hospital sultan ismail, johor bahru

HOSPITAL SULTAN ISMAIL,

JOHOR BAHRU

HOSPITAL SULTAN ISMAIL

•Built 1999, Started

operation 2006

•THIS hospital

•704 Certified Beds

•22 wards, 18 OT

•49,000 Admissions

•12,044 Births

•218,391 Specialist

Clinic Visits

•99,369 Emergency dept visits

•64 resident specialists/ 18

specialist services with 20

subspecialties

•2100 Employees

•RM258m Operating Budget

Southern Region Oncology Center

PROBLEM STATEMENTS

The waiting time for all types of cancer to start radiotherapy ranges from 8-20 weeks after

being referred to the Hospital for treatment.

For Head and Neck cancer the average waiting

time is about 120days using the Clinac iX.

Dissatisfaction amongst clients and other

stakeholders

Project Goal

Comparative Assessment

KPIs and challenges to go forward:

Team members:

[1] Aspiration:

To improve the waiting time of head and neck cancer patient to

start radical radiotherapy treatment after first consultation by

Oncologist at Hospital Sultan Ismail Johor Bahru using the

Clinac iX Linac.

Sponsor: Minister of Health

Leader: Director General of Health & Deputy Director

General of Health (Medical)

Buddy: ‘Jabatan Kesihatan Negeri Johor’, Director Hospital

Sultan Ismail.

Team members: Dr Mohd Roslan Haron, Dr Fong Chin

Heng,En Hassan Bin Ali, Pn Halimaton Saddiah Paiman,En

Hanannan Bin Kepli, En Mohd Khairee Aripin, Pn Azizah

Caroshau, JT Siti Norsiah Ibrahim , KJ Rafi’ah Othman, KJ

Zaidah Othman

[2] Current Situation:

Average waiting time is 120days from first oncology consultation

[3] Project Scope:

Only patients confirmed to have Head & Neck cancer .

Waiting time: From the time of decision to treat using radiotherapy

[1] Benchmark: NHS - 31days

The Advisory Board Company Oncology Round Table - 26days

RANZCR – 28days

[2] Comparative assessment:

Hospital Umum Sarawak 3-4 weeks

[1] KPI: To start 60days after first consultation

[2] Challenges:

Inadequate Linear Accelerators and other related

equipments

Insufficient manpower such as clinical oncology, radiation

physicist, therapy radiographer

Hospital Sultan Ismail, Johor Bahru4 QUADRANT

CT Scan and Simulation

To create BDS Mask & Establish Mapping

Mask valid 3 mths onlyTx : ~ 45min/ pt

- MC Frequent Down- MC year (2004)

- Maint. done -Monthly- After process, pat.

went home w/o next treatment date.

- Will inform few days before treatment

available

PlanningOpen File/ Counseling

Set appt. for Simulation –Ave within 2~3wks

-5 Planner Plus 1 Sup.

Computer Planning

-Tech: 3 PhysicistTrack pat status by Excel

segregated by Doctor.-Ave lead time (1-mth) due to Inv: High (80)

-MC: (Ecllipse-3) @15min(Plato -2) @ 45 min

(for Contouring)

1.Contouring by Phy. (15 min)2. PTV by Oncologist2. Planned by Physict (5-8 hrs)3. Approved by Oncologist Send to Planning

Dose Calculation(transfer data and verify)

Cut and paste

Prepare Kad Carta Rawatan (Blue Card)

(30% Rejected / need Re-plan)

1

3

2

4

5

6

7?

?

?

R

Treatment

3 MC (Clinac@ NPC plus 2 Primus)

- #3 Radiotherapist Ave Tx = 15 min/pt

Cap: 35 pt/ dayMC maint- monthly plus cal . Quarterly.

1 NPC pat = 35 #( req.35 days)

Process Flow forRadiotherapy Treatment

… a serial precision complex processesInvolves coordination between various units

Value Stream Mapping – Oncology Radiotherapy treatment

Value stream mapping is a lean manufacturing technique used to analyze the flow of materials and information currently required to bring a product or service to a

consumer.

~ 1.5 mths ~

2.5mths

Convert to Value Stream Mapping (VSM)

http://en.wikipedia.org/wiki/Lean_manufacturing

Kaizen Burst #1 : To increase Clinac machine capacity --> Goal to reduce treatment waiting time from current 10weeks to at least 5 weeks

Kaizen Burst #2 : To reduce backlog files (inventory) from current 120 files to less than 5 files at any station --> Goal to reduce planning work from 6 weeks to 3 weeks

Kaizen Burst #3 : To reduce re-plan works (rework) from 30% to less than 10%

We then identified Kaizen Bursts on areas for improvement

Identification of ConstraintsInternal Assumption: Inadequate machine/ facilities and staff long queue (4mths)

Actual Finding:

Clinac (Qty: 1 unit)

- New machine (10 mths old)- Highly demand because having high capability,

high accuracy, fast speed- Better shielding features- Mostly used for NPC cases (head /neck area)

- Daily new cases = 1/5- Ave treatment = 30 patients/day

Utilization = 8.30am – 5pm @ 30% Only

Primus (Qty: 2 units)

- Old machine (10 years-old)- High downtime/ breakdown- Low capability, accuracy and speed- Limited shielding cannot used for NPC

cases for tumor head/neck- Daily new case = 4/5 @ 2 machines- Ave. treatment = 50 patients/day

Utilization = 8.30am – 5pm @ 25%

Why Clinac waiting time > 4 months

- Every patient must undergoes 35 consecutive treatments @ 1.75 mths- Ave. Machine capacity = 30 patients/ day- Daily there will be 1.2 new cases added to Clinac- Note: Machine operate 8 hrs/day @ 5 day/wk

Finding:

LEAN IMPROVEMENTS

Kaizen Activities conducted atPusat Rawatan Onkologi

Action Items / Counter measure

Check/ Follow-up / Recommendation

Prepared by: Date: 25th Oct 2013 Rev 1.0

Radiation & Oncology Department

HOSPITAL SULTAN ISMAIL JOHOR BAHRU

Kaizen #1 :Title

To increase Clinac machine capacity, Running 2 shifts at Clinac

Background•Clinac Machine only operated from 8am to 5pm (8 working hours)

•Only 4 dedicated Radiation Therapist operating this machine

Current Condition/ Situation

Analysis and Goal•Analysis:

•More patients can be treated if longer duration of machine

utilisation

•Goal:

To optimised utilisation of Clinac Machine

Items PIC Date

1. Discussion between head of Radiation Therapist with all his team members

En Hananan 25th Oct 13

2. To inform Head of Department. En Hananan 14th Nov 13

Current manpower

2 Radiotherapists to handle system console 2 Radiotherapists to handle machine and

patient

Cli

nac

Pri

mu

s M

LCP

rim

us

Kaizen #1 : To increase Clinac machine capacity(Increase Radiation Therapist Skills and Capability)

Cross training was conducted -to privilege (qualified) ALL Radiation therapist (JXRT) to capable handling ALL types of machines.

CLINAC MLC PRIMUS

FAIRUL √ √ √

JAMIL √ √ √

FIFI √ √ √

AZRUL √ √ √

WAN ANUAR √ √ √

SHAFAZAWA √ √ √

BAZILAH √ √ √

ZANA √ √ √

NAIM √ √ √

SHAHIR √ √ √

HANNANAN √ √ √

AZIZAH √ √ √

MD NOOR √ √

ALI √ √

UMAIRAH √ √

100% JXRT Trained and Privileged

Current manpower 1st shift @ 7am -2pm

Kaizen #1 : To increase Clinac machine capacityRunning 2 shifts at Clinac

Cli

nac

Pri

mu

s M

LCP

rim

us

2 Radiotherapists to handle system console

2 Radiotherapists to handle machine and patient


1 Radiotherapists to handle machine and 1 Pembantu Perawatan Kesihatan to handle patient

2nd shift @ 2pm -9pm


1 Radiotherapists to handle machine and 1 “PPK” to handle patient

To increase machine capacity from 30 to 42 pts /day

• OPTIONS:

1) Plan for daily overtime (3 hrs) constraint: physicist to stand-by2) To run 2-shift constraint: inadequate radiation therapist (JXRT – U29)

Note: 1) Limited radiotherapist graduate from Kolej Sains Kesihatan Bersekutu, Sg.Buloh2) New graduate consumed by IKN (Institiut Kanser Negara)

4/7/2016

Month Sept Okt Nov Dis Jan Feb Mac

Plan Capacity 500 600 650 700 800 900 1000

Actual

Session/Mth549 602 652 622 696 803 750

Average

Patient/day27 30 33 31 35 40 33

Remarks Overtime Overtime Overtime 2nd Shift2nd

Shift

2nd

Shift

Kaizen #1 : To increase Clinac machine capacity

Number of Sessions treated on Clinac Machine

Why Planning work takes 1.5 mths

Value Stream Mapping – Oncology Radiotherapy treatment

1) Inadequate radiation oncologist ( Currently 2 Only )2) Inadequate physicists ( currently 5 )3) CT Scan /Simulation for mask making was delayed (2 ~ 3

weeks ) to avoid “mask expiring”

4) Current files backlog (Inventory ) too high .

Actual Finding:

Target : To reduce planning works to 2 weeks; refer A3 Report

4/7/2016

Kaizen Burst #2 : To reduce backlog files (inventory)

Issue on Physicist shortage at

Computer Planning stage .

Due to long medical leave and physicist

occupied more time to solve machine

down.

Month Oct Nov Dec Jan Feb Mac

Plan Qty 100 80 60 55 50

Actual Qty 126 98 86 78 62 50

Number of inventory (Patients in queing) from registration to complete planning (Awaiting Treatment)

All backlogs for Aug, Sept and Oct

2013 have been Cleared !!!

Month Sept Okt Nov Dis Jan Feb Mac

Plan Qty 100 80 60 55 50

Actual Qty 130 126 98 86 78 8 13

Number for Inventory (Patients in queing)- from registration to complete Awaiting treatment

Kaizen Burst #2 : To reduce backlog files (inventory)

Kaizen Burst #3 : To reduce re-plan works (rework) from 30% to less than 10%

BacklogsBy doing

Kaizen Burst #1 and #2

Backlogs Cleared by Mac 2014

Kaizen #4 : For Sustainability

Planning Tracking Sheet (Using Pull System)

Every new case will be registered in Patient’s Trace Record dan Statistic

Notification will be given when the case is due for treatment

Patients Trace Record & Statistic

Kaizen # 5 : PaTRest

• Patrest expanded use of Physics Unit to Unit Planning in June 2015

Sustainability PaTRest System

•PaTRest used in Physics Unit since 2013

•PaTRest improved and updated from time to time

Patients Trace Record & Statistic at Planning

Room using PaTRest

•VISUAL MONITORING

•DIGITAL MONITORING (PaTRest)

•MONITORING CARD & CHECKLIST

•FIFO CARD

•2013•2014

•2014•2015

Kaizen # 6 : Backlog Clearance at Computer planning

25 cases will be approved by oncologist for

treatment every week to reduce backlog

TARGET CHART

Kaizen # 7 : Daily Queuing Patient System

PRIMUS PRIMUS MLC CLINAC

Daily Queuing Patient System

•Small slot boxes represent 15 mins waiting time

•Appointment card

•information• August 2014 ,

applied at Primus MLC

• 2015 this imitative was applied to other treatment machines.

EXTENSION OF SERVICES

• April 2015 Intensity-Modulated Radiation Therapy (IMRT) for Head & Neck and prostate cancer patients.

• July 2016 Stereo tactic Radiation Therapy(SRT) for AV malformation and meningioma

Value Creation Matrix

No. KPI / Value CreationCurrent

indicatorTarget Achievement

1. Reduce waiting time 120days 60days 30days

2. Increase patient survival rate Mortality rateZero while awaiting

for treatment

Until today no patientpassed away while

waiting for treatment

3.Optimizing asset/ machine capacity

8am - 5pm(8 hrs / day)

8am - 9pm(15 hrs/ day)

8am - 9pm(15 hrs/ day)

4.Optimizing human capital utilization

4 RadiationTherapist

3 Radiation Therapist + 1 Pembantu Perawatan

Kesihatan

3 Radiation Therapist + 1 Pembantu Perawatan

Kesihatan

5.Improve Oncology Teamwork and Communication & Creativity

Number of Kaizen

Continuous Kaizen Burstby department

3 New Kaizen has been done ,

1 new Kaizen still pending

6.

Patient/Customer oriented process- Towards PCC (Patient Centered Care)

Basic flow chartVSM – patient process

flow based.

5 minutes standing meeting at Kaizen

Corner continuously perform

Achievements

120

62

57

29.8

26.221.5 16.2

28.7225.37

32 30

21

38 42

0

20

40

60

80

100

120

140

Oct 13

Dec 13

Jan 14

Feb 14

Mac 14

Apr 14

May 14

June 14

July 14

Aug 14

Sept 14

Oct 14

Nov 14

Dec 14

Average Waiting Time For Radical Radiotherapy

Days

•Target

•World Benchmark

AVERAGE WAITING TIME FOR RADICAL RADIOTHERAPY HSIJB

SubjectOct

2013

Dec

2013

Jan

2014

Feb

201431 March

2014

April

2014

May

2014

Average

Waiting Time

For Radical

Radiotherapy

Target :

60days

World

Benchmark :

30 days

120

days

62

days

57

days

29.8

days

26.2

days

21.5

days

16.2

days


SubjectJune

2014

July

2014

Aug

2014

Sept

2014

Oct

2014

Nov

2014

Dec

2014

Average

Waiting Time

For Radical

Radiotherapy

Target :

60days

World

Benchmark :

30 days

28.72

days25.37

days

32

days

30

days

21

days

28

days

42

days

All Types Of Cancer Patients

36 38

31

35

3231

2933

3440 41

42

0

20

40

60

80

100

120

140

Average Waiting Time For Radical Radiotherapy

Days

•Target

•World Benchmark


SubjectJan

2015

Feb

2015

Mac

2015

April

2015

Mei

2015

Jun

2015

Average

Waiting Time

For Radical

Radiotherapy

Target :

60days

World

Benchmark :

30 days

36

days

38

days

31

days

35

days

32

days

31

days



SubjectJul

2015

Ogos

2015

Sept

2015

Okt

2015

Nov

2015

Dis

2015

Average

Waiting Time

For Radical

Radiotherapy

Target :

60days

World

Benchmark :

30 days

29

days

33

days

34

days

40

days

41

days

42

days


Conclusions

• D : 30% Rejection Resolved• O : No Expired Beam Direct Shield mask • W : Waiting Time To Get Treatment achieved

target• N : By Giving Privileging To All Radiation Therapist to

operate Clinac IX• T : No Transporting Patient To Private Hospital• I : Backlogs Cleared• M : PaTRest (Patients Trace Record & Statistic)• E : No Rejection computer planning work

COST EFFECTIVENESS1. No Additional Treatment Machine Required = RM20 million

2. No Overtime Claimed Needed(RM15x 4person)= RM5280/mth

3. Lead Time Improvement = 75%

4. Processing Time Improvement = 75%

5. Saving Cost = 100%

6. Rework Improvement = 100%

7. Backlogs Improvement = 100%

Thank You

Hospital Director : Dr Hj Arbain Bin Lani

Head Of Department : : Dr Mohd Roslan Haron

Team Members :

Dr Khursiah Binti Daud

En Hassan Bin Ali

Pn Halimaton Saddiah Paiman

En Hanannan Bin Kepli

En Mohd Khairee Aripin

Pn Azizah Caroshau

JT Siti Norsiah Ibrahim

KJ Rafi’ah Othman

KJ Zaidah Othman

hospital sultan ismail, johor bahru

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