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ObjectiveTo determine the impact of lean thinking on the original time required to prepare the necessary documentation in relation to the preparation of parenteral chemotherapy/monoclonal antibodies.MethodFour pharmacists and one pharmacy technician from the oncology hospital (Malta) all participated in eight focus groups linked to the different constructs of Normalisation Process Theory (NPT): coherence, cognitive participation, collective action and reflexive monitoring. The value stream documentation process was mapped by analysing all steps in the process where each activity must add value for the patient; tools of lean thinking were applied. Points causing delay in processing were considered critical; possible changes to minimise time waste were discussed and implemented. Time spent on critical points was measured by timing in minutes each step of the process 1 month before and after the changes had been implemented and calculating the mean±SD. An audit was performed comparing the process with standard operating procedures to determine whether any steps required quality improvement.ResultsThree critical points were identified: time required to search for pharmacy patient medication records for chemotherapy/monoclonal antibodies required on the day; time to generate preparation labels; and time to generate worksheets. Overall, a total of 122±8.6 min (p=0.06) were saved per day, a 37% decrease from the original documentation time. Five deficiencies were identified in the documentation process audit; corrective action was proposed.ConclusionsBy applying lean thinking, non-value-added steps leading to time waste in the documentation process were eliminated. This concept could be implemented by using NPT as part of a strategic system to reduce waste.

It is with great interest that we read the article by Davies et al. describing a simple technique making use of two irrigation bags at different heights to ensure continuous irrigation during arthroscopy. We encounter a similar situation during endo-urological procedures.We have, therefore, made use of this technique to ensure uninterrupted flow of irrigant while performing transurethral resection of prostate (TURP) and bladder tumours (TURBT). During such procedures, interrupting the flow of irrigant, even for a very short period to change the bags, may severely compromise the surgeon's visibility due to bleeding and unnecessarily prolong and complicate the surgery. Therefore, we also note a significant additional technical advantage when making use of this modification to the irrigation fluid set-up.One common problem in patients on the wards with gross haematuria requiring continuous bladder irrigation is blockage of the catheter by clots when the irrigation bags empty and are not promptly replaced, particularly at night. We, therefore, also suggest the use of this set-up on the urology ward in patients requiring bladder irrigation after TURP or TURBT in order to preventing clot occlusion of the catheter.