Vol. 32 No.
1 January/February 2010 59
Lead-Time Reduction Utilizing Lean Tools
Applied to Healthcare: The Inpatient
Pharmacy at a Local Hospital
Omar Al-Araidah, Amer Momani, Mohammad Khasawneh, Mohammed Momani
Lean manufacturing principles, introduced by
the Japanese automotive industry, namely the
Toyota production system, are being applied
successfully in manufacturing as well as service
arenas. Utilizing lean tools, improvement ideas
are pursued and implemented in a systematic
manner. Lean thinking drives out wastes so
that performed work adds value and serves in-
tended needs. In assessing improvement
opportunities, it should be noticed that prob-
lems might result from people doing their job
incorrectly or from incorrect work procedures.
Lean methods are relatively low cost tools that
help companies reduce costs, increase quality,
and enhance timely delivery of services (Kra-
jewski, Ritzman, & Malhorta, 2007). By
eliminating or reducing waste, lean focuses
on value-added activities as perceived by cus-
tomers. In healthcare, lean aims to improve
care by eliminating waste activities that under-
mine efficient treatments. Moreover, lean
enhances the quality of care by reducing de-
lays and waiting for care, and by speeding up
processes such as the delivery of drugs to the
patient. While these may lead to cost savings,
profit must not be the primal goal in health-
care; efforts should be oriented toward
improving the quality of care.
The lean thinking process begins with iden-
tifying value-added and nonvalue-added steps
in a process. To this end, a process can be im-
proved by eliminating unnecessary steps,
combining steps, reordering steps, simplifying
procedures, or improving the reliability of the
process (Meyers & Stewart, 2002). Unlike many
production and service processes, unreliable
healthcare can be lethal and results in serious
consequences for the health organization.
Eliminating, combining, or simplifying steps,
on the other hand, reduces the cycle time of
the process and hence enables physicians and
nurses to spend more time caring for patients.
As a result, this may improve the quality of
healthcare and reduce costs that make it more
affordable to many.
Public and publicly-owned healthcare en-
terprises are largely experiencing efforts to
Abstract: The healthcare arena, much like the manufacturing in-
dustry, benefits from many aspects of the Toyota lean principles.
Lean thinking contributes to reducing or eliminating nonvalue-
added time, money, and energy in healthcare. In this paper, we
apply selected principles of lean management aiming at reducing
the wasted time associated with drug dispensing at an inpatient
pharmacy at a local hospital. Thorough investigation of the drug
dispensing process revealed unnecessary complexities that
contribute to delays in delivering medications to patients. We
utilize DMAIC (Define, Measure, Analyze, Improve, Control) and 5S
(Sort, Set-in-order, Shine, Standardize, Sustain) principles to
identify and reduce wastes that contribute to increasing the lead-
time in healthcare operations at the pharmacy understudy. The
results obtained from the study revealed potential savings of
445% in the drug dispensing cycle time.
improve quality of care and cut down operat- Keywords
ing expenses. Consequently, savings can be uti- Quality of healthcare
lized to invest in medical care technologies that lean thinking
further help improve customer satisfaction. DMAIC
This confirms the growing need to eliminate 5S
wastes, optimize procedures, and improve reli-
ability and efficiency. Lean principles have
been successfully adapted to the healthcare
environment enabling hospitals and clinics to
streamline their operations and to focus on
value as perceived by their patients. Many
healthcare organizations have sought the sup-
port of lean manufacturing to improve their
efficiency. Examples include Virginia Mason
Medical Center, ThedaCare Inc., The Clear-
view Cancer Institute, Mayo clinic Division of
Cardiovascular Diseases, WestCare Heath Sys-
tem, Midwestern Regional Medical Center,
Hotel-Dieu Grace Hospital, Western Pennsyl-
vania Hospital, and University of Pittsburgh
Medical Center. These and more examples and
studies can be accessed through the URLs of
American Society for Quality, U.S. National Li-
brary of Medicine (PubMed), Lean Enterprise
Institute, and Healthcare Financial Manage-
ment Association referenced below.
Recent investigations show that significant
accomplishments have been reported in
healthcare environment worldwide using lean Journal for Healthcare Quality
process tools. Van Lent, Wineke, Goedbloed, Vol. 32, No. 1, pp. 59–66
& 2010 National Association for
and Van Harten (2009) applied a lean thinking Healthcare Quality
60 Journal for Healthcare Quality
approach for a hospital-based chemotherapy
day unit. The method improved process design
and led to increased efficiency and more timely
delivery of care. Bisgaard and Does (2009)
provided an example of the application of
Lean Six Sigma to healthcare. They investi-
gated reducing the length of stay of patients
with chronic obstructive pulmonary disease.
Obtained results illustrate the possibilities of
improving quality while at the same time re-
ducing cost. Dickson, Singh, Cheung, Wyatt,
and Nugent (2009) used lean manufacturing
techniques in the emergency department (ED)
in an effort to enhance patient and staff satis-
faction. The implementation followed a six-
step process of lean education, ED observation,
patient flow analysis, process redesign, and new
process testing. Results showed a slight de-
crease in length of stay and a significant
increase in patient satisfaction without raising
the cost per patient. Other studies focused on
improving efficiency (Arbos, 2002), developing
and using quality indicators (Lloyd, 2004), and
reducing medical errors (Raab, Andrew-Ja,
Condel, & Dabbs, 2006). Promising outcomes
of such studies encourage interest from the
healthcare sector. Various opportunities exist
to deploy lean in healthcare including reducing
waiting time and delays, reducing redundant
walking, reducing paperwork, and speeding up
communications. Improvement efforts would in-
clude health delivery processes and associated
supporting procedures.
In this article, we present a multistep procedure
for identifying and investigating improvement
opportunities in the healthcare organization.
We focus on time-intense activities that largely
contribute to increasing the lead time of the pro-
cess. Moreover, such activities require extensive
human efforts with low or no added value. By
eliminating waste activities, human efforts are
redirected toward value-added operations. The
rest of the article is organized as follows: The next
section discusses lead-time reduction techniques
and tools. The following section introduces a
lead-time reduction case study performed at the
inpatient pharmacy at a local hospital. The final
section presents lessons learned from the study
and introduces concluding remarks.
Lead-Time Reduction
Lead time is the total time required to com-
plete one unit of a product or a service.
Therefore, lead-time reduction focuses on
eliminating wastes in time that result from
nonvalue-added activities. In this section, we
present a DMAIC (Define, Measure, Analyze,
Improve, Control) based procedure for identi-
fying and reducing wastes that contribute to
increasing lead time in healthcare operations.
Moreover, we utilize 5S (Sort, Set-in-order,
Shine, Standardize, Sustain) principles in iden-
tifying, tagging, and eliminating nonvalue-
added activities.
DMAIC is a systematic Six Sigma quality
improvement procedure developed based on
methodologies for improvements proposed
by Deming, Juran, and Crosby (Evans & Lind-
say, 2005). The define phase of DMAIC
focuses on identifying project critical to qual-
ity (CTQ), defining the process map, and
developing team charter. The measure phase
concentrates on defining performance stan-
dards for CTQs, collecting data, and verifying
the adequacy of the measurement system to
measuring the selected CTQ. The analyze
phase focuses on identifying the gap between
the performance of the current process and
the required performance, investigating vari-
ation sources, and identifying root causes.
The improve phase of DMAIC focuses on
generating ideas for removing or solving the
problem. The control phase concentrates on
ensuring that key variables remain within ac-
ceptable limits under the modified process.
This may include establishing new standards
and procedures, training the workforce, and
instituting control measures to ensure sus-
tainability. On the other hand, the 5S meth-
odology is based on clearing and cleaning the
workplace from unwanted items. Moreover,
the process fixes locations for necessary
equipment and tools in the workplace. Pro-
cedures for performing sorting, organizing,
and shining are then standardized and sus-
tained by management and employees. In this
article, we propose a five-phase procedure for
identifying and eliminating nonvalue-added
steps in a process based on DMAIC method-
ology. The proposed procedure is subdivided
into five phases including data collection,
analysis of current state, improvement, anal-
ysis of future state, and validation and
implementation of results.
In the data collection phase, efforts are on
documenting details of the process under in-
vestigation. To this end, the process is
subdivided into activities and information
about each activity is documented. The activ-
ities are then categorized into value-added,

nonvalue-added, and support activities. An ac-
tivity without which the process cannot be
completed is considered a value-added activity.
Moreover, no outcome is achievable from the
process if a value-added activity is eliminated.
On the other hand, eliminating a nonvalue-
added activity does not affect the outcome of
the process. Support activities do not add value
to the process but at the same time, the process
cannot be completed without them. Such ac-
tivities are required to connect value-added
activities (transportation), assure that a value-
added activity never starves (waiting lines/in-
ventory), and assures the quality of output of a
value-added activity (inspection). Although
supporting processes are vital for the contigu-
ity of the process and the quality of the
outcome, customers are not willing to pay for
such activities. If long times are spent at sup-
port processes, then such times are considered
waste.
In phase two, the time required to perform
each activity is measured and documented. Us-
ing a Gantt chart, activities are represented in
sequence along the timeline where a box with a
width equal to the time required to perform an
activity represent that activity. Moreover, one
can use Pareto chart to identify the 20% of the
activities that contribute to 80% of the cycle
time of the process. These activities are to be
considered foremost during the improvement
phase.
To improve an activity, we walk through de-
tails about why the activity is performed, when
it is performed, where it is performed, and who
is performing it. To this end, Brainstorming
and the 5 Whys are very useful tools for an-
swering these questions. Results obtained from
this investigation help us decide whether to
eliminate the activity, combine it to another
activity, or simplify the way it is performed. For
pure nonvalue-added activities, this study
should favor the elimination of such activities.
For support and value-added activities, various
solutions may be proposed based on the nature
of the way the activity is performed and the
recourses used in performing that activity. Ex-
amples of improvements include relocating
successive value-added activities close to each
other to cut down on transportation; this saves
effort and time of employees and/or custom-
ers. Assuring the availability of materials and
equipment at the workplace reduces waiting
time for customers and assures utilization of
employees. Cross-training of employees en-
Vol. 32 No. 1 January/February 2010 61
hances flexibility and ensures the contiguity
of work. Preventive actions performed in the
workplace avoid unexpected malfunctions/
mistakes. The control of activity outcomes as-
sure customer satisfaction by reducing errors
and rework, and by minimizing the time
needed to perform the activity. Moreover, time
and effort are further optimized using tech-
nology, especially information technology.
Examples of the use of information technol-
ogy in healthcare is electronic medical records
that ease access to patient records by medical
and administration personnel throughout the
medical organization.
The various improvement opportunities are
evaluated in the future state analysis and im-
plementation phases. One may select among
the many opportunities based on ease of
implementation, cost of implementation, ex-
pected savings in effort and/or time, expected
losses, or any combinations of these objectives.
An improvement plan is then documented and
validated with management before applying
improvements. Customers are re-approached
for evaluating the process after the implemen-
tation of the improvement plan. Standardizing
work procedures and communicating them
to employees is a vital step that assures the
holding of gains. Furthermore and to ensure
sustainability, efforts must include monitoring
and auditing of procedures on continuous
bases. Table 1 summarizes details of the pro-
posed phases.
Model Assessment
In this section, we apply the proposed model to
the drug dispensing process from the inpatient
pharmacy at a local hospital. The inpatient
pharmacy consists of 10 pharmacies including
the main pharmacy (IPS), the chemotherapy
pharmacy, and eight satellite pharmacies lo-
cated on the third–sixth and the ninth–twelfth
floors of the hospital. Initial investigation of the
process shows that the average cycle time of the
process exceeds 2.5 hr. In this study, we aim at
simplifying the process and reducing the cycle
time without jeopardizing the quality of the
dispensing process. Moreover, the improve-
ment process must be at low or no added cost
to the hospital.
Data Collection
The process of dispensing the medication from
the inpatient pharmacy is rather complicated
62 Journal for Healthcare Quality

Table 1. A Lean-Based Procedure for Lead-Time Reduction

Work Activities Tools
Data collection
1. Select a process.  Project selection criteria
2. List and document all the activities required to complete the process.  Problem statement
3. Identify value-added, support, and nonvalue-added activities.  Brainstorming
4. Consult internal and external customers of the process.  VOC (voice of the customer)
 Flowcharts
Current state analysis
1. Measure the time required to perform each activity.  Time study
2. Collect information about the few activities that contribute to the  Gantt chart
largest percentage of time in the work cycle.  Pareto charts
3. Document losses and gains.
Improvement
For each activity under investigation, ask the following questions and  Brainstorming
act consequently  5 Whys
1. Can we eliminate this activity?  Relocation/layout
2. If not, can we combine it to another activity?  Prevention
3. If not, can we simplify the way it is performed?  Cross-training of employees
 Use of technology
 Setup time reduction
 Increasing reliability
Future state analysis
Using results from the improvement phase  Flowcharts
1. Document the remaining activities.  Time study
2. Compute savings.  Gantt chart
3. Document losses and gains.  Losses and gains chart
4. Develop an improvement plan.
Implementation and control
1. Validate improvements and results with management.  VOC
2. If approved, apply improvements.  Work sampling
3. Consult customers for after implementation consequences.  Statistical process control
4. Develop written work guidelines.
5. Train employees on new procedures.
6. Develop monitoring and audit procedures.
7. Repeat the improvement process.

and time consuming. Moreover, the process
has plenty of paperwork and many check
points. This complexity results in large delays
in the delivery process that may be fatal to
patients. In addition to on-time delivery, the
quantity of the medication must be correct
because under-dosage and over-dosage might
be life threatening to patient. Internal and
external customers agree that the process is
lengthy and has many inspection activities.
of patients (sample size). For each ward, the
times required for performing each activity in
Table 2 are measured and documented. Table
3 illustrates activity times and the average time
to complete a medication dispensing process.
The cycle time for a ward equals the summa-
tion of times required to complete all activities
for all patients
P in that ward (Cycle time for
ward i ¼ time to perform activity j, for all
activities

After medications are prescribed by physicians,
the drug dispensing process consists of the
activities detailed in Table 2.
Current State Analysis
Sixteen wards utilize the satellite pharmacy of
the fourth floor. The wards exist on various
wings of the floor and have different numbers
j activities performed on ward i). The average
cycle time equals
P
ðnumber of patients in ward  cycle time of wardÞ
ward
:
Total number of patients
From Tables 2 and 3, note that the process is
rather complicated and includes different time-
consuming inspection points. Moreover, many
 Vol. 32 No. 1 January/February 2010 63

Table 2. Activities Performed During the Drug Dispensing Process

Location of Personnel Involved Value; No
Activity Description Activity in Activity Value; Support
1 For each patient in the medical Satellite Satellite pharmacist Value-added
ward, information about each pharmacy
drug in the medical record is
typed to the computer utilizing
the special form. This infor-
mation includes drug name,
strength (100 mg, 200 mg,
etc.), the route of administra-
tion (IV, IM, etc.), and
duration (1 day, 2 days, etc.)
2 A copy of prepared prescription Satellite Satellite pharmacist Support
sheet is printed for each pharmacy
patient
3 On each prescription sheet, the Satellite Satellite pharmacist Value-added
quantity for each drug is hand pharmacy and head nurse
written to place in the sheet
4 Transportation of prescription Between floors Satellite pharmacist Support
sheets to IPS
5 For each sheet, drug doses and IPS Satellite pharmacist Support
quantities are verified with the and IPS pharmacist
IPS pharmacist. Drug
information is typed into the
computer.
6 For each patient, labels are IPS IPS pharmacist Value-added
manually prepared for each
drug.
7 Preparing medications for all IPS IPS pharmacist Value-added
patients in the ward
8 Medications are received and IPS Satellite pharmacist Support
checked by the satellite and IPS pharmacist
pharmacy pharmacist
9 Transportation of prescription Between floors Satellite pharmacist Support
sheets to satellite pharmacy
10 Medications are received and Satellite Satellite pharmacist Support
checked by the head nurse at pharmacy and head nurse
the level.

activities are manually performed and others
are redundant ones.
It is worth noting that the time consumed by
activities 1 (data entry at satellite pharmacy), 5
(data verification and re-entry at IPS), 6
(label preparation at IPS), and 7 (drug prep-
aration at IPS) contribute to 460% of the
cycle time. Moreover, redundant data entries
of the same information are performed at
the satellite pharmacy (activity 1) and at IPS
(activity 5). Four inspection activities of drug
quantities (activities 3, 5, 8, and 10) are per-
formed at various locations and include
different personnel. In addition to consuming
440% of the total cycle time, the inspection
process takes valuable efforts from many staff
members.
Improvement Suggestions
The drug dispensing process can be largely
simplified using information technology. It
is worth mentioning that computers at the
various levels of the hospital are connected
through a network of fiber optics. Utilizing
computers, medical software already in use,
and networking, various activities can be elim-
inated or simplified and hence save time and
effort. Explanations of suggested improve-
ments follow:
64 Journal for Healthcare Quality

Table 3. Time (minutes) per Activity and Cycle Time (minutes) for the Drug
Dispensing Process at the Satellite Pharmacy of the Fourth Floor
Activity
# of Cycle
Ward Patients 1 2 3 4 5 6 7 8 9 10 Time
4C 17 20 3 5 15 22 20 30 11 12 12 150
20 20 3 7 13 30 22 36 13 10 15 169
20 17 4 8 16 36 24 35 12 13 13 178
21 20 4 9 17 40 21 32 14 14 10 181
4B 21 19 4 9 15 33 18 33 13 12 13 169
20 21 3 8 16 15 20 28 12 14 13 150
21 17 3 9 10 28 21 20 11 9 14 142
18 17 3 8 13 45 17 25 11 12 13 164
PICU 6 15 3 6 10 13 10 15 10 19 10 111
5 8 2 5 12 55 8 9 8 13 8 128
2 12 2 4 7 20 7 10 6 11 9 88
4 10 2 3 9 23 9 13 8 15 7 99
GICU 11 16 4 9 7 30 15 35 14 11 18 159
10 19 5 8 9 22 16 40 15 10 21 165
10 20 3 9 5 40 14 25 16 7 20 159
11 22 3 10 7 25 17 27 18 11 18 158
Average time 18.36 3.38 7.91 12.60 30.58 18.56 28.87 12.58 11.83 13.76
per activity
Average cycle time 158.43

 Activities 2 (printing records) and 3 (man-
ual documentation of drug quantities):
These activities only contribute to assuring
that drug quantities are correctly docu-
mented. Note that combining activity 1
(data entry of drug information excluding
drug quantities) and activity 3 eliminates
the need for activity 2, adds little time to
activity 1, and eliminates the time needed
to perform activity 3. This requires the
presence of the head nurse at the satellite
pharmacy for parts of the data entry pro-
cess. Note that this combination saves
valuable times for both the nurse and the
pharmacist.
 Activity 4 (transporting drug sheets to IPS):
This process can be eliminated as drug
sheets are communicated to IPS using in-
formation technology. This saves time for
the satellite pharmacy pharmacist.
 Activity 5 (verification of drug information
and re-entry of data): The activity is redun-
dant to activity 1 and hence can be
eliminated. Remember, verified drug in-
formation is digitally transferred to IPS
using computer network.
 Activity 6 (manual preparation of drug
labels): This process is vital and can only
be simplified. To do so, we suggest the use
of a label printing setup that includes a
word template, label paper, and a printer.
This assures that label preparation can
be performed in a fraction of the original
activity time.
 Activity 7 (drug preparation): This is the
most value-added activity that can be
speeded up through the practice and study
of the medication order picking process.
For the purpose of this study, we assume
that the process is optimal.
 Activity 8 (receiving and checking medica-
tions at IPS): This activity is vital and hence
will be unchanged.
 Activity 9 (transporting drugs to the floor):
This activity is vital and hence will be un-
changed.
 Activity 10 (receiving and checking medi-
cations at satellite pharmacy): The activity
is redundant to activity 8 and hence can be
eliminated.
Future State Analysis
We eliminate activities 2, 3, 4, 5, and 10 and
speed up activity 6 such that the process will
take approximately 5 min for any ward. More-
over, we increase the time for performing
activity 1 by 5 min per ward. Table 4 illustrates
activities and times for the modified drug dis-
 Vol. 32 No. 1 January/February 2010 65

Table 4. Time (minutes) Per Activity and Cycle Time (minutes) for the Drug
Dispensing Process After Improvement
Activity

Ward # of Patients 1 6 7 8 9 Cycle Time

4C 17 25 5 30 11 12 83
20 25 5 36 13 10 89
20 22 5 35 12 13 87
21 25 5 32 14 14 90
4B 21 24 5 33 13 12 87
20 26 5 28 12 14 85
21 22 5 20 11 9 67
18 22 5 25 11 12 75
PICU 6 20 5 15 10 19 69
5 13 5 9 8 13 48
2 17 5 10 6 11 49
4 15 5 13 8 15 56
GICU 11 21 5 35 14 11 86
10 24 5 40 15 10 94
10 25 5 25 16 7 78
11 27 5 27 18 11 88
Average time per 23.36 5 28.87 12.58 11.83
activity
Average cycle time 81.64

pensing process. Note that the average cycle Acknowledgments

time is reduced from 158 to 82 min, which is a The authors express appreciation for the re-
time savings of 76 min, or 448% of the original viewers’ suggestions leading to improvements
cycle time. in this article.

Concluding Remarks
Lean manufacturing principles found various
successful applications in service organizations
including healthcare. Many hospitals world-
wide reported savings attained using lean
thinking. Lean tools focus on eliminating
wastes from the medical delivering process
aimed at saving efforts and times of internal
and external customers. This reduces the cost
of healthcare and gives the medical staff more
time to spend with patients. To this end,
we present a systematic DMAIC-based proce-
dure for analyzing and improving ongoing
processes with the focus on lead-time reduc-
tion. Moreover, we offer alternative tools for
documenting and evaluating each step of the
procedure. The procedure is validated through
a case study performed for improving the lead-
time of the drug dispensing process at the in-
patient pharmacy of a local hospital. Results
obtained from the study show potential savings
of 448% in the cycle time.
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Authors’ Biographies
Omar Al-Araidah is an Assistant Professor in the Indus-
trial Engineering Department at Jordan University of
Science and Technology. He received his PhD in Decision
Sciences and Engineering Systems from Rensselaer Poly-
technic Institute, New York, in 2005. His research
emphasizes links between the multidisciplinary areas of
Industrial Engineering.
Amer Momani is an Assistant Professor in the Industrial
Engineering Department at Jordan University of Science
and Technology. He received his PhD in Industrial Engi-
neering from University of Pittsburgh, Pennsylvania, in
2005. His research focuses on functionality-based design,
decision analysis, cost management, and performance mea-
surement and evaluation.
Mohammad Khasawneh is an Associate Professor in
the Department of Systems Science & Industrial Engineer-
ing at the State University of New York at Binghamton.
He received his PhD in Industrial Engineering from
Clemson University, South Carolina, in August 2003.
His research has an interdisciplinary emphasis that
links human factors in manufacturing, quality, and
simulation.
Mohammed Momani works at the quality assurance de-
partment at Shifa Pharmaceutical Industries, Aleppo,
Syria. He worked at the in-patient pharmacy at King
Abdullah University Hospital, Jordan, at the time of the
study. He received his MSc in Pharmaceutical Technology
from Jordan University of Science and Technology, Jordan,
in 2006.
For more information on this article, contact Omar
Al-Araidah at alarao@just.edu.jo.