Bakgrund: Inom SVF för bröstcancer är målet att 80 procent av alla patienter med välgrundad misstanke om cancer inom 28 kalenderdagar ska få påbörja sin första behandling. Region Kronoberg har inte lyckats uppnå målet, vilket är en problematik som grundar sig i resursbrist, ofullständig samordning och koordinering samt en funktionsorienterad struktur. Användningen av vårdlogistiska verktyg och teorier kan bidra till att identifiera vårdförloppets utmaningar samt bidra till förbättra dem.  Syfte: Ur ett logistiskt perspektiv syftar studien till att identifiera utmaningar för Region Kronobergs standardiserade vårdförlopp för bröstcancer. Förbättringsförslag för dessa utmaningar kommer att undersökas och presenteras, för att kunna bidra till att Region Kronoberg närmar sig målet om att 80 procent av alla patienter med välgrundad misstanke om bröstcancer ska få påbörja behandling inom 28 dagar.  Metod: Studiens metod utgör en kvalitativ fallstudie med en deduktiv ansats, där primärdata har samlats in genom semistrukturerade och ostrukturerade intervjuer. Utöver primärdata har även sekundärdata från Cancercentrums och Region Kronobergs statistik samlats in. För att besvara studiens forskningsfrågor har dessa analyserats i relation till studiens teoretiska referensram, som utgörs av vetenskapliga artiklar och litteratur.  Slutsats: Ett antal utmaningar har identifierats inom SVF för bröstcancer, inklusive resursbrist och problem med remitteringshantering. En funktionsorienterad struktur och långa beslutsvägar hindrar utvecklingsarbetet. För att närma sig det nationella målet föreslås användning av Theory of Constraints, ett standardiserat system för att skicka remisser, kapacitetsplanering, en större grad av processorienterad struktur, förbättrad kommunikation samt lean healthcare-konceptet.  Studiens bidrag: Resultatet kan ha praktisk betydelse för att väcka diskussion och väcka frågor som kan stimulera till ytterligare forskning inom vårdlogistik och SVF. Teoretiskt kan studien bidra till att skapa medvetenhet och driva förändringar, vilket kan bidra till effektivisering.  Nyckelord: Flaskhals, Kapacitetsplanering, Koordinering, Lean healthcare, Process management, Samordning, Standardisering, Supply chain management, Theory of constraints / Background: Within the CCP for breast cancer, the goal is for 80 percent of all patients with well-founded suspicion of cancer to initiate their first treatment within 28 calendar days. Region Kronoberg has not been able to achieve this goal, which stems from resource constraints, incomplete coordination and a function-oriented structure. The use of healthcare logistics tools and theories can help identify challenges and contribute to their improvement.  Purpose: From a logistics perspective, identify challenges in Region Kronoberg's standardized care pathway for breast cancer. Improvement proposals for these challenges will be explored and presented to help Region Kronoberg get closer to the goal of ensuring that 80 percent of all patients with well-founded suspicion of breast cancer initiate treatment within 28 days.  Method: The study employs a qualitative case study with a deductive approach, where primary data has been collected through semi-structured and unstructured interviews. In addition, secondary data as statistics have been collected from the Cancer Center and Region Kronoberg. To address the research questions, these data sources have been analyzed in relation to the study's theoretical framework, consisting of scientific articles and literature.  Conclusion: Several challenges have been identified within the CCP for breast cancer, including resource shortages and issues with referral management. A function-oriented structure with long decision-making processes hinder improvement efforts. To approach the national goal, the use of  TOC, a standardized referral system, capacity planning, a higher degree of process-oriented structure, improved communication, and lean healthcare concept are suggested.  Contribution: The results may have practical implications for initiating discussions and raising questions that can stimulate further research in healthcare logistics and CCP. Theoretically, the study can contribute to raising awareness and driving changes, which can lead to streamlining and efficiency improvements.  Keywords: Bottlenecks, Capacity planning, Coordination, Lean healthcare, Process management, Standardization, Supply chain management, Theory of Constraints

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

Bakgrund: I sjukhusets unika miljö kan vikten av effektiva flöden ha avgörande betydelse för liv eller död. Förutsättningarna för logistiken i ett sjukhus är föränderlig och för att hänga med i olika förbättringstekniker måste sjukhusen utvecklas. Lösningen kan vara lean i sjukvård, men forskningen inom området är begränsad, vilket ger upphov till fortsatta studier inom ämnet.   Syfte: Studien syftar till att ge utökad kunskap om lean genom att ta reda på utmaningar för samordning av två varuförsörjningsflöden samt identifiera faktorer för effektiv varuförsörjning inom sjukvården. Metod: För att besvara syftet och forskningsfrågorna har en abduktiv ansats använts, där litteraturen inhämtats parallellt med empirisk data från en fallstudie på Gävle sjukhus. Teori från litteraturen och resultatet från fallstudien har analyserats, diskuterats och utifrån analysen har en slutsats utarbetats. Resultat: Studiens resultat är en värdeflödesanalys av processen för den interna varuförsörjningen av förbrukningsartiklar på Gävle sjukhus. Genom kartläggningen åskådliggörs slöserier som de separata flödena ger upphov till.     Begränsningar: Området för lean och logistik i sjukvård är delvis outforskat och området är i behov av utvecklad kunskap. Då sjukhusets avdelningar tycks ha olika hantering för den interna varuförsörjningen hade ett utökat antal inkluderade informanter varit gynnsamt för studien. Implikationer: Studien utökar kunskapen för ämnet genom att identifiera utmaningar med arbetskulturen samt svårigheter i att standardisera processer och eliminera slöserier. Studien identifierar därtill informationsflöde, systemstöd och värdeflödesanalys som betydelsefulla faktorer för effektiv varuförsörjning på ett sjukhus. Dessutom definieras ett uttryck för logistiken i sjukhus – sjukhuslogistik. / Background: In the unique environment of a hospital the importance of efficient logistics can be a matter of life and death. The conditions for the logistics in a hospital are constantly changing and to keep up with progress being made in different techniques of improvement hospitals must evolve. The answer could be lean healthcare but the research in this area is limited and thus more studies are required. Purpose: This study aims to broaden the knowledge about lean healthcare, through exploring the challenges involved with coordination of supply flows and also by identifying success factors of efficient supply flows. Method: To answer the purpose and the research questions the study utilizes an abductive approach where the literature has been acquired in parallel with the empirical data from a case study made on Gävle hospital. Both theoretical and empirical data has then been analyzed and through this analysis a conclusion has been formed. Findings: The study is made by a value stream mapping of the internal supply chain of consumable goods at Gävle hospital. Through the mapping numerous areas of waste can be identified, which is the result of having separate supply chains. Limitations: More research in the area of using lean and logistics in combination with healthcare are still needed. Since management of the internal supply chain varies at the different hospital departments an increased number of informants would have been favorable for the study. Implications: This paper explores the topic by identifying challenges within the work culture, difficulties with standardization of processes and eliminating waste. The study also identifies flow of information, system support and value stream mapping as success factors for an efficient internal supply chain within a hospital. Because there is a lack of vocabulary for describing the area of healthcare logistics in the Swedish Language, a definition for this is also contributed in the study.

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

Made available in DSpace on 2016-06-02T19:48:25Z (GMT). No. of bitstreams: 1 6129.pdf: 11930388 bytes, checksum: 9c57a3ab9291678573bfcf44623bc50f (MD5) Previous issue date: 2014-02-24 / The dissertation presented here is entitled Lean Healthcare: strategy for qualifying management in healthcare and nursing, and it was aimed at implementing and evaluating the application of the lean methodology principles to improve both the managerial work process of nurses and healthcare quality. It all started from the idea that managers of healthcare organizations need to apply management tools which enable the assessment of their organizational processes, thus ensuring that the services rendered to the population have the best possible quality. In this sense, the lean healthcare system is presented as a philosophy, a management method with a set of tools which come from lean production and were introduced in healthcare scenarios as a possible alternative to change the way these organizations are managed. Given this context, nurses are presented as central professionals who seek to articulate management and assistance dimensions in healthcare, which makes maintaining the quality of services rendered dependent basically on remaining close to patients. Bringing the nursing management practice and lean methodology into focus as potential tools for process improvement led to the implementation of such methodology practices and tools in this investigation. This is an applied research, exploratory and the case study type. It is divided into three stages: 1) mapping of processes, 2) modeling of processes, and 3) practical application of lean tools and practices. In order to achieve the proposed objectives and confirm the hypothesis, the theoretical and methodological framework of Lean Healthcare was used in all stages of the research, as well as the supporting methods Business Process Modeler Notation and the Bizagi® software in the second stage and the management improvement tool Plan-Do-Check-Act in the third stage. Data analysis proceeded with a qualitative and quantitative approach. The results of the first two stages indicated that the work management process of nurses Management in Nursing Personnel Schedule should be studied in depth in the third stage. Lean principles guided the analysis of the situation encountered and the proposition of the future situation. Its practices and applied tools led to a reduction of 94% in the amount of time nurses spend on activities that were not worthwhile as well as to reducing waste inherent in their management work process. It was concluded that nurses can act effectively to promote best practices and contribute substantially to the change process in healthcare. The results are promising as they indicate a path to implement lean practices in healthcare, starting with small problems. However, the research suggests that the motivation to seek improvements must be systemic and therefore lean healthcare can be adopted as a management strategy focused on creating value for patients, improving healthcare management and assistance essentially. / A dissertação que aqui se apresenta intitula-se Lean Healthcare: estratégia para a qualificação da gestão em saúde e enfermagem e teve como principal objetivo implementar e avaliar a aplicação dos princípios da metodologia lean para a melhoria do processo de trabalho gerencial do enfermeiro e da qualidade da assistência em saúde. Partiu-se da concepção de que os gestores das organizações de saúde necessitam aplicar ferramentas gerenciais que possibilitem a avaliação dos seus processos organizacionais, garantindo que os serviços prestados à população tenham a melhor qualidade possível. Nessa direção, o sistema lean healthcare é apresentado enquanto uma filosofia, um método de gestão com um conjunto de ferramentas provenientes da produção enxuta e introduzidas nos cenários da saúde como um possível caminho para mudar a forma com que essas organizações são gerenciadas. Diante deste contexto, o enfermeiro é apresentado como um profissional central, que busca articular as dimensões gerencial e assistencial do cuidado, o que faz com que a manutenção da qualidade do serviço prestado dependa basicamente da sua permanência junto ao paciente. Focalizando a prática gerencial do enfermeiro e a metodologia lean como ferramenta potencial para a melhoria de processo é que se procurou implementar práticas e ferramentas dessa metodologia nesta investigação. Trata-se de uma pesquisa aplicada, exploratória e do tipo estudo de caso. Encontra-se dividida em três etapas: 1) mapeamento de processos; 2) modelagem de processos e; 3) aplicação prática de ferramentas e práticas lean. Para alcançar os objetivos propostos e confirmar a hipótese levantada utilizou-se do referencial teórico-metodológico Lean Healthcare em todas as etapas da pesquisa, os métodos apoiadores Business Process Modeler Notation e software Bizagi® na segunda etapa, e a ferramenta de gestão de melhoria Plan-Do-Check-Act na terceira etapa. A análise dos dados procedeu com abordagem qualitativa e quantitativa. Os resultados das duas primeiras etapas apontaram para o processo gerencial do trabalho do enfermeiro Gestão da Escala de Pessoal de Enfermagem para ser estudado em profundidade na terceira etapa. Os princípios lean nortearam a análise da situação encontrada e a proposição da situação futura. Suas práticas e ferramentas aplicadas levaram à redução de 94% do tempo do enfermeiro gasto com atividades que não agregavam valor e redução dos desperdícios inerentes ao seu processo de trabalho gerencial. Concluiu-se que o enfermeiro pode agir efetivamente em prol das melhores práticas e contribuir substancialmente para o processo de mudança na saúde. Os resultados são promissores ao indicar um caminho para implementar a prática lean na saúde, começando por pequenos problemas. Contudo, a pesquisa aponta que a motivação para buscar melhorias deve ser sistêmica e, assim, o lean healthcare pode ser adotado como uma estratégia de gestão centrada na criação de valor para o paciente, melhorando essencialmente a gestão e a assistência à saúde.

A crescente demanda por serviços de saúde, juntamente com a necessidade de proporcionar um cuidado com qualidade e com segurança, trazem desafios para as instituições que trabalham nessa área. Buscando-se soluções para esse problema, hospitais vêm aderindo a filosofia Lean Healthcare (LH), contudo é necessário ressaltar a dificuldade que essas aplicações podem ter, em longo prazo, por ser uma abordagem distinta da gestão tradicional e não levar em consideração a natureza complexa da saúde. Esse estudo buscou em desenvolver um Framework para análise e intervenção em Sistemas Complexos (SC), por meio da integração entre princípios de gestão de sistemas enxutos e princípios da ciência da complexidade. Para isso, lançou-se mão de métodos, como mapeamento de fluxo de valor, mapeamento de processos e Functional Resonance Analysis Method (FRAM). O Framework proposto estruturou-se em 6 etapas, sendo construído por meio da Design Science Research. O estudo aplicado ocorreu em um hospital universitário na análise do fluxo do paciente grave do Serviço de Emergência para a Unidade de Terapia Intensiva. Como resultado dessa aplicação, foi possível identificar 16 problemas nesse fluxo, propondo-se um plano de ação para um dos problemas e simulando os potenciais impactos por meio da utilização do FRAM. Concluiu-se que é possível unificar as visões de LH e de SC, gerandose uma visão aprofundada dos problemas enfrentados no cotidiano dos serviços da saúde, criando meios para intervenções mais seguras e que proporcionem maior qualidade no cuidado prestado ao paciente. / The increasing demand for healthcare, altogether with the necessity to provide quality and secure care, bring challenges for institutions in this domain. Pursuing solutions for this problem, hospitals are implementing Lean Healthcare (LH) philosophy, although, it is important to consider difficulties that this application might have in a long term. This is due to the fact LH differs from a tradition approach and does not take in consideration the complex nature of healthcare systems. This study sought to develop a Framework for analysis and intervention in Complex Systems (CS) through integration of principals from Lean Production Management and Complex Science. In this way, methods such as Value Stream Mapping, Process Mapping, and Functional Resonance Analysis Method (FRAM) were used. The proposed Framework had six stages, been based in Design Science Research. The Framework application took place in an university hospital, focusing in the critically ill patients flow from the emergency service to the intensive therapy unit. As a result, it was possible to identify 16 problems in the flow and an action plan was proposed for one problem using FRAM for potential impacts simulation. In conclusion, the integration of LH and CS was possible, generating a deeper understanding of day-by-day problems in healthcare, creating means for secure interventions and allowing more quality in patient care.

Bakgrund: För ett sjukhus är kvalitetssäkringsarbetet en grundläggande faktor för att göra vården säker. I detta avseende nämns patientsäkerhet som en viktig faktor och med ett ökat behov i vården med omfattande personalminskningar och negativ ekonomisk utveckling skulle en metod för att leverera högre hälsovårdskvalitet till lägre kostnader vara ovärderlig. Lösningen kan vara att tillämpa lean inom sjukvården men forskningen inom detta område är begränsad, vilket ger upphov till fortsatta studier inom ämnet. Syfte: Detta arbete syftar till är att undersöka rutiner för ett sjukhus städprocess med fokus på att öka patientsäkerhet och spårbarhet kopplat till lean. Metod: I denna studie har en abduktiv ansats antagits där empiriskt material från en fallstudie på Gävle Sjukhus inhämtats parallellt med teori från litteraturen. Det empiriska materialet bygger på intervjuer och observationer och har utifrån teori från litteraturen analyserats och diskuterats, för att efter analys mynta ut i en slutsats. Resultat: Resultatet visar framförallt att bland de intervjuade respondenterna finns stora utmaningar med att säkerställa patientsäkerheten i ett sjukhus städprocess. Brist på standardiserade arbetssätt och kunskap är en avgörande faktor som denna studie visar. Begränsningar: Det korta tidsomfånget för denna studie har begränsat antalet inkluderade respondenter samt avdelningar på sjukhuset då ett utökat antal hade kunnat vara gynnsamt för studien. Slutsats: Studien identifierar utmaningar i sjukvården för att säkerställa spårbarhet och öka patientsäkerheten med möjligheter att applicera lean som ett angreppssätt. En implementering av lean i sjukvården kan vara en förbättringsstrategi men är ett relativt outforskat område och kräver fler studier. / Background: Quality assurance for a hospital is a fundamental factor in making the healthcare safe. In this regard, patient safety is mentioned as an important factor and with an increased need for healthcare with extensive staff reductions and negative economic development, a method for delivering higher health care quality at lower costs would be invaluable. The solution may be to implement lean in healthcare, but research in this area is limited, which gives rise to further studies in the subject. Purpose: This work aims to investigate routines for a hospital cleaning process with focus on increasing patient safety and traceability linked to lean. Method: In this study, an abductive approach is chosen where empirical material from a case study at Gävle Hospital was obtained in parallel with theory from the literature. The empirical material is based on interviews and observations and has been analysed and discussed on the basis of theory from the literature, to finalize a conclusion after analysis. Results: The results show that there is a major challenge to ensuring patient safety in a hospital cleaning process among the interviewed people. Lack of standardized working methods and knowledge is a crucial factor shown by this study. Limitations: The short timeline for this study has limited the number of included respondents as well as departments in the hospital. An increased number could have been advantageous for the study. Conclusion: This study identifies healthcare challenges to ensure traceability and increase the patient safety with opportunities to apply lean as an approach. An implementation of lean in healthcare could be a strategy with opportunities but the area is unexplored and requires more research.

I dag ställs höga krav på effektivitet, tillgänglighet och kvalitet inom hälso- och sjukvården. Utvecklingssatsningarna har som syfte att sträva efter en så god och kvalitativ vård som möjligt samt att använda sina resurser på ett kostnadseffektivt sätt, dock glöms ofta medarbetaren bort i dessa sammanhang. Syftet med denna magisteruppsats är att studera vilken påverkan förbättrings- och utvecklingsarbetet inom vården har på medarbetaren vid ett akutsjukhus. Studien belyser olika frågställningar såsom vad förändringarna betyder för den anställdes arbetshälsa, med avseende på stress, krav och kontroll. Ett annat syfte är att utifrån olika perspektiv belysa frågeställningen om de nya arbetsmetoderna förändrat personalens arbetsförutsättningar. Studien behandlar endast de områden som berör den anställdes påverkan inom ramen för det professionella utövandet av yrkesrollen, den behandlar ej frågeställningar om hur den anställde påverkas utanför arbetet. Studien har utförts med hjälp av en kvalitativ metodinriktning i form av en fallstudie, där två vårdavdelningar på Norrtälje sjukhus, tillhörande TioHundras sjukvårdsområde har studerats. Studien utfördes genom semistrukturerade intervjuer. Den teoretiska referensramen arbetades fram med hjälp av vetenskapliga artiklar och böcker. Resultatet visar att de anställda upplever mindre stress i arbetet efter att ett flertal förändringsprojekt har genomförts. Detta har också genererat en minskad känsla av krav och kontroll och en bättre balans i arbetslivet. Studien pekar på att de anställdas arbetsförutsättningar har förändrats i en positiv riktning genom att en tillåtande miljö för förändringar har skapats. En viktig slutsats är; för att lyckas i ett förändringsarbete i denna verksamhet är de anställdas delaktighet samt tillit till ledningen av största vikt, såväl som att förstå innebörden av att förändringsmetoderna måste anpassas till den aktuella verksamheten samt att ha en förståelse och ett förhållningssätt till den egna organisationen. / Today the high standards of efficiency; accessibility och quality within healthcare is very high. The aim for the development efforts is to seek for as good quality care as possible and to use the resources in a cost effective manner, however, the employee is often forgotten in these contexts. The aim of this master thesis is to study the impact of improvement and developments in the health sector on the employee. The study highlights different questions as: What the changes mean for the employee´s health, in terms of stress, demands and control. Another aim on the basis of different perspective is to illustrate the issue if the new methods changed the employee´s working conditions. The study covers only the areas that affect the employee´s within the professional practice of the professional role. Questions about how the employee is affected outside work will not be addressed in this thesis. The study was conducted using a qualitative method, focus in the form of a case study. Two wards at Norrtälje hospital within TioHundras healthcare field have been studied. The study was conducted through semi-structured interviews. Scientific articles and books were used for the theory study. The result shows that employees experience less stress at work, which also generates a reduced sense of demands and control. The study reveals that employee´s working conditions have changed for the better; a permissive environment for changing processes has been created. An important conclusion is; to succeed in a change process the participation of the employees and their trust in the management, is the utmost importance as well as to understand the implications of that change method must be adapted to the particular environment. It is also very important to have an understanding and an approach for its own organization.

The pressure on the healthcare sector is increasing all over the world. The amount of treatable diseases increases and the time spent with each patient decreases. As a reaction towards the way the healthcare works today, patient-centred healthcare has become increasingly popular. Bringing the patient into the centre also needs changes in the staffs’ way of working. One way of making these changes is by implementing Lean healthcare. This thesis uses a systematic review approach to find out what organisational changes have been made at hospitals where they have implemented Lean healthcare and how the implementations were done. The results showed that the most important thing was to engage the staff at an early point. Those hospitals that had representatives from all the different categories of the staff were the ones who managed to make the modifications with less effort and they also had an easier way of maintaining them. The most obvious similarities in the organisational changes the hospitals had made were that they clearly defined who were supposed to do what and that they changed the work into multi-disciplinary teams. By that the hospitals saved a lot of time both for the staff and for the patients. Lean thinking has similarities theories of cognitive science, like distributed cognition and safety barriers and it could get inspiration from these areas to enhance the implementations. There are few articles concerning the organisational changes that have been made at hospitals when implementing Lean healthcare. However the results of this thesis was that the most important thing when implementing Lean healthcare is to involve everyone at an early stage and the only way to get Lean healthcare to really work is by changing the attitude and making people realise that improvement is a never ending process. The changes that were most common among the hospitals were to clearly define and document who was supposed to do what and to change the structure to multi-disciplinary teams working together.

Submitted by Patrícia Valim Labres de Freitas (patricial) on 2016-04-01T17:52:53Z No. of bitstreams: 1 Thiago Antonio Souza.pdf: 1549573 bytes, checksum: 50bb2fe3750913e23e67747ffad33743 (MD5) / Made available in DSpace on 2016-04-01T17:52:53Z (GMT). No. of bitstreams: 1 Thiago Antonio Souza.pdf: 1549573 bytes, checksum: 50bb2fe3750913e23e67747ffad33743 (MD5) Previous issue date: 2015-12-23 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / CNPQ – Conselho Nacional de Desenvolvimento Científico e Tecnológico / Hospitais brasileiros tipicamente convivem com um desnivelamento entre capacidade e demanda. Os subsistemas público e privado são incapazes de coordenar situações de falta e excesso de capacidade identificados, de forma concomitante, em suas respectivas estruturas. Custos tornam-se um elemento focal em ambos os casos, quer visando qualidade e segurança quer visando incremento de capacidade, enfocando áreas chave do serviço hospitalar: serviços cirúrgicos, de internação, de emergência e de diagnóstico. O Lean Healthcare, neste contexto, se torna uma filosofia possível para a mudança organizacional dos processos hospitalares visando o incremento de sua eficiência. Este estudo discute a aplicação de conceitos do Lean Healthcare em serviços cirúrgicos, com base em evidências coletadas de três estudos realizados integradamente em um hospital universitário de grande porte, pertencente ao subsistema de saúde público brasileiro. O primeiro estudo enfoca a análise de eficiência do centro cirúrgico, propondo e aplicando o indicador Operating Room Effectiveness (ORE). O segundo, analisa e propõe formas de nivelar a produção (Heijunka) de cirurgias de diferentes demandas competindo pelo mesmo centro cirúrgico, em um contexto de capacidade inferior à demanda. O terceiro estudo desenvolve o conceito de Planejamento, Programação e Controle do Fluxo de Pacientes (PPCFP), com vistas ao planejamento integrado de consultas, cirurgias, pré-operatórios e aquisição de materiais. A aplicação dos modelos conceituais propostos revela potenciais vantagens, ainda a serem estudadas em amplitude e longitude como alternativa para outras organizações do setor. Como resultados locais, além do aporte de conceitos de Engenharia de Produção aplicada ao contexto de saúde, foram identificados: ganho operacional médio de 12% de eficiência nas salas de cirurgia; redução em 40% do tempo médio de espera para cirurgias eletivas; redução média de filas para consultas em 50%; melhor planejamento e controle de eficiência e produção; e economia de cerca de R$ 5.000.000,00 resultante dos três casos. / Brazilian hospitals typically work with a depression between capacity and demand. The public and private subsystems are unable to coordinate situations of shortage and excess capacity identified in their respective structures, concomitantly. Costs become a focal element in both cases, aiming to quality and safety or to increase capacity, focusing on key areas of hospital service: surgical services, admission, emergency and diagnostic. In this context, Lean Healthcare becomes an attractive philosophy for organizational change of hospital processes aiming at increasing its efficiency. This study discusses the application of Lean Healthcare concepts in surgical services, based on evidence collected from three studies integrally in a large University Hospital, part of the Brazilian public health subsystem. The first study focuses on the operating room efficiency analysis, proposing and applying the indicator Operating Room Effectiveness (ORE). The second study analyzes and proposes alternatives to level the production of surgeries (Heijunka) of different brands, competing for the same operating room, at a low capacity context. The third study develops the concept of Planning, Programming and Control of Patient Flow (PPCPF), to establish integrated planning consultations, surgeries, preoperative and acquisition of materials. The application of the proposed conceptual models reveals potential advantages, yet to be studied in amplitude and longitude as an alternative to other industry organizations. As local gains, in addition to the approximation of Industrial Engineering concepts to the health context, it have been identified: 12% increase in the surgical center’s average efficiency; 40% reduction in the average waiting time for elective surgery; 50% reduction in the number of queued consultations; better planning and control efficiency and production; and savings of about R$ 5,000,000.00 resulting from the three cases.