精實思維－檢驗流程改善

前言：醫學檢驗之品質管理於現今醫療視為不可或缺的一環，面對眾多醫療同業的競爭下，提升醫學檢驗的品質使顧客能得到更好的醫療服務是醫療行業的祈望。臨床實驗室面對不同的顧客群，除了要保證實驗結果的準確性與時效性外，醫院的醫學實驗室是需要嚴謹的管理以符合國際認可的標準作業規範來證明實驗室所分析的數據具有其醫療價值以提供醫師及患者作出適當的建議或治療，還需藉由品質管理來監測及改善實驗室的不足之處以增加內外部顧客的滿意度。研究目的：利用精實思維( Lean Thinking)在有限資源（最小成本、時間、移動路線等）改善檢驗流程，使檢驗人員可以更快更流暢地將報告的結果在最短的時間內正確地釋出，此外亦藉由精實思維模擬改善前後庫存及實驗室移動路線之差異。研究步驟：精實思維源自於日本豐田系統的生產系統，「已展開的事情絕對要完成，不虎頭蛇尾，不怠於追蹤」就是豐田的作業模式。目的是為改善其品質及提高生產力，掌握問題的真正原因，藉由消除不必要的浪費以助提供更好更多的產量。將「確認價值、確認價值溪流、暢流、後拉式及完善」等概念應用於實驗室內體液房中，模擬改善尿液、體液常規檢查、庫存管理及實驗室之移動路線藉此收到之效益。研究結果：尿液常規檢查於改善前及模擬導入精實思維後之改善情況其報告周轉時間下降2-4倍左右；體液常規檢查之報告周轉時間約下降至1倍左右；而模擬導入精實思維後之庫存省略較多之人手及降低庫存量，並釋出較多的空間作其他試藥之存放。至於改善後之移動路線則較改善前好，降低了因檢測樣本而移動的需要（從檢體簽數處由50步大幅下降至5步；所需要移動之時間由27秒下降至3秒。結論：精實思維乃是眾多醫療機構用作管理之趨勢，從一些文獻可觀察導入後有顯著改善之效果，如處理急診部門樣本之常規生化（鄭雅文　et al., 2014）或應用於醫學分子檢驗部門等都均可見到成果（王美嘉　et al., 2014），其成效主要反應於工作人員在檢驗科中進行分析時之動線、成本效益與報告週轉時數( Turn Around Time)等，祈可將精實思維結合其他管理工具或方法，將實驗室整體之運作流程持續改善（檢驗流程、空間規劃、庫存管理等）至更流暢，達至「更好」。

關鍵字

精實思維；報告周轉時間；庫存管理；實驗室移動路線

並列摘要

The quality management of medical examination is regarded as an indispensable part of today's medical and healthcare services. In the face of the competition from many of its peers, improving the quality of medical laboratory testing for providing better medical services to the customer is the clear vision and common wish of a hospital. In addition to ensuring the accuracy and timeliness of the experimental results, medical laboratories in hospitals, faced with different customer groups, need rigorous management in compliance with internationally recognized standards of practice to demonstrate the test results issued by the laboratories are trustworthy and appropriate for making medical advices and treatment. Besides, quality management can be used to reveal and overcome laboratory deficiencies so as to increase internal and external customer satisfaction. Purposes: Use “Lean Thinking” to improve the testing process in spite of limited resources (minimum cost, time, moving routes, etc.) so that the testing personnel can smoothly and flawlessly release the results of a report in the shortest possible time. In addition, it also improves the difference about inventory and the movement of laboratory through simulate lean thinking before and after. Method: Lean thinking is derived from the production system of the Toyota Motor System in Japan. “Everything that has a beginning must be definitely carried through. It must not turn out to be something with a fine start but poor finish. Untiring efforts must be exerted to oversee the process in full gear.” Those are the essence of Toyota’s mode of operation. It aims to improve quality and increase productivity, to grasp the real cause of the problem, and to help provide better and more output by eliminating unnecessary waste. Concepts such as confirmation value, confirmation value stream, smooth flow, post-pulling, and perfection are applied to the body fluid room in the laboratory and the simulated improvements of routine inspections, inventory management and movement routes are employed to work out the possible benefits in the laboratory. Results: The simulated introduction of lean thinking results in a 2-4 fold drop of the sample turnaround time (TAT) in urine routine examination, while the TAT is halved with the body fluid routine. Lowering of the level of inventory and manpower is expected in inventory management and as a result, more space is available for the storage of other reagents. As for the improved movement route, the need to move a specimen in testing is tremendously reduced (distance of the specimen travelled is decreased from 50 steps to 5, while the time of travel diminishes from 27 s to 3. Conclusion: Lean thinking is a trend that many medical institutions use for management. According to some documents, significant improvements after introduction of lean thinking can be observed as in processing emergency department samples in routine biochemistry（鄭雅文　et al., 2014）or application to medical molecular testing.（王美嘉　et al., 2014）. Their effectiveness is mainly reflected in the line of action, cost-effectiveness, and turnaround time when the testing staff conducts analysis in the clinical laboratory. Combining lean thinking with other management tools or methods, the continuous improvement of the overall operation process of the laboratory (inspection process, space planning, inventory management, etc.) will be a lot smoother and better in the near future.