HRVP-IOV Case presented as poster in october 2011, London, using lean methods to improve processes and safety.

1. ELIMINATING WASTE AND BUILDING CAPACITY using Lean methods IN A OUTPATIENT
CHEMOTHERAPY UNIT IN A BRAZILIAN PUBLIC HOSPITAL
Pinto C F; Marota EA; Taborda MF; Coelho SM; Reis SV; Santos CM.
Hospital Regional do Vale do Paraíba - Medical Oncology Unit - Taubaté - São Paulo - Brazil
Background: Major aims were to reduce access queues and improve capacity
HRVP is a 300 beds specialized public hospital with fixed budget due our growing demand.
covering an area of 1,5 million inhabitants. The growing demand for No space or personnel investment available.
cancer care and the limited capacity to invest in new resources led our
organization to experience lean methods as a performance Methods:
improvement method. Fifty collaborators work in this unit, including The Value Stream Map (VSM) tool was extensively used to identify and
physicians and all other personnel. The first project started in 2008 and reduce waste. VSM is a tool based on PDSA that uses other QI tools but
several others were introduced to improve flow and reduce waste. Lean drives special attention to the seven wastes and the value added
is a Quality Improvement method focused in waste-reduction, workflow activities, trying to eliminate non-value added ones. Lean training
improvement and differentiation from value added and non-value added involved distance learning (Leading Edge Group) for one leader and
activities. Despite limited evidence based reports associating lean additional training using avaliable books like “Learning to See” (Rother
methods with healthcare improvements, this approach has solid and Shook) and “Lean Hospitals” (Graban) to replicate and to guide us.
grounds on the PDSA (Shewhart) cycle, where substantial evidence is We were also supported by our previous experience using the PDSA
available. cycle.
We used Change Management techniques (as proposed by P. Kotter)
Problem: that involved behavioural and culture change to design projects for three
HRVP is expected to absorb our continuously growing regional demand incoming years (using Rolling Wave Project Planning). Physicians,
that requires more and more resources. The hospital has a fixed annual nurses, pharmacists, managers and office personnel were trained using
budget and cancer care is at the end of the line for new investments at “belts concepts”, allowing “learning by doing”: projects planning and
this public unit. We had to find ways manage our growing demand execution were part of the training process. Projects were sequenced to
without new facilities and human resources (that would be useless focus on the “patient journey”: from admission to discharge.
without more space).
Results:
Ten projects were open between 2008 and 2010, and followed our planned
time frame. Each project involved a functional team including at least one
person from each major step in the Value Stream. Projects that significantly
impacted capacity are listed below.
(1) Admission and Registration Area Capacity Leveling. This project
improved attending capacity in 25% by reducing mean time to admit new
patients from 14 to 5 minutes developing internal supermarkets and layout
improvement. Time from triage to 1st medical appointment reduced from a
Fig 1: Annual Appointments Fig 2: Median of patients in
median of 14 days to 3 days. chemotherapy per month.
(2) Medical Orders Standard Work. Pareto analysis of our medical order
allowed us to focus on major problems and work load. Billing and prescription errors were reduced to zero
(0%) and 0,0001%, respectively.
(3) Medical Appointments Leveling. With medical orders standard work and schedule leveling, the capacity
improved 60%, and new value added activities were included (like group Q&A sessions, Facilities
Presentation, etc). (Fig 1).
(4) Nurse Station and Chemo Infusion Leveling. 50% of useless steps and activities were completely
eliminated or merged using error proof techniches (jidokas & poka-yokes); Pareto; work batches and lay out
improvement. Capacity improved by 65% in three years. From 450 patients under chemotherapy per month
to 1100 patients in 2010. (Fig 2)
Fig 3: Overtime reduction in 2010
Using value stream mapping and lean tools, in three years (red line). Personnel working in our two
we improved our capacity in 60%, overtime decreased 40%, units in 2010 (blue line). Trend = 40%
and our customers satisfaction improved. reduction in overtime (black line).
(5) Quality and Safety Improvements. To guarantee sustainable quality we use an Internal Customer Overall Satisfaction Survey (that
improved from 66% to 85%) and a Patient Overall Satisfaction Survey (that is preserved, 75% of our customers consider our services
“excellent”). We were also able to reduce overtime slowly, but in a consistent pace (Fig 3). In 2010 our unit was awarded with the Excellence
Certificate by the National Accreditation Organization (ONA), distinguishing our commitment with quality and customer satisfaction.
Conclusion: Waste-reduction, workflow improvement and focus on value added activities are distinctive focus of lean methods and have clear
impact in healthcare, a system deeply associated with waste, broken flows (information, reference, “hands off”) and lack of focus. Lean methods can
be perfectly aligned with the awaited quality improvement and cost reduction in healthcare industry.
Our first 3 year implementation involved careful change management planning and intensive “hands on” training. Deep leadership involvement was
also crucial to support our projects and change initiatives.
Correspondence: Keywords:
Carlos Frederico Pinto MD
e-mail: carlosfpinto@iov.com.br PROCESS IMPROVEMENT
Hospital Regional do Vale do Paraiba CANCER OUTPATIENT CARE
Instituto de Oncologia do Vale LEAN THINKING - PDSA
Avenida Tiradentes, 280 Taubaté - São Paulo - Brazil