Processes Optimisation in Public Health: Gauteng

SAIIE Online Webinar

Date: 28 July 2022

14h00 to 16h00

Presenters:

David Kruger

Mosia Ngaka

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Waiting time for patients

According to Einstein…………..

“The onerous nature of the South African health-care landscape, against a backdrop of management ineptitude and governance failures, necessitates the adoption of contemporary health-care management approaches which are shown to be effective for operational efficiency within resource constrained environments.”

LOGANDRAN NAIDOO (UKZN)

Journal of Contemporary Management

Volume 18 Issue 1

2021

Pages 407-432

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BACKGROUND

• Hospital project commenced in 2016
• All three target hospitals was on the East Rand. Then moved to Central Gauteng. Found same issues all hospitals
• Management complained about long queues and messy paperwork
• My colleague and me visited the hospitals for first observations.
• The entrances to the hospital allow direct access to patient waiting area
• What we saw was disturbing
• Patients were packed in waiting area. Some waiting for files while others waiting to consult with a clinician.
• A large percentage were old people and many of them you could observe was unwell

BACKGROUND (CONTINUED)

• Combined in the group of waiting patients, is patients known as chronic patients. Had chronic ailments and need constant supply of drugs
• Had to wait just as other patients even though only purpose is collection of their monthly medication
• The other group of chronic patients was waiting to consult a clinician to renew their 6 monthly script
• Informal questioning reveal that many of the patients arrived as early as 5h00 to be first in the queue. If they are early enough night shift clerks would assist them
• First point of visit is to submit blue hospital card as evidence they are outpatients at the hospital. At this point cards are batched. Collecting 20 cards, then clerks will remove patient files
• Literally the staff commence hunting for patient files

BACKGROUND (CONTINUED)

• Filing is not done regularly and filing done incorrectly
• Easiest solution is to open a duplicate. Some patients told us they have at least 5 files. Not one of the files contain their full medical records.
• The clinician is flying blind because of a lack of patient history
• Questioning the patients how long they spend in the queue, the average was 10 hours before they could leave
• Queues were evident throughout the processes
• Another bottleneck was the pharmacy
• Files were collect from patients and dump in a stack on a table.
• 3 pharmacists were consulting with patients while medicines were collected from shelves by??????????

Conclusion

Hospital is a complex System

1.The hospital is complex system that requires optimization of mechanisms to handle patient needs which are the inputs to the system. We need to manage our technical medical response to the service demands and to medical service provision systems that responds to the patient needs.

2. The designed system must be the planning matrix, design attributes, the technical response and the interrelationships management in the hospital. This include the relationships between the patient and the medical staff patient journey design attributes.

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3. IF the WHO health system framework followed, will have the following outcomes:

• Improved health
• Responsiveness
• Social and financial risk protection
• Improved efficiency

4. The focal point of the improved system is the people, good governance, Good information system, Resources optimization (ensuring financial well-being) and therefore a high service delivery rate.

5. Ability to source good medicines and technologies (through SC logistics)

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Maslow’s Hierarchy of Needs

The Route to Optimisation

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1.The six building blocks of a health system: (a) service delivery; (b) health workforce; (c) information; (d) medical products, vaccines, and technologies; (e) financing; and (f) leadership and governance. Thus, a hospital Complex system ( Ice Berg phenomenon)

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2. Efficient function a system view is indispensable

3. Medical ward is a demand system paradigm (4M control system)

4. 4M are Manpower; Machine; Money (e.g. resources); Material(e.g. Medical supplies)

5.In execution of a healthcare service the 4Ms are integrated and controlled by management. Thus a system approach is required.

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6. The number of patients coming into the system is higher than the capacity available in the hospital Therefore, the patient journey needs to be optimized.

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7. Optimization means streamlining medical processes; increasing throughput, Creating SOPs; removal of systems waste; Reducing waiting lines; Reducing service process times; Optimizing Beds management; Optimizing staff utilization; streamlining support services e.g. radiology.

Gaps in the system

• Communication – Working in Silos, stress and burnout increase risk of errors
• Assumptions – The Responsibility or Function lies else where, expect same outcome for the same activity
• Perceptions- errors of perception, seeing, hearing and feeling of something that is not there
• Lack of an integrated approach and patient centeredness

Shingo Model

Shingo Triangle

The Shingo Price

Shingo/Lean Six Sigma Methodology

Two dimensional Kano Model

Measuring customer satisfaction and dissatisfaction

Percentage

Time line

Delighters

Basic

Satisfiers

1

2

3

Cynefin Frameworks PowerPoint Template

Disorder

Domains of the Cynefin model

• Simple - The relationship between cause and effect is obvious to all:
• Known knows
• Questions and answers exist
• Clear cause and effect
• Repeating patterns
• Procedures, standards, processes, protocols and manuals exists
• A clear enough future

Domains of the Cynefin model (Continued)

• Complicated – The relationship between cause and effect requires analysis or some other form of investigations:
• Known unknowns
• Questions and several right answers
• Expert’s domain
• Procedures, standards, processes, protocols and manuals exist
• Alternate future

Domains of the Cynefin model (Continued)

• Complex – The relationship between cause and effect can only be perceived in retrospect:
• Unknown knows
• Unpredictability
• No questions and answers – become clear in hindsight
• Emergent patterns
• Many competing ideas

Domains of the Cynefin model (Continued)

• Chaotic – No relationship between cause and effect at systems level:
• Unknown knows
• High turbulence
• Questions and answers do not exist
• No clear cause and effect
• True ambiguity

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Domains of the Cynefin model (Continued)

• Disorder -There are total disorder in the system where normal procedure will not suffice:
• Try and find different points of view
• Most individuals interpret central space (disorder) according to their own preferences
• If comfortable with stable order, wants to create or enforce rules
• Experts – conduct additional research and accumulate new data
• Politician – Seek to increase effectiveness
• Dictators – eager to take advantage of the chaotic situation and seek absolute control

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E

ENVIRONMENT

Availability of Staff, Medicines

Response time of trouble/incident, Time to solution and/or conclusion�

O

OWNER

The custodian of the system and/or process

W

WORLDVIEW

Managing the customer industry, with the available resources and constrain

T

TRANS-FORMATION

This is the entire process from arrival until departure with correct diagnosis and medicine

Upon discharge patient cured

A

ACTORS

The people rendering the treatment

People in the system other than clinicians

Treatment by nurses and other medical staff

Food distribution

C

What are the patients needs

Ensure it is understood to direct them to correct treatment centre

One size does not fit all

CUSTOMER

Arrival Rate

Patient Demand for service

Patient Info Admin

Admission and

Medical Process

Discharge

Incoming

Rate

Release

Rate

Service

delay

Patient released

Disenablers

Enablers

Quality defect elimination process

Process execution and confirmation

System Dynamics of the Patient Journey

Bottle Neck

And

Execution failure

Beds, Medical Staff

Process failure, Bottlenecks, no execution, no capacity& capability

System Engineering management

Optimization

Patient Arrival and

Patient Info Admin

Work Flow in the system

[Demand Management integrated Capacity Plan]

Patient Admission

Medical service

Process execution

Patient discharge

1.Does the level severity require admission?

2. Is there capacity in terms of the required staff compliment?

3. Is there a capability to handle the demand (Resources)?

4. What is the PI index of the section

5. Are there standards service requirements e.g. LOS, SOP, etc.

1. Beds availability
2. Targeted LOS
3. Confirmation of service records
4. Value stream Map
5. Reduce waiting time and reduce waste plans

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1. Standardized work method
2. elimination and reduction of operating errors
3. Daily accountability implemented
4. Control system implemented
5. Visual management and Process confirmation

Bottleneck

formation

Service Delivery

Failure & Increased LOS

Long waiting lines

formation

Clinic closure

Poor service management & increased waste

Poor Service deliver Plan

Lewin's Change Management

What is Lean ?

Define Value.

Lean Principles

Map Value Stream.

Create Flow

Establish Pull

Pursuit Perfection

End of the Journey.

The commencement of the Lean Adventure.

The Kaizen Philosophy

• Derived from Japanese - Kai meaning “change” and Zen meaning “good”
• Hence, interpret to mean improvement
• Approach that motivates people to continually improve their surroundings
• Small changes to correct them as part of their ordinary work routine
• Small steps, building on each other over time, lead to significant ongoing improvement
• Working with Deming and other consultants, Japanese industries created several new management approaches, one of which was Kaizen
• W. Edwards Deming famously said “It is not enough to do your best, you must know what to do, and then do your best
• In Western mindset the kaizen is done top down – I tell - you do as I say

The Kaizen Philosophy (Continued)

• Some common elements of Western business philosophies are:
• Managers assess reports and issue decisions
• Employees are expected to follow procedures
• Innovation comes from the designated “innovators”
• Final quality comes from strong initial design
• Reliability comes from fail-proof machines
• Large inventories are kept to prevent shortages
• Specialization is important because “redundancy” means “someone’s losing a job”
• Changes to the system are declared by the powers that be in response to something going wrong

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The Kaizen Philosophy (Continued)

• Under Kaizen, some of the common elements of business philosophy change drastically:
• Managers see how things are done, organize, and implement changes
• Employees are expected to offer improvements to procedures
• Innovation can come from anyone with an idea
• Final quality comes from attention at every step of production
• Reliability comes from good maintenance processes�Small inventories are kept to reduce waste; production problems should be caught and resolved before a shortage arises
• Specialization is useful, but understanding “before” and “after” gives extra insight (making each employee that much more valuable)
• Changes to the system are made constantly, in small steps, at every level of the company, to achieve ongoing improvement

The Planned Optimisation Journey

Bridge Diagram Risks Involved

RISK

FUTURE STATE

Actual Work Process

05

04

03

02

01

New process firmly established.

Second time measurement

Apply 21 days methodology.

First time measurement for improvement

Deicide improvement tool(s).

Start improvement

Study selected area to be improved

House of Lean

House of Lean

The central principles of healthcare Optimization

Continuous improvement - Lean is an approach built on continuous improvement. Lean healthcare means developing a culture of constant improvement in which leaders are continually raising the bar to drive more value.

Value-creation - The ultimate goal of Lean is to provide more value from the patient's perspective -- focusing not just on what we do, but also on what the patient is trying to achieve in terms of health goals.

Unity of purpose - Lean can unify teams around shared goals and desired outcomes.�

Respect for the people who do the work - Healthcare leaders must empower front-line workers to drive positive change, supporting and coaching them, when needed, in a collaborative way.

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Visual management - Visual management tools help Identify problems, provide easy access to data, and serve as places for communicating concerns and new opportunities.

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Root cause problem solving - In the context of Lean, workers must identify root causes of problems and change standards to optimize processes.�

Eight Wastes of Lean in Healthcare

1. Defects/Mistakes

The waste of defects includes the time spent creating a defect, reworking these defects, and inspecting these defects:

• Misdiagnosis
• Administration of incorrect medications
• Hospital-acquired infections and other harm
• Incorrect codes entered

2. Waiting

Waiting in healthcare is a problem for both patients and Hospital:

• Patients in waiting rooms (or exam rooms)
• Emergency department patients and physicians waiting for test results
• ED patients waiting to be admitted to the hospital

Eight Wastes of Lean in Healthcare (Continued)

5. Over-processing

Over-processing means doing more work, making it more complex or more expensive than is necessary. It takes the form of:

• Ordering complex diagnostic imagery (MRI) when a simpler method would suffice (X-ray or physical therapy)
• Surgical intervention instead of an equally effective medical alternative
• Treatment by specialists that primary providers could do�

6. Inventory

Healthcare organizations seek to minimize inventory to reduce costs related to storage, movement, spoilage, and wastage. 

• Medication that may expire
• Overstocked consumables
• Excess bedside equipment

Eight Wastes of Lean in Healthcare (Continued)

7. Motion

Motion refers to the unnecessary movement of providers and staff within a facility or campus. This happens when:

• Office or hospital layout is not consistent with workflow
• Supplies are not stored where patient care occurs
• Equipment is not conveniently located

8. Human Potential

Some early sources in the Lean literature refer to 7 wastes of Lean. In recent years, though, most publications have started referring to the eighth type of waste—failing to utilize people's talent or human potential. Examples include:

• Not listening to employees
• Pressuring people to hide and cover up problems
• People habitually working below their level of competence

Kaizen – Three Major Types of Waste

Ohno Circle Template for Ohno Chalk Circle Template for PowerPoint

Ohno’s Chalk Circle

• The Toyota Production System (TPS) mainly develop by him.
• TPS can thus be seen as a proxy for lean production (manufacturing)
• His famous chalk circle was developed to teach new employees the production line. Usually new engineers commencing work at Toyota.
• They had to stand in the circle between 30 – 90 minutes and observe the line. Must make notes of their observations.
• The instruction given to the engineer was simple: “Watch!”
• At the end of the period, Ohno would come back and asked the engineer what he observed.
• If the answer were unsatisfactory, he required another period of observation

Ohno’s Chalk Circle (Continued)

• Firstly, the human mind is incapable to absorb large amounts of information
• Secondly, everything is not happening simultaneously
• Thirdly, focus on a small part of the line. Understanding of the line happens over a long time
• The following steps must be taken:
• Simply walk through the shop floor. Managers will practice their deception tactic: “How to Misguide your Visitor”
• Observe a few cycles. This will occur in the 30 – 45 minute interval alluded to earlier.
• Thereafter, do an entire shift of between 4 – 8 hours
• Record observations over multiple days

The Gemba walk

• Genchi Genbutsu literally translates "real location, real thing”. Observe work being done onsite.
• It is also known as go and see.
• Hence, to truly understand the work being carried out, one needs to observe what is happening at the site where work actually takes place.
• Known as the Gemba. One definition is that it is "collecting facts and data at the actual site of the work or problem
• Genchi Genbutsu is, therefore, a key approach in problem-solving. If the problem exists on the shop floor then it needs to be understood and solved at the shop floor.
• Since real value is created at the shop floor in manufacturing, this is where managers need to spend their time.

5 Whys Causality Root cause analysis Map

Why?

Why?

Why?

Why?

Why?

Why?

Waiting

Time

Excessive

Process

[PPP]

HR

Material

Environment

Policy on Breaks

Workload Mngt

Labelling and dispensary

SOP

Communication

Medicine files

House keeping

Service-scape

Cubicle privacy

NCS

E-Systems e.g. RX

Ergonomics

Security

Space/Layout

Demand Plan

Materials/Stock

Management

Asset Life

Cycle mngt

Security

Workload

Mngt

Supervision

Work distribution

Staff shortages

Work duplication

Policy

Pharmacy Fish Bone

Kanban - Push vs Pull

Requirements

Design

Build

Test

Pull

In this instance the work station will pull enough work to fulfil their immediate need. No excess material

Requirements

Push vs Pull PowerPoint Template

Value!

Design

Build

Test

Push

In this instance the downstream operation push as much inventory to clear their operation of WIP without a concern for the capacity of the following operation

Requirements

Rowing Different Directions Concept

Try and achieve own goals and targets

Try and achieve own goals and targets

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6W Model of Customer Analysis Slide Template

W1

W3

W2

W5

W6

W4

6W

Model