| 1. BackgroundWith the development of social economics and change of population gross and structure, pattern of disease presents new features, and the demands of civil medical care service in China is increasingly rising. However, statistics of China’s Health Development Statistical Bulletin in 2014 indicates that the number of health care organization of first and second grade is over 3 times of that of third grade, while the growth rating of service quantity is less than half of the later. It illustrates that with the increasing demand of civil medical care service in China, basic medical institutions which can provide patients with fair and available medical service seriously are turnover, at the same time, the patients of third grade hospital increase rapidly. In order to solve imbalance between supply and demand of health service, new health-care reform takes main task on strengthening grass-root medical institution. In 2015, the State Council put forward the guiding opinion on setting the first diagnosis and treatment in fundamental as the primary target. With the guidance of the policy, the major hospitals and the small hospitals can optimize their respective the amount, quantity and structure of patients and exert its supply and demand adjustment function of hierarchical diagnosis and treatment system only through concluding community of common interest and establishing a two-way flow channel for patients.From the constructional practice aspect of hierarchical diagnosis and treatment system, it’s frequent to see that the major hospitals and the small hospitals conclude the community of common interest with the trusteeship pattern. Under the domain of the major hospitals, the realization of strengthening grass-root medical care system collaboratively includes mainly:management and reform, technical assistance and resource allocation. Documents reported that technical assistance and resource allocation in the trusteeship pattern are the key performance of high quality resource sinking, but it is uneasy to catch the point of hospital reform accurately in that the management system in hospital of being mandated is yet to reform. Therefore, the cultural integration fails and a significant mechanism for long development is failing to establish and merely becomes a formality.From the functional positioning that the construction of hierarchical diagnosis and treatment system takes on medical institutions at all levels, the level of fundamental medical technology can provide the patients with basic medical services. Besides, medical service quality is the key to attract patients in fundamental health care organization. Clinic is the key service content of grass-root public hospital in future, as the link the doctor and patient contact the most, the procedure of clinic embodies medical service quality which can directly affect patients’satisfaction and trust degree to hospital. Therefore, to optimize medical service quality through the procedure of clinic is the strategic management of fundamental public hospital and is also the effective penetrating point to realize the goal of keeping patients in grass root to implement the construction of hierarchical diagnosis and treatment system. However, according to the literature review:comparing with the third grade hospitals, the procedure of clinic of fundamental hospital has a weaken foundation in optimization and research; the number of research is small; the measure of optimization is more simple; at the same time, it is different from the major hospital in reality, which determines that there is no experiences to copy; besides, process management of public hospital based on the theory of lean management is relatively blank.2. ObjectiveBased on analysis of research background and literature review above, the research selects a third grade public hospital hosting a second grade as a case to study the reform of fundamental public hospital which takes optimization of clinical procedure as penetrating point, innovates management mechanism with lean management and realizes cultural integration in order to achieve the purpose of research as following:(1) provide reference with optimization of grass-root public hospital’s clinical procedure and related study; (2) supply reference for reform of management and cultural integration mechanism after the major public hospitals hosting fundamental public hospital.3. Thought and Methods3.1 Research thought:(1) Trough literature and data review, summarize research status of domestic hospital outpatient service process optimization and experience enlightenment of lean application at home and abroad, as well as collect research background materials of case study to lay foundation for the project. (2) Undertake case study and implement lean practice projects in a good order based on project frame, including stages of project selection, step-by-step implementation and continuous improvement, as well as project definition, team building and training, status measurement, reason analysis, optimization plan formulation and implementation, effect evaluation and continuous improvement. Brainstorm, value stream analysis, pareto principle, causal analysis and 3 wlh table are involved in application of lean tools during the procedure. (3) Optimize lean project summary based on case study, including discussion on case study, conclusion of research characteristic and innovation and review of study limitations.3.2 Research methods:literature material law, field observation method, unstructured interviews, brainstorming method and cases study method. Using Minitab software for data statistical analysis, statistical description, normal inspection, equi-variance test, Non parametric test and Two sample T-test.4. Results4.1 Result of case:background of trusteeship research. (1) The motivation of carrying out trusteeship and cooperation is that government, hosting hospital and hosted hospital all the three look forward to realize construction of regional4 grading hierarchical diagnosis and treatment system though the pattern of trusteeship, and realize the basic public hospital reform of strengthening grass root with program of clinic lean optimization. (2) Implementing trusteeship pattern of compact type. In a case, term of trusteeship and cooperation reaches to 50 years, which decentralizes the hospital core power, requires the hosted hospital to implement integrated management, and carries out hospital reform in the start reconstruction of organization, revision of management system and process, dispatching business management cadres, technical association and other kinds of reform. (3) Cultural background of lean management of hosting hospital support theory and practice basis of management, cultural integration for the reform of hosting fundamental hospital.4.2 Status measurement results:the "Three Longs and One Short" problem of medical treatment outpatient process is outstanding, as average process would spend 148.6 minutes, ranging from 75 minutes to 215 minutes. Non-value added time defined as waste time of 124 minutes takes 83.4%. However, over 80% non-value added time happens in links of waiting for treatment, inspection, results and payment, as waiting area, inspection area and payment area are major waste areas. At last, major waste links shall be analyzed profoundly to determine tertiary problem tree of 12 specific questions behind the waste.4.3 Cause analysis results:through brainstorm, it is found that the basic cause of long non-value added time lies in physical environment, management system, personnel organization and information construction, with best improvement factors of input and output including:unreasonable discipline venue layout, insufficient using of service window, low readability of recognition system, low personnel competence of leading examining, unreasonable organization of payment people with doctor scheduling, insufficient reservation service, lacking of standardized examination process, trivial refund process, low utilization rate of doctor workstation, lacking turn calling system and outdated medical insurance settlement system.4.4 Implementation of plan formulation and implementation results:formulated 3W1H progress schedule with 13 specific optimization measures of four factors carried out:(1) disciplines site layout adjustment design based on the integration management; (2) scientific and rational organization of outpatient service staff (3) implementation of standardized and intensified f service management improvement (4) making good use of external platforms to promote the construction of hospital informatization.4.4 Performance evaluation results. Through lean optimization of outpatient service process to implement targeted management within project time, following five aspects achievements and four point of continuous improvement are obtained:Effectiveness evaluation:(1) Volume of business increase obviously:from January,2015 to April,2016, growth rating of volume of clinic, acceptance and operation rises apparently year on year. With trusteeship pattern of concentrated type, lean optimization of clinical procedure improves effectively volume of business of hospital and is benefit to achieve the goal of constructing hierarchical diagnosis and treatment system in order to keep patients in fundamental hospital. (2) Non added-value time apparently reduces:after T-test or Non parametric test, total cycle time of process and total non-value-added time shown outstanding difference (P< 0.05), with 40 minutes and 42 minutes decreased respectively. Among those, first waiting time of treatment, total payment time, result waiting time, time difference between result waiting and actual reporting time shown outstanding difference (P< 0.05), with 11,13,17 and 20 minutes decreased respectively. (3) Resource utilization rating increases:about 200 m2 area of space is saved for original ground; per capital patient flow is reduced obviously; "bank-hospital link" project is introduced for free to solve grass-root investment and technical weakness. (4) A series of working standards are formed:management system of outpatient visits, appointment and so on, check time management indicators like 0.5 hour of DR results etc, discipline integration in clinical ward management, discipline classification of clinical emergency management.(5) Internal and external customers’satisfaction improves significantly:56% interviewed patients hold the approval attitude; complaints of clinical service cut down 5 every month in average; the internal department establishes the cross-sector cooperation mode of work, accumulates practice experience of lean management and exerts a patients centered service concept with unconscious influences.Continuous improvement points:(1) to conduct inspection sub-processes of lean optimization.(2) to strengthen the feasibility discussion of hospital informatization construction plan.(3) to increase patients satisfaction survey research content lately.(4) to organize a volunteer team of medical wisdom using and promotion.5. ConclusionsStanding from two aspects:one is process optimization research level of basic outpatient service:this study uses lean management concept and method, formulates and implements lean optimization project accord with the actual situation of basic-level hospitals, solves the problem of hospital outpatient service process management of basic-level, activates original force of self-development and self-maintenance to realize transmission from coarse management towards fineness. The other is basic custody research level in classification medical treatment background, with active influence on grassroots public hospital trusteeship via hospital reform practice of lean management concept and method of innovation mechanism based on the outpatient service process. It summarizes successful factors of lean implementation with application outlook of lean management in effective integration of personnel and culture.6. Significances(1) With the consequence that optimization of fundamental clinical procedure isn’t enough, the case studies on the problem of solving practical procedure with lean management of appliance, which will support impetus and direction for improving factors and results visualization, realize the transformation from extensive management to exquisite one, and have a certain value of reference for management and reform of fundamental clinic.(2) It also designs lean and exerting framework in the process of program combining with lean experiences and practical conditions, and offers methodology reference for implementing lean program.(3) It is the common thing that trusteeship is the pattern of China’s public hospital management reform. Individual case studies the action that optimizes and penetrates clinical procedure and innovates mechanism with lean management, which can realize effectively patients to keep in grass root and implement the four grade hierarchical diagnosis and treatment system in Hospital Health Alliance. It is a reform practice of fundamental public hospital with reference meaning.(4) In the link of lean medical care research, individual case studies and conclude the successful elements of exerting lean innovative mechanism, at the same time, it explores and analyzes the appliance prospect of cultural integration in exerting trusteeship.7.LimitationsIn the aspect of project design, sampling objects are merely those who need examination; sub-procedure lacks of complete study; in later research the informants and procedure should be classified in detail. In the aspect of research contents, because of the time limitation, part of contents haven’t enough statistics to support research analysis and statistic monitoring analysis will be last next step. In the aspect of methodology, members of program group and I don’t grasp rich lean theory and appliance of methodology, and we still need to learn deeply and practice actively. |
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