الفهرس 
Introduction and Aim of the present studyOnly 14 pages are availabe for public view
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Abstract
Health care systems are currently facing multiple challenges related to safety,quality, efficiency and the rapid rise in costs. Healthcare providers are under continuous
pressure to improve their services by reducing waste and adding value. Variety of
methodologies is available for process improvement including Lean management.
Implementation of Lean approaches within healthcare has widely increased worldwide.
Lean implementation within the ambulatory care setting is seen in the continuous
identification and elimination of waste within the process by reducing waiting time,
queues, eliminating repeat visits, errors, and inappropriate procedures, reducing the patient
walking and increasing patients‘ and staffs‘ satisfaction, identification of bottlenecks that
slow health care delivery process, shifting of nonessential activities away from these
bottlenecks and generating extra work capacity from the existing resources rather than
adding additional ones.
The aim of the present study was to study the application of Lean methodology to
antenatal care services provided within a family health center in Alexandria. A nonrandomized
quasi-experimental pretest-posttest study design was used. The study was
conducted in Smouha family health center an accredited family health centers in Sharq
district affiliated to MoHP. Antenatal care services are provided through four family
medicine clinics, one gynecology specialty clinic, one internist specialty clinic, one dental
clinic, a pharmacy, vaccination unit, and the laboratory.
The study was composed of three phases for data collection; Pre Lean, Lean and post
Lean phase. The Pre-Lean assessment phase was where a brief description of the current
state of the antenatal care process was done through observation using structure assessment
check lists, human resource assessment check lists, flow charts, spaghetti charts, SIPOC
diagrams and time flow analysis. Listening to the voice of the customer through
administrating a structured interview schedule to the antenatal care enrollees (210 pre/post
Lean) to determine their satisfaction about the antenatal care services they receive. A semistructured
interview schedule was used to collect data from 40 internal customers
regarding descriptive details about the way they provide antenatal services in order to
detect the existence and determine any of the seven Lean waste activities within the
provided services. At the end of this stage three problem were prioritized using Pareto
charts which were the long waiting time at the family medicine and gynecologist clinics
and the delay of medical record distribution. In the second Lean intervention phase a
kaizen team was formed of nine members and carried four kaizen meeting; the first was a
lecture about Lean methodology tools and principles, in the second and third meetings the
current and future value stream maps were depicted and an analysis of the value stream of
antenatal care sub process was done, root cause analysis of the prioritized problems using
fish bone diagram and the five whys‘ technique was done. In the last meeting, the kaizen
team voted using the decision matrix for the long waiting time at family medicine clinics,
delay in medical records transfer, disorganized medical record room and long waiting time
at the gynecology clinic as prioritized to be solved according to being more frequently
occurring, feasibility for improvements to be implemented, importance to be solved and
availability of resources. An A3 report was developed and an action plan was set to
implement and apply the different lean tools and initiatives for improvement.Counter measures were directed to overcome four areas through the application of
eight improvement remedies. First to overcome the medical record transfer problem an
application of 5S to the medical record room was done, and organization of the
responsibilities and duties about transfer of medical records (booking window, recollected
and referral medical records) by manual workers was arranged. Second countermeasure
that was based on the queuing analysis of the booking process was to assign an additional
employee to the booking office. Third counter measure was to apply an appointment
system to the family health clinics and finally measures were applied to increase health
care providers‘ punctuality. In the post Lean phase, evaluation of lean implementation was
done using predetermined set of indicators in the action plan.
The main results of this study could be summarized as follow:
Pre Lean phase:
For antenatal care initial visits, the longest non-value added mean times during antenatal
care sub processes‘ that were recorded were 28.31 min±20.15 the waiting time for
registration with range 45 min, 62.30 min ± 38.99 the waiting time for family medicine
clinic consultation with range 175 min, and 32.9 min ± 17.63 the waiting time for
gynecologist with range 62 min. The mean time for the whole visit duration of 27
antenatal care enrollees with initial visits was 151.70 min ± 45.74 with range 179 min.
For antenatal care return visits, the longest non-value added mean waiting times
during antenatal care sub processes‘ that were recorded were 64.23 min±36.00 the
waiting time for family health clinic consultation with range 145 min and 53.70 min
± 31.26 the waiting time for gynecologist with range 109 min. The mean time for the
whole visit duration of 78 antenatal care enrollees with return visits was 124.44 min
± 46.55 with range 176 min.
The I control charts for the waiting time for family medicine consultation detected
the presence of three data points out of the control limits revealing special cause of
variation in the waiting time for family health consultations where patients had to
wait more than two hours and 30 minutes till having their consultation. Common
causes of variation in the family health consultation waiting time were detected in the
form of two data points above 2 standard deviation from the average time where
patients had to wait more than 60 minutes.
The most common causes of antenatal care enrollees‘ dissatisfaction within the
antenatal care process prioritized by Pareto charts were the long waiting time at
family medicine clinics, delayed medical record transfer and long waiting time at
gynecologist clinic.
The most common Lean wastes mentioned by the internal customers within the
antenatal care process prioritized by Pareto charts were the delayed medical record
transfer, long waiting time at family medicine clinics, delayed release of medical
records from medical record room, delayed transfer of referred medical records,
insufficient work force, long waiting time at gynecologist clinic and the
unpunctuality of family medicine staff.
The value added time for antenatal care enrollees with initial visits was 44 minutes,
the lead time was 192 minutes and the process cycle efficiency (PCE) was 21.87%.
The value added time for antenatal care enrollees with return visits was 61 minutes,
the lead time was 222 minutes and the process cycle efficiency (PCE) was 37.30%.Post Lean phase:
For Lean antenatal care initial visits, the longest non-value added mean times during
antenatal care sub processes‘ that were recorded were 41.67 min ± 27.04 for waiting till
having family medicine clinic consultation with range 80 min and 49.15 min ± 26.66
waiting time for gynecologist with range 80 min.
For Lean antenatal care return visits, the longest non-value added mean times during
antenatal care sub processes‘ that were recorded were 21.94±20.47for waiting till
having family medicine clinic consultation with range 95 min and 35.26±26.31waiting
time for gynecologist with range 91 min.
The mean value added and non-value added times for initial visits of antenatal care
sub processes showed a significant decrease in non-value added time taken for ticket
booking (P= 0.002) to 1.81±1.30min, waiting at family health consultation (P=0.019)
to 45.89±25.42 min. Regarding the value added times there was a significant increase
in the family health consultation duration (P= 0.020) to 11.4±4.32 min, a significant
decrease in the total laboratory investigations (P= 0.001) to 9.81±3.84min,
medication dispensing from pharmacy (P= 0.009) to 3.50±1.93 and there was a
significant decrease (P= 0.000) in the total visit duration to be 92.59±28.08 min after
being151.07 ±45.74 post Lean implementation.
The mean value added and non-value added times for return visits of antenatal care
sub processes showed a significant decrease in non-value added time taken for ticket
booking (P= 0.000) to 1.73±1.314, waiting at family health consultation (P=0.000) to
23.62±20.031min and waiting for gynecology specialist (P= 0.018) to
35.26±26.31min. Regarding the value added times there was a significant decrease
in the family health consultation duration (P= 0.005) to 10.36±4.279 min, the total
laboratory investigations (P= 0.000) to 9.22±2.76min, vaccination (P= 0.021) to
3.71±1.63 min, medication dispensing from pharmacy (P= 0.000) to 3.52 ± 1.73 min
and dental consultation duration (P= 0.053) to 2.17±0.71 min and there was a
significant decrease (P= 0.000) in the total visit duration to be 60.95 ±27.75 min after
being 124.44 ± 46.55 min post Lean implementation.
For initial visits, the lead time for a complete antenatal care visit with all sub process
decreased to 164 minutes with 49 minutes value added time and the process cycle
efficiency was 29.87%. For the return visits in the post Lean phase, the lead time for
a complete antenatal care visit with all sub process decreased to 126 minutes with 47
minutes value added time and the process cycle efficiency was 37.30%.
There was a significant increase in antenatal care enrollees‘ satisfaction level for
medical record transfer (P=0.000) with 85.2 % enrollee satisfied and there was a
significant increase in antenatal care enrollees‘ satisfaction level regarding the
waiting time for family health consultation (P= 0.000) with 76.2 % enrollee satisfied.
Steps saved during the antenatal care visits were 242 footsteps=184 meters walked
per visit.Based on the results of the current study, the most important recommendations
include the following:
1- Institutional application of a mixed registration- type individual block
appointment system for the family medicine clinics where all scheduled patients
will be assigned unique appointment times spaced and distributed over the
working hours during morning and evening shifts.
2- Extension of application of a mixed type appointment system to the specialty
clinics to maintain continuity of care.
3- Organization and arrangement between scheduled and unscheduled walk-in
patients for their order to enter their visits.
4- To increase health care provider‘s punctuality, it is recommended that punctuality
be one of the evaluation factors of health care providers to motivate them to be
more on time, more strict managerial penalties are recommended to adjust
physician‘s arrival as well as the application of a finger print device.
5- To avoid queues and crowd hour‘s three booking employees should be assigned in
position at the booking office during the morning shift.
6- The medical record transfer duty assigned and distributed among the manual
workers should be maintained under continuous close supervision.
7- Standardization and sustainably of 5S methodology in the medical room and
extending its‘ application to other offices within the center.
8- Standardization of antenatal care visit and standardize the number of gynecologist
referrals by not exceeding the indicated number of ultrasound imaging during
antenatal care to avoid the long waiting time at the gynecology specialty clinics.
9- Training and workshops on Lean methodology is needed to be applied to the
largest number of employees and health care providers in order to be able to allow
Lean cultural transformation where the focus should be on developing and
sustaining a Lean philosophy and avoid using Lean as an initiative for short term
isolated Lean improvement projects.
10- Provision of the sonicate device, antihypertensive drugs, vitamins and iron
supplements and laboratory kits to overcome its continuous shortage and maintain
compliance.