Implementation of the 5S-KAIZEN-TQM approach in a public hospital in Tunisia.

INTRODUCTION: The 5S-Kaizen-TQM is a step-by-step approach, originally implemented in the Japanese industry as a continuous improvement strategy. AIM: To underline the positive impact of its implementation in three pilot departments in Tunisia public hospital. METHODS: The 5S-KAIZEN-TQM introduced into three clinical departments lasted 6 months from February 2021 to July 2021. Firstly, we organized seminar to introduce this approach and training sessions on 5S and Kaizen activities to each department staff members. To collect data, we conduct satisfaction surveys, face to face interviews, meetings, and brainstorming sessions. To present these data, checklists, Analytic Hierarchy Process (AHP), Ishikawa chart, Value stream mapping (VSM) charts and visual management techniques were adopted. Then, with the participation of the staff members, we implemented the two steps of this approach and evaluated their performance by the identification of indicators related to each step and to each Departement. RESULTS: The project had positive implications on employee and patient satisfaction. 5S step activities leaded to the reduction of the item research time and the releases of space. Improving the working environment increased staff satisfaction. Kaizen activities conducted to the reduction of process lead time and the error reductions which increased patient satisfaction. CONCLUSION: This project, first in Tunisia, was undertaken by Tunisian National Health Evaluation and Accreditation Agency (INEAS) and partners as part of the program for the research on organizational innovation in health. The fundings of this project can be disseminated and perpetuated the 5S-KAIZEN-TQM approach in the health sector in countrywide.

Estimating the cost of home dialysis in Tunisia: Application of the Activity-based costing methodology.

INTRODUCTION: In Tunisia, in-centre haemodialysis (ICHD) is the most common type of dialysis. Despite the increasing demand, the number of haemodialysis machines per 100,000 inhabitants is still low. Home Haemodialysis (HHD) is a candidate solution to this problem. Despite its confirmed benefits over ICHD, HHD has not taken place in Tunisia. AIM: To describe the processes of home dialysis modalities, especially HHD, evaluate their costs, analyse them, in the context of medical practice in public health structures in Tunisia. METHOD: The Activity-Based Costing technique was applied: the processes of home dialysis modalities were modelled, the main activity and resource cost drivers identified, and cost equations developed. Based on data from the nephrology department of Sahloul hospital, the cost per session and annual costs for each home dialysis modality were calculated and analyzed. RESULTS: Home Peritoneal Dialysis, already implemented in Tunisia; presented the lowest annual cost per patient 25344 TND versus 29232 TND for Conventional HHD and 54144 TND for Short-Daily HHD. The cost per session of the Short-Daily HHD (188,8 TND) was comparable to ICHD (180 TND). Consumables presented the most expensive resource for these modalities. Finally, the cost structure of HHD was comparable in Tunisia and France as well as in previous costing studies. CONCLUSION: The cost of one session of HHD is estimated to 188,8 TND. The Tunisian ministry of health could adopt a flexible policy to start HHD program by implementing Conventional HHD first.

A tool for the management of personal protective equipment during COVID-19 pandemic: Abderrahmen Mami Hospital case study.

INTRODUCTION: The COVID-19 pandemic is causing management difficulties in the Tunisian healthcare system inventory management and the supply of Personal Protective Equipment (PPE). AIM: Calculate the number of PPE needed for MAMI Hospital Ariana (dedicated hospital to COVID patients) to avoid stock-outs. METHODS: This study proposed a calculation method of the PPE needs for the intensive care and pneumology departments. We developed a mathematical formulation of the number of PPE needed according to the number of visits per medical and other teams, their types, the number of patients, and the validity of each type of PPE. RESULTS: Considering as input data: the number of visits for the different intervening teams (medical, paramedical, worker or other), the capacity of the different services (number of beds), the average length of stay of patients, the validity duration of an equipment and urgent visits, the developed model generates the required number of PPE (especially surgical masks, FFP2 masks, disposables gowns and coveralls). This allows to calculate the number of personal protective equipment (PPE) needed by the Mami hospital's pharmacy in this period of COVID-19 crisis. CONCLUSION: Our configurable application allowed us to calculate PPE requirements for the intensive care and pneumology departments and estimate their use duration.

A pull-strategy for the appointment scheduling of surgical patients in a hospital-integrated facility.

This paper addresses the daily appointment scheduling (AS) of patients in a hospital-integrated facility where outpatients and inpatients are treated simultaneously and share critical resources. We propose a lean approach based on the pull-strategy "Constant Work in Process" (ConWIP) to develop robust and easy-to-implement AS rules. Our objective is to reduce patients' waiting time and maximise the use rate of resources while considering the global surgical process and stochastic service times. The AS rules based on ConWIP are evaluated using a Discrete-Event-Simulation model. Numerical experiments based on a real-life case study are carried out to assess the proposed appointment rules' performance and compare them to AS rules developed in the literature. The results highlight the robustness of our approach and demonstrate its usefulness in practice.

Activin-A receptor expression patterns in prepubertal goat oocytes and derived embryos.

This study examines the presence of activin IIA and IIB receptors (ActR-IIA and ActR-IIB) by Western blotting and immunocytochemistry in immature and IVM-oocytes, 2 to 8-cells embryos and blastocysts from prepubertal goats. Western blotting revealed that activin receptors are synthesized during oocyte maturation and embryo development. In the immunocytochemistry experiments, no immunostaining for either receptor was detected in oocytes while both receptors were immunolabelled in all the cells of cleaved embryos. In blastocysts, while ActR-IIA expression appeared evenly distributed in the two cell lineages, inner cell mass and trophectoderm, the ActR-IIB immunosignal was restricted mainly to the inner cell mass. Our findings reveal the presence of activin type II receptors (ActR-IIA and ActR-IIB) in in vitro matured prepubertal goat oocytes and blastocyst-stage embryos. The expression of these receptors could be a key factor in understanding differences between competent and incompetent oocytes.

Linoleic (LA) and linolenic (ALA) acid concentrations in follicular fluid of prepubertal goats and their effect on oocyte in vitro maturation and embryo development.

In this study we assessed the concentration of linoleic acid (LA) and linolenic acid (ALA) in follicular fluid of prepubertal goats according to follicle size (<3mm or ≥3mm) by gas chromatography and tested the addition of different LA and ALA (LA:ALA) concentration ratios (50:50, 100:50 and 200:50µM) to the IVM medium on embryo development, mitochondrial activity, ATP concentration and relative gene expression (RPL19, ribosomal protein L19; SLC2A1, facilitated glucose transporter 1; ATF4, activating transcription factor 4; GPX1, glutathione peroxidase 1; HSPA5, heat-shock protein family A 70 kDa; GAPDH, glyceraldehyde-3-phosphate dehydrogenase; DNMT1, DNA methyltransferase 1; GCLC, glutamate-cysteine ligase catalytic subunit; SOD1, superoxide dismutase 1). Oocytes were in vitro matured, fertilised or parthenogenetically activated and zygotes were cultured following conventional protocols. LA concentration ranged from 247 to 319µM and ALA concentration from 8.39 to 41.19µM without any effect of follicle size. Blastocyst production from the different groups was: control FCS (22.33%) and BSA (19.63%), treatments 50:50 (22.58%), 100:50 (21.01%) and 200:50 (9.60%). Oocytes from the 200:50 group presented higher polyspermy and mitochondrial activity compared with controls and the rest of the treatment groups. No differences were observed in ATP concentration or relative expression of the genes measured between treatment groups. In conclusion, the low number of blastocysts obtained in the 200:50 group was caused by a high number of polyspermic zygotes, which could suggest that high LA concentration impairs oocyte membranes.

Effect of oocyte quality on blastocyst development after in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) in a sheep model.

OBJECTIVE: To compare blastocyst production, after IVF and ICSI, from sheep oocytes of various quality. Sham-injected oocytes and parthenogenetic activated oocyte groups were considered as control. DESIGN: Prospective experimental study. SETTING: University. ANIMAL(S): Three- to 6-month-old sheep. INTERVENTION(S): Oocyte quality was assessed with the use of brilliant cresyl blue (BCB) stain. Adenosine triphosphate content was measured. Intracytoplasmic sperm injection and IVF were performed and blastocyst development and cell numbers were analyzed. MAIN OUTCOME MEASURE(S): Adenosine triphosphate content, embryo development and blastomere numbers. RESULT(S): After IVF, BCB-stained (BCB+) oocytes developed up to the blastocyst stage at higher percentages and with more cells per embryo (24.1% vs 4.0% and 69.7 vs 43.9, respectively) than unstained (BCB-) oocytes. Using intracytoplasmic sperm injection, no differences were found in blastocyst production (14.3% vs 11.8%) and number of cells per embryo (71.1 vs 54.3) between BCB+ and BCB- oocytes. Adenosine triphosphate content was higher before in vitro maturation than after in both types of oocytes. Brilliant cresyl blue-stained oocytes had more adenosine triphosphate content than BCB- oocytes. CONCLUSION(S): Brilliant cresyl blue-stained oocytes show more adenosine triphosphate content than BCB- oocytes. Results from IVF were affected by the oocyte quality while ICSI did not produce differences in embryo development or blastomere numbers.