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Process Improvement in A Radiology Department: Hatice Camgoz-Akdag and Tu Ğçe Beldek
Process Improvement in A Radiology Department: Hatice Camgoz-Akdag and Tu Ğçe Beldek
Process Improvement in A Radiology Department: Hatice Camgoz-Akdag and Tu Ğçe Beldek
www.emeraldinsight.com/1463-7154.htm
BPMJ
26,3 Process improvement in a
radiology department
Hatice Camgoz-Akdag and Tuğçe Beldek
Department of Management Engineering,
786 Istanbul Technical University, Istanbul, Turkey
Received 12 March 2019
Revised 2 April 2019 Abstract
Accepted 2 April 2019
Purpose – The purpose of this paper is to improve the mammography and ultrasound screening processes to
increase the healthcare system quality and patients’ pleasantness while decreasing costs.
Design/methodology/approach – The data storage system is very insufficient so that data are collected
from hospital staff and by personal observations. A lean management tool, value stream mapping is used to
see the general view of the radiology department with its problems at a glance. Data and the map are used as
a guide to conduct a quality house to make a prioritization between the problems, to decide which one to solve
first, of patients at the hospital.
Findings – Problems of the radiology department related to mammography and ultrasound and suggestions
to these problems according to the quality house conducted.
Originality/value – The paper consequently focuses on the value creation process and on how to revisit
managing for quality in the systems perspective.
Keywords Quality function deployment, Value stream mapping, Process improvement,
Lean management, Healthcare systems
Paper type Research paper
Introduction
Today quality definition is totally turned out to satisfy customers on time. This goal can
be reached by some calculations in a production line but it is more difficult for a service
sector. Especially in healthcare systems, it is more important to give a high-quality service
to the patients. When the human life is considered, it is vital to start the treatment quickly.
Waiting is the biggest problem at a hospital, which increases the risk of exacerbation of
the disease. Even at the beginning of the healthcare system, patients try to get an
appointment from the hospital and they wait for long time periods, sometimes for months,
to see the doctor.
These kind of delays leads to the integration of lean management and healthcare
systems. Lean management aims to eliminate actions which do not add any value to the
process that are defined as “waste.” Elimination of non-value added steps, shortens the
lead time of the process which means to reach customer more quickly. The current state of
the hospitals’ departments can be provided by some lean management tools. With the help
of the value stream mapping (VSM), the big picture of a whole process can be seen.
This picture shows every step that the patient will follow and it also tells about the cycle
time for each service. If any of the service steps are not necessary, it is tried to be
eliminated such as walking between too many doors, waiting for the reports, waiting for
registration, etc.
Non-value added activities’ elimination is not the only thing that should be considered.
Patients’ satisfaction is also important and it should be checked if they want anything
according to the system and the hospital as a building. The way to convert customers’ needs
to real developments is to use “House of Quality” (HOQ) which is a tool for quality function
Business Process Management
Journal deployment (QFD). Voice of customer leads to technical properties of the thing that can be
Vol. 26 No. 3, 2020
pp. 786-797
either a product or a service, and new product/service development will be the result.
© Emerald Publishing Limited
1463-7154
The needs of patients’ are very important to draw the future state map of the hospital’s
DOI 10.1108/BPMJ-03-2019-0109 department. Both current state map and HOQ will help to conduct future state map of the
value stream. In this study, data are taken from the paper which gives details about the Radiology
radiology department’s current situation at Şişli Hamidiye Etfal Hospital in Istanbul, department
Turkey (Camgöz-Akdağ et al., 2017). The radiology department is considered with its
mammography and ultrasound units. The purpose of this paper is to improve the
mammography and ultrasound screening processes to increase the healthcare system
quality and patients’ pleasantness while decreasing costs.
After the introduction part, lean management and lean in healthcare topics will be 787
covered under literature review. In the third part, methodology will be explained and then
current state of the radiology department will be mentioned. HOQ will be studied at the fifth
part and finally a future state map will be shown before the conclusion part.
Literature review
Lean management
Lean manufacturing, which is also called the “Toyota Production System (TPS)” was a new
process-driven production system for the industry, founded by Japanese leaders
(Abdulmalek and Rajgopal, 2007). The main aim of lean manufacturing is to get rid of
the “waste” while increasing the quality of the product (Sundar et al., 2014). Waste types can
be classified in eight different ways: producing more than the need, inventory, defects,
waiting, transportation, extra motions, non-value added activities and the unused human
ability. These waste cost nearly 95 percent of the whole production cost which is mentioned
by Taiichi Ohno who is one of the leaders of TPS (Kilpatrick, 2003). Main action of TPS is to
eliminate different types of waste, such as defective products, inventory, transportation,
waiting, movement and overproduction (Ohno, 1988).
Lean principles mainly aim to make a sustainable production line while eliminating non-
value added activities. This line has to work with customer orders which mean a pull system
(Sundar et al., 2014).
In August 1997, a non-profit organization “Lean Enterprise Institute, Inc.” was founded
by James P. Womack. He aimed to explain lean thinking in accordance with the Toyota
system which is being used by many different sectors spread wide (Lean Enterprise
Institiute, 2000). The Lean Enterprise Institute website gives detailed information about lean
principles which is summarized in Figure 1.
2. Map
1. Identify
the Value
Value
Stream
5. Seek 3. Create
Perfection Flow
4.
Establish
Pull
Figure 1.
Source: www.lean.org/WhatsLean/Principles.cfm Lean principles
(accessed March 5, 2018)
BPMJ Not only in manufacturing but also service industry uses lean principles in spite of
26,3 application of mentioned ones are certainly different. The difference is that many service
area works with pull system, which means the customers’ needs trigger the production of
the service. If the system has problems in terms of the process, then waiting periods will be
longer (Maleyeff, 2006).
Methodology
Value stream mapping
Implementing lean principles starts with the analysis of current situation to classify value
added and non-value added activities. VSM is one of the most efficient way to do this
classification. The map shows the whole process of the production or service line with
symbols. Its minimal structure is mainly related to “lean thinking.” The process drawn in
the value stream map starts from the beginning that raw materials come from suppliers, and
ends at the shipping department. The expert which draws the map, follows both the
production steps and information flow at a random time and captures that moment.
This map is called “current state map” (Gahagan, 2007).
Current state map shows the bottlenecks on a one picture. With lean principles, these
problems which are classified as non-value added activities, should be eliminated or
improved. After eliminating those “waste” improvement areas are shown in “future state
map” (Rahani and Al-Ashraf, 2012).
One of the key applications of lean management is VSM. It helps to identify each process
step at an organization. This map makes all actors at the supply chain, to understand the
production or service process line and with the elimination of non-value added activities to
improve it. Workers from different actors should come together to study on VSM to improve
the process via lean thinking. VSM should be very detailed to show every kind of non-value
added activities to make a big change in the whole picture. These small activities have to be
decided if they add any value to the patient in a hospital process or not. If the activity
creates a value then it should remain in the process flow. After current state analysis, future
maps are drawn to see the improvement and this step should be repeated to reach ideal state
(Gellad and Day, 2016).
VSM is being used in different areas also for healthcare systems. Hoffmann studied HIV Radiology
services to observe medical processing time for each step in South Africa (Hoffmann et al., department
2018). Ramaswamy studied at Kenya, for quality improvement of a healthcare system with
the light of lean principles and VSM (Ramaswamy et al., 2017).
Customer
(Infrastructure WHATs HOWs
User) Input
WHAT-1 HOW-1
Prioritize
Correlation
WHAT-n HOW-n
Relationship Absolute
Weights
Ranking
Figure 2.
Steps of QFD
Source: Bolar et al. (2017)
BPMJ was applied to the Maltese hospital to validate its efficiency (Buttigieg et al., 2016). Another
26,3 study used QFD to convert residents’ needs to technical properties to improve municipality
works at a Swedish urban community (Kullberg et al., 2013).
House of quality
According to the aim non-value added processes, which extends lead time unnecessarily,
have to be eliminated or minimized. HOQ will help to understand customer needs
and prefer which area to improve primarily. The reference signs of HOQ are defined
at Figure 4.
With the help of experts in their study area, doctors, personnel, academicians, has
decided the correlation weight between different customer needs and improvement area.
At the end the priority is clearly occurred by the HoQ calculations. The HoQ is given in
Figure 5. This HoQ shows patient requirements and relations between technical properties
of the radiology department and relative weights of these relationships. As a technical
property, cabinets are strongly related to the examination moment and the privacy of the
patient. A new digital mammography device is strongly in relation with the patient needs
of taking the service on time and relying to the test. Another very important technical
property is radiologist’s experience that effects nearly every patient requirement.
The experience and training are very important to do the screening process in a quickly
and truly manner. Percentage of a technical requirement weight is represented
by the relative weight score, which is the rate of importance weight to the total weight
(Camgöz-Akdağ et al., 2016).
The calculations show different levels of relative weight, which are related to the
technical requirement. Technical requirement is defined according to customer needs. The
Radiology
department at the Patient
hospital
Registration Examination Mammography Registration Intern Preparation Test Dressing up Report Report Doctor Medication Ultrasound Registration Registration Test Doctor
desk desk desk result date desk desk
Cycle Time CT: 5.1 min CT: 3 min CT: 2.5 min CT: 0.7 min CT: 4 min CT: 7 min CT: 3 min CT: 7 min CT: 5 min CT: 3 min CT: 3 min CT: 5 min CT: 2 min CT: 3.5 min CT: 8 min CT: 5 min
(CT): 0.5 min
0.5 min 5.1 min 3 min 2.5 min 0.7 min 4 min 7 min 3 min 7 min 5 min 3 min 3 min 5 min 2 min 3.5 min 8 min 5 min
2 min 2 min 5,760 min 3 min 1.2 min 1 min 1 min 0.25 min 5,760 min 2 min 2 min 5,760 min 3 min 1.2 min 1 min 1 min
department
Radiology
791
Figure 3.
Current state map
BPMJ Process name Cycle time (minutes)
26,3
Registration desk 0.5
Examination 5.1
Mammography desk 3.0
Registration desk 2.5
Intern 0.7
792 Preparation 4.0
Test 7.0
Dressing up 3.0
Report 7.0
Report result 5.0
Doctor 3.0
Medication 3.0
Table I. Ultrasound date 5.0
Cycle times of the Registration desk 2.0
radiology department Registration desk 3.5
process steps in the Test 8.0
current state Doctor 5.0
Legend
Strong Relationship 9
Moderate Relationship 3
Work Relationship 1
Positive Correlation
Negative Correlation
Objective is To Minimize
Figure 4. Objective is To Maximize
House of quality-sign
descriptions Objective is To Hit Target
results of the HoQ give priority to “Radiologist Experience” with 13.4 relative weight. Then,
the second more important subject is “Appointment Duration,” which is a big problem for
patients to wait for a long time even the illness continues. Also this problem is clear in the
current state map.
It can be said that training is more important than other factors as seen from HoQ.
The technical side of reporting comes after which can be defined as “instant reporting.” The
manual reporting, doctor dictates to a nurse, takes so much time that the patient is not able
to get the report on the same day. New dictation technologies may be considered to use at
the radiology department.
Another important factor is “Database.” Lack of database causes missing information
about the patient, and this situation causes duplication of tests or false measurements.
These problems will be considered for future improvement at the radiology department.
Radiology
++ ++ department
++
++ +
++ ++
+ ++ + + ++
–– ++ ++ ++ 793
+ –– –– ++
++ ++ ++ –– ++ ++ +
Column no. 1 2 3 4 5 6 7 8 9 10
Direction of Improvement:
Minimize (▼), Maximize (▲) or Target (x)
Quality
Requirements” or
Radiologyst Experience
True Test Requirement
Appointment Duration
Weight/Importance
Instant Reporting
Relative Weight
Demanded Quality
Database
Cabinets
Hygiene
Row no.
(a.k.a. “Customer
Requirements” or
“Whats”)
1 9 5, 6 2, 0 Guidance
2 9 2, 8 1, 0 Registration Moment
6 9 8, 3 3, 0 Radiologyst Attitude
Difficulty
(0 = Easy to Accomplish, 10 = Extremely Difficult)
Figure 5.
Max Relationship Value in Column 9 9 9 9 9 9 9 9 9 9 House of
Weight/Importance 438, 9 516, 7 655, 6 300, 0 688, 9 566, 7 455, 6 522, 2 366, 7 700, 0 quality (HoQ)
Relative Weight 8, 4 9, 9 12, 6 5, 8 13, 2 10, 9 8, 7 10, 0 7, 0 13, 4
794
BPMJ
Figure 6.
Future state map
Radiology
department at the Patient
hospital
Cycle Time CT: 5.1 min CT: 3 min CT: 2.5 min CT: 2 min CT: 6 min CT: 2 min CT: 5 min CT: 2 min CT: 3 min CT: 3 min CT: 5 min CT: 2 min CT: 3.5 min CT: 8 min CT: 5 min
(CT): 0.5 min
0.5 min 5.1 min 3 min 2.5 min 2 min 6 min 2 min 5 min 2 min 3 min 3 min 5 min 2 min 3.5 min 8 min 5 min
2 min 2 min 1,440 min 4 min 0.25 min 1,440 min 2 min 2 min 1.2 min 1 min 1 min
1,440 min 3 min
Process name Cycle time (minutes)
Radiology
department
Registration desk 0.5
Examination 5.1
Mammography desk 3.0
Registration desk 2.5
Preparation 2.0
Test 6.0 795
Dressing up 2.0
Report 5.0
Report result 2.0
Doctor 3.0
Medication 3.0
Ultrasound date 5.0 Table II.
Registration desk 2.0 Cycle times of the
Registration desk 3.5 radiology department
Test 8.0 process steps in the
Doctor 5.0 future map
nearly 4 days at the current situation that means extending the treatment process. With the
correct arrangement of appointments and the required test plan, patients will come on
time and will not wait for long queues. In front of the mammography and ultrasound rooms
there may be electronic screens to show the coming appointment. This will also improve
satisfaction at a less crowded hospital isle.
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