Pan Assortment Pune Presentation By Sarmistha, Rachana & Preyesh
Rx for Improvement:
A Case Study in an Outpatient Pharmacy
n an era of ever-decreasing
I staffing and that there is a 7%
reimbursement for healthcare vacancy rate, while both inpatient
services, increased ﬁscal restraint, and outpatient hours have
and a very real shortage of critical increased (Pedersen et al., 2003;
professionals, an urgent need ASHP, 2002). Prescription drug
exists for imaginative approaches volume is predicted to grow about
for increasing efficiency and 29% between 2000 and 2005,
effectiveness in the delivery of while the number of pharmacists
healthcare services. This case study is expected to increase only about
describes one such effort pursued 4.5% in that time period (Eder,
in the outpatient pharmacy of a 2002).
large academic medical center in A recent American Hospital
the Southwest. Signiﬁcant changes Association publication indicated
were introduced and sustained by that approximately 21% of institu-
utilizing simple but innovative tional pharmacist positions are
methods for involving an extremely currently unﬁlled (Anderson, 2002).
busy work group in the problem Because of U.S. demographics,
identiﬁcation, root-cause analysis, there has been a 47% increase in the
solution generation, and ultimate number of prescriptions ﬁlled since
implementation of a major process 1992, but for the same period the
improvement. number of licensed pharmacies has
only grown by 2.9% (Parks, 2001).
Review of the Literature In an astonishing note, buried in an
annual report of retail pharmacies,
a chain of drug stores proudly
Concerns regarding employee
announced that it was rolling out
satisfaction are particularly relevant
“a one-half hour lunch program
today, due to increasing volumes
for pharmacists—perhaps the ﬁrst
of prescriptions and an alarming
large chain in the nation to make
shortage of pharmacists. Current
this move” (Zappier, 2001). This
research shows that there has been
proud announcement, allowing
an 8.5% decrease in pharmacy
36 THE JOURNAL FOR QUALITY & PARTICIPATION Spring 2005
pharmacists to actually take a lunch break, speaks to important interaction between the pharmacist and
the frantic pace of the profession. Only technology has the patient (Eder, 2002).
enabled the industry to keep up with the increase in
volume, while the shortage of personnel continues. Technological Improvements
By far the greatest efforts to improve the dispensing
process have focused on technological solutions. “With
The increase in volume challenges the overworked the graying of America and increased prescriptions
pharmacy staff to maintain job satisfaction, while relative to the flat growth in pharmacists, technology
simultaneously trying to please their customers. One is critical to meeting the healthcare needs of the
industry survey identified the community” (Parks, 2001).
main factor in “choice of Additional technological
The long waits for prescriptions
pharmacies…is the time spent solutions involve electronic
by pharmacists in counseling patient signature capture,
were legendary, prompting the
those patients, recommending barcode scanning of each
technicians to inform customers
ancillary products, and helping prescription, (Eder, 2002),
to be prepared to wait up to
them manage their disease.” hand-held personal digital
Among the biggest drivers of assistant (PDA) use to transmit
two to three hours. Both
patient satisfaction are ‘friendly prescriptions via fax to
patients and employees were
and courteous pharmacists’” pharmacies (Parks, 2003), and
(Frederick, 2002). automated robotics, which
The greatest area of customer can “automate the dispensing
dissatisfaction in pharmacies is of 1,750 prescriptions per
wait times. “Customers hate waiting 20, 30 minutes, hour” (Drug Store News, 2003). These technological
or longer to pick up their prescriptions” (Fried, 1998). advances “relieve some of the stress level…and have
More worrisome, “Today, a significant number of raised job satisfaction…” (White-Sax, 2003).
A major stumbling block regarding adoption of these
prescriptions written by physicians are never filled,
programs is the need for multiple stakeholders to work
often because patients do not want to wait...” (Health &
together to reduce the time and cost of integrating
Medicine Week, 2003). The literature is replete with ideas
these systems...” (Drug Store News, 2003). Bringing all
of how to make the wait less painful, such as developing
the necessary stakeholders together to formulate
an “Internet lounge” in the waiting area, (Drug Store
optimum solutions, and more important, to guide the
News, 1999). The pharmacist is caught between a need to
implementation brings us to the core of the case study.
spend time counseling patients, which delays ﬁlling the
next prescription, thus contributing to the long wait.
Case Study: Outpatient Pharmacy Improves
The literature points to many attempts to ease Chartering a Team
the dispensing process and reduce stress levels for Similar to situations cited in the literature, the
pharmacists. The Brooks Pharmacy chain recently outpatient pharmacy in this large academic medical
introduced a double-layer counter system (Zappier, center was faced with steadily increasing volumes of
2001). Rite Aid introduced a new pharmacy prototype prescriptions to ﬁll, in a physical working environment
that reconﬁgures the space and the workﬂow behind that hadn’t changed in more than a decade. While
the pharmacy counter. The reconﬁguration created significant technological enhancements had been
significantly more work area, and positioned the implemented, such as bar coding and robotics for
pharmacist as much as possible in front of the automatic prescription fill, the complaints about
customer and away from the computer screen. The customer service issues continued to mount. The long
pharmacy technicians work the drop-off area, and waits for prescriptions were legendary, prompting the
enter the information into the computer system. This technicians to inform customers to be prepared to wait
allows the pharmacist to ﬁll the prescription and then up to two to three hours. Both patients and employees
were highly dissatisﬁed.
present it to the customer. This sets the stage for the
The medical center leadership requested that If benefit information is not captured upon
the Office of Performance Improvement charter a registration, the process in the pharmacy is delayed
Performance Improvement because the technicians
(PI) team to undertake the must gather the informa-
Since there were so many opportunities
challenge of turning the tion and determine if the
for improvement, the team decided
situation around. As the medication reimbursement
literature noted, bringing is included in the patient’s
that the best approach would be to
the multiple stakeholders plan. Therefore, the
work on several areas in parallel. All
together to work on team sampled the online
solutions is essential. In demographic information
the while, the focus of the team was to
this case, the division for 50 randomly selected
improve the patient satisfaction and
head, the director, two patients to determine the
employee satisfaction while focusing on
supervisors, a physician, percentage in which beneﬁt
a clinic administrator, information was captured
improving overall business processes.
a representative from upon registration. Only
pharmacoeconomics, 10% of those patients
facilities management, were found to have that
managed care, two pharmacists, and two volunteers information included. This was improved to 50% after
(who were also former patients) were asked to serve implementing process changes.
on the team.
The team identified three elements of the project Root-Cause Analysis
mission: A detailed root-cause analysis was performed with
the PI team to identify process delays. Additionally, the
1. Improve patient satisfaction.
team decided to involve the busy pharmacy staff itself
• Reduce wait time.
in the root-cause analysis by printing a customized
• Improve patient satisfaction survey scores.
ﬁshbone diagram to be completed by each employee at
• Reduce patient complaints. his/her workstation. One hundred percent participation
2. Improve employee satisfaction. was rewarded with a pizza party.
The PI team also organized a roundtable discussion
• Improve Work Environment Scale (WES) scores.
with a large group of volunteers, who were also former
• Reduce attrition.
patients. The purpose of that gathering was to ask for
3. Improve business practices.
more improvement ideas.
• Improve collection of benefit information in
patient registration, therefore increasing charge Where Do We Begin?
capture. Since there were so many opportunities for
• Decrease mean fill time. improvement, the team decided that the best approach
would be to work on several areas in parallel. All the
Baseline Data Collection while, the focus of the team was to improve the patient
The team gathered baseline data for all three project satisfaction and employee satisfaction while focusing
elements. The patient satisfaction scores were divided on improving overall business processes. As such, in
into ﬁve general areas: handle ﬁnancial issues, sharing the months that followed, the team succeeded in:
information, caring attitude, wait time, and overall
• Renovating the waiting area.
satisfaction. These were rated on a 5-point Likert scale,
• Remodeling the actual pharmacy work
in which 1 was unsatisfactory, and 5 was very satisﬁed.
The WES was administered to establish a baseline
• Opening an additional cashier’s booth.
for employee satisfaction with their environment. The
group scored higher than national healthcare workers • Ordering a point-of-sale system that provided
on work pressure and lower than average on physical tracking of the transaction throughout the entire
comfort elements. filling process.
38 THE JOURNAL FOR QUALITY & PARTICIPATION Spring 2005
Figure 1: Comparison: Baseline to Pilot Figure 3: Outpatient Pharmacy Patient Satisfaction
Mean Score Strongly Disagree: 1
Strongly Agree: 5
Mean Fill Time
Handle Financial Caring Wait Overall
Issues Information Time
Figure 2: Individual Chart: Outpatient Pharmacy Mean
Time to Fill Rx
Figure 4: Outpatient Pharmacy Work Environment
Time to Verify in Minutes
Decrease Increase in
in Work Physical
A LCL= 4.00
Implementing revised pharmacy data screens for
collection of patient insurance information.
Developing an electronic prescription order entry
Developing a “wait watcher” brochure to manage March 1999 5.89 5.83 5.94 6.28 5.39 7.56 5.61 4.50 4.78 2.67
July 2001 5.16 5.6 6.6 6.12 5.8 6.04 5.92 4.92 5.92 6.56
No No No No No Yes No No No Yes
Establishing a permanent help desk staffed by
hospital volunteers. 5.43 5.24 4.82 5.2 5.7 5.65 4.5 5.57 3.9 3.77
Shifting staff schedules to accommodate daily
prescription volume fluctuations.
Adding a telephone triage system to include Internet
access to the refill process. a baseline of 78.15 minutes to the pilot rate of 34.95
minutes, a reduction of approximately 44 minutes.
Piloting an “express line” concept.
The Final Results
The “Express Line” Pilot
The pilot energized the entire pharmacy to work
The express line was a simple concept. The process
even harder on improvements. A chart was devised
separated levels of prescriptions at the front window
that plotted prescription fill times and volumes of
into “fast ﬁlls” and “routines.” This involved providing
prescriptions processed every day. These data were
dedicated personnel to the express line process (one
easily available electronically and were posted by the
order entry technician and one pharmacist), and
supervisors on a very large poster in the middle of
increased stafﬁng for an existing automatic dispensing
unit (robotics) from 8 hours to a full 12 hours.
The PI staff helped the pharmacy staff to under-
The results of the pilot were compelling, as shown
in Figure 1. The overall mean fill time decreased from stand the project by “setting up shop” in a tiny alcove
in the back of the pharmacy to do PowerPoint pre- “Drug Emporium Looks to Ease Pharmacy Wait Time,” Drug
Store News, February 1, 1999, Vol. 21 Issue 2, 4, pp.1-9.
sentations about the data and the successes achieved
to date. Everyone soon understood that a statistical Eder, R. “Chains Sharpen Pharmacy Efﬁciencies With Technology
and New Designs,” Drug Store News, August 12, 2002, p. 63.
shift in the mean of the fill time was the goal. When
that day came, there were celebrations throughout “E-Script Service Expanded Through Partnership,” Health &
the pharmacy. Medicine Week, March 17, 2003, p. 15.
Figure 2 illustrates the statistical shift in the mean Frederick, J. “Diabetics Demand Personal Attention From Chain
ﬁll time from the 78 minutes to 44 minutes. That Pharmacy,” Drug Store News, March 25, 2002, p. 6.
success was accompanied by the hoped-for statistically Fried, L. “New Rite Aid Commercials Highlight Pharmacy
signiﬁcant shift in patient satisfaction shown in Figure 3. Advantages,” Drug Store News, September 7, 1998, p. 3.
Additionally, the repeat measure of employee Parks, L. “Chains Upgrade Technology, Increase Pharmacy
satisfaction with their work environment in Figure 4 Efﬁciency,” Drug Store News, December 17, 2001, Vol. 23 Issue 18,
showed signiﬁcant improvements in physical comfort p. 62, 2p, 1c.
and lessened work pressure. Parks, L. “Technology Unites Rx Operations,” Drug Store News,
April 28, 2003, p. 103.
Conclusion Pedersen, C.A., et al. “ASHP National Survey of Pharmacy Practice
The staff continues to monitor volume and ﬁll in Hospital Settings: Dispensing and Administration—2002,”
times, and the pharmacy has increased improvement American Journal of Health-System Pharmacists, 2003, 60, pp. 52-68.
activities to involve the staff in everyday “Kaizen” White-Sax, B. “Efﬁciency is Aim at Northwest,” Drug Store News,
efforts. The experience in this pharmacy is an excellent April 28, 2003, p. 111.
example of the importance of involving and energizing
Zappier, A. “Technology is Key to Maximizing Pharmacy
the “frontline” staff to participate in improving its own Efﬁciencies at Brooks,” Drug Store News, August 20, 2001, p. 59.
work environment and performance, which, in turn,
ultimately improves the service to the customer.
Jyme Arthur has managed a group in the Performance
Improvement Ofﬁce at M.D. Anderson Cancer Center
Anderson, R.W. “Health-System Pharmacy: New Practice
in Houston, TX, for the past six years. She was a
Framework and Leadership Model,” American Journal of Health-
System Pharmacists, 2002, Vol. 59, pp. 1163-72. director of education for large medical centers for
13 years, followed by a period as a management
“Annual Report of Retail Pharmacy,” Drug Store News, August 20,
2001, p. 59. consultant. She has taught courses in leadership,
change management, and innovation in an MBA program. Contact
“Central-Fill Expansion is Prescription for Success,” Drug Store
News, January 20, 2003, p. 52. her at email@example.com.
40 THE JOURNAL FOR QUALITY & PARTICIPATION Spring 2005