The number of complaints from the patients was high.. A general feeling of dissatisfaction with the medical records service among physicians and patients.. A lack of motivation and feelings of frustration at the problems by the medical records service staff.. The large number of passive medical records and obsolete documents in the warehouse.. When, in April , it was decided that the Logistic Services Clinical Documentation fell under the economic-administrative management, a baseline analysis was conducted in order to identify areas for improvement.
Within this analysis, performance evaluation indicators, previously non-existent, were established e. Upon application of a series of TOC-philosophy-guided interventions, which will be described in the following section, the status of the medical records service showed a number of major improvements as reflected in the following figure and tables.. The average daily number of potential undelivered MR latent risk was reduced between and Fig. Average percentage of inaccessible medical records, requested medical records and latent risk March October Table 1 shows how the number of complaints has decreased since , starting from a previous situation Complaint Forms about medical records turned in by patients Personnel cost per delivered medical records and productivity ratio Information only available for between March 1st and December 31st.
Daily statistics were not carried out until March 1st Information only available for between January 1st and October 31st. Daily statistics have not been carried out since then.. The personnel involved in processing medical records not including the storage middle-management.. Faced with the initial situation of the medical records service described in Section 3. Among TOC tools and techniques, the manager chose those linked to the ongoing quality improvement perspective and, specifically, the five-focusing-steps FFS method.
Previous to its implementation, it requires Ronen et al. Although TOC represents a global management approach for the organization, it can also be implemented in sub-systems or specific processes, as long as the goal of the latter is perfectly in line with the goal of the whole system or organization Reid, In the case of a public hospital such as HUVM, the goal is to maximize the high-quality medical service provided to customers, at present and in the future, subject to two conditions: meeting budget constraints, and providing safe and satisfactory working environments to employees Reid, ; Ronen et al.
So that the performance measures in MR could achieve the final goal, three operational measures were considered: customer satisfaction, delivery date compliance, and operational expenses. When tackling the initial situation of MR at the HUVM in April , a major lack of awareness was observed of the scope of the problem as there were scant performance assessment indicators. In view of the situation, a number of these indicators were established, such as the calculation of the daily average of MR that had not been delivered in time, which reached at least 2.
Further observation of processes, as well as of other established indicators, such as the claims received by storage, the physical conditions of the MR storage areas, and the working environment, led to the identification of a number of what in TOC are called undesirable effects, UDEs see Table 3 below. The analysis allowed identification of the main causes Table 3 and, from among these, the determination of the potential constraints or bottlenecks in bold in Table 3. As can be observed, one process was particularly problematic, where most constraints were found: storage , with both physical and political constraints..
Main problems and constraints in medical records management at March Physical constraints resulted in the lack of storing capacity. The demand for the service was growing and room was becoming more and more scarce. Furthermore, there were three storage areas in different centers, which made MR management even more complicated.
Furthermore, storage and lending-out preparation shared the same physical area, which prevented them from being carried out at the same time.. Political constraints emerged from the inefficient organization of storage and the imbalance in human resources, due to the assignation of a disproportionately higher number of workers to lending-out preparation for consultations than to taking back the MR to the storage area. Despite the help given by 8 employees from external companies, a daily average of 13, MR remained awaiting storage.
As a consequence of this, although consultations were prepared, the daily lack of MR rose above 2. Therefore, approaching the goal i. Although the ideal is to approach constraints one by one, the managers decided to tackle, almost at the same time, both physical and political constraints. As far as the physical constraint is concerned, in order to make better use of the storage area, the first step to take was to filter and identify passive MR. An appointment analysis revealed that Therefore, this was established as the new criterion to distinguish between active and passive MR, which led to , MR being taken out of storage and the further freeing-up of space.
Moreover, it was decided to filter, at least once a year, the MR storage. As regards the second source of constraints, political constraints, three measures were taken so as to improve those constraints with the available resources: elimination of compact sliding file cabinets, changes in the codification system these two measures were essentially aimed at making storing procedures more dynamic , and re-assignment of personnel..
Focusing on the first measure, most MR were filed in compact cabinets with sliding shelves on rails, leaving just one real corridor for normal operations. The solution was to keep the compact cabinets as fixed shelves by removing several cabinets in each module. This change brought about the loss of some storage space, but time for MR storage was also reduced as well as that for accessing MR.. The second measure was to adapt all files to the terminal triple-digit system as opposed to the double-double digit or sequential systems that had previously been used.
This system, while allowing for a balanced growth in the storage area, makes storing procedures easier to carry out.. The last measure was to re-assign personnel who had been working in lending-out preparation to be allocated to the storage process, thus increasing the bottleneck process potential and balancing the flow within the system. In this particular case, the actions taken in this phase would refer to the other two processes presenting difficulties see Table 3 , but were not bottlenecks: lending-out preparation for consultations and taking MR back to storage collection. The purpose of these actions was to prevent either of these processes from affecting the storage process which, as we should bear in mind, was the bottleneck of the system..
Actions consisted of: 1 restructuring and simplifying MR lending-out preparation procedures; 2 in the case of the taking-back process, carrying out several actions on delayed MR.. In order to prevent this re-assignment of personnel from making the preparation process become a bottleneck, it was decided to carry out process re-engineering from the analysis of some good-practice experiences in storage management.
Prior to this, the whole process of preparing the daily MR demands implied three phases and it took one day.
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Such a complex process required a lot of manpower, since the MR were handled several times before being delivered for consultation. The solution was to simplify the procedure, reducing it to two phases, while consultation carts were replaced, small boxes were introduced, and the preparation area was redesigned. Today's process takes 6 hours, one hour to take out all MR of the day, and 5 hours to put the 3, MR into the small boxes..
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The MR taking-back process after consultations also affected the operations of the system. Due to erroneous operations in the storage process, medical services tended to retain the MR of those patients who had another consultation. The MR, being a unique document, prevents any other service from having access to those MR when needed. The following actions, among others, were adopted to avoid this dysfunction of the system: setting up daily checks on the accumulated MR by each service and, every now and then, checks on the number of delayed MR those retained for more than 10 days ; collective and individual meetings with the delaying services; establishing MR regulations with a specific section for requesting and lending the records out; fixing specific points at medical services to leave and collect MR; collecting delayed MR still in the possession of the services and eliminating any illicit MR mini-archives in those services.
It was decided to transform the three storage areas of the HUVM into only one storage area. Taking into account that the aforementioned actions in previous phases could not eliminate the lack of storage capacity and that, due to the storage unification, there was even more need for space, then the constraint was increased, which in this case involved expanding the space for MR storage. This was possible thanks to the freeing-up of space after moving the hospital's consumable supply storage to a logistics platform.
In total, the storage space was increased by 1, m 2 , equivalent to 3, lineal meters for shelves to hold , MR. In this way, at the end of the expansion process, the HUVM Central Archive had a total area of 6, lineal meters and a storage capacity of , MR..
Moreover, a new working area was made available, and was provided with IT equipment for MR records and storage, and so both processes, lending-out preparation and storage, could be dealt with at the same time. Within a very short time, only one month and 20 days , this change led to the reduction, to zero, of the number of MR waiting to be filed, for virtually the whole period remaining under study..
As far as political constraints are concerned, since the personnel re-assignment in Phase 1 ended up being insufficient, it was decided to hire more workers temporarily. In this particular case, since so many measures and changes, both physical and in policies and procedures, had been carried out, it was necessary for managers to be on the watch.
It was especially essential to continue making the most of the storage space, and to keep a constant filter of passive MR.
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It was also important to maintain order and accuracy in MR location, and to replace the envelopes for others with color codes instead of with numbers, which makes any errors in the storing process easier to detect. Furthermore, it was also important to watch and adjust the new working procedures in the preparation process.. By implementing all these measures, it became clear that the new constraint was to be found on the demand side external constraint.
In order to analyze the level of success of the changes applied in management and of the measures adopted in the MR logistics service, according to TOC we should check to what extent the system has moved closer to its goal: maximization of the number of complete MR delivered in time. Since we are trying to establish a causal relationship between the application of TOC and results, internal validity is an important issue. Setting this validity implies ruling out other factors that may cause the results rather than the application of TOC.
Although this is difficult in a study such as this, the evolution of the results that will be presented next and the connection with the timetable of measures taken allow us to conclude that the results are at least largely due to the implementation of the measures taken following TOC.. Therefore, we can affirm that the system is approaching the goal.
Another piece of evidence that the goal is being approached is the reduction in the number of complaint forms about MR turned in by the hospital patients, as can be seen in Table As pointed out above, there are two mandatory conditions on approaching the goal. The first is budget restrictions or economic efficiency. In the case under study, the main cost is that of personnel. Table 2 shows the evolution between and October of the number of workers, the annual cost of personnel and the personnel cost per medical record delivered.
It also shows how both the annual cost and the cost per unit per clinical record delivered have decreased since This improvement in efficiency is better observed in the last column in Table 2 , which reveals how the daily productivity ratio number of delivered MR per employee- Moreno Vernis, has risen during the period under study, especially for the last two years involved.. The second necessary condition is to create a proper, safe working environment for employees. Let us remember that lack of motivation was one of the undesirable effects found in the previous situation analysis.
Along these lines, in addition to the changes in work procedures and in the storage, numerous actions aimed at improving working conditions or operation security were adopted: provision of dressing rooms, establishment of new actions for protection against fire, freeing-up emergency corridors, a new safety ladder, air-conditioning in working areas, significant improvement in the lighting system, new work clothes and security footwear, etc..
The main purpose of this research work was to analyze the applicability of the Theory of constraints TOC principles to the logistics of clinical documents in a hospital. This experience has clearly shown that they are perfectly applicable, as the MR storage is in fact a circular process, where there are bottlenecks and which needs ongoing improvement in its management. In the case of MR, the interest lies in the constraint being situated on the demand side, which ideally must be completely covered..
The previous analysis provided evidence that, in the period before April , inefficient results were obtained in spite of the intensive use of resources. The results of a comprehensive conception of clinical record logistics and determined action based on TOC appeared satisfactory regarding the goal of the MR management service. Apart from all these achievements, the working and safety conditions of the hospital personnel have also significantly improved. What's more, at the same time, better organization allowed the hospital to reduce personnel, completely eliminate the participation of external companies for the storage internal activities, and increase productivity..
Beyond its application in MR management, whose future depends on digitalization and the extinction of the physical format, the main contribution of this research work is to illustrate TOC application to a previously unexplored field Young, This study shows that TOC can be very helpful when processes are circular and that some agents, in the search for their own optimum, may negatively affect the entire service.
Finally, the fulfillment was shown of OPT rules that predict, in the case of bottlenecks, their influence on the final results, thereby rendering the actions in non-bottleneck phases useless.. The main barriers faced during the application of TOC to MR management include: the difficulties in incorporating the changes in the culture of the organization in order to make it sufficiently rigorous regarding the new MR management process, and the establishment of the importance that MR has on the whole process of healthcare.
The infrastructural and economic barriers were not relevant in this case due to the minor economic impact. This situation could be similar in other medical contexts with significant constraints, such as the aforementioned central sterile services department, and in other situations, such as that of the emergency department, and surgical processes.. Suggestions to overcome these barriers include: First, attain a clear mandate from the CEO in order to be authorized to do whatever necessary to solve the problem.
Second, analyze the whole process carefully in order to find the actual constraints and to clarify the location of the problems. Third, learn from the experience of others. Fourth, act vigorously and quickly to achieve success as soon as possible; this will enable you to win the confidence of the professionals. Fifth, explain your project to all the people implied managers, professionals, workers, etc. Sixth, make no major technological or infrastructural changes before the manual changes have shown their full potential.
And seventh, be persistent in the changes and pay attention to new constraints which will surely appear in the process.. Apart from those limitations of this research work originated by the chosen research methodology case study , we want to remark that a more detailed analysis of the results of applying TOC could be carried out by studying other applicable performance measures..
Moreover, another possible limitation of this research work, as mentioned in Section 2. Nevertheless, we have striven to counteract this with the participation of two researchers unrelated to the case and by rigorously applying the research methodology. Furthermore, this circumstance allowed us to manage more and better data and to carry out a deeper analysis than other similar studies.. The authors wish to acknowledge Virgen Macarena Hospital's managers and Medical Records Logistics Service personnel, for their kind help in the production of this study..
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Developing lean and agile health care supply chains | Emerald Insight
Download PDF. Corresponding author. San Francisco Javier, , Seville, Spain.
This item has received. Under a Creative Commons license. Article information. Table 1. Table 2. Table 3. Show more Show less. JEL classification:. In these cases, the prevention of bottlenecks is especially important because, once one is formed, other parts of the process then suffer from that constraint. Medical records management circular process. Figure 1. Figure 2. Daily statistics have not been carried out since then.
The personnel involved in processing medical records not including the storage middle-management. The authors wish to acknowledge Virgen Macarena Hospital's managers and Medical Records Logistics Service personnel, for their kind help in the production of this study. Hospital kanban system implementation: Evaluating satisfaction of nursing personnel. Aguilar-Escobar, P. Garrido-Vega, N. Improving a hospital's supply chain through lean management. Revista de Calidad Asistencial, 28 , pp. Lean logistics management in healthcare: A case study. Aoki, S.
Ohta, N. Kikuchi, M. An introduction to the theory of constraint and how it can be applied to medical management.
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Physician executive, 34 , pp. Asensio Villahoz, J. Barratt, T. Choi, M. Qualitative case studies in operations management: Trends, research outcomes, and future research implications. Journal of Operations Management, 29 , pp. Breen, T. Burton-Houle, D. Applying the theory of constraints in health care: part 1-the philosophy. Quality Management in Healthcare, 10 , pp. Chou, C-H. Lu, Y-Y. Identifying inventory problems in the aerospace industry using the theory of constraints.
International Journal of Production Research, 50 , pp. Cox III, J.
McGraw Hill Professional, ,. Gibbert, W. Ruigrok, B. Strategic Management Journal, 29 , pp. Goldratt, J. North River Press. Goldratt, R. Groop, K. Reijonsaari, P. Constraints management—recent advances and practices. International Journal of Production Research, 41 , pp. Gupta, D. International Journal of Production Research, 47 , pp. Mabin, S. In order to build an empirical framework for using both lean and agile strategies in health care supply chain management illustrative examples are provided from a Swedish health care setting describing the patient flow and planning processes.
Supply chain management has potential to work well as a philosophy for patient flow in the health care sector. However, it should not only be about the use of the concept of lean in health care, as in fact is the case in practice today. It is rather about organizing for quick response and flexibility in a hybrid strategy through combining lean and agile process strategies.
This can only be done if a systems approach is applied together with a strategic orientation, where cooperative efforts by the supply chain members should synchronize and converge operational as well as strategic capabilities into a unified whole. The analysis in the paper underlines the importance of focusing on both agility and leanness combined. Hospitals or health care systems that introduce such an approach, as opposed to only relying on lean strategies, could gain both competitive advantages and improved performance.
In health care, even more so than in the manufacturing industry, containment of costs without sacrificing quality is important.
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This paper applies SCM techniques, tools and concepts that have not been used previously for patient flow in a health care setting, combining lean and agile in one and the same analysis. Aronsson, H. Emerald Group Publishing Limited. Please share your general feedback. You can start or join in a discussion here.
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