Question

Transforming a pharmacy together: the Charlotte Maxeke Johannesburg Academic hospital.

Before 2015, the patient experience at the Charlotte Maxeke Johannesburg Academic Hospital pharmacy went something like this: take the day off work to have your prescription filled; line up at dawn before the pharmacy opens in hopes of beating the rush; once inside, wait up to several hours for your prescription to be filled; or worse, wait only to experience a “false stock out”—a phenomenon in which a medication appears out of stock but is in fact available in pharmacy storerooms—and go home empty-handed.

Charlotte Maxeke Johannesburg Academic is one of the largest central hospitals in South Africa, which sits in the province of Gauteng. The hospital pharmacy dispenses almost a quarter of a million prescriptions each year—yet it had a reputation for poor service and facilities. For example, patients discharged from the hospital with prescriptions—a patient category known as “to take outs”—spent on average six hours waiting for prescription medication to be delivered to the ward after discharge. Every day, an average of 20 percent of out-patients visiting the pharmacy experienced false stock-outs.

In September 2014, the Gauteng Department of Health began a province-wide project to provide pharmacy customers with more professional and efficient visits. The department wanted to prove that it could offer better service wherever needed, and the troublesome situation at the Charlotte Maxeke pharmacy made it an excellent place to make its case.

With so much ground to cover, the leadership at Charlotte Maxeke needed a step-by-step plan for the pharmacy transformation.  

The consultants began by working with managers to narrow their focus to improving the physical environment, prescription-filling process, and stock management, the main factor behind lengthy waiting times. To kick off the project, the consultants focused on making the physical premises more welcoming and attractive to patients and staff. One Saturday, Department of Health officials, including a member of the executive council, the pharmacy manager and CEO of the hospital, infrastructure-department representatives, and the consultants, all pitched in for a day-long cleaning. The idea was to show staff how committed leadership was to turning around the pharmacy. The volunteers painted and decorated walls; added amenities like water coolers, TVs, and coffee machines in the waiting room; and supplied pharmacists with monogrammed lab coats. Patients and staff immediately appreciated the more cheerful and professional atmosphere.

Then the consultants turned to improving the process of prescription filling. A consulting team mapped the existing process and studied each step to identify bottlenecks and areas of wasted activity. They then devised a streamlined approach using three principles of lean production.

The first was called “first time right” and aimed to stop invalid prescriptions from entering the filling process. A senior pharmacist became the first point of contact for each patient. The pharmacist would filter out patients whose prescriptions were invalid (because they were not yet due for refills) or could not be filled because of stock shortages. Second, they removed the batch system, which meant prescriptions were no longer dispensed in batches of ten, but were made available to be dispensed as soon as each one was ready. Finally, the team introduced a “demand-pull” system, which enabled staff actually to dispense these prescriptions to patients in a timely fashion. The existing process began with taking in scripts as fast as possible, and then filling them. The result was a huge buildup of filled scripts that were waiting to be labelled and dispensed to patients (in other words, a “push” approach). The team shifted the focus to the end of the process—dispensing—and ensuring that there was sufficient staff to distribute prepared scripts, thus “pulling” prescriptions through the process more efficiently.

Relatedly, the team addressed false stock-outs, another important factor behind long wait times. These were resolved by implementing a two-bin system on the pharmacy shelves with pre-defined refill levels. Essentially, when one bin of medications was empty, pharmacists would begin retrieving medications from a second bin. The refill levels for a bin—how many medications to place inside—were calculated for each medication based on dispensing frequency. The consultants also revised each staff member’s role in the process and adjusted the layout of the pharmacy to make it more orderly. This included outfitting each workstation with laminated posters that displayed the new process rules. They also designed management tools—for example, a daily roster with role allocation and a performance dashboard—that the pharmacy manager was then responsible for implementing.

Under the new system, pharmacy staff rotated between duties to ensure that there was no build-up of scripts. This required knowing how many people to assign to each stage of the process and shifting staff when someone was absent, at lunch, or when there was a backlog. The team initially oversaw these shifts, but then coached the pharmacy staff on identifying and resolving bottlenecks quickly, with the senior pharmacist on the floor ultimately responsible for managing the workflow.

In conclusion, the teamwork and process review that was provided helped staff to work smart and not hard. Improving the working environment of staff, listening to their concerns and supporting them through change management has definitely improved the quality of care and the experience that the patients and communities received from the hospital.

QUESTION 1           [60]

1.1 To ensure that all processes in the Charlete Maxeke Johannesburg Academic hospital were streamlined, the consultants provided many useful methods to improve the situation of the hospital. Analyse the case study to justify the methods utilised. (5 x 6marks =30)

1.2 Provide a critical account of how the total quality management (TQM) concept could have been used in the case study? (30)

Answer 1

I. Here is the gist of the case study of Charlete Maxeke Johannesburg Academic Hospital.

The well known hospital in the city experienced poor customer service and quality care. To address these issues, the management analysed the root causes for the problems to which they have listed out the following;

1. Late prescription filling process

2. Long Waiting time to receive prescription

3. False stock out in pharmacy

4. Less maintenance of store rooms

5. Poor facilities and environment

Having these issues at hand, the Consultant come up with the methods to resolve the above. Let’s have a view on the same.

• Physical Environment

First of all, the Consultant worked with the managers to improve the work environment attractive and more professional. For that, Television, coolers and coffee machines were kept in waiting room and Pharmacy people were given labcoats. The sudden change in environment gave the staff and patients more comprising and improve the quality of the hospital.

• Prescription filling process

The major constraint for the hospital's poor service was then analysed and modified with the streamlined process. In order to achieve this, three principles of Lean production process were taken into account.

First time right- the Senior Pharmacist was asked to be a first point of contact for the patients where the invalid Prescription are identified and avoid entering the filling process.

No Batch system- once the prescriptions are ready, the same will be dispensed to the patients immediately. Hence, batch system of dispensing bulk prescriptions to the patients are cut down abruptly. This in turn reduces the waiting time after discharge of patients.

Demand pull approach- with this approach the staffs were able to dispense the prescriptions in a timely fashion but there occurred a problem that huge buildup of filled scripts to be labelled and dispensed. Hence, they focussed in dispensing alone and appointed sufficient staffs to handle the dispensing process efficiently.

• Two Bin system

This system was implemented to improve the false stock outs and long waiting time. In this system, when one bin of medication is used, the staff will use the second bin wherein refilling process will take place. Based on the refill levels, the number of medication were calculated.

With this implementation, the staffs were asked to perform shift duties and roles were modified accordingly. Thus, ensures the quality of work and environment makes the healthier customer service.

II. If Total Quality Management(TQM) concept were used in the case study, below are the things would have been in place.

TQM is a concept for a customer-focused organization that involves all employees in continual improvement. Here are the 8 principles of TQM taken into account to address the issues of Charlete Maxeke Johannesburg Academic Hospital.

• Customer-focused: The customer here are the patients who determines the level of quality. In order to improve the quality, training of employees, integrating quality into the design process, or upgrading the working system should be taken into consideration.

• Employee involvement: All staffs includes the top management must participate in working toward common goals. High-performance work environment integrates continuous improvement efforts with normal routine operations.

• Process-centered: handling the patients and delivering The better service is the major aim of hospital. The process need to be defined and aligned as such and the same need to be monitored on regular basis to find the deviation.

• Integrated system: Though an organization may consist of many different functional specialties often organized into vertically structured departments, it is the common processes interconnecting these functions that are the focus of TQM. Thus, an integrated system connects business improvement elements in an attempt to continually improve and exceed the expectations of customers, staffs, and other members in the hospital.

• Strategic and systematic approach: A major part of the management of quality is the strategic and systematic approach to achieving an organization’s vision, mission, and goals. Here, the approach needs to have a quality service as a major component.

• Continual improvement: The continual process improvement drives an organization to be both analytical and creative in finding ways to become more competitive and more effective at meeting daily activities.

• Fact-based decision making: TQM requires that an organization continually collect data on activities of staffs in order to improve accuracy in decision making.

• Communications: when there is a change management, as well as part of day-to-day operation, effective communications plays a major part in maintaining morale and in motivating staffs at all levels.

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