Automation in Healthcare Internal Logistics: A Case Study on Practice ...

Mälardalen University Post-Print Reference to this paper should be made as follows: Granlund, A. and Wiktorsson, M. (2013) ‘Automation in healthcare internal logistics: a case study on practice and potential’, International Journal of Innovation and Technology Management, Vol. 10, No. 3. DOI:10.1142/S0219877013400129

AUTOMATION IN HEALTHCARE INTERNAL LOGISTICS: A CASE STUDY ON PRACTICE AND POTENTIAL ANNA GRANLUND* and MAGNUS WIKTORSSON† School of Innovation, Design and Engineering, Mälardalen University Box 325, SE-631 05 Eskilstuna, Sweden * [email protected] † [email protected] http://www.mdh.se/idt/ipr

The current demographic development puts even greater demands on the healthcare sector which already struggle with scarce resources and constant pressure of cost reductions. This paper aims at through a multiple case study describe how automation of hospital internal logistics can be a tool in improving the efficiency. The results include several potential implementations for patient transports, waste handling and small goods transports. However, organizational issues as lack of ownership and a strategic view render difficulties and needs to be dealt with. The authors conclude that transfer of knowledge and technology used in manufacturing industry would be beneficial. Keywords: Automation; internal logistics; healthcare; case study.

1. Introduction The healthcare industry is under constant pressure from politics and public to increase service levels and decrease escalating costs. The demographic trend and profile in combination with increasing treatment possibilities, leads to a tremendous challenge to increase healthcare productivity. Facing these challenges, numerous technology management strategies regarding process, organization, function and applications have been proposed and implemented. In striving for productivity leaps, technology will play a key role, as is the case in the manufacturing industry. This paper takes its stance in automation of internal logistics as a means for improving efficiency and supporting the value-adding core processes. We study the internal logistics system, and its activities concerning both information and materials handling. A well functioning internal logistic system is critical for the overall function of healthcare operations, but often is the value adding processes of patient care diminished by numerous logistic activities required by the hospital staff. The vision is an efficient supportive logistic system, enabling the staff to focus on activities value adding for the patient. The objective of this multiple case study of three Scandinavian hospitals is to (1) bear witness and analyze how hospitals in different aspects work with internal logistic activities and (2) conclude how automation can be a tool in improving hospital internal logistic systems.

In order to reach these objectives, the following aspects are covered: qualitative and quantitative analyses of resources usage and ways of working with improvements, areas in need of improvement, and possible applications of automation in hospital internal logistic systems. 2. Frame of reference In many countries in the developed part of the world the older part of the population is increasing. According to Statistics Sweden [2010] the share of the Swedish population older than 75 years is expected to be doubled within 40 years. The demographic development does not only increase the demand on healthcare by sheer numbers. A growing elderly population puts even greater demands on the healthcare since older adults have high rates of health services utilization [Institute of Medicine (2008)]. The rise in patients with multiple conditions and chronic illnesses is already influencing hospitals and will increase to do so in the future [The Joint Commission (2008)]. Many countries therefore face the dilemma of managing increasing health needs under financial restrictions [Swinehart and Smith (2005)]. The hospitals challenge is to increase their productivity and focus on using their available resources in the most efficient way [Chow-Chua and Goh (2000); Poulin(2003); Hendrich et al. (2008)]. The productivity quota concerns two dimensions: increasing the value and decreasing the cost [Tangen (2005)]. It concerns how much and how well one produce from the resources used [Bernolak (1997)]. The term efficiency can be described as “doing things right” and is according to Tangen [2004] linked to the utilization of resources and hence mainly deals with the input of the productivity quota. This apparent simple quota of input and outputs is in reality often a complex matter. The value is created by resources, thus in changing the set of resources, the value adding activity is modified. For the healthcare industry, the definition of value adding is an intricate issue. The manufacturing industry is built on the fundamentals of productivity. In the fierce competition and increased globalization, the only way to success is to increase value and decrease cost. The Lean production paradigm has over the last decades emerged as the most important way for production and the winds of Lean have reached the healthcare industry, in the form of Lean healthcare. As pointed out by Finnsgård [2009], in Lean production the value-adding operator is in specific focus - only performing value-adding work from a customer’s perspective [Monden (1998); Ohno (1988)]. Materials are exposed to aid the operator in creating customer value [Liker (2004)]. However, compared to other engineering approaches, materials supply systems have not received the same attention [Gupta and Dutta (1994)]. As Rubinovitz and Karni [1994] suggest, materials supply systems are often addressed as a final stage in the development, after product, process, and layout design are complete. However, according to Mattsson and Jonsson [2003] can a well formulated and correctly used logistics system increase the efficiency in many ways for an organization and therefore it should be of great interest in wide variety of organizations, including the healthcare. Özkil et al. [2009] state that one of the major and usually underestimated support services in hospitals is the logistics. But within the healthcare sector, the logistics research has been reluctant to make the comparison between itself and the manufacturing

sector [Jarrett (1998)]. As Rivard-Royer et al. [2002] reports, the healthcare supply chain is characterized by its complexity, consisting of multiple suppliers, distribution channels and a complex internal logistical network. The synchronization of these parts is a challenge often resisted by organizational and responsibility boarders. In Kitsiou [2007], the authors analyze the healthcare supply chain and identify the core entities, processes, information flows, and system integration challenges which impede supply chain quality improvements to be realized. In Poulin [2003] it is stated that 30% to 46% of hospital expenses are invested in various logistical activities, and that almost half of the costs associated with supply chain processes could be eliminated through the use of best practices. Within the manufacturing industry, automation is a well known means for improving productivity and efficiency [Frohm et al. (2006)]. By standardization, automation and process control, predictable and highly productive value-adding processes are established. Automation is however undergoing a transformation in scope and the range of applications is increasing. Besides manufacturing as the activity being most closely connected to automation, new application areas such as logistics, healthcare, transportation, maintenance, and retail are emerging. The area of logistics automation within health care is a crowing industrial sector, but the witnesses from live cases are scarcely documented in scientific contexts. As stated earlier, this paper relies on automation in the internal logistic systems as a means for improving efficiency and supporting the value-adding core processes in hospital operations. The study is a contribution to the body of knowledge regarding how the necessary productivity leaps and efficiency gains within the healthcare sector could be reached. 3. Methodology This paper is based on the results from a multiple case study, with the purpose of studying hospital internal logistics systems and concluding how automation can be a tool in improving them. In answering this “how to” question, a case study series was chosen, although it never give bases for a statistical generalization but relies on observation and analysis as the basis for conclusions [Yin (1994)]. In order to fulfill the objectives, the study consists of three cases with different purposes, aims and approaches, individually described below. The main logic of conducting the multiple case study was to build an comprehensive understanding, where the findings from the different sub-studies together build a total knowledge mass of critical aspects. Thus the three sub-studies were selected in order to complement each other. Case 1 is the most comprehensive case and was the base of the study. Following Case 1, two sub-studies (Case 2 and Case 3) were included to cover a wider range of hospitals with different prerequisites and levels of applied automation. 3.1. Case 1 The base of the multiple study was a case study at a Swedish hospital with 400 beds. The research questions during Case 1 was (1) how is the internal logistics system structured and how are logistic activities carried out and (2) what improvement areas are there and

how could automation be used to improve these? This was answered by analyzing the current way of working, detecting areas in need of improvement and, using input from the sub-studies, investigate how the logistic system could be improved using automation. Case hospital 1 was chosen since its physical and organizational conditions represent a typical Scandinavian hospital in terms of size, age, and constraints in technology management. Case 1 was a descriptive study with a timeframe of eight months. Three main methods for data collection were used in order to triangulate information: observations, interviews (open and semi-structured) and archival records/documents. The observations were conducted during 12 occasions at nursing wards and the transportation department. During the observations the researchers were guided through the operations and studied the daily work of nurses and transportation staff. Through the direct observations the study could cover events and their contexts in real time [Yin (1994)] and also make observations that the personnel daily involved in the activities do not notice. Activities that were time consuming, ergonomically flawed, or in other aspects in need of improvement were identified, and notes were made individually during the observations and then compared and compiled after each occasion. During the analysis the observation notes were scanned for general themes mentioned and also compared with the results from the following interviews. 23 semi-structured and open interviews were conducted with nurses, the respective head of three nursing wards, the director of the ward division, the hospital coordinator, the supervisor of the transportation department and employees at the transportation department. Most interviews were conducted with one interviewee but there were interviews of discussion character with several informants. The interviews ranged from 20 to 90 minutes and at least two researchers were taking notes during each interview. The interviews covered current practices, routines and time estimates, improvement areas and visions of a future state. Information material, reports and other internal documentation were studied in order to triangulate or further investigate aspects emerged during observations and interviews. Among others was a time study, performed at 13 nursing wards, analyzed. During the time study activities were mapped by the nurses every ten minutes, day and night, during 14 days on a form with 30 predefined activities. The material was compiled by the researchers, describing which activities were most time consuming, and during the analysis compared with the results from the other parts of the study. 3.2. Case 2 The second case was a focused study concerning the topic of improvements within the logistic system at a large dual-site hospital. Case Hospital 2 is one of Europe’s largest hospitals with 1680 beds over two sites and was selected since it actively works with improving the logistic system, using e.g. automation. The hospital is also in process of planning and designing a new, future site. The research question was: How can and should automated improvements of hospital internal logistics systems be structured? In Case 2, being a descriptive study, data for analysis were gathered mainly by observations and interviews, in line with Blessing [2002]. The two hospital sites were visited once each for four hours during which the researchers observed and were guided

through the way of working by the supply manager. The studied areas relate to material handling and internal transports of both patients and goods. Semi-structured interviews were conducted with the manager of supplies and the persons responsible for the different automated systems observed. The main aspects covered were the way of working today and with improvements of the current logistic system. The project manager for the logistic system in the new, future hospital was also interviewed to cover how the hospital strategically works with designing a new logistic system. Besides observations and interviews, information material, reports and other internal documentation were gathered and studied in order to verify or further investigate areas discussed. 3.3. Case 3 The third case aimed at being a role-model and describing what the future in hospital logistics could be. The hospital with 675 beds was inaugurated late 2008 and was selected since it is a new hospital (operating for eight months when visited) with a high level of automation. They call themselves Europe’s most modern hospital with regards to the level of technology and the way of working. The research question was: What is the state of practice of modern hospital internal logistics systems in terms of technology and automation? Case hospital 3 was visited once for five hours during which the researchers were guided through the hospital and introduced to the way of working and the technology used. The guides were the person responsible for coordinating the user needs during the construction, the manager of the Information, Communication and Technology department and the manager of the Service and Technology department. Open and semistructured interviews were conducted during the visit, information material and internal documents were gathered and studied to complement the observations and interviews. 4. Empirical Findings The findings from the cases are presented as a base for the analysis and discussion regarding how hospitals in different aspects work with internal logistic activities and how automation can be a tool in improving hospital internal logistic systems. The findings are structured according to: Case 1 • Current state description of logistic activities, transportation department • Time consuming logistic activities, nurses perspective • Quantitative time study of nursing activities • Improvement areas and future state visions Case 2 • Current state description of internal logistic solutions • Future state description Case 3 • Development, solutions and initial problems in a new hospital internal logistics system

4.1. Case 1: Current state of logistic activities, transportation department Case hospital 1 has a transportation department, working as an external part from which the hospital buys services. The department is responsible for all transportation activities that belong to the internal service of the hospital, e.g. transports of waste material, laundry, food, pharmaceuticals and patients. They are also responsible for the mail service and the main supply room at each ward including ordering and distributing supplies. The department only operates during dayshift (07.00 – 17.00) and employs 20 workers and one supervisor with an operative role. In the following, key functions of the transportation department are briefly presented, on the basis of interviews and observations. 4.1.1. Equipment The transportation department owns all their equipment such as industrial trucks and carriages used for internal transports. The transportation department only have contract with the hospital for two year periods. Due to this, the manager expressed concerns regarding the ownership of new investments, enabling a long term view. 4.1.2. Patient transports The wards book patient transports from the transportation department by giving the date, time and place for pick-up and destination, and if necessary information regarding the patients’ status etc. The transportation department performs approximately 15 000 patient transports per year representing 87% of all patient transports. The remaining patient transports are made by the nursing staff either due to too short notice (acute) or no available transportation staff. Bookings of patient transports are supposed to be made by fax before 07.00 the day of the transport. Each morning the transportation staff plan and divide the day’s transports between the staff. However, only 50% of the bookings are made in advance, 30% are received by phone during the day and the remaining 20% constitutes return transport of patients back to the wards. One difficulty expressed was that the staff does not have any communication equipment that works in the culverts. Normally they use cell phones but since these are not allowed or functioning in all areas of the hospital, it is difficult to manage and coordinate transports or staff already on assignments. This obstructs the planning, lowers the flexibility and increases the lead time, since much time is lost when staff must return to the transportation department to receive new work orders. The most common means of transport is when the transportation staff walks, manually pushing the bed/wheelchair. There are however aids, for example a carriage that can be connected to the industrial truck and also a “bed pusher” which lifts the bed and makes it easier to maneuver. But these tools do not fit in the elevators and can hence only be used on the ground floor and in the culverts connecting the hospital buildings. The carriage is the preferred means of transport especially in the culverts since those transports are physically demanding due to long distances and steep slopes. However, today is the one carriage used to its maximum capacity.

4.1.3. Waste material and laundry Two types of waste are handled, regular waste (such as scraps of food) and clinic waste (such as biological waste, syringes and other sharp or potentially contaminated material). For the non clinical waste there are chutes on several locations in the hospital where the nursing staff drops bags of waste from the wards. These chutes lead down to the basement where the waste ends up in a dumpster. The dumpster need to be manually replaced when full, but there is no indication for this. Instead the transportation staff regularly controls them in order to avoid congestion in the pipes or overflow of waste. The procedure is the same for laundry bags: chutes at the wards lead the laundry bags to roller cages that need to be replaced when full. Approximately one ton of laundry is handled per day at the hospital. 4.1.4. Food handling The transportation department picks up food carriages from the hospital kitchen and transports them to the wards three times a day (breakfast, lunch and dinner). The carriages are transported to the elevator hallway nearest to each ward. The nursing staff brings the food carriages into the ward. After each meal the nursing staff brings the carriages back to the elevator hallway where the transportation department collects them for return to the kitchen. 4.1.5. Samples Rounds for picking up samples at the wards and taking them to the laboratory are made several times a day. Sample transportation is often done together with mail transportation, but with no fixed schedule. The nurses also deliver many samples, especially urgent samples, to the laboratory. There is a pneumatic tube system between the laboratory and wards that each day handles a vast number of samples (for example for the emergency room). The system is old and not adjusted for the current layout. Only a few connections exist and the capacity is low leading to use only for urgent samples. 4.1.6. Mail handling The transportation department sort and distribute external and internal mails, a task which is equivalent two full time positions. 1 300 000 external letters are sent from the hospital per year (incoming and internal mail not included). There are 158 pickup/drop off mailboxes at the hospital and one main distribution round per day in each direction. However, the staff often brings back mail from the wards if they have been there. 4.1.7. Goods All packages over two kg sent to/from the hospital are handled as goods. The hospital receives approximately 26 000 packages per year. Upon package arrival, two copies are made of the delivery note or address label. One is taped to the box and one is put in a binder. When the package is delivered, the receiver signs the delivery note on the box, which is brought back and placed with the other copy in the binder as confirmation that the package has been delivered. This procedure was

during the observations experienced as intricate and not fully dependable, a view that was supported during interviews. The task is time consuming, complicated, offers low traceability since delivery notes often go missing during the process. 4.2. Case 1: Time consuming logistic activities, nurses perspective During interviews, the nursing staff w asked about logistic issues influencing their work load. One reoccurring issue was the large amount of patient transports made by nursing staff, despite being the transportation departments’ responsibility. The transportation department was perceived as not having capacity to handle all transports and not always arriving in time for booked transports, leaving the nurses to perform the transports. The transports are time consuming but also physically straining due to long distances. Other time consuming, not directly patient related activities, was transporting samples to the laboratory, collect/leave food carriages in the elevator hallway, but also information logistic activities such as preparations before rounds, discharges and paper work. The time with the patients was perceived as a little part of the total time. 4.3. Case 1: Quantitative time study of nursing activities In order to analyze the nurses’ time in detail, a quantitative time study was performed at 13 of the nursing wards, described in detail in section 3.1. The activities in the time study were separated in four categories. Direct care is activities carried out face-to-face with the patient for example treatments and examinations. Indirect care is patient related activities not performed in direct contact with the patient, for example logistic activities, preparing medication and food. Administration refers to administrative tasks that are not directly patient related such as economic planning or education. Personal time includes all pauses besides lunch for using the restroom, coffee breaks etc. within the regulated working hours.

Administrative time 9%

Personal time 7%

Direct care 30% Indirect care 54%

Diagram 1: Time distribution per category

Diagram 1 shows the average time distribution for nurses during the day shifts (07.00 – 22.00). The indirect care category is the largest category occupying 54% of the nurses’ total time. The direct care occupies 30% of the time followed by administrative time (9%) and personal time (7%). In Table 1, the categories are broken down on activity level. The individually most time consuming activity was patient hygiene (12,5%) which is a direct care activity, followed by five indirect activities: report/information (8,7%), food handling (7,7%), own transportation (6,6%), handling of medicine (5,6%), and care documentation (5,4%). Table 1. Time distribution per activity

Activity

T ime (%)

Direct care Patient hygiene Nutrition T reatment Observation/examination T ransportation/physical training Support and information/teaching Category sum

12,5 3,9 3,9 3,5 3,2 2,8 29,8

Indirect care Report/information Food handling Own transportation Handling of medication Care documentation On-call/Preparedness Paper/computer work Cleaning/bed-making Phone calls (incoming/outgoing) Rounds T ransport outside the unit/ward Medicine preparation Supply room handling Washing/dishing Care planning Monitoring Category sum

8,7 7,7 6,6 5,6 5,4 3,7 3,2 2,7 2,2 2,2 1,7 1,3 1,3 1,1 0,2 0,1 53,6

Administrative time Conference/education/information Administrative paper/computer work Staff planning/recruitment T eaching/supervision of staff and students Staff/support dialogue General assignments Quality/research/improvement work Category sum

3,0 2,2 1,8 1,0 0,7 0,6 0,3 9,6

Personal time

7,1

T otal sum

100

4.4. Case 1: Improvement areas and future state visions Improvement needs regarding infrastructure reoccurred during the interviews with the nurses. The staff experienced a lot of “running around”; getting supplies to patients, going between desks and patient rooms etc. The internal logistics was expressed as cluttered and disorganized. A specific area in need of improvement was the laundry and waste handling. In weight a bag averages 10 kg, but can weigh up to 30 kg, leading to heavy lifts when throwing them down the chutes. All wards are individually responsible for its finances. Purchase and procurement are however managed for the entire hospital. This means that the only way for a ward to control its expenses is basically through the level of staff. A general opinion among nurses was that the work load had increased both regarding number of tasks but also physically over the latest decade since the patients are older and less mobile. The pressure on the healthcare was expressed as increased while the level of staff has decreased. During a group interview with the ward director and the head of two nursing wards, a vision of healthcare and hospital logistics in 10 years was dealt with. The most farreaching vision was that the nursing staff should be liberated from all non nursing tasks such as supply replenishment, unpacking laundry and putting it in cabinets, food handling, doing dishes, making errands for patients, etc. Other aspects were lifted such as different layout with individual patient rooms and better ways of communication between patient and nurses to avoid waiting times and reduce the ”running around” for the nurses. 4.5. Case 2: Current state description of internal logistic solutions Case hospital 2 was studied in order to complement Case 1, in the aspect of improvements of hospital internal logistics in a larger hospital context with dual sites. 4.5.1. Patient transports at site 1 Site 1 consists of 50 buildings distributed over a large area with 6 kilometers of connecting culverts. 130 000 patient transports are carried out per year of which the logistic department performs 90%, the remaining are mainly of acute nature. The hospital uses an IT-system for ordering, planning and managing the transports. The nursing staff state pick up place, destination and latest time of arrival, priority and possible remarks regarding the patient status. The system plans the transports by arranging them after arrival time, priority, and destination and tries to co-ordinate transports in order to minimize unnecessary travel. Manual adjustments are however necessary and a transportation planner coordinate the transports depending on available staff. All logistic staff carries a positioning hand computer allowing the planner to distribute the orders. The planner also sends new transportation orders to the staff that accepts or rejects it depending on their work load.

4.5.2. Pneumatic dispatch at site 1 In late 2004 a new pneumatic dispatch system was put in use at site 1. There are 110 dispatch stations and over 2000 shipments are sent on weekdays and approximately 1200 during weekends. Only authorized personnel can open the shipments and the system is used for samples and blood as well as medicine, paperwork, and money. The laboratory is by far the largest recipient of dispatches. Therefore, an industrial robot handles the shipments by opening the tubes and emptying the content on different conveyors (content is stated when shipping). The robot cell also handles the return shipments of the tubes. This cell was greatly appreciated as it handles a highly repetitive task. This system was described as very modern and has received much attention and also been the inspiration to many installations all over the world. The biggest advantages are the decreased lead time, increased flexibility and the reliability of the system. 4.5.3. Automated Guided Vehicles at site 2 Site 2 consists of only one building. This has created good conditions for the use of 21 Automated Guided Vehicles (AGVs) that handle the major part of all deliveries of food, linen, laundry, waste, and goods. Some special transports are however performed manually. The AGVs uses designated elevators and assigned pickup/drop off positions both in elevator hallways and at the transportation department at the bottom floor. 4.5.4. Small goods at site 2 At site 2 the only pneumatic dispatch line is between the emergency room and the laboratory. The major part of the small goods transports, such as samples, blood, and pharmaceuticals are made by nursing staff. Some scheduled and coordinated transports are made with industrial truck by staff from the logistics department. According to a study initiated by the hospital, all small goods transports equals 55 full time employees on a normal work day. Due to the high amount of small goods transports, site 2 plans a pneumatic dispatch system similar to site 1. The payback period for the investment is expected to be five years only based on the times savings for the nurses. 4.6. Case 2: Future hospital logistics Case Hospital 2 is in the process of planning and building a new site replacing site 1 in 2017. A major strategic study of the logistic needs was conducted as a step in the planning. The result was gathered in a report [Elmfeldt and Kardbom (2009)], approved by the hospital management as guidelines for the future internal logistic system. Automatic transports will be a founding principle for the future logistics, due to increasing demands for efficiency, accessibility, shorter lead times, and round the clock service. AGVs, pneumatic dispatch systems and air pressured waste/laundry systems are necessities in the future site. A high degree of automation is strived for by e.g. IT systems for ordering materials, tracing equipment and staff. Equipment for picking and packing medicine for patients is also to be integrated with the pneumatic dispatch system. There is also a general wish to “professionalize the logistic processes” [Elmfeldt and Kardbom (2009)]. The logistic flows are vital but too expensive to customize to each ward. A standardized way of working with focus on an efficient flow is desired. Several

Lean principles are also mentioned as customer focus (part of Total Quality Management), Just-In-Time deliveries and continuous improvements. Today is the logistic department an internal department but in the new hospital the property-owner will be responsible for the logistic function, i.e. it will be outsourced. 4.7. Case 3: Development, solutions and initial problems Case hospital 3 was studied in order to complement Case 1, as a role-model and describing what the future in hospital logistics could be. As described in the methodology section, Case hospital 3 is a new hospital, inaugurated late 2008. Prior to planning the new hospital, an analysis of the previous hospital was made. The analysis concerned the nurses’ time usage for the main activities and their related bottlenecks. The result is compiled in Table 2. The results from the analysis pointed out focus areas when designing the new hospital. Inspiration was gathered from hospitals in the UK and USA, as well as from the building contractor and the hospital staff. A goal for the new hospital was to own as much of the equipment as possible and being able to perform the majority of the task/services internally. 4.7.1. Layout The hospital consists of two sections. One side contains the nursing wards and the other the treatment units. The aim was that wards and units with many transactions and patient transports should be close situated. For example is the emergency room located close to the cardio intensive care unit and the blood bank. All the nursing wards follow the same layout regarding patient rooms as well as placement of pneumatic dispatch stations, supply storages etc. Table 2. Resource demanding activities and bottlenecks Main activity

Time usage

Admission

5%

• Rearrangement of patients • Administration incl. information gathering

• •

Rooms with multiple beds Computer availability, double work in information gathering

Medical treatment, outside post

10%

• Order/plan examinations, adherent paperwork • Wait for available time for treatment/examination • Transport of patients

•

Lost paperwork, physically distribute orders

•

Service department and doctor capacity

•

Elevator capacity

• Examination and pre-examination

•

• Handling/preparation of medication

•

• Information exchange between shifts

•

Waiting for other staff, takes time among others due to inexperienced nurses/doctors Double-checking and administration related to medications Verbally form, source of error, little use of written documentation

Care/treatment on post

4050%

Resource demanding activities

Bottlenecks

Discharge

10%

• Organization of departure

•

Poor preparation, escort patient, call local authorities, wait for papers.

Support activities

2530%

• General cleaning • Ordering • Staff planning

• • •

Lack of overview what to clean Additional medical tasks Additional management task

4.7.2. Automated Guided Vehicles An AGV system with 22 vehicles transports food, linen, supplies etc. to and from the wards. The system performs approximately 750 transports per day and equals15 full time employees, with improved ergonomics as another much appreciated gain. The AGVs uses the same elevators as visitors, staff and patients but do not enter the wards. Instead there is one pickup and two drop off positions in the elevator hallway outside each ward. The staff does not order transports, instead sensors at the pickup position signals a transport for pick up. When the AGVs leave a delivery in the hallways the system signals the ward staff by phone. 4.7.3 Pneumatic dispatch When designing the pneumatic dispatch system the goal was one station per 14 patients. There are 110 stations in the hospital connected with 5,5 km tubes. 1300 shipments are sent each day and text messages are used to signal the staff. At the laboratory, there is an identical robot cell as site 1 in Case 2 for opening and emptying the large amount of incoming deliveries. 4.7.4. Waste material and laundry There are separate chutes for laundry and waste material at each ward. The bags with laundry and waste are transported by air pressure directly to the laundry facility in a nearby building and the waste room respectively. 4.7.5. Medicine handling There is an integrated process for medicine handling where the physician registers the patient’s ordered medication using a portable hand computer or a computer installed at each bed. A pharmacist controls the prescription and adds the order to the “Pill-Picker” a high-speed tablet packaging equipment integrated with a automated storage and retrieval system. The “Pill-Picker” prepares all medication to each patient for the next 24 hours. The medication is packed in unit doses placed on a loop in the order to be given to the patient. The loops with medication are automatically sent to the wards with the pneumatic dispatch system and placed in medication carriages. Before the medication process, the nurse scan the patient’s bracelet bar-code and the medicine using a hand computer. This ensures the correct medicine and dose given to the patient at the right time and increases the traceability. According to interviewed staff this system cost more than the previous way of working but has freed time for the nurses. The biggest gain is however increased safety for the patients since the number of faulty medications has decreased. With this system medicine deliveries can be made round the clock. Each ward still has storage with acute and common types of medicine such as painkiller etc. 4.7.6. Initial problems According to the technical manager there were several initial problems until all functions ran smoothly (some were still not running properly at the time of observation). Some areas as the waste and laundry system was however running in full pace earlier than

expected. The manager of the Service and Technology department mentioned that the technology in itself worked well, but there were problems caused by faulty handling of the equipment/systems. The current hospital, with a higher level of technology compared to the previous hospital, also puts higher demands on the Service and Technology staff, requiring higher competence and more diverse skill in technology and IT. 5. Discussion In this section, the findings from each case are discussed in relation to posed research questions. The section is concluded with a general discussion on technology management. 5.1. Reflections from Case 1 The question in Case 1 was (1) how is the internal logistic system structured and carried out and (2) what improvement areas are there and how could automation be used to improve these? In the previous section, the first question was elaborated. Case hospital 1 have much to learn from Case hospital 2 and 3, and the following improvement areas could be seen, in brief: •

•

•

•

•

Indication for full dumpsters and roller cages. Introducing a sensor system indicating when the collecting containers for laundry and waste are full would free a lot of time. The sensor system should be integrated with a communication system sending signals directly to the transportation staff. A more advanced approach is a track with several carriages that automatically pushes the full container away and places an empty one under the pipe. Small goods and mail handling. A more extensive pneumatic dispatch system would be timesaving for both nurses and transportation staff in transportation of small goods such as mail, samples and blood. However, it is much more costly and a bigger procedure to install a pneumatic dispatch system in an existing hospital building, in this case with partly low ceiling height and thin inner walls, compared to integrating it from start. Patient transports. A better planning system (preferably computer based) for the patient transport similar to the one in Case 2 would most likely increase the share of transports preformed by the transportation department, and not by nursing staff. Additional and better suited equipment for pushing the beds (that for example fits in the elevators) would also improve operations. Internal communication and planning. A better system for internal communication between the transportation staff, e.g. by use of hand computers, would reduce unnecessary travel to pick up new orders, make it possible to better plan tasks and hence render more efficient use of the staff. Handling of packages. A software system integrated with barcodes and barcode readers would both decrease the amount of manual handling and increase the possibility to trace goods using less effort.

•

Lifting aids for laundry and waste bags. The physical strain of handling laundry and waste bags could be relieved with help of automatic lifting equipment or even manual lifting aids when transporting the bag and lifting it to throw down the chutes.

5.2. Reflections from Case 2 The question during Case 2 was: How can and should automated improvements of hospital internal logistics systems be structured? The process of planning and building the new future hospital involves a massive amount of work and parameters to take into consideration. It is of strong importance that all functions, including internal logistics, are involved in early phases when designing the new hospital. The hospital has performed an evaluation of the current way of working to identify improvement needs and created a vision for the future hospital internal logistic system. This is most pleasing and according to the Joint Commission [2008] important to help the hospital in meeting the future needs of patients and public. A vision and clear goals for the logistic function is something that has been lacking in the other case hospitals. As found, site 2 was when built a technically advanced hospital, but the fixed solutions made it hard to upgrade, giving a somewhat obsolete solution. Flexibility and scalability must be a key aspect when designing new solutions to also fit future needs and demands. 5.3. Reflections from Case 3 For calling themselves Europe’s most modern hospital, Case hospital 3 has a low degree of completely new technology. The overall level of automation is high but the news value is more related to how they managed to combine a large number of existing technologies, and also the comprehensive view when creating this hospital. By building a new facility, all aspects could be integrated together from start to best suit the demands. The case hospital has embraced the role as “role-model” manifested in many visitors and openness to show the hospital and also the problems they have experienced. This benefits the development of the healthcare sector as there are valuable lessons to be learned and technology to be adapted from others. During the design phase the hospital took help from building constructors and nurses regarding layout and function. It is very important and beneficial to gather opinions, ideas and knowledge from many different functions and levels both inside and outside the organization when designing new internal logistic systems. 5.4. General discussion Besides the more case-specific reflections on the logistic activities, five problem areas regarding technology management and the use of automation in the internal logistic system were discovered. 5.4.1. Division of work The time study in Case 1 showed that only 30% of the nurses’ time was spent on direct care activities similar to the results from the pre study at Case hospital 3 (see Table 2). The result is also in line with the result from previous studies by Hendrich et al. [2008]

and also assessment from other Swedish hospitals [Elmfeldt and Kardbom (2009); Johnreden (2003)]. The majority of the nurses’ time is spent on indirect care activities, often connected to logistics. Many of these activities are not the core competence of the nurses. As stated by Poulin [2003] many activities that could be carried out by support personnel are often on the list of duties performed by healthcare personnel. Therefore should these tasks be transferred or assigned to e.g. the transportation department or another in-ward service position that can carry out non patient related tasks. This together with the use of automated solutions would free nursing time for patient related activities which is a more efficient way of using the resources. 5.4.2. Ownership During the interviews the lack of ownership and clear responsibility for new, especially long term, automation investments, was revealed. As the internal logistics often is an outsourced function, no one takes a strategic responsibility for developing the logistic activities. This is similar to other European hospitals where the logistics function is more fragmented compared to US hospitals with more centralized logistics management [Aptel (2001)]. It is however clear that hospitals need to focus on the management of the internal supply chain to maximize service levels, as pointed out by Pan and Pokharel [2007]. 5.4.3. Overall strategic view There is a lack of overall strategic responsibility of the healthcare process, including the technology management of the internal logistics. The wards are individually responsible for their economy, but left with basically only one way to control the expenses: the level of staff. The visionary views of the future hospital articulated in the Case 1 interviews were quite modest with only small details differing from the current situation. It is important to fit the ideas and suggestions from the staff that work in the processes, as found in Case 3, with a strategic overview of the whole hospital as seen in Case 2. Studies have shown that especially small hospitals are more seldom involved in quality improvement [Chow-Chua and Goh (2000)] but there are well documented methods for development work, often with origin from the manufacturing industry, that have proven to be useful also in the healthcare sector [Swedish Association of Local Authorities and Regions (2009)]. 5.4.4. Physical limitations Comparing Case Hospital 1 with Case hospitals 2 and 3 it is evident that there is available automation technology and ways of working that Case hospital 1 would benefit from. Apart from improvements suggested above, an AGV system would yield a much more flexible transportation plan not limited to the available human work power and also allow more frequent deliveries both night and day time [Özkil et al. (2009)]. However, the physical structure of the hospital is a limitation when trying to adapt new technologies, such as AGVs, in old buildings with for instance steep inclines/declines in culverts and narrow elevators. This is one reason why, despite mature technology, it is still a costly investments.

5.4.5 Transfer of knowledge There are a number of automated solutions and aids available for hospital activities today. Other lines of business can also be an inspiration since the internal logistics supply chain is fundamentally the same as for example in the trade sector or industry [Jarrett (2006); Arvidsson (2007)]. In many aspects is the healthcare organizationally and regarding technical adaption similar to the state in producing industry a decade ago. The main issue is not the lack of available technology and role models, but rather how the knowledge is transferred and how to adopt the knowledge and technology to best suite demands and needs. 6. Conclusions The ever increasing pressure on the healthcare system leaves the hospitals like any other business forced to focus on using their resources in the most efficient way. This study corroborates earlier studies that the nursing staff spends most of their time with indirect care activities of which many are connected to logistic activities. Several of these tasks should instead be carried out by the logistics department or non nursing staff in the wards, with proper technology support, to free nurses’ time for direct care activities. There are also many ways to improve the internal logistic system by rationalizing the tasks performed and hence increase the efficiency. Automation of both the physical flow and the flow of information has proved to be one successful way to achieve this. The study shows that there is existing technology that can improve hospital internal logistics and valuable knowledge and experiences is found within and outside the healthcare sector. The difficulty lies in finding the right type and level of automation to suit needs and physical and organizational prerequisites. This study also showed that a strategic responsibility for the internal logistic system is often lacking which lead to poor management and development of the system. A vision and goals for the logistic function is often lacking which together with unclear ownership can make new investments hard to motivate. The use of automation and a more strategic way of handling, viewing and improving the logistic system is a way to efficient healthcare. Acknowledgments The authors would like to thank Daniel Gåsvaer and Patrick Phua for their work during the data collection and support during the writing process. Gratitude is sent to the case hospitals for their time, kind reception and openness. Acknowledgments are also given to Robotdalen and Vinnova for financing the study via the research project Lean Automation. The study was performed in the context of the XPRES environment at Mälardalen University. References 1. Aptel, O. (2001). Improving activities and decreasing costs of logistics in hospitals: a comparison of US and French hospitals. The Int. J. of Accounting Education and Research 36(1): 65. 2. Arvidsson, L. (2007). Vårdlogistik (In Swedish, English title: Care logistics). Swedish Association of Local Authorities and Regions.

3. Bernolak, I. (1997). Effective measurement and successful elements of company productivity: the basis of competitiveness and world prosperity, Int. J. Prod. Econ. 52(1-2): 203-13. 4. Blessing, L. (2002). What is this thing called Design Research? Annals of 2002 International CIRP Design Seminar, Hong Kong. 5. Chow-Chua, C. and Goh, M. (2000). Quality improvement in the healthcare industry: some evidence from Singapore. International Journal of Health Care Quality Assurance 13(5): 223229. 6. Elmfeldt, M. and Kardbom, A. (2009). Framtidens Logistik – Slutrapport (In Swedish, English title: Future Logistics – Final report ). Karolinska Universitetssjukhuset. 7. Finnsgård, C. (2009) Assembly processes and materials supply systems design. Thesis for the degree of licentiate of engineering. Chalmers University of technology, Sweden. 8. Frohm, J., et al. (2006). The industry's view on automation in manufacturing. Proceedings of the 9th symposium IFAC on Automated Systems Based on Human Skills and Knowledge, Nancy, France. 9. Gupta, T. and Dutta, S. (1994). Analysing Materials Handling Needs in Concurrent/ Simultaneous Engineering. Int J Oper Prod Man, 14(9): 68-82. 10. Hendrich, A., et al. (2008). A 36-Hospital Time and Motion Study: How Do Medica -Surgical Nurses Spend Their Time? The Permanente Journal 12(3): 25-34. 11. Institute of Medicine (2008). Retooling for an Aging America: Building the Health Care Workforce, Committee on the Future Health Care Workforce for Older Americans. National Academics Press 12. Jarrett, P.G. (1998). Logistics in the health care Industry. International Journal of Physical Distribution & Logistics Management, 28(9/10): 741-772. 13. Jarrett, P. G. (2006). An analysis of international health care logistics. Leadership in Health Services 19(1): i-x. 14. Johnreden, A.-C. (2003). Den framtida personalförsörjningen inom vård och omsorg Tillgång och rekryteringsbehov till år 2015 (In Swedish, English title: The future supply of staff in healtcare and care – Supply and need for recruitments to year 2015). Arbetsmarknadsstyrelsen. 15. Kitsiou, S., et al. (2007). Evaluation of integration technology approaches in the healthcare supply chain. International Journal of Value Chain Management. 1(4): 325 – 343. 16. Liker, J. K. (2004). The Toyota way: 14 management principles from the world's greatest manufacturer. New York: McGraw-Hill. 17. Mattson, S.-A. and Jonsson P., (2003). Produktionslogistik (In Swedish, English titel: Production logistics), Studentlitteratur, Lund. 18. Monden, Y. (1998). Toyota production system: an integrated approach to just-in-time 3rd ed. Norcross, Ga.: Engineering & Management. 19. Ohno, T. (1988). Toyota production system: beyond large-scale production. Cambridge, Mass.: Productivity Press. 20. Pan, Z. X. T. and Pokharel, S. (2007). Logistics in hospitals: a case study of some Singapore hospitals. Leadership in Health Services, 20(3): 195-207. 21. Poulin, E. (2003). Benchmarking the hospital logistics process: A potential cure for the ailing health care sector. CMA Management 77(1): 20-24. 22. Rivard-Royer, H., et al (2002) Hybrid stockless, a case study: Lessons for health-care supply chain integration. Int J Oper Prod Man, 22(4): 412 - 424. 23. Rubinovitz, J. and Karni, R. (1994). Expert system approaches to the selection of materials handling and transfer equipment. In Mital A. and Anand S. (Eds.), Handbook of Expert Systems Applications in Manufacturing: Structures and Rules (pp.238-268). Chapman & Hall, London. 24. Statistics Sweden (2010) The future population of Sweden 2010-2060 25. Swedish Association of Local Authorities and Regions (2009). Utvecklingen i svensk hälsooch sjukvård (in Swedish, English Titel: The Development in Swedish healtcare).

26. Swinehart, K. D. and Smith, A. E. (2005). Internal supply chain performance measurement: A health care continuous improvement implementation. International Journal of Health Care Quality Assurance 18(7): 533-542. 27. Tangen, S. (2004). Evaluation and revision of performance measurement systems. Doctoral thesis. Department of Production Engineering, KTH, Sweden. 28. Tangen, S. (2005) Demystifying productivity and performance. International Journal of Productivity and Performance Management. 54(1): 34-46. 29. The Joint Commission (2008). Health Care at the Crossroads: Guiding Principles for the Development of the Hospital of the Future 30. Yin, R. K. (1994). Case Study Research – Design and Methods, SAGE Publications Inc., London. 31. Özkil, A. G., et al. (2009). Service Robots for Hospitals: A Case Study of Transportation Tasks in a Hospital. Proceedings of the IEEE International Conference on Automation and Logistics Shenyang, China. revision