This was a floor stock system on the nursing unit. This was the 1980’s. It was a floor stock system that wouldn’t exist in this day and age.
Imagine nursing units possessing medication that could be administered to the patient at no charge whatsoever! Unheard of! But it existed back then.
It didn’t involve every medication that a patient was getting. There were some drugs that were ordered and charged to the patient. But each nursing unit had a predetermined list of medications that they used for their patients. Nursing welcomed the floor stock system for the following reasons:
Nursing did not like going to the pharmacy for their medications. The pharmacy did have a messenger service that delivered meds from the pharmacy to the nursing units. But they ran every two hours. Thus, if the nurse needed medication in between, they would have to leave their unit. With floor stock medications, nurses could just go to their med room to obtain their medications.
Floor stock lists and levels were tailor made by nursing and could be changed at any time. Thus, if a lot of patients were using ibuprofen 400mg tablets this month, then nursing would just add ibuprofen 400mg tablets to their floor stock list.
There were no quantity limits. The pharmacy would send 20 tablets of ibuprofen 400mg tablets today, but that number could jump to 40, 60, or 80 tablets depending on the nursing unit’s needs.
There were no time restrictions. Thus, 40 tablets of ibuprofen 400mg tablets could be requested today, then this afternoon, then tomorrow, and then the next day. It was not unusual to find over 200 tablets of a floor stock medication on a nursing unit.
As I said these practices would not be tolerated in today’s society. But this was the 1980’s.
A nurse came to the pharmacy. She handed me a floor stock request sheet. The nurse was requesting six boxes of aspirin 325mg tablets.
One box of aspirin 325mg tablets contained 100 tablets. Thus, six boxes contained 600 tablets. There were 25 patients on the nursing unit. Let’s assume that they were all taking aspirin tablets.
1 patient had taken 4 tablets a day, and
25 patients would have taken 100 tablets a day (25x4),
It would have taken all the patients 6 days to use the six boxes of aspirin 325mg tablets.
What I found more annoying was that another nurse from the same nursing unit requested eight boxes of aspirin 325mg tablets yesterday AND WE FILLED IT! I saw no need to give 14 boxes of aspirin 325mg tablets in a two-day period as floor stock. I refused to fill the six boxes of aspirin 325mg tablets.
The nurse became upset.
“But we need them,” she cried.
“I’m sorry, but 14 boxes in a two-day period is a lot,” I said.
“Fine,” she exclaimed and she grabbed the floor stock list and left.
Or so I thought. Five minutes later, she was back. She had her head nurse with her.
“I understand that you refuse to fill our floor stock request,” said the head nurse.
“Hold on,” I replied and I went to get my boss. I explained the situation to him with the head nurses and the other nurse standing there.
“Don’t you think requesting 14 boxes of aspirin 325mg tablets is a little excessive?” asked my boss.
“No,” said the nurse, “we’ll use them, eventually.”
“Eventually?!” I said.
“Yes, eventually,” said the head nurse. She continued, “Look, if you’re refusing to fill the floor stock request, I’ll call my VP, who’ll call you’re VP…”
No one spoke for thirty seconds. My boss really didn’t want his VP involved.
Finally my boss said, “Fine. You can have the 14 boxes.” He walked away. I stood there dumbfounded.
Understanding Six Sigma Concepts
Six Sigma was a class provided by my hospital. It was held in-house for five days, and offered to select hospital employees and managers.
In class, I was taught how to improve operations or processes by eliminating variables that affected their outcome. Considering the equation:
Y= f (X) + E
Where Y is the outcome, X is inputs and how we implement (f) them, and E is variables that may cause problems. Using Six Sigma concepts, I learned how to minimize/eliminate the variables as much as possible in order to maximize outcomes. I received my green belt certification having completed the Six Sigma course.
Using the Six Sigma concepts, I often oversaw teams of people directly in need of improving their processes. We would implement the Six Sigma fundamentals of DMAIC which were
Define - Set the objectives as well as define where possible areas of improvement might be.
Measure - Obtain baseline measurements and identify places that can be measured for improvement purposes
Analyze - Use data and procedures to analyze each step, looking for (possible) breakdowns and where variables might occur
Improve - Identify and fix those portions of the process which will lead to greater outcomes.
Control - Implement controls to guarantee and maintain the achieved outcomes.
I was extremely pleased with the Six Sigma methodology for the following reasons:
It was all data driven. Thus, in the case of floor stock requests, comments like “But we need them,” or “We’ll use them eventually,” were never used.
All team members positions and their opinions were equal. Thus a vice-president’s comments carried the same weight as a staff member’s comments. In fact, sometimes a staff member’s comments were more readily accepted since they were the ones most directly involved with the process.
The team owned the process. It was their baby. They implemented it. They did everything in order to make it successful.
Guaranteeing Your Team’s Success
It was the first day of a new process. Several nurses and several members of my pharmacy staff had formed a team. They had participated in a Six Sigma session, where they used the methodology to address a medication delivery process.
The team was quite pleased with their solution. It met all the required criteria. They were excited to put it into action and expected it to succeed.
I was meeting with an associate of mine. Her name was Stephanie. She had also taken the Six Sigma course that the hospital had offered. Stephanie had received her green belt certification. She had also overseen this team that had devised and implemented this new medication deliver solution.
As we were sitting in my office, Evelyn (my Assistant Manager) came in.
“I have my concerns about this new process that the pharmacy and nursing staff are performing,” said Evelyn. “For one thing, I feel that neither staff is ready for the drastic changes necessary. In fact, both sides lack a strong leader to address the changes in procedure.”
Evelyn continued, “I also think that the new procedures would be detrimental to nursing since it would take them away from direct patient care. Also, these new procedures would be a very time consuming process for the pharmacy staff.”
Having said all that, Evelyn wanted to know what I thought.
I paused. Both Evelyn and Stephanie were waiting for my reply.
I said nothing for about thirty seconds, then I spoke.
I explained, “With a Six Sigma event, a green belt (I pointed to Stephanie) brings a team together to address an issue or problem. Now one of the first things that is communicated to the team is the objectives or criteria within which their solution must fall.
So the team goes through the entire Six Sigma practice and determines a solution. Their solution must fit the guidelines. If it does, then provided the solution in not illegal or violates some unforeseen principles, then you must allow the team to put it into practice.”
I continued, “If you do, you are empowering them. They will take ownership of the process. They will do everything within their power to make it succeed.
However, let’s assume that you don’t allow them to put their plan into action. Let’s say you don’t like their idea and you want to implement your plan instead. Then you’ve lost these people. For they will do everything grudgingly and cause your process to fail. It will then be your fault when everything doesn’t work out.’
Evelyn and Stephanie said nothing.
“There is another problem that occurs if you don’t accept their plan,” I stated, “By not allowing them to implement the process that they developed, they will not be happy. In fact, they will resent it.
Then the next time you need help, they will remember this time. They will remember all the hard-work that they put in to devise a solution for this process. They will also remember how their efforts were cast aide for a so-called better procedure.
Thus, you will have lost them. They will never do anything for you ever again. Because why should they? You asked them to provide a solution and then you tossed their plan out and did it your way! Why should they help you in the future?
“I’m going to let them implement their plan,” I said, “I’m going to supply them with whatever support and resources that they need. I’m going to do everything I can to make it successful.”
Evelyn and Stephanie agreed with my comments.
The team’s solution has been in effect for a while. It appears to be working quite well.
Reconvening If It Doesn’t Work
I was sitting at lunch when I was approached by three of my pharmacy techs. They were members of a seven-person pharmacy team which had recently participated in the Six Sigma process. The team had devised a plan to address delivery times of unit dose medication to the nursing units.
The pharmacy techs were not happy. The Six Sigma solution that they developed was not working. They were thinking of scrapping the process.
They wanted my thoughts. I brought up the following three issues.
“First of all,” I stated, “Scrapping the project and going back really isn’t an option. Because what are you going back to? Something that originally didn’t work, right?
If you want to scrap the project, that’s fine. But you’ll have to promptly meet with your fellow team members and develop another solution.
In addition, I advise you to do that before you scrap the project. In other words, put something else in place before you scrap what’s there.”
“My second point is rather than cancel the entire process, maybe your team can go back and examine what you’ve instituted. See if you can identify and keep the parts that are working— the parts that are successful and tweak the rest.”
“What’s the third suggestion?”asked one of the pharmacy techs.
“The third suggestion is to give it more time.” I replied.
“How much time?”asked one of the techs.
I smiled and said, “ That’s up to you. How long has the new process been in place?
“Two days,” replied a tech.
“Okay, two days,” I responded, “Maybe you want to give it a week or two weeks. Or maybe a month. In other words, let everyone get used to it and then make a decision.”
The pharmacy techs agreed. But they still weren’t very happy.
Six Sigma methodology is a good process. However, it does not work each and every time. (Omigosh did I just write that?)
Sometimes it may be necessary for teams to reconvene and devise an alternate plan. Sometimes it may be advantageous to modify an existing plan. Or it may be beneficial to give a solution more time.
But that is up to the team that originated the solution. They may not realize it, but the team is being given a tremendous gift. They are being empowered.
It is the team that lives with the system on a daily basis. They are the ones “in the trenches” every day.
The team knows the pitfalls of their projects and how to correct them. They also know what it needs to succeed.
The team should be the decision maker of any process. Not have a manager or outside person (who doesn’t know the system) tell the team what to do.
Producing Powerful Results
My hospital wanted to reduce its costs. Each department manager (including me), needed to develop and implement a cost cutting program for our respective department. Then, after a few weeks, I had to meet with both the Chief Operating Officer (COO) and Chief Financial Officer (CFO) to discuss its success.
I submitted a presentation where I had used Six Sigma Methodology to minimize overtime expenditures.
I obtained data from my pay period reports and focused on incidental or unapproved overtime.
To reduce incidental overtime, I educated my pharmacy staff members as to the pitfalls of using inappropriate overtime. I told them to arrive and leave work promptly. They were instructed not to punch in early or linger around after their scheduled time.
The results of my data were extremely positive. Beginning with pay period 15, my pharmacy had accrued 35.04 hours of incidental overtime. After six pay periods, incidental overtime dropped to 0.48 hours, resulting in a 98.6% reduction.
Both the COO and the CFO were ecstatic. I was commended for my program and for using Six Sigma practices which I learned from the hospital’s course.
I was trained that Six Sigma was an effective technique to provide process improvement. I was taught that Six Sigma:
Provided guidelines for defining and measuring inputs,
Analyzed data which led to improvements in procedures, and
Established control limits to maintain the process.
Daniel Shifrin, R.P., M.S. is a recently retired pharmacist who enjoys sharing his insights about hospital pharmacy. He is proud to own one of the largest collections of Pharmacy Stamp First Day Covers.