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Table 6. Core Administrative Topics Included in the Learning
Experience Description.
Organizational structure of the Department of Veterans Affairs,
Veterans Health Administration, Veterans Integrated Service
Network, and Roudebush
Lines of authority
Organization of pharmacy service
Committees within the VA and how they relate
How policies are formulated, approved, revised, and monitored
Various pay systems
How performance requirements are formulated, evaluated,
communicated, and acted upon
Recruitment, selection, hiring, and retention
Scopes of practice for inpatient and outpatient
Scopes of practice versus collaborative practice agreements
Staff development programs for professional and nonprofessional
staff
Workload and productivity monitoring
Scheduling and approving leave requests
Managing underperformers
Utilization of automation and contract personnel
Procurement differences between federal and non-federal
institutions
Formulary making bodies
Adding a drug to the drug file
Techniques for forecasting and monitoring budgets
Contract negotiating bodies and principles of contract adherence
Mechanisms for control of high cost drugs
Procurement methods and inventory control
Process for handling backorders
Procurement of specialty drugs
Automated dispensing system inventory management and drug
accountability
Joint Commission and Office of the Inspector General
preparation
Security and safety requirements for pharmaceuticals
Internal and external disaster plans
Security measures for the facility, pharmacy, and employees
Plans and resources for a weapons of mass destruction event
Pharmacy service contingencies for a loss of utilities or computer
systems
Private sector and business plans
Developing a residency program
Certifications-importance in practice
Leading from an entry-level position
Pharmacy organization memberships
Compliance with controlled substance regulations
Substance abuse recovery programs
Prescription drug monitoring programs

addition, the residents had one area within Box 2, the Initial
State, that was not addressed in the completion plan, and this
was committee involvement. During the lean process, residents realized the importance of exposure to multiple committees in a health-system versus long-term exposure to only
1 committee. The residency program is currently designed to

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allow PGY1 residents to participate with their monthly preceptors on numerous committees, to enable them to see how
each group integrates with each other and the health-system
overall. In addition, patient care demands on various learning experiences may preclude full participation in a single
longitudinal committee assignment. Therefore, after discussion, the residents decided not to pursue changes to this
format.
Besides communication, another factor that can enhance
sustainability includes driving change from the "bottom up"
versus the "top down." If individuals doing the work are
involved in driving the change, there will likely be greater
support over time, and this was clearly displayed during this
yellow belt project based on the level of engagement among
the residency class and an 80% action item completion rate.
Finally, the lean process is often more successful if new procedures or methods are implemented in small incremental
changes and if the entire team is held accountable for performance metrics.

Conclusion
Lean techniques were effectively utilized within a residency
program to enhance the health-system pharmacy administration learning experience and maintain compliance with
ASHP standards. Successful implementation of lean requires
engagement of multiple individuals within the health-system,
timely communication of the new processes, frequent reassessments, and appropriate accountability.
Authors' Note
The contents do not represent the views of the US Department of
Veterans Affairs or the US Government.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
material is a result of work supported with resources and the use of
facilities at the Richard L. Roudebush VA Medical Center,
Indianapolis, Indiana.

References
1. Womack JP, Jones DT. Lean Thinking: Banish Waste and
Create Wealth in Your Corporation. New York, NY: Simon &
Schuster; 1996.
2. Liker JK. The Toyota Way: 14 Management Principles From
the World's Greatest Manufacturer. New York, NY: McGrawHill; 2004.
3. Aboumatar HJ, Winner L, Davis R, et al. Applying lean sigma
solutions to mistake-proof the chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86.

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