HOSPITAL SULTAN ISMAIL, JOHOR BAHRU · HOSPITAL SULTAN ISMAIL •Built 1999, Started operation 2006...
Transcript of HOSPITAL SULTAN ISMAIL, JOHOR BAHRU · HOSPITAL SULTAN ISMAIL •Built 1999, Started operation 2006...
HOSPITAL SULTAN ISMAIL,
JOHOR BAHRU
HOSPITAL SULTAN ISMAIL
•Built 1999, Started
operation 2006
•THIS hospital
•704 Certified Beds
•22 wards, 18 OT
•49,000 Admissions
•12,044 Births
•218,391 Specialist
Clinic Visits
•99,369 Emergency dept visits
•64 resident specialists/ 18
specialist services with 20
subspecialties
•2100 Employees
•RM258m Operating Budget
Southern Region Oncology Center
PROBLEM STATEMENTS
The waiting time for all types of cancer to start radiotherapy ranges from 8-20 weeks after
being referred to the Hospital for treatment.
For Head and Neck cancer the average waiting
time is about 120days using the Clinac iX.
Dissatisfaction amongst clients and other
stakeholders
Project Goal
Comparative Assessment
KPIs and challenges to go forward:
Team members:
[1] Aspiration:
To improve the waiting time of head and neck cancer patient to
start radical radiotherapy treatment after first consultation by
Oncologist at Hospital Sultan Ismail Johor Bahru using the
Clinac iX Linac.
Sponsor: Minister of Health
Leader: Director General of Health & Deputy Director
General of Health (Medical)
Buddy: ‘Jabatan Kesihatan Negeri Johor’, Director Hospital
Sultan Ismail.
Team members: Dr Mohd Roslan Haron, Dr Fong Chin
Heng,En Hassan Bin Ali, Pn Halimaton Saddiah Paiman,En
Hanannan Bin Kepli, En Mohd Khairee Aripin, Pn Azizah
Caroshau, JT Siti Norsiah Ibrahim , KJ Rafi’ah Othman, KJ
Zaidah Othman
[2] Current Situation:
Average waiting time is 120days from first oncology consultation
[3] Project Scope:
Only patients confirmed to have Head & Neck cancer .
Waiting time: From the time of decision to treat using radiotherapy
[1] Benchmark: NHS - 31days
The Advisory Board Company Oncology Round Table - 26days
RANZCR – 28days
[2] Comparative assessment:
Hospital Umum Sarawak 3-4 weeks
[1] KPI: To start 60days after first consultation
[2] Challenges:
Inadequate Linear Accelerators and other related
equipments
Insufficient manpower such as clinical oncology, radiation
physicist, therapy radiographer
Hospital Sultan Ismail, Johor Bahru4 QUADRANT
CT Scan and Simulation
To create BDS Mask & Establish Mapping
Mask valid 3 mths onlyTx : ~ 45min/ pt
- MC Frequent Down- MC year (2004)
- Maint. done -Monthly- After process, pat.
went home w/o next treatment date.
- Will inform few days before treatment
available
PlanningOpen File/ Counseling
Set appt. for Simulation –Ave within 2~3wks
-5 Planner Plus 1 Sup.
Computer Planning
-Tech: 3 PhysicistTrack pat status by Excel
segregated by Doctor.-Ave lead time (1-mth) due to Inv: High (80)
-MC: (Ecllipse-3) @15min(Plato -2) @ 45 min
(for Contouring)
1.Contouring by Phy. (15 min)2. PTV by Oncologist2. Planned by Physict (5-8 hrs)3. Approved by Oncologist Send to Planning
Dose Calculation(transfer data and verify)
Cut and paste
Prepare Kad Carta Rawatan (Blue Card)
(30% Rejected / need Re-plan)
1
3
2
4
5
6
7?
?
?
R
Treatment
3 MC (Clinac@ NPC plus 2 Primus)
- #3 Radiotherapist Ave Tx = 15 min/pt
Cap: 35 pt/ dayMC maint- monthly plus cal . Quarterly.
1 NPC pat = 35 #( req.35 days)
Process Flow forRadiotherapy Treatment
… a serial precision complex processesInvolves coordination between various units
Value Stream Mapping – Oncology Radiotherapy treatment
Value stream mapping is a lean manufacturing technique used to analyze the flow of materials and information currently required to bring a product or service to a
consumer.
~ 1.5 mths ~
2.5mths
Convert to Value Stream Mapping (VSM)
Kaizen Burst #1 : To increase Clinac machine capacity --> Goal to reduce treatment waiting time from current 10weeks to at least 5 weeks
Kaizen Burst #2 : To reduce backlog files (inventory) from current 120 files to less than 5 files at any station --> Goal to reduce planning work from 6 weeks to 3 weeks
Kaizen Burst #3 : To reduce re-plan works (rework) from 30% to less than 10%
We then identified Kaizen Bursts on areas for improvement
Identification of ConstraintsInternal Assumption: Inadequate machine/ facilities and staff long queue (4mths)
Actual Finding:
Clinac (Qty: 1 unit)
- New machine (10 mths old)- Highly demand because having high capability,
high accuracy, fast speed- Better shielding features- Mostly used for NPC cases (head /neck area)
- Daily new cases = 1/5- Ave treatment = 30 patients/day
Utilization = 8.30am – 5pm @ 30% Only
Primus (Qty: 2 units)
- Old machine (10 years-old)- High downtime/ breakdown- Low capability, accuracy and speed- Limited shielding cannot used for NPC
cases for tumor head/neck- Daily new case = 4/5 @ 2 machines- Ave. treatment = 50 patients/day
Utilization = 8.30am – 5pm @ 25%
Why Clinac waiting time > 4 months
- Every patient must undergoes 35 consecutive treatments @ 1.75 mths- Ave. Machine capacity = 30 patients/ day- Daily there will be 1.2 new cases added to Clinac- Note: Machine operate 8 hrs/day @ 5 day/wk
Finding:
LEAN IMPROVEMENTS
Kaizen Activities conducted atPusat Rawatan Onkologi
Action Items / Counter measure
Check/ Follow-up / Recommendation
Prepared by: Date: 25th Oct 2013 Rev 1.0
Radiation & Oncology Department
HOSPITAL SULTAN ISMAIL JOHOR BAHRU
Kaizen #1 :Title
To increase Clinac machine capacity, Running 2 shifts at Clinac
Background•Clinac Machine only operated from 8am to 5pm (8 working hours)
•Only 4 dedicated Radiation Therapist operating this machine
Current Condition/ Situation
Analysis and Goal•Analysis:
•More patients can be treated if longer duration of machine
utilisation
•Goal:
To optimised utilisation of Clinac Machine
Items PIC Date
1. Discussion between head of Radiation Therapist with all his team members
En Hananan 25th Oct 13
2. To inform Head of Department. En Hananan 14th Nov 13
Current manpower
2 Radiotherapists to handle system console 2 Radiotherapists to handle machine and
patient
Cli
nac
Pri
mu
s M
LCP
rim
us
Kaizen #1 : To increase Clinac machine capacity(Increase Radiation Therapist Skills and Capability)
Cross training was conducted -to privilege (qualified) ALL Radiation therapist (JXRT) to capable handling ALL types of machines.
CLINAC MLC PRIMUS
FAIRUL √ √ √
JAMIL √ √ √
FIFI √ √ √
AZRUL √ √ √
WAN ANUAR √ √ √
SHAFAZAWA √ √ √
BAZILAH √ √ √
ZANA √ √ √
NAIM √ √ √
SHAHIR √ √ √
HANNANAN √ √ √
AZIZAH √ √ √
MD NOOR √ √
ALI √ √
UMAIRAH √ √
100% JXRT Trained and Privileged
Current manpower 1st shift @ 7am -2pm
Kaizen #1 : To increase Clinac machine capacityRunning 2 shifts at Clinac
Cli
nac
Pri
mu
s M
LCP
rim
us
2 Radiotherapists to handle system console
2 Radiotherapists to handle machine and patient
2 Radiotherapists to handle system console
1 Radiotherapists to handle machine and 1 Pembantu Perawatan Kesihatan to handle patient
2nd shift @ 2pm -9pm
2 Radiotherapists to handle system console
1 Radiotherapists to handle machine and 1 “PPK” to handle patient
To increase machine capacity from 30 to 42 pts /day
• OPTIONS:
1) Plan for daily overtime (3 hrs) constraint: physicist to stand-by2) To run 2-shift constraint: inadequate radiation therapist (JXRT – U29)
Note: 1) Limited radiotherapist graduate from Kolej Sains Kesihatan Bersekutu, Sg.Buloh2) New graduate consumed by IKN (Institiut Kanser Negara)
4/7/2016
Month Sept Okt Nov Dis Jan Feb Mac
Plan Capacity 500 600 650 700 800 900 1000
Actual
Session/Mth549 602 652 622 696 803 750
Average
Patient/day27 30 33 31 35 40 33
Remarks Overtime Overtime Overtime 2nd Shift2nd
Shift
2nd
Shift
Kaizen #1 : To increase Clinac machine capacity
Number of Sessions treated on Clinac Machine
Why Planning work takes 1.5 mths
Value Stream Mapping – Oncology Radiotherapy treatment
1) Inadequate radiation oncologist ( Currently 2 Only )2) Inadequate physicists ( currently 5 )3) CT Scan /Simulation for mask making was delayed (2 ~ 3
weeks ) to avoid “mask expiring”
4) Current files backlog (Inventory ) too high .
Actual Finding:
Target : To reduce planning works to 2 weeks; refer A3 Report
4/7/2016
Kaizen Burst #2 : To reduce backlog files (inventory)
Issue on Physicist shortage at
Computer Planning stage .
Due to long medical leave and physicist
occupied more time to solve machine
down.
Month Oct Nov Dec Jan Feb Mac
Plan Qty 100 80 60 55 50
Actual Qty 126 98 86 78 62 50
Number of inventory (Patients in queing) from registration to complete planning (Awaiting Treatment)
All backlogs for Aug, Sept and Oct
2013 have been Cleared !!!
Month Sept Okt Nov Dis Jan Feb Mac
Plan Qty 100 80 60 55 50
Actual Qty 130 126 98 86 78 8 13
Number for Inventory (Patients in queing)- from registration to complete Awaiting treatment
Kaizen Burst #2 : To reduce backlog files (inventory)
Kaizen Burst #3 : To reduce re-plan works (rework) from 30% to less than 10%
BacklogsBy doing
Kaizen Burst #1 and #2
Backlogs Cleared by Mac 2014
Kaizen #4 : For Sustainability
Planning Tracking Sheet (Using Pull System)
Every new case will be registered in Patient’s Trace Record dan Statistic
Notification will be given when the case is due for treatment
Patients Trace Record & Statistic
Kaizen # 5 : PaTRest
• Patrest expanded use of Physics Unit to Unit Planning in June 2015
Sustainability PaTRest System
•PaTRest used in Physics Unit since 2013
•PaTRest improved and updated from time to time
Patients Trace Record & Statistic at Planning
Room using PaTRest
•VISUAL MONITORING
•DIGITAL MONITORING (PaTRest)
•MONITORING CARD & CHECKLIST
•FIFO CARD
•2013•2014
•2014•2015
Kaizen # 6 : Backlog Clearance at Computer planning
25 cases will be approved by oncologist for
treatment every week to reduce backlog
TARGET CHART
Kaizen # 7 : Daily Queuing Patient System
PRIMUS PRIMUS MLC CLINAC
Daily Queuing Patient System
•Small slot boxes represent 15 mins waiting time
•Appointment card
•information• August 2014 ,
applied at Primus MLC
• 2015 this imitative was applied to other treatment machines.
EXTENSION OF SERVICES
• April 2015 Intensity-Modulated Radiation Therapy (IMRT) for Head & Neck and prostate cancer patients.
• July 2016 Stereo tactic Radiation Therapy(SRT) for AV malformation and meningioma
Value Creation Matrix
No. KPI / Value CreationCurrent
indicatorTarget Achievement
1. Reduce waiting time 120days 60days 30days
2. Increase patient survival rate Mortality rateZero while awaiting
for treatment
Until today no patientpassed away while
waiting for treatment
3.Optimizing asset/ machine capacity
8am - 5pm(8 hrs / day)
8am - 9pm(15 hrs/ day)
8am - 9pm(15 hrs/ day)
4.Optimizing human capital utilization
4 RadiationTherapist
3 Radiation Therapist + 1 Pembantu Perawatan
Kesihatan
3 Radiation Therapist + 1 Pembantu Perawatan
Kesihatan
5.Improve Oncology Teamwork and Communication & Creativity
Number of Kaizen
Continuous Kaizen Burstby department
3 New Kaizen has been done ,
1 new Kaizen still pending
6.
Patient/Customer oriented process- Towards PCC (Patient Centered Care)
Basic flow chartVSM – patient process
flow based.
5 minutes standing meeting at Kaizen
Corner continuously perform
Achievements
120
62
57
29.8
26.221.5 16.2
28.7225.37
32 30
21
38 42
0
20
40
60
80
100
120
140
Oct 13
Dec 13
Jan 14
Feb 14
Mac 14
Apr 14
May 14
June 14
July 14
Aug 14
Sept 14
Oct 14
Nov 14
Dec 14
Average Waiting Time For Radical Radiotherapy
Days
•Target
•World Benchmark
AVERAGE WAITING TIME FOR RADICAL RADIOTHERAPY HSIJB
SubjectOct
2013
Dec
2013
Jan
2014
Feb
201431 March
2014
April
2014
May
2014
Average
Waiting Time
For Radical
Radiotherapy
Target :
60days
World
Benchmark :
30 days
120
days
62
days
57
days
29.8
days
26.2
days
21.5
days
16.2
days
AVERAGE WAITING TIME FOR RADICAL RADIOTHERAPY HSIJB
SubjectJune
2014
July
2014
Aug
2014
Sept
2014
Oct
2014
Nov
2014
Dec
2014
Average
Waiting Time
For Radical
Radiotherapy
Target :
60days
World
Benchmark :
30 days
28.72
days25.37
days
32
days
30
days
21
days
28
days
42
days
All Types Of Cancer Patients
36 38
31
35
3231
2933
3440 41
42
0
20
40
60
80
100
120
140
Average Waiting Time For Radical Radiotherapy
Days
•Target
•World Benchmark
AVERAGE WAITING TIME FOR RADICAL RADIOTHERAPY HSIJB
SubjectJan
2015
Feb
2015
Mac
2015
April
2015
Mei
2015
Jun
2015
Average
Waiting Time
For Radical
Radiotherapy
Target :
60days
World
Benchmark :
30 days
36
days
38
days
31
days
35
days
32
days
31
days
All Types Of Cancer Patients
AVERAGE WAITING TIME FOR RADICAL RADIOTHERAPY HSIJB
SubjectJul
2015
Ogos
2015
Sept
2015
Okt
2015
Nov
2015
Dis
2015
Average
Waiting Time
For Radical
Radiotherapy
Target :
60days
World
Benchmark :
30 days
29
days
33
days
34
days
40
days
41
days
42
days
All Types Of Cancer Patients
Conclusions
• D : 30% Rejection Resolved• O : No Expired Beam Direct Shield mask • W : Waiting Time To Get Treatment achieved
target• N : By Giving Privileging To All Radiation Therapist to
operate Clinac IX• T : No Transporting Patient To Private Hospital• I : Backlogs Cleared• M : PaTRest (Patients Trace Record & Statistic)• E : No Rejection computer planning work
COST EFFECTIVENESS1. No Additional Treatment Machine Required = RM20 million
2. No Overtime Claimed Needed(RM15x 4person)= RM5280/mth
3. Lead Time Improvement = 75%
4. Processing Time Improvement = 75%
5. Saving Cost = 100%
6. Rework Improvement = 100%
7. Backlogs Improvement = 100%
Thank You
Hospital Director : Dr Hj Arbain Bin Lani
Head Of Department : : Dr Mohd Roslan Haron
Team Members :
Dr Khursiah Binti Daud
En Hassan Bin Ali
Pn Halimaton Saddiah Paiman
En Hanannan Bin Kepli
En Mohd Khairee Aripin
Pn Azizah Caroshau
JT Siti Norsiah Ibrahim
KJ Rafi’ah Othman
KJ Zaidah Othman