the lean initiatives to transform the a&e in htar
TRANSCRIPT
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
4
• 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.
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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
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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
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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
Outpatient registration & payment
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
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• 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
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1. Drop Zone & Primary Triage
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
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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
1. Drop Zone & Primary Triage
Before
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INPUT
After• Refined KK-ED processes with FMS
1. Drop Zone & Primary Triage
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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
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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
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1. Drop Zone & Primary Triage
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
Outpatient registration & payment
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
Kaizen BurstKaizen BurstPRE-PRE-LEANLEANWasteWaste
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
Kaizen BurstKaizen BurstPRE-PRE-LEANLEANWasteWaste
THROUGHPUT
Before• PRO counter not visible • Limited operational hours• Floor ambassador function
just limited to Green Zone
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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.
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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
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4. Consultation, Investigation &
Treatment
THROUGHPUT
• Haphazard piling of case notes and large numbers of patient files make time tracking difficult after initial consultation
Before
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4. Consultation, Investigation &
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
4. Consultation, Investigation &
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
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4. Consultation, Investigation &
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
Kaizen BurstKaizen BurstPRE-PRE-LEANLEANWasteWaste
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
Kaizen BurstKaizen BurstPRE-PRE-LEANLEANWasteWaste
THROUGHPUT
• Lab specimens are generated at multiple sites
• Sent in uncoordinated way
Before
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4. Consultation, Investigation &
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
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4. Consultation, Investigation &
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
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4. Consultation, Investigation &
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
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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
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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!
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THANK YOU
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