Experience of integrating lean technologies into the quality management system of a medical organization providing primary medical and sanitary care

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Introduction

Currently, the indicator "satisfaction with the quality of medical care" is given considerable attention. The latest technologies are used, including the experience of lean manufacturing to implement new models, improve processes in primary health care and improve the quality of primary health care. The concept of "satisfaction" is traditionally used to assess quality. However, these concepts are not identical. The quality of medical care from the perspective of healthcare organizers and supervisory agencies is compliance with standards, clinical recommendations, that is, what was laid down in the treatment rules. The patient's subjective assessment of what is happening in the clinic plays a major role in satisfaction with medical care, but he may not always know and correctly assess the prescribed treatment [1]. Therefore, in order to continuously improve the work of medical organizations, it is important to know how patients themselves evaluate treatment and stay in a medical institution. Traditionally, the greatest burden of patients is borne by the primary link: city clinics. Most of the quality and satisfaction problems are found there. Moreover, the problems are identical in different regions of our country. Thus, in the Tomsk region, as a result of a survey of patients, the following problems were revealed: long queues at the registry office, staff shortages, problems with patient navigation in the clinic, and heavy workload of doctors [7]. In 2018, in Moscow, patients of the Clinical Hospital of the Federal Government Health Institution “Medical Unit of the Ministry of Internal Affairs of Russia for the City of Moscow” rated the overall level of satisfaction at 70 % [2]. In 2019, a survey in the Republic of Bashkortostan showed that patients were generally satisfied with the medical institution, showing a result of 77 %. However, there have been comments about the shortage of doctors, which is generally a fairly common problem for the entire outpatient sector [5]. Numerous studies have identified the main reason that prevents Russians from visiting outpatient clinics more often: constant queues, unsatisfactory service levels from government agencies, and the bureaucratic nature of the process [3]. In order to optimize the system, the Russian government has been actively implementing reforms in healthcare in recent years. One of the main tasks is to redirect the focus of medical care from expensive hospitals to the more accessible outpatient stage.

The pilot and then priority project “Lean Polyclinic”, which was launched in 2016, was designed to improve the availability and quality of medical care for the population by optimizing processes and eliminating losses. At present, this is a federal project, steadily operating in 85 territorial entities of the Russian Federation [4]. There are positive results of the implementation of measures. In the Udmurt Republic, a survey of 352 patients revealed that 88 % of visitors were completely satisfied with the services provided in the new clinic that implemented the “Lean Clinic” project. The main changes noted by respondents were a reduction in waiting time at the registry office and the ability to make an appointment online, which significantly simplifies the process for potential patients and helps save their time [6].

It is interesting that our foreign colleagues are studying satisfaction as a marker of the quality of medical care. For example, in 2018, a study was conducted in Henan Province, China, on the satisfaction of 630 outpatients with the provision of medical care. For example, in 2018, a survey was conducted in Henan Province, China, to assess the satisfaction of 630 outpatients with medical care. It was found that the overall satisfaction of such patients was quite low, but communication between the doctor and the patient received the highest scores. The study also found that the expansion of the hospital scale had a positive impact on outpatient satisfaction, but satisfaction would decline as the hospital scale was expanded to its maximum. This is due to the fact that in smaller hospitals, outpatients have more time and opportunities to communicate with doctors, which has a direct impact on satisfaction with outpatient services [8; 9].

In the modern world, the quality of medical care is one of the headline indicators of success in the healthcare system. The main aspects of the assessment are accessibility, efficiency, safety and focus on patients of the clinic. Patients should have access to qualified general practitioners within a reasonable time and without unnecessary bureaucratic hoops; achieve maximum treatment results with minimum expenditure of resources using modern diagnostic and treatment methods; be protected from unwanted events and errors, and be able to obtain information about their rights and responsibilities. Patients should be involved in decisions about their treatment and have the opportunity to receive information about their health status.

The aim of the study is to assess the effectiveness of the implementation of lean manufacturing methods in the practical activities of primary health care using the example of the State Healthcare Institution “Saratov City Polyclinic No. 2”.

Materials and methods

The study design included three stages: primary data collection through an anonymous sociological survey using telecommunication devices (phone or tablet), the second stage – timing, elimination of identified deficiencies, implementation of improvements into everyday practice, the third stage – a repeated survey of patients (using the same method and the same questionnaire) and assessment of satisfaction. The authors conducted a survey of 296 residents of Saratov receiving primary health care at the State Healthcare Institution “Saratov City Polyclinic No. 2”. A specially designed author's questionnaire was created electronically using Google Form and posted online. It included information about the respondent, as well as a block of questions about the quality of medical services provided at the State Healthcare Institution “Saratov City Polyclinic No. 2” and the level of patient satisfaction with their quality (including questions regarding the comfort of patients’ stay in the clinic).

Permission to conduct the study was granted by the Local Ethics Committee of the Saratov State Medical University named after V.I. Razumovsky (Local Ethics Committee protocol No. 2 dated  October 17, 2023). The study was conducted with voluntary informed consent from patients in accordance with the declaration of compliance with international and Russian ethical principles and standards (extract from protocol No. 19 of the meeting of the Bioethics Committee dated October 26, 2018). The study was carried out in accordance with the requirements of the Declaration of Helsinki of the World Medical Association (as amended in 2013).

For mathematical processing, the research results were initially entered into an electronic database; the analysis of the research results was carried out using the method of descriptive statistics.

Results and discussion

The sociological survey involved 296 people who sought medical assistance at the State Healthcare Institution “Saratov City Polyclinic No. 2”, 69.3 % of which were women and 30.7 % – men. The largest proportion of respondents were in the 60–74 year class (32.8 %), 27.7 % of respondents were 45–59 years old, 26 % were 18–44 years old, and 13.5 % were 75 years and older. The most common reason for visiting a medical organization was a visit to a medical specialist (36.5 %). The next most important reasons were: visiting a general practitioner (26.4 %); visiting a medical facility to perform various procedures, such as intradermal, intramuscular and subcutaneous injections (17.2 %); visiting a diagnostic department (13.2 %); visit to the diagnostic department (13.2 %); day hospital (4.4 %); prevention department (2.4 %) and others (p = 0.044). When evaluating the results of the first stage of the study, it was found that the majority of respondents were satisfied with the work of the registry office, with 67.2 % of patients giving the highest score. But there were also those who were dissatisfied with the work of the registry office (0.3 %) and left negative feedback. When asked about satisfaction with the organization of an appointment with a doctor, 56.8 % responded that they were completely satisfied, while 3.7 % of people were completely dissatisfied
(p = 0.049). Half of those surveyed said that they were satisfied with the length of the wait to see a doctor, with 48 % saying “completely satisfied” and only 5.4 % saying “completely dissatisfied”. Also, a significant proportion of respondents (75.7 %) were satisfied with the professional qualities of doctors, their interest in the result, and their attitude towards patients. Only 0.7 % believed that there were incompetent medical workers in the clinic. When assessing the work of the mid-level medical staff of the clinic in performing diagnostic and treatment procedures, 81.1 % of patients gave the highest score. And only 0.3 % of people believe that nurses are not friendly and responsible enough. The majority of respondents (78.4 %) are completely satisfied with the design of the premises, information signs and plates on the doors, and the design of waiting areas for visitors. When answering the question "Are you satisfied with the work of our institution as a whole?" 69.6 % of patients answered that they were completely satisfied. Almost a third of visitors (31.1 %) considered it necessary to write down their wishes and suggestions for improving the organization of work of the State Healthcare Institution “Saratov City Polyclinic No. 2”. Among them: to be notified about the medical appointment booking in the morning or at least the day before the appointment, change the procedure for making appointments at the registry office, make more doctors available so that there are no long queues, more specialists, introduce a Wi-Fi network accessible to patients.

After analyzing the results of the survey, the clinic conducted a time-keeping study in accordance with the methodology for assessing the achievement of targets ​​of the first-level criteria of the “new model of a medical organization providing primary health care” [9]. Based on the results of the study, improvement measures were developed, including:

1. Attracting more call center workers to speed up the time it takes to register at the clinic.
2. Alerting patients to the time of day for their appointment to the specialist with the longest waiting time.
3. Conducting practical classes with doctors and nurses on the topic of "Psychology of Communication with Patients" at the Educational and Methodological Center "Center for the Development of Lean Technologies in Healthcare – Process Factory" of the Saratov State Medical University.
4. Installation of new information boards to reduce the time it takes for patients to find the necessary specialist.
5. Placement of forms with a questionnaire on assessing satisfaction with medical care in a given medical institution at the desks of the registry offices and in each department of the clinic for continuous monitoring of the quality of services provided.

After the implementation of improvements, the third stage of the study was carried out. It turned out that overall satisfaction with the work of the registry office increased by 69.5 %, and the organization of an appointment with a doctor became more convenient, which is confirmed by the responses of respondents (69.1 %) (p = 0.048). The competencies of doctors and nurses received higher ratings compared to October (78 and 83 %, respectively), which confirms the positive impact of the training sessions on communication issues in the “doctor-patient” paradigm. However, the waiting for an appointment with a specialist remained the same (48 % of patients are satisfied with this parameter). At the first stage, 47.5 % were satisfied. This fact confirms the postulate that issues of staffing cannot be resolved by lean manufacturing methods; further multi-vector actions by the management of the medical service are necessary.

As a result of all three stages of the research, we consider it important to formulate key points. The majority of respondents expressed satisfaction with the quality of medical care provided under outpatient treatment. This is confirmed by the high level of satisfaction and the relatively low percentage of dissatisfied patients. After implementing measures to improve performance using lean manufacturing methods, this figure increased. Patients highly appreciate the professionalism and interaction with their doctors. This demonstrates the focus of the medical care organization on the needs of patients and the desire to satisfy their requests. Conducting classes and trainings with practicing doctors on issues of communication with patients improves the quality of interaction. The majority of patients are confident in the high competence of working doctors (75.7 %) and nurses (81.1 %), and after practicing the skills of “Psychology of Communication with the Patient”, the indicators increased by 2 and 3 %, respectively (p = 0.046). The organization of the front office and the premises of the clinic in accordance with the requirements for the new model of an organization providing primary health care allowed patients to achieve high evaluation of the information stands and the waiting area for specialists (78.4 %). One of the most important issues regarding patient care is related to the process of making an appointment with a doctor. Research has shown that the low level of patient satisfaction (56.8 %) was significantly contributed to by inefficient organization of the registry office (67.2 %). To solve the problem, it is necessary to optimize the work of the registry office by introducing modern technologies, such as electronic registration for an appointment with a doctor, improve the functioning of the call center, and ensure an even distribution of responsibilities among registry office employees. The lowest results were obtained for the length of the waiting for a doctor’s appointment (only 48 % of patients gave the maximum rating), which explains the clinic’s need for specialists and the high workload of the medical institution.

Conclusions

Assessing public satisfaction with the quality of primary health care is becoming an increasingly important component in health care management. The organization of medical care requires certain changes to improve the quality and availability of services. Patient satisfaction with the organization of the treatment and diagnostic process can be modeled taking into account several factors. Average patient satisfaction may be affected by aspects such as waiting time to see doctors, waiting time for medical services after an appointment, and availability of diagnostic tests and medical care from specialist doctors. Identifying and addressing problem areas is a key aspect of improving the organization of the treatment and diagnostic process, and it is important to individually approach each of the above factors in order to increase patient satisfaction. Conducting continuous internal timekeeping and auditing in a medical organization in order to identify factors that influence patients’ expectations when receiving medical services, and subsequent adjustment of these factors, including using lean manufacturing principles and methods, will improve the level of satisfaction with medical care.

About the authors

Yu. N. Belyaeva

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0000-0001-8893-1907

Assistant of the Department of Polyclinic Therapy, General Medical Practice and Preventive Medicine

Russian Federation, Saratov

V. A. Piskaryova

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0002-3734-3800

6^th-year Student of the Medical Faculty

Russian Federation, Saratov

A. Yu. Malenova

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0006-2891-8501

6^th-year Student of the Medical Faculty

Russian Federation, Saratov

M. A. Polidanov

Medical University «Reaviz»; University «Reaviz»

Author for correspondence.
Email: maksim.polidanoff@yandex.ru
ORCID iD: 0000-0001-7538-7412

Research Department Specialist, Assistant of the Department of Biomedical Disciplines, Postgraduate Student of the Department of Surgical Diseases

Russian Federation, Saratov; Saint Petersburg

A. S. Myasnikova

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0000-9333-2757

6^th-year Student of the Medical Faculty

Russian Federation, Saratov

K. A. Volkov

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0000-0002-3803-2644

2^nd-year Student of the Medical Faculty

Russian Federation, Saratov

S. R. Zekiev

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0000-5644-0820

5^th-year Student of the Dental Faculty

Russian Federation, Saratov

A. Z. Bakarova

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0002-6548-6147

5^th-year Student of the Dental Faculty

Russian Federation, Saratov

A. I. Pavlenko

Saratov State Medical University named after V.I. Razumovsky

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0007-1882-5261

6^th-year Student of the Medical Faculty

Russian Federation, Saratov

Kh. S. Dzhabrailova

Kabardino-Balkarian State University named after Kh.M. Berbekov, Medical Academy

Email: maksim.polidanoff@yandex.ru
ORCID iD: 0009-0008-0628-4389

6^th-year Student of the Medical Faculty

Russian Federation, Nalchik

T. B. Bisultanova

Kabardino-Balkarian State University named after Kh.M. Berbekov, Medical Academy

Email: maksim.polidanoff@yandex.ru

6^th-year Student of the Medical Faculty

Russian Federation, Nalchik

L. Sh.-M. Chinaeva

Kabardino-Balkarian State University named after Kh.M. Berbekov, Medical Academy

Email: maksim.polidanoff@yandex.ru

6^th-year Student of the Medical Faculty

Russian Federation, Nalchik

References

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