الفهرس 
INTRODUCTION AND AIM OF THE WORKOnly 14 pages are availabe for public view
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Abstract
Depending on the forecasts of global population growth for the next years, the increased aging of population and the government’s intention to extend the coverage of health services, it can be said that healthcare industry is one of the sectors with the highest growth potential in the coming years. Healthcare industry is currently working under the increased pressure of reducing operational costs and enhancing quality levels of care. Lean and Six-Sigma provide an understandable framework and set of tools to achieve these goals, and their benefits have been widely proved in multiple healthcare scenarios.
The present work aimed at using Lean-Six Sigma methodology to improve chemotherapy process, in a chemotherapy day unit.
The study was conducted in the Chemotherapy Day Unit (CDU) at Alexandria Ayadi Almostakbal Oncology Centre.It provides mainly free diagnostic and therapeutic services to oncology patients who are unable to pay, as well as paid services. The hospital has 46 inpatient beds, four intensive care beds and an emergency room composed of 2 beds and 7 chemotherapy administration chairs. The outpatient services cover five consultant clinics for diagnosis and follow up, a radiotherapy unit and a chemotherapy day unit.CDU consists of 7 chemotherapy rooms (six of them are for free cases, located on the ground floor) and (one for paying cases, located on the first floor) and one specialist clinic for patients’ assessment before receiving the prescribed protocol. Each chemotherapy room has from four to seven chemotherapy administration chairs and one or two beds, one of the rooms is for paediatrics’ chemotherapy but not exclusive. CDU operates from nine to six o’clock from Saturday through Wednesday, and an average of 40 patients receive their chemotherapy through the CDU daily.
Data collection methods included the five Six Sigma phases: Define, Measure, Analyse, Improve, and Control. Define phase included: identifying customers, listening to their voice, analysing it using Pareto chart, the defined problem was confirmed, finally the project charter and Gantt chart were displayed for project management. Measure phase involved: problematic process analysis using process flowchart, Spaghetti diagram, and value stream mapping. Also, in this phase the defect and “what to be measured” were defined and then we started data collection. Analyse phase composed of analysis of drug preparation data inside the pharmacy, time analysis, movement analysis, analysis of the defect, calculating baseline sigma level, process capability analysis, analysis of patient waiting time using control chart, analysis of the queue of patient files waiting chemotherapy preparation and studying the probabilities of improvement. Improve phase included improvement efforts: assignment of 2 additional pharmacy staff for preparation process, and improvement conducted by the researcher and process owners. The later involved a lecture explaining lean Six Sigma principles, root cause analysis session to the problem, identification of the root causes and remedies, prioritizing and planning improvement efforts and finally assessment of post improvement results. Control phase included: communication of the results to process owners, designing the control plan and finally celebrating the results.
The present study uncovered the following results:
1- DEFINE PHASE:
- “Long waiting time from specialist assessment till receiving chemotherapy” was the most encountered problem by the internal and external customers’ voices, specifically “from file entry to the pharmacy to drug dispensing”
- Mapping the whole chemotherapy process was done
- Run chart revealed median patient waiting time was 51 minutes
- Project charter and Gantt chart were displayed
2- MEASURE PHASE:
- Layout of the pharmacy and Spaghetti diagram were displayed
- Chemotherapy preparation process SIPOC involved suppliers: chemotherapy assigned nurse, pharmacist (registering), physician, cashier, 1st pharmacist (revising), 2nd pharmacist (revising), pharmacist (collecting), and pharmacist (preparing). Inputs involved (patient’s file, patient and drug data, incomplete file, complete file, patient and drug data & invoice, printed order & invoice, revised file, drug labels, collected and labelled premedication, collected unprepared chemotherapy, prepared, labelled chemotherapy. Outputs are received patient’s file, incomplete file, complete file, printed order & invoice, paid invoice, revised file, drug labels, collected and labelled premedication, collected chemotherapy, prepared & labelled Chemotherapy, prepared Chemotherapy & file. Customers are pharmacist (registering), chemotherapy assigned nurse, physician, cashier, pharmacist (revising), 2nd pharmacist (revising), pharmacist (collecting), pharmacist (preparing).
- Operational definition of the defect was defined as “any patient’s waiting time that exceeds the mean value-added (cycle) time for drug preparation (defectives or non-conformities”
- Current state VSM revealed cycle time of every process step and waiting between steps
3- ANALYSE PHASE:
- Mean value-added time for chemotherapy preparation is 42 min. Value added ratio was 57% 0f the total patient’s waiting time.
- Time analysis revealed the need to 5.6 ≈ 6 staff members to satisfy the process.
- Defect Proportion was 77%
- Process capability index Ppk = -0.25
- Mean Patient waiting time was 65.5 minutes
- Analysis of the current patient files queue behaviour revealed that average rate of files arrival/ hour (6.95 ≈ 7), average service rate/ server (0.941), utilization of servers (184%), average number of patient files waiting in the queue (-7.2) and average waiting time in the queue (-62.2 min).
4- IMPROVE PHASE:
- Assignment of 2 additional pharmacy staff for the preparation staff.
- Root cause analysis session and fishbone diagram was used to know the causes of the problem “Long waiting time from specialist assessment till receiving chemotherapy”, 12 causes were identified. The root cause of each cause was identified using 5 whys technique.
- Staff diagnosed 10 remedies, 5 was selected for implementation.
- Assessment of post intervention improvements was done using, control charts, queue analysis and PCA
o Defect Proportion was 72%
o Process capability index Ppk = -0.19
o Mean Patient waiting time was 59 minutes
5- CONTROL PHASE:
- Control plan was designed by the researcher and process owners, quality improvement department was involved for data management and reaction plans.
In the view of this work results the suggested recommendations were:
1- As the study was started by drawing the physical layout of the hospital, organizational chart, and chemotherapy process mapping. All have consumed considerable time from define phase. Also, pharmacy’s physical layout was drawn in measure phase to be used for Spaghetti diagram. Each hospital should display its physical setting layout, organizational chart and mapping to the processes it provides, or to be available on request.
2- Lean Six Sigma improvement methodology must be executed by a team, each member should have a degree of training in LSS. Also, the hospital wishes to use LSS methodology to improve its processes should involve it in its strategy. The study project requires intensive work, it would be very hard to be executed by one person especially if the involved staff have no idea about this methodology.
3- Voice of customers’ interview questionnaire, better to be replaced by service satisfaction surveys, as Kano analysis. Kano Analysis is used for better classification of customers’ requirements.
4- Continuous assessment of the chemotherapy preparation process and patient waiting time for chemotherapy preparation, as planned in control plan, using control charts for better observation of the process even before being symptomatic
5- Problems other than “Long waiting time from specialist assessment till receiving chemotherapy”, that are diagnosed by the voice of customers should be the target for next improvement efforts.
6- Other remedies which are suggested by pharmacists, but not selected for improvements should be reassessed by the hospital CMO and quality improvement department to be deployed.
7- Uniform documentation of the treatment plan and updating chemotherapy pre-printed orders are of utmost importance and must be executed as soon as possible.
8- Further researches are required for:
a. Using queue analysis to study long time problems in healthcare service
b. Assessment of cost of processes while conducting Lean Six Sigma improvement project.