Introduction

The healthcare sector is one of the priority areas of development in Russia, but it is particularly complex. First of all, organizations of various forms of ownership and legal forms function in this area. At the same time, an organization can provide services on a paid and free basis, within the framework of compulsory health insurance. This raises the problem of mandatory differentiation of services. Secondly, the medical service involves a set of professional actions, the range of which is quite wide. Thirdly, in the provision of medical services there may be several participants: the client, the medical organization and the customer (compulsory health insurance Fund, insurance company, etc.), each of whom protects his or her interests. Fourth, the concept of quality is a subjective concept, therefore, it is difficult to clearly define the criteria for quality medical services.  Fifth, with increasing requirements, health care financing does not improve significantly. There are other characteristics that indicate the complexity of this area, all this makes it difficult to quickly obtain good results. New approaches to management, such as lean production, can help in addressing the challenges facing health care today.

Purpose of work. Despite all the difficulties, health care faces great challenges, and, above all, one of them is to ensure that the medical service is safe, high-quality and effective. This is not to say that these are new tasks, but the requirement today is the development of new approaches to solving the tasks. The study of the practice of successful application of tools and methods of lean production in various areas of production indicates the possibility of their adaptation for use in health care. Therefore, the purpose of this study is to determine the sequence of stages of implementation of lean production and priority values at each stage. In the process of achieving this goal, it is necessary to highlight the problems that arise during the implementation of lean production in medical organizations and the factors that ensure success. As the object of the study, medical dental organizations were identified.

Materials and research methods. In the framework of this study, theoretical research methods were used. The multilateral analysis of the literature presented in the Russian Scientific Electronic Library was carried out eLIBRARY.ru, integrated with the Russian Science Citation Index (RSCI), dedicated to the use of lean production tools and methods in medical organizations. At the same time, the works of foreign authors on the topic of research published in journals included in the Scopus citation database, as well as published in the Google Scholar scientific publications system, were studied. A comparison and generalization of the theoretical material was carried out, which made it possible to determine the tools and methods of lean production suitable for use in medical organizations.

The empirical research was based on study of the introduction of the concept of lean in the RSAHI "Dental clinic № 1 of Belgorod". The study of practical experience allowed us to identify the problems arising in the process of using lean production methods associated with the sectoral features of medicine.

The integration of the results of the theoretical and empirical research has allowed us to develop the stages of implementation of the concept of lean production in medical organizations and to consider the possibility of adaptation of individual methods of lean production to the studied area.

Main body

This study is based on the fact that the concept of lean production finds practical application in various fields of activity. That is, there is a real experience in the implementation of both individual methods of lean production and a holistic concept. At the same time, the authors give various recommendations for the implementation of lean production, different approaches to the determination of priority principles and the sequence of their implementation.

M. A. Shapovalova, V. A. Bondarev, L. R. Koretskaya defined the algorithm of introducing lean production in the medical organization, which includes:

- definition of a change leader-conductor,

- obtaining knowledge of the Lean system,

- search or creating a crisis,

- mapping the entire value stream for each service,

- work in the main areas,

- focus on quick results,

 implementation of continuous improvements in the Kaizen system [Shapovalova, M. A., Bondarev, V. A., Koretskaya, L. R., 2015].

When considering the issues of adaptation of lean production to the medical field, it is advisable to proceed from the two defining characteristics of lean health care, highlighted by Rotter T.:

- lean philosophy consisting of the principles of thrift and continuous improvement,

- lean activities, including lean activities, in terms of resource use and lean improvement activities [Rotter, T. et al.,2 018].

From our point of view, it is necessary to start with the study of the philosophy of lean production, and the result should be a corporate culture corresponding to this philosophy. Lean activity is an intermediate link to achieve the goal. You need the right combination of these two components.

Therefore, it is possible to distinguish the preparatory stage for the introduction of lean production. It is the most important task, as it largely determines the success of not only the implementation, but also the functioning of lean production as a management concept.

Lean production involves an integrated system, so many are mistaken when a single proposal to improve the processes and the implementation of even a set of projects to improve perceived as implemented concept. It is important that all actions to improve the process take a systematic character.

As part of the preparatory phase, training should be provided to ensure not only familiarization with the principles and basics of lean production, but also the formation of a team of mature executives who can provide support for the implementation of lean production. Training involves the mandatory adaptation of tools and methods to a specific industry. It should be understood that in medical organizations there are two types of activities:

- provision of medical services,

- administrative and economic activities.

Approaches to the use of tools for each activity may differ. Practice shows that it is easier and simpler to implement lean production in administrative and economic activities [L. A. Zimakova, L. Gorbatyuk, D. Y., Shetan, J. G., 2017]. Medical services are too complex and the traditional approaches to conducting a routine analysis do not always bring a positive effect.

James Womak and Daniel Jones were among the first to raise the question on the purposefulness of the use of the concept of lean production in various fields. At the same time, they believe that an important difference of lean production is the correct definition of value, which has clear quality and cost characteristics. That is, it is necessary to start with identifying the desires of the consumer and determining the most important criteria for its products and services. At this stage, the first problem arises in medical organizations – all patients want to be healthy, but it is necessary to understand that it is not in the capacity of medical workers and pharmaceuticals drugs. In this study, dental services are considered and, in this sector, it is easier to determine what the patient wants: to cure a diseased tooth, insert an implant, etc.

Determining the needs of customers – it is quite a complex, long and expensive process, so many organizations do not pay enough attention to it, arguing that, in principle, they understand the customer or customers well, so their opinion does not matter. Only big business can afford serious marketing research, not just a survey of customers. Small and medium-sized businesses have low capital accumulation, which creates problems that limit the possibility of its development.

An important indicator of performance evaluation in organizations implementing lean production is customer satisfaction. Therefore, it is necessary to understand what hinders the quality of service. The research conducted by T. Young, S. Brailsford, ConnellC., Davies R., Harper P., Klein JH. has shown that the use of lean production in health care minimizes or eliminates delays, repeated visits, mistakes and unnecessary procedures, resulting in improved customer satisfaction and reduced service costs [Young, T., Brailsford, S., Connell, C., Davies, R., Harper, P., Klein, JH., 2004]. Developing and deepening the idea of customer satisfaction, Dickson E. W., Singh S., Cheung D. S., Wyatt C. C., Nugent A. S.  emphasize the need for satisfaction and awareness of all interested parties of the quality and safety of services provided by medical organizations [Dickson E. W., Singh, S., Cheung D. S., Wyatt C. C. and Nugent, A. S., 2008]. As factors for the success of lean production, Morrow, E., Robert, G., Maben J. and Griffiths P. provide a clear definition of quality targets, improved data availability, understanding of customer value, knowledge of processes and stakeholder involvement in initiating change [Morrow, E., Robert, G., Maben, J. and Griffiths, P., 2012.] Spear S. highlighted the most important benchmarks of the concept of lean production for implementation in medical organizations – patient orientation, continuous improvement and empowerment of employees. He notes that this can be implemented by both physicians and managers of medical organizations [Spear, S., 2005].

Dickson E.W., Singh S., Cheung D.S., Wyatt C.C. and Nugent A.S. conducted empirical studies, while in the implementation of lean production, the orientation was towards improving quality, which is the basis of corporate success. As a result, the volume of services has increased by 9.23% per year, patient satisfaction has increased significantly without increasing the cost per patient (but there was an adjustment for inflation) [Dickson, E.W., Singh, S., Cheung, D.S., Wyatt, C.C. and Nugent, A.S., 2008].

In accordance with GOST 56406-2015 “Lean Production. Audit Questions for evaluating the management system "interested parties should include consumers, shareholders, society, government agencies, suppliers and partners [GOST R 56406 - 2015]. Already at this stage, you can face a contradiction of interests. For example, a shareholder is interested in making profit, which is made up of client’s payments, who in turn, is interested in paying less for a service. If we consider tax authorities as components of state bodies, then they are interested in increasing taxes paid by a medical organization, and the compulsory health insurance fund, as a fund implementing state policy, is interested in reducing the cost of services.

Therefore, already at the preparatory stage it is necessary to coordinate the interests of all the participants, without prejudice to anyone. The developed priority directions of development should be formulated and placed in open access. For example, Table 1 presents the goals of the interested parties RSAHI "Dental Clinic № 1 of Belgorod" and identifies certain indicators for their assessment.

Table 1

Characteristics of stakeholders of the dental clinic №1 (Belgorod)

The next stage of implementation of lean production is associated with the use of the simplest method of lean production – "5 S".

Burykin I. M., Khafiz'yanova R. H., Aleeva G. N recommend to start with the introduction of the 5S method into the practice of medical institutions and to achieve on this basis a rationally organized working space, which will serve as a basis for eliminating various kinds of losses [Burykin, I. M., Khafiz'yanova, R. H., Aleeva, G. N., 2012]. The 5S Method includes five components, three of which must be strictly observed in all medical institutions, based on the General requirements of SanPiN: sorting, order, cleanliness.  

RSAHI "Dental clinic № 1 of Belgorod" has developed a set of instructions and regulations as well as a comprehensive program of production control over compliance with sanitary regulations and the implementation of sanitary and epidemic (preventive) measures as part of the implementation of this stage.

Problems arise with standardization and improvement, which are components of the "5S" method. Standardization involves the development, approval and familiarization of employees with the workplace standard, as well as monitoring of the workplace, which, at the early stages, is carried out daily. In practice, we are faced with the fact that everyone theoretically knows how the employee's workplace should look like, but very often small (sometimes even significant) deviations are allowed. The lack of approved standards:

- does not allow managers to make demands on persons responsible for the state of the workplace;

- complicates the work of newly hired employees;

- creates an uncomfortable environment for employees temporarily arriving at the workplace (due to the replacement of a permanent employee);

- complicates the process of improving and creating a rational space for employees.

The introduction of 5S can be a good start not only to streamline the workspace, but also to form a team. Thus, restoring order in the workplace is very good, but the lack of workplace standards makes it difficult for managers to exercise control.

Michael Ballé, Anne Régnier, note the expediency of the complex use of the 5S method and the "just-in-time" system, which involves the provision of materials and tools in strictly limited quantities, ensuring the current needs of the [Ballé,M., Régnier, 2007. Lean as a Learning System in a Hospital Ward, 2007]. Its use avoids stocks that lead to losses.  Developing this idea, the authors emphasize the need for the team to be ready to use it. After all, the lack of necessary medicines and tools can lead to failures in the provision of services and cause the opposite of the expected effect. Training and preparation of the team for coordinated work should be carried out at the preliminary stage.

The "just-in-time" system assumes the possibility of creating a single integrated external and internal supply chain, that is, its component is the effective management of material flows. According to Chakraborty, the management of material flows has a direct link with the quality of medical services and should become a mandatory component of the management of material flows in medical organizations [Chakraborty, S., Gonzalez, J. A., 2018].

Material flow management includes:

- supply and movement of medicines, materials, tools,

- information exchange, ensuring timely ordering of necessary materials, execution of relevant documentation and its movement, informing suppliers about the quantity, quality and timing, obtaining feedback on planned deliveries;

- the financial flow assuming payment of material values.

At the same time, physical and information flows include internal and external movement of values and information, so it is necessary to initially approach from the point of view of their integration, taking into account the possibility of a time lag.

The third stage of implementation of lean production involves the definition of a pilot process, which uses other lean production tools.  

According to Popova E. O., it is advisable to use a tool such as mapping of the value stream in medical institutions [Popova, E. O., 2016]. The usefulness of its application cannot be denied, but the importance of choosing the right process to be mapped should be noted.  

The adaptation of the University of Michigan health care system (UMHS) to lean thinking involved two phases: training and a pilot project. The choice of the pilot project was not accidental, but justified: patients had clear symptoms (bone and brain metastases); treatment planning and delivery procedures had a proven standard; input information was received very quickly. It is a thoughtful approach to the selection of the project provided the ability to effectively map the process and get the planned result. A team was formed to map the process, including not only medical, but also administrative and service personnel. The working team was prepared, as a result, all the steps were visualized, the whole process was improved, and not only its individual parts were optimized. Of the initial 27 steps, 17 were left, and the time of the process became stable [Kim, C. S., 27, Hayman, J. A., Billi, J. E., lash, K. and Lawrence, T. S., 2007].

The management of the RSAHI "Dental Clinic № 1 of Belgorod" selected the patient's X-ray process as a pilot project. It peculiarity implies a large volume of services provided. The diagnoses of almost all dental diseases require an X-ray examination. In addition, the patients of the RSAHI "Dental clinic № 1 of Belgorod" X-ray services are clients of other dental clinics. The process of providing services on a fee basis differs from the services provided on the basis of a health insurance policy by the number of operations performed by employees of the X-ray room. The clinic has precise rules for passing this procedure. The number of types of services provided in this study is limited: a detailed snapshot, computed tomography, a panoramic snapshot.

The process mapping and timing were carried out by a team of employees of the RSAHI "Dental Clinic № 1 of Belgorod", involving real patients. Repeated monitoring has allowed us to form a complete picture of the process under investigation, the results of which are presented in Table 2.

Table 2

Calculation of the cycle time of the x-ray examination process

RSAHI «Dental Clinic №1 of the city of Belgorod»

At the next stage, a diagram of spaghetti movements of the lab technician (Figure 1) and the movement of the patient.

Figure 1. Diagram of spaghetti movement of the laboratory assistant during x-ray examination in  OGAUZ «Dental Clinic №1 of the City of Belgorod»

A comparison of the operations to move the lab technician and the patient, the distance they travel and the time spent on it allowed the laboratory technician to determine the extra movement and record the a too long process of preparing the patient for the procedure.

Popova E. O. also recommends using the Ishikawa diagram and "5 Why" [Popova, E. O., 2016]. There are no obstacles in the application of these tools in the administrative activity, but in terms of the discovery of problems directly in medical activity, these tools cannot be effective, since it is not always possible to clearly identify the cause-and-effect relationships between events.

Hasle P., Nielsen A. P., Edwards K. pay attention to the limited use of tools in medical organizations, they emphasize that the most important elements of lean production such as flow, extraction and standardization are rarely used, especially in the main functions and processes of the hospital. These authors outlined the reasons explaining this fact:

- lack of adaptation of lean production for health care,

- the lack of coordination between the efforts of lean production to simplify work and the complex nature of medical activity,

- the ambiguity of judgment regarding value for the patient [Hasle, P., Nielsen, A. P., & Edwards, K., 2016].

Thus, all of the above indicates the possibility and effectiveness of the concept of lean production in medical organizations. 

Conclusion

On the basis of the theoretical and empirical research, the stages of the introduction of lean production in medical organizations were developed and the characteristics of the tools and methods used at these stages were given.

The first stage – preparatory – includes familiarization of employees with the concept of lean production, with the principles underlying it, the formation of leaders capable of becoming agents of lean production. The managers of the organization should identify the needs and wishes of customers, group them and highlight the most important values ​​for customers, and also coordinate them with assessment indicators and values ​​for all stakeholders.

The second stage involves the use of the “5S” Method in practical activities. In case of its successful application, it is possible to supplement it with the “just-in-time” Method and the Material Management System. This combination in the complex allows to achieve the maximum effect from the implementation of the “5S” Method.

The third stage is focused on defining a process that will act as a pilot project, as part of the implementation of lean production. It is important to correctly and reasonably choose a process that will be mapped and improved.

The next steps will be related to the promotion and dissemination of lean production methods in the organization. As a result of the phased implementation of lean production, a new medical service must be obtained, not fundamentally new, but one that has certain distinctive characteristics that are important for the consumer and provides cost reduction.