​Do you know that our Cardiac Laboratory performs close to 45,000 Echocardiography (Echo) procedures a year; which means the department has to manage more than 100 scans a day?

The high volume has inevitably resulted in longer lead times for patients to get an appointment for scan. Determined to identify a solution to this, the outpatient Echo Lab embarked on the Lean Skills Development Programme (LSDP)* in September 2017.

First, the group conducted a series of Go-See^ observations where they followed patients through their journey at the Cardiac Lab. They then identified the activities at service points and differentiated the activities into value-added versus non value-added in a Value Stream Map (VSM) ^; allowing the team to sift out opportunities for improvement.

NHCS Cardiac Lab Lean process
The VSM identified the long wait time for a scan (the wait for assessment prior to a scan and the wait to be called to enter the scan room) as the main issue.
In this instance, the Echo team identified the long wait time between Counter to Scan, and hence formulated Standard Work^ to help the staff in the assessment room and to smoothen the flow in the lab.  

Improvement 1: Numbered door tags and visual board

Previously, while both the Cardiac Technologist and Echocardiologist knew they were working hard, no one knew the volume of work done.  Now, with the use of numbered door tags and boards, everyone is aware of the utilisation of the scan rooms as well as the patient volume and flow through the department.

The information on the board also allows the Floor Manager, a newly added role who manages and facilitates patient flow, to know which room is attending to a complicated case and may require assistance.

NHCS Cardiac Lab door tags
Numbered tags and visual board outside each scan room keeps activity visible.

Yvonne Chua, Deputy Manager of the Lab shared that the visual board is split equally into the morning and afternoon sessions - the number tags refer to the case number currently being performed, and the coloured magnets indicate the time taken to complete each case. For instance, the number two in the picture above means that the room is being used to scan the second patient of that particular session.

Siti Nur’ain Binti Awalludin, Senior Cardiac Technologist added, “Our Patient Service Associates no longer need to go knocking on doors to ask for help in scanning patients who turn up late. Now, they can just look at the tags on the doors and know whom to approach directly.”

The enhancement benefits the cardiologists as well. Asst Prof Kurugulasigamoney Gunasegaran, Senior Consultant, Department of Cardiology said, “With the technologists scanning the patients earlier, we (doctors) can validate the scan reports earlier too.”

NHCS Cardiac Lab Visual Board
Everyone is kept abreast of the department’s workload, thanks to a consolidated visual board. 

The work in each room is recorded and summarised on a central board placed in the Echo reporting room. This Daily Visual Management (DVM) ^ ensures that everyone is up-to-date on the work they have done as a department.

Improvement 2: Daily huddle with staff

Perhaps the most impact change Lean has brought to the team is a daily five-minute get-together time, a practice which has completely changed the way the Cardiac Lab communicates.

“During the initial implementation, the morning huddle was where we shared about Lean thinking and reassured staff how it can improve patient experience,” shared Chiong Siau Chien, Senior Manager, Cardiac Laboratory.

The department started the daily huddle since 29 January 2018. It has now  evolved into a platform for staff to reflect on patient flow the day before and getting everyone ready for the day ahead. This stage is also used to exchange feedback, with staff bouncing ideas off one another for quick fixes, as well as for timely staff recognition.

Blossoming environment

The Lean journey has brought about vast improvements in both the hard- and soft-ware of the department. Utilisation of scan rooms have increased and waiting times for scans on the day of appointment have dropped significantly by 57%. The average wait time for initial patient assessment has reduced from 10 to three minutes, and for scans, from 17 to four minutes.  

“My most gratifying moment is seeing that we did all these with the rest of the department - from the patient service associates, healthcare assistants, nurses, to medical technologists and reporting doctors! Together, we learned to provide better services to patients,” shared Assoc Prof Ewe See Hooi, Director of the Echo Lab and Senior Consultant from the Department of Cardiology. She added that Lean has taught the Lab how to visualise their work daily as well as to monitor performance in a clear yet simple manner.

The positive results have also paved the way for other Lab areas to follow. For instance, the DVM concept has since been adopted by the inpatient arm of the Echo Lab, and the Device Check Area.

*The LSDP, a 10-month programme which aims to train professionals in Lean thinking and practices, is organised by the Singapore Institute of Technology and delivered by the Lean Global Network.

^Lean tools and principles.