الفهرس | Only 14 pages are availabe for public view |
Abstract Health care systems are currently facing multiple challenges related to safety,quality, efficiency and the rapid rise in costs. Healthcare providers are under continuous pressure to improve their services by reducing waste and adding value. Variety of methodologies is available for process improvement including Lean management. Implementation of Lean approaches within healthcare has widely increased worldwide. Lean implementation within the ambulatory care setting is seen in the continuous identification and elimination of waste within the process by reducing waiting time, queues, eliminating repeat visits, errors, and inappropriate procedures, reducing the patient walking and increasing patients‘ and staffs‘ satisfaction, identification of bottlenecks that slow health care delivery process, shifting of nonessential activities away from these bottlenecks and generating extra work capacity from the existing resources rather than adding additional ones. The aim of the present study was to study the application of Lean methodology to antenatal care services provided within a family health center in Alexandria. A nonrandomized quasi-experimental pretest-posttest study design was used. The study was conducted in Smouha family health center an accredited family health centers in Sharq district affiliated to MoHP. Antenatal care services are provided through four family medicine clinics, one gynecology specialty clinic, one internist specialty clinic, one dental clinic, a pharmacy, vaccination unit, and the laboratory. The study was composed of three phases for data collection; Pre Lean, Lean and post Lean phase. The Pre-Lean assessment phase was where a brief description of the current state of the antenatal care process was done through observation using structure assessment check lists, human resource assessment check lists, flow charts, spaghetti charts, SIPOC diagrams and time flow analysis. Listening to the voice of the customer through administrating a structured interview schedule to the antenatal care enrollees (210 pre/post Lean) to determine their satisfaction about the antenatal care services they receive. A semistructured interview schedule was used to collect data from 40 internal customers regarding descriptive details about the way they provide antenatal services in order to detect the existence and determine any of the seven Lean waste activities within the provided services. At the end of this stage three problem were prioritized using Pareto charts which were the long waiting time at the family medicine and gynecologist clinics and the delay of medical record distribution. In the second Lean intervention phase a kaizen team was formed of nine members and carried four kaizen meeting; the first was a lecture about Lean methodology tools and principles, in the second and third meetings the current and future value stream maps were depicted and an analysis of the value stream of antenatal care sub process was done, root cause analysis of the prioritized problems using fish bone diagram and the five whys‘ technique was done. In the last meeting, the kaizen team voted using the decision matrix for the long waiting time at family medicine clinics, delay in medical records transfer, disorganized medical record room and long waiting time at the gynecology clinic as prioritized to be solved according to being more frequently occurring, feasibility for improvements to be implemented, importance to be solved and availability of resources. An A3 report was developed and an action plan was set to implement and apply the different lean tools and initiatives for improvement.Counter measures were directed to overcome four areas through the application of eight improvement remedies. First to overcome the medical record transfer problem an application of 5S to the medical record room was done, and organization of the responsibilities and duties about transfer of medical records (booking window, recollected and referral medical records) by manual workers was arranged. Second countermeasure that was based on the queuing analysis of the booking process was to assign an additional employee to the booking office. Third counter measure was to apply an appointment system to the family health clinics and finally measures were applied to increase health care providers‘ punctuality. In the post Lean phase, evaluation of lean implementation was done using predetermined set of indicators in the action plan. The main results of this study could be summarized as follow: Pre Lean phase: For antenatal care initial visits, the longest non-value added mean times during antenatal care sub processes‘ that were recorded were 28.31 min±20.15 the waiting time for registration with range 45 min, 62.30 min ± 38.99 the waiting time for family medicine clinic consultation with range 175 min, and 32.9 min ± 17.63 the waiting time for gynecologist with range 62 min. The mean time for the whole visit duration of 27 antenatal care enrollees with initial visits was 151.70 min ± 45.74 with range 179 min. For antenatal care return visits, the longest non-value added mean waiting times during antenatal care sub processes‘ that were recorded were 64.23 min±36.00 the waiting time for family health clinic consultation with range 145 min and 53.70 min ± 31.26 the waiting time for gynecologist with range 109 min. The mean time for the whole visit duration of 78 antenatal care enrollees with return visits was 124.44 min ± 46.55 with range 176 min. The I control charts for the waiting time for family medicine consultation detected the presence of three data points out of the control limits revealing special cause of variation in the waiting time for family health consultations where patients had to wait more than two hours and 30 minutes till having their consultation. Common causes of variation in the family health consultation waiting time were detected in the form of two data points above 2 standard deviation from the average time where patients had to wait more than 60 minutes. The most common causes of antenatal care enrollees‘ dissatisfaction within the antenatal care process prioritized by Pareto charts were the long waiting time at family medicine clinics, delayed medical record transfer and long waiting time at gynecologist clinic. The most common Lean wastes mentioned by the internal customers within the antenatal care process prioritized by Pareto charts were the delayed medical record transfer, long waiting time at family medicine clinics, delayed release of medical records from medical record room, delayed transfer of referred medical records, insufficient work force, long waiting time at gynecologist clinic and the unpunctuality of family medicine staff. The value added time for antenatal care enrollees with initial visits was 44 minutes, the lead time was 192 minutes and the process cycle efficiency (PCE) was 21.87%. The value added time for antenatal care enrollees with return visits was 61 minutes, the lead time was 222 minutes and the process cycle efficiency (PCE) was 37.30%.Post Lean phase: For Lean antenatal care initial visits, the longest non-value added mean times during antenatal care sub processes‘ that were recorded were 41.67 min ± 27.04 for waiting till having family medicine clinic consultation with range 80 min and 49.15 min ± 26.66 waiting time for gynecologist with range 80 min. For Lean antenatal care return visits, the longest non-value added mean times during antenatal care sub processes‘ that were recorded were 21.94±20.47for waiting till having family medicine clinic consultation with range 95 min and 35.26±26.31waiting time for gynecologist with range 91 min. The mean value added and non-value added times for initial visits of antenatal care sub processes showed a significant decrease in non-value added time taken for ticket booking (P= 0.002) to 1.81±1.30min, waiting at family health consultation (P=0.019) to 45.89±25.42 min. Regarding the value added times there was a significant increase in the family health consultation duration (P= 0.020) to 11.4±4.32 min, a significant decrease in the total laboratory investigations (P= 0.001) to 9.81±3.84min, medication dispensing from pharmacy (P= 0.009) to 3.50±1.93 and there was a significant decrease (P= 0.000) in the total visit duration to be 92.59±28.08 min after being151.07 ±45.74 post Lean implementation. The mean value added and non-value added times for return visits of antenatal care sub processes showed a significant decrease in non-value added time taken for ticket booking (P= 0.000) to 1.73±1.314, waiting at family health consultation (P=0.000) to 23.62±20.031min and waiting for gynecology specialist (P= 0.018) to 35.26±26.31min. Regarding the value added times there was a significant decrease in the family health consultation duration (P= 0.005) to 10.36±4.279 min, the total laboratory investigations (P= 0.000) to 9.22±2.76min, vaccination (P= 0.021) to 3.71±1.63 min, medication dispensing from pharmacy (P= 0.000) to 3.52 ± 1.73 min and dental consultation duration (P= 0.053) to 2.17±0.71 min and there was a significant decrease (P= 0.000) in the total visit duration to be 60.95 ±27.75 min after being 124.44 ± 46.55 min post Lean implementation. For initial visits, the lead time for a complete antenatal care visit with all sub process decreased to 164 minutes with 49 minutes value added time and the process cycle efficiency was 29.87%. For the return visits in the post Lean phase, the lead time for a complete antenatal care visit with all sub process decreased to 126 minutes with 47 minutes value added time and the process cycle efficiency was 37.30%. There was a significant increase in antenatal care enrollees‘ satisfaction level for medical record transfer (P=0.000) with 85.2 % enrollee satisfied and there was a significant increase in antenatal care enrollees‘ satisfaction level regarding the waiting time for family health consultation (P= 0.000) with 76.2 % enrollee satisfied. Steps saved during the antenatal care visits were 242 footsteps=184 meters walked per visit.Based on the results of the current study, the most important recommendations include the following: 1- Institutional application of a mixed registration- type individual block appointment system for the family medicine clinics where all scheduled patients will be assigned unique appointment times spaced and distributed over the working hours during morning and evening shifts. 2- Extension of application of a mixed type appointment system to the specialty clinics to maintain continuity of care. 3- Organization and arrangement between scheduled and unscheduled walk-in patients for their order to enter their visits. 4- To increase health care provider‘s punctuality, it is recommended that punctuality be one of the evaluation factors of health care providers to motivate them to be more on time, more strict managerial penalties are recommended to adjust physician‘s arrival as well as the application of a finger print device. 5- To avoid queues and crowd hour‘s three booking employees should be assigned in position at the booking office during the morning shift. 6- The medical record transfer duty assigned and distributed among the manual workers should be maintained under continuous close supervision. 7- Standardization and sustainably of 5S methodology in the medical room and extending its‘ application to other offices within the center. 8- Standardization of antenatal care visit and standardize the number of gynecologist referrals by not exceeding the indicated number of ultrasound imaging during antenatal care to avoid the long waiting time at the gynecology specialty clinics. 9- Training and workshops on Lean methodology is needed to be applied to the largest number of employees and health care providers in order to be able to allow Lean cultural transformation where the focus should be on developing and sustaining a Lean philosophy and avoid using Lean as an initiative for short term isolated Lean improvement projects. 10- Provision of the sonicate device, antihypertensive drugs, vitamins and iron supplements and laboratory kits to overcome its continuous shortage and maintain compliance. |