The Quality Plan Strategy of the Spanish National Health System includes the improvement of patient safety in health centres as a priority, with a special focus on the need to implement quality systems1.

In order to improve quality and safety, many health care systems have adopted solutions such as Lean Management, which was initially created within the industrial sector2. This methodology includes a set of practices or tools whose objective is to improve the workplace by identifying opportunities for improvement. These practices include the assessment of current processes in order to reduce “waste”, create value, and increase quality3. This methodology has come to maturity in the automotive and logistics sectors. Its adaptation to hospitals and the health care sector has become known as Lean Management in Healthcare4. This approach includes several tools that can be applied to the hospital health care context such as 5S, visual control, standardisation, priority matrix, and value chain analysis. Its implementation has led to rapid improvements adapted to real needs and has a marked impact on staff, patients, and process management5,6. The 5S method was created in Japan and is based on five Japanese words that begin with S: Seiri (Sort), Seiton (Set in order), Seiso (Shine), Seiketsu (Standardize), and Shitsuke (Sustain). Its objective is to create and maintain an organized, clean, and safe workplace in which high-level processes can be conducted. Thus, 5S is considered to be a key factor in the implementation of Lean Management7.

Regarding dispensing medication in hospitals, the Unit Dose Distribution System provides patients with the highest level of safety. This method involves the daily dispensing of individualized medication8. However, all nursing departments have medication kits for emergency access to medications. These kits should be adapted to include the drugs most widely used in the department. The drugs should be rationally organised, stored in previously agreed fixed amounts, and correctly labelled. High-risk drugs (HRD) and dangerous drugs should also be easily differentiated from all other drugs9,10. Final responsibility for the management of medication kits rests on the hospital pharmacy11, although other health care and management bodies are also involved.

After the implementation of innovations aimed at improving safety in health systems12, it is advisable to assess the level of satisfaction of the health care staff involved. The assessment process should include nursing staff subgroups to take into account different types of shifts and different work departments13. Although Lean Techniques have been widely used in the health care sector, little is known regarding their effectiveness or on levels of satisfaction among health care staff after their implementation14–17.

The main objective of this study was to assess the results of applying Lean Methodology in the design of a standardized storage model in the hospitalization departments (HD) of a tertiary university hospital and assess the level of satisfaction among health care staff after its implantation. Secondary objectives were to describe the design, pilot, and scaling stages of the model's implementation.

Descriptive and retrospective study conducted between September 2017 and January 2019 in a 1,200-bed tertiary university hospital.

A multidisciplinary team was created comprising five pharmacists, two quality and innovation staff, and two preventive medicine staff. Two external experts (a doctor and a nurse) working in the area of clinical and health care acted as consultants. The study also received the support of the hospital's medical and nursing management. Periodic meetings were scheduled.

The Lean Healthcare tools used were process and components standardization, priority matrix, visual control, value chain analysis, and the wastage of medication stock.

Assessment stage

The Nursing Management team sent the nursing staff of the departments involved a secure internal email message containing the link to the questionnaires. The user satisfaction questionnaire was designed to assess whether the new storage model increased perceived safety and facilitated the management of medications in the department, especially HRDs (Figure 1). The questionnaire collected information on the type of schedule of the nursing staff (fixed or rotating shifts) and the department in which they worked (the nursing staff were subsequently classified into surgical or medical departments). The questionnaire comprised six closed questions using a Likert-type response scale. Three of the questions were scored from 1 to 5, where 1 represented the lowest value and 5 represented the highest. These items referred to safety when accessing medication, ease of access to medication and the visual organization of the medication boxes. The three remaining questions had a yes/no format and referred to whether the identification of the medication by active ingredient was correct, whether staff knew the meaning of the round red stickers placed on the boxes, and whether the probability of medication errors was reduced with the measures implemented.

Figure 1.

Satisfaction survey of nursing staff to assess whether the new storage model increases perceived safety and facilitates the handling of medications in the department.

(0.37MB).

We calculated an overall satisfaction score, which ranged between 1 and 10.

A statistical analysis was conducted using the SPSS version 19 software package to determine if there was an association between the six questionnaire items (i.e. “ease of access to medication”, “safety when accessing medication”, “visual organization of storage”, “correct identification by active ingredient”, “knowledge of the meaning of the round red stickers”, and “decrease in medication errors”) and the nursing staff's type of shift schedule and/or the type of nursing department. The score of the responses to the first three items was divided into two categories: scores of 1 and 2 were considered negative and scores of 3, 4, and 5 were considered positive.

Regarding overall satisfaction, we analysed the normality of the data distribution in each group and applied the Mann-Whitney U test to compare the values between the groups, ascertain any differences, and determine their significance.

A P-value of <.05 was used as a cutoff for statistical significance.

Standardization is needed to deliver higher quality health care. The application of various Lean methodology tools to an area of drug management (i.e. the medication kits in the HD) facilitated the design and implementation of a standardized medication storage model.

D'Andreamatteo et al.18 suggested that projects based on Lean Methodology represent a strategic choice for entire organizations and must led by the management team. Our Lean Methodology-based project was presented to the Management Committee and was supported by both the Medical and Nursing Management. Therefore, we agree with the vision of D'Andreamatteo et al. that entire health organizations need to commit to the implementation of these types of projects.

One of the Lean Tools used, 5S methodology was of particular relevance in our study. In fact, 5S tools have also been used in previous studies that have implemented Lean Methodology to improve health care, such as the one conducted by Sari et al.19. These authors studied the level of economic investment in the implementation of Lean initiatives to improve quality and health in health care. They estimated that, over the period 2012 to 2014, the total cost of implementing a Lean Approach, including consultants and new hires, ranged between $44 million CAD to $49.6 million CAD. They suggested that the outcomes of these investments should be assessed prior to Lean implementation. In our study, the application of the Lean methodology led to quite different economic costs for the following reasons: it was conducted without external consultants; the multidisciplinary expert team were already part of the staff; and the team included staff from the Hospital's Quality Assurance department. Thus, the only real cost, which was negligible, was purchasing the identification labels and printing the HRD posters

Fields et al.20 addressed the use of Lean methodologies to streamline the processing of requests for medical equipment and supplies for children with complex conditions. They estimated that the decrease in processing time led to annual cost savings of approximately $11,000. Their study, like ours, quantified economic “waste” after the implementation of Lean methodology, although it differed from ours in the scope of its implementation.

Our successful attempt to reduce the number of HRDs in the HD medication kits was in line with the recommendations of the Collaboration Agreement between the Ministry of Health and Consumer Affairs and the University of Salamanca. This agreement addresses activities related to improving the safe use of medicines in Spanish hospitals and establishes that the number of dosage forms of HRDs in the Pharmacotherapeutic Guide or in a specific health care department should be reduced to a minimum in order to reduce the risk of error10.

Previous studies have applied Lean Methodology in several areas of hospital pharmacy: sterile products areas14, the categorisation of the activities of clinical pharmacists as “waste” or “non-waste”15, pharmacy residency training programs16, and the analysis of the factors affecting medication safety in mental health facilities17. However, the literature search did not find any study related to the application of Lean methodology to drug management in medication kits at hospitals.

Our study opens up a new line of research strategy, in the sense that it has pioneered the quantification of waste in medication storage in HDs. Although it is clearly relevant to use Lean methodology to improve quality, we must do this in practical terms by quantifying the waste costs determined by the use of Lean. In this study we achieved savings of €25,357.98 in medication stock.

In total, 69.40% of the nurses reported being satisfied (≥ 5 points) with the implementation of the new storage model. This percentage was higher than that found in the study by Berdot et al.21 in which 56% of nurses were satisfied with traditional storage. However, their objective differed from ours in that their study compared automated drug dispensing cabinets versus traditional storage.

In our study, the survey response rate was 20.70%. Although low, other studies, such as that of Parekh et al.22, have reported rates as low as 12.6%. However, their study differed from ours because it compared doctors and nurses and because their survey had a different rationale. On the other hand, other studies, such as that conducted by Ardern-Jones et al.23, have reported response rates as high as 77.9%, due to the fact that the questionnaires was re-distributed two weeks after the initial distribution. Their study had fewer participants, included physicians, and assessed the implementation of an automated storage system.

Regarding type of department, 66% of the questionnaires were sent to nurses from medical departments. This percentage is similar to that reported by other studies. The returned questionnaires showed that 62% of the nurses belonged to this type of department.

This study is limited by the low number of staff who responded to the survey and the high percentage of respondents who did not specify the type of department in which they worked.

The standardized medication storage model identified significant waste (56%) through the intradepartmental pharmacy medication agreement in the HDs.

Most of the staff who responded to the survey on the standardized storage model considered that the implemented measures had increased safety.

In conclusion, we planned, implemented, and assessed a set of measures over a 16-month period involving Medical and Nursing management, middle managers, the Pharmacy Service, and the Quality and Innovation department. This initiative had a real and marked impact on improving effectiveness and efficiency in optimizing the process, patient and staff safety, and quality of care.

No funding.

We would to extend our thanks to all the EOXI Vigo staff who collaborated in the development of this project. We would also like to thank the Methodology and Statistics Unit of IIS Galicia Sur for all the help provided.

No conflict of interests.

Part of this work has been presented as an oral communication at the 21st National Congress of Hospitals and Health Management, Santiago de Compostela, Spain (May 8, 2019).

Part of this work was included within the project entitled: “Improvement in drug safety: impact of a global strategy for prevention and risk management”. It received a Special Prize from the Jury in the IV Convocatoria del Premio Sham (2019).

Grupo de Trabajo de Almacenaje de Medicación de la EOXI Vigo:

Hadriana Fernández-Vega. Fundación biomédica de Pontevedra, Vigo y Orense (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Belén Leboreiro-Enríquez. Servicio de Farmacia, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Susana San Martín-Álvarez. Servicio de Farmacia, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Carmen Gallastegui-Otero. Servicio de Farmacia, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Antonio Pérez-Landeiro. Servicio de Farmacia, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Cristina Casanova-Martínez. Fundación biomédica de Pontevedra, Vigo y Orense (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Karina Lorenzo-Lorenzo. Servicio de Farmacia, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Alicia Martín-Vila. Servicio de Farmacia. Centro Sanitario Centro Penitenciario A Lama, Pontevedra. Spain.

Inmaculada Pardo-Lemos. Unidad de Calidad e Innovación, Xerencia de Xestión Integrada de Vigo (Servicio Gallego de Salud, SERGAS), Vigo. Spain.

Esther Casal-Rodríguez. Dirección Médica, Xerencia de Xestión Integrada de Vigo (SERGAS), Vigo. Spain.

María Dolores Muíños-Pérez. Subdirección de Enfermería, Xerencia de Xestión Integrada de Vigo (SERGAS), Vigo. Spain.

Susana Cerqueiro-Gómez. Dirección Médica, Xerencia de Xestión Integrada de Vigo (SERGAS), Vigo. Spain.