the lean initiatives to transform the a&e in htar

The HTAR Emergency Department LEAN Team

Presented by:Dr Ahmad Tajuddin Mohamad Nor

Emergency Physician

Emergency Department - ED (Emergency Rooms)

• Has a unique position in the healthcare service elements of any given health network or system in the world– More often than not, it is THE only portal of entry to national or

local health care system that is open 24 X 7 X 365• It is a lifeline to communities and persons alike for solutions to

their:– actual health crisis (various extremes – physical and mental)– perceived emergencies (just surfacing undifferentiated health

situations)– unmet health concerns

• We are no different here in Malaysia

FACT FILE

3

• ED performance is grossly inferred by many from the ‘response times’ including ‘patient waiting times’

• Non-performance may have life determining consequences

6

• When the outcry came:Malaysian Emergency Departments in crisis…

Star, Sunday 16 Feb 2014

7

UK – despite the NHS Revamp

US Congress Presidential

Commission (Pre- Obama years). Also addresses ambulance and

pediatric emergency care services crisis

• … it was already a recognized national crisis in other parts of the developed world much much earlier

• The Honorable Minister of Health and higher management team MOH visited HTAR February 2014 on ‘fact finding mission’

• Declared HTAR as Business Process Reengineering Site for KKM

• Current Quality Assurance & Quality Improvement initiatives in the department is not enough to take us forward• …there’s no finish line to quality

‘Sorry Doc. Don’t take this too personally. Sometimes it does not matter what you think but

the customer (patient)’

PROBLEM STATEMENT

Patient Patient PressurePressure

2ND BUSIEST hospital in the COUNTRY

Admissions - 95, 295 (261 daily)

Emergencies – 220,575 (603 daily)

Specialist Clinics – 298,328 (1,120 daily)

Facility Facility CongestionCongestion

763 beds 1094 beds (>43.4%)

Bed Occupancy Rate – 100 %

UK 2.9

Singapore 2.0

Japan 13.3

BED TO POPULATION RATIOBeds per 1000 Population

Hospital 1.9 (1990) 0.5 - 1.1 (2010)

2nd BUSIEST in Country

220,175 patients (603 daily/ 1 patient every 2

minutes)

74% (450 patients) Non-Critical Patients (Green Zone)

Mean Wait Time – 3 hrs. 12 min.

•Population•Morbid population

•Non Communicable Diseases •Hospital development

•Affordability•Accessibility

•Specialist service needs•Public perception

•District hospital referrals

•Epidemics – “Dengue”•Private hospital referrals

•By passing District Hospitals

•Foreign patients

CAUSES FOR HTAR CONGESTION

PATIENT FACTORPATIENT FACTOR •District health care system

HEALTH FACILITIESHEALTH FACILITIES

•Access Time to Ward• Admission Criteria

ADMISSION FACTORSADMISSION FACTORS

•Patient disposition•Investigation results (TOT)•Discharge Process Time

•Bed Clearance Time

THROUGHPUT FACTORSTHROUGHPUT FACTORS

•Facility constraints

FACILITYFACILITY

• Collaboration with PEMANDU (Performance Management and Delivery Unit, Prime Minister’s Department)

• Methodology to be used: LEAN for Healthcare Improvement

Rx:

PROJECT FRAMEWORK AND PROGRESS

Implementation of Kaizen improvement

activities

What is LEANThe core idea is to maximize customer value while

minimizing waste. Simply, LEAN means creating more value for customers with fewer resources.

• A lean organization understands customer value and focuses its key processes to continuously increase it.

• The ultimate goal is to provide perfect value to the customer through a perfect value creation process that has zero waste.

17

Some CONCEPT & TOOLS

MU-DA : Futility, uselessness - WASTE

MU-RA : Unevenness

MU-RI : Overburden

KAIZEN : Incremental minor changes

KAIKAKU : Fundamental and radical changes

KANBAN : Demand indicator to initiate activation of supply chain

The word Kaizen means "continuous improvement". It comes from the Japanese words

改 ("kai") which means "change" or "to correct" and 善("zen") which means "good”.

kai.zen

18

LEAN: 9 Healthcare wastes

D Defects : Work that contain errors, lack in value, variation, fragmented, patient readmissions

O Over production : Redundant work: duplicate forms, charting, copies

W Waiting : Idle time created when people, information, equipment or materials are not at hand, wait for approval, batching, queue

NNon-utilized talent/ Human potential

: Not using workers knowledge or talent; Not engaging employees, listening to their ideas, or supporting their ideas

N Not Clear (confusion)

: Unclear process, instructions or system

T Transporting : Unnecessary movement (patient, delivery or retrieve) of items, specimens; poor layout

I Inventory : Storing too much; non optimize resource leveling

M Motion : Excess motion – looking for material, people; not adding value; unnecessary walking, incorrect floor layout

E Excess processing

: Too much, too soon from patients perspective, unnecessary verification loops

SUSTAINED(Discipline) shitsuke

sentiasa amal

Make a habit of maintaining established

procedure

SET IN ORDER

seiton susun(Orderliness)

Keep needed items in the correct place to allow for easy and immediate retrieval

SHINE seiso sapu

(Cleanliness)Keep the workarea

swept and cleanSTANDARDIZE seiketsu seragam

(Standardized Cleanup)

This is the condition we support when we maintain the first three pillars

SORT seiri sisih

(Organization)

Clearly distinguish needed items from unneeded items and eliminate the latter

5 S

20 min/pt.

2.6 min/pt.2.6 min/pt.On average every 2.6 minutes, 1 patient will

pass through

Secondary Triage (Assessment)

2.6 min/pt.

3.

Admission: Registration &

Payment

9.In-patient

Beds

START HERE

Walk InReferral

(7.5 – 10%)

A Patient’s Journey in Emergency Department…

Own transport Ambulance 999

(5-7%)

‘WELL’Green Green ZoneZone

65% of patients

Primary Triage

(Screening)

1.0 min/pt.

2.

Registration & Payment

3.8 min/pt.

4

1.Drop Zone

ED

Red Red ZoneZone

YellowYellowZoneZone

ILL

30%5%

8. Follow-up & Referral

5. Consultation

5.4 min/pt.

Investigation, Procedure, Referral

(eg: Lab/X-Ray)

5-20 min/pt.

6.

Pharmacy/Home

QueueQueue

QueueQueueQueueQueue

QueueQueue

QueueQueue

QueueQueue

QueueQueue QueueQueue

QueueQueue

…… a big portion of it is on activities which are non value added!

7.Disposition(Closure)

2.0 min/pt.

END HERE !

Total Queue Time

Average Length of Stay

197 minutes139.6 - 154.7

minutes

WASTE: (70-91%)

80-85%

Referral

Ambulance 999

Public Services – Journey A

(in MERS999)

Public Services – Journey B

(in KK)

Public Services – Journey C

(in ED)

Public Services – Journey D(in Wards)

Customer satisfaction can either be augmented or severely depreciated further downstream

? ?

Emergency Department - Emergency Department - Process Relook

22

End

Start

INPUT THROUGHPUT

OUTPUT

ED – as a manufacturing line?:

Emergency Department - Emergency Department - Process Relook

23

End

Start

INPUT THROUGHPUT

OUTPUT

Medical

The whole experience as a manufacturing line:

End

Start REGISTRATIONREGISTRATION

SECONDARY TRIAGE

CONSULTINVESTIGATE

TREAT DISPOSITION

PRIMARY TRIAGE

INPUT THROUGHPUT

OUTPUT

Emergency Department - Emergency Department - Process Relook: Existing Lead Process

The BOSS of the Emergency Department is the

Emergency Physician

Really?

26

Hospital Managem

ent:

IT Dept

Registration & Bill Payment Unit

Heads of Non-Clinical Department/ Unit:

Heads of Clinical Department:Radiology

Pathology & Lab

Emergency Department - Emergency Department - Process Relook: Line ownersCommunity Private

Hospitals/ Clinic

Govt. clinics

Govt. hospit

alsPrehospital Care and

Ambulance Services service

Family Medicine

MOH HQ:Quality

UnitPolicy Unit

Health System- Research

& Dev

PRIME MINISTERS DEPARTME

NT

Hospital Admission UnitSpecialist Clinic (Hospital)

Nursing Managers of In-patient WardsPharmacy Dept

PORTERAGE

ED Department Staff

PR UnitEngineers: Facility Managers

Other Dept/ Unit Staff

Quality Unit

HOSP VISITOR BOARD

PORTERAGE

Drop zone / Primary

triage

Secondary triage

Outpatient registration & payment

ConsultationDisposition

Diagnostic support & Referral

Legend: R Red zone Y Yellow zone G Green zone

Re-consultation

• Depart: Home + Pharmacy

• Referred:Specialist Clinic Appointment

• Community Clinic• Admit In-patient

Inpatientbed ready

R RY Y

G G

Emergency Department - Emergency Department - Process Relook - LINEAR

Drop zone / Primary

triage

Secondary triage


ConsultationDisposition

Diagnostic support

Arrival to consult (ATC) KPI : > 70% within 1 ½

hours

Bed waiting

time (BWT)Length of stay (LOS) KPI : > 70% within 2

hours

Legend: R Red zone Y Yellow zone G Green zone

Re-consultation• Depart to pharmacy /

home• Referred to specialist /

health clinic• Inpatient registration &

bed assignment (patient can move to patient

pond)

Inpatientbed ready

1

2

3

R RY Y

G G

EMERGENCY SERVICESEMERGENCY SERVICES

Improving patient congestion at Green Zone by reducing patient throughput time

Reducing Patient Length of Stay at Non-Critical Zone at EDReducing Patient Length of Stay at Non-Critical Zone at EDAspiration

1. Workload Levelling (Policy)2. Work Process Re-engineering (Operational)

Strategy

Methodology

LEAN for Healthcare

Length of stay (LOS) KPI : > 70% within 2 hours

1. Length of Stay < 2 hours 18% 70.4%

2. Average length of stay 3 hrs. 12 min 1 hr. 28 min

Arrival to consult (ATC) KPI : > 70% within 90 minutes

ATC within 1 ½ hours 82% 88%

Bed waiting time (BWT)

Average (longest only) BWT 4 hrs. 19 min 3 hrs. 25 min.

POST LEANPOST LEANPRE-LEANPRE-LEAN

Validated by

Pemandu- UniKL

WE would like to share what WE did….

End

Start REGISTRATIONREGISTRATION

SECONDARY TRIAGE

CONSULTINVESTIGATE

TREAT DISPOSITION

PRIMARY TRIAGE

MORE HEALTH CLINICS EXTENDED HOURS

IMPROVED REFERRALS DIRECT ADMISSION

FLOOR MAP

OUTPATIENT INPATIENT REGISTRATIONS IT

INTERFACE COMMON FUNCTIONAL

COUNTER PATIENT INSTRUCTION SLIP

BED WATCHER SYSTEM ADMISSION COORDINATOR

PATIENT POND

DOCUMENT WINDOW TRIAGE DOCTOR

INTERVENTION WALKWAY LINK

LINK CALL SYSTEM IMPROVED PUBLIC

RELATIONS

QUEUE BOX “NEXT-PATIENT” WAITING CHAIR

CENTRALISE PORTERRAGE COORDINATED SPECIMEN

DISPATCH PNEUMATIC TUBE

RADIOLOGY UPGRAFE LABORATORY UPGRADE

• 65% of emergency department attendance are stable patients including non-emergencies

33

• They come from various communities nearby HTAR Klang and often by-passing nearer Klinik Kesihatan.

Source of patient in relation to nearest Klinik Kesihatan

Klinik Kesihatan in Red are the most

relevant

1. Drop Zone & Primary Triage

INPUT

Increased number of Klinik Kesihatan extended hours (resource leveling):

Before

34


After

Total 5 additional Klinik Kesihatan had opened extended hours

INPUT

Outcomes/ Impact

Patient Attendance to Emergency Department before and after extended hours from 2 KKs

Date of 2 KKs beginning extended hours operations

– 15 July

35

1. Drop Zone & Primary Triage After

Outcomes/ ImpactINPUT

• All admissions from klinik kesihatan must go through ED.

• All stable patients from KK need to under-go re-triage process in ED


Before

36

INPUT

After• Refined KK-ED processes with FMS


37

After

• Admission Form distributed to KK for direct admission. (Mostly Pediatric and Obstetrics cases)

INPUT

• All stable referral patients seen immediately on arrival by a senior doctor in Consultation Room 5

• Pre-referral (WhatsApp alert) consult for Resuscitation, Emergent &

Urgent cases

INOVASI

Before

• No directional floor map to guide patient journey in ED

38

1. Drop Zone & Primary Triage After

• Location Map at various points to guide patient journey

INPUT

Before

• Patient are not familiar with processes in ED results in occasional mis-steps

39


INPUT

After

• Maximizing the use of empty space on back of receipt with valuable information for patient while waiting

INOVASI

Document Window

Primary Triage to Secondary Triage

Documents need to be manually carried

from Primary Triage to Secondary Triage

Secondary Triage

& WaitingArea

POST POST LEANLEAN

Kaizen BurstKaizen BurstPRE-PRE-LEANLEANWasteWaste

THROUGHPUT

Drop zone / Primary triage

Secondary triage


Disposition

Diagnostic support

G G

R / Y R / Y

Re-consultation• Depart to pharmacy /

home• Referred to specialist /

health clinic• Inpatient registration &

bed assignment (patient can move to patient

pond)

Inpatientbed ready

+Consultation

Secondary

Triage & Waiting

Area

PRE-PRE-LEANLEANWasteWaste

POST POST LEANLEAN

Kaizen BurstKaizen Burst

Senior doctor placed at Secondary

Triage can jump-start consultation for

selected cases

18% patients

off-loaded

Steps required to eventually see a

doctor can be long despite having

only simple ailments

Consultation

THROUGHPUT

Month Total Patient in Seen in See &

Treat

As % from Total number of Green

Zone Patient

July 1831 15.8%August 2323 20.6%

September 2153 19.5%

October 2019 18.64%

After

Outcomes/ Impact

Secondary Triage See And Treat Monthly

42

2. Secondary Triage

& WaitingArea

THROUGHPUT

Month Type of Intervention at See & Treat

Discharges X-RAY Lab IxJuly 1050 562 219

August 1178 620 252

September 1253 598 302

October 1104 523 392

After

Outcomes/ ImpactSecondary Triage See And Treat Monthly

43

2. Secondary Triage

& WaitingArea

THROUGHPUT

Overcrowded patient in Green

Zone overflow to adjacent canteen

44

Walkway Link to Canteen

Secondary Triage

& WaitingArea

POST POST LEANLEAN


Canteen ED

THROUGHPUT

No system to call patients waiting in

canteen

…create link to call system for canteen

QUE Caller System in Canteen

QUE Caller System -

Green Zone Waiting Area

Secondary Triage

& WaitingArea

POST POST LEANLEAN


THROUGHPUT

Before• PRO counter not visible • Limited operational hours• Floor ambassador function

just limited to Green Zone

46

2. Secondary Triage

& WaitingArea

THROUGHPUT • Improve lighting at counter• Extend PRO operational hours

from current 0800 – 2300H to 0200H using Hospital AMO On call

• Scheduled visit by PRO at various points in ED

After

Before• Two separate systems

exists for Out-Patient and In-Patient (Admission) Registration

47

3. Registration3. Registration

THROUGHPUT

After

• Integrate Out-patient and In-patient registration systems

INOVASI

Before

• Admitted patients need to walk far to a separate In-Patient Counter for ward registration

• Registration Counter in ED can register only 2 patients at anyone time

48

3. Registration3. Registration

THROUGHPUT

INOVASI

• Co-locate Out-patient and In-patient Registration counter in ED

• Increase ability to handle 4 registrations at anytime

After

• There is considerable lag time for patient to be seated after being called

Before

After

• Put next patient chair outside the consultation room.

49

4. Consultation, Investigation &

Treatment

THROUGHPUT

Outcomes/ ImpactMonth Total Green

Zone patient waiting

Average time taken from waiting area to be

seated in the consultation room

Idle time in seconds per month (hr)

Hour saved in a month

May 5400 45 saat 243,000 (67.5)

June(from 3rd June)

5890 4 saat 23,560 (6.5) 61

July 6045 4 saat 24,180 (6.7) 60.8

August 5550 4 saat 22,200 (6.1) 61.4

September 5475 4 saat 21900 (6.1) 62.4

October 5246 4 saat 20984 (5.8) 59.7

After

50


Treatment

THROUGHPUT

• Haphazard piling of case notes and large numbers of patient files make time tracking difficult after initial consultation

Before

51


Treatment

THROUGHPUT

After

• Patient wait time Cue Viewer Box in all consultation rooms

5 ‘S’ Principle – SORT, SEPARATE

Waiting since 0800

Waiting since 0900

Waiting since1000

(current time)

Hour slots of the day

Easy & At-a-glance monitoring of wait time post consultation!Wait-time handover at shift

change!

52


Treatment

THROUGHPUT

INOVASI

• There is considerable turn around time for x-rays and lab test results to come back:• Batching difficult for ED, porterage service limited & not

integrated• ED X-ray room requires major renovation and main

imaging dept situated far from ED• 65% of lab tests in ED need to be sent to Central Lab

which is situated away from ED (35% done in ED Mini-lab/ POCT)

• Performance of the existing pneumatic tube link to main lab and imaging department is unpredictable

Before

53


Treatment

THROUGHPUT

Upgrade - physical area repair and equipment replacementED X-ray room requires

major renovation to support ED requests

Consultation, Investigation &

Treatment

POST POST LEANLEAN


THROUGHPUT

Mini-Lab ED upgraded to ED Lab with better capacity and area

65% of lab tests in ED need to be sent to Central Lab -

situated away from ED (35% done in ED Mini-lab/ POCT)

Consultation, Investigation &

Treatment

POST POST LEANLEAN


THROUGHPUT

• Lab specimens are generated at multiple sites

• Sent in uncoordinated way

Before

56


Treatment

THROUGHPUT

Zon Hijau

Zon Kuning

Zon Biru

After

• Centralized collection point• Collection schedule every

30 minutes

• Performance of the existing pneumatic tube link from ED to main laboratory and x-ray department is unpredictable

Before

57


Treatment

THROUGHPUT

Picture of commemorative plaque

– 1st Pneumatic tube system in the country for MOH is in HTAR

ED

ACC/ Specialist

Clinic

Main Block HTAR

Radiology (X-ray/ CT scan

Central Lab

Blood bank

Pneumatic tube highway

Wards

Bahagian Hasil

Radiology (X-ray/ CT scan

Central Lab

• Revitalization of pneumatic tube services

After

58


Treatment

THROUGHPUT

ED

LaboratoryRadiology

Route R Route L

Request forms for mobile

XRay in Red Zone

Request forms and specimens for Central Lab

Date Route Transmit Receive %

(Test)4/10/2014 Pneumatic

TubeBiochemistry Lab

21 75%

5/10/2014 Pneumatic Tube

Biochemistry Lab & Radiology

35 92%

(Live)20/10/2014

Onwards

Pneumatic Tube

Biochemistry Lab & Radiology

145 – 165 / Day Samples

100%

• Real-time monitoring of number of patient admitted and discharged patients not available

• Inter-ward variation: ie medical versus surgical wards

0600 1200 1800H0000

No.

of p

atien

ts

Time

Discharge/ Depart from Ward

Patient Attendance (and Admission)

in ED

Before

Discharge > Admission Empty beds available; access time to in-patient beds SHORT

Admission > Discharge No beds available; CONGESTION, LONG waiting for beds

Admission = Discharge DESIRABLE59

OUTPUT

5. Disposition

Water reticulation concept

Balancing Tank – to control pressure

and overflow at storage tank

Storage TankDistribution Tank

From ED

Patient Pond for patient

transit

Discharge

Pull systems

Medical Ward

• Able to avoid congestion at ED and MW by managing patient flow (input and output using pull systems)

24 X 7X 365

M T W T FS S PH

No scaling down of resources after hour/ scaling up weekends/

PHAdmission starts to peak

before 12 Significant scaling down of resources after hours/

weekendsDischarge begin only after

12 pm

61

AfterSelepas

OVERALL BED SITUATION DISCHARGES BY HOUR ADMISSIONS BY HOUR

Actual Screen Snapshot of Hospital Bed Status 1 October 2014

• BED WATCHER application for HTAR allowing real-time monitoring of admission and discharge volumes hospital wide• Options also include assigning bed to patient,

bed booking, patient tracking

OUTPUT

5. Disposition

INOVASI

After

• Appointment of Hospital Bed Manager for HTAR with executive power and Admission coordinators for ED

• Supported by IT, clerical staff from working in Admission and Discharge (Bahagian Hasil) Counters

62

OUTPUT

5. Disposition

63

6. Others

Before

• Yellow Zone is prone to surge situations, variable casemix and overcrowding

• Work morale in Yellow Zone was low

64

6. Others After

• Refined processes using ‘5s’ and establish functional patient cohort cubicles in Yellow Zone and staff assignment

65

6. Others

To manage surge situations:

• Observation Ward capacity can be increased to 26 from current 16

• a patient pond can be created in 30 minutes – 20 canvas beds at old ED walk corridor

After

66

30%Operation speed increase

for intervention

16% (32 min)Time saving

Increase

41%of asset utilization

(7 KKs)

744,062Klang population affected

To HTAR

35%congestion reduce

To Rakyat

Klang

To Nation

1.5 million people (including

movement) affected

The Transformation Benefits

Bersama, kami telah lakukannya!

67

THANK YOU

68

the lean initiatives to transform the a&e in htar

Education