University of Michigan Health System Pharmacy Administration
Department of Pharmacy Services
Program and Operations Analysis
Workflow Analysis of Discharge Island in Taubman Pharmacy
Final Report
Prepared for: Lindsey Kelley, Pharmacy Assistant Director
Ambulatory Care Services, Taubman Pharmacy
UH B2 D301, UMH Retail Pharmacy
Shasta Branch, Staff Pharmacist
UMH Taubman Pharmacy
B2D400, Department of Pharmacy Services
Corrie Pennington-Block, Lean Coach
C.S. Mott Children’s Hospital and Von Voigtlander Women’s Hospital
N14D11, CW Mott Administration
Dale Jackson, POA Fellow
Program and Operations Analysis
2101 Commonwealth, Suite A
Dr. Mark P. Van Oyen, IOE Associate Professor
Industrial and Operations Engineering
2853 IOE
Prepared by: IOE 481 Project Team #4
Dylan Conlon
Zachary Costello
Fan Hong
Amanda Lee
Date: December 10th, 2013
Table of Contents
Executive Summary …………………………………………………………………….
Data Collection and Analysis ….………………………………………………...
Findings and Conclusions ………………………………………………………..
Recommendations ………………………………………………………………
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Introduction …………………………………………………………………………….
Background …………………………………………………………………………….
Key Issues
…………………………………………………………………………….
Project Scope …………………………………………………………………………….
Data Collection ………………………………………………………………………….
Takt Time
…………………………………………………………………….
Phone Calls …………………………………………………………………….
Labor Analysis and Spaghetti Charts …………………………………………….
Data Analysis ...………………………………………………………………………….
Takt Time and Orders ………………………………………………………….
Phone Calls …………………………………………………………………….
Labor Analysis and Spaghetti Charts …………………………………………….
Findings ……....………………………………………………………………………….
Takt Time and Orders ………………………………………………………….
Phone Calls and Other Interruptions …………………………………………….
Labor Analysis and Spaghetti Charts …………………………………………….
Conclusions .......………………………………………………………………………….
Takt Time and Orders ………………………………………………………….
Phone Calls and Other Interruptions …………….……………………………….
Labor Analysis and Spaghetti Charts …………………………………………….
Recommendations ……..…………………………………………………………………
Large-Scale …………………………………………………………………….
Small-Scale …………………………………………………………………….
Expected Impact ………………………………………………………………………...
References ……………..…………………………………………………………………
Appendices ………….…………………………………………………………………
Appendix A …………………………………………………………………….
Appendix B …………………………………………………………………….
Appendix C …………………………………………………………………….
Appendix D …………………………………………………………………….
Appendix E …………………………………………………………………….
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List of Figures and Tables
Figure 1: Incoming orders by time of day at the Discharge Island …...………………….
Figure 2: Total calls by position ………………………………………………………….
Figure 3: Process time for each employee position ……………..……………………….
Figure 4: Process time at each employee position with absent Filler Technician ……….
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Table 1: Average order size at each island with prescription takt time …………………. 11
Order Entry Technician Spaghetti Chart ...……………………………………………….
Order Entry Technician Stacked Chart ….……………………………………………….
Filler Technician Spaghetti Chart ……………………………………………………..…
Filler Technician Stacked Chart ………………………………………………………….
Checking Pharmacist Spaghetti Chart …..……………………………………………….
Checking Pharmacist Stacked Chart …………………………………………………….
Triage Pharmacist Spaghetti Chart ……………………………………………………….
Triage Pharmacist Stacked Chart ...……………………………………………………….
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EXECUTIVE SUMMARY
The Taubman Outpatient Pharmacy relocated in April 2013. With the new location, the
pharmacy has been experiencing long lead times, which are increasing the order backlog and
decreasing employee and customer satisfaction. The purpose of this project is to provide the
pharmacy with a detailed analysis of the current state and provide solutions for reducing the lead
time and backlog for patient orders and increase overall employee and patient satisfaction.
Employees of the pharmacy are concerned that the current layout and processes within the
pharmacy are inefficient and unnecessary movement and actions of each employee are increasing
backup of orders that must be completed by the end of the day. The current layout of the
pharmacy includes three “Islands.” The focus of this project is the detailed operation of the
Discharge Island. Once an order is received, the Order Entry Technician processes the order,
sending it to a Filler Technician who retrieves the correct amount of medication from inventory.
The prescription is then processed through the Checking and Triage Pharmacists, who double
check the medicine through a process called “medication reconciliation.”
Hour-long lunch shifts begin at staggered times for the employees, so the island is never
completely vacant. Issues with backlog arise during this time. Additionally, the priorities of each
prescription often contribute to backlogs and delays. For standard discharge prescriptions,
priority is given to the orders for patients with the closest upcoming discharge time.
Data Collection and Analysis
The team’s data collection and analysis processes covered three topics: takt time, phone calls,
and labor analysis.
Takt Time
To determine the takt time (rate of order arrivals) of each island, the pharmacy provided the team
with order data for a normal Monday-to-Saturday week, totaling 679 orders, including the order
size and arrival time. Information was collected for all three islands to confirm the busiest island
is indeed the Discharge Island.
The order arrival time and size data was stratified by island and day of the week. The student
team determined the order takt times, average order size, individual prescription takt time, and
total prescriptions. This data was used in conjunction with the labor analysis to compare the takt
time with the process time for each employee. The takt time provided the student team with a
baseline that assisted in determining process bottlenecks.
Phone Calls
The student team also collected data regarding employee distraction, which was largely
attributed to incoming and outgoing phone calls at the Discharge Island. Phone calls were
observed for arrival time, duration, employee position, incoming/outgoing, and reason. Through
direct observation, the student team recorded 258 phone calls.
Analysis was conducted in Excel and stratified by either day of the week, arrival time, reason for
call, and/or position. The student team determined average phone call duration and the
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percentage of each hour that is consumed with an employee on the phone, as well as which
employee processes the most phone calls. These calculated values assisted the team in
identifying a source of potential process waste.
Labor Analysis and Spaghetti Chart
The team’s observation of the pharmacy process resulted in a labor analysis and creation of
spaghetti charts. Each member of the student team viewed each of the four positions at the
Discharge Island (Order Entry Technician, Filler Technician, Checking Pharmacist, and Triage
Pharmacist) to determine each position’s task types, task completion times, and movements
throughout the workstation and environment. After 90 total hours of observation, spaced over
eight weeks, the team had sufficient data for analysis.
The collected data through the labor analysis of the Discharge Island’s positional tasks was
stratified by position. The student team calculated the average times for each task, providing the
student team with a standard completion time for each position’s commonly repeated task. These
averages were used to create stacked bar charts and were synchronized with the spaghetti charts
to identify the largest wastes in movement and help the team develop recommendations to ensure
each position’s tasks were completed within the takt time.
Findings and Conclusions
The data analysis of the takt time and orders, phone calls, and labor analysis and spaghetti charts
helped the team form conclusions from the data to assist in creating recommendations.
Takt Time and Orders
The overall takt time of the Discharge Island was calculated to be 9 minutes and 43 seconds, as
compared to 9 minutes 12 seconds, and 173 minutes 20 seconds for the Non-Discharge and
Transplant Islands, respectively.
The Discharge Island is confirmed to be the busiest of the three islands, claimed by comparing
the average order sizes with their takt time, and considering the number of prescriptions handled
per day. Much of the backlog experienced can be attributed to understaffing throughout the day,
with the most impact during the staggered lunch hours of the Discharge Island employees.
On average, the hour between 9:30 AM and 10:30 saw the greatest influx of orders. The
Transplant Island experienced the highest average order size with over 9 prescriptions per order,
followed by 3.1 and 1.6 prescriptions per order from the Discharge and Non-Discharge Islands,
respectively.
The Discharge Island handled 165 prescriptions from 54 orders per day, whereas the other
islands handled much less per day: 92 prescriptions from 57 orders at the Non-Discharge Island,
and 33 prescriptions from 4 orders at the Transplant Island. Accounting for the arrival, lunch,
and departure schedules, 186 orders, or 57.8% of all orders arrived when the island was
understaffed.
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Phone Calls
The Discharge Island averaged 12.17 phone calls per hour. The average duration of the calls was
59.74 seconds, but varied depending on the reason of the phone call. Out of the 258 phone calls
observed, 59 regarded the order status. Of the total calls that the Filler Technician, Order Entry
Technician, and Triage Pharmacist handled, order status calls accounted for 37%, 25%, and 23%
of all calls, respectively. Order completion phone calls accounted for 28% all calls observed.
With the frequent arrival of phone calls, pharmacists were interrupted from their current work, or
they worked less efficiently throughout the call. A significant portion of calls are adding zero
value to the order filling process because there is no pertinent information received.
Additionally, obtaining insurance information is one of the largest inhibitors of order completion.
This is outside of the project’s scope, but reevaluating the check in process so the pharmacy is
supplied with the required insurance information will significantly decrease the lead time, order
backlog, and overall organization within the pharmacy.
Labor Analysis
After completing the labor analysis, the team compared each position’s average process time
with the order takt time of the Discharge Island. The student team found that all four employees
of the island complete their processes for each order well within the takt time of each order.
However, when a staff member is absent from the Discharge Island, the staff member may be
replaced by someone else within the pharmacy, but if a replacement is not available, the
remaining staff on Discharge Island will have to absorb the missing staff members job duties.
Therefore, the actual individual process completion time is often greater than the takt time, since
the Discharge Island operates at less than full staff for several hours throughout the day.
With each task defined as value-adding (necessary actions) or non-value-adding (waste within
process), the student team found that the Discharge Island Process is 19.96% value-adding. Also,
the spaghetti charts outline the physical movements of the employees throughout the pharmacy
workspace. Overlaying each position’s spaghetti chart indicates no areas of heavy traffic, and
movement for each employee remains efficient, with no extra walking or reaching evident in
their movements.
Recommendations
After the data was collected and analyzed, the student team derived ways to reduce lead times
and backlogged prescriptions. Because there are several phone calls – many of which that add
zero value to completing the prescription – these phone calls need to be greatly reduced or
possibly even eliminated. An easy, quick implementation would involve the installment of a ‘no
order status calls policy’ throughout the hospital. This policy would eliminate 28% of the calls
that require the pharmaceutical staff to postpone their required duties. Also, redistributing the job
duties or adding a Rotating Technician among the staff members of the Discharge Island will
reduce unevenness, and thus reduce backlog when one of the island positions is vacant.
A large-scale recommendation would be the installation of an automated order database and
tracking system that will monitor each order through completion. Ideally, this system will be able
to notify the hospital staff who would normally be calling the pharmacy to check the order status.
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Introduction
The Taubman Outpatient Pharmacy within The University of Michigan Health System supplies
prescriptions for transplant, non-discharge, and discharge patients for all three main Ann Arbor
Hospitals: C.S. Mott Children’s Hospital, the University Hospital, and the Cardiovascular
Center. A recent change in the pharmacy’s location has provided an opportunity to analyze the
current substandard operations. A student team from the University of Michigan College of
Engineering’s Industrial and Operations Department has been recruited through the IOE 481
course to analyze these operations. Specifically, the area within the pharmacy that is the
designated location for discharge prescriptions, the Discharge Island, is experiencing long lead
times and frequently backlogged orders, according to time studies previously performed by the
student team’s lean coach. According to Taubman’s staff, pharmaceutical employees are
working overtime to successfully complete the orders. To solve these issues, the Pharmacy
Assistant Director has requested the IOE 481 student team to determine inefficiencies with the
current layout of the pharmacy. To successfully do this, the student team determined the order
takt time for all three islands within the pharmacy, performed a detailed labor analysis of the
discharge island, and identified any potential waste of time or resources. Once sufficient analysis
was completed, the student team formed recommendations to reduce lead time, backlogged
prescriptions, and increase employee and patient satisfaction. This document discusses the
methods for data collection and analysis, the findings and conclusions made from the data, and
recommendations for the pharmacy to implement.
Background
The Taubman Outpatient Pharmacy relocated in April 2013. With the move, a new layout in the
pharmacy was implemented; since the implementation of the new layout and relocation,
representatives of the pharmacy have been experiencing long lead times for patient orders, which
are increasing the order backlog and decreasing employee and customer satisfaction.
The pressing issue to be remedied is the long lead time for each order. Employees of the
pharmacy are concerned that the current layout and processes within the pharmacy are
inefficient. The unnecessary movement and actions of each employee are slowing work
progress, creating an increasing backup of orders that must be completed by the end of the day.
The current layout of the pharmacy includes three “Islands” through which all types of
prescriptions are filled. The focus of this project is the detailed operation of the Discharge
Island. Currently, the process at the discharge island involves four employees: two Pharmacy
Technicians and two Pharmacists. Once a prescription order is received, the Triage Pharmacist
then prepares and compiles the necessary information needed, giving it to the Order Entry
Technician who processes the order and sends it to a Filler Technician who retrieves the correct
amount of medication from inventory. The prescription is then processed through the Checking
Pharmacist, who double checks the accuracy of the filler prescriptions. At this point the order
has been completed, and the patient can come to the pharmacy to receive their prescriptions.
Throughout the day, the duties of each employee at the Discharge Island are shifted as they
attend external meetings, address issues that arise, or leave for lunch. The hour-long lunch shifts
begin at staggered times for the employees, so the island is never completely vacant. The new
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lunch schedule was implemented in August of 2013, and has been in effect for four months.
Still, issues with backlog arise during this time, especially when one of the remaining three
employees must leave his or her post to address another matter, or a backup is unavailable.
In addition to employee schedules and interruptions, the priorities of each prescription often
contribute to backlogs and delays. For standard discharge prescriptions, priority is given to the
orders for patients with the closest upcoming discharge time. For example, a patient being
discharged at 11:00 am will have his or her order filled before a patient being discharged at
11:45 am. The pharmacy employees report that they are not always given enough notice to meet
these time constraints.
Key Issues
To summarize, the main issues of concern within the pharmacy include:
1. Lengthy lead times of completing patient orders
2. Order backlog increase at busier times in the day
3. Employee dissatisfaction due to overtime hours and stressful, high-pressure situations
4. Patient complaints due to long waiting times
Project Scope
This project focused on improving the efficiency of the Discharge Island in the pharmacy.
Information that influences the work efficiency of Discharge Island was collected and analyzed,
including the pharmacy layout, the working process, responsibilities of each employee, as well as
their daily schedule. The takt time and order information for all three islands within the
pharmacy, however, work analysis for the Transplant Island or Non-Discharge Island are not
included in the project scope. The pharmacy inventory analysis, prescription writing and
anything before the orders arrive through the pneumatictube station are out of project scope as
well as any process after the prescription has been filled and is ready for pickup.
Data Collection
With the assistance of the project coordinators, the team developed a data collection plan to
reduce the lead time and backlog of orders at the Discharge Island. The plan included
determining the order interarrival times (takt time) for each of the three islands in the pharmacy.
Next, the team conducted a detailed labor analysis for each employee at the Discharge Island,
including the creation of spaghetti charts to determine the standard movements required to
complete the employee’s process. The student team began collecting data with a general
observation of the pharmacy processes during normal operating hours, spanning over eight
weeks for a total of 90 hours. Accuracy of the data was ensured by comparing each observer’s
data against the others and looking for anomalies.
Takt Time
To determine the takt time of each island, the team gathered data provided by the pharmacy that
included the arrival time of each order for a normal Monday-to-Saturday week, as seen in
Appendix A. Also provided on these documents was the order size, or the number of
prescriptions within each order. The data was supplied in several forms, including aggregated
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charts and individual order routing slips. A total of 679 orders were included in the analysis,
including 18, 339, and 322 orders from the Transplant Island, the Non-Discharge Island, and the
Discharge Island, respectively.
Phone Calls
Because the student team was observing a fairly inconsistent process, the student team also
collected data regarding pharmaceutical process “noise,” which essentially refers to employee
distraction. After the student team had a sufficient overall understanding of the process, the noise
was largely attributed to incoming and outgoing phone calls from the Discharge Island. After
realizing phone calls are the main contributor to distraction, phone calls were recorded for the
following attributes: arrival time, duration, employee position, incoming/outgoing, and reason. In
total, 258 phone calls were recorded through direct observation by all members of the student
team.
Labor Analysis and Spaghetti Charts
Observation of the pharmacy process resulted in the student team performing a labor analysis
and creating spaghetti charts. To understand the overall workflow of the pharmacy, the team
observed each hour of the day (9am-6pm) at least twice, as well as observing for some time on
each day of the week (Monday-Friday) at least twice. This coverage gave the team a complete
view of the pharmacy operations and how the process may change throughout the day and week.
Also, each member of the student team viewed each of the four positions at the Discharge Island
(Order Entry Technician, Filler Technician, Checking Pharmacist, and Triage Pharmacist) to
determine each position’s task types, task completion times, and movements throughout the
workstation and pharmacy environment. After 90 total hours of observation, spaced over eight
weeks, the team had sufficient data for analysis.
Data Analysis
To analyze the data collected through on-site observation, the student team conducted a takt time
analysis, a phone call analysis, a labor analysis, extracting data from observations and spaghetti
charts. All members of the student team compiled their data in a clean, non-aggregated form (for
easier manipulation) within Microsoft Excel. Once collected, each team member’s data was
compared to the others’ data to identify discrepancies or statistical outliers. If any such
measurements were found, they were eliminated from the final analysis.
Takt Time and Orders
Microsoft Excel was used to perform the takt time and order analysis. The data (supplied by the
pharmacy) regarding order arrival times was stratified by island and day of the week. The student
team utilized the embedded Excel functions to determine the following:
 Patient order takt times
 Average prescriptions per patient order
 Individual prescription takt time
 Total prescriptions handled
This data was used in conjunction with the labor analysis to compare the takt time with the
process time for each employee. The takt time provided the student team with a baseline that
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assisted in determining process bottlenecks. More information on the data collected regarding
takt time can be found in Appendix A.
Phone Calls
Phone call analysis was conducted in Excel and stratified by either day of the week, arrival time,
reason for call, and the position within the Island that handled the call. The reason of the phone
calls was separated into one of the 8 categories that were established by the student team, found
in Appendix B. Using embedded Excel functions, the student team determined a variety of
averages and percentages integral for developing recommendations. Most importantly, the
percentage of each hour that is consumed with an employee on the phone, which employee
position processed the most phone calls, and the most prevalent phone call reasons were
determined. These calculated values helped the team in identifying sources of process waste.
Labor Analysis and Spaghetti Charts
Deriving information from the labor analysis and spaghetti charts was completed through
Microsoft Excel. The collected data through the labor analysis of the Discharge Island’s
positional tasks was entered into a spreadsheet, stratified by employee position at the island. The
student team used embedded Excel functions to calculate the average times for each task. These
averages provided the student team with a standard completion time for each position’s
commonly repeated task, and were used to create stacked bar charts, creating a visual
representation of each position’s time allocation. The stacked bar charts were synchronized with
the spaghetti charts to identify the largest wastes in movement. The student team plotted the
stacked charts against the takt times for the Discharge Island allowing the team to develop
recommendations to eliminate process unevenness, and ensure all process times remain less than
the takt time. Also, the student team analyzed each position using the spaghetti charts to find
any movement wastes or heavy traffic areas within the pharmacy. The layout of the pharmacy in
Appendix C, supplied by the pharmacy employees, was used to create the spaghetti charts.
Findings
This section covers the findings from the data analyzed using the methods previously described.
Included are the results of the takt time and order analysis, the phone call analysis, and the labor
analysis. The main points explain that the Discharge Island handles 165 prescriptions per day,
more than the other two Islands. Also, most of the phone calls observed are either order status or
order completion calls. The labor analysis shows the Filler Technician processes are the most
time-consuming, while the Triage Pharmacist processes are the least time-consuming.
Takt Time and Orders
The full takt time and order analysis results can be found in Appendix A. The overall takt time
of the Discharge Island was calculated to be 9 minutes and 43 seconds, as compared to 9 minutes
12 seconds, and 173 minutes 20 seconds for the Non-Discharge and transplant islands,
respectively.
The Transplant Island experienced the highest average order size with over 9 prescriptions per
order. This large order size is countered by the long takt time of the Transplant Island compared
to the other islands. The project clients had previously indicated that the Discharge Island was
the location of the pharmacy with the largest workload, however no previous analysis was
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conducted to confirm this. The student team collected order information for all three islands to
confirm the busiest island is indeed the Discharge Island, supported by data seen in Table 1.
Table 1 below shows the average order size for each island, and how it compares to the takt time,
achieving a new metric: the prescription takt time, which is a better indicator of workload.
Table 1: Average order size at each island with prescription takt time
Island
# Rx per Day
(SD)
Order Takt
Time
Order Size # Rx
(SD)
Rx Takt
Time
Transplant
27.33 (20.0)
173 min 20 s
9.11 (8.7)
19 min 2 s
Non-Discharge
92 (23.2)
9 min 12 s
1.63 (1.2)
5 min 39 s
Discharge
165 (58.6)
9 min 41 s
3.07 (3.0)
3 min 9 s
Data collected 10/21/2013 – 11/9/2013 (n = 679 orders)
The Discharge Island handles the most prescriptions per day.
As seen in the table above, the average order size and order takt time can be used to calculate the
prescription takt time. The prescription takt time can be used as a more specific indicator of
differences in average workload between the islands. Similarly, the number of prescriptions
handled per day provides insight into the workload at each island. Through the observed
Monday - Saturday period, the Discharge Island handled 165 prescriptions from 54 orders on a
daily basis, whereas the other islands handled much fewer per day: 92 prescriptions from 57
orders at the Non-Discharge Island, and 33 prescriptions from 4 orders at the Transplant Island.
By stratifying the orders by day of the week, most orders arrive at the Discharge Island on
Thursday and Friday. The busiest recorded day, Thursday, saw 64 orders, resulting in a takt time
of 8 minutes 26 seconds, whereas the lightest day, Monday, only saw 45 orders, resulting in a
takt time of 12 minutes.
Separating all orders by time of day, the hour between 9:30 AM and 10:30 saw the greatest
influx of orders, averaging over 9 orders at this time each day. This hour span is the peak time of
order arrivals at the Discharge Island; orders throughout the rest of the day steadily decline until
the close of the pharmacy at 6 PM. This data is shown in Figure 1 below.
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Incoming Orders
6
5
4
3
2
1
8 - 830
830 - 9
9 - 930
930 - 10
10 - 1030
1030 - 11
11 - 1130
1130 - 12
12 - 1230
1230 - 13
13 - 1330
1330 - 14
14 - 1430
1430 - 15
15 - 1530
1530 - 16
16 - 1630
1630 - 17
17 - 1730
1730 - 18
18 - 1830
1830 - 1900
0
Time of Day
Data collected 10/21/2013 – 11/9/2013 (n = 679 orders)
Figure 1: Incoming orders by time of day at the Discharge Island
Most orders arrive between 9:30 AM and 10:30 AM.
Figure 1 above shows that many orders arrive before 10:00 AM, when the island first becomes
fully staffed. The number of orders diminishes throughout the day, with no orders arriving after
6:00 PM when the Pharmacy Closes.
Additionally, knowing the arrival, lunch, and departure schedules of both the pharmacists and
technicians at the Discharge Island, the team found that 186 orders, or 57.8% of all orders within
the observed week arrived when the island was understaffed. Understaffing happens early in the
morning before all workers arrive, midday when the workers take staggered lunch breaks, or in
the evening when some workers leave before others. A detailed daily schedule for each position
can be found in Appendix D. It is important to note that employees from other islands within the
pharmacy are sometimes available to cover for the vacant Discharge Island employee when there
are several orders not ready in time. However, as seen through the general observation time, a
replacement is often not available, and the position will remain vacant throughout the scheduled
time.
Phone Calls and Other Interruptions
There was 12.17 phone calls per hour, which includes both incoming and outgoing calls. The
average duration of the calls was 59.74 seconds, but varied dependent on the reason of the phone
call. This data can be found in Appendix B. When taking a short-duration call, where the
employee would spend less than 1 minute on the phone, the employee would stop his or her
current task to complete the call before resuming the current task. However, when answering a
call that lasted 3 or more minutes, the employee continued working on the tasks at hand while on
the phone. The type and duration of phone calls vary by position, with each employee handling
en unequal percentage of all phone calls. This data is shown in Figure 2 below.
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Data collected 10/1/2013 – 11/7/2013 (n = 258 calls)
Figure 2: Total Calls by Position
The Filler Technician handles the majority of all phone calls at the Discharge Island.
As Figure 2 shows, the Filler Technician handles nearly half of all phone calls at the Discharge
Island. The Order Entry Technician and Triage Pharmacist handle nearly 1 quarter of calls each,
with the Checking Pharmacist handling the least phone calls at 10 percent.
A significant portion of the phone calls in the pharmacy are people calling in to receive a status
on their order. Out of the 258 phone calls observed, 59 of these were about the order status. Of
the total calls that the filler technician, order entry technician, and triage pharmacist handle, 37%,
25%, and 23% are order status calls, respectively.
Another potential source of wasted time was the pharmaceutical staff – specifically the filler
technician and triage pharmacist – calling the designated department to notify the staff that the
patient’s order is complete. These order completion calls account for 28% of all phone calls at
the Discharge Island. A more detailed breakdown of the phone calls can be found in Appendix B.
In addition to phone call distraction, pharmaceutical staff in Discharge Island are sometimes
interrupted by the need to complete social work, which entails contacting doctors, insurance
companies, or other departments in the hospital to check the insurance information on the
patients’ cases to discharge the patient. Social work and other insurance-related tasks range in
duration from 5 minutes to several hours or, on occasion, across several days.
Labor Analysis and Spaghetti Charts
Upon the completion of the labor analysis, the team compared each position’s average process
time with the order takt time of the Discharge Island. The student team found that all four
employees of the island complete their individual processes for each order well within the takt
time of each order. This claim is expressed in Figure 3 below.
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Total Time (Full Strength)
Data collected 10/31/2013 – 11/7/2013
Figure 3: Process time for each employee position
At full strength, all employees complete their position’s tasks within the order takt time.
As seen in Figure 3, each position’s tasks are completed in less time than the orders arrive, which
is represented by the red dashed line at the top of the graph. However, the situation in the chart
above is for a fully staffed island. During lunch time at the Discharge Island, employees stagger
their 1-hour breaks from 12:00 noon to 3:30 PM. A full lunch break schedule can be seen in
Appendix D. If little to no pending orders were at the Discharge Island, one or more remaining
technicians or pharmacists would absorb the duties of the absent technician or pharmacist. If
several pending orders were at the Island, a technician or pharmacist from another island would
temporarily move to the Discharge Island, and take over the duties for the absent worker. If one
or more positions are vacant at the island, the total process time for each employee will increase
with the added duties of the absent worker. For example, when the Filler Technician is absent,
their duties will be shared between the Order Entry Technician, the Checking Pharmacist, and
the Triage Pharmacist. A visual representation of this situation is shown in Figure 4 below.
Here, the total process time of the Checking Pharmacist is above the takt time, indicating a
backup is likely to occur at that position, further delaying orders and increasing order lead time.
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Total Time (Without Filler Technician)
Data collected 10/31/2013 – 11/7/2013
Figure 4: Process time at each employee position with absent Filler Technician
With the Filler Technician absent, tasks are distributed to the remaining employees.
Additionally, the process time stacked bar charts for each employee can be found in Appendix E.
Each stack is separated by task, positioned in order, first task on the bottom, and final task on
top. Each task is defined as value-adding (VA), non-value adding (NVA), or semi-value-adding
(SVA). These terms indicate whether or not the process adds value to the product (the patient
order’s prescriptions). Overall, the Discharge Island Process is 19.96% value-adding.
Another result of the labor analysis comes from the linking of the spaghetti charts for each
position to the task list and process times. A spaghetti chart, task list, and process time chart for
each position can be found in Appendix E. The spaghetti charts outline the physical movements
of the employees throughout the pharmacy workspace. These can be used to find areas of the
pharmacy with heavy traffic, where one employee’s movements may interfere with another’s
movements. Fortunately, overlaying each position’s spaghetti chart indicates no areas of heavy
traffic, and movement for each employee remains efficient, with no extra walks or reaches
evident in their movements.
Conclusions
This section covers the conclusions derived from all data analysis methods considering the
findings from labor analysis, phone call analysis, and takt time analysis. Overall, the Discharge
Island is confirmed to be the busiest island, handling the most prescriptions per day. Phone calls
are the largest source of distraction for all employees. The labor analysis indicates that most
backlog is attributed to vacancies throughout the day at the Discharge Island.
15
Takt Time and Orders: The Discharge Island is the busiest Island
Despite the takt time from the Non-Discharge Island being shorter than that of the Discharge
Island, the Discharge Island is confirmed to be the busiest of the three islands. This claim was
made by comparing the average order sizes of the three islands with their takt time, and
considering the number of prescriptions handled per day. Also, the time of day when most
orders arrive (9:30-10:30 AM) is before lunch, and nearly 60% of daily orders arrive during
times when one or more positions at the Discharge Island is vacant. Therefore, much of the
observed order backlog can be attributed to understaffing. Understaffing means that all tasks
normally distributed between four employees are now covered by only two or three workers,
which can cause long order lead times and backlog, especially on the busiest days of the week,
Thursday and Friday.
Phone Calls and Other Interruptions: Phone calls are the largest source of distraction
Per hour, 12.17 phone calls are handled by the discharge Island, averaging 56.82 seconds per
call. With the arrival of phone calls, pharmacists were interrupted from their current work, or
they worked less efficiently. Some of these phone calls provide the staff with a piece of valuable
information (i.e. insurance information, order specifications, etc.), but a significant portion of
these calls are adding zero value to the order filling process.
Additionally noticed through observation, obtaining insurance information is one of the largest
inhibitors of order completion. This is outside of the project’s scope, but reevaluating the checkin process so the pharmacy is supplied with the required insurance information will significantly
decrease the lead time, order backlog, and overall organization within the pharmacy.
Labor Analysis and Spaghetti Charts: Backlog forms from vacancies at the Discharge Island
As seen in the Figure 3 above, each position’s tasks for each order are completed in less time
than the orders arrive. That is, the backlog and long lead times are not a product of the workflow
within the fully-staffed Discharge Island, rather from times of the day when the island is not
fully-staffed, or from out-of-scope issues, such as insurance or social work. Since the schedule
in Appendix D indicates that the Discharge Island is not fully staffed for over half of the day,
issues with backlog and long lead times can arise from tasks not being evenly distributed among
the remaining employees.
Between three and five times per day, a high priority order arrives at the Discharge Island.
When this order reaches them, each of the pharmacists and technicians in the Discharge Island
would stop their current work to begin handling the high priority order. When an order with a
compound prescription arrived, extra time was taken for the filler pharmacist to repeat walking
between the inventory and the island and again to fill the complex prescription. Some of other
special cases occurred within the order entry portions of the Discharge Island process, such as
prior authorization, insurance check, and social work, which increased the lead time even though
the prescription was already filled.
16
Recommendations
Based on the results of the student team’s general observation and data collection and analysis,
recommendations have been formulated to help the Taubman Outpatient Pharmacy reduce lead
time and order backlog. Both a large-scale change recommendation and several small-scale
recommendations were developed, giving the pharmacy options to consider with varying costs,
implementation times, and expected impacts.
Large-Scale Recommendation: Order database with tracking system
A sustainable, yet costly and difficult-to-implement solution would be the installation of a
tracking system that will monitor the order for completeness. Ideally, this system will notify the
patient’s care provider, which includes nurses, doctors, clerks or anyone calling the pharmacy to
check the order status. The goal of this system is to eliminate all order status calls, as well as the
order completion calls placed when the order is ready for pickup, which make up 56.1% of the
total calls. This system will assign a tracking number to each order that the nurses from the
hospital floor will be able to access throughout the order’s time within the pharmacy. At each
step, the employee will use one of the computers (or portable tablet) to “check-in” the order at
their position, which will update the status of the order across the entire database. The order will
be checked in at the following points:
1. At the point of order retrieval from the pneumatic tube station
 A worker will enter the number into the system or scan a barcode. This order will
enter the “current orders” queue, where it will remain until it is completed
 This process will replace the current A.C.P. log at the Discharge Island, and
create a searchable, editable, and permanent database of orders
 The order record will still have the same information, including the arrival time,
discharge time, and number of prescriptions
2. At the beginning of order entry
 The Order Entry Technician will indicate that the technician has begun the order
entry work
3. At the beginning of the filling process
 Once the Filler Technician receives the order to begin filling, the technician will
update the status of the order
4. At the beginning of the checking process
 The Checking Pharmacist will indicate that the order has begun the checking
process
5. At the completion stage of the order, when it is ready for pickup
 Upon indicating that the order is complete and ready to be picked up, a worker at
the pharmacy will enter the co-pay information, which will be included in the
relay message to the corresponding floor of the hospital where the patient is
located
17
6. At order pick-up
 Once the patient has picked up and paid for their order, the order will be removed
from the “current orders” queue, where it will be stored in the permanent
database.
As Alexis Garrobo indicated in the article from the Tribune Business News, having a tracking
system gives an “element of control” to the viewers of the tracking system, which in this case are
the care providers. Many of the order status calls are to see if the order was received by the
pharmacy, so implementing a tracking system allows the care providers to immediately check
whether the placed order was indeed received. Letting the nurses know the status of all orders
they may be concerned with will allow them to “...monitor the changes instead of waiting to be
notified” [1].
Small-Scale Recommendations
The large amount of phone calls, many of which add zero value towards completing the
prescription, needs to be greatly reduced or possibly even eliminated. One way to reduce the
order status calls is to simply educate the care providers on how the process within the pharmacy
works. Another option involves the installment of a ‘no order status calls policy’. This policy
would eliminate 28% of the order status calls that require the pharmaceutical staff to postpone
their required duties.
To counter the increased job process time when the Discharge Island is not operating at full staff,
the Filler Technician tasks should be more evenly distributed between the Triage and Checking
Pharmacists. Specifically, designating the “Receive/Log Order” task to the Triage Pharmacist
will make the job requirements more evenly distributed. Assigning the Triage Pharmacist as the
primary phone call handler will also make the job requirements more evenly distributed.
Currently, when the Filler Technician goes to lunch, the Checking Pharmacist takes over the
roles of filling orders in addition to checking them immediately afterwards. This method reduces
the effectiveness of a different employee performing the checking of the prescriptions. As a
result, the student team recommends that one pharmacist, either the Checking or Triage
Pharmacist, fill the order, and the other pharmacist checks the orders. The leveling of tasks
would result in an average takt time of 6.1 minutes per position, which is significantly less than
the current 9.7 average takt time. Even with potential positional vacancies, the average job task
time per position would be 8.15 minutes with one vacancy and 12.23 minutes with two
vacancies. These times show that leveling of duties will speed up the entire order completion
process.
Because the Discharge Island is operating at less than full capacity for 56% of the day, adding a
rotational Technician would reduce the number of understaffed hours, which will greatly reduce
prescription backlog. Most importantly, the rotating technician would be present at the Discharge
Island during lunch breaks (12:00 – 2:00 pm) effectively eliminating the two hours of
understaffing at the Filler Technician and Order Entry Technician positions, which have the
longest processing time.
18
Expected Impact
The recommendations will improve the overall flow of orders at the Discharge Island. The
backlog and lengthy lead times of the orders are also expected to decrease, or possibly be
eliminated. The workload of each pharmacist in Discharge Island will be balanced, which will
also lead to less high-pressure situations. With reduced backlog, the work left for the next day
will be reduced and the daily work will become better organized. The environment of pharmacy
will become more harmonious which will make the employees and patients feel more
comfortable, and increase overall satisfaction.
19
References
[1]
Garrobo, A. (2008, Feb 10). Hospital gets patient tracking system. McClatchy – Tribune
Business News. Available:
http://search.proquest.com.proxy.lib.umich.edu/docview/465936886?accountid=14667
20
Appendix A: Takt/Order Time Analysis
Orders received: Collected 10/21/2013 – 11/9/2013 (n = 679 orders)
NonTransplant Discharge
Discharge
Monday
2
55
45
Tuesday
1
71
57
Wednesday
6
67
54
Thursday
4
59
64
Friday
5
66
61
Saturday
0
21
41
TOTAL
18
339
322
Before 9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
After 6
NonTransplant Discharge
Discharge
2
8
33
0
47
53
2
44
40
2
38
49
3
41
30
3
34
28
2
30
34
3
34
33
1
30
15
0
23
7
0
10
0
Takt Time (Min)
Orders Per Hour
Order Size
Rx Takt Time
Rx Per Hour
Takt Time
NonTransplant Discharge
Discharge
173.33
9.20
9.69
0.35
6.52
6.19
9.11
1.63
3.07
19.02
5.65
3.15
3.15
10.62
19.04
173m 20s 9m 12.21s
9m 41.37s
679
Discharge,
average
per day
5.50
8.83
6.67
8.17
5.00
4.67
5.67
5.50
3.00
1.40
0
21
Appendix B: Phone Call Analysis
Phone Calls: Collected 10/1/2013 – 11/7/2013 (n = 258 calls)
Phone Calls by Position
Position
Checking Pharmacist
Filler Technician
Order Entry Technician
Triage Pharmacist
Total
Calls
25
115
63
55
Average
Duration (s)
74.11
56.16
60.15
48.53
In
Out
Percentage
9
58
36
26
14
38
14
23
9.69
44.57
24.42
21.32
Time on Phone Per
Order
11.38
52.35
28.68
25.04
Phone Calls by Reason
Reasons
Cancellation
Order Completion
Insurance
No Answer
Order Change
Order Status
Page Response
Question
Total In
1
1
59
0
21
8
2
9
9
9
59
57
3
3
56
43
Out
0
58
13
1
0
2
0
13
CP %
0.00
16.95
4.76
0.00
0.00
1.69
33.33
12.50
FT % OE %
100.00 0.00
47.46
1.69
38.10 52.38
0.00 100.00
22.22 55.56
59.32 20.34
33.33
0.00
33.93 30.36
TP %
0.00
33.90
4.76
0.00
22.22
18.64
33.33
23.21
Average Duration
150.00
23.96
117.71
17.50
81.00
47.71
40.00
67.21
Phone Call Reason by Position and Reason
Reasons
Cancellation
Order Completion
Insurance
No Answer
Order Change
Order Status
Page Response
Question
CP (s)
0.00
50.00
5.00
0.00
0.00
5.00
5.00
35.00
FT (s)
1.06
29.79
8.51
0.00
2.13
37.23
1.06
20.21
OE (s)
0.00
2.08
22.92
4.17
10.42
25.00
0.00
35.42
TP (s)
0.00
41.67
2.08
0.00
4.17
22.92
2.08
27.08
22
Appendix B: Phone Call Analysis (continued)
Phone Calls by Position without ‘Order Status’ Calls
Position
Total Calls
CP
FT
OE
TP
24
80
51
44
Average
Duration
76
57.55
65.73
49.30
In
Out
Percentage
9
24
24
15
13
37
14
23
12.06
40.20
25.63
22.11
Time on
Phone/order
11.89
39.65
25.27
21.81
Calls recorded by time of day
Call Start times Calls Recorded
9:00 - 12:00
97
12:01 - 3:00
65
3:01 - 6:00
39
23
C: Pharmacy Layout
24
D: Pharmacy Staffing Schedule
Time
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
Average Patient
Average
Orders
Prescriptions
Triage
Order
Checking Received per
Received per
Pharm. Entry Tech. Filler Tech. Pharm.
day
day
2.50
14.83
3.00
9.33
Arrive
Arrive
3.67
9.83
5.17
14.83
Arrive
Arrive
4.00
9.17
2.67
6.33
4.00
12.33
4.17
10.33
Lunch
2.00
10.00
Lunch
Lunch
3.00
5.67
Lunch
Lunch
2.17
8.67
Lunch
2.50
11.50
3.67
11.00
Lunch
2.00
6.00
Lunch
3.83
13.33
1.67
2.67
1.67
2.17
0.83
1.50
Leave
0.83
4.00
0.33
1.50
Leave
0.00
0.00
Leave
0.00
0.00
25
Appendix E: Labor Analysis (Spaghetti Charts, Detailed Job Elements, Stacked Charts)
Order Entry Technician Spaghetti Chart:
26
Appendix E: Labor Analysis (continued)
Order Entry Technician Detailed Job Elements:
1. Data Entry
a. Fill out required data fields in computer software from data on orders
*If there is missing insurance information then proceed to 2.
*If there is missing information for a drug, proceed to 4b.
2. Third-party communication
a. Alphanumeric page to UMHS affiliates for no insurance, prior authorization, or
prescription edits
b. Call insurance companies if insurance is rejected
c. Instant message social work (guest assistance)
3. Printing and Script Arrangement
a. Prints prescription labels
b. Folds labels and prescription
c. Places in basket
4. Walking (4s)
a. Delivers completed order to filler technician.
Typically, the order entry technician will place the basket on top of the order tech’s desk,
but if information needs to be conveyed to the filler technician then they will walk to the
filler technician and deliver the order as well as any other necessary information.
b. Retrieves drug from inventory if NDC is not known
5. Phone Calls
a. Responses to alphanumeric pages
b. Discusses order information with care provider
Order Entry Technician Stacked Chart:
600
500
⑤ Phone Calls (NVA)
400
④
⑤
③
②
300
200
④ Walking (NVA)
③ Printing/script arrangement
(NVA)
①
② Third party communication
(SVA)
① Data Entry (SVA)
100
0
Order Entry Technician
27
Appendix E: Labor Analysis (continued)
Filler Technician Spaghetti Chart:
28
Appendix E: Labor Analysis (continued)
Filler Technician Detailed Job Elements:
1. Walk to tube station (11s)
2. Receive/log order
a. Open tube and extract contents
b. Time stamp contents
3. Walk to Island (11s)
a. Enter order information into handwritten log
4. Set workstation
a. Select appropriate container
b. Match container with each prescription
c. Prepare labels for application
5. Walk through inventory shelves to retrieve items (27.8s)
Each prescription is in a different location within the inventory shelves. The Filler
Technician will only walk to the appropriate locations.
6. Fill prescriptions
a. Measure correct drug amount
b. Fill and seal containers
c. Apply container labels
d. Pass to Checking Pharmacist
7. Phone calls
a. Answer incoming order status and question calls
b. Make order completion calls
Filler Technician Stacked Chart:
600
⑦
500
⑦ Phone Calls (NVA)
400
⑥
⑥ Fill Prescriptions (VA)
300
⑤ Walk to inventory
(NVA)
④ Set Workstation (NVA)
200
100
0
⑤
③ Walk to island (NVA)
④
② Receive/Log Order
(SVA)
③
①
②
Filler Technician
29
Appendix E: Labor Analysis (continued)
Checking Pharmacist Spaghetti Chart:
30
Appendix E: Labor Analysis (continued)
Checking Pharmacist Detailed Job Elements:
0. Receive order materials from Filler Technician
1. Walk to computer (3.4s)
2. Walk to Island (3.4s)
Repetitions of walking between computer and island workspace happen normally once
for each prescription in the order.
3. Check prescriptions
a. Check the prescriptions in the basket for accuracy
If an issue arises, consult with Triage Pharmacist, proceed to step 4.
b. Pack the items into pick-up bag
c. Deposit bag into center of island, ready for pick-up
4. Walk to Triage (3.5s)
This walk occurs only when an issue with an order arises, where the Checking
Pharmacist consults the Triage Pharmacist, who may contact the patient’s care provider.
5. Walk to front desk (5.4s)
This walk occurs only when the patient receiving the order is waiting in the lobby, and
the order must be placed behind the front desk for pickup.
6. Phone calls
Checking Pharmacist Stacked Chart:
600
500
400
⑥ Phone Calls (NVA)
⑥
300
⑤
④
⑤ Walk to front desk (NVA)
④ Walk to triage (NVA)
③ Check Prescriptions (SVA)
② Walk to island (NVA)
200
① Walk to computer (NVA)
③
100
②
0
①
Checking Pharmacist
31
Appendix E: Labor Analysis (continued)
Triage Pharmacist Spaghetti Chart:
32
Appendix E: Labor Analysis (continued)
Triage Pharmacist Detailed Job Elements:
1. Printing
a. Pull up and check order prescription information - “digis”
b. Print digis
2. Walk to printer (6s)
3. Walk to Island (6s)
a. Order and paperclip materials
4. Walk to Order Entry (4.4s)
a. Deposit materials
5. Phone Calls
a. Out to patient’s care provider to solve issued found by Checking Pharmacist
Triage Pharmacist Stacked Chart:
600
500
400
⑤ Phone Calls (NVA)
④ Walk to order entry (NVA)
300
③ Walk to island (NVA)
② Walk to printer (NVA)
① Print (NVA)
200
④
⑤
100
③
②
①
0
Triage Pharmacist
33