#4 Summer 2015

Deceptively easy fix for many problems at SA hospitals

A new project in four of Gauteng’s hospitals shows it is possible to reduce waiting times, improve operations at pharmacies and cut down on wasteful processes resulting in huge improvements to service delivery.

At one of Gauteng’s largest state hospitals, there is a little room with thousands upon thousands of patient files, haphazardly thrown onto aluminium bookshelves without any kind of noticeable filing system or method to the madness. Some files lie on the ground in a disorganised heap.

At another Gauteng health facility – which deals with around 300 outpatients per day – a small team is assigned to the duty of retrieving files for waiting patients. It is a long journey to the filing office and back to the waiting room and when calculated, it was found that this team covered, in one day, a distance of about 56km – more than the average marathon!

Creaking filing systems were only one of the problems a team of lean management experts found when they examined four Gauteng state hospitals: Chris Hani Baragwanath, Leratong, Sebokeng and Kopanong, as part of a hospital turnaround programme initiated by the Gauteng Department of Health and supported by the Department of Performance Monitoring and Evaluation (DPME) within the Presidency in 2014.

Two of these hospitals, Chris Hani Baragwanath and Leratong, formed part of an investigation by Public Protector, Advocate Thuli Madonsela in 2013. She was concerned about what she found. She heard of a dire shortage of medical personnel, medication and critical equipment, like ventilators and incubators. In some wards, electric plugs and live wires hung from the walls. Patients complained of long waiting periods for files, medical attention and to receive medication.
The MEC for Health in Gauteng, Ms Qedani Mahlangu, appointed the Lean Institute Africa (LIA), a research unit associated with the GSB, to take on the classic public hospital challenge, waiting times for outpatients at these four hospitals, and then expand to other points of need.

The hospital turnaround programme is ground breaking, not in the sense that the approach is novel or innovative. On the contrary, the lean management system forged in the automotive industry in the 1990s is tried and tested. The novelty is in applying it in a concerted manner in the public sector and to four hospitals concurrently.

Lean management has its roots in the Japanese automotive industry (The Toyota Way) and focuses on eliminating unnecessary procedures and time-wasting efforts and ensuring fluent operations. There is a convincing body of research stretching over 30 years, establishing the benefits of lean management, how it builds capacity, improves efficiency and staff morale.

After drawing up a plan to address specific problem areas in the Gauteng hospitals, lean management teams worked with staff to improve flow and reduce waste. In just a few months, following intensive training and coaching with staff, a reduction of overall patient waiting times in selected areas of between 19 and 65% was achieved, resulting in massive improvements to the experience of patients at these hospitals.

Hospital employees were also extremely positive following the programme, putting in many requests for more training and further coaching. This is currently part of further discussions with the Department of Health in Gauteng.

Averaging the results at the four hospitals, waiting times were reduced by 56% in the amount of time it took to get patient files, a 45% reduction was achieved in waiting times at the targeted clinics and around 50% faster service was achieved in the pharmacies.

In some cases, it was a simple solution of changing hospital layout and reorganising key processes. In the case of the unfortunate team that had to walk more than a marathon a day, for example, changing the layout meant a reduction to a third of that – still too far, of course! This is strong evidence that even hospitals with limited resources can perform better and improve service delivery.

“Lean leadership allows for the fastest and most efficient response to a problem,” says Dr Anton Grütter, CEO of LIA and lecturer in the principles of lean management at the GSB. “It relies on the continuous improvement of processes, paired with respect for people, no matter what their position within the organisation. This leads to a non-hierarchical decision-making landscape, where employees are empowered to solve problems quickly.”

One of the key elements of a lean leadership approach is to ‘go see’ what the problems are –on the ground. And the results of seeing clearly can be revelatory, prompting one hospital CEO to remark just three months into the programme: “I am beginning to understand how my hospital works.”

Lean is about understanding the processes that are used to deliver (or not deliver) services and spotting instances of waste and removing these and improving the value proposition; it is about delivering value to customers, which in this case are the patients.

The LIA specialises in applying the principles of lean management to areas outside the automotive sector. After promising results elsewhere in the world, the institute began looking at how this could be done in South Africa in public sector environments – like hospitals, courts and the Department of Trade and Industry.

There are tens of thousands of service delivery points across the country. But the beauty of the lean management approach is that it is scalable, delivering short-term relief that can be made sustainable over the long term – as long as there is buy-in from senior managers.

One of the biggest challenges to the success of work done by the DPME in the public sector and with public sector officials is the gap between the commitment of MECs and facility heads. In some instances, officials fail to take ownership of the actual improvement process, don’t attend crucial facility-level meetings or in one instance in the broader project, government officials were unable to even agree on a date for a training workshop.

For lean management to work, there has to be a rhythm of management practice: daily, weekly and monthly follow-ups, and so on. It is an issue of practice and habit-formation. If the objective is real progress with problems in the public sector, then these principles have to become part of the daily routine – like brushing your teeth – not something done once or for a few weeks and never again.

South Africans have become too used to shoddy service delivery. It is a case of abnormal becoming the new normal. Employees don’t expect equipment to work or be replaced; they are used to doctors and municipal managers arriving late or not at all. It is an extraordinary situation. But there are many very conscientious and competent people in the public sector who are themselves frustrated and worn down by the state of affairs.

The hospital project teaches us that instead of immediately trying to find additional resources or budget, an approach as simple as supporting key employees and helping them to achieve more in their particular sectors can deliver much-needed improvement in service delivery in the public sector that is both impactful for patients and motivating for staff.

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