The challenges facing South Africa’s public health sector are well documented. Recently there were headlines about babies dying in a Pretoria clinic — and such tragedies are not isolated.
Overworked staff and under-resourced departments are often cited as contributing factors in the failure of the public health sector, but recent evidence from the Lean Institute Africa at the University of Cape Town’s Graduate School of Business shows that by changing the way people think about the problem and reorganising the way they do things, drastic changes can be effected.
It’s a philosophy called “lean thinking”. It is more commonly associated with the motor industry. Toyota made it famous in the 1980s and continues to benefit from it. However, the principles are gradually permeating to other sectors with positive results.
The premise of lean thinking is that through observing a situation, one comes to understand what adds value and what does not and why challenges or bottlenecks occur. From there it is possible to identify simple steps that may lead to improvements and ways to implement them.
In May 2010 the Lean Institute Africa set out to test the efficacy of the lean approach in South Africa’s public hospitals, using 18 hospitals in remote and/or needy areas as trial sites. The experiment included 336 hospital staff members, who participated in 18 one-week workshops during which they were invited to consider key issues that would lead to a lean solution.
The considerations included identifying major problems and their root causes, suggesting possible countermeasures, identifying how to ensure buy-in from relevant stakeholders, developing an implementation programme and measuring the results of the proposed measures. The outcome of the workshops was impressive: 65% of the participating hospitals reported improved practices, which they could further enhance or at least sustain.
The success stories included a KwaZulu-Natal hospital that reduced the waiting time at the in-house pharmacy from a frustrating three hours to an astonishing 15 minutes.
A busy hospital west of Pretoria experienced a similar triumph. The waiting period used to be just less than four hours, but now it stands at less than an hour. This has had implications for staff. In the past each staff member was required to work two hours overtime to address the backlog. Now overtime is thing of the past.
What was most notable was that the hospitals did not secure additional resources to attain these results. Rather, they examined their existing infrastructure and resources and reorganised them for greater efficiency. For example, in the case of the Pretoria hospital, the previous system relied on patients delivering their own files to a clerk, who would transfer them, in batches, to the pharmacy on an hourly basis.
The pharmacist would fill the prescriptions and place the medicine on a trolley. Once the trolley was full, patients were called by name to collect them. This unwieldy process was overhauled. Patients now deliver their files to the pharmacist. Medicines that are more frequently requested are placed at the front to ensure they are easily accessible and two staff members man the dispensary. The staff member who used to receive and batch the files now monitors the queue. This has had enormously positive implications for work flow, with batching — the enemy of efficiency — entirely eliminated.
Another example of a greatly improved facility was in a Limpopo hospital. The HIV outpatients, who rely on the hospital for ARV medication, were accustomed to waiting an average of eight hours for their check-up and prescriptions — and this was after they had already travelled a day or more to reach the remote clinic.
The wait was caused by a logistically complex system that involved patients walking to several sites to collect their files, be examined by a doctor and then fetch their prescriptions from the pharmacy.
The solution was simple: the pharmacy was relocated closer to the examination rooms, reducing walking time for patients. The time allocated to administrative duties was increased and the filing system was rearranged to improve flow.
In the Free State the poor layout of equipment in an emergency room meant that nursing staff walked the equivalent of 520 kilometres each year in the course of their duties. Their time could be put to better use and all the walking added unnecessarily to the strain on the nurses. With some simple restructuring and rearranging of equipment the hospital was able to reduce the distance by half. More improvements were effected by removing the number of duplicate files for each patient (one patient had 16 files under his name), again clearing the way for greater efficiency.
Of course, not all the hospitals reported such progress: the situation remained largely unchanged at 35% of the workshop participants’ hospitals. Reasons for this are difficult to pinpoint. They could include resistance to change. People are often convinced that they do things the best possible way and it takes courage to decide to do things differently. Frequently hospital staff lack the appropriate support: although doctors and nurses are, for the most part, hardworking and dedicated, management does not always display the same level of engagement.
Government has recognised that this is a problem. The health minister has laid the blame for the poor performance of the healthcare sector on factors such as inadequate managerial skills, a failure to act on known deficiencies and poor accountability.
Although these issues certainly play a role, it is clear that the correct approach, such as lean thinking, can play a major role in revolutionising service delivery. With this in mind, the Lean Institute is lobbying government to expand the project to hospitals throughout the country. If successful, the positive results recorded by the majority of the participants in this study can be replicated elsewhere, with surprisingly little effort and extraordinary impact.
Professor Norman Faull is director of the Lean Institute Africa at the UCT Graduate School of Business