emergency department non- critical zone (& internal ...€¦ · tengku ampuan rahimah hospital,...

Sharing Experience With

the Implementation of LEAN at

Tengku Ampuan Rahimah Hospital

Klang, Malaysia

Dr Ahmad Tajuddin Mohamad Nor Emergency Physician

Ministry of Health Malaysia

Patient Congestion:

Emergency Department Non-

critical Zone (& Internal

Medicine Wards)

LEAN HEALTHCARE HANDS-ON WORKSHOP (LEAN HOW) AND SHARING LEAN HEALTHCARE BEST PRACTICES 2016 Malaysian National Productivity (Kelantan) 11 April 2016

Tengku Ampuan Rahimah Hospital,

Klang, Selangor

Selangor - Located 39 km west from KL city centre; Malaysia’s most developed state and most densely populated:

Area: 8,153 km2

Stretches 170 km from east to west and 180 km from north to south at its longest points.

Population: 5.1 million (2010)

3 major highways, train and

commuter services linking it to KL

Klang – royal town, former cap. of Selangor

Kuala Lumpur International Airport

Port Klang (the busiest port of Malaysia)

HTAR population catchment: 1.2 Million

2

Operational - 1985 Size – 1094 beds Rank – 2nd Busiest in Country Type • State Specialist Hospital • Referral Hospital • Teaching & Training Hospital

Service Provision

• 48 clinical specialty / subspecialty

• 16 clinical supports

• Teaching & Training

• Research

Staff 4,025 (89%) Budget RM 352 million

Operational - 162 M

Emolument - 190 M

Achievements ISO 9001:1998 Certification

GRED A – Performance Indicators

Medical Programme

Baby Friendly Hospital GMP (Dietetics)

INTRODUCTION

3

Critical 3.15% – 3.3%

Non-critical/ Green Zone

Non-critical – 69.7% - 78.5%

Semi-critical - 18.2% - 27.18%

EMERGENCY DEPARTMENT

Working Days Weekends / PH

3-8pm. 7-10 am.

Fast Tract

Green

CaRSS

Fever

OSCC

Daily

420-450 pts.

Normal 3.4 min / pt.

Peak 1.7 min / pt.

33-35 admission

Mean Wait Time –

3 hrs. 17 min.

2nd Busiest in Country

Annually - 220,175 pts.

Daily - 603 patients

7-11 pm. 2-4 pm

Mean Wait Time Non-Peak – 2.06 hr., Peak – 5.19 hr.

Mean Wait Time Non-Peak – 2.19 hr. Peak – 5.17 hr.

4

7209

9372

10725

14418

19711

29119 32002

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

1985 1990 1995 2000 2005 2010

MEDICAL INPATIENTS

BUSIEST in Country 2013– 33,002 admissions (91 daily) 362 beds (initial 160 beds) BOR – 135%, ALOS – 3.59 days

Medical Admissions

5

CHALLENGES

Patient

Pressure

2ND BUSIEST hospital in the COUNTRY

Admissions - 95, 295 (261 daily)

Emergencies – 220,575 (603 daily)

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

Facility

Congestion

763 1094 beds (>43.4%)

Bed Occupancy Rate – 100 %

6

UK 2.9

Singapore 2.0

Japan 13.3

BED TO POPULATION

RATIO

Beds per 1000 Population

Selangor 1.53

Hospital 1.9 (1990) 0.5 - 1.1 (2010)

Target

2020

2.5

Nation 1.92 (Range 1.27 – 4.4)

7

When the outcry came: Malaysian Emergency Departments in crisis…

Star, Sunday

16 Feb 2014

8

MEDIA REPORT – Hospital Congestion ALARM BELLS HAD BEEN RINGING A LONG WHILE….

9

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

10

The Honorable Minister of Health and higher management team

MOH visited HTAR February 2014 on ‘fact finding mission’

11

HOD

Emergency HOD

Medical

• Your current Quality Assurance & Quality Improvement initiatives in the department (hospital) is not enough to take us forward

‘Sorry Doc. Don’t take this too

personally. Sometimes it does

not matter what you think but

the customer (patient)’

12

Collaboration with PEMANDU (Performance

Management and Delivery Unit, Prime

Minister’s Department) and partners

Methodology to be used:

LEAN for Healthcare Improvement

Design Thinking for an improved patient

emotional dimension

Rx:

13

EMERGENCY SERVICES

Improving patient congestion at Green Zone by reducing patient throughput time

70% of non-critical patients will leave the Emergency Department within 2 hours

Reducing Patient Length of Stay at Non-Critical Zone at ED

KPI

Aspiration

1. Workload Levelling (Policy)

2. Work Process Re-engineering (Operational)

Strategy

14

15

Lean?

Who best finish a marathon run (42.19km)?

16

Who best finish a mountain climb?

17

18

Lean organizations use:

less human effort to perform their work,

less material to create their products and services,

less time to develop them, and

less energy and space to produce them

while maintaining an unrelenting focus on providing

customer value.

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

N Non-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

19

20 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 In

Referral

(7.5 – 10%)

A Patient’s Journey in Emergency Department…

Own

transport Ambulance 999

(5-7%)

‘WELL’

Green

Zone

65% of patients

Primary

Triage

(Screening)

1.0 min/pt.

2.

Registration

& Payment

3.8 min/pt.

4

1. Drop Zone

ED

Red

Zone Yellow

Zone

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

Queue

Queue

Queue

Queue

Queue

Queue

Queue Queue

Queue

…… 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 minutes 139.6 - 154.7 minutes

WASTE: (70-91%)

80-85%

20

The BOSS of the

Emergency Department is the

Emergency Physician

Really?

21

22

Hospital

Manageme

nt:

IT Dept Registration &

Bill Payment

Unit

Heads of Non-

Clinical

Department/

Unit:

Heads of

Clinical

Department: Radiol

ogy

Pathol

ogy &

Lab

Emergency Department - Process Relook: Line owners

Community Private

Hospitals/

Clinic Govt.

clinics

Govt.

hospita

ls Prehospital

Care and

Ambulance

Services service

Family

Medicine

MOH HQ:

Quality Unit

Policy Unit

Health

System-

Research &

Dev

PRIME

MINISTERS

DEPARTMEN

T

Hospital

Admission

Unit Specialist

Clinic

(Hospital)

Nursing

Managers of

In-patient

Wards Pharma

cy Dept PORTER

AGE

ED Department

Staff

PR

Unit

Engineers:

Facility

Managers

Other Dept/ Unit

Staff

Quality

Unit

HOSP VISITOR

BOARD

PORTER

AGE

Emergency Department - Process Relook

23

End

Start

INPUT THROUGHPUT

OUTPUT

ED – as a product (processing) line with problems?:

Emergency Department - Process Relook

24

End

Start

INPUT THROUGHPUT

OUTPUT

Medical

The whole experience as a

manufacturing line:

End

Start REGISTRATION

SECONDARY TRIAGE

CONSULT INVESTIGATE TREAT

DISPOSITION

PRIMARY TRIAGE

INPUT THROUGHPUT

OUTPUT

Emergency Department - Process Relook: Existing Lead Process

25

Drop zone

/ Primary

triage

Secondary

triage Outpatient

registration

& payment Consultation

Disposition

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

Inpatient

bed ready

R R Y Y

G G

Emergency Department - Process Relook - LINEAR

26

Drop zone

/ Primary

triage

Secondary

triage Outpatient

registration

& payment Consultation

Disposition

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)

Inpatient

bed ready

1

2

3

R R Y Y

G G

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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 LEAN PRE-LEAN

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WE would like to share what WE did….

In ED

29

End

Start REGISTRATION

SECONDARY TRIAGE

CONSULT INVESTIGATE 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

‘Q’ (CUE, QUEUE) BOX

“NEXT-PATIENT” WAITING CHAIR

CENTRALISE PORTERRAGE

COORDINATED SPECIMEN DISPATCH

PNEUMATIC TUBE

RADIOLOGY UPGRADE

LABORATORY UPGRADE 30

31

• 65% of emergency department

attendance are stable patients

including non-emergencies

• They come from various

communities nearby HTAR

Klang and often by-passing

nearer Klinik Kesihatan.

Source of patient in relation to

nearest Klinik Kesihatan (community clinic)

Klinik Kesihatan in

Red are the most

relevant

INPUT

1. Drop Zone & Primary Triage

Increased number of Klinik Kesihatan

extended hours (resource leveling):

PRE-LEAN Waste

32

INPUT

Outcomes/ Impact




Total 5 additional Klinik Kesihatan had opened extended hours

POST LEAN Kaizen Burst

PRE-LEAN Waste

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

Date of 2 KKs beginning extended hours operations – 15 July

33

Outcomes/ Impact





INPUT

• All admissions from klinik kesihatan must go through ED.

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

34


Improved Referral Process with clinics


PRE-LEAN Waste

INPUT

34

35

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

• 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


Improved Referral Process with clinics


INPUT

• No directional floor map to guide patient journey in ED

36

INPUT


• Location Map at various points to guide patient journey


PRE-LEAN Waste

36

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

37

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


PRE-LEAN Waste


Process steps summary on back of receipt

INPUT

Documents need to be manually carried

from Primary Triage to Secondary Triage

Primary Triage to Secondary Triage

Secondary

Triage

& Waiting

Area

Document Window


PRE-LEAN Waste

THROUGHPUT

38

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)

Inpatient

bed ready +

Consultation

Secondary

Triage

& Waiting

Area

PRE-LEAN Waste


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

39

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%

Outcomes/ Impact

Secondary Triage See And Treat Monthly

40

Triage – Early Intervention 2. Secondary

Triage & Waiting Area

THROUGHPUT


Overcrowded patient in Green

Zone overflow to adjacent canteen

41

Secondary

Triage

& Waiting

Area

PRE-LEAN Waste


Canteen

ED

THROUGHPUT

41

No system to call patients

waiting in canteen

…create link to call system for canteen

QUE Caller

System in

Canteen

Secondary

Triage

& Waiting

Area


PRE-LEAN Waste

QUE Caller

System -

Green Zone

Waiting Area

THROUGHPUT

42

• Two separate systems exists for Out-Patient and In-Patient (Admission) Registration

43

• Integrate Out-patient and In-patient registration systems


PRE-LEAN Waste

THROUGHPUT

Integrate Out-patient and In-patient

Registration System

2. Secondary Triage & Waiting Area

• 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

44

PRE-LEAN Waste

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

• Increase ability to handle 4 registrations at anytime


Co-locate counters 3. Registration

THROUGHPUT

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

45

• Put next patient

chair outside the

consultation room.


PRE-LEAN Waste

Next – in line chair 4. Consultation,

Investigation & Treatment

THROUGHPUT

Outcomes/ Impact

Month 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 secs 243,000 (67.5)

June (from 3rd June)

5890 4 secs 23,560 (6.5) 61

July 6045 4 secs 24,180 (6.7) 60.8

August 5550 4 secs 22,200 (6.1) 61.4

September 5475 4 secs 21900 (6.1) 62.4

October 5246 4 secs 20984 (5.8) 59.7

46


Next – in line chair 4. Consultation,


THROUGHPUT

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

47

PRE-LEAN Waste

Install ‘Q’ (Cue, Queue) Viewer 4. Consultation,


THROUGHPUT

5 ‘S’ Principle – SORT, SEPARATE

Waiting since

0800

Waiting since

0900

Waiting since

1000

(current time)

Hour slots of the

day

Easy & At-a-glance monitoring of wait

time post consultation!

Wait-time handover at shift change!

48

Install ‘Q’ (Cue, Queue) Viewer 4. Consultation,


THROUGHPUT

• Patient wait time Q (Cue, Queue) Viewer Box in all consultation rooms


• Lab specimens are generated at multiple sites

• Sent in uncoordinated way

49

Zon Hijau

Zon Kuning

Zon Biru

Centralized specimen collection point and

porterage

4. Consultation, Investigation & Treatment

THROUGHPUT

• Centralized collection point

• Collection schedule every 30 minutes


PRE-LEAN Waste

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

50

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

PRE-LEAN Waste

Revitalize pneumatic tube system 4. Consultation,


THROUGHPUT

• Revitalization of pneumatic tube services

51

ED

Laboratory Radiology

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

Tube Biochemistry 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%


Revitalize pneumatic tube system 4. Consultation,


THROUGHPUT

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

• Inter-ward variation: ie medical versus surgical wards

0600 1200 1800H 0000

No

. of

pat

ien

ts

Time

Discharge/ Depart from Ward

Patient

Attendance

(and Admission)

in ED

Discharge > Admission Empty beds available; access

time to in-patient beds SHORT

Admission > Discharge No beds available;

CONGESTION, LONG waiting for

beds Admission = Discharge DESIRABLE

52

OUTPUT

5. Disposition

PRE-LEAN Waste

53

Selepas

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

Bedwatcher System (App)


OUTPUT

5. Disposition

• 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

55


Appoint Bed Manager and admission

coordinators

OUTPUT

5. Disposition

56

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

• Work morale in Yellow Zone was low

PRE-LEAN Waste

5 S in Yellow Zone

6. Others

57

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

5 S in Yellow Zone

6. Others


Department institutionalization efforts:

– Train a LEAN buddy (ies)

– 5 S day – every first Tuesday of the month

– Spot a waste? Tell/ Share your ideas

Expansion:

– Involvement of the other disciplines and wards

– Day Care Services – to use the framework from other MOH

centres for matching services

– Institution wide use of the bed watcher system

Ways forward – Emergency

Department/ Services

LOCAL

58

16

Hospitals

16

Hospitals Other

Hospitals

Incubation phase

“Anchor” hospital

(HTAR)

“Ideal ED & MW” template –

ready for photocopy

MW

ED

Ways forward – Emergency

Department/ Services

NATIONAL

59

HTAR is the anchor hospital for the design of Ideal

Emergency Department & Medical Ward…

Bersama, kami telah lakukannya!

60

61

Wishing you an exciting LEAN journey

62

Hospital Tengku Ampuan Rahimah Klang

together with

KKM, PEMANDU, UniKL

had captured our LEAN and Government Transformation Program

journey in 3 video clips.

Drop me an email, I can send you links to them.

[email protected]