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APPLICATION OF LEAN MANUFACTURING TO IMPROVE THE PERFORMANCE OF HEALTH CARE SECTOR IN LIBYA
OSAMA M. ERFAN Department of industrial engineering and manufacturing systems, Garyounis University, Libya On leave from Bany Suief University, Egypt osamabanyswef@yahoo.com ABSTRACT The complete elimination waste is the target of any qualified system. This concept is vitally important today since in todays highly competitive world there is nothing we can waste. This paper attempts to apply the principles of lean manufacturing in the service sector in Libya with the purpose of eliminating wastes and increasing capacity. Value Stream Mapping tool was used to expose the waste and identify a proposed plan for improvement. The results achieved in the proposed plan showed significant improvements in the overall performance of the system, which allowed to be more productive, flexible, smooth and with high quality service Keywords: Lean manufacturing Value Stream Mapping takt time - capacity INTRODUCTION In lean manufacturing the wastes are defined as anything which does not add value to the end product. If customer sees the value with the end product, it is very much fair to define a waste in this way. Customers do not mind how much it costs you to repair damage, cost for your huge stocks and stores or other over heads. There are wastes that can be avoided, but some are unavoidable to many reasons. When identifying the wastes and categorize them in to avoidable and unavoidable, you have to think about removing the wastes from the system. However, lean manufacturing always talks about removing, not minimizing. The wastes are everywhere in many different forms. Every organization wastes majority of their resources. Therefore it is worthier to have a closer look at these wastes. These wastes are categorized in to eight categories. These waste categories are over production, waiting, including time in queue, work In Progress (WIP), transportation between workstations or between supplier and customers, inappropriate processing, excess motion or ergonomic problems, defected products, and underutilization of employees[1].

Lean Manufacturing Tools

Lean manufacturing is based on continuous finding and removal of the wastes. Value is defined from the customers point of view. Therefore all the tools in lean manufacturing aim to identify and remove wastes from the system continuously. There are four steps in implementing lean manufacturing. They are; 1. Identifying the fact that there are wastes to be removed, 2. Analyzing the wastes and finding the root causes for these wastes, 3. Finding the solution for these root causes, and 4. Application of these solutions and achieving the objective. When this is done recalling stage 1 and continue this loop over and over again. To become lean it is very necessary to understand the fact that wastes are there. It must also be able to find out where these wastes do exist. Then it will be able to find out the root causes for these problems and then come up with a way to solve it. To find out where in the process these wastes exist there is a very powerful and simple tool. This well known tool is process mapping. Process map simply maps all the processes and the activities which are carried out in bringing a specific product or a service in to a reality. Irrelevant of the value they add to the final product or the service, the process map includes all the activities from the point of development or order inquiry to making and shipping the goods and up to the point where customer collects the goods.

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REVIEW OF RELATED WORKS

Womack and Jones (2003) advocate the application of Lean thinking in the medical systems. They argue that the first step in implementing Lean thinking in medical care is to put the patient in the foreground and include time and comfort as key performance measures of the system. Having multi-skilled teams taking care of the patient and an active involvement of the patient in the process is emphasized [2]. Karlsson et al. (1995) argue that Lean product development, supply chain management, and Lean manufacturing are important areas also in healthcare. The focus on zero defects, continuous improvements and JIT in healthcare makes Lean concepts especially applicable. The establishment of customer interaction is equally important in the manufacturing industry as it is in the healthcare sector [3]. Young et al. (2004), see an obvious application of Lean thinking in healthcare in eliminating delay, repeated encounters, errors and inappropriate procedures [4]. Similarly, Breyfogle and Salveker (2004), advocate Lean thinking in healthcare and give an example of how Lean management principles can be applied to health care processes through the use of the Six Sigma methodology, which in many ways resemble the Lean production techniques [5]. Several case stories on Lean thinking initiatives in healthcare sector can be found in Miller (2005), and Spear (2005) [6,7]. In a recent publication by the Institute of Healthcare Improvement, two health care organizations in the US showed positive impact on productivity, cost, quality, and timely delivery of services after having applied Lean principles throughout the Measuring Lean Initiatives organization. Dickson et al (2009), described the effects of Lean, a process improvement strategy pioneered by Toyota, on quality of care in 4 emergency departments (EDs). Participants in 2 academic and 2 community EDs that instituted Lean as their single process improvement strategy made observations of their behavioral changes over time. They also measured the following metrics related to patient flow, service, and growth from before and after implementation: time from ED arrival to ED departure (length of stay), patient satisfaction, percentage of patients who left without being seen by a physician, the time from ordering to reading radiographs, and changes in patient volume. The results showed that length of stay was reduced in 3 of the EDs despite an increase in patient volume in all 4. Each observed an increase of patient satisfaction lagging behind by at least a year. The narratives indicate that the closer Lean implementation was to the original Toyota principles, the better the initial outcomes. The immediate results were also greater in the EDs in which the frontline workers were actively participating in the Lean-driven process changes. In conclusion, Lean principles adapted to the local culture of care delivery can lead to behavioral changes and sustainable improvements in quality of care metrics in the ED. These improvements are not universal and are affected by leadership and frontline workforce engagement. [8]. Wong, Wong, and Ali (2009), investigated the adoption of lean manufacturing in the electrical and electronics industry in Malaysia. A questionnaire survey was used to explore 14 key areas of lean manufacturing namely, scheduling, inventory, material handling, equipment, work processes, quality, employees, layout, suppliers, customers, safety and ergonomics, product design, management and culture, and tools and techniques. The respondents were asked to rate the extent of implementation for each of these areas. The average mean score for each area was calculated and some statistical analyses were then performed. In addition, the survey also examined various issues associated with lean manufacturing such as its understanding among the respondent companies, its benefits and obstacles, the tools and techniques used etc. The survey results show that many companies in the electrical and electronics industry are committed to implement lean manufacturing. Generally, most of them are moderatetoextensive implementers. All the 14 key areas investigated serve as a useful guide for organizations when they are adopting lean manufacturing. This was the first study that investigates the actual implementation of lean manufacturing in the Malaysian electrical and electronics industry [10].
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EXPERIMENTAL WORK AND RESULTS

The Emergency Departments (EDs) play a vital role in providing care to patients and they are recognized for their contribution that they make to the society. The available statistics make it clear about the indispensability of this healthcare service operations that the country relies upon to provide medical services to the patients on a 24/7 basis. The ED healthcare service delivery system represents one of the most visible service sectors where the effects are very stark. Poor service delivery can often make the difference between life and death. The serious issue concerning healthcare in hospitals' ED is that they are very crowded and the waiting times are so long that it is rarely a smooth and satisfying experience. Causes for ED overcrowding are well known and include hospital bed shortage, high medical acuity of patients, increasing patient volume, shortage of examination space and shortage of medical staff. Even though these issues are well recognized, alleviation of these problems in ED is not trivial and requires addressing the complex systems issues. Our work concentrates on exploration of improving effectiveness of ED operations. By creating a framework for eliminating waste in healthcare front-end processes, significant long term benefits can be gained (e.g., shorter lead times, which meaning more patients served), less personnel required, more satisfied patients etc. The Al-Jala hospital is a teaching hospital with a 460-bed facility. It serves the entire population of the eastern region of LIBYA. Table 1 below shows average annual statistics obtained from Statistics and Documentation Unit of the hospital. Table 1 Hospitals Annual Statistics
Description Patient visits to hospital Admission cases Minor operations Major operations ED visits Number 130,000 19,500 6,100 5,000 35,000

Current ED Service Delivery Process

In the ED procedures patients are categorized according to the severity level of their medical condition. Walk-in patients are categorized as being the least emergent. Most emergent patients that require immediate care from a physician are served first, while other patients are expected to see a physician upon a number of visits to the ED, however, they have been witnessed to be waiting over an hour in the waiting room. The ED provides medical service to the patients on a 24/7 basis of two shifts. Each shift includes one main physician at examination room. The ED also contains one observation room of 16 beds. The ED service delivery process can be represented by the following set of core activities. These activities occur in a sequential manner; some of the steps are either rearranged or are omitted for different patient types. Figure 1 shows general process flowchart and patient flow through the system.

Takt Time Analysis

Takt time is the important tool needed for the assessment of current system. It is a tool used to eliminate over servicing. The ED works sometimes in two shifts with 12 hours per shift, and sometimes in three shifts with 8 hours in each shift. The lunch breaks as well as other necessary breaks for the working staff are covered by another staff. So the total available time is 24 hours a
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day which equal to 86400 sec. As mentioned in Table 1, in average, the annual ED visits (flow) is 35,000, which is equivalent to 96 visits per day. So the Takt Time for each process of the service is the same and calculated below with the reference to formula mentioned in [9]. = 900 sec per patient Patient Registration takt time = Patient Evaluation takt time = Diagnostic Tests takt time = Therapy takt time = Results Evaluation takt time = = 900 sec per patient = 900 sec per patient

= 900 sec per patient = 900 sec per patient

After collecting the information needed with regard to the patient and information flow, it is easy now to draw the value stream map VSM for the current state. A value stream is defined as all the actions (both value added and none value added) required to bring a specific product, service or a combination of products and services, to a customer. The VSM of the ED is created by using a predefined set of icons (shown in figure 2). These icons include the process icon, the data box, the outside source, finished goods to customers icon, and information flow icon.

Patient arrives by as walk-in

Patient is entered to ED

Patient arrives by ambulance

Registration and wait for service

Patient is evaluated

Diagnostic testing and/or therapy required?

No

Yes

Tests are conducted (lab, radiology)

Therapy is conducted

Results arrive and decide what additional treatments are required

Need for further care?

No Yes

Admission Discharge

Figure1 ED Service Delivery Process Flowchart

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C/T = C/O = Waste =

Process

Data Box

Outside Source

Finished Goods to Information Customer Flow

Figure 2 Value Stream Mapping Icons The operations to be carried out per cycle are shown in Table 2 The VSM of current ED state is presented in Figure 4.3. The service commences with registration by taking patient information. Following the registration, the patient is ready to assessed by the physician. Following the assessment by the physician the patient undergoes the diagnostic testing and/or therapy, and after evaluation of the diagnostic reports and/or medical assessment, a decision to admit or discharge the patient is made. Entries in the data box underneath the process icon include entries for cycle time, change over time and waste time. As discussed previously, cycle time is the time it takes to service a patient. Cycle time includes issues like face to face contact with the patient and physical examination. The values of the cycle times shown for each process were obtained from the relevant people and have been included as the cycle time for each stage in the service delivery process. The change over time included in the data box accounts for cleaning and preparation for the next patient. Waste time is the time the patient takes until they start serving him/her in each process. For the purpose of service control there are weekly schedules for physicians, nurses and other clinical staff. Utilizing all these concepts the VSM for the current state of the process is shown below.

Table 2 Data Collection of ED Operations .

No 1 2 3 4 5 Description Patient Registration Patient Evaluation Cycle Time (C/T) in (sec) 300 900 1200 1800 600 4800 Available Time of Related Clinical Staff (sec) 86400 86400 86400 86400 86400 345600

Diagnostic Tests Therapy

Results Evaluation Total

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Service Control Weekly Schedule

Patient arrival with care needs

Discharge

Registratio n

Patient Evaluatio n (1)

Diagnosti c Tests

Therapy

Results Evaluatio n

C/T = 5 min C/O = 2 min Waste = 8 min 8 min 5 min 25

C/T = 15 min C/O = 5 min Waste = 25 30 15

C/T = 20 min C/O = 5 min 20 20

C/T = 30 min C/O = 5 min 30 30

C/T = 10 min C/O = 5 min Waste = 30

Admissio n

10

Lead Time = 193 min Value-Added Time = 80 min

Figure 3 VSM for the Current State From the data presented in the case, the capacity of the individual unit per hour has been calculated. This value is not uniform. It indicates that there will be lot of idle time for the staff as well as in the process. It is observed that, in the present system only 48 patients can be served per day. So it is decided to improve the service capability by applying lean manufacturing philosophy. At this stage, the total number of relevant clinical staff required is equal to 5. The idle time for each operation is calculated and shown in Table 3. The total idle time is calculated as (201600 sec). This idle time must be utilized in order to increase service capability. The main objectives of applying lean principles are to reduce wastages, idle time of operators and to increase the production/service capability by combining some of the operations or adding new ones. These analyses are discussed in the subsequent sections.

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Table 3 Service Details of Current ED State

Cycle Time (C/T) in (sec) 300 900 1200 1800 600 4800 Number of Related Clinical Staff 1 1 1 1 1 5 Available Time of Related Clinical Staff (sec) 86400 86400 86400 86400 86400 432000

No

Operation Description Patient Registration Patient Evaluation Diagnostic Tests Therapy Results Evaluation Total

Capacity per Clinical Staff/Day 288 96 72 48 144 -

Utilized Time = 48 x C/T 14400 43200 57600 86400 28800 230400

Idle Time per Clinical Staff/Day 72000 43200 28800 0 57600 201600

Capacity /Hour

1 2 3 4 5

12 4 3 2 6 -

Figure 4 shows the relationship between cycle time and their respective operations. Bottleneck problems within the processes are seen very clearly, represented in diagnostic testing and/or therapy operations, which have largest cycle times respectively.

Figure 4 Cycle Time Vs ED Operations Similarly, Figure 5 shows the relationship between capacity per day and their respective operations. It can be clearly seen that the bottleneck problems is in the

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Figure 5: Capacity per Day Vs ED Operations Diagnostic testing and/or Therapy operations, where their capacity per day is clearly low compared to other operations. The Proposed Plan In the proposed plan, the patient evaluation operation has been combined with each of diagnostic testing and therapy operations so that the same clinical staff doing diagnostic tests or therapy can read the reports and evaluate the results, and then make decision either for continuing service (admission) or leaving the ED (discharge). Also, another new physician was suggested to be added at the combined operation (Therapy and Results Evaluation). This will reduce the waiting time, increase the serviceability and patient flow at the observation room, as illustrated below. Next, changes that could be done to the current system and how it will affect the overall performance and the improvement in service capability has been illustrated. These improvements mentioned above led to increasing the patients served (capacity) from 48 to 72 (50%), reducing idle time from 201600 sec to 129600 sec (36%) and increasing utilized time from 230400 sec to 302400 sec (31%), while the number of clinical staff remains the same with 5. The detailed results of these improvements are shown in Table 4. Initially diagnostic testing/therapy and patient evaluation operations are carried out by three clinical staff, which led to an idle time of 86400 sec per day. In the proposed plan after combining the operations the idle time has been reduced to 43200. In the proposed methodology, one clinical staff is engaged in the diagnostic testing and Patient Evaluation operation. So the capacity of the operation has been improved to 72, but the maximum capacity of the system is 288 which is higher than the capacity of the diagnostic testing and patient evaluation operation. The difference can be eliminated by reducing waste time and change over time of operations and adding more units especially for diagnostic testing.

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Table 4 Service Details of Future ED State

Operation Description Patient Registration Patient Evaluation Diagnostic Tests and Results Evaluation Therapy and Results Evaluation Total Cycle Time (C/T) in (sec) 300 900 Number of Related Clinical Staff 1 1 Available Time of Related Clinical Staff (sec) 86400 86400 Capacity per Clinical Staff/Day 288 96 Utilized Time = 72 x C/T 21600 64800 Idle Time per Clinical Staff/Day 64800 21600 Capacity /Hour

No

1 2

12 4

1200

86400

72

86400

1800 4800

2 5

172800 432000

96 -

129600 302400

43200 129600

4 -

In this way, the service capability has been improved. The improvement in service provided, idle time and utilized time are plotted and shown in Figures 6, 7 and 4. below.

Figure 6 Improvement in Capacity

Figure 7 Improvement in Idle Time

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Figure 8 Improvement in Utilized Time

Value Stream Mapping for Future ED State The future stream map is a method of showing the desired achieved future goals. It also shows service delivery processes after using lean tools to improve it. The future stream map is similar to the current stream map, where both give visual representation of the material, information and time flow, and it is used to show the level of successes and changes. The future stream map will be used to demonstrate how the product flows, eliminating all the wastes shown in the current state and achieve lean manufacturing. It is a powerful tool, it provides a clear statement of a vision for where the organization is going, however if the ideas are not implemented within a short time, it will lose its force and it will become another "has been" of manufacturing technique. The future stream map (or VSM) in this case study, which represents the future vision of the ED, is shown in Figure 9. The results achieved in the future stream map resulted from using some of the lean manufacturing; these techniques are helping the ED to be more productive, flexible, smooth and with high quality output. This will enhance the ED overall performance, lead time, changeover time and the delivery time to patients. It can be seen that the lead time of the service at ED has been reduced from 193 sec to 153 sec (20.7%).

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Service Control Weekly Schedule

Patient arrival with care needs

Discharge

Registration

Patient Evaluation (1) Physician

Diagnostic Tests and Results Evaluation

Therapy and Results Evaluation

C/T = 5 min C/O = 2 min Waste = 8 8 min 5 min 25 min

C/T = 15 min C/O = 5 min Waste = 25 min 30 min 15 min

C/T = 20 min C/O = 5 min Waste = 30 min 20 min 20 min

C/T = 30 min C/O = 5 min Waste = 20 min

Admission

30 min

Lead Time = 153 min Value-Added Time = 70 min

Figure 9 VSM for the Future State By implementing the lean manufacturing techniques, ED at Al-Jala Hospital for Surgery and Accidents will gain lots of benefits with regard to its healthcare services provided to the patients. Some of these advantages can be seen directly from the future stream map and can be considered as long term advantages. Table 5 below shows the differences in results between the current state and the future state. Table 5 Comparison of Results Between Current State and Future State
Item Current State Future State % of Improvement

Capacity Idle Time Utilized Time Number of Operations

48 201600 sec 230400 sec 5

72 129600 sec 302400 sec 4

50 36 31 20

CONCLUSIONS
In general, it was shown that the Value Stream Mapping is an ideal tool to expose the waste in a value stream and to identify tools for improvement. It was also illustrated that lean manufacturing
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tools can greatly reduce wastes identified by the current state map. The development of the future state map is not the end of a set of value stream activities. It should be stressed that the value stream should be revisited until the future becomes the present. The idea is to keep the cycle going because if sources of waste are reduced during a cycle, other wastes are uncovered in the next cycle. Lean manufacturing can thus be adapted in any manufacturing situations albeit to varying degrees. The results achieved in the proposed plan showed significant improvements in the overall performance of the ED, which allowed it to be more productive, flexible, smooth and with high quality service. These improvements include reducing the lead time of the service at ED from 193 sec to 153 sec (20.7%), which increased the patients served (capacity) from 48 to 72 (50%), reducing idle time from 201600 sec to 129600 sec (36%) and increasing utilized time from 230400 sec to 302400 sec (31%). Finally, it is concluded that an improvement in Capacity, Idle time and Utilized time has been achieved as a result of implementing lean manufacturing principles REFERENCES 1- Fawaz Abdullah, "Lean Manufacturing Tools and techniques in the Process Industry with a Focus on Steel", PhD Thesis, University of Pittsburgh, 2003. 2- Womack, J.P. and Jones, D.T., "Lean Thinking", Simon & Schuster, London, 2003. 3- Karlsson, C., Rognes, J. and Nordgren, H., " Model for Lean Production", Institute for Management of Innovation and Technology, Goteborg, 1995. 4- Young, T., Brailsford, S., Connell, C., Davies, R., Harper, P. and Klein, J.H., Using industrial processes to improve patient care, British Medical Journal, Vol. 328 No. 7432, pp. 162-4, 2004. 5- Breyfogle, F. and Salveker, A., "Lean Six Sigma in Sickness and in Health", Smarter Solutions, Austin, TX, 2004. 6- Miller, D., "Going Lean in Health Care", Institute for Healthcare Improvement, Cambridge, MA, 2005. 7- Spear, S.J., Fixing health care from the inside, today, Harvard Business Review, Vol. 83(8), pp. 78-91, 2005. 8- E. W. Dickson, Z. Anguelov, D. Vetterick, A. Eller, and S. Singh, "Use of Lean in the Emergency Department: A Case Series of 4 Hospitals", Journal of Annals of Emergency Medicine, 2009. 9- Mikll P. Groover, "Automation, Production System and Computer Integrated Manufacturing", Second Edition, Prentice Hall, 2002. 10- Yu Cheng Wong, Kuan Yew Wong, and Anwar Ali, "A Study on Lean Manufacturing Implementation in the Malaysian Electrical and Electronics Industry", European Journal of Scientific Research, ISSN 1450-216X Vol.38 No.4 (2009), pp 521-535, 2009.

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