Six Sigma Applied To Reduce Patients' Waiting Time in A Cancer Pharmacy
Six Sigma Applied To Reduce Patients' Waiting Time in A Cancer Pharmacy
Six Sigma Applied To Reduce Patients' Waiting Time in A Cancer Pharmacy
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Eman Sallam
Indiana University Bloomington
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Alaa AlSamhouri
The Department of ERP System,
Head Office,
Anabtawi Sweets Company,
550 Amman 11941, Jordan
E-mail: [email protected]
1 Introduction
For many years, the healthcare industry focused on quality improvement initiatives, such
as continuous quality improvement (CQI) and total quality management (TQM).
However, the momentum and popularity of TQM was lost due to the lack of data-driven
analysis, and many managers and physicians became disillusioned with the prospects of
quality improvement (Langabeer et al., 2009). In recent years, Six Sigma has been
introduced to establish and sustain competitive advantage and achieving long-term goals.
Six Sigma offers time and cost savings, revenue enhancement, metrics to indicate current
process, outcome or service quality, and a focus on improving critical to quality
characteristics vital to internal and external customers (Black and Revere, 2006).
Six Sigma was first introduced by Motorola in the late 1980s. It was further developed by
General Electric in the late 1990s (Breyfogle, 2003; Pyzdek and Keller, 2003).
Six Sigma advocates seeking high quality results having as an ultimate goal of
virtually all products, attributes, or services producing fewer than 3.4 defects per million.
A 3.4 defect per million is equivalent to a Six Sigma quality level (SQL). This goal might
be difficult to achieve; however, applying Six Sigma methodology and tools will help
improve quality of service nonetheless.
Six Sigma started on the shop floor and then moved into the front offices (Munro,
2009). Nowadays, Six Sigma is being used in many organisations and environments (for
example, manufacturing, services, schools, and banks).
Hospital personnel experience time constraints in providing optimal patient care.
Workplace stress and overload occur when the job expectations are high and the ability to
make decisions and problem-solve are low (Bojtor, 2003). The impact on safety can be
measured by treatment delays, higher error rates (JCAHO, 2004). Thus, Six Sigma
Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy 107
projects in this respect can be implemented to reduce patient over-waiting and other
symptoms of the overcrowding problem.
The Six Sigma principles has been utilised in a number of cases in the healthcare
environment to improve both patient care and business processes (Sehwail and Deyong,
2003; Southard et al., 2012). A comprehensive review of Six Sigma applications in
healthcare industry by Taner et al. (2007) reveals that Six Sigma principles have
improved the overall operations of the healthcare organisations utilising them. Since then,
others have also applied Six Sigma framework in healthcare (Kumar and Bauer, 2009;
Mandahawi et al., 2010, 2011; Kumar and Kwong, 2011, Taner et al., 2012, Taner,
2013).
This work presents an application of the Six Sigma DMAIC methodology to improve
processes in an outpatient pharmacy in a cancer hospital. Specifically, the work aims at
increasing patient satisfaction by reducing prescription preparation time. DES and design
of experiments are utilised to examine the different factors affecting the performance of
pharmacy operations.
2 Methodology
The define, measure, analyse, improve, and control methods (DMAIC) present a clear
strategy for the deployment of Six Sigma projects (Sehwail and Deyong, 2003).
In the define phase, we start by identifying improvement opportunities, clarifying
scope, and defining goals. Identifying improvement opportunities is accomplished by
capturing the voice of the customer (VOC). Customers may be classified as internal or
external. In healthcare, internal customers are directors, physicians, clinicians, nurses,
and employees, external customers are patients (Carey and Lloyd, 2001). In the measure
phase, data collection is carried out and the initial performance is measured against
customer requirements. Sampling data are compared with the baseline and the SQL is
calculated. The analyse phase consists of analysis of the root cause(s) accounting for the
errors or defects that are quantified by the data collected. In the improve phase,
alternative solutions to eliminate the root cause(s) or errors or defects are examined and
the optimal one(s) are selected; the system performance is then evaluated after
implementing the process improvements. The control phase entails development and
implementation of a monitoring system to reduce future errors, documentation of results,
and recommendations for additional action.
3 Case study
The Six Sigma project is implemented at a local hospital specialised in cancer treatment.
The outpatient pharmacy at the hospital serves approximately 33,350 patients each year.
Prescriptions are classified depending on the number of medications requested in each
prescription. AB prescriptions are prescriptions with one or two medication types.
Table 1 illustrates the different prescription categories.
108 M. Arafeh et al.
Figure 1 Prescriptions preparation swimlane flowchart (see online version for colours)
Following the reception process, the prescription waits in a queue for the data entry
process, where the patient’s profile is updated. Data entry is performed by two staff
members. The prescription then waits in another queue before it is picked up and moved
to the filling area, where actual preparation of the prescription takes place. In this work,
this step will be referred to as the ‘filling step’. Because of the busy work schedule, the
prescription waits in a third queue before a pharmacy staff member starts the filling step.
Three staff members are available for this step. Once the prescription is filled, it waits in
a queue before it is checked manually for the correct dosage and by a computer in order
to confirm the right prescription is prepared for the right patient. Checking is performed
by one staff member. Prescriptions are then dispensed to the patients by one staff
member.
Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy 109
Figure 2 illustrates the details of the used methodology and the inputs and outputs of each
of the DMAIC phases.
Figure 2 Basic tools used in each phase of the Six Sigma project (see online version for colours)
The team prepared a detailed process map as shown in Figure 1. One of the main
purposes of drawing a process map is to clarify processes, roles, and set a clear scope for
the project. The process map enlightened the pharmacy staff members because they have
never seen their processes modelled end-to-end. They only knew fragments of the
process and were unaware of how what they did fits into the overall outcome.
Figure 3 presents the scope, operational definitions, and project objectives. The
purpose of the project is to achieve the objectives stated within the scope and under the
operational definitions, as agreed by the improvement team.
To collect the VOC, a survey was prepared and distributed to a random sample of
patients at the pharmacy. The random sample included patients from the three
prescription categories. The survey aims at identifying the important factors ‘drivers’
directly affecting patients’ satisfaction. In the survey patients are asked to specify the
wait time acceptable to them. Figure 4 shows how patient satisfaction decreased with
increasing wait time. The figure is used to select upper specification limits for
prescription preparation time. For example, to achieve customer satisfaction of 80% or
more for patients waiting for AB prescription, wait time must be 15 minutes or less. After
consultation with the project champion, 80% patient satisfaction was selected for all
prescription categories.
Analysis of the survey results identified three major patient satisfaction drivers.
Patients’ satisfaction was driven by the patient receiving fast, professional, and quality
service. Figure 5 presents a critical-to-quality characteristics (CTQC) tree diagram which
is used to translate the general drivers (What’s) into specific (How’s). Using this tool,
each of the major drivers is broken down into secondary drivers.
times at each step (data entry, filling, and checking), and time spent in each queue,
in addition to the number of prescriptions returned or delayed because of errors.
Data collection revealed that half the prescriptions handled are AB prescriptions as
shown in Table 2.
Figure 4 Patient satisfaction vs. wait time (see online version for colours)
After data collection is completed, individual-moving range (I-MR) control charts are
created to identify the presence of special cause variations in each of the pharmacy
processes. Special causes of variation include events that the pharmacy staff, when
properly alerted can remove or adjust. Figure 6 presents an I-MR for AB prescriptions
where points identified by 1 are special causes. Special cause events will be addressed in
the analyse phase.
Process capability analysis (PCA) is performed using Minitab 15 to assess the pharmacy
performance in the initial state. The main purpose of a capability study is to determine
whether a process is capable of meeting certain requirements (Borror, 2009). Figure 7
shows a sample result for PCA performed for AB prescriptions. Capability analysis
involves the calculation of percentage of defect and their corresponding SQL.
The calculated SQL at and the percentages of defective prescriptions are summarised
in Table 3. For example, 58% of the pharmacy’s AB prescription customers (patients or
family members of patients) had to wait for more than 15 minutes. This is equivalent to a
process running at 1.27 SQL.
Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy 113
Figure 7 Process capability for AB prescriptions (see online version for colours)
PPT (min)
Category Mean Standard deviation % >USL SQL
AB 17.09 5.11 58 1.27
CD 31.62 20.3 34 1.94
EF 58.46 39.2 70 1.03
PPT: Prescription preparation time.
EF prescriptions have the highest error percentages. This can be explained by the fact that
EF prescriptions have the largest number of medications to be prepared, which raises the
likelihood of errors occurrence.
Table 5 presents a brief description of the causes identified in the C&E diagram.
Table 5 Brief description of causes of long prescription preparation time and suggested
solutions
Table 5 Brief description of causes of long prescription preparation time and suggested
solutions (continued)
Another important potential cause not mentioned in the table is understaffing. In the case
of this pharmacy, understaffing may occur:
• when pharmacy staff are absent for the whole day
• during lunch break
• when one or more step out of the pharmacy (tea break, toilet, etc.).
Unorganised breaks create instability in the pharmacy operations leading to long queues
and long prescription preparation times. The pharmacy management presented the
improvement team with the following two important questions:
• Is the staffing policy adequately meeting the staffing requirements?
• What are the dynamics and effects of changing staff assignment to the different
pharmacy main processes (data entry, filling, and checking) on prescription
preparation time?
Answering these two questions is detailed in the improve phase.
Figure 9 Conceptual model with ProModel simulation statements (see online version for colours)
118 M. Arafeh et al.
The null hypothesis (H0) states that changing the number of data entry staff from two to
three will not affect prescription time. On the other hand, the alternative hypothesis (H1)
states that changing the number of data entry staff from two to three will have a
significant effect on prescription preparation time.
Simulation results
The simulation model is run and the generated prescription preparation time data is
analysed using Minitab 16®. The results of the analysis are summarised in Table 7 where
all p-values less than 0.05 indicate a factor with significant effect on prescription
preparation time.
p-values
Factor AB CD EF
Data entry 0.104 0.048 0.001
Filling 0.000 0.006 0.000
Checking 0.000 0.000 0.000
Entry-filling 0.806 0.377 0.587
Entry-checking 0.251 0.607 0.676
Filling-checking 0.695 0.769 0.357
Entry-filling-checking 0.977 0.482 0.803
Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy 119
Figure 11 Main effects and interaction plots (see online version for colours)
(a) (b)
(c) (d)
I-MR control charts are generated for the simulated data under optima staffing levels.
Figure 12 presents an I-MR control chart for AB prescriptions. One can easily observe
the reduction in the mean prescription preparation time and the process variability.
The reduction in prescription preparation times for AB, CD, and EF prescriptions is
shown in Table 9. The table reports a calculated reduction in prescription preparation
time by as much as 48% for AB prescriptions, 47% for CD prescriptions, and 39% for EF
prescriptions. The table also shows the improvement in the process capability expressed
in sigma quality levels.
result of staff absenteeism. The simulated prescription preparation times for the different
scenarios are shown in Figure 13 with scenario 10 identified as the optimal scenario
circled for each prescription type.
Figure 12 I-MR chart for AB prescriptions at the initial (left side) and improved (right side) states
(see online version for colours)
Figure 13 Prescription preparation time under the different scenarios (see online version
for colours)
By examining Figure 13, we can see that the absence of a filling staff (scenario 8) has
more significant effect on prescription preparation time than the absence of a data entry
staff (scenario 4). However, the absence of a checking staff (scenario 9) has a greater
effect when compared to the absence of a data entry staff or a filling staff. This
observation is very important since the research team noticed that when staff members
took the day off, or had a temporary leave, obtaining a temporary replacement was not
always a priority for the pharmacy manager. Also when faced with a situation where a
checking staff is absent and no outside replacement is available, it is better to find an
inside replacement, even if one of the filling staff is switched to perform checking duties
than to keep one checking staff alone.
The control phase requires that policies and procedures be established to maintain the
improvements created. Monitoring procedures must be established to ensure that the
prescription preparation time remain within acceptable levels. I-MR control charts can
assist in this control through its ability to detect shifts in process performance, especially
when they are used to gather and report information in real time, providing immediate
visibility into the process. Training and mentoring plan was put into place, new job
description for the receptionist was written, and changes in managerial policies regarding
absenteeism and temporary replacements were implemented.
5 Conclusions
In this paper, the Six Sigma DMAIC framework is used to reduce the prescription
preparation time by developing customer-oriented processes in a cancer outpatient
pharmacy.
Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy 123
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