There was a meeting on Saturday 20.07.2019 connected people that are enthusiast of lean management. It was another meeting from series Lean is for people lead by Krzysztof Dobrowolski. It was my first meeting and opportunity to lead the workshops. Our common goal was to know more and exchange our experience from lean management field. I’m very appreciated that I could took part in this event and share my best practices.
The event was dedicated for healthy way of life and how lean in healthcare can improve processes- not the tools but the way of thinking. Thanks to Optinav company we had great chance to see production process of medical devices and solutions.
Some people thinks that lean management is just a tool that can standardize processes and solve problems in organization. When we do that we just extinguish the fire, not looking for the root cause of the problem. This is short-term actions that can generate overprocessing and low efficiency.
I presented the way of value stream mapping of clinical process in hospital using 4.0 med- technology. Due to limited time and high interest of subject I decided to focus on wastes, problems and their root causes.
We did short map of patient flow in hospital and then I show the potential of real lean management approach. We analyzed process from two sides:
We generate 106 problems that could occured in our mapped process, which could cause:
This lead us to create new solutions how to prevent all this problems and control the process.
In order to understand patient expectations we should remember about basic rules in communication, understanding and interpretation. Thanks to creative workshop I did in next phase all team had chance to experience how difficult is to collect and understand what patient has in mind, want and expect.
The more we know, collect measurable criteria, know the priorities, rely of facts not opinions, our imaginations then the easier we can fulfill expectations.
It was very creative and cheerful workshop.
Dear guests we would like to thank you for participating in first in Poland LEAN HEALTHCARE SYMPOSIUM that took place 31 of may in Torun in Poland.
The attendance was high and we had chance to meet in medtech specialist group in place that encourages to thinking outside of box, start-up center Business Link Torun.
The main purpose was promotion of effective process management methods in healthcare and sharing best practices of value stream mapping and problem solving using ISHIKAWA diagram and 5WHY. Its keynote was improving level of quality in healthcare services.
First presentation hosted by Anna Zlotowska- Lean Healthcare Expert was about improving access to medical services and improving financial effectiveness using lean healthcare approach in best examples all over the world hospitals.
We appreciate very much practical knowledge that is why we tried to map patient reception on emergency department process with broken leg. Workshop were conducted by Katarzyna Zlotowska that specializes in process optimization and improving financial effectiveness and Anna Zlotowska.
We did process map with details: defining people responsibilities for every activity and evaluated cycle time. Team also pointed all wastes (8 type of wastes) and show which activity in process is the most critical. Because that point can lead to different subprocesses with different effects. During process analysis team calculated patient LT lead time through process (LEAD TIME) and value added activities (VAT VALUE ADDED ACTIVITY). Some participant proposed improvement ideas, which can make process shorter and decrease risk that occurs. Risk management approach is not connected only with lean healthcare but also with innovative technologies as internet of medical things (IOmT), augmented reality (AR), artificial intelligence (AI) and actions and decisions made based on DATA DRIVEN and network centric.
Also we show teams how to analyze problem of patient falls during hospitalization in cardiology department. First team had to understand the problem definition and know ISHIKAWA tool. Simplicity is very important that is why we don’t focus on complicated tools and methods. We know that user experience and purpose is primary role. We just need paper and pencil. During brainstorm we collected plenty of potential causes of problem, some of them recurs so it was much easier to choose next potential causes for next level 5WHY analysis. Based on collected data team was very encouraged to make decision regarding preventive actions.
Teams were very opened and well integrated. Representative of every medical unit, lean passionate had chance to give a comment. It was very nice work together. Teams were multifunctional, thanks to our two colours of bands it was very easy to divide participants into two groups.
Additionally workshops were supported MEDTECH technologies, that together with lean healthcare can improve processes and quality of healthcare services.
MEDAPP is polish company that creates new technology solutions using HOLOLENS and augmented reality AR in clinical processes. One of the pioneer projects concerns using HOLOLENS glasses for analyzing some scenario of heart operation. All participants had chance to wear this glasses.
MEDIDESK is growing company that implement software which improve quality of patient registration process in medical units.
NEXTWAVES is a company with rich know-how in digital transformation and industry 4.0.
We had special guest on the event- Director of Emergency and Defence Services Department in Ministry of Health Jan Gessek. During presentation Jan Gessek introduced us new project of Ministry of Health TOPSOR. The main purpose of the project is to implement medical segregation of patient at emergency department in order to improve effectiveness of the process. Jan Gessek said that the project is very important and fit into lean healthcare approach. The project is a chance for better availability of emergency department services for most needy patient so the risk connected with hospitalization should be decreased. Thanks to visual management solution in TOPSOR stable patient shouldn’t go directly to emergency department but to other processes, improving patient flow in ED.
To sum up all event, thanks to very interactive form it was an interesting meeting with specialists that want to improve healthcare system. People wanted to share their experience, listen others, learn and create new ideas. It was place to exchange know-how with the best lean healthcare practicioners and met with medtech representants. It was first edition of this event and we hope that we created value added for everyone.
We would like to thank our sponsors: Medidesk, Medapp, Nextwaves, Thinkdrum and companies that share a media sponsorship: Ototorun.pl, Lean Time, Lean po polsku and Business Link team Torun. Great atmosphere, very creative.
See you next year! Know more about our Lean Leader Healthcare Academy!
ZAPROSZENIE NA SYMPOZJUM LEAN HEALTHCARE
Mamy przyjemność zaprosić Państwa na jedyne w Polsce Sympozjum Lean Healthcare, które odbędzie się 31 maja 2019 w Business Link Toruń Toruński Inkubator Technologiczny AIP w Toruniu.
Celem wydarzenia jest przedstawienie innowacyjnej metody zarządzania w placówkach medycznych, szpitalach, przychodniach jak i laboratoriach zgodnie z podejściem lean management- szczupłego zarządzania tj. lean healthcare. Program planowanego Sympozjum ma za zadanie w zwięzły sposób przedstawić możliwości wykorzystania narzędzi lean healthcare w pokonywaniu problemów w codziennym funkcjonowaniu placówek ochrony zdrowia, w tym m.in. skrócenia czasu pobytu chorego w szpitalu bez szkody dla jakości opieki i leczenia, przekładając to na wzrost efektywności finansowej organizacji, poprawy bezpieczeństwa pacjenta, minimalizacji ryzyk, zdarzeń niepożądanych, poprawy komunikacji oraz optymalizacji zapasów magazynowych.
Wydarzenie ma charakter sympozjum, na które zapraszamy kadrę zarządzającą oraz właścicieli placówek medycznych z Polski, a także personel medyczny odpowiedzialny za organizację i przebieg procesów klinicznych, pion finansowy jednostek, pełnomocników SZJ jak i pasjonatów lean management. By zaszczepić nowoczesne rozwiązania, zapraszamy również studentów.
Jest to pierwsze takie wydarzenie w Polsce, zorganizowane w formie bezpłatnej dla uczestników. Agenda wydarzenia jest nietypowa, ponieważ proponujemy wykłady jak również praktyczne warsztaty.
Swoją obecność potwierdziła Pani Wiceminister Zdrowia Józefa Szczurek- Żelazko
Podczas wydarzenia dowiesz się jak wykorzystać rozszerzoną rzeczywistość w procesach klinicznych- okulary HOLOLENS i firma MEDAPP zaprezentuje ciekawe i praktyczne rozwiązania przyszłości.
Również będziesz miał możliwość zapoznania się z rozwiązaniami dla procesu rejestracji pacjentów w placówce medycznej – Medidesk.
Jeśli są Państwo zainteresowani wydarzeniem, bardzo prosimy o wypełnienie formularza zgłoszeniowego do 30 maja 2019 dostępnego na stronie www.leanhospitals.pl. Ilość miejsc jest ograniczona, decyduje kolejność zgłoszeń.
Organizatorem jest właściciel marki LEAN HOSPITALS
LEANMED sp. z o. o.
78-400 Szczecinek, ul. Lelewela 12
NIP: 673-16-22-179 REGON: 330919360
Tel. +48 94 372 88 50 mobile: +48 606 335 302 / +48 508 238 811
e-mail: firstname.lastname@example.org, www.leanhospitals.pl
Bank: BBS o/Szczecinek SWIFT: GBWCLPLPP Konto: PL 98 8566 1042 0500 3266 2004 0001
Kapitał Zakładowy: 2.002.500,00 zł SR w Koszalinie IX Wydział KRS 0000050584
Every day while working in a hospital, a doctor’s office or laboratory there may occur situations that can cause errors and generate costs. Sometimes these are necessary activities related to the provision of a medical service, sometimes these are activities that could be avoided. These activities may be related to mistakes and errors that are not detected at an early stage of creation can bring huge losses to the organization. Not only financial but also reputational losses. Analyzing the operating costs of medical institution, they can be divided into fixed and variable costs.
Fixed costs usually remain at a comparable level, while variable costs depend not only on the number of patients who use the hospital services each year but also on the number and complexity of processes, i.e. services offered by the medical institution. Each hospital ward, clinic, laboratory consists of main and auxiliary processes. Each process consists of activities in which there are potential risks. Each risk is a potential cost for the company and additional work.
Failure mode and effects analysis FMEA is not only an additional way to solve problems but also a way to meet the new requirements of the Quality Management System according to ISO 9001: 2015. Risk management is a set of activities that are aimed at controlling the risk. Clinical risk is the combination of the probability of an event and its consequences, which will have a negative impact on the outcome of the patient treatment. There are many methods of risk management and what will be chosen depends not only on the decisions of main management but also on:
FMEA analysis is different from the others because it is very detailed and work-intensive. It depends on the team how the process will be analyzed and whether all information will be taken into account. The analysis should be objective and true. The analysis determines three factors on the basis of which the product is calculated which shows the level of risk. These are:
The rating scale is from 1 to 10, with 1 being the least negative impact while 10 means the highest negative impact. The scale is universal and is used throughout the world by various industries.
Only after collecting information about the process, knowing the sequence of individual activities and critical places in the process, which are particularly important and influence the result of the process, it is possible to undertake the analysis of potential risks. Potential causes of errors can be collected by usage of tools such as:
The result of the RPN indicates for which risks improvement and prevention actions should be taken and which can be accepted without taking major measures. The universal scale indicates that for risks above 100 points, actions should always be taken. Such a risk is defined as critical and is probably a threat to the participants of the process, the indicated errors can be expected in the near future. The risk in the 60-100 range is high and taking action depends on the organization and decisions of not only the team but also the main management. Actions may be implemented but not mandatory. For risks below 60 points it is not needed to take action, as it is usually an acceptable level of risk. You can find more about risk management in the next article.
How to maintain the implemented changes and reduce the level of potential risks? The PCP-PROCESS CONTROL PLAN, which is created on the basis of the FMEA analysis will help us.. The plan allows for continuous monitoring of the process and the implementation of any post-audit actions. Remember that every change in the process carries with it new, potential risks that can change the action plan. For each time the order of action in the process changes, new medical equipment arrive, the place of health care implementation changes, the FMEA analysis should be reviewed and updated.
It should be remembered that without having many detailed data on risk, it isn’t possible to assess but only to estimate its level. Estimation is related to the opinion of a multidisciplinary team, which is able to determine the potential risk based on their own experience. Advantages of the method:
Disadvantages of the method:
Practical experience shows that a well-made FMEA analysis allows to implement processes without any errors or mistakes. Such a positive result is achieved due to the consequences of the action and compliance with the procedures. The system created by everyone, both employees and customers.
Effective methods of cost management in a medical institution using lean accounting.
Running a business involves great responsibility and responsibilities. Both the knowledge of legal requirements and expectations of other interested parties and the most important clients, have great importance in the success of the project. The type of industry in which the company operates and financial management are factors that affect the level of expenses and profits of the organization. The goal of every financial management company is to get and use the right amount of funds to increase the value of the company. The measure of efficiency and business proficiency is profitability. Profitability is defined as a higher level of revenues over expenses. In order to gain a competitive advantage, an institution should achieve better economic results by choosing appropriate methods of cost management.
One of the discussed methods will be the ABC – Activity Based Costing method. The ABC method activity costs account allows you to accurately determine indirect costs, which fall on the offered service and product. According to this method, indirect costs are billed to products. Due to the large number of processes that occur in the company, they lead to the creation of a product at the exit of the process.
The stages of the ABC method are based on four basic steps:
Assumptions on which the ABC method is based relate to:
In the discussed case, two methods of cost management for a medical institution will be presented. Each hospital, clinic, doctor’s office are entities that provide medical services. The main purpose of the activity is to provide medical services. Depending on the business profile, the main process may be a clinical process, e.g. basic health care, hemodialysis process and outpatient specialist care. On the implementation of health services consist, depending on the expectations and needs of the patient, such sub-processes as:
Part of the processes depends not only on the profile of the medical institution (whether it is a public, multi-specialized hospital, private medical center, clinic, laboratory, other private unit providing for example magnetic resonance services), also depends on size and structure (e.g. number of hospital departments, complexity of hospitalization processes and procedures, type of management – silo or horizontal, process awareness and quality management systems). Another factor influencing the scope of services is the impact of the main management approach to the knowledge of the lean healthcare method and the awareness of the occurrence of problems and the level of process maturity. The higher the level of maturity, the more criteria and information on the basis of which the process can be controlled and planned. The implementation of lean healthcare projects may concern:
Referring to the processes occurring in a medical institution, it can generate costs due to:
Based on the ABC, it is very easy to identify activities that exist in the organization.
For example, it is possible to analyze the patient’s treatment process. Table 1 shows the path of the patient from registration to discharged from the hospital ward.
Table 1, Identified actions, source: own work
After identifying the activities, it is possible to determine the volume measurement unit of each measure. The proposals are presented in the table No. 2.
Table 2, Identified measures for actions, source: own work
The next step is to determine the costs of activities. They are determined individually. There also occur variables such as:
The estimated costs of each activity for the medical service delivery process are listed below. It consists of both variable and fixed costs. Fixed costs are:
Variable costs apply to those activities that can be performed repeatedly, such as:
Each patient is unique, therefore the medical service is adapted to the type of process. (e.g. performing operations on the operating block), number of participants (doctors, nurses, instrumenter, ward nurse, duration of the process (non-invasive surgery – 3h, invasive surgery-7h).
Table 3, Data for costs of actions, source: own work
The last activity is the settlement of the costs of activities for particular services / treatments. Thanks to the process approach, it is possible to optimize the activities occurring in it, which may affect the costs of the process. The ABC method allows to customize the service that is offered by medical institutions to patients in a specific chapter on activities. Because of having information about the costs of the operation, the hospital or other medical entity has the possibility of real valuation of the service and offering a flexible offer to clients. Another method that will allow to effectively manage available resources, mostly human resources and time is the Time Driven ABC method. In order to apply this innovative method, the main and auxiliary processes and their structure should be very well known. Each activity is closely related to the work of a individual person. Due to the complexity of the processes occurring in the hospital, their number and interrelationships, the employee’s time intended to the activities presented in Table 1 is different. At the beginning of the medical service, the time can be estimated.
In order to analyze business processes, service processes must be documented in detail and a set of skills necessary for their implementation must be specified. A tool that will help in understanding the process is VSM-value stream mapping, which indicate activities that add value in the process and bottlenecks. It is a detailed analysis of activities, their sequence and time of performing particular activities. Map of the value stream mapping for the operation process in the orthopedics ward is described below. Obtaining such a map by the hospital allows not only to evaluate each activity, but also to assess the duration of activity. The map indicates inefficient places (both in terms of waste of time and financial resources). In order to achieve lower costs of services, it would be necessary to eliminate these activities (orange marked), which generate unnecessary costs.
On the basis of detailed knowledge of service processes, it is possible to define the time frame necessary for the implementation of activities and then the costs of their implementation.
Diagram nr 1, Current state map, source: own work
Based on the information contained in Diagram 1 it is possible to:
The TD ABC method is an opportunity for every medical institution, because of the ability to manage variable costs. Based on adjusting the time of work of medical staff to the needs of the client / patient, the company can achieve profits proportional to the used resources (working time of the medical staff, used medicaments, disposable materials). It is a method for business risk management, e.g. potential risk – lack of possibility to perform laparoscopy due to the shortage of disposable materials and medicines.
The type of activity of each medical institution allows to cost management through ABC and time driven ABC methods, which are a chance to improving the company’s operations and increasing financial efficiency. This choice increases the possibilities of gaining a competitive advantage. A detailed elaboration of the costs of the implementation of the main processes, including the necessary time for implementation, will allow to secure the services and their continuity, without the risk that the company has unqualified specialists, lack of needed staff or lack tools to perform the treatment.
Effective management of the treatment process affects the outcome of treatment and satisfaction of patient and employees. The success of a medical unit depends, among others, from the effectiveness of the treatment and effectiveness of treatment depends on many factors.
Factors that affect effectiveness include:
Even when having the best material resources, without a well-coordinated and collaborative team, managing the treatment process will be difficult or impossible. Each hospital or medical clinic should have a defined map of the processes and participants. Proper communication is the first step in the proper implementation of medical services.
Quality is a certain grade of excellence. Every self-respecting company, both production and service, is making best efforts to satisfy the customer. The satisfied customer is best business card of the company, therefore, it is worth to strive for the positive consideration of the recipient. All employees of the company should be involved in shaping a high level of quality, because the decisions they make – both strategic and tactical – are responsible for meeting customer requirements. When thinking about quality in health care we mean that any fulfillment of requirements that primarily affect the health of the client which in this case is the patient. Selected topic is about medical services i.e. hemodialysis. Service can’t be seen or touched because it is intangible, diverse and unstable, which means that it exists only at the time of consumption and it isn’t possible to acquire the right of ownership of it. The service provider should be solid and reliable, as well as a certainty that is determined by appropriate qualifications and training to provide service and reduce the risk of medical errors and issues. The basis of a prosperous economy is health, therefore, it is important to invest in improvement of health because it provides long-term benefits.
The purpose of the study was to provide information on patients’ satisfaction from the provided service, atmosphere and working conditions. The study was conducted among patients and staff of three dialysis stations. The customer’s assessment reflects the level of satisfying his expectations for the service, therefore the patient “is a judge in assessing the quality of provided medical services.” Due to the extensive nature of medical services, a group of patients treated with hemodialysis was selected. The subjects of the study were three dialysis stations, two of which have implemented and certified quality management system in accordance with the requirements of ISO 9001: 2009 standard and one doesn’t have an implemented QMS with accordance to ISO 9001: 2009. The subject of the study was to evaluate satisfaction with the quality of provided services on the basis of anonymous surveys among patients during hemodialysis and first-contact staff (doctors, nurses). The study was conducted by the direct surveys.
The theoretical basis of the study contain ISO 9001: 2008 [Dykowska 2002, s.1-18] and information about quality, in particular the quality of provided medical services. Respondents answered closed-ended questions in an anonymous survey, which is the author’s own elaboration and relates to the assessment of the relationship on the patient-doctor, patient-nurse, patient- dialysis center environment and patient health education, employee and his workplace.
The study involved a total of 127 patients (65% men and 35% women) with average age 62.3 years for women and 56.9 years for men with predominant secondary education (48.03%) and 31 employees (3% men and 97% women) with an average 39.7 for women and 28-year-old men with predominant higher grade education (41%).
Doctors and nurses are perceived as a group of people whose primary task is to maintain and restore the health of the treated patients.
Dedicated time by doctor and nurse and their willingness to act is important for patients. The emotional side of treatment has a significant impact on the satisfaction of the patient, who will change the doctor until he reaches the specialist, which in addition to making the right diagnosis, will satisfy their emotional needs and be as engaged in the patient treatment as the patient. [Bishop 2000, s.295] The level of assessment of questions from the group regarding the relationship between the patient and the nurse is formed in all three dialysis stations at a similar level (scores above 4). Better and more intense contact on the patient-nurse line increased patient confidence and satisfaction with during treatment in dialysis station. In order to satisfy the final recipient of the provided services, all medical staff must be involved. First of all, those who have direct contact with patients, i.e. doctors and nurses. They should mostly understand patients, get into and listen to them. Communication skills determine this, because this ability enhances the integration and involvement of the patient and the medical staff. It has also been noted that the absence of a TV in the dialysis room has improved the contact between patients and nursing staff. It is important to make communication tools easy to understand. You should use understandable words adapting to the level of the recipient.
Figure 1 Average scores for each question group for all dialysis stations, Source: own elaboration based on survey results
Group: A-patient-doctor relationship, B-patient-nurse relationship, C1-6 social environment of patient in dialysis station, C7-patient health education
The technical area is the so-called the package of service, i.e. external and internal appearance of medical institution and its location. The visual appearance influences patient satisfaction of level of quality of provided service. The look of the waiting area, whether it is neat and clean and whether the chairs are comfortable – it also determines the patient’s opinion about the medical unit as well as the appearance of the employees (clean uniforms, nice apparition, IDs). These factors give patients confidence and feeling of professional attitude towards the patient [Opolski,2010, s.32].
The level of assessment of questions from the group describing the social environment of the patient in the dialysis station is more diverse. The station which doesn’t have an implemented QMS that complies with the standards ISO 9001: 2008 had the best results (rating was 4,7), ratings of the remaining two dialysis stations were 4.1. In this case, patients under study were primarily diagnosed with chronic disease that why the agreement on the patient-doctor line because it is a long-term cooperation is even more important. Patients must regularly use dialysis, which makes them dependent on medical devices and staff [ Daugirdas 2003, s.287]. Satisfaction of patients with health education was best assessed in station no. 1 (the rating is 4.4), rating of station no. 2 was 4.1, rating of station no. 3 was 3.5.
Quality planning isn’t just about implementing QMS that complies with the requirements of ISO 9001 standard but primarily on identifying customer expectations and creating processes that will implement these expectations in a legal manner and with safe precautions for life and health through continuous improvement of medical staff. This is a dynamic, multi-stage process involving all staff in the medical institution. Only full involvement of the management and first-contact staff will make the implementation of the QMS compliant with the requirements of ISO 9001 effective, easier and more pleasant. Station No. 2 with implemented QMS compliant with ISO 9001 standard outperformed stations No. 1 and 3 in the overall assessment of patients’ satisfaction with the provided services.
The most valuable investment of any organization is investment in human resources. Building and selecting the right team of employees is an important element in creating the environment. Employees should have access to training and improving their qualification, managers should develop employee development plans, regularly evaluate employees and motivate them to engage in the personal development. Exactly it is the medical staff that creates the image of the organization which is the hospital and health care facility. Lack of good communication both in the vertical and horizontal structure will override the largest investments of the management. Both tangible and intangible costs incurred for the implementation of the QMS may be reimbursed if the system is successfully implemented and it will receive regular feedback in the form of process measurements and customer satisfaction surveys. The lack of expected results should motivate the management to check for causes and changes that will provide proper quality and increase patient satisfaction. At dialysis station No. 1, 33,30% of employees don’t know whether the dialysis center implemented QMS compliant with ISO 9001 standard and 66,70% of staff are aware that the dialysis station doesn’t have an QMS compliant with ISO 9001 standard. At Station No.2 all employees know that there was implemented QMS compliant with ISO 9001 standard. At Station No. 3 20% of employees are unaware there was implemented QMS compliant with ISO 9001 standard. 80% of them know about the existence of the implemented QMS compliant with ISO 9001 standard in the dialysis station. The overall employee satisfaction rating is highest in dialysis station number No. 1 (rating 4.3), station No. 2 rating was 4.2 and station No. 3 rating was 3.7.
Providing high quality medical services allows organizations to benefit both internally and externally. Primarily:
Organization creates confidence in patients and also by defining objectives and quality policy improves performance of the organization. There occurs a better organization of work and an efficient circulation of medical records. The external advantage is the increase in the competitiveness of the medical institution, the strengthening of loyalty and credibility, thereby raising the hospital’s status in the medical services market. The management should establish and maintain a Quality Manual, quality policy and quality objectives. Operational staff should develop procedural instructions. The instructions concern the treatment of the patient, medicines used and the usage of appropriate medical equipment. Direct contractor of the procedural instructions are doctors and nurses who have direct contact with the patient. They have the greatest influence on the perception of the quality of service provided at dialysis stations. On their behavior, procedures and approach to the patient depends the end result and the satisfaction of the patient. The greater the number of satisfied patients, the greater the company’s profit and better opinion of medical institution among patients and competition [Krodkiewska-Skoczylas 2009].
Pneumatic tube system as a lean healthcare tool
How to make the hospital more competitive also for internal customers? Can facilitating of the distribution system of medicines, biological material, documents help? An interesting solution of the 21st century is the pneumatic tube system connecting the individual organizational units, buildings that may be spaced apart or organizational units such as a laboratory, hospital pharmacy or cord blood bank. This is a solution that can be applied both in the design of a hospital building and in an already existing institution.
In this case the innovation will be pneumatic tube system as an innovative technical solution for the transfer of small and lightweight materials with usage of special pipes. Implemented innovation allows to increase the competitiveness of the hospital among other institutions in Poland. The first institution in Poland equipped with a pneumatic tube system in 2003 was the Bielański Hospital in Warsaw [bielanski.med 2011].
The hospital complex, which uses pneumatic tube, consists of six buildings which include:
Pneumatic tube is a system used for sending items, results of medical examinations, surgical instruments, medicines, documents, biological material (blood and urine samples), which meet the transmission requirements from point A to point B with usage of the piping system. In general, the system creates a network of transceiver stations using RFID technology ( Radio Frecquency Identification). It is a technology for remote reading identification of data. This allows for automatic sending and returning of transport tubes to established points. Items for dispatch are placed in special tubes, which protect the item from damage and the environment. They are some kind of piston that is attached directly to the pipeline and is moved by the air that is pumped into the pipe. Pneumatic tube system operates within several buildings allowing for a easy and extremely fast delivery system for needed tools and materials.
The installation of a pneumatic mail system connects 3 buildings. The installation of pneumatic mail for medical devices refers to the combination of the mentioned above transceiver points.
The contractor of the installation has certified with appropriate results of laboratory tests that the consistency of the structure of the medical samples won’t change as a result of their transport, i.e. the used pneumatic tube system.
The system is controlled by a central microprocessor unit (this is an industrial computer) type CSS. It controls all components of the installation. It is equipped with microprocessors that work with the same processors in the cards that control the steering and the transceivers. Includes one serial output to enable possibility to connect external dot matrix printer and continuously print any information that contains system installation data. The software installed allows for 24-hour control over the entire system as well as the implementation of additional functions. It is possibility to turn off the station if necessary so that no delivery from the station is sent or accepted by other station. The control panel may indicate the location of a potential issue of the system and may trigger an alarm when occurs a shipping blockage while specifying the section where the tube was blocked. The control unit stores information about shipments made in the built-in memory module (up to 1000 records). The control panel performs simple maintenances. This is self-regulation of mechanical parts.
These stations are used for sending and receiving shipments, automatic unloading of shipped samples and re-shipping of tubes. SATURN type of transceivers were used to the installation. These are fully automatic devices. They have electrically closed and opened transparent doors with overload protection. Transceivers are equipped with a control terminal that informs about the work of a particular station and the whole system. Stations allow for supervised and controlled user access based on the data read from user identification card. This solution secures the shipment from unauthorized access. The container is stored in the station until the recipient has confirmed authorization and to register the actual time and place of delivery. In the absence of reception, the system automatically sends the tube to the addressee.
The main propulsion device is 1600 W SC-30 centrifugal fan. This allows for seamless transport of tubes from the transmitting stations to the receiving stations. It’s equipped with acoustic mufflers (Effectively dampens up to 25 dB) as well as anti-vibration dampers. Shock absorbers are designed to suppress the noise and vibration caused by blower.
Pipelines allow the transmission of the tubes. Pipes and arches have a certain diameter. The entire pipeline is made of PVC in technology that guarantees smoothness and resistance to abrasion of their internal surfaces. Connections of any branching of the pipes are made with usage of a muff and glued.
Branches of pipelines are implemented by linear steering. When a tube with a sample is sent from hospital building A to building B, the shipment must be redirected to the corresponding “address” in the steering.
A special system cable is used, which is installed on the pipeline from the outside, making it easy to find when occurs a system issue. The entire structure secures the pneumatic tube system against external pulses.
Delivery tubes are on both sides, pivotally opened to facilitate discharge operations. They are made of high-impact plastic. Tubes consist of a transparent body, making it easy to determine if they are empty or contain a shipment. At each end, they are equipped with programmable integrated circuits. chips. Containers may contain material up to 2.5 kg. The transmission speed is between 7 and 15 m/s and is suitable for medical transportation. Because of the transfer of blood and biological material, speed can’t be too high due to the possibility of destroying a valuable sample of material. Tubes have a simple self-closing system for moving parts, which excludes spontaneous opening of the tubes in the pipeline. In addition, there are special inserts inside the containers to protect the deliveries with the transfer bags. These bags are designed to protect the shipped material from moving during transportation. They are suitable for washing and multiple disinfection. Each tube is described by the name of the organizational unit to which it belongs. All devices consisting of the pneumatic tube system have EMC certificate. It is a certificate of electromagnetic compatibility, which demonstrates their resistance to external electrical fields generated by the operation of other radio link systems, paging, cellular, Power and computer networks and the most important – medical equipment such as computed tomography. These devices aren’t the source of any interference [air-mix 2008].
Every pneumatic tube system is suited to specific needs of the customer. The extent of the transmission system depends on the reach of the mail (whether it within a single building, two or within a complex of buildings), type of sent items (their weights, sizes) , way of communication (one-way and two-way communication are distinguished). It can be installed in buildings on many floors or it may also be connections between distant buildings. Pneumatic tube system improves many operational processes that can be made at a lower working cost of nurses and doctors, less financial resources and most important – less time resources. Hospital employees are already accustomed to working with pneumatic tube system and judge it as a very useful tool.
To fully realize the medical service such as to take the blood sample from the patient for examination it is needed to contact the laboratory. The blood sample taken from a patient who is in the pediatric ward In the main hospital building on the third floor the nurse must take it to the laboratory, which is located in clinic on the fourth floor. The nurse must cross a very long way to the laboratory. The walking time will take several minutes while the sending blood sample by pneumatic tube system will take her a few seconds. The saved time the nurse can spend with the patient – that is where she should be during her working hours.
Thanks to the innovation of pneumatic tube system, the hospital has a better chance of participating in various programs affirming modern hospitals, which can advertise a medical institution, Raise its competitiveness and encourage potential patients to use fast and professional service and health treatments.
Pneumatic tube system is also a convenience for employees. Nurses and doctors have a hard and absorbing job. Each day they struggle with difficult situations and the behavior of patients who have emotional problems. The employee fully utilizes his time resources and strengths, trying to do everything to make the patient feel better, recovered and was satisfied with the course of treatment and the conditions in which he spent time at the hospital. Thanks to it staff increases the quality of provided medical services.
The pneumatic tube system allows to work in better conditions which causes employee to be satisfied and have the strength to perform duties. Employee isn’t exposed to external factors that may endanger health or life, utilizing working time to move between individual wards or buildings to send a document or biological material.
First of all, pneumatic tube system is used to send any blood or urine samples and swabs from patients to the laboratory which is located in a separate building on the third floor.
Everyday the nurses send deliveries. As often as the biological material are sent paper documents, test results, medical certificates or prescriptions. Surgical equipment, surgical sutures, other items or instruments that may fit in the transport tube are less commonly delivered. The delivery system works 24 hours a day. Estimating that on average 90% of patients are in the ward and that everyone has to have their blood tested, the number of blood samples sent to the lab is high. This is the amount that medical personnel would not be able to deliver (all samples) in as short a time as a pneumatic tube system.
Based on the conducted research, it can be stated that pneumatic tube serves the hospital primarily for the transmission of samples with biological material. System replaces the work of nursing staff so that the patient has the opportunity to interact more intensively with the nurse. Also often sent are documents, these are referrals for research to the lab and the results of the research.
Traveling was associated with considerable physical effort, which depends on the age of the nursing staff is larger or smaller range, so times are different. There are other factors that affect the travel time that extends that time. These factors are:
Taking into account the above factors, a study was conducted to measure the time which was needed to finish the delivery. Several transceiver points were taken into account and the traveled distance was repeated.
Pneumatic tube system is a mechanical system and therefore there is the possibility of issues and temporary downtime. Sometimes there are situations in which it is impossible to use system. Such situations are:
Thanks to the hospital’s additional financial resources for the purchase of the system, the medical institution saved large amounts of material, financial and time resources while improving own image among the direct recipients of services, i.e. patients.
As a result of the implementation of pneumatic tube system, there was a triple reduction in time needed to deliver materials to the selected organizational unit. Pneumatic tube system improved the efficiency of the hospital’s processes. There was a reduction in the transit time of samples between organizational cells. The transport of material is more efficient and doesn’t involve the working time of the nursing staff. The hospital no longer has loses in form of damaged laboratory samples or destroyed medical equipment. Employees fulfill their duties without neglecting any. The number of medical incidents has decreased since the introduction of system. Patient satisfaction increased during hospital treatment. Pneumatic tube system leads to the unification of the method of transport of materials, which makes uniform quality and maintain a certain level, which is in line with the expectations of the recipients. In this case, the client is both a patient and an employee. Employee is an internal customer. Based on the developed survey and graphs, the results of the employee satisfaction with the usage of pneumatic tube system are mostly positive. System has improved their work, they are satisfied, it is 68% of employees. The tube system is an improvement in the patient’s treatment process. Implemented lean management reduces the sample transfer time from the customer and faster intervention of the doctor after receiving the results of the materials collected for the research. Innovation also allows to minimize the patient’s waiting time for the results of laboratory tests. The efficiency of transport of the material has been improved and the number of incidents and minor issues at work has decreased. An additional advantage of system is that in case of a issue, it possible to quickly find the point where it occurred while during the traditional method of transport it is difficult to determine who was responsible, made a mistake and at which stage of the process it occurred, so the material was delivered to another ward or delivered differently than expected. Everyone has assimilated most of the necessary knowledge needed to handle pneumatic tube system and most of the staff are satisfied and accustomed to this innovation.
Andon is a visual way of communicating by using light signals. When a issue is detected, a light signal appears and the production line can be stopped to remove the problem or the medical service may be interrupted. The main tool is an board that uses light signals or tones to tell where the problem appears. The signal can be used directly by medical personnel or a patient who felt worse and requires help. The signal can be sent by a remote located near the patient bed. There are two standard colors of signaling that are used – green and red. Every issue is serious and threatens the potential health or life of the patient, alarm activation is related to appearance of a red light signal. Medical personnel and patients should be aware of the usage and responsiveness of signals. Alarms should not be abused by patients or their families. Detection of issues (incorrectly set parameters for treatment) allows for removal, finding the source of the problem, introduction of improvements and also reducing the costs associated with patient complaints. In some hospitals, the number of alarm calls and stopping for medical services is monitored on a regular basis.
Internal communications is an important aspect that has an impact on the quality of provided services. Each participant passes his or her performed work to the next person in the process, providing important information, such as the patient’s vital parameters. The information should be transferred smoothly not only within the organization unit but also horizontally, passing through each department.
Vertical communication is a contact between management and employees and vice versa. Information sent from management to subordinates most often concerns the segregation of duties, instructions and job instructions and information sent from subordinates to management includes requests, complaints, information, proposals, petitions or reports. Horizontal communication occurs between the same groups of employees, ie between nurses, doctors and administrative staff [Czerw i in. 2012]. In medical institutions occur direct and indirect contact. the direct contact consists of management communication with employees, conversations between administrative staff and medical staff, contact between medical staff, communication of medical staff with patients, communication between patients, management contact with persons unrelated to the company, ie suppliers, co-operators, competitors, there are also trainings, conferences and phone conversations. Direct contact include e-mail communications, leaflets and medical journals, boards for patients and staff, board information from patients to other patients and associations boards that provide information to patients, also letter communication, regulations and orders. By analyzing the communication process, it is possible to to identify many of its forms, which can be related to outdated and possible issues at work, it is important to identify factors that could disrupt the process. Barriers can occur on the sender side – by sending opposing signals to the receiver-due to prejudice and noise in the environment [Czerw i in. 2012].
Medical institutions may introduce brochures, flyers, and patient magazines on topics related to healthy living, nutrition and exercises. While waiting for a medical visit, the patient may read about diet, kidney disease, patient’s rights and medical ethics.
Boards as one of the indirect forms of communication can be placed in different places because of the information included on them, their degree of sensitivity as well as the different target audience. The board can contain:
Management can implement a modern information flow system based on the use of modern technology – intranet. It is an internal, private computer network that is adequately secured and separated from rest of the environment [slownik.infoweb 2013]. Access to information on the intranet platform may be determined by the administrator. Each employee has an individual login and password, range of content that they can view, load, edit or print, every new information on the platform is marked with a visible green color with the mention “new” or “changed”, thanks to it every employee knows the changes and can adjust to them. Information necessary for appropriate functioning, such as documents and procedures, can be accessed without additional passwords just by logging on to the computer. Any change made on the platform is identifiable. In functioning in distant units, fast communication is essential because it allow to access information at every location, ie at every unit equipped with computer with internet access, it allows to access to information at any time and by any staff member.
Access to actual information is essential to ensure proper patient care. Intranets allows to access content that improves work, sometimes it may be necessary to use the procedure entitled implementation of the patient to the medication program to be able to provide services in accordance with the contract with the National Health Fund and the rules change many times during the contract, which would require a meeting each time to discuss the changes and transfer of the modified formulas of the documents while destroying the printouts of the previous version. Patterns of medical documentation, forms or prints may be available on the intranet without memorizing or typing additional passwords (Permissions are granted by the administrator) so the nurse or doctor can use them without delay. Documents available on the intranet can be updated and each user receives information about the changes. The intranet allows standardization of procedures and documents, there are only current content in actual flow. The objective of Intranet is also to provide feedback in the form of sets, reports or statistics. For this purpose the e-mail system may also be used, particularly in the reporting from nurses to the human resources department and the management. There are also other modern forms of communication resulting from the principles of lean management of processes which should not be forgotten like shade tables in utility rooms or treatment rooms, horizontal signs on the floor indicating the storage areas for particular medical equipment such as wheelchairs. The separation of mop and wipes by coloring, the corresponding color is attributed to the type of dedicated surface to be cleaned.
Analysis of the communication process can be divided into communication on the lines of different occupational groups:
Incorrect co-operation between representatives of different occupational groups results in improper communication between people, as well as intergroup which may have an impact on the medical institution, the process of providing benefits which causes lower quality of functioning [Kęsy. 2012].
Cooperation may involve direct verbal communication and the use of internal telephone communications; when required, management may send information by e-mail, employees responsible for specific places have assigned business addresses – which allows management to direct the information to the correct addresses by controlling the availability of mail. Communication between the management and the secretariat should be smooth and carried without interruption or delay.
The most common form of communication is direct telephone conversation; Management can also use the intranet system to send actual communications, internal procedures and orders.
Currently working doctors should have continuous contact with nursing staff. The form of communication is morning doctor’s round, during the working shifts doctors also contact by telephone and cooperate directly within the therapeutic team to perform medical services together and complete medical records as well as plan specific medical actions to the discussed patients. The formal way of communication may be the records of medical orders and confirmation of their implementation in the individual documents of patients – so-called Individual (Medical) Order Sheets.