Submitted by Rubia Fernanda Toledo de Oliveira null (rubia_rfto@hotmail.com) on 2017-09-17T21:12:17Z No. of bitstreams: 1 DISSERTAÇÃO MESTRADO FINAL.pdf: 12884115 bytes, checksum: 32c6d00d52407caf9fc15e460b7d8e17 (MD5) / Made available in DSpace on 2017-09-19T18:44:23Z (GMT). No. of bitstreams: 1 oliveira_rft_me_guara.pdf: 12884115 bytes, checksum: 32c6d00d52407caf9fc15e460b7d8e17 (MD5) Previous issue date: 2017-08-14 / Approved for entry into archive by Monique Sasaki (sayumi_sasaki@hotmail.com) on 2017-09-19T18:44:23Z (GMT) No. of bitstreams: 1 oliveira_rft_me_guara.pdf: 12884115 bytes, checksum: 32c6d00d52407caf9fc15e460b7d8e17 (MD5) / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) / O setor de saúde no Brasil vive uma crise que se traduz por baixa qualidade, ineficiência e iniquidade. Um conjunto de fatores como, problemas ligados à demora no atendimento, insegurança do paciente, erro médico e aos crescentes custos do processo de atenção à saúde, tem constituído um obstáculo importante para que avanços maiores e mais consistentes sejam conseguidos. Uma forma de melhorar esta situação é o setor de saúde examinar seus processos operacionais e prestar cuidados de forma mais eficiente e eficaz. Nesse contexto a aplicação de conceitos, métodos e ferramentas Lean destaca-se como uma alternativa para a reestruturação dos processos de saúde, denominado por Lean Healthcare. Neste sentido a presente dissertação tem como objetivo analisar a aplicação dos conceitos e ferramentas do Lean Healthcare na melhoria do atendimento em uma unidade de Assistência Médica Especializada (AME). Se tratando dos métodos abordados, foi utilizada a técnica de pesquisa-ação, obtendo resultados desejados não apenas na solução dos problemas imediatos, mais também no aprendizado. Como resultado, uma série de melhorias foram sugeridas com base nos mapeamentos, observações in loco e entrevistas, destacando uma potencial diminuição no tempo de permanência do paciente dentro da unidade em até 18% em um dos processos, caso seja implantado. Possíveis dificuldades encontradas para uma implantação do Lean, assim como, seus benefícios e vantagens também foram apresentadas. / The health sector in Brazil is experiencing a crisis that translates into poor quality, inefficiency and inequity. A number of factors, such as delayed care delivery, patient insecurity, medical error, and the rising costs of the health care process, have been a major obstacle to greater and more consistent advances. One way to improve this situation is for the health sector to examine its operational processes and provide care more efficiently and effectively. In this context the application of Lean concepts, methods and tools stands out as an alternative to the restructuring of health processes, called Lean Healthcare. In this sense, the present dissertation aims to analyze the application of the concepts and tools of Lean Healthcare in the improvement of care in a unit of Specialized Medical Care (AME). When dealing with the methods discussed, the research-action technique was used, obtaining desired results not only in the solution of immediate problems, but also in learning. As a result, a number of improvements were suggested based on the mapping, on-site observations and interviews, highlighting a potential decrease in patient stay time within the unit by up to 18% in one of the procedures, if implemented. Possible difficulties encountered for a Lean deployment, as well as its benefits and advantages were also presented.

En kvalitetsförbättrande metod som senaste åren blivit vanlig inom Hälso- och sjukvård är Lean Healthcare - en verksamhetsfilosof som går ut på att eliminera slöseri och skapa värde för patienterna. I takt med att informationssystem och informationsteknik (IT) har utvecklats har informationsförsörjning fått en allt viktigare roll i vårdprocessen. Tidigare undersökningar visar dock att vårdpersonalen upplever att det finns många brister kopplade till informationssystem och IT. En explorativ fallstudie genomfördes där kvalitativ data samlades in med hjälp av intervjuer, dokumentstudier samt observation. Syftet var att beskriva hur informationsförsörjningen påverkats i ett kliniskt mikrosystem och i en vårdprocess som infört Lean. Resultatet visar att mikrosystemets leaninförande har fått positiva resultat inom framgångsgrupperna patienter, personal, resultat/processer/flöden och ledarskap. Däremot har information och IT haft mycket litet betydelse i förbättringsarbetet. Mikrosystemets informationsmiljö har dock förändrats, den visuella informationen har blivit mycket viktig och den analoga mer allmänna informationen har påverkats positivt.  Trots mängden analog och visuell information är det inom digitala informationssystem och dokumentation som mikrosystemet upplever att det förekommer mest slöseri. När det gäller analog information känner vårdpersonalen att de kan eliminera slöseri med hjälp av leanprinciper och metoder, exempelvis 5S. Däremot anser de inte att de har möjlighet att påverka den digitala informationen i samma utsträckning och för vårdpersonalen faller sig inte förbättring av informationsflöden lika naturligt som att förbättra patientnära aktiviteter i vårdprocessen.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Nowadays, retailers in the trade industry are focused on meeting customers’ needs, as their priority is to make as many sales per day as possible. Stockouts lead to unattended sales, which mean loss of income. This endangers the place of the MSBs in the industry. This paper aims to prove that proposing a supply management model will reduce the number of lost sales due to stockouts. For this study, we analyzed three key processes (purchasing, storage and distribution), where we identified problems such as incomplete shipments and unfulfilled POs and replacement requests. To prove the viability of our proposal, a pilot was carried out in a pharmacy that has five dispensing premises and a central warehouse, which improved its stock availability from 82% to 89.5%.

Bakgrund: Offentliga organisationer har under de senaste decennierna utsatts för förändring, detta till följd av ett ökat krav på effektivitet. Som svar på detta har styrinstrument (management verktyg) från industriella sammanhang hämtats för att bemöta denna effektivitet, ett av dessa verktyg är Lean, som i hälso- och sjukvården fått namnet Lean Healthcare. Lean kan ses vara ett koncept som färdats från tillverkningsindustrin in till hälso- och sjukvården där den översatts, något som medfört att det teoretiska ramverket översättningsmodellen används för att förstå denna översättning i hälso- och sjukvården.   Syfte: Syftet med studien är att beskriva och förklara hur olika hälso- och sjukvårdsorganisationer översätter Lean. Detta för att bidra med kunskap om vad Lean står för i hälso- och sjukvården, samt vilka möjligheter och svårigheter som existerar.   Metodval: En kvalitativ flerfallstudie har genomförts för att kunna förstår hur Lean översatts i hälso- och sjukvården. Datainsamlingen har genomförts genom semistrukturerade intervjuer på kliniknivå vilket inneburit att vi haft kontakt med läkare, sjuksköterskor, fysiker, specialistsjuksköterskor, barnmorskor samt administrativ ledning. Vi har även tagit del av olika dokument som medfört en bredare förståelse för hur översättningen sett ut.   Slutsatser: Vi har sett hur idén, Lean, genomgått olika faser i klinikerna där det översatts till att bli något eget i klinikernas lokala praktiker. Vi kan konstatera att Lean i hälso- och sjukvården blir något som står för effektivitet, processtänk, samarbete och problemlösning, standardisering, visualisering, att ledarna investerar i sina anställda samt mätning och sökande efter överlevnadsgrad. Vidare kan vi konstatera att Lean i hälso- och sjukvården skapar möjligheter då det lett till effektivare behandlingstid, bättre tillgänglighet av personal, förkortade ledtider, förbättrade patientflöden, bättre arbetsmiljö och en bättre struktur. Svårigheter som visat sig uppkomma är att finna balans och anpassning, svårigheter med professioner, svårigheter med koppling till det industriella sammanhanget samt den komplexitet som hälso- och sjukvården består av där oförutsägbara händelser ofta uppstår. / Background and discussion: Public organizations have in recent decades been subjected to change, and this is due to an increased demand for efficiency. The control instrument (management tool) from industrial settings has been taken in response to this efficiency and one of them is Lean, in Healthcare named “Lean Healthcare”. Lean can be seen as an idea that has been translated from the manufacturing industry to healthcare, and the theoretical framework translation model has been used to understand this in this paper. Purpose: The purpose of the study is to describe and explain how different healthcare organizations translate Lean. This is to provide knowledge of what Lean stands for in Healthcare, as well as the difficulties and opportunities that exist. Method: A qualitative case study has been conducted to understand how Lean is translated into Healthcare. Data has been collected through semi-structured interviews at the clinic level, which meant that we had contact with doctors, nurses, physicists, specialist nurses, midwifes and administrative management. We have also taken note of the documents that enabled us to have a broad understanding of how the translation looked which has given us an understanding of the opportunities and difficulties that existed. Conclusions: We have seen how the idea, Lean, has undergone various phases in both of the clinics, where it was translated into something local. We can conclude that Lean in Healthcare is something that stands for efficiency, the process of thinking, collaboration and problem solving, standardization, visualization, leaders investing in their employees, and measurement of quest for survival. Furthermore, we note that Lean in Healthcare creates opportunities as it leads to more effective treatment, better availability of personnel, shorter lead times, improved patient flow, better work, better structure and a better working environment. Difficulties arise as proven by finding balance and alignment, difficulties with professions, difficulties related to the industrial context and the complexity of healthcare where unpredictable events are common.

Den här studien görs som avslutande del av universitetsutbildning, kandidatprogram i Industriell teknik inom ämnesområdet kvalitetsteknik. Studien kan användas för vidare verksamhetsutveckling och analys av röntgenavdelningens behov av produktivitetsmått, vid Visby lasarett. På grund av restriktioner relaterade till covid-19, samt det geografiska avståndet mellan Göteborg och Visby, utfördes studien på distans genom datainsamling från intervjuer och enkätundersökning. Vidare samlades information från vetenskaplig litteratur, lagar, förordningar och dokumentanalys. I studien användes ett abduktivt arbetssätt genom att induktivt analysera insamlad data och utifrån det formulera lämplig teoretisk bakgrund som sedan på ett deduktivt sätt kunde användas för att generera ett resultat och förbättringsförslag. För att analysera och argumentera för erhållna resultat användes vetenskapliga forskningsstudier, kvantitativ data från organisationen och statistiska verktyg. Använda teorier för studien baseras på offensiv kvalitetsutveckling, processledning och Lean Healthcare. DASIAS modell användes som metod för att på ett systematiskt sätt arbeta med data från diagnostisering av problemet till implementerings- och uppföljningsförslag. Genom studien beaktades de etiska aspekter och alla inblandade subjekt informerades med hänsyn till informations-, konfidentialitets-, anonymitets-, objektivitets-, nyttjandes- och samtyckeskraven. Erhållna resultat i form av produktivitetsmått relaterar till processkartläggning, produktivitet, flödeseffektivitet, vårdbehov, kapacitetberäkning, patientsäkerhet och kötider. Analysen visar att valda indikatorer kan användas för att förbättra verksamheten men förutsättning till detta är bättre verksamhetsplanering och effektivare resursutnyttjande för att uppnå en hög flödeseffektivitet och produktivitet. Slutsatsen är att valda indikatorer kan nyttjas för förbättringsåtgärder samt att prioriteringsområden bör väljas enligt 10M analysen. Studien lämnar vissa obesvarade frågeställningar som presenteras som förslag till framtida studier.Nyckelord: / This study is conducted as a final part of the University candidate program Industrial engineering and within the field of study quality technology. This study is suitable for business development as well for the analysis of the X-ray department's needs for productivity measures, at Visby Hospital. The study was carried out at a distance by data collection from the interviews, questionnaire survey and document analysis. An abductive approach was used to generate a result and suggestions for improvement. To analyse and argue for results obtained, scientific research studies, quantitative data from the organization, statistical tools, tables and diagrams were used. The theories for this work are based on TQM, BPM and Lean Healthcare. DASIA's model was used as a method to work in a systematic way with data from diagnosing the problem to implementation and follow-up proposals. The study took into account the ethical aspects and all the subjects involved were informed regarding ethical requirements. Results obtained in the form of productivity measures relate to process mapping, productivity, flow efficiency, care needs, capacity calculation, patient safety and healthcare waiting time. The analysis shows that selected indicators can be used to improve the business, but a condition for this is better business planning and more efficient resource utilization. The conclusion is that selected indicators can be used for improvement measures and that priority areas should be selected according to the 10M analysis. The study leaves some unanswered issues that are presented as proposal for future studies in the discussion chapter.

Sistemas de saúde têm sido cada vez mais exigidos a serem mais eficientes, o que encorajou o uso de iniciativas de melhoria de processos. A partir de então, a Produção Enxuta (PE) surgiu como uma abordagem amplamente utilizada. Alguns resultados insatisfatórios da PE podem ser, parcialmente, explicados pela falta de considerar a complexidade dos serviços de saúde. Os sistemas de saúde são classificados como sistemas sócio-técnicos complexos (SSTC) devido à incerteza, diversidade e interações não-lineares. De acordo com a literatura, as implementações de Lean em serviços de saúde geralmente envolvem Kaizen, que tende a produzir ganhos significativos de eficiência e segurança através de mudanças relativamente pequenas e localizadas. Contudo, as melhorias locais podem implicar resultados globais indesejados, uma vez que as interações entre os elementos de sistemas complexos podem não ser lineares. Para isso, este trabalho desenvolve e aplica uma framework que visa avaliar projetos de melhoria em SSTC. O estudo foi realizado em uma unidade de internação de um hospital escola. As interações entre os projetos foram modeladas através do desenvolvimento de um diagrama de loop causal, o qual representou variáveis relacionadas a cinco projetos de melhoria analisados e um modelo FRAM. Os projetos também foram avaliados quanto ao seu impacto no sistema e sua adesão a boas práticas em Kaizen, identificadas na literatura. A framework demonstrou-se eficaz em elencar as variáveis para que possam influenciar positivamente os resultados dos projetos e embasar recomendações para a condução de novos projetos de melhoria por meio de uma visão sistêmica. / Healthcare systems have been increasingly demanded to be more efficient, which has encouraged the use of process improvement initiatives. From these, lean production has emerged as a widely used approach. Some disappointing results of lean production can be partially due to the lack of consideration of the complexity of healthcare. Health systems are classified as Complex socio-technical systems (CSTS) due to the uncertainty, diversity, and non-linear interactions. According to the literature, the implementation of Lean in healthcare usually involves Kaizen, which tends to produce significant gains in efficiency and safety through relatively small and localized changes. However, local improvements may imply unwanted overall results, since interactions between elements of complex systems may not be linear. For this, this work develops and applies a framework that aims to evaluate improvement projects in CSTC. The study was performed in an in-patient surgical ward of a teaching hospital. The interactions between the projects were modelled through the development of a causal-loop diagram, which accounted for variables related to all five projects, and a FRAM model. The projects were also evaluated as to their impact on the system and their adherence to good Kaizen practices identified in the literature. The framework proved to be effective in highlighting the variables so that they can positively influence the projects results and support recommendations for conducting new improvement projects through a systemic view.

Sistemas de saúde têm sido cada vez mais exigidos a serem mais eficientes, o que encorajou o uso de iniciativas de melhoria de processos. A partir de então, a Produção Enxuta (PE) surgiu como uma abordagem amplamente utilizada. Alguns resultados insatisfatórios da PE podem ser, parcialmente, explicados pela falta de considerar a complexidade dos serviços de saúde. Os sistemas de saúde são classificados como sistemas sócio-técnicos complexos (SSTC) devido à incerteza, diversidade e interações não-lineares. De acordo com a literatura, as implementações de Lean em serviços de saúde geralmente envolvem Kaizen, que tende a produzir ganhos significativos de eficiência e segurança através de mudanças relativamente pequenas e localizadas. Contudo, as melhorias locais podem implicar resultados globais indesejados, uma vez que as interações entre os elementos de sistemas complexos podem não ser lineares. Para isso, este trabalho desenvolve e aplica uma framework que visa avaliar projetos de melhoria em SSTC. O estudo foi realizado em uma unidade de internação de um hospital escola. As interações entre os projetos foram modeladas através do desenvolvimento de um diagrama de loop causal, o qual representou variáveis relacionadas a cinco projetos de melhoria analisados e um modelo FRAM. Os projetos também foram avaliados quanto ao seu impacto no sistema e sua adesão a boas práticas em Kaizen, identificadas na literatura. A framework demonstrou-se eficaz em elencar as variáveis para que possam influenciar positivamente os resultados dos projetos e embasar recomendações para a condução de novos projetos de melhoria por meio de uma visão sistêmica. / Healthcare systems have been increasingly demanded to be more efficient, which has encouraged the use of process improvement initiatives. From these, lean production has emerged as a widely used approach. Some disappointing results of lean production can be partially due to the lack of consideration of the complexity of healthcare. Health systems are classified as Complex socio-technical systems (CSTS) due to the uncertainty, diversity, and non-linear interactions. According to the literature, the implementation of Lean in healthcare usually involves Kaizen, which tends to produce significant gains in efficiency and safety through relatively small and localized changes. However, local improvements may imply unwanted overall results, since interactions between elements of complex systems may not be linear. For this, this work develops and applies a framework that aims to evaluate improvement projects in CSTC. The study was performed in an in-patient surgical ward of a teaching hospital. The interactions between the projects were modelled through the development of a causal-loop diagram, which accounted for variables related to all five projects, and a FRAM model. The projects were also evaluated as to their impact on the system and their adherence to good Kaizen practices identified in the literature. The framework proved to be effective in highlighting the variables so that they can positively influence the projects results and support recommendations for conducting new improvement projects through a systemic view.

Sistemas de saúde têm sido cada vez mais exigidos a serem mais eficientes, o que encorajou o uso de iniciativas de melhoria de processos. A partir de então, a Produção Enxuta (PE) surgiu como uma abordagem amplamente utilizada. Alguns resultados insatisfatórios da PE podem ser, parcialmente, explicados pela falta de considerar a complexidade dos serviços de saúde. Os sistemas de saúde são classificados como sistemas sócio-técnicos complexos (SSTC) devido à incerteza, diversidade e interações não-lineares. De acordo com a literatura, as implementações de Lean em serviços de saúde geralmente envolvem Kaizen, que tende a produzir ganhos significativos de eficiência e segurança através de mudanças relativamente pequenas e localizadas. Contudo, as melhorias locais podem implicar resultados globais indesejados, uma vez que as interações entre os elementos de sistemas complexos podem não ser lineares. Para isso, este trabalho desenvolve e aplica uma framework que visa avaliar projetos de melhoria em SSTC. O estudo foi realizado em uma unidade de internação de um hospital escola. As interações entre os projetos foram modeladas através do desenvolvimento de um diagrama de loop causal, o qual representou variáveis relacionadas a cinco projetos de melhoria analisados e um modelo FRAM. Os projetos também foram avaliados quanto ao seu impacto no sistema e sua adesão a boas práticas em Kaizen, identificadas na literatura. A framework demonstrou-se eficaz em elencar as variáveis para que possam influenciar positivamente os resultados dos projetos e embasar recomendações para a condução de novos projetos de melhoria por meio de uma visão sistêmica. / Healthcare systems have been increasingly demanded to be more efficient, which has encouraged the use of process improvement initiatives. From these, lean production has emerged as a widely used approach. Some disappointing results of lean production can be partially due to the lack of consideration of the complexity of healthcare. Health systems are classified as Complex socio-technical systems (CSTS) due to the uncertainty, diversity, and non-linear interactions. According to the literature, the implementation of Lean in healthcare usually involves Kaizen, which tends to produce significant gains in efficiency and safety through relatively small and localized changes. However, local improvements may imply unwanted overall results, since interactions between elements of complex systems may not be linear. For this, this work develops and applies a framework that aims to evaluate improvement projects in CSTC. The study was performed in an in-patient surgical ward of a teaching hospital. The interactions between the projects were modelled through the development of a causal-loop diagram, which accounted for variables related to all five projects, and a FRAM model. The projects were also evaluated as to their impact on the system and their adherence to good Kaizen practices identified in the literature. The framework proved to be effective in highlighting the variables so that they can positively influence the projects results and support recommendations for conducting new improvement projects through a systemic view.

El presente estudio se llevó a cabo en el departamento de emergencia y cuidados críticos del Hospital Nacional Hipólito Unánue, hospital de tercer nivel de atención. El motivo del estudio se basó en realizar una mejora en los procesos buscando una excelencia operativa que permita reducir los tiempos de espera, mejorar el manejo de información y eliminar actividades que no generen valor en los procedimientos. Para llevar a cabo el proyecto se utilizó diversas herramientas de la técnica Lean HealthCare con la finalidad de eliminar las ineficiencias y lograr que todo el trabajo realizado proporcione valor y cumpla con las necesidades de los pacientes. En primer lugar, se realizó un estudio de las técnicas lean y de la situación actual de la institución en estudio. Posteriormente se realizó un diagnóstico mediante una simulación de la situación actual y analizar las causas raíces de los problemas que se suscitan en el centro de salud. Seguido de ello se evaluó la situación actual del área e identificar los puntos de mejora buscando brindar una atención en el menor tiempo posible. Finalmente se realizaron mejoras, ya que se redujeron los tiempos de atención y se mejoraron los procedimientos de atención que se realizan en el departamento de emergencia y cuidados críticos más eficiente y eficaz. / The present study was carried out in the emergency and critical care department of the Hipolito Unanue National Hospital, a third-level care hospital. The reason for the study was based on making an improvement in the processes seeking operational excellence that allows to reduce waiting times, improve the handling of information and eliminate activities that do not generate value in the procedures. To carry out the project, various tools of the Lean HealthCare technique were used in order to eliminate inefficiencies and ensure that all the work done provides greater value and meets the needs of patients. In the first place, a study of the lean techniques and the situation of the institution under study was carried out. Subsequently, a diagnosis was made through a simulation and the root causes of the problems that arise in the health center were analyzed. Following this, the points of improvement were evaluated and identified, seeking to provide attention in the shortest possible time. Finally, improvements were made, since the attention times were reduced and the care procedures performed in the emergency department and critical care were improved. / Trabajo de Suficiencia Profesional

Inom den svenska offentliga sjukvården har det under en längre tid implementerats ett antal olika styrmedel som i grunden är skapade för den privata industrin. Dessa styrmedel går under samlingsnamnet New Public Management (NPM) och riktar in sig på att rationalisera bort icke värdeskapande aktiviteter i verksamheten. Under de senaste åren är det framförallt Lean som har varit det populäraste NPM-styrmedlet inom svensk sjukvård. Det finns idag forskning kring Lean Healthcare ur ett globalt perspektiv, främst från USA och England, men relativt lite forskning finns kring hur Lean Healthcare har påverkat den svenska offentliga sjukvården. Vi har i denna studie valt att genom en fallstudie på Region Västerbotten undersöka hur implementeringen av Lean Healthcare har påverkat organisationen, och hur denna process har upplevts av tjänstemän i organisationen. Åtta personer med koppling till Region Västerbotten har genom semi-strukturerade intervjuer fått redogöra för hur de upplever att deras vardag påverkats av implementeringen av Lean, samt om de upplever att arbetet med Lean hittills kan anses ha varit framgångsrikt. Dessa åtta intervjupersoner är tjänstemän i chefsställning inom Region Västerbotten som på olika sätt har varit en del av processen från det att beslutet om att en implementering ska ske, till att nu idag kunna följa det dagliga arbetet med Lean på ett flertal avdelningar inom Region Västerbotten. Det visade sig under arbetets gång att intervjupersonerna är eniga om att implementeringen av Lean har haft en positiv inverkan på arbetet inom kärnverksamheten. Här nämns framför allt att det är positivt att nya tankar och idéer kring hur vården ska bedrivas är av godo, och på så vis undvika att hämma utvecklingen av vårdarbetet. Den kritik som riktats mot Lean menar de medverkande intervjupersoner främst brukar framkomma initialt i implementeringsprocessen för att sedan avta i takt med att Lean etablerats inom verksamheten. Den kritik som idag ännu finns inom organisationen är vanligast på de avdelningar som ännu inte helt har kommit ur implementeringsfasen.