation- discuss every

matter with the individuals affected

2.5.2 LEADERSHIP ROLES/STEPS

A change agent or Lean leader requires guidelines as to how to approach a Lean operation.

The following table from Mann (2005) describes eight dimensions of leadership that are

necessary for successful Lean conversion projects and the maintenance of Lean:

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Table 9. Dimensions of leadership

Attribute For Project Implementation For ongoing Operations

1.Passion for

Lean Passionate about the potential for

Lean to make the enterprise more

successful and work more fulfilling

for all involved

Same as Project Implementation

Willing to make personal changes in one‘s own

work, including using standardized work for

his/her own position.

2. Disciplined

adherence to

process-

accountability

Sets expectations, regularly uses a

process to track and follow-up on

actual accomplishment of assigned

tasks.


Exhibits intense commitment to focus on

explicitly defining processes and disciplined

adherence to them

3.Project

management

orientation

Prior experience in successfully

implemented projects.

Uses a defined process to track

performance and completion of

task assignments

Identifies corrective action where

necessary and follows up on it

Able to identify needed changes based on daily

process data and assign small-bite daily tasks

leading to successful implementation of the

changes

Uses explicitly defined visual processes to track

and follow up assignments and take appropriate

corrective action

4.Lean

thinking Understand Lean concepts

Has had experience applying Lean

concept

Talks about and promotes a Lean

future state

Finds ways to apply and illustrate

Lean concepts in daily project

work processes

Serious about ongoing improvement based on a

goal of perfection

Sees with ―kaizen eyes‖

Holds and coaches a root-cause orientation to

corrective action

Has learned process improvement/problem

solving methods; able to personally lead Lean

process improvement

5.Ownership Thinks and talks about the area as

his/hers to lead, set direction for

change, and improve


Eager to empower others in the area through

structured ways to elicit and implement their

ideas

Acknowledges and celebrates improvements

made by others at all levels

6.Tension

between

applied and

technical

Understands the need to sweat the

details, as well as to get things

done.

Willing to listen to technical

experts and consider their advice in

planning for the implementation

Understands and respects the details behind

elements of Lean, such as flow, pull,

standardize, work, etc.

Actively supports steps to upgrade performance

and expose previously hidden impediments

Takes a ―What can we do today‖ orientation to

making change happen steadily, step-by-step.

7.Balanced

commitment

to production

and

management

systems

History of effective give and take

with people and ideas.

Evidence of process focus beyond

a ―hit the numbers‖ approach to

management.

Eager for greater participation by

production people as well as others.

Personally treats process focus as crucial to the

area‘s success; is able to see waste and

opportunity even in Leaner processes.

Insists on compliance with requirements for

visually tracking process performance and

execution

Insists on analysis and appropriate, timely

action on impediments to normal operation of

processes

8.Effective

relations with

support

groups

History of getting things done with

support from operations support

groups such as engineering,

quality, production control, safety.

Finance, HR

Understands roles, responsibilities, and

expertise of support groups

Incorporated support groups appropriately in

plans for improvement and responses to

problems

Makes expectations explicit for support group

performance in support of production processes

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The table above indicates that ―Lean Thinking‖ is an important attribute for a leader to have.

The Joint Commission Resource (2005) believes that there are four ways that leaders can use

to change traditional thinking into Lean thinking within the organization. This is seen in

Column ―A‖ and ―B‖ below. Zak (2008) also identifies steps that are required for leaders to

adopt Lean thinking. These two sets of suggestions are related in the table below:

Table 10. Steps required for adoption of Lean thinking

A.

Task/Quality

B. Description C. Zak (2008)

1.Personal engagement Attend meetings regularly

Ensure performance data

reaches everyone involved

Acquire support from the

organization and publicly

support these efforts

Determine staff abilities to

undertake a new culture

2.Relationships with Clinical Staff Maintain regular contact with

clinical staff

Understand the clinicians needs

Find common ground with

clinicians

-Discourage complacency

-Require frank discussion of

problems and sensitive

topics

3.Promotion of an Improvement-

Based Organizational Culture Establish shared goals within

the organization that are

aligned with a focus on

improvement.

Promote interdepartmental and

multidisciplinary collaboration

through the organization

Seek new approached to

problem-solving

Let go of old processes that

don‘t work

-Define specific staff

responsibilities and roles,

provide empowerment to

perform new roles, and

establish an accountability

system pertaining to new

individual and team goals;

and

-Participate in incorporating

changes and demonstrate

unwavering leadership

support.

-Communicate new

organizational objectives

and expectation throughout

the organization

4.Support of Improvement

through Organizational

Structures

Teams should be able to

address identified opportunities

for improvement

Inform teams to report to senior

management so data can be

considered in decision making

Determine top leadership

and management‘s abilities

to model the organizations

changed cultural values;

5.Procurement of Organizational

Resources Distribute sufficient resources

to support the organization‘s

collection, analysis, and

reporting needs

Allocate sufficient time for

staff to perform necessary

duties

-Visualize the desired

culture

-Assess the present culture

-Develop baseline data

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2.6 ATTITUDES TOWARDS CHANGE

Self & Schraeder (2009) defines readiness as the ―cognitive evaluation made by the member

that can lead to the member‘s support for or resistance to the change initiative‖. If the

implementation process is properly done, this would guide the employees to either accept the

change or reject it.

2.6.1 INHIBITORS

Kotter & Schlesinger (1979) suggest that in this ever changing environment (new technology,

new government legislation, new products, etc.), change within organizations is essential to

attain, and a manager‘s biggest task is to find ways to implement change while taking into

consideration those individuals who resist it. Securing leadership buy-in is important to

facilitate a change process. However, there are those that resist a change and cannot see that a

more flexible, responsive system enables an organization to solve individual problems

quicker.

The table below is a compilation of different factors that can contribute to inhibiting change.

They are attained through different authors:

Table 11. Different factors contributing change

SOURCE REASONS EMPLOYEES RESIST CHANGE

Zak (2008) Staff members can lose interest in the project if : leadership is

vague or conflicting in support of its stated goals; if the goals do

not relate directly to the employee‘s work; if they feel they have

no input in the process; and if there is lack of leadership support,

encouragement and empowerment of the staff.

Kotter & Schlesinger’s (1979)

reasons for fear of

reorganization processes

―Disturbance of status quo; job security; and disturbance of the

normal ways of doing things within the organization‖.

Lucey et al. (2005) Lack of clear and effective communication to employees; lack of

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monitoring outcomes; and lack of supportive and sympathetic

HR policies

O’Toole ( 1995) People distrust or have past resentments toward those leading

change; Confidence in the ability to perform

Jacobsen (2008) Middle-managers are not interested in getting on board with the

change initiative.

It is important to note that leaders and managers are able to be resistors to change for the

same reasons employees at the front-line can be, therefore showing that resistance occurs at

any level within the organization (Audia et al., 2000).

According to Kotter & Schlesinger (1979), managers should also be aware of the following

four characteristics/reasons to resistance by an organization:

Parochial self-interest: A desire not to lose something of value. People start focusing

on their own interests and lose focus on the organizations best interest. This results in

‗politics‘ or ‗political behaviour‘. Political behaviour starts to manifest when what is

the best interest for one group or individual within the organization, is not in the best

interests of the total organization.

A misunderstanding of the change and its implications. Individuals believe that

there is a greater cost outweighing the benefit to change. This can result from

individuals not understanding the valid reasons for change. This misunderstanding

normally happens when there is a lack of trust between the employees and individuals

initiating the change. Relationships and communication therefore play an important

role in relaying the correct message and eliminating misunderstandings.

A belief that the change does not make sense for the organization. Here, people

also recognize, through their own assessment, that the costs outweigh the benefits, for

themselves and the organization as a whole. Managers should avoid assuming that

both they and their employees have the exact knowledge, and facts regarding the

initiation of change.

A low tolerance for change. People fear that they will be inadequate in developing

the talent or skills that will be required of them in order to adapt to these new changes.

Drucker (1954) cited by Kotter & Schlesinger (1979) argues that the major inability

for an organization to grow is that managers are unable to change their attitudes and

behaviours simultaneously with the change that the organizations require.

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2.6.2 ENABLERS

Zak (2008) states that there are three enablers that front-line staff can exhibit, that would aid

in an effective Lean implementation. Those are: Seeing things with a new perspective allows

the fast identification of waste and bottlenecks; being enthusiastic and motivated about the

improvement process- through management‘s acceptance of their ideas; and open

communication and sharing of information.

The diagram below illustrates that in a time of change, interpersonal relationships seem to

shape people‘s readiness to change. Focus is placed on building supportive and trusting

relationships that will manage change successfully.

Figure 5. Classification of Climate dimensions, adapted from Bouckenoogehe et al. (2009).

Bruckman (2008) claims that allowing the group to take ownership of their suggestions, is

important to conduct a successful change. A leader‘s or manager‘s words must also be

consistent with their actions for employees to start trusting them. Building the trust enables

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the employees to accept the tasks that are handed to them because they can trust the leader‘s

actions.

2.6.3 ENABLING EMPLOYEES-OVERCOMING RESISTANCE

A challenge in implementing Lean in a healthcare setting is that staff shows scepticism at

first, because it is a drastic change from the traditional approach. For healthcare individuals,

this might appear to be just another performance improvement program, but one that looks

too difficult to implement. This is when the healthcare leaders who are committed to Lean

should address their concerns ―because health care is so complex with so many variable

human factors, its leaders cannot quantify care nor measure improvement‖. (Zak, 2008)

For a Lean project to work there needs to be buy-in from all levels in the organization, with

the intention of committing to the project for an extensive period (Burge, 2008). Burge

(2008) states that there are four ways in which the presence of resistance can be restricted.

Suggestions from Zak (2008) also relate to Burge‘s four ways. This is discussed in the table

below:

Table 12. Ways in which presence of resistance can be restricted.

Burge‘s (2008) four ways of

overcoming resistance:

Solutions to Lean implementation challenges (Zak, 2008):

1.Explaining to all stakeholders the journey

of the project, the goal, and the outcomes

Step-by-step guidance in Value-creating Activity-Invite a

consultant to conduct classes and Lean process simulations. The

consultant should conduct this process by asking questions.

Organizations use this approach both to initially implement Lean

and for follow-up consulting if the need arises.

2.Easing the fear of change- employees fear

a loss in the job, salary, or transferred to

another area

Acknowledgements and rewards- to sustain empowerment and

encouragement amongst the staff through announcements at staff

meetings or commendation letters. It is also important to

acknowledge teams rather than individuals. Grooming talented

individuals for a management position and ignoring others who

contribute should be avoided.

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3.Produce, uphold and encourage a

successful and practical system for

communication such as daily/weekly

reports, breakthrough meetings; and

4. Create an environment where all

stakeholders feel comfortable in voicing

their ideas and in which their ideas are

acknowledged and responded to.

Approaches such as conducting a

brainstorming session, having ―ice-breaker‖

activities, or giving the team a Case Study

that shows similarities with their

organization, might help individuals feel

more comfortable in generating ideas.

-Staff involvement-staff must be able to analyze what they are

doing and determine whether or not they are reaching the desired

outcomes. This allows them to become involved and be held

accountable, as they are now helping to create, alter, and manage

the processes. Having an active role with more responsibility

allows them to take ownership of their actions

-Researching Lean success stories

Healthcare individuals often are reluctant to adopt Lean principles because they regard it as

an industrial model. A way to overcome this is to start a ―pilot program‖, one which involves

a small number of staff, training them to become experts in Lean thinking. Successes from

this pilot program will then be a good selling tool to allow Lean to echo throughout the

organization. They then become the change agent for the rest of the organisation (Zak, 2008).

The following table lists more ways in which resistance can be dealt with:

Table 13. Ways in which resistance can be dealt with.

Approach Commonly used in

situations

Advantages Drawbacks

Education &

Communication

Where there is a lack of

information or inaccurate

information analysis

Once persuaded, people

will often help with the

implementation of the

change.

Can be very time-

consuming if lots of

people are involved.

Participation &

Involvement

Where the initiators do not

have all the information they

need to design the change,

and where others have

considerable power to resist.

People who participate

will be committed to

implementing change,

and any relevant

information they have

will be integrated into the

change plan.

Can be very time

consuming if

participators design an

inappropriate change.

Facilitation &

Support

Where people are resisting

because of adjustment

problems.

No other approach works

as well with adjustment

problems.

Can be time-consuming,

expensive, and still fail.

Negotiation &

Agreement

Where someone or some

group will clearly lose out in

a change, and where that

group has considerable

power to resist.

Sometimes it is a

relatively easy way to

avoid major resistance.

Can be too expensive in

many cases if it alerts

others to negotiate for

compliance.

Manipulation & co-

optation

Where other tactics will not

work, or are too expensive.

It can be a relatively

quick and inexpensive

solution to resistance

problems.

Can lead to future

problems if people feel

manipulated.

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Explicit & Implicit

coercion

Where speed is essential and

the change initiators possess

considerable power.

It is speedy, and can

overcome any kind of

resistance.

Can be risky if it leaves

people mad at the

initiators.

2.7 LEAN TOOLS/CONCEPTS

The tools mentioned below are important to understand in order to make a connection

between the occurrences within the case and the Lean tools. Some of the tools will be

required to answer the learning objectives, and some will be used to describe what processes

were used within the case.

2.7.1 CELLULAR FLOW

Flow improvements do not come from doing value-adding work faster, but rather from

eliminating or reducing any interruptions in the process. A mismatch in workloads can

exacerbate delays. This occurs when Heijunka11

is not applied. A pharmacy‘s response time

is also undermined when the layout comprises the work flow. Staff might walk extra steps to

get to the required medication. This would encourage them to batch up their work to decrease

their walking. (Graban, 2008)

A manufacturing cell is a dedicated area where products/tasks that require similar processing

are conducted (Jacobs & Chase, 2008). They are there to perform specific processes. Many

cells can be set up to develop an end product. They are normally used for producing ―when

needed‖ products. Cellular working shows that work flows from one step to the next without

interruptions (Baker et al., 2009). Each person must be capable of completing their activity at

their relevant steps within takt12

time.

11

Heijunka is levelling the variety and/or volume of items produced at a process over a period of time. It

is used to avoid excessive batching of product types. 12

Is the available working time per day divided by the demands

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Figure 6. Cellular Working: no delays between steps

The above diagram illustrates how the dispensing process within a pharmacy should operate

in order to be more efficient. The entire process can be paired between 2 individuals, a

―Buddy system‖. This would allow better flow of work.

2.7.2 VALUE STREAM MAPPING

Metha (2009) describes Value Stream Mapping as the ability to ―capture information flow

simultaneously‖ to allow Lean practitioners to observe the flow of the complete service steps

in a graphical structure. Womack & Jones (1996) suggest that after leadership, knowledge,

and sense of urgency is established, a value stream map of the processes in the organization

should be conducted. Mapping the individual departments is more effective than mapping the

entire organization. So instead of mapping all 5 pharmacy departments within the hospital

under study, the OPD would be beneficial to map.

The principles of Lean thinking which was mentioned earlier by Zak (2008) are based on

Womack & Jones (1996). Lummus et al. (2006) who cites Womack (2002) puts the same

principles in a context used for Value stream mapping:

―Value‖ is specified by the customer. In this case, the value that the pharmacy

personnel are adding to assist the patient.

Value streams that produce each product can be identified and wasted steps

challenged. Pin-pointing where the delay is in each dispensing step will allow the

―roadblocks‖ to be identified.

Product should continuously flow through value-creating steps. Thereby producing

efficient dispensing of medication within a pharmacy.

Product should be pulled through steps where flow isn‘t possible.

Task1

1

Task4

4

Task2

2

Task3

3

Direction of Work

Flow

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Processes should be managed towards perfection to continuously reduce the time

needed to serve the customer. Within a pharmacy setting, this is seen as imperative.

This will allow more time to counsel patients on their medication use, and less time

on waiting for their medication. Therefore, optimizing patient compliance and care.

Implementation of the principles mentioned above includes the process of Value Stream

Mapping (VSM). The diagram below reinforces the concepts mentioned above about the

―value‖ of a VSM.

Figure 7. Value-stream mapping, adapted from Rother & Shook (2003), cited by Zak (2008)

2.7.3 PLAN-DO-STUDY-ACT (PDSA) CYCLE & A3 TOOL

Similar to the concept of the Value Stream Map, Associate in Process Improvement13

developed a Model for Improvement. This is a tool used in healthcare organizations that

13

API develops methods, works with leaders and teams, and provides education and training to help

organizations improve their products and services and to build their capability for ongoing improvement.

The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-

Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check"

with "Study." [See Deming WE. The New Economics for Industry, Government, and Education...

Cambridge, MA: The MIT Press; 2000.]

Using the Value-stream Mapping Tool

Determine the value stream to be

improved

Understanding how things

currently operate, the foundations

for the future state

Designing a loan flow through the

application of Lean principles

The goal of mapping

Value Stream

Current-state drawing

Future-state drawing

Planning and

implementation

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allow for acceleration of process improvements. The model consists of two parts: The three

fundamental questions and the Plan-Do-Study-Act (PDSA) cycle. This cycle is used to test

and implement changes in real work settings. This cycle determines whether a change can be

regarded as an improvement. For the cycle, a graphical presentation, such as the VSM, can be

used to determine whether positive or negative change has occurred.

Figure 8. Model for improvement adapted from the Institution for Healthcare Improvement.

Another model like the PDSA cycle, which is aimed at identifying processes for continuous

improvement, is called the ―A3‖ tool. The A3 is a problem-solving report, adapted from

Toyota. It documents the key results of problem-solving efforts. This provides organizations

with a deeper understanding of the way the work is currently being done. The A3 report

flows from top to bottom on the left-hand side, then top to bottom on the right-hand side

(Sobek & Jimmerson, 2004).

When this tool is implemented properly, it allows an organization to see what processes need

to be optimized in order to reach their ideal state. Below is a table that indicates what the A3

SETTING AIMS

Improvement requires setting aims. The aim should be time-specific and

measurable

ESTABLISHING MEASURES

Teams use quantitative measures to determine if a specific change actually

leads to an improvement.

SELECTING CHANGES

All improvement requires making changes, but not all changes result in

improvement. Organizations therefore must identify the changes that are

most likely to result in improvement.

TESTING CHANGES

The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real

work setting — by planning it, trying it, observing the results, and acting on what is

learned.

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tool consists of. It also compares each step to the suggestions of Baker et al. (2009) with

regard to change processes. These suggestions are aligned with the steps of an A3-tool. The

reasons to test change – generated from the Institute for Healthcare Improvements – shows a

relation to the A3 steps. Similarity exists between all three sources.

Table 14. Components of A3 tool

A3 Tool-Sobek &

Jimmerson ( 2004)

Institute for Healthcare

Improvemnt:PDSA Cycle

Suggestions, Baker et al.(2009)

1.Background of the problem Get the facts before making a

decision

2.The current situation (

including a VSM)

To increase your faith in the ―change‖ and

believing that it will lead to improvements.

To decrease resistance upon execution of the

change.

Go see the processes and engage

with staff

3.Root cause analysis To decide ―which combinations of changes

will have the desired effects on the important

measures of quality‖

Keep checking and asking “Why” to

determine the root cause of the

problem

4.Target/Goal To estimate how much improvement will

result from implementing change.

Each member needs to demonstrate

respect for each other throughout the

change process.

5.Recommendations-

Countermeasures to be

undertaken

To establish which proposed strategy or

process will lead to the desired outcome.

Test assumptions at each step- this is

a way to build consensus and create

alignment by debating disagreements

that surface.

6.Implementation Plan To determine whether the proposed change

will be practical in the environment of

interest.

7.Follow-up plan To estimate factors such as ―costs, social

impact, or side effects‖ that have resulted

from the implementation of the change.

2.7.4 5S, FISHBONE

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With regard to problem solving, asking the ―Five Whys‖14

is not significant enough. Having a

problem solving process is essential in determining the root cause (Mann, 2005).

When determining the root-cause to problems it is best to illustrate it through the fishbone

concept. This is a useful way of ―visualising how different work activities need to be

synchronised and co-ordinated‖ .It allows greater collaboration between staff and establishes

a forum in which they can debate and discuss changes that would be beneficial to everyone.

(Baker et al., 2009)

Each ―bone" of the ―fish‖ is labelled according to the major categories listed below15

:

The 4 M‘s:

o Methods, Machines, Materials, Manpower

The 4 P‘s:

o Place, Procedure, People, Policies

The 4 S‘s:

o Surroundings, Suppliers, Systems, Skills

A problem is stated, and the four ―bones‖ are there to uncover the root of the problem.

Lean hospitals utilize the Lean ―tool‖ called 5S. The 5S methodology reduces ―waste through

improved workplace organization and visual management‖ (Graban, 2008). This becomes

useful in pharmacy settings that have constant build-up of stock (medicines), as well as

processes that require a lot of admin work. The following steps can be adopted:

1. Sort: sorting out unneeded items, and keeping items which are frequently used.

2. Store: Focus on reduction of waste, through proper organising. Items used frequently

should be given attention to when considering their storage proximities.

3. Shine: Keeping a clean and tidy workplace daily.

4. Standardize: Keeping a workplace that is consistently organised. If an item is missing,

it should be easily identifiable.

5. Sustain: a system for ―ongoing support of the previous 4S‖.

14

By repeating “why” five times, the nature of the problem and its solution becomes clear. 15

http://quality.enr.state.nc.us/tools/fishbone.htm

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These steps reinforce the concept of the PDSA cycle, which deals with constant process

improvement. This methodology of Lean can act as a starter point (along with Value Stream

Mapping) for departments to start understanding and adhering to the concepts of Lean.

2.8 SUSTAINABILITY

The purpose of a Lean management system is to sustain a Lean production system. In order

to act on sustainability the following processes should be followed and implemented (Mann,

2005):

Table 15. Processes for acting on sustainability

Ways to sustain processes according to

Mann(2005):

Suggested ways on how to sustain

Using your standard work to adhere to a routine of

monitoring your processes and the standard work

of others

See 2.4 CREATING A LEAN CULUTURE

Doing follow-ups on your visual controls.

Informing people that they are responsible for

updating the charts with accurate and complete

information regarding important decisions made.

Teach individuals about the purpose of the visual

controls and how they benefit a Lean system.

The following tools can be used to assist in seeing the

problems:

Value-Stream Maps

PDSA cycle

A3 Tool

Fishbone

See 2.7 LEAN TOOLS

Following- up on what is expected from your daily

three-tier accountability meetings. Assign tasks

that improve the area. Follow-up on assignments.


Seeing processes differently, and asking questions:

“What is the process here? Is it working? How is it

sustained?”

It is important for the Lean staff to ask questions such

as ( Bahri, 2009):

“You would like to improve a process; what

part of the process isn’t working?”

“What is your proposed countermeasure?

What are the disadvantages and

advantages?”

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“What other countermeasures have you

thought of?”

Establishing an assessment schedule and planning

to phase it in. Share it widely and post results were

it is easily visible. Be able to see evidence of

improvement processes such as A3s and daily task

assignments in order to establish low-performing

categories.


Realizing that a Lean practice is always ongoing

and taking steps to avoid burnouts. Organize

regular process for sharing internal best practices,

and acknowledge the successes everyone has

achieved.


Bahri (2009) believes that in order for a team to feel continuously motivated, thereby

sustaining Lean, a sense of ―emergency mode‖ is needed all the time, however, without

creating constant stress. What unites staff and makes them more efficient is the ability of each

individual to see the problems that they are faced with and which are hindering them from

achieving the desired outcome. This stimulates them to collectively take corrective action.

Suggested ideas between staff start to flow logically from each other.

As mentioned earlier on Zak (2008) believes that by incorporating changes and

demonstrating firm leadership support, a leader can help an organization change from

traditional to Lean thinking. This will also help to sustain the principles. Mann (2005)

believes that changes and improvement efforts can be placed in the following categories:

Table 16. Categories of change and improvement

Duration

of task

Typical focus How managed

1-5 days Fix an immediate problem,

implement a simple improvement,

simple cause analysis

Daily task assignment board; follow up at

three tier meetings

6-30 days Problem solving process for more

complex cause analysis, solution or

recommendation

Via one-page A3 visual project plan

reviewed at weekly project review session

30-90 days Longer-term or more complex

problems or opportunities

Via one-page A3 visual project plan

reviewed at weekly project review session

2.9 CONCLUSION

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The literature review indicated a dominant focus on people, staff and/or frontline-workers. If

guided by the right principles and processes, they would be able to bring about a successful

change to the organization. The importance of proper implementation is so crucial to the

progression towards a sustainable Lean environment. The models and steps within this review

were used as a guide of evaluating how Lean was managed within the context of the Case

Study. This also pointed out the gaps that managers needed to develop or fulfil in order to go

forward with any Lean principles.

The following table will describe the linkages between the literature, and the research area:

Table 17. Linkages between literature and the research area

1. LITERATURE 2. RESEARCH

QUESTIONS

3. RESEARCH

PROBLEM

3. RESEARCH

INSTRUMENTS

The literature has provided

information regarding:

- what factors inhibit

individuals to change,

- what can managers do to

overcome this resistance,

- what can managers do to

implement successful change

strategies,

- what can managers do in

ensuring sustainability of

Lean principles,

- the usefulness of Lean in

hospital,

- tools used in a Lean hospital

settings

- the reasons why Lean can

be applied in Hospitals

- The importance of having

Daily accountability practices

that aid in implementation

and sustainability of Lean.

The literature has

been focused

around the

learning

objectives/research

questions.

It also assists the

learner in

understanding

certain aspects of

the Case Study

that uses Lean

tools and thinking.

Data gathered during the

research will be used in

trying to find a

commonality to what the

literature has suggested.

Investigating and

interpreting what has

occurred within the

Pharmacy will be related to

what the literature has

suggested. Gaps between

these two variables

(literature and data) will be

noted and highlighted

within the teaching notes.

Instruments:

- Semi-structured

interviews will be

complied with

questions that will

focus on the

concepts of

―feelings towards

processes‖,

―management‖,

―change‖, and

―sustainability‖.

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3. CASE METHODOLOGY

Descriptive qualitative research would be applicable to this area of research as it will be

dealing with detailed subjective viewpoints from respondents, through data gathering, as well

as observing the processes within the Pharmacy. These viewpoints and observations will be

the basis on which interpretations can be drawn from, and consequently linking them to the

corresponding literature that deals with what the enablers or inhibitors are, that influence

employees to carry out/ sustain processes like Lean. The focus on how Lean was

implemented and the results obtained from this procedure will be described, along with its

relevance and effectiveness within the Pharmacy. The research will allow me to draw

conclusions only about that participant or group and only in that specific context. The

discovery of universal knowledge or truth, as well as a cause-effect relationship would not be

applicable as emphasis is placed on exploration and description. The research study will be

used as a teaching Case Study for the University Of Cape Town Graduate School Of

Business, with the purpose of informing students about the applicability and effectiveness of

Lean processes outside the manufacturing environment. As mentioned earlier, focus will also

be placed on change management.

3.1 SAMPLING

Miles & Huberman (1994) state that sampling involves two actions:

Setting boundaries in order to define what you can study, as well as being able to

connect directly to the research questions.

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Create a sample frame to assist in uncovering, confirming, or qualifying the basic

constructs that advocates the study.

It was first important to understand the hierarchy within the pharmacy division before

attempting to gather the sample. The following diagram illustrates the order within this

division.

Figure 9. The hierarchy within the pharmacy division

A purposive sampling was used because the interviewees were selected on the basis of their

ability to contribute to the theoretical understanding of a situation. Individuals were selected

because they were already involved in the research subject.

Head Pharmacist

In-Patients Pharmacy Department (IPD)

Out-Patients Pharmacy

Department Pharmacy Manager

5 Pharmacists7 Pharmacist Assistants

Chief Operational Pharmacist

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There are 70 pharmacy personnel within the hospital, 12 of those are situated in the

Outpatient Pharmacy Department (OPD). The sample within OPD will consist of the

following 10 individuals:

The OPD Pharmacy manager: who is a pharmacist; who was present while Lean had

been implemented and saw its success; left OPD for a rotation; and is now back at

OPD where Lean has now deteriorated.

A previous OPD Pharmacy manager: who is now in IPD and left OPD soon after they

started with Lean. This individual will give insight, as an ―outsider‖ of OPD, of what

others perception of Lean is. This will indicate how the message of Lean spread,

whether the remaining pharmacies within the hospital perceived Lean either positively

or negatively.

The OPD pharmacy manager who came into OPD during a rotation and after Lean

had been implemented. This individual will give their side of the story as to why Lean

had declined during their rotation in OPD.

A locum16

Pharmacist who has been working in OPD for a number of years. Her

insight will provide this research with a genuine outsider‘s point of view with regard

to the operations within OPD.

A new employee in OPD whose insight will give an indication of whether Lean

principles that were implemented before are still being adhered to.

A pharmacist assistant who will provide the insight of the assistant‘s job and

perceptions within OPD.

Head Pharmacist who will give insight on how the staff were informed and managed

with regard to the change.

Chief Pharmacist- who will give insight on how the staff were informed and managed

with regard to the change.

Lean facilitator or Change Agent who will provide insight to the steps that was taken

to facilitate the initial change and how it was maintained.

3.2 DATA COLLECTION METHODS

16 A Locum pharmacist is a pharmacist who is not contracted to any Pharmacy and helps out on a

temporary basis when required.

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Voss et al. (2002) describes that when collecting data for a Case Study research, a principle

of triangulation should be used. This means that various data collection methods would be

applied as opposed to using one. The benefit in applying this principle is that reliability of

data would be increased. Voss et al. (2002) suggests that a funnel method17

be applied when

taking the interview question‘s sequence into account. This ensures that all topics that the

researcher would like to focus on, is covered.

There following methods for data collection was applied in this research:

1. Archival records and documents:

Information entailing Value Stream mapping of the operations within OPD

before and after Lean implementation. This was obtained by the Change Agent

Dr Brey;

documents of complaints from patients regarding processes;

minutes from meetings held during Lean implementation and during the

rotations;

important documentation that explains how Lean principles helped reduced

waiting time; and

any documents containing information pertaining to research or work done in

improving pharmacy operations

2. Direct Observation:

Gathering data through observation of the OPD operations at present;

3. Semi-structured Interviews:

Interview with the facilitators of Lean implementation;

Interview with OPD personnel relating to what inhibits or promotes their

working manner. This will also allow for greater depth on information

regarding certain topics; and

Interviews with pharmacy personnel outside of OPD.

17

Start off with broad and open-ended questions first, to becoming more specific and detailed questions

later on in the interview.

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3.3 DATA ANALYSIS METHODS

The data analysis method that will be utilized in this research study will involve the use of

coding. Interpreting or analysing data through coding means systematically searching/reading

through data in order to identify specific characteristics or observable actions. These apparent

actions then become the primary variables within the study. Merriam (1988) suggests seven

analytic frameworks for the organization and arrangement of data:

1. ―The role of participants.

2. The network analysis of formal and informal exchanges among groups.

3. Historical.

4. Thematical.

5. Resources.

6. Ritual and symbolism.

7. Critical incidents that challenge or reinforce fundamental beliefs, practices, and

values‖.

The purpose of these frameworks is: to find patterns/connections among the data and to

determine patterns that give meaning to the Case Study. Feedback to the respondents

( facilitators) regarding the preliminary findings will be essential as to determine whether or

not the ‗framing‘ of the data into different themes show any relevancy to what has/is being

experienced.

Coding analysis is preferred over ‗Holistic‘ analysis for this Case Study, as holistic analysis

doesn‘t disintegrate the evidence into parts, but rather make inferences based on the text as a

whole. It is important to find key themes from the data as this will be the basis to forming

connections with the literature and therefore aiding in the descriptive research style.

The coding scheme that is suggested by Strauss & Corbin (1990) will be followed. This

includes three important steps:

1. Open coding: fragmentation of data, thereby leading to analytical processes that form

concepts from the data.

2. Axial coding: Framing the data in new ways, with the objective of regrouping data

and linking categories.

3. Selective coding: selecting a core category and relating it to other categories.

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3.4 RESEARCH INSTRUMENTS

Data was collected through Semi-structured interviews that had a commonality of questions

between each interview. Data was collected on the successes, problems encountered, and

issues relating to management.

3.5 A TEACHING CASE METHODOLOGY

The advantage of writing a teaching case is that it is a ―question-orientated‖, and not a

solution-based approach to teaching and learning. It allows students to partake in decision

making processes and to first understand the questions/theme of the case. This in turn

prevents them from formulating predetermined answers. (Farhoomand, 2004)

Farhoomand (2004) believes that before a case is written, the following ―design‖ questions

should be asked:

1. What theories or concepts will be outlined throughout the teaching case?

2. Are there any interesting events or incidents that can bring the story together?

3. Is there sufficient contextual nuances (the setting, personalities, cultures, urgency of issues)

within the case?

4. How would students react to the case? Would they think it was challenging or interesting?

5. Is there sufficient ―dynamic tension‖ in the case to produce debatable and competing

views?

The teaching case describes a story of what happened, and should therefore be written in past

tense. The following table highlights important aspects that should be considered when

writing a teaching case (Farhoomand, 2004):

Table 18. Composition of a teaching case

Three parts

of a Teaching

case

Description

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1.Opening

Paragraph

-Paint a concise picture of the main issue

-Describe the context in which the case occurs

-Introduce the principal protagonist

-Set the timeline

-Finish the paragraph with one or two overriding questing that are facing the

characters

-The paragraph should tie into the purpose of writing the case

-Opening paragraph should describe:

• WHOSE role is the student to assume?

• WHO is the key decision maker?

• WHAT is the nature of the issue/problem?

• WHEN did the case take place?

• WHERE did the case take place; what organization?

• WHY did the issue/problem arise?

2.Body of

Case

-Rest of the story is told in a chronological order

-Information about the company background, business environment, and

issues faced by company/characters

-Exclude dynamic tension

-Include more than one person‘s side of the story

-Good case revolves around a major issue that is easily identified but not

easily resolved

-Use quotes of interviewees to engage the readers

3.Closing

Paragraph

-Provide a short synthesis of the case to reiterate the main issues

-Raise new questions

The teaching notes-which is written in present tense- is ―designed to provide the instructor

with a general understanding of the case content, objectives, key issues or questions, and

suggested teaching approaches of the case‖ ( Farhoomand, 2004). According to Farhoomand

(2004), the teaching notes should contain:

• Teaching objectives

• Case description

• Basic issue(s)

• Possible discussion questions

• Suggested student assignments

• Suggested additional readings or references

• Analysis of the case

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4. CASE STUDY: SERVICE IMPROVEMENT IN A

HOSPITAL PHARMACY

―We are short-staffed today; we need help down here,‖ were not words that Susan Henry,

pharmacy manager of the Outpatients Pharmacy Department (OPD) had used for the first

time. As she put down the phone with the Chief Operational pharmacist Amy Rice, Susan

looked out into the pharmacy and observed her staff. She watched how they were trying their

best to attend to the needs of the large number of patients who were waiting for hours. Susan

asked herself:

How did we get back to this position? Patients waiting 2-3 hours for their medication. My

staff working under pressure. I thought this problem was sorted out!

Susan had worked as a pharmacist at Glenwood Hospital for 10 years. She was exposed to

the different pharmacy departments within the hospital, and played important managerial

roles within them. It was in the autumn of 2008, when Susan and her team first implemented

Lean practices in their pharmacy department. She catalysed the progression of Lean

implementation by conducting meetings that helped to facilitate in changing the operations of

OPD. Her department had experienced the success of Lean implementation. However,

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Susan‘s thoughts were being overwhelmed by the period before the Lean implementation.

She remembered the days when she arrived at work at 7am, just to clear the backlog from the

previous day. She also remembered the increasing amount of overtime that her staff had to

work.

It was now November 2009, and the situation in OPD resembled the problems of before. The

familiarity started to worry Susan, as she thought those days were over.

1. ORGANIZATIONAL BACKGROUND

Glenwood Hospital was a Tertiary Academic hospital that formed part of the public health

sector within South Africa. It was a large, government-funded, teaching hospital situated in

Cape Town, South Africa. The hospital had an annual budget that exceeded R1 billion, had

40 000 admissions per year, and employed more than 3500 personnel. The hospital developed

a number of hubs of expertise in fields such as neurosurgery, haematology, and cardiology

and transplant medicine.

The pharmacy within the hospital setting was the area in which medicine originated and was

distributed to the other sectors (Intensive Care Units/ICU‘s, Wards, Patients) in the hospital.

Within this tertiary institution there were five different types of pharmacy departments, with

70 pharmacy personnel that were distributed amongst these departments:

The Inpatient Pharmacy Department (IPD) that supplied medication to cater to

patients that had been hospitalized and for those who were being discharged from the

hospital.

The Outpatient Pharmacy Department (OPD) that supplied medication to day

patients. Day patients included those individuals who approached the hospitals

clinicians (doctors) with ailments that did not require them to be hospitalized.

The Bulk Pharmacy which operated as the storage facility of medication.

The Chemotherapy Pharmacy that focused on drugs used for treating cancer patients.

The Sterile Unit that dealt with Total Parental Nutrition (TPN), which were nutritional

formula‘s administered intravenously (through the vein) to patients.

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2. OUTPATIENTS PHARMACY DEPARTMENT – OPD

OPD was the busiest pharmacy hub in Glenwood. It had a staff complement of 5 pharmacist

assistants, and 7 pharmacists. A strong hierarchy has always existed in healthcare. According

to the South African Pharmacy Council (SAPC), a pharmacist assistant has certain

restrictions related to the dispensing of medication. They do not have a 4-year degree that

pharmacists have, and therefore are not entitled to either query scripts or dispense the

medication to patients as they lack pharmacological knowledge18

. They need supervision and

confirmation from the pharmacists during any dispensing of medication.

With an average of 500 folders coming in every day, and patients waiting for an average of 3-

4 hours on end, the pressure building up in OPD was not a favourable one. It seemed like no

matter how hard they had worked, or how fast they had executed their process, the waiting

time still averaged around 4 hours. This problem had been ongoing for 8-10 years. Staff

turnover within OPD had always been extremely high. This was attributed to the pressurised

environment that was apparent to the staff. This caused staff to give in to the temptation of

experiencing better working conditions and receiving a more lucrative salary package in the

private sector of healthcare. However, there was a certain stable workforce that remained.

They had typically been around for 4-5 years.

Patient satisfaction surveys and staff complaints caught the attention of top management.

Given that the South African Public Healthcare sector dealt with budgetary constraints, it was

difficult to factor in more staff resources to resolve the problem. Management initially

thought that they would extend the waiting area to accommodate the patients, but the problem

outside the pharmacy was a symptom of the processes taking place inside OPD.

2.1 THE DISPENSING PROCESS

Patients handed in their folders to the pharmacy with the expectation of being attended to

promptly. However, the process of assembling their medication was not that simple.

18

Pharmacology deals with the characteristics of medicine/drugs, and includes the understanding of how

those drugs interact with the body.

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The OPD had one entrance window where patients dropped off their scripts, and 5 exit

windows reserved for medicine collection. However, by embracing the historic image of a

single pharmacist dispensing medication to the patients, OPD made 4 out of 5 windows

redundant (See Exhibit 1 for Process Flow – The Dispensing Process).

A patient would hand in his folder to the clerk and be issued with a waiting number. A

pharmacist accepted the folders, and started to Triage 19

them. A pharmacist would accept the

role of the triage pharmacist for 3 hours per day. There would be 3 shifts of triage

pharmacists per day. Folders were sorted into a Fast-track (Priority), Deliveries, and

Mainstream pile. The Fast-track, which was 10% of the folders that were dispensed per day,

consisted of one or two items on a script that could be attended to much faster. Folders with a

―Priority‖ label were also placed in the Fast-track pile. Priorities included elderly people,

people in distress, or wheelchair patients. Mainstream scripts had a greater number of items

and made up 71% of folders. Deliveries made up the remaining 19% of the folders and

included those patients that would receive their medication the following day through a

delivery service. The fee was R25. Patients who waited for their medication included those

who had Fast-track and Mainstream folders. One dedicated pharmacist was allocated to do

the delivery stream.

After being triaged, folders were processed by pharmacist assistants, using four dedicated

computers. Labels were printed out for the medication that needed to be picked. Once done,

the folders and labels were placed on the trolley waiting to be picked by the pharmacists.

After the pharmacist had assembled the medication, he/she would check the folder to ensure

that everything had been processed correctly. The folder was then placed on the trolley, and

waited for another pharmacist to dispense the medication at the single ―exit-window‖. The

patient waiting-number that corresponded to the number on the folder was called out. The

dispensing pharmacist did a second check before issuing the medication to the patient. The

mandatory step of counselling the patient on the medication was the final step in the process.

A signature was required from the 5 individuals who executed each step in the process.

19

Triaging consisted of checking that the script had a signature and date, and was therefore valid;

querying the doctor’s prescription, if there was an incorrect dose or incorrect drug name and sorting the

folders

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2.2. THE DRAWBACKS

OPD staff could not afford to spend time on spotting the problems in the dispensing system.

The fast-paced routine did not allow them to count the number of setbacks experienced daily.

The single-entrance queue for individuals to hand in folders consisted of a variety of patients

and queries. Patients with scripts, individuals with queries, and patients who wanted to pay

for their medication delivery all waited in this queue. When folders were being sorted by the

triage pharmacist, they would have to sift through the pile to come across the priority folders.

Brian the clerk who had been working in OPD for 2-3 years, understood the processes of

OPD very well, and had noticed something interesting:

Patients started taking advantage of this quick service, and soon everyone regarded their

medication as a priority. It became difficult to decipher who would become priority.

Having one triage pharmacist meant that they were solely responsible for calling up the

doctor if there were any queries pertaining to the script. Time was wasted on the phone as

they had to track the doctor down. This put a halt on the other folders waiting to be triaged,

and in turn hindered the next step of processing the scripts by the pharmacist assistants. This

caused a blockage in the system which starved the downstream process‘s steps. To make

matters worse, there was no restriction on the numbers of folders that were received by OPD

at any given time. Folders would start to pile up in the pharmacy, worrying the staff, and

adding to the pressurized environment.

The Process Flow diagram shown in Exhibit 1 indicates that there was only one dispensing

pharmacist. This pharmacist dispensed all the completed folders that were placed on the

trolley. The rate of the dispensing step was determined by the time taken to check the script,

counsel the patient, and dispense the medication. This rate would vary with each script. Susan

was concerned about this:

Even though the staff might have accelerated their work speed, patients were still not getting

their medication fast enough. The dispensing pharmacist had to dispense all the completed

folders. This took a lot of time. And we saw this as a blockage, because our completed folders

would start to pile up on the trolley, waiting to be dispensed.

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Although having the traditional approach of employing one pharmacist to dispense

medication, the reason that other windows were shut was to protect the staff from being

viewed by the patients. According to Susan, there was good reasoning in taking this

approach:

A patient who received a later number and collected his medication before a person, who had

received a number an hour earlier, probably had a script that was a fast-track item or a

priority. Patients waiting didn’t understand that. All they could see through the available

windows was that there was a full house of staff running around. They just assumed we

weren’t doing our jobs adequately. What they didn’t know was that delivery scripts were

done simultaneously with the mainstream. Even though it was only for the following day, it

had to be done. If a pharmacist was scheduled to do deliveries, they had to stick to that slot,

irrespective of whether mainstream patients were waiting. These were discrepancies that the

patient didn’t understand.

While the patients were being given their medication, they would realise that they did not

require certain medication because they had stock of it from previous scripts. This showed

waste in the staff‘s work, as this was only realised after the entire dispensing process was

done.

2.3 THE NEED FOR CHANGE

OPD‘s main purpose was aligned with taking care of the patients first, and then taking care of

their staff. This is what Amy Rice, chief operational pharmacist, believed should be

maintained:

Pharmacists were supposed to be smiling every day, emitting a good attitude. I have seen it

turn to scenarios where patients were shouting because they couldn’t understand why they

had to wait for so long. Pharmacists would retaliate by shouting because of the pressure that

they were working under. Retaining staff was a problem. And many pharmacists would leave

the public sector to reap the benefits of the private sector.

Amy oversaw the operational aspect in the pharmacy. She dealt with the staff rotation that

happened every 3 months for the pharmacists and pharmacist assistants, and every 6 months

for the pharmacy managers. She responded to the ―cries for help‖ the OPD had by shifting

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people from different pharmacies within Glenwood to work in OPD. Their management style

was open door, although communication was done predominately via emails.

Knowing that patients were irritated by the long waits, and that there were more folders piling

up constantly within the OPD meant that the dispensing pharmacist would have a minimal

amount of time to counsel the patients on their medication. Folders needed to be cleared.

Amy was concerned that the OPD‘s goal of optimum patient care was disappearing:

With all the pressure the pharmacists were under to dispense the medication faster, I was

afraid that patients were not being compliant to medication because of possibly rushed

counselling.

OPD‘s 8am to 4.30pm operating hours could not accommodate the volume of patients. There

would be times that the pharmacy had to turn patients away as they had to ―close shop‖.

Susan knew firsthand what those repercussions meant for patients:

Patients needed our help. Sending patients away didn’t guarantee that they would be able to

come back the next day. The system gave a sign that we couldn’t even help the most desperate

patient. I lived in Gugulethu, a township situated away from the Central Business District,

and I knew how far it was, and how difficult it was for patients in townships to travel to the

city. This ongoing problem of the waiting period had categorised Glenwood’s OPD as a

department in which quality care had plummeted. The staff in the unit were stressed, morale

was low, and we struggled to retain people to work in that stressful environment. I knew that

this long term dilemma caused staff to resign due to unfavourable working conditions. This

made it even harder for OPD to adhere to their core principal of generating the optimal

healthcare for patients.

3. INTRODUCING LEAN

With Glenwood Hospital not being able to provide OPD with extra resources, they focused

their objectives on utilizing the current staff levels and identifying the processes that were

ideal for process improvement. This linked to increasing the quality of care and reducing

frustration amongst staff. Hospital management employed a process analyst within the health

sector, Dr Cole, to tackle the issue experienced in OPD. A process analyst was a position that

had never been defined in the healthcare setting. Dr. Cole entered Glenwood after completing

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his MBA. Having a medical background gave him insight to processes in hospital settings.

However, to secure his position he needed to prove himself by attempting to ease the OPD

problem with the resources at hand. It was in April 2008 that Pharmacy in Glenwood

embarked on the principles of Lean (See Exhibit 2 for Timeline of events). At that point in

time, Susan was the Pharmacy manager of OPD.

3.1 PHARMACY MANAGEMENT

Natasha Pillay was the head pharmacist that co-ordinated services amongst the various

pharmacies in Glenwood. She was responsible for staff recruitment, staff performance

assessment, resolving disciplinary issues, training of staff, management of resources, stock

management and monitoring of expenditures. Dr Cole approached her and Amy Rice with the

idea of Lean implementation. They were open to this change.

Amy was familiar with the Toyota Production System and understood its efficiency. She

gained this knowledge through seminars that she had attended. She was concerned about

OPD staff neglecting any new changes:

Staff might be negative towards change because of previous failures. They would sit in their

comfort zones. Staff might also be feeling some pressure of whether to join a group that

would be drivers for the project, or have negative influence toward it. I played a more

supportive role with the Lean project.

3.2 THE PROGRESSION

The first introductory workshop was held with some people from OPD. Dr Cole believed that

the staff expressed a feeling of optimism. He then decided to involve the entire OPD

pharmacy staff, which also consisted of the stakeholders like the clerks and quality assurance

managers. Dr Cole decided to conduct an open session where he explained his purpose and

role for pharmacy. This led to a brainstorming session to determine what factors were causing

the long waiting times. He needed to understand the situation from the frontline-workers‘

perspective. Following that, his interaction with the staff progressed into more formal

meetings, in which he started going through the improvement process. He decided to attend

weekly pharmacy meetings where he would engage with the staff. The first part consisted of

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a communication session, while the second part was used to discuss the Lean project and the

interventions. The project leader to the Lean project was the manager in the OPD, Susan, who

was assisted a great deal by Dr Cole .Susan attempted to inform staff that this was a ‗win-

win‘ situation; the Lean project will not only reduce the waiting times but also reduce stress

on staff. Although some staff resisted Susan focused on attaining buy-in from those that were

willing. She knew that everyone was experiencing stress, so she encouraged them to ―get on

board‖ by responding to their concerns. Susan explained:

In OPD trust was not about the words exchanged, it was about the working and

professionalism conveyed.

Natasha Pillay facilitated the communication between Dr Cole, the OPD pharmacy manager

and the staff. Natasha knew:

Getting more staff/resources was not an option. Therefore, we could only improve on the

resources currently at hand. With Lean, we could critically evaluate the processes within the

organisation to make it as efficient as possible. My biggest challenge was time. I made a

conscious effort to be more available to staff, chatting to staff on a regular basis, and

attending weekly meetings. So my role was to motivate staff and show them that the change

would be positive for them.

Top management was not present at the meetings. They had a reputation of rarely giving

praise for good work, and would only be present if a traumatic week had been experienced.

As Leila, a pharmacist assistant who has been working in Glenwood for 15 years, said:

The time I have been working here, I have seen top management twice in OPD. Once when

they helped out with folders, as in logistically just moved the folders closer to the pharmacists

to pick and check. The other time they did a walk-about to see what could be done. We on the

floor, we were just coming in and doing what we had to do and went home. No one was

saying, you know what, maybe we can do something to change it.

When employees were introduced to Lean, they wondered whether this would either

aggravate or help eradicate the divide between pharmacist and pharmacist assistants. As an

assistant herself for 15 years at Glenwood, Leila knew the downside to this:

An inferiority complex started to develop with us assistants. Pharmacists were not aloof

about it. There seemed to be a divide between assistants and pharmacists. This dynamic that

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existed had never been managed appropriately. The role of the pharmacist assistant was

either to pick the medication, or capture the script on system. Some had those roles all day!

Scepticism dominated OPD. They thought additional staffing was the answer. As the

meetings progressed, staff began to realise that some of the Lean principles introduced to

them were actually used unofficially in the past, but not to the full extent. The ―leisure time‖

during meetings helped them communicate their concerns and honest opinions.

3.3 THE FACILITATOR’S AIM

Dr Cole wanted the pharmacy staff to be aware of how the patients categorised the level of

service that they were receiving from OPD. He collected patients‘ comments with the

intention of identifying the extent of work that needed to be done to turnaround these

perceptions (See Exhibit 3 for Patients’ Comments). Dr Cole realised that not everything

would go smoothly:

Developing a case for change within the OPD was essential. I received a mix of early

adopters, fence sitters, and late laggards to change. Fence sitters were the majority that said

maybe. The challenge was getting those on board to encourage experimentation in OPD by

defying the ethos of not being able to experiment in healthcare. They weren’t all receptive but

the difference is they weren’t all frankly resistant. You have those who were in the

background being dragged into the process. I went in assuring them that the problem would

be sorted out quickly.

Dr Cole did not want to transmit a message that depicted a big picture of what the plan of

action was. Suggestions came from the floor, since he was not a pharmacist who knew all the

intricate details of a pharmacist‘s role. He only suggested that small interventions be tried and

statistical data be captured by him and reviewed after 2 weeks to see if it was effective. He

wanted to avoid the impression of management imposing ways on how to improve their

processes. He clarified that he was there to facilitate and support the staff and make them take

ownership of their suggestions. Dr Cole claimed:

I don’t suggest solutions. I rather ask the right questions and spend time on the floor, gaining

insight on how the process is, even though it might be the broad principles. This builds trust.

Making them feel acknowledged helped construct that relationship. Staff won’t always see the

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benefits of change that would affect them directly. They might perceive a change as them

having to work harder. Convincing people that the perceived work level will be less is a

challenge, especially before any short term results show. Lean requires on-going training,

and I incorporated the Lean informally into the meetings. It is imperative not to have your

knowledge plateau.

4. A CHANGE HAS COME

In order to pin-point the blockages in the dispensing system, a Value Stream Map (VSM)

needed to be constructed. The OPD staff was encouraged by Dr Cole to participate in this

construction directly. He asked them to help with the gradual data gathering through timing

steps within the dispensing process. This carried on until May 2008. In June 2008, the results

of the timing survey were presented in the form of a Value Stream Map (See Exhibit 4 for the

Current State Map). It exposed the bottle-necks that were occurring in the dispensing

system.

With the aid of an A3 tool that was drawn up during a brainstorming session with OPD staff

(See Exhibit 4 for the A3 Tool for OPD), it was decided to introduce an intervention at the

triaging point where there were significant amount of queries with the doctor. To quantify the

problem, a volunteer sat and measured the time for 2 days. The result showed an average of

up to 40 minutes wasted on the phone for certain scripts. Best practice exchange between the

doctors and pharmacists needed to be implemented. This was done by returning the script to

the doctor with a query slip outlining the query (See Exhibit 4 for an outline of the Query

Slip). A memo was sent out to doctors to inform them about this decision. It was not applied

to wheelchair patients. Query slips were collected to determine the stats of whether there had

been a decrease in incidents. This ensured that the doctor accepted more responsibility.

Certain aspects of the dispensing process had also changed. A Buddy System was created in

September 2008 (See Exhibit 5 for Process flow – The Buddy System). The system paired up

a pharmacist and a pharmacist assistant. Patients handed in their folders to the clerk, who

then checked the script for validity. They received a number and sat in the waiting room with

their folder. This prevented staff being intimidated by the continuous pile-up of folders. The

Buddy pairs called for 5 folders at the window. The folder was triaged by a pharmacist at the

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window, and queries were caught before processing of folders occurred. If a query existed

patients were instructed to walk back to their doctor. They would return to the doctor with the

folder and the query slip. After triaging, folders were processed and labelled. Medication was

assembled by the pair. The pharmacist assistant still required the pharmacist to check off their

actions. When medication was ready to be dispensed, the dispensing pharmacist would

acquire the completed folders and call out the numbers to the crowd.

The Fast-Track was not long lived. It was functional for a few months, but fell away early in

2008, because of the shortage of staff. It was never re-introduced. Priority was given to the

person who could not afford to pay the R25 for the deliveries, and who waited for their

medication. The queues were now categorised as waiting, and non-waiting. And with regard

to the exit windows, two were now opened. This accommodated two dispensing pharmacists.

Pharmacists also started to ask patients, before any dispensing steps were taken, whether or

not they needed all the medication.

Through observation, Dr Cole recognized that the reason staff felt tired was because they

walked excessively: 10 000 steps in an 8-hour shift. This occurred because expensive

medication was located at the back of the pharmacy. Dr Cole had the hospital carpenter

construct a cupboard that was placed closer to the domain of the pharmacy.

4.1 THE OUTCOMES

The most distinctive result from the Lean intervention showed a change in the workflow of

the dispensing process .Measurable results such as triage queries showed a 60% reduction

(See Exhibit 6 for the Value Stream Map with Lean). Unnecessary medication which was

sometimes up to 80 items per day was reduced. Waste of walking 10000 steps per shift was

eliminated. And the most defining results were the 75% reduction in waiting time.

When folders started piling up on the dispensing trolley the staff created a sense of urgency to

remove them. Some pharmacists would assist the dispensing pharmacist. However, failed

initiatives were not managed well. When patients were asked about requiring all their meds, it

didn‘t occur to the pharmacists how they would indicate it if patients responded, ―No‖.

Pharmacists scratched it out on the script. They didn‘t realise that in 6 months time when the

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patient returned for their repeat medication20

, they required all their medication. But the

prescription had been scratched out.

The Buddy system helped bring down the divide between pharmacist and pharmacist

assistant. It was created with the intention of sharing knowledge and skills, because by

combining the pair it counteracted the imbalance of the experienced and inexperienced. A

pharmacist and pharmacist assistant would dispense 5 folders at a time. A different

pharmacist would dispense the medication. During the dispensing process, the pharmacist

assistant gained more responsibility and insight as to information pertaining to pharmacology.

Pharmacist assistants were not restrained to just picking or capturing the scripts on the

computer. If the pharmacist within the pair was processing on the computer, the assistant

would assemble the medication, or vice versa. The Buddy system was implemented internally

after reaching consensus with staff. Pros and cons were discussed. Susan had teamed up with

the weaker individuals so that they could receive some training and development. A

minimum of 5 pairs of buddies were required in OPD.

Generally with the top-down approach it would be managers introducing change, but the

Lean project took a step back, waited for input and buy-in from staff, and implemented those

suggestions. Angela, a pharmacist who was initially extremely resistant towards Lean

transformed her conscious decision of not getting involved with the project. She became one

of the biggest contributors and motivators. This happened as soon as the project started

getting traction. She explained:

I could see it made a difference. Patients were happy, and staff worked more closely together

- as a unit. With the buddy system there was no time to procrastinate or do things other than

pharmacy. We would constantly check with the clerk what number he had issued. We would

compare it with the number we were working on. No one wanted to lag behind. With this

project it highlighted that what you perceive to be a solution might not be the solution. The

increased level of togetherness of the team reduced the divide between pharmacists and

pharmacist assistants. The cross-training made assistants feel more valuable. There was

more open communication taking place.

20

Repeat medication is issued to the patient every 6 months. Because patients are not allowed to receive

more than a 6 month supply of medication, repeat scripts accommodate for this condition.

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The public sector did not cater to increasing benefits or a bonus when progress was shown.

This called for managers to be more creative in their approach relating to appraisal of staff.

Dr Cole realised that the OPD Lean project had also changed his preconceived ideas about

how the project would run:

I use to test my own hypothesis about how to facilitate change. My role has been, in all the

projects a facilitation role, of motivating people around change and getting them to think in a

slightly different way. When I first started, my thinking was, “I am a process analyst”. I

thought that change in healthcare was 85% process. When we did the VSM, I took it down to

the pharmacy and said I have the solution. Biggest mistake ever! I have no pharmacy

background, been here for couple of weeks, then I started proposing solutions to them. I said

we must focus here and tried to justify it. Then I learnt that you don’t just give advice. If you

want to come to an answer, you ask questions. I think people also didn’t have the technical

knowledge, so I helped by telling them to gather certain data, analysing it and feeding it back

to me.

5. STAFF ROTATION

Having to work under pressure for a long period did not help the employees‘ morale. They

were rotated amongst the different pharmacy departments. This prevented people from

getting frustrated in one location and focused on keeping stability in the team and the

relationships. Gaining experience from working within the other pharmacies was also a factor

contributing to rotation. However, there were also negatives associated with rotation. Staff

rotation had removed the critical mass and diluted the processes and knowledge that was

already in place.

5.1 LEAN FOLLOWING A ROTATION

In March 2009, Susan rotated out of OPD as the pharmacy manager and made way for

Tammy Merrick. Tammy had taken ownership of the Lean project that started in Inpatient

Pharmacy Department (IPD), which commenced soon after results from the Lean project in

OPD showed. Tammy was therefore familiar with Lean. However, the processes between

IPD and OPD were very different. Verbal communication was used to inform the new

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management rotation about the Lean interventions that was used in OPD as proper

documentation never existed.

During her rotation, Tammy seemed to have deviated from the core understanding of what

had been implemented in OPD. She was trying to establish her management style and tried to

get the team working. Other priorities were at hand, while Lean took a back seat. Her main

focus was on team building and keeping a good atmosphere. The main consequence of this

was the deterioration of the waiting period.

In April 2009 the waiting time was over 2.5 hours. At the OPD meetings, discussion around

the triage pharmacists surfaced. Tammy wanted all pharmacists to have a chance to triage the

Delivery folders during the day. This interrupted their work on the Mainstream and caused

delays in the dispensing process which had an effect on the waiting time for patients. And in

May 2009 it was suggested that if the Mainstream was busy, the Delivery pharmacist should

help, therefore disrupting the processes. Employees also suggested that pharmacist assistants

process all the deliveries in the morning on the computers and pharmacists should only check

it later on in the day-seeing that it was only necessary for the following day. This deviated

from previous thinking in OPD of not leaving things unfinished. The Buddy system was also

only used when the area was fully staffed. Tammy resorted to doing what they thought

worked best for them. People who worked fast on the computer captured the data on the

scripts, in order to get maximum output. Pharmacy management was informed and didn‘t

object.

During Susan‘s rotation, pharmacist assistants were allowed to call in folders at the window

for their Buddy pair to process. Tammy didn‘t want pharmacist assistants to take the folders

from the window because each needed to be triaged by the pharmacist. This caused a break in

the cycle. Leila explained how this affected her responsibilities as a pharmacist assistant:

The Buddy pair called out 5 folders, processed it, and picked it. This is the job that both I and

a pharmacist could do. The pharmacist only checked my script to see if it had been done

correctly. While I waited for the pharmacist to do the check I called out 5 more folders. This

closed any big void in the dispensing process, as it made it a continuous flow. Tammy

eradicated the call-out step for the pharmacist assistants. I wasted time by just waiting for

the pharmacist to complete the check before the cycle could start again.

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June 2009 showed discussion around delivery patients who complained as they required

immediate assistance because they didn‘t want to wait. This compromised people in the

waiting room. Staff saw this delivery services as a disadvantage because pharmacists would

get interrupted to triage the delivery scripts for these delivery patients21

. A note was put up to

adjust the expectations of the delivery patients. They were informed that they had to wait 15-

20 minutes.

Wheelchair patients seemed to be an issue in July 2009 because patients used this towards

their own benefit to get served quicker. It was decided before that no priority was given and it

would remain that way. Older patients felt mistreated, and by August 2009 things changed.

Wheelchair patients were given priority. The waiting period also averaged around 3 hours.

5.2 FACILITATORS REALIZATION

The best handover was between pharmacists because they understood the finer details.

During the initial phases of Lean Dr Cole was there constantly from April to September 2008

in the initial Lean project. Soon after, he began dealing with other projects within Glenwood

that consumed most of his time. He assumed that when rotation happened everything was

embedded into the pharmacy processes. Hearing about the deterioration he asked Tammy to

set up a discussion session with him, but it never happened. He couldn‘t go there with 6

months worth of meeting minutes and say, ―This is how we did it‖. He gave them the broader

principles. Tammy however felt differently about the whole situation:

I defined the quality of service by the perceived value of the patient. It helped when I heard

that the community spoke positively about how the service had improved. However, we never

received help from IPD. Staff from IPD used to help out in OPD when there were staff

shortages. I didn’t feel the openness required for voicing concerns. The Lean facilitator was

not there continuously. Personnel who were involved in the initial OPD Lean were

approached by management regarding the processes that I executed. I felt that there was no

round table discussion between staff and management that would aid in helping the situation.

There was also no contact between me and Susan. We had no instructions of what the

interventions were. The different pharmacy departments were not on par. Top management

21

Delivery patients couldn’t leave until the pharmacist had triaged the scripts and made sure that it was

valid.

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didn’t inform each of the departments about the procedures and interventions that took place.

If we were on par we would have been well equipped with information when rotation

occurred.

6. GOING FORWARD

Just before the end of her rotation, Tammy and five other pharmacy managers were sent on a

Lean Enterprise Workshop in September 2009. Dr Cole initially taught them about Lean

through informally introducing it in the meetings, and giving presentations. However, from

the workshop, Susan and Tammy decided to have an informal conversation about what

needed to happen before the next rotation. The main points gained from the talk were: make

changes visible, practice 5S, and document. They realised that without structure the whole

project would fall away.

Susan re-entered OPD for her new rotation as pharmacy manager in October 2009. She

wanted to avoid the disappearance of the Lean project and attempted to save it by being

aware of the changes that happened prior to her return. As the weeks progressed Susan

realised the flaws in previous attempts to manage the Lean project. Because of the initial

success with the Lean project, different managers adopted different practices. Unlike Susan

some looked at it in a casual way. For example, if they started at 8am and there were 10

patients waiting, the proper step would be to clear the backlog of patients. However, certain

managers took a more relaxed approach. They thought that if the era before Lean use to be

bad, a lag of 10 patients was not a problem. But unfortunately the system outside was not

providing them with a constant influx of patients (See Exhibit 7 for Patients comments after

Lean). Natasha, the head of pharmacy, suggested:

We were in a stage where we as a team needed to document. The excuses of not having the

time to document interventions needed to dissolve. We needed visible instructions that would

make processes easier to understand for the new interns and new staff from the rotations. It

would have clarified the operations. A Standard Operating Procedure that related to Lean

would have also helped to sustain the project. The meetings around change and the Lean

project needed to change. Procedures should be reviewed as often as possible. People lost

enthusiasm because they didn’t see the benefit in doing things a certain way. Staff were also

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frustrated from the different changes between the rotations, especially with no visual aid that

guided these changes.

Susan constantly pushed her employees in a direction that allowed them to be effective. She

knew that being hands-on created openness and acknowledgment of her employees. Her

passion took control because she was there at the commencement of the Lean project and

didn‘t want it to disappear. Even when people were off or on leave, Susan understood the

importance of the Buddy System and maintained its use: two assistants to a pharmacist if

necessary. She knew that the Buddy system pushed people:

If the clerk just issued a number 50 to the patient, and we were busy completing folder

number 35, we knew that we had to work faster to complete the next 15 patients. We didn’t

want to lag behind. We tried to keep up with the influx of patients. There were days where

OPD was 80 folders behind, and everybody began to push themselves to try and erode the

backlog. Employees didn’t want to see their hard work fall away. Immense effort was put into

the project to try and convert people’s perception of Lean.

As Susan tried to re-establish the Lean project, misconceptions developed between Amy and

OPD operations. Amy assumed that because no ―cry for help‖ came from initial stages of

Susan‘s return to OPD, everything was running fine. This message was relayed to top

management. When Amy called to enquire whether they were fine, Susan answered ‗Yes‘.

However, according to Susan this is where the misunderstanding developed:

I meant “yes” we were surviving but the patients outside were “dying”. Staff were fine

because we were comfortable in the pharmacy, but what we portrayed to the patients was not

fine. It was not picked up as a problem. Then Dr Cole came to OPD to observe the processes

and realised that the system was keeping patients there for 1-2 hours. He realised the waiting

period had increased.

This caused Dr Cole to be aware of his past assumptions that occurred during Tammy‘s

rotation. He didn‘t want to repeat his mistakes because he realised his assumptions were far

from reality:

It seemed that management in OPD were not trying to defy Lean but rather felt comfortable

in adopting their own processes. They did this because they didn’t understand certain aspects

of the Lean processes that were put in place. This is what I realised about Tammy’s

management period. They didn’t want to feel like they were incompetent because this project

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ran for a year. The team was focusing on getting work done at the expense of Lean. I created

an agreement with the OPD staff that said, “If you showed me that you were doing your best

to sustain the Lean project, I would fight for other OPD problems with top management”.

Those were problems like resource allocation. What didn’t occur to me was the fact that I

needed to be present on a regular basis during crucial events, like the staff rotation.

After reviewing all the steps that had taken place subsequent to when the Lean project was

implemented, Susan started to incorporate all the information, comments, and expectations

that would enable her to make a change for the better. She remembered the outcomes of the

workshop and decided to implement those suggestions. Before she walked into the OPD

domain, Susan stopped, picked up her pen, grabbed a piece of paper, and prepared a draft of

what was to be discussed at the next meeting. She kept in mind that this change would only

be possible if everyone was correctly informed and experienced some accountability with the

project.

EXHIBIT 1: Process Flow- The Dispensing Process

PLEASE NOTE: THIS SHOWS THE PROCESS FOR MAINSTREAM AND PRIORITY FOLDERS, NOT DELIVERIES

Clerk checks for validity:

date and signature

Patient hands in folder

to clerk

Patient sits in

waiting room

Clerk gives

folder to Triage

Pharmacist

Folder is left on the trolley for the

dispensing pharmacist

Folder waits to be Triaged

Pharmacist Assistant captures folders and

prints labels. Folder is signed.

Folder is placed on trolley with its

labels Pharmacist picks medication, and

places labels on the medication packets.

Folder is signed to indicate which

person had assembled the medication

Pharmacist checks the folder to see if the

processing has been done correctly, and if

everyone had signed next to their task.

Folder is signed.

Dispensing pharmacist checks the folder

to see if every step has been done

correctly and if the medication is

correct. Folder is signed.

Triage Pharmacist takes the folder

Proceeds to the computers

Triage Pharmacist: validity check; scripts

are queried; and sorted. Folder is signed.

Dispensing pharmacist calls the

patient, counsels them, and

Delay occurs if scripts

are queried.

Delay in dispensing of scripts occurs because of

only one dedicated pharmacist who is available

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EXHIBIT 2: Timeline of events

DATE EVENT

APRIL 2008 OPD was introduced to the concept of Lean by Dr Cole.

Susan Henry was OPD manager.

MAY 2008 Data gathering was done. Timing of the steps within the

dispensing process was conducted.

JUNE 2008 Results were shown: The Value Stream Map was presented.

SEPTEMBER 2008 Buddy System created. Waiting time declined to 55 minutes.

MARCH 2009 Staff rotation occurs for Tammy Merrick- new OPD

manager.

APRIL 2009 Waiting time over 2.5 hours

JULY 2009 Wheelchair patients become a priority again. Waiting time

average 3 hours

SEPTEMBER 2009 Lean Enterprise Workshop

OCTOBER 2009 Staff rotation-Susan re-enters OPD as manager

EXHIBIT 3: Patients Comments

KEY CAN BE DONE

ONLY BY A

PHARMACIST

CAN BE DONE BY

PHARMACIST AND

PHARMACIST

ASSISTANT

I think you are doing a greatest job. Please

keep it up. We will also try to be patient.

Everyone should open at the same

time

The staffs are too slow! Add some more staff.

In the past there were old pharmacists that

use to work in the chemist and they were very

fast. We didn’t need to sit long till our name is

being called. Now there are younger people

here and they are slow. We need to go home

Why staffing problems? Four

windows should be opened at all

times. Upgrade the computer

system.

When patients hand in their

folders they must be asked if they

INSPECTION/CHECK

FLOW OF

THE FOLDER

DELAY

TASK

STORAGE/WAITING

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EXHIBIT 4: A3 Tool for OPD (4/6/8) *The Value Stream Map within this A3 was developed by the lean facilitator Dr Cole.

RECOMMENDATIONS

To decrease time spent on

queries ( Tracking Dr‘s)-

Incorrect scripts will be sent

back

Query Slip will be given to the

patient. They will with these

slips. The slips will indicate what

is wrong with the script and what

the doctor needs to do to rectify

it.

Query slips won‘t apply for

Wheelchair cases

CURRENT STATE MAP

Average of 500 folders per day

Average waiting time of 3-4 hours for medication

Constant shortage of staff

BACKGROUND

Providing the medication to patients who are not hospitalised

Patients need to wait for their medication from the busy OPD

CURRENT SITUATION

Staff frustration with queries

Lots of non-value added time spent with queries

Causing downstream delay

Long Inter-process Waiting Times

10% ‗Value‘ ADD time ( 875s out of 8800s)

Cycle time 100sec

60-70sec (out of 100sec)= Non Value Added time

FOLLOW-UP ANTICIPATED ISSUES:

-Time to implement

-Low staffing in June

-Memo not filtered down to doctors (

doctors might not be informed about the

decision to send scripts back if it had a

query)

PLAN

Trial run for one week

Memo for interns and new staff

about these query slips

Would only use this while clinics

were opened

GOAL

Triage, decrease 30% Non-value adding time

Increase patient satisfaction

Won‘t wait >= 10 min for a Doctor

Get Doctors to fill in scripts correctly because ― they‖

disadvantage patients

ANALYSIS

Delay at Triage

Spend a lot of time on queries

Taking Responsibility for Dr‘s

Don‘t complete scripts correctly

Knowledge

Not enough time

Not realising the consequences

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KEY

INSPECTION/CHECK

FLOW OF THE FOLDER

DELAY

TASK

EXHIBIT 5: Process Flow- The Buddy System

Buddy Pair receives folder

DONE ONLY BY

PHARMACIST

DONE BY

PHARMACIST AND

PHARMACIST

ASSISTANT

Clerk checks for validity: Date and doctors signature

Patient is given a number

Buddy pair calls 5 folders,

therefore 5 patients (calls the

number that the patient was given)

Pharmacist within the Buddy pair

triages the folders. Folders are:

checked, for validity; queried; and

sorted. Folder is signed.

Buddy pair processes the folders on the

computer, prints out the labels, and

picks the medication. Folder is signed

at each task.

The folders are checked by the Pharmacist to

see whether processing of the folders was done

correctly, and whether all signatures are evident

Folders are checked by the dispensing

pharmacist to ensure that the correct

medication has been given. Folder is

signed.

Dispensing pharmacist hands out the

medication and counsels the patients

Patients are called

Folders, along with their

medication, are placed on the

trolley for the dispensing

pharmacist

Folders are given to the Pharmacist

within the Buddy Pair to check

Folders proceed to the computers,

while patient returns to waiting

room

Patient goes to waiting room

and sits with the folder and

waits to be called

Clerk receives the folder

Patient hands in folder to clerk

STORAGE/WAITING

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EXHIBIT 6: Value Stream Map with Lean

*The following document was developed by the lean facilitator Dr Cole. This was used in OPD.

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EXHIBIT 7: Patients comments after Lean

There was a time when it was

much faster service. Now I am

getting frustrated waiting.

The patients’ needs must

be priority. They need to

work faster

I can see them doing what they

can.

I feel like I receive my proper

counselling. I like that they ask

me first if I need all my

medication because I don’t like

keeping and using unnecessary

medication.

It is better than it used

to be. But it seems it’s

getting worse. I still

think you need more staff

I don’t like going back

to the doctor when the

script is wrong. I have

to spend more time

waiting for my

medication.

I can’t afford money to

pay for Deliveries. I have

to wait here for my

medication and I expect

Pharmacists to make us

their priority.

Sometimes I see so many staff

in the pharmacy and still think

why we are waiting so long. I

don’t understand

I feel like they care about us

more. I know they are trying to

make it better.

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5. TEACHING NOTES

5.1 CASE SUMMARY

The Outpatient Pharmacy Department (OPD) had been experiencing an ongoing problem of

the patients waiting 4 hours on average for their medication. This placed pressure on the

pharmacy staff to try and complete the patient‘s scripts faster. Shortage of staff had

aggravated the problem, and hospital management was not willing to supply resources to

acquire more staff. As a result, quality of care – the aim of any healthcare facility – was

deteriorating.

In April 2008 hospital management decided that OPD should utilize a process analyst to

attend to the problem that they were facing. He introduced the Lean principles to the

pharmacy department and received immediate buy-in from the head pharmacists. A

brainstorming session was held to determine where the problems lie, and subsequently a

Value Stream Map was constructed. Problems were identified: Folders within the pharmacy

were only being worked on for 15 minutes, and waited to be processed for 160 minutes.

Small interventions were implemented to counteract the prolonged problems that caused the

increase in non-value adding work. Results appeared after a week: Folders were now being

worked on for 11minutes, and waited for 60 minutes to be complete. By September 2008,

patients only waited 55 minutes for their medication. OPD staff started to believe in the Lean

concepts. Although success showed, no documentation was done in response to interventions

that were implemented.

Staff rotation occurred in March 2009, and a new management team entered OPD. Because

of the lack of documentation and no proper communication between the old and new

management team, the new team shifted the focus of the OPD from a Lean environment to a

HR-related environment, in which the staff‘s needs were the main focus. This caused the

waiting period for patients to increase, as processes were changed and not adhered to. OPD

management believed that Lean could only be used when they were fully staffed.

In October 2009, after another staff rotation, the original OPD pharmacy manager was back

in office. She was now faced with having to deal with the aftermath of what had happened in

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the previous management‘s rotation. She plans on taking action that would aid in the

sustainability of Lean in OPD.

5.2 LEARNING OBJECTIVES

The learning objectives are underlined below:

The Case Study consists of three scenarios that focus around Lean implementation, and

sustainability within a Public Healthcare facility, which in this case is the Outpatient

Pharmacy Department (OPD).

The first scenario describes the situation before the initial Lean intervention. The dispensing

process is introduced, along with its related problems, with the intention of allowing students

to develop proposed ideas on what the pharmacy manager should do.

The second part introduces the implementation of Lean, and indicates the steps that were

taken to implement Lean, showing the positives and negatives. This should provide the

student with ideas of what they would identify as missing steps in the process.

The final part describes how performance deteriorated, and the reasons behind the increase in

waiting time. Students should take into consideration the issue of the staff rotation, lack of

documentation and proper communication, before establishing proposed solutions to what

the Pharmacy Manger should do next.

Change management plays a central role in the Case Study, especially the approach that

management took to achieve team buy-in. Students must realise the importance of a change

agent, and the characteristics that change agent’s should demonstrate to provide a successful

Lean transformation in an organization. Being aware of factors that influence employees to

resist change are imperative to determine ways to overcome resistance and enable them to

take on change.

Although the emphasis is placed on Change management in this Case Study, students must be

aware of the importance of the Lean tools. They must be able to develop a “root-cause

analysis” from this case to determine why the deterioration happened and how it hindered the

current situation. Understanding the Value Stream Maps before and after Lean

implementation is important as it will allow them to see the benefits of the Lean

implementation.

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5.3 CASE PREPARATION

Table 19. Steps in preparation

PREPARATION FOR TEACHER PREPARATION FOR THE STUDENT

- Should have read the Literature review - Should have read the Case Study prior to class

- Should have read the Case Study - Should have read literature that is relevant to

the context of the case. This should be given

by the Teacher.

- Should make the following literature available

to students prior to the lecture: Change

management, and Creating a Lean culture –

Section 2.4 of the Literature Review

- The following article should also be given to

the student: Golden, B. (2006). Change:

Transforming Healthcare Organizations.

Healthcare Quarterly, 10, 10-19.

- Should complete the assignment questions

prior to class.

- Must prepare slides for the discussion session

- Must have slides for the assignment answers

5.4 DISCUSSION SESSION

Prior to the assignment questions, the following steps should be taken by the Teacher to

provide the class with the appropriate information for understanding the essence of the case:

The teacher should ensure that he/she has read the Literature review for this case, and

understands the concepts behind it. If additional information is required, they should

acquire information that they feel is related to the case.

Begin the lecture with a brief slide presentation around Lean in Hospital. This can be

obtained from the literature. Allow students to understand the concept of Muda in

hospital. The ―Five steps of Lean‖ by Zak (2008) describe the importance of Lean in

hospitals. See section 2.2 of the Literature Review.

Briefly describe an outline of Lean management and the importance of a Change

Agent, Section 2.5 of the Literature review.

Question for discussion: What steps do you think are required to bring about a

successful change?

After the class has brainstormed some suggestions, show a model for change

management from the literature. The use of the ‗Transforming Healthcare

Organizations‘ which is adapted from Golden (2006) should be a good model to

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utilize. This model incorporates some of the thinking of Kotter who is recognized as a

leader in ‗change‘. See section 2.3.1 of the Literature Review.

Proceed to the assignment questions.

5.5 ASSIGNMENT QUESTIONS & ANSWERS

Question 1: What enabled and inhibited employees to adopt the

Lean Project? In your answer, mention how the Value Stream Map

helped.

The following answer is related to the initial responses of the frontline-workers (the

Pharmacy personnel in OPD), excluding any managers, as it is important to understand how

the value-adding individuals understood the Lean Project. (The Teacher should refer to

Section 2.6 of the Literature review to clarify any concerns)

Enablers included:

Employees who knew that they would get support from their supervisors if they

accepted this project because their management team had already bought-in to it.

Referring to the literature, it is suggested that if implementation was done well a

successful change could be brought about, thereby allowing the employees to be

supportive of change (Self & Schroeder, 2009). Dr Cole initially received buy-in from

top management, who then influenced the OPD manager and staff.

The brainstorming session held by Dr Cole allowed for open communication amongst

all stakeholders. (Zak, 2008)

The Buddy system which was an idea that was used before, but wasn‘t maintained

because of lack of team buy-in. It was reintroduced, thereby showing that the

frontline-workers‘ suggestions have been acknowledged. Management was accepting

of their ideas (Zak, 2008). This made it easier for staff to take ownership of their

suggestions and efforts. (Bruckman, 2008)

Trust between the staff and facilitator developed because he had spent time on the

floor observing and taking part in the dispensing process. Employees could see that

their concerns were being addressed and acknowledged. (Bruckman, 2008)

Motivation to bring back quality of care. Quality of care for patients had also dropped

because sick patients had to wait hours on end for their medication.

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The Lean project meetings allowed for openness and took the form of a round table

discussion.

Needed a favourable working area

Short-term results showed after a week, and convinced the employees, and the late

laggards to adopt the Lean culture.

Participation- Staff were collecting data for the VSM and felt part of the process. See

Table 12 of the Literature Review.

When the Lean project was started, staff didn‘t have a solution because they didn‘t

see the problems. When problems were identified they were reviewed and underwent

constant improvement. However, before this had occurred, a Value Stream Map had

to be constructed to help employees see things differently.

The following graphs below were constructed using the Value Stream Maps from the

Appendices (Exhibit 4 & 6). It shows the value-adding work that was done during the

dispensing process. Students will not be required to draw this. It should rather be used

by the Teacher to illustrate how steps were Eliminated, Combined, Sequenced, and

Simplified (ECSS). (Baker et al., 2009)

The Steps included:

Step 1: Clerk receives folder and gives patient a number

Step 2: Triage-validity check, scripts queried, and sorted

Step 3: Processing: register script and print labels

Step 4: Picking and Labelling

Step 5: Checking

Step 6: Checking and dispensing, 2nd

check, counsels, and dispenses

The graph below illustrates the steps prior to Lean implementation. Takt time was

calculated to be 57.6 sec to a folder = [(480min/500 folders)*60]. Cycle times are

longer than the takt time which indicates that each step, besides step 1, the processes

were taking too long to complete.

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Figure 10. Cycle times against takt times

After reviewing the VSM, and applying the interventions (like the query slips, and the

Buddy system), the following resulted:

Figure 11. Cycle times after ECSS against takt time

Steps 3 and 4 were combined because staff wanted to prevent any build up of folders

from occurring. So the pair who processes the scripts on the computer will pick

medication and label their 5 scripts. They would not be waiting for another team or

person to start picking the medication and labelling it. This gave a Buddy pair the

responsibility of receiving 5 folders and making sure that the folders were completed

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before they could call in another 5 folders, and in turn, eliminating the chance of non-

value adding time being evident due to folders waiting inside the pharmacy.

The Non-value adding time indicated on the Value Stream Maps showed staff the

extent to which folders had been waiting in OPD before they were given back to the

patients. It also indicated where blockages existed – when triage pharmacists wasted

time on the phone trying to track down the doctors, which in turn, hindered the rest of

the process.

All these realisations from the VSM‘s have helped them adopt the Lean project, as it

made sense to them, and they understood the need for improvement.

Inhibitors included:

Negative attitude towards things that was tried in the past. ( O‘ Toole, 1995)

Some individuals might not have felt comfortable in voicing their concerns. (Zak,

2008)

Set in their ways, not open to new changes. (Kotter & Schlesinger, 1979)

Sceptic: Lean‘s not the answer. ( O‘ Toole, 1995)

Peer pressure: individuals might experience conflict as to whether to join the resistors

or acceptors.

Afraid of management imposing their ideas

Employees didn‘t see the benefit in Lean for themselves. (Kotter & Schlesinger,

1979)

Distrust or a negative relationship with Top management, questioning why they

would care now after numerous of years of complaining. (Kotter & Schlesinger, 1979)

Question 2: What are the traits of the change agent that either

promoted or inhibited the Lean transformation through the Case

story?

Aligning James Womack‘s suggestions of focusing on People, Process and Purpose, with

how Dr Cole had conducted the Lean transformation, will allow us to identify important

aspects of his leadership (The Teacher should refer to Section 2.5 of the Literature review for

this question):

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With the initial meetings Dr Cole stated his purpose for intervening with OPD

procedures. He gathered patients‘ comments to find out how they perceived OPD‘s

operations, which was basically defining the value of care they were receiving in the

eyes of the patients.

He allowed cross-training to be developed through the staff‘s suggestion of the Buddy

System, which broke the divide between the pharmacist assistants and pharmacists.

Pharmacists assistants know felt part of the whole dispensing process and not only

utilized for capturing the folders into the computer system.

A problem solving culture was built, however, the steps of the PDSA cycle was not

documented. This contributed to the bad handover of information to the new staff

rotation.

Staff started trusting him because they heard that he had talks with Top management

regarding other issues within OPD-like small resource allocation. Dr Cole developed

a relationship that stated, ―If you show me you are adhering to Lean, I will help you

out in other battles‖.

The eight dimensions of leadership listed by Mann (2005) can also be used to determine how

effective Dr Cole was with the transformation process:

Table 20. Dimensions of leadership

DIMENSION ENABLED LEAN INHIBITED LEAN

1.Passion for Lean - He informed staff that both they and the patients

would benefit from Lean implementation

2. Disciplined

adherence to

process-

accountability

- He assigned tasks to the staff during the data

collection process of constructing the VSM. He

followed up on the results and informed OPD staff

about the VSM and what the outcomes were.

He wasn‘t present on a continuous

basis during the new

management‘s rotation.

3.Project

management

orientation

- Used VSM to show bottlenecks

- During implementation, he helped with reviewing

the interventions

4.Lean thinking - Introduced staff to Lean Principles informally

during the meetings

- Handed out Cases to the staff relating to Lean in

Hospitals

5.Ownership - Acknowledged the staff as experts in the system - Had initially told them that he

would sort the problems out

quickly. This might have given

false hope.

6.Tension between

applied and

technical

- Informed OPD staff about documenting - Understands the importance of

documentation , however didn‘t

check firsthand whether OPD staff

were in fact documenting

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7.Balanced

commitment to

production and

management

systems

- Created a forum to allow the OPD to participate in

the Lean Project.

- He asked questions that allowed staff to respond

and participate.

- No ideas were forced

8.Effective

relations with

support groups

- Liaised with top management to support OPD

with some resource allocation

Question 3: How should management handle the sustainability of

Lean principles? Was it beneficial that the Lean Project created an

“emergency mode”?

The teacher can refer to section 2.8 of the Literature Review for any concerns.

With the first part of the question, students should be able to identify the benefits of the

workshop that was mentioned in the Case. The pharmacy managers (Tammy and Susan), who

attended the Lean Enterprise Workshop, decided that utilizing the key points that were

obtained from the workshop was important to ensure sustainability and success in Susan‘s

new rotation. This included documenting the interventions and processes, as well as

providing proper communication between the different staff rotations. Informing the other

pharmacy departments about each other‘s process and recent developments with regard to

Lean will allow them to be familiar with these processes when staff rotation occurs, thereby

preventing the fall of Lean practices. It is also important that the facilitator be present during

crucial stages like staff rotations. He needs to be involved for a constant period before

allowing him to assume that the procedures are embedded into their system.

Because they initially missed the steps of documentation and conducting constant meetings

on Lean, management should follow the 4 principles suggested by Mann (2005) of the Lean

management system.

As Mann (2005) suggests that managers should be able to do the following if they want to

have a sustainable project: Monitor processes; use visual controls; follow-up on daily

accountability meetings; ask questions; assess low-performing processes; and acknowledge

the employees. Any of these suggestions could be used. However, students need to provide

reasoning for their suggested answers- Table 15 of the Literature Review should be useful.

Reasons could involve the following:

Stick to the standardized work of monitoring everyday process, such as the Buddy

system or any one of the processes within the pharmacy, and determine whether there

is room for improvement. If a Buddy pair had brought awareness to a problem,

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document it, and discuss with the team what the countermeasure would involve.

Monitor the results of the intervention and decide what the next steps should be. This

process would entail adhering to the PDSA cycle.

A visual control should be employed in OPD, documenting all the interventions,

reasons for failure, and countermeasures taken. It should be made accessible to all

employees, and be easy enough to understand if any employee is in doubt. Employees

should also understand the benefit of these visual controls.

If the manager had asked the employees to try out a new intervention and asked them

to monitor its effectiveness for the day, the manager should remember to contact those

employees to determine if there was any success. For example, this could apply to the

process of asking patients whether they need all their medication. A measure should

be put into place to determine how effective it is in keeping track of patients who

decline some medication, without causing confusion for the future. Triage

pharmacists who tackle this job need to be given responsibility when dealing with

this.

Asking questions during all the processes, to evaluate whether it is working at its

optimal level.

If processes don‘t work, they must be identified and assessed. This should be added

onto a visual control. Head pharmacist also mentioned the Standard Operating

Procedures pertaining to Lean and documentation should be implemented.

Acknowledgement of the improvements involving the team is imperative in order to

keep them constantly motivated, seeing that monetary rewards aren‘t realistic.

The second part of the questions deals with what Bahri (2009) and Kotter suggest about

creating a sense of urgency within the environment. This can be identified in the Case, under

4.1 Outcomes which shows that after the Lean Project was implemented, employees were so

enthusiastic about it that they would constantly check up whether they were lagging behind.

They would enquire with the clerk to determine which number he had issued, and then judge

by the number that they were currently working on. This kept them constantly motivated,

giving them the drive to sustain Lean processes. There was no time to procrastinate as no

team wanted to lag behind.

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Question 4: Construct a fishbone diagram to illustrate how the

problem of the increased waiting period, after Lean implementation,

had occurred.

The problem is: The increased waiting period. (The teacher can refer to section 2.7 of the

Literature Review).

Students may suggest anything relating to the following causes:

1. People

Rotation: New management enters; Information not communicated clearly

between old and new rotation.

Wrong perceptions from Chief Pharmacist: called in to see whether OPD was

fine but never physically observed procedures

Presence of the facilitator – was not coming regularly between July-October

2009 – had other commitments.

Top management hardly attended meetings and gave no praise to the OPD

staff when things went well.

No follow up to scheduling meetings between facilitator and new

management; each waited for the other to respond

New management (from the staff rotation) felt negative towards top pharmacy

management because she was not approached directly when they enquired

about the processes. See 5.2 of the Case Study.

2. Materials

Lack of documentation

Lack of small resource allocation such as a computer

Lack of visual controls

3. Methods/Processes

Different management styles: New rotation focused on providing a happy

environment at the expense of Lean

―Get by‖ methods used – fastest people put on computers – to get maximum

output of processed scripts.

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Buddy System would fall away: Shortage of staff /not enough pairs to carry it

out. Therefore ―cellular workflow‖ was not applied. See section 2.7.1 of the

Literature Review.

No set instructions on which stream the triage pharmacist would work on:

Management wanted triage pharmacists who were working on mainstream, to

interrupt their work and triage delivery folders as well.

May 2009: Delivery folders back to batch processes: pharmacists assistants

returned back to their ―old routine‖ of just capturing the scripts on the

computer: Pharmacists could just check the work and pick later on in the

process; pharmacist assistants are not allowed to check so are given the batch

work to do.

Wheelchair patients were made priority-they felt they were being mistreated,

especially elderly patients.

Delay in folders being called into OPD: Pharmacist assistants couldn‘t call in

more folders at the window: a pharmacist should call the folders in when they

are ready to be triaged; pharmacist assistants wait for pharmacist to check their

completed scripts, and pharmacist assistants have nothing else to do but wait

for the pharmacist to call in the next 5 folders.

4. Machinery/Equipment (This is not a prominent feature in this Case Study)

Only 4 computers available.

5.6 TIME ALLOCATION

DISCUSSION TIME

DISCUSSION SESSION 20 MINUTES

QUESTION 1 25 MINUTES




TOTAL 110 MINUTES

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INTERVIEW LOG BOOK

Table 21. Interviews

DATE INTERVIEWEE/S

26th October Head pharmacist

30th October Head pharmacist

3rd November Two Pharmacist assistant, two pharmacists, OPD

pharmacy manager of 2008

9th November Chief operational pharmacist, process analyst

12th November OPD Pharmacy manager of March 2009

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INTERVIEW 1: VARNI –HEAD PHARMACIST- 26 OCTOBER 2009

In terms of what is happening in OPD, do you think there is just a “BEFORE” lean and

“AFTER” lean situation?

I think that there is actually a part ―C‖. Management is trying to get the lean process

sustainable and back to where we were. Last week the waiting period was sitting at

71minutes. We had a bad period before when the waiting period was between 2-3 hours on

average. Now we back to about 60-70 minutes.

What do you think brought this increase in waiting on?

Staffing for one. We had a very difficult period were it was winter; there was lots of flu going

around. We had lots of people off and were therefore short staffed. Change in management –

we had two new managers to the area that hadn‘t done lean and weren‘t involved before.

They were trying to first establish their management style. And I think that complicated the

process because they were trying to get their team working with them. At that point Lean

took a back seat. They had other priorities at that period. They were trying to facilitate it but

it wasn‘t the main goal. And I think that was part of the problems.

Did anyone communicate to the new management about lean and the change in

processes?

They did communicate it but not as clearly as it should be done and not in writing. There

wasn‘t a clear document that was handed over that said these are the interventions. Reasons

weren‘t given. Only verbal communication was given, saying we did this and that. If new

management didn‘t understand why it was done a particular way, or it didn‘t make sense,

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they went back and did it their own way. No document to say why it was done, how it was

done, and how did we get to this stage in the process.

How did the discussion of Lean come about?

A lot of it was conversation, it started off with a session were Dr. Brey said this is what it‘s

all about. It was a brainstorming session to kind of determine what the factors are causing the

long waiting times. We had weekly meetings where he would engage with staff, and be told

about lean. Obviously initially there was a lot of resistance, and then slowly we made gains

and slowly the team came on board.

And the new management today, are they aware of lean?

I wouldn‘t say ―new‖, because the management who is currently in OPD today is the initial

lean manager. So she is aware of it. So she knew exactly what was done and why it was done.

So it is easier for her to sustain the project because she knows all the work that we intend to

get to that stage.

What exactly do you think the problem was in OPD with regard to the waiting period?

Firstly a shortage of staff, inexperienced staff, and staff under pressure. We had a lot of steps

in our process. Double checks in the system that was done more for our safety but ultimately

there was many queues. And that‘s the problem. We had a queue to hand in the folder, a

queue to put it through the PC, a queue for it to be picked, and handed out. So the idea was to

try and eliminate and limit those queues and to make it one queue to hand in the folder. There

was a lot of time when folder was not been worked on, the folder just sat there.

How were the staff carrying out these processes?

Problem was more pharmacists‘ assistants in training or pharmacists that moved from one

area to the other. What they are currently doing is the buddy system- pairing the staff-that

pairing helps in sharing knowledge and skills because by combining the pair you can

counteract the balance of experienced versus inexperienced. That‘s where the Buddy system

helps- to bridge that gap.

What did this pair consist of?

Usually a pharmacist and assistant, but depends on availability of staff. It could be a

pharmacist and an intern. But given that there will always be a pharmacist in the pair.

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Can you describe the process of rotation between the different pharmacies within the

hospital?

Firstly you can say there are 4 locations- OPD IPD+sterile, Bulk, and TPN. Rotation is

mainly between OPD and IPD. It is a 3 month rotation; everyone has to, because it allows

them to get exposure to both departments. Rotation occurs in the other departments as well,

that is a 6 month rotation. IPD has a weekend shift, and people who would only be in OPD

wouldn‘t be able to experience that weekend duty in IPD if no rotation could occur. An

important point regard to rotation is that we don‘t want people to get frustrated in one

location. Also keeping relationships well promotes stability in the team. Managers however

don‘t do the 3 month rotation; they do 6months to 1 year. 30-60% of the people rotate.

Do you have pharmacy/staff meetings?

Yes, Pharmacy meetings are weekly at times that are most suitable. The first part of the

meeting is a communication session, and the second part is the project part where we look at

lean and the interventions on what happened.

How were the staff informed about lean?

We didn‘t want to make it a management vs. Staff situation. It has always been a pharmacy

issue that staff doesn‘t want to feel that they being forced to do things from a management

perspective. We informed them about what lean was, then they did an open session with Dr

Brey where he explained his purpose and role for pharmacy. He made it an open approach.

Employees were very sceptical though. They thought staffing was the answer. When they

were introduced to lean people were not convinced. Management also made it a focus that

lean was not only for reducing waiting times but also to reduces stress on staff. If the

environment is less stressful they will have better working conditions.

What do you think needs to be done in order to sustain lean principles?

Meetings, documenting, putting it up in a visible place-especially all the interventions. So

when staff rotation happens people can see. Keeping better minutes of meetings so we can try

and keep better records of the interventions that were done. Appointing a reliable project

manager is also important.

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INTERVIEW 2:VARNISHREE NAICKER-HEAD PHARMACIST-30TH OCTOBER 2009

Describe your role? And with regard to Lean?

I co-ordinate the services amongst various pharmacies. I am responsible for Human

resource management- the recruitment of staff, staff performance assessment,

resolving disciplinary issues, training and allocation of staff, management of

resources, stock management, and expenditure monitoring. With regard to lean, the

Project leader was the manager in the area and was assisted a great deal by Dr Brey.

Mine was more of a facilitating role between Dr Brey, and the manager and staff.

More facilitating and trying to get the project on the go and keep people motivated.

How were you informed about the Lean processes that was about to happen?

It came up as a suggestion from senior management. They appointed Dr Brey. They

knew the pharmacy had been under strain and resource. They suggested he get

involved in OPD. We then met him.

What do you think about Lean processes? About the tools such as the VSM?

Good idea. It makes you think differently about what happens in your pharmacy and

allows you to look at different reasons to why things didn‘t work, because you always

tend to focus on resources, and seeing that as the main problem. But now you

critically evaluate what happens in the pharmacy, when it happens, how it happens,

who does what task.

The tools like the Value Stream Map is quite eye opening. You think you know all the

processes but when you see it clearly documented you can see blockages in the

system.

After I saw the value stream map, I saw that there were so many queues in the system

and then saw the redundancy in having them.

How would you describe lean?

Critically evaluating the processes within your organisation to make them as efficient

as possible.

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Are you a risky person? If No, what made you take on this process? Could you have

declined?

I‘m not a risky person. The only reason I took it on was because it seemed that there

was no other option for us. Getting more staff/resources was not an option. Therefore

we needed to improve on the resources that were currently at hand.

We could have declined but there was nothing to lose. The situation wasn‘t going to

improve. Our patients wouldn‘t disappear- so if you didn‘t take the risk nothing would

have improved.

Have the Pharmacy tried to implement other procedures before to reduce waiting time?

IF yes, what are they? And have they been sustained?

We had a lot of changes over the year. We implemented a ―triage‖ system and what

we call a ―fast track‖- one and two items get handled differently. We were doing it on

our own; we were only looking at one area, so the change wasn‘t big enough and we

couldn‘t sustain it. People lost enthusiasm after a while because they couldn‘t see the

benefit in doing it that way. We also didn‘t review it as often as we should have. After

a few weeks it fell off, but no one was constantly checking-are we doing it? Is it

happening? Why isn‘t it happening? And what should we do differently? We used

lean probably unofficially but not to the full extent so therefore I think it didn‘t really

succeed. We were not planning and checking on our actions constantly. The ideas

were there. A lot of the ideas implemented now are not new ideas. We have tried them

before but it hasn‘t worked-because we haven‘t followed it through. The ― Buddy

System‖ is one of them . About 3 years ago we tried it, worked well for a week, fell

away and never got back on track with it-because it was one person‘s initiative. Team

buy-in wasn‘t there. A pharmacist assistant was passionate about the idea, she got the

system in place but people were not convinced.

Can you explain the concept of Triage?

The amount of queries on script is a big problem. Before the concept of ―triage‖ a

folder would come into the pharmacy and stay on pile. A pharmacist assistant would

put it through, and then pharmacist would check it. That check would only happen 3

hours later, and at that stage the pharmacist realised that there are problems with

script ( Dose wrong, no signature). Then the triage was introduced. The folder was

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handed in, a pharmacist looked at the script and therefore problems get picked up

within 15minutes

Can you explain the “Fast track” concept?

This consisted of folders with scripts that had a smaller number of items. It was

quicker to process one-itemed scripts. Therefore we had a dedicated pharmacist

working on one-itemed scripts. This worked well but the problem was shortage of

staff. Then the system fell away, and was never re-introduced. There are different

processes now in OPD so I don‘t think there is a need to reintroduce that. There is a

similar process called the non-waiting stream, but I don‘t think we would introduce

the fast track. Once again team buy-in and not monitoring allowed processes to fall

away.

What positives, according to you, did you see in management trying to encourage the

employees about lean?

It got us to work closer as a team. Generally it is managers introducing change, but

Lean is about taking a step back and waiting for input and buy-in from staff. It also

reduced a divide. Staff felt more part of the team. Their input was implemented.

With your Pharmacy meetings, how do you evaluate whether people are really happy

about Lean?

They are honest and outspoken about lean. If they feel it‘s not working they will

mention it. It also depends on the individual. I try to have a one-on-one conversation

because there are still people not happy to communicate in a big group.

You said there was always a management vs. staff relationship, how has that changed?

And what have you personally done to change it?

We became more of a team. Lean has helped to reduce a divide. There is more open

communication now .Before it was more of a top-down approach. I try to talk a lot

more to staff on face to face basis. However, my biggest challenge is time. I made a

conscious effort to be more available to staff, chatting to staff on regular basis, and

attending weekly meetings.

What factors influence your ability to bring about change?

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Staff perceptions or their receptions- whether they are prepared to listen to the idea or

see value. So my ability is to motivate staff and show that the change will be positive

for them.

What factors influence your ability to provide a sustainable process?

―Staff‖ is the biggest factor. Being able to fill the post and keep people. A lot of staff

rotate.

What in your opinion do you think are the main inhibitors for employees to adopt

change?

Distrust or negative relationships. Whenever there is going to be change staff are not

convinced, they always want to know what is management‘s intentions. They don‘t

see it as the change is being introduced for their benefit. You have to convince them

that it is.

What in your opinion do you think the main enables are for employees to adopt change?

If they can be convinced that it will make their environment better, and if they can see

how it will make their jobs easier. Or if they know it‘s been applied and done

successfully somewhere, they are likely to accept it. Staff turnover rate is high. We

have a stable force that has been here for 4-5 years. The working conditions and

salary can get better in private sector.

INTERVIEW 3-LELITHA-PHARMACIST- USE TO BE THE MANAGER IN OPD DURING

LEAN-3RD NOVEMBER 2009

Describe the situation before lean? How were you feeling, work wise etc

Initially the wait was 3-4 hours. When it was implemented it went down. Just after we

implemented it I wasn‘t managing OPD. I was working in ―Bulk‖. Pat was there in

OPD. They managed to maintain it. Staffing and managers then changed, there were

severe staff shortages which caused the time to go between 1-2 hours. Pat left, and

then Ferosa and Shivani were there. Shivani resigned. They came in while lean was

there. Pat was very much in touch with the whole system. She was there when it was

just implemented. I Left quite soon after that. I would think it would be change in

management and staff shortage caused increase. But now it‘s improved again because

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Pat is back there. Dr Brey was the only facilitator in lean. Every week was a lean

meeting to plot the whole progress and intervention- whether it was working or not.

At the moment they don‘t let the folders come in straight away into the pharmacy,

which has a dramatic effect because when you see the pile of folders, immediately it

stresses the staff out, the stress levels increase. Now it‘s calmer and not as stressful as

then.

Where you happy with procedures before?

No. Now there is the ―Buddy system‖, and the ―waiting and non-waiting queues‖.

Before it was everybody was in that long queue. Now the only scripts that are getting

done are the ones waiting there.

Describe your role with regard to Lean?

There were different things we had to do, for example collecting data. I was involved

in getting the sheets together and everyday giving new sheets to fill in. We all needed

to do the timing process. I assisted in making sure everyone filled the slips properly so

that they could do the Value Stream Map (VSM).


There was a talk arranged, and lean was introduced.


Extremely helpful. I can see where the bottlenecks are. I was not familiar with lean

before. The suggestions came from the staff during the meetings. The whole process

only works if staff are willing to do it. Management didn‘t want to tell them what to

do. The buddy system was there before. The difference before- it didn‘t work because

it was probably staffing issues, and because everybody was in one queue.



There was far more interest from management, because it was something new to try in

a process that looks like nothing can improve.

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about Lean?

It comes out quite clearly because people will say what they feel. Dr Brey went into

the field to get an idea of what the implications were. There was no prompting from

him, which is why it is so stunning that it can come from the people that work there.

Dr Brey supported the ideas, to the extent of getting the engineers to design a

cupboard.



It has changed because the assistants came up with these interventions and got

recognition for it with a reward they got. That has brought them closer to

management. Before it was ―oh we can‘t get anything positive out of them‖. It makes

them feel more valued now.

How often are employees concerns being seen to? Is it only done through meetings or

one-on-one?

Varni is always available to the staff. Pressure in the pharmacy takes a toll on staff.

People become irritated and frustrated- that is where the rotation helps.


Knowledge of what can be done to improve it. So education. Not being under stress.

Positive input from top management.

What factors influence your ability to provide sustainable process?

Staff numbers, if there is a lack of staff you won‘t be able to sustain the process. Less

―Buddy‘s‖ means your workload increases.

What in your opinion do you think are the main inhibitors for employees to adopt

change?

Negative attitude towards things that have happened in the past, and they feel

whatever you do it‘s not going to help. And maybe salary.

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What in your opinion do you think the main enablers are for employees to adopt

change?

If you reach a certain level of frustration you will do anything to improve it. I don‘t

think that it‘s about job security. Here it is very hard to fire people because

pharmacists are like a scarce skill. You can get away with murder.

Now lean is declining, what do you think is the problem?

Staff rotation-the new staff have not seen the process work very well and they don‘t

have confidence in it because they didn‘t experience it. Every day we use to get the

phone call to help. This was when Shivani and Ferosa were there. Pat use to help them

and do the orders. Shivani and Ferosa didn‘t really take on lean, they were supposed

to sustain it but they didn‘t, because they were ignorant of it that it doesn‘t work.

Is there something management should have done? Are they doing something wrong?

What are positives out of this?

There is always a time issue. There may be wasn‘t time to watch over the new group

to see if they were doing everything right. Pat couldn‘t check this because she wasn‘t

there. And the staffing.

Can you provide details of interventions and implementation dates?

In August 2008 it started with the small interventions. Dr Brey was there from April

2008. We had to time the process to see where bottlenecks were. Timing process went

through May 2008. The initial thing went through slowly. We collected data in

June/July 2008. And before August 2008, interventions were suggested- asking

patients whether they need all their medication, and moving the cupboard nearer. The

Buddy system happened in September 2008. A different queue was also introduced-

not waiting and the waiting.

Query slips were also introduced. Instead of waiting on the phone for a doctor to

query the script we would send it back with the patient.

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INTERVIEW 4-PATRICIA-PHARMACIST-OPD PHARMACY MANAGER AT CURRENT-3RD

NOVEMBER 2009


Working under pressure. The system entailed that we taking a whole load of patients

and taking their folders into the pharmacy- and having that whole pressure inside. The

people outside the premise of the pharmacy didn‘t know what was happening inside.

Staff turnover was bad. We had a lot of people off sick. People were physically tired.

Now it is better, because of the lean. We have two groups in a pharmacy- between the

Pharmacist Assistants and Pharmacists. Before it was segregation and there was

always envy within the pharmacy. With lean you have a pair, P with PA-constant

interaction. This would be your

―Buddy‖ for a week. We would rotate to avoid any irritation.

What made you take on change?

We tried a lot of changes. I wanted it to be better. Any idea that came about we were

willing to try. We were losing pharmacists; they didn‘t want to work in OPD, only

IPD. I wanted to make the place favourable to work.


No I wasnt‘.We had 500 folders that would come in a day. The pharmacist assistant

would capture the folder. The folder was in front of everyone in the pharmacy; it

would upset you because you see the workload.

We had one entrance queue and one exit queue. If people were coming to pay for their

deliveries, everything was mixed up. Even if you had worked so hard, there was still

only one exit, because folders didn‘t go out because it was sitting in the pharmacy.

This was a backlog.

When the folders entered the pharmacy, we spilt it. We had the ―fast lane‖, deliveries,

and main stream- which had the patient waiting. People outside who are mainstream

don‘t know that there is a delivery; don‘t know that there is a fast lane item. If you are

number 10 you think that you should be going out at this particular time. Inside the

team was split. In ―delivery‖ is a patient paying and going home. Mainstream is

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waiting. Even though the delivery is for tomorrow, we doing it the same time as the

mainstream. That person doesn‘t know. So patients couldn‘t understand.

On the old system there was no priority. If you were appointed to do deliveries you

had to do that even if there were people waiting. But with the new system we give

priority to the people sitting and waiting here. Deliveries are at home now, so the

priority is given to the person who can‘t afford to pay the R25, and who is waiting.

Delivers were a huge number, because people knew they would get their meds, and

the pharmacist assigned had no chance to help other streams. Patients didn‘t

understand the difference between fast and main stream items and would be confused

as to why a patient who came later than them would get their meds earlier- because

the folders were spilt inside. Those were the discrepancies that patients didn‘t

understand.


OPD Pharmacist manager in pharmacy. I foresee all the floor work. Take in

register/attendance. Stats With regard to lean I was the project facilitator and

facilitating the meetings and the reviews of each step that was done.


I had to realise what we were actually doing. Dr Brey came to introduce what we

would be doing. Because we have been doing it for years and there will be resistance.

We had to time what we were doing on daily basis-to see the points that we needed to

change. Everyone voiced their queries. Even on the first day of starting project people

were still sceptical. I told them they must just try it for a week, if it doesn‘t work we

move on. Results showed in a week which motivated people.


As a manager I was coming here at 7am everyday because there was a backlog from

the day before, and ordering to be done. So it was long hours. By the time the lean

system started, and documenting things we became more professional. People could

voice concerns. The old system was just discussion- for example... ―This needs to

happen etc.‖

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The documentation was the results of intervention. It‘s a learning curve, we learning

more and more as we documenting. I was here when it was a mess, stayed on, gave

way to other managers, went on rotation, then came back. I had a 6 month rotation.



Dr Brey has been with us every step of way, as well as with management. He had to

first motivate managers, who would then motivate staff. Every meeting had ― leisure

time‖ were they would comment or say what they felt. All the pharmacist assistant

could do was pick and put through on system- some people use to pick all day. But

now with pairing, you are supporting that person who has just one role and at the

same time training them. The old system didn‘t allow that. If you could not put

through, you pick, or vice versa. They have a chance to see a prescription before it is

being captured, whereas they just use to sit the whole day and see labels before. So it

is ongoing training for them. It encourages them to want to be here


about Lean?

Depends on people‘s assertiveness. But most of my employees bring it up, if it

happened during that week. If there is something that they do not understand about

the situation, I try to get them on the same level.



Does change but certain things are still ongoing and will crop up once in a while. It is

a round table thing now in the meetings. Previously people did have problems but

wouldn‘t say anything, because they weren‘t given recognition. People do have that

motivation now.


We here every day, we need a place where we going to be at everyday to be

favourable. Patients also need our help. In the old system we would send back patient.

And whether they would be able to come back the next day couldn‘t be judged. The

system at the moment was giving a sign that we couldn‘t even help the most desperate

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patient. I live in Gugulethu, and I know how far it is, and how difficult it is for

patients in townships .It is expensive to come here.


It was a lot of work to introduce the system, and we have seen it is valuable to the

pharmacy and employees. It has helped patients and staff. We don‘t want to throw

away hard work. There were a lot of obstacles and people‘s attitudes that we had to

get through. We had to change people‘s view. So we make sure new people who

come, we make sure they know what to do.

What in your opinion do you think the main inhibitors for employees to adopt change?

When we initially started people resisted because we had already had a whole lot of

systems that failed, and then they had no hope for a new one.

What in your opinion do you think are the main enables are for employees to adopt

change?

We all experience OPD. If there was a slight feeling or fact that we could change this

place for a better place, not only the management, the slightest change will be a factor

that people wanted to try. Management and pharmacists have tried a lot, so we were

keen to do this.

Now that lean is declining, what do you think is the problem?

Before, we would have been calling the other pharmacies for help. Then now they

would pick up and say ―hey OPD didn‘t call today‖, or they will call and OPD will

say ―we fine‖. So they would come in and be curious to what is happening in OPD.

We inform people about lean, but it is difficult. Monday meetings, we review

developments. Need to put people on par .Top management and decisions should be

rotated around as well. So for example IPD will be informed what is happening in

OPD, and vice versa.

We always have different attitudes towards how the old and new system is. Some

people will actually look at it in a casual way. For example, if you start in the morning

and open a window at 8 o clock, and there are 10 patients waiting, you need to finish.

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But for certain managers they think if we are 10 behind we are fine, you put people in

relaxed mood. But unfortunately the system outside is not providing us with a

constant/ continuous influx of patients. It is hard to judge when it will get busy or not.

Like the morning it is fine, but afternoon it increases. Even if the patients came in 50

batches at one time, the waiting room needs to be cleared. People don‘t understand

that because they think just because it is fine in the morning they can take it easy, you

then run into trouble. They also created that closed net that this is pharmacy this side

and patients outside, there was no communication to inform patients and no feeling.

Is there something management should have done? Are they doing something wrong?

What are positives out of this?

Top management should have done something- like Irena. When Dr. Brey called her

he asked if everything is fine in OPD, and she said yes because they weren‘t asking

for help. She assumed we were ok. The daily routine never knew what was happening

in OPD. We were ―fine‖ because they were comfortable because they were in the

pharmacy, but what they portrayed to the patients was not fine, it was not picked up as

a problem. The system was keeping patients here for 1-2 hours, but it wasn‘t affecting

the inside of the pharmacy- that‘s why they assumed system was fine. But the system

is for the patients.

Are employees still adopting this?

Yes they are.

INTERVIEW 5-NISHA-LOCUM PHARMACIST-3rd NOVEMBER 2009


I was here when they started it. I was there when the waiting time was long. It was

hectic and a lot of pressure on ―Triage‖ pharmacists, because you get slots for about 3

hours where you had to triage prescriptions. So you had to deal with doctor- patient

queries and answering the telephone. So that impacted a lot.


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I don‘t think anyone had a particular role. It rotates on a weekly basis. We paired with

different people in the buddy system. Initially we had a meeting once a week for a

very long time for a couple of months to highlight the problems in the pharmacy.

What can be done etc. before any lean was implemented. There were a lot of changes

during the building up process. But there are still meetings even currently to try and

chop and change things to make it better. Staff rotation is a big problem. For me

communication is a big problem and because some people have been here for a long

time they are kind of set in their ways and aren‘t open to new changes. They are

comfortable in doing things in a particular way. They would change but not as

drastically as you would need to change in a lean project. Bad habits engrained will

take a lot of time to change. It is difficult to change perception in a couple of months,

and especially with all the different personalities as well. From my point of view it

has a big impact on the lean project. There was a time when it ran quite effectively,

we had no problems.


Initially I was not for it. I thought it‘s just blowing hot air, and that‘s not the real

solution to the problem. ―We needed more staff, and no matter what you do, if you

don‘t give me more staff, nothing is going to change‖-that was my thinking. So I was

presently surprised that even with the shortage of staff we were able to pull it off. It

was a big paradigm shift for me.



There are plenty. But to highlight one at this point...Dr brey brought on huge change,

because everybody was of the opinion that he was wasting his time. The problem was

staff -according to us. But that thought process was a big turnaround. The hidden

problem within pharmacy- was visible on surface level- that was holding back

productivity. It was interesting that when he started with the lean project other issues

came out that needed to be dealt with but wasn‘t raised in normal meetings but raised

in his projects.


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Change is good because you can so easily get into a rut. It‘s nice to have change

because it pulls you out of a rut. With this project it highlights that what you perceive

to be a solution might not be the solution.


Because I think it‘s working, I can see it makes a difference. Patients are happy, and

staff has to work closer together as a unit. With the ―Buddy system‖ there is no time

to procrastinate or do things other than pharmacy. Because if you don‘t finish your

folders you will lag behind, so it kind of forces you to do other things.


I think them not embracing it in the way management would like them to embrace it.

Because when we started it, it worked. And because in my mind I know it worked the

first time, I know we can keep it up and it needs to be maintained. But if it hadn‘t

worked, I would have had a very different perception about the whole thing.

What in your opinion do you think are the main enablers are for employees to adopt

change?

When you raise issues or problems that are actually being addressed and you can see

that it is being seen to, that would motivate me. The flip side of that is that if you keep

on raising the issue and nothing is being done it is very de-motivating and I think

some people have gotten to that point. It is a drawback for me.

Now Lean is declining, what do you think is the problem?

We told Dr Brey that he needs to be present. There was a time that he was absent, and

as we go through different managers- from the staff rotation-the manager would have

different levels of experience. Some people are put in positions were they not really

experienced enough to carry the pharmacy. With some who are experienced, things

are good in the pharmacy, and vice versa. That is one of the problems.

Sometimes there are things brewing and people don‘t want to raise it because it may

cause problems, it‘s unvoiced. Thirdly the rotations. People say they understand and

don‘t really- I think it‘s more a personal thing if they don‘t understand. They need to

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ask-maybe they feel targeted, for e.g. ―It‘s been running for more than a year how can

you not understand how it works‖.

Dr brey was absent for quite some time. When he was here constantly it was almost

like being visible. And so that kind of dwindle. Now they ask him to attend meetings.

He is the person that started it, and he knows everything and people listen to him. I

am the locum, so even though I know the system, I am not allowed to say things

because I am not part of the staff per say. It is de-motivating. So people are not happy

that locums should be interfering.

How long have you been here for?

I have been here for 3-4 years.

INTERVIEW 6-AKEELA-ASSISTANT MANAGER-OPD-NEW EMPLOYEE-3rd NOVEMBER

What is your role?

Well I just started in OPD.I am a pharmacist. This is the first time I‘m working in

OPD. Some afternoons I use to come over to help.

Are you being informed about lean? What do you think about it?

Yes .I think we were lucky because we had a lot of sessions that explained it to us,

from beginning to end. Dr Brey still helps facilitate. The last 4 months he was not

coming regularly, but there were two other managers here.

How is it different from how you use to work?

It‘s less stressful. The folders use to pile up and it would be put through and people

just pick one by one. Now it is more organised.

Do you think you can adhere to it?

I think so, we have been pretty good in trying to maintain the system, but there are

times when it is difficult to maintain.

What have management done to sustain it?

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They try to be present at the meeting- top management. They don‘t give praise for

good work. I think there are occasions in which they will come and give you

appraisal, but only if you had complained and got a really bad week then they will

come.

What are causing you to carry lean on?

The conditions we working under now, is better than before. It has improved so much

you don‘t mind going to work. Now we have time to do other things we don‘t usually

get a chance to do. We try not to lag behind, because you have to prepare for the

following day.

What is stopping you from carrying lean on?

It is a bit difficult with the staff rotation, if the team that is working now is fine with

the decisions, the new team might not be happy with the decision and they give you a

really hard time, and then you have to go back to the whole process. I think the team

that was here previously probably didn‘t consult with us- that is what they thought.

We didn‘t have much documentation and that is something we want to change. No

formal documents to say this is the intervention etc.

What stands out to you the most?

The Buddy system makes a good difference. We still ask questions to patients

whether they need all their meds, but there is a communication problem they don‘t

understand what you say.

What do you enjoy about your job?

The atmosphere within the pharmacy, it‘s so much better, more fun. Before it was just

work, work. So now we have that team spirit, where my team wants to be better than

the other.

We got 5 pharmacist assistants and 9 pharmacists. So there would be 2-3 pairs with 2

more pharmacists.

Do you feel management is aware of your concerns? Do they play a part in getting the

pharmacy right?

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We would inform our chief and deputy director, and they have more contact with top

management.

Do you feel comfortable in communicating with them.

Our pharmacy management. Yes. They are open.

What do you think are the problems now?

The problem comes in now with the rotation, where responsibility and procedures are

being handed over, and we don‘t have documentation on what we were doing and

what we planning on doing. They started last year with lean it was good, then they

started to fall away from March till about now this year, and it only went back into it

about 3 weeks ago.

INTERVIEW 7 -NARIMA- PHARMACIST ASSISTANT- 15 YEARS- SHE HERE WAS

BEFORE AND AFTER LEAN-3rd NOVEMBER 2009


Before it was haphazard, chaotic. I wouldn‘t say there was no order but you never

knew where you were at. There was priority but everybody became a priority. They

could spin any story at the reception area, and it would become a priority. It would be

wheelchair, a child crying for example. You end up doing priority, and then other

people who are prepared to wait have to wait much longer because of these

―emergencies‖.

What made you take on change?

I think we were all open to change and so fed up in not knowing. We didn‘t know

how it was going to pan out. We tried lean a few years ago, but not as invasive as this

one was. It was a matter of the folder came into the pharmacy and the matter within

the pharmacy it would be like, me and you lets be buddies and try and finish the

folder. We tried it for 2 days and it fell apart, because no one really realised it was a

winner. We didn‘t know it was lean at that point. Before we use to be lots of

pharmacists and lots of assistants and you would get some people who would just hide

and not push the work, so we wanted to try and equal the work load.

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Before this ―lean‖ there weren‘t actually Deliveries. Before deliveries there was just

mainstream and priority. So it was actually one line and in-between you would get a

priority. So if you go to the window at reception and took a pile, in that pile there

would be priorities. So you still had to sift through the pile. You would put it through

the system and see and then put it on the fast track and pick it. At that point there

wasn‘t numbers, we just tried putting it into piles, and priorities was one pile. This

was happening 2 years ago. And then the numbers came in which was giving it an

order, just to get stats. This was before any lean came in.

What was your take on managers?

Nothing came from them. I don‘t know what our managers spoke to top management

about. But from being on the ground it felt like nobody was worried about Pharmacy,

unless there was a patient crying out or fainting, top management would come. For

the years that we have been busy, I think I saw top management twice in pharmacy.

And the one time they came and did some folders- as in logistically just moved the

folders closer to the pharmacists to pick and check-and the other time they did a walk-

about to see what can be done. I think that outside pressure or patients caused them to

look at us because I don‘t think we did as a pharmacy. Nobody took that into their

own hands and said this is what I want to look at and want to change. From us on the

floor, we were just coming in and doing what we had to do and went home, no one

was saying, you know what; maybe we can do something to change it. I mean from

my side, in the old pharmacy I would use to write labels with my hand to indicate to

new employees were to pick. I was still young at the time and had energy. I thought it

would minimise having someone looking at what do I need and where to start

looking. Some had generic names and not trade names. I just matched it up. Now we

computerised. I like OPD because it keeps me on my toes.


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Dr Brey was the first person to introduce it to us. He didn‘t come in and say this is the

big picture and this is what I want you to do. He came with small stuff. Let‘s try this

at the window and see how it works. Then we had to take stats and see if it worked.

Then after a month or 2 weeks he could see that from the stats it is working and would

say ―let‘s see if we can do this now‖. After small projects we integrated the whole

thing. So the way he introduced it was a good way. He came with this big idea, but

most of the ideas came from the floor. He would throw something in the works but we

would say no not this one etc. or maybe this way would be better. So I wouldn‘t say it

came from him, because everybody just threw something in to the whole pot. And he

would try and not brush it aside. Unless he would say it hadn‘t worked before.


If everybody goes with it, it really works. I was here when we put everything together,

as I said it was all small projects then it became this one integrated thing, and it

worked like a bomb. We did start it on a Friday which was a quiet day and our

waiting time was 20 min. It was quick results. And also we knew on the next Monday

or Tuesday it would be longer than that. But I must admit it does make a tremendous

difference who the manager is in the place. Pat was here at the time when it started

and it worked like a bomb. Then Ferosa and Shivani – when rotation happened- came

in and the buddy system fell away because they didn‘t like it but at the same time they

weren‘t here went it was being implemented. They weren‘t here when the small

projects were being integrated into the bigger one. I wasn‘t here when they were there

but they needed more help. When we started with the Buddy system, we almost never

asked for help from the other side, but when they came and even with Lelitha when

she came, it also fell a little by the waste. If the manager is hands on, it works like a

bomb. Like Patricia even if you think she is not watching, she is.



I didn‘t see people being motivated, except for Patricia, she would be like come

people lets push it we need to get this time down. We felt passionate about it because

we were here from the start. When rotation came and then people just didn‘t feel as

strongly because they weren‘t part of the process initially. Even when people were off

or on leave, Patricia would still try keep the Buddy system, two assistants to a

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Pharmacist, while the rest of them would say no buddies today, let‘s just take in the

folders. If you compare the waiting times the buddy system works because it keeps

you on your toes.


about Lean?

I think Dr Brey was very open to suggestions. We had weekly pharmacy meetings to

say: how far are we; what did we do for the last week; what new interventions did we

try; what stats do we have to say that it works or didn‘t works; and were to improve.

When you say something and come up with an idea but when you put it into practice

and you see a little bit of hiccups here and there and where it can be streamlined. We

tried to make interventions that are already there better or to determine whether some

should be left.



In OPD we are definitely close. I‘m not sure about IPD. For instance if Akeela was

the manager in IPD she would be hands on like how Pat is here, but now Lethita &Mr

Levine ( Managers) is there, you see them and you don‘t see them, they not really

hands on. Lots of people wouldn‘t go to them with a query because they almost never

have an answer for you. They will take forever coming back to you, so some people

resort to leaving it out, or letting someone else pick it up along the way, which is not a

way, and other people will just do their own thing. That is why when mistakes comes

out on the other side, yes you have to check it, but your manager must be hands on,

and that‘s what people expect from managers. If I say, ―Pat what is the dose for etc‖ I

expect them to know. And if they say they will come back to you, they must.

Everybody was complaining before because they had to stay late, that might have

helped top management to look in the OPD.


It‘s how you feel towards your work. For me it‘s about the patient. I get fed up with

people (pharmacists) taking the easy way. We are supposed to make the patients lives

easier. If we are struggling with opening a bottle of medication, what you think the

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patient is going to do with it. From our side we should see that that patient will be

compliant because we made it easier for them.


It comes down to being a human being. I worked in Sterile for 6 months of the year

and enjoyed it thoroughly. We mixed chemo, and they don‘t know what you doing

and we don‘t have the man power to have a pharmacist watching you all the time. So

you must know what you are doing. And to have that in your mind gives you that

challenge.

The buddy system pushes you. You ask the reception person, what number are you at,

then you can know what number you are calling in. Then you can see the

discrepancies and see how far behind you are. There was this one day we were 80

behind and everybody would just push it. It‘s nice because you see everybody doing

the same thing. Now if they 30 or 40 behind, so what.

When Pat was here, pharmacist assistant could take the folders to window and put

through. when Shivani was here pharmacist assistant couldn‘t take the folders from

the window because it has to be triaged by the pharmacist. For me there was a break

in the cycle, because in the morning we would both take folders- me and my buddy-

we would start with 10. We would both put through, and then start picking. Then if

she picks first, and I‘m done with mine, I‘ll start picking, and she starts sticking and

checking. While she checks I will get more folders-put it through- then we start

picking- there is no gap in the process. Now with the system that Shivani brought in

that pharmacist assistant couldn‘t take folder s from the window because she said that

it has to be triaged first. So I was forever waiting for folders because there were never

folders for me to put through. For me it was a waste of time.

For management sake, buddy system was not aborted as far as they are concerned. It

wasn‘t actually running.


Scepticism. We all reluctant to change because we all people of habit. If I saw results

I would be ok.

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What in your opinion do you think are the main enables are for employees to adopt

change?

If patient doesn‘t wait that long, if it‘s going to bring patient compliance up. And

make sure pharmacists have more time counselling patients as they should be. I have

children, and this for me is me time.

Now Lean is declining, What do you think is the problem?

I am currently working in sterile now, but they called me in because they are short

staffed. I believe that if there is a strong manager things can be sorted out. With the

new managers being here now, you need to give it a while. Pat checks fast. I call her

―Miss convenient‖.

Me personally I wouldn‘t like to stay in one place at the time- this rotation is a good

thing. If you a manager that knows your staff, and your pairing your pharmacist with

a pharmacist assistant. Pat always puts weak pharmacist assistants with her. You can‘t

just pair up people for the sake of it, because then there is a weak link in the chain.

It‘s good of Pat to do that. She does that with a new pharmacist, she puts a good

pharmacist assistant with them.

INTERVIEW 8-IRENA-CHIEF OPERATIONAL PHARMACIST-SECOND IN CHARGE-9

NOVEMBER

Describe your role? With regard to lean?

I oversee the Operational management in pharmacy. Our staff consists of 70 people. I

place people in places and departments, pharmacist assistant and pharmacist rotate

every 3 months. I am making it to 6 months now because the project fell away with

the rotations. People call me when they need help-with people absent. I will shift

people from Sterile for example. I was manager of OPD some time ago. The cry for

help changes with management change. In October 2008 change happened. Now we

are seeing results. I was more of a supportive facilitator. We all suggested things and

added to the list.

How did you approach them?

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It was done by us and by Dr Brey. He was the person from outside trying to help,

because we were always in crisis, staff wise. Varni and I went to lean course about the

Toyota Production system, so we were familiar with it. We were constantly in contact

for help with top management. It was a year till we got help.

Top management didn‘t give any specific reason to not giving help. Our medical

superintendent doesn‘t even bother now. They could give us praise but they didn‘t

know how to help us. They say they don‘t have a budget; you work with what you

got.

Did you have faith that the lean would work?

Yes. Not mainly that it would work. I knew it was a good idea. I believe it can work

in pharmacy.

Do you feel that there is still a management vs. staff relationship? And what have you

don’t to eradicate it?

It‘s changed because of the management style; we are like open-door management.

They can contact us anytime. Communication via emails is better. We use to have

pharmacy meetings with everyone, managers, pharmacist, pharmacist assistant. Varni

and I were preaching and no one was listening, and when they finished people behind

our backs started to talk. Then we stopped this. Then we started to have managers

meetings, with managers only and slowly but surely having weekly meetings.

Mangers then became assertive and started organising their own area meetings. And

then they use to ask me if I wanted to join. And if they needed help for something

they would ask me to attend. Then it became a norm that I would be attending.

Why would want to see change?

A bad experience. Our major goal supposed to be taking care of our patients then our

staff. If they waiting 2-3hours, and being sick, we need to help them as soon as

possible. Patients complaints also. Staff stress levels. They suppose to be smiling

everyday but they don‘t, they had attitude, rude. Patient shouting, pharmacists

shouting. Retaining of staff is also a problem. Pharmacists might come here for

experience and leave for other sectors.

Can you tell me about Ferosa and Shivani’s management time?

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Ferosa has a different management style. A lot of negativity. They were good but their

main focus was on team building and keeping the atmosphere good. They had a

shortage of staff and pressure was high, but the results were that they built a team that

felt like family. The meeting was not around lean and waiting time and what we

should do. The meetings was general information about what‘s happening in the

pharmacy. There was no focus on the lean project like what Pat is doing now. They

walked into OPD after Pat left. They came in March 2009-October 2009. The hand

over wasn‘t great. Although Pat tried her best to put in writing about the

implementations it was difficult to learn it and put into action. That is why now we

have decided to write everything-not only minutes, but what is happening within the

pharmacy. We put the poster up in OPD because we want to sustain it. Visual display

is important. This only started happening 3 weeks ago, recording the minutes-how

many folders, waiting time.

The visual difference resulted from sending 6 pharmacy managers on lean workshop.

They were then aware of the tools and started putting into practice the 5s , Visual

management and documented. They realised the whole project can go away.

What are you doing to help sustain Lean?

We are in this moment in time to sustain we need to document and put in the

information available to whole team. Roster changes, new interns, etc, at orientation

day we can say this is what we do in this place. SOP pertaining to lean and

documentation will help sustain.

It is important being with the team and constantly motivating them.

What do you think about lean?

Great learning experience that lean can be implemented in hospital. When I was at

varsity I was not exposed to this. Hospital management allowed me to take courses

like leadership management. This equipped me with different knowledge, group

work, and diversity management.

What do you think enables employees?

Being ambitious. Challenges. Being involved. Trying new things. Thanks to them

something is happening.

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What inhibits them?

Bad experience, previous experience. Staff might think why bother now if nothing

worked. Peer pressure, might be staff keen to do something then another group being

negative and now the person is thinking which group she should go with. You will

have drivers of a project and negative pressure. It works so well in OPD, but we

didn‘t start it properly in IPD because people don‘t want to change. It suits them well;

they don‘t want to go out of their comfort zone.

INTERVIEW 9-DR ZAMEER BREY-FACILITATOR & CHANGE AGENT-9 NOVEMBER 2009

Describe your role? With regard to lean?

I am the hospital‘s process analyst. It was never defined. Never there before. No one

really knew what to put in the job description. I use to test my own hypothesis about

how to facilitate change. My role has been, in all the projects a facilitation role, of

motivating people around change and getting them to think in a slightly different way.

So largely I have resisted the temptation to give solutions. I asked more questions to

get people thinking about what the solutions are. I think people also don‘t have the

technical knowledge so I helped out in that sense such as telling them gather the data,

analyse it and feed it back. Now in the OPD they doing it on their own they don‘t

need constant supervision.

The other role, I had to develop a case for change with them. There were people that

said ―yes‖, there were people that said ―no‖. And there was the majority that said

―maybe‖. It was getting those people onboard to say lets experiment, let‘s try it out; if

it doesn‘t work we leave it. So I helped to frame the case for change for the OPD.

What made you decide to choose the OPD?

It was a test run to see what I could do. This was a huge problem for the hospital for

about 8-10 years running. It would come up in patient satisfaction surveys, that

patients were waiting longer, quality of care was dropping, etc. What also was a

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problem was that the staff in the unit was stressed, morale was low, and they were

struggling to retain people to work in that stressful environment. So they had a long

term dilemma that they goanna lose people because of this stressful environment. So I

think that it was recognition on the hospital management side that they realised they

have a problem and they didn‘t have the time to figure it out-but here is a process

analyst and let‘s see if he can do something.

How did you approach OPD?

I approached Varni and Irena and said, ―Do you think this is a good idea?‖ What they

said was, ―absolutely‖. Then we then had our first introductory workshop, with some

people from outpatients and then there was a kind of feeling that maybe we could try.

We needed to involve the whole pharmacy. We then had a meeting with the entire

pharmacy, and the stakeholders like the clerks and quality assurance managers and

from there it started becoming a formal meeting. We then started going through the

improvement process. The response wasn‘t a, ―please come help us‖. There was one

or two early adopters-Varni and Irena. Locally in the project- one or two people said

yes, the majority was fence sitting. It‘s a weird feeling as a team of Pharmacists and

Pharmacists assistants having a doctor saying, ―Let‘s turn the ship around!‖I went in

and said, ―Look I will sort this out quickly‖. I learnt not to do that, and rather say let‘s

see how quickly you can turn this ship around. So they weren‘t all receptive but the

difference is they weren‘t all frankly resistant. There was one extremely resistant

person. She made a conscious decision that she would not get involved, she would sit

quietly in meetings. Then as soon as we started to get traction, she got involved in a

huge way. She became one of the biggest contributors and motivators.

They would address their concerns in meetings, but it becomes difficult if you have

evidence that it works-you have the group in the middle saying let‘s indulge it, and

the 1-2 people in the background that get dragged in the whole process. That is what

happened in OPD. With other projects you get those that just resist.

What was the most important aspect about your message you wanted to bring across to

them? What did you want to make sure was the most important thing you brought

across?

Liberating them from the whole ethos of ―we don‘t experiment in healthcare‖,

especially with processes. And to give them some structure to start the smaller

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experiments. I being a manager was to give them the support. When we started we

didn‘t have a solution because we didn‘t have the problems, but it‘s to use a PDCA

structure or a way to understand what was the problem, did it change, why did it

work/ why didn‘t it, and keep improving.

Small project for example was like when Triage pharmacist spent half the day on

phone. I confronted the pharmacist and said,‖ What are you doing?‖ They were

looking for the doctor to correct the scripts. Then the story emerged that doctors were

not filling scripts out properly. The first part was to quantify the problem- how do we

as a team quantify how much time this is consuming. We measured, and volunteers

would sit and measure for 2 days and see how long they would have to sit on the

phone. Then we said, ―Let‘s send a note back to doctors saying you haven‘t

completed the script properly‖. We started it with one clinic, and then grew to the

whole hospital. So best practice exchange implemented now.

What did you personally do to encourage employees?

The issue around encouragement and motivation of staff is difficult in healthcare

especially around the state sector, because you can‘t go to someone just because they

improving the system and saying ―ok we going to give you a bonus‖. Therefore you

need to become creative with regard to encouraging people. What we tried to do was

not to encourage ideas, but also to encourage participation. So for me the outcome

was that not all the ideas necessarily work, but are people engaging in the process?

My role was a change agent. People start engaging as people got more involved. I told

them they must acknowledge their input and say it‘s a good idea, so that the person

owns the solution and change to the process. My encouragement was verbal, saying

look I think we on a good streak. I also wanted them to enter a couple of

competitions. They then also entered the Premier Service excellence where they came

third. This gives them encouragement. Main difficulty is how you reward people.

Small intervention failed sometimes. When I first started, my thinking was, ―I am a

process analyst, I thought that changing in healthcare is 85% process people don‘t

worry we will drag them along‖. When we did the VSM, I took it down to the

pharmacy and said I have the solution-biggest mistake ever! I have no pharmacy

background, been here for couple of weeks, then I started proposing solutions to them.

I said we must focus here and tried to justify it. I thought I needed to give something.

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Then I learnt you don‘t just give advice, if you want to come to an answer, you ask

questions.

With regard to failed initiative, they would say, ―This one was used before‖ and were

planning on using it now because they remembered why it failed and therefore

stopped it. Another Initiative that failed was one were they would ask the patient, ―Do

you need all meds?‖ This was asked because they would get it at the day hospital, or

are not compliant, and would only need their medication when required. Therefore

when they come back to hospital this stock pile needed to be thrown away. Therefore

medication that OPD worked hard to prepare was being discarded. The pharmacist

assistants said, ―I think we need to ask patients‖. What we didn‘t think about was

what was going to happen when they said they don‘t all their meds. We would scratch

it out on the script or not make a note next to it, not realizing that in 6 months they

will need the script and the meds but now they won‘t get it because it was scratched

out. Pharmacists picked it up after a couple of runs that we had a problem-what was

problem, when did we notice, what did we change, why did we change, the outcome.

This is what they documenting now, so when you as the next manager comes they

know what to try and not to try.

They weren‘t monitoring the interventions. I told them to document. They always

changing, there is no manager to manager hand over. I did take it upon myself to go

inform management and explain about lean during the new rotation. But I couldn‘t

exactly go there with 6 months of recorded minutes and say these are the things that

changed and why, so I would give them the broad principles but that was obviously

not sufficient.

Do you feel that there is still a management vs. staff relationship? And what have you

don’t to eradicate it?

I think it‘s more than a management vs. Staff situation. One needs to be sensitive

because in healthcare you have strong hierarchy you need to be sensitive to. Be aware

of the dynamic that exists and manage it accordingly. If you know that there is a

dynamic between pharmacist and pharmacist assistant, but you say it‘s ok. It‘s not ok.

There is a feeling that if there is inferiority amongst the pharmacist assistant- because

of no 4 year degree-and even if pharmacists are not aloof about it, there is that feeling

that it needs to be managed. I spoke to managers and they should take away words

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like ―us‖ and ―them‖, and ‗down there‖- if it was pharmacy at lower level. I couched a

few of the managers, and said when you as a pharmacist are talking to a pharmacist

assistant, don‘t say ‗we‖. Rather talk about the system, does it work, does it provide

better care for the patient. I de-personalize the debate. On a few occasions I had to

diffuse a few acrimonious encounters because it was around personal issues. If the

pharmacist assistant is lower down in the system they need to be encouraged more,

given more attention and participate more. I try to mention people by name, especially

the pharmacist assistants –who might have felt that they not part of the team. I also

give pharmacist assistants as much attention when I go there. I come in as a neutral

role player. I didn‘t want to be seen as, ―oh I am a manager so I only talk to

managers‖.

Describe the processes that were taken place in the Pharmacy and their benefits?

There were 5/6 big ones. First, we reduced the time the triage pharmacist spent on

phone-by making sure doctors took a bit more responsibility. Second we reduced the

no. of unnecessary issues of drugs-this was only found out at the end of the process

when patients said ok I don‘t need this. We also created ―Buddy pairs‖ which was like

cellular work. Pharmacists use to walk to much- 10 000 steps in an 8 hour shift. The

reason was expensive medication was at back at pharmacy. We then moved it closer

to them, to have better control of it. We changed break times as it had an impact on

work; there was no one in the pharmacy.

There were also too many folders that were complete but needed to get dispensed.

Now they are monitoring how long it takes to get the folders complete out. Once there

are 10 folders there, bells and whistles should go on to dispense it. That would be part

of the small interventions that took place.

They also have 4 exists-3 run whole days, 1 for staff runs between 11-1pm. They had

5 windows before but only used one, because it was historic, it became historic that

only one person dispenses. So imagine the strain on one person dispensing, then if I

can‘t dispense you can‘t dispense. Part of the reason that they didn‘t want to open the

windows was because they wanted to protect themselves from the patients. We then

collected patient comments-during the time patients weren‘t impressed. Then I asked

do you want to know what your patients think.

What do you think that the reasons for reducing the waiting time were?

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I think it was the end of last year that we managed to bring it down to 75%- an hour-

then earlier this year March/April leadership changed. There wasn‘t a good handover.

Secondly, I think that the new leadership was focused on something else. Staff will

say we are happier. When you speak to Irena you ask how is OPD? She said that they

never call in for help, and then I went on the floor, and saw waiting time increasing.

When Irena gets a signal to say it‘s ok, that doesn‘t mean patients are getting served

quickly. Irena and I sat in the office and said, ―I think Shivani and Ferosa are doing a

good job‖. But when I asked about waiting time, she said , ―No I thinks its fine

because whenever I phone them they say it‘s ok‖. So I said lets go and see. So we

went but I knew the waiting time was 2-3 hours. Then she realised that when we

meant we were ok, she meant the staff is ―alive‖, while patients are ―dying‖.

If leadership doesn‘t buy in you can‘t force it. What I found during that time, was that

through observation that some of the changes that have been made were not being

adhered to mainly because they didn‘t understand it, not to defy it. So they as the

leaders and the team would change it in order to move forward. Secondly there wasn‘t

good documentation. When I asked what was the actual waiting time- they wouldn‘t

know, but today they would. The team was focusing on getting work done at an

expense of lean. What they did well was getting team spirit up.

It has now increased...D o you think it is something management should be looking

into? What according to you do you think should be done?

I think they were confident in their own to take it through, then rotation came. Then

people were taken out. So in a sense it removed too much of the critical mass and

diluted what was there by removing the people. Maybe we need a year or 2 to embed

it in the system.

Pharmacy managers should take responsibility because my role here is limited, and I

think they have training to do it. I go to make sure they are doing the PDCA,

measuring feedback. The meetings go on without me. I am always there for support.

The role the process analysts plays would become different. They need us there

intensely at first, getting the team to think differently, collecting data. Later on I am

there to say, ―look is there something you really struggling with?‖I become more of a

consultant.

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Can you tell me about Ferosa and shivani’s period?

I said, ―Let‘s make time to sit down‖. Three months later I was still waiting because

they got so consumed in the process, I don‘t know if they thought it was unnecessary.

So there wasn‘t a clear hand over and it was difficult for me as a facilitator or change

agent to come in and say, ―This is how we have done it, and this is what we need to

do to sustain it‖. Because remember the best handover is between pharmacist where

they understand the finer details.

They very seldom came to me to say clarify this. It is not often that they would come

to me, because I have in a sense said that it is your responsibility but if you need

assistance, call me. So occasionally I get an email from managers saying, this is the

problem, what do you think, but I always try and attend the meetings. My flaw at that

stage was that I was involved in another project. A change agent /facilitator needs to

be present for the first 6 months. When you change management I thought that

changes would be embedded in the process. They got lost. So for every leaderships

change we need a facilitator at the beginning, and not assume that it is embedded.

What according to you do you think is important to sustain Lean?

Rotation hampered sustainability. And Varni and Irena are trying to see how they can

get around it. They want to give pharmacists exposure to the different departments,

but that comes at an expense, because if you keep changing and there is nothing

embedded to improvement we going to keep free-wheeling, and then people will get

change fatigue.

Management buy-in at a departmental level and hospital buy-in. We don‘t have it here

because hospital management might say we don‘t know why you doing this we don‘t

need a facilitator, we can use the money to employ a pharmacist.

There needs to be some support on small resource allocation. If the team says that

they will try their best, then you need to provide them with a computer or cupboard

that will help facilitate the process. There needs to be that agreement that you try your

best, and once you got there, we will give you resources. If there isn‘t that then there

is no motivation. It affects their enthusiasm to stay involved.

Staff leaving can affect sustainability.

What do you think enables employees?

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Acknowledge the employees as the experts to change the system. There needs to be

management support-I saw Varni and Irena attend meetings. They would follow up on

things they were suppose to do.

I fall part of the broader hospital structure, so my guarantee to them was if I‘m

convinced that you guys are trying your hardest, I will be your voice at the middle

management or top management meetings. So issues totally not related to lean, I

would defend it - for example issues around resource allocation, and pharmacy

overtime. I would speak to COO‘s and that message who go back and they would

here that Dr Brey is fighting the fight. Therefore the team would be more receptive.

Structured meetings around change. It must be formal. One hour a week. Trying to

smooth out hiccups. Addressing issues like where are we, what are we changing, did

we achieve it etc.

What inhibits them?

They resist you because you are coming from management and you showing us how

to improve our processes. To overcome that I say well actually I‘m not going to show

you how, I will facilitate and support you and if you take ownership –you‘ll feel

better. Therefore I say don‘t suggest solutions. Ask the right questions and spend time

on the floor

They resist because they don‘t trust. How do you build it? Spend time on floors and

acknowledge people. I am at the stage where I can have a conversation with Varni

about problems at meetings that she might not have with her people. I established that

relationship to with the staff. They don‘t always see what‘s in it for them. To them

you are asking them to work harder. So you need to say up front that if any of the

interventions make you feel like you are working harder, we need to stop it

immediately. And hold by what you say. With change process you need to convince

people that the perceived work level will be less-the way you do it will make you feel

like you less tired and stressed.

You need on-going training. I try and build lean training into the meetings. If you

don‘t keep on adding to their knowledge of training they will plateau.

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INTERVIEW 10-FEROSA- OPD MANAGER DURING THE ROTATION- INTERVIEW 12

NOVEMBER 2009

When you came in for your staff rotation, did they inform you about the processes of

lean that was already implemented?

When we came in we were briefed, but I wouldn‘t say 100%. We had to learn every

day. What we found when we started was that we weren‘t always following lean.

There was a shortage of staff and did what would work best for us. For example we

would put the fastest people on the computer, just to put through and get maximum

output. So the buddy system wouldn‘t always be there.

It would have helped to stick to lean if there was more documentation on what to do.

Different managers have a different way of doing things. You would maybe do your

own things that were right at the time.

We stuck to the deliveries stream and mainstream. Didn‘t change those slots. The

staff before rotation was the same as after, but it use to be up and down, because

others would help out especially when there was absenteeism. We however never get

a lot of help from inpatients. We did call but never got that much help.

I knew about lean in IPD. We were running it there, which is different, and it wasn‘t

totally new when we went into OPD.

Did management approach staff correctly?

Zameer did everything the right way when he introduced it. It was only when we got

into OPD when we weren‘t really explained properly. There wasn‘t that handing over

properly. Zameer was there for some meetings but it wasn‘t continuous. The big

reason we didn‘t adhere was because of shortage of staff. I think lean is very good. It

was just when we took over; it was not properly carried on. No one said that this is

what required or what was expected. So under the circumstances we did what was

best. When we were fully staffed it was very good .

How were the meetings in OPD?

Our meetings were more around problems within pharmacy because staff wasn‘t

happy. Sometimes you find the role players -who were previously involved -would be

approached more , and ―us‖ we weren‘t informed properly. It wasn‘t like let‘s get

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together and see what should be done. There wasn‘t that guidance that we needed. Pat

never phoned up and said how things were. No contact between old managers and

new managers. Procedures before was stressful. With lean, if you have a full staff and

follow protocols, lean will work.

How did top pharmacy management help out?

Varni and them were always encouraging. At times we were very frustrated but I felt

sometimes that there wasn‘t that openness. Certain people would be approached and I

didn‘t find that right. They should have called a meeting and we all discuss it. But you

would find people that were previously involved would be singled out and they would

be chatting, discussing lean. I thought it would happen but not once did Irena, Varni,

or Zameer say let‘s have a round table discussion. We informed them that we not

doing the buddy because of short staff, and they let me go ahead, they didn‘t object.

What would make you want to change?

There should be an improvement in service delivery. At the end you have a patient

there. It means a lot to me. Because if you go out into the community you hear a lot of

comment about the hospital, and with lean you feel people are saying service is better.

What is important to sustain?

Openness is important. Each team player is as important as the next. Get everybody

involved and don‘t isolate. If you have cooperation from everyone, things would go

smoother.

What do you think are Inhibitors to change?

If things are forced upon them without discussion.

Enablers?

Discuss with them and find out how they feel about it. If people work late, if there is

maybe a need- assess and find out who is willing, what are the benefits, and pros and

cons.

T o be happy, valued, and recognised. We must have something to motivate you to be

part of a team.

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Waiting time... what is the problem?

If you are a full house and the waiting time has increased, it is a problem on our part.

But if you don‘t have enough staff, it is difficult, we need more staff.

Can you tell me about the lean workshop you attended?

From there I took points and decided to apply. My main points were: make changes

visible, what you want to do must be visible-remind of everyday practice; 5 s.

All the managers went. I was there at the last meeting, after the workshop. We had a

preliminary meeting to say this is what we would like or this is what is most

beneficial and what we would like to take forward. After the workshop I had a last

meeting in OPD and that‘s when we said this is what we want to do. We also

addressed the staff. I was informing new rotation staff. We should have had that at the

beginning of the whole lean, although Dr Brey taught us a lot. He delivers what he

wants to get across. He did inform us, he gave us presentations. I wasn‘t too sceptic

because I was in IPD when they started, so I knew the results showed.

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