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研究生:王騰寬
研究生(外文):Teng-KuanWang
論文名稱:以精實原則及模擬最佳化求解醫療系統流程設計問題
論文名稱(外文):Leveraging Lean Principles and Simulation Optimization for the Healthcare System Design Problem
指導教授:楊大和楊大和引用關係
指導教授(外文):Ta-Ho Yang
學位類別:博士
校院名稱:國立成功大學
系所名稱:製造資訊與系統研究所
學門:工程學門
學類:電資工程學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:英文
論文頁數:65
中文關鍵詞:精實醫療價值流圖單元工程佈置群組技術模擬最佳化
外文關鍵詞:Lean healthcareValue stream mappingCellular manufacturingGroup technologySimulation optimization
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隨著國民生活水準的大幅提升,民眾對於醫療服務的要求日益殷切,包括政府部門及醫療院所也積極進行管理效率與服務品質的改善。根據我國衛生署統計,外傷也是十大死亡原因的第二名,有1/4的病患是因為外傷的問題在緊急醫療系統就診,其重要性在醫療中無可言喻。
為了提供不特定數量的受傷病患緊急醫療照護最佳化,所需的資源包含了急診醫護人員、檢驗部、住院病房、開刀房的連貫式流程作醫療改革,大家都認同及時治療十分關鍵,但卻很少有文獻探討系統性的緊急醫療改善,以減少病人接受治療所花費的時間。
在製造業的改善活動中,精實及豐田生產方式經常為大眾所提及,本研究嘗試以精實管理原則去針對緊急醫療的系統做解析其效率不佳的原因,在於系統因為高度專業化、複雜化的分工架構下,容易造成流程銜接上的失誤。為提供醫院決策者最佳的解決方案,本研究導入精實管理原則觀點進行流程設計並結合離散事件模擬。
急診為緊急醫療系統中的重要一環,然而近年來急診的服務量日漸增多,但醫院的空間與人力配置皆未改變,使得急診壅塞日漸嚴重。為了減少75%的門診病患的等待時間和使流程間能連續流動,設計單元工程佈置以減少過多的走動,且考慮到病患到達、醫護人員診療及檢體檢驗時間的隨機性,本研究依據急診環境產出4種單元工程佈置方案進行分析與比較,並以模擬最佳化求解不同班別的醫護人員配置,發現直線型設計相較於其他三種設計可使病患流動更為順暢並進而減少護理人力9名減少至6名的情況下,並能使病患的平均等候時間從78分鐘減少為38分鐘,改善幅度為51%;服務水準也從54.86%上升至88.55%,改善幅度為61%。
急診門診病患在改善過程中,進行深度分析後發現病患在尖峰時段流程上仍舊會因檢體因素而有所耽擱,若檢驗週期時間太長會耽誤醫師對病患病情的判斷,因此如何縮短檢驗週期時間達到服務水準最大化為本研究關切的議題,提出以價值流圖的手法辨識檢驗流程浪費所在,以此為契機就離心機的集批時間以及生化分析儀(DXC)的派工規則作改善,並提出CONWIP(Constant Work-in-Process)生產策略,控制系統內流動的檢體量,以上策略得以縮短54.51%的檢驗週期時間,檢體的周期時間減少更讓急診部門診病人的等候時間又減少為30分鐘。
最後仍有25%的急診住院病患受限於病房因素而留置於急診內,病房延宕最大原因之一是開刀房排程的變異而使醫護人員加班時間增長,進而使動刀病人留置病房時間增長,因此如何縮短開刀房的加班時間為本研究關切的議題,提出將手術時間分群後,以節拍時間(Takt Time)拉動各組手術以減少流程中的變異後,並提出各群組最佳化開刀房資源分配,以上策略得以縮短流程間88%的等候時間及減少46%的加班時間。
本研究揭示精實原則能應用在急診部門的專案,檢驗部和開刀房在績效上也獲得顯著改善,為了有效增加病人的價值更須橫跨不同的部門,考量整體緊急醫療系統的流程設計,不僅能夠更好的管理,也能消除系統中的浪費。
The healthcare spending has been increasing due to a growing population. In response to the rising cost, the government and hospital are to increase efficiency. Efficient allocation of healthcare system involves planning and coordinating several resources. One of the most expensive and highly specialized is considering the emergency care, which is critically important to the seriously ill and injured patients. The injuries are the number one killer of people between the ages 1 to 44. Therefore, improving the emergency care system has potential not only to decrease the cost but also faster access to the care. Lean, which adopts the principles of the Toyota Production System (TPS), is a systematic approach for identifying and eliminating non-value-added activities through continuous improvement by crossing multiple departments derived from patient requirements. This research applies Lean principles and explores the healthcare system problem by proposing specific design procedures for the problems of emergency department (ED), laboratory test, and operating room (OR). First, the crisis of overcrowding in ED is a very important issue worldwide. To ensure that ED patients receive prompt attention and timely treatment, especially under dynamic and stochastic demands, most countries use triage scoring to prioritize ED patients according to their clinical urgency. The triage process based on the emergency severity index (ESI) system and current layout design cause the phenomenon of sequential batch processing. The average time of a patient in a queue will increase because of the variability of the batch. Most patients will still not meet the requirement of timely care. Second, laboratory results are essential for physicians to diagnose medical conditions. Because of the critical role of medical laboratories, an increasing number of hospitals use total laboratory automation (TLA) to improve laboratory performance. The system becomes congested during periods of peak demand. The cycle time usually exceeds the lead time during the peak time. Third, surgery assignment must balance capacity utilization and demand so that the arrival rate does not exceed the effective production rate. However, authorized overtime increases because of random patient arrivals and cycle times. This research is based on value stream mapping (VSM) for the design and analysis of the ED, TLA, and OR. Subsequently, this research investigates the methodologies to improve the performance. With increasing technological advances in the medical industry, patients will continue to care not only about the quality of service but also about the efficiency of treatment. Therefore, ways to shorten patient waiting time and improve patient satisfaction becomes a very important issue for hospitals.
摘要 i
SUMMARY ii
GLOSSARY TERMS iii
ABSTRACT iv
誌謝 v
TABLE OF CONTENTS vi
LIST OF FIGURES ix
LIST OF TABLES x
1. INTROUDCTION 1
1.1 Motivation 1
1.2 Research Objectives 3
1.3 Research Procedure 3
2. PROBLEM STATEMENT 5
2.1 Emergency Department Problem 5
2.2 Laboratory Test Problem 6
2.3 Operating Room Problem 7
3. LITERATURE REVIEW 8
3.1 Lean Manufacturing 8
3.2 Lean Healthcare 9
3.3 Value Stream Mapping 10
3.4 Cellular Manufacturing 10
3.5 Constant Work in Progress 11
3.6 Group Technology 11
3.7 Takt Time Approach 12
3.8 Simulation 13
3.9 Simulation Optimization 13
4. EMERGENCY DEPARTMENT PROBLEM 15
4.1 Overview 15
4.2 Emergency Department Description 15
4.3 Analysis of Emergency Department 16
4.4 Performance Measurement 18
4.5 Development of the Methodology 18
4.6 Simulation Assumption 22
4.7 Simulation Runs 23
4.8 Verification and Validation 24
4.9 Simulation Optimization 25
4.10 Experimental Results 30
4.11 Section Summary 32
5. THE LABORATORY TEST PROBLEM 33
5.1 Overview 33
5.2 Total Laboratory Automation Description 34
5.3 Analysis of Total Laboratory Automation 36
5.4 Performance Measurement 38
5.5 Development of the Methodology 38
5.5 Simulation Run 40
5.6 Verification and Validation 41
5.7 Simulation Optimization 41
5.8 Experimental Results 42
6. THE OPERATING ROOM PROBLEM 45
6.1 Overview 45
6.2 Operating Room Description 47
6.3 Analysis of Operating Room 47
6.4 Performance Measurement 50
6.5 Development of the Methodology 51
6.6 Simulation Assumption 52
6.7 Simulation Run 52
6.8 Verification and Validation 53
6.9 Simulation optimization 53
6.10 Experimental Results 54
7. CONTRIBUTIONS AND CONCLUSIONS 56
7.1 Contributions 56
7.2 Conclusions 56
8. FUTURE RESEARCH OPPORTUNITIES 58
8.1 Limitation and Future Research in Emergency Department 58
8.2 Limitation and Future Research in Total Laboratory Automation 58
8.3 Limitation and Future Research in Operating Room 58
REFERENCES 60
APPENDIX A: VALUE STREAM MAPPING ICONS EXPLANATION 64
VITA 65
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