improving pharmacy quality using six sigma

Improving Pharmacy Quality Using Six Sigma

Dr. John W. Watson, RPh, MBA, DBA, FASCP

What is quality and who determines quality?

• Many definitions• “meeting customers’ expectations and/or specifications”

• Quality is determined by the customer (patient).

Factors that contribute to quality

• Types of quality• Performance

• Features or attributes designed into the product or service• Example: a website

• Conformance• How well a product or service conforms to desired goals or

specifications• Examples: weights and measures, graduated cylinders, syringes

Products and Services. What is the Difference?

• Products• Tangible goods

• Service• Intangible

• Bundling products and services together• Example: pharmacies


• Dimensions of product quality (product = tangible) • Performance• Features• Reliability• Conformance• Durability• Serviceability• Esthetics• Perceived value


• Dimensions of service quality (service = intangible) • Tangibles• Reliability• Responsiveness• Assurance• Empathy

Using Six Sigma to Improve Quality

• What is Six Sigma?• Definition

• Six Sigma is a method of process improvement that emphasizes setting extremely high objectives, collecting data, and analyzing results to systematically reduce defects in products or services.

• Sigma – a statistical term that represents standard deviation (an indicator of the degree of variation in a process).

• Six Sigma – a statistical concept that measures a process in terms of defects. At a six sigma level, a process is generating only 3.4 defects per million opportunities (3.4 DPMO)

• The Six Sigma method of managing focuses on eliminating process defects.


• What Six Sigma IS NOT:• Just about statistics• A quality program• Only for technical people• Used when the solution is known• Used for “firefighting”


• Understanding Six Sigma

Normal distribution with 6 standard deviations (6σ)



Current prescription dispensing process

Mean prescription dispensing time = 15 minutes



Current prescription dispensing process that is not operating at a six sigma level

Upper Spec Limit = 10 minutes Mean prescription dispensing

time = 15 minutes



Improved prescription dispensing process

Upper Spec Limit = 10 minutesMean prescription dispensing

time = 4.36 minutes


• Understanding Six Sigma• Levels of sigmaSigma level DPMO Percentage yield

1 691,462 68.26%

2 308,538 95.46%

3 66,807 99.730%

4 6,210 99.9937%

5 233 99.99943%

6 3.4 99.999998%


• Understanding Six Sigma• Our world at a 4σ level:

• 4000 prescriptions filled incorrectly each year• More than 3000 newborns accidentally falling from the hands of

nurses and doctors each year• Two long or short landings at an American airport EACH DAY• 400 lost letters every hour by the Post Office.


• Understanding Six Sigma• What is an acceptable sigma level for an industry or a

process?• The acceptable sigma level depends on the nature of the

business and what customers expect.• A 4σ level (99.99%) for the drive-thru at a fast food restaurant is

most likely very acceptable. This equates to approximately 6 incorrect orders at the drive-thru for every 1000 customers.

• A 4σ level is most likely unacceptable for maintenance workers in the aircraft industry.


• What is Six Sigma?• History

• The term “Six Sigma” is credited to Motorola engineer Bill Smith.• Motorola credits over $16 billion in saving from using Six Sigma.• Six Sigma creates a cultural change within companies.• Hundreds of companies are now using Six Sigma, including

Honeywell, IBM and General Electric.


• What is Six Sigma?• An emerging process improvement strategy

• In 1980’s, Six Sigma shifts from purely defect reduction to a process improvement methodology.

• In 1991, Motorola certified its first Six Sigma “Black Belt” experts.

• In 1995, GE’s Jack Welch credited Six Sigma methods with over $750 million in cost savings for GE.

• By 2000, many firms offering Six Sigma training and certification.

The Six Sigma Protocol

• DMAIC• Define• Measure • Analyze • Improve • Control

DMAIC: Define

• Define• Define who the customers are.

• What are their requirements, needs and expectations?• External customers (end users)• Internal customers

• Determine the Voice of the Customer (VOC).• Example of not listening to the VOC New Coke• Sample pharmacy problem: It takes too long to get prescriptions

filled.

DMAIC: Define Project CharterProject Information Contact

name/number

Project Title Decreasing prescription dispensing time Project leader Pharmacy Manager

Project Location Project mentorStart date Process ownerEstimated end date ChampionProject details

Problem statement

Customer satisfaction is declining due to long wait times for prescriptions. As a result, prescription volume may decrease as customers seek alternative options.

Project description

A survey was provided to customers over the most recent 6 month period by placing the survey in their bag at the prescription checkout register. Eight hundred and fifty‐four surveys were returned. The top concern/complaint on the survey was the long wait period for prescriptions. Thirty‐seven percent of responders raised this complaint.

Business case

Benefits and constraints Project goals

Business benefits Increased prescription volume Success metric Metric unit Baselineperformance

Goalperformance

Customer benefits Increased customer satisfactiondecrease in average dispensing time

min:sec Ave: 17.5 min Ave < 10 min

Support requiredTeam members Pharmacists, techniciansLimitations $250 budget for materials, supplies

*Larger image available in the handout

Polling Question #1

• Who determines quality?• Managers?• Customers?• Investors?• Regulatory agencies?

Polling Question #1

• Quality is determined by CUSTOMERS.

DMAIC: Define

• Define• Tools to use

• Surveys• Interviews• Focus groups• Suggestion boxes

DMAIC: Define


• Surveys• Advantages:

• Low cost, easy distribution• Low error rates, data easily analyzed• Convenient data gathering• Little or no observer subjectivity, low sample bias

• Disadvantages• Inflexible design• Low response rate, lack of personal contact• Can be annoying to customers

DMAIC: Define


• Interviews• Advantages:

• Customers can discuss any topic• In person or by telephone

• Disadvantage:• May escalate if customer starts to “vent”• Time-consuming• Data may be hard to quantify• Risk of interview bias

• Focus groups• Suggestion boxes

DMAIC: Define

• Define• The payback for the problem identified for improvement must be

worth the effort. Customer satisfaction must be improved.• Define phase deliverables:

• A well-defined project scope• Six Sigma team formation. Includes project champion as well as

roles and responsibilities for all members.• Risk identification and mitigation plan. The team identifies all

possible project problems and develops contingencies to address them.

DMAIC: Measure

• Measure• Characterize the process

• Flow chart or process diagram

• Baselining (determine current state)• Quantifying the goodness (or badness!) of the current process,

before ANY improvements are made, using sample data. The key to baselining is collecting representative sample data

• Determine the type of data that is to be collected (unbiased).

DMAIC: Measure• Sample Process Flow Chart


DMAIC: Measure

• Measure• Pharmacy example

• Decrease prescription waiting time – time stamp data• Beginning time – ending time = dispense time.

• Sample size – determine how many data points to collect.• Large enough to be an accurate representation of average

dispensing time.

DMAIC: Measure

• Measure• Deliverables

• Key variables are identified and agreed upon.• A solid data collection plan is identified that includes a

description of the collection method.• All team members are informed about the variables and the

data collection plan.

DMAIC: Analyze

• Analyze• Find the top 2 or 3 causes of the problem.• Seek team input to identify potential causes.

• Fishbone diagram (Ishikawa diagram)• 5 Whys

DMAIC: Analyze• Fishbone diagram examples


DMAIC: Analyze• Fishbone diagram examples: increased dispensing time

Increased Rx Dispensing Time

Environment Machines

Phone calls

Customer distractions

Slow internet

Software gliches

Hardware malfunctions

Supplies not stocked

Inventory out-of-stock Staff multi-tasking

Patient information missing


DMAIC: Analyze• The 5 Whys technique

• Made popular by Toyota• Goal: get to the root cause of the problem by repeating the

question “why”.• Example:

• Problem: The Washington Monument was disintegrating.• Why? Answer: Use of harsh chemicals.• Why? Answer: To clean pigeon poop.• Why so many pigeons? Answer: They eat spiders and there are a lot of

spiders at monument.• Why so many spiders? Answer: They eat gnats and lots of gnats at

monument.• Why so many gnats? Answer: They are attracted to the light at dusk.• Solution: Turn on the lights at a later time.

DMAIC: Analyze• The 5 Whys technique: Pharmacy example

• Problem: Increased prescription dispensing time• Why is the prescription not ready for pickup?

• Claim rejected by insurance.• Why was claim rejected by insurance?

• Insurance information on file was incorrect.• Why was insurance information on file incorrect?

• Insurance information was not verified before adjudicating?• Why was insurance information not verified before adjudicating?

• Insurance card not available.• Why was insurance card not available?

• Insurance card was not requested from patient at prescription drop-off.• Why was insurance card not requested from patient at prescription drop-off?

• Requesting insurance card for verification is not part of the prescription intake process. (root cause of the problem).

Polling Question #2

• Surveys are a common method used to determine the VOC (Voice of the Customer). The advantages of surveys include all, BUT:

• Low cost• Low error rate• High response rate• Ease of analysis

Polling Question #2

• Surveys are a common method used to determine the VOC (Voice of the Customer). The advantages of surveys include all, BUT:

• High response rate

DMAIC: Analyze• Summary

• Identify the gaps between the current performance of the process and the goal performance.

• Root cause analysis• Generate a list of possible causes (sources of variation)• Segment and stratify the possible causes (sources of variation)• Prioritize a list of “vital few” causes (key sources of variation)

DMAIC: Improve

• Identify and implement solutions• Brainstorming

• Include people who actually perform the process• Encourage current process rules and assumptions to be

challenged. (Look for new ways of doing things).• Ideas should not be judged.• No ideas are eliminated.• Even outlandish ideas may prompt someone to think of an idea

that will work.

DMAIC: Improve

• Identify and implement solutions• Select solutions to test

• Involve the people closest to the process• Establish reasonable implementation procedures and evaluation

criteria• Timelines• Due dates for deliverables• Budget requirements or restrictions

• Develop a data collection plan.• Determine roles and responsibilities

DMAIC: Improve

• Identify and implement solutions• Anticipate the effects of change

• Introduce change management techniques• Fully communicate changes to all participants• Ensure managements commitment to the project• If change issues arise, they should be mitigated by the Six Sigma

team so that the project stays on track

DMAIC: Improve

• Identify and implement solutions• Evaluate the results of implemented solutions (measure)

• Compare the post-improvement data to the baseline data collected in the Measure phase.

• First attempts at improvement may not always yield improvement. If not, repeat the process until correct process change results in improvement.

• Pilot test

DMAIC: Improve

• The pharmacy example: decreasing prescription processing time (1st attempt)

• Brainstorming• Missing patient information

• Solution• Develop a questionnaire or checklist for the technician at

prescription drop-off.• Train all staff on how and when to use the new

questionnaire/checklist.

• Results• Only a small decrease in prescription processing time. • Did not reach target goal. Management requested further

reduction in prescription processing time.

DMAIC: Improve

• The pharmacy example: decreasing prescription processing time (2nd attempt)

• Brainstorming• Missing patient information

• Solution• Update the telephone voice response system to request a call-

back number for patients if additional information is needed.• Update website refill tool to require a call-back number also.• Ask patient when desired pickup is (may not decrease time, but

may increase customer satisfaction).

• Results• Average prescription time decreased again. The total decrease

from the two attempts reached the target goal.

DMAIC: Improve

• Summary• Generate (and test) possible solutions• Select the best solutions• Design implementation plan

• Communicate process changes to all participants• Include goals and timelines• Anticipate process change problems• Outline post-improvement measurement procedures

DMAIC: Control

• Goal: Maintain improvements achieved• Standardize the improved process

• Reduces variation in the process• Repeat the process the same way EVERY time.

• Pharmacy example• The technician uses the questionnaire/checklist at the

drop-off counter for EVERY prescription taken in.• The completed questionnaire/checklist is sent with the

prescription through the entire process.

DMAIC: Control• Development control plan

• Control chart• The voice of the customer (from surveys) indicates that

customers want prescriptions ready for pickup within 10 minutes.

Ave, 4.360

UCL, 10

LCL, 0.000

0

2

4

6

8

10

12

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Range

Sample #


DMAIC: Control

• Develop and implement a monitoring plan• Standardize the improved process• Document new procedures

Why Companies Need Six Sigma

• Reduces dependency on “Tribal Knowledge”• Decisions based on facts and data rather than opinion

• Attacks the high-hanging fruit (the hard stuff)• Eliminates chronic problems (common cause variation)• Improves customer satisfaction

• Provides a disciplined approach to problem solving• Changes the company culture

• Creates a competitive advantage• Improves profits!

Questions?

improving pharmacy quality using six sigma

Documents