At Barnes-Jewish Hospital in St. Louis, Missouri, negotiating medication shortages and repackaging bulk medications commercially unavailable in unit dose are routine pharmacy responsibilities. Therefore, it is key to implement best practices for providing unit-of-use doses whenever possible to ensure patient safety. As a result of a recent analysis of our unit dose repackaging process, including inquiry into the frequent inability to meet daily demand, the pharmacy tasked itself with improving processes to increase efficiency without compromising patient safety.
The general consensus upon performing the analysis was that pharmacy’s repackaging operation was inefficiently designed. In our initial system, three problematic elements stood out: several technicians would rotate through the repackaging area with no standard work structure in place, the area where packaging was performed was located some distance from the drug supply storage, and the exact meaning of daily demand was not well defined. Daily demand at that time was construed as the selection of bulk medications that the purchasing department ordered for a given day plus whatever drugs happened to run out from the automated central carousel used to store the pharmacy’s drug supply. At the time, pharmacy was using a daily report that detailed medications requiring repackaging each day. This report was populated by an alert triggered when par levels for specific items held in the carousel dropped below established minimums. Although this report appeared to identify the proper daily demand, we were still unable to meet it on a daily basis. Ultimately, we credited this to a lack of standardized work, a misunderstanding of what exactly we were expected to replenish, and insufficient staffing and oversight. In order to improve repackaging operations, we embarked on a series of rapid improvement events.
Increased Efficiencies through Rapid Improvement
In order to best implement a rapid improvement process, the pharmacy department solicited for and assembled a rapid improvement team from interested employees, including several repackaging-trained technicians and pharmacists familiar with the operation. The team evaluated our repackaging operations, including errors, and then applied lean techniques and concepts, such as relocating and redesigning the repackaging operation using a 5S organization methodology—sorting, straightening, systematic cleaning, standardizing, and sustaining—and determining the cycle times for each type of item packaged (ie, machine packed solids, bubble packed solids, syringe packed liquids, unit dose cup packed liquids). Examination of our typical repackaging errors revealed that most could be traced back to a poorly designed, generic check sheet used to document the repackaging process. Of main concern, the check sheet did not prompt the checking pharmacist for each item that needed to be checked and each sheet was used for multiple batches of the same product. To remedy this, we created a standardized production form for each item that we repackaged with clear prompts and check boxes to aid the checking pharmacist in ensuring the product was properly repackaged and labeled (see Figure 1). We decided that on alternating days, the technician would work the list from A-Z, then Z-A, thereby allowing for completion of the required repackaging at least every other day.
Our next rapid improvement event focused on creating a repacking cell to focus the activities of repackaging in a single space. After using spaghetti diagrams to track all physical movements a technician needed to make to repackage a single medication, we decided to relocate the bulk drug inventory to the repackaging cell from the central carousel. This step eliminated the time needed to travel to and from the carousel, as well as the time spent waiting to retrieve the bulk drug supply; accessing the carousel has a tendency to create a critical bottleneck in our drug distribution system because only one person can access it at a time. So, moving the bulk drug inventory reduced the number of interruptions to general carousel access, thereby speeding up those operations as well. Segregating bulk medications also enabled improved control and monitoring of this inventory.
Subsequent rapid improvement events included the replacement of an older, manual repackaging machine with a larger, high-speed automated repackaging machine that has internal drug storage. This helped speed up repackaging by allowing us to batch several drugs together and allows for parallel processing where a repackaging technician can work on other product types (eg, liquids or hazardous drugs) while the machine runs the batch.
Managing House-wide Inventory
Even with these improvements, we continued to struggle with consistently meeting our daily demand. As mentioned, we realized part of the issue was that we had not clearly defined what exactly was meant by daily demand. Upon examination, we discovered that the daily demand list was being generated using incomplete information. We found that we appeared to be producing what the daily demand list specified, but this list was only based on stock levels in the central carousel—it did not consider the distributed stock of medications located throughout the hospital in our automated dispensing cabinets (ADCs). Because of the failure to account for ADC stock, we were repackaging everything on the list to replenish the central carousel, leading to overproduction, which in turn led to an increase in the amount of unit dose medications that ultimately expired and had to be destroyed.
To resolve this, we developed a daily procedure to examine distributed drug inventory and return unneeded doses to the central carousel. Now, each morning the assigned repackaging technician prints the daily demand list, then goes to the ADC console and runs additional reports. The first report—house wide med summary—is run for the medications on the daily demand list; this produces a list of all locations that stock medications with the current inventory. The second report—all orders by med—is then run for each medication. These two lists are compared, and the repackaging technician crosses off any medications that are standard stock on the floors or that have current active orders against them. This results in a list of medications that can be returned to the central carousel and removed from the repackaging list for that day. The repackaging technician makes a copy of this list for each delivery technician to complete.
Change Management and Staff Buy-in
We understood that these changes could be perceived as additional work to our already very busy delivery technician staff. So, in order to facilitate this change we included some of the delivery technicians ad hoc to the teams so we could show where we were and what we wanted to accomplish. We also decided to incorporate processes they were already familiar with, such as our drug recall shortage processes. We emphasized that the new process would not require any special trips, since the delivery technicians now unload and pick up targeted medications whenever they travel to those specific units, thereby resulting in a minimal increase in workload for this group. As with all workflow changes, repetition has ingrained this new procedure into the delivery technicians’ regular workload.
Now, by returning the unutilized inventory back to the central carousel, we are able to cycle these doses back out to locations where they are being used. This process improvement helped eliminate overproduction of repackaged medications and yielded an annualized savings of over $190,000 (calculated as cost of drugs that were returned, plus the labor and supply costs saved by not producing these doses). Increased drug availability and reduced user congestion at the central carousel has led to improved patient care and less waste, as fewer drugs expire on the floors.
Focus and Define Repackaging Work
In order to augment the expertise of personnel working in our repackaging cell, we chose to eliminate the rotation of several technicians through the operation and instead assigned one primary technician to repackaging, with a few other trained technicians on standby to cover weekends and days off. The assigned technician has become quite skilled at operating the high-volume packager and is able to reuse and repurpose drug canisters as our drug supply and repackaging needs evolve. Furthermore, limiting the number of personnel working in the repackaging cell reduces the chance of human error due to inexperience.
In addition to establishing standard work for each type of product packaging, we have also established standard work for the day. Our packaging shift starts at 6am and runs through 2:30pm. At the start of the day, the repackaging technician runs the daily demand report and then starts the medication retrieval process; this is done first in order to give the delivery technicians ample time to complete the process. The repackaging technician will pull the medications to be repackaged from our bulk inventory (now kept at hand in the repackaging cell) and prompt a pharmacist to refill the canister medications for the high-volume repackager. During the canister refill process, the repackaging technician cleans the repackaging machine and begins to print out and prepare the paperwork for the medication to be repackaged. Once the high-speed packager canisters are refilled, unit dose medications are all processed in a single batch, and while the machine is running, the repackaging technician can complete the paperwork and print labels for the other medications to be prepared. Each medication that cannot be repackaged in the machine is then placed into a color-coded bin and placed in a designated location on a counter, providing a highly visual format to track work in progress. Blue bins are used for liquids, yellow stripes indicate hazardous medications, purple stripes indicate controlled substances, and red stripes are for waiting/add-on medications (medications that are needed but were not on the daily demand list). Readying all medications for production and placing them in individual bins allows us to track work progress throughout the day simply by observing the repackaging cell.
Although this process has greatly improved the efficiency and thoroughness with which we provide unit dose medications, we do outsource some medications for repackaging, particularly high-use liquid dosage forms, because these items are time consuming to produce in the quantities we use.
By incorporating a repackaging cell area, identifying and reducing waste, defining demand, standardizing work, and outsourcing when appropriate, we are now able to consistently meet our true daily demand for unit dose packaged medications. Based in part on this success, we have added the task of bar coding the unit dose medications to the repackaging cell. Using lean concepts and techniques, we have been able to make our repackaging operation more efficient and safe, and look to continue using these concepts going forward.
Mark Menkhus, RPh, is a pharmacy supervisor at Barnes-Jewish Hospital located in St. Louis, Missouri. He graduated with a bachelor of science degree in pharmacy from Butler University. Mark focuses his professional practice on pharmacy repackaging operations.
Stephen Newlon, MEd, is a retired Air Force officer now engaged in lean transformation processes at Barnes-Jewish Hospital (BJH) in St. Louis, Missouri. He left the Air Force to lead the lean transformation at BJC HealthCare and initially consulted with hospitals across the system. Recognizing the need for transformation versus process improvement, Steve focused his attention on BJH, which is now engaged in an aggressive Lean Sigma deployment effort. He also is speaker and examiner for the National Shingo Prize for Excellence in Manufacturing and has served as a Missouri Quality Award examiner. Steve received his Master’s degree in education from Boston University.
Christine Swyres, PharmD, is a pharmacy manager at Barnes-Jewish Hospital. She graduated with a BS in pharmacy from Drake University and went on to complete her PharmD at the University of Kansas. Christine is an active member of the Missouri Society of Health-System Pharmacists (MSHP) as well as ASHP.
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