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LEAN INITIATIVES IN HOSPITAL RAJA
PEREMPUAN ZAINAB II KOTA BHARU, KELANTAN
DR MONNIATY MOHAMED
CONSULTANT PHYSICIAN /
LEAN CHAMPION
HOSPITAL RAJA PEREMPUAN ZAINAB II
HRPZII’ S KEY FACTS WORK LOAD
• BOR : 80% ( 2015)
• In Patients : 273,540
• Out Patients (A&E ): 106,393
• Out Patients(Pakar) : 176,398
• Deliveries : 12,605
• Established since 1930s
• Bed Capacity : 937 (2016)
• Number of Staffs : 3,912
• 16 Clinical Disciplines
&
13 Non Clinical Support
Unit
• Received Multiple Quality
Awards
Ist Class 2nd Class Medical
Surgical Maternity Leprosy Venereal Diseases Prison Ward
1930S 1961…ward blocks
1990S… HKB
2005… HRPZII
2016… ACC
THOSE WERE THE DAYS…..
THE PRESENT…..
HOSPITAL RAJA PEREMPUAN ZAINAB II
Main Quality / Innovative Achievements
• MS ISO 9001:2008 Certified
• MS ISO 15189:2014 Certified for Pathology Lab
• HACCP ( Hazard Analysis and Critical Control Point) & GMP certified for Dietetic Dept
• Certified as Baby Friendly Hospital Initiative Global Criteria
• Multiple Awards at State and National level For ICC, QAP and Innovation activities
ANUGERAH KUALITI PERDANA MENTERI
SEKTOR AWAM 2002
WHY LEAN ?
As part of PSDT programme, HRPZII decided to take this opportunity to implement LEAN management as tools • To Improve Efficiency and Quality of care delivered to our patient ( Identify and Eliminate wastage through continuous improvements efforts) ► To focus on Customer Centered Care ► To Improve patients’ and employees’ satisfaction
STARTING THE JOURNEY : HRPZII
Meeting with MPC
Identification & Training Of Core Team
Engage Sensei
JUST Do IT
Set Up Committee identify project
LONG OUTPATIENT TREATMENT TIME IN PHYSICIAN CLINIC (Medical )
LONG WAITING TIME FOR PATIENTS TO BE DISCHARGE FROM MEDICAL WARDS (Medical/Pharmacy/ Revenue)
LONG LABORATORY TURN AROUND TIME FOR URGENT BUSE REQUEST (Pathology /Wards/Clinic )
REDUCING THE TIME SUBMITTING APPLICATION FOR PROSTHESES UNDER TBP FUND BY THE REHAB PHYSICIAN THROUGH JAB KERJA SOSIAL PERUBATAN(JKSP) (Rehab And JKSP)
DELAY IN COMPLETION OF MEDICAL REPORT FROM ORTHOPEDIC DEPARTMENT (Orthopedic and Record)
FORM A COMMITTEE
DECIDE DEPARTMENT INVOLVED
IDENTIFY LEAN HEALTHCARE PROJECT
AWARENESS
ADOPTION OF LEAN
THINKING
GEMBA
DEVELOP CURRENT STATE VSM
IDENTIFY WASTE AND KAIZEN BURST
DATA COLLECTION
ESTABLISH IMPROVEMENT PLAN
DEVELOP FUTURE STATE VSM
KAIZEN BURST ACTIVITY
IMPROVEMENT EFFECTIVENESS
FINAL BASELINE VERIFICATION
PROCESS STANDARDIZATION
MAY 2014
JUNE 2014
Sharing our journey in lean………
JULY 2014
HRPZII embark our journey in Lean Initiative in May 2014 as part of our initiative in Public Services Delivery Transformation in collaboration with MPC
AUG 2014
SEPT 2014
DEC 2014
PROJECT PERFORMANCE JUNE-DEC 2014
MOH expands LEAN To all hospital
PHASE 1
PHASE 2
PHASE 3
PHASE 4
LEAN THINKING CURRENT STATE VSM
IMPROVEMENT ACTIVITIES
FUTURE STATE VSM
TRAINING PHASES
AWARENESS
Team charter a
KAIZEN BURST
• Awareness • Team charter
• Perceive vs.
Actual • Data Collection • Kaizen Burst
Identification
Tools and • Tools and
Techniques • Solution implementation
Project completed
Monitoring and standardization P • Project
completed • Monitoring &
Standardisation
?QC TOOLS
Senior Management Buy in….
LEAN AWARENESS WORKSHOP
GEMBA HRPZII
EQUIPPING AND EMPOWERING STAFF
Instilled LEAN thinking and Breaking the Silos
Ortho & Record Wards & Laboratory
Create VSM- Visualize the process before going to the
field
Achievements
PROJECT
PRE - LEAN POST - LEAN
Long Treatment Time At Physician Clinic
109 min 74 min
Long waiting Time for patients to be discharge from Medical wards
175.8 min 110.7 min
Long Laboratory Turn around Time for urgent BUSE request
25% (standard MOH: less than 45 min)
77.3%
Reducing the time submitting application for Prostheses under TBP Fund by Rehab Physician through JKSP
7 weeks 2 weeks
External Recognition - Visits
DATO AMIN , DIRECTOR PEMANDU DATIN AKMAL , MOH
EN NIK MUSTAFA , DIRECTOR IECMPC.
Visit by the Director General of MPC
22 /12/2014
Time & Commitment
Competing Priorities eg our Clinical Responsibilities
& Administrative Workloads
Management Engagement
Senior Management Buy in - a challenge
Ability of senior management to engage, inspire
and motivate
Breaking the silo – a challenge
Staff Numbers
Large population. Makes Cascading of information
challenging
Our Strength 1.Top- down commitment solid support from top management and majority of HOD 2. Bottom –Up involvement good Team Work Engaging middle managers 3. Culture of Continuous Improvement Effort in place.
CONTINUIING THE JOURNEY… 2015
We have began our first baby step…. We were confident we can maintain the momentum to 2015 onwards Prepare our Road map and strategy in concordance to MOH master plan
Ministry Public hospitals / Medical institutions
Ministry of
Health
(MoH)
14
State Hospital
26
Major Hospital
27
Minor Hospital
66
Non-specialist Hospital
Total = 133 Specialist Hospital
The LEAN pilot projects …
HTAR, Klang
1) ED
2) Medical Ward (MW)
East Coast
1. Kelantan HRPZII
2. Terengganu HSNZ
3. Pahang HTAA
HSI, Johor
1) Oncology
2) Orthopaedic
PEMANDU Bahagian Perkembangan Perubatan, KKM UNIKL IHSR MPC
Public Service Delivery System
Transformation for Healthcare
• Currently 2 group ED & Medical Wards are doing
LEAN initiative 2015
…agile approach
Take a sequential
approach – hospital by
hospital
1
Take an agile approach – one pilot IDEAL
process and repeat at other hospitals
(RED door) 2
Stability 1st
Re-design
LEAN – making process efficient
(functional)
DESIGN THINKING – bring
emotion into the functional
improvement
MOH objective is to transform 133 hospitals…
We take one “pilot”
area under LEAN
( ED/ MW ). This is
our “anchor”
hospital
We bring 16 hospitals’ ED / MW staff &
introduce Lean Agile
Ideal
ED & MW
(LEAN
&
Service)
We then roll out to 117 hospitals in
batches of 20
1 2 3 4
2015
Training Lean
Healthcare
STAGE -1 Design
Thinking
Understandi
ng
•LEAN
Healthcare
•LEAN
Implementa
tion @
HTAR for
ED/ MW
1.Design
Thinking workshop 2.LEAN
exposure
STAGE -2 STAGE- 3
1 day 5 days 2 days
LEAN Awareness
VSM &
Kaizen Project
Closure
Develop
•Current
VSM
•Baseline
data
•List of
Kaizen
Kaizen IMPLEMENTATION
Phase
Finalised :
•Kaizen List
•Future VSM
•Performanc
e data
Ideal
Design for
ED & MW
Analysis / Reporting /
Presentation
Outcome:
Design ideal ED
& MW
•Kaizen List
•Future VSM
•Performance
results
Overall Approach and
Implementation
Month 0 1 2 3 4 5 6
Month
On-Site Consultation &
Monitoring
ON-SITE
CONSULT
ATION
On-Site
Consultatio
n if required
• 1. MEDICAL TEAM- DECONGESTING MEDICAL WARDS
• 2. ED TEAM – DECONGESTING GREEN ZONE AT ED
this group are performed Lean Initiatives in AGILE Approach under UniKL and PEMANDU
Year 2015 1. Create Awareness And Promotion HRPZII 2. Training & Education 3. Create Lean Corner
HOSPITAL
LEVEL
LC
Department Department
Create Awareness
& Knowledge transfer
LC
LC
►Created LEAN Corner -
expose our staff to LEAN
terminology
►Present in Hospital
CMES
►Through Hospital
Website
LEAN CORNER
PSTD TRANSFORMATION - LEAN HEALTHCARE
REDUCING OUTPATIENT TREATMENT’S TIME IN
PHYSICIAN CLINIC HRPZII
CLINIC ATTENDANCE BY YEAR
NUMBER
OF
PATIENTS
80% are follow –up patients
27852
INCREMENT OF PATIENTS BY 105 %
TRIAGE
COUNTER
REGISTRATI
ON
COUNTER
WAITING
ROOM
CONSULTATI
ON ROOM APPOINTMENT
COUNTER
APPOINTMENT
NO APPOINTMENT
PATIENT
URINE
ANALYSIS
BLOOD
INVESTIGATION
ECG
ECHO
SCREENING
COUNTER
VITAL
SIGN
COUNTER
CONSULTATI
ON ROOM
1
8 6
5 4 3 2
9
7
85%
15%
EXIT
ARRIVAL
(screening
based on Appt
card and
Questioning)
Screen
based on
patient’s File
(Screen based
on patient’s
blood pressure
and BMI)
(Appointment date given
Prescription slip given
Form for blood test
given
KPI MOH
LEAN INITIATIVE
ARRIVAL EXIT
REGISTRATION SEE DOCTOR
Patient’s Pathway…..
PC process and metrics
……………………Waiting time…………..
LEAD time = Patient’s treatment time
4
7
TOTAL
P/T 3 MIN 6 MIN 8 MIN 4 MIN 16 MIN 6 MIN 43 MIN
W/T 5 MIN 4 MIN 12 MIN 7MIN 20 MIN 18 MIN 66 MIN
L/T 8 min 10 min 20 min 11 min 36 min 24 min 109 MIN
FTQ 0.98 1 1 0.98 1 0.98 0.94
TRIAGE
COUNTER
REGISTRATI
ON
COUNTER
WAITING
ROOM
CONSULTATI
ON ROOM APPOINTMENT
COUNTER
APPOINTMENT
NO APPOINTMENT
VSM CURRENT STATE
P/T 3min
W/T 5min
D 8 ft
P/T 8 min
W/T 12 min
D 12 ft
P/T 6 min
W/T 4 min
D 36 ft
PATIENT
URINE
ANALYSIS
BLOOD
INVESTIGATION
ECG
ECHO
SCREENING
COUNTER
KAIZEN
2
VITAL
SIGN
COUNTER
CONSULTATI
ON ROOM
KAIZEN
3
KAIZEN
4
P/T 4 min
W/T 7min
D 30 ft
P/T 16 min
W/T 20 min
D 50 ft
P/T 6 min
W/T 18min
D 22 ft
Total distance : 158 feet (48.2 meter)
Takt Time : 15.2 min /patient
PE: 39.4 %
KAIZEN
5
1 8
6
5 3
9 2
KAIZEN
1
EXIT
ARRIVAL
Head of Dept
Department office
Consultation room
Consultation room
Consultation room
Consultation room
Consultation room
Consultation room
Consultation room
Blood taking room
3. Registration & Payment
2. Screening Counter
Start here
4. Vital Sign Counter
1. Triage Counter
6.Appointment Counter
5. Consultation Room
exit
Arrival of Patient
Bird’s eye view……. Patient’s pathway
Update GL Payment QMS given
Clinic layout
SPAGHETTI DIAGRAM Current State
Total Distance patient Has to walk 158 feet ( 48.2 meter)
berjalan masuk keluar
Physician Clinic LEAN Initiatives
1. Improve patient’s flow by
► Remove Triage and Vital sign Counter
► Proper Layout Plan and Signage
► Introduce Communication Sheet
► Create Job Specification and focus work process
► Establish Information / Help counter
2. Capacity Management
► Prepare schedule for doctors ( schedule
levelling)
► Introduce Penalty Box –avoid unevenness
KAIZEN AND PLAN (KP) SHEET
KAIZEN THEME REASON FOR SELECTING KAIZEN THEME KAIZEN BY
Combination of Counter – (Triage and Screening ) and Eliminate Vital Sign Counter
To speed up the receiving process and registration
of patients and Reduce waiting time
PROBLEM CONTENT EXPECTED EFFECT
-Too many counter for patients
- Too many manpower involved manning different counter
--Waiting time to go to multiple counter for various process - Transportaion involving patients and materials
- reduced waiting time
- reduced patient’s motion
--Eliminate buffers between process
Registration
counter
Screening
counters
Triaging
counters
Appointm
ent
counter
Vital Sign
counter
Registration
counter
MAIN counter
Appointm
ent
counter CONSULTATION
ROOM
CONSULTATION
ROOM
BEFORE KAIZEN AFTER KAIZEN
KAIZEN SHEET
KAIZEN THEME REASON FOR SELECTING KAIZEN THEME KAIZEN BY
Create Job Specification and Focus work process
The staffs at different counters were multitasking and doing duplication of work with each other.
BEFORE KAIZEN AFTER KAIZEN
PROBLEM CONTENT COUNTER MEASURE
-Duplication of work at each counter -Interruption of main activity eg registration, screening
- The staff had job specification at each counter- Job focus - Create Continuous flow in patients movement - Complete work process more efficiently
Triage
counter
Screening
counter
Registration
counter
Appointment
counter
Registration
counter
MAIN
counter
Appointment
counter
Information
counter
INTRODUCE PENALTY BASKET
BEFORE AFTER
Introduce penalty basket for optimal appointment scheduling Avoid unevenness/ overload of patients at a time Re-enforce patient on schedule given ( staggered time )
EFFECTIVE ON 10th DEC 2014
Previously , no penalty to those who do not abide to staggered Appointment time. Overload the clinic
Schedule Leveling
The
ESTABLISH INFORMATION / HELP COUNTER
BEFORE AFTER
Kak, boleh tanya? Mano klinik kulit ?
Ubat saya habis tenggelam masa
banjir. Boleh sambong ubat ko
Sekejap ya. Saya nak daftar ni
Cik, saya nak tukar
appointment
• To deal with any queries from walk in patients
• To assist patients in need • To answer phone call
and deal whatever queries / request
• Frequent interruption To the staff at counter . • Affected work process. • Contributed to long turn-around time
EFFECTIVE ON 15th SEPT 2014
SCHEDULE LEVELING
(HEIJUNKA)
BEFORE AFTER
• Previously doctors will come down to clinic after their ward round.
• Clinic usually start at 9.00-9.30 am. • Usually clinic run through lunch • Clinic finished by 3 pm
Complete ward work
1. Prepare schedule for Doctors to start clinic early. 2. Improve Our Patients schedule (schedule based on no of patients & our capacity)
time No of DR No of pts
8.00-9.00 4 16
9.00-10.00 6 23
10.00-11.00
11 41
11.00-12.00
11 41
12.00-1.00 11 41
CLINIC
EFFECTIVE ON 10th NOV 2014
Improving Patient’s experience………
beverages
Diabetes class
HYPERTENSION CORNER
TV / EDUCATIONAL
Reading material
ACHIEVEMENTS
MATRIC BEFORE AFTER REDUCTION
LEAD TIME (TREATMENT TIME)
109 min 74 min 32%
DISTANCE 158 FT (48.2 meter) 92 FT (28 meter) 41.2%
PROCESS 21 steps 12 steps 42.8%
Comparison of VSM
CURRENT VSM FUTURE VSM
SPAGHETTI DIAGRAM
BEFORE AFTER
Total distance : 92 feet (28.0 meter)
Total distance : 158 feet (48.2 meter)
Monitoring Average LEAD Time (Min.)
Month
Flood & Move to ACC
KPI MOH: Waiting time to see doctor within 90 min May-Dec 2014
2014
Performance indicator of MOH : waiting time to see doctor at Specialist Clinic is ≤ 90 minutes ( from registration (QMS) till see doctor } in ≥ 90% of patients
2015
Flood & Move to ACC
What’s Next…..
We Have move To the new Ambulatory Care Center in FEB 2015 FACE CHALLENGES IN SUSTAINING Lean Initiatives in the new environment.
CONVERT TO ELECTRONIC SYSTEM
SPPv3
BEFORE AFTER EFFECTIVE ON APR 2015
Appointment book
Manual system
MAIN
COUNTER
WAITING
AREA
CONSULTATI
ON ROOM
APPOINTMENT
NO APPOINTMENT
VSM CURRENT STATE (ACC) PATIENT
URINE
ANALYSIS
BLOOD
INVESTIGATION
ECG
ECHO
CONSULTATION
ROOM
ARRIVAL
EXIT REGISTRATION
COUNTER
1 2 3 4
5
6
NEW KAIZEN FOR SUSTAINABILITY
Improve patient’s flow by
► Fully function on IT based SPPv3
► Create Additional Registration Counters
► Pit Stops –outside sub-speciality
consultation rooms
► Remove Appointment counter
Total Average LEAD Time at Gen Medical
Clinic, PC HRPZII(ACC) 2015
MONITORING
Lean Is Not a Destination, It’s a Journey
Every big change begins with a small step
