Hospital outpatient areas have become much busier in recent years, but lack the human and structural resources needed to meet this increased demand1. Improving patient care in outpatient areas should be considered a priority and Lean Management methodology can be a useful tool for quality improvements.

Lean Management is based on continuously improving the way in which we work by addressing the needs of patients and involving all health care staff by means of efficient processes. Lean Methodology defines value solely from the perspective of the customer or, in our case, patients. Any activity that helps in the treatment of patients adds value, whereas anything else is considered waste. There are a number of techniques that must be applied systematically to eliminate processes that do not add value for patients. The ultimate goal is to generate a new culture of improvement based on communication and teamwork2-4.

We identified several points in the dispensing and pharmaceutical care process that provided little value as well as processes that could be streamlined. Long waiting times for patients is a clear example of waste.

Lean Methodology was applied to improve the quality of the Outpatient Area by involving all staff who work in the outpatient care and dispensing processes. In our setting, Lean Methodology defines value from the patients’ perspective: thus, understanding their needs is fundamental to knowing where to focus our efforts in the improvement process.

The aim of this study was to improve the quality of outpatient dispensing and pharmaceutical care processes by involving patients and applying Lean Methodology. We also analysed the results in terms of efficiency and their impact on patient satisfaction.

Six patients attended the focus group meeting out of the 12 patients who were originally invited (50%). The 3 women and 3 men were aged between 35 and 57 years. Three of them were receiving antiretroviral therapy and the other 3 were receiving cancer therapy.

The participants gave positive assessments of the information they received about treatment, both in person and by telephone. However, it was noted that not all the patients received adequate written information on logistic and organisational aspects and this led to interruptions. All the participants strongly appreciated the quality of service.

The main issues reported by the focus group were waiting times and the physical space itself. The group thought that the following issues should be prioritised: avoiding the transport of goods through routes shared with patients, dealing with the backlog of patients in the middle of the day, and improving conditions in the waiting room.

More than 30 improvement actions were identified by the multidisciplinary team and patient focus group. Of these 30, 9 improvement actions were prioritised, which were mainly related to structural and circuit changes. Table 1 shows the topics covered by the focus group, the main comments from patients, and the main improvement actions that were proposed by the work group based on Lean Methodology.

These actions were implemented progressively. In some cases, this process took more than one year because it required the collaboration of external services such as those related to Infrastructures and Information Systems.

Waiting times were significantly improved by these actions. The percentage of patients waiting for more than 30 minutes fell from 30% before improvements to 4.5% after improvements. Figure 1 shows the evolution of pre- and post-implantation waiting times.

Figure 1.

Evolution of the waiting time indicator (percentage of patients waiting for more than 30 minutes to be seen).

(0,05MB).

All patients can now sit while waiting and can do so in better conditions. This target was achieved by enlarging the waiting area and improving the air-conditioning system.

Table 2 summarises the results of the questionnaires on patient satisfaction sent out in 2019 and 2020.

Significant differences were found in waiting times and overall satisfaction between the two periods. In both cases the satisfaction scores were higher in the second survey.

Figure 2 shows the suggestions provided by the patients in the satisfaction questionnaires. Both surveys showed that the most frequent comment was to thank the staff for their kindness and professionalism, followed by requests for better conditions in the waiting room. After the improvement actions were implemented, the most significant change was fewer complaints about long waiting times.

Figure 2.

Comments made by the patients surveyed (expressed as a percentage of the total number of comments).

(0,07MB).

The implementation of improvement actions should involve all health care staff who form part of the dispensing and pharmaceutical care process and should be based on an understanding of the patients’ experiences of the Outpatient Area.

We used several Lean Methodology tools to analyse the processes in depth and to identify and implement the most appropriate improvement actions in our Outpatient Area, while ensuring all staff were involved.

Lean Methodology has been used to improve different areas of hospital pharmacy5-13, but very few studies have addressed the dispensing process and outpatient pharmaceutical care.

The two approaches (focus group and satisfaction questionnaires) allowed us to obtain a great deal of information on the patients’ opinions and to identify the weak points of the service from patients’ perspective.

The results from the focus group and the satisfaction questionnaires were similar: the highest-rated aspects were the care and service provided, whereas the worst-rated aspects were the state of the waiting room, waiting times, location, and privacy.

These results are very similar to those of surveys conducted in other hospitals14-17. However, it should be noted that most of these studies used a 5-point Likert scale (1 to 5) whereas we used a 6-point Likert scale (0 to 5). This means that there was no neutral response and patients had to choose one way or the other.

The implementation of the improvement actions improved the patients’ assessment of waiting times and therefore overall satisfaction. However, the first survey showed that overall satisfaction was already acceptable. This is likely due to our patients’ positive assessment of the quality of the pharmaceutical care received, because this factor has the strongest correlation with patient satisfaction18.

The results of the focus group and surveys showed that satisfaction with service was very high, but that there were aspects that did not meet the patients’ expectations. Hospital management needs to be aware of the perspectives of patients receiving health care and to be involved in any improvements needed. Their approval is required for improving the area's facilities, obtain better IT resources, and extend opening hours and staffing levels.

The worst-rated aspects reported by other hospitals are similar to ours, such as waiting room conditions and waiting times15-17,19-21. Many hospitals have experienced growth in the number of patients, but this has not been matched by equivalent growth in outpatient areas. Resources should be adapted not only to dispensing but also to providing pharmaceutical care according to the CMO (capacity-motivation-opportunity) model22-24.

One of the limitations of this study is that the satisfaction questionnaire used was not validated because we had to adapt the questionnaire to our needs. The EVASAF25 scale is a validated questionnaire, but it only assesses pharmaceutical care received. In our case, we had to assess logistic aspects because the focus group had identified them as weak points in our service.

We were unable to implement some of the improvements requested by patients, such as moving the Pharmacy Service closer to the outpatient rooms or addressing the awkward location of the current waiting room. The size of the hospital makes it difficult to change the location of the specialty area. However, the suggestions of the patients who contributed to this study will be of great help in improving these aspects in redesigning the Pharmacy Service.

In any case, Outpatient Areas have changing needs and therefore continuous assessment is needed to identify any new opportunities for improvement that may arise over time.

We analysed the situation of our Outpatient Area and designed the most appropriate improvement actions according to the resources available. This initiative was achieved through patient participation (via focus group and mass surveys), the participation of health care staff, and the application of Lean Methodology.

This process has also helped with the internal organisation of the area and its future size in order to achieve maximum satisfaction among patients and the health care staff involved in the area.

No funding.

No conflict of interest.