Before After

CSVSM is a method to describe a value stream mapping (VSM), to measure

value-added activity and time spent on key events in patient
non-value- added activity, thus all pathways, with an embedded study of
process could be seen.12 cost
Health Services and Delivery Research, No. 4.3.

Pinkney J, Rance S, Benger J, et al.

Southampton (UK): NIHR Journals Library; 2016

Jan.How can frontline expertise and new models of
care best contribute to safely reducing avoidable
acute admissions? A mixed-methods study of four
acute hospitals.

Fish bone analysis as one of RCA
method was done in this study. The
purpose of analysis was to simplified
the clinician and researcher in
CEMONC mapping process.14
A cause and effect diagram, also known
as an Ishikawa or "fishbone" diagram, is
a graphic tool used to explore and display
the possible causes of a certain effect.
Use the classic fishbone diagram when

causes group naturally under the

categories of Materials, Methods,
Equipment, Environment, and People.
Use a process-type cause and effect
diagram to show causes of problems at
each step in the process.
http://www.ihi.org/resources/Pages/Tools
/CauseandEffectDiagram.aspx

Hospital accreditation is used to Accreditation has been developed to

maintain healthcare quality.15 improve the quality of care and patient
safety.Moreover, quality indicators have
been introduced in the accreditation
process in order to give a quantitative
assessment of hospitals quality.
Gurin S, Le Pogam M, Robillard B, et al
Can we simplify the hospital
accreditation process? Predicting
accreditation decisions from a reduced
dataset of focus priority standards and
quality indicators: results of predictive
modelling
BMJ
Open 2013;3:e003289. doi: 10.1136/bmjo
pen-2013-003289

Alkenizan et al study, which stated Accreditation has been developed to
that accreditation could improve a improve the quality of care and patient
quality and patient outcome in safety.Moreover, quality indicators have
hospital.16 been introduced in the accreditation
process in order to give a quantitative
assessment of hospitals quality.
Gurin S, Le Pogam M, Robillard B, et al
Can we simplify the hospital
accreditation process? Predicting
accreditation decisions from a reduced
dataset of focus priority standards and
quality indicators: results of predictive
modelling
BMJ
Open 2013;3:e003289. doi: 10.1136/bmjo
pen-2013-003289

Yusof et al found a non-value Lean methodologies focus on eliminating

activity in pre-anestesia process was
contributing in prolonged process at
Institut Jantung Negara, Malaysia.17
non-value added waste within a
system.22 This includes any and all
actions and activities that do not add
value to the consumer in question, in this
case the patient. In the case of radiology
testing, there are a number of areas of
potential waste, much of which manifests
as waiting for serial process steps. As a
result, several factors may have
contributed to the success of this
Lean-based intervention.
Benjamin A. White, Brian J.
Yun, Michael H. Lev, and Ali S.
Raja.Applying Systems Engineering
Reduces Radiology Transport Cycle
Times in the Emergency
Department.West J Emerg Med. 2017
Apr; 18(3): 410418.

Waste waiting was also found in
Chan et al study, which stated that
waste waiting is a common waste
occurred in ED, then it inhibit early
medical treatment and decision to
At two sites over 50% of the average
patient journey time occurred once the
decision to admit or discharge was made,
coinciding with waiting for beds
(approximately 50% of known patient
waits), or to leave the hospital. Neither of
 patient.7
Based on Quality of Care theory
from Institute of Medicine, facility
factor was a hospital tool, which
could improve worker and patient
safety.15 Dinesh et al stated that
lacking support facility could inhibit
a process to move faster and
accurate.18
Bleetman also stated that staff
competence in both clinical or
non-clinical, including leadership
and management were important in
emergency care aspect.19
these sites used a patient discharge
lounge. The combination of these two
factors implied the existence of barriers
to admitting and discharging their
patients.
Swancutt Dawn , Sian Joel-Edgar,
Michael Allen, Daniel Thomas, Heather
Brant, Jonathan Benger,et al. Not all
waits are equal: an exploratory
investigation of emergency care patient
pathways.BMC Health Services Research
201717:436
Reiling et al stated that hospital layout was a
contributing factor in staff performance,
patient and worker safety.
Reiling John, et al. Patient Safety and
Quality: An Evidence-Based Handbook for
Nurses. Chapter 28:The Impact of Facility
Design on Patient Safety. Agency for
Healthcare Research and Quality (US); 2008
Apr.
Melanie et al in 2013 also stated that
elimination of overload procedure in hospital
could improve service time.
Michael Melanie. Improving Wait Times and
Patient Satisfaction in Primary Care. Journal
for Healthcare Quality, Volume 35, Issue
2,March/April 2013
Leadership, and more specifically
medical leadership, is an unmeasured
potential that has the power to influence
every aspect of a persons professional
life and its challenges and is more evident
in times of emergency. Medical
leadership is receiving increasing
recognition especially in discussing
actions to be taken in times of stress and
emergency.
Oded Hershkovich, David Gilad, Eyal
Zimlichman, Yitshak Kreiss. Effective
medical leadership in times of
emergency: a perspective. Disaster and
Military MedicineThe Journal of
Prehospital, Trauma and Emergency Care
2016 2:4
 Ishijima stated that work the
standardization by SOP could environment by the application of the 5S
minimize human error 20
Study in Singapore by Ho et al also
stated that quality of care was not
only focused on clinical competence
aspect in physician and nurse but
also work environment, work flow,
and communication. A successful
intervention thus depends on
solutions that are being provided and
incorporated into hospital
regulation.21
Pati et al also stated that hospital Sama
architecture as medical instrument
could provide innovative solutions
improvement of the work
management method (termasuk dalam
proses pembuatan SOP) was observed to
have motivated staff in a healthcare
facility where resource constraints and
other demotivating factors prevail.
KanamoriShogo , Seydou Sow,Marcia C.
Castro, Rui Matsuno, Akiko
Tsuru,and Masamine Jimba.
Implementation of 5S management
method for lean healthcare at a health
center in Senegal: a qualitative study of
staff perception.Glob Health Action.
2015; 8: 10.3402/gha.v8.27256.
the challenges presented by nurses who
manage the emergency care reinforced
the need for being a creative, critical, and
reflective professional to suggest actions
related to the organization and structuring
of the unit and of the healthcare system
for emergency care. The need for
advancements in the organization of the
healthcare system is undisputed, so that
attention to urgent care can be performed
in other ports of entry. However, the
system will only be improved from the
moment each service and health worker
recognizes and assumes its share of
co-responsibility in the pursuit of changes
pointing to better resolution of the health
needs of the population.
Jos Lus Guedes dos Santos; Maria
Alice Dias da Silva Lima; Aline Lima
Pestana; Estela Regina Garlet; Alacoque
Lorenzini Erdmann.Challenges for the
management of emergency care from the
perspective of nurses.Acta paul.
enferm. vol.26 no.2 So Paulo 2013
 for patient and worker safety.22
Arcidiacono et al stated that while
accreditation was an important
method for quality improvement
however lean hospital was twice
more important than accreditation.24
Betterment of quality of care could EM residents use a full range of
be achieved through leadership adult-learning
support, succinct plan, training, and strategies and supports for learning
effective hospital management.23
Accreditation systems in the majority of
developing countries, although might
have positive impacts on quality of care
are possibly established without
considering all necessary arrangements.
Aidin Aryankhesal.Strategic Faults in
Implementation of Hospital Accreditation
Programs in Developing Countries:
Reflections on the Iranian Experience. Int
J Health Policy Manag. 2016 Sep; 5(9):
515517.
strategies, yet the
clinical skills are considerably broader
and more deliberate than those for
learning leadership skills. There is much
opportunity for enhancing the learning
practices related to leadership among EM
residents by including models of
self-directed learning; providing formal
training in leadership and teamwork;
focusing feedback on leadership skills;
sharing best practices; and formally
including attending physicians, nurses,
and other team members in the learning
process.
Ellen F Goldman, Margaret M Plack,
Colleen N Roche, Jeffrey P Smith,
and Catherine L Turley.Learning Clinical
Versus Leadership Competencies in the
Emergency Department: Strategies,
Challenges, and Supports of Emergency
Medicine Residents.J Grad Med Educ.
2011 Sep; 3(3): 320325.