By Annette M. Boyle
JOINT BASE SAN ANTONIO-LACKLAND, TX — Process improvement efforts oftentimes frustrate staff and irritate patients, but the 59th Medical Wing pharmacies at Joint Base San Antonio have implemented 65 process improvements during a seven-month period with results that save time and please nearly everyone.
No single change made a huge difference, but the time savings add up quickly across the 2,400 patients the pharmacies see each day.
“You think 15 or 20 minutes here or there is not a big deal, but it makes an incredible difference,” said Air Force Lt. Col. Rodney Jorstad, pharmacy flight commander. “I calculated that we saved patients 700 waiting hours per day.”
The initiatives addressed some basic issues while taking a broad view of the total prescription process.
“We focused first on implementing a consistent process across the seven pharmacies in Lackland,” Jorstad said. Pharmacists and technicians work at multiple sites, so having different procedures at different locations created uncertainty and frustration. The pharmacies also train pharmacists and technicians for the Air Force and a local pharmacy technician program, making consistency and implementation of best practices across the board even more important.
Some of the changes focused on seemingly little issues, such as how to label a pill bottle so it did not obscure the bar-coding and require rework. Others addressed larger matters such as automating the initial count of the three most-prescribed narcotics. The counts must still be confirmed manually, but the process cut the time consumed by nearly half.
In addition, the pharmacies have looked beyond their doors to improve the entire prescription process. One of the greatest changes involved embedding pharmacy technicians in the clinics that issue the most prescriptions — family health, internal medicine and pediatrics — to verify that each prescription is correct and review it with the patient before electronically sending it to the pharmacy.
The team also sought to ensure the pharmacies have medications when they are needed. “Any time we’re out of stock of a medication, we have to go through two or three more processes with that prescription, and the patient has to make a separate trip to pick it up, once we have it,” Jorstad said. Maintaining proper levels reduces the frequency of out-of-stock situations and makes the process more efficient for everyone.
Jorstad said he approached continuous process improvement at the pharmacies as a leadership training opportunity.
“At each pharmacy, the officer and NCO really engaged in the improvements. Each team set its own goals for processing time, and that created a little friendly competition between the pharmacies,” he noted. “I would have been ecstatic, if they had gotten the time down to 20 minutes, but two now have an average under 15 minutes.”
Another pharmacy cut the average fill time from 77 minutes in December to 25 minutes at last measure.
Generally, the patient reviews have been good. “We get eight positives for every negative,” Jorstad said. “People can’t believe how fast it is now.” When patients have to wait, they can see how long it will take to fill their prescription on a monitor in the pharmacy. That allows them to determine whether they want to stay or come back to pick up the prescription.
Patients at a pharmacy that had previously filled prescriptions as they were faxed in or electronically transmitted had the hardest time adjusting to the changes. Some missed being able to walk in and pick up their medications, but the pharmacy staff is winning them over.
“Now we fill their maintenance prescriptions for 90 days, so we point out that they save eight visits each year,” Jorstad said. “And they like that they have more interaction with the staff and better customer service.”
The changes made a big difference behind the window, too. “The stress used to be palpable, now it’s much calmer and the staff [members] are much happier,” he noted.
Not immediately filling prescriptions when received but waiting for the patient request accounted for a substantial amount of the improvement in pharmacy morale. One pharmacy had a 30% rate of filled but not picked up prescriptions, Jorstad said. That meant that pharmacists spent time filling the prescription, looking through extra bags for pickups and returning unclaimed medications to stock.
In another step toward streamlining, technicians call prescribers who send a fax and tell them about e-prescribing. The calls have halved the number of faxed prescriptions and reduced the transcription errors and time consumed by transferring faxed information into the pharmacy information system.
Now that the pharmacies have common processes, the team has turned its attention to patient safety. “We’re looking at errors and near misses to tweak processes and analyze how we can improve,” Jorstad said. “We maintain a 99.99% accuracy rate, which is very good for the volume we do. But, for patient safety, zero errors is the goal.”
The team is looking at how to prevent defects from coming into the pharmacy in the first place. Ideas include helping providers better understand the DoD prescribing system and considering ways to reduce prescribing errors, such as using clearer typography or changing instructions for patients.
Jorstad said he hopes the improvements ultimately free up one or two technicians to staff a call center. That way, patients can have their questions answered quickly, and the other staff can focus on the patients at the window without the distraction of answering the telephone.
All the improvements ultimately center on improving customer service, said Jorstad. “Federal medicine tends to be transactional. We’ve made it more interactional and have time to do more counseling. That’s how pharmacy should be.”