The current issue and full text archive of this journal is available at www.emeraldinsight.com/2040-4166.

htm

IJLSS 1,3

Decision support system and the adoption of lean in a Swedish emergency ward
Balancing supply and demand towards improved value stream
Djoko Setijono
Division of Production Economics, Linkoping University, Linkoping, Sweden

234

Ashkan Mohajeri Naraghi

PAUD RAAD Industrial Group, Tehran, Iran, and

Uday Pavan Ravipati

Gayathri Institute of Hardware Technology, Hyderabad, India
Abstract
Purpose Facilitated by a decision support system tool, the purpose of this paper is to nd the best allocated number of surgeons and medicine doctors that reduce patients non-value-added time (NVAT) and total time in the system (TTS). Design/methodology/approach Interview and observation are rst conducted in order to get general insights about (and to understand) the emergency ward of Sahlgrenska Hospital in Gothenburg (Sweden) and its value stream (ow). Then, time-related data are collected by conducting time measurements empirically and through the triage database. The statistics of the collected empirical data represent the initial state of the system and are utilised as the input of ARENAw simulation. A simulation scenario is designed by constructing a 3 3 table ( nine combinations) that contains a varying number of surgeons and medicine doctors allocated in the emergency ward. For each combination, 1,000 replications apply ( 10 runs @ 100 replications). Runs are the cycles or how many times the simulation is executed, while replications refer to how many times a computer (automatically) repeats the simulation in a single execution. The simulation length of a single replication was set at 24 hours due to the fact that an emergency ward was always open. The selected feasible solution is the best combination of surgeons and medicine doctors that reduces the existing NVAT and TTS while ensuring that the resource utilisation is at a reasonable level (and did not exceed 100 per cent). Findings The simulation output indicates that the emergency ward may achieve considerable reduction in a patients NVAT and total patients time in the system by assigning three medicine doctors and three surgeons. This combination leads to (in average) 13 per cent reduction of NVAT while maintaining the TTS at approximately the same level. Research limitations/implications An expanded simulation model with a higher level of complexity and ability to accommodate, e.g. cost of care, ow/layout reconguration would be greatly needed and is of interest. It would also be relevant to add greater exibility by assigning more parameters in the simulation model (other than medicine doctor and surgeon). Originality/value Simulation can be considered as a valuable decision-support tool in the adoption of lean in healthcare due to its exibility in the sense that it is able to show the output (outcome) of various scenarios before any actual change is made. The results of our study present another side of the adoption of lean thinking besides layoff. Keywords Lean production, Accident and emergency, Sweden, Supply and demand, Simulation Paper type Research paper

International Journal of Lean Six Sigma Vol. 1 No. 3, 2010 pp. 234-248 q Emerald Group Publishing Limited 2040-4166 DOI 10.1108/20401461011075026

1. Introduction Emergency room is characterised by, e.g. excessive waiting and overload medical personnel (Khurma et al., 2008). Waiting time usually represents the largest component of non-value-added time (NVAT) in an emergency ward. A possible major cause of this excessive waiting is imbalance between supply (available doctors) and demand (number of patients need to be served) besides other causes such as availability of other resources (e.g. examination rooms). According to Brandao de Souza (2009) and Towill and Christopher (2005), balancing demand and supply may improve patient ow by, e.g. reducing NVAT. Therefore, it is advantageous to view healthcare delivery from supply chain perspective (Parnaby and Towill, 2008). Ability to supply is very much related with capacity. Healthcare capacity measurement, in terms of resources or inputs, is particularly challenging (Bamford and Chatziaslan, 2009) because of, e.g. the direct link between effective capacity management and performance (McDermott and Stock, 2007), the interaction of capacity decisions with each other (Bamford and Chatziaslan, 2009; Gemmel and van Dierdonck, 1999) meaning that healthcare capacity management needs to consider the interdependence (interaction) among resources. A major problem experienced by the emergency ward of Sahlgrenska Hospital is that patients need to wait for hours before being examined by doctors. Owing to the emphasis on ow and viewing healthcare delivery from supply chain perspective, total patient episode viewpoint (Kujala et al., 2006) or total patient time in the system becomes necessary to be used as an additional indicator of improved patient ow. The purpose of this paper is, with the help of decision support system (DSS), to nd the best combination of resources that will reduce the NVAT and total time in the system (TTS). The denition of resources is limited to as two types of doctors (i.e. surgeon and medicine) because these doctors handle approximately 80 per cent of patients coming to Sahlgrenska emergency ward. Other resources such as nurse, assistant nurse, secretary, and examination rooms are assumed to be deterministic (static). The remainder of this paper will be arranged as follows. We rst describe lean in healthcare sectors and the role of DSS. Then, we present the methodology chapter where we describe the empirical setting, data collection, simulation scenario and decision-making criteria. Next, we describe the simulation (input, model and output) in the result and analysis section, which is followed by managerial implications before the conclusion and future research. 2. Theoretical background 2.1 Lean production The term lean production was rst coined by Krafcik (1988) and then gained its momentum after the launch of The machine that changed the world (Womack et al., 1990). The concept is actually originated from Toyota Production System and/or Just-in-Time Manufacturing. Toyota Production System is indeed complex and multifaceted (Shah and Ward, 2007) which continuously evolves and disseminates worldwide (Pil and Fujimoto, 2007). Applying lean production in non-manufacturing sectors is possible due to the fact that lean concept can be viewed from philosophical and practical perspectives. Implementing lean production in, e.g. service sector, will certainly have its own challenges.

Decision support

235

IJLSS 1,3

236

2.2 Lean healthcare Heinbuch (1995), Jacobs and Pelfrey (1995) and Whitson (1997) are among the rst publications adapting lean concept from manufacturing to healthcare. Bushell and Shelest (2002) and Freinstein et al. (2002) provide specic reports about the implementation of lean in healthcare which claim good results. Laursen et al. (2003) suggest that lean healthcare evolved from the application of lean thinking in service management (which is originated from operations management, especially automotive industry). Healthcare is a more complex system than any manufacturing industry. As a service provider with major human component, there are safety and efciency issues rather than cost and efcacy, which separate healthcare from industry (Patwardhan and Patwardhan, 2008). Implementation of lean principles translates into a variety of local process redesigns (Dickson et al., 2009a), which follows Berwicks (2008) model of a complex social system undergoing change that context mechanisms outcome. Therefore, quality management tools designed for industry should be applied to healthcare services with proper selection, caution, and care (Patwardhan and Patwardhan, 2008). Implementation of lean in healthcare especially improving patient ow can benet a lot from: . reducing the gap between demand and capacity; and . process streamlining based on the concept of ow and pull (Brandao de Souza, 2009). To meet the challenges of a demanding marketplace and the need for more cost-effective use of resources, it is imperative to nd a better way to balance supply and demand in healthcare (Towill and Christopher, 2005). In the healthcare system, end-to-end processing time is more important than separating inpatient, outpatient, and other queues into neat statistics which can be meaningless to an individual patient (Towill, 2006). This view is in congruence with total patient episode viewpoint (Kujala et al., 2006), where the time a patient spent in a health service provider can be classied into: diagnostic and care, administrative, and waiting. The institution of lean in emergency department has been associated with improvements in patient ow, patient satisfaction, and an increase in patient visits (Dickson et al., 2009b). Length of stay (LOS) is a relevant performance measure (Dickson et al., 2009a) although it is also necessary to complement it with throughput rate (or time). Kujala et al. (2006) state that process reconguration and/or removing non-value-added activities will minimise throughput time. Hence, NVAT and TTS are considered as appropriate time-related performance measures when implementing lean in emergency department reecting the importance and the necessity of systems approach/engineering (Parnaby and Towill, 2008). 2.3 DSS for lean healthcare Decision support can be dened as any computer-based application which helps the user to make better decisions (Clayton and Hripcsak, 1995). Simulation (which falls into the category of model-based DSS) is commonly applied in healthcare in order to estimate and evaluate the potential effect of changes by mimicking the behaviour of a healthcare system (Aktas et al., 2007).

Sharma et al. (2007) found that simulation analysis has proved to be an effective tool in the selection of optimum resources for the service management process in hospitals (thus eliminating the trial-and-error approach) also helps quantifying the impact of suggested changes on the existing work ow or process under study. Combinatorial use of lean (healthcare) and computer simulation (Brandao de Souza et al., 2008) can be considered as an innovative approach leading to reduction of waiting list (Brandao de Souza, 2009). Combining lean and simulation provides quantiable results and comparison between current and future states (Khurma et al., 2008). 3. Methodology 3.1 Empirical setting The Sahlgrenska University Hospital, founded in 1772 and named after Niclas Sahlgren, is one of the renowned hospitals in Goteborg (Sweden). The present Sahlgrenska University Hospital is the result of merger of three independent hospitals (Molndal, Ostra, and Sahlgrenska). The hospital provides emergency and basic care and is well equipped with state-of-the-art medical technology with over 2,700 beds divided into 165 wards and approximately 16,000 employees. The emergency ward of Sahlgrenska University Hospital provides round the clock services with 130 employees of different professions (nurses, assistant nurses, secretaries, doctors, counselors, and physiotherapists). The hospital introduced and developed a new protocol called medical emergency triage and treatment system (METTS) (Widgren and Jourak, 2008), which has been implemented in the emergency department since January 2005. The aim of this protocol is to establish a higher sensitivity, medical safety to identify and stratify patients into ve priority levels: red (most critical cases that need immediate medical attention), orange (potentially ill and medical care is necessary within 20 minutes), yellow (stable condition with medical care necessary within 120 minutes), green (patients with stable condition and that do not require immediate medical attention), and nally blue (ordinary diseases and medication is prescribed or referred to primary care if necessary). METTS is modeled to diagnose the vital symptoms of patients at admission and further observe the changes in these vital parameters with clinically signicant laboratory pathology during the treatment process. Depending on the diagnosis of vital symptoms and signs, patients are referred to a doctor in one of the following major disciplines: medicine, surgery, ONH[1] (ear, nose, and throat), and orthopedics. 3.2 Flow of patients in the emergency ward Patients arrive at the ward can generally be categorised into walk-in (through the main entrance) and by ambulance (through the back entrance). Here, there is a reception desk manned by a nurse and a receptionist to provide information to the incoming patients. Patients need to wait before examination in one of the two triage rooms. Walk-in patients are usually examined in the rst triage room, while the second triage room is mainly allocated for patients coming by ambulance. The hospital also has an acute room and a trauma room for critical cases. In the triage room, the vital signs[2] are rst checked by three triage staff members (nurse, assistant nurse, and secretary) to observe the ailments of patients. Vital signs of walk-in patients are measured approximately within ten to 15 minutes, while it is almost immediately for patients arrived by ambulance. The ambulance personnel

Decision support

237

IJLSS 1,3

238

inform the kind of disease (injury or sickness) of a patient with vital signs measured during the course of their arrival and handover the triage form to the triage staff. The nurse takes anamnesis[3] and writes down examination results (which are recorded in the patients case le), and then decides case of the patient. For example, if the patient should see a surgeon or medicine doctor, which blood samples will be taken and if the patient needs any further examination (EKG[4], Bladder-scan[5]) to determine the patients condition. Depending on the results of lab test, nurse decides the priority number of a patient. An assistant nurse performs tests such as: blood pressure, pulse and temperature reading, pulse oximeter (measures the oxygen saturation of a patients blood), and breathing frequency. The secretary registers the patient in different computer systems and prints out old journals with information about the patient that is relevant for the nurse to know about. The secretary also prints out the blood sample labels that the nurse requires. When the examination is nished the secretary registers the patients priority and discipline. After triage assessment, the nurse of triage room will report to the nurse in charge of each discipline (medicine, surgery, etc.). The colour-ID of the patient is determined according to the vital signs identied in the triage system. After identifying the colour-ID and the priority number, the patient has to wait in the examination room for seeing the doctor. The waiting time depends on the colour-ID assigned to the patient and also the type of doctor who will examine the patient. Hence, it may be clear that colour-ID is being used mainly as an indication of how urgent is a patient in need for care. There are four blocks consisting of rooms for admitting the patients until the doctor arrives for rounds. Each room has a monitoring system including a bed, a sink and a chair for visitors. In the middle of the emergency ward they have a separate block with two desks on both sides to keep in track of the proceedings of the patients case and to inform the doctors about the list of patients waiting to be examined by a doctor. The doctors check this information before attending a patient and keep a le of the particular case he/she is attending to. Doctors have a separate section in this block to study the patients prole before going to see the patient. The patients database is recorded and updated continuously as the patient proceeds step by step from triage till waiting for the doctor to be examined until discharged from the ward or admitted to another ward at the hospital. Figure 1 describes the ow of patients in the emergency ward. The concerned doctor (e.g. surgeon and medicine) examines the patient according to their ailments. A surgeon is specialized on operation skills, all kinds of trauma, wounds, abdominal pain, and urological diseases. In case of a wound, the surgeon will stitch it up together or sends the patient for an X-ray and after checking the X-ray report decides whether the patient can go home or will be sent to another ward. The surgeon makes a dictate, after the rst visit to that patient and then does some complements if the patient will be seen twice. A medicine doctor is specialized on the internal homeostasis in the human body, i.e. heart diseases, lung diseases, head ache, thrombosis in lungs or legs, diabetes, and endocrinological diseases. After examination by doctor, a treatment process starts and the time of treatment depends on the patients disease. In fact, it is a recovery process that a patient follows the doctors dictate and the related nurse takes care of patient during the treatment time. According to the doctor comments, the nurse may give some drugs to the patient or just monitors the vital signs of the patient till the patient is admitted into another ward or discharged from the hospital.

Emergency ward Triage database

Decision support

239
What illness? What colour ID?
IN

Not enough beds

OUT

Long waiting Triage examination Doctor examination Treatment

16 min 12 min

138 min 33 min 234 min

Total time in the system = 433 min Value added time = 279 min

Figure 1. The value stream of Sahlgrenska emergency ward

3.3 Limitation In this paper, we emphasise mainly on the most obvious elements of NVAT in the ow, i.e. patients waiting time before examination in a triage room and patients waiting time before examination by a doctor. We do not focus on the time to transfer patients between processes due to the fact that in the emergency ward of Sahlgrenska Hospital, this kind of time is considerably small in comparison with, e.g. waiting time (most likely because of the layout of the ward). A process may also contain non-value-added components (such as idle). However, considering the nature of service operations, especially in the emergency ward (where high capacity cushion[6] seems to be necessary), we do not further consider (investigate) the NVAT within a process. In this study, we focus on time-related performance measures although costs can certainly be added later in the simulation. 3.4 Empirical data collection From the end of April 2009 until the end of June 2009, we recorded the time when patients arrived in the ward. Through triage database, we are able to collect data such as a patients waiting time, examination time, and treatment time. During this time period, approximately 9,000 data were collected. Besides patient-related data, we also observed and estimated the percentage of doctors time being allocated for examining patients and interact with them.

IJLSS 1,3

240

3.5 Distribution tting In order to be able to use the empirical data as the input for simulation, it is necessary to rst identify which statistical distributions that various data sets follow and then extract the relevant parameters related with the statistical distribution (e.g. mean and standard deviation for normal distribution). For this purpose, we use Minitabw statistical software to nd which statistical distribution t, e.g. patients time between arrival data, doctors examination time, etc. As a general rule, we choose statistical distribution where the level of signicance is above 5 per cent. If there is more than one statistical distribution full this condition, we select the distribution with the highest p-value. 3.6 Simulation scenario We develop a simulation scenario by varying the number of surgeons and medicine doctors. For the purpose of manageability, we set limitation on the numbers (level) that will be simulated. As shown by Table I, nine combinations will be executed by the simulation program. For each combination, the simulation length in ARENA is set at 24 hours and being replicated 100 times. In our scenario, this represents one run (cycle). In order to achieve as high as possible level of credibility in the simulation results, we further extend the simulation by setting the number of runs (cycles) at ten. Equivalently, each combination is simulated with 1,000 replications at 24 hours simulation length in each replication. 3.7 Decision-making criteria The selected combination of surgeons and medicine doctors is the combination that will produce less NVAT, TTS, and resource utilisation (RU) than the similar performance measures in the initial state. 4. Analysis and result 4.1 Initial state Based on the patients ow and the collected data, we found that, in average, a patient spent about seven hours in the ward, in which approximately 35 per cent is waiting time. The results shown in Table II become our reference and to be compared with simulation output. 4.2 Simulation input and model Prior to running the simulation, a simulation model needs to be developed. The model (Figure 2) is a translation of the value stream map (Figure 1) into simulation language. When constructing the simulation model, it was our intention to, as much as possible, reect the real situation at Sahlgrenska emergency ward. We split patients arrival to the ward (Figure 2) by creating two arrive modules because the characteristics of arrival event (i.e. time between arrivals and entities
Medicine doctor 3

Discipline Surgeon Table I. Simulation scenario 1 2 3

per arrival) are different between walk-in patients and patients arrive by ambulance. In total of 55 per cent of patients are walk-in patients and the remaining patients arrive to the ward by ambulance. The statistical distributions of patients arrival are shown by Table III. Walk-in patients, in average, need to wait approximately three times longer than patients by ambulance (Table IV) before they are being examined in the triage rooms. Based on Table V, the examination time at triage room one and two shows no meaningful difference. Table VI shows the proportion of patients according to his/her colour-ID, where patients categorised as orange, yellow, and green dominate the emergency ward. It is also shown that a patient can wait until three hours before seeing a doctor. The majority of patients (80 per cent) need to see a surgeon or a medicine doctor (which is why these two disciplines become the focus of the simulation study). It is shown in Table VII that examination time among disciplines does not indicate great variation. A doctor approximately spends 40 per cent of his/her time to examine and interact with patients. After being examined by a doctor, a patient spends (in average) four hours in the treatment process (Table VIII). 4.3 Simulation output With regards to the selected indicators of system performance (i.e. NVAT, TTS, and RU), Table IX presents the summary of simulation output. The output shows a general pattern that the number of doctors allocated in the emergency ward inuence more on TTS and RU than on NVAT. From the modelling (simulation) point of view, the steadiness of NVAT is perhaps due to the fact that the distribution functions being used to randomly generate patients waiting time (prior to doctors examination) are estimated based on the colour identities assigned to them (i.e. red, yellow, blue, etc.) instead of generating patients waiting time from distribution functions that are estimated based on the types of doctor who will examine the patients. The fact that patients waiting time before triage examination are randomly generated from distribution functions that are estimated based on patients means of arrival (i.e. walk-in or by ambulance) may also contribute to the atness of NVAT because at this stage, a patient has not yet been assigned to a certain type of doctor. From the empirical perspective, the concurrent effect of allocated surgeons and medicine doctors may level (attened) the volatility of patients waiting time. As expected, Table IX indicates a clear pattern that more allocation of surgeons or medicine doctors reduces the RU. Increasing the number of medicine doctors reduces

Decision support

241

Average (minutes) Waiting time before triage examination Waiting time before doctors examination Triage examination Doctors examination Treatment 15.73 137.71 153.44 11.55 32.66 234 278.21 431.65

Category Non-value-added Non-value-added Sum of NVAT Value-added time Value-added time Value-added time Sum of value-added time TTS

Table II. Categorisation of a patients time while in the ward

IJLSS 1,3

On-foot

Wait

Triage 1

Need to see a doctor? N Exit ward

242

By ambulance

Wait

Triage 2

Which doctor?

Red Orange Yellow Green Blue Admit patient? N Treatment

Surgeon Medicine doctor Other

Figure 2. Simulation model

Hospital

Walk-in Distribution Parameter(s) Table III. Statistical distribution of patients arrival Number of patients per arrival Exponential l: 1/mean : 1/(9.294) minutes Mean: 1.088 SD: 0.298

By ambulance Normal Mean: 23.885 minutes SD: 17.404 minutes 1 (in majority of the cases)

Walk-in Table IV. Distribution of patients waiting time before triage examination Distribution Parameter(s) Normal Mean: 22.810 minutes SD: 14.700

By ambulance Exponential l: 1/(7.067) minutes

the NVAT but leading to the increase of TTS. NVAT increases as the number of surgeons increased, while allocating more surgeons seems to concave the TTS (i.e. forming a negative quadratic function). In the case of NVAT, we may interpret that increasing the number of surgeons and medicine doctors has an opposite effect. We argue that the behaviour of TTS is inuenced by, not only the allocated number of doctors, but also by the treatment time where the length of treatment depends heavily on the severity of illness and patients condition (thus less inuenced by the number of allocated doctors). The fact that our simulation model randomly generates patients treatment time from a single distribution function (instead of several distribution functions which are estimated based on, e.g. the types of illness) could also inuence the behaviour of TTS although we believe that the effect is minor.
Walk-in Distribution Parameter(s) Normal Mean: 10.560 minutes SD: 4.060 minutes By ambulance Normal Mean: 12.750 minutes SD: 5.379 minutes

Decision support

243

Table V. Distribution of triage examination time

% Red Orange Yellow Green Blue Unidentied (discharged) 7.2 24.3 42.2 21.9 3.0 1.4 100

Distribution N/A (no waiting) Weibull Normal Normal Lognormal Total

Parameter(s) N/A 2.19 (shape) 56.61 (scale) Mean: 187.620 minutes SD: 66.445 minutes Mean: 191.603 SD: 66.224 minutes 4.27 (location) 0.74 (scale)

Table VI. Distribution of waiting time before doctors examination

% Surgeon Medicine doctor Other 37 42.6 20.4 100

Distribution Normal Normal Normal Total

Parameter(s) Mean: 37.56 minutes SD: 13.89 minutes Mean: 30.38 minutes SD: 22.30 minutes Mean: 26.57 minutes SD: 16.81 minutes

Table VII. Distribution of doctors examination time

Distribution Parameter(s)

Exponential l: 1/(234) minutes

Table VIII. Distribution of treatment time

IJLSS 1,3

Surgeon 1 1

Medicine doctor 2 3 4 2 3 4 2 3 4

Average NVAT (minutes) 130.80 136.80 128.90 136.70 134.80 135.40 139.50 133.50 137.80

Average TTS (minutes) 420.50 435.50 418.90 463.60 461.70 472.90 443.60 446.70 475.90

Average RU (%) 154.13 (S) 113.93 (MD) 138.57 (S) 72.87 (MD) 145.61 (S) 57.92 (MD) 87.49 (S) 101.15 (MD) 85.18 (S) 82.89 (MD) 86.92 (S) 55.41 (MD) 60.82 (S) 97.56 (MD) 65.08 (S) 68.95 (MD) 66.46 (S) 54.08 (MD)

244

1 2 2 2 3 3

Table IX. Simulation output

The numerical gures in Table IX thus remind us regarding the multidimensionality and complexity of service productivity (Bamford and Chatziaslan, 2009). Allocating only one surgeon leads to unreasonably high RU although the NVAT and TTS are acceptable. Readers may notice that there is a difference between the actual and simulated performance indicators in the current state of the emergency ward (i.e. one surgeon and two medicine doctors). We acknowledge that our model, as any other model, cannot precisely predict the behaviour of a real system. Additionally, we suspect that this condition is affected by the previously dened limitations that, when developing the simulation model, we focus on the most obvious non-value-added activities and on the observable elements of the ow in the emergency ward. The RU is slightly improved when two surgeons are allocated, but the NVAT and the TTS show an unexpected increase. All indicators of system performance are, to some extent, acceptable when three surgeons are allocated. With reference to the initial state, it can be suggested that the allocation of three surgeons and three medicine doctors in the emergency ward will likely improve the wards performance. The average NVAT is 133.50 minutes (where the 95 per cent condence interval of this value is 129.26 and 137.74). This gure clearly indicates an average reduction of 13 per cent compared to the initial state. The average TTS is 446.70 minutes (the interval of this value is between 416.56 and 476.84 at a 95 per cent condence interval). Although the reduction of TTS cannot be conrmed, it can be maintained at approximately the same level in the sense that the condence interval of actual TTS is likely overlap with the condence interval of the simulated TTS. 5. Managerial implication The simulation results indicate that with only one surgeon and two medicine doctors, the emergency ward of Sahlgrenska Hospital experiences imbalance between supply

and demand, in the sense that the resources (in this case, medicine doctors and surgeons) are highly exploited. This imbalance situation contributes to patients long waiting time before they are being examined by doctors. The simulation results suggest that, by allocating more surgeons and medicine doctors, patients NVAT can be reduced while maintaining the TTS at approximately the same level. The reduction of patients NVAT fulls our expectation from the simulation model. On the other hand, our expectation regarding the decrease on the TTS does not seem to be fullled. We suspect that the latter may be inuenced by the fact that we used aggregate data in the simulation input. Therefore, improvements in the simulation model can be conducted by, e.g. separating arrival event in the simulation into day and night, estimate the distribution functions of patients waiting time based on the type of doctors, and specifying patients treatment time according to, for example, the types of illness. The most valuable lesson learned from the simulation is perhaps the insight that system performance is complex and concurrently addressing other inuencing factors seems to be necessary in order to gain more signicant improvements. It may be worth to notice that minimising patients throughput time may not lead to cost reduction of care. However, due to the fact that time can be the most inuential cost driver (Kujala et al., 2006) in the healthcare value chain, minimising throughput time may eventually reduce the cost of care. Placing ow ahead of efciency is critical to the success of lean implementation in emergency department (Dickson et al., 2009b). Hence, the emergency ward of Sahlgrenska Hospital may be able to further reduce waiting time and LOS by having multiple ow streams, which are separately managed by different personnel (Kelly et al., 2007; OBrien et al., 2006), such as fast track and regular track (Leraci et al., 2008). Fast-track patients are those who have obvious clinical requirements and who are likely do not require hospital beds (i.e. low-complexity patients). Another option could be by having different ow streams which separate patients who are likely to be discharged from patients who are likely to be admitted (King et al., 2006). 6. Conclusion and future research The paper presents a case study where DSS tool can be considered as benecial in the implementation of lean, in the sense that DSS is able to show the impact of different change scenarios driven by lean. The simulation model is developed based on the real situation at Sahlgrenska emergency ward. The primary data, which have been collected through empirical measurement and through triage database, are being used as the input of the simulation as well as being referred to as the initial state of the emergency ward. A simulation scenario is then developed by varying the number of allocated medicine doctors and surgeons. The simulation results indicate that the emergency ward of Sahlgrenska Hospital with currently two medicine doctors and one surgeon experiences imbalance between supply and demand, which is reected by the unreasonably high level of resource (i.e. medicine doctor and surgeon) utilisation. This condition thus causes excessive patients waiting time. Instead, if there are three medicine doctors and three surgeons allocated in the emergency ward, patients NVAT can be reduced (in average) 13 per cent while maintaining patients TTS at approximately the same level. It seems obvious that by allocating more medicine doctors and surgeons, the pressure on doctors can

Decision support

245

IJLSS 1,3

246

be reduced. When looking at patients average NVAT, patients average TTS, and average RU, the allocation of three medicine doctors and three surgeons creates a much better balance between supply and demand in the emergency ward of Sahlgrenska Hospital. The main contribution of our paper on healthcare operations management literature seems to be on the use of DSS and applying the logic of design of experiments (DOE) in determining the allocation of healthcare resources (capacity) which leads to optimum system performance. It will be of interest to develop an expanded simulation model accommodating the cost of care. The term resources may also be broadened including hospital facilities (e.g. hospital beds and examination rooms). Changes driven by the implementation of lean should involve and consider the impacts on employees in the ward. Besides, time- and cost-related performance measures, it seems necessary to measure the impact of lean adoption on value stream performance seen from customer perspective. DisPMO, DePMO, left-side, and right-side sigma levels (Setijono, 2008, 2009, 2010) may be appropriate to use even though they are Six Sigma-related measures.
Notes 1. ONH stands for Oron, Nasa, Hals (Swedish language). 2. Measurement of pulse rate, breathing frequency, blood pressure, and body temperature. 3. Medical history. 4. Electrocardiogram or electrocardiography. 5. To verify an empty bladder or urine retention. 6. Capacity cushion 100% utilised capacity. References Aktas, E., Ulengin, F. and Sahin, S.O. (2007), A decision support system to improve the efciency of resource allocation in healthcare management, Socio-economic Planning Sciences, Vol. 41 No. 2, pp. 130-46. Bamford, D. and Chatziaslan, E. (2009), Healthcare capacity measurement, International Journal of Productivity and Performance Management, Vol. 58 No. 8, pp. 748-66. Berwick, D.M. (2008), The science of improvement, The Journal of the American Medical Association, Vol. 299, pp. 1182-4. Brandao de Souza, L. (2009), Trends and approaches in lean healthcare, Leadership in Health Services, Vol. 22 No. 2, pp. 121-39. Brandao de Souza, L., Pidd, M. and Gunal, M.M. (2008), Lean healthcare and computer simulation: a soft-hard approach, Proceedings of Operations Research Applied in Health Services Conference, Toronto, ON. Bushell, S. and Shelest, B. (2002), Discovering lean thinking at progressive health care, Journal for Quality & Participation, Vol. 25 No. 2, pp. 20-5. Clayton, P.D. and Hripcsak, G. (1995), Decision support in healthcare, International Journal of Bio-Medical Computing, Vol. 39 No. 1, pp. 59-66. Dickson, E.W., Anguelov, Z., Vetterick, D., Eller, A. and Singh, S. (2009a), Use of lean in the emergency department: a case series of 4 hospitals, Annals of Emergency Medicine, Vol. 54 No. 4, pp. 504-10.

Dickson, E.W., Singh, S., Cheung, D.S., Wyatt, C.C. and Nugent, A.S. (2009b), Application of lean manufacturing techniques in the emergency department, Journal of Emergency Medicine, Vol. 37 No. 2, pp. 177-82. Freinstein, K.W., Grunden, N. and Harrison, E.I. (2002), A region addresses patient safety, American Journal of Infection Control, Vol. 30 No. 4, pp. 248-51. Gemmel, P. and van Dierdonck, R. (1999), Admission scheduling in acute care hospital: does the practice t with the theory?, International Journal of Operations & Production Management, Vol. 19 No. 9, pp. 863-78. Heinbuch, S.E. (1995), A case of successful technology transfer to health care, Journal of Management in Medicine, Vol. 9 No. 2, pp. 48-56. Jacobs, S.M. and Pelfrey, S. (1995), Applying just-in-time philosophy to health care, Journal of Nursing Administration, Vol. 25 No. 1, pp. 47-52. Kelly, A.M., Bryant, M., Cox, L. and Jolley, D. (2007), Improving emergency department efciency by patient streaming to outcomes-based teams, Australian Health Review, Vol. 31 No. 1, pp. 16-21. Khurma, N., Bacioiu, G.M. and Pasek, Z.J. (2008), Simulation-based verication of lean improvement for emergency room process, in Mason, S.J., Hill, R.R., Monch, L., Rose, O., Jefferson, T. and Fowler, J.W. (Eds), Proceedings of 2008 Winter Simulation Conference, Miami, FL, pp. 1490-9. King, D., Ben-Tovim, D.I. and Bassham, J. (2006), Redesigning emergency department patient ows: application of lean thinking to health care, Emergency Medicine Australasia, Vol. 18 No. 4, pp. 391-7. Krafcik, J.F. (1988), The triumph of lean production system, Sloan Management Review, Fall, pp. 41-52. Kujala, J., Lillrank, P., Kronstrom, V. and Peltokorpi, A. (2006), Time-based management of patient process, Journal of Health Organisation and Management, Vol. 20 No. 6, pp. 512-24. Laursen, M.L., Gertsen, F. and Johansen, J. (2003), Applying lean thinking in hospitals exploring implementation difculties, available at: www.lindgaardconsulting.dk/pdf/ altih.pdf (accessed 26 September 2009). Leraci, S., Digiusto, E., Sonntag, P., Dann, L. and Fox, D. (2008), Streaming by case complexity: evaluation of a model for emergency department fast track, Emergency Medicine Australasia, Vol. 20 No. 3, pp. 214-49. McDermott, C. and Stock, G.N. (2007), Hospital operations and length of stay performance, International Journal of Operations & Production Management, Vol. 27 No. 9, pp. 1020-42. OBrien, D., Williams, A., Blondell, K. and Jelinek, G.A. (2006), Impact of streamlining fast track emergency department patients, Australian Health Review, Vol. 30 No. 4, pp. 525-32. Parnaby, J. and Towill, D.R. (2008), Seamless healthcare delivery systems, International Journal of Health Care Quality Assurance, Vol. 21 No. 3, pp. 249-73. Patwardhan, A. and Patwardhan, D. (2008), Business process re-engineering saviour or just another fad? one UK health care perspective, International Journal of Health Care Quality Assurance, Vol. 21 No. 3, pp. 289-96. Pil, F.K. and Fujimoto, T. (2007), Lean and reective production: the dynamic nature of production models, International Journal of Production Research, Vol. 45 No. 16, pp. 3741-61. Setijono, D. (2008), DisPMO and DePMO as Six Sigma-based forward-looking quality performance measures, TQM Journal, Vol. 20 No. 6, pp. 588-98.

Decision support

247

IJLSS 1,3

248

Setijono, D. (2009), The application of modied Defect Per Million Opportunities (DPMO) and sigma level to measure service effectiveness, International Journal of Six Sigma & Competitive Advantage, Vol. 5 No. 2, pp. 173-86. Setijono, D. (2010), Normal approximation through data replication when estimating DisPMO DePMO, left-side and right-side sigma levels from non-normal data, International Journal of Quality & Reliability Management, Vol. 27 No. 3, pp. 319-33. Shah, R. and Ward, P.T. (2007), Dening and developing measures of lean production, Journal of Operations Management, Vol. 25 No. 4, pp. 785-805. Sharma, V., Abel, J., Al-Hussein, M., Lennerts, K. and Pfunder, U. (2007), Simulation application for resource allocation in facility management processes in hospitals, Facilities, Vol. 25 Nos 13/14, pp. 493-506. Towill, D.R. (2006), Viewing Kaiser Permanente via the logistician lens, International Journal of Health Care Quality Assurance, Vol. 19 No. 4, pp. 296-315. Towill, D.R. and Christopher, M. (2005), An evolutionary approach to the architecture of effective healthcare delivery system, Journal of Health Organisation and Management, Vol. 19 No. 2, pp. 130-47. Whitson, D. (1997), Applying just-in-time systems in health care, IIE Solutions, Vol. 29 No. 8, pp. 32-7. Widgren, B.R. and Jourak, M. (2008), Medical Emergency Triage and Treatment System (METTS): a new protocol in primary triage and secondary priority decision in emergency medicine, Journal of Emergency Medicine (in press). Womack, J.P., Jones, D.T. and Roos, D. (1990), The Machine that Changed the World, Rawson Associates, New York, NY. Corresponding author Djoko Setijono can be contacted at: djoko_setijono@yahoo.com

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com Or visit our web site for further details: www.emeraldinsight.com/reprints