Breast Cancer Care Network coordination: analysis in the light of the lean methodology for early diagnosis

Gurgel, Ana Gerúsia Souza Ribeiro; Aragão, Joyce Mazza Nunes; Vasconcelos, Maristela Inês Osawa; Magalhães, Aline Lima Pestana; Cristino Filho, Gerardo; Parente, José Reginaldo Feijão

doi:10.1590/1413-81232023288.05472023EN

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ARTICLE • Ciênc. saúde coletiva 28 (8) • Aug 2023 • https://doi.org/10.1590/1413-81232023288.05472023EN copy

Breast Cancer Care Network coordination: analysis in the light of the lean methodology for early diagnosis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study aimed to analyze the application of the lean philosophy in the Health Care Network (RAS) for the early diagnosis of breast cancer. This case study was produced with data from interviews, document analysis, and observation and was conducted from June to July 2019. The setting was the seat of the municipality of the North Metropolitan Region, Ceará State, Brazil, involving three points of the RAS (Primary Care Unit, Medical Specialties Center, and Polyclinic). The following issues were identified: long waiting times, first-come-first-served care, and insufficient medical workload. Implementing the theoretical model of lean philosophy would reduce the total process time from 36 days to 15 in the Primary Care Unit/Medical Specialty Center flow and from 33 to 13 days in the Primary Care Unit/Polyclinic. The presented model is an efficient reference for improving the management and early diagnosis of breast cancer in the RAS.

Key words:
Primary health care; Health Services Network; Lean healthcare; Early diagnosis; Breast neoplasms

Sectors	Current VSM (Waste)	Application of lean techniques	Future VSM (improvements)	Number of improvements	Results
Reception	First-come-first-served care - Pre-established professional schedules and no slots available for acute situations; - Administrative workers with the same attributions in the SAME	VSM, Gemba, kaizen, 5S, standard work, teamwork, multifunctional workers, work according to takt time (standard time), sector layout.	Appointment scheduling by hour blocks; - Flexible professional schedules, alternating walk-in and scheduled appointments; - Distribution of administrative workers’ attributions.	3	Reduction of user waiting time at reception from 30 minutes to 15 minutes
Nursing outpatient clinic	A day reference nurse does screening.	VSM, Gemba, kaizen, standard work, work according to takt time (standard time).	The nurse in the assigned area must do the screening	1	Reduction of waiting time from 120 minutes to 30 minutes
Medical outpatient clinic	Referred from screening or prior scheduling	VSM, work according to takt time (standard time).			The 35-minute lead time was maintained
Appointment and test regulation sector	- Forms and requests manually to be delivered to the booking center; - Disqualified specialty waiting lists; - Appointments communicated through the community health worker; - Reassessment appointment, in case of denial, within three days; - The appointment scheduler inserts requests into the system, monitors appointments, and communicates them to the health worker	VSM, Gemba, kaizen, 5S, standard work, teamwork, multifunctional workers, kanban, work according to takt time (standard time), autonomation	- Forms and orders entered into the system in the office; - Qualification of specialty waiting lists; - Implementation of tele-scheduling for scheduling communication; - Expedite appointment in up to 24 hours for reassessment; - Current appointment scheduler function replaced with regulation and tele-scheduling assistant	5	Reducing waiting time for the delivery of the test request in the sector (variable time, considering the waiting line and minimum of 15 minutes) for immediate insertion during the medical appointment; Standard work eliminates pending issues and waiting time

Sectors	Current VSM (Waste)	Application of lean techniques	Future VSM (improvements)	Number of improvements	Results
Reception	First-come-first-served care - Two waiting stages: reception and test room; - Incomplete or incorrect forms received from the UBS.	VSM, kaizen, 5S, standard work; Work according to takt time (standard time), and cellphone layout	- Service carried out by scheduling by hour blocks (blocks of appointments scheduled by hour); - Requiring complete and correct completion of UBS requests	2	Waiting time reduction of 180 minutes. Avoid rework
Imaging sector	- Excess of sheets and worksheets with the same purpose; -Conventional mammography device.	VSM, kaizen, 5S, standard work; Zero defect quality control	- Reduction of sheets and worksheets; - Replacement of the conventional mammography device with the digital one	2	Reduction of waiting time (from 55 minutes to 40), improved image quality, investment return, increased image quality, reduced steps in the work process, and increased user and technician satisfaction
Report analysis sector	The doctor comes once a week to do the tests	VSM, work according to takt time (standard time)	Availability of daily medical workload	1	- Accumulation of tests to analyze and delay in issuing reports; - The daily availability of physicians to carry out reports would imply an impact on reducing the LT from seven days to 24 hours
Report issuing sector	- Insufficient number of computers; - User is notified when the test is ready to be received; - Does not provide UBS with information about users who underwent tests; - Administrative agent informs the user when the test is altered and about scheduling with a mastologist	VSM, Gemba, kaizen, 5S, standard work, teamwork, multifunctional workers, work according to takt time (standard time)	- Acquisition of a computer; - Deadline for receiving the test already defined and informed to the user when the test is performed; - UBS receives information about users who underwent tests for better follow-up; - Establishment of a protocol that guarantees humanized and receptive diagnostic communication	3	- Acquisition of a computer for typing reports would take LT from two days to 24 hours; Lead time of two days. - Work backlog due to waiting for the test and computer unavailability; - Time reduction and care coordination by the PHC
Specialist/mastologist outpatient clinic	Appointments with specialists scheduled for users with tests moved to the nearest available date.	VSM, work according to takt time (standard time)	Protected slots in specialists’ agendas daily for users with altered tests	1	Scheduling from 72 to 24 hours

Sectors	Current VSM (Waste)	Application of lean techniques	Future VSM (improvements)	Number of improvements	Results
Reception	- The user enters two receptions: the general reception and the imaging reception	VSM, kaizen, 5S, standard work; Work according to takt time (standard time)	The user directly applies to the imaging reception, which receives the agenda from the regulation center	1	Reducing waiting time by 60 minutes by eliminating the general reception (Does not add value)
Imaging sector	- High process time to fill out incomplete and incorrect forms; - Excess files and spreadsheets with the same purpose, waiting until the quality of the images is checked	VSM, kaizen, 5S, standard work; zero defect quality control	- Complete and correct forms received from the UBS through the checklist; - Streamlining processes by reducing files and spreadsheets with the same utility	2	Reducing waiting time by 30 minutes; streamlining for test room entry and a more positive user experience
Report analysis sector	The radiologist doctor attends two shifts a week to report	VSM, work according to takt time (standard time)	The radiologist doctor reorganizes the work process and shows up daily to report	1	Reduction from 72 hours to 24 hours
Report issuing sector	- The user does not know the exact date that the test will be ready; - Information on users who underwent tests at the UBS is unavailable	VSM, Gemba, kaizen, 5S, standard work, teamwork, multifunctional workers, work according to takt time (standard time)	- The user knows the exact date of receiving the test result; - UBS receives information about users who underwent tests for better follow-up	2	Reduction from 72 hours to 24 hours
Mastology outpatient clinic	Specialist appointments are scheduled for the closest available slot	VSM, work according to takt time (standard time)	Reserved slots in specialists’ agendas daily for users with altered tests	1	Scheduling from 72 to 24 hours

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[1] Chief editors:

Romeu Gomes, Antônio Augusto Moura da Silva