Review of Lean Method Application for Improvement in Health Information Systems Soudabeh Khodambashi and Maryati Mohd Yusof UKM University, Bangi, Malaysia
[email protected] [email protected] Abstract: Medical care is undergoing considerable change due to the application of information technology and management tools and techniques. Health Information Systems (HIS) are used extensively in healthcare to enhance data processing. Various tools and techniques including quality management methods are available to improve efficiency of HIS. Lean method has become relatively popular in improving clinical process cycle and work flow, eliminating non-value added activities known as waste. By applying Lean that optimizes clinical work flow, we can gain safe, efficient and high quality care as well as cost reduction. The aim of this paper is to investigate the application of Lean method and its effectiveness in healthcare. We also focus on several Lean techniques, its major implementation steps as well as the requirements for implementing Lean in healthcare. The focus would be on implementation of Lean on clinical process related to HIS. The paper also highlights critical success factor for healthcare organization to consider when implementing Lean method. Keywords: lean method, health information system, value stream mapping, clinical work flow
1. Introduction Health Information Systems (HIS) are used extensively in healthcare organizations to support various conventional data processing tasks. They are also used for scheduling, automating nurse stations, monitoring intensive care patients, and providing preliminary diagnoses. The simplest HIS collects and processes data (Yusof et al., 2008b). The application of information technology in healthcare highlights significant potentials and benefits, particularly with regard to innovations in improving both clinical and administrative processes. A number of quality management methods have been extensively employed in order to improve health care quality since the last decade. For example, in optimizing clinical workflow as one of the critical factor of HIS adoption, Lean method would be a better choice (Schweikhart and Dembe, 2009, Yusof et al., 2008a). Health care organizations adopt Lean in their clinical processes. Some of the public healthcare systems are planning to use Lean or have already adopted it for improving safety and quality of healthcare (Holden, 2010, Jones and Mitchell, 2006). It was reported that 53% of the current hospitals, implemented Lean method (Holden, 2010). The aim of this paper is to represent the key findings of a literature review on adoption of Lean method in clinical practices. This paper focuses on Lean concept, tools that would be useful and applicable in healthcare, and some of the critical success factors for Lean implementation.
2. Lean method Lean concept was introduced from Toyota Production System and it was first implemented in a US auto manufacturing. Lean is a quality improvement tool which uses quantitative methods for tracking data to reach the stated goals by documenting progress to improve quality and reduce costs (DelliFraine et al., 2010). Lean aims to improve efficiency by eliminating non-value added activities that is known as waste (Schweikhart and Dembe, 2009). In Lean method, all steps and activities which add value will be maintain by eliminating intermediate steps, time, and people (Poppendieck, 2002). This goal could be achieved by reducing delivery cycle or shortening delivery batches without adding additional cost (Hines et al., 2004). Lean concept has been divided into five categories that are value, value stream, flow, pull, and perfection (Staats et al., 2010). Some of the tools and methods in Lean include Value Stream Mapping, Kaizen (short-cycle continues improvement, Work Standardization, 5S, cellular manufacturing, inventory management, root cause analysis, A3 report, Poka-yoke (mistake-proofing), change over time reduction (Singh et al., 2010, Monden and Engineers, 1998, Hines et al., 2004, Monden and Engineers, 1983, Schonberger, 1986, Harrison, 1992, Vinodh et al., 2010, Holden, 2010).
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Soudabeh Khodambashi and Maryati Mohd Yusof One of the primary steps of Lean which is also important is known as the Value Stream Mapping (VSM) (Vinodh et al., 2010). In Lean methodology, patient pathway is considered as a value stream. VSM is a structured diagram, originated by Toyota which includes steps that are all key activities such as resources, people, information, and material flow is mapped graphically in a clear and explicit manner (Singh et al., 2010). VSM is used to identify and track all types of waste and process flow integration to increase process efficiency by reorganizing and redesigning the system (Schweikhart and Dembe, 2009, Singh et al., 2010, Vinodh et al., 2010, McDonald et al., 2002, Lasa et al., 2008).
3. Lean application in healthcare Application of Lean in healthcare focuses on eliminating wastes (delays) and repeated errors and inappropriate procedures (Liptak and Patras, 2007). Lean supports users to improve their process around the customer requirements, values, and expectations. In the healthcare environment, the customer can be a patient, their family, a physician, a nurse, an administrator or any other stakeholder in the process. Since one of the important objectives of HIS is to assist physicians and nurses to trace most of the activities in automatic clinical workflow, identifying all the steps which are involved in HIS should be documented and reviewed. VSM creates a holistic schema of all the processes and workflows to understand interdependency of functions, departments and even the whole unit over another. Once the value stream is mapped, the next step is to identify the critical path. Possible improvements should also be studied to improve value stream (Singh et al., 2010). When improvements in VSM are identified, the future VSM state should be created to show how a process should work after it is redesigned. If redesigning is implemented in the VSM, smaller number of steps and also shorter waiting time between steps could be achieved. As a result, HIS will fit into the clinical pathways if VSM is implemented in advance. Most studies on HIS implementation, reported efficiency in their processes. For example, medical error reduction, especially drug interaction and other prescription errors, increased patient safety and foster just in time approach could achieved by integrating IT system such as electronic medical records (Liptak and Patras, 2007). Based on the literature, Lean method has been implemented in many hospitals in their clinical workflow such as histology laboratories, operating room and emergency department. Buesa (2009) reported that workflow improvement is attributed by 40% reduction of operational costs in technical personnel, increased productivity and decrease bottleneck as a result of Lean implementation in fifteen histology laboratories. Other studies reported process improvement in terms of reduced patient waiting time and other turnaround time (DelliFraine et al., 2010b). A number of challenges have been identified from the pertinent literature. One important issue in improving the VSM is that isolated improvements within one department or part of the system that belongs to one department increased the risk of sub optimization that helps the individual departments but harms the overall system. In order to consider limited time and budget when a VSM as a starting point of Lean is designed, problems should identified, prioritized and solved according to their impact on patients and the other stakeholders. In addition, physician resistance exists during quality improvement process. Thus, employee involvement and empowerment in suggesting and making changes could be helpful. As a result, a Lean project team could prepare a draft of documentation, then, the entire department can provide their inputs and comments in the draft. Furthermore, formalizing of methods would be helpful for better management and improving of the workflow. To achieve quality improvement, culture and creative thinking should be given more attention. While traditional management tries to blame individuals for errors, Lean mindset shows that 94% of errors “belong to the system” (Graban, 2008, Deming, 1994). When we learn from errors, we can use knowledge to prevent future errors (Black, 2005). There are so many companies that failed in Lean implementation especially in the stage of cultural changes (Yamamoto and Bellgran, 2010). On the other hand, training through standardized work decreases the risk of verbal training. Even with external expert in Lean, internal stakeholders also are needed to translate Lean from general tools to local context (Holden, 2010).
4. Discussion and conclusion Lean has potential to healthcare process and applicable in healthcare as it increases efficiency, reduces medical errors, increases patient safety, reduces operational cost and decrease bottleneck. By using Lean, we aim to improve and increase collaboration and team work across departments, so
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Soudabeh Khodambashi and Maryati Mohd Yusof the risk of sub-optimization can be minimized. By only designing the overall process, the entire problems will not be solved. However, prioritizing them based on constraint to solve them is an important aspect to consider. Clinicians are the ones who are very familiar with the details of their work, hence, they can help to identify better. On the other hand, standardizing the work as a foundation of Lean should also be considered. In order to have clinician’s agreement to accept standardized work, it is important to get them involved in the process. Cultural changes are also needed to achieve the stated result. Furthermore, having a formal training helps us to reach much better result. Leadership commitment and involvement of internal stakeholders also is another factor in achieving the goal (Graban, 2008). To conclude, it is worth mentioning that implementing quality management tools in healthcare which is adopted from a different industry requires an adaption from its original form and context. The understanding of actors, roles and responsibilities, clinical workflow, processes, and critical success factors in Lean implementation in healthcare are crucial to achieve success. Furthermore, considering Lean method before implementation could be helpful for a project manager to have a speedy development since standardized work has been done and wasteful activities has been deleted from the clinical process. Moreover, Lean concepts could be helpful in mapping the value stream of development processes in software development. This paper is potentially useful for researchers who desire to conduct study on Lean method in HIS and evaluate IT applications in healthcare settings.
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Minna Isomursu, PhD, is a research professor of networked services and media at VTT Technical research centre of Finland. Her research explores how social media can be used to enhance and enable ICT-based services. Her current research projects study use of social media and new ICT based service concepts for older adults. Tiko Iyamu is a Professor of Information Systems at the Tshwane University of Technology, Pretoria. His research interests include mobile computing, enterprise architecture and information technology strategy. He focuses on actor network theory and structuration theory,and is the author of numerous peer-reviewed journal and conference proceedings articles. Paulo João is a PhD. student in Statistics and Operations Research at the University of Lisbon, with a Msc and Bsc in Statistics and Information Management (ISEGI-UNL), a post-graduate degree in Systems and IT (UNI) and Evaluation and Organizational Development (ISCTE). He worked for 20 years in the police and currently works as a computer specialist responsible for IT security in the central administration of the Portuguese health system. Adam Jansen is a Ph.D. student in Archival Studies at the University of British Columbia and a research assistant on InterPARES. He earned an MSc from Eastern Washington University in Business Administration and Computer Science, and worked most recently as the Deputy Washington State Archivist. His current research focuses on preservation and the forensic analysis of trustworthy digital records. Hallur Leivsgarð Joensen is a Business Development Engineer from AU Herning 2009. Hallur is currently employed as an associate on a research project on the conversion of recreational ships to renewable energy propulsion. At the same time, Hallur is on an MSc study program in Technology Based Business Development, with particular emphasis on cleantech. Björn Johansson holds a PhD in Information Systems Development from the Department of Management & Engineering at Linköping University. He currently works as Associate Senior Lecturer in the Department of Informatics, Lund University. Previously, he worked as a Post Doc. at the Center for Applied ICT at Copenhagen Business School. He is a member of the IFIP Working Groups IFIP 8.6 and IFIP 8.9. Ghassan Kbar is the Director of the Research and Business Development department at Riyadh Techno Valley RTV, Saudi Arabia. He holds a PhD in Computer Networking from UNSW Australia-1997, and a Master‘s in Engineering Studies from the University of Sydney. He has roughly 22 years of experience in R&D and Academia and has published 50 articles in international conferences and journals. Soudabeh Khodambashi holds a Bachelor’s degree in information technology from the Polytechnic University of Tehran, Iran. He is now studying for a Master‘s in Management Information System at the University of Kebangsaan, Malaysia. His research area is the evaluation of Health Information Systems and clinical process re-engineering. Erdem Kirkbesoglu graduated from Baskent University in 2004. He is a Ph.D student in the Department of Management and Organizations and his research interests include Organisation Theory and Organisational Behaviour. He is currently a full-time lecturer at Baskent University. Bert Kleersnijder holds a Master’s in Business Administration, specialising in Business and ICT, and studied under the guidance of Professor E. Berghout. His thesis subject was ‘The Assessment of project portfolio management’, at the municipality of Groningen in the Netherlands. He is currently ‘Informationmanager’ and his research interests are in information management, portfolio management, IT evaluation, and business cases. Juha Kontio is a Director of Education in the Faculty of Telecommunication and e-Business at the Turku University of Applied Sciences. His current research interest connects to higher education related topics. He has presented and published in numerous international conferences, on topics such as quality assurance, staff development and organisational issues in information systems. Ermelinda Kordha Ph.D. is currently teaching Management Information systems at Faculty of Economy, University of Vlora, Albania. Dr. Kordha has been participant in a number of national and international conferences, has published her work in several national and international journals and has been organizer of scientific activities in the university. Sevrani Kozeta Ph.D. is teaching Management Information Systems and is Head of the Department of Mathematics, Statistics and Applied Informatics, at the Faculty of Economy, University of Tirana. She is part xi
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