The JOURNEY

WHO CC for HSR

1988WHO CC

for HSR & QA/I

2000Redesignated as

WHO CC for HSR & QA/I

2009Redesignated as

WHO CC for HSR & QA/I

2013Redesignated as

WHO CC for HSR & QA/I

2014-2017

TERMS OF REFERENCE (2014-2017)

To carry out relevant health systems research, to propose and participate in multinational collaborating studies, and to support dissemination and application of research results to countries in the Western Pacific Region.

To identify best practices in HSR and QA/I, support the development and application of relevant tools, approaches and methodologies.

To provide technical support for capacity building in best practices in HSR and QA/I and their institutionalization in health facilities and health management for countries in the Western Pacific Region.

To transfer experience and expertise in the above areas through production of technical briefs, inter-country meetings, panels of experts, and international networking

Research

Best Practices

Transfer expertise

Technical Support

Our SDG focus

IHSR ACTIVITIES & OUTPUT 2014-2016: HIGHLIGHTS

SITI HANIZA Mahmud, LOW Lee LanInstitute for Health Systems Research, Ministry of Health, MALAYSIA

Poster Presented at the 2nd Regional Forum of WHO Collaborating Centres in the Western Pacific,28 – 29 November 2016, Manila, Philippines

Technical support / transfer of expertise

Area AHealth Systems Strengthening

Area BEfficiency of Health

Systems

Area CPrevention and Control of NCD

Area DQuality Assurance/

Improvement

Research

Best practices

Technical support

Transfer expertise

Publications

ACKNOWLEDGEMENT

Director General of Health, Ministry of Health Malaysia for permission topresent this poster. WHO for their continuous support for the Centre. Allthe agencies for their grants. All the staff in IHSR for their quest to build newknowledge.

Who is this for?

Policymakers

Program Managers

Hospital Directors

Health Care Providers MOH

Researchers

Purpose of this summary

To share the findings from study on improving patient flow from primary triage to disposition at Green Zone, Emergency Department

Thumbs Up ! SHORTER LENGTH OF STAY

at ED Green Zone Issue

Emergency department (ED) crowding is a major concern that affects both patients and providers1. About the Green Zone in Emergency Department, Hospital Tengku Ampuan Rahimah (HTAR) 300 to 400 patients need to wait for an average of 6 hours per day (360 minutes), from Primary Triage to disposition, mainly after office hours and weekends2. As part of Public Service Delivery Transformation Program by the government, LEAN Healthcare Initiatives Program was introduced to look into reducing waiting time at hospitals3. Lean principles seek to increase efficiency, decrease waste, and improve patient’s flow through the system3.

Key Messages

HTAR utilized lean principles and managed to improve the performance at ED green zone as below:

88 minutes average length of stay

70% of patients seen and discharged within 2 hours

88% of patients seen by the doctor within 90 minutes

205 minutes average bed waiting time

Average call not attended 20 patients per day

Lean flow works and is an essential tool implement to improve efficiency

Embracing LEAN thinking and challenging status quo are two critical success factors for LEAN initiatives.

MOH/S/IPSK/119.5(RR)

RESEARCH HIGHLIGHT IHSR Improving Patient Flow from primary triage to disposition at Green Zone, Emergency Department Hospital Tengku Ampuan Rahimah, Klang.

This summary is based on: Sukumar M, Ahmad Tajudin MN, Thurairajah G, Ranjini S, Norzila AZ, Norafizan MA, Zakiah MJ, Mohan C, Mariappan R, Pathma Nathan S, Siti Zainab S, Lim BL, F.Fasehah M, Nur Amalina N, Ratna Irina R, Kahiril Abzanizam MG, Rozalina MJ, Ushananthiny S, Zuraiman I, Nurul Azwin Y, Irwan J, Aisyah T. Improving Patient Flow from primary triage to disposition at Green Zone, Emergency Department Hospital Tengku Ampuan Rahimah, Klang.

For further information and to provide feedback on this document please contact: Dr Zalina Libasin zalina.l@ihsr.gov.my Ms Zaiton Kamarruddin zaiton.k@ihsr.gov.my

Disclaimer The views, interpretations, implications, conclusions and recommendations are those of the authors alone and do not necessarily represent the opinions of the investigators participating in the project nor the views or policy of the Ministry of Health.

Project reference number: . Funded by:

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Reference:

1. Karen L. Murrell, Steven R. Offermanm Mark B. Kauffman. West J. Applying Lean: Implementation of a Rapid Triage & Treatment System Emergeny Led. 2011May; 12(2): 184-191 .

2. Project Closure Report – HTAR ED Green Zone Improving Patient Flow v1.2(2)

3. Medical Development Division. Ministry of Health. Lean Healthcare Implementation Guideline Draft ver 1.0 (January 2015)

Additional information:

This summary was prepared by: Zalina L, Zaiton K, Muniamal K, Ku Anis Shazura IP, Suhaizanzulailla A, Sharimah A, Ahmad Tajuddin MN, Conflict of interest: There is no conflict of interest.

Acknowledgement: This document has been peer reviewed by:

Dr Wan Rasydan Wan Abdullah, Emergency Specialist Physician, Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan

Dr Mohd Ridzwan Shahari, Institute for Health Systems Research

Dr Juanita Halili, Institute for Health Systems Research

We thank the Director General of Health, Ministry of Health Malaysia for permission to publish this research highlight.

. Keywords: Emergency Department, Green Zone, Lean Initiatives, Length of Stay Copyright © 2015. Institute for Health Systems Research, Kuala Lumpur, Malaysia. Improving Patient Flow from primary triage to disposition at Green Zone, Emergency Department Hospital Tengku Ampuan Rahimah, Klang.

The Institute for Health Systems Research provides scientific evidence to policy makers and health managers at every level, to enable them to make evidence-based decision making on health matters. www.ihsr.gov.my

Evidence Informed Policy Network (EVIPNet) is an international network of partnerships between policy-makers, researchers and civil society in low and middle-income countries that support the use of research evidence in health policy-making. www.who.int

Ministry of Health Malaysia EVIDENCE-INFORMED POLICY NETWORK

MALAYSIA

Method Lean principles, tools and techniques and the 4- quadrant template for problem identification and goal setting were adopted to enable continuous improvement. Comparative assessment based on international benchmarks and Ministry of Health (MOH) performance indicator was used. All non-critical patients attended Green Zone within the duration of 6 months from May to October 2014. Performance metrics were summarized using frequencies and percentages.

‘Length Of Stay’ – The total time interval from patient arrival at ED, doctor consultation to disposition (discharged pharmacy, admitted to the ward or discharged home)

Project reference number:

(NMRR-15-1297-24604) Funded by:

How much does a laboratory test cost in primary care?

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Disclaimer The views, interpretation, implications, conclusions and recommendations are those of the author alone and do not necessarily represent the opinions of the investigators participating in the project nor the views or policy of the Ministry of Health, Malaysia.

References: ¹ Shepard DS, Hodgkin D, Anthony YE. Analysis of Hospital Costs,. Eds. A manual for Managers: World Health Organization 2000. ² MOH Health Facts 2013 ³ Mazura M, Ramli Z, Zulkarnain Ak, Nazhiyah H, Zurriyati Y, Roslinah A. Research Highlight: How much does primary care cost? Institute for Health Systems Research, Kuala Lumpur, 2011.

This summary was prepared by: Nurul Salwana AB, Nur Hidayati Abdul Halim, Nur Azmiah Zainuddin, Ridzwan Shahari, Nur Hani Zainudin,

Shakirah Md. Sharif, Santhi A, Safiee I, Ramli Zainal. Conflict of interest: There is no conflict of interest.

Acknowledgement: This document has been peer reviewed by Dr. Mazura Mahat from Oral Health, Dr. Santhi Armugam from Family Health Development Division, Anis Syakira Jailani & Kong Yuke Lin from Institute for Health System Research. We thank the Director General of Health, Ministry of Health Malaysia for permission to publish this research highlight.

This summary should be cited as: Salwana AB, Nur Hidayati AH, Nur Azmiah Z, Ridzwan S, Nur Hani Z, Shakirah MS, Santhi A, Safiee I, Ramli Z.

Keywords: Laboratory costing, primary care, Malaysia, Copyright © 2015. Institute for Health Systems Research, Setia Alam, Malaysia.

Methods Cost analysis was done from the provider perspective of the Family Health Development Division, Ministry of Health, Malaysia.

1. This is a cross-sectional study design using retrospective secondary data

analysis.

2. This study uses direct allocation techniques.

3. Data obtained for January - Disember 2013 from respective clinics and

Family Health Development Division. Data includes laboratory workload

returns, e-SPKB, salary schedule from JPA and AG data for the financial year

of 2013. This information will reflect the clinic and laboratory workloads,

staffing levels, emoluments, general cost and cost for materials in 2013.

4. Total annual cost comprising of overhead and recurrent cost were

tabulated. Overhead cost consist of capital cost (building, vehicles and

equipment) while recurrent cost includes emoluments, utilities, reagents,

consumables, maintenances and clinical waste management.

5. Total number of Biochemistry, Hematology, Microbiology, Serology and

Parasitology tests were calculated. The average cost per test was calculated

from the total annual cost divided by the number of test perform annually.

Who is this for? Health Policy Makers Family Health Development Division Health Facility Managers

Purpose of this summary To inform and highlight on the average cost per test in primary care services.

Issue The availability of cost information can serve as an indicator of efficiency, assist future budgetary planning and help to establish schedule fee¹. A better knowledge of cost and resource utilisation will increase efficiency and provide important information to physician. There is an increasing trend in the utilisation of public outpatient services in Malaysia². This will eventually lead to an increase in resource consumption. An earlier study has shown that laboratory cost constitutes of 3% of the total distribution of patient cost³. To date, there is limited information on the average cost per test of laboratory analysis although these services are available nationwide. Clinical laboratory results provide information that guides the physician in making evidence-based decisions for their patients. This helps to maximise effective care delivery in today’s complex healthcare system.

This document provides an insight on the average cost of laboratory tests done in primary care in 3 settings namely Klinik Kesihatan (KK) Jinjang, Klinik Kesihatan Bandar Botanik and Klinik Kesihatan Kelana Jaya.

Key Messages

Total number of laboratory test calculated for the respective clinics varies from 287 867 tests to 457 976 tests.

A maximum of 24 types of test were offered in the selected primary care settings.

Average cost per test ranges from RM 2.20 to RM 2.71.

Top 5 tests performed are Full Blood Count (25%), Renal Profile (20%), Blood Glucose (14%), Urine Sugar/Albumin (9%) and Liver Function Test (6%).

Major cost drivers are laboratory staff emoluments and reagents.

MOH/S/IPSK/117.15 (RR)

The Institute for Health Systems Research provides scientific evidence to policy makers

and health managers at every level, to enable them to make evidence-based decision making on health matters. www.ihsr.gov.my

Evidence Informed Policy Network (EVIPNet) is an

international network of partnerships between policy-makers, researchers and civil society in low and

middle-income countries that support the use of research evidence in health policy-making.

www.who.int

Ministry of Health Malaysia

Institute for Health Systems Research

This summary is based on: Salwana AB, Nur Hidayati AH, Nur Azmiah Z, Ridzwan S, Nur Hani Z,Shakirah MS, Santhi A,Safiee I, Ramli Z. Technical Report of Cost Analysis of Laboratory Services for Primary Care.

For further information and to provide feedback on this document please contact: Nurul Salwana Abu Bakar nurulsalwana.ab@ihsr.gov.my

Project reference number: (NMRR-14-595-21342) Funded by:

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Disclaimer The views, interpretation, implications, conclusions and recommendations are those of the author alone and do not necessarily represent the opinions of the investigators participating in the project nor the views or policy of the Ministry of Health, Malaysia.

References: 1. World Health Organization (The World Health Report 2000) Country Health Plan

(10th Malaysia Plan) (2011–2015). 2. Malaysia Health System Review 2013. 3. Graig, L., & Perosino, K. (July 2011). Applying lean to improve the patient visit

process at three federally qualified health centers. Retrieved from http://altarum.org/sites/default/files/uploaded-related-files/Applying-Lean-Report_FINAL.pdf.

4. Institute for Healthcare Improvement (2005) Innovation Series: Going Lean in Health Care

5. Zulkarnain AK, Sararaks S, Azman AB & Nora’i MS. Queue Density as a Predictor for Outpatient Waiting Time. Journal of Health Management Vol 9, No 2/2010.

This summary was prepared by: Hazlina Abu Bakar, Zalilah Abdullah, Ahmad Syafiq Ishak & Nur Khairah Badaruddin Conflict of interest: There is no conflict of interest. Acknowledgement: We would like to thank the Director General of Health Malaysia for his permission to publish this research highlight. The authors also would like to express their sincere appreciation to Klinik Kesihatan Bukit Kuda and Klinik Kesihatan Greentown. This document has been peer reviewed by:

1. Pn. Haniza Mohd. Anuar 2. Pn. Zaiton Kamarruddin, Institute for Health Systems Research 3. Dr. Muniamal Krishnan, Institute for Health Systems Research

This summary should be cited as: Hazlina AB, Zalilah A, Ahmad Syafiq I & Nur Khairah B. Re-engineering Work Processes in Health Clinics. Institute for Health System Research, MOH, 2015. Keywords: Primary care, re-engineering, waiting time, Lean Copyright © 2015. Institute for Health Systems Research, Shah Alam, Malaysia.

MMeetthhooddss

The study carried out during a 6 months period from November, 2014 to May, 2015.

Klinik Kesihatan Bukit Kuda (KKBK), type 3 and Klinik Kesihatan Greentown (KKGT), type 2 clinics were purposively sampled. The LEAN methodology was introduced to the selected clinics.

It was conducted over three phases. Phase 1 involved process evaluation, where problems and bottlenecks were recognised.

In phase 2 identified waste was removed and new work process was created.

In phase 3, implementation of the redesigned processes and evaluation were done.

A waiting time mean difference sample size calculation was done, where 42 patients were systematically selected for data collection from the identified clinics.

Data were collected through time motion study.

Patients were followed from arrival till exit, the time of each process and waiting were recorded using a standard stop watch.

Data were collected by trained data collectors.

Who is this for?

Policymakers

Health Department Managers

Primary Health Care Practitioners

Researchers

Purpose of this summary Provides evidence to assist in formulation of appropriate policies to reduce waiting time at primary care.

IIssssuuee

In many countries, long waiting time at primary care clinics is an issue, due to growing population, increasing number of patients seeking treatment and limited resources [1].

Outpatient utilisation rates had increased with a 4.3% annual increment, which is twice the average annual population growth [2].

Despite continuous improvement in health services and the expansion of public health clinics in Malaysia long waiting time persists to be a major problem in our primary care setting.

Lean is well regarded as an effective tool for quality management in manufacturing industries, but its implementation is relatively new in Malaysian healthcare setting.

KKeeyy MMeessssaaggeess

Lean reduced waiting time by 30 – 50 %.

Lean has a potential to be used as a tool to reduce waiting time in clinics with different systems/settings.

Lean empowers staff members to become active participants in the change process.

Lean can be an effective change management and continuous process improvement strategy in the primary care setting.

MOH/S/IPSK/121.16 (RR) Re-engineering Work Process in Health Clinics

The Institute for Health Systems Research provides scientific evidence to policy makers and health managers at every level, to enable them to make evidence-based decision making on health matters. www.ihsr.gov.my

Evidence Informed Policy Network (EVIPNet) is an international network of partnerships between policy-makers, researchers and civil society in low and middle-income countries that support the use of research evidence in health policy-making. www.who.int

Ministry of Health

Malaysia

Institute for Health Systems Research

This summary is based on: Institute for Health Systems Research (IHSR), Ministry of Health. Re-engineering Work Processes in Health Clinics 2015. NMRR-14-595-21342

For further information and to provide feedback on this document please contact: Hazlina Abu Bakar hazlina.ab@ihsr.gov.my Zalilah Abdullah zalilah.a@ihsr.gov.my Ahmad Syafiq Ishak ahmadsyafiq.i@ihsr.gov.my Nur Khairah Badaruddin nurkhairah.b@ihsr.gov.my

In progress