Redesigning an Outpatient Pharmacy Workflow Using Generic ...

[Pages:69]Redesigning an Outpatient Pharmacy Workflow Using Generic Simulation Modelling to Maximize a Renovation

Opportunity

by

Janet C. Izumi

A thesis submitted in conformity with the requirements for the degree of Master of Applied Science

Department of Mechanical and Industrial Engineering University of Toronto

? Copyright by Janet C. Izumi 2015

Redesigning An Outpatient Pharmacy Workflow using Generic Simulation Modelling to Maximize a Renovation Opportunity

Abstract

Janet C. Izumi Master of Applied Science

Department of Mechanical and Industrial Engineering University of Toronto 2015

The renovation plans of the outpatient pharmacy at Princess Margaret Cancer Centre presented an opportunity to apply discrete event simulation (DES) to help decision makers estimate the resource and space required for the pharmacy to support prescription volume growth over a tenyear horizon. There is an extensive literature on renovating existing pharmacy workspaces, but research on future capacity planning of pharmacy workspaces is sparse. The trend of increasing spending on prescription drugs underscores the importance of researching capacity planning of outpatient pharmacies. The goal of this study was to develop a generic simulation model that could be reused to plan the future capacity of any outpatient pharmacy. The generic DES was applied to two different pharmacies to explore different workflow configurations and assess the impact of introducing automation. Recommendations were provided to each pharmacy management team on the number of workstations and space required to achieve the target patient wait time.

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Acknowledgments

I would like to thank my supervisor, Professor Michael W. Carter, for his patience and guidance throughout this research. Every meeting with you challenged me to look at the problem from different perspectives and always ended with encouragement. I am inspired by your commitment to improving the health care system. I would also like to thank the outpatient pharmacy team at Princess Margaret Cancer Centre and Toronto General Hospital. The strong leadership of Esther Fung, Vivian Choi, Karen Chuk, and Christine Tse was critical to the success of this research and the acceptance of the results. The staff at University Health Network is dedicated to delivering the very best for patients and gave their honest feedback throughout this research. Tessa Pietropaolo has been instrumental in analyzing and summarizing data. I thank her for her positive energy and insightful discussions. Carolyn Busby has been a great mentor and I would like to thank her for the technical expertise and support. Finally, I thank my family for their unwavering support and patience. I would like to recognize my parents in supporting me in my academic pursuits and a special thanks to my sister and her husband, Jennifer and Toby McNeill, for their belief in me.

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Table of Contents

Acknowledgments.......................................................................................................................... iii Table of Contents ........................................................................................................................... iv List of Tables ................................................................................................................................. vi List of Figures ............................................................................................................................... vii Chapter 1 ......................................................................................................................................... 1 1 Introduction ................................................................................................................................ 1 Chapter 2 ......................................................................................................................................... 4 2 Background and Problem Analysis ............................................................................................ 4

2.1 Case Study 1: Princess Margaret Outpatient Pharmacy ..................................................... 5 2.2 Case Study 2: Toronto General Hospital Outpatient Pharmacy ....................................... 12 2.3 Research Objectives .......................................................................................................... 14 Chapter 3 ....................................................................................................................................... 15 3 Literature Review..................................................................................................................... 15 3.1 Hospital renovation planning ............................................................................................ 15 3.2 Pharmacy workflow and technology implementation ...................................................... 17 3.3 Generic Discrete Event Simulation................................................................................... 18 Chapter 4 ....................................................................................................................................... 20 4 Methodology ............................................................................................................................ 20 4.1 Specific Discrete Event Simulation .................................................................................. 20

4.1.1 Model design......................................................................................................... 20 4.1.2 Validation.............................................................................................................. 25 4.2 Generic Discrete Event Simulation................................................................................... 26 4.2.1 Model design......................................................................................................... 26 4.2.2 Validation.............................................................................................................. 29

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4.3 Square footage estimates................................................................................................... 29 Chapter 5 ....................................................................................................................................... 31 5 Results ...................................................................................................................................... 31

5.1 Case Study 1: Princess Margaret Outpatient Pharmacy ................................................... 31 5.1.1 Scenario 1: Double check workflow with barcode technology ............................ 32 5.1.2 Scenario 2: Triple check workflow with barcode technology .............................. 33 5.1.3 Sensitivity Analysis on prescription demand increase.......................................... 34

5.2 Case Study 2: Toronto General Hospital Outpatient Pharmacy ....................................... 35 5.2.1 Scenario 1: Changes in staffing level and skill-mix ............................................. 36 5.2.2 Sensitivity Analysis on prescription demand increase.......................................... 37

Chapter 6 ....................................................................................................................................... 38 6 Discussion ................................................................................................................................ 38

6.1 Case Study 1: Princess Margaret Outpatient Pharmacy ................................................... 38 6.2 Case Study 2: Toronto General Hospital Outpatient Pharmacy ....................................... 39 Chapter 7 ....................................................................................................................................... 40 7 Conclusion and Future work .................................................................................................... 40 Chapter 8 ....................................................................................................................................... 42 8 References ................................................................................................................................ 42 Appendix A: Kroll Workflow matrix ........................................................................................... 47 Appendix B: Process flow maps ................................................................................................... 48 Appendix C: Simulation screenshots ............................................................................................ 51 Appendix D: Input data analysis results ....................................................................................... 53 Appendix E: Pharmacy Floor plans .............................................................................................. 61

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List of Tables

Table 1. Percentage of fully and partially automated prescriptions by number of drugs on prescriptions .................................................................................................................................. 10 Table 2. Input parameters for Princess Margaret Specific DES ................................................... 22 Table 3. Specific DES output of resource utilization and same day patient percentages ............. 24 Table 4. Comparison of actual PM data and simulation results of performance metrics ............. 25 Table 5. Space model for estimating square footage per workstation/work area of the current state and future state of PM .......................................................................................................... 30 Table 6. PM Generic DES results of double-check workflow scenario with barcode technology32 Table 7. PM Generic DES results of triple-check workflow scenario with barcode technology . 33 Table 8. Prescription and patient count projection for 4%, 6% and 8% annual growth rate scenarios........................................................................................................................................ 34 Table 9. PM Generic DES results of sensitivity analysis on annual prescription growth rates.... 34 Table 10. TGH data for nine input parameters ............................................................................. 35 Table 11. Comparison of actual TGH data and simulation results of performance metrics......... 35 Table 12. TGH Generic DES results of different skill-mix and staff levels................................. 36 Table 13. TGH Generic DES results of sensitivity analysis on annual prescription growth rates 37

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List of Figures

Figure 1. Canadian Drug Store and Hospital Purchases Audit, 2010, IMS Brogan. ...................... 6 Figure 2. Princess Margaret Cancer Centre prescription and patient process flow ........................ 7 Figure 3. Same day patient percentage as a function of expected wait time .................................. 8 Figure 4. Toronto General Hospital prescription and patient process flow .................................. 13 Figure 5. Specific Outpatient Pharmacy DES model of Princess Margaret Cancer Centre ......... 21 Figure 6. Lognormal PDF and histogram of Take-in service times (left), Q-Q plot of Take-in service times (right) ...................................................................................................................... 23 Figure 7. Specific DES output of same day wait times by day of week and time of day............. 24 Figure 8. Generic DES patient and prescription process flow...................................................... 27 Figure 9. Generic Outpatient Pharmacy DES model .................................................................... 28

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1

Chapter 1

1 Introduction

Space in a hospital is limited and thoughtful allocation is required to plan for future growth or decline. In April 2015, the Princess Margaret Space Transformation (PMST) project was initiated to renovate the first floor of the Princess Margaret Cancer Centre (PM), which presented a rare opportunity to redesign and expand the capacity of the hospital's outpatient pharmacy. In early planning meetings with architects and external consultants on the PMST project, the critical decision of how much space the pharmacy would require to sustain future growth was left up to the pharmacy management team to determine based on experience working in the pharmacy. The team lacked decision support tools to make an informed decision and capitalize on this opportunity to design a more efficient pharmacy. External consultants specializing in pharmacy redesign gave general suggestions, but with few specifics on the number of workstations and space required.

The pharmacy management team was inspired by the Pebble Project research initiative of the Centre for Health Design to implement evidence-based design, which is the process of basing decisions on credible research to achieve the best possible outcome (Taylor & Keller, 2010). Operations research techniques provide evidence-based decision support tools for redesigning the workflow to meet goals such as maximizing resource utilization and improving patient outcomes through shorter wait times. There is extensive literature on renovating and retrofitting the existing space of a pharmacy, but research on future capacity planning of pharmacy workspaces is sparse. The trend of increasing spending on prescription drugs underscores the importance of researching capacity planning of outpatient pharmacies. This research developed a generic discrete event simulation to evaluate and estimate the pharmacy's resource and space requirements for different workflow scenarios.

Opening or relocating to a new facility provides a perfect opportunity to implement process change in an organization. In order for the pharmacy to remain in operation throughout the renovations, the pharmacy would need to move to a new location on the first floor. This was an opportunity for the pharmacy staff to think outside the box and challenge the status quo, as they

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