Healthcare is an essential component of the economy that aims not only at healing people, but also cooperating with research entities and striving to adopt innovative solutions. Hospital is an institution that provides a patient with medical treatment by specialist staff and with the use of the specialist equipment. A patient should never disrupt the functioning of the organization. Both infrastructure and processes taking place in hospital should be organized in such a way that a patient, being the most important person, can smoothly, consciously and without unnecessary waiting go through the whole medication, as a partner and co-decision maker together with the doctor. Just as the surgeon in the operating room is equipped with a toolbox containing forceps, scissors, surgical blades, bum bag as well as a team of specialists, including an anesthesiologist, nurse, and a circulating nurse, that are needed to carry out an operation on a patient, the manager that manages the processes taking place in a medical facility and is responsible for quality also needs the “toolbox” allowing them to analyze the clinical processes, effectively manage resources and eliminate bottlenecks and other problems. There is increasing talk of the efficient flow with respect to the services rather than manufacturing industry exclusively, in the case of which a car might be such an element, whereas in healthcare facility it is a patient. Patient, being an “element” of the flow process, is treated in various ways from the need-disease diagnosis to the moment it is satisfied, which means that the patient has recovered or their state of health has improved. Lean healthcare aims at generating adding value for a patient, by shortening the time of patient’s “journey” and increasing patient’s safety. The more efficient the flow is, the more effective the use of resources is, for instance when a patient makes an appointment with a medical specialist, be it a diabetes specialist, and has to wait 10 days (240h) for a visit, and the visit itself lasts 30 minutes (0.5h), the efficiency of the process equals 0.5/240=0.2%. This is the only part of the whole process that contributed to the patient’s awareness of their health conditions and choosing the right therapy, all the rest was useless. So how can we organize the process so that its efficient flow rate is high? We should eliminate bottlenecks and places, in which no added value is generated, and avoid waste. Lean healthcare tools are needed in healthcare processes for treatment to be successful and resources to be effectively used. What tools do they comprise?
Flowcharts for clinical processes
A process consists of a variety of activities that transform data inputs into data outputs. Each medical facility should identify the clinical processes, which are the processes in which a patient is directly involved. Doctors act in accordance with the current medical knowledge, legal requirements and their own experience; requirements and experiences of all the process participants should be gathered in order to define one standard for a process. Defining labor standard is connected with choosing the most effective way of implementing the clinical process. The objective is not to introduce strict patterns of behavior but rather to define the line of action that would enhance the safety and quality level. Defining what kind of processes take place in a given facility (and the boundaries of these processes) is not easy; what is known are the procedures and the delivered services (payments between the Payer and service providers specialists are responsible for that). It is more difficult to define them in multi-specialist hospitals that consist of 40 various departments rather than a small FP clinic. It is worth to answer the questions below:
- What are the patient’s medical problems that made them visit our clinic?
- What kind of activities are we going to perform in order to satisfy our clients and meet their requirements?
- What kind of services do we provide to the patients with similar problems and medical diagnosis?
- Which services are provided most frequently or which services constitute the most important part of the organization?
Answering the questions above will allow us to choose the major processes that take place in a department, in a medical facility. Upon getting informed on the process, it is worth to list all the stages it comprises and activities that are performed. Remember that it is a patient that initiates the process (they ask for a particular service) and terminates it. As far as activities are concerned, it should be established which people are responsible for performing them and providing vital documents, blank forms and tools. Creating a flowchart requires from its author the use of particular shapes-graphics, the most important of which is so called a decision point. On the one hand it is very often a critical point in the whole process, but on the other hand it divides the process into two different patterns of actions. Visualization of the process is not the objective itself, a flowchart is located in the places where the services are delivered, for instance in a nephrologist’s office. Despite being aware of the procedures, each doctor may perform the same treatment in a different way; standardization fosters increased safety of a patient during the process, improvement of the flow and elimination of errors and risks that might occur. The risk of committing a mistake, omitting an important step in the process or forgetting to fill the medical documentation is substantially smaller when the medical staff abides by the flowchart (there always occur some deviations that depend on patient’s health conditions). This solution has been widely approved by the medical workers, who are involved in making necessary adjustments whenever the law, requirements or the process itself changes.
Visual management: color scheme, andon, safety cross
The picture is able to convey the message much more effectively than words. Visual management aims at optimizing clinical processes and specifying the further treatment in the process. VM is composed of light and sound signals, pictures and graphics, which allow us to monitor the process and respond immediately in case of any disturbance, evaluate the current state and compare it with the desired state – the one that is planned. VM facilitates the work of medical staff by indicating critical situations. The example of VM application can be found in a clear separation between the “soiled” and clean working areas in the operating room that is indicated by different floor colors. Blue color stands for the sterile area, whereas non-sterile places are characterized by the red color of the floor (soiled locker room, soiled warehouse, utility room);
- sound information (andon) regarding incorrect parameters during the process of hemodialysis in the form of an audible alarm and a red lamp (a flashing alarm)
- daily analysis of incompatibilities: undesirable events, medical incidents and situations which potentially may be a source of accidents are marked on a board called the LeanCross – a safety cross. Everyday situation on the ward is assessed on the board – if there was an accident or a dangerous situation on the given day or perhaps the day was peaceful, without any accidents.
3. 5S Method
The aim is to create an organized workplace which will allow for reducing the number of errors and the amount of resources used as well as facilitating the flow of values during a process. The task is to make possible constant work basing on the same principles as well as to allow for the introduction of improvements. The method comprises 5 steps which are systematically assessed and analyzed. It is a constant process of maintaining order and assessment of a workplace that uses instruments of visual management allowing for solving problems, such as:
- searching for medical instruments, materials, medicines which are urgently needed;
- lacking medicines and other materials that are quickly used up;
- excessive moving from one room, ward or building to another, which not only exhausts the staff but also leads to an increased number of errors made;
- lack of space needed for the realization of a process;
- disorder, keeping the materials needed in the rooms most distant from the place of the realization of a service.
An effective implementation of the 5S method allows for reducing or eliminating the wastage occurring in a clinical process.
4. FMEA risk analysis in the clinical processes
It is a new use of an instrument, known from the sixties of the twentieth century, which serves to predict causes and consequences of potential errors. According to the rule “prevention is better than cure”, the best proactive way to eliminate or minimize the clinical risk is a constant analysis of a process. FMEA, the analysis of causes and consequences of potential flaws, allows for predicting errors which may occur in the process and taking actions to prevent them, instead of introducing corrective measures after the error has occurred. If we familiarize ourselves with the process well, conduct an analysis of every activity it comprises, gather specialists’ opinions (the interdisciplinary team for the FMEA analysis), we may predict errors and design a process in such a way that in the next few years no significant risk will occur. FMEA is employed not only to design new processes but also for the existing ones. The improvement of quality depends to a great extent on the management, culture and possibility of creative thinking rather than on the implementation of specific methods and instruments (M. Graban). This is why employing only a method, without persons involved in a process (physicians, technicians, unlicensed assistive personnel, registered nurses) and without brainstorming conducted preferably in the GEMBA – the place where the medical service is realized, will not be effective but short-lived. The most important steps during the analysis are:
- To determine possible problems which may occur, basing also on historical data.
- To investigate if these problems have a great influence on the life and health of the patient.
- To define in what ways we may detect the error.
It should be remembered that after every interference in the process, after every change in the procedures, after using new resources another analysis should be conducted and the risk reassessed.
How to optimize a process in an easy and money-saving way, appreciating the staff at the same time? Introduce the Kaizen card – a form where an employee notes down propositions of an optimization of a process. These may regard redesigning of the process, a change in the system of infrastructure, a purchase of only a minor instrument or organization of a meeting to discuss the current problems, to analyze them and to detect the root cause of their occurrence. The added value is not only ideas of employees but the fact that they are involved and want to have influence on the process they participate in.
The most frequently optimized areas are:
- the hospital warehouse of medicines, equipment and single-use materials
- areas concerning the care of the patient
- treatment rooms
- transportation of the sick
- bedlinen management
6. Error analysis using 5Why and Ishikawa diagram
In a medical facility every day there occur situations which have a negative influence on the patient’s health. They may be prevented by analyzing the root causes of the occurrence of the error. Why? The sole correction of the error will erase it but will not be a warrant that it will not occur any more. This is why the source-factor which caused the flaw must be identified. Sometimes there are many causes which regard various areas. Ishikawa diagram divides these causes into groups and allows for defining visually which group had the greatest influence on the occurrence of the problem. When conducting an analysis with Ishikawa diagram we use also the 5Why method. We ask a question, the answer for which is another question.
To conclude, in the article there were presented some of many instruments and methods used in healthcare facilities in Poland and in the world. The type of the method depends on the scale of a facility, the vision of the management, the staff’s involvement and the resources available. The use of lean healthcare instruments in order to optimize clinical processes is an example that management innovations have a positive influence on the healthcare sector. We should remember that the way to achieve positive results is not simple nor fast. The medical staff has to adapt to new rules. This is achieved more easily by implementing lean “with small steps”, gradually. If the staff sees the sense and potential in using a new procedure, if they even demand more maps of a process (the mapping of clinical processes technique), we may proceed with the next stage and name specific instruments without scaring the employees off.
Katarzyna Złotowska – lean hospitals engineer, proxy of System Zarządzania Jakością (Quality Management System). A specialist in optimization of clinical processes, quality management, safety of information management and process risk management for the healthcare sector. The owner of LeanHospitals (www.leanhospitals.pl). You may send your questions to: firstname.lastname@example.org