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Transforming a pharmacy together: The Charlotte Maxeke Johannesburg Academic Hospital

Transforming pharmacies in South Africa

Before 2015, the patient experience at the Charlotte Maxeke Johannesburg Academic Hospital pharmacy went something like this: take the day off work to have your prescription filled; line up at dawn before the pharmacy opens in hopes of beating the rush; once inside, wait up to several hours for your prescription to be filled; or worse, wait only to experience a “false stock out”—a phenomenon in which a medication appears out of stock but is in fact available in pharmacy storerooms—and go home empty-handed.

Charlotte Maxeke Johannesburg Academic is one of the largest central hospitals in South Africa, which sits in the  province of Gauteng. The hospital pharmacy dispenses almost a quarter of a million prescriptions each year—yet it had a reputation for poor service and facilities. For example, patients discharged from the hospital with prescriptions—a patient category known as “to take outs”—spent on average six hours waiting for prescription medication to be delivered to the ward after discharge. Every day, an average of 20 percent of out-patients visiting the pharmacy experienced false stock-outs.

In September 2014, the Gauteng Department of Health began a province-wide project to provide pharmacy customers with more professional and efficient visits. The department wanted to prove that it could offer better service wherever needed, and the troublesome situation at the Charlotte Maxeke pharmacy made it an excellent place to make its case.

Working together for change

With so much ground to cover, the leadership at Charlotte Maxeke needed a step-by-step plan for the pharmacy transformation. The Social Advancement Foundation—a nongovernment organization that McKinsey established to fund healthcare, welfare, and education projects in South Africa—agreed to fund the project and McKinsey deployed a team of consultants. The foundation agreed, with McKinsey consultants taking on implementation. 

McKinsey began by working with managers to narrow their focus to improving the physical environment, prescription-filling process, and stock management, the main factor behind lengthy waiting times. To kick off the project, McKinsey focused on making the physical premises more welcoming and attractive to patients and staff. One Saturday, Department of Health officials, including a member of the executive council, the pharmacy manager and CEO of the hospital, infrastructure-department representatives, and McKinsey consultants, all pitched in for a day-long cleaning. The idea was to show staff how committed leadership was to turning around the pharmacy. The volunteers painted and decorated walls; added amenities like water coolers, TVs, and coffee machines in the waiting room; and supplied pharmacists with monogrammed lab coats. Patients and staff immediately appreciated the more cheerful and professional atmosphere.

McKinsey experts then turned to improving the process of prescription filling. A consulting team mapped the existing process and studied each step to identify bottlenecks and areas of wasted activity. They then devised a streamlined approach using three principles of lean production. The first was called “first time right” and aimed to stop invalid prescriptions from entering the filling process. A senior pharmacist became the first point of contact for each patient. The pharmacist would filter out patients whose prescriptions were invalid (because they were not yet due for refills) or could not be filled because of stock shortages. Second, they removed the batch system, which meant prescriptions were no longer dispensed in batches of ten, but were made available to be dispensed as soon as each one was ready. Finally, the team introduced a “demand-pull” system, which enabled staff actually to dispense these prescriptions to patients in a timely fashion. The existing process began with taking in scripts as fast as possible, and then filling them. The result was a huge buildup of filled scripts that were waiting to be labeled and dispensed to patients (in other words, a “push” approach). The McKinsey team shifted the focus to the end of the process—dispensing—and ensuring that there was sufficient staff to distribute prepared scripts, thus “pulling” prescriptions through the process more efficiently. 

Relatedly, the team addressed false stock-outs, another important factor behind long wait times. These were resolved by implementing a two-bin system on the pharmacy shelves with pre-defined refill levels. Essentially, when one bin of medications was empty, pharmacists would begin retrieving medications from a second bin. The refill levels for a bin—how many medications to place inside—were calculated for each medication based on dispensing frequency.

The consultants also revised each staff member’s role in the process and adjusted the layout of the pharmacy to make it more orderly. This included outfitting each workstation with laminated posters that displayed the new process rules. They also designed management tools—for example, a daily roster with role allocation and a performance dashboard—that the pharmacy manager was then responsible for implementing.

Under the new system, pharmacy staff rotated between duties to ensure that there was no buildup of scripts. This required knowing how many people to assign to each stage of the process and shifting staff when someone was absent, at lunch, or when there was a backlog. The McKinsey team initially oversaw these shifts, but then coached the pharmacy staff on identifying and resolving bottlenecks quickly, with the senior pharmacist on the floor ultimately responsible for managing the workflow.

Finally, the team introduced a “demand-pull” system, which enabled staff actually to dispense these prescriptions to patients in a timely fashion. The existing process began with taking in scripts as fast as possible and then filling them. The result was a huge build-up of filled scripts that were waiting to be labeled and dispensed to patients (in other words, a “push” approach). The McKinsey team shifted the focus to the end of the process—dispensing—and ensuring that there was sufficient staff to distribute prepared scripts, thus “pulling” prescriptions through the process more efficiently.

Relatedly, the team addressed false stock-outs, another important factor behind long wait times. These were resolved by implementing a two-bin system on the pharmacy shelves with pre-defined refill levels.  Essentially, when one bin of medications was empty, pharmacists would begin retrieving medications from a second bin. The re-fill levels for a bin—how many medications to place inside—were calculated for each medication based on dispensing frequency.

The consultants also revised each staff member’s role in the process and adjusted the layout of the pharmacy to make it more orderly. This included outfitting each workstation with laminated posters that displayed the new process rules. They also designed management tools—for example, a daily roster with role allocation and a performance dashboard—that the pharmacy manager was then responsible for implementing.

Under the new system, pharmacy staff rotated between duties to ensure that there was no build-up of scripts. This required knowing how many people to assign to each stage of the process and shifting staff when someone was absent, at lunch, or when there was a backlog. The McKinsey team initially oversaw these shifts, but then coached the pharmacy staff on identifying and resolving bottlenecks quickly, with the senior pharmacist on the floor ultimately responsible for managing the workflow.

What we achieved

Behind the counter, these reforms yielded a better working experience and higher morale. For patients, it meant a significant decrease in wait time.  Average wait time fell by 24 minutes for long prescriptions (more than four items), from 74 to 50 minutes. For shorter prescriptions (four items or less), waiting time was reduced from 30 to less than 5 minutes, with 33 percent of patients served in less than 3 minutes. False stock-outs were eliminated and the wait time for “to take out” patients dropped from six to two hours.

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Tania Holt

Tania Holt is a partner based in Johannesburg.

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Transforming a pharmacy together: The Charlotte Maxeke Johannesburg Academic Hospital

Before 2015, the patient experience at the Charlotte Maxeke Johannesburg Academic Hospital pharmacy went something like this:... take the day off work to have your prescription filled; line up at dawn before the pharmacy opens in hopes of beating the rush; once inside, wait up to several hours for your prescription to be filled; or worse, wait only to experience a “false stock out”—a phenomenon in which a medication appears out of stock but is in fact available in pharmacy storerooms—and go home empty-handed.