Monday, March 05, 2007

Prescription for Success… Or Failure?

The city in which I live—Chico, California—is a wonderful place. It’s a relatively small city (about 75,000 residents), but it’s home to California State University, Chico, so there’s always a lot of fun stuff going on. Chico is safe, clean, and has most of the modern amenities considered vital in today’s world: Starbucks, Barnes & Noble, Costco, etc.

Oddly enough, however, Chico only has one 24-hour pharmacy: Walgreens. This is problematic for those of us with small children, who are prone to get sick after the doctor’s offices and regular pharmacies have closed.

A few days ago, all three of my kids came down with some nasty bug. So we loaded up the minivan and headed off to the local after-hours clinic. The doctor phoned in three prescriptions of antibiotics for the kids. Walgreens was our only option. After we loaded up the kids for the ride home, my wife remembered that we had a little bit of antibiotic left over from the last illness so we decided to pick up our prescription the next day.

The following day I head to Walgreens to pick up the prescriptions. I wait 10 minutes in line only to be told that they haven’t been filled yet. I remind the woman behind the counter that the prescription had been called in 16 hours earlier (remember, this is a 24-hour pharmacy). She tells me that the best they can do is fill them in about 10 minutes.

I wait 10 minutes and then get back in line for another 10-minute wait. When I get to the counter again, I am told that they didn’t bill my insurance, so I’ll have to wait another 10 minutes while they do the insurance billing.

OK, at this point, the Quality Curmudgeon’s blood is boiling. I am mad, mad, mad! Such incompetence! I vow never again to use this pharmacy (even though I know I will have to). I realize that my anger really was out of proportion to the situation. So, being the nice guy that I am, I didn’t say anything. I just waited along with everyone else.

After another 10-minute wait, I am called back to the window and told that Blue Cross doesn’t seem to have my daughter in their system. OK, I was about to lose it at this point, but something curious happened. My anger at Walgreens and Blue Cross turned into sympathy and compassion for Andrea, young woman who was helping me. Rather than just say, “Sorry, I can’t help you,” she called Blue Cross and spent 15 minutes on the phone arguing on my behalf. When a supervisor at Blue Cross finally told her that my daughter didn’t exist and there was nothing Blue Cross could do, Andrea just hung up and called back. She spoke to a different person who was able to find my daughter in the system and (hopefully) fixed the problem for good.

I thanked Andrea for her help. “This happens all the time,” she said shrugging her shoulders. “It’s no big deal.”

Andrea then told me that she had to have a pharmacist check the prescription before she could sell it to me, so I had to wait another five minutes. When I was called back to the counter to pay, Walgreens’ computer system wouldn’t let them sell me one of the prescriptions. At this point, I wasn’t really so much angry as I was amused. Five different employees tried in vain to override the computer system. Finally, one of the pharmacists told the cashier to just manually enter the info and sell me my prescription.

I was in the pharmacy for over an hour. In that time, I went from annoyed, to angry, to exasperated, to sympathetic, to amused.

So, what lessons did I take away from all of this? Who’s fault was it? Mine for not encasing my children in a plastic bubble? Greedy lawyers for driving up the cost of health insurance with frivolous lawsuits? Incompetent management at Walgreens for not designing a better process? Computer software manufacturers for not designing better software? Blue Cross for a lack of training and inefficient processes? So how can I improve this situation for the future? Let’s examine my options:
• Move to a bigger city.
• Encase the children in plastic bubbles.
• Try to get to the doctor earlier in the day so I can use a different pharmacy (though given the state of health care these days, there’s no guarantee that I will have a different experience with a different pharmacy).
• Switch insurance companies. Again, there’s no guarantee that would be a better solution.
• Accept the fact there are some things that I just don’t have any control over, do the best that I can and not be so intolerant of those caught up in the process.

I think the last solution is probably best. I know that Andrea and the other people at Walgreens were doing the best they could with the system they had to work in. The same is probably true of the reps at Blue Cross. Many of our readers face similar scenarios every day. You’ve got to follow somebody else’s processes and make the best of it. Isn’t that what this quality stuff is all about? Making the best of somebody else’s process and adapting your organization’s capabilities to meet the customers’ (external and internal) needs.

What processes drive you crazy. Share your experiences here.


At 4:35 PM , Anonymous Anonymous said...

Perhaps the process that drives me crazy more than any other is the one by which people jump to conclusions without having applied any of the tools that we in the quality profession have been trained to apply to analyze a situation.
I am currently practicing pharmacy in a retail setting, but have also been a CQM and a trained Baldridge examiner in previous roles, so I like to think I might know a little something about designing and assessing processes. I did not invent the prescription filling process at Walgreens or the one where I work. I have studied and analyzed it and while there are, as always, opportunities for further improvement, I find that if one tried to value stream map it ( or apply any other tool that you like) one would end up not changing it dramatically. Nevertheless, every day, people who probably cannot spell pharmacist ( congratulations, you got it right) insult and abuse me because of my incompetence, certain that they could/would perform orders of magnitude better than a fool such as myself, without a single clue about what the process involves.
Let's analyze your experience in context. As you and I know, a process consists of inputs and output. Perhaps your prescription was not filled in that 16 hour window due to missing inputs, over which your pharmacist had no control. You indicated that Walgreens was your only option for this after hours visit, so perhaps you had not previously used their services. The prescription filling process usually requires that a patient profile be established including name, address, date of birth, sex, drug allergy information, and insurance information. Most of that information is in required fields as it would be necessary to do even a minimal evaluation of the appropriateness of the therapy, communicate with the patient in case of a problem, etc.. Without them, the system will not allow a prescription to be filled. Would the quality curmudgeon recommend that these critical control checkpoints be eliminated so that the customer might be served more quickly even if it meant that birth control pills could be dispensed to a 6 year old male patient or penicillin dispensed to your penicillin alllergic child without the opportunity for the pharmacist to challenge it, or is it reasonable for a competent pharmacist to await these inputs from the patient's representative before starting the process, even if it is 16 hours after the order was first placed?
Another reason that the prescription may not have been filled is that some drugs, including many antibiotics for children, have to be reconstituted with water prior to dispensing. Once the water is added, these drug have very limited shelf life and if the patient does not pick them up (e.g. finds they still had some, uses some samples that the doctor gave them and the kid gets better, or doesn't like the taste and won't take it, etc.), they are waste and cannot be returned to stock. What would you recommend here just keep absorbing the losses in the interest of improving customer service by a few minutes?
There are too many other possible reasons that your prescription may not have been filled to list them all, but will provide a small sampling of them and invite you to explore them and then advise on some process improvements that you would recommend.
You mentioned that your insurance was not billed. That is usually not a required field, and I have often filled a prescription knowing that I would to have to reverse it and reprocess it after the patient arrives and the insurance information is provided. This is a service we are happy to provide, if we had all of the required info (it appears in your case they did not), although most quality professionals would probably advise against such duplication of effort in an efficient process and even when you do this, you are still incompetent because they still have to wait while you reprocess it. If I ordered something from Quality Digest and you had old expired credit card information on file, would you fill the order? Would I be justified in being outraged when that order did not arrive on time?
I have also seen instances in which the prescription was called in to another (perhaps their usual) pharmacy, filled there and then called or faxed to a second more convenient pharmacy, but when that pharmacy attempts to fill it, the claim is rejected as a duplicate claim and cannot be processed until the patient arrives, confirms that it was not picked up at the other pharmacy and they can be contacted to reverse their claim so the "second one" will process.
Another common reason that prescriptions are not filled is that insurance companies reject claims based on cost considerations and require that the claim obtain prior authorization by having the doctor call the insurance company to justify the more expensive therapy. All of these things translate into an incompetence of the pharmacist issue and while we are trying to placate the irate customers victimized by our shortcomings by spending 15 minutes (often much more) on the phone trying to resolve them, the next customer comes along wanting to know why it takes so long for me to count out 30 pills? What incompetence he shouts to all within earshot and some outside of what most would consider normal earshot range if talking in civil tones (or if he has access to a different medium, writes mad 3 times with exclamation points for emphasis lest anyone miss the point of how stupid the pharmacist is).
Am I correct that in your expert quality opinion, having a final quality check by the pharmacist at the end of the prescription filling process is a frivolous waste of time and ought to be removed from the process to speed it up? Or did I miss your point on that one?
I guess that your final conclusion that none of your proposed CAPAs (if you could call them that) would really fix the problem and it was mostly an emotional overreaction on your part that you ought to just get over, finally hit the mark. It was, however, still a little disappointing to me. I have come to accept that the customer's with a third grade education will want to insult me because of their frustration with the system and fell better about how much smarter than me they are. It is just part of my job and every day when I step behind the counter I just have to remind myself that all I can possibly hope for is to be able to make the best of a bad situation for yet another day. Curmudgeons are a part of every life in retail, but at least none of them profess to be practitioners of quality. I certainly would never have expected a fellow quality professional to be so quick to make judgments without data (what would Dr Deming say?) Would you audit a process without learning the design, intent, parameters and expectations of the system? I wouldn't. It would be like me judging your competence based on a single error or incident of dissatisfaction with your work. It would be like me concluding that your job is so easy that any moron could do it as well or better since you have so many opportunities to draft and redraft and your deadlines are measured in weeks and months instead of minutes like a retail pharmacist, and you are never standing just a few feet away from your dissatisfied, irate and potentially even violent customers, but I realize that I don't have enough data on which to base such conclusions. There is probably much more involved in your job that I do not know about or understand. Therefore, I would not attempt such a critique. As the GEICO caveman might say, maybe next time try a little research

At 6:09 PM , Blogger Scott Paton said...

I certainly seem to have hit a nerve with you. You missed the point. I wasn't critical of anyone at Walgreens, which I do HAVE to frequent and have frequented in the past. In fact, I was sympathetic. My point was that sometimes you just don't have control over all the stuff that is thrown at you and you have to deal with it the best way you can, which I did and the hardworking people at Walgreens did.

BTW, it you are abused on a daily basis by your customers, isn't something wrong with your process?

At 1:21 PM , Anonymous Anonymous said...

On the side of the worker bee's of the world: We are in a time of the "instant gratification". The pharmacist gets abused for doing his job, but is it his process or is it a majority of people want their stuff NOW? Even small delays seem to make people more impatient and quick to anger. I agree that your experience may demonstrate that there are things that can be done to improve the process, but we as a society also need to take a deep breath and remember that somethings take a little time. I want my pharmcist to do a good job, not feel rushed and make an error. Just an observation on the changes in our society over the years, I feel that it can make a good process seem disfunctional, not because it is flawed but because we can no longer stand to wait for anything.

Just as an aside, I hope you were speaking metaphorically about the antibiotics; having "left overs" from a previous illness is not a good thing. Even Quality Curmudgeons need to read instructions FULLY. The creation of resistant microorganisms is accelerated by people not following the directions. Yes, I know, it isn't the point of the article but it is a serious problem. From a Microbiology Curmudgeon

At 4:57 PM , Anonymous Anonymous said...

Hi Scott,

I like the microbiologist’s spin on this. I think you missed my point too. I was trying to hold you, as a quality professional, to a higher standard than the rest of the world. I didn’t miss the point that got to eventually, but my expectation was that you should have started there! Getting there as a last desperate admission of defeat doesn’t count.
Seek first to understand, try to fix the problem and not the blame, focus on the process and not the people, etc. Your “reminder that it was called in 16 hours ago” was not seeking to solve the problem, it was to insult and embarrass the people who dropped the ball. Your focus on, “Who’s fault was it” isn’t our way is it? I look at your picture at the top of your column and I see a successful, young, influential leader. When I read your behavior, I visualize a slightly older gent in a dirty tee shirt, looking 10 months pregnant, needing a shave and with a sole purpose in life of trying to make others as miserable as he is. If you’re going to carry my flag, I just expect more. Maybe this whole Quality Curmudgeon concept has grown old on me. Quality should be more positive.

BTW, the micro guy is also right about the misuse of antibiotics.

At 8:12 PM , Blogger Scott Paton said...

OK. Let me address a few things here. The antibiotic was not old. We had got it the week before and it was unopened. Remember, I have three kids. Also, this was NOT the first or second or third or fourth or fifth time I had had an experience like this. I have to use Walgreens because it is the only choice in my town. Also, I have to address your comment about not collecting enough data to make an informed decision. I am not mass producing thousands of parts in a process that allows me to take random samples and do statistical analysis. A service interaction is an entirely different scenario. How many times should I eat at a restaurant with bad service before I decide that I prefer not to eat there? How many times must I get treated poorly at a pharmacy before I decide the service is awful? Where do I go to look up the number of times I should do that? Do you really think Deming would tolerate poor service in the name of data collection? I knew that man, and I can assure that he would not. He had little tolerance for anything but excellence. Most service interactions are one or two or three-shot deals. That's why excellent customer service is so critical.

At 5:09 AM , Anonymous Anonymous said...

OK. You win, the moniker is apparently appropriate. I don't doubt that Dr. Deming would have been unhappy, but I hope he would not have embarassed the workers for handing him red beads. I still think that before anybody cares how much you know, they want to know how much you care. I guess that is why I am not the quality curmudgeon.

At 7:19 PM , Anonymous Robert K. Smith said...

In response to your request to share experiences with processes that drive you crazy.

What I describe here could be called “A Tale of Two Processes.” Both relate to mis-priced merchandise. The second incident occurred while I was still waiting for a response to the first one.

Process in Store A
1. I notice an item marked as $10, with multiple ‘50% off’ signs over it.
2. The item rings up as $15 rather than the $5 I expected to pay.
3. I go to ‘Customer Service’ and point out the problem.
4. The clerk sends an employee back to verify that the price was $10. I accompany him because I (correctly) doubt he will be able to find it himself.
5. The employee verifies the price on the self is $10.
6. The clerk has trouble figuring out how to process the refund but eventually gets it and gives me $5 back.
7. I ask what the ‘50% off’ sign signified since I expected to get $10 back.
8. The clerk sends the employee back to verify the price again.
9. After a while it becomes clear the employee isn’t coming back.
10. I go back and return with one of the ‘50% off’ signs.
11. The clerk still doesn’t know what to do and calls an apparently more senior clerk.
12. I repeat the whole story to the senior clerk, which takes a while.
13. The senior clerk obviously does not want to honor the 50% off, but eventually agrees.
14. The senior clerk has to help the first clerk figure out how to process the additional $5 refund.
15. The clerk hands me the extra $5 and then picks up the item, which has been sitting on the counter between us, and tosses it into a bin to be restocked. (Yep, I get to pay the $5 I expected, but they’re keeping the item.)
16. I find this hard to believe and point out what just happened to the more senior clerk.
17. The more senior clerk tells me that I’m a jerk, that I’m being insulting, and that he doesn’t have to put up with me, but does tell the other clerk to get the item out of the bin and give it to me.
18. I tell the senior clerk that I will be definitely sending a complaint to their corporate office.
19. The senior clerk tells me that he could care less about that and that I should “Blow them a kiss” from him in my letter.
20. I tell the senior clerk that I consider that to be insulting. According to the various register receipts this process has taken over 20 minutes and there is a ring of customers standing a few feet back from the counter with horrified looks on their faces.
21. I send a complaint to the corporate office by both email and regular mail.
22. About three days later I get a phone call from the local manager who assures me that he is looking into the incident and points out that the price I eventually paid for the item is below their cost.
23. A month later I call the local manager back and am told that he has ‘just been looking over the information’ and will get right back to me.
24. I call back an hour later to make sure the local manager has my home phone number.
25. The local manager then calls back and says that:
a. The employees concerned have been given retaining sessions,
b. That given the signs the $5 I expected to pay was correct,
c. That several of the signs they use come from their corporate office, and
d. That they now realize that employees hired in November do not have enough time to be properly trained for Christmas sales positions.
26. I ask if I should consider the information he is giving me to be in the nature of an apology.
27. He assures me that he hopes I would consider it as such and indicates that he also hopes that I will be willing to shop there again in the future

Process in Store B
1. I pick out an item marked “4 for $5”. (I already know that in this store I am NOT required to buy X items to get the sale price in an X for $Y situation.)
2. The item rings up for $2.50, twice what I expected to pay.
3. I point out to the sales clerk that the sign by the items indicates “4 for $5”.
4. The sales clerk:
a. Cancels the $2.50
b. Manually re-rings the item at $1.25.
c. Calls the department responsible for the item to notify them that the computer code needs to be updated.
d. Apologizes for the delay.
5. Elapsed time, about 15 seconds.

Which store do you think I go back to?

Robert K. Smith
935 Koster Ave
Idaho Falls ID 83040

Home (208) 522-7151
Work (208) 557-6476

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