Analysis of hospital flow management: the 3 R’s approach

Gayer, Bruna Dones; Marcon, Érico; Bueno, Wagner Pietrobelli; Wachs, Priscila; Saurin, Tarcisio Abreu; Ghinato, Paulo

doi:10.1590/0103-6513.20200033

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Sumário

Research Article • Prod. 30 • 2020 • https://doi.org/10.1590/0103-6513.20200033 copy

Analysis of hospital flow management: the 3 R’s approach

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Paper aims

This article aims to study the logistics problems in Brazilian hospitals through Lean methods, approaching different aspects of logistics and the procedures adopted in health institutions such as receiving, storage and transporting.

Originality

The rising of hospitals’ costs is importantly impacted by hospital logistics. They are caused by aspects such as unstandardized processes and inadequate layout and equipment in critical stages of logistic operations. However, these problems are rarely addressed in literature.

Research method

We developed, through Design Science Research and lean tools, a model based on route, rhythm and routine (3 R’s) that enables the identification of logistics problems.

Main findings

Hospitals present complex logistic operations. The application of the model developed identified improvement opportunities due to unnecessary activities, lack of space and infrastructure, and lack of standardized procedures. These findings enable improvements in operations and a better comprehension of the factors that impact the processes of internal logistics.

Implications for theory and practice

The model provides a comprehensive view of the logistical process, its stages and aspects of improvement. Therefore, hospital managers can better identify and address logistical problems directly at non-value adding activities. Adaptations may be required due to the healthcare environment specificities.

Keywords
Route; Rhythm; Routine; Hospital logistic flow; Lean healthcare

	7 wastes in lean logistics	Description of each waste
1	Overproduction	It is the delivery of materials before they are needed.
2	Delay/Waiting	It is any delay between the end of one activity and the start of the next activity (e.g. the time between the arrival of a truck for a pick-up and the loading of the trailer).
3	Transportation/Conveyance	Unnecessary transport that results in added cost.
4	Motion	Unnecessary movement of people (e.g. walking, reaching and stretching).
5	Inventory	Any logistics activity that results in more inventory being positioned than needed or in a location other than where needed.
6	Space	Use of space that is less than optimal. Examples include less than full/optimal trailer loads, cartons that are not filled to their full capacity, inefficient use of warehouse space, and even loads over the capacity.
7	Errors	Any activity that causes rework, unnecessary adjustments or returns (e.g. billing errors, inventory discrepancies, and defective/wrong product).

Steps	Expected outputs	Strategies to operationalize the proposed model
Establishing common ground about the problem studied	Initial phase, important for setting a conceptual alignment between the problem studied and expectations. The expected output for this step is the definition of the study problem and the characterization and overview of the context studied.	Meetings and observations of the context.
Analysis of the subject´s flow	Identification and description of the main events that the subject that flows goes through over time and space.	Value Stream Mapping (VSM)
Definition of a flow for in-depth analysis	The definition of the flow for the in-depth analysis should take into account the necessity of the context (a critical flow) or a simple flow to develop the pilot study and improvement implementation.	Meetings and results of the VSM
Deep analysis of the flow	Highlight the variability of the work done in the gemba and analyze of the logistics, considering the route, routine and rhythm.	3R´s Checklist, supported by observations, interviews and document analysis.
Identification of opportunities for improvement	The final step has as outcome a list of improvement opportunities, related to the 3Rs in logistics.	Meetings to discuss the results of the previous steps.

Instruments for data collection	Description	Data collection
Observation	Non-participant observations to deepen the understanding of the context.	70 hours in different shifts and times
Interviews	Semi-structured interviews to capture information about the material flow and to identify improvement opportunities.	6 interviews (10-20 minutes each, a total of 107 minutes). Participants that work in the logistics unit, covering the areas of planning and procurement, separation of medications, warehouse, restocking, inventory, and dispatch.
Document analysis	Aims to understand the prescribed work, so to compare with the real work and to understand the material flow.	The analyzed documents were invoices, material requisitions (internal request), operating system documents.

	Requirements	Source of evidence
1. Route	1.1 Locations for material storage are specific and easy to access, optimizing the route.	To observe and/or interview employees of the material storage area.
	1.2 Material is stored in the proper place at the first time, avoiding further replacing.	To observe the route from the receiving sector to the stock of the material.
	1.3 Adequate space for sorting, selecting and checking batches of materials to be transported.	To observe and/or interview employees that prepare the material for transportation.
	1.4 Adequate space for people to move around.	To observe and/or interview employees from the logistics and storage units.
	1.5 Adequate space for transport devices (e.g. trolley, skid steer loader, stretcher, and wheelchair).	To observe and/or interview employees from the logistics and storage unit and to identify aisles with adequate width.
	1.6 Presence/availability of vertical and horizontal displacement devices (e.g. service elevator and pneumatic tubes).	To observe displacement devices availability, and if it is shared with other services.
	1.7 Identification of a standard transportation route.	To observe and/or interview and analyze documents about the routine of the logistics and storage units.
2. Rhythm	2.1 Supplier rhythm of delivery dictated by customer demand.	To interview employees from the planning area and/or review documents, such as contracts with the supplier.
	2.2 Inventory size based on demand.	To interview employees from the planning area and review documents, such as inventory sizes records.
	2.3 Transportation rhythm dictated by the demand of the client process.	To interview employees from the logistics and distribution units and review documents, such as material requisition records.
3. Routine	3.1 Team mobilized at predetermined times for receiving, preparing and transporting materials in standardized frequency.	To observe and/or interview and review documents about the routine in the logistics and storage units.
	3.2 Materials standardly stored.	To observe if the stock has signalized and delimited stocking spaces.
	3.3 Standardized sequence in batch preparation and material distribution.	To interview employees from the logistics and material distribution and observe the existence of devices (cards, frames, empty boxes) that represent the production sequence.
	3.4 Standardized routine for returning empty boxes and empty transport devices.	To interview employees from the logistics and material distribution and to observe if the routine of returning empty boxes and empty transport devices is performed in a standardized frequency.

	Route	Rhythm	Routine
Receipt	- Materials are not stored correctly at first; - Congestion of boxes that arrive at the same time from suppliers, hindering the movement of employees;	- It is not dictated by the hospital's request (customer), resulting in large delivery batches;	- There are no predetermined times for the transportation of boxes from the receiving area to the stock; - There is no team mobilized at predetermined times to transport boxes from receipt to stock; - Unavailability of staff due to other tasks;
Stock	- Physical space for storage is insufficient; - Inadequate space for the separation, selection, and checking of materials to be transported; - Transport of trolleys impaired by lack of space; - Narrow aisles; - There is no standard route of transportation until the expedition;	- Inventories last approximately 15 days, being unbalanced with the rhythm printed by the patients;	- Material disposed in the stock in a non-standard way (without visual management with fixed demarcation for storage); - Absence of a standardized sequence in the preparation of serum to be dispatched; - Time is wasted by removing the serum from the cardboard boxes and placing them into green boxes; - Unbalanced workload;
Delivery	- Lack of space for people movement and carriage, due to the congestion of materials; - Too much material waiting to be transported; - The service elevator is used by different support areas, causing waits; - There is no standard route of transportation to the units.	- Rhythm of expedition unbalanced with the rhythm of preparation of materials in the stock, resulting in a large amount of material waiting to be transported.	- There is no team mobilized at predetermined times to supply the units; - Absence of standardized sequence in the transport of materials, being at the discretion of the team which unit will be supplied first; - Unbalanced workload; - There is no standardized routine for the return of trolleys and boxes.

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