Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare


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The adoption of a single managerial approach does not seem to be enough to simultaneously improve the efficacy, efficiency, and effectiveness of care quality. A poor level of care is often due, not to the laziness and incompetence of the healthcare staff, but rather to systems that are not adequately projected and managed Reason, Over time, approaches to quality management have become more proactive in healthcare, as in many other sectors, with a focus on designing and adopting quality systems that aim to reduce the possibility of errors.

From the perspective of quality control and assurance, many organizations have implemented Total Quality Management TQM , where everybody, at any level of the firm, has to be involved and provide a contribution to quality management, thereby pursuing excellence.

However, according to Bohmer and Ferlins , TQM was problematic due to its emphasis on a hierarchical control on the processes that occurred at the top levels of management, and by the extreme rationalization required for every decision. Other approaches were not suitable for a healthcare organization. In particular, Six Sigma was a purely statistical methodology that allowed for a small percentage of errors, but was still unacceptable for healthcare.

Traditional quality management initiatives, such as quality control, quality assurance, and Six Sigma, assume a retrospective approach and are not applicable to the entire system, and it seems that they do not lead to a proper reduction and prevention of errors Herring, ; Schwappach, ; Berte, Currently, process management provides the basis for advanced quality management, and the methodologies that have been considered thus far are Business Process Reengineering, Business Process Improvement, Lean Management, and Lean Six Sigma.

In particular, Health Lean Management aims to develop a hospital culture that is characterized by increased satisfaction through continuous improvements, in which all employees actively participate in identifying and reducing non-value-adding activities i. The definition of value in healthcare should be linked to the attributes identified for quality of care Arah et al.

Clinical Risk Management should also be performed starting from the stage of process analysis, according to its system approach. Only in this way it is possible to develop defensive systems and processes to detect, prevent, and avoid errors.


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CRM is a particular kind of risk management that focuses on clinical processes that directly or indirectly involve patients. It includes the organizational structures, processes, instruments, and activities that enable hospital employees to identify, analyse, contain, and manage risks while providing clinical treatment and patient care Walshe, ; Briner et al.

CRM is often deemed to be the opposite of HLM, because it is focused on identifying and managing risks, rather than eliminating waste and aiming to improve efficiency. The latter is a typical objective of HLM, which aims to eliminate all the waste and all the obstacles that hinder the flow of the analysed process.


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The focus of the two managerial approaches seems conflicting. However, in a healthcare organization, risks should be managed and prevented and, at the same time, efficiency enhancement is required by diverse external pressures, as aforementioned. To this extent, a methodology that combines HLM and CRM could permit the development of new solutions that would reach multiple objectives. According to McDermott and Venditti , learning about the effectiveness, tools, and practices of lean management in a knowledge-based work environment needs to be increased. As the settings are different from the manufacturing industry, the key elements required for a successful project implementation could vary.

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Lean Systems – Bóksalan

Several authors denoted the paucity of research on human elements of HLM adoption, such as motivation, team working, training, empowerment, and respect for people, which constitute the key factors for the long-term sustainability of any lean programmes Yang et al. For this reason, in the current study, these dimensions are part of the analysis framework, in which operational improvements, outcomes of quality of care, an overall focus on patient safety, impacts on organizational climate, and employee satisfaction have been included.

As Joosten et al. In particular, top managers should support HLM in order to develop an environment where collaboration and teamwork permit the achievement of higher performance levels than those achievable by a single person. As demonstrated by Waring and Bishop , if people are not involved they will often comply with the new procedures, but only in a superficial way, without demonstrating a profound conversion, and they will often return to the previous situation or procedure as soon as possible. Therefore, in the cases analysed in the current research, the support of top management and employee involvement will also be investigated.

In the literature, phases of HLM implementation are suggested by Poksinska Amin, In particular, three cases from two hospitals Alpha and Beta have been chosen; two of them concern front-office processes, while the other is focused on back-office processes. The cases come from similar fields of application, which support literal replication Yin, After defining a designed research protocol Saunders et al. From this contact, snowball sampling took place, and the most appropriate people to interview were identified Harris et al.

Table 1. Information about data collection.

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Internal documentation and reports about the projects and the HLM experience, documents from the hospital website. Initial meeting with a brief presentation of the project and interventions of the general director, documents from the hospital website. The adoption of the same framework permitted the development of three tables with the same format, allowing for a simple comparison of the three cases according to the most relevant variables. The context of hospital Alpha. Alpha is a highly specialized Italian university hospital, a centre of teaching and research, built many years before With approximately beds and 3, employees it provides basic local and specialized services for about , and , citizens respectively.

The presence of the Medicine Faculty adds additional national and international value to this hospital, especially in relation to the specialized services, which increase the number of potential patients that can access the hospital. The mission of the hospital is to assure the highest possible level of health care, reconciling research and teaching, and making the organization comparable with the most prestigious university hospitals.

What Is Lean Healthcare?

Listening, information, and support are offered to patients in a service that has to be global, personalized, safe, and evidence-based. One of the hospital objectives is to improve the service level through high professionality and specialization, providing a service that has value for the patient in a safe and comfortable place, and which integrates a high level of clinical assistance with attention to human and relationship aspects.

Therefore, the patients are at the centre and pathways have to be developed according to their needs. The hospital is organized into eight departments, and three separated units of staff work under the hospital director and are in charge of HLM, CRM, and quality. Since the first adoption of HLM, more than 30 projects have been implemented, also thanks to a yearly competition that awards the best projects developed inside the hospital.

Moreover, the HLM unit has been providing HLM training courses at different levels more than people are already trained in order to create an efficient and collaborative work environment that has to be continuously improved and in which waste is eliminated through adoption of HLM. So far, the realized projects aim mainly to reduce time, costs, movement, space, and defects not directly linked to patients e.

However, the HLM unit seems to not be integrated with CRM, which was not involved in the two projects analysed in this research. In addition, the quality unit was not involved even though, among other things, it had to accredit the procedures required for HLM adoption. In general, the quality department uses audits, checklists, and questionnaires to monitor adherence to defined standards, and it supports the definition of assistance pathways.

Beginning from quality evaluations performed by the quality department, improvement actions can be requested and carried out by the interested unit. Moreover, the hospital follows the institutional accreditation, ISO , and the accreditation for providing Continuous Medical Education.

The context of hospital Beta. With more than 2, employees and approximately beds, it serves a catchment area of approximately , inhabitants. The LHU intends to guarantee, among others, the principles of:. In particular, reflecting the objectives of its regional authority, it aims to improve the healthcare and the well-being of the population, satisfaction and participation of citizens, and efficiency and sustainability of the system. It has also started to redefine its assistance settings according to the intensity of a care-based model, which has involved reorganizing the surgery and medical areas, developing a model of assistance continuity through integration of the hospital with the other healthcare organizations distributed in the territory, and defining the roles of medical tutor and referent.

This LHU has reported excellent results in terms of quality of the healthcare processes, especially in demonstrating the existence of adequate diagnostic and therapeutic pathways shared between emergency department and inpatient wards. Moreover, due to integration between the hospital and the other healthcare organizations in the territory, the hospitalization rate for this LHU is lower than the regional mean.

Lean Six Sigma Case Studies in the Healthcare Enterprise

The management of admissions and discharges is evaluated using measurement indicators such as hospitalization rate, discharge rate, and percentage of hospitalizations of over 30 days. The above-mentioned results were obtained in an organizational structure that includes three units in staff who work under the general hospital director: the quality and accreditation unit, the CRM unit, and the HLM unit. There is no integration among these units, even though the clinical risk manager has required at least some integration between CRM and the quality and accreditation unit.

The latter unit deals with all the activities concerning institutional accreditation, maintenance of the quality book, and procedures regarding the general management. This LHU is also strongly committed to implementing procedures for reducing clinical risks. The CRM unit executes audits e. Furthermore, it draws up a plan, a budget, and a final report.

In addition to checking the execution of best practices, monitoring compliance with protocols and procedures or guidelines, and application of the ministerial recommendations, the hospital Beta uses reference standards and compares the results with the available literature. The key strategic aspects of the two hospitals are reported in Table 2. Table 2. Key strategic aspects of the interested hospitals. Results from the three case studies. The first project selected in Alpha was implemented in the emergency department. The emergency service manages about 50, patients per year.

Lean 5S in MSICU

Thanks to regional funds, this project was implemented in order to improve patient flow and reduce waiting times, thereby enhancing patient service. The regional authority was a financial and technical supporter of this project, and therefore no external consultants were included on the project team, which consisted of people from the HLM unit who were already trained. We have a dedicated site for Germany.

This book provides a detailed description of how to apply Lean Six Sigma in the health care industry, with a special emphasis on process improvement and operations management in hospitals.

Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare
Lean Systems: Applications and Case Studies in Manufacturing, Service, and Healthcare

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