Improving the Waiting Time in Outpatient Clinics Using Lean Approach in Hospital: A Systematic Review

@#Introduction: The use of the lean approach in healthcare has rapidly gained popularity globally, although this approach was more routinely used in the manufacturing sector as opposed to health. Besides, recent studies confirm the suitability of the lean approach applications for improving the quality of medical care. This study aimed to determine the Lean approach’s capacity to improve the waiting time in outpatient clinics in hospitals. Methods: The systematic review approach was employed to help in the research procedures. Search databases used included Ovid, Google scholar, PubMed, MEDLINE, and archive. Besides, search terminologies such as the Lean approach, Hospital-implementation, waiting time, and patient flow were used to help identify sources that best suited the investigation process. Results: The review revealed that the lean approach is suitable for the reduction of waiting times as well as for improving efficiency in the clinic. The outcomes provide a basis for reducing the average waiting time within the hospital. Conclusion: This study recommended that healthcare facilities and departments should take a keen interest in implementing the Lean approaches, as they are crucial for reducing waiting time.

Modelación de los flujos de pacientes de alto riesgo con COVID-19 en Matanzas con enfoque Lean

Introducción: En el contexto de la pandemia, la gestión eficiente de los flujos de pacientes con enfoque en su trayectoria es crucial. En este sentido, el enfoque Lean permite aumentar el rendimiento del sistema sanitario, al eliminar actividades que no generan valor al paciente. Objetivo: Realizar un análisis integral de los flujos de pacientes de alto riesgo con COVID-19 en Matanzas, utilizando el enfoque Lean. Materiales y métodos: Se implementó una metodología de tipo cuantitativa, estructurada en cuatro etapas, para la gestión integrada de los flujos de pacientes de alto riesgo con COVID-19, mediante el enfoque Lean. Esta metodología integra herramientas para la selección de expertos, representación de procesos, análisis estructural y mapas de flujos de valor. Se aplicó durante del período de mayor incidencia de la pandemia en Matanzas (1 de mayo al 1 de agosto de 2021). Resultados: Se identificaron deficiencias relacionadas con los flujos de pacientes de alto riesgo con COVID-19 en Matanzas. Se realizó un análisis integral de los flujos, con el fin de realizar una propuesta de mejoras con enfoque Lean. La propuesta garantizó una optimización de 1510 minutos por ciclos de atención, con una eficiencia del 85,86 % del tiempo total de cada ciclo (etapa del tratamiento), y del 59,38 % de los tiempos de espera entre ellos. Conclusiones: Las herramientas Lean permiten realizar un análisis integral de los flujos de pacientes, además de mostrar una vía para su gestión, centrada en la trayectoria y no en la ocupación del recurso.

Introduction: In the context of the pandemic, the efficient management of the patients flow with a focus on their trajectory is crucial. In this sense, the Lean approach allows to increase the performance of the health care system, eliminating activities that do not generate value for the patient. Objective: To carry out an integral analysis of the high risk patients flow with COVID-19 in Matanzas, using the Lean approach. Materials and methods: A quantitative methodology, structured in four stages was implemented for the integrated management of the flow of high risk patients with COVID-19, using the Lean approach. This methodology integrates tools for the selection of experts, process representation, structural analysis and value flow maps. It was applied during the period of highest incidence of the pandemic in Matanzas (May 1st to August 1st 2021). Results: Deficiencies related to the flows of high risks patients with COVID-19 in Matanzas were identified. A comprehensive analysis of the flows was carried out in order to make a proposal for improvements with a Lean approach. The proposal guaranteed an optimization of 1 500 minutes per service cycle, with an efficiency of 85.86% of the total time of each cycle (treatment stage), and 59.38% of the waiting times between them. Conclusions: Lean tools allow a comprehensive analysis of the patients' flow, in addition to showing a route for their management, focused on the trajectory and not on the occupation of the resource.

A novel study on recently discovered fatty acid taste detection threshold among young lean and overweight individuals

Background: It is likely that the sense of taste evolved to alert humans to the nutritive or poisonous nature of possible foods. This study has been undertaken to unravel and highlight a possible relationship between the fat taste threshold and obesity, especially among young population. Aims and Objectives: The aim of the study was to detect the fat taste threshold in young lean and overweight individuals and to compare the threshold in these individuals with age- and sex-matched normal individuals. Materials and Methods: The taste threshold for fat was detected in 50, normal (Body mass index [BMI] (18.5–24.9 kg/m2), lean (BMI <18.5 kg/m2), and overweight individuals (BMI of 25.0–29.9 kg/m2) of both sexes with the age between 18 and 30 years. The statistical analysis was done using Analysis of variance test. Results: Young lean individuals could detect the fatty acid taste at the lower concentration compared to overweight individuals, who detected at higher concentration (P < 0.01). Conclusion: Lean male and female showed a significant taste detection threshold for fat at low concentration compared to overweight male and female as well as with normal individual. Fatty acid taste detection is very important in day-to-day life for the disease-free life.

PREVALENCE AND RISK FACTORS OF NON–ALCOHOLIC FATTY LIVER DISEASE IN LEAN INDIVIDUALS: A HOSPITAL BASED STUDY.

Introduction: According to epidemiological studies, NAFLD affects 9% to 53% of India's general population, with a higher frequency among those who are overweight or obese, those who have diabetes, or those who have prediabetes. There is emerging evidence of NAFLD occurring in lean or normal weight individuals. Studies show that between 5 and 34% of lean people have NAFLD. The highest prevalence rates, which were above 30%, were seen in India. Furthermore, Asian men who are slender, healthy, and active have insulin resistance prevalence that is three to four times higher than that of men in the rest of the world. Aim: To access the prevalence and risk factors of NAFLD among lean individuals attending Gauhati Medical College & Hospital with diagnosed Fatty Liver Disease. Materials and methods: A Hospital based Cross sectional study was done. The Gastroenterology department was used to choose the study participants using a purposive sampling method. The sample was made up of all patients with fatty liver disease who visited the gastroenterology outpatient department. The study found that the prevalence of NAFLD in lean individuals is Result: 16.9%. Females are at higher risk (P=0.0313 OR: 0.08316) of developing NAFLD in lean patients. Diabetes (P=0.0260 OR: 3.667) and Hypertension (P=0.0149 OR: 4.189) are significant risk factors. Altered bilirubin levels (P=0.0035 OR: 5.829), lipid profile (P=0.0013 OR: 7.367) and AST/ALT (P=0.0166 OR: 4.321) levels is also associated with NAFLD in lean individuals. NAFLD affects 16.9% of lean Conclusion: people with a BMI under 23. Among the lean population, women have a higher chance of getting NAFLD than men. In the study population, important risk factors for NAFLD include diabetes and hypertension. Patients with NAFLD (BMI <23) are more likely to have abnormal lipid profiles, AST/ALT values and bilirubin levels than non-NAFLD fatty liver patients with BMI <23.

Influence of probe position in the measurement of muscle thickness and its association with lean mass: an ultrasound study / Influencia de la posición de la sonda en la medición del grosor muscular y su asociación con la masa magra: un estudio ecográfico

SUMMARY: Skeletal muscles play a fundamental role in people's lives and their evaluation provides significant information on health. Different tools have been used to evaluate muscle mass, and the evaluation of muscle thickness (MT) using ultrasound has been included as an alternative, which can be performed with the probe in different positions; however, these could present differences. The objectives of this study were to determine whether there are differences in the measurement of MT in the vastus lateralis (VL) muscle using the probe in the longitudinal or transverse position, and to determine its association with the lean mass of the lower limbs. The results indicated no significant differences between MT measurements with the probe in the longitudinal and transverse positions (p =0.084). However, when associating these measurements with lower limb lean mass, it was found that transverse measurements had a strong association (r =0.547; p < 0.001), while longitudinal measurements had a moderate association (r =0.351; p =0.007). This suggests that measurements with the probe positioned transversely to measure the MT would be the best option. Therefore, it could be useful as an indicator of lower limb lean mass in the absence of tools, such as bioelectrical bioimpedance or magnetic nuclear resonance.

El músculo esquelético cumple un rol fundamental en la vida de las personas, y su evaluación entrega mucha información de la salud. Se han utilizado diferentes herramientas para evaluar la masa muscular, y el último tiempo se ha incluido la evaluación del grosor muscular (MT) a través de la ecografía como una alternativa para estimarla, las cuales se pueden realizar con la sonda en distintas posiciones, sin embargo, estas podrían presentar diferencias. Los objetivos del estudio fueron determinar si existen diferencias en la medición de MT en el músculo vasto lateral (VL) utilizando la sonda en posición longitudinal o transversal y determinar su asociación con la masa magra de los miembros inferiores. Los resultados indican que no existen diferencias significativas entre las mediciones de MT con la sonda en posición longitudinal y transversal (valor p: 0.084). Sin embargo, al asociar estas mediciones con la masa magra de los miembros inferiores, se encontró que las mediciones transversales poseen una asociación fuerte (r: 0.547; valor p < 0.001), mientras que las mediciones longitudinales presentan una asociación moderada (r: 0.351; valor p: 0.007). Esto sugiere que las mediciones con la sonda posicionada transversal para medir MT serían la mejor opción. Por lo tanto, podría ser de utilidad como un indicador de masa magra de los miembros inferiores en caso de no contar con herramientas como la bioimpedancia bioeléctrica o resonancia nuclear magnética.

Coordenação da Rede de Atenção ao Câncer de Mama: análise à luz da filosofia lean para o diagnóstico precoce / Breast Cancer Care Network coordination: analysis in the light of the lean methodology for early diagnosis

Resumo Objetivou-se analisar a aplicação da filosofia lean na Rede de Atenção à Saúde (RAS) para o diagnóstico precoce do câncer de mama. Trata-se de estudo de caso, com produção dos dados por entrevistas, análise documental e observação, desenvolvido entre junho e julho de 2019. O cenário foi o município sede da Região Metropolitana Norte, CE, Brasil, envolvendo três pontos da RAS (Unidade Básica de Saúde, Centro de Especialidades Médicas e Policlínica). Identificaram-se como problemas: elevado tempo de espera, atendimento por ordem de chegada e insuficiência da carga horária médica. A implementação do modelo teórico da filosofia lean reduziria o tempo total dos processos de 36 dias para 15 no fluxo Unidade Básica de Saúde/Centro de Especialidades Médicas e de 33 para 13 dias na Unidade Básica de Saúde/Policlínica. Verificou-se que o modelo apresentado se configura como referencial eficiente para melhoria da gestão e do diagnóstico precoce do câncer de mama na RAS.

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.

Analysis of Lean Six Sigma Use in Pharmaceutical Production

Abstract Over the last years, pharmaceutical industries have adopted continuous improvement and operational excellence programs to optimize processes, improve quality and reduce operational costs. Worldwide, Lean Manufacturing (LM) and Six Sigma (SS), as well as the integration of the two methods: Lean Six Sigma (LSS) are the most used approaches in the continuous improvement of industries and services. This work aims to investigate the employment of the Lean Six Sigma methodology in the productive areas of pharmaceutical companies located in Brazil. Interviews were conducted with managers of pharmaceutical industries that apply the approach. The results indicated the greater use of Lean Manufacturing tools compared to Six Sigma and the influence of specific peculiarities of the pharmaceutical industry on the benefits that are achieved with the use of Lean Six Sigma. The approach is considered of great value as it provides substantial benefits to the pharmaceutical industry. It is concluded that the work corroborates to the theoretical and empirical knowledge about the methodology use in the context of Brazilian pharmaceutical industries, as well as contributes to the implementation, reformulation, and improvement of Lean Six Sigma programs in this industrial segment.

Association of lean tissue index with arteriovenous fistula dysfunction in maintenance hemodialysis patients / 中华肾脏病杂志

The clinical data of maintenance hemodialysis (MHD) patients from twenty hemodialysis centers in Guizhou province from June to September 2020 were collected by cross-sectional study. The patients were divided into AFD group and non-AFD group according to whether AFD had occurred. LTI was measured by body composition monitor. The results showed that the incidence of AFD in 2 781 MHD patients was 30.0% (835/2 781). Median LTI level was 15.2 (13.2, 17.5) kg/m 2. The LTI level in the AFD group was higher than that in the non-AFD group ( P < 0.05). According to the tertiles of LTI, low LTI group (LTI ≤ 13.9 kg/m 2) had the highest incidence of AFD (35.5%, 334/940), and the high LTI group had the lowest incidence of AFD (26.3%, 241/916), and the difference among the three groups was statistically significant ( χ2=20.182, P < 0.001). Multivariate logistic regression analysis showed that low LTI group as the reference, the risk of AFD in moderate LTI group (13.9 kg/m 2 < LTI ≤ 16.6 kg/m 2) and high LTI group were associated with the 20.0% ( OR=0.800, 95% CI 0.650-0.986, P=0.036) and 22.8% ( OR=0.772, 95% CI 0.616-0.966, P=0.024) decrease, respectively. These results suggest that low LTI level is independently associated with an increased risk of AFD in MHD patients.

Research on Management Efficiency of Hospital Low-value Consumables in Nursing Unit under Lean Management Mode / 中国医疗器械杂志

Aiming at the management efficiency problems in the traditional medical low-value consumables management mode of the nursing unit, based on the perspective of supply chain management, this study uses lean management method to construct the lean management mode of low-value consumables with a whole cycle and whole process information monitoring, and analyzes the application effect of this mode. The results show that after the application of lean management mode, the low-value consumables of the nursing unit can achieve "consumables in use=priced consumables + un-priced consumables", the settlement cost is significantly reduced and its stability is high, and the efficiency of "supply-inventor-distribution" link is significantly enhanced. This model effectively improves the management efficiency of low-value consumables in the hospital, and also provides a reference for other hospitals to improve the management level of low-value consumables.

Preliminary Framework of Lean Healthcare Sustainability Performance Measurement for Health Sector

@#Introduction: Lean sustainability has gained prominence in the health sector for operational and business advantages. However, understanding the link between lean and healthcare sustainability, especially in social and environmental aspects, remains limited. This study introduces a preliminary framework for measuring lean healthcare sustainability in hospitals. The framework aligns Critical Success Factors (CSFs) with sustainability objectives and business strategies to ensure successful and enduring lean deployment. Methods: The study was conducted among 52 Lean Agile Hospitals in Malaysia using a cross-sectional approach. The validated questionnaire was employed for data collection. A reliability test and Exploratory Factor Analysis (EFA) were also performed to assess and validate the framework using Statistical Package for Social Sciences (SPSS) version 27. Results: The content validation was 0.9, which indicates that the instrument is sufficient to measure the research objective. The data screening test was performed to eliminate problem observation. The overall reliability value was over 0.830 which depicts data consistency and stability. The Kaiser-Meyer-Olkin exceeded 0.6, Bartlett’s test was under 0.001 and factor loading was between 0.507 to 0.948, thus indicating a significant correlation matrix among at least some of the variables. Therefore, the latent factors were significant to specific items of the research. Conclusion: It is concluded that important CSF is aligned with the strategic level influence of lean deployment in healthcare, which has a specific impact on certain sustainability performance. Thus, this paper proposed a generic preliminary framework to measure lean healthcare sustainability.

Official Position of the Brazilian Association of Bone Assessment and Metabolism (ABRASSO) on the evaluation of body composition by densitometry—part II (clinical aspects): interpretation, reporting, and special situations

Abstract Objective: To present an updated and evidence-based guideline for the use of dual-energy x-ray absorptiometry (DXA) to assess body composition in clinical practice. Materials and methods: This Official Position was developed by the Scientific Committee of the Brazilian Association of Bone Assessment and Metabolism ( Associação Brasileira de Avaliação Óssea e Osteometabolismo , ABRASSO) and experts in the field who were invited to contribute to the preparation of this document. The authors searched current databases for relevant publications in the area of body composition assessment. In this second part of the Official Position, the authors discuss the interpretation and reporting of body composition parameters assessed by DXA and the use of DXA for body composition evaluation in special situations, including evaluation of children, persons with HIV, and animals. Conclusion: This document offers recommendations for the use of DXA in body composition evaluation, including indications, interpretation, and applications, to serve as a guiding tool in clinical practice and research for health care professionals in Brazil.

Cambios en la composición corporal y ángulo de fase durante la pretemporada en jugadores de fútbol profesional / Changes in body composition and phase angle during pre-season in professional soccer players

RESUMEN: El análisis y el control de la composición corporal son claves en el fútbol por su implicación en el rendimiento. El objetivo de este estudio fue identificar, en jugadores de futbol profesional, el ángulo de fase (PhA) de miembros inferiores con los posibles patrones de mejora del componente magro en los mismos medido por DEXA. Al mismo tiempo, se estudió mediante BIA la evolución de parámetros hídricos de los jugadores, sometidos a un entrenamiento intenso y a un control nutricional de su alimentación y suplementación. Se evaluaron a 18 jugadores (26,28 ± 5,1 años; 85,09 ± 9,16 kg; 185,5 ± 4,32 cm) de un equipo de la primera división de fútbol italiana. Se llevó a cabo el estudio durante cuatro semanas, entre el 11 de julio (pre-test) y el 11 de agosto de 2021 (post-test). La intervención se llevó a cabo en su totalidad en pretemporada, con un confinamiento en modalidad de aislamiento o burbuja total por prevención al contagio del COVID-19, dónde se monitorizaba en un alto porcentaje la vida del jugador, incluyendo factores como la alimentación, el entrenamiento y el descanso. La suplementación estuvo basada en antioxidantes, multivitamínicos, minerales y ácidos grasos poliinsaturados y dos productos en polvo (uno a base de creatina, glutamina y leucina, y otro, a base de aminoácidos esenciales). Los jugadores presentaron una mejora del PhA y del componente magro en los miembros inferiores, con una moderada correlación (r = 0,6). Con respecto al agua intracelular y extracelular, señalar que, a pesar de la alta intensidad del ejercicio durante cuatro semanas, éstas se han mantenido constantes sin presentar variaciones significativas durante el periodo de estudio, lo que indica que no se ha producido un proceso de deshidratación del jugador.

SUMMARY: The analysis and control of body composition is essential in soccer due to its implication in performance. The aim of this study was to identify, in professional soccer players, the phase angle (PhA) of the lower limbs with possible patterns of improvement of the lean component measured by DEXA. At the same time, the evolution of hydric parameters of the players, subjected to intense training and nutritional control of their diet and supplementation, was studied by means of BIA. Eighteen players (26.28 ± 5.1 years; 85.09 ± 9.16 kg; 185.5 ± 4.32 cm) from an Italian first division football team were evaluated. The study was conducted for four weeks, between 11th July (pre- test) and 11th August of 2021 (post-test). The intervention was carried out entirely in pre-season, with confinement in isolation or total bubble mode for prevention of COVID-19 infection, where a high percentage of the player's life was monitored, including factors such as diet, training and rest. Supplementation was based on antioxidants, multivitamins, minerals and polyunsaturated fatty acids and two powdered products (one based on creatine, glutamine and leucine, and the other one, on essential amino acids). The players showed an improvement in PhA and in the lean component in the lower limbs, with a moderate correlation (r = 0.6). With regard to intracellular and extracellular water, it should be noted that, despite the high intensity of exercise during four weeks, these have remained constant without significant variations during the study period, indicating that there has not been a process of dehydration of the player.

Profile of Levothyroxine Replacement Therapy in Graves’ Disease patients with Hypothyroidism Post-Radioactive Iodine Ablation: Focus on different weight-based regimens / Journal of the ASEAN Federation of Endocrine Societies

Objective@#To evaluate the status of euthyroidism achieved among Thai patients with post-ablative hypothyroidism and to examine the difference between various weight-based daily levothyroxine (LT4) replacement regimens in these patients.@*Methodology@#We conducted a retrospective review of Thai patients with Graves’ disease (GD) who developed hypothyroidism following radioactive iodine treatment from 2016 to 2020 at Theptarin hospital. Daily LT4 dose was calculated based on actual body weight (ABW), ideal body weight (IBW), and estimated lean body mass (LBM).@*Results@#We reviewed a total of 271 patient records. Of these, 81.2% were females with a mean age of 40.8±11.7 years, LT4 intake duration of 27.1±14.6 months, and LT4 dose/kg ABW of 1.4±0.5 μg/kg/day. At the final follow-up, 62.4% of patients achieved thyroid-stimulating hormone (TSH) levels within the reference interval, 15.5% had TSH levels over, and 22.1% had TSH levels under the reference range. Obese patients required a lower daily LT4 dose relative to ABW and higher daily LT4 dose relative to IBW to attain euthyroidism (ABW 1.1±0.4 μg/kg/day and IBW 2.0±0.8 μg/kg/day). Estimated daily LT4 dose based on LBM showed a constant dosage of 2.0 μg/kg/day in all BMI categories.@*Conclusions@#Suboptimum LT4 replacement therapy was found in almost half of hypothyroid patients with GD treated with radioactive iodine. Estimated LBM was a better indicator for dosing calculation in these patients compared with ABW and IBW.

Magrario: un nuevo genotipo para producir carne ovina de calidad / Magrario: a new genotype to produce quality sheep meat

RESUMEN En la producción de carne ovina en Argentina existe escasa tradición para la comercialización de reses de corderos pesados con bajo tenor de grasa. Un nuevo genotipo cuya marca registrada es Magrario (M) fue obtenido en el Campo Villarino de la Facultad de Ciencias Agrarias de la Universidad Nacional de Rosario (33º S, 61º O) por cruzas absorbentes de una raza tradicional en la zona, Ideal (I) (Polwarth), hacia la raza Texel (raza reconocida por producir reses magras). A partir de la población base de la tercera retrocruza se seleccionó a los machos por el Aumento Medio Diario relativo hasta los tres meses de edad y a las hembras por la fertilidad de sus madres. Se verificaron diferencias significativas en la composición de la res en lo referente a depósitos grasos de este nuevo genotipo respecto a la población fundadora I tanto en confinamiento posdestete durante dos meses como en condiciones de cría a campo. También se compararon en confinamiento corderos M con los de la raza Hampshire Down (HD) siendo los depósitos grasos significativamente superiores en esta última raza. También se analizaron cruzamientos de M con HD e I verificando un efecto semi-dominante del nuevo genotipo para reducir tenor de grasa en las cruzas. La reducción de grasa subcutánea en el Longissimus Dorsi de (MxHD) se redujo un 20%. Esta experiencia demostró que Magrario puede ser utilizado como progenitor en cruzamientos si se desea producir corderos con menores depósitos grasos en condiciones de suplementación posdestete.

ABSTRACT Generally there is poor tradition to produce and to commercialize heavy lean lamb carcasses. To achieve a better product for the ovine meat market Ideal (Polwarth) breed ewes were backcrossed to Texel breed rams (breed recognized to reduce carcass fat). Ideal breed (I) is one of the most ordinary breeds in Argentina. However, when their lambs are reared in feedlot conditions, a high fat content is found in their lamb carcasses. After three generations of backcrosses followed by a breeding program for increase male lamb weaning weight and female fertility a new genotype was obtained for the local ovine meat production systems. This new genotype registered as Magrario (M) was obtained at Villarino Field Station of UNR (Zavalla, Santa Fe, 33º S, 61º W). It was verify that M produced more lean meat than I breed under feet lot conditions. M rams were introduced in flocks of Hampshire Down (HD) breed to evaluate lamb crosses with lean meat. Genotype M was compared under feed lot conditions with HD lambs during two months in the post weaning. Also crosses (MxHD), (MxI) and (IxHD) were evaluated in the same conditions. At the end of the experiment ultrasonic methods were used to evaluate fat depot on Longissimus dorsi. The (MxHD) showed a reduction of 20% respecting to HD. These results suggested that M genotype could be a useful paternal genotype to reduce fat depots when the aim is to produce lamb crosses under feed lot conditions in a short period of time.

Mapa de cadena de valor como una herramienta para la mejora de los procesos de cosecha y postcosecha en una empresa productora de piña / Value Stream Mapping as a tool for the improvement of harvest processes and postharvest in a pineapple production / Mapeamento do Fluxo de valor (VSM) - como ferramenta para a melhoria dos processos de colheita e pós-colheita numa empresa de produção de ananás

RESUMEN La metodología mapa de cadena de valor se ha convertido en una herramienta fundamental para los gerentes debido a su capacidad de diagnosticar procesos empresariales, donde se identifican las actividades que no agregan valor y se proponen alternativas de mejora basadas en distintas técnicas Lean Manufacturing. En el presente artículo, se aplica la herramienta mapa de cadena de valor en los procesos de cosecha y postcosecha de una empresa que se dedica al cultivo y comercialización de piña para el mercado nacional e internacional. Al final de la investigación se identifican desperdicios dentro del proceso como el exceso de manipulación, la falta de capacitación al personal y la ausencia de planes eficientes de mantenimiento de maquinaria. A partir de estas debilidades, se logra definir un plan de acción para la empresa, el cual es simulado utilizando el software Flexsim, donde se contrasta los escenarios "antes" y "después" de la operación con el fin de ilustrar a los gerentes, los beneficios potenciales de la implementación de las propuestas de mejora, en donde se logra establecer una reducción del tiempo de ciclo en aproximadamente un 19% lo que permite aumentar los volúmenes de producción y cumplir con la demanda del cliente final.

ABSTRACT The Value Stream Mapping methodology has become a fundamental tool for managers due to its ability to diagnose business processes, where activities that do not add value are identified and improvement alternatives based on different Lean Manufacturing techniques are proposed. In this article, the Value Stream Mapping tool is applied in the harvesting and postharvest processes of a company that is dedicated to the cultivation and sale of pineapple for the national and international market. At the end of the investigation, waste is identified within the process, such as excessive handling, lack of training for personnel and the absence of efficient machinery maintenance plans. From these weaknesses, it is possible to define an action plan for the company which is simulated using the Flexsim software, where the "before" and "after" scenarios of the operation are contrasted in order to illustrate to the managers, the potential benefits of the implementation of the improvement proposals, where it is possible to establish a reduction in cycle time by approximately 19%, which allows increasing production volumes and meeting the demand of the end customer.

RESUMO A metodologia do Mapeamento do Fluxo de Valor tornou-se uma ferramenta fundamental para os gestores devido a sua capacidade de diagnosticar processos de negócios, onde atividades que não agregam valor são identificadas e alternativas de melhoria são propostas com base em diferentes técnicas de Lean Manufacturing. Neste artigo, a ferramenta de Mapeamento do Fluxo de Valor é aplicada aos processos de colheita e pós-colheita de uma empresa dedicada ao cultivo e comercialização do abacaxi para o mercado nacional e internacional. Ao final da pesquisa, foram identificados resíduos dentro do processo, tais como manuseio excessivo, falta de treinamento de pessoal e a ausência de planos eficientes de manutenção de máquinas. A partir destes pontos fracos, é possível definir um plano de ação para a empresa, que é simulado utilizando o software FlexSim, que contrasta os cenários "antes" e "depois" da operação a fim de ilustrar aos gestores, os benefícios potenciais da implementação das melhorias propostas, onde é possível estabelecer uma redução no tempo de ciclo em aproximadamente 19%, o que permite aumentar os volumes de produção e atender a demanda do cliente final.

Lean: Introduction of a Quality Improvement Concept into Percutaneous Nephrolithotomy to Improve Efficiency while Maintaining Safety / Lean: introducción de un concepto en la nefrolitotomía percutánea para mejorar la eficiencia mientras se mantiene la seguridad

Introduction and objective Standardization of surgical interventions reduces complications and costs and positively impacts intra and postoperative outcomes. Implementation of the lean concept, initially proposed in the auto industry, now becomes an interesting approach in the surgical setting. We want to present the results of how percutaneous nephrolithotripsy (PCNL) in a high-level center can be positively impacted by implementing the lean concept. Methods We evaluated a total of 140 PCNL procedures. Group 1 included all cases operated prior to implementing the lean concept and group 2 was composed of those operated after implementing the lean concept. We looked for all seven sources of waste to identify and modify our practice to improve efficiency and safety. We then collected intraoperative times and compared the ones prior to those after the implementation. Results After implementing the lean concept, with an average of six PCNL cases per day, a comparison was made to an equivalent number of cases prior to the lean implementation (group 1). The average total operative time for PCNL preintervention was 138 (confidence interval [CI]: 79 to 170) minutes and postlean intervention was 71.1 (CI: 43 to 157) minutes. Surgical time (cystoscopy to skin closure) was 36.1 (CI: 25 to 50) minutes prelean and 50 minutes postlean (CI: 23 to 154). For this last one, bilateral procedures were performed. Operative room turnover time was 27.8 (CI: 21 to 38) minutes prelean and 5.67 (CI: 3.5 to 12) minutes postlean. Induction time was 16.5 (CI: 5 to 55) minutes prelean and 5.4 (CI: 3.5 to 7.5) minutes postlean. Conclusion Implementation of the lean concept enables optimization of the surgical procedure, allowing hospitals to reduce costs and standardization.

Introducción y objetivo La estandarización de los procedimientos quirúrgicos reduce complicaciones, costos, y mejora resultados intra y postoperatorios. El concepto lean fue utilizado por primera vez en la industria automotriz. El presente trabajo busca implementar el concepto lean para optimizar el procedimiento de nefrolitotomía percutánea (NLP) en nuestro medio. Métodos Se realizaron 140 procedimientos de nefrolitotomía percutánea, los cuales se dividieron en 2 grupos: uno en el cual se registraron los tiempos intraoperatorios, y el segundo en que se registraron los tiempos luego de la implementación del concepto lean. Resultados Durante el período estudiado, se realizaron 70 procedimientos luego de la implementación del concepto lean, y se logró realizar un promedio de 6 procedimientos por día. Se compararon los tiempos operatorios, y se encontró un tiempo operatorio total promedio de 138 (intervalo de confianza [IC]: 79 a 170) minutos pre-lean, y de 71,1 (IC: 43 a 157) minutos post-lean. El tiempo quirúrgico (cistoscopia a cierre de piel) pre-lean fue de 36,1 (IC: 25 a 50) minutos, y el post-lean fue de 50 (IC: 23 a 154) minutos. Para este último, se trató de procedimientos bilaterales. El cambio de sala fue de 27,8 (IC: 21a 38) minutos pre-lean, y de 5,67 (IC: 3.5 a 12) minutos post-lean. El tiempo de inducción fue de 16.5 (IC: 5 a 55) minutos pre-lean, y de 5.4 (IC: 3.5 a 7.5) minutos post-lean. Conclusiones La implementación del concepto lean permite optimizar el procedimiento, con reducción de costos y estandarización del modelo de atención para cualquier centro asistencial. La movilización de los especialistas en nuestro modelo de atención permite un mayor cubrimiento poblacional de alta calidad.

Satisfacción con el servicio de posortodoncia de la Universidad Santo Tomás según métricas Lean-Six-Sigma / SatisfactionService Post-Orthodontic University Santo Tomas According ToLean-Six-Sigma Metrics

Introducción: La metodología Lean-Six-Sigma es utilizada actualmente en el área de la salud con el objeto de mejorar la calidad y competitividad de los servicios; pero aún no se tienen reportes de su uso en el área de ortodoncia. Objetivo: Determinar la satisfacción posortodoncia por medio de niveles sigma de los pacientes que asisten a una clínica docente-asistencial en Bucaramanga, Colombia. Métodos: Estudio observacional, descriptivo, transversal. La población estuvo constituida por 100 pacientes de ambos sexos, que ya habían concluido el tratamiento de ortodoncia. Se seleccionó toda la población que hubiera finalizado el tratamiento entre julio de 2017 y junio 2018 de acuerdo con criterios de inclusión y exclusión. Se realizó una encuesta telefónica de 17 preguntas y siete dimensiones de satisfacción. La confiabilidad del cuestionario se evaluó con la consistencia interna del cuestionario mediante el alpha de Cronbach en el que se obtuvo 0,87, y para la validez se utilizó el método de Lawshe. Se usó la metodología Lean-Six-Sigma para evaluar la calidad de la satisfacción; se presentan los resultados en porcentaje y niveles sigma. Resultados: La calidad en satisfacción en el servicio fue de 91,27 por ciento (medido convencionalmente) y 1,36 sigmas; en el grupo de 16-19 años fue de 93,6 por ciento y 1,52 sigmas; y para el grupo de más de 27 años, 84,9 por ciento y 1,03 sigmas. El sexo femenino reportó un 88,57 por ciento y 1,2 sigmas, mientras que el masculino, 93,46 por ciento y 1,51 sigmas. Conclusiones: Los resultados de satisfacción en ortodoncia, medidos por métodos convencionales, mostraron porcentajes aceptables, pero mostraron resultados incompetentes al medirse con niveles sigma, lo cual indica que existen problemas ocultos por identificar y que corresponderían a una siguiente investigación(AU)

Introduction: The Lean-Six-Sigma methodology is currently used in the health area in order to improve the quality and competitiveness of services; but there are still no reports of its use in the orthodontic area. Objective : to determine the post-orthodontic satisfaction by means of sigma levels of the patients who attend a teaching-assistance clinic in Bucaramanga, Colombia. Methods: Observational descriptive cross-sectional study. Population: 100 patients (female and male) who finish orthodontic treatment. Sample selection method: the entire population that had completed the treatment between July 2017 and June 2018 was selected according to inclusion and exclusion criteria. A telephone survey of 17 questions and seven dimensions of satisfaction was carried out. The reliability of the questionnaire was evaluated with the internal consistency of the questionnaire by means of the Cronbach's alpha in which 0.87 was obtained, and the Lawshe method was used for validity. The Lean-Six-Sigma methodology was used to assess the quality of satisfaction; Results are presented in percentage and sigma levels. Results: The quality of service satisfaction was 91.27 percent (conventionally measured) and 1.36 sigmas; in the group of 16 to 19 years it was 93.6 percent and 1.52 sigmas; and for the group over 27 years old, 84.9 percent and 1.03 sigma. The female sex reported 88.57 percent and 1.2 sigmas, and the male reported 93.46 percent with 1.51 sigmas. Conclusions: The satisfaction results in orthodontics, measured by conventional methods, showed acceptable percentages, but showed incompetent results when measured with sigma levels, which indicates that there are hidden problems to be identified and that they would correspond to a subsequent investigation(AU)

Application of LBW index combined with energy spectrum CT in reducing the contrast agent dose of liver enhanced CT / 西安交通大学学报(医学版)

【Objective】 To compare the enhancement effects of lean body weight （LBW） and total body weight （TBW） as indexes to calculate the contrast agent dosage under the condition of energy spectrum CT scanning. 【Methods】 A total of 218 patients who received liver enhancement CT from November 2018 to January 2019 were enrolled in this study. There were 101 patients in LBW group and 117 patients in TBW group. Both groups were scanned by energy spectrum CT， and the parameters of scanning and reconstruction were identical. The contrast agent dose was 500 mgI/kg （LBW） in LBW group and 450 mgI/kg （TBW） in TBW group， and the injection rate was 2.8 mL/s. Images were transferred to a GE AW4.7 workstation and the 50 keV monochromatic images were analyzed. We compared the dosage of contrast medium， CT value of aorta in arterial phase （HU-aorta）， hepatic enhancement CT value in venous phase （-liver）， the rate of reaching the enhancement standard and variability in the two groups. 【Results】 Compared with TBW group， LBW group had lower contrast agent dosage， HU-aorta and ∆-liver （P0.05）. The variation rate of HU-aorta and ∆-liver in LBW group was lower than that in TBW group. Using LBW as an index to calculate the dosage of liver enhanced CT also made the enhancement of liver parenchyma more consistent in different patients. 【Conclusion】 Even on the premise of energy spectrum CT scanning， using LBW-based contrast injection in liver enhanced CT can not only reduce contrast dose， but also make the enhancement in liver parenchyma more consistent among different patients.

Construction and practice of a lean mode for COVID-19 epidemic prevention / 中华医院管理杂志

A lean management practice had been in place in Taizhou Enze Medical Center during the COVID-19 epidemic period, featuring the " principle-system-tool" theory of the Shingo model, in an effort to build a new model of COVID-19 prevention and control. The center upheld such five principles of lean management as overall planning, total involvement, system collaboration, concern with process and continuous improvement, and people-oriented practice. Under such principles, the center set up five supportive systems of lean management tools, namely risk identification, rapid screening, homogeneous treatment, customized follow-up and employee care. Integrated use of multiple tools of lean management, had improved the hospital′s crisis response ability, achieving desirable outcomes in stages in combating COVID-19 epidemic.

Índice de asimetría bilateral morfológica de extremidades inferiores y superiores en jugadores de baloncesto universitario / The upper and lower limb bilateral morphological asymmetry index in university basketball players

Introducción: El baloncesto es objeto de múltiples estudios que incluye la valoración mediante tecnologías actuales como la bioimpedancia. Objetivo: Comparar los índices de asimetría (IA) de las extremidades superiores e inferiores en jugadores de baloncesto universitario por nivel deportivo. Método: Se evaluaron 24 jugadores de baloncesto de diferente nivel competitivo, representativo 1) universitario (n = 12) y 2) facultad (n = 12). Se determinó la circunferencia de brazos y piernas, además de masa magra y grasa por bioimpedancia. Se determinó el índice de asimetría de los miembros inferiores y superiores y se compararon por nivel deportivo. Resultados: La comparación de los índices de asimetría entre brazos y piernas en el grupo total identificó diferencias estadísticamente significativas (p < 0,05) en lo referente a la masa grasa, con mayor adiposidad en extremidades superiores, y un índice de asimetría de -10,8. Cuando se compararon las mismas variables en función del nivel deportivo, los jugadores representantes de la universidad mostraron mayores valores (p < 0,05) en el índice de asimetría de la masa total, circunferencias, masa magra y masa grasa. Las comparaciones intergrupales señalan diferencias en los índices de asimetría del brazo vs. la pierna en masa magra para ambos grupos (p < 0,05) mientras que los de la facultad mostraron diferencia también para grasa con índice de asimetría de 18,3 (p < 0,05). Conclusiones: Indistintamente del nivel deportivo, existen diferentes niveles del índice de asimetría entre extremidades superiores e inferiores en el componente de masa grasa, aunque menores valores del índice de asimetría fueron característicos de los individuos de mayor nivel deportivo(AU)

Introduction: Basketball has been the object of many studies, including assessments based on current technologies such as bioimpedance. Objective: Compare the asymmetry indices (AI) for upper and lower limbs in university basketball players. Methods: An evaluation was conducted of 24 basketball players from different competitive levels, representing 1) the university (n = 12) and 2) the school (n = 12). Determination was made of arm and leg circumference, as well as lean mass and fat by bioimpedance. The lower and upper limb asymmetry index was estimated and compared between the competitive levels. Results: Comparison of the arms and legs asymmetry indices in the total group revealed statistically significant differences (p < 0.05) as to fat mass, with greater adiposity in the upper limbs and an asymmetry index of 10.8. Comparison of the same variables between the sports levels found that players representing the university displayed higher values (p < 0.05) in the asymmetry index for total mass, circumferences, lean mass and fat mass. Comparison between the groups found differences in the arm vs. leg asymmetry indices for lean mass in both groups (p < 0.05), whereas the school players also showed differences for fat, with an asymmetry index of 18.3 (p < 0.05). Conclusions: Regardless of the sports level, different asymmetry indices are found between upper and lower limbs as to fat mass, though smaller asymmetry index values were characteristic of individuals from a higher sports level(AU)