Submitted by Maike Costa (maiksebas@gmail.com) on 2016-04-19T13:49:51Z No. of bitstreams: 1 arquivo total.pdf: 5424467 bytes, checksum: 801d02752f22cdbc2f419432ff437a77 (MD5) / Made available in DSpace on 2016-04-19T13:49:51Z (GMT). No. of bitstreams: 1 arquivo total.pdf: 5424467 bytes, checksum: 801d02752f22cdbc2f419432ff437a77 (MD5) Previous issue date: 2015-05-27 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / The main objetive of this work is to develop a methodology for the implementation of lean manufacturing in hospital operations. For this purpose, it was initially performed an analysis of the relevant literature on the topics: lean manufacturing, hospital operations and lean services (focusing on health care services). Based on the literature, some categories of lean health were identified. The research is classified as qualitative, applied and exploratory, and was conducted through multiple case studies in three hospital operations in São Paulo state. Based on the literature and case studies, it was possible to suggest guidelines for the application of the lean techniques, organizing them in order to compose the proposed methodology for the implementation of the lean in hospital operations. First the methodology consisted of two phases: (I) initiatives to implement the lean; (II) the implementation of the lean techniques and the development of lean culture. After it was submitted to the experts' analysis on the subject (researchers, consultants and hospital management) with two goals: to be refined, or improved, based on the suggestions of the experts. The experts evaluated the methodology based on Platts’s (1993) criteria: feasibility, usability and utility. After the refinement and avaliation of the experts, the final proposal remained with the two phases, however, some suggestions were made and were considered to the upgrading of the methodology. The final methodology showed predominatly modifications in the second phase and considered the following aspects: the support of the senior management, the training of a team to manage the improvement projects, the empowerment of the improvement teams, the development of leaders in the lean technique, the binding of the implementation of the lean to the strategic planning, the performance of the improvement projects, as well as the management of all projects through the PDCA, a training program to the employees, the application of the kaizen events; the application of the Ishikawa diagram to identify the root cause of the losses and the development of appropriate performance indicators. The experts considered that the methodology: can be followed, can be easily followed and provide a useful step in the lean implementation on the operations health. / Esta dissertação tem como principal objetivo desenvolver uma metodologia para implementação da produção enxuta em operações hospitalares. Para tanto, inicialmente foi realizada a análise da literatura relevante nos temas: produção enxuta, operações hospitalares e produção enxuta em operações de serviços (com foco nos serviços de assistência à saúde). Com base na revisão da literatura foram identificadas algumas categorias de análise da produção enxuta em operações hospitalares. A pesquisa classifica-se como qualitativa, aplicada e exploratória, e foi realizada por meio de estudos de casos múltiplos em três operações hospitalares do estado de São Paulo. Fundamentando-se na literatura e nos estudos de casos foi possível sugerir diretrizes para aplicação das técnicas enxutas, organizando-as de forma a compor a metodologia proposta para implementação da produção enxuta em operações hospitalares. A proposta inicial da metodologia consistia em duas fases: inciativas para a implementação da produção enxuta; implementação das técnicas enxutas e desenvolvimento da cultura lean. Após a elaboração final, esta foi submetida a análise de especialistas no tema (pesquisadores, consultores e gestoras hospitalares) com dois objetivos: ser refinada, ou seja, aprimorada com base nas sugestões de melhoria dos especialistas; ser avaliada tomando como base os critérios sugeridos por Platts (1993): utilização prática, facilidade de uso e utilidade. Após o refinamento e avaliação dos especialistas, a proposta final permaneceu com as duas fases, entretanto foram feitas algumas sugestões, as quais foram consideradas para o aprimoramento da metodologia. A proposta final da metodologia apresentou predominantemente modificações na segunda fase e considerou os seguintes aspectos: o apoio da alta gestão; a formação e capacitação de uma equipe para gerir os projetos de melhoria; a capacitação das equipes de melhoria; o desenvolvimento de líderes em lean; a vinculação da implantação da produção enxuta ao planejamento estratégico; a implementação sistêmica; a execução dos projetos de melhoria assim como a gestão de todos os projetos por meio do PDCA; um programa de treinamento para os colaboradores; a utilização de eventos kaizen; a utilização do diagrama de Ishikawa para identificar a causa raiz das perdas; e, o desenvolvimento de indicadores de desempenho adequados. Quanto à avaliação da metodologia, os especialistas a consideraram: passível de ser utilizada na prática, fácil de ser usada e útil.

Emergency department (ED) overcrowding is a global concern. To help mitigate this issue, this thesis studies impediments to efficient patient flow in the ED caused by suboptimal worker behaviors and patient routing policies. I focus on three issues: (i) admission batching, (ii) hallway placement and (iii) under-triage behavior, and empirically demonstrate their impact on patient flow and quality of care. These studies are summarized as follows. Admissions batching: We study the behavior of admitting patients back-to-back (i.e., batching) by ED physicians. Using data from a large hospital, we show that the probability of batching admissions is increasing in the hour of an ED physician’s shift, and that batched patients experience a longer delay from hospital admission to receiving an inpatient bed. We further show that this effect is partially due to the increase in the coefficient of variation of inpatient bed-requests caused by batching. However, we also find that batching admissions is associated with a higher shift-level productivity. An important implication of our work is that workers may induce delays in downstream stages, caused by practices that increase their productivity. Hallway utilization: A common practice in busy EDs is to admit patients from the waiting area to hallway beds as the regular beds fill up. Using data from a large ED, we first perform a causal analysis to quantify the impact of hallway placement on wait times and quality of care – as defined by disposition time, room-to-departure (R2D) time and likelihood of adverse outcomes. We find that patients admitted to the hallway experience a significantly lower door-to-doctor time at the cost of longer disposition and R2D times. Hallway patients are also substantially more likely to experience an adverse outcome. Next, using a counterfactual analysis we show that a pooling policy, where hallway beds are used only if all regular beds are full, significantly reduces wait times, albeit at the cost of a slightly higher hallway utilization. Also, too little or too much wait tolerance for rooming patients may result in under- or over-utilization of the hallway space, both of which are detrimental to overall ED length of stay (LOS) and wait times. Under-triage behavior: Triaging ED patients upon arrival to the ED and assessing their urgency for treatment is crucial for timely service to all patients. Despite the standard patient classification algorithm by which all nurses are trained, we hypothesize, and show, that the ED’s workload impacts the perceived patient urgency, and subsequently, patient severity scores. We first use a predictive model to predict a patient’s true triage level using information collected at triage and define under-triage, accordingly. We find that under-triage is decreasing up to a certain point of workload but increasing after (U-shape). We also quantify the impact of under-triage on disposition time, room-to-departure time and risk of readmission. Collectively, this thesis demonstrates how patient-flow may be improved without the need to increase explicit physical capacity in the ED (e.g., beds). It offers practical solutions to managers and contributes to the operations management literature.