5 hours.

That is the average time taken for a patient to be examined, consulted and disposed in the emergency department.

Some patients may have to wait longer and the key factors responsible for the delays are mainly the unavailability of vehicles for transport, emergency investigations or imaging, time taken for consultation, examination of patient and the admission procedure. This happens in both private and public hospitals in Malaysia.

Long waiting times in healthcare is an important health policy issue in many countries and is the result of demand and supply imbalance. Many including Malaysia have introduced some form of national waiting time guarantees.

The length of waiting times in the ER can prove to be taxing on patients and linked to inefficiencies in health care and dissatisfaction among both patients and caregivers.

One doctor, Dr. Nor Akma bt Yusuf, Deputy Director of the Hospital Management Services unit in the Ministry of Health, set out to change this by reducing the waiting times for patients in public hospitals.

When Dr. Nor Akma proposed her transformation project - called the LEAN healthcare - , she faced scepticism and doubt. The LEAN healthcare began with a pilot project carried out at Hospital Sultan Ismail in Johor Bahru to demonstrate its 'proof of concept'. The orthopaedic specialist clinic and its oncology treatment centre were selected as its first two areas of improvement.

Colour coding to address the bed dilemma

Dr. Nor Akma's team of six first sought out the common problems faced across hospital departments to be addressed.

For example, the unavailability of beds has posed a serious problem, causing large numbers of patients to have to wait for a bed and consequently prolonging the overall waiting times. The fault lies in the inefficient discharge process in emergency departments.

"That is the issue of all our busy hospitals," she says. Patients have to wait up to six to seven hours for a bed and "it's so uncomfortable".

To address this problem, the team worked with the hospital staff to come up with cost-effective and simple solutions to make the management better. Hospitals without efficient technology were asked to improvise using traffic light coloured magnets to coordinate bed allocations.

Beds that were ready to be filled had green magnets; those that were filled with patients in care had red magnets and those with patients that were soon to be discharged, had yellow magnets.

"All that gives you a visual" edge, she says and it's a "very fast" way for nurses to allocate bedding in wards.

Transport home for older patients has also caused a delay in the discharging process. Older patients often wait on beds as it is more comfortable than standing around. Dr. Nor Akma's team suggested setting up discharge lounges for these patients who were cleared to leave, but had to wait for transport home. Discharge lounges could just consist of reclining chairs in a dedicated area for patients to rest while waiting.

Other simple solutions include placing queue display panels in canteens to tackle patient overcrowding, which allows patients to eat while waiting in turn , as well as opening up more registration counters to speed up administrative tasks.

Gaining recognition after just 6 months

Dispelling all scepticism and doubt of the project, success was recorded over a six-month period. At the oncology department, the waiting time for patients diagnosed with head and neck cancer to receive radiotherapy was reduced from four months to one month, which is the standard recommended by the World Health Organisation. At the orthopaedic specialist clinic, the waiting time was almost halved from 115 minutes to 62 minutes.

Upon receiving these encouraging results, the Ministry of Health ordered the LEAN system to be expanded to the emergency department of Hospital Tengku Ampuan Rahimah in Klang.

"The ED is the frontline of any hospital. Patients are mostly sent to the medical wards if their condition is deemed to warrant admission," said Dr. Nor Akma.

The start of the relay race to improve waiting times

Optimising patient flow through the initiatives of the LEAN project has since become the main focus from 2014. Ever since then, it was found that both patients and medical staff benefitted from the project. Patients had a reduced waiting time and work also became more efficient for the medical staff, making them happier.

Dr. Nor Akma is taking a step further by building LEAN consultancy skills within the government. Previously, her team depended on outsourced consultants and now she believes there will be a time when her team has to stand on its own.

The Ministry of Health is now looking to implement the LEAN healthcare to all public hospitals to treat patients more quickly and increase the turnover rate. Therefore, the Institute of Health Systems Research has developed a unit to carry out the training for hospitals.

The simple fixes proved useful and allowed big hospitals to make a step forward in improving waiting times. More hospitals are adopting the LEAN system and some hospitals have started training their own staff to adapt to the new system.

“It’s not just a project, but a form of knowledge transfer,” Dr. Nor Akma says. “People who are already familiar with the LEAN principles can go on and train other teams, and spread the ‘seed’ that way.” It was an epic relay race, one medical staff passing the baton to another.

However, Dr. Nor Akma believes that her efforts will be in vain if departments within hospitals do not work together. The waiting time of patients also depends on how fast labs, imaging departments and pharmacies work as the hospital processes involve "many departments which need to work together".

Targeting bigger and busier hospitals such as state and specialist hospitals for now, Dr. Nor Akma and her team of six intend to change the healthcare delivery of the whole country. As ambitious as that goal may seem, she believes her evidence base will help convince others of the benefits.

“When we first started, nobody knew what LEAN was; today, everybody understands the system,” she says, which is proof that many small steps are sometimes more efficient than one big step. MIMS


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