Lean improvementsimplementation of a kanban inventory system in a regional pharmacy service

quality Summit, May 6, 2014saskatoon, SKPresenters: sharna sernowski lindsay sperlingshannan neubauer, bsp, Pharm d

rationale

Challenged ↓ inventory

Substantial drug wastage due to expiration

System to support us, rather than one that ran us

Eagerness to remove waste to “find additional staff capacity” to direct to more value-add activities

Sunrise health regiondepartment of regional pharmacy services

MEDICATION SYSTEMOn Each Ward / Unit

Wardstock Urgent need &/or low risk meds

Narcotic and Controlled drugs Secured, monitored, counted

Patient specific (24-hr supply) IV’s and oral meds

Patient specific multi-dose Inhalers, liquids, ointments

Nightcupboard or Automated Dispensing Cabinet

To obtain medications during off-service hours

Pharmacy Department Supplies DISTRIBUTION MODELSWardstock Traditional top-up; kanban system, automated disp cabinet

Narcotic/Controlled Secured med-cart drawer; automated dispensing cabinet

Unit-dose 24-hr med-cart supply; automated dispensing cabinet

Intravenous doses Aseptically admixed clean room; counter-top prep by nurse

Drug inventory systemRoutine Inspection System

Maximum/Minimum Quantities Short lists (communication) Individual decisions (non-standard) Ward-based order forms Cramped storage spaces Drug “caches” Substantial wastage

Kanban Signaling system

Defined quantities (PAR) Kanban card set inside

inventory Supply before card used; pull

card (signal – everyone knows what it means)

Cycle time (everyone knows when to expect its arrival)

Safety stock Kanban on the wards; in

community hospital Kanban inside the Regional

Health Centre Pharmacy

APPROACH – YRHC EXTERNAL

Project lead:

Sr Pharmacy Technician

“Belongs” to whole staff, therefore, everyone engaged Begin in care areas - impact demand for medications Work WITH the care staff Finite amount of storage space

Review of all wardstock items (addition required a deletion) Review of required quantities Maintained frequency of replacement cycle (ie. twice a week)

Local nurse champion partner Kanban cards Lots of communication at daily huddles on wards

EMERGENCY DEPT – STORYProject lead:

Lindsay Sperling / Jamie Zulyniak

Review of space and organization Sort – Simplify – Sweep – Standardize – Sustain Local champion Communicate, communicate, communicate

Kanban cardsexample cards

Kanban Inventory CardST ANTHONY’S

Acetaminophen 500MG Tablet

SS: 10014 – 1 – (TUES)

REFILL QTY: 100Pharmacy Services

APPROACH – COMMUNITY HOSPITAL

Project lead: Sr Pharmacy Technician (+ Pharmacy Technician & Pharmacist)

Engaged Health Services Manager (2 meetings) Worked WITH the care staff

Communications with nursing staff (no more “ordering”) How kanban would work

Finite amount of storage space Required new drug storage bins to hold kanban cards right place

Pharmacy team sent to convert the system in a day

CHALLENGES: physical distance, ongoing education/ communications, ordering off-cycle

SAH Medication Roomphotograph

APPROACH – regional pharmacy

Project lead: Sr Pharmacy Technician (+ Pharmacy Technician Pairs)

Kanban inside the 24-hour patient cassette area Kanban overall drug storage areas

fridges shelving bins purchased parenterals high-alert products electrolyte LVPs)

CHALLENGES: pace of completion, agreement on safety stock, lengthening of delivery times by vendor, unit-dose packaging time

What did we reduce?

improvements

Transportation – courier costs to St. Anthony’s (q2wks cycle) Motion – reduced technician steps Overproduction - unit doses produced Over Processing – reduced time to order by care area / reduced time

to process in Pharmacy Inventory – reduced quantities ordered (care areas) and in Pharmacy Waiting (Affiliate Hospital) – reduced turn around time Waste (Expired Drugs) – reduced wastage

Improvements inventory

Facility or Unit

Inventory Value(Pre)

Inventory Value(Post)

Percent Change

Annual Projection

$76,000

Affiliate $11,065 $5,751 ↓48% (2mos)

$30,000 savings

Medicine $3,269 $3,050 ↓ 7% (3mos) =

Surgery $4,187 $6,069 ↑ 45% (3mos)

$6,000 more

ED $32,368 $25,409 ↓ 21% (3mos)

$28,000 savings

Critical Care $12,606 $10,573 ↓16% (1mos) $24,000 savings

Affiliate Hospital Drug Order Variance

1 2 3 4 5 6 7 8 9 10 11

Kanba

nOct 9

th

Oct 30th

Nov 13

th

Nov 27

th

Dec 11

th

Dec 23

rd0

50

100

150

200

250

300

350

400

450

ACET500CEFTRX1TAZOCIN

Inventory Orders

Qua

ntity

Ord

ered

Impact of Kanban Inventory on Medication Quantities Sent

Improvements other wastesWaste

ReductionsPre Post Percent Change

Affiliate wait-time (days)

7 4 ↓43%

User order time (min/wk)

46 4 ↓91%

Motion (steps) 2774 1387 ↓50%

Processing (min/wk)

210 90 ↓57%

Drug Expiry per Quarter ($)

7,400 1,200 ↓84%

Production of unit-doses (units)

Data available in March

Pharmacy drug inventory ≠ mat.mgmt process

X 24 Medicine

X 36 Surgery

X 24 Critical Care

Medications for hospital patientsinclude time consuming value-added activities

Medication inventory level low

Place order Receive medication

Enter medication into inventory

VENDOR

Sterile IV admixture preparation service

Unit-dose (oral solids) packaging service

Other parenterals Topical dosage forms

Oral liquids Inhalation productsJIT Just in Case

Substantial Value-Add

Incredibly labor intensive

Many safety checks

Require expertise of trained Pharmacy Technicians

Value add Sterile compounding

Value-add unit-dose packaging

Just in Time

JIDOKA

Machine work completed by machine

Quality assurance – draws technician to the defective package

Bar-coded packages

interdependency - Staff / inventory level and how we package

Num

ber

of st

aff Inventory Level

Pack

agin

g (h

uman

/ m

achi

ne)

↔ ↓

↑ efficiency

Sunrise health regiondepartment of regional pharmacy services

5S – Sept ‘13

5S/kanban – Oct ‘13

5S/kanban – wards spring ’13

Kanban – Phcy Nov ‘13-Jan ‘14

5S/kanban - April ‘14

SUMMARYWastes Outcome Metric

Inventory – care areas ↓ $

Inventory - Pharmacy ↓ $

Drug Expiry ↓ $

Overproduction ↓ Unit doses pkgs

Over processing ↓ Minutes/week

Motion ↓ Steps

Waiting ↓ Days

acknowledgements

Sharna Sernowski, Sr. Pharmacy Technician

Nurse Champions – Yorkton Regional Health Centre

Daniela Fiske, Health Services Manager, St. Anthony’s

Nurses - YRHC and SAH

Kendra Soyka, Pharmacist

Pharmacy TechniciansStacey Boychuk Tamera Dozorec

Marcy Gunther Brandi Helmeczi

Kyla McLeod Karen Ransome

Sarah Rogalski Lindsay Sperling

Heidi Topliss Kim Volman

Jamie Zulyniak

Questions1. Which of the 7 types of

waste were reduced or eliminated by this new kanban inventory system?

2. How is a hospital pharmacy’s kanban inventory system different than one in materials management? Hint: what other factor influences your cycle time and safety stock levels

3. Inventory stock level, personnel available to package and the type of packaging machine are INTERDEPENDENT. Explain.

4. Why is it important to begin your inventory conversion at the point-of-care, rather than in the supply department?

5. What is Jidoka?