INTRODUCTION
Hospitals are one of the
health service institutions that have an essential role in improving public
health, so hospitals are challenged to become health services that are easily
accessible, accessible, safe, thorough, efficient, and cost-effective (Poksinska, 2010). The increasing number of
hospitals requires that the function of hospital services be gradually improved
to provide satisfaction to patients, families, and the community (Kemenkes RI,
2009). Hospitals must provide quality services per established standards and
can reach all levels of society (Kemenkes RI, 2008). Quality service means
providing services to patients based on quality standards to meet their needs
and desires to obtain satisfaction that can ultimately increase patient trust
and will be loyal to the hospital (Sari, 2020).
One way to provide good
service to consumers can be realized if the hospital can manage the resources
available and maximize them (Graban, 2016). A service is said to be
suitable for the patient if the services provided can meet the patient's needs,
using the perception of the service received. Satisfaction starts from the
service to the patient from when the patient first arrives until the patient
leaves the hospital (Novitasari et al., 2014). Quality in health services
consists of consumer quality, professional quality, and management quality
Ovreveit (Munawarah et al., 2020).
Each installation in the
hospital must continue to evaluate, repaired, and developed, including
pharmaceutical installations. Pharmacy installation is part of the supporting
service unit. Besides that, it is also the last unit that can determine patient
satisfaction with hospital services, so the good and bad of the services
provided will affect the related service units so that they are required to
improve the quality of their services in a continuous manner (continuous
improvement) because it has a considerable contribution to the management of
pharmaceutical supplies to the quality of service and hospital income.
One of the management methods
or principles that can be applied in hospitals to achieve quality services is
to use the lean concept (Graban, 2016). Implementing management
improvements in hospitals aims to reduce errors in implementing health services
in an installation to improve the quality of services in hospitals. Lean
hospitals are needed to optimally meet patient needs and provide the maximum
possible health services by reducing waste or waste to create added value for
the hospital. Hospitals in Indonesia that have successfully implemented lean,
namely RSIA (Mother and Child Hospital) Kemang Medical Care, has succeeded in
reducing the number of drugs in the perinatal unit by 58% from 90 items to 38
items, and for six months of the implementation of a lean hospital can save
monthly costs of Rp. 90,524,887 (Oktaviati, 2021). Implementing lean management
can reduce the waiting time for the repatriation process of inpatients at Panti
Waluyo Surakarta Hospital. The average waiting time for the repatriation
process of inpatients at Panti Waluyo Hospital has decreased significantly from
3 hours 10 minutes to 2 hours 14 minutes (Sakit et al., 2019).
The local government of
Karanganyar Regency owns Karanganyar Regency Hospital. It is a type C hospital
with several medical service facilities, one of which is inpatient services,
where patients undergo a treatment process by health professionals. Problems at
Karanganyar Regency Hospital still have obstacles in providing services derived
from service procedures, patient satisfaction, quality of employees, and
officers' role in helping patients.
Based on the background above,
it is necessary to make improvements to improve the quality of service at
Karanganyar Regency Hospital using the lean hospital method, thus encouraging
researchers to conduct research with the title "Evaluation and Improvement
of Waste with the Lean Hospital Method in the Service Process at the Inpatient
Pharmacy Installation of Karanganyar Regency Hospital".
Research purposes
This study aimed to determine
the critical waste in the service process at the Inpatient Pharmacy
Installation at the Karanganyar Regency Hospital. Knowing the root causes of
critical waste problems that occur in the service process at the Inpatient
Pharmacy Installation of the Karanganyar Regency Hospital and providing
evaluations and suggestions for improvements using the lean hospital method to
minimize waste that occurs in the service process at the Inpatient Pharmacy
Installation at the Karanganyar Regency Hospital.
Benefits of research
Based on the formulation of
the problem and research objectives, the benefits that can be obtained from
this research are:
For Karanganyar District
Hospital
As a consideration for
hospitals in using the lean hospital concept to be applied in hospital
management.
For the management of
Karanganyar District Hospital
As the material for
consideration or input for improvement, development, and improvement in
improving the service process using the lean hospital method so that it can
contribute to improving the quality of service at the hospital.
For Society
Hopefully, this will provide
additional insights and information and a deeper understanding of lean
hospitals.
METHODS
This study uses a
non-experimental research design and is descriptive qualitative. This study
aims to determine the waste that occurs in the inpatient Pharmacy service
process at the Karanganyar District Hospital, and it is hoped that the results of
this study can become an evaluation and recommendation to improve the service
process at the Inpatient Pharmacy at the Karanganyar District Hospital. The
data collection techniques in this study were qualitative and quantitative.
Qualitative data were obtained by means of observation, interviews and document
review, while quantitative data were in the form of numbers obtained from the
results of distributing questionnaires. The data obtained was carried out
descriptive analysis as a material consideration in the process of designing
improvement proposals. The subjects in this study were 13 inpatient pharmacy
officers consisting of 2 pharmacists and 11 pharmacy technicians (TTK) as well
as inpatients who were undergoing treatment at class III inpatient wards at
Karanganyar District Hospital. This research was conducted at the inpatient
pharmacy outlet of the Karanganyar Regency Hospital which is located at Jl.
Rear Admiral Yos Sudarso, Bejen, Karanganyar. When the research was carried out
in October-December 2020. The population in this study were all inpatient
pharmacy installation staff and inpatient BPJS patients who were undergoing
treatment at the class III inpatient ward at the Karanganyar Regency Hospital.
Before carrying out the research, the preparations made by the researcher were as follows: submitting a research permit on September 24, 2020, for the Administrative Section of the Faculty of Pharmacy, Setia Budi University, which was addressed to the Director of the Karanganyar Regency Hospital. The Faculty then issued this research permit on September 25, 2020, with attachment number 042/D3-04/25.09.2020, which can be seen in (attachment 1). On September 28, 2020, the researcher submitted a research permit and research proposal to the Administrative Section of the Karanganyar Regency Hospital. On October 26, the researcher consulted with the Education and Research Department of the Karanganyar District Hospital regarding the administrative requirements that must be met in connection with the procedure for conducting research at the Karanganyar District Hospital, which was then forwarded to the medical record department, pharmacy installation, and class III inpatient ward.
Results of
the Validity and Reliability Test of the Patient Value Questionnaire
Validity test
Based on the results
of validity testing using the reproducibility coefficient formula (Kr), a value
of = 1 is obtained, and the scalability coefficient (Ks) obtains a value of = 1
can be seen in (appendix 4). The instrument is highly valid if the
reproducibility coefficient is ≥ 0.90 and the scalability coefficient is
≥ 0.60 (Singarimbun & Effendi, 1989). The conclusion from the results
of validity testing is that the questionnaire used in this study has very high
validity, which means that the questionnaire is declared valid and can be used
as a data collection tool in this study.
Reliability test
Based on the results of testing the reliability of the questionnaire
using the Kuder-Richardson formula (KR-20) can be seen in (appendix 6), the
reliability value (KR-20) is 0.6441. Under the reliability criteria, according,
the reliability coefficient is in the range of 0.60-0.799, which is included in
the substantial criteria, so it can be concluded that the reliability value of
0.6441 is acceptable and can be used as a data collection tool in this study.
Patient Value of Inpatient Pharmacy
Installation at Karanganyar District Hospital
Collecting value data of inpatient pharmacy
installation patients by distributing patient value questionnaires to 30
respondents, namely patients or patient families, based on the criteria
determined in this study, namely patients currently undergoing treatment in
class III inpatient wards, at least 17 years old and able to write and read. The
patient value questionnaire used in this study used the same questionnaire from
previous research conducted by Nancy (2014) entitled "Lean Hospital
Approach for Continuous Improvement in the Process of Pharmacy Installation
Services at Bethesda Hospital, Yogyakarta).
The value questionnaire in this study aims to
identify what values patients desire for inpatient pharmacy services at
Karanganyar District Hospital. According to Gasperz (2007), one of the lean
principles is to identify product value based on a customer perspective, where
customers want quality products at competitive prices and timely service. In
order to satisfy customers or patients as recipients of health services in
hospitals, it is necessary to identify in advance what are the wants, needs,
and expectations of customers or patients so that the sacrifices made by
customers are comparable to those obtained from inpatient pharmaceutical
services at the Karanganyar Regency Hospital. The results of the recap
calculation of the value questionnaire for inpatients at the Karanganyar
Regency Hospital can be seen in the following table:
Table 1. Recapitulation results of the value questionnaire calculation
in terms of product
|
|
Statement type |
Yes (%) |
No (%) |
|
|
A. Products |
||||
|
1 |
The quality
of medicines and medical devices received is considered important |
100 |
- |
|
|
2 |
The
accuracy of the drugs and medical devices received is considered important |
100 |
- |
|
|
3 |
The
completeness of medicines and medical devices received is considered
important |
100 |
- |
|
|
4 |
Brands of
drugs and medical devices provided by the pharmaceutical installation are considered
important |
96 |
4 |
|
|
5 |
Labels or
labels for medicines and medical devices received are considered important |
100 |
- |
|
|
6 |
Packaging
or packaging of drugs and medical devices received is considered important� |
90 |
10 |
|
Based on table 1, it can be seen that the
results of calculating the patient value questionnaire in terms of product show
that four values have absolute value (100%), namely the value of quality,
accuracy, completeness, and labeling or labeling of drugs and medical devices.
This shows the patient expects value from the inpatient pharmacy's services at
Karanganyar District Hospital. The percentage results regarding drug and
medical device brand statements received by patients were 96%, and the
percentage results for statements that considered it unimportant or did not
want this value were 4%. The percentage results from statements on the
packaging or packaging of drugs and medical devices desired by patients are
90%, and the percentage results from statements that consider it unimportant or
do not want this value are 10%.
Table 2. The results of
the recap of the calculation of the value questionnaire in terms of service
|
|
Type of statement |
Yes (%) |
No (%) |
||
|
B. Service |
|
||||
|
1 |
The speed
of obtaining needed medicines and medical devices is considered important |
100 |
- |
||
|
2 |
The
expertise of officers in answering and conveying drug information is
considered important |
100 |
- |
||
|
3 |
When the
officer visits the treatment room to meet the patient is immediately
considered important |
100 |
- |
||
|
4 |
The
accuracy of the information on drugs and medical devices received is
considered important |
100 |
- |
||
|
5 |
Complete
information on drugs and medical devices received is considered important |
100 |
- |
||
Based on table 2, it can be seen that the results of the calculation of the patient value questionnaire in terms of services provided by the inpatient pharmacy of Karanganyar Regency Hospital show that the value of absolute value (100%) is the speed of obtaining medicines and medical devices, the expertise of officers in answering and conveying information, the time of the officer's visit to the treatment room, as well as the accuracy and completeness of the pharmaceutical supply information expected by the patient when receiving services from pharmaceutical installation of Karanganyar Regency Hospital.
Table 3. Recapitulation of the results of calculating the value
questionnaire in terms of the patient's relationship with the inpatient
pharmacy installation
|
|
Type of statement |
Yes (%) |
No (%) |
|
C. The
patient's relationship with the inpatient pharmacy installation |
|||
|
1 |
The
friendliness of the staff in providing services is considered important |
100 |
- |
|
2 |
Officers
wear neat clothes when providing services considered important |
93 |
7 |
|
3 |
Pharmacy
installations must understand my condition and needs regarding medicine and medical
devices |
100 |
- |
|
4 |
Ease of
contacting pharmacy officers or installations (by telephone, etc.) is
considered important�������� |
96 |
4 |
Based on table 3, it can be seen that the
results of calculating the patient value questionnaire in terms of the
relationship between the patient and the inpatient pharmacy at the Karanganyar
Regency Hospital show that the absolute value (100%) is the friendliness of the
staff in answering and conveying information and responding to patient needs
regarding the pharmaceutical supplies received and expected by the patient.
Meanwhile, the percentage of officers who dress neatly dressed when providing
services is 93%, and the percentage of statements that consider it unimportant
or do not want this value is 7%. The percentage results regarding the ease of
contacting pharmaceutical officers or installations (by telephone, etc.) are
96%, and the results of statements that consider it unimportant or do not want
value are 4%.
Show that the absolute value of inpatients
(100%) is 6, namely the value of quality, accuracy, and completeness of
pharmaceutical supplies, as well as the accuracy and completeness of
information on pharmaceutical supplies received by stakeholders, plus the
friendliness of pharmacists and staff in giving service. Many factors can
affect patient satisfaction, one of which is the quality of services provided
by the hospital.
Service quality is one way that can be used to
fulfill user desires that are free from deficiencies so that they can provide
satisfaction for service users. Patients, as service users, always demand
service providers or services to fulfill all their needs by providing the best
service. Karanganyar Regency Hospital, as a health service provider, is
required to continue to improve and pay attention to the quality of health
services provided. Implementing lean hospitals can provide a perspective,
especially for medical staff, to create better service capacity and establish
new rules and more effective service delivery methods (Papadopoulos, 2011). The
use of lean, especially in health services, has the goal of removing activities
that do not provide added value (non-value added) from the process so that each
activity in the process provides added value (value added) from the patient's
perspective.
The researcher provides additional columns that
respondents can fill into the questionnaire if necessary things have yet to be
mentioned regarding products, services, and patient relationships with the
inpatient pharmaceutical installation of the Karanganyar Regency Hospital.
Based on the questionnaire results, respondent number 2 said "about the
hours of drug administration to patients," and respondent number 26 said
that adding the function of drug administration and drug side effects was
necessary. Drug information services are an integral part of the implementation
of pharmaceutical services in hospitals, one of which is for inpatients who
need special attention. Health services are required to provide services
according to standards, so it is necessary to determine whether the inpatient
is satisfied. To health services (Kurniawan et
al., 2016). There is a significant relationship
between providing drug information and patient satisfaction. Customer
satisfaction will lead to customer loyalty to hospital services resulting in
repeated purchases or reuse, with the identification of value from the
patient's point of view so that the Karanganyar Regency Hospital as a service
provider can meet the needs or desires of patients as service users (Sulo, 2020).
Value Stream Mapping and Value Added Assessment
of Service Processes in Inpatient Pharmacy at Karanganyar District Hospital
Value stream mapping (VSM) is an overview of service
activities from the patient requests until the request is fulfilled. The
determination of VSM in this study aims to determine the activities included in
value-added and non-value-added activities throughout the service process (value-added assessment). During the
observation, the researcher identified the time at each process stage during
the service.
The time data identified in this study include
CT (cycle time), VA (value-adding time), NVA (non-value-adding time), VAR (value-added ratio), and LT (lead time) data. CT is the time used to
complete one service process cycle or stage. VA is the time spent working on a
process or activity that adds value or is helpful to the patient. NVA is the
time spent working on a process or activity that does not add value or is
unwanted by the patient. VAR is the ratio of comparing the total value-adding time with the total cycle time. LT is the time used to
complete a service process from the first stage to the last stage, or it can be
said that the lead time is the accumulation of the total cycle time (Putra, 2023).
Process (VSM) value stream mapping This study describes several stages, namely,
stage 1 and stage 2. These stages describe the flow of the service process at
the inpatient pharmacy outlets of the Karanganyar Regency Hospital based on
standard operating procedures and observation results. The description of the
stages in the service process at the inpatient pharmacy outlets of the
Karanganyar Regency Hospital is as follows:
The first stage
This first stage includes the nurse from the
treatment room entering the prescription into the inpatient pharmacy outlet.
The pharmacist receives and signs the prescription handover book. The
prescription is separated between the prescription for inpatients, which consists
of daily dispensing and new patients and patients going home. The pharmacist
writes down the delivery time and the number of prescriptions at the inpatient
pharmacy outlet. Next, the pharmacy officer conducts a prescription review,
including an assessment of administrative, pharmaceutical, and clinical
requirements. Administrative screening includes the patient's name, patient's
age, patient's gender, medical record number, patient's address, name of the
examining doctor, doctor's license, examination date, and doctor's signature or
initials. Pharmaceutical screening includes, among other things, dosage form,
strength or dosage, amount of drug, stability and availability, rules for use,
method of use, and exact time of administration. The clinical screening
included the suitable indication, the correct dose, duplication, allergies,
drug interactions, and contraindications. The officer put a check mark yes or
no at each review point and put initials in the prescription review column.
Suppose there are problems or ambiguities when conducting a prescription
review. In that case, the pharmacist must communicate this to the doctor and
write down the recommendation or confirmation from the doctor on the
prescription review sheet (Susiloningtyas, 2020).
Prescriptions that have been reviewed are
submitted to the prescription data entry officer. For prescriptions with
guaranteed patients, a check is made to check the similarity of the patient's
identity written on the prescription with that written on the SEP. Then the
data entry officer opens the SIMERSI application and enters the patient's
medical record number data to bring up the patient's identity data. Then the
officer checks the data that appears monitored with the identity data on the
patient's prescription, including the suitability of the treatment room. If
there is a discrepancy, the pharmacy officer immediately contacts the treatment
room officer to ensure the correctness of the data. If the identity data is
correct, the officer continues data entry, including the name and amount of
drug given, then the officer re-checks the entry results.
Second stage
This second stage starts when officers serve
pharmaceutical supplies according to doctor's orders in prescriptions. Setup on
UDD recipe (unit dose dispensing) Oral
drug packaging is packed in plastic with different labels, namely
"morning" for morning, "afternoon" for afternoon,
"afternoon" for evening, and "evening" for the night. As
for the packaging of injection drugs or ampoules (vials) are packaged in
separate plastics. Then the pharmacy officer conducts a final screening.
Namely, the officer gives labels for all pharmaceutical supplies that have been
prepared. At the end of the process, the officer conducts a drug review or
matches the prepared pharmaceutical supplies with those written on the
prescription. The drug review carried out by officers included the first,
namely whether the drug was prepared according to the prescription, the second,
whether the dose given was appropriate, the frequency of administration, the
route of use, and the exact patient. After that, the pharmaceutical supplies
that have been prepared are put into medicine bags and grouped into the wards
and then taken by transporters to be handed over to the inpatient ward (Adrizal et al., 2019).
Based on the results of VSM (value stream mapping) in the
non-concoction recipe service process, Figure 4 shows the total obtained lead time (LT) for the service process
of the 30 non-concoction prescriptions studied, namely 3918 seconds or 65
minutes, the lead time is the time spent getting the complete service from the
receipt of the prescription to the inpatient pharmacy outlet until the
prescription is completed, with a VA: NVA value ratio of 21, 2 minutes:43
minutes and VAR values (value added
ratio) of 32.6%, the calculation results can be seen in (appendix 13). VAR (value-added ratio) at the end of the
VSM measures the efficiency of the process, namely the percentage of
value-added time compared to the total time to complete the process. The higher
the VAR value, the more significant the portion of the activity that is added
value or desired by the patient compared to the waste in a service process. Perusahaan dikatakan lean apabila nilai rasio antara waste dengan total aktivitas telah
melebihi 30%. Based on the results obtained, shows that drug prescription
service activities at inpatient pharmacy outlets are included in the category lean. This shows that the service
process at the inpatient pharmacy outlets of the Karanganyar Regency Hospital
is quite good. However, there are still high activities that are wasteful which
must be immediately identified and minimized, so it is necessary to apply the
method of the lean hospital to reduce or
eliminate non-value added activities (waste), to shorten service processing
time and add value to patient satisfaction to increase effectiveness,
efficiency, and quality of service at inpatient pharmacy outlets at Karanganyar
District Hospital.
CONCLUSION
Based on the study results, waste critical to the service process at the inpatient pharmacy installation of Karanganyar Regency Hospital is a waste defect and waiting. Based on the study's results, the problem's root cause is the critical defect in prescribing drugs by doctors outside the formulary and the waste of critical waiting. That is, the prescription from the inpatient room came in simultaneously. Proposed improvements by the method lean hospital is to monitor and evaluate the implementation of the formulary on an ongoing basis, implement electronic prescribing, and provide software specifically for data entry.
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