2. The HTAR Emergency Department
LEAN Team
Presented by:
Dr Ahmad Tajuddin Mohamad Nor
Emergency Physician
3. 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
5. • ED performance is grossly inferred
by many from the ‘response times’
including ‘patient waiting times’
• Non-performance may have life
determining consequences
6. 6
• When the outcry came:
Malaysian Emergency
Departments in crisis…
Star, Sunday
16 Feb 2014
7. 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
8. • 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
9. • 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)’
11. UK 2.9
Singapore 2.0
Japan 13.3
BED TO POPULATION RATIO
Beds per 1000 Population
BED TO POPULATION RATIO
Beds per 1000 Population
Hospital 1.9 (1990) 0.5 - 1.1 (2010)
12. 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.
13. •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 CONGESTIONCAUSES 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
14. • Collaboration with PEMANDU
(Performance Management and Delivery
Unit, Prime Minister’s Department)
• Methodology to be used: LEAN for
Healthcare Improvement
Rx:
15. PROJECT FRAMEWORK AND PROGRESSPROJECT FRAMEWORK AND PROGRESS
Implementation of
Kaizen improvement
activities
16. What is LEAN
The 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.
17. 17
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
18. 18
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. 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. 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 In
Referral
(7.5 – 10%)
A Patient’s Journey in Emergency Department…
Own
transport Ambulance 999
(5-7%)
‘WELL’
GreenGreen
ZoneZone
65% of patients
Primary
Triage
(Screening)
1.0 min/pt.
2.
Registration
& Payment
3.8 min/pt.
4
1.
Drop Zone
ED
RedRed
ZoneZone
YellowYellow
ZoneZone
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
QueueQueue
QueueQueue
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 minutes
139.6 - 154.7
minutes
WASTE: (70-91%)
80-85%
21. 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
? ?
22. Emergency Department -Emergency Department - Process Relook
22
End
Start
INPUT THROUGHPUT
OUTPUT
ED – as a manufacturing line?:
23. Emergency Department -Emergency Department - Process Relook
23
End
Start
INPUT
THROUGHPUT
OUTPUT
Medical
The whole experience as a
manufacturing line:
25. The BOSS of the
Emergency Department is the
Emergency Physician
Really?
26. 26
Hospital
Management:
IT DeptRegistration &
Bill Payment
Unit
Heads of Non-
Clinical
Department/
Unit:
Heads of
Clinical
Department:
Radiolo
gy
Patholo
gy &
Lab
Emergency Department -Emergency Department - Process Relook: Line owners
Community Private
Hospitals/
Clinic
Govt.
clinics
Govt.
hospital
s
Prehospital Care
and Ambulance
Services service
Family
Medicine
MOH HQ:
Quality Unit
Policy Unit
Health
System-
Research &
Dev
PRIME
MINISTERS
DEPARTMENT
Hospital
Admission
Unit
Specialist
Clinic
(Hospital)
Nursing
Managers of In-
patient Wards
Pharmac
y Dept
PORTER
AGE
ED Department
Staff
PR
Unit
Engineers:
Facility
Managers
Other Dept/ Unit
Staff
Quality
Unit
HOSP VISITOR
BOARD
PORTER
AGE
27. 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 RY Y
G G
Emergency Department -Emergency Department - Process Relook - LINEAR
28. 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 RY Y
G G
29. 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 ED
Aspiration
1. Workload Levelling (Policy)
2. Work Process Re-engineering (Operational)
Strategy
Methodology
LEAN for Healthcare
30. 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 LEANPOST LEANPOST LEANPRE-LEANPRE-LEANPRE-LEANPRE-LEAN
Validated
by
Pemandu-
UniKL
33. • 65% of emergency department
attendance are stable patients
including non-emergencies
33
• 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
1. Drop Zone &
Primary Triage
INPUT
34. Increased number of Klinik Kesihatan extended hours
(resource leveling):
Before
34
1. Drop Zone &
Primary Triage
1. Drop Zone &
Primary Triage
After
Total 5 additional Klinik Kesihatan
had opened extended hours
INPUT
Outcomes/ Impact
35. Patient Attendance to Emergency Department before and after extended
hours from 2 KKs
Date of 2 KKs beginning
extended hours operations
– 15 July
35
1. Drop Zone &
Primary Triage
1. Drop Zone &
Primary Triage
After
Outcomes/ Impact
INPUT
36. • 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
1. Drop Zone &
Primary Triage
Before
36
INPUT
After
• Refined KK-ED processes with FMS
37. 1. Drop Zone &
Primary Triage
1. Drop Zone &
Primary Triage
37
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
38. Before
• No directional floor
map to guide
patient journey in
ED
38
1. Drop Zone &
Primary Triage
1. Drop Zone &
Primary Triage After
• Location Map at various points
to guide patient journey
INPUT
39. Before
• Patient are not
familiar with
processes in ED
results in occasional
mis-steps
39
1. Drop Zone &
Primary Triage
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
40. Document Window
Primary Triage to Secondary Triage
Documents need to be manually carried
from Primary Triage to Secondary
Triage
Secondary
Triage
& Waiting
Area
Secondary
Triage
& Waiting
Area
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
PRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
THROUGHPUT
41. 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
Secondary
Triage
& Waiting
Area
PRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
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
42. 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
& Waiting
Area
2. Secondary
Triage
& Waiting
Area
THROUGHPUT
43. Month Type of Intervention at See & Treat
Discharges X-RAY Lab Ix
July 1050 562 219
August 1178 620 252
September 1253 598 302
October 1104 523 392
After
Outcomes/ Impact
Secondary Triage See And Treat Monthly
43
2. Secondary
Triage
& Waiting
Area
2. Secondary
Triage
& Waiting
Area
THROUGHPUT
44. Overcrowded patient in Green
Zone overflow to adjacent
canteen
44
Walkway Link to Canteen
Secondary
Triage
& Waiting
Area
Secondary
Triage
& Waiting
Area
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
PRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
Canteen ED
THROUGHPUT
45. 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
& Waiting
Area
Secondary
Triage
& Waiting
Area
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
PRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
THROUGHPUT
46. Before
• PRO counter not visible
• Limited operational hours
• Floor ambassador function
just limited to Green Zone
46
2. Secondary
Triage
& Waiting
Area
2. Secondary
Triage
& Waiting
Area
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
47. Before
• Two separate systems
exists for Out-Patient and
In-Patient (Admission)
Registration
47
3. Registration3. Registration3. Registration3. Registration
THROUGHPUT
After
• Integrate Out-patient and
In-patient registration
systems
INOVASI
48. 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. Registration3. Registration3. Registration
THROUGHPUT
INOVASI
• Co-locate Out-patient and In-
patient Registration counter in
ED
• Increase ability to handle 4
registrations at anytime
After
49. • There is considerable lag
time for patient to be
seated after being called
Before
After
• Put next patient
chair outside the
consultation room.
49
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
50. 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 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
50
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
51. • Haphazard piling of case
notes and large numbers of
patient files make time
tracking difficult after
initial consultation
Before
51
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
52. After
• Patient wait time Cue Viewer Box in all
consultation rooms
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!
52
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
INOVASI
53. • 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
53
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
54. Upgrade - physical area repair and
equipment replacement
ED X-ray room requires major
renovation to support ED
requests
Consultation,
Investigation &
Treatment
Consultation,
Investigation &
Treatment
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
LEANLEAN
Kaizen BurstKaizen BurstPRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
THROUGHPUT
55. 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
Consultation,
Investigation &
Treatment
POSTPOST
LEANLEAN
Kaizen BurstKaizen Burst
POSTPOST
LEANLEAN
Kaizen BurstKaizen BurstPRE-PRE-
LEANLEAN
WasteWaste
PRE-PRE-
LEANLEAN
WasteWaste
THROUGHPUT
56. • Lab specimens are
generated at multiple sites
• Sent in uncoordinated way
Before
56
4. Consultation,
Investigation &
Treatment
4. Consultation,
Investigation &
Treatment
THROUGHPUT
Zon
Hijau
Zon
Kuning
Zon
Biru
After
• Centralized collection point
• Collection schedule every
30 minutes
57. • Performance of the existing
pneumatic tube link from ED
to main laboratory and x-ray
department is unpredictable
Before
57
4. Consultation,
Investigation &
Treatment
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
58. • Revitalization of pneumatic tube
services
After
58
4. Consultation,
Investigation &
Treatment
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
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%
59. • 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.ofpatients
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 DESIRABLE
59
OUTPUT
5. Disposition5. Disposition
60. 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 7
X 365
M T W T F
S S PH
No scaling down of
resources after hour/
scaling up weekends/
PH
Admission starts to peak
before 12 Significant scaling down
of resources after hours/
weekends
Discharge begin only after
12 pm
61. 61
After
Sele
pas
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. Disposition5. Disposition
INOVASI
62. 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. Disposition5. Disposition
63. 63
6. Others6. Others
Before
• Yellow Zone is prone to surge situations, variable casemix
and overcrowding
• Work morale in Yellow Zone was low
64. 64
6. Others6. Others After
• Refined processes using ‘5s’ and
establish functional patient cohort
cubicles in Yellow Zone and staff
assignment
65. 65
6. Others6. 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. 66
30%
Operation speed increase
for intervention
16%
(32 min)
Time saving
Increase
41%
of asset utilization
(7 KKs)
744,062
Klang population affected
To HTAR
35%
congestion reduce
To Rakyat
Klang
To Nation
1.5 million
people (including
movement) affected
The Transformation Benefits
