JIHM - Jan/2017: Special Issue

January/2017

Editorial Board Editor Li Li Min Associate Editors Alice Sarantopoulos Gabriela Spagnol Scientific Committee Robisom Calado (USF) Maria Silvia Teixeira Giacomasso Vergílio (UNICAMP) Flávio Bressan (PUCCAMP) Li Shi Min (UFSC) Messias Borges Silva (USP) Advisory Committee Germana Barata (LabJor/UNICAMP) Patrícia Tambourgi (USP) Public Relations Alice Sarantopoulos Gabriela Spagnol jihm@gigs.org.br Administration ADCiência

Editorial

The Group of Innovation and Healthcare Management is delighted to launch the first volume of the Journal of Innovation and Healthcare Management. The articles featured have been presented as oral communication during the V Lean Day held in RibeirĂŁo Preto, Brazil during October 6th and 7th, 2016. Among these studies, there are experiences of successful improvement initiatives in different healthcare services, as well as in an office and in the industry. Authors depict in detail how and which tools they applied, before and after implementing a change to improve the process. In this sense, in this very first volume, we present to our readers different scenarios and approaches in service improvement, contributing to the body of knowledge and evidence regarding client-centered projects and continuous improvement implementation. Therefore, as editor, I am privileged and honoured to first hand share these reports wi th you hoping to inspire and guide future initiatives in your workplace.

Cheers and welcome to JIHM! Li Li Min, MD PhD BBA

Organizing Committee Special Issue: V Lean Day Li Li Min, MD PhD BBA Presidente do V Lean Day Coordenador do GIGS-UNICAMP Alice Sarantopoulos, RN MSc Secretária Executiva do V Lean Day Gabriela Spagnol, RN MSc Coordenadora Científica do V Lean Day Scientific Committee Brazilian Researchers Robisom Calado Maria Silvia T. G. Vergílio Flávio Bressan Ademir Jose Petenate Oscar Salviano Silva Filho Gabriela Salim Spagnol Alice Sarantopoulos Jéssica Elias Vicentini Stela Maris Antunes Coelho Wigberto Antonio Spagnol Marco Nascimento Cristiano Torrezan Iara Tammela Alessandra N. C. P. Roscani Isaac Fernandes de Carvalho Renan de Lima Branco International Researchers David Newbold Sushil Shetty

Summary

Audit of medical orders for hepatitis B in a tertiary university hospital: when less is more

4

Falango and Bollela Evaluation of physical aspects of the work environment through a study in an engineering office

13

Peres, Caldeira and Calado Lean Thinking to Improving Access to Cancer Patients in a Public General Hospital Coelho, Pinto and Silva

27

Development of a successful model to sustain quality after a health surveillance project

33

Colombrini et al.

Process Improvement in a Cancer Outpatient Chemotherapy Unit using Lean Healthcare

41

Marotta, Pinto and Silva Implementation of a Continuous Flow in a Post-Machining Process Claudino et al.

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Proceedings of the 2016 Lean Day

Audit of medical orders for hepatitis B in a tertiary university hospital: when less is more D. Falango¹, V. R. Bollela² ¹Serology Laboratory Hospital das Clínicas School of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP); ²Department of Infectious diseases at FMRP-USP.

Abstract Hepatitis B (HB) serology involves six markers but initial screening requires only two. This study aims to evaluate an intervention designed to adjust HB orders. Methods: Data collected from medical HB requests were analyzed over a period of seven months before (2012-2013) and nine months (2014-2015) after an intervention, and classified as “adequate”/“inadequate”. Results: Ther e was 10.23% and 1.86% of inadequacies, r espectively, dur ing the two per iods and it was possible to save R$21,301.05 after the intervention. Discussion: By reviewing HB orders focusing on patient needs and the existing guidelines it was possible to reverse a trend of inappropriate tests and waste.

Keywords: Labor ator ies, Hospital; Quality management; Hepatitis B; Lean thinking

1. INTRODUCTION There has been an ample debate about health management, especially in view of the recent economic crisis. The search for cost-effectiveness in all activities related to health care should be constant and is usually one of the criteria taken into account in the elaboration of clinical protocols. Within this context, laboratory tests are of fundamental importance for screening, diagnosis and monitoring of countless diseases.

Their use is increasing, so that today 80% of clinical decisions made by doctors are directly influenced by complementary exams requested during the phase of diagnostic investigation or of clinical monitoring of the patient [1].

In a 2013 meta-analysis, Zhi et al. pointed out that laboratory tests represented the most voluminous medical activity, with 4 to 5 billion measurements performed each year in the United States [2]. CAMPANA et al. (2011), in an analysis of complementary health data for Brazil in 2008, reported that there were about 41 million users of health plans and 450 million tests requested and carried out each year [1]. In the scenario described by the authors, this volume of exams covered about 21.58% of the Brazilian population.

Laboratory tests are estimated to represent about 3 to 5% of the total health expenditures in the world, and 11% of the expenditures in Brazil [1,2]. In absolute numbers, the National Health Service (NHS) of the United Kingdom calculated that expenses with laboratory investigation reach 2.5 billion pounds per year [3]. Although these tests are complementary and have a well-established role in clinical practice, when requested in excess or without due indication, as in the absence of a specific clinical suspicion, they may be harmful for both the patient and the sustainability of the health system/organization itself.

Inadequate requests increase the chance of occurrence of “false-positive” results. Exams with a discrete alteration compared to values considered normal are unlikely to be of clinical relevance, a fact that may lead to prolonged investigation and even to unnecessary treatments [3]. Several factors can explain the improper request of exams on the part of doctors: lack of doctor’s preparation in order to request the correct exam and/or an overestimate of the characteristics and performance of the test; lack of accurate interpretation of the results; a rapid advance in technology and new available tests that represent a challenge for the doctor to upgrade his knowledge [4].

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Falango and Bollela

Zhi et al. (2013) listed the main determinants of the excessive number of test requests: lack of welldefined request criteria (protocols); excessive freedom given to less experienced professionals; inability of the doctor to assess the diagnostic value of the test; inappropriate interpretation of results; inadequate supervision; poor utilization of clinical management tools [2]. May et al. (2006) stated that this reality is worse in university hospitals linked to teaching institutions where exams are often requested by professionals in training and with less clinical experience [5].

A proven successful way to add value to processes and reduce costs has been the use of the “Lean Thinking” principle, which is a consolidated management tool created by Toyota industries in Japan after World War II. Basically, it is the way of always doing more with less and less. In a review of 33 articles, Mazzocato et al. (2010) analyzed the applicability of Lean Thinking to health services and observed that the concept was useful for a varied gamut of services, with positive results in all of them. The authors listed some measures that should be adopted for a successful application of this tool to health: to implement methods that will aid the retransmission of information for problem solving and to create stable structures for continuous improvement, permitting in turn the improvement of learning patterns with sustained positive results; to engage in ongoing management of problem solving; to adopt a more holistic view and to connect with a broader context [6].

Data of the University Hospital (HCRP) of the School of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP) for the last 20 years demonstrate that there was a 30% increase in the number of active beds, surgeries and ambulatory care, while there was a 100% increase (from 1.4 to 2.8 million) in the number of complementary tests performed during the same period. HCRP is a teaching and reference high complexity hospital serving a region of about 4 million people in the northeast of the state of São Paulo.

Among the 30 exams most frequently requested at the hospital between 2003 and 2012, the determination of the surface marker of hepatitis B virus (HBsAg) was the 25th, starting with 16,899 tests and reaching 19,630 tests (+16%) nine years later.

There are six markers for the investigation of hepatitis B, and in principle the doctor can request any of these: HBsAg, Anti-HBs, Anti-HBc IgTotal, Anti-HBc IgM, HBeAg and Anti-HBe. However, if the reason for a test is an initial investigation (screening) of hepatitis B, there is no need to test all markers in the first exam. The rationale, and as recommended by state Resolution SS 91 of 31-10-2006 of the Health Secretary Office of the State of São Paulo [7], is to test the HBs antigen and the HBc IgTotal antibody since the former, is present in all phases of active disease and the latter indicates a previous contact with the virus. In 2012, the coordinating committee of the Serology Laboratory of HCRP set up a routine for the assessment and adjustment (correction) of inadequate requests for hepatitis B, testing only for the HBsAg and Anti-HBcAg IgTotal markers according to the above guideline. Similar practices have been reported in the international literature under the term “reflective testing” and “reflex testing”. In “reflective testing”, a team of specialists belonging to the laboratory itself (biomedical and medical staff) adjusts the requests for better accuracy, considering the diagnostic hypothesis as the starting point, as well as other information such as the availability of results of previous exams or of other laboratory determinations for the patient.

The “reflex testing” employs the technology of information by means of automatically executed algorithms and expert systems, exclusively based on the results obtained [8].

2. AIMS

The objective of the present study was to assess the result of implementing adequacy of the medical requests for serological markers of hepatitis B sent to the Serology Laboratory of HCRP and the impact of a screening initially performed in a manual manner (phase 1) and later programmed in the electronic system for the request of tests of the hospital (phase 2).

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Proceedings of the 2016 Lean Day

3. METHODS This is a descriptive and retrospective study based on data collected through the eletronic system of HCRP containing the requests made by doctors and sent to the laboratory.

The analysis of requests for the determination of hepatitis B markers was carried out in two stages: a pilot study in which requests already made were manually reviewed (one by one) together with the intervention by the technical team of the Serology Laboratory, with adjustment of requests so that they would follow the guideline (phase 1). In a second phase, parameters were inserted into the electronic system for automatic screening and determination of adequacy at the time of medical request using resources of interfacing and information technology (phase 2).

All serological tests for hepatitis B were carried out using the automated equipment Architect i2000 SR – Abbott Laboratories, which is already available for the laboratory routine of the hospital. Data were collected from the Laboratory Information system (LIS), which is the laboratory management tool available with the support of the Information and Analysis Center of HCRP. In the investigation of hepatitis B, the selection of tests to be performed (screening) was based on the guideline adapted for hospital routine. Based on these restrictions, requests for the investigation of hepatitis B by doctors are limited to screening exams (HBsAg and/or HBc IgTotal antibody). These are markers initially tested even when other markers are requested concomitantly. Depending on the positive results obtained for some of these markers, other tests are carried out on the same patient serum sample and made available to the medical team.

Table 1 - Examples of possible scr eening situations for hepatitis B, and how they wer e classified based on the São Paulo state guideline [7].

Situation

Markers HBc IgMAb

HBsAg

HBc IgTotalAb

1

X

X

2

X

X

X

3

X

X

X

4

X

5

X

HBeAg

HBeAb

ADEQUATE Inadequate X

X

X

X

X

7 9 10

X

Inadequate Inadequate

X X

Inadequate ADEQUATE

6 8

Classification

X

X X X

X

Inadequate Inadequate

X

Inadequate ADEQUATE

3.1. Qualitative and quantitative assessment of requests for serological tests for hepatitis B The requests were assessed and analyzed in two phases:  Phase 1: fr om August 2012 to Febr uar y 2013 (7 months) when ther e was still no r estr iction.

During this period, requests made by doctors in the electronic system were printed and analyzed manually by coordinators of the Serology Laboratory. The following data were inserted in a Microsoft Excel spreadsheet: date of request, institutional registration number of patients, clinic of the requesting doctor, serological markers requested and results of the HBsAg marker. Only screening markers were tested according to the guideline for hepatitis B tests.

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Falango and Bollela

Phase 2: Fr om J uly 2014 to Mar ch 2015 (9 months) after par ameter ization of the electr onic system which limited requests of younger doctors and medical residents (doctors under training), while permitting access to all markers to the more experienced assistant physicians.

During this period it was possible to obtain data directly from the electronic system, generating reports that were exported in the form of a Microsoft Excel spreadsheet containing the following data: date of sample collection, institutional registration number of the patient record, patient’s gender, clinic of the requesting doctor, diagnostic hypothesis, serological markers requested, and results of the exams performed.

In the first phase, it was not possible to assess the adequacy of the diagnostic hypothesis since this information was not available for a considerable number of requests (the doctor did not fill it in). In these cases, adequacy was assessed only on the basis of the serological markers requested. In the second phase, it was possible to assess adequacy also taking into consideration the diagnostic hypothesis, which was obligatorily recorded in order to finalize the request. All requests that in the initial screening investigation contained the serological markers HBeAg, Anti-HBe and Anti-HBc IgM, each alone or all together were considered “inadequate”.

It is important to point out that all requests in which the HBsAg marker showed a positive result were complemented with tests for other specific markers for the disease. This is justified by the fact that it is necessary for the clinician to be aware of disease stage as provided by the serological status, as recommended by São Paulo state Resolution SS 91 [7].

The numbers of adequate and inadequate exams were analyzed in the two periods and the difference between them was determined by the chi-square test. We also analyzed expenditures of the institutions for hepatitis B tests after serological screening, as well as the amount that would have been spent if the intervention process had not been implemented. We listed the clinics with the largest number of requests considered inadequate. The value in Reais (R$) of each test performed was used for the financial analysis of the screening and adequacy process. These data were provided by the Costs Sector of HCRP and included direct and indirect costs, i.e., purchase of the reagent and allotment of water, light and human resources of the cost center responsible for the tests (Serology Sector). This information was made available for the year 2014. 

4. FINDINGS Phase 1: qualitative/quantitative analysis for the period from August 2012 to February 2013: During this period, 11,167 medical requests of serological HB markers were analyzed, 10,024 of which (89.76%) were considered adequate and 1,143 (10.23%) inadequate (Table 2). The inadequacy most frequently observed was the request of the Anti-HBc IgM marker, alone or together with other markers, present in 1,058 (92.56%) of the 1,143 requests considered inadequate.

The financial analysis of this seven month period demonstrated that R$ 335,547.46 would have been spent if the screening process (reflective testing) had not been used. With the screening, this amount reached R$ 315,930.21, corresponding to a saving of R$ 19,617.25 during the period. By projecting these values observed within a period of seven months to an one year period, the total amount spent without the screening process would have been R$ 575,211.34, being reduced to R$ 541,582.52 with the screening, with estimated savings of R$ 33,628.82 (Table 2).

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Proceedings of the 2016 Lean Day

Table 2 - Total number of requests with analysis of adequacy and financial analysis with and without the intervention implemented between August 2012 and February 2013.

Costs (R$)

Requests of the determination of hepatitis B markers

Without intervention

With intervention

11,167

335,547.46

315,930.21

Adequate

10,024 (89.76%)

277,765.04

277,765.04

Inadequate

1,143 (10.23%)

57,782.42

38,165.17

Total for 7 months

The distribution of inadequate requests varied from clinic to clinic within the institution, as follows: sterility (188/16.45%), hematology (129/11.29%), neurology (90/7.87%), nephrology (86/7.52%), immunology (74/6.47%), pediatrics (65/5.69%), internal medicine (54/4.72%), dermatology (47/4.11%), gastroenterology (45/3.94%), gynecology (45/3.94%), and orthopedics (39/3.41%). The total number of requests made by the remaining clinics was 281, representing 24.59% of the total number of inadequate requests.

When considering all HB requests sent to the laboratory by the above clinics, the percentage of inadequacy per clinic was as follows: sterility (35.10%), hematology (24.62%), neurology (28.75%), nephrology (13.96%), immunology (31.09%), pediatrics (43.92%), internal medicine (17.09%), dermatology (15.67%), gastroenterology (15.36%), gynecology (5.46%), and orthopedics (19.40%) (Table 3).

Table 3 – Distribution of inadequate requests among clinics of the hospital and percent inadequacy considering the total number of requests within the clinic itself (Total=1,143 inadequate requests) Requesting clinic

n

General percentage

Intraclinic percentage

Sterility Hematology

188 129

16.45% 11.29%

35.10% 24.60%

Neurology

90

7.87%

28.70%

Nephrology

86

7.52%

14%

Immunology

74

6.47%

31.10%

Pediatrics

65

5.69%

43.90%

Internal Medicine

54

4.72%

20.60%

Dermatology

47

4.11%

18.60%

Gastroenterology

45

3.94%

15.40%

Gynecology

45

3.94%

5.50%

Orthopedics Others (< 3.0%)

39 281

3.41% 24.59%

19.40%

Phase 2: qualitative/quantitative analysis of the electronic requests from July 2014 to March 2015 A total of 13,482 medical requests for HB tests sent to the Serology Laboratory were analyzed during this period. Mean patient age upon request of test was 42.5 years (95% Confidence interval 41.6-43.4), with most patients being females (62.46%) and 37.54% being males.

Of the total number of requests made with the electronic system, 13,231 (98.14%) were considered adequate and 251 (1.86%) inadequate. Again, the most frequent inadequate request was that for Anti-HBc IgM, alone or together with other serological markers, present in 218 of the 251 inadequate requests (86.85%). Financial analysis of the nine month period demonstrated that R$ 376,187.63 would have been spent if the electronic screening process (reflex testing) had not been applied to the inadequate requests.

With the screening, this value was R$ 374,503.83, representing a saving of R$ 1,683.80. By projecting this scenario to a 12 month period, the value spent without the screening process would have been 8

Falango and Bollela

R$ 501,583.51 and the value spent with the screening process would have been R$ 499,338.44 (- R$ 2,245.07) (Table 4).

Table 4 - Total number of requests, analysis of adequacy and financial analysis with and without the intervention implemented between July 2014 and March 2015.

Costs (R$)

Requests of the determination of hepatitis B markers

Without intervention

With intervention

13,482

376,187.63

374,503.83

Adequate

13,231 (98.14%)

366,631.01

366,631.01

Inadequate

251 (1.86%)

9,556.62

7,872.82

Total within 9 months

The inadequate requests mostly originated from the following clinics of the institution: sterility (79/31.47%), hematology (20/7.97%), neurology (20/7.97%), private clinic (16/6.37%), internal medicine (14/5.58%), gastroenterology (13/5.18%), nephrology (10/3.98%), gynecology (8/3.19%), and pediatrics (8/3.19%). The total number of inadequate requests made by the remaining clinics was 63, representing 25.1% of the total. When considering all HB requests sent to the laboratory by the above clinics, the percentage of intraclinic inadequacy was as follows: sterility (12.17%), hematology (3.21%), neurology (3.87%), private clinic (7.44%), internal medicine (3.17%), gastroenterology (2.18%), nephrology (0.89%), gynecology (0.40%), and pediatrics (3.07%) (Table 5).

Table 5- Distribution of inadequate requests among clinics of the hospital and percentage of inadequacy considering the total number of requests within the clinic itself (Total=251 inadequate requests). n

General percentage

Intraclinic percentage

Sterility Hematology

Requesting clinic

79 20

31.47% 7.97%

12.17% 3.21%

Neurology

20

7.97%

3.87%

Private

16

6.37%

7.44%

Internal medicine

14

5.58%

3.17%

Gastroenterology

13

5.18%

2.18%

Nephrology

10

3.98%

0.89%

Gynecology

8

3.19%

0.40%

Pediatrics Others (<3.0%)

8 63

3.19% 25.10%

3.07%

Table 6 shows the distribution of adequate and inadequate requests in two phases (before and after intervention) according to the month of occurrence. It can be seen that during the pre-intervention period the percentage of inadequacy ranged from 8.96% to 11.81%, with a clear reduction occurring in the subsequent phase when this percentage ranged from 1.21% to 3.25% (when grouping all months: Ď&#x2021;2(1GL) = 646.45 ; p<0.001).

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Proceedings of the 2016 Lean Day

Table 6 â&#x20AC;&#x201C; Total number of inadequate requests and percentage of inadequacy before and after intervention.

Phase 1 (2012-2013)

Phase 2 (2014-2015)

Adequate

Inadequate

%

Total

Adequate

Inadequate

%

Total

Agust

1,675

194

10.38%

1,869

1,577

53

3.25%

1,630

September

1,469

174

10.59%

1,643

1,675

35

2.05%

1,710

October November December January February Total

1,576 1,341 1,115 1,535 1,313 10,024

211 143 114 151 156 1,143

11.81% 9.64% 9.28% 8.96% 10.6% 10.23%

1,787 1,484 1,229 1,686 1,469 11,167

1,584 1,328 1,143 1,432 1,378 10,117

26 19 14 19 25 191

1.61% 1.41% 1.21% 1.31% 1.78% 1.85%

1,610 1,347 1,157 1,451 1,403 10,308

p value

< 0.001

Based on the data collected in Phase 2 (2014-2015), we evaluated the requests of hepatitis B tests that were justified by the diagnostic hypothesis: preoperative exam. In general, hepatitis B serology is not an exam indicated before elective surgeries. This caught our attention in the final analysis of phase 2 data and may indicate that the exam had been indicated unnecessarily, representing another type of inadequacy.

Since the diagnostic hypothesis became available only after complete informatization of the serological markers requests, this information was available only in the second phase of the study.

The number of requests justified by the fact that this was a preoperative exam was 997, corresponding to 7.39% of the medical requests of HB tests received in phase 2 of the study. The total cost of these exams of debatable indication was R$ 15,398.56.

5. DISCUSSION Inadequate requests for medical exams contribute to significant losses such as increased hospitalization time and unnecessary investigation and/or treatments. In addition, they have a negative impact on preanalytical and analytical processes, result in more laboratory reports, increase the use of material for collection and storage of biological material, unnecessary utilization of reagents, and may also produce more residues that require appropriate treatment for disposal. [3] Many studies have assessed interventions aiming to restrict the demand for laboratory tests. Several successful cases have been reported, based on multifaceted measures and on actions that provide constant updating and feedback for the medical team [3, 5, 9, 10].

The intervention studied here proved to be effective during the two periods explored, the first based on the intervention of the technical team (Reflective testing) and later with the inclusion of these restrictive parameters in the electronic system using resources of health informatics & technology (Reflex testing).

During the first period there was a 5.85% saving in the total costs of hepatitis B exams, corresponding to R$ 19,617.25, and during the second period the saving was of R$ 1,683.80, corresponding to a 0.45% reduction. The impact on phase 2, was lower (0.45% versus 5.85%) due to the inclusion of administrative restrictions directed to less experienced physicians.

The percentages of inadequacy measured before and after restrictive intervention (10.23% and 1.86%), although numerically expressive, were lower than those determined in other studies such as the meta-analyses of Zhi et al. (44.8% and 20.6%) [2], Driskell et al. (49%) [9], and Kwork and Jones (16,78%) [10]. It should be pointed out that exams scenarios analyzed by these authors were different because they analyzed different tests at the same time and not only requests for hepatitis B markers, as proposed by this study.

We demonstrated the effectiveness of an administrative action to limit requests for some restricted serological HB markers only to professionals with greater clinical experience. During phase 2, the rate of 10

Falango and Bollela

inadequate medical requests for HB tests decreased 6 fold, from 10.23% to 1.86%, compared to the previous period, when this limitation did not exist. The introduction of restrictive intervention led to a statistical significant reduction (p<0.001) of inadequacies when comparing the same period of the year (August to February) in 2012-2013 (phase 1) and 2014-2015 (phase 2).

The present study indicated opportunities for improvement since it was observed that, even after restriction, some more experienced doctors continued to prescribe exams in an inadequate manner. In addition, we observed that, during both periods, doctors had difficulties in recognizing the correct indication of Anti-HBc IgM test, which was the major detected inadequacy. This marker should be requested in the presence of suspected acute infection and is not a good option for the screening of hepatitis B. This result indicates the need to train the medical teams with guidelines about the request of markers and with special emphasis on this question.

Studies on this topic which evaluated the knowledge of health professionals about hepatitis B, and more specifically about the serological markers commercially available, have shown that 29.5% of general clinicians refer patients to a specialist after obtaining positive results for Anti-HBs, which indicates the presence of a cured infection or only vaccination against hepatitis B [11]. Another study that assessed the knowledge about hepatitis B among health professionals participating in an internal medicine congress in Canada showed that 55% of the interviewees were unable to identify HBsAg as a marker of chronic hepatitis B infection. In addition, about 44% of the interviewees did not know that chronic HB infection can be controlled with medications [12].

At the end of the second phase, it was possible to perceive also that there are situations in which the request is made in a correct manner, although the medical indication is debatable since there are doubts about the real necessity to request hepatitis B markers for persons to be submitted, for example, to elective orthopedic surgeries. In phase 2, almost 1,000 tests were requested for patients in this situation. This finding indicates the need for preoperative protocols discussion and review. HB tests should be limited only to those cases where there are strictly indications and it could really mean benefit to the patient care and outcome. In addition, these requests represented 7.39% of the total and an amount of R$ 15,398.56 of the financial resources. Ladeira (2007) alerted about the redundant request of many perioperative tests and the risks involved in this practice [13].

During the first period, there were nine specialty clinics that leaded inadequate HB markers request which represented 68.06% of the total inadequacies and 74.9% during the second period. However, the number of these inadequate requests was much smaller during the second period, 188 as opposed to 778 during the first phase of the study. When we compare five clinics of the first and second periods that had the largest number of inadequacies, the percentage of intraclinic inadequacy, i.e., the percentage of inadequacy in relation to the total number of requests processed by the clinics themselves, ranged from 13.96 to 35.1% during phase 1 and from 3.17 to 12.17% during the second period, representing another indicator of improvement.

The screening and adequacy determination process of the requests for HB implemented by the Serology Laboratory of HCRP has a parallel in the Lean concept because it offers the “value” that the “client” really needs, since it first involves the determination of the markers that are essential for the screening process of the disease, thus helping the medical team [6]. The elimination of some non-priority markers also follows lean thinking by eliminating waste, executing only what is necessary. The reduction of unnecessary markers permits the processing of a larger number of samples per work day and reducing Lead time, or the time elapsed from request to delivery.

The present findings support the need for a multiprofessional and interdisciplinary approach to the decision about the protocols to be used to request complementary tests in medicine both in public health institutions, where the greatest contingent of medical residents and of medical training is located, and in supplementary health in order to reduce costs and to improve diagnostic accuracy for the benefit of the patient.

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Proceedings of the 2016 Lean Day

6. CONCLUSIONS In summary, the data reported here demonstrate the cost-effectiveness of the processes set up by the Serology Laboratory of HCRP, which included analysis and adequacy of the requests of hepatitis B markers by technical team (reflective testing) and electronic screening (reflex testing). These measures also accelerate the release of relevant results for clinical decision making. We demonstrated that it was possible to reduce costs by optimizing the request/execution of serological tests for hepatitis B and, by understanding this process we envisaged opportunities for improvement by training medical teams that still request exams in an inadequate manner without a clear indication, as is the case, for example, for the preoperative period of elective surgeries.

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Driskell, O.W., Holland, D., Hanna, F.W., Jones, P.W., Pemberton, R.J., Tran, M., Fryer, A.A., 2012, “Inappropriate requesting of glycated hemoglobin (Hb A1c) is widespread: assessment of prevalence, impact of national guidance, and practice-to-practice variability,” Clinical Chemistry, 58(5), 906-915.

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Kwok, J., Jones, B., 2005, “Unnecessary repeat requesting of tests: an audit in a government hospital immunology laboratory.” J. Clin. Pathol., 58, 457-462.

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Wallace J., Hajarizadeh B., Richmond J., McNally S., 2012, “Investigating general practice and Hepatitis B,” 09 May. 2016, <http://www.researchgate.net/ publication/258344938_Investigating_General_Practice_and_Hepatitis_B>.

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Dulay, M., J. Zola, J. Hwang, A. Baron, C. Lai, 2007, “Are primary care clinicians knowledgeable about screening for chronic hepatitis B infection?”. Presented at the 30th annual meeting of the Society of General Internal Medicine (SGIM), Toronto, Canada. Journal of General Internal Medicine 22(1), 100.

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Ladeira, M.C.B., 2007, “A necessidade de exames complementares pré-operatórios.” Revista do Hospital Universitário Pedro Ernesto, UERJ, 6(1), 20-27.

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Evaluation of physical aspects of the work environment through a study in an engineering office P. I. S. Peres1, R. A. Caldeira², R. D. Calado³ ¹Engenheira Metalúrgica, Mestranda UFF; ²Engenheira de Produção, Mestranda UFF; ³Pós Doc, Professor UFF. Abstract In technical offices, where concentration and attention are necessary, the concept of open environment, in which the division of working places is limited by low height partitions, might not be the most suitable. This article presents a case study in an office with integrated engineering activities, showing advantages and disadvantages of using this layout according to the work performance and physical comfort of employees. From a questionnaire with specific questions related to thermal, acoustic and luminal comfort, it was possible to map satisfaction of staff members in this workplace. In addition, the concept of relationship map was used to suggest a more appropriate layout for these workers. The result of this study showed frustration from employees concerning the noise in their work environment. This noise is caused, mainly, by conversations among workers and the telephone sound produced when it rings, which causes a greater attention deficit and reduction of work performance. It was noticed that, in this work environment, the acoustic treatment was not prioritized. Thus, this article aims to evaluate physical aspects in the work environment and to present a proposal to improve it.

Keywords: Work environment, noise, temperature, lighting, layout.

1. INTRODUCTION In order to create a proper work environment, aspects of interpersonal relationship and integration techniques among workers must be taken into account, in terms of functional physical aspects, as well as furniture, layout, illumination, acoustic treatment and temperature. From the physical aspect, it is possible to adapt it, applying some concepts based on the ABNT standards (Brazilian Association of Technical Standards), RS (regulatory standard) and of engineering methods, adjusting the work environment and bringing more comfort to employees of a company.

The Regulatory Standard, in the chapter about Ergonomics – NR 17, informs that in workplaces where activities require constant attention and concentration are performed, such as: control room, laboratories, offices, developing room or project analysis, among others, the following comfort conditions are recommended: · Levels of noise according with what is established in the NBR 10152, Brazilian standard established by INMETRO; · Index of effective temperature between 20 and 23°C; · Airspeed not higher than 0.75 m/s; · Relative humidity no less than 40%.

According to Niebel and Freivalds (2009), method analysts must provide work conditions in a safe and comfortable way for employees. These same authors state that plans with favorable work conditions may contribute to significant progress with more efficiency and therefore increase production, reducing absenteeism, the number of people who arrive late and staff turnover, raising the confidence of employees and improving interpersonal relations.

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It is not possible to predict a specific amount of what is lost with the health of employees in an inappropriate work environment. However, Luizetto (2014) presents data acquired by Willian Fisk â&#x20AC;&#x201C; table 1, which estimated in 1996 the values of costs and gains of productivity in relation to a healthy environment, in the USA, in spite of difficulties in measuring these losses and the considerable uncertainty of these estimations.

Table 1 â&#x20AC;&#x201C; Estimation of potential gains of productivity, due to improvements in conditions of comfort of the environment. (Luizeto (2014)

This paper is meant to show the importance of the analysis in an office with 40 employees, distributed in 8 interrelated activities. For this study, we used a questionnaire, with questions about noise, illumination, temperature and layout, in order to verify the level of satisfaction of these items in the office studied. This survey was conducted with 75% of the employees. After this result, it was possible to draw the aspects that are adequate and which must be reevaluated using engineering methods.

2. THEORICAL FRAMEWORK In this topic, concepts are presented based on the ABNT and NR17, about the analyzed theme, based on literature review, covering mainly the method used to suggest a well-structured work environment to improve productivity of employees.

2.1 Illumination In order to have a cozier work environment, the natural illumination provides more comfort, although for practical reasons, its use becomes very restrict. Hence, the implementation of artificial illumination has been increasingly used, and consequently there are specific standards establishing amounts and distribution of illumination, in the most appropriate way for various work environments.

As stated by Kliemann et al. (1998), poor illumination at a workplace may cause displeasure or visual fatigue, headache, reduction of visual efficiency, glare, high accident rate, as well as a negative psychological influence on people.

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According to the NBR 5413 that deals with interior illumination, the definition of illuminance is the limit of the reason of luminous flow received by the surface around a considered point, in the area of surface, when it tends to zero. This standard presents the illuminance necessary for each type of activity, where the average values determined for the work area classified as office is between 500 to 1000 lux.

Another important criterion that must be considered is the spacing between the light fixtures so that it has a uniform distribution of the artificial light. In agreement with Guerrini (2008), a maximum distance between the light fixtures must be respected, provided through the expression (1): (1)

eL ≤ 1,5h Where: eL – the distance between the light fixtures h – height of the light fixture to the working level The maximum distance between the light fixtures and the walls will be (2): (2)

eLP ≤ 0,75h Being eLP the distance between the light fixtures and the walls. eL = 3,6 m e eLP = 1,8m.

2.2 Temperature The thermal comfort is one of the most important parameters in the physical aspects in a work environment because it can increase or harm the productivity of employees.

Kliemann et al. (1998) quotes in his article the required conditions to ensure a comfortable work environment, to promote a better work performance in an office. These are the conditions: · The temperature in the winter must be 21°C. In the summer, temperatures between 20 and 24°C are perceived as pleasant; · The temperature of limiting surfaces must be of the same magnitude of the air temperature. Deviations of 2 and 3°C in average should not be overpassed; · The relative air humidity must not be under 30% in the winter, to avoid the risk of extreme of dehydration of upper respiratory tracts. In the summer, natural rates of relative humidity vary between 40 and 60%, which is normally perceived as pleasant; · The movement of the free air must not overpass, on the seat level, on the head and knees level 0.2 m/s.

2.3 Acoustic Comfort

Nowadays, the acoustic preoccupation is not only a matter of conditioning the acoustic environment, but also of controlling noise and preserving the environmental quality.

Souza, Almeida e Bragança (2006) inform that noise is object of an increasing number of studies, once its harmful effects to the human being are not limited only to lesions in the auditory system, it may have physical and psychological effects. When it comes to physical aspects, we can mention: loss of hearing up to permanent deafness in extreme cases, headaches, fatigue, cardiovascular disorders, hormonal dis15

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orders, gastritis, digestive disorders, and allergies, among others. As far as psychological aspects are concerned, the exposition to noise can lead to loss of concentration and reflexes, permanent irritation, sleep disorders, to emotional insecurity, among others.

The NBR 10152 – levels of noise for acoustic comfort, provides acceptable levels for several jobs, indicating the level from 35 to 45 dB (A), for office environments.

The improvement of acoustic performance is directly connected with the existing components of the work environment, to the configuration of this place and to the behavior of sound according with form and type of surfaces in the workplace. The result of this relationship influences quality of activities. Therefore, materials that are highly reflexive do not help the absorption of noise that has been produced in the environment. Thus, it is extremely important to count with evaluations and supervisions by teams of engaged professionals, either from the health department as well as from civil construction department and production engineering, in order to achieve effective solutions in terms of noise control.

The use of resistive and reactive materials to sound must be evaluated. According to Gonçalves et al.

(2008), resistive materials, for its characteristics, absorb better the medium and treble sounds, transforming sound energy in thermal energy. Those are the polyurethane foam, for example, but these materials must receive treatment with additive flame retardants. The reactive materials are used as attenuators for bass sounds, reducing its intensity to imperceptible levels to the human ears. Those are, for example, the resonator panels lifted and disposed in perpendicular direction to the ceiling.

The NBR 12179 standard helps in queries related to the acoustic treatment in closed rooms, listing different materials that may be used in this sort of environment and rates related to soundproof that these materials can provide.

2.4 Office Layout As defined by Anton, Eidelwein e Diedrich (2012), layout, also called physical arrangement, is the equipment disposition in an area including the human figure that is part of the context where procedures occur, aiming the balance among movement, production and ambience, or a product disposition inside a warehouse in a given space. The layout is present in any environment, even if it is not in accordance with the ideal arrangement, and has great focus of application in industries, offices, stores, banks and others.

An office layout must consider the closeness and privacy that defines to be set between 5m² and 7m² per employee. According to Augusto Junior et al. (2009), privacy in the work environment guarantees that some reserved subjects can be conducted in a proper way. Nowadays, “open” layouts are preferred, ones like landscape, with low height office partitions.

According to studies, the human voice is the most uncomfortable sound source in panoramic offices (PASSERO; ZANNIN, 2009). The conversation that causes greater distraction comes from the closest work stations. So, the speech privacy between workstations must be the greatest as possible, but this is typically lower than in enclosed private offices. The sound level in landscape offices are usually between 55 to 65 dB(A), while in closed offices the level is around 35 dB(A).

In an office, people (or workplaces) are supposed to be placed as close as possible to their activities, avoiding problems concerning crossed information, materials and people. This way, the use of the tool SLP – Systematic Layout Planning) must be applied. According to Silva e Moreira (2009), the SLP consist of a method that systematize knowledge and tools available for physical arrangements that aims greater and efficient production. The same author defines SLP as a systematization of projects of physical arrangements that suggests procedures for identification, evaluation and visualization of elements and of areas in a workplace involved in the planning. It is a tool that may help in the process of decisions related to the optimum combination of industrial sites, inside the available space. One of the tools uses to help this planning is the use of the Relationship Map.

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2.4.1 Relationship Map Kliemann et al. (1998) indicates which information should be raised to draw the relationship map, those are: collecting data referred to the type of work performed, the position of each worker and his or her needs, auxiliary services used and the frequency, as well as other information that help preparing the relationship map.

During the elaboration of the relationship map (or preferential interconnections letter), a triangular matrix is used where the proximity degree is represented and the type of interrelation between a certain activity to each one of the others. The first objective of the letter is to show which activities must be located next and which will be moved away from each other, shown on Figure 1.

Figure 1 - Relationship Map (Kliemann et al., 1998)

3. RESEARCH METHODOLOGY The study was developed in a technical office of the petroleum field industry responsible for the engineering activity of installing surface equipment, in which a group of 40 people are distributed in the following areas: design automation, cathodic and coating protection, corrosion engineering, material engineering, permutation and pressure ducts, valve engineering, planning and management. For ethical reasons, the name of the company was preserved, and authors of this paper have all the responsibility about the information described.

For the development of this study, a technique of information gathering was applied using a questionnaire, with 12 questions, distributed in the following aspects: noise, temperature, illumination and layout.

A detailed constructive and functional technical evaluation of the office was done, giving emphasis to the studies of the physical aspect of this environment. The problematic points were observed, indicating the possible items to be improved. In order to perform this task, standard concepts and the software CAD were used to redesign a more functional and more adequate layout for the performance of these employees.

4.

Results and Discussion

The work done was divided in 4 stages: gathering the main physical aspects through a questionnaire applied to employees from this specific office; elaboration of a relationship map for the study of a proper 17

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layout to approach the areas which have more technical aspects in common; recommendation of a new layout to help those activities; and, finally, through the analysis of the top relevant problems found in the survey, propose improvements in this environment.

4.1. Data Gathering A questionnaire has the objective of generating data to obtain information to check and analyze a specific subject. In this study, 12 questions related to 4 topics analyzed were asked. In table 2, the questions can be observed. They were distributed on the topics: Layout, Illumination, Thermal Comfort and Noise. In this table, the different possible answers are also shown.

Table 2 - Questionnaire used in the research Aspect

Question 1) Are you satisfied with the room´s layout?

LAYOUT

2) The concept of open environment – landscape office, and the interaction with other activities is adequate to your activity?

3) Are you satisfied with the room´s illumination?

ILUMINATION

4) Which kind of illumination is the best for doing your work?

5) Are you satisfied with the room´s temperature?

TERMIC COMFORT

6) If it were possible, would you change the type of the air conditioning equipment?

7) Do people talking, telephone ringing and other noises disturbs your concentration on work?

8) If we have isolated offices in this place, do you believe you would have a increase your performance in the work?

9) When someone is talkingto another one close to you, or yours’s colleague phone rings, can you keep your concentration on work?

NOISE

10) Does your work require much attention?

11) Do you care if the noise that you can procuce (talking, answering the phone) is disturbing your colleague?

12) Are you satisfied with the room´s acoustic isolation?

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Answers Yes No It doesn´t matter Yes No It doesn´t matter Yes No It doesn´t matter Natural Light Artificial Light Never Sometimes Most of the time Always Yes No It doesn´t matter Never Sometimes Most of the time Always Yes No It doesn´t matter Never Sometimes Most of the time Always Never Sometimes Most of the time Always Never Sometimes Most of the time Always Yes No It doesn´t matter

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The survey was applied to a total of 30 people from the office studied. From this number, 24 are male and 6 female. The survey was performed with at least 2 or more employees from each different activity area of the office.

In Figure 2, the percentage of satisfaction and dissatisfaction in relation to the four aspects analyzed is shown. It is possible to notice that, for this work environment, the greater level of dissatisfaction was related with the roomâ&#x20AC;&#x2122;s acoustic isolation: 86.7% of dissatisfaction. The second greater complaint, with 50% of disapproval, was related to the layout. The illumination, as seen in Figure 2, attends technical requirements, and workers are satisfied with it. Regarding thermal comfort, satisfaction levels are divided - 53.3% are satisfied. This fact happened due to body mass, which will influence directly the level of satisfaction concerning this theme. In other words, even if the temperature is within the pre-determined standard range, some people might feel it is too cold/warm.

Figure 2 - Satisfaction level concerning physical aspects in the office

According to results presented in Figure 2, physical aspects related with acoustic comfort and layout will be analyzed in detail, due to its greater percentage of dissatisfaction. In the graphic of surface, presented in Figure 3, results for the following questions can be observed: concentration, concept of open environment and preoccupation with the level of noise that may occur. Among the interviewees, 87.7% referred that lose concentration with telephone rings and conversations. This number is worrisome, knowing that tasks performed in this environment require a lot of concentration. Therefore, 66.7% of interviewees believe that if activities were isolated, their work performance would improve.

Despite these results, still analyzing the graphic of Figure 3, 63.3% defend the concept of open environment, due to their interaction with other activities in the same office. However, only 63.3% are worried about not disturbing co-workers with noise that comes from telephone talks and conversations with other colleagues.

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Figure 3 - Results of physical aspects analysis

In Figure 4, it is possible to have an overview of the office. Activities are separated by bays, being possible to have up to two activities in the same group of 8 bays. It is possible to notice through the material used for making the furniture, floor and ceiling, that they are not specific and proper for reducing the effects of noise. In this office, the possible sources for noise production are conversations and telephone rings, mainly. Although there are computers and printers, this equipment does not produce relevant acoustic discomfort.

Figure 4 - General view of the office.

Despite the fact physical aspects illumination and temperature did not present high levels of dissatisfaction, questions were asked according to personal preferences. For illumination, we asked if employees preferred natural or artificial light. As in Figure 5, 53% prefer the artificial light that had being used up to that moment. This preference occurs due to the necessity of constant illumination throughout the day, to perform their activities more effectively. The 47% that prefer natural light, and justified that they would 20

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feel more comfortable if the illumination could be from this source. Concerning the air conditioning, 64% prefer not to change the distribution and keep it “central” because the individual distribution, using a split or window, could lead to discussions on which would be the proper temperature to be set.

Figure 5 - Preferences concerning the kind of light and the air conditioning distribution in the office.

4.2 Relationship Map of activities The Preferential Interconnection Diagram or letter aims to help the construction of a layout and the identification of ideal proximity relations among several sectors of a company. For this reason, the letter and the map below were made aiming to identify relations of office activities, in a way that, by the end of the study, it would be possible to point which activities should be set apart or closer to each other.

The Figures 6 and 7 indicate, respectively, the letter and the Relationship Map of the office. It is possible to notice that some activities are extremely important in terms of relations, while others are not connected.

Activities related to “planning” and “management” are connected to all other activities, so the concept “important” or “very important” was given to them. Consequently, these two activities must be centralized in the office layout in order to help as much as possible other activities.

Figure 6 - Preferential Interconnection Diagram

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Figure 7 - Relationship Map of the office

4.3. Current layout and proposal of a new layout The office area under analysis corresponds to approximately 250 m2 (23,75 m x 10,50 m). As presented in the pictures of the workplace, Figure 4, this office uses the concept landscape, with divisions of work posts limited by low partitions. In Figure 8, the simplified ground plant of the current layout can be observed. In this design, some work posts are found crosshatched. These work posts are not currently used.

Figure 9 presents the same layout, indicating activities distributed in this environment.

It is possible to identify that, according to the map and the relationship letter shown on Figure 6 and 7, the “management” and “planning” activities are not positioned in a central position, due to the fact that these activities interact more often with others.

Figure 8 - Current office’s layout

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Figure 9 - Current office’s layout with “activities”

In this article, a new layout will be suggested based on the concepts presented and on the necessary changes for a better work flow and interaction among activities. As shown in the survey, interactions have a degree of relevance, so the concept of landscape will be preserved. However, on the next topic, some suggestions of improvement in the acoustic treatment will be offered.

The suggestion of a new layout is shown on Figure 10. Some bays that were not used will be removed and a new layout for 40 workers was proposed, including two “meeting rooms” that will help, in an indirect way, the noise reduction from conversation. The new “meeting rooms” will allow the debate of work issues in an adequate place.

In addition, the management and the planning area will be moved to the central area, due to the fact that these two activities require more interaction with others. Another relevant aspect related to the activity of “planning” is that it also includes the activity of “reception”, hence, the new layout will position this activity in a better place: next to the front door, allowing an easier identification by visitors. Figure 11 shows the suggestion to the new distribution of 8 activities in the new layout.

Figure 10 - Proposal for the new layout for the office

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Figure 11 - New display for activities in the new proposed layout

4.4. Suggestion for improving acoustic isolation According to answers obtained from the questionnaire filled by employees, aspects concerning illumination and thermal comfort will not be changed, due to the fact that most of them were satisfied. Based on results presented on Figure 2 that indicates the level of satisfaction and dissatisfaction of the main physical aspects of the office, the main cause of dissatisfaction is related to the lack of acoustic treatment because this fact causes loss of concentration in activities during the work. Therefore, this topic demands to be improved. The most appropriate is to measure the noise in this environment before and after changes, to check and compare benefits achieved with the acoustic treatment.

According to Passero e Zannin (2009) the acoustic of panoramic offices can be improved technically by three main factors: · Abortion of the room, which reduces reverberation and recent reflexes; · Barriers that control the direct sound; · Artificial sound masking, which promotes a uniform sound environment in panoramic offices.

The options for performing an acoustic treatment in this office are: · Spatial organization by group of workers related to their activities. Among those groups there must be a space of a corridor so that there is more distance between groups and sound sources, making them independent, so that the noise of one group do not disturb others. · Coating of partitions by applying an absorbent material, which reduces direct sounds, since the height is 1.20 m and it represents the average height of a person sitting; · Increase of the acoustic absorption of the environment.

The first item has already been taken into consideration in the design of the suggested layout. The second item is relevant, since nowadays the partitions used do not have any kind of coating with absorbent material, contributing to reduce sound.

The first item has already been taken into consideration in the suggested design. The second is relevant, since nowadays partitions used do not have coating with absorbent material, contributing to spread the sound. The third item is extremely relevant, since the office has cold floor and ceiling with plasterboards, without any kind of isolating material. On the floor, it is suggested to use carpets or treads with rough surface, to minimize the spread of sound. On the ceiling, materials listed on Table 3 must be used, according to Passero e Zannin (2009). For a better absorption of noise, walls should also have absorbent material.

These same authors proved that, with a simple acoustic project, it is possible to reduce the level of sound pressure in approximately 5 dB, with the use of acoustic material on the ceiling and part of the walls.

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Table 3 - Material that are indicated to promote the sound absortion (Passero e Zannin, 2009)

Figure 12 - Suggestion for the place to set the acoustit absorbent material. (Passero e Zannin, 2009 â&#x20AC;&#x201C; adaptado)

5. CONCLUSION This article showed, through a case study, the importance of using engineering methods, especially in the design of a work environment, in order to increase the efficiency, performance and productivity of work, and reduce distractions that can take away the concentration and also reduce the quality of work in the work place. Through the results of a questionnaire, answered by the employees and, after analyzed, it was possible to identify the dissatisfaction concerning the acoustic aspect. Therefore, a Relationship Letter and a map were made to help suggesting a new layout. Furthermore, a new design for the work environment was suggested.

In the end, suggestions for the improvement of the acoustic treatment were presented, recommending specific material to minimize the effect of noise produced by conversation and telephone rings. However, 25

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the sound level in landscape offices usually range from 55 to 65 dB (A), and it is not in accordance to the NBR 10152 recommendation, which indicates the level from 35 to 45 dB(A), for office environments.

Nonetheless, the use of the landscape is being increasingly used because it helps interaction among people that perform interrelated activities, saving time and improving productivity. Thus, it is important to emphasize the necessity of a sense of awareness, especially by the managers, to inform the employees about the importance of new working habits, aiming to reduce unnecessary conversations at the workplace.

REFERENCES

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1.

Anton, Charles Ivan; Eidelwein, Heloísa; DIEDRICH, Hélio. Proposta de melhoria no layout da produção de uma empresa do Vale do Taquari. Revista Destaques Acadêmicos, Porto Alegre, v. 4, n. 1, p.129-148, jan. 2012. Disponível em: <http://www.univates.br/revistas/index.php/destaques/article/viewFile/287/230>. Acesso em: 05 abr.

2016.

2.

Associação Brasileira de Normas Técnicas. NBR 5413: Iluminânica de Interiores. Rio de Janeiro: ABNT, 1992. 13 p.

3.

Associação Brasileira de Normas Técnicas. NBR 10152: Níveis de ruído para conforto acústico. Rio de Janeiro: ABNT, 1987. 4 p.

4.

Associação Brasileira de Normas Técnicas. NBR 12179: Tratamento acústico em recintos fechados. Rio de Janeiro: ABNT, 1992. 9 p.

5.

Augusto Junior, Antonio Travassos et al. LAYOUT: A Importância de escolher o Layout ideal devido à exigência no mercado competitivo. In: ENCONTRO UNISALESIANO, 2., 2009, Lins. II Encontro Científico. Lins: Unisalesiano, 2009. p. 1 - 12. Disponível em: <http://www.unisalesiano.edu.br/encontro2009/trabalho/aceitos/ CC28207504862.pdf>. Acesso em: 12 abr. 2016.

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Gonçalves, Cláudia Giglio de Oliveira et al. Ambiente de trabalho e a saúde do trabalhador: uma proposta do controle de ruído. Interfachs: Revista de Gestão Integrada em Saúde do Trabalho e Meio Ambiente, São Paulo, v. 2, n.

3, p.1-19, ago. 2008. Disponível em: <http://www.interfacehs.sp.senac.br/br/artigos.asp?ed=8&cod_artigo=143>.

Acesso em: 12 abr. 2016.

7.

Guerrini, Délio Pereira. Iluminação: Teoria e Projeto. 2. ed. São Paulo: Érica, 2008. 134 p.

8.

Kliemann, André Hein et al. Guia de referência para layout em escritório envolvendo aspectos ergonômicos. In: ENEGEP, XVIII, 1998, Niterói. Encontro Nacional de Engenharia de Produção. Niterói: ADEPRO, 1998. p. 1 - 8.

Disponível em: <http://abepro.org.br/biblioteca/ENEGEP1998_ART346.pdf>. Acesso em: 05 abr. 2016.

9.

Luizetto, Luciano E. F. Conforto térmico em ambientes de escritório. 2014. 69 f. Monografia (Especialização) Curso de MBA em Gerenciamento de Facilidades, Escola Politécnica, Universidade de São Paulo, São Paulo, 2014. Disponível em: <http://poli-integra.poli.usp.br/library/pdfs/39e10afeb57382ae3333cabcb204c9fb.pdf>.

Acesso em: 10 abr. 2016.

10.

Niebel, Benjamin W.; Freivalds, Andris. Ingeniería Industrial: Métodos, estándar es y diseño del tr abajo. 12. ed. Mexico: Mcgrawhill, 2009. 614 p.

11.

Normas Regulamentadoras. Legislação Complementar. Segurança e Medicina do Trabalho. 59. ed. São Paulo: Atlas, 2006. 672 p. (NR 17)

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Passero, Carolina Reich Marcon; Zannin, Paulo Henrique Trombetta. O conforto acústico em escritórios panorâmicos: estudo de caso em um escritório real. Ambiente Construído, Revista On-line, v. 9, n. 1, p.93-105, 20 fev.

2009. Disponível em: <http://www.seer.ufrgs.br/ambienteconstruido/article/view/6764>. Acesso em: 10 maio 2016.

13.

Silva, Mônica Gomes da; Moreira, Bruna Brandão. APLICAÇÃO DA METODOLOGIA SLP NA REFORMULAÇÃO DO LAYOUT DE UMA MICRO EMPRESA DO SETOR MOVELEIRO. In: ENEGEP, 29, 2009, Salvador. Encontro Nacional de Engenharia de Produção. São Paulo: ADEPRO, 2009. p. 1 - 12. Disponível em: <http:// www.abepro.org.br/biblioteca/enegep2009_tn_stp_091_618_13943.pdf>. Acesso em: 10 abr. 2016.

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Souza, Léa Cristina Lucas de; Almeida, Manuela Guedes de; Bragança, Luís. Bê-a-bá da acústica arquitetônica: ouvindo a arquitetura. São Carlos: Edufscar, 2006. 149 p.

Coelho et al.

Lean Thinking to Improving Access to Cancer Patients in a Public General Hospital S.M.A. Coelho1, C.F. Pinto2, M.B. Silva3 1,2

School of Engineering of Guaratinguetá (FEG-UNESP) Guaratinguetá, SP, Brazil; 3School of Engineering of Lorena (EEL-USP) Lorena, SP, Brazil.

Abstract

Unbalanced treatment scheduling and over-crowding is a common problem for cancer centers in Brazil, with huge access restrictions due to system inefficiencies and poor assistance design. The purpose of this report is to show how lean thinking can be applied to healthcare by using lean methods and production leveling. The case study/report presented was adopted in order to describe the approach, techniques and findings of this project, as part of a lean initiative. Lean Value Stream Mapping tools and leveling tools improved the unit performance by increasing unit capacity freeing treatment slots by leveling and decreasing waiting time for cancer treatment. The process redesign also eliminated unnecessary movement and overtime.

Keywords: Lean Manufactur ing, Pr oduction Contr ol, Queues.

1. INTRODUCTION Lean management principles have been used effectively in manufacturing companies for decades, particularly in Japan. The Institute for Healthcare Improvement (IHI) believes that lean principles can be successfully applied to the delivery of health care. Even though health care differs in many ways from manufacturing, there are also similarities: whether building a car or providing health care for a patient, workers must rely on multiple and complex processes to accomplish their tasks and provide value to the customer or patient. Waste of money, time or supplies always decreases value.

According to Soares (2012), the Brazilian government faces serious difficulties in promoting health services to the population. One of the main difficulties is related to the lack of ability of the public sector to provide care, which is related to the gap between the constitutional responsibility and budget availability, since it is not sufficiently resourced to support a universal system, conceived in a context of democratization along with political crisis.

Lean thinking in healthcare proposes creation of value and better quality services for the patient and the society. The elimination of non-value added activities along with all other types of waste helps to establish a flow value for the patient, increasing operation efficiency, while improving quality of care (Womack, 2003).

According to Womack and Jones (2003), Silberstein (2006), initiatives to implement the Lean philosophy in medical services and healthcare are just beginning.

The provision of health services presents many sources of inefficiency and quality issues that are a real challenge for managers of the area (ARAUJO, 2005).

The study involved the use of lean thinking for the removal of waste and queue management at an oncology clinic of a public hospital in the city of Taubate, São Paulo, Brazil. The Unit of Clinical Oncology, Hospital Regional do Vale do Paraíba (HRVP) faces queues in all process of treatment. Our aim was to eliminate waste associated with disconnected information flow between sectors, to improve occupation of treatment slots and waiting time for first access in cancer treatment.

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2. LITERATURE REVIEW Lean Thinking is being widely used in UK National Health Services (NHS) (Yousri, 2011) and in several other organizations around the world to improve patient care, safety, access and timelines. There is no common sense for a definition of lean production (Howleg 2007).

Academic books and articles still struggle to define clear measures for lean production (Shan 2007); one well established and popular tool, Value Stream Mapping (VSM) as proposed by Shook and Rother (1999) is used to identify and analyze, as well as suggests solutions to production problems.

2.1 Value Stream Mapping

The value stream mapping consists in identifying “all the value-added and non-value-added actions required to bring a specific product, service, or a combination of both to the customer; including those in the overall supply chain as well as those in internal operations” (Womack, 1990).

The value stream map enables the organization to understand the current process, identify nonadded-value steps and provide a vision of gains and benefits associated with waste removal. The VSM is basically a PDCA cycle (Plan-Do-Check-Act) involving the following simplified steps: identify the value stream (current state); problem (look into) analysis; value proposition (future state); action plan (value delivery); and sustainability (action). For problem analysis, we used common lean and quality tools: Pareto Analysis; Cause-Effect Diagrams; Affinity Diagrams; Five Whys; and Spaghetti Diagram (Pinto 2010).

2.

Leveling production

In the Brazilian healthcare system, unbalanced production creates a capacity problem: most units are overcrowded and do not provide coordinated care, with several disconnections through the process. Production leveling, also known as “heijunka” is one fundamental component of the Toyota Production System (Bohnen, 2011). We used Value Stream Mapping (VSM) tool as proposed by Shook and Rother (1999) to identify and analyze problems and smooth our daily production agenda, aiming to reduce or eliminate wastes such as waiting, movement, rework, delays.

2.1.2 Kanban Kanban is defined as a mechanism that communicate the time to replenish or produce exactly what is being requested and the amount due, enabling the production flow is pulled (Junior et al., 2008; Slack, 2008).

The principal reasons to choose Kanban System instead of computerized system are (Y. Sugimori et al, 2007).

- Reduction of cost processing information. It calls for huge cost to implement a system that provides production schedule to all the processes and suppliers; - Rapid and precise acquisition off acts; - Limiting surplus capacity of preceding shops.

METHODOLOGICAL PROCEDURES This is an action research study, in which we identified a problem, applied problem analysis tools and defined a value proposal, as stated by Shook et al (1999). In this part of the article, we will present the local case study and service procedures.

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Coelho et al.

Scenario The Hospital Regional do Vale do Paraiba (HRVP) is a public general hospital in Taubaté, São Paulo State, Brazil, that covers cancer treatment for a population of 1 million inhabitants from more than 40 cities. The hospital is 100% public and 2/3 of our patients need government assistance to travel and get access to HRVP. Most of them travel from 1 to 2 hours to get to the hospital or its resources. Waiting time to access is reasonable (2 weeks on average), but other resources like mammograms, biopsies, CT scans and surgery require longer queues. The hospital is responsible for complex care, providing resources for cancer center, general surgery, head and neck, cardiovascular and neurosurgery, renal and hypertension centers.

Major Problems The disease staging at the treatment start is one of the most important factors that determine patient prognosis.Thus, delays in diagnosis or treatment allows tumor growth resulting in lower chances of cure for patients.

Our aim was to improve treatment access by shortening waiting time for surgery and/or chemotherapy/radiation therapy for cancer patients in 50%. The average of waiting time for surgery was 90 days including 5 to 7 visits to the HRVP (Figure 1, three months median waiting time for access). On average, access to an oncologist was achieved 114 days after initial registration.

Actions We receive about 250 new breast cancer patients’ yearly or 20 new patients monthly. This study represents the pilot project involving breast cancer patients. We developed a multi professional team involving the patient care coordinator, nurse managers and quality managers from the hospital and the cancer center, medical oncologists, breast surgeons, and radio- oncologists. This project was elaborated to focus the needs of patients, leaving requirements of the various departments involved in the background.

The challenge was to make these professionals see and draw how would be an ideal process of caring for these patients. With this vision and the collaboration of these professionals, we proposed a new flow, ensuring that no one would have workload with the new changes.

We used the value stream mapping (VSM) to design our current state (Shook, J. Rother, M. Aprendendo a Enxergar, 2ª edição, LIB, São Paulo, 2010) to identify the current state, perform problem analysis and propose a future state with a plan to implement and sustain these improvements (a complete PDSA cycle).

Figure 1 - Current state: timeline for breast cancer treatment access

The future state was to develop a “FAST TRACK” for newly diagnosed or “highly suspected” breast cancer patients. The track was designed to accomplish 4-7 weeks of activities in one single day by coordinating care and patient and processes flow.

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Redesign schedules of medical care and examinations 2a. The patient care was concentrated in a single day and in one place, changing the times and days of appointments with the experts involved (breast cancer specialist, oncologist, anesthetist and radiation oncologist). The new patients with breast cancer started to have appointments only on Mondays in a dedicated flow. They also had dedicated flow for mammograms, ultrasound, radiological examinations of chest CT scans (for patients with advanced disease), ECGs and laboratory tests according to each bundle of standardized tests and procedures.

Figure 2 - Future State: â&#x20AC;&#x153;FAST TRACKâ&#x20AC;? for breast cancer patients

In this study, we applied three basic interventions: - Establish standard procedures for each type of patient (each new flow); - Redesign schedules of medical care and examinations; - Establish service agreements between the various actors in the process.

Establish standard procedures for each type of patient (each new flow) 1a. We created a "service flowchart" to direct the flow. It is called "Care Patch Kanban" and follows the patient during the day, as a document easily accessed by all involved in the process. It is checked at every stage, ensuring that all requirements of each step have been fulfilled.

1b. 2 flows were defined: the first one for patients without diagnosis but with highly suspected cancer (clinical or imaging exam). The aim of this flow was to perform a biopsy on the same day and plan the definitive surgical treatment within 21 days, in order to finish the day with a biopsy. The second flow for patients already diagnosed with cancer. These patients should plan surgery or in advanced cases, start neoadjuvant or palliative treatment.

1c. Exam bundles were defined for each of the flows that would be performed in accordance with the 30

Coelho et al.

predicted sequence for each flow.

Establish service agreements between the various actors in the process 3a. Agreement 1: “4 open slots on Mondays, every Monday(s).”. For the image center (mammograms); lab center (EKG, labs); Anesthesiologist and breast surgeon appointments.

3b. Agreement 2: “2 open slots on Mondays, every Monday(s)”. For breast biopsies, pathologists and medical oncologists.

3c. Agreement 3: “1 attendant trainee for flow improvement”. To guide patients throughout their daylong journey.

3d. Agreement 4: “lunch and rest will be provided for all patients by IOV social services”.

Figure 3 - Care-path 1st day Kanban

4. RESULTS Between 09/01/2014 to 04/30/2015 120 patients were included with the following results: The average waiting time for surgery which was about 90 days. Now it is 35 days, which represents an outcome 61% better. The average time to start chemotherapy was 114 days. Now it is 56 days, an improvement of 50%. Our next challenge is to develop “FAST TRACKS” to breast, head and neck, colorectal and prostate cancer, covering 85% of our expected cancer patients demand.

A significant reduction in the waiting time for treatment not only ensured a faster treatment but also dramatically reduced the number of hospital visits, eliminating between 5-7 visits (for starting the process) 31

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to begin chemotherapy. This performance not only improves the quality of service but also reduces the physical and emotional distress of patients, and eliminates waste in the value chain as dozens of hours of waiting, unnecessary travel, excessive movement within the hospital and disconnection of the information in care processes.

5. CONCLUSION Patients who were diagnosed with cancer treated in public service suffer significant delays at various stages of their diagnoses and cancer treatment. Reducing access to initial treatment seems to be the most common strategy, but it is imperative to have a system with means and organization to act on the abnormalities on the flow.

Lean tools enable to improve healthcare flow without adding cost to the process. The project was capable of significantly reducing waste in processes (handling, overprocessing, defects, waiting, transport) without increasing the workload for stakeholders.

REFERENCES

32

1.

Araujo, C. A. S. (2005) Fatores a serem gerenciados para o alcance da qualidade para os clientes internos: um estudo em um conjunto de hospitais brasileiros. Rio de Janeiro: UFRJ/COPPEAD. Tese de Doutorado em Administração,.

Disponível em: <http://www.dominiopublico.gov.br/pesquisa/DetalheObraF orm.do? select_action=&co_obra=105686>. Acesso em 12 de setembro de 2012.

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Bohnen F, Maschek T, Deuse J. (2011). Leveling of low volume and high mix production based on a Group Technology Approach. Journal of Manufacturing Science and Technology 4 247–251.

3.

Holden, RJ (2011). Lean Thinking in Emergency Departments: A Critical Review Annals of Emergency Medicine 57(3)

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Holweg M. (2007) The genealogy of lean production. Journal of Operations Management 25 420–437.

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Mazzocato P, Savage C, Brommels H, et al. (2010) Lean thinking in healthcare: a realist review of the literature.

Qual Saf Health Care. doi:10.1136/qshc.2009.037986.

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Junior et al., 2008; Slack, 2008. Indepent Jounal of Management & Production (IJM&P). Acesso em http:// www.ijmp.jor.br v. 5, n. 11, august 2015. ISSN: 2236-269X. DOI: 10.14807/ijmp.v5i4.245

7.

Pinto C, (2010) “Improving Wait Times at a Medical Oncology Unit” in J. Aherne & J. Whelton, editors, “Applying Lean in Healthcare”, Productivity Press, NY.

8.

Shook J and Rother M, (1999) “Learning to See”, Lean Enterprise Institute, Boston.

9.

Silberstein, A. C. L. (2006) Um estudo de casos sobre a aplicação de princípios enxutos em serviços de saúde no Brasil. Dissertação (mestrado) – UFRJ/ COPPEAD/ Programa de Pós-graduação em Administração.

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Soares, A. Empréstimos externos para o setor saúde no Brasil: soluções ou problemas. Saúde e Sociedade.

São Paulo, 2012.

Avaliable at: <http://www.scielo.br/scielo.php?pid=S01012902009000600 012&script=sci_arttext>. Accessed25/aug/2012.

11.

Spears, S (2005) Fixing Health Care from the Inside, Today. Harvard Business Review Sept.

12.

Womack JP, Byrne AP, Fiume OJ (2005). Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement.

13.

Womack, JP, Jones DT, and Roos D (1990). The Machine That Changed the World. Free Press, New York.

14.

Womack, JP, Jones, DT (2003). Lean Thinking, revised ed. Free Press, New York.

15.

Y. Sugimori a , K. Kusunoki a , F. Cho a & S. Uchikawa (2007). Production Control Department , Toyota Motor Co., Ltd , 1 Toyota-cho, Toyota-shi, 47, Japan. International Journal of Production Research. Acesso em http:// www.tandfonline.com/doi/abs/10.1080/002075477089 43149, 11, august 2015.

16.

Young T and McClean S. (2008) A critical look at Lean Thinking in healthcare. Qual Saf Health Care 17: 382386.

17.

Yousri TA, Khan Z, Chakrabarti D, Fernandes R, Wahab R (2011) Lean thinking: Can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury, Int. J. Care Injured 42: 1234–1237.

Colombrini et al.

Development of a successful model to sustain quality after a health surveillance project M.R.C. Colombrini1; C.S. Tozzi1; R.F.R. Silva1; S.M.Q. Costa1; R. Higa1; C.R.G. Machado1; M.R. Guimaraes1; M.D.S.B. Rodrigues1; P.M. Silva1; A.S. Iaderozza1; V.S. Ito2; G.S. Spagnol3

1

Hospital of Clinics, University of Campinas. email: hospdia@hc.unicamp.br; 2Secretaria Municipal de Saúde de Campinas; 3Faculdade de Ciências Médicas da UNICAMP e Grupo de Inovação e Gestão na Saúde (GIGS-CNPq).

Abstract

Introduction: the Health Surveillance Project (VISA Project) began in May, 2006, developed by nurses from the Day Hospital (DH) at the Hospital of Clinics (HC), University of Campinas (UNICAMP) after a series of inspections performed by the Health Surveillance Agency (VISA-Norte) at the Hospital of Clinics. These inspections pointed nonconformities in order to promote improvements towards a higher service quality. From that time to the present day, our team has improved work processes related to hygiene, infrastructure and care processes. Thus, we seek to sustain quality in health care, incorporating new technologies, learning and technical enhancements. For this reason, we developed a specific worksheet based on the criteria of VISA for the Day Hospital. Materials and Methods: nurses, nurse technicians and administrative staff, together with the advisor of the Department of Nursing / HC (DENF) conducted this study in the Day Hospital (HC/UNICAMP), a unit aimed to allow deinstitutionalization of patients. The worksheet was implemented in the DH in December, 2011. Between 2011 and 2016, we conducted 13 surveys. Results were registered and analysed in Excel®. Events of non-compliance were categorized into themes: "Nursing / Processes", "Structure" and "Cleaning". Results: formal requests were sent to the Division of Engineering in order to perform and monitor corrections in the infrastructure. There was in-service training and follow-up for cleaning teams, nursing and administrative staff. Runtime: 3-4 hours / quarter / survey. The first survey in 2011 had 821 items and the last (in 2016), 1479. The median percentages of approval were: 88.2% for "Nursing / Process", 91.6% for "Structure" and 79.7% to "Cleaning", with a total average of 82.2%. Discussion: The literature proposes to conceptualize as "great" when approval is between 90-100% of the items; "Good" between 70-89%; "Regular" between 50-69% and "Bad" when less than 49% [2]. We applied the management tool Plan-Do-Study-Act progressively, continuous and in spiral [3]. Conclusion: data shows that the inspection process has guaranteed a continuous improment of the area and processes, keeping them within the concept of "good" and "great". Respect between professionals was essential, and DENF was a facilitator for the development of indicators. The Division of General Services / HC (responsible for outsourced cleaning contract) and the Division of Engineering / HC have been partners in the correct execution of cleaning and preservation of public property.

Keywords: Service quality, health surveillance, improvement, team, health services.

1.

INTRODUCTION

The nurses from the Day Hospital (HD) of the Hospital das Clinicas (HC-UNICAMP) started the Health Surveillance Project (VISA Project) in May 2006, when a series of surveys conducted at the Hospital of Clinics by the Health Surveillance Region North / Campinas (VISA-North) pointed numerous noncompliances regarding good health practices. At that time, the services had to adapt and seek to correct the distortions in work processes related to hygiene, building structure and care processes.

It is noteworthy that VISA offers an external look at the conditions of service in the health unit and contributes to improvements. It is one of the executive arms that structures and operationalizes the SUS in the pursuit of achieving the social right to health, through its main function to eliminate or minimize the health risk involved in the production, circulation and consumption of certain products, processes and services. Briefly, VISA has an important role in the structuring of the SUS, mainly due to: 33

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Rules and actions on services, products and therapeutic inputs of interest for health;  Ongoing evaluation of the need for risk prevention;  Possibility of constant interaction with society in terms of health promotion, ethics and citizenship rights (1).

In 2006, the Director of Medical Surgical Nursing Service II was a member of the Multidisciplinary Commission (026/2006/HC/UNICAMP) who designed an educational program to encourage the community to improve the issues appointed by VISA and to become knowledge multipliers. this program, lectures were held in workshops with dissemination of texts and guidance booklets. Between 2006 and 2008, our team participated in the development, implementation, and analysis of the VISA survey spreadsheet developed to control the cleaning items, work processes and maintenance of infrastructure. Among the eleven members of the team responsible for this work, six were employees from the Day Hospital.

In 2008, the Day Hospital service, which was provided in the 6th floor of the Hospital of Clinics, moved to separate building. The nursing staff sustained the methodologies and work processes that had brought good results in LD in order to learn from experience and develop and/or improve other techniques and methods. It is known that learning and the incorporation of soft-hard technologies do not happen quickly in services with crops already defined, as is the case of public service. Thus, our team has developed a spreadsheet to the Day Hospital with the criteria of VISA, named as the "VISA Spreadsheet Application " (Table 1). 

Table 1 - Example of the evaluated items in one of the areas of the Day Hospital, using VISA worksheet developed for the DH between 2011 and 2016. Campinas, 2016.

AUDITORIA VISA Data: Legenda S (Sim); N (Não); SR (Sem resposta) Área Branca Acolhimento A porta está limpa?

A maçaneta está funcionante?

A maçaneta está limpa?

O piso está limpo?

Os vidros estão limpos?

As paredes estão limpas?

A iluminação está funcionante?

A iluminação está limpa?

O balcão está limpo?

A mesa com preservativo está limpa?

A mesa com preservativo está funcionante?

A mesa de prontuários está limpa?

A mesa de prontuários está funcionante?

As gavetas estão limpas?

As gavetas estão organizadas?

As gavetas estão funcionantes?

O computador está funcionante?

O computador está limpo?

A impressora está limpa?

A impressora está funcionante?

O telefone está limpo?

O telefone está funcionante?

A lixeira de copos está limpa?

Os dispensadores de álcool (espera e entre consultórios) gel estão limpos?

Os dispensadores de álcool (espera e entre consultórios) gel estão funcionantes?

A caixa da ouvidoria está limpa?

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2. METHODS This study was performed at the Day Hospital, a unit aimed to deinstitutionalize patients. The average of daily attendance achieves 30 patients in the program for HIV/AIDS. In January 2013, the Day Hospital expanded its activities to the average attendance of 25 outpatients treated for infectious diseases. In August 2014, the HD began to serve patients from other medical specialties for outpatient parenteral antimicrobial therapy.

The executors of the "VISA Project" were: nurses, nursing technicians and administrative HD technician, together with the assistant of the Department of Nursing / HC (DENF).

The expertise of the nursing staff was essential to build the HD VISA sheet between 2009 and 2011, with initial implementation in December 2011. Thus, eight steps were used, as follows:  Step 1. The team separated the Day Hospital areas: white (reception); Purple (healthcare assistance area); Green (administrative area, changing rooms, kitchens).  Step 2. We listed the VISA items in each place during survey visits, categorizing them in items in the following axes: 1. CLEANING: the place and furniture; 2. STRUCTURE: maintenance and operation of equipment, furniture and physical structure; 3. NURSING / PROCESS: control of supplies and medicine validity, following the established care processes contained in the Day Hospital Process Manual.  Step 3. Questions set for each item could be answered as "yes" or "no". Example: Is the door clean?

If the door is clean, one may reply “yes”. If it is dirty, “no” is the answer.  Step 4. All participants (nurses, nurse assistants and administrative staff) were instructed and trained to carry out the survey distinguishing between "yes" and "no".  Step 5. In December 2011, it was defined that the sheet would be applied three times a year, suiting the survey conditions with the area routine, the availability and involvement of nursing professionals.  Step 6. Results were tabulated and analyzed in Excell®.  Step 7. According to non-compliance events, orders of services were requested to the Division of Engineering (Hospital of Clinics), as well as training or guidance were provided to cleaning and nursing teams.  Step 8. We followed up the implementation of the requested services, the proper execution of care processes and hygiene and cleanliness.

Runtime: 3-4 hours / trimester / survey.

3. RESULTS Data show the work of HD nursing team with the assistant of DENF / HC in the last five years, demonstrating how it is essential to integrate the frontline staff and managers to enhance results and to incorporate views that complete themselves to a qualified performance.

Table 1 shows the evolution of the evaluated items, with 821 items in the first survey of 2011 and 1447 items in 2016, distributed in "Nursing/Processes", "Structure" and "Cleaning".

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Table 2 - Total number of inspections carried out between 2011 and 2016, with the evolution of the total of items by analysis axis: "Nursing / Process", "Structure", "Cleanliness" Campinas, 2016.

ITENS AVALIADOS dez/11 abr/12 jul/12 set/12 mar/13 jul/13 nov/13 fev/14 ago/14 nov/14 jun/15 out/15 mar/16

ENFERMAGEM

ESTRUTURA

LIMPEZA

TOTAL

145 241 240 251 253 222 222 216 211 212 213 216 213

155 308 312 346 344 327 325 333 325 328 330 312 322

521 901 915 963 1043 950 915 985 963 976 936 911 912

821 1450 1467 1560 1640 1499 1462 1534 1499 1516 1479 1439 1447

Charts 1 and 2 show the evolution of approval with the median of 88.2% for "Nursing / Process", 91.6% for "Structure" and 79.7% for "cleaning". According to previous studies, above 70% it is considered as "Good" (2). These data indicate that there is variation, but when the inspection process is carried out continuously, it provides permanent assessment regarding the needs of each area.

Graph 1 - Total items approved in the surveys from 2011 to 2016 and the percentage of approval Campinas, 2016.

Graph 2 - Percentage of approval. Campinas, 2016.

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Colombrini et al.

The systematic and periodical application of this assessment process allowed the nursing staff to continuously evaluate the HD. This reiterates the essentiality of ensuring processes and agreed routines, whereas those axes account for assistance space organization, proper conservation of inputs (materials and medicines), maintenance of assistance and administrative equipment, with operation analysis and cleaning. Partnerships have been established with the Division of General Services (responsible for the contract with the cleaning company) ensuring that perpetrators of this service were driven continuously and directed to the correct maintenance and hygiene, along with the collaboration of the Division of Engineering, that adopted preventive measures to preserve public property and avoid damages. In 2011, VISA-North assessed the Day Hospital and issued a report as "Satisfactory with restrictions", and the most significant trends for correction were processes developed in Hospital of Clinics that resulted in non-compliance in the DH. These outcomes demonstrate in a very concrete way that the HD nursing staff is committed to the requirements for good health practices defined by the HC, the Ministry of Health and the VISA-North.

Image 1 - A report to the Hospital Day nursing and cleaning staff professionals. Campinas, 2016.

After this evaluation two main actions were developed, the team prepared a spreadsheet with the 5W2H tool (4) (Table 3) to organize the monitoring of actions and corrections processes.

37

38

Posto de Enfermagem: 1. Frasco com substância química (Formol) sem identificação de acordo com os padrões de qualidade, identidade e segurança

Sala de procedimentos com: 1. Suporte de soro com ferrugem 2. Biombo com áreas de ferrugem 3. Ausência de tela milimétrica na janela

Responsável pelo envasamento no HC Equipe de Enfermagem /

Enfª Rosa (Responsável pelo HD), Técnico Administração. e/ou Eq. Enferm.

HD

Conscientizar sobre nosso papel de cuidar e zelar pela segurança do nosso usuário.

Viabilizar uma prática segura de assistência.

Impedir que substâncias sejam trocadas no momento de utilização.

Garantir a segurança do paciente, equipe e instituição.

Impedir a entrada de insetos e outros animais.

Manter condições adequadas de boas práticas de saúde.

Ou/Nov/11

OS 2070/2009 para medição e instalação de tela (doc.

Anexo).

Nova OS: nº 9924/11 em 21/11/11

OS 7707/11 em 28/11/11 para o suporte e biombo.

Unidade: Hospital Dia AÇÃO: Melhorias de processos relacionados à Vistoria da Vigilância Sanitária no HD em 18/11/11 QUANDO (WHEN) PARA QUE QUEM O QUE (WHY) (WHO) (WHAT) Dez/11 Prof. Dr Rogério Para se ter o cadastro Ausência de inscrição do preconizado pela Responsável Técnico no legislação vigente Conselho de Classe

HD / HC

HD/Engª/HC

DRS

ONDE (WHERE)

Data: 02/12/2011 QUANTO CUSTA COMO (HOW MUCH) (HOW) Prof. Dr Rogério, menciona que fez a Valor da inscrição (?) entrega da documentação necessária para a Coordenadoria de Assistência / HC que regulariza anualmente os documentos A Divisão de Engenharia e Manutenção Encaminhar OS para DEM (dois suportes de soro e um biombo com a (DEM) mediu por duas vezes essas pintura um pouco descascada, mas áreas, mas o sem presença de ferrugem). custo de Medir as janelas e grelhas de todo o instalação não ficou viável.

HD. Verificar custo da instalação.

Instalar as telas.

Tempo dos Foi enviado um email para o DENF em 06/10/11 com o fluxo existente profissionais, equipamentos (documento anexo) para possíveis correções. Recebemos a informação necessários para que o processo pelo DENF (novembro/11) de que seja feito de esse processo de envasamento, forma correta. identificação, distribuição será revisado para todo o HC junto à Enfª Rosemary da Assessoria da Superintendência do HC.

Quadro 3. Planilha de 5W2H de novembro/2011 para monitorar o desenvolvimento das correções das não conformidades. Campinas, 2016.

PLANO DE AÇÃO - 5W2H

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Colombrini et al.

4. DISCUSSION The data in this study show the dynamism and variation of the number of items evaluated between the first and the last survey, with an increase of 626 items. The literature proposes to conceptualize as "great" when the approval is between 90-100% of the items; "Good" between 70-89%; "Regular" between 50-69% and "Bad" when less than 49% (2). This study shows that the inspection process has guaranteed a permanent evaluation of each area and processes, sustaining the concept "good" and "great".

Methods applied in this project can be replicated in all health facilities in a university hospital, especially in the University of Campinas, such as the Hospital of Clinics, the CAISM (Center of Integral Attention to Women's Health), CECOM (Community Health Center), Gastrocentro, HEMOCENTRO, and expanded for nurseries, laboratories, pharmacies, health centers, restaurants, clinics, and restaurants. The scope and capacity of this project includes all facilities under the responsibility of the Health Surveillance in Campinas and also other sectors, such as heritage preservation and ongoing review processes.

The participation of DH nursing staff has been decisive to enable the use of management tools, as the PlanDo-Study-Act (PDSA), in a progressive, continuous and ascending way (spiral) (3), where: a. Plan: Planning the day (s) of the survey with DH nursing team, according to the routine; b. Do: Making the axle inspection (cleaning, structure, procedures) in a specific worksheet c. Study: Studying and acting towards improvement through development of training in service, request for services from other areas and performing activities in the standard, in accordance to guidelines from Hospital of Clinics regarding healthcare assistance and safe management practices. d. Act: Evaluating results and applying actions for continuous improvement processes.

This study also shows that this assessment prevented permanent damage to the building structure, due to preventive maintenance. Regarding cleaning, we affirm that the environment in health services has been the focus of special attention to decrease the spread of microorganisms, since proper disinfection may eliminate the source of potential pathogens that cause healthcare-related infections such as multidrug-resistant microorganisms. The cleaned and disinfected surfaces can reduce in about 99% the number of microorganisms, while surfaces that were only cleaned reduce in 80% (5).

Thus, a clean healthcare service can prevent mild, moderate or severe damage to users with cost reduction because there is a minor risk of environmental contamination and spread of hospital infections. In regard to healthcare processes, it is true that when inputs are within expiration dates, it avoids waste of public money and assures reliability. Thus, the project plays an important role to reaffirm public policies such as patient safety, defined in the National Patient Safety Program from the Ministry of Health. Considering that the Day Hospital was not sued by Visa, we may also affirm that public resources were well administered.

The time spent to apply the survey was 3 to 4 hours for each professional per quarter, generating a total average of 12 to 15 hours per quarter, whereas there were four to five professional for inspection. Given the optimized resources, process improvement, coupled with the fact that the survey is performed when routine and working conditions allow, not interfering in patient care, the time spent is reasonable and justified for each professional and team.

5. CONCLUSION The methodology enables to meet immediate expectations, as it allows the services (structures), products and raw materials to be permanently evaluated. And it allows to meet future expectations in order to ensure repairs and necessary adjustments to prevent deterioration, waste and generating quality service.

The project allowed the HD to have a satisfactory evaluation of the Health Surveillance of Campinas in 2011, and this result did not bring application of a fine to the HC by the inspection agency, optimizing public resources (the HC and the University). The project could be applied to all units of the Hospital of Clin39

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ics / Unicamp benefiting all internal and external users involved in them, as well as other areas of the hospital complex in Campinas.

It is important to note that mutual respect between services and professionals, promoting the participation of all, was essential to the success of the project. The areas involved were the Department of Nursing, as a facilitator for the preparation of this work indicators and a staff incentive to perform complex jobs; the Division of General Services / HC (responsible for the outsourced contract cleaning company) has ensured that the executors of this service are directed to the proper maintenance of hygiene; and the Division of Engineering / HC, as the partner performing preventive measures for the preservation of public property avoiding permanent damage to the building structure and furniture.

REFERENCES

40

1.

ANVISA (Brasil). A Vigilância Sanitária no Sistema Único de Saúde. 2008. Disponível em http:// www.anvisa.gov.br/divulga/conavisa/cadernos/eixo2_texto05.pdf. Acesso em: 31 jul 2015.

2.

SETZ, V.G; D´INNOCENZO, M. Avaliação da qualidade dos registros de enfermagem no prontuário por meio da auditoria. Acta Paul Enferm. 2009;22(3):313-7.

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NHS Institute for Innovation and Improvement. Quality and Service Improvement Tools, Plan, Do, Study, Act. Disponível em: http://www.institute.nhs.uk/quality_and_service_improvement_tools/ quality_and_service_improvement_tools/plan_do_study_act.html. Acesso em: 31 jul 2015.

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PORTAL ADMINISTRAÇÃO. 5W2H - O que é e como utilizar? Disponível em: http://www.portaladministracao.com/2014/12/5w2h-o-que-e-e-como-utilizar.html. Acesso em: 31 jul 2015.

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RUTALA, W.A.; WEBER, D.J. The benefits of surface disinfections. American Journal Infection Control. 2004; 32(4): 226–231. http://doi.org/10.1016/j.ajic.2004.04.197.

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Process Improvement in a Cancer Outpatient Chemotherapy Unit using Lean Healthcare E.A.S Marotta1, C.F. Pinto2, M.B. Silva3 ¹Instituto de Oncologia do Vale São José dos Campos, SP, Brazil, Laboratory Hospital das Clínicas School of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP); ²School of Engineering of Guaratinguetá (FEG-UNESP) Guaratinguetá, SP, Brazil; 3School of Engineering of Lorena (EEL- USP) Lorena, SP, Brazil.

Abstract This case study describes how processes were improved using Lean Value Stream Mapping tools and Queue Theory tools. Major outcomes were focused on decreasing the variation of the agenda. After the first generation map, the variation of the agenda was decreased by 60%. After the second generation map, the process redesign was able to eliminate 92% of waiting time for patient to get inside chemotherapy room and start treatment with a planned access.

Keywords: Lean Value Str eam Mapping, Queue Theor y.

1. INTRODUCTION

The concept called of “lean thinking” is most commonly associated with Japanese manufacturing, particularly the Toyota Production System (TPS). Much of the TPS way of thinking is based on the work of quality Edwards Deming, who taught, among other things, that managers should stop depending on mass inspection to achieve quality and, instead, focus on improving the production process and building quality into the product in the first place. (Institute for Healthcare Improvement Cambridge, Massachusetts© 2005 Institute for Healthcare Improvement).

Since the first reports of lean initiatives in healthcare in US by Virginia Mason Medical Center, many others attempted to apply lean thinking in healthcare to address crowding, delays and safety (Holden 2011).

One of the landmark results presented by Virginia Mason was the substantial capacity improvement with only area redesign (Womack 2005). The Brazilian government has the constitutional obligation to provide healthcare assistance to the entire Brazilian population; however, it faces serious capacity and quality restrictions while promoting it. One of the most serious restrictions related to the lack of ability to care provided by the public sector is the resource allocation that is insufficient and poorly managed. According to several national surveys, healthcare assistance is the second most cited problem needing better attention (Aranda 2012).

In several countries lean thinking applied to healthcare has proven to improve access and quality of the services provided; even in private organizations or mixed systems (like Brazilian and American); lean thinking in healthcare has produced impressive results. Lean consists basically in separating waste from value; removing non-added value activities from value streams and eliminating waste in a continuous pattern. Most common wastes are transportation, activities or unnecessary processes, material or patient handling, inventory, defects or failures, delays and overproduction. Other problems addresses as waste as well are interactions between enterprises or areas; poor communication and misuse of resources. Most common benefits are associated to direct and indirect cost reduction, set free capacity and personnel. Initiatives to implement the lean thinking in medical services and healthcare are just the beginning (Womack and Jones, 2003; Spears 2005 and Silberstein, 2006).

Queues is healthcare are quite frequent and are usually considered to be created by bottlenecks in the process. For Womack and Jones (1998) lean is a way to do more with less and at the same time offer 41

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customers exactly what they want. This means using less human effort, equipment, time and space to increase the value and minimize waste simultaneously. There are five general principles of lean thinking as shown: specify value from the standpoint of the end customer by product family, identify all the steps in the value stream for each product family, eliminating whenever possible those steps that do not create value, make the value-creating steps occur in tight sequence so the product will flow smoothly toward the customer, As flow is introduced, let customers pull value from the next upstream activity and as value is specified, value streams are identified, wasted steps are removed, and flow and pull are introduced, begin the process again until a state of perfection is reached.

2. LITERATURE REVIEW There is no common sense about the definition of lean production and there is not a “single point” to guide the concept definition (Howleg 2007). Lean Production is a dynamic, multifaceted and complex system with multiple interdependent connections. Academic books and articles still struggle to define clear measures for lean production (Shah 2007); one well established and popular tool, Value Stream Mapping (VSM) as proposed by Shook and Rother (1999) is used to identify and analyze, as well as suggest solutions to production problems.

2.1 Value Stream Map The value stream consists in identifying “all the value added and non-value-added actions required to bring a specific product, service, or combination of products and services to a customer; including those in the overall supply chain as well as those in internal operations” (Womack, Jones and Roos, 1990). The value stream mapping enables the organization to understand the current process, identify the three types of tasks: (1) value-added, (2) necessary but not value-added, and (3) non-added-value steps (Womack and Jones 2003); and provide a vision of gains and benefits associated with waste removal. The VSM is basically a PDCA cycle (PlanDo-Check-Act) involving the following simplified steps: identify the value stream (current state); problem analysis; value proposition (future state); action plan (value delivery); and sustainability (action). For problem analysis, we applied common lean and quality tools: Pareto Analysis; Cause- Effect Diagrams; Affinity Diagrams; Five Whys; and Spaghetti Diagram (Pinto 2010).

2.2 Queue Theory Tools Queue theory is the study of queue process formation and propagation to access any kind of service and its formation is a common phenomenon is systems with unbalanced capacity and demand. Queue theory is used by lean thinking to address capacity problems and is one of the seven wastes (waiting). In the Brazilian healthcare systems, queues are usually accepted and perceived as a capacity problem: the capacity is always below demand. This assumption is frequently a misconception and expresses poor management of the queue. Queue disciplines are rules applied to queues to reduce waiting times and process (Hiller and Lieberman, 1995).

2.3 Kanban Kanban represents any mechanism applied to communicate the time to replenish or produce exactly what is being requested and the amount due, enabling the production flow is pulled (Junior et al., 2008; Slack, 2008). The main reasons to employ Kanban System instead of computerized system are as follows (Y. Sugimori et al, 2007):

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Reduction of cost processing information. It calls for huge cost to implement a system that provides production schedule to all the processes and suppliers; Rapid and precise acquisition of supplies; Limiting surplus capacity of preceding shops.

2.4 Pareto analysis A quality tool called “Pareto analysis” is commonly referred as a statistical technique in decision making for the selection of a limited number of tasks that produce significant overall effect. It is a relatively simple methodology used when trying to determine which tasks or factors in an organization will have the greatest impact (Cervone, 2009). It ranks the data/factors in the descending order from the highest frequency of occurrences to the lowest frequency of occurrences. The total frequency is summed to 100 percent. The “vital few” items occupy a substantial amount (80 percent) of cumulative percentage of occurrences and the “useful many” occupy only the remaining 20 percent of occurrences, which is also known as the 80-20 rule. Results of a Pareto analysis are represented in a bar graph in the form of a descending order and helps to predict easily which factors are vital few and those factors which have least amount of benefits (Talib et al.,. 2011).

3. METHODOLOGICAL PROCEDURES This is an action research study, in which we identified a problem, used problem analysis tools and defined a value proposal, as stated by Shook J and Rother M, (1999). In this part of the article will be presented a local case study and it's service procedures.

3.1.1 First generation of Value Stream Map Chemotherapy - 2011 The chemotherapy treatment process involves many steps as follows: First the patient arrival at front desk, where patient chart is prepared; Second, the triage start the process for vital signs and basic interview; Then, start 3the medical appointment where he or she will be evaluated and a prescription is filled with the required drugs for chemotherapy treatment; Following, the prescription is checked and treatment is scheduled, usually for the same day; Then, the nurse checks the prescription again (a double check for right name, dose, age, and other safety barriers); After, the prescription is sent to the pharmacy; Then, there is another crosscheck by the pharmacist and finally it is filled; At the treatment room, the patient is evaluated by a nurse before the chemotherapy is started.

Each treatment plan requires different criteria of evaluation; Then, if the patient is cleared, chemotherapy and medication is administered; By the end of the treatment, the patient is reassessed for clinical condition; Finally, the patient is discharged and leaves the unit.

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Figure 1 - Representation of VSM for Chemotherapy process.

Source: Prepared by the author (2012).

First action in 2011: We studied the epidemiology of weekly chemotherapy treatment schedule at IOV. That showed us the five most common types of cancers we treat in the chemotherapy room as follow: - 27% Breast Cancer; -13% Colon-rectum cancer; -13% Prostate Cancer; -9% Head & Neck; -5% Lung Cancer; -33% all other cancers.

3.1.2 Major Problems A previous Value Stream Map of Chemotherapy had established the utmost limit of 30 patients a day, but we observed that in some days we had less than 30 patients with a long delay. On the other hand, in other occasions we had some quiet days with more than 30 patients. For this reason, we needed to detail the problem.

We developed a multiprofessional team involving the stakeholders (chemotherapy nurses, triage nurse, doctor, pharmacist, lean team, director). We used the value stream mapping (VSM) to design our current state and develop our future state and action plans.

We identified the unevenness in productivity due to the various protocols carried out during the week. There was a concentration of patients for chemotherapy infusion with the diagnosis of colon-rectum cancer on Mondays, Tuesdays and Wednesdays represented by a red triangle in figure 2.

The short-duration chemotherapy (green circle) and the breast chemotherapy (red circle) was scheduled as the patientâ&#x20AC;&#x2122;s availability or without a standard. The chemotherapy agenda was overloaded not only by the number, but by the complexity of the protocols.

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Figure 2 - Chemotherapy schedule representation before the improvements.

3.1.2 Actions In order to level the schedule of chemotherapy treatment, besides the several improvements possible using lean thinking, the major problem for the unit was the waste associated to waiting time for queues, caused by instability or â&#x20AC;&#x153;MURAâ&#x20AC;? (variation). This instability could be seen on weekly schedules, Daily Treatment Plan (daily production plan) and queue management.

We focused on queue theory to develop stability to the entire system by applying queue discipline into several steps of the VSM and process leveling to daily and weekly schedules. The unit used the FIFO (First In-First Out) system for all of its queues and delivering poor services due long waiting time. Using the queue theory we settled bundles. The two larger volumes are colon/ rectum and breast cancer. We distributed then as follows: Patients of colon and rectum cancer from Mondays to Wednesdays; Patients with breast cancer from Thursdays to Fridays.

The rest of the cancer patients would be distributed according to the complexity: low complexity from Mondays to Wednesdays and high complexity from Thursdays to Fridays.

Figure 3 - Chemotherapy schedule representation after the improvements.

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3.2 Second generation of Value Stream Map - 2014 3.2.1 Major Problems 1 - Increased number of patients: 31% of increase of patients/day from the year of 2011 to the year of 2014 in the chemotherapy room with the same number of chemotherapy chairs (14).

2 - Waiting time for treatment: Average waiting time of 40 min per patient to get inside the chemotherapy room.

3- Unevenness in the agenda: We identified two flows of patients. The main flow of patients was already scheduled on the agenda and the minor flow was of patients that met the doctor that day, without schedule for treatment (only a prevision) but with the proposal for continuous flow. Based on these flows, was identified times of peaks in the chemotherapy room graph 1: Pareto analysis by hour.

Graph 1 - Pareto analysis by hour in chemotherapy room Countermeasures

1: Chemotherapy clearance: A new work station was defined with work force realocation. The aim was to manage the second flow eliminating wastes to ensure the service â&#x20AC;&#x153;flowsâ&#x20AC;? to the customer without any interruption, until the chemotherapy room.

Figure 4 - New work station(chemotherapy clearance)/work force realocation

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2: New agenda of chemotherapy Definition of a new agenda of chemotherapy with schedule for patients in the two flows. All the stakeholders were trained to access the agenda.

3: Kanban in the chemotherapy room door (figure 5) In order to manage vacancies in the chemotherapy room, we applied kanban (green kanban identifies that there is vacancy, red kanban identifies that it is fully occupied).

4: Visual management in the chemotherapy room door (figure 6) Whenever there is a patient waiting to go to the chemotherapy room and there is no place in the chemotherapy, we use a red folder. The problem is visible and the coordinator is able to take an action.

Figure 5 - Kanban for managing chemotherapy room

Figure 6 - Managing problems with colorful folders

4. RESULTS With the first generation map, after distributing patients in bundles, the variation of the agenda was decreased in 60%. With the second generation of the map we were able to reduce 92% of waiting time for patient to get inside chemotherapy room and start treatment.

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Graph 2 - Reduction in waiting time to get inside chemotherapy room

5. CONCLUSION Queue theory is the study of waiting lines and its behavior and predictability. According to Hiller and Lieberman (1995), “Queuing theory itself does not solve this problem directly; however, it does contribute with vital information required for such decisions by predicting various characteristics of the waiting lines...”. The application of lean techniques helps to identify and minimize waste generated in the processes, ensuring greater productivity. Value Stream Mapping and Lean Thinking embraces the waiting process as one of the most frequent seven wastes. Our study addressed countermeasures to deal with a “queue” using lean thinking and queue theory with positive results. Leveling queue access and integrating apparently independent processes led these major results.

This study showed that the unit was able to level agenda in 60% and reduced 92% of waiting time per day using value stream mapping; queue management; and gathering information to improve and connect major flows in the process: the patient, the information and involved personnel.

REFERENCES

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1.

Aranda, F. “Brasil soma 85 mil doentes sem radioterapia, Portal IG São Paulo, 26/04/2012, http://saude.ig.com.br/ minhasaude/2012-04-26/brasil-soma- 85-mil-doentes-sem-radioterapia.html

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Barraza MFS, Smith T, Dahlgaard-Park SM (2009). Lean- kaizen public service: an empirical approach in Spanish local governments. The TQM Journal 21 (2): pp. 143-167.

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Hiller FS and Lieberman GJ. (1995) Introduction to Operations Research. 6th Edition, McGraw Hill, New York,.

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Holden, RJ (2011). Lean Thinking in Emergency Departments: A Critical Review Annals of Emergency Medicine 57(3)

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Holweg M. (2007) The genealogy of lean production. Journal of Operations Management 25 420–437.

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Junior et al., 2008; Slack, 2008. Indepent Jounal of Management & Production (IJM&P). Acesso em http:// www.ijmp.jor.br v. 5, n. 11, august 2015.

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Mazzocato P, Savage C, Brommels H, et al. (2010) Lean thinking in healthcare: a realist review of the literature.

Qual Saf Health Care. doi:10.1136/qshc.2009.037986

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Pinto C, (2010) “Improving Wait Times at a Medical Oncology Unit” in J. Aherne & J. Whelton, editors, “Applying Lean in Healthcare”, Productivity Press, NY.

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Shah R, Ward PT. (2007) Defining and developing measures of lean production. Journal of Operations Management 25 785–805.

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Shook J and Rother M, (1999) “Learning to See”, Lean Enterprise Institute, Boston.

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Silberstein, A. C. L. (2006) Um estudo de casos sobre a aplicação de princípios enxutos em serviços de saúde no Brasil. Dissertação (mestrado) – UFRJ/ COPPEAD/ Programa de Pós-graduação em Administração.

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Spears, S (2005) Fixing Health Care from the Inside, Today. Harvard Business Review Sept.

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Talib Faisal, Rahman Zillur, Qureshi M.N., 2011. Pareto analysis of total quality management factors critical to success for service industries. 5th International Quality Conference Center for Quality, Faculty of Mechanical Engineering, University of Kragujevac.

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Womack JP, Byrne AP, Fiume OJ (2005). Going Lean in Health Care. Cambridge, MA: Institute for Healthcare Improvement.

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Womack, JP, Jones, DT (2003). Lean Thinking, revised ed. Free Press, New York.

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Womack, JP, Jones DT, and Roos D (1998). The Machine That Changed the World. Free Press, New York.

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Y. Sugimori a , K. Kusunoki a , F. Cho a & S. Uchikawa (2007). Production Control Department, Toyota Motor Co., Ltd , 1 Toyota-cho, Toyota-shi, 47, Japan. International Journal of Production Research. Acesso em http:// www.tandfonline.com/doi/abs/10.1080/002075477089 43149, 11, august 2015.

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Young T and McClean S. (2008) A critical look at Lean Thinking in healthcare. Qual Saf Health Care 17: 382386.

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Implementation of a Continuous Flow in a PostMachining Process L. R. P. Claudino¹, P. de Senna Junior², I. Tammela1, R. D. Calado¹ 1

Departament of Engineering, Science and Technology Institute, UFF; ²Department of Production, Affiliation.

Abstract This work is aimed at the implementation of a continuous flow process using concepts of the Lean Thinking, as applied to operational performance improvement in the steel industry. By adapting the Lean concepts and considering the continuous flow implementation’s steps proposed by Rother et al. (2002), a method was devised consisting basically of analyzing the flow using the process diagram, classification of value added activities and line balancing. Finally, improvements have been implemented, standardized from the standard work implementation and sustained by standard audits execution. This approach provides several benefits such as increased productivity, quality improvement, and lower costs.

Keywords: Lean Manufactur ing, continuous flow, post-machining process, line balancing.

1. INTRODUCTION In the current business scenario, many companies have tried to stand in the market from the differentiation of their products and processes, enabling greater profitability in business. According to Esposto (2008), the emergence of lean production brought a new way of managing production based on waste reduction, which as a result, leads to reduction of production costs and higher profit margins for companies [1] (GORI, 2012).

The Toyota Production System, also known as "Lean Thinking" became the subject of great interest after the 1973 oil crisis. On this economic scenario, it is observed that the Toyota Motor Company achieved higher profitability than other companies in the same industry. Analyzing the differences between these companies, we could find that the majority of automakers used the conventional system of mass production developed by Henry Ford, which did not apply to the slow economic growth scenario. On the other hand, Toyota developed the Toyota Production System, with the main objective of producing a wide variety of products in small quantities [2] (OHNO, 1997).

Womack and Jones (1998) define lean thinking as a way to specify value, line up the best sequence of actions that create value, perform these without interruption, more effectively, ie it is a way to do more with less - less human effort, less equipment, less time and less space - and at the same time, offering exactly what customers want [3].

According to Womack (2010), the following principles should be implemented when applying Lean Manufacturing tools: value identification, value stream mapping, and the creation of a continuous flow [4].

Rother and Shook (1999) define continuous flow as producing one piece at a time, with each item passing immediately from a process step to the next without waste creation between them. This approach provides several benefits such as reduced lead-time, quality improvement, and lower costs [5].

Among the Lean Manufacturing tools, we can mention the line balancing like a big waste reduction tool, by aligning different tasks in order to have a continuous flow of production, reducing operating idle50

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ness and equipment [6] (ROTHER & HARRIS , 2002).

This work is aimed at the implementation of a continuous flow process using Lean Thinking concepts, as applied to operational performance improvement in the steel industry. In the company analyzed in this study, there was a delay regarding value design, value stream and streaming in the post-machining process.

We found that before the implementation of continuous flow there were losses at the process level, such as excessive movement, inventory between processes, idles, and waiting caused by lack of necessary tools and rework.

2. CONCEPTS AND TOOLS OF LEAN THINKING APPLIED TO CONTINUOUS FLOW 2.1 Continuous Flow According to Womack (2010), continuous flow it’s the third principle of the Lean Thinking, and that means produce items without waste between each step of the process, such as excessive stocks, rework, idleness, overproduction and unnecessary movements [4]. Womack et al (1998) says that to achieve success applying the continuous flow, it’s necessary a machine and operators with high capability, in other words, the team production needs to operate under a favorable condition to achieve a good performance, quality and precision doing the work. Considering this, it is necessary that the production team has skill in tasks performed, that the machines are always available and that work is strictly standardized [3].

2. 2 Value Flow Womack et al. (1998), in his constant searching to reduce wastes through the Lean Thinking principles, propose the creation of a value stream mapping, identifying all the necessary activities of the process to project, require and produce an specific product, in order to divide them in three cathegories [3]: Activities that create value for the costumer, as required by them; Activities that don’t create value, but are necessaries for the system of product development, order fulfillment or production, therefore cant be eliminated; Activities that don’t create value according the costumer requirement, ie, are wastes that could be eliminated after a process analysis.

One of the main tools used to analyze the value stream mapping it’s the process diagram. This analysis tool leads the team to have an sistemic vision of the process, being very important to define improvements for the process, in order to reduce the non value added activities. Furthermore, this tool allows include the quantification of another indicators, such as, the lead time of the process, the distance walked by operators and the number of employees involved in the process [7].

According Ferro et al. (2007), before analyze the value flow, it’s important to consider the product families definition. The product families are caracteristics of products that have similar process steps, having consequently a similar cicle time. Thus, the product families will be used as analyse unit of the value flow, since, being of similar characteristics avoid discrepant analysis [8].

2.3 Line Balancing According to Tapping, Luyster e Shuker (2002), balance an production line it’s the process in which the work load is divided between the operators in order to suit to the takt time, ie achieve rhythm of client request [9]. Apply the line balancing brings some advantages for the process, one of the main it’s that each workstation produce in a synchronized way and adequate volume, generating a constant flow without process interruptions [10] (ABDULLAH, 2003).

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One of the tools used to realize the line balance is operator Balancing graph (GBO), also known as Yamazumi frame, that consists of a graph which contains the distribution of labor between the production line operators and their times and relates to the takt time, based on actual data observed. This tool is quantitative, simple, visual, removes the approximations in the design and allows engineers, managers and operators work together using facts, being very useful to develop our own "eyes to the flow", meaning the full process understanding [6].

For the Operator Balancing Chart be carried out effectively, it is crucial to apply the following steps [5]: Identification of the work elements: identification of micro activities that make up the operation performed by operators, as well as the identification of mudas (waste) intrinsic to the operation.

Elimination of activities that do not add value: Realization of actions that eliminate the mudas (waste) of operations.

Measurement of time of each activity, and distribution of work by operators: after implementing the improvements, the time of the activities must be measured and the work elements distributed between the operators so that the cycle time be as closely as possible the takt time.

2.4 Standardization Work Based on Ohno (1997) & Liker et al. (2007), Standardized Work consists of a detailed specification of the basic activities of a process in order to be performed by operators with minimal losses in adequate time to customer demand and low inventory levels [11] (FAZINGA & SAFFARO, 2012).

According to Monden (1997) and Dennis (2007), Standard Work is expressed by three elements (Figure 11) [12,13]: Cycle time and takt time; Work sequence, ie the best way to do the process; In-process stock, ie only the necessary inventory for the process.

Among the standardization tools, Denis (2007) highlights the â&#x20AC;&#x153;standard work combination tableâ&#x20AC;? as an important tool to define the work elements and their sequence, time per work elements and the interaction between operators and machines or between different operators. This analysis tool makes kaizen easier, breaking down the movements of the operators and synchronizing them [13].

3. THE METHOD The method applied in this project consists of seven steps based on Rother et al.â&#x20AC;&#x2122;s (2002) tools and assumptions for continuous flow implementation [6] (Figure 1): Figure 1 - Method of continuous flow implementation

Analysis of actual situation

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Identification of process for continuous flow implementation

Identification of value flow

Definition of the working elements and their optimal time

Implementation of the line balancing

Development of Standardized Work

Routine Audits creation

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4. THE CONTINUOUS FLOW IMPLEMENTATION 1 Situation Analysis As the first step of the proposed method, a failure analysis was performed through the â&#x20AC;&#x153;5 Whysâ&#x20AC;? tool, in order to find the root causes operating in the system.

Upon completion of the analysis, was identified the main root causes that generate a low productivity (0.09 parts / man / hour) in the production process. From this, it became apparent the need to implement the continuous flow in the process, as well as the Lean tools necessary to achieve this result and the impact on the process that is expected after the implementation of improvements (Table 1).

Table 1 - Synthesis of Root cause analysis Root Cause

Improvement Proposition

Lack of a productive flow with the Lean Man- Define Productive Flows and Product Famiufacturing concept. lies

Process Impact Reduction of crane use and buffers in order to raise the productivity and reduce lead time.

The production isn't balanced. There isn't a clear definition of processes bottleneck for each productive flow and product family. Perform the Line Balancing and define bottle- Better use of resources and adequacy of manpowneck er

Lack of standardization and sequencing of activities between operators.

Synchronize operational activities

Minimization of idleness.

Sequence operational activities

Increase the pace of production and reduction of rework.

Lack of planning tools and supplies before and Apply visual management tools and materials during production stocks.

The quality criteria are not clear

Operational Standard is not clear and objective

4.2

Develop a Defects Book for inspection of quality criteria.

Create Operational Standard, following concepts of Lean Manufacturing

Reduction of waste and interruptions.

Reduction of rework and production stoppages due to uncertainties and consultations.

Greater adherence to

Standard

Identification of process for continuous flow implementation

First of all, we mapped all production flows possibilities in the post-machining process. Material goes through a special finishing process, creating different flows that can run in parallel with different materials.

After defining the production flow, the product families were created in order to separate the flow by materials with different characteristics that impact directly on the sequence of production. This definition was necessary because activities to be carried out on the pipe depend on characteristics of the product.

Thus, there was a survey of all production flows that have occurred in the last six months. After that, the demand for each flow was quantified and prioritized, in which three main flows corresponded to 78% of the parts produced at the shop.

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4.3

Identification of value flow

After we define and prioritized production flows, the next step of methodology was to identify the value flow of the process. In order to achieve this purpose, we used the process diagram and the classification AV/NAV as a process analysis tools (Figure 2).

First of all the process diagram was done, as well as the breakdown of activities between operation, transportation, inspection, hold/stops and activities that generate in-process stocks. This diagram allowed an analysis of the problems found in the process and their possibilities for solutions.

After the process diagram was written, data was used to perform the value added analysis, in which we separated value added activities of non-value added activities. Following the completion of this step, it was noticed that 43% of the total lead time correspond to performing activities that do not add value to the process, ie, activities that do not provide a final product as expected, and wastes in transport, handling, inspection, among others.

Figure 2 - Value flow analysis

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4.4

Definition of working elements

The definition of working elements and their times consist of the time of completion for each activity by each operator, first considering losses due to unavailability of inputs and, after completion of actions, of availability of inputs in order to obtain data for the next step: line balancing. For this step, we used a table to record time.

4.5

Implementation of the line balancing

From the data collected in the timing before and after improvements made through the process diagram and value added activities analysis, we held a graphical analysis of cycle times in comparison with the takt time in three scenarios, represented as "Actual Situation", "Loss Elimination" and "Line Balancing" in order to optimize the production line reducing waste and balancing times of each operator (Figure 3).

1. Actual Situation: This gr aphic por tr ays the initial scenar io r egar ding the compar ison between cycle time to perform activities for each operator and takt time. In this graph, it is possible identify the bottleneck of the flow (second painting operator), and especially it can be seen that the customer rhythm was not being achieved in this scenario, since the time of painting operations cycle was longer than takt time.

2. Loss Elimination: The scenar io 2 depicts the r eality of pr oduction after implementation of actions generated in the process diagram analysis and Charter AV / NAV. It can be noticed a reduction in the flow cycle time of 1 to 64%, enough to be below 21% of takt time, or view client pace.

3. Line Balancing: This scenar io aimed to equalize time of activities, i.e. make the oper ations time as close as possible of the other and of the takt time to avoid idleness and generation of stocks, in order to allow implementation of continuous flow, i.e. the production piece-by-piece. As the line bottleneck was already serving the takt time, it was used as base to grouping operations with less time in order to equalize them to the bottleneck, as was the case of related transactions to operators 1 and 2, which had their unified activities and carried out by only 1 operator. Because of this, the operator 1 has become the new bottleneck, and the cycle time was 15% below the takt time. Through this action, was reduced the number of operators necessary for the flow studied.

Figure 3 - Line balancing

4.6

Development of Standardized Work After the implementation of the proposed improvements in the flow 1, we used the Standardized Work tool as a way of sustaining the actions implemented through standardization. The completion of this step enabled the creation of three standards: standardized work instruction, standard work combination table and operational sequencing. These forms complement each other so that the operator has access to the description of how to carry out the activities, the standard time for performing the same, standardized timing between operators and the visual management of the sequence of activities that must be followed by 55

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each operator.

Standard Work Instructions: This for m standar dizes which oper ations must be per for med dur ing the production process, how and when these operations must be performed, as well as the visual representation thereof. In addition to descriptions, there is the classification of activities in 6 icons with the goal to reinforce the operator's attention on specific issues and guide the same as the actions that must be performed aligned with each symbols.

Standard Work Combination Table: This for m allows to align activities between oper ator s according to their times, so as to give rhythm to the production and reduce idleness among operators. Furthermore, it is an exposed visual management document in the work station panel in order to be used as a guide by the operator so that it knows what standard time to perform each activity, and when it should be performed in comparison with the activities of other operators (Figure 4).

Figure 4 - Standard work combination table

3. Operational Sequencing Table: This for m is intended to standar dize visual manner the sequence of activities that each operator must perform. Overall, this pattern brings many benefits to operating performance, since it summarizes all activities that must be performed on a single sheet, from photos of the process in flowchart format. This form was exposed in the Workplace panel, enabling a practical way to query the sequence of activities that must carry out in order to increase adherence to standard and reduce rework index (Figure 5).

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Figure 5 - Operational sequencing table

4.7

Routine Audits creation

After standardization of operational activities in easier, safer and more productive way, we realized the need to routinely evaluate the use of these documents in order to verify the effectiveness of the implemented tools, their correct use by operators and to identify opportunities to improvement standards. In order to promote this monitoring and continuous improvement in the standardization of implemented tools, we proposed the creation of a routine for standard audits.

First of all, it was defined that the line manager would perform the default audit, with the frequency of audit set from the manager of the proximity level with the operational routine, for example, the technician would perform audits weekly, the supervisor biweekly and engineer monthly.

During these audits, a standard audit form must be used, which has the function to direct the auditor to what should be observed during each visit. In general, the auditor must first observe the general aspects related to standards, for example, if it is exposed in the workplace and whether there is evidence of operator training on the standard used. After these, the auditor will observe the operations being performed for about 30 minutes in order to confront if activities are performed as described in the Standardized Work Instructions, if conform to the following Operational Sequencing Table and if the runtime is near the standard time described in Standard work combination table. If any activity performed by the operator is noncompliant with respect to standards, the auditor should perform actions that could solve the problem that prevents the operator to perform the work as standard, and thus promote continuous improvement of existing standards, training and discipline of the operators on implementation of standards.

5. RESULTS To measure the results of this study, we used as the main way a productivity indicator (part / man / hour), and as the second indicator the rework of Marking workstation. These indicators are both representative for the work, because reflect the purpose of this project, that is to promote an increase in productivity 57

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and to eliminate the rework through continuous flow implementation (Table 2). The results were favorable and allowed to achieve the main goal, demonstrating effectiveness of the methodology applied.

Table 2 - Summary of Results Indicator

Result

Piece/man/hour

67% increase

Lead Time (days)

39% reduction

Internal Rework (%)

100% reduction

Operator reduction

68% reduction

Work Shifts (capacity)

Elimination of 3rd shift with 2016 demand service

The indicator of piece/ man/ hour is calculated by dividing the number of parts produced by the amount of hours available in the month multiplied by the number of operators who work in the area. Analyzing this performance indicator, one can see that from the project implementation there was an increase in productivity by 67%, i.e. each operator makes 67% more parts each time available for production.

In addition to productivity, another critical factor considered in the process under study is painting activities rework. In order to measure the rework of painting process, we designed an indicator of rework which is the ratio between the reworked parts and processed parts of the process in question. Analyzing Rework indicator, it is clear that before the implementation of continuous flow approximately 11% of processed parts were reworked later. This reworking occurred most often because of the lack of standardization of quality control, lack of the reaction rules in case of any defect and the undefinition of sequence of activities that each operator should perform. After the implementation of continuous flow and standardization of tools the rework was eliminated from the painting process.

The improvements evidenced in productivity and rework indicators had a major impact on reducing operating costs. After implementation of the project, the number of operators required to perform the operations was reduced in 56%, making it possible to eliminate the 3rd shift, in addition to the gains from consumption of raw materials were reduced along with the reduction of rework.

6. Conclusion This project was aimed to implement a continuous flow from the application of Lean Manufacturing tools in a process of post-machining to increase operational productivity and reduce rework on selected streams for the study. It appears that through the application of root cause analysis tools, line balancing, visual management, work standardization and definition of the timing between operators, which are part of lean thinking, it was possible to improve operational performance from the increased productivity (parts / man / hour) in 67% and the elimination of existing rework the painting station.

It is worth mentioning the importance of the participation of factory managers and operators during the implementation of this project. Operators actively participated in each stage, pointing out recurring problems during work execution, suggesting improvements and mainly running the operating pattern. In addition, managers had the important task of motivating the team in performing this project, which was one 58

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of the keys to effectively achieve our goal.

However, in order to obtain a full and sustainable results with the implementation of streaming in the post-machining process, it is suggested to carry out further work, such as to continue the implementation of the proposed method to streams that were not part our scope; to carry out the implementation of standard audit systematic, in order to disseminate the culture of standardization across all levels of shop; and to encourage operators to identify improvement opportunities in processes with standard modification. The operating standard modification is one of the main evidence that continuous improvement is occurring.

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