Department of Radiation Oncology, Royal Hospital, Muscat, Oman *Corresponding Author’s e-mail: sanjoor123@gmail.com تطبيق تقنيات إدارة لني يف قسم طب األورام اإلشعاعي م�شطفى حممود البلو�شي و زاهد املنذري abstract: Objectives: Lean management (LM) principles were first developed by a Japanese manufacturing company to maximise value and minimise waste in the automotive industry. However, these principles can also be applied in the healthcare sector. This study aimed to illustrate the process of implementing LM principles in a radiation oncology department to streamline workflow and identify and reduce waste. Methods: This study took place in the Department of Radiation Oncology, Royal Hospital, Muscat, Oman, in December 2016. A value stream map (VSM) was created for the chain of processes followed in the department. A waste analysis was conducted to determine which processes did not add value for the patient or healthcare provider. Results: Based on the VSM analysis, only six out of 13 steps were found to be of value. Necessary and unnecessary non-value-adding activities were identified. Sources of waste included parking and registration. In addition, variabilities in workload were noted. Conclusion: Overall, LM principles improve workflow, reduce waste and enhance patient and staff satisfaction. In the current study, the application of LM principles helped to improve value in a radiation oncology department. Keywords: Health Services Administration; Healthcare Quality Assurance; Total Quality Management; Organization and Administration; Efficiency; Oman. �شناعة يف الهدر وتقليل القيمة من قدر اأق�شى لتحقيق يابانية ت�شنيع �رسكة قبل من تطويرها مت لني اإدارة مبادئ الهدف: امللخ�ص: ا يف قطاع الرعاية ال�شحية، تهدف هذه الدرا�شة اإىل تو�شيح عملية تطبيق مبادئ اإدارة ال�شيارات، وبالإمكان تطبيق هذه املبادئ اأي�شً لني يف ق�شم طب الأورام الإ�شعاعي لتي�شري تدفق العمل وحتديد الهدر وتقليله. الطريقة: اأجريت هذه الدرا�شة يف ق�شم طب الأورام الإ�شعاعي بامل�شت�شفى ال�شلطاين يف م�شقط، ُعمان، وذلك خالل �شهر دي�شمرب 2016، مت اإن�شاء خريطة تدفق القيمة ل�شل�شلة العمليات املتبعة يف الق�شم، مت بعدها مت اإجراء حتليل للهدر لتحديد العمليات التي مل تكن لها اأي قيمة اإ�شافية �شواءاً للمري�ص اأو للموظف ال�شحي. النتائج: ا�شتناداً اإىل حتليل خريطة تدفق القيمة، مت العثور على �شتة خطوات فقط من اأ�شل 13 خطوة والتي كانت ذات قيمة. مت كذلك حتديد الأن�شطة ال�رسورية وغري ال�رسورية التي مل تكن لها اأي قيمة م�شافة، �شملت م�شادر الهدر مواقف ال�شيارات وعمليات الت�شجيل، بالإ�شافة اإىل ذلك، لوحظت تفاوت يف اأعباء العمل. اخلال�صة: ب�شكل عام، تعمل مبادئ اإدارة لني على حت�شني �شري العمل وتقليل الهدر اإ�شافة اإىل تعزيز مدى الر�شا لدى املر�شى واملوظفني، وقد �شاعد تطبيق مبادئ اإدارة لني على تعزيز القيمة يف ق�شم طب الأورام الإ�شعاعي. الكلمات املفتاحية: اإدارة اخلدمات ال�شحية؛ �شمان جودة الرعاية ال�شحية؛ اإدارة اجلودة ال�شاملة؛ التنظيم والإدارة؛ جناعة؛ عمان. Implementing Lean Management Techniques at a Radiation Oncology Department *Mustafa M. Al-Balushi and Zahid Al-Mandhari clinical & basic research Sultan Qaboos University Med J, August 2018, Vol. 18, Iss. 3, pp. e362–366, Epub. 19 Dec 18 Submitted 3 Feb 18 Revision Req. 22 Mar 18; Revision Recd. 14 Apr 18 Accepted 10 May 18 doi: 10.18295/squmj.2018.18.03.016 Advances in Knowledge - This study delineates the steps involved to apply lean management principles at a radiation oncology department in order to streamline work flow and reduce waste. Application to Patient Care - In the healthcare sector, lean management principles can help to increase patient satisfaction by increasing value (e.g. timely treatment delivery, reduced waiting time, etc.) and reducing wasteful activities and processes. Lean management (lm) principles were first developed to improve production and inc- rease customer satisfaction in the automotive industry by the Toyota company (Toyota Motor Corp, Aichi Prefecture, Japan).1 Since then, LM principles have been widely applied in various sectors with trem- endous success, including in healthcare delivery.2–4 The aim of LM tools and techniques is to organise processes, leading to increased value which manifests as increased customer satisfaction and the elimination of waste.5,6 However, LM principles are not designed as a set of regulations and rules to be applied at a certain stage; instead, the aim is the continuous improvement of existing processes.7 One specific LM tool is the creation of a value stream map (VSM). This technique involves the identification of the chain of processes involved in the creation and distribution of a product or a service, thus helping personnel to detect inefficiencies, work load variability or non-value-adding (NVA) activities that lead to increased Mustafa M. Al-Balushi and Zahid Al-Mandhari Clinical and Basic Research | e363 waste.8−10 It is an integral instrument used in LM interv- entions to assist in delineating the steps which would help an organisation to reach its goals. However, a VSM is quite different from other flowcharts in that it incorp- orates both materials and information.9 In healthcare, LM is defined as “an organization’s cultural commitment to applying the scientific method to designing, performing and continuously improving the work delivered by teams of people, leading to measurably better value for patients and other stake- holders”.11 The focus is on the movement of the patient through the system, rather than individual interactions between patients and healthcare providers.12 In health- care facilities, LM techniques have been documented to reduce costs, errors and time wastage as well as improve patient and staff satisfaction.7,9 Moreover, one hospital in the USA reported that LM techniques resulted in the timely initiation of 99% of its operations, while another managed to reduce inpatient total care costs by 25% and improve patient satisfaction by almost 100%.11 Prior to the delivery of radiotherapy treatment, multiple important steps must be completed; however, any initial setbacks or wastage is reflected in subsequent steps, resulting in treatment delays and decreased patient satisfaction. The Royal Hospital is a tertiary care centre in Muscat, Oman, and is the only centre in the country to offer radiotherapy. In December 2016, one of the hospital’s two radiotherapy treatment units was shut down while a new radiotherapy machine was being commissioned. This resulted in a greater patient load at the remaining unit, thereby obligating staff to work harder to ensure that there were no unnecessary delays in treatment. Based on previous research, LM implem- entation was deemed an appropriate measure to help enable a smoother transition during this period.9,11 This study was therefore undertaken to delineate the process of implementing LM principles to improve workflow and identify and eliminate sources of waste in the context of radiotherapy treatment. Methods This study was conducted in the Department of Radiation Oncology at the Royal Hospital in December 2016. A value stream map (VSM) was developed to document all the steps being undertaken prior to the patient receiv- ing treatment. Subsequently, the VSM was analysed using the ‘3MUs’ tool to detect muda (activities with no value), mura (unbalanced workload) and muri (the overburdening of staff and processes). Of the activities which were designated NVA, the researchers sought to determine whether these were nonessential or necessary as well as those which constituted sources of waste. Finally, heijunka, another LM tool, was utilised to level workload. Other LM tools were either not applicable to the department or it would have been too early to implement them. For the purposes of the study, value was defined as achieving patient satisfaction through the timely delivery of treatment. Sources of waste were identified in eight categories, consisting of transportation, inventory, motion, waiting, overproduction, overprocessing, defects and intellect/skills [Table 1].6 Prior to the implem- entation of LM principles, all personnel affiliated with the department participated in a series of continuing medical education activities to introduce underlying LM concepts and how to implement these principles effectively. The VSM was constructed using ConceptDraw OFFICE software, Version 11 (Computer Systems Odessa, Odessa, Ukraine). Radiation oncologists, medical phys- icists, dosimetrists, radiotherapy technologists and oncol- ogy nurses all helped in formulating and editing the VSM. The VSM started from the moment the patient first arrived at the hospital’s parking lot for their first clinical appointment and ended with the conclusion of treatment. This study was approved by the Centre of Studies & Research at the Ministry of Health in Oman (SRC #4/2018). Informed consent was not deemed necessary as there were no direct encounters with patients. Further- more, no information was obtained from electronic patient records during the course of this study. Results A VSM was constructed to delineate the steps involved in the provision of radiotherapy treatment at the Royal Hospital [Figure 1]. After analysing the VSM, six out Table 1: Categories of waste according to lean manage- ment principles4 Category Definition Transportation Unnecessary transportation of a product through a system Inventory Unnecessary storage of a product Motion Non-productive motion that adds no value to the patient or healthcare provider Waiting Unnecessary waiting for the next event/ step in the process Overproduction Overproduction of supplies Overprocessing Overprocessing in which more value than necessary is added to the product Defects Defects in equipment/processes Intellect/skills Steps/actions which do not utilise the full intellectual capacity or skills of the employees Implementing Lean Management Techniques at a Radiation Oncology Department e364 | SQU Medical Journal, August 2018, Volume 18, Issue 3 of 13 steps were deemed value-adding. These constituted the patient’s first visit to the outpatient department, simulation, re-simulation, treatment, the actual radio- therapy sessions and the conclusion of treatment. Steps which did not add value, but which did not involve the patient’s presence at the hospital, included importing, contouring and planning. Parking and registration were waste generating steps that were deemed necessary NVA activities [Table 2]. Parking was deemed a source of waste in the waiting category. However, no intervention to reduce parking- related waste was possible as the designated parking lot for radiotherapy patients was also being utilised by other hospital visitors; furthermore, any intervention Table 2: Procedural steps and their value for the chain of processes followed at the Department of Radiation Oncology at the Royal Hospital, Muscat, Oman Step Details Role Value 1 Parking Time spent by the patient to secure a parking space Patient Waste-generating/ necessary NVA 2 Registration Time taken for the patient to register at the hospital Patient Waste-generating/ necessary NVA 3 OPD Time spent during the first visit to determine indication for and doses of radiation Physician Value-adding 4 Simulation Duration of radiotherapy simulation Radiotherapist Value-adding 5 Importing Duration of importing simulation images to the medical physics department Medical physicist Necessary NVA 6 Contouring Determining target planning volumes Physician Necessary NVA 7 Planning Calculating patient dosage Medical physicist Necessary NVA 8 Re-simulation Duration of radiotherapy re-simulation Radiotherapist Value-adding 9 Treatment Inclusive of steps 10 to 13 - Value-adding 10 Parking Time spent by the patient to secure a parking space Patient Waste-generating/ necessary NVA 11 Registration Time taken for the patient to register at the hospital Patient Waste-generating/ necessary NVA 12 Radiotherapy Duration of radiotherapy sessions Radiotherapist Value-adding 13 Conclusion Final radiotherapy session, including provision of a treatment summary Physician Value-adding NVA = no-value-adding ; OPD = outpatient department. Figure 1: Value stream map for the chain of processes followed at the Department of Radiation Oncology at the Royal Hospital, Muscat, Oman. OPD = outpatient department. Mustafa M. Al-Balushi and Zahid Al-Mandhari Clinical and Basic Research | e365 required approval by the hospital administration. Regist- ration was also identified as a source of waste in the transportation, waiting and overproduction categories. In order to register, the patients had to go to the main hospital building and wait alongside outpatients attending other departments. Additionally, the patients had to bring separate appointment slips at every visit for the duration of their treatment, which usually spanned a few weeks. This was solved by introducing a registration desk in the department itself and providing patients with appointment charts that included the dates of each appointment. The simulation step was also identified to const- itute a potential source of intellectual waste. This was because of variations in patient load; on some days, the radiation oncologists sent a large number of patients for simulation while, on other days, there were no patients at all. This problem was solved by abandoning the ‘push’ system of appointments and implementing a ‘pull’ system instead. This involved picking a treatment start date slot in the clinic, with the simulation technicians authorised to create simulation appointment slots. Furthermore, medical physicists were encouraged to prioritise cases based on a thorough discussion with the concerned physician, instead of on a ‘first come, first served’ basis. Finally, a two-shift system was introduced in order to reduce the intellect waste caused by having an excessive number of employees working at the same time. Discussion During the study period, the Department of Radiation Oncology at the Royal Hospital was undergoing a period of transition as one of two treatment machines was being decommissioned to facilitate the commission and installation of a new one. This transition created a great deal of stress within the department, with staff anticipating severe treatment delays and patient dissat- isfaction. Hence, the current study was conducted to implement LM principles so as to improve efficiency and reduce unnecessary waste, thereby enhancing workflow and, ultimately, ensuring the delivery of treatment in a timely manner.9,11 Prior to the application of LM techniques, the dep- artment utilised a ‘push’ system to book appointments for simulation. The radiation oncologist, as the individual who first saw the patient and decided to administer radiation therapy, would book the patient in for simul- ation, thus ‘pushing’ the patient through the system. During times when multiple cases presented simult- aneously, all of the patients would be sent for simulation at the same time, placing unnecessary pressure on the simulation staff to finish each case as soon as possible so as not to delay treatment. However, on other days, the radiation oncologist would not send any patients for simulation and the staff would not have any work to do, leading to intellectual waste. This practice resulted in mura (an unbalanced workload) as well as muri (over- pressuring of staff ). The simulation step itself was there- fore seen as a muda (source of waste); this can also be extrapolated to subsequent steps in the treatment chain. In contrast, a ‘pull’ approach was a simple solution wherein the physician could decide on a treatment start date based on available treatment slots. The term ‘pull’ indicates that, as all other steps were initiated after the prescribed start date, every event in the chain of events was ‘pulled’ towards that date. This new appointment system ensured that treatment slots were not available during a particular period if a pre-set number of patients was exceeded, ensuring that patient load would not exceed staff capacity at any stage. The workload therefore became completely predictable, with the fluctuations previously observed in the number of patients greatly reduced. Hence, heijunka (levelling of the workload) was achieved, eliminating mura and muri. Several interventions helped to reduce waste in the transportation, inventory and intellectual/skills categ- ories. These involved the introduction of a registration desk in the treatment unit, eliminating the need for patients to go to the registration desk at the entrance of the hospital and then return to the radiotherapy treat- ment unit, as well as the provision of an appointment chart, which helped reduce the overuse of registration slips. Additionally, a two-shift system was introduced in order to reduce intellect waste caused by having more employees than required during working hours due to the presence of only one treatment unit. Finally, cases were prioritised according to those who needed to undergo treatment first rather than on a ‘first come, first served’ basis. Currently, three more LM-related projects have been initiated at the Royal Hospital to improve the efficiency of radiotherapy delivery and sustain current improvements. The authors hope that the results of this study inspire other healthcare researchers to seek solutions to waste and escalating costs of care by applying LM principles. However, it should be noted that LM principles are not temporary solutions to address acute issues arising in a department. Fundamentally, LM involves a long-term cultural shift that needs to be adopted by all personnel in a particular setting in order to be effective and produce positive results.1,6 Overall, LM interventions should form part of a continuous cycle of quality improvement with no set endpoint. The current study was subject to certain limitations. First, a survey to assess patients and staff satisfaction was not conducted; this would have been a valuable tool to assess the increase in value and reduction in waste Implementing Lean Management Techniques at a Radiation Oncology Department e366 | SQU Medical Journal, August 2018, Volume 18, Issue 3 as a result of applying LM principles. Additionally, the survey could have highlighted areas of staff overwork potentially arising as a result of introducing LM inter- ventions. Second, the data were not statistically analysed in terms of the timeliness of treatment delivery, which is the ultimate goal. Further observational studies are therefore needed to evaluate the effect of implementing the abovementioned techniques. The Department of Radiation Oncology is currently working on integrating LM principles within the electronic hospital software. This will allow personnel to record the exact time taken to complete each step of the treatment delivery process. Conclusion Applying LM principles is a promising technique to identify sources of waste and streamline workflow in healthcare delivery. Although not all sources of waste were completely eliminated in the current study, they were reduced following the implementation of LM principles; in addition, these principles also enabled a smoother transition process from two treatment units to a single one by improving workflow and workload predictability. c o n f l i c t o f i n t e r e s t The authors declare no conflicts of interest. f u n d i n g No funding was received for this study. References 1. Liker JK. The Toyota Way: 14 management principles from the world’s greatest manufacturer, 1st ed. New York, USA: McGraw-Hill, 2004. Pp. 67–330. 2. Teichgräber UK, de Bucourt M. Applying value stream mapping techniques to eliminate non-value-added waste for the procure- ment of endovascular stents. Eur J Radiol 2012; 81:e47–52. doi: 10.1016/j.ejrad.2010.12.045. 3. Kim CS, Spahlinger DA, Kin JM, Billi JE. Lean health care: What can hospitals learn from a world-class automaker? J Hosp Med 2006; 1:191–9. doi: 10.1002/jhm.68. 4. Institute for Healthcare Improvement. Going lean in health care. From: www.ihi.org/resources/Pages/IHIWhitePapers/Go ingLeaninHealthCare.aspx Accessed: Apr 2018. 5. Nowak M, Pfaff H, Karbach U. Does value stream mapping affect the structure, process, and outcome quality in care facil- ities? A systematic review. Syst Rev 2017; 6:170. doi: 10.1186/ s13643-017-0563-y. 6. Simon RW, Canacari EG. A practical guide to applying lean tools and management principles to health care improvement projects. AORN J 2012; 95:85–100. doi: 10.1016/j.aorn.2011.05.021. 7. Moen R, Norman C. Evolution of the PDCA cycle. From: www. i d e m p l o y e e . i d . t u e . n l / g . w. m . r a u t e r b e r g / l e c t u r e n o t e s / D G000%20DR P-R/reference s/Mo en-Nor man-2009.p df Accessed: Apr 2018. 8. Rath F. Tools for developing a quality management program: Proactive tools (process mapping, value stream mapping, fault tree analysis, and failure mode and effects analysis). Int J Radiat Oncol Biol Phys 2008; 71:S187–90. doi: 10.1016/j.ijrobp.2007. 07.2385. 9. Ramaswamy R, Rothschild C, Alabi F, Wachira E, Muigai F, Pearson N. Using value stream mapping to improve quality of care in low-resource facility settings. Int J Qual Health Care 2017; 29:961–5. doi: 10.1093/intqhc/mzx142. 10. Gellad ZF, Day TE. What is value stream mapping, and how can it help my practice? Am J Gastroenterol 2016; 111:447–8. doi: 10.1038/ajg.2016.38. 11. Toussaint JS, Berry LL. The promise of lean in health care. Mayo Clin Proc 2013; 88:74–82. doi: 10.1016/j.mayocp.2012.07.025. 12. Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: Issues and observations. Int J Qual Health Care 2009; 21:341–7. doi: 10.1093/intqhc/mzp036. https://doi.org/10.1016/j.ejrad.2010.12.045 https://doi.org/10.1002/jhm.68 https://doi.org/10.1186/s13643-017-0563-y https://doi.org/10.1186/s13643-017-0563-y https://doi.org/10.1016/j.aorn.2011.05.021 https://doi.org/10.1016/j.ijrobp.2007.07.2385 https://doi.org/10.1016/j.ijrobp.2007.07.2385 https://doi.org/10.1093/intqhc/mzx142 https://doi.org/10.1038/ajg.2016.38 https://doi.org/10.1016/j.mayocp.2012.07.025 https://doi.org/10.1093/intqhc/mzp036