Available online at ScienceDirect. Procedia Computer Science 37 (2014 ) Soudabeh Khodambashi*

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1 Available online at ScienceDirect Procedia Computer Science 37 (21 ) The th International Conference on Current and Future Trends of Information and Communication Technologies in Healthcare (ICTH-21) Lean Analysis of an Intra-operating Management Process - Identifying Opportunities for Improvement in Health Information Systems Soudabeh Khodambashi* Norwegian University of Science and Technology (NTNU), Sem Sælandsvei 7-9, Trondheim, Norway Abstract The application of information systems in clinical processes needs to be evaluated to maximize alignment between the new applied information systems and the process. This study focuses on the evaluation of a health information system (HIS) adoption to intra-operating management of the anesthesia process in heart operation. We conducted a case study and applied the Lean method to the intra-operating management process. We applied the Value Stream Map and the A3 method as the common tools of the Lean method to evaluate the anesthesia process. Using the value stream mapping and A3 problem solving tool assist us to map the process and remove the "non-value" added steps and actions in the process, enhance data integration and process integration. This paper and the related results can guide clinicians and practitioners in the application of the Lean method to HIS to reduce waste in the clinical workflows. 21 The Authors. Published by by Elsevier B.V. B.V. This is an open access article under the CC BY-NC-ND license Peer-review ( under responsibility of the Program Chairs of ICTH-21. Peer-review under responsibility of the Program Chairs of EUSPN-21 and ICTH 21. Keywords: Lean method; Health information systems; Anaesthesia process 1. Introduction Healthcare organizations adopt health information systems (HIS) in their process. To achieve best result and performance from the application of information technology (IT), it is necessary to evaluate the clinical process after IT adoption to align the clinical workflow to information technology while implementing HIS (1, 2). A 5% fail rate of information systems was reported due to user resistance (3-5), so the feedback and suggestion of main users who * Corresponding author. Tel.: address: soudabeh@idi.ntnu.no The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( Peer-review under responsibility of the Program Chairs of EUSPN-21 and ICTH 21. doi:1.116/j.procs

2 31 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) interact with an HIS is important to maximize the alignment between HIS and user routines in the clinical process. Since HIS implementation affects clinical workflow, application of quality management methods as one of the existing solutions can maximize the alignment by analysis of the process. One of the management methods which optimize workflow is the Lean method, which is used to analyze the process components to eliminate "non-value" added activities known as waste (6, 7). The Lean method and related tools are discussed in section 2. We applied the Lean method to the Intra-operating management process (IOMP) related to HIS, known as "Intelliviue Clinical Information Portfolio" (ICIP), and evaluated the process as the process owner reported certain problems regarding the applied HIS to the current workflow after HIS adoption. These problems include waiting and delay in the process, especially to record data in ICIP. The ICIP is used before, during and after operation to increase efficiency in anesthesia process. In the studied process, the anesthetists interact with the ICIP during operation. Furthermore, all patients vital signs such as heart beat and temperature are automatically recorded to the ICIP during operation. Anesthetists record all the necessary information such as dose of drugs and related comments during operation manually into the ICIP. The ICIP software is implemented in Malaysia s premier heart center, which is the national referral center for cardiovascular disease, treating adult and pediatric patients. The IOMP includes all the activities during the day of operation before transferring the patient to the intensive care unit (ICU). The documented steps in this process include 1) Pre-induction check and review, 2) Pre-anesthesia preparation, 3) Anesthesia management, ) Cardiopulmonary Bypass management, 5) Post-Cardiopulmonary Bypass, 6) Transfer patient to the ICU or ward. To have a clear understanding about the identified problems, analyze them and find the root cause of the problems and remove them, we applied the Lean method and its related tools to the IOMP. In section 2, background, we briefly introduce the Lean method and its tools. The applied method for this research is discussed in section 3 and followed by results and conclusion in chapter. 2. Background The Lean method was introduced when the Toyota Production System was studied at Massachusetts Institute of Technology and qualified in 1988 (8), aimed to improve efficiency by eliminating "non-value added" activities known as waste (7) as one of the management methods. In addition, the Lean method was applied in different settings related to clinical process to remove waste, identify inefficiencies and improve outcome (9, 1). Waste does not add any value to the product or service but uses resources (11). Based on the TPS, waste can be classified in seven most common categories as "overproduction, waiting, transport, inappropriate processing, unnecessary inventory, waste of motion, and defects" (12). The Lean method concentrates on workflow and the existing problems to identify waste and improve the process. The tools we applied are first the so-called value stream mapping tool (VSM) (13, 1). In VSM, key people, resources, activities and information flows, which are required to deliver a service or product, are mapped graphically to identify opportunities to reduce waste and integrate process steps, thus improving process efficiency (12). The second applied tool is called A3 (15). A3 problem solving helps to search directly for the root of the process problem by articulation the identified problems. A number of studies reported the application of the Lean method in the analysis in healthcare such as operating theatre changeovers (16), radiology (17), academic operating room (18) with the aim of reducing waste and improve the process flow. However, the focuses of their research were not HIS in the context of healthcare. The aim of this case study preliminary was the application of Lean method in health care in relation to HIS and finds the possibilities for improvement and reducing waste. 3. Method We conducted a case study to investigate the application of the Lean method in improving clinical processes by observation, unstructured interview and analysis of the workflow. The main purpose of the case study was to understand the ICIP application within the anesthesia process in heart operation at national heart institute, in Malaysia. Site observation of the process for each selected respondent involved in operation allowed us to validate flow of data from the start of the process to the end.

3 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) The selected respondents were seven consultant anesthetists, three anesthetists, three clinical specialists and six fellows, two senior medical officer and six attachment doctors in this case study to have a clear understanding about the detail of the process and involved actors. Based on the site observation and following each respondent in the identified process and recording the time for each task in the process, we mapped the IOMP in evsm. The evsm is a software (19) which is designed to support maps and other visuals commonly leveraged in lean implementations, including value stream maps. To eliminate waste from the clinical workflow and find the root cause of the problems, we adapted A3 method. We designed the "as-is" and the "to-be" process map of the studied process in evsm. First we designed the "as-is" process and collected the anesthetist's feedback about the designed VSM. Later, we designed A3 map for each identified problem and collected respondent's feedback about them. In the last phase, we designed the "to-be" process which is verified with the process owner, respondents, who are familiar with the studied process and problems.. Results We conducted a case study to have a better understanding about the process and to design the VSM. The detail of the result of observation and interview is discussed in this section. Based on our observation, all anesthetists, from consultant to attachment doctors, have access to ICIP. Each user has their own account. So, if more than one anesthetist is involved during an operation and they interact with the ICIP, all the information recorded based on the defined user account in the system. In addition, level of accessibility is different for each user in the system. The process starts by a request that is initiated by a nurse in the operation theatre (OT) to transfer the patient to the operation room. The OT technician transfers the patient to the assigned OT and prepares the patient for operation. Later, the anesthetist performs the pre-induction check and pre-anesthesia preparation in OT. Once the anesthetist has started the anesthesia process, he or she logs-in to ICIP and opens an "anesthesia record flow sheet" that was assigned to the patient. All information related to vital signs of the patient is recorded automatically after the anesthesia record-flow sheet has been opened. ICIP records all vital signs that are necessary for the anesthetist from the patient every five minutes. However, after starting by-pass process, anesthetist starts to enter the related data of the pre-induction check, pre-anesthesia preparation and medication into the ICIP. Normally more than one anesthetist is involved in the operation for one patient, so for each new record that is inserted or updated into the database, ICIP requests user account information to record the inserted data linked to the user accounts. Based on our observation, in every case, they had delay to start the anesthesia record-flow sheet as the form should be opened before anesthesia process starts to record all the patient vital information into the database. In addition, two out of ten cases, the OT technician logs-in to ICIP to start the anesthesia record-flow sheet. At the end of the operation, the completed form is printed to keep in the patient s file as archive. Based on the observation we designed the VSM and added the measured time taken in each step. Data such as the least, most, and average delay between steps as well as the least amount of time, the longest amount of time, and the average time consumed by each step were identified in the VSM is shown in Figure 1. The current state map presents us in which order each step of the process occurs, how long each step takes for completion, and the delays between each step. However, based on the average delay between steps, we calculated total "non-value added" time which is the sum of all average delays between steps. In addition, we calculated the total "value added" time for the whole process by totaling the average time for each step. The total "non-value added" activities are 2 minutes which is % of the whole process. The map shows the area of waste in two parts. The first one is between "pre-induction check pre-anesthesia preparation" and "anesthesia" steps. The second one is between the "anesthesia" and "record vital information" steps..1. Analysis of the "as-is" map The measure of delay enables us to determine how much of the total time spent in the process is "value-added" as opposed to "non-value added" to the patient. The lowest number reflects the minimum amount of time required to complete the step and the highest number shows the maximum required time for the activities, which highlight

4 312 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) unusual complex sets of activities or many interruptions or work-arounds may have occurred and lead to longest waits. Once a first view of the problems was developed, we analysed the problems further. In order to find the root cause of the problems, we adopted root cause analysis in the A3 problem solving method to find reasons for the problems more in details. Fig. 1. The "as-is" value stream map of IOMP In the IOMP, we identified the "waiting" waste (Figure 1). This "waiting" waste was identified from the patient perspective as a patient is transferred to the OT attached room but has to wait for the anaesthetist or OT technician to start the process. The other identified "waiting" waste is a delay in starting the anaesthesia record-fellow sheet. As each of "waiting" waste has a different root cause and the solutions are different, we have developed two different A3 maps. The root-cause analysis of the problems and suggested solutions related to the first "waiting" waste is shown in Figure 2. The A3 map related to second "waiting" waste is shown in Figure 3. Both figures (2 and 3) are based in the standard format of A3 method..2. The future state map In the future state map, "to-be", activities inside process boxes may need to be eliminated or combined, and the number of steps (process boxes) may be reduced or placed in a different order. The time spent in each process box may be redefined and a plan to eliminate "non-value added" activities within it should be developed as the next step in cutting wasted activities. The future state map must be achievable and also leads us closer to the ideal state (19). To remove the "waiting" waste, the nurse who calls to the ward to transfer the patient to the OT attached room should co-ordinate with the OT technician. So, when the previous surgery is about to finish, they transfer the patient to the room to start pre-induction and pre-anesthesia assessment. This increases integration between the steps in the process. Furthermore, as the recorded information on the anesthesia record flow sheet does not start on time, and

5 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) therefore has a delay, the OT technician should make the form ready to record all necessary information before anesthesia starts. Therefore, based on the suggestions which were explained, we calculated total "value-added" and "non-value added" time of the process in the designed future state map in Figure. The total "value-added" time increased to 67.6 %, and total "non-value added" time decreased to %. 5. Discussion and conclusion Fig. 2. A3 map of Intra operating management process (delay to start operation) We conducted a case study to apply the Lean method in order to remove waste from the clinical process related to HIS. We analyzed data which was collected from site observation, unstructured interview and analysis of workflow and discussed how the identified wastes can be removed from the studied clinical process. Multiple workflows that the actors were different were studied to validate data collection. In addition, we applied VSM to identify problems and wastes and developed an A3 problem solving for each identified problem to design the "to-be" process. Based on the Lean analysis of the process, we classified the identified issues in the process into "collecting", "maintaining", "organizing", "process integration" and "standard procedure". In the "collecting", the identified problems are 1) fragmented information (different information systems with no integration between them such as lab information systems and hospital information systems) and 2) late reporting such as the confirmed name of patient on the operation list, the name of patient is not entered into ICIP and delay of the lab report. In "maintaining", the identified problems are 1) duplicate data, such as general data of the patients like name, age, etc. In "organizing", the identified problem is lack of integration between different databases of information systems. For example, information from the lab report is recorded in another IS and should be printed

6 31 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) and be inserted manually to ICIP which increases human error in data entry. Lack of process integration is a reason for miscommunication. IT staff availability in the right time, in case of issue regarding the computer or the software, availability of the patient, availability of the room for pre-anesthesia check delayed the process that are examples of lack of process integration. "Standard work procedure" is another identified issue which means every person does not work in the same way and there is no standardized method of work in the process. When the activities that are included in one process are not standardized, it increases verbal direction for medication and reduces use of ICIP as all the information is not entered into the system. Furthermore, it causes more delay in the process, as well as increasing waste. Fig. 3. A3 Intra operating management (delay to start recording data) In the assessment and redesign of the workflow related to HIS, we proposed an integrated HIS (lab, ICIP and hospital IS) at the database level to increase integration of features and database consistency and completeness. We applied the Lean method to increase collaboration and teamwork, standard the process, identify "value added" and "non-value added" time and increase collaboration and teamwork. We plotted the results of the "as-is" and "to-be" processes of "value added" and "non-value added" activities to identify improvements for the studied processes (Figure 5). As it is shown in Figure 5, the total "value-added" time in the "to-be" process decreased. The reason is that there are activities that were "value-added" but not necessary to be in the process and by removing those activities we simplified the process to flow. To assure about the correctness of the VSM, we validated every rendition of VSM with the people who are involved in the process and the process owner.

7 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) Intra operating management OT Nurse Patient Ward Nurse OT technician OT A A1 Patient check in Fill operation form by nurse Check information of patient tag with patient file.5 1 A2 Pre_Induction check Pre-Anesthesia preparation Prepare patient for operation by OT technician Pre- anesthesia preparation Re asses patient by anesthetist 8 2 Record vital information OT technician login to ICIP Search for patient nameintheot list Open Anesthesia record flow shit A3 anesthesia Start anesthesia A5 CPB Start by pass Insert medication information Fill ICIP handover2 Finish by pass A6 Surgery report Write necessary report during surgery by anesthetist Send all forms to the printer by anesthetist 5 A7 Patient check out Transfer patient to ICU Insert printed file in patient history file by OT technician Total NVA Total VA NVA % % VA % 67.6 % Fig.. The "to-be" of Intra-operating management process Fig. 5. Comparison of the total "value added" and "non-value added" time in the IOMP A key advantage of the Lean transformation is to establish the culture of continuous improvement and organizational learning. Continuous improvement is an important point after Lean implementation to monitor and measure changes. For continues improvement, measuring performance effectively is necessary. Timely measures give us more information, and immediate feedback helps us to find the root cause of a problem faster to prevent a

8 316 Soudabeh Khodambashi / Procedia Computer Science 37 ( 21 ) problem occurring. As a suggestion for continues improvement, Kaizen method also could be considered as a Lean tool for managing suggestions from employees to engage actors in the process improvement. Acknowledgements We thank the Norwegian university fund (UNIFOR) "Norges tekniske høgskoles fond" for conference support. I would like to express my gratitude to my master degree supervisor, Dr. Maryati Mohd Yusof for her valuable feedback and special thanks to Dr. Ariffin for his valuable comments as a clinical supervisor. Special thanks to Dr. Dirk Ahlers for helpful comments on the paper. References 1. Berg M. Implementing information systems in health care organizations: myths and challenges. International journal of medical informatics. 21;6(2): Ammenwerth E, Brender J, Nykänen P, Prokosch H-U, Rigby M, Talmon J. Visions and strategies to improve evaluation of health information systems: Reflections and lessons based on the HIS-EVAL workshop in Innsbruck. International journal of medical informatics. 2;73(6): Dowling Jr AF. Do hospital staff interfere with computer system implementation? Use and impact of computers in clinical medicine: Springer; p Anderson JG, Jay SJ. Use and impact of computers in clinical medicine: Springer-Verlag New York, Inc.; Zheng K, Padman R, Johnson MP, Diamond HS. Understanding technology adoption in clinical care: clinician adoption behavior of a point-of-care reminder system. International journal of medical informatics. 25;7(7): Yusof MM, Khodambashi S, Mokhtar AM. Evaluation of the clinical process in a critical care information system using the lean method: a case study. BMC Medical Informatics and Decision Making. 212;12(1): Schweikhart SA, Dembe AE. The applicability of Lean and Six Sigma techniques to clinical and translational research. Journal of investigative medicine: the official publication of the American Federation for Clinical Research. 29;57(7): Buesa RJ. Adapting lean to histology laboratories. Annals of diagnostic pathology. 29;13(5): Vats A, Goin KH, Fortenberry JD. Lean analysis of a pediatric intensive care unit physician group rounding process to identify inefficiencies and opportunities for improvement*. Pediatric Critical Care Medicine. 211;12(): Yousri T, Khan Z, Chakrabarti D, Fernandes R, Wahab K. Lean thinking: Can it improve the outcome of fracture neck of femur patients in a district general hospital? Injury. 211;2(11): Singh B, Garg S, Sharma S, Grewal C. Lean implementation and its benefits to production industry. International journal of lean six sigma. 21;1(2): Vinodh S, Arvind K, Somanaathan M. Application of value stream mapping in an Indian camshaft manufacturing organisation. Journal of Manufacturing Technology Management. 21;21(7): Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation: Free Press; Rother M, Shook J. Learning to see: value stream mapping to create value and eliminate muda: Lean Enterprises Inst Incorporated; Jimmerson CL. A3 problem solving for healthcare: A practical method for eliminating waste: Productivity Press; Meredith JO, Grove AL, Walley P, Young F, Macintyre MB. Are we operating effectively? A lean analysis of operating theatre changeovers. Operations Management Research. 211;(3-): dge A, Bamford D. New development: using lean techniques to reduce radiology waiting times. Public Money and Management. 28;28(1): Collar RM, Shuman AG, Feiner S, et al. Lean management in academic surgery. Journal of the American College of Surgeons. 212;21(6): Jimmerson C. Value stream mapping for healthcare made easy: CRC Press; 21.J,