Thailand's 'Lean' Hospitals

Bangkok Blog #6 – Friday, January 28, 2011

By Michele Jordan, VP Quality Improvement and Transformation, RVHS

There are five Thailand hospitals that participated in the first phase of the Lean demonstration project. We visited three of them this week. The other two are somewhat far from Bangkok so it was more cost-effective to have their representatives come and present to us.

We started by hearing two case study presentations by physician leaders at the Songklanagarind Hospital. Songklangarind is an 860 bed university teaching hospital with a very advanced Health Information System (HIS). They have made very impressive progress and have a really good grasp of how to apply Lean tools.

Dr. Rungsun Bhurayanantachai discussed how Lean was used to improve flow in the chemotherapy program. Problems included: long waits to get an available bed; patients turning up at hospital for admission without adequate prep, unnecessarily long lengths of stay, too much time spent on documentation and lack of a team approach. A few of the many Lean solutions they put in place to alleviate all of these problems included:

• Completing patient documentation and the medical order before admission- patient asked to do the medical condition checklist before they come to the hospital; order written and saved in the computer system to be activated when the patient is admitted; when patient arrives on day of admission they go directly to the ward.

• Implemented an “e-Kanban” system – pharmacy sends an alert through the computer system to let the ward know that the chemo drug is ready for pick up.

• Visual controls - a sticker is placed on the chemo bag to mark when there is 3 hours left for chemo administration; this gives the doctor 3 hours to complete the discharge summary; when the last bottle of chemo has been put up, the nurse puts a sign on the door to alert housekeeping that discharge will be today and when the patient leaves the room they are asked to turn the sign around to the other side which indicates that the room is ready to be cleaned.

The one-year results of the combination of these actions are:

• A reduction in length of stay for chemotherapy from 72.3 hours to 53 hours;

• An increase in bed utilization (i.e. the number of patients per bed per week) from 2.3 to 3.2;

• An increase in patient satisfaction scores from 3.2 to 4.6;

• Staff satisfaction increased for all indicators related to work speed, work process and team work.

Dr. Nipat Aui-aree, a Neuro-Opthamologist, discussed how load leveling principles were applied to the Bolulinum Eye Clinic. This clinic uses botox injections to treat people experiencing involuntary facial spasms. Before the Lean initiative, it was not unusual for patients to arrive at 8am even though the clinic did not open until 1pm. After applying Lean, turnaround has been reduced from 333 minutes (5.5 hours) to only 50 minutes. The number of steps in the process has been reduced from 15 to 11. Patient satisfaction is up from 2.77 out of 4 to 3.5 out of 4 and continues to rise.

Next we heard about the progress being made at the Suratthani Hospital, an 800-bed facility that sees 2,000 outpatients and 150 admissions per day. Dr. Suwicha Saringkarnpoonperm described the interesting approach the hospital is using to promote Lean. They are using the concept of “Dr. Lean”. They launched their process by visiting all departments of the hospital and using value stream mapping, spaghetti diagrams and genchi genbutsu to ‘diagnose’ problems. The 7 wastes are described as ‘symptoms’. The various Lean improvement tools are described as ‘drugs’ for treating the symptoms. They do 3 to 5 corporate projects per year. Their first corporate initiative was aimed at streamlining and leveling flow in the outpatient department. The improvements they implemented based on Lean Thinking included:

• Set up satellite units with general practices and well-trained nurses

• Set up call centre (a non-medical team) for management of the consulting system

• Set up an improved appointment management process and better communication with the GP and the patient

As a result, their outpatient process time has dropped from 5 hours to 2 hours and 40 minutes.

In the afternoon, we had a lengthy discussion with the international delegates on their learnings from the conference and each delegate had to describe one-specific action they will taken when they return home to advance Lean in their country. We also discussed how to get started with Lean. Professor Philip Choo and I shared the lessons we have learned in our individual hospitals.

Today was the final day of the conference. The week went by very quickly and it was somewhat sad to see it all come to an end. There was a lot of picture taking and exchanging of gifts. I gave each of the delegates a Rouge Valley pen and they were all very appreciative. We have all vowed to stay in touch so I’m looking forward to being part of this dynamic international network. Bangkok was a great host city for this conference and the organizers did an outstanding job.