Pharmacy sales at

a hospital in India
were lower than
benchmarks, despite
increased outpatient
ow.
A team used DMAIC
and lean tools to
tackle the problem.
The resulting sustain-
able improvements
reduced wait times,
improved cycle
time efciency and
increased patient ow
into the pharmacy.
by Shirshendu Mukherjee by Shirshendu Mukherjee
A Dose of
In 50 Words
Or Less
Hospitals Six Sigma and lean
efforts benet patients and
protability
RUBY HOSPITAL, a multispecialty for-prot
facility in Calcutta, India, was the rst in Eastern India to
embrace the ISO 9001 quality management standard and is
the only one in the country to have successfully deployed
a Six Sigma improvement program.
The advantage of Six Sigma in a small setting, such as
a hospital, is that the projects links to organizational strat-
egy can be short, direct and strong.

August 2008 QP 45
CASE STUDY
DMAIC
QP www.qualityprogress.com 46
This was the case with the Ruby project, which
was initiated directly from the strategic dashboard top
management uses to run the hospital.
Project initiation
The dashboard had consistently indicated revenue
from drug sales was lower than industry benchmarks
and staying steady despite consistent increases in pa-
tient ow at outpatient (ambulatory care) clinics.
Various initiatives, such as round-the-clock service
and free home delivery in the neighborhood, had been
undertaken but had not been successful in driving
sales upward. Once Six Sigma had been deployed else-
where in the organization, top management decided it
was time to take up the pharmacy problem as a Six
Sigma dene, measure, analyze, improve and control
(DMAIC) project that would not only improve the bot-
tom line, but also improve patient satisfaction.
Dene
A project team was created, and one of the rst tasks
the team undertook was a gemba investigation.
1
A
gemba investigation basically involves going to a work
area and directly observing the real action taking place.
This was essentially a quick, direct, observation-based
data collection of information, such as:
The percentage of outpatients that was prescribed
drugs.
How many patients purchased from Rubys phar-
macy, and how many did not.
Whether those who purchased actually bought the
complete prescription.
The results were surprising: Only 31% of patients
with drug prescriptions purchased them from Rubys
pharmacy, and only 50% of the prescribed items were
purchased. Also, the billing database indicated 68% of
the sales took place between 9 a.m. and noonthe
rush hours at the outpatient department.
This data gathering was quickly followed by col-
lecting voice of customer (VOC) feedback. Feedback
identied what factors inuenced their preference for
a particular pharmacy over others, what level of these
factors would satisfy them and how Rubys pharmacy
fared on each of these factors vis--vis their preferred
pharmacy.
VOC indicated two major purchase inhibitors:
SIPOC diagram / FIGURE 1
Wait
time
Walk to
pharmacy
Handover
prescription
Substitute
Retrieve medicine
from shelf
Bill
Cash and
delivery
Substitute?
Patient exits
Advise dosage
(consultation)
No
Yes
Suppliers Inputs Process
C 0 I S P
Outputs Customers
Medicines
Dosage advice
Bill
Patient or
responsible
party
Prescription
Telephone
Computer
Printer
Drugs directory
Buying time
< 12 minutes
All prescribed
medications
be available
Critical
to quality
Doctor
Patient
or responsible
party
Wait
time
August 2008 QP 47
lengthy time to make the purchase and nonavailabil-
ity of the complete prescription at the pharmacy. The
patients also complained about the long time it took to
walk to the pharmacy and the subsequent waiting and
billing time at the counter, which sometimes was as
long as 30 minutes.
As a result, most patients preferred dropping in at
their neighborhood pharmacy and picking up the pre-
scribed items on their way home or at another more
convenient time.
The data collected through the VOC instrument
helped translate the wait time requirements into a one-
sided specication of 12 minutes. Nearly 80% of pa-
tients surveyed said that once they were through with
medical consultation, they would tolerate no more than
12 minutes at the hospital (walking, waiting and buying
time combined) for purchasing the prescribed items.
This time limit was identied despite the unique ad-
vantages of buying medicines from the hospital phar-
macy as opposed to outside retail establishments, ad-
vantages such as tightly controlled storage conditions,
genuine supplies procured from legitimate suppliers
and a returns accepted policy in case treatment is
changed after a follow-up consultation.
Nonavailability of prescriptions is a different prob-
lem that is complicated by the fact that in India, doc-
tors mostly prescribe by brand names. As many as
8,000 different brands of commonly prescribed medi-
cines are available.
The team thought it would be best to take up the
nonavailability reduction opportunity as a separate
project and sought the sponsors approval. A project
charter did the following:
Identied the project Y (medicine buying time).
Dened the defect (buying time exceeding 12 min-
utes).
Spelled out how not meeting customer expectations
on this critical-to-quality characteristic impacts
high-level organizational goals by reducing revenue
generation from pharmacy sales.
Scoped out the project (reducing buying time dur-
ing the rush hours of 9 a.m. to noon).
Indicated a likely timeframe to achieve project suc-
cess through DMAIC.
The VOC summary; supplier, inputs, process, out-
puts and customers (SIPOC) diagram (see Figure 1);
and project charter were presented to the project
steering committee at the dene phase tollgate review
meeting.
The project then moved to the next phase with a
new caveat: No additional pharmacy personnel could
be hired.
Measure
In the measure phase, the team came up with a data
collection plan to baseline the current situation and
ensure that accurate and valid data required for analy-
sis in the next phase was available.
To identify and prioritize the variables on which the
data was to be collected, the team rst brainstormed
a cause and effect diagram, shown in Figure 2 (p. 48).
Many potential causes were identied that were later
to be veried in the analyze phase.
The data collection plan took into consideration
each brainstormed potential causeexcept those that
were completely absurd, immeasurable or unanimous-
ly voted to be untrue. The team measured total buying
time as the sum of the cycle times of each individual
step in the process, along with waiting times.
Each day, the team tracked and measured three pa-
tients movements and ow with a stop watch. We used
systematic process sampling: We treated the rst pa-
tient coming out of the doctors consultation room dur-
ing each of the three hours between 9 a.m. and noon
as a sample. The team thought the one-hour gap would
prevent autocorrelation in the cycle time data.
Before two members of the team collected the cycle
time data, a gage repeatability and reproducibility study
was conducted to ensure measurement error was within
acceptable limits. The measurement error (percentage
of study variation) was found to be 9.8%. Because it was
less than 10%, it was deemed to be acceptable.
CASE STUDY
The improved capability level was
maintained despite a 61% increase in
patient ow.
The team collected the buying time data for three
weeks and assessed it for distribution t (it was found
to t the normal distribution shown in Online Figure 1
at www.qualityprogress.com). An individual X control
chart (I-chart) was created after removing the Sunday
observations. The Sunday observations were removed
because patient inow on Sundays is only 20 to 30% of
the inow on weekdays. Analyzing those data together
with the rush-hour weekday data would mix up differ-
ent populations (volume effect) in the data set and vio-
late the project scope denition.
As seen in Online Figure 2, the buying time data
was found to be in control. This meant the team could
now condently baseline the medicine buying process
in terms of its capability to meet customer specica-
tions. It came as no surprise that the medicine buying
process was highly incapable of meeting customer
requirements (see Online Figure 3).
Analyze
In this phase, the goal was to identify and verify the
root cause that led to unacceptably high buying time
for customers. By now, the data were in place, and the
team started by analyzing the contribution of the vari-
ous process steps to total cycle time (buying time).
The Pareto chart in Online Figure 4 identied walk
to pharmacy as the biggest contributor, followed by
retrieval. Together, they made up 64% of the buying
time. The process steps, however, contributed only
11.03 minutes. The remaining 10 minutes was waiting
time in front of the various service desks.
The team suspected this high wait time during the
peak hours was due to demand overwhelming capacity
and felt challenged by the hiring constraint placed by
the steering committee. The team also believed it had to
focus on the retrieval process because the walk to the
pharmacy was a hospital design outcome and could not
be directly impacted through the project.
Nevertheless, the team decided to verify the hypoth-
esis developed earlier with shbone diagramming that
many patients were taking a long time to reach the phar-
macy because of inadequate signage. The team randomly
selected a sample of patients and asked whether nd-
ing the pharmacy was a problem. Respondents who an-
swered yes were asked whether they thought this could
be corrected by more signage. The answers proved nd-
ing the way to the pharmacy was not a real issue at all
only an assumption of the team.
As part of analysis activities, the team also needed to
verify most of the other brainstormed potential causes
from the shbone diagram. At this point, I reminded
the team to do a thorough analysis instead of making
unnecessary assumptions or being overwhelmed with
imaginary challenges.
It was suggested that some lean tools could be used
to gain additional insights or help focus the improve-
ment project. The team decided to use value stream
mapping (VSM) from the lean toolkit to analyze the
process from cycle time, takt time and value-added
perspectives.
2

VSM is a type of process mapping that is more com-
plex than traditional owcharting. It captures not only
workow, but also information ow, material ow and
several process data attributes in a single map. Takt
time is the rate at which the customer buys your prod-
uct. A takt time of two minutes means that over the
course of a day, week, month or year, the customers
are buying at a rate of one every two minutes.
Most of the causal hypotheses from the shbone di-
agram did not hold up against data and evidence, with
two exceptions:
1. Whenever substitution was resorted to, it took extra
Methods Measurement Person
Retrieving from rst
oor takes longer
Buying time not
currently measured
Busy in retrieving
Not immediately
available for counseling
Doctor too busy
to pick up phone
Young and
inexperienced
Substitution takes long
Some pharmacy
staff are slow
Too few staff
during peak hours
Long
buying
time Pharmacy is far away
Time wasted
in nding way
Signage visibility
Environment
Illegible prescriptions
Handwritten
by doctor
Materials
Printer slow
Billing application slow
Machine
QP www.qualityprogress.com 48
MORE FIGURES ONLINE
Seven additional gures illustrating work done by the Ruby Hospital
improvement team can be found at www.qualityprogress.com.
Cause and effect diagram / FIGURE 2
August 2008 QP 49
time because doctorsalready busy with their pa-
tientswould often be late in answering calls from
the pharmacist.
2. Retrieval took a long time because almost one-third
of the prescriptions needed to be obtained from
storage on a different oorthe rst oor.
Although a third pharmacist was permanently sta-
tioned on the rst oor to take care of this require-
ment, the handover and search added time to this ac-
tivity. This was a clear conclusion from the multivari
chart shown in Online Figure 5, which was created to
analyze retrieval times and identify the major sources
of variation. The team used a stratied random method
of sampling to select the data for this analysis.
Another reason for this long retrieval time was
multitasking by the two pharmacists, who counseled
the billed-and-waiting patients on dosage instructions
as they retrieved medicines from storage.
The team created a current state VSM for the medi-
cine buying process (see Figure 3), which depicts the
process, with separate branches showing customer
and provider workow. The timeline toward the bot-
tom of the map shows the time traps for each nonval-
ue-added activity while also showing the time spent on
each value-added activity and bottoming out to a lower
level to indicate the valued-added times.
The team understood value-added activity to be
only what added value from the patients perspective
and for which they would therefore be ready to pay.
The lead time in the map refers to the sum of all value
added time (VA/T), as well as nonvalue-added activity
times. The ratio of the VA/T to the lead time is the pro-
cess cycle efciency (PCE).
The value stream exercise pointed out that the buy-
ing process was running with a cycle time efciency,
or PCE, of only 10.2%. That means as much as 89.8% of
the process time was adding no value for the custom-
ers and was a waste from their perspectives. A large
component of this was the wait time before retrieval,
billing and counseling.
Considering the peak hours of demand, retrieval,
billing and counseling were all bottlenecks in the pro-
cess (each of the individual cycle times was larger
than the takt time requirement), it became clear this
constraint needed to be addressed to improve ow and
reduce wait time.
Even more interesting was the insight that patient
ow and information ow (prescription) were bun-
dled. Unbundling these two ows, in theory, would
lead to increased efciency. This brought the walk to
pharmacy step back into focus and proved to be an
eye-opener and an exciting challenge to be addressed
in the improve phase.
Improve
With a small number of causes, or Xs, to work
with, the improvement phase now focused on these
root causes to come up with effective solutions. To
address the retrieval time, the team developed the
idea that the medicines being stored on the rst oor
CASE STUDY
Original current-state medicine buying VSM / FIGURE 3
Prescription
Yes
Walk to
pharmacy with
prescription
Total C/T = 5.5 minutes
NVA = 5.5 minutes
Total C/T = 3.4 minutes
NVA = 3.4 minutes
Customer
exit gate
Customer demand:
60 prescriptions per hour
(takt time: 1.2 minutes)
Yes: throughput: 30%
Total C/T = 4 minutes
NVA = 4 minutes
NVA = nonvalue added, C/T = cycle time, = Waiting in line for service, = Information ows, VA/T = value added activate time
Handover
prescription
Total C/T = 5 seconds
NVA = 5 seconds
4 minutes 5.5 minutes 0.0833 minutes 1.5 minutes 3 minutes 3.4 minutes
120 seconds 10 seconds
3 minutes
10 seconds
Lead time = 22.8 minutes
VA/T = 140 seconds
PCE = 10.2%
Total C/T = 1.5 minutes
NVA = 1.5 minutes
Total C/T = 3 minutes
NVA = 3 minutes
Substitute
Retrieval
from shelf
Billing
Prescription,
bill, medicine
Medicine
Dosage
advice
Final process
Wait in
service
Cash and
Delivery
No
Purchase
prescribed
items?
Doctor
consultation
room
Wait in
service
Wait in
service
Total C/T = 2 minutes
Total C/T = 10 seconds Total C/T = 10 seconds
Defect = 50%
Total C/T = 3 minutes
NVA = 3 minutes
Q
Q
Q Q
Q
could instead be shelved on the ground oorthe
same oor as the pharmacy.
Simple 5S principles could be used to free up more
space on the ground oor. A shelf reorganization plan
was developed so ground oor shelves could carry
more variety and lighter inventory. The third retriever
now could be stationed on the ground oor and be bet-
ter utilized.
The rest of the causes were not so easy to address.
Asking the retrievers not to multitask would decrease
retrieval time even more but add to the queue and wait-
ing time prior to the dosage counseling step. Reducing
queues and waiting times without increasing manpow-
er at the pharmacy looked like a tall order, too.
VSM clearly indicated the existence of bottlenecks.
Conguring calls from the pharmacy so they would
sound with a different ringtone was technically possi-
ble, but would it lead to doctors actually giving priority
to these calls and answering them more quickly?
Reducing the walk time still seemed to be an impos-
sible idea, although VSM analysis suggested the clues
mentioned earlier. Using creativity techniques helped
at this point. Separation principles and TRIZ 40 prob-
lem solving principles developed by Russian scientist
Genrich Altshuller helped unearth a novel approach.
3

TRIZ Principle 22 basically says, Turn lemons into
lemonade. The team concluded that if it couldnt get
the patients to the pharmacy any faster, why not use
that walk time to do activities in the process that are
nonvalue added from the patients perspective but are
business value added from the hospitals perspective?
A breakthrough idea took shapecapturing and
transmitting a digital image of the paper prescription to
the pharmacy before the patient started his long walk.
This would allow retrieval to start long before patients
reached the pharmacy in person.
The team created a solution package along with a to-
be process map. Instead of helping on the ground oor,
the former rst-oor retriever could instead be moved
upstream and stationed at the outpatient department
common area. There, he or she would meet patients
coming out of consultation rooms and counsel them on
dosage instructions while also capturing and transmit-
ting a digital image of the prescription.
The team ran simulations on this new process mod-
el to understand the impact on the total cycle time. The
results were quite encouraging. The total cycle time
dropped to an average of 9.21 minutes, with 81.43% of
QP www.qualityprogress.com 50
New current-state medicine buying VSM / FIGURE 4
2 3
e-Prescription
Yes
Walk to
pharmacy
Total C/T = 2.5 minutes
NVA = 2.5 minutes
Customer
exit gate
Customer demand:
83 prescriptions per hour
(takt time: 0.723 minutes)
Yes: throughput: 50%
Total C/T = 4 mins.
NVA = 4 mins.
Total C/T = 5 seconds
NVA = 5 seconds
Handover
prescription
15 seconds
0.5 minutes 0.167 minutes 4 minutes 2.5 minutes 0.0833 minutes
120 seconds 8 seconds
Lead time = 9.63 minutes
VA/T = 140 seconds
PCE = 10.2%
Total C/T = 2 seconds
NVA = 2 minutes
Substitute
Retrieval
from shelf
Billing
Prescription,
bill, medicine
Medicine
Dosage
advice
Capture and
transmit image
Cash and
delivery
No
Purchase
prescribed
items?
Doctor
consultation
room
Wait in
service
Total C/T = 8 seconds Total C/T = 10 seconds
NVA = 10 seconds
Total C/T = 30 seconds
NVA = 30 seconds
Total C/T = 15 seconds
Total C/T = 2 minutes
Q
Healthcare needs solutions that address
both patients and providers and not
just one at the expense of the other.
August 2008 QP 51
CASE STUDY
patients experiencing a buying time of less than 12 min-
utes (see Online Figure 6).
Before piloting the concept, the team conducted a
failure mode effects analysis (FMEA) and neutralized
foreseeable risks. The pharmacy and outpatient depart-
ment personnel were fully trained, and a pilot spanning
two 3-hour rush periods over two days was success-
fully conducted.
Following this, the team documented the improve-
ment plan and rolled it out under close supervision.
Within a month, the team conducted a tollgate review
and presented the results of the implementation, in-
cluding the new capability.
Cycle time efciency had increased from 10.2% to
25.3%. Compared with no patients experiencing a total
buying time of 12 minutes or less before the project, the
improvement efforts resulted in as many as 88.9% of pa-
tients experiencing a total buying time of 12 minutes or
less (see Online Figure 7). The average buying time had
decreased from 21.10 minutes to 9.26 minutes.
By now, more and more patients were aware of the
improvement, and as a result, patient ow into the
pharmacy increased by 23%. Management was happy
with the improvement but expressed concern that the
new arrangement could again come under pressure as
patient ow increased further. To take care of this even-
tuality, the team indicated that it had worked out a plan
to cross-train the purchase clerk and storage assistant
in the pharmacy to help with billing whenever the pa-
tient queue in front of billing exceeded three people.
The team also committed to run further simulations
to understand at what point additional resources (such
as a biller and retriever) would be required to maintain
the buying time commitment to patients.
Control
Over two months, the team developed a new as-is VSM
(see Figure 4), and the new process was made a part
of the ISO 9001 QMS documentation to enable process
control through regular QMS audits.
The team once again validated the measurement
process to ensure data was still being collected in a
repeatable and reproducible manner. A process capa-
bility study was again carried out, and the team found
the improved capability level was being maintained de-
spite a 61% increase in patient ow.
A comparative control chart shown in Figure 5
demonstrates the improvement achieved. The team de-
veloped a control plan for regularly and consistently
measuring the buying time and taking timely correc-
tive action in case the data indicated negative trends
or points in the control chart that suddenly appeared
outside the control limits, signifying sudden process
shifts due to assignable causes.
Lessons learned
Healthcare across the world today sorely needs solu-
tions that address both patients and providers and not
just one at the expense of the other. This case study
proves once again that Six Sigma methods can be suc-
cessfully applied across countries and cultures irre-
spective of industry or sector.
Best of all, it shows how a problem that was iden-
tied at the business level was actually solved at the
customer level, resulting not only in benets just for
customers, but also as a windfall for business. QP
NOTE
The ideas and opinions in this article are the authors and do not reect those
of the Deutsche Bank Group.
REFERENCES
1. Masaaki Imai, Gemba Kaizen: A Commonsense, Low-Cost Approach to
Management, McGraw Hill, 1997.
2. Michael L. George, The Lean Sigma Pocket Toolbook: Quick Reference Guide
to 100 Tools for Improving Quality and Speed, McGraw Hill, 2004.
3. Genrich Altshuller and Dana W. Clarke Sr., 40 Principles: TRIZ Keys to Innova-
tion, extended edition, Technical Innovation Center, 2005.
Observation
T
i
m
e

i
n

m
i
n
u
t
e
s
99 33 44 55 77 88 66 22 11 1
25
20
15
10
5
_
X = 9.26
UCL = 13.93
LCL = 4.58
Post Pre
USL = 12
I-chart of total buying time before
and after improvement / FIGURE 5
SHIRSHENDU MUKHERJEE is assistant vice president of
Deutsche Bank Group in Bangalore, India. He earned
an MBA from the Institute of Management Studies in
Indore, India. Mukherjee is a member of ASQ, an ASQ
certied Six Sigma Black Belt and Indian Statistical
Institute Master Black Belt.