الفهرس 
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Abstract
In today’s competitive healthcare setting, organizations are under pressure to continuously enhance the quality of care offered to an ever-patient population. They necessitate a basis for planning, testing, and implementing changes. Lean thinking is a paradigm for developing an integrated system of concepts, practices, tools, and methodologies to eliminate waste or NVA operations, synchronizing processes and controlling product flow unpredictability. Lean thinking in health facilities concentrates on key methods and seek to enhance standardized processes.In specific, lean thinking has been applied in EDs to reduce waste, such as waiting times, improving patient flow, maximizing value to the customer, improving quality, and increasing efficiency.
Aim of the study
Assess the waiting time that patient may encounter in the emergency department using lean thinking.
Setting
This study was conducted in an ED at one of the private hospitals (for-profit) which is located in Alexandria, Egypt. It is one hospital of a group of healthcare organizations (corporation). The group has been at the forefront of medicine since 1982, when it cared for the first patients. Each year more than 1.15 million patients walk through hospital doors, the group comprises a total of 26 outpatient clinics, 250 beds, and 13 labs across Alexandria and Behira. Its mission is to provide quality patient care through unrivaled lean operations and availing expertise in every specialty and sub-specialty, the services characterized by consistency, diversity, and flexibility. The selected hospital for this study has an ED unit which is equipped with 10 beds capacity and number of highly qualified staff from nurses, physicians, other healthcare providers, as well as ancillary personnel. Average of patients’ admission to ED was about 100 patients daily.
Subject
The study sample included two categories (patients and ED staff) as follows:
1. Patients:
A. A convenience sample size of 100 patients visited the ED, in the morning and afternoon shifts in the previously mentioned setting, were selected to observe the processes they passed through in their journey to the ED and the inherited waiting time they encountered linked to these processes.
B. Out of the previously selected 100 patients, only 35 were chosen conveniently to study their satisfaction with waiting time (VOC) they might experience in their journey in the ED.
2. ED staff (VOB-N= 32), including 50% of the staff and management personnel who are responsible for providing of care or supervising and directing of operations in this department were selected conveniently, and are representing: 13 nurses, 7 physicians, 6 nursing and medical managers/leaders, 1 quality coordinator, and 5 clerical workers.
Tools
Four tools of data collection were used in this study:
Tool 1: Voice of Customer (VOC) Structured Interview:
This tool was developed by the researcher based on the current related literatureto assess patients’ level of satisfaction in relation to waiting time spent in the ED. It consists of 11 items to assess patient’s level of satisfaction in 35 patients regarding waiting time in every process based on the following time interval: from arrival to registration, from registration to the first assessment, from the first assessment to consultation, from consultation to intervention, and from intervention to disposition decision. In addition to their general information sheet.
Tool 2: Voice of Business (VOB) Semi-Structured Interview:
This tool was developed by the researcher based on the currrent related literature to capture the perspectives of people working in the ED (nurses, physicians, quality coordinator, and clerical workers) and managers/leaders (nursing and medical management personnel) in relation to the provided services and processes carried out to care for patients in the ED and their recommendations to decrease waiting time (12 items). In addition to 3 items were used to assess the mother nature. Furthermore, their perspectives of causes of increased waiting time and the required improvements. Also, their general information were mentioned.
Tool 3: Voice of Process (VOP)
Proposal A3 report was developed by the researcher based on the current related literature. Proposal A3 was written in 8 sections, each clearly labeled and arranged in a logical flow as following: Title, Background, Current condition, Proposal statement/goals, Root cause analysis,Plan details/Countermeasure, Implementation and Follow up. The first five sections are written on the left side of the A3 sheet, and the other 3 sections are on the right side. Once the left and right sides have been completed sequentially, the sponsor approval lines are provided for signoff.
Tool 4: Emergency Department Physical Design Assessment Tool.
This tool adopted by the researcher based on the work of Majidi et al. (2014). It consists of 165 items to measure the physical design of the studied ED by the researcher. The items were categorized in to six major domains: accessibility; physical spaces, structures, and equipment; patient accommodations; personnel accommodation; patient privacy and personnel privacy. The response system of the preliminary checklist that was developed was modified from (yes/no) to: no (1), yes incomplete (2), and yes complete (3) to fit the current Egyptian needs and resources.
Method
1. An approval was obtained from the Research Ethical Committee at the Faculty of Nursing, Alexandria University to approve the protocol.
2. An official communication was released from the management of the Faculty of Nursing, Alexandria University to the hospital authority to get an agreement to conduct the study.
3. The researcher took permission from the hospital administrator who encouraged the staff for cooperation with the researcher.
4. Tools I and II were developed by the researcher in English and back to back translation was done (from English to Arabic and vice viscera).
5. Tools I, II and IV were tested for their face and content validity.
6. The tools I,II, and IV were tested for their reliability.
7. A pilot study was carried out on 5 patients and 5 VOBs rather than who were included in the study.
Data Collection
In this study, the data collection framework of Al Owad (2015) was adapted by the current researcher. Both qualitative and quantitative data were collected as following these steps:
First phase (VOP)
- At first, the researcher started with an individual meeting with the medical and nursing directors of the hospital to explain the aim of the study to get their cooperation and support.
- The first-line nurse manager (FLNM) of the studied ED provided the researcher a brief description about ED environment and system. Then, the researcher had an initial tour with the FLNM to get a clear picture of the ED environment.
- The FLNM introduced the researcher to the ED staff (physicians, nurses, quality coordinator and clerical workers etc.) who were working in the same department between morning and afternoon shifts to provide an introduction about the study aim, the quality and lean concepts, and the importance of the current research in terms of ED improvement at the studied hospital.
- Due to absence of identical similarities of the theoretical processes that patients pass through in their journey to the ED, so the 5 main processes that were observed including; arrival followed by registration, initial assessment, that involves initial assessment by a nurse and initial assessment by a physician, the consultation that included the needed investigations and screening by consultants, all interventions done to patients according to their diagnoses, and ended with type and time of disposition decision. In such phase, the researcher used record note, pencil, and stopwatch to record what was actually done to each patient and the time taken in each task within each process and sub-process.
- The researcher observed 5 processes and 872 sub-processes of 100 patients visited the ED unit in the morning and evening shifts in the period started from September 2020 to March 2021. Based on the previous data the researcher drew the actual process map.
- In the selected hospital, the ED team did not perform triage process for any of the studied patients, so the researcher triaged cases by herself based on the Australian triage scale (ATS), that was adopted and reflected in hospital policy.
- Simultaneously, the researcher measured the physical design of the studied ED.
Second phase (VOC)
- A structured interview with 35 patients was done by the researcher on individual base with each patient to determine their satisfaction with the waiting time they might encountered in their journey in the ED. The structured interview was carried out by the researcher at the final stage (waiting the disposition decision) to be able to interact after receiving of the required treatment using tool I.
Third phase (VOB)
- The semi-structured interview was done by the researcher using tool II (VOB), with the ED staff, to assess their perspectives toward patients waiting time with patient flow and care processes.
- At first, lean concept was introduced to the staff. Then the staff were asked about their satisfaction level regarding available bed capacity, available equipment and supplies, the unit design, waiting time in the unit, etc.
- The semi-structured interview took around half an hour with each individual of the ED staff and sometimes the interview was interrupted by arrival of patients to the ED and took more time.
Fourth phase (A3 proposal)
- Proposal A3, was written during the plan step and before the do step. The reason is that proposal A3 reports address situations where the investment is significant (either in financial or human capital), the implementation is fairly involved, and/or the recommendation is far-reaching across the organization. As such, proposal A3 report typically addressed issues such as policy, management practice, organizational processes, or any situation where the organization would like careful consideration, planning, and (to the extent possible) consensus on the recommendation before deciding or authorizing action. Through 8 parts which included: Thematic title, Background, Current condition, Goal of the proposal, Root causes analysis, Plan details/Countermeasure, Iimplementation, and Follow up.
The following were the main results of the present study:
- The distribution of triage categories for the patients admitted to ED was found to be 48% imminently life-threatening.
- Non- value waiting time represents 55.39% of overall LOS with highest mean score for waiting for consultation.
- There is a significant difference in overall waiting time according to classification of patients according to ATS p= 0.001.
- 85.7% of interviewed patients had low to moderate level of satisfaction regarding waiting time in the ED.
- 75% of interviewed staff had low to moderate level of satisfaction regarding waiting time in the ED.
- ED under the study moderately met the overall design structure standards with 61.4%.
The finding of this study results in the following recommendations:
- Introduce the A3 proposal to the hospital managers and collaborate with them to implement A3 proposal in the ED and follow up its implementation with the ED staff.
- Ongoing training for ED staff and participate in implementing the programs- it is not achieved through a one-off action or training, but should be done on a regular basis, as part of the staff general work cycle and based on the assumption that quality can always be improved.
- Develop social group with nurses as what’s app for sharing videos presentation as a method of teaching that helps nurses to retain more knowledge.
- Assist in developing triaging protocols and develop a handbook in Arabic to facilitate acquiring knowledge regarding triage for healthcare providers and develop posters and signs related to how to triage different patients’ categories.
- Initiating on a triage team to be the first point in the unit that helps in decreasing the misuse of resources by non-urgent patients.
- Contribute to developing ED policies and regulations through reviewing different policies regarding ED and consult them about uncovered areas and weak points must be covered.