IOP Conference Series: Materials Science and Engineering OPEN ACCESS Quality Service Analysis and Improvement of Pharmacy Unit of XYZ Hospital Using Value Stream Analysis Methodology To cite this article: Jonny and Januar Nasution 2013 IOP Conf. Ser.: Mater. Sci. Eng. 46 012022 Related content - Lean manufacturing analysis to reduce waste on production process of fan products I Siregar, A A Nasution, U Andayani et al. - 5S program to reduce change-over time on forming department (case study on CV Piranti Works temanggung) Septika Rosiana Dewi, Budi Setiawan and Susatyo Nugroho W P - Multi-Criteria Knapsack Problem for Disease Selection in an Observation Ward N Lurkittikul and O Kittithreerapronchai View the article online for updates and enhancements. This content was downloaded from IP address 148.251.232.83 on 12/05/2018 at 13:02
Quality Service Analysis and Improvement of Pharmacy Unit of XYZ Hospital Using Value Stream Analysis Methodology Jonny and Januar Nasution School of Industrial Engineering, Faculty of Engineering, Bina Nusantara University, Jl. KH Syahdan No. 9, Palmerah, Jakarta, 11410, Indonesia E-mail: jonny@binus.ac.id Abstract. Value stream mapping is a tool which is needed to let the business leader of XYZ Hospital to see what is actually happening in its business process that have caused longer lead time for self-produced medicines in its pharmacy unit. This problem has triggered many complaints filed by patients. After deploying this tool, the team has come up with the fact that in processing the medicine, pharmacy unit does not have any storage and capsule packing tool and this condition has caused many wasting times in its process. Therefore, the team has proposed to the business leader to procure the required tools in order to shorten its process. This research has resulted in shortened lead time from 45 minutes to 30 minutes as required by the government through Indonesian health ministry with increased %VA (valued added activity) or Process Cycle Efficiency (PCE) from 66% to 68% (considered lean because it is upper than required 30%). This result has proved that the process effectiveness has been increase by the improvement. 1. Introduction Based on Indonesian Hospital Quality Service Standard, the quality service of pharmacy unit can not be separated from the holistic quality service of a hospital and therefore, the hospital should focus on patient safety through providing high quality medicines to its patients as required by the practitioners in the hospital. In a hospital, pharmacy services could include services to outpatient and inpatient with their unique characteristic. For outpatients, the pharmacy services starts from consultation (during in outpatient unit) to medicine handover (in pharamcy unit), whereas for inpatients, the pharmacy services starts from instruction given by responsible practioners through inpatient visit to medicine handover to the patient s responsible nurse. The kind of services given to patient are determined by what kind of the patient served by the hospital that may include 1) general or 2) company s patient or insurance s patient. Each of these services may vary from one to another based on the responsibility bearer. On the other hand, the type of precribed medicines also determines the kind of pharmacy services that may also include 1) patent or 2) self-produced medicine. For the second type, the pharmacy should produce self-produced medicine by mixing several patent medicines as required by practioners Content from this work may be used under the terms of the Creative Commons Attribution 3.0 licence. Any further distribution of this work must maintain attribution to the author(s) and the title of the work, journal citation and DOI. Published under licence by Ltd 1
whereas for the first type, the pharmacy only needs to pack prescribed medicine as required by the practioners. The Indonesian Health Ministry has determined that lead time for pharmacy service related to selfproduced medicine should be less than 30 minutes to ensure the patient s quick recovery. Therefore, XYZ Hospital should also obey this standard in order to stay acknowledged by the government. Up to now, the pharmacy service related to self-produced medicine in XYZ Hospital was still above 30 minutes. This condition has triggered many complaints from patients and urged this research in order to evaluate dan improve the process by deploying value stream analysis methodology. In order to get focus, this research is designed to focus only on self-produced medicine using sample around 30 general outpatients with same diagnostic health problem. These samples are drawn from busiest scheduled internist outpatient unit with gastro diagnosed disease due to its longest lead time triggered by number of self-produced medicines up to 30 to 40 capsules per patient [6]. Based on Value Stream Analysis methodology, this research is designed 1) to depict the current state value stream mapping (VSVSM) of the self-produced medicine process in pharmacy unit, 2) to identify the root causes of longer lead time and their solutions, 3) to develop the future state value stream mapping (FSVSM) of the process, 3) to implement the solution to ensure the condition is improved as stated in its future state value stream map. 2. Literature Review In 1996, Womack and Jones has introduced lean lean thinking as alternative solution to quality improvement for many companys including hospital. Actually, lean thinking has prior introduced by Taichi Ohno through Toyota Way. This concept is designated to make the process become more flexible in order to adapt the fluctuation of demand, decrease waste, optimize process, improve process control and optimally ulitize human resources. To implement this concept, there are several methodology including value stream mapping (VSM) [15]. Value stream mapping (VSM) is used to map value and non value added activities conducted to produce product or service to its customers. This VSM tool is one of improvement tools that help the organization to visualize the process including both material and information flow to improve product and service by finding its waste and source [11]. To apply this methodology, we can use the following methodology: Figure 1. Value Stream Analysis Methodology 2
From the above methodology, there are 6 steps that we should follow in order to improve the process. First of all, we determine the scope of business process, what is value add to customer and measurable objectives. For this research, the scope of business process is self-produced medicine to general patient (Internist Outpatient). The measurable objectives used to ensure whether the improvement has taken place or not are lead time, value add time (using cycle time [2]), non value add time, and percentage value add time or known as Process Cycle Efficiency (PCE) [12]. First indicator named as lead time is measured by adding time used to perform both value and non added value activities by pharmacist and its staffs. Secondly, value added time is measured by adding all cycle time performed by each value added activity and same to non value added time but from all non value added activities. Lastly, percentage of lead time or called as Process Cycle Efficiency (PCE) is measured by deploying the following formula: VA PCE x100% (1) Leadtime In second step (current state map), The authors visualize process flow and identify value add and non-value add activities using related data. In this research, the value add activities are outpatient admission, preparation, quality assurance I by pharmacist, production, quality assurance II by pharmacist, and handover. Whereas, non-value add activities are those activities including waiting time for preparation, waiting time for quality assurance I by pharmacist, waiting time for production, waiting time for quality assurance II by pharmacist, and waiting time for handover. In third step, from current state, the authors develop future state map by considering improvement ideas to eliminate non-value added, challenge to NVA required, question to VA and creative leap. In this research, the author try to decrease NVA due to the impossibility to eliminate NVA. In fourth step, the authors develop implement plan and implement it by conducting training and communication plan. Furthermore, the authors also monitor its implementation and evaluate to ensure the improvement has taken place. 3. Result The following diagram is current state value stream mapping for high level process: Figure 2. CSVSM: High Level Process The above figure has shown that general patients are required to register themselves through admission before having consultation with the practioners. After that, they should complete the payment before they go to pharmacy to get their medicines. The self-produced medicine (mixing patent medicine required by practioners done by pharmacist)process that is targeted to improve starts from outpatient administration (after consultation) to pharmacy (handover) with detailed as follows: Figure 3. CSVSM: Low Level Process 3
The above data and information flow are based on observation conducted in XYZ hospital by using research design as depicted in the following table. Table1. Research Design Indicator Current State Future State Number of sampel 30 patients from Interniste Outpatient with Gastro diagnosed disease 30 patients from Interniste Outpatient with Gastro diagnosed disease Number and types of 30-40 capsules wtih 2-3 type 30-40 capsules wtih 2-3 type prescribed medicines Observation day of prescribed medicines 30 day with in Internist Outpatient during busiest schedule in XYZ hospital of prescribed medicines 30 day with in Internist Outpatient during busiest schedule in XYZ hospital The observation result from the above research design is also provided from the following table: Table 2. Observation: Current State Result 4
Figure 3depicts that the research focus is ranged from outpatient administration and pharmacy. In details, the processing including several more steps such as outpatient administration, preparation, QA by pharmacist I, Production, QA by pharmacist II and Handover. Also from the diagram we can see that the lead time required 45 minutes for the patient to get the medicine which is far more than the standard (30 minutes). This was caused by nonvalue added time about 15 minutes. Furthermore, this resulted in %VA (PCE) only 66% by deploying PCE formula as follows: 30 PCE x 100% 66% (2) 45 Then, the authors listed the value add time and found that production and preparation time should be improved in order to shorth the non value add time of waiting time for those two processes. In order to depict what happen in pharmacy unit, we develop spaghetti diagram as follow: Figure 4. Spaghetti diagram: a) high level process and b) low level process From the above figure, there are 2 problems identified which have caused longer lead time. First is preparation and second is production. Therefore, we proceeded with root cause analysis as shown in the following diagram: 5
Figure 5. Root Cause Analysis From figure 5, we can see that no storage bin and no capsule packing tools have caused longer lead time. Therefore, we plan and implement the improvement initiative as shown in table 3 as follows: Tabel 3. Implementation Plan From table 3, the team has made initiative to procure about 50 storage bin and 2 packing tools in order to help the staffs to improve the process. In order to implement this initiative, the team also conducted training and communication forums to ensure that all staffs can use the tools properly. After conducting the required training, all staffs are seemed ready to implement the tools for shortening the lead team of their process. 6
The results are shown as follow: 1) Initiative 1: Storage bin a) No storage bin b) Using storage bin Figure 6. Implementation result: a) before, b) after Before implementation, medicines were stored without storage bin (as shown in fig. 6.a). This has caused confusion when the staffs are about to pick up the patient medicine from the shelf. From patient safety perspective, this arrangement may also trigger high risk to false medication. Therefore, the team has decided to procure storage bin. There were about 50 storage bins used to place the medicine based on its medicine name and its maintenance is properly maintained by rolling schedules of the staff. After improvement was taken placed, medicines were stored by storage bins (as shown in fig. 6b). 2) Initiative 2: capsule packing tool a) Capsule packing by manual b) Capsule packing by tool Figure 7. Implementation result: a) before, b) after Before implementation, capsules were packed manually by hand (fig. 7a). This has triggered long time to complete the patient s requirement. During observation, by preparing medicine in this way has caused customer to wait about almost 1 hour. This condition, of course, has triggered high number of complaints filed to XYZ hospital. Therefore, the team also decided to improve this process by procuring 2 capsule packing tools as shown in fig. 7b. After improvement, capsules were packed by using the tools and it has proven to cut the process about 50% and also decrease the patient s complaint files. After implementation, the authors evaluated the result which is confirmed as its future state value stream mapping as follow: 7
Figure 8: Future State Value Stream Mapping. The above figure is depicted by observation data during the implementation is taken place which can be described by following table: Table 4. Observation: Future State Result After implementation, we can see that the lead time has reduced to 30 minutes for the patient to get the medicine below required standard (30 minutes) consisting undenieable nonvalue added time 8
about 9 minutes and value added time 19 minutes. Furthermore, this resulted in %VA or PCE improved to 68% by deploying PCE formula as follow PCE 19 x 100% 28 68% 4. Conclusion Based on the result, this research has resulted 1) current state value stream mapping (VSVSM) with information that lead time 45 minutes, value added 30 minutes, non value added 15 minutes and %VA or PCE 66%, 2) future state value stream mapping with information that lead time 28 minutes, value added 19 minutes, non value added 9 minutes with %VA or PCE 68%, 3) improvement by procuring storage bin and packing capsule tool to overcome root causes as no storage bin and no capsule packing tool. The implication of this research is that the staff should maintain the usage of storage bin and capsule packing tool in order to maintain the improved %VA or PCE by providing Standard Operating Procedure. Acknowledgment The authors would like to thank Bina Nusantara University for financial support of research grant No. 113/ DRIC/ IV/ 2012 and XYZ Hospital for its technical support during research in XYZ Hospital. References [1] Arthur, Jay 2011 Lean Six Sigma for Hospitals (New York, McGraw-Hill Companies) [2] Barnes, Ralph M 1980 Motion and Time Study Design and Measurement Work (USA, John Wiley and Sons) [3] Chase, Aquilano, Jacobs 2001 Operations Managemen for Competitive Advantage (New York, McGraw-Hill Companies) [4] Graban, Mark 2006 Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction (New York, CRC Press) [5] Heizer, Render 2001 Operations Management (USA, Prentice Hall) [6] Koelling, Etiel, Mahapatra, Messner, Grov 2013 Value Stream Mapping the Emergency Department (Available online via <http://www.iienet.org/uploadedfiles/shs/resource_library/details/180.pdf> [accessed January 27, 2013]) [7] Liker, Jeffrey K. 2004 The Toyota Way. (New York, McGraw-Hill Companies) [8] Nahmias, Steven 2005 Production and Operation Analysis (New York, McGraw-Hill Companies) [9] Ravindran, Philips, Solberg 1987 Operations Research: Principles and Practice (Singapore: John Wiley & Sons) [10] Rother M. & Shook 2003 Learning to See: Value Stream Mapping to Create Value and Eliminate Muda (Brookline: The Lean Enterprise Institute) [11] Vincent Gaspersz 2007 Organizational Excellence (Jakarta Gramedia) [12] Wachter, Robert M 2008 Understanding Patient Safety (New York, McGraw-Hill Companies) [13] Winston, Wayne L 1991 Operations Research: Applications and Algorithms (USA: PWS- KENT Publishing Company) [14] Womack, J.P. and Jones, D.T. 1996 Lean Thinking: Banish Waste and Create Wealth in your Corporation (New York: Simon & Schuster) 9