This marks the last in a three-part series exploring last mile distribution of temperature-sensitive drug products. This month: a true story of innovative best-practice solutions for vaccine management in a high-volume, urban medical practice.  

Doctor Leslie Tim is a petite, unassuming and amiable woman and a partner in the prestigious Associated Internal Medicine Medical Group located in Oakland, CA. Intensely passionate about her work, Dr. Tim has been nominated by her peers and nationally recognized by bestdoctors.com (along with two other doctors in her group) as one of the best internal medicine doctors in the entire San Francisco Bay region.
This comes as no real surprise to me. I have known Dr. Tim for more than 20 years and I can attest that she is as gifted as a doctor as she is genuinely compassionate about the people she serves. She possesses many qualities that endear her to her patients and have elevated her to a rarified status of respect among the local medical community.

On a recent business trip to San Francisco I met Leslie and her husband, Tom, for dinner. Before dessert had arrived I was educated on the importance and diligence of how one woman’s seemingly small and insignificant process improvements added up to substantial cost savings, office efficiency and improved patient care.

Dr. Tim has always been thoroughly involved in her practice and is constantly looking for ways to “improve the patient experience,” as she put it. She has a unique ability to rally those around her to take ownership of the improvements. “So I can get back to doctoring — which is fine with me,” she modestly said.

“When I joined the group in 1994 there were six doctors. I was the first female,” she stated. “Now we are 15 doctors, most are women, and we have an amazing support staff. All but one of the original people have retired or moved on. The practice was only three years [old] when I joined. We were so focused on patient care that we were a little lax on the business management side. We were sometimes running out of supplies and vaccine inventory, or ordering too much inventory and getting stuck with lots of expired vaccine. Worse yet, running out of needed vaccine to where we were scurrying up and down the halls looking for products. It was inefficient and led to a negative customer experience.”

Leslie spearheaded a quality improvement project for vaccines within the fledgling group in addition to her physician responsibilities and serving a two-year stint as secretary/treasurer of the nearby Alta Bates-Summit Medical Center. These process improvements were inspired, she said, from two unlikely sources: former General Electric chief executive officer Jack Welch and his concepts of Six Sigma application, and a just-in-time inventory model from the GM/Toyota automobile manufacturing plant in Fremont, CA.

Leslie explained that she had read Jack Welch’s biography, Straight From The Gut, which described GE’s use of Six Sigma business management strategy. Although the concept was new to her, she learned the benefits of how even the smallest of process improvements in their office management and supply inventory would result in higher quality, reduced costs and an improved doctor and patient experience. “I brought the idea up at a doctor meeting and no one objected, so I just did it!” she explained over our Calamari Fritto appetizer.

“And then, I was reading about something called just-in-time inventory management that the NUMMI [Toyota] auto plant used over here in Fremont and I thought: that’s it! We should do this with our vaccines!” she chimed as our salads arrived.

“I started by making a list of all the vaccines we used and made sure the staff manually inventoried each one from our refrigerators every time they administered a dose. We kept close track of this for two months. Then I assessed our usage patterns and wastage and realized we were over-ordering some of our vaccines and decided to put a demand management strategy in place.” At first, Leslie arranged an agreement with their wholesale vaccine suppler and authorized the representative to come in and assess the group’s supplies and vaccine inventories. She determined that optimally they should keep a two-week running inventory level. She implemented a first-expiry-first-out (FEFO) stock rotation, worked-in seasonal adjustments for flu season and for summer, when students are home from school, and tied pneumonia vaccines with flu vaccine volumes.

Later, the group adapted the use of electronic medical records and has been able to fine-tune the ordering process. “The results have been amazing!” Leslie exclaimed.
“Instead of ordering 1,500 doses of vaccines at one time, we purchase in smaller quantities, and as the seasons taper down we taper down our inventories. Our wastage and disposal rate has decreased by over 95% since we implemented these practices. This has saved us thousands of dollars, improved efficiencies throughout the office and greatly improved customer satisfaction.”

“An improved patient experience,” I said, diving into my entreé. 

“Exactly. And improved doctor experience as well! That’s important too,” she noted.
“It’s been interesting to see how our office management structure has evolved throughout the process. It’s much more formalized now. And with the increase in patient satisfaction, our practice has really grown to the point where we now operate with two office managers: an operations manager, who, in addition to having many other duties, is in charge of vaccine procurement, and a manager in charge of contracts and billing.”

She noted that the practice’s current vaccine supplier recommended that they use special digital refrigerator thermometers and segregate their vaccines with dividers. “We have appointed Olga Zherebnenko, who we call our ‘Vaccine Czarina,’ to check the daily temperatures of the refrigerators, and all matters related to our vaccine stock, supply and rotation,” she told me.

“Have you ever thought about mapping your refrigerator?” I asked. 

“What do you mean, ‘map’?” she asked.

As I began to explain the process she stopped eating and quickly searched for her smart phone so she could take notes.

Along with her medical group’s growth came a considerable increase in vaccine demand and supplies. “We were receiving several Styrofoam boxes every week with our vaccine shipments and it really bothered us to see them just thrown in the garbage along with all those gel packs and cardboard boxes. What a waste, right? Why not recycle them? Our office manager, Donna, worked with our vaccine supplier to have them shipped back. They even provide a pre-paid return address label. Our UPS driver picks them up a couple of times a week and off they go.” 

As we sipped our espressos after dinner, I asked Leslie if she had any other challenges or concerns. She was quick to respond. “Sometimes,” she said, “we are in the refrigerator a lot — six doctors using one refrigerator means the door is frequently opened and the temperature can get higher. What if the power goes out? We don’t have an auxiliary power unit for the refrigerator and when my office manager looked for one, she couldn’t find one. Maybe we need a better refrigerator?” She thought aloud.

I explained to Leslie that there were specialized refrigerators for such applications and she grew excited when I told her there are also alarm systems that can notify when the temperatures exceed pre-defined limits or of power failures and that there are services that can manage this information, even sending notifications to her smart phone. 

We left the restaurant and strolled the two blocks back to the cable car at Union Square. We said our good-byes and I thanked my friends for a truly wonderful evening. 

“You can be proud of the GXP’s you have implemented to ensure the last mile, Leslie,” I said. 

She looked at me quizzically. “What are GXPs?” She asked. I chuckled and boarded the cable car. The world could use a lot more Dr. Leslie Tims, I thought as we made the climb up Nob Hill.  

Kevin O’Donnell is director and chief technical advisor to industry at Tegrant Corp., ThermoSafe Brands. He can be reached at kevin.o’[email protected]. His blog, Where Cooler Heads Prevail, can be found at http://www.coolerheadsblog.com/blog/