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Total Quality Management (Long Patient Waiting Time at Princess Marina Hospital Out-Patient Dispensa)
PRINCESS MARINA REFERAL HOSPITAL
Botswana

The Problem

The problem was encountered at Princess Marina Hospital Outpatient Dispensary where patients get their medications. Patients waited for too long before getting their services. Data collected during the month of October 2006 before the initiative, showed that 95 % (282/297) of sampled patients waited for an average of 2 hours 21 minutes instead of 1 hour the expected time (target the team decided on). The long patient waiting time was due to the following factors
• Long winding dispensing system and work processes in place such as frequency of meetings and rotational schedules.
• Inadequate allocation of Pharmacy staff within departments. The Pharmacy has about 7 sub units. As according to the Government Establishment Register, the Pharmacy department has a limited allocated number of staff which needs to be spread to all different units of the department.
• High volume of patients due to self referrals. Princess Marina serves as a referral hospital but it serves patients who come from the local clinics and other health facilities because of limited stock clinic list and out of stock of medication.
The above resulted in some patients going away without their medication, complaints and thus expressing dissatisfaction. On the other side staff fatigue and strain was on the increase due to late knocking off time. The normal closing time is 1630 hours but staff used to knock off at about 1900 hrs on a daily basis.

Solution and Key Benefits

 What is the initiative about? (the solution)
The waiting time was reduced from an average of 2 hours 21 minutes to 60 minutes by February 2007 .This improved customer satisfaction and reduced staff fatigue. The knock time was reduced by 2 hours from about 1900 hrs to about 1700 hrs.
The number of departmental meetings was rescheduled from 4 meetings to 3 per week. The departmental meetings include the General meeting, TQM and Management meetings. Furthermore the general meeting duration was also reduced from one and half hours to about an hour. This allowed more time for staff to serve at the dispensary.
The frequency of staff rotation within the department was reduced from 12 rotations per year to 4 times. This allowed a better understanding of their work stations and reduced re orientation thus increasing effectiveness and productivity.
Morning relief was introduced to increase staffing at the out patient dispensary by an average of 4 staff members from other units within the pharmacy on a daily basis. This was done for two hours in the mornings. However skeletal staff remained at other units to continue their routine activities.
Some selective prescriptions (e.g. prescriptions from urology and eye clinic) were issued in full where applicable. Normally patients with more than one month refill of medication come every month to refill until the prescription is exhausted. This reduced the number of visits by patients and therefore reduced patient load.
The patients benefited in respect of reduced waiting time. They were served much quicker and expressed gratitude for the timely services. The hospital as a whole benefited from the above because of the good public image.

Actors and Stakeholders

 Who proposed the solution, who implemented it and who were the stakeholders?
Princess Marina Hospital Pharmacy Total Quality Management Team in liaison with Hospital management, Pharmacy Management and staff proposed and implemented these solutions. Patients, Pharmacy staff, Ministry of Health, Institute of Development Management and BOTUSA were among the major the stakeholders.

(a) Strategies

 Describe how and when the initiative was implemented by answering these questions
 a.      What were the strategies used to implement the initiative? In no more than 500 words, provide a summary of the main objectives and strategies of the initiative, how they were established and by whom.
The TQM team used the Countermeasure Matrix tool to identify strategies to implement after identifying root causes. The team identified three objectives.
The first objective was to review the allocation of staff and frequency of rotation. To achieve this, the team came up with the following strategy.
• Introduction of relief schedule: The team put in place a relief schedule to increase staff within the first two hours of the morning.
The second objective was to review long winding dispensing system and processes in place. This was achieved by the following strategies.
• The opening of a card collection and an enquiries window. This was done to reduce the crowding of patients at the dispensing points .A data entry officer was appointed to register new patients and to help at the enquiries window.
• Frequency of departmental meetings was reduced. The number of meetings used to be four in a week and was reduced to three.
• The Issuing of two months supply to selected prescriptions: e.g from urology and eye clinic was introduced, where applicable.
• The number of prepacks packed in a day was increased from three to four items per day. New items were also included in to prepack list. This helped reduce the time taken to count items during the process of dispensing.
The last objective was to inform patients to get medication from the nearest clinic / health facility. This was achieved by
• Educating patients: to get medications from their nearest clinics by conducting educational talks and providing educational pamphlets created by pharmacy TQM team.
Dispensary supervisor was tasked to ensure that all these strategies were implemented.

(b) Implementation

 b.      What were the key development and implementation steps and the chronology? No more than 500 words
Pharmacy TQM team went through Brainstorming of the problems, Clarification stage, Multivoting, Theme selection matrix, Fishbone diagram, Pareto Chart, Countermeasure Matrix and Standardization.
The brainstorming of the problems was done to come up with all the problems the department encountered.
The Theme Matrix Selection was done to select the process problem based on impact on the external customers (patients) and need to improve.
Fishbone Diagram was used to analyse and identify root causes of the problem. This was followed by Pareto Chart to prioritise the actionable root causes.
The Countermeasure matrix was done in order to help the team compare the different countermeasures for each objective and decide which strategies to choose by considering its effectiveness and feasibility.
The Aids and Barrier analysis was also done to identify and evaluate the forces that may resist or assist the proposed change.

(c) Overcoming Obstacles

 c.      What were the main obstacles encountered? How were they overcome? No more than 500 words
The following main obstacles were encountered and they were over come by adopting appropriate strategies.
• The shortage of staff at the out patient dispensary: This was overcome by introducing morning relief where selected staff members from other units were engaged to help patients at the dispensary.
• Resistance of staff to change: The staff members were involved in the implementation of the strategies and the Pharmacy Management played a key role in support of the change.
• Limited time for TQM team meetings: The team had to meet after hours and during weekends to complete the project.
• Breakdown of Prepacking Machinery: To repair this machine a Technical service team was outsourced and is now in operation.
• Patient crowding at dispensing window: The opening of an enquiries window helped to decongest dispensing window.

(d) Use of Resources

 d.      What resources were used for the initiative and what were its key benefits? In no more than 500 words, specify what were the financial, technical and human resources’ costs associated with this initiative. Describe how resources were mobilized
The Human resources included:
• The Institute of Development Management expert who provided technical help during the course of project.
• The Pharmacy staff who carried the project by carrying out activities like drawing up the relief and rotational schedules at no cost.
• The hospital management who provided support and approved the initiative.
Other resources included
• Stationary and computers. An educational pamphlet was developed for patient education by using Microsoft Publisher and copies were printed to give out to patients. This was done by the team, within the Pharmacy with the available resources without any additional costs involved.
• Infrastructure: The team meetings and the project were carried out within the PMH Pharmacy premises. The In-service office was used to present the project.

Sustainability and Transferability

  Is the initiative sustainable and transferable?
The Princess Marina Hospital Pharmacy TQM project of reducing long patient waiting time is a sustainable initiative. This project was carried out at no cost and by using limited available resources. The team motto was “Do what you can with what you have where you are”
This initiative can be replicated or transferred any where in the world to increase productivity and improve service delivery. The project was presented at ministry of health mini convention and Botswana National Pharmacy workshop. . The project was also presented at the Botswana National Public Service Convention and was awarded trophies, medals and certificate of recognition. A letter of appreciation was received from head of department as well.

Lessons Learned

 What are the impact of your initiative and the lessons learned?
• TEAM SPIRIT
Through oneness and support the team achieved the desired goal and focus on the project.
• COMMITMENT AND DEDICATION:
The team with their full commitment and dedication was able to overcome obstacles to achieve the desired target.
• OUR MOTTO
Do what you can with what you have where you are!
• With the positive attitude there is always room for improvemen

Contact Information

Institution Name:   PRINCESS MARINA REFERAL HOSPITAL
Institution Type:   Government Agency  
Contact Person:   MOTLALEPULA T. THAGA
Title:   PHARMACIST  
Telephone/ Fax:   00267-3957575
Institution's / Project's Website:   00267-3973776
E-mail:   m_thaga@yahoo.com  
Address:   PHARMACY DEPARTMENT, P.O.BOX 258
Postal Code:  
City:   GABORONE
State/Province:  
Country:   Botswana

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