NATIONAL TEAM EXCELLENCE (NTEX) ON INNOVATIVE … · national team excellence (ntex) on innovative...

Date : 25 - 27 October 2016Venue : PUTRAJAYA INTERNATIONAL

CONVENTION CENTRE

NATIONAL TEAM EXCELLENCE (NTEX) ON

INNOVATIVE AND CREATIVE CIRCLE (ICC) CONVENTION

JOHOR CORPORATION

KPJ HEALTHCARE BERHAD

KPJ SPECIALIST HOSPITALS

KPJ TAWAKKALKPJ DAMANSARAKPJ SENTOSAKPJ RAWANGKPJ KLANG

CENTRAL NORTHERN KPJ SELANGORKPJ AMPANG PUTERIKPJ SEREMBANKPJ KAJANGKPJ PAHANG

CENTRAL SOUTHERN

KPJ JOHORKPJ PASIR GUDANGKPJ PUTERIKPJ KLUANGKPJ MAHARANI

SOUTHERN

KPJ IPOHKPJ PENANGKPJ TAIPINGKPJ KEDAHKPJ PERDANA

NORTHERN

KPJ KUCHINGKPJ SIBU

KPJ DAMAI

KPJ DAMANSARA

HOSPITAL BACKGROUND

KPJ Damansara Specialist Hospital (DSH) is the 8th Hospital under the flagship of the KPJ Healthcare Bhd, the largest healthcare group in the Malaysian and South East Asian region which has under its wings, 18

reputable and strategically located hospitals in Malaysia and 2 in Indonesia.

119 Jalan SS 20/10, Damansara Utama47400 Petaling Jaya, Selangor

Website : www.kpjdamansara.comTEL : 03-77181000FAX : 03-77222617EMAIL : dsh@dsh.kpjhealth.com.my

211 Beds710Staffs52 Consultants

As at June 2016

-Patient, 16th June 1997.

-Patient, 23rd June 1997.th April 1998.

th Hospital to join KPJ Healthcare Group.

CORE VALUE

SAFETY

COURTESY

INTEGRITY

PROFESSIONALISM

CONTINUOUS

IMPROVEMENT

MISSION

DELIVER

QUALITY

HEALTHCARE

SERVICES

VISION

PREFERRED

HEALTHCARE

PROVIDER

BREAST CARE CENTRE ENDOSCOPY

ONCOLOGY CENTRE HAEMODIALYSIS

IN VITRO FERTILIZATION IVF)

WEIGHT MANAGEMENT CENTRE

ADVANCED SURGICAL & WEIGHT MANAGEMENT CENTRE

5th Floor

FERTILITY & IN-VITRO FERTILIZATION (IVF) CENTRE

2nd Floor

CARDIAC CENTRE

PLASTIC & RECONSTRUCTIVE SURGERY

ORTHOPAEDIC SURGERY

VASCULAR/ENDOVASCULAR SURGERY

Angiography Machine

CATHLAB SERVICES

DIAGNOSTIC IMAGING SERVICES

LABORATORY SERVICES

CONSULTANT’S CLINIC

Linear Accelerator

ONCOLOGY SERVICES

Sensation Open CT Simulator

ONCOLOGY SERVICES

SLEEP STUDY LABORATORY

5th Floor

PAEDIATRIC TREATMENT ROOM

5th Floor, East Wing

RENAL DIALYSIS CENTRE

Puan Jasimah HassanDeputy Chairman

En Amiruddin Abdul SatarChairman

En Mohd Taufik Hj IsmailExecutive Director

Dr Thajunnisa HassanDirector

Datin Sabariah Fauziah JamaluddinDirector

Encik Mohd Sahir RahmatDirector

Dr Gunasegaran PT RajanDirector

Dr Roslan MahamudMedical Director DSH

Dr Rozman Md IdrusDirector

Dr Noor Hisham MansorMedical Director RSH

Pn Mah Lai HengDirector

Pn Noreen Abdul RashidDirector

En Onn Bin IsmailDirector

(Rawang Specialist Hospital Sdn. Bhd.)

Ms Eng Siew LayFinance ManagerCik Jaliah Mat Jani

Chief Nursing Officer

Dr Roslan MahamudMedical Director

En Mohd Taufik Hj IsmailExecutive Director

Cik Fawziah MuhammadChief Executive Officer

Dr Ellyana IsmailClinical and Operation Manager

Dr Rozman Md IdrusDeputy Medical Director

Dr ThajunnisaHassan

Dr GunasegaranPT Rajan

Dato Dr ZainuddinMd Zin

Dato Dr HaronAhmad

Dr Abdul Malik Mohamed Hussein

Dato Dr Wan NikAhmad Mustafa

Dr MubbashirIftikhar

En Mohd Hafiz Abu Bakar

Pn ErnizaMd Badurshah

(KPJ Damansara Specialist Hospital)

CIK JALIAH MAT JANI

CHIEF NURSING OFFICER

EN MUNIR ABU NOH

ADMINISTRATION

MS BOH SHI HUI

DIETETIC

EN MUHAMMAD AIMAN BIN

KAMARUZAMAN

INFORMATION TECHNOLOGY

EN KHAIRUL AZUWAN HUSSEIN

DIETARY

SECURITY (TERAJU FOKUS)

EN MOHD TAUFIK HJ ISMAIL

EXECUTIVE DIRECTOR

DR ROSLAN MAHAMUD

MEDICAL DIRECTOR

DR. VINOD KANNANGANAT VRINDAVAN

MEDICAL OFFICER IN CHARGE

CONSULTANTS

BOARD OF DIRECTOR

PN SAMMEZAH SAM

DEPUTY CHIEF NURSING OFFICER

EN MOHD HAFIZ MAT SAAD

HEALTHCARE ENGINEERING

SERVICES

DR ELLYANA ISMAIL

OPERATIONS & CLINICAL MANAGER

PN NORZIEYANA YATIM

ACCOUNTANT

NON CLINICAL /

SUPPORT SERVICES

( A Member of KPJ Healthcare Berhad Group )

KPJ DAMANSARA SPECIALIST HOSPITAL (236067-T)

HOSPITAL ADMINISTRATION ORGANISATION CHART

TUAN HAJI AMIRUDDIN ABDUL SATAR

CHAIRMAN

NURSING SERVICES

UM NORHELMI

OT / CSSD / COT

UM ROZALIZA

PAEDS ORTHO

UM HASLIZA

NIGHT UM

UM NURUL SYAZWANI

PREMIER WD

UM AURLMARY FRANCIS

CICU / CHDU

MS ENG SIEW LAY

FINANCE MANAGER

CIK NORLIZA KASSIM

CUSTOMER SERVICE

PN NORLIZA ABD HAFIZ

PR / MARKETING

NI ASMIDA

INSTRUCTOR

UM KHAIROLBARIYAH

MEDICAL MESRA

EN MOHAMAD ROSLI YUSOF

TALENT MANAGEMENT

EN NOR HISHAM OTHMAN

MEDICAL RECORD

EN TAHARUDDIN BAHARIN

PURCHASING

PN NORKHAIRIAH SUDIN

QUALITY

UM NORHAYATI

PAEDS & SCN WD

UM SITI ZABEDAH

ACCIDENT &

EMERGENCY

UM RUSMAINI

SPD / WMC / SCOPE

EN ABD MALIK MD ISA

DIAGNOSTIC IMAGING

CIK AZRIM MARIAM AMIR

PHARMACY

EN ZULKIFLI

ABDULLAH

RADIOTHERAPY

MS PARWATHI ALAGIRISAMY

REHABILITATION

CIK ALINA OTHMAN

CASE REVIEW

EN SYUKRAN JAMIL

OUTSOURCE SERVICES

UM SITI ZUBAIDAH

SURGICAL EAST

UM HAZURA

SURGICAL WEST /

WAQAF / ICO

UM MASTURA

HAEMODIALYSISUM

HASIMAH

NIGHT UM

UM SITI ADZWANI

MEDICAL WD

UM SUSANA

MATERNITY WD

CIK FAWZIAH MUHAMMAD

CHIEF EXECUTIVE OFFICER

CLINICAL /

SUPPORT SERVICES

OUTSOURCED /

SHARED SERVICES

HOUSEKEEPING

WASTE MANAGEMENT

* CLINICAL

* GENERAL

LAUNDRY

PEST CONTROL

SANITARY

FINANCE &

BUSINESS

SERVICES

TENANTS

* FLORIST

* CONVENIENCE SHOP

* METRO PARKING

* PHARMACARE

* COFFEE BEAN

• PICANTE CAFETERIA

• MELITA

• 1901

UM TAN EWE ENG

ONCOLOGY /

PATIENT EDUCATOR

MS SAW HUI LIN

EN SYED MUHAMAD ISA

SYED MOHAMAD ALWI

LABORATORY

LABLINK ( M ) SDN BHD

UM SALFARINA

ICU / HDU / NICU

EN FAIZUL YUNOS

OCCUPATIONAL, HEALTH &

SAFETY

NI JULIZA

INSTRUCTOR

NORBEEHAYAH

EVENING UM

PN ARMAH MOHIDIN

CLINICAL SURVEY

NI NORHAYATI

INSTRUCTOR

UM ZAIDAH

EVENING UM

DR ROZMAN MD IDRUS

DEPUTY MEDICAL DIRECTOR

CONSULTANTS

1998 Participation in KPJ Quality Convention

2002 - Participated in QMEA

2004 - Accreditation By MSQH

2004 - Best Hospital Award by KPJ

2005 - BFHI by MOH

2005 - Enterprise 50

2005 - IMS Certification

2011 - Food Safety Certification

2014 - Baby Friendly Hospital 4th Cycle

2013 - IMS Recertification

2013 Accreditation 4th Cycle

2011 5S Certification

2015 5S Recertification

2017 Towards Planetree Gold Recognition

2016 MSOSH award Gold Class II

2015 HR Award Work Life Balance Award

2014 Anugerah Kecemerlangan Industri

TEAM MEMBER

ALYANI AMINUDDIN

TEAM MEMBER

AZRIM MARIAM AMIR

TEAM LEADER

LEE SIN HENN

FACILITATOR

KHAIROLBARIYAH

BINTI ABDULLAH

Let the gift of medicine promote life

not destroy life

TEAM MEMBER

MOHD HANIF ADLI

1ST OCTOBER 2015

DATE FORMED

PHARMACY

SERVICES

15TH OCTOBER 2015

PROJECT START

JULY 2016

PROJECT COMPLETED

PROJECT NO

- GOLD AWARD AT MPC REGIONAL TEAM EXCELLENCE CONVENTION 2016 (EAST COAST)

- 2nd RUNNER AT 18TH KPJ QUALITY CONVENTION 2016 - 1ST RUNNER UP AT QUALITY CONVENTION CENTRAL

NORTH REGION 2016

ACHIEVEMENT

Let the gift of medicine promote life

not destroy life

trust, loyalty and integrity

Strength, passion

Creativities, determination success encouragement

ORANGE

wisdom , confidence and intelligence

ancient greek word that describes a medical professional who formulates and dispense drugs or medication

TEAM APOTHECARIST

represents the Pharmacy Services and its profession in its entirely.

RX, PESTLE AND MORTAR

CRITERIA

RESULTCommitted

towards quality

improvement

Minimal 2 years

working experience

Recommendation

from Head of Services

Good in Public

speaking

Has positive values

Voluntary

LEE SIN HENN

√ √ √

AZRIM MARIAM

√ √

MOHD HANIF ADLI

√ √

ALYANI AMINUDDIN

√ √

LEE SIN HENN CHIN JERN HUAT FAIZUL BIN YUNUS ALYANI AMINUDDIN

Attendance of Meeting

Attend Absent

No. of Meeting : 33

Attendance % : 98%Venue : Pharmacy Consultation Room Frequency : Once a week Monday (2 hours)

NAMEProblemSelection

Understand the problem

Set Target

Data Analysis

IdentifyCounter Measure

ImplementCounter Measure

MonitoringStandardiza

tionContinuousMonitoring

LEE SIN HENN

AZRIM MARIAM

MOHD HANIF ADLI

ALYANI AMINUDDIN

MAIN RESPONSIBILITY ASSISTANT

DURATION

ACTIVITYOct 2015 Nov 2015 Dec 2015 Jan 2016 Feb 2016

2016April 2016 May 2016 June 2016

PROBLEM

SELECTION

UNDERSTAND

PROBLEM

SET TARGET

ANALYSIS

IDENTIFY

COUNTER

MEASURE

IMPLEMENT

COUNTER

MEASURES

CKMONITORING

STANDARDI-

ZATION

CONTINUOUS

MONITORING

Implementation take longer time than

expected due to longer time required to

prepare and complete bin label

Due to delay of implementation. Decided to take another week to

monitor

No. TERM DEFINITION

1 Indent Process of daily item requisition start at 8.30am to replenish stock in pharmacy

2 Urgent IndentRequisition of an item on an immediate basis due to a need for the item but out of stock or not available from the pharmacy

3 Indent Book Item requisition documents used to order and replenish stock in pharmacy

4 Par LevelMaximum quantity of an item allowable to be kept in the pharmacy at any one time for optimum business operation

5Medication Par

Level ListThe complete list of all items in the pharmacy inclusive of item description, par-level and packing size information

6 Packing Size Smallest unit size of an item sellable by the supplier

7 Product Code 8 digit unique identifiable code for each item in the pharmacy

8Product

DescriptionFull description of an item inclusive of generic, brand name, dosage form and strength.

9 Reorder Level Minimum quantity of an item in the pharmacy shelve before indent is required

10 CheckingVerification of the items and quantity on requisition by pharmacist before submission for preparation of purchase order

11 OrderingPreparation of purchase order by storekeeper based on approved item requisition documents and submission to supplier

12 Purchase OrderDocument issued to the supplier for the purchase of an item that includes item name, quantity and price

BRAINSTORMINGDELAY SUPPLYING MEDICATION TO THE WARDS

MEDICATION STOCK INSUFFICIENT

QMS SYSTEM DOWN INSUFFICIENT INFORMATIONPROVIDED IN GUARANTEE LETTER

HIGH INCIDENCES OF NEAR MISS IN MEDICATION SUPPLY

UNOPENED EPISODE AND SUSPENDED ACCOUNT

MEDICATION OUT OF STOCK HITS AND KCIS BREAKDOWNFREQUENTLY

LONG OUTPATIENT PHARMACY WAITING TIME

DELAY IN ANSWERINGDOCTORS AND NURSES QUERRIES

LONG TIME TAKEN FOR INDENTING PHARMACY STOCK

DESCRIBE WHAT, WHY & HOW THE PROJECT WAS SELECTED1

INTRODUCTION OF PROBLEM

CREATIVE & INNOVATIVE FINAL SOLUTION

RESULT & IMPACT OF THE PROJECT

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

DRILL DOWN PROCESS PROBLEM IDENTIFICATION

Patient Waiting Time (OP – 1)(achievement of the quality objective 85% within 15 minutes)

1. QMS SYSTEM DOWN2. LONG OUTPATIENT PHARMACY WAITING TIME3. INSUFFICIENT INFORMATION IN PROVIDED

GUARANTEE LETTER4. HITS AND KCIS SYSTEMS BROKE DOWN

FREQUENTLY5. UNOPENNED EPISODE AND SUSPENDED ACCOUNT

TTA Waiting Time (IP – 1)(achievement of the quality objective 80% within 30 minutes)

At least 9 months (75%) of the year the ISO Objective is achieved

1. DELAY SUPPLYING MEDICATIONS TO WARD2. LONG TIME TAKEN FOR INDENTING PHARMACY

Customer Satisfaction Ratings

More than 80% customers rated as Good (more than 60% customers rated as Excellence)

1. HIGH INCIDENCE IN NEAR MISS IN MEDICATION SUPPLY

2. MEDICATION STOCK SUFFICIENT.3. MEDICATION OUT OF STOCK.4. DELAY IN ANSWERING DOCTORS AND NURSES

QUERRIES ON MEDICATIONS

KRA KPI

At least 9 months (75%) of the year the ISO Objective is achieved

PROBLEMS / ISSUES

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

THEME INDENTIFICATION FORCE RANKING

No. PROBLEM CRITICAL TEAM ABILITY RESULT

1 DELAY SUPPLYING MEDICATION TO THE WARDS 7 8 √

2 QUEUE MANAGEMENT SYSTEM (QMS) DOWN 6 4 X

3 HIGH INCIDENCES OF NEAR MISS IN MEDICATION SUPPLY 8 5 X

4 MEDICATION OUT OF STOCK 7 4 X

5 LONG OUTPATIENT PHARMACY WAITING TIME 7 8 √

6 MEDICATION STOCK INSUFFICIENT 7 5 X

7INSUFFICIENT INFORMATION PROVIDED IN GUARANTEE LETTER

8 UNOPENED EPISODE AND SUSPENDED ACCOUNT 5 6 X

9 HITS AND KCIS BREAKDOWN FREQUENTLY 8 4 X

10 LONG TIME TAKEN FOR INDENTING PHARMACY STOCK 8 9 √

11DELAY IN ANSWERING DOCTORS AND NURSES QUERRIES ON MEDICATION

Critical Level 1 10 Team Ability 1 10

Least Important Most Important Low High

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SHORT LISTED ISSUEDelay supplying medications to the wardTime taken more than 30 minutes to dispense To Take Away (TTA) medication to patients in the wards.

JULY AUGUST SEPTEMBER

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SHORT LISTED ISSUEDelay supplying medications to the wardTime taken more than 30 minutes to dispense To Take Away (TTA) medication to patients in the wards.cc

NO. OF DAYS ACHIEVED

DAILY TARGET20 18 23

NO. OF DAYS DID NOT

ACHIEVED DAILY TARGET

11 13 7

PERCENTAGEOF DAYS DID

NOT ACHIEVED

DAILY TARGET36.67% 41.93% 23.33%

Average Scoring

(36.67% + 41.93% + 23.33%)/3 26.51%

36.67% 41.93%

23.33%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Percentages of days DID NOT achieved daily

targets

26.51%

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SHORT LISTED ISSUELong Outpatient Pharmacy Waiting timeTime taken more than 15 minutes to dispense Outpatient medication to patients.

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Long Outpatient Pharmacy Waiting timeTime taken more than 15 minutes to dispense Outpatient medication to patients.

DAILY TARGET29 27 27

NO. OF DAYS DID NOT

NOT ACHIEVED

DAILY TARGET

6.45% 12.90% 10%

Average Scoring

(6.45% + 12.90% + 10%)/3 9.78%

6.45% 12.90% 10.00%

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%

100.00%

Percentage of Days DID NOT Achieved Daily

Target

SHORT LISTED ISSUE

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SHORT LISTED ISSUELong Time Taken for Indenting Pharmacy StockTime taken more than 1.5 hours ( > 10am) to complete Indenting Pharmacy Stock

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SHORT LISTED ISSUELong Time Taken for Indenting Pharmacy StockTime taken more than 1.5 hour (after 10am) to complete Indenting Pharmacy Stock

92.59% 92.59%

100.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Percentage of Days DID NOT Achieved Daily Target (>1.5 hours or

after 10am)

DAILY TARGET3 1 0

NO. OF DAYS DID NOT

22 24 24

NOT ACHIEVED

DAILY TARGET

88% 96.00% 100%

Average Scoring

(88% + 96% + 100%)/3 94.7%

AVERAGE94.7%

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROBLEM SELECTION MATRIX TABLE BENEFIT ANALYSIS

CRITERIA

TOTALNo. List of ProblemTime(X3)

Quality(X2)

IMAGE(X1)

1DELAY SUPPLYING

MEDICATION TO THE WARDS 1 2 1 8

2LONG OUTPATIENT

PHARMACY WAITING TIME 1 1 1 6

3LONG TIME TAKEN FOR INDENTING PHARMACY

STOCK3 3 1 16

WEIGHT 1 2 3

TIMEINPATIENT < 30 MINUTES

OUTPATIENT < 15 MINUTESINDENTING < 1.5 HOURS

INPATIENT 30 -45 MINUTESOUTPATIENT 15 - 20 MINUTESINDENTING 1.5 - 2.0 HOURS

INPATIENT 45 -60 MINUTESOUTPATIENT 20 - 30 MINUTES

INDENTING > 3 HOURS

QUALITY < 2 COMPLAINT/month 4 COMPLAINT/month > 6 COMPLAINT/month

IMAGE(EXPOSURE)

PUBLIC VIP PRESS

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Approval letter DESCRIBE WHAT, WHY & HOW THE PROJECT WAS SELECTED1

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT TITLELONG TIME TAKEN FOR INDENTING

PHARMACY STOCK

TO ENSURE THAT ALL PATIENTS RECEIVE SAFE, EFFICACIOUS AND HIGH QUALITY PHARMACEUTICAL PRODUCTS IN ADDITION TO

ADVICE ON THE RATIONAL USE OF THE PRODUCTS

OVERCOMING LONG TIME TAKEN FOR INDENTING PHARMACY STOCK

1. TO ENSURE 85% OF OUTPATIENT PRESCRIPTIONS ARE DISPENSED WITHIN 15 MINUTES

2. TO ENSURE 80% OF TAKE AWAY PRESCRiPTIONS ARE READIED WITHIN 30 MINUTES UPON RECEIPT FROM WARDS

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

LONG TIME– Staff taking more than 1.5 hours (start at 8.30 and finish later than 10am) checking and ordering medicine stocks at pharmacy services.

INDENTING – Process of daily item requisition start at 8.30am to replenish stock in pharmacy.

Definition -LONG TIME TAKEN FOR INDENTING PHARMACY STOCK

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROBLEM DEFINITION 5W 1H

WHAT IS THE PROBLEM?

LONG TIME TAKEN FOR INDENTING PHARMACY STOCK

IS IS NOT

LONG TIME TAKEN FOR INDENTING PHARMACY STOCK MORE THAN 1.5

HOURS (After 10am)

FAST AND EFFICIENT INDENTING TIME LESS THAN 1.5 HOURS (Before

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IS IS NOT

PHARMACY SERVICES WARD AND OTHER SERVICES

WHERE IT OCCUR?

PHARMACY FLOOR PLAN

STOCK LOCATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

STOCK LOCATION

IS IS NOT

PROCESS DURING INDENT (start at 8.30am) TAKING

MORE THAN 1.5 HOURS ( Finishlater than 10am)

PROCESS DURING INDENT NOT TAKING LESS THAN 1.5 HOURS AND DISRUPTING

OTHER DAILY TASKS

WHEN IT HAPPENED?

DURING INDENTING PHARMACY STOCK

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

WHY IS IT A PROBLEM

DELAY RECEIVING STOCKWASTE STAFFS AND CUSTOMERS TIMESTAFFS AND CUSTOMER COMPLAINTINCREASES MANPOWERDISRUPT DAILY TASKS

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IS NOT

JUNIOR PHARMACY ASSISTANT

WHO IS INVOLVED

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PHARMACY STAFFSPHARMACY STORE STAFFSNURSESPATIENTS AND THEIR FAMILY MEMBERS

PROCESS FLOW OF INDENT

COUNT PHYSICAL STOCK ON HAND

CHECK PAR LEVEL AND PACK SIZE FROM

MEDICATION PAR LEVEL LIST

ITEM < PAR LEVEL

INDENT ( WRITE IN THE INDENT BOOK)

CHECK BY PHARMACIST

SEND TO STOREKEEPER

STOREKEEPER PREPARING PURCHASE ORDER

SEND TO SUPPLIER

NO INDENTNO NO

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

COUNT THE PHYSICAL QUANTITY ON HAND

OF AN ITEM

REFER TO THE MEDICATION PAR LEVEL LIST

CHECK THE SUGGESTED PAR LEVEL OF THE ITEM IN THE

CHECK THE PACK SIZE OF THE ITEM IN THE MEDICATION PAR

LEVEL LIST

WRITE THE DESIRED INDENT QUANTITY INTO THE INDENT

15 seconds

10 seconds

20 seconds

Average time taken for 1 item > 65 seconds

Average items indent for one day = 140

Time required for indent process > 2 and half hours (11am)

65 Seconds

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROBLEM DEFINITION 5W 1HHOW?

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Staffs need to take Urgent Indents due to Shortage of Pharmacy Stocks

Insufficient stocks for peaks hours(11am – 1pm)

Insufficient Staffs due to staffs running for Urgent stocks

Disrupt the Pharmacy Operations Especially Outpatient Pharmacy

ISSUE OF CONCERNLong Indenting Time

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Item out of stock in pharmacy

Decide quantity to be taken based on Par Level in medication

par level list

Obtain Item from pharmacy store on urgent basis

3 minutes per item

Process flow for urgent indent

Urgent Indent: Requisition of an item on an immediate basis due to a need for the item but out of stock or not available from the pharmacy

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

ISSUE OF CONCERN –urgent indentUrgent Indent – Requisition of an item on immediate basis due to a need for the item but out of stock or not available from the pharmacy. An urgent indent takes around 3 minutes to complete.

September 2015 Urgent Indent Item

August 2015 Urgent Indent Item

July 2015 Urgent Indent Item

JULY URGENT ITEM AVERAGE/

DAY = 52 ITEM

52 X 3 = 156 minutes

AUGUST URGENT ITEM

AVERAGE/ DAY = 64 ITEM

SEP URGENT ITEM AVERAGE/

DAY = 61 ITEM

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

ISSUE OF CONCERN – Outpatient Peak hour

11am- 12pm: 76Rx12pm- 1pm : 64RxPEAK HOUR (11-1pm) > 50 Rx/hr

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT DATA

8:00:00 AM

8:30:00 AM

9:00:00 AM

9:30:00 AM

10:00:00 AM

10:30:00 AM

11:00:00 AM

11:30:00 AM

12:00:00 PM

12:30:00 PM

1:00:00 PM

1:30:00 PM

2:00:00 PM

1 2 3 4 6 7 8 9 10 11 13 14 15 16 20 21 22 23 24 25 27 28 29 30 31

Daily Time Of Indent Completion July 2015

Time Finish Indent

Cut off Point for Daily Indent Time

Pharmacy Peak Hour Start Time

Indent Start Time

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT DATA

92.59% 92.59%

100.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Percentage of Days DID NOT Achieved Daily Target (>1.5 hours =

after 10am)

DAILY TARGET3 1 0

NO. OF DAYS DID NOT

22 24 24

NOT ACHIEVED

DAILY TARGET

88% 96.00% 100%

Average Scoring

(88% + 96% + 100%)/3 94.7%

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT RELATIONSHIP WITH

Service Meeting showed Head of Services Cik Azrim urged the indent has to be done before 10am

(Start at 8.30 am take 1.5 hours)

How the project supports aligns with the organisation’s goal2

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT OBJECTIVESHow the project supports aligns with the organisation’s goal2

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPACT

CUSTOMER• Long Waiting Time• Insufficient

Medication for Patient

• Customer Complaint

• Loss of Trust from Patients and Family members

ORGANISATION• Impact on

Hospital Revenue• Losing Patients to

Other Competitors• Lack of Trust from

Patients

STAFF• Loss of Trust from

Patients and Family members

• Loss of confidence• Stress and

demotivated

Who are the potential stakeholders and how they may impacted by this project3

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Creative and Innovative Final Solutions

Ishikawa diagram 1

Short of manpower

Lack of teamwork

LONG TIME TAKEN FOR INDENTING

PHARMACY STOCK

Staff too tired

Stress

Too many phone calls enquiry

Lack of knowledge

MACHINE

METHOD

Indenting process too long

Indenting toooften

Process to send PO too complicated and long

Too many authorizationsteps

Too tedious to refer medication par level list

MATERIAL

Medication par level listnot user friendly

Indent book not user friendly

ENVIRONMENTAL

Wait too longfor lift

Pharmacy department temperature too high

Too many distraction

How Final Solution was Determined4

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Outdated software

Outdated computer

HITS system down

Trolley malfunction

Slow printer

CAUSE EXPLAINATION FINDING RESULT

Short of manpower• Too many staffs taking EL and

MC at the same time• High staff turnover

• Enough staffs for replacement• Does not significantly affect

operationRejected

Lack of teamwork• Lack of responsibility and

motivation• Tasks delegated to every staff Rejected

Staff too tired

• Staff given multiple tasks at one time

• Not enough rest due to overwork

• Tasks delegated in a fair manner to every staffs

• All staffs were given one hours break

Rejected

Stress• Lack of support from senior

staffs• Too shy to ask questions

• Newly recruited staffs were attached with preceptor

Rejected

Too many phone calls enquiry

• Too many phone enquiry in the pharmacy while doing indenting

• There were other staffs answering the phone call

Rejected

Lack of knowledge• Staffs lack of confidence and

knowledge• Mostly newly recruited staff

involved

VERIFICATION OF POSSIBLE OF CAUSES -MAN

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Outdated software• Old version software not user

friendly• Limited budget to upgrade

• Periodical update by IT Rejected

Outdated computer• Old hardware, slow computer

performance• Computer prone to error

• Main computer for critical work has been updated

Rejected

HITS system down• HITS system in-operational due

to power failure, server breakdown

• Happen infrequently• IT can restore system within an

acceptable time frameRejected

Trolley malfunction• Defects on trolley resulting

transport of pharmacy stock difficult

• Sufficient new trolley available to replace defected trolley

• Any fixable defects are attended to immediately by Maintenance Services

Rejected

Slow printer• Slow printing of

label/documents

• Use of old printer model with a slow printing speed

• Does not significantly affect operations

Rejected

VERIFICATION OF POSSIBLE OF CAUSES -Machine

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Too many steps involved in medication indenting process

Long time taken to refer to medication par level listfor packing size and par level

Indenting too often• High demand• High turnover rate• Keep to little stock

Par Level in process of revisionRejected

Process to send PO too complicated and long

Too many steps to export and import purchase order

Job performed by experienced storekeeper

Rejected

Too many authorization steps

Check by senior pharmacy assistant and pharmacist or chief pharmacist

Part and parcel of the indent process procedure

Rejected

Too tedious to refer medication par level list

• Too many items and thick medication par level list

• Font in the medication par level list is too small and not attractive

Searching for item in medication par level list is time-consuming

VERIFICATION OF POSSIBLE OF CAUSES - METHOD

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

767676

Medication par level list not user friendly

• Font size in medication par level list

• too small• medication par level list• too thick

Staffs take longer time when referring to the medication par level list due to small font size.

Indent book not user friendly

• Have to write manually and limited space to write

Not all staffs having this problem Rejected

VERIFICATION OF POSSIBLE OF CAUSES - MATERIAL

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

77777777

Wait too long for lift Staffs who do the indenting have to bring the indent book along with trolley to the storekeeper.

Staff who do the indenting not necessary to bring trolley along.

Rejected

Pharmacy department temperature too high

• Air-conditioning breakdown.• Not enough coverage of air-

conditioning.

New air-conditioning installed. Rejected

Too many distraction • Too many enquiry by pharmacy staffs.

Other staffs are available to answer quires.

Rejected

VERIFICATION OF POSSIBLE OF CAUSES - ENVIRONMENTAL

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SUMMARY AFTER FIRST FILTRATION

FACTOR CAUSESMan Lack of knowledge

Method Indenting process too long

Method Too tedious to refer medication par level list

Material Medication par level listnot user friendly

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Ishikawa diagram 2

MAN LONG TIME TAKEN FOR INDENTING

PHARMACY STOCK

Lack of knowledge

MACHINE

METHOD

Too tedious to refermedication par level list

MATERIAL

Medication par level listnot user friendly

ENVIRONMENTAL

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

COUNT PHYSICAL STOCK ON HAND

CHECK PAR LEVEL AND PACK SIZE FROM MEDICATION PAR

LEVEL LIST < PAR LEVEL

INDENT ( WRITE IN THE INDENT BOOK)

CHECK BY PHARMACIST

SEND TO STOREKEEPER

STOREKEEPER PREPARING PURCHASE ORDER

SEND TO SUPPLIER

NO INDENTNO NO

PROJECT FOCUS

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

FLOW CHART – CHECKING PAR LEVEL AND PACK SIZE FROM MEDICATION PAR LEVEL LIST

COUNT THE PHYSICAL QUANTITY ON HAND OF

AN ITEM

LEVEL LIST

WRITE THE DESIRED INDENT QUANTITY

INTO THE INDENT BOOK

TIME CONSUMING

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT TARGET 1COUNT PHYSICAL

CHECK PAR LEVEL AND PACK SIZE

ITEM < PAR LEVEL

INDENT (WRITE IN THE INDENT BOOK)

CHECK BY PHARMACIST

SEND TO STOREKEEPER

STOREKEEPER PREPARING PURCHASE

SEND TO SUPPLIER

COUNT PHYSICAL STOCK

CHECK PAR LEVEL AND PACK SIZE FROM

ITEM < PAR LEVEL

INDENT (WRITE IN THE INDENT BOOK)

CHECK BY PHARMACIST

SEND TO STOREKEEPER

STOREKEEPER PREPARING PURCHASE

SEND TO SUPPLIER

BEFORE THE PROJECT

AFTER THE PROJECT

Start indenting at 8.30am and finished process around 11am(> 1.5 hours)

Start indenting at 8.30am and finished process before 10.00am (< 1.5 hours)

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT TARGET 1 SHORTEN THE TIME TAKEN IN CHECKING PAR LEVEL AND PACK SIZE

FROM MEDICATION PAR LEVEL LIST

OF AN ITEM

LEVEL LIST

15 seconds

10 seconds

20 seconds

Average time taken for 1 item > 65 seconds

Average items indent for one day = 140

Time required for indent process > 2 and half hours (11am)

Target Average time taken for 1 item <40 seconds

Target time required for indent process < 1.5 hours (1oam) 65 Seconds

Peak hour 11- 1pm

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROJECT TARGET 2 - Reduce the need of urgent indent

September 2015 Urgent Indent Item

August 2015 Urgent Indent Item

July 2015 Urgent Indent Item

July Average Urgent Indent item per day = 52 items

August Average Urgent Indent item per day = 64 items

September Average Urgent Indent item per day = 61 items

To reduce Urgent Indent to 35 items a day

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Justification OF TARGET SETTING

Service Meeting showed Head of Services Cik Azrim urged the indent has to be done within

1.5 hours (Before 10am)

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

pre data collection1. Lack of knowledge

Very Low Low Neither High Very High

Responses 5 13 1 5 0

Survey: Confidence Level Of Conducting Indent Independently

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

pre data collection

Very Low Low Neither HighVeryHigh

Survey: Knowledge Level Of Items' Par-Level

Survey: Knowledge Level Of Items' Packing Size

1. Lack of knowledge

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

pre data collection2. INDENTING PROCESS TOO LONG

COUNT THE PHYSICAL

QUANTITY ON HAND OF AN ITEM

REFER TO THE MEDICATION PAR LEVEL

CHECK THE SUGGESTED PAR LEVEL OF THE ITEM IN THE MEICATION PAR

LEVEL LIST

CHECK THE PACK SIZE OF THE ITEM IN THE

WRITE THE DESIRED INDENT QUANTITY INTO

THE INDENT BOOK All Pharmacy staffs were asked to perform the process and

the time required to finish the process was recorded.Total Staffs involved were 24.

30-35seconds

35-40seconds

40-45seconds

45-50seconds

50-55seconds

55-60seconds

60-65seconds

65-70seconds

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

pre data collection3. Too tedious to refer medication par level list

Survey: Ease Of Looking Up Information On Par-Level & Packing Size

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

4. Medication par level list not user friendlypre data collection

Survey: Ease Of Looking Up Information On Par-Level & Packing Size

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Survey: Overall Indenting Process Work Satisfaction Level

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

pre data collectionWork satisfaction level

Indenting pharmacy done by experienced pharmacy assistant2 Junior staffs to do indent each timeStaffs to start indenting process earlier (Before 8.30am)

Current mitigation done before implementing

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROPOSED SOLUTION

WEEKLY CME

COMPULSORY KNOWLEDGE TEST EVERY MONTH

ONLY SENIOR PA ALLOWED TO DO INDENT

Delegate indent responsibility according formulations

SYSTEM AUTO-INDENT

PAR LEVEL INFORMATION ON THE BIN LABEL

PACK SIZE INFORMATION ON THE BIN LABEL

IMPLEMENT THE USE OF E-MEDICATION PAR LEVEL LIST

COLOUR CODE THE MEDICATION PAR LEVEL LIST

IMPROVE THE FONT TYPE AND FONT SIZE

INCLUDE THE PAR LEVEL AND PACK SIZE INFORMATION ON THE BIN LABEL

INDENTING PROCESS TOO LONG

TOO TEDIOUS TO REFER MEDICATION

PAR LEVEL LIST

DRUG MEDICATION PAR LEVEL LIST NOT

USER FRIENDLY

MENTOR AND MENTEE TAGGING SYSTEM

PROBLEM ROOT CAUSEPROPOSED SOLUTION

LACK OF KNOWLEDGE

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

ANALYSIS PROPOSED SOLUTION

Se l e c t I o n c r I t e r I a

Root Cause Suggestion

LACK OF KNOWLEDGE Weekly CME Compulsory

knowledge test every month

Mentor and mentee

tagging system

DURABILITY 2 2 5

IMPACT TO QUALITY 2 1 5

COST 3 2 4

COMPLETION 3 4 4

PRACTICABILITY 3 1 5

TOTAL SCORE 13 10 23

ADVANTAGES AND DISADVANTAGES

Available to all staff but not all staff are able to

attend.

Increase knowledge but time consuming

Increase knowledge in more practical

RESULT NO NO YES

DISAGREE AGREE STRONGLYAGREE

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Se l e c t I o n

c r I t e r I a

INDENTING PROCESS TOO LONGOnly senior PA allowed to do

indent

Delegate indentresponsibility

System auto-indent

DURABILITY 1 3 3

COST 2 2 1

COMPLETION 2 5 2

ADVANTAGES AND DISADVANTAGESSenior may not

available all the time

Less workloadbut more

manpower required

Practical but not able to implement

immediately

RESULT NO YES NO

DISAGREE AGREE STRONGLY AGREE

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

TOO TEDIOUS TO REFER MEDICATION PAR LEVEL LIST

Par Level information on

the bin label

Pack size information on

the bin label

Implement the use of E-medication

par level list

DURABILITY 5 5 4

COST 4 4 4

COMPLETION 4 3 4

ADVANTAGES AND DISADVANTAGES

Practical and Easy to access

Practical but might have breakdown

problem

RESULT YES YES NO

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

MEDICATION PAR LEVEL LIST NOT USER FRIENDLY

Colour code the medication par

level list

Improve the font type and font size

Include the par level and pack

size information on the bin label

DURABILITY 3 3 5

COST 4 4 4

COMPLETION 4 4 3

ADVANTAGES AND DISADVANTAGE Easy to implement but

impractical

Easy to implementbut impractical

Practical and Easy to access

RESULT NO NO YES

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

SUMMARY OF PROPOSED SOLUTION

1 LACK OF KNOWLEDGE Mentor and mentee tagging system

INDENTING PROCESS TOO LONG

TOO TEDIOUS TO REFER MEDICATION PAR LEVEL LIST

MEDICATION PAR LEVEL LIST NOT USER FRIENDLY

Delegate indent responsibility

•Par level information on the bin label•Pack size information on the bin label

Include the par level and pack size information on the bin label

PROBLEMS PROPOSAL

TO REDUCE TIME TAKEN TO INDENT PHARMACY STOCK

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Approval letter for project implementation

Expected Benefits by implementing the solutions5

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Milestone chart for the proposed solution

PROPOSE SOLUTION MARCH APRIL

W2 W3 W4 W1 W2 W3 W4

Mentor and mentee tagging system

Reduce Indenting process to alternate day

PAR LEVEL and PACK SIZE information on the bin label

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROPOSED SOLUTION 5W1HSOURCE:

LACK OF KNOWLEDGEWHAT ?Is the suggestion?

To implement mentor and mentee tagging system

WHY?To implement?

New staffs have no practical exposure to stock level and usage

WHO?Is involved?

Senior and junior pharmacy assistant

WHERE?To implement?

Pharmacy services

WHEN?To implement?

MARCH 2016

HOW MUCH?Cost that needed?

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATION mentor and mentee tagging system

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATION –mentor and mentee tagging system

Junior staffs was attached to senior staffs to explain the usage medication as well as the pack size and par level.

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

INDENTING PROCESS TOO LONGWHAT ?Is the suggestion?

Delegate indent responsibility

WHY?To implement?

Indenting by one staff takes up too much time

WHO?Is involved?

Pharmacy assistant

WHERE?To implement?

Pharmacy services

WHEN?To implement?

MARCH 2016

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATION Delegate indent responsibility

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATIONDelegate indent responsibility

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

TOO TEDIOUS TO REFER MEDICATION PAR LEVEL LISTMEDICATION PAR LEVEL LIST NOT USER FRIENDLY

WHAT ?Is the suggestion?

Par Level and Pack size information on the label (EMBLEM™ system)

WHY?To implement?

Referring to the medication par level list takes up a long time

WHO?Is involved?

Pharmacy assistant

WHERE?To implement?

Pharmacy services

WHEN?To implement?

MARCH 2016

RM100.00

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

BEFORE EMBLEM™ systemIMPLEMENTATION

Product Name

Product Code

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

COUNT THE PHYSICAL QUANTITY ON HAND OF AN

REFER TO THE MEDICAITON PAR LEVEL LIST

CHECK THE SUGGESTED PAR LEVEL OF THE ITEM IN THE MEDICATION PAR

LEVEL LIST

CHECK THE PACK SIZE OF THE ITEM IN THE MEDIDCATION PAR LEVEL LIST

THE INDENT BOOK

BEFORE EMBLEM™ systemIMPLEMENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

AFTER EMBLEM™ sysTEM IMPLEMENTATION

ITEM PACK SIZE

TOP : PAR-LEVELBOTTOM : REORDER LEVEL

PRODUCT NAME

PRODUCT CODE

EMBLEM™ System

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Post data collectionSo, what do you think about the new bin labels?

Is there anything we can improve

Umm… the new bin labels are better than the old one but I think there are still a few issues such as the font is too small and the font type is difficult to read plus

there is no colour to differentiate the max & min par-level. So, it is not very

reading-friendly.

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Post data collection

Indent Start Time

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

PROBLEM ROOT CAUSE PROPOSED SOLUTION

Poor Label readability

• Small Font size• Font type that

difficult to read• No color coding

to differentiate Minimum and Maximum Par Level

• Increase font size• Use the reading

friendly font type• Use colour coding to

differentiate minimum and maximum par level

Corrective action Proposed solution

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Corrective action –Proposed suggestion

Proposed Solution Sample Explanation Result

Proposed solution 1 • Background Colourtoo dark.

• Font type not reading friendly.

Rejected

Proposed solution 2 • Soothing background colour

• Reading friendly Font type

Proposed solution 3 • Font type not reading friendly.

• Dull background colour (Not user friendly)

Rejected

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

implementation after corrective action

ITEM PACK SIZE(bolded)

TOP : PAR-LEVELBOTTOM : REORDER LEVEL(colour coded)

PRODUCT NAME (font changed for easy reading)

PRODUCT CODE (bolded)

EMBLEM™ System

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

First Implementation Second Implementation

ACCEPTED

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

post-implementationExpected Benefits by implementing the solutions5

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Productivity

• Shorten the time required for indenting.

• Ease of accessing Par level and packing size information

• Process indenting more efficient

Quality

• Increase staff work satisfaction level

• Increase staff knowledge

• Increase patient’s satisfaction level

• Increase hospital image

• Increase work efficiency

• Reduce manpower cost

Morale

• Increase staff confidence level

PQCDSM

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Uniqueness of the

Solution

Can be implemented

in every hospital

Teamwork

Clear and Strong Impact

Can be implemented immediately

Minimal Cost

User Friendly

FIRST EVER IN KPJ

HOSPITAL!!!!

Uniqueness of the Solution6

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Result and impact of the project

30-35seconds

35-40seconds

40-45seconds

45-50seconds

50-55seconds

55-60seconds

60-65seconds

65-70seconds

1 0 0 0

30-35seconds

35-40seconds

40-45seconds

45-50seconds

50-55seconds

55-60seconds

60-65seconds

65-70seconds

COUNT THE PHYSICAL QUANTITY

ON HAND OF AN ITEM

REFER TO THE MEDICATION PAR LEVEL

CHECK THE SUGGESTED PAR LEVEL OF THE ITEM IN

THE MEDICATION PAR LEVEL LIST

CHECK THE PACK SIZE OF THE ITEM IN THE

THE INDENT BOOK

BEFORE AND : All Pharmacy staffs were asked to perform the process and the time required to finish the process was recorded.

PQCDSM: PRODUCTIVITY

How the project has contributed to the organization & has helped to impact its strategies or operational performance7

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Pharmacy Peak Hour Start Time Cut-off Point for Daily Indent Time

Time Finish Indent

Indent start time

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

124124

OF AN ITEM

LEVEL LIST

COUNT THE PHYSICAL QUANTITY

ON HAND OF AN ITEM

CHECK THE SUGGESTED PAR LEVEL USING EMBLEM™

SYSTEM

CHECK THE PACK SIZE OF THE ITEM USING EMBLEM™ SYSTEM

15 seconds 15 seconds

15 seconds

10 seconds5 seconds

20 seconds 20 seconds

BEFORE THE PROJECT AFTER THE

PROJECT

65 Seconds 40 Seconds

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

REDUCED 25 SECONDS

No. of Urgent items taken after implementation W1

WEEK 1 2 3 4 5 6 7 8

Average urgent items per day

31 32 33 30 35 34 33 31

Manage to reduce the urgent items from 59 items per day to an average of per day.

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

REDUCED 26 ITEMS

177 MINUTES

99 MINUTES

AVERAGE TIME SAVINGS FOR URGENT INDENT ITEMS (BEFORE & AFTER)

BEFORE AFTER

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

REDUCED

78 MINUTES

Notes : 3 minutes per items

Survey: Knowledge Level Of Items' Par-Level(AFTER IMPLEMENTATION)

Survey: Knowledge Level Of Items' Par-Level(BEFORE IMPLEMENTATION)

PQCDSM: QUALITY

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Survey: Knowledge Level Of Items' Packing Size (AFTER IMPLEMENTATION)

Survey: Knowledge Level Of Items' Packing Size (BEFORE IMPLEMENTATION)

PQCDSM: QUALITY

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Survey: Ease Of Looking Up Information On Par-Level & Packing Size (AFTER IMPLEMENTATION)

Survey: Ease Of Looking Up Information On Par-Level & Packing Size (BEFORE IMPLEMENTATION)

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Survey: Overall Indenting Process Work Satisfaction Level (AFTER IMPLEMENTATION)

Survey: Overall Indenting Process Work Satisfaction Level (BEFORE IMPLEMENTATION)

PQCDSM: QUALITY

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

• Average time taken to complete indent before implementation = (2:31:07)• Average time taken to complete indent after implementation = 1:25:12• Total time saving PER DAY = (2:31:07) – (1:25:12)

= 1:05:55 (1.1 Hours)• Total time saving PER MONTH (26 DAYS) = 28:33:50

• Locum pay-rate PER HOUR = RM 15.00• Savings PER DAY = RM 15.00 X 1.1 Hours

= RM 16.50• Savings PER YEAR (312 DAYS) =

Average Time Saving: 1:05:55

RM 5,148.00

PQCDSM: COST

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Average Urgent item taken before implementation

(July + August + September 2015) : (52 + 64 +61)/3 = 59 per day

Time (minutes) required to handle urgent is 3 minutes = 59X 3

= 177 minutes (2.95 Hours)

Average Urgent item after implementation = 33 per day

Time (minutes) required to handle urgent a day = 99 minutes (1.65 Hours)

Total time saving PER DAY = 78 minutes (1.3 Hours)

Locum pay-rate PER HOUR = RM 15.00

Savings per day = RM 15.00 X 1.3 Hours

= RM19.50

Savings PER YEAR (312 DAYS) =

RM 6,084.00

PQCDSM: COST

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Survey: Confidence Level Of Conducting Indent Independently (AFTER IMPLEMENTATION)

Survey: Confidence Level Of Conducting Indent Independently (BEFORE IMPLEMENTATION)

PQCDSM: MORALE

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

BEFORE AFTER

STANDARDIZATION PROCESS: ARRANGEMENT & LABELLING OF STATIONARIES

How the results of the shows continual improvement8

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

BEFORE AFTER

STANDARDIZATION PROCESS: REPLENISH LEVEL MARKING

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

BEFORE AFTER

STANDARDIZATION PROCESS: STOCK STATUS INFO

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Contraindicated In Breastfeeding

Contraindicated In Pregnancy

Allergy Alert

May Cause Drowsiness

‘TRAFFIC LIGHT SYSTEM™’

VISUAL SYSTEM to create awareness on availability of multiple strengths medication for MEDICATION SAFETY

Only single strength available (GO)

Two strengths available (CAUTION)

Three or more strengths available (WARNING)

‘ADVISORY SYMBOL SYSTEM (AVIS™)’

VISUAL SYSTEM on medication cautionary advice for MEDICATION SAFETY

FIRST IN KPJ

HOSPITAL!!!!

ORIGINAL!™

EXTENDED LABEL FUNCTIONS (EVEN MORE IMPROVEMENTS!!)

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Identify the opportunity of the project to be commercialized 9

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATION AT : PHARMASERVE, KPJ DAMANSARA BRANCH

BEFORE AFTER

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

IMPLEMENTATION AT : Klinik Wakaf,An-nur

AFTERBEFORE

CUSTOMER• Improved Waiting

Time• Ample Medication

stock for Patient• Reduce Customer

Complaint• Regained Trust

from Patients and Family members

ORGANISATION• Increase Hospital

Revenue• Patient’s Hospital

Choice• Regained Trust

from Patients

STAFF• Regained Trust

from Patients and Family members

• Increase confidence level

• Reduced work stress

Impact of the project to the environment of stakeholders

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

validation

Feedback from pharmacy assistantWow… what a great

improvement. The newly improved labels are now easy & fast to read. Great

Describe the final solutions/improvement actions and explain how the team validated the final solution/ improvement actions

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

Feedback from PharmAcy Assistant

RESULT & SUSTAINABILITY

LESSON LEARNED &

PRESENTATIONVALIDATION

Feedback from Pharmaserve staff

LESSON LEARNED &

Feedback from Klinik Wakaf,An-nur staff

LESSON LEARNED &

Feedback from Head of Services

LESSON LEARNED &

Feedback from customers

Saya berpuas hati

dengan layanan

yang diberikan.

Perkhidmatan

yang cepat dan

efisien.

Very satisfied with

service. Clear &

good information

given by the

pharmacy staff.

LESSON LEARNED &

Result and sustainability

COUNT THE PHYSICAL QUANTITY ON HAND OF AN

CHECK THE SUGGESTED PAR LEVEL OF THE ITEM IN THE MEDICATION PAR

LEVEL LIST

CHECK THE PACK SIZE OF THE ITEM IN THE MEDICATION PAR LEVEL LIST

THE INDENT BOOK

BEFORE EMBLEM™ sysTEM IMPLEMENTATIONDescribe the procedure, system, or other changes that were made

VALIDATIONRESULT &

SUSTAINABILITY

LESSON LEARNED &

PRESENTATION

OF AN ITEM

CHECK THE SUGGESTED PAR LEVEL USING EMBLEM SYSTEM

CHECK THE PACK SIZE OF THE ITEM USING EMBLEM SYSTEM

AFTER EMBLEM™ sysTEM IMPLEMENTATION

Describe the procedure, system, or other changes that were made

VALIDATIONLESSON

LEARNED & PRESENTATION

Sop Standardization BEFORE AFTER

EMBLEM™ sysTEM INCORPORATED INTO PHARMACy INDENT PROCEss

VALIDATIONLESSON

5S auditDescribe the procedure, system, or other changes that were made

VALIDATIONLESSON

Lesson learned and presentation

Radar Chart: Intangible Benefits

Understand The Company'sVision

Usage Of ICC Tools

Commitment

Cooperation

Understanding Of ICC Concept

Public Speaking

BEFORE AFTER Understand The Company’s Vision• The importance of good

image to the company• Loyalty to the company

Usage Of ICC Tools• Data collection• Drawing of

graphs

Commitment• Attend meetings• Dedicating time for

project completion• Participation &

dedication

Cooperation• Working as a team to meet

goals• Amicable discussion

Understanding Of ICC Concept• Definition of ICC• Brainstorming• Identifying &

prioritizing problems

Public Speaking• Deliver speech/talk

in front of audiences with confidence

Describe how lesson learned were identified and addressed

VALIDATIONRESULT &

SUSTAINABILITYLESSON LEARNED & PRESENTATION

ConventionsInvitation LettersWorld Pharmacist Day

Monthly Pharmacy Bulletin

Unit MeetingsCentral Orientation

Programme (COP)Sharing to Wards

Result how result were shared with stakeholders

VALIDATIONRESULT &

TO ENSURE CONTINUOUS IMPROVEMENT

VALIDATIONRESULT &

FuTuRE PROjECT….

VALIDATIONRESULT &

Thank you!

NATIONAL TEAM EXCELLENCE (NTEX) ON INNOVATIVE … · national team excellence (ntex) on innovative...

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