Journal of International Trade, Logistics and Law, Vol. 2, Issue 1, 2016, 35-47 NECESSITY FOR HAVING A MEDICAL ASSISTANT IN THE PROCESSES FOR THE SUCCESS OF THE HOSPITAL INFORMATION SYSTEMS Harun Dumantepe, (Graduate Student) Department of Management, Social Sciences Institute of Istanbul Commerce University F. Serab Onursal (PhD) Istanbul Commerce University Abstract: In order to realize the objectives of the organization, first of all, they are required to have a healthy structure and proce ss. Gaining competitive advantage by a health care facility should be managed with scientific methods in addition to providing good service. Accurate, reliable and prompt data entry in the information systems is under the responsibility of the medical personnel in t he health institutions. This process causes heavy burden for doctors who work very busy and results in delays. It also ca uses completion time of works to increase and sometimes causes works not to be completed, economic losses, cause employee dissatisfaction and even losses of patients. This study will focus on the need of medical assistant in the success of Hospita l Information System. The conceptual framework was created in this context, literature search was made and process improvement example was presented for an IVF embryology laboratory process. Keywords: Hospital Information System (HIS), Process Improvement, Medic al Assistance 1. Introduction Meeting the requests and expectations of the customers is the biggest purpose of the companies in order to accomplish in the world changing every day. With this purpose, catching the continuous change in the positive direction becomes mandatory for the organizations and has created a ruthless competition environment between them. Applying the correct management systems, following up the technology and fast access to the information have substantial importance in the context of sustaining the success. The software programs which are developed in order to fast access to the information enable that millions of different data entry are made to different sectors and different databases. It is seen that the new software used in the healthcare sector and the requirements in the data entering related with this software prevent the doctors, nurses and medical employees from doing the healthcare service, which is their main task. The healthcare personnel who has to pay attention the responsibility of their main task at the forefront fiercely refuses to do data entry to the patient information systems which make that they waste time and which they cause delays and mistakes because they don’t pre sent the necessary concentration. In this study, it is investigated what kind of improvement should be made in the processes by taking the problems of the healthcare personnel into account; the necessity of the assistant healthcare personnel; the qualifications it is anticipated that the medical assistant, as auxiliary healthcare personnel, has to have are stated, the application for the embryology laboratory process of a test -tube baby center was performed in the findings part. 36 Harun Dumantepe, F. Serab Onursal 2. Hospital Information Systems Hospital information systems (HIS) mean the system which brings to the integrity of the information by collecting the information and reporting these data in order to meet the expectations of the internal and external customers of the hospital organizations (Akbolat, 2014:110). The foundation stone of the process and information management system is the adequate, correct and accessible data. It is required that all information and medical records, descriptive of the patient, should be processes suit able and in a detailed way. Together with the HealthNet project, commissioned by the Ministry of Health, it was made mandatory that all health institutions and organizations, providing healthcare service, see the data, included in the scope of the national health data standards 2.0, in the HealthNet system (Yılmaz, 2014). It is seen that a lot of studies are included when the literature related with the hospital information software is scanned however even though the necessity of the auxiliary personnel i n data entering is mentioned, the articles and theses written related with the medical assistance can’t be seen. Şenel, mentioning the necessity of the auxiliary personnel on the process improvement in the healthcare centers (Şenel, 2004), has found that the doctors are closed to new systems and inadequate in the data entry in the findings based on the results of the tests he made; states that the doctors have hard time for making data entry because of dealing with the problems of the patients as the basis for this determination and points out that they are received a warning from the management of the hospital. Narlı (Narlı, 2009), in his thesis study, he made, on the patient satisfaction, states that the doctors can’t do data entering in due time to the hospital software systems because of the patient intensities. Bektaş (Bektaş, 2013), in his study related with the material management processes in the hospitals, states that the material requests and demands are not in due time in the medical departments and the necessary consumptions are not deduced from the stocks in timely in the hospital software. In order to use the data obtained from the health records, they should be adequate, timely and correct. The reliability of the results obtained is completely depend on this quality. It is required that all processes are defined and that the persons who know the work done and can understand the responsibility are assigned and that it is ensured that the works are done timely, correctly and understandably, instead of unqualified and unskilled personnel, for the works to be done become more efficient and produ ctive. Karapinar (Karapinar, 2006), performed a process improvement study in a hospital enterprise through workflow analysis. She dealt with the topics of process, process improvement and process mapping in his study for production of each product or service, offered to the customer, in line with demands and expectations of the customer and with a low cost for the enterprise. She dealt with the concept of process map and workflow scheme for easier performance of the works in a shorter period. 3. Process Improvement And Control Lack In order that everybody understands the same thing by the processes, it is required that the description activities are made, the process definition cards, process maps and work flows are established and therefore it is ensured that the process is sensed easily. Preparing the process map: the process maps contain the stages of each one of the processes, the inputs and outputs of the stages, the decisions to be taken in each stage, the persons who will perform the processes, the duration required for each stage and the relations between the processes. Necessity for having a Medical Assistant in the Processes for the Success of The Hospital 37 Work flow chart: flow chart means a quality tool used for establishing the formation histories of the product or service by adding the steps end to end, monitored in the process of formation of a product or service. It is used for determining how the material, required for producing the product/service, flows. The flow charts have importance with respect to decide for determining, observing and finally improving the problems which we will face in the process. It is required know the flow of the process primarily for keeping a process under control. By this way, work flows are mainly used for determining the problem. Furthermore, the work flow chart, in cases where more than one person carry out a task, provides easiness with respect to make it visual with all details as well (Şenel, 2004). The process improvement is the activity targeting meeting the expectations of internal and external customers at the top level while increasing the total quality, work performances and productivity and decreasing the costs in an organization. (Eroğlu, 2006:43). What should be considered in the process improvement is being able to determine correctly the critical work process. 3.1. Determining critical work processes. The process which is important but the level of which is low, i.e. which is required to be improved immediately is called critical process. Having too many critical processes indicates that the organization is really in a very bad condition. The process showing one or several of these signs is a critical process and should be improved: • There are internal, external customer complaints, grievances, • High process costs, • Completing the process takes too much time, • It is seen, known that there are better ways of conducting the process when looking at others, • New technologies emerged. When determining the critical processes, the customer satisfaction surveys, employee satisfaction surveys, competition information, product or service quality information, financial and operational performance information, and the experience and anticipation of the top managers are used. Once the process is designed, it is put into service and no improvement is made on it unless there is any complaint. Each complaint, even if it is at the bottom level, creates a form of the judgment of internal/external customer. What is correct is to find the basic reasons for the main failure, to develop solution and to ensure continuity in improvement, instead of adding a new control and cost layer to the process such that this problem never occurs again upon the complaint. The enterprise, which suggested its targets and strategies, must present the processes whereby it may ascertain the current status of activities by suggesting owners of these processes and must define the critical processes. Thus, the processes may be improved (Teymur 2009 p.63) Process improvement is increasing the performance level of the process. The process management and process improvement is not a method for one time; it is important that it is continuous. Because process improvement will be done in the institution, the employees of the institution should be made adopted that it contains continuity and the participation of the employees to the improvement should be ensured. Let’s have an example to process improvement areas from hospitals; such as having physical arrangements compatible with the process flow in polyclinics, monitoring the official papers in the service departments, preventing movement of papers exposed by establishing automation system. 3.2. Methods used for process improvement Simplification: it is decreasing by eliminating or combining the unnecessary steps, such as waiting, repeated activities, number of approvals, which doesn’t add value, not containing any conversation, in the process (İdea 2001 s.169). 38 Harun Dumantepe, F. Serab Onursal Since the processes are complex, the improvement activities must be organized. When we consider the process improvement activities from with a team approach, it enables us to get long-term results and minimize the implementation period (Gonca 2008,p.53). Changing the decision points: if a decision point will be placed in the process, it is putting these decision points forward, therefore ensuring that all the activity m ade is made for nothing as a result of negative decision when waning to entire process. Parallel working: in multiple applications, one activity starts after another one ends. It is ensuring that the activities, which can be done simultaneously, of the ac tivities following each other, are performed before waiting for the process ends in order to decrease process cycle time(Bozkurt 2003). Simplification: is changing the way the task is done and it is made that it is done simpler. Outsourcing: is focusing on the activity, which is the organization’s main reason for being, by this way procuring the other activities from external resources, therefore ensuring that it is done both with lower cost and by the expert persons. Authorization/team work: it is decreasing the process cycle time by expanding the task done by the person, decreasing the control and approval steps, authorizing the person, and ensuring the autocontrol. In process improvements and progress of the system, the participation of the employees with recommendations is ensured. It is ensuring that the problem is solved at the source by going down to the root causes and by developing recommendations by the ones doing that task. Systemic improvements: Such improvements, based on information system, are performed usually as below: • Doing the activities which are manual at present with integration, carrying out the activities inside the software, • Speeding up the access to information and the systems, • Using expert systems. In order to be able to eliminate the problems occurring in the process, primarily all processes, including the subprocesses, are evaluated and the reasons found are placed to the cause and effect diagram (fish bone diagram). The cause and effect diagram is a tool for finding different reasons of a problem, putting in an order (Eroğlu, 2006). It is a graphical method for establishing a relation between any problem and factors causing it. The main problem is placed to the head side of the fishbone, the basic and subcauses on the a rrows on the spine (Figure 3). 4. Material And Method In this study, the process flow chart, fishbone diagram prepared by the process owners of embryology laboratory process of a test-tube baby center and the form times table, filled by the, embryologists , and the tables indicating the task times were used. The application was made in a test-tube baby center having activities in Istanbul since 1996. As a method, process improvement and process control were preferred and the results are examined together with the control tables indicating the task times of the employees. Necessity for having a Medical Assistant in the Processes for the Success of The Hospital 39 The steps followed up in the study are: Step 1: Determining the critical process Step 2: Defining the processes with the work flow chart Step 3: Measuring the forms and filling times and conveying them to the tables, Step 4: Determining the purpose of the study, Step 5: Using the cause and effect diagram (fishbone) for solving the problem, Step 6: Establishing the new work flow, and Step 7: Entering the new measurement data to the control tables. 4.1. Main processes of the tube baby center in the application The test-tube baby centers, structurally, have three main processes. These consist of medical, embryology and administrative services. There are physicians and medical support departme nts under the medical services. The physicians consist of gynecology and obstetrics experts, specialized in their area. The parts which are stated as medical support are psychologist, anesthesia expert, urologist, and alternative treatment experts, outsour ced. Embryology is the kitchen of the test-tube baby centers. Embryologists consist of biologists graduated from biology. The administrative services consist of nurses and patient admission personnel. 4.2. Tube baby treatment processes Tube baby treatment process consists of 5 subprocesses (Figure 1). These processes are completed in 4 weeks in total (Jinekoloji ve Gebelik .Com). The first process: the first interview and evaluating the couples: in this stage, the couples are examined; if they did have other tube baby trials beforehand, the analysis and treatment information related with them are taken. The pregnancy, miscarriage or birth histories are listened and, after the necessary evaluations are made, the treatment planning is made. The second process: stimulating the ovary and forming egg: in this stage, it is targeted to develop more than one egg by stimulating the ovaries of the mother to be stimulated by using various medicines. This stage is a process of approximately 10 – 12 days. The third process: Oocyte picking up process (OPU): in this stage, the eggs developed by using various medicines are picked up, accompanied by ultrasound, by the expert physician under anesthesia in the day and time determined. The sperm sample is taken from the sp ouse in the same day, if there is no sperm, the sperm is taken with the microtesticular sperm extraction (TESE) process. The fourth process: intracytoplasmic sperm injection (ICSI) method: in this stage, the oocytes picked up and the sperm sample taken from the spouse are passed through special procedures and a sperm selected from the pool is injected to each matured egg in the determined time. After 16 and 18 hours, it is checked whether they are fertilized or not. The eggs, normally fertilized, are moni tored inside special devices (incubator) in the embryology laboratory. This stage is a process of 2 to 5 days. The fifth process: transferring the embryo inside the uterus: in this stage, the embryo or embryos, reached the required quality, are placed to the uterus of the mother by the expert physician by means of a special cathater. The transfer process is a process lasting shortly like 5 minutes and painless. It is checked whether pregnancy occurs or not by pregnancy test after 13 to 15 days from the tr ansfer procedure. 40 Harun Dumantepe, F. Serab Onursal Figure 1. Tube baby treatment process (Jinekoloji ve Gebelik .Com) 4.3. Determining the critical process and process improvement steps In the study, the experience of the owner of the process and team on the subject was used. Step 1: the importance leveling was made based on the tasks made and it was determined that the main tasks of the embryologists are treatment and analysis. The tasks, not completed during work hours of the day, causes overly setbacks and dissatisfactions. It was determined that the critical process is the embryology laboratory. Step 2: The work flow charts belonging to the process was formed (Figure 2). The condition of the process was analyzed by using the work flow chart. Necessity for having a Medical Assistant in the Processes for the Success of The Hospital 41 Figure 2. Flow chart of the embryology laboratory before process improvement Step 3: The times used for the forms filled were measured and entered to the tables (Table 1). With the performance indicators form, in time, the total times of the tasks made by the embryologists were calculated in the tasks done by the embryology laboratory among the tasks analyzed (Table 2). Table 1. Form times, filled in the embryology laboratory before process improvement Form Time (min) NUMBER Total (min) Embryology form 1 60 60 Embryo freezing form 2 10 20 Embryo thawing form Embriyo 2 10 20 Embryo destruction consent form 1 3 3 Sperm freezing form 1 3 3 Sperm thawing form 1 1 1 Sperm destruction consent form 1 0,5 0,5 Semen analysis form 1 6 6 Intrauterine insemination form: 1 0,2 0,2 Embryo transfer report form 1 10 10 Information on the price of embryo freezing without transfer 1 10 10 Notifying the payment information of the patients to the accounting department 1 15 15 148,7 2 hours 30 minutes Total minutes Total hours 42 Harun Dumantepe, F. Serab Onursal Table 3. Task times of the embryology laboratory employees before process improvement Tasks Attendant Average time per task (minutes) Average daily number of patients Total time Thawing the frozen embryos before transfer procedure. Embryologist 20 10 200 Freezing the embryo Embryologist 20 11 220 Doing embryo monitoring and evaluation. Embryologist 3 40 120 Making the embryo transfer procedure. Embryologist 8 8 64 Participation in the quality control and routine cleaning procedures in the embryology laboratory. Embryologist 30 1 30 Performing the procedure for puncturing the membrane (Zona pellucida) surrounding the embryo by means of the method called as membrane opening when required. Embryologist 1 5 5 Participating in the general laboratory cleaning made once a week. Embryologist 30 1 30 Giving information on fertilization to the patients for which the procedure is applied. Embryologist 1 10 10 Measuring and recording temperature and CO2 values without opening incubators. Embryologist 2 15 30 Assessing whether the eggs are fertilized or not after 18-20 hours following intracytoplasmic sperm injection (ICSI) or insemination (IVF) procedure and keeping the necessary records related with this subject and informing the laboratory chief or related physician on the cases which have fertilization problem. Embryologist 3 10 30 Assessing the embryos developing from the eggs fertilized with respect to the number and quality of cells after 66-68 hours following intracytoplasmic sperm injection (ICSI) or insemination (IVF) procedure and selecting the embryos to be transferred together with the laboratory director. Embryologist 2 60 120 Making the oocyte picking up procedure (egg picking up) Embryologist 20 10 200 Denudation procedure (making elimination) Embryologist 7 10 70 Making contribution to the preparation of culture dishes. Embryologist 1 10 10 Making microinjection procedure (ICSI). Embryologist 25 10 250 Taking blastomer from embryos with biopsy procedure for preimplantaion genetical diagnosis. Embryologist 10 1 10 Preparing various solutions used in the procedures for assessing semen macroscopically and microscopically. Embryologist 3 1 3 Regularly checking the liquid nitrogen amount present in the liquid nitrogen tank and informing the laboratory officer on the amount of the remaining liquid nitrogen amount. Embryologist 5 1 5 Making the macroscopic and microscopic assessment of the semen by taking sperm samples given from the sperm collection container. Embryologist 1 1 1 Performing the sperm washing procedure. Embryologist 30 1 30 Answering the incoming telephones of the tube baby laboratory and directing them to the related persons. Embryologist 1 30 30 Completing the missing documents and forms in the patient files. Embryologist 2 40 80 Placing the material order for the embryology laboratory and recording the incoming material invoices to the computer. Embryologist 15 1 15 Entering the data of the patients related with the embryology laboratory to the computer environment and making them ready for analysis. Embryologist 5 60 300 Informing the patients on the date and time when the transfer procedure will be done. Embryologist 1 10 10 Preparing the list of the patients for which Opu and Transfer procedures will be made. Embryologist 1 15 15 1888 377,60 6 hours 30 minutesHour per person The list of the tasks done by 5 embryologists in the application center Total time (minutes) 5 Embryologists (time per person) Necessity for having a Medical Assistant in the Processes for the Success of The Hospital 43 Step 4: Determining the improvement needs One of the most important factors for the success of test-tube baby treatment is the quality of the assisted reproductive treatment (APT) laboratory. In general it is assumed that the effect of the laboratory and embryologists is 50% with respect to the contribution to the total success in the tube baby application. It is required that the tasks providing that such a success occurs are fulfilled with care. It is expected that the embryologists, in addition to treatment and analysis tasks, record the data to the patient monitoring system, used by the hospital, to the systems where statistical data is monitored mandatorily and Healthnet screens within the terms of reference, stated. There are forms required to be filled by embryologists after each process in Embryology and it is known that there is no time left for data input tasks after completing the main tasks. They cause delays and errors unintentionally. A big problem requiring solution is experienced. Step 5: Fishbone diagram (Figure 3). The reasons affecting not entering data in time, correctly and efficiently to the hospital software are evaluated. The main problem is reached when the subreasons of the reasons are enquired among themselves. Figure 3. Not making the data entry to the hospital software in due time. Fishbone diagram Step 6: The reasons were determined and new flow chart was issued for the solution (Figure 4). It was decided to employ auxiliary healthcare personnel however the necessity that this person should have medical knowledge among the qualifications was emphasized. The definition of this personnel to be employed was included to the organization as “medical assistant”. 44 Harun Dumantepe, F. Serab Onursal Figure 4. Flow chart of the embryology laboratory after process improvement Step 7: it was assessed which ones of the times calculated are the tasks without value added for the embryologists. The time performance durations were calculated for the tasks to be done by the medical assistant. The tasks for which change of duty would be done were distributed related with the process. The time for filling the forms by the medical assistant were measured and the gains were determined (Table 3) and the total times of the tasks done by embryologists were measured (Table 4). Table 2. Form times, filled in the embryology laboratory after process improvement Form The percentage of the tasks assumed by the medical assistant Medical assistant Embryologist Embryology form 50% 30 30 Embryo freezing form 40% 8 12 Embryo thawing form Embriyo 40% 8 12 Embryo destruction consent form 100% 3 0 Sperm freezing form 50% 1,5 1,5 Sperm thawing form 50% 0,5 0,5 Sperm destruction consent form 50% 0,25 0,25 Semen analysis form 0% 0 6 Intrauterine insemination form: 50% 0,1 0,1 Embryo transfer report form 100% 10 0 Information on the price of embryo freezing without transfer 100% 10 0 Notifying the payment information of the patients to the accounting department 100% 15 0 86,35 62,35 1 Hour 25 Minutes 1 Hour 05 Minutes Total minutes Total hours Necessity for having a Medical Assistant in the Processes for the Success of The Hospital 45 Table 4. Task times of the embryology laboratory employees after process improvement. Tasks Before Now Current embryologist time Current medical assistant time Thawing the frozen embryos before transfer procedure. Embryologist Embryologist 200 Freezing the embryo Embryologist Embryologist 220 Doing embryo monitoring and evaluation. Embryologist Embryologist 120 Making the embryo transfer procedure. Embryologist Embryologist 64 Participation in the quality control and routine cleaning procedures in the embryology laboratory. Embryologist Embryologist 30 Performing the procedure for puncturing the membrane (Zona pellucida) surrounding the embryo by means of the method called as membrane opening when required. Embryologist Embryologist 5 Participating in the general laboratory cleaning made once a week. Embryologist Embryologist 30 Giving information on fertilization to the patients for which the procedure is applied. Embryologist Embryologist 10 Measuring and recording temperature and CO2 values without opening incubators. Embryologist Embryologist 30 Assessing whether the eggs are fertilized or not after 18-20 hours following intracytoplasmic sperm injection (ICSI) or insemination (IVF) procedure and keeping the necessary records related with this subject and informing the laboratory chief or related physician on the cases which have fertilization problem. Embryologist Embryologist 30 Assessing the embryos developing from the eggs fertilized with respect to the number and quality of cells after 66-68 hours following intracytoplasmic sperm injection (ICSI) or insemination (IVF) procedure and selecting the embryos to be transferred together with the laboratory director. Embryologist Embryologist 120 Making the oocyte picking up procedure (egg picking up) Embryologist Embryologist 200 Denudation procedure (making elimination) Embryologist Embryologist 70 Making contribution to the preparation of culture dishes. Embryologist Embryologist 10 Making microinjection procedure (ICSI). Embryologist Embryologist 250 Taking blastomer from embryos with biopsy procedure for preimplantaion genetical diagnosis. Embryologist Embryologist 10 Preparing various solutions used in the procedures for assessing semen macroscopically and microscopically. Embryologist Embryologist 3 Regularly checking the liquid nitrogen amount present in the liquid nitrogen tank and informing the laboratory officer on the amount of the remaining liquid nitrogen amount. Embryologist Embryologist 5 Making the macroscopic and microscopic assessment of the semen by taking sperm samples given from the sperm collection container. Embryologist Embryologist 1 Performing the sperm washing procedure. Embryologist Embryologist 30 Answering the incoming telephones of the tube baby laboratory and directing them to the related persons. Embryologist Medical Assistant 30 Completing the missing documents and forms in the patient files. Embryologist Medical Assistant 80 Placing the material order for the embryology laboratory and recording the incoming material invoices to the computer. Embryologist Medical Assistant 15 Entering the data of the patients related with the embryology laboratory to the computer environment and making them ready for analysis. Embryologist Medical Assistant 300 Informing the patients on the date and time when the transfer procedure will be done. Embryologist Medical Assistant 10 Preparing the list of the patients for which Opu and Transfer procedures will be made. Embryologist Medical Assistant 15 1438 450 287,60 90 5 Hours 1 Hour 30 Minutes The list of the tasks done by 5 embryologists in the application center (after medical assistant) Total time (minutes) 5 Embryologists (time per person) Hour per person 46 Harun Dumantepe, F. Serab Onursal 5. Findings And Comments It was found that the embryologists get over the daily working time of 7,5 hours (Table2) and work for 9 hours. The embryologists stated that they postpone the forms required to be filled after the daily works and data entering issue to the next day as secondary task and they place importance to the analysis tasks which are their main tasks. They stated that they conveyed their complaints on the other administrative tasks to the management and wait for the conclusion. They mentioned that they experience motivation and focusing on the work problem and the drawback they experience that this may cause big mistakes with respect to both data entering and the main tasks. It was found that correct, timely, reliable, and errorfree data entering is made after the medical assistant started working. The time used by the embryologists for the daily works decreased to 6 hours 5 minutes and it was observed that the ratio of making mistake also decreased because the embryologist can do the works he does during the day more calmly, slowly and regularly. 6. Conclusion and Recommendations In this study, process improvement was made and the result has shown that the medical part who has difficulties for completing the main works because of intensity during the daily working hours needed assistants in the administrative and systemic tasks. The candidate pool was established by the management related with a medical assistant need, which have biology or medical assistantship training, experienced in hospital software, the interviews were started with the candidates who are expert in their area. As the medical assistant assumes certain tasks, it was measured that the performance of the medical personnel increased. It should be an inevitable obligation for all departments that it is adopted that the similar studies are also made in the other processes of the hospitals and the times seen as lost are gained and information reliability is ensured. Today, HIS is considered as a key part which is essential of the clinics for the quality healthcare service. Thanks to HIS, medical education quality increases and the waiting times and bureaucratic procedures decrease. At the same time, thanks to HIS, patient care and medical treatment quality standards also increase and it is prevented that the information belonging to the patients are lost (Yilmaz, 2014). The biggest hinder before sustaining the successes in the domestic and abroad healthcare services is actually not keeping the files and data of the patients correctly, timely and completely. Regardless how big is the software cost, not being able to produce correct, timely and reliable data brings to patient loss and failure. It is inevitable that suitable precautions are taken. References Akbolat, M. (2014), Sağlık Kurumlarında Bilgi Sistemleri. Eskişehir: Anadolu Üniversitesi. Bektaş, M. (2013), Hastanelerde Malzeme Yönetim Süreci: Bir Üniversite Hastanesi Örneği. 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