Methods of risk management

Each medical institution is struggling with high fixed and variable costs. In the risk of reducing the funds allocated for the realization of health services, it is worth to adapt lean healthcare and eliminate all sources of waste which generate high costs.

Below are examples of tools to minimize waste which occur in processes:

• KAIZEN
  is a method of continuous improvement which consist of the search and implementation of little or small improvements, which are considered more efficient and cheaper than sporadic, large reorganizations of the company. The basis is kaizen form to which every employee of the company – both an office worker and an operator has access. The form is the basis for demonstrating a new idea that improves the process , work station or conveyor belt. The method allows all employees to be involved in improving the management of the company. Kaizen helps to shape the employee so that he looks for ways to better do perform his duties. It is important to allow employee to make changes and make him not afraid to offer improvements to the supervisors while focusing on the process [Robaszkiewicz 2006].

• Empowerment is transmission of authority and increase of employee permissions. This is one of the concepts of human resource management. It involves encouraging employees to make decisions, increase involvement in work and to take responsibility for his actions. Empowerment allows employee involvement in the process and suggesting his own improvements and ideas. The result of this concept is increasing the sense of belonging to the company, improved team relationships, feeling of responsibility and Increase of awareness of process costs. KAIZEN form can be a suitable instrument [mfiles 2013].

• 5S is a method of reorganizing workstations to increase work efficiency, systematization and arrangement of the workplace. This is a visual management system.

• JIT – just in time is the method in which required components and raw materials like disposable materials and medicines (for example Unit dose system, which allows the hospital to distribute medicine according to the patient’s current needs. The objective is to supply the patient with a single dose of medicine instead of the entire package  which will not be used. This is the future of Polish hospitals) are delivered in a given production process on  exact time. This method eliminates or minimizes component storage and most important –  to minimize delivery time. Taiichi Ohno  is considered to be the creator of it.

• JIS – just in sequence is modern sequential system, it aims to optimize and automate main processes so the parts used during the treatment process are delivered to the destination of medical services according to the order previously determined [psi 2013].

• VSM – value stream mapping
  is a method of acquiring knowledge of the entire production and service process, which consists of drawing a process map and then improvement of it. It is a overall design process, starting with a project and creation of idea for its implementation [Rother i Shook, 1998]. The method allows you to understand the flow of materials and information, allows you to find the muda and its source. This is the only widespread instrument that shows the relationship between the flow of materials and information. The method uses a standard graphical language that is understandable to everyone who deals with VSM. With VSM you can concentrate on flow and create a vision of ideal, desired situation so-called –  future state map. With starting of VSM it is needed to develop a state of the current map by collecting information directly from the place of production or service. The next step is to analyze the map and develop a future state map. It is important to remember and include customer requirements in any action that improves the process. The values characterizing the lean production process are:

• C/T cycle time – determines the amount of seconds needed to create a new service. The shorter the cycle time, the less time elapses between the payment for the raw material and the payment for the finished product.

• T/T tact time – determines the time at which one piece of the product should be produced or the realization of a single service to fulfill the needs. It allows to synchronize the rate of service delivery with rate of sale. Calculated as the ratio of working time for one change (given in seconds) to the number of ordered products per shift, this is theoretical time, which requires short downtimes and rearmaments.

• L/T lead time is the time it needed to the to go through the process by the patient from start to finish.

• VA value added time is the time when actions that increase the value of the patient’s treatment process are performed and for which the client is willing to pay [Rother i Shook 1998].

• SMED– single minute exchange of die is the replacement of the instrument within one-digit minutes. The method allows to quickly rearmament / prepare the room for the next treatment including times required by law. This is an important time because the shorter it is, the less time is lost due to downtime and waiting of patient to receive the treatment.

• TPM total productive maintenance is a technique that allows to increase involvement of employee and staff serving maintenance machinery. Its aim is to reduce accidents at work, shortages and downtimes. TPM’s goals are:
  servicing medical devices and equipment at a specified frequency
  Increase of productivity of machines
  Involvement  of all employees and increase of their scope of responsibility

• TOC– Theory of Constraints is a method of continuous development aimed at maximizing current and future profits of the company, which focuses on processes that reduce the organization’s processing capacity. The TOC method consists of three steps: drum – action to find restriction, the process that lasts the longest, buffer – is the definition of the size of stocks and people in front of the “bottleneck”, such as instuments for sterilization or queue of patients to the doctor’s office, rope – is the supply of such material or the amount of patients that is necessary for the continuous work of the “bottleneck” [Kabut 2011].

• One piece flow is the principle of the flow of one piece, it means that there is one patient in the place where the health care is provided for which the service is given at a this moment. Each employee is simultaneously a product quality controller. The one piece flow system allows to reduce material stocks, shortening the time of performed actions, elimination of unnecessary activities, reduction of product flow time which leads to receive a faster payment for the product from the customer. The principle of flow of one piece can be implemented in one workstation or at a macro scale, it can be deployed throughout the whole hospital. This principle also takes into account the ergonomics of workplace and quality of work [ progresja 2013]. Referring to the clinical process, the principle will reflect the transition of one patient throughout the treatment process which focus on the implementation of actions which will accelerate the discharge process of patient from hospital.

• Jidoka – is the basic pillar of Toyota’s manufacturing system, which allows to maintain the fluidity of service process. It allows to quickly stop the production line or medical treatment if an issue is detected. Referring to ISO 9001: 2015 it is important not only to plan a medical treatment but also in case of occurrence of issue, indication of the person responsible for its re-release. This may be the doctor who directs the institution and will make an entry in the medical report for such event. When the anomaly is detected, the line stops, the issue source is determined and / or fixed. The system is also called automation because it allows automatic detection of a defect by medical equipment. The goal is to provide security of the service, maintain a high level of process quality and increase of its effectiveness. The system uses the  tool Andon [Superfabryka 2013].

• Andon is a visual way of communicating with usage of light signals.

• Visualization
  is a lean management tool, which support the service process. Traditional methods such as reports, circulars and analyzes aren’t readable enough and effective at work, therefore a simple, but very clear, visual method for immediate interpretation of results and decision-making has been introduced. Visualization is a graphical method for creating, interpreting and transferring of information. It is used in many areas of life, also in medicine, didactics, art or logistics and production. The target of visual management is to make quick and effective decisions on introduction of best practices, increase of security, quality and wide interpretation of results, which isn’t possible only on the basis of the calculations themselves, mathematical analysis or surveys research. Examples related to aspects of production:
  Warehouse – marked storage areas for medicines and disposable items
  Production – staff wearing clothes of a certain color depending on the work at each workstation, doctor-white coat, nurse- blue uniform
  Internal logistics – marked places for infectious waste and disposable materials.

• Hoshin kanri is method of proposing improvements by adopting goals for each tier of organization in cooperation with employees at all levels. It is considered to be the spine of Kaizen. Top management establishes policy of objectives and actions. This policy is analyzed and determined with lower level managers – the so-called departments which establish objectives and actions which are agreed with unit managers and operational staff. This method requires the involvement of all employees.

• Genchi genbutsu is lean philosophy that involves personally checking the place where the mistake, defect  or source of the problem occurred, the so-called gemba. It relies on self-observation of the place and its analysis by the department manager or unit manager and a direct conversation of  management with the medical staff [mfiles 2013].

• PDCA
  is principle of improvement is based on four processes: plan, do, check, act. Plan is about setting objectives and processes that are necessary for proper product / service implementation. Do concerns implementation of processes. Check involves measuring and monitoring processes based on policy and objectives. Occasionally, inconsistencies may occur, which should be removed, apply corrective actions and further monitor the process. The next stage is act which refers to perfoming action that involves continuous improvement [quality-management 2013]. PDCA was used by quality guru Edward Deming.

• Chaku chaku – in Japanese it means load-load. A method of continuous flow of materials as well as the patient in the clinical process and the realization of medical treatment within a single office, ward or unit. Activities from several workplaces such as doctor’s office, office for performing ultrasounds, office for blood collection, office for education may be combined into one section, while retaining the principle of the economics of elementary movements and the principle of ergonomic shaping of workplaces. This method is introduced after 5S implementation. The benefits of chaku chaku implementation are the elimination of unnecessary movements, reduction of the area of workplace, reduction of material flow time and  shorter waiting time for employees [staworzynski 2013].

The lean management system has several definitions. The definition of “two pillars” says that the lean management system consists of the total elimination of waste and manifestation of respect for people. According to Womack and Jones, there are five principles of lean thinking: “First, it is to determine the value from the client’s point of view, secondly to identify all stages in the value stream, while eliminating all steps that don’t add any value, thirdly, putting the steps to add values in a strictly defined order, which ensure uninterrupted workflow, fourthly, it is the customer’s attainment of value and fifth it is the aspiration of perfection by the method of continuous improvement ” [Graban 2011].

In conclusion, elimination of muda allows to improve quality and reduce delays and in consequence it leads to quicker repayment of receivables for produced products and services. Lean hospitals and lean management are systems based on the knowledge and experience of lean manufacturing used in the manufacturing industry.

1. Robaszkiewicz M., 2006, Kaizen as good way of company management, Gnieźnieńska Agency of Economic Development sp. z o. o., http://ksu.parp.gov.pl/res/pl/pk/pakiety_informacyjne/05f/05f_21_kaizen.rtf.
2. Empowerment, 2013, http://mfiles.pl/pl/index.php/Empowerment,
3. Kabut M., 2011, Theory of constraints, concept and practical examples , BA dissertation, Warsaw Uniwersity, Management Department, Warsaw http://vento.net.pl/images/!!TOC/TOC-30-Praca%20licencjacka%20TOC.pdf,
4. One piece flow, 2013, http://progresja.com.pl/baza-wiedzy/definicje/one-piece-flow-przeplyw-jednego-detalu/202,
5. Jidoka, 2013, http://www.superfabryka.pl/jidoka,
6. Genchi Genbutsu, 2013, http://mfiles.pl/pl/index.php/Genchi_Genbutsu,
7. PDCA 14 rules of Deming philosophy, 2013, http://quality-management.pl/pdca/70-14-zasad-filozofii-deminga.html,
8. Chaku chaku, 2013 http://www.staworzynski.com/?chaku-chaku,119,
9. Graban M., 2011, Lean Hospitals Improving Quality, Patient Safety and Employee Satisfaction, ProdPublishing, Wroclaw