ANALYSIS OF THE PATIENT CARE FLOW IN HEMODYNAMICS SUPPORTED BY LEAN THINKING

an exploratory-descriptive case study carried out in the Hemodynamics service of a public university hospital from southern Brazil. Data collection was conducted through participant observation with twelve members of the multiprofessional team and interviews with five participants from May 2021 to February 2022. The analysis was based on the Lean framework and on the stages foreseen in Value Stream Mapping.

Results:

the Value Stream Map of the current situation of the service was prepared, identifying suppliers and customers of the process and their requirements. A total of 61 problems related to unmet requirements were listed, of which 12 were prioritized in order to promote improvement planning.

Conclusion:

with Value Stream Mapping it was possible to establish improvement priorities that exert impacts on operational performance of the service. It was identified that improvements related to standardization of the activities minimize waste from failures and waiting times, which were the most prevalent in the service, among others observed.

DESCRIPTORS:
Health management; Hospital Cardiology service; Workflow; Assessment of processes in health care; Quality improvement; High-cost technology

Process stage		Description of the problem
Input - Scheduling the procedure		1. Lack of organization of the shifts by specialty to optimize room occupancy. 2. Imbalance between demand for procedures and capacity to perform them.
Admission		3. Lack of procedure scheduling in the surgical map. 4. Delay in patient arrival due to delay in transporting patients by stretcher bearers. 5. Delay in admission due to lack of ICU space or delay in confirming the space. 6. The consent form to carry out the procedure is not checked/applied. 7. Non-standardization of procedures that require blood component reserves, generating non-confirmation of blood reserves. 8. Non-standardization and absence of confirmation record for specific medications (e.g., chemotherapy). 9. Non-standardization of patient identification checks. 10. Lack of patient preparation for surgery in the inpatient unit. 11. Absence of an institutional communication system to activate transport by stretcher bearers. 12. Non-assessment of priorities to define the transport order. 13. Incomplete surgical map forecast (schedules, surgery order, necessary materials). 14. Physical area with insufficient space for simultaneous admission and recovery of patients. 15. Absence of a flow for defining the cancellation of elective procedures. 16. Absence of a definition of criteria for emergency procedures.
Procedure	Preparation of the procedure room	17. Medication supplies by the pharmacy do not cover the entire opening hours of the sector. 18. Lack of preventive maintenance of the devices, outdated system and deficient control. 19. Failure to control dispensing of psychotropic medications. 20. Lack of adequate cushions for patient positioning.
	Procedure	21. Lack of suitable-size lead PPE for the team. 22. Surgeon attire before completing the preparation of the operating table and anesthesia of the patient. 23. The Hemodynamics sector is far from the support services, with a Materials Center and Pharmacy. 24. Lack of surgical material resources for backup when converting an endovascular procedure to open surgery. 25. Absence of a definition regarding the procedures that can be performed in the Hemodynamics sector. 26. Failure to record the materials used. 27. Failure to register the patient on the examination equipment. 28. Absence of a definition regarding the responsibilities of each team member. 29. There is no patient temperature monitoring and warming protocol. 30. Failure to carry out a safe surgery checklist. 31. Lack of ultrasound equipment for the sector. 32. Delay in arrival of the medical team. 33. The surgical time forecast does not correspond to the scheduled time. 34. Delay or cancellation of other surgeries. 35. Lack of staff to continue providing care to patients after the department’s opening hours.
	OPSM stock checks	36. Low quality of materials due to lack of a systematic evaluation. 37. Lack of OPSM checks before the patient enters the procedure. 38. Failure to replenish OPSM stock. 39. There is no administrative assistant for the relevant activities. 40. Nurse leaving the sector to replace materials and medications. 41. Failure to deliver the OPSM traceability registration copy to the patient and the report on the procedure performed. 42. Non-standardization in the list of materials per procedure.
	Anesthetic procedure	43. Absence of a checklist for checking materials in the anesthesia cart. 44. Non-standardization of criteria in pre-anesthetic evaluation in relation to the indication of special exams and ICU space.
	Cleaning and organizing the procedure room	45. Organization of the room by nurses simultaneously with cleaning by the hygiene team. 46. Arrangement of sterile materials in the room for the next procedure before cleaning from the previous procedure is completed. 47. Absence of an exclusive cleaning professional in the sector who works during all opening hours.
Transport to recovery		48. Non-standardization of the location for removing the introducer. 49. Lack of equipment to monitor patients during transport to the ICU.
Recovery		50. The medical prescription of medications administered in the procedure that have continuity is not checked. 51. Absence of a contingency plan to continue providing care to patients after the department's opening hours. 52. Failure to record the anesthetic recovery assessment scale. 53. There is no dedicated nursing technician for patient recovery.
Discharge		54. Waiting for transport by stretcher bearers. 55. Lack of medical discharge record by the responsible surgeon. 56. Absence of medical staff in the sector until the patient's discharge. 57. Lack of information about diet and medications in transitional care. 58. Non-standardization in patient discharge instructions, whether verbal or written. 59. Difficulty passing patient information on to the destination sector during shift changes in the sectors.
The entire process		60. Lack of indicators for process management. 61. Failure to manage chemical, recyclable and infectious waste.

Process stage		Problems prioritized	Waste
Admission		3. Lack of procedure scheduling in the surgical map. 6. The consent form to carry out the procedure is not checked/applied. 9. Non-standardization of patient identification checks.	Failure, overproduction, waiting time, inventory and movement.
Procedure	Procedure	28. Absence of a definition regarding the responsibilities of each team member. 30. Failure to carry out a safe surgery checklist.	Failure, overproduction, transport, waiting time, movement and human potential.
	Anesthetic procedure	43. Absence of a checklist for checking materials in the anesthesia cart.	Failure, transport, waiting time and movement.
	Cleaning and organizing the procedure room	45. Organization of the room by nurses simultaneously with cleaning by the hygiene team.	Failure and overproduction.
Transport to recovery		48. Non-standardization for removing the introducer.	Failure and waiting time.
Recovery		50. The medical prescription of medications administered in the procedure that have continuity is not checked. 51. Absence of a contingency plan to continue providing care to patients after the department's opening hours.	Failure and waiting time.
Discharge		57. Lack of information about diet and medications in transitional care. 58. Non-standardization discharge instructions, whether verbal or written.	Failure and waiting time.

Universidade Federal de Santa Catarina, Programa de Pós Graduação em Enfermagem Campus Universitário Trindade, 88040-970 Florianópolis - Santa Catarina - Brasil, Tel.: (55 48) 3721-4915 / (55 48) 3721-9043 - Florianópolis - SC - Brazil
E-mail: textoecontexto@contato.ufsc.br

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[1] CORRESPONDING AUTHOR
Aline Lima Pestana Magalhães. aline.pestana@ufsc.br