Embed Size (px)
Citation preview
1
LEAN THINKING TECHNIQUES TO REDUCE TIME IN
LIVER TRANSPLANTATION LOGISTICS PROCESSES
Vera Lucia Monteiro, 1,2 Helder José Lessa Zambelli, 3 Ilka de Fátima Santana Ferreira
Boin 3 and Orlando Fontes Lima Junior 2
1 School of Technology (FATEC) from São José dos Campos, 2 Learning Laboratory of Logistics and Transports
(LALT), School of Civil Engineering, Architecture and Urban Design, State University of Campinas (UNICAMP),
3 School of Medical Sciences, Department of Surgery, State University of Campinas (UNICAMP)
Keywords
Lead Time, Process Redesign, Value Stream Mapping
Running Title
Lean Techniques applied to a Liver Transplantation
2
Correspondence:
Vera Lucia Monteiro, Av. Albert Einstein, 951 - sala 8 – Cid. Universitária “Zeferino Vaz”
CEP 13083-852 – Campinas – São Paulo – Brasil
Tel/Fax.: +55 19 3521 2346
e-mail: [email protected]
Helder J. L. Zambelli: e-mail: [email protected]
Ilka de Fátima S. F. Boin: e-mail: [email protected]
Orlando F. Lima Jr.: e-mail: [email protected]
Abbreviations:
SNT – Brazilian National Transplant System
VSM - Value Stream Mapping
ABTO - Brazilian Association of Organ Transplantation
OPO - Organ Procurement Organization
3
Abstract
The Lean Thinking Techniques have been widely applied in industries; however they have also
been effective in healthcare activities. Thus this study attempted to use these techniques in the
logistics activities of a liver transplant, trying to reduce its cycle time because time is the main
and the most important constraint for transplantation proceedings.
The research was developed in partnership with Organ Procurement Organization at the Clinic
Hospital in State University of Campinas. The procedures involved the mapping of all logistics
processes, from organ procurement until transplantation into the recipient. After mapping, critical
analyses were made to look for waste in each stage. By applying the appropriate lean tool to the
situation observed it was possible to propose a process redesign that could reduce the waste,
leading to gains of more than 30% on its total lead-time.
This research demonstrated that lean thinking techniques are capable of adding important
improvements to the logistics processes of transplantation proceedings, following the tendency of
other healthcare-related activities.
4
In Brazil, the waiting list for transplants has grown year by year and according to the
Brazilian National Transplant System (SNT) the second major cause of non-realization of organ
transplantation, after confirmation of brain death, refers to logistical issues as shown in Table 1.
In this paper logistics issues refer to activities such as materials supply, packaging,
transport and flow of good and related information among all stakeholders.
Womack & Jones refer to lean thinking as the "antidote to waste”. According to them,
waste is any human activity that does not add value. The concept of waste should be expanded to
include not only human activities but also any other type of activity that contributes to the
increase of cost and time and does not contribute to the customer satisfaction.1
According to Redfild and Holmes, some of the tools typically used for the implementation
of the lean philosophy are presented in Table 2.
The value stream mapping (VSM) is a tool introduced by Mike Rother and John Shook in
1999 that helps to identify specific activities that occur throughout the value stream on a process.
It plays a fundamental role in the construction of the current processes and the perspective of
future scenarios, with less waste for the organizations. The main VSM objective is to evaluate
and classify each activity of a process as being or not value-adding and show which points can be
changed in order to optimize the process. 2
According to Redfild and Holmes in the Lean Healthcare Pocket Guide XL, value-added
activities are those that satisfy customers by directly fulfilling their needs. 3
The lean philosophy, once applied only to the production area, can nowadays be clearly
extended to all sectors and organizations, even those that strictly provide service such as the
healthcare system. The application of its concepts results in higher velocity, sensitivity to the
wishes of the customers and more competitive potential.4
5
A good management of logistics activities in organ transplants is important to raise the
quality of procedures and increase the efficiency of the process as a whole. Because there is an
intersection between the areas of logistics management and organ transplants that, if well
managed, effectively planned, will result in process efficiency. 5
From the logistics standpoint, the transplantation proceedings includes the processes of
packaging, storage and transport, taking the time of cold ischemia of each organ and the distance
between the organ donor and its recipient into consideration. It also includes the provision of
specific resources such as scheduling of surgical rooms, equipment, material and staff, as well as
the entire information flow between all teams involved in this process. 6
In the organ transplantation, six key logistics processes can be identified for value stream
analysis and mapping. Such processes are: organ procurement or organ removal, packaging,
transportation, preparation, transplantation into the appointed recipient and also the information
flow between all medical teams.
The Purpose of Lean is to eliminate from a process all waste and any other activities that
do not add value to the customer (patients). The wastes in the healthcare area are distributed in
eight categories, as mentioned in the Lean Healthcare Pocket Guide XL: unnecessary services or
overproduction, mistakes or defects, delays or waiting, unnecessary motion or movement, over
processing, excess inventory, excess transport, unused creativity.3
Such waste categories were carefully searched into the mapped processes, in order to minimize
them through the implementation of suggested improvements.
According to recent data from the Brazilian Association of Organ Transplantation
(ABTO), Brazil is currently third in the world in number of transplants, preceded only by the
United States and China.7
6
SNT has the responsibility for managing the national single list of recipients, with all the
essential information for a successful search for organs. It is also its responsibility to give formal
permission to the hospitals and medical teams to carry out the procurement, transportation and
organ transplantation. This process starts with the identification of brain death in a potential
donor and the subsequent notification to the local Organ Procurement Organization (OPO). This
process effectiveness depends on the speed and accuracy with which such activities are
conducted.8
This paper has taken as its basic premise the statement that, for organ transplantation, time
is the main and very important constraint. From the moment the organ donation process starts, it
should be conducted within the shortest period of time from the procurement to the
transplantation surgery. 9
This research expected to demonstrate that even for non-controlled environments such as
the process of organ transplantation, the techniques of lean thinking are capable of producing
improvements such as reducing waste, streamlining logistics processes and consequently
minimizing its total cycle times.
The suggestions in this paper refer exclusively to the Logistics activities. Other studies
could attest the effectiveness of the method in cases of medical procedures.
7
Experimental Procedures
The main activities of this study were based on data collection (primary and secondary).
The primary data were collected through direct observation, monitoring and mapping the case
chosen (from liver procurement until its transplantation) into the surgical center and interviews
with the teams from OPO. Secondary data were obtained from publications of healthcare and lean
sectors, and from Brazilian departments specialized in transplantation proceedings, especially
SNT and ABTO.
The researcher taking care not to interfere with medical staff and equipped with a
chronometer measured the time elapsed (initial time and end time) in the processes below:
1- Removal of the donated organ
2- Organ preparation process
3- Organ packaging process
4- Organ transportation process
5- Organ transplantation process
During these observations, the researcher also measured the time and described the waits or
delays due to:
1- unavailability of goods, instruments and/or equipments that were not previously provided
in the surgical center preparation;
2- excessive movement inside the surgical center;
3- unavailability of medical staff to start the procedures;
4- failure on training of nursing staff;
5- interruptions during the transportation process.
Beyond the above, the researcher still observed the inefficiencies in the communication
process among the hospital, medical staff and OPO.
8
As the tool VSM proposes after the processes: organ removal, packaging, transportation,
preparation and transplantation have been followed and monitored, a current state value stream
mapping was drawn (figure 1). Then, critical analyses were made and the application of typical
and appropriate lean tools was suggested in order to reduce some of the waste identified.
After that, a process redesign was proposed, represented by a hypothetical future state
value stream mapping (Figure 2), which should be applied to another case to prove the
highlighted gains. The idea is to repeat these steps several times, always seeking to detect and
eliminate new waste in a process of achieving continuous improvements.
Results and Discussion
The improvements listed below suggested the use of one or more tools common used in
lean philosophies implementation. These tools are enclosed in parentheses, right after the
suggestions. They were all based on the Current Value Stream Mapping, designed by direct
observation of the individual processes above mentioned:
HOSPITAL OPO SNT
W WRMV PCKW W TPT PRP W TRPL
WASTE = 194 min. = ~ 3 h.
TOTAL = 598 min. = ~ 10 h.
13
37
27
3
80
120
49
76
25
168
Figure 1 –Current State Value Stream Mapping.
Value-added time = 404 min. = ~7 h. Total = Total Lead –Time.
OPO: Organ Procurement Organization. SNT: Brazilian National Transplant System .
9
W: Waste. RMV: Removal. PCK: Packaging. TPT: Transportation.PRP: Preparation.
TRPL: Transplantation.
Improvements Suggested:
1- Review the protocol for the preparation of surgical rooms and training staff = (Five S’s - 5S)
2- Formulate a check-list for surgical center preparation = (Five S’s - 5S)
3- Establish a routine to inform the responsible surgeon for the transplantation proceeding once
the organ arrives at the hospital, whenever the organ removal team is different from the organ
transplantation team = (Visual Control - VC)
4- Standardize packaging, according to the organ size and Sanitary Agency specification =
(Standardization - S)
5- Develop a new plastic bag in order to accelerate the packing process = (Standardization - S)
6- Create a standard report to go along with the documents during the process of organ
transportation informing occurrences of non-compliance that bring risks to the integrity of
the transported organs or to the people involved in the transportation = (Standardization - S)
7- Establish a regulation for vehicles that transport organs for transplant so that they are fully
equipped to prevent damages to the organs due to mechanical shock and/or sliding along the
way and also to ensure the fastest transport = (Standardization - S)
8- Implement an electronic data interchange system for documents (EDI) via web in order to
guarantee agility, accuracy and economy to the information exchange among teams = (EDI)
A redesigned process, with less waste, is represented by the hypothetical future state value
stream mapping, as shown above:
10
HOSPITAL OPO SNT
RMV PCK TPT PRP TRPL
WASTE = 0 (Goal)
TOTAL = 404 min. = ~ 7 h.37 3 120 76 168
Figure 2 – Hypothetical Future State Value Stream Mapping
Value-added time = 404 min. = ~7 h. = Total Lead –Time.
OPO: Organ Procurement Organization. SNT: Brazilian National Transplant System.
W: Waste. RMV: Removal. PCK: Packaging. TPT: Transportation.PRP: Preparation.
TRPL: Transplantation. EDI: Eletronic Data Interchang. VC: Visual Control. S: Standardization.
5 S: Five S’s (Japanese methodology for workplaces organization).
By implementing the suggestions described above it is expected to obtain a gain in total
cycle time of about 30% (3 hours). This gain in cycle has to be confirmed by monitoring of
other complete transplantation processes, in which the hypothetical future state value stream
mapping built in this study will be the current state value stream mapping of the new processes.
The Lean Thinking methodology enforces a continuous mapping processes, detecting and
removing other waste in order to establish a culture of continuous improvement between the
groups and their activities (Kaizen).
EDI
EDI
5 S
VC
VC S
S
EDI
5 S
11
REFERENCES
1. Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation, Simon & Schuster,
UK, 2003.
2. Rother M, Shook J. Aprendendo a Enxergar: Mapeando o fluxo de valor para agregar valor e eliminar o
desperdício, Lean Institute, São Paulo, 1999.
3. Redfild, D, Holmes S. The Lean Healthcare Pocket Guide XL: Tools for the Elimination of Waste in
Hospitals, Clinics and Other Healthcare Facilities, ELHI, USA, 2004.
4. Dickson EW, Singh S, Cheung DS, Wyatt CC, Nugent AS, Application of Lean Manufacturing Techniques in the
Emergency Department, The Journal of Emergency Medicine, 2009; Vol. 37, pp. 177–182.
5. Genç, R. The Logistics Management and Coordination in Procurement Phase of Organ Transplantation. The
Tohoku Journal of Experimental Medicine, v.216 , n. 4, p. 287 – 296. Istanbul, 2008.
6. Ratz W, Indicadores de Desempenho na Logística do Sistema Nacional de Transplantes:Um estudo de caso,
Universidade Federal de São Carlos, São Paulo, 2006.
7. ABTO - Associação Brasileira de Transplantes de Órgãos [home Page na Internet], disponível em:
< http://www.abto.org.br>. Acesso em 22/10/2009.
8. SNT – SISTEMA NACIONAL DE TRANSPLANTES. Legislação sobre Sistema Nacional de Transplantes.
Disponível em: <http://portal.saude.gov.br/portal/saude/area.cfm?id_area=1004>. Acesso em: 29.09.2010.
9. Fuzzati R, Organ Transplantation Management, Swiss Federal Institute of Technology, Lausanne, 2005.
12
TABLES
TABLE 1: Causes of non-realization of organ transplantation after brain death diagnosis
2002 2003 2004
Nº % Nº % Nº %
Total Brain Death Notification 4.346 100 4.771 100 5.050 100
Effective Donor 959 22 1.198 5 1.417 28
Family Refusal 1.387 32 1.504 2 1.282 25
Logistics Issues 1.159 27 1.129 24 1.208 24
Cardiorespiratoryarrest 653 15 779 16 844 17
Serology 188 4 171 4 298 6
Source: Adapted from SNT
13
TABLE 2: Tools used in the implementation of the lean philosophy
LEAN HEALTHCARE TOOLS
5 SInterruptions and Random
ArrivalsPaper File System Standard Work
Continuous FlowJust in time Physical Layout Takt Time
Cycle Time Kaizen Events Predictable OutputValue Stream
MappingError Proofing
Kanban for supplies Problem Solving Visual Controls
Goals and OutcomesLeveling Pull Systems Waste
Goal CardMeasurement Techniques Six Sigma Work Load Balancing
Source: Adapted from Lean Healthcare Pocket Guide XL
14
FIGURE LEGENDS
Figure 1 –Current State Value Stream Mapping.
Value-added time = 404 min. = ~7 h. Total = Total Lead –Time.
OPO: Organ Procurement Organization. SNT: Brazilian National Transplant System .
W: Waste. RMV: Removal. PCK: Packaging. TPT: Transportation.PRP: Preparation.
TRPL: Transplantation.
Figure 2 – Hypothetical Future State Value Stream Mapping
Value-added time = 404 min. = ~7 h. = Total Lead –Time.
OPO: Organ Procurement Organization. SNT: Brazilian National Transplant System.
W: Waste. RMV: Removal. PCK: Packaging. TPT: Transportation.PRP: Preparation.
TRPL: Transplantation. EDI: Eletronic Data Interchang. VC: Visual Control. S: Standardization.
5 S: Five S’s (Japanese methodology for workplaces organization).
