Similar to other healthcare systems worldwide, Kuwait faces challenges of increased demand and cost while trying to operate with constrained resources. There are some data suggesting that Lean methodology, first used by Japanese car manufacturer Toyota, could improve system efficiency or flow by waste elimination, may be useful in addressing some of the challenges found in healthcare. Lean has so far not been used in Kuwaiti primary healthcare centres. This thesis explores the case for using Lean in Kuwait by examines issues around diabetes, as Kuwait rank the six highest in the world. In Kuwait, patients with diabetes are mainly managed in primary healthcare centres. The case for using Lean was explored across five interrelated studies which are summarised below: Study 1 involved a review of the literature which found that Lean tools have been used mostly in hospital settings without any rigorous evaluation and with little or no attention paid to primary healthcare or in developing countries. Study 2 was a systematic documentary review of the challenges facing the healthcare system of Kuwait. In Kuwait, expenditure on healthcare services is expected to double within five years. Life expectancy is increasing, while the percentage of the elderly population is growing, leading to increasing demand of services to treat non-communicable disease such as diabetes. Kuwait still sends many of its patients overseas for treatment. Currently, 10 mega projects worth approximately 2 billion Kuwaiti Dinar are being constructed in Kuwait that will result in a doubling of the bed capacity. However, the average occupancy rate between 2006 to 2015 was 63.6%, which is considered low compared to the average occupancy rate in European Union countries. Study 3 sought the views of Kuwaiti healthcare leaders about Lean and challenges facing the healthcare system of Kuwait. The key findings were: (1) Most leaders agreed that the current healthcare system in Kuwait faces difficult challenges and needs to change its management approach; (2) Lean as a management approach is considered a new concept among leaders of Kuwaiti healthcare organisations; (3) They did not have adequate knowledge regarding Lean but were willing to support any future Lean improvement initiatives. Study 4 explored the knowledge of Healthcare Workers regarding Lean within Kuwait’s primary healthcare centres through a cross-sectional survey in four primary healthcare centres. Only 11% of participants were familiar with Lean. None of the participants were involved or had an ongoing Lean initiative or project but 80% of participants were willing to be involved in future Lean initiatives. Study 5 mapped the flow of patients with type 2 diabetes in primary healthcare centres to identify potential waste and make recommendations for improvement. Patients with type 2 diabetes typically visit their General Practitioner at least every two months for a review appointment. When a blood test is required to monitor blood sugar levels, three more visits are required, involving the blood test, collection of test results by the patient and a review of the results with the general practitioner. Four potential improvements were identified: using point of care testing, the posting of laboratory results to general practitioner computer systems, the introduction of guidelines that standardise the practice for the patient’s visit and permitting the general practitioner to prescribe medication that will last four months. The process map of patients with type 2 diabetes has highlighted waste and improvement suggestions that may reduce workload, enhance patient satisfaction, avoid unnecessary visits, enhance the timeliness of laboratory testing, improve communication between and across departments and minimise the use of resources without undermining the quality of care. These suggestions, if implemented on the national level, could bring tremendous benefits but still need to be rigorously evaluated. The thesis concludes by noting that there is considerable potential in adopting Lean to improve the healthcare services in Kuwait, but further work is required to implement the changes and rigorously evaluate them.

Thesis (PhD)--Stellenbosch University, 2013. / ENGLISH ABSTRACT: This PhD study investigated the organisational structure of medical communicative facilities and the related communicative experiences of health care providers and patients in HIV and AIDS care centres where there is language discordance between physicians and patients. Such discordance refers specifically to communication in contexts where patients and health care providers speak a number of different, mostly mutually unintelligible first languages (L1s) and where speakers have varying levels of proficiency in a lingua franca such as English. This study considers key moments within the organisational communication structure to assess how well the structure meets its communicative aims. The sites of care that provided empirical data in this study, were a public health clinic which is a division of a state hospital, and a privately run day care clinic both located near Maseru, the capital city of Lesotho. The participants were drawn from four categories, namely physicians, nurses, lay interpreters and patients. Data collection was done through semi-structured interviews, focus group discussions and direct observations of the study sites. The data was later transcribed interpreted and analysed according to insights gained from Organisation Theory on the one hand and Thematic Analysis and Qualitative Data Analysis on the other hand. The most important result of the study is the recognition of organisational fragmentation of care into different units which helps to facilitate communication where patients and physicians show marked language discordance. Further results illuminate several challenges that are encountered by participants in mediating and making meaning where language diversity is such that physicians’ linguistic repertoire does not match the repertoires of patients and local HCPs. The study highlights several institutional and interpersonal strategies that are used to overcome these challenges and to assure effective communication in the particular institutions. It also shows how some of these strategies fail to fully address the communicative challenges identified. The findings of this study suggest that in multilingual clinical contexts there is a need for more dedicated attention to interpreting practices, to the kinds of material distributed among patients and, more generally, to make consultative decisions on improved systems to put in place in order to facilitate communication related to quality health care. / AFRIKAANSE OPSOMMING: Hierdie PhD-studie het die organisatoriese struktuur van mediese kommunikatiewe geleenthede en die verwante ervarings van beroepsmense in gesondheidsorg van pasiënte in HIV-versorgingsentra ondersoek, waar die taalvaardighede van dokters en pasiënte nie gesinchroniseer is nie. Die taaldissonansie verwys spesifiek na kommunikasie in kontekste waar pasiënte en beroepsmense in gesondheidsorg 'n verskeidenheid tale praat wat meestal onderling onverstaan-bare eerste tale (T1e) is van sprekers met ongelyke vlakke van vaardigheid in 'n lingua franca soos Engels. Die studie vestig aandag op sleutelmomente binne die struktuur van die kommunikasie van die organisasie om vas te stel hoe goed die bepaalde struktuur sy kommunikatiewe doelstellinge verwesenlik. Die terreine van gesondheidsorg wat empiriese data vir hierdie navorsing voorsien het, was 'n openbare kliniek wat verbonde is aan 'n staatshospitaal, en 'n privaat dagsorgkliniek wat albei naby Maseru, die hoofstad van Lesotho, geleë is. Die deelnemers behoort aan vier kategorieë, naamlik dokters, verpleegpersoneel, leke-vertalers/-tolke en pasiënte. Data insameling is gedoen deur middel van semigestruktureerde onderhoude, fokus groepbesprekings and direkte waarrneming by die betrokke instansies. Die data is later getranskribeer, geinterpreteer en geanaliseer volgens insigte uit Organisasie Teorie aan die een kant en Tematiese Analise en Kwalitatiewe Data Analise aan die ander kant. Die belangrikste bevinding van die studie is herkenning van die organisatoriese fragmentering van die sorg in verskillende eenhede wat help om kommunikasie te fasiliteer binne ‘n konteks waar pasiënte en dokters merkbare taaldissonansie vertoon. Verdere bevindinge werp lig op verskeie uitdagings wat deelnemers ervaar in die bemiddeling en skep van betekenis waar taaldiversiteit sodanig is dat die talige repertoires van die mediese praktisyns nie aangepas is by die talige repertoires van die pasiënte of plaaslike mediese beamptes nie. Die studie vestig aandag op verskeie institusionele en interpersoonlike strategieë wat gebruik word om uitdagings te oorkom en om effektiewe kommunikasie binne die betrokke instansies te verseker. Dit wys ook hoe sommige van hierdie strategieë misluk in die aanspreek van bepaalde kommunikatiewe uitdagings. Die bevindinge bevestig dat in die omgewing van ‘n veeltalige kliniek daar ‘n behoefte is aan meer toegewyde aandag aan tolkingspraktyke, aan die soort materiaal wat onder pasiënte versprei word, en in meer algemene terme, aan die neem van besluite gegrond op konsultasie sodat verbeterde stelsels geimplimenteer kan word om kommunikasie wat verband hou met goeie kwaliteit gesondheidsorg, te help bedien. / The African Doctoral Academy for financial support