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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
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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
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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
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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.
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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
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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 %
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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)
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When the outcry came: Malaysian Emergency Departments in crisis…
Star, Sunday
16 Feb 2014
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MEDIA REPORT – Hospital Congestion ALARM BELLS HAD BEEN RINGING A LONG WHILE….
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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
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The Honorable Minister of Health and higher management team
MOH visited HTAR February 2014 on ‘fact finding mission’
11
HOD
Emergency HOD
Medical
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• 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
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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
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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
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15
Lean?
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Who best finish a marathon run (42.19km)?
16
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Who best finish a mountain climb?
17
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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.
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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
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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
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The BOSS of the
Emergency Department is the
Emergency Physician
Really?
21
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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
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Emergency Department - Process Relook
23
End
Start
INPUT THROUGHPUT
OUTPUT
ED – as a product (processing) line with problems?:
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Emergency Department - Process Relook
24
End
Start
INPUT THROUGHPUT
OUTPUT
Medical
The whole experience as a
manufacturing line:
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End
Start REGISTRATION
SECONDARY TRIAGE
CONSULT INVESTIGATE TREAT
DISPOSITION
PRIMARY TRIAGE
INPUT THROUGHPUT
OUTPUT
Emergency Department - Process Relook: Existing Lead Process
25
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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
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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
27
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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
28
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WE would like to share what WE did….
In ED
29
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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
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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
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32
INPUT
Outcomes/ Impact
1. Drop Zone & Primary Triage
Increased number of Klinik Kesihatan
extended hours (resource leveling):
Total 5 additional Klinik Kesihatan had opened extended hours
POST LEAN Kaizen Burst
PRE-LEAN Waste
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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
1. Drop Zone & Primary Triage
Increased number of Klinik Kesihatan
extended hours (resource leveling):
POST LEAN Kaizen Burst
INPUT
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• All admissions from klinik kesihatan must go through ED.
• All stable patients from KK need to under-go re-triage process in ED
34
1. Drop Zone & Primary Triage
Improved Referral Process with clinics
POST LEAN Kaizen Burst
PRE-LEAN Waste
INPUT
34
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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
1. Drop Zone & Primary Triage
Improved Referral Process with clinics
POST LEAN Kaizen Burst
INPUT
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• No directional floor map to guide patient journey in ED
36
INPUT
1. Drop Zone & Primary Triage
• Location Map at various points to guide patient journey
POST LEAN Kaizen Burst
PRE-LEAN Waste
36
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• 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
POST LEAN Kaizen Burst
PRE-LEAN Waste
1. Drop Zone & Primary Triage
Process steps summary on back of receipt
INPUT
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Documents need to be manually carried
from Primary Triage to Secondary Triage
Primary Triage to Secondary Triage
Secondary
Triage
& Waiting
Area
Document Window
POST LEAN Kaizen Burst
PRE-LEAN Waste
THROUGHPUT
38
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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
POST LEAN Kaizen 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
39
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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
POST LEAN Kaizen Burst
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Overcrowded patient in Green
Zone overflow to adjacent canteen
41
Secondary
Triage
& Waiting
Area
PRE-LEAN Waste
POST LEAN Kaizen Burst
Canteen
ED
THROUGHPUT
41
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No system to call patients
waiting in canteen
…create link to call system for canteen
QUE Caller
System in
Canteen
Secondary
Triage
& Waiting
Area
POST LEAN Kaizen Burst
PRE-LEAN Waste
QUE Caller
System -
Green Zone
Waiting Area
THROUGHPUT
42
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• Two separate systems exists for Out-Patient and In-Patient (Admission) Registration
43
• Integrate Out-patient and In-patient registration systems
POST LEAN Kaizen Burst
PRE-LEAN Waste
THROUGHPUT
Integrate Out-patient and In-patient
Registration System
2. Secondary Triage & Waiting Area
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• 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
POST LEAN Kaizen Burst
Co-locate counters 3. Registration
THROUGHPUT
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• There is considerable lag time for patient to be seated after being called
45
• Put next patient
chair outside the
consultation room.
POST LEAN Kaizen Burst
PRE-LEAN Waste
Next – in line chair 4. Consultation,
Investigation & Treatment
THROUGHPUT
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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
POST LEAN Kaizen Burst
Next – in line chair 4. Consultation,
Investigation & Treatment
THROUGHPUT
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• 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,
Investigation & Treatment
THROUGHPUT
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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,
Investigation & Treatment
THROUGHPUT
• Patient wait time Q (Cue, Queue) Viewer Box in all consultation rooms
POST LEAN Kaizen Burst
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• 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
POST LEAN Kaizen Burst
PRE-LEAN Waste
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• 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,
Investigation & Treatment
THROUGHPUT
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• 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%
POST LEAN Kaizen Burst
Revitalize pneumatic tube system 4. Consultation,
Investigation & Treatment
THROUGHPUT
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• 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
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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)
POST LEAN Kaizen Burst
OUTPUT
5. Disposition
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• 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
POST LEAN Kaizen Burst
Appoint Bed Manager and admission
coordinators
OUTPUT
5. Disposition
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• 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
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• Refined processes using ‘5s’ and establish functional patient cohort cubicles in Yellow Zone and staff assignment
5 S in Yellow Zone
6. Others
POST LEAN Kaizen Burst
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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
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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…
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Bersama, kami telah lakukannya!
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Wishing you an exciting LEAN journey
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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.