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Review article

SIPOC method of optimizing the clinical process in obstetrics

Edin Međedović1,2, Lara Spalldi Barišić3, Enida Nevačinović4, Admir Rama5, Anida Kurtović6, Anis Cerovac7,8

ABSTRACT

The promptness of providing services to patients directly affects the success of healthcare organizations. In this regard, the implementation of contemporary concepts in healthcare organizations is synonymous with success.

Subject of research: The subject being researched in this paper is the possibility of applying the SIPOC method to the clinical process in obstetrics. A more precise application of the abovementioned method would mean a prompter implementation of activities within the clinical process (pregestational counseling, antenatal care of expectant mothers, deliveries, supervision of women during puerperium). Through the activities of the abovementioned clinical process, an effort is made to meet the health needs of expectant and new mothers. The application of the SIPOC method is not sufficiently present in clinical processes, especially the clinical process in obstetrics, and therefore this paper opens a new research area.

Aim: The aim of this paper is to indicate the relevance of the SIPOC method as one of the tools within the Lean methodology, which can be used to improve the clinical process in obstetrics.

Materials and methods: The following materials and methods were applied in this study: the method of analysis, the inductive – deductive method, the method of synthesis, the method of description, the method of proof. Case analysis was also used in the application of the SIPOC matrix at a gynecology and obstetrics outpatient clinic.

Results: The results of the research showed that there was a positive impact on improving the efficiency of the provision of health services, through the implementation of modern methods. The SIPOC method affected the improvement of the efficiency of the clinical process in obstetrics. The review of the literature and the obtained results revealed that there is no formalized concept with instructions on the implementation of clinical process improvement methods.


INTRODUCTION

The issue of implementing contemporary models at the tertiary level of healthcare is currently a particularly relevant topic. The SIPOC method (suppliers, inputs, process, outputs, customers) has found its application in the management of different organizations [1],[2], and the challenge is implementing this method in healthcare organizations. Its implementation in the gynecology and obstetrics field would be based on the data available so far regarding the purpose and the manner of implementation [3], and would further be enhanced by the knowledge obtained from local experience [4], which can be especially significant for improving the performance of healthcare institutions during public health crises, such as the COVID-19 pandemic [5].

The increase in the demand for the promptest, least costly services of the best possible quality in the healthcare sector, with limited resources, places before tertiary healthcare the necessity of finding and applying new models and tools aimed at improving the functioning of the system. This is why we feel that the research area in question has merit and is a challenge for researchers. Bearing in mind the service users in the clinical process in obstetrics (expectant and new mothers), the improvement of efficiency through the implementation of contemporary models is especially important. The clinical process in obstetrics encompasses the following activities: pregestational counseling, antenatal care of expectant mothers (ultrasound diagnostics, physical examination, monitoring hematological and biochemical test results in expectant mothers), deliveries, supervision of women during puerperium. We feel that, for a clinical process involving such a set of activities, the application of contemporary improvement models is necessary.

The paper will further present the optimization of the clinical process in obstetrics through the application of the SIPOC method. The implementation of the method itself, includes the following steps: defining the service suppliers (doctors and other medical staff), the inputs (expectant and new mothers with their clinical presentations), the processes (examinations, therapies), the outputs (health status of expectant and new mothers).

MATERIALS AND METHODS

As a part of this study, data were collected from the latest relevant research articles and books, and healthcare systems implementing the contemporary concepts of optimizing clinical processes were analyzed.

The methods employed in this study belong to the analytical and the synthetic group.

The method of analysis was applied in analyzing available literature dealing with the subject of this study, as well as for analyzing the results obtained in the research.

The inductive method was used as the process for logical deduction, based on the analysis of the research problem and research results.

The deductive method was applied in reaching conclusions on whether the aim of the study had been achieved and in reaching general conclusions resulting from the research.

The method of synthesis was used in order to connect all elements into an integral whole and for the purpose of reaching a general conclusion of the study.

The descriptive method was used in describing processes.

REVIEW OF EARLIER RESEARCH

In the review of previous studies, we will describe the most important research within the Lean methodology, with a focus on the SIPOC method. We believe this to be important, as SIPOC is merely one of the methods within the Lean methodology. Lean represents an entire concept, while SIPOC is just a method stemming from the implementation of the Lean methodology. Another reason is that, through Lean methodology and its effects, it is possible to clearly point out the necessity of implementing contemporary models in healthcare organizations.

A study by Dickson et al. [6], on the implementation of the Lean methodology at the emergency departments of four public hospitals in Massachusetts, Worchester, Orlando, and Iowa City, showed that, with the help of the Lean methodology, the patients’ waiting time was reduced. The decreased waiting time directly affected the increase in the satisfaction of the patients.

A study by Zoe Radnor [7] showed that the implementation of this methodology at the Scotland Cancer Treatment Center resulted in a reduction of the time patients waited for examinations, as well as in the improvement of patient flow through the system of service provision by 48%.

Based on the review of the literature dealing with the research topic of the present study, a research hypothesis was formulated: the application of the SIPOC method can positively affect the efficiency of the clinical process in obstetrics.

In order to achieve the research goal and prove the proposed hypothesis, the matrix of implementing the SIPOC method in the clinical process in obstetrics will be presented.

Opportunities for implementing contemporary models in healthcare

There are many challenges which healthcare institutions face when implementing contemporary models. There are many unclear issues when it comes to determining values in healthcare. A particularity of determining value in healthcare lies in the fact that patients cannot completely comprehend the entire scope of the service provided, nor the expenditure of the said service. The greatest challenge of implementing contemporary models in healthcare is finding a way to improve service for patients.

The implementation of contemporary models is not a simple task, but it can help healthcare organizations improve their operation and results, reduce costs, as well as increase patient satisfaction. The expected improvements resulting from the implementation of the model are intended for: patients, healthcare workers, healthcare institutions. Although the implementation itself is not simple, the benefits that will be presented in the following paragraphs indicate the necessity of implementing these models.

For patients [8]:

  • Decrease in the time spent in hospital
  • Increase in satisfaction
  • Decrease in waiting time
  • Improvement of service quality
  • Decrease in the number of errors
  • Improvement of information flow

For healthcare workers [9]:

  • Elimination of waste
  • Decrease of overtime
  • Decrease of the workload
  • Increase in satisfaction
  • A more peaceful and better organized work environment

For healthcare institutions [10]:

  • Decrease in equipment
  • Increase in the number of examined patients
  • Decrease in costs
  • Improvement of information flow

Opportunities for implementing the SIPOC method in the clinical process in obstetrics

The implementation of the SIPOC model in the clinical process in obstetrics makes it possible to improve the quality of the services that this process includes, as well as to meet the needs of expectant and new mothers in the most efficient manner. The success of SIPOC method implementation in the given clinical process depends on the support provided by the management in all the activities shown in the matrix presented further in this text. The implementation of the SIPOC method in the said clinical process may be based on Ambler’s approach. According to the said author, it is necessary to identify the main elements of the model, on the basis of his predetermined construct, which includes the following five components [11]:

  1. suppliers
  2. inputs
  3. process
  4. outputs

The key preparatory activities, before defining the elements of the model, are as follows:

  1. Mission
  2. Limits of the process
  3. Results

Mission: The process of monitoring expectant mothers throughout the key activities of the process leading to and including care for new mothers, through the participation of the medical staff of the gynecology and obstetrics departments of clinics/hospitals.

Limits of the process: This process begins with registering the expectant mother’s pregnancy and ends with the new mother’s discharge from hospital.

Results: The team involved in process assessment will record the processes, as well as map out the processes and the value flow, by implementing the SIPOC model. The final results of implementing contemporary tools should be, as follows: reduced complications in expectant mothers as well as reduced time in hospital for new mothers – from delivery to discharge.

As the clinical process in obstetrics is a part of gynecology and obstetrics, the following subjects made up the tested population: medical doctors – specialists, residents, nurse practitioners, nurses, and administrative staff of the Clinic of Gynecology and Obstetrics. The proposed matrix may be applicable at any gynecology and obstetrics clinic, with the following key participants: expectant and new mothers.

The success of the implementation of the SIPOC method depends on the understanding of the process. The first step in the implementation of this model relates to determining the mission of the process that we are aiming to improve. After this, the elements of the SIPOC diagram are defined. When determining the activities for improving the process it is useful to apply the holistic approach of increasing satisfaction with the service, in the long-term. This depends on the human resources of healthcare organizations and their satisfaction.

Table 1. SIPOC matrix for the clinical process in obstetrics

0801

Examples of reducing wastefulness in healthcare and of positive impact on efficiency in obstetrics

According to theory, eight forms of waste in processes have been defined and classified: activities that do not increase value, hyperproduction, equipment, waiting, deficiencies, excess movement, unnecessary transport, and insufficient use of human resources capacities [12].

For the purpose of determining the degree of resource waste in the process, it is necessary to measure the different aspects within the processes [13]. In this study, measurements were made by different activity groups.

At the admitting unit of the Clinic of Gynecology and Obstetrics, the duration of performing activities was recorded. The duration (time) of the activities varied within a different range of intervals, as presented in Table 2.

Table 2. Duration of activities in the clinical process

0802

Table 2 shows a wide range in the duration of the activities. Waiting, i.e., hold-ups in the activities, resulting from the uneven duration of the activities, are evident. Other causes may stem from unscheduled patients entering the doctor’s office or from other activities that the doctor may become involved in as the result of emergencies or unexpected cases.

As a result of the analyses performed and the application of the method of observation, the discrepancies between the time planned for the activities and the actual time that it took for a health service to be provided became evident. This directly reflected on the waiting time. After the implementation of the SIPOC method, the efficiency of the process of service delivery was increased.

The following are some of the proposals for future research [14],[15]:

  1. Improving methodologies for measuring the performance of systems in healthcare institutions
  2. Developing simulation models adapted to a specific healthcare institution
  3. Identifying different problems that influence the time necessary to provide a health service
  4. Identifying the impact of modern equipment that would shorten the time necessary for providing the health service
  5. Identifying a modern information system which would enable an easier and more efficient work process for the doctors and medical personnel.

Table 3. Duration of activities after improvement

0803

CONCLUSION

In the healthcare system, the implementation of contemporary concepts, such as the SIPOC method, is very important, from the aspect of timely execution of all the demands defined by the end user (patient). This study offers a review of sources dealing with this particular subject matter, which was the basis for creating a framework for improving the clinical process. Also, different approaches to ranking the processes that need to be improved, were recognized.

In this study, the initial premise was that, in order to improve the clinical process, it is necessary to minimize errors and improve service delivery through decreased waiting time. This confirms the basic premise of the method – the rationalization of the clinical process.

The success of healthcare organizations is in direct correlation with the quality of the resources used to provide services [16],[17]. To that effect, it is necessary to use tools that enable the control of resource expenditure. Such a corrective method is the SIPOC method. In the particular clinical process analyzed, hold-ups and waiting are evident in the process of health service delivery, which is why the implementation of the SIPOC method is completely justified. Testing of the proposed model shows improvement, i.e., a decrease in the time that the patient spends waiting for a health service. In addition to the above stated, the application of equipment that would improve and more promptly provide necessary information, as well as help medical personnel provide prompter service, is also proposed.

Future research should focus on assessing the effects of implementing the SIPOC method in the clinical process. According to our study [18], in order to achieve the full effect of SIPOC method implementation, it is necessary to integrate activities and processes. The integration of activities and processes provides a clear outline of inputs, processes, and results.

  • Conflict of interest:
    None declared.

Informations

Volume 3 No 3

Volume 3 No 3

September 2022

Pages 354-361
  • Keywords:
    methods, health services, obstetrics
  • Received:
    04 July 2022
  • Revised:
    22 July 2022
  • Accepted:
    10 August 2022
  • Online first:
    25 September 2022
  • DOI:
Corresponding author

Edin Međedović
Clinic of Gynecology and Obstetrics, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
71000 Sarajevo, Bosnia and Herzegovina
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


  • 1. Brown C. Why and how to employ the SIPOC model. J Bus Contin Emer Plan. 2019 Jan 1;12(3):198-210. [HTTP]

    2. Sharma P, Gupta A, Malik SC, Jha PC. Quality Improvement In Manufacturing Process Through Six Sigma: A Case Study Of Indian MSME Firm. Yugoslav Journal of Operations Research 2019; 29(4):519–37. DOI: https://doi. org/10.2298/YJOR190115007S. [CROSSREF]

    3. Hadek A, Bakkali S, Ajana S. Sipoc Model In Moroccan Engineering Education Context: Lean Approach. International Journal of Education 2019;7(1):47–60. DOI: 10.5121/ije.2019.7104 47. [CROSSREF]

    4. Chyon BSc FA, Ahmmed BSc MS, Shuvo BSc MKA, Suman BSc MNH, Hossain PhD MM. Measuring Process Capability in a Hospital by Using Lean Six Sigma Tools-A Case Study in Bangladesh. Glob Adv Health Med. 2020 Oct 8;9:2164956120962441. doi: 10.1177/2164956120962441. [CROSSREF]

    5. Reshad AI, Rahman MM, Chowdhury NM. Performance of Epidemic Healthcare Management during COVID-19 Outbreak using LSS DMAIC Approach: A Case Study for Bangladesh. Proceedings of the 5th NA International Conference on Industrial Engineering and Operations Management, Detroit, Michigan, USA, August 10 - 14, 2020. Dostupno na: http://www.ieomsociety. org/detroit2020/papers/132.pdf

    6. Dickson EW, Anguelov Z, Vetterick D, Eller A, Singh S. Use of lean in the emergency department: a case series of 4 hospitals. Ann Emerg Med. 2009 Oct;54(4):504-10. doi: 10.1016/j.annemergmed.2009.03.024. [CROSSREF]

    7. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012 Feb;74(3):364-71. doi: 10.1016/j.socscimed.2011.02.011. [CROSSREF]

    8. Stoiljković V. Lean u Zdravstvu Srbije. [Internet]. [pristupljeno 07.06.2022.]. Dostupno na: http://www.cimlss.rs/wp-content/uploads/2014/08/Lean-u-Zdravstvu.pdf. [HTTP]

    9. Ambler T. Marketing and the Bottom Line. 2nd ed. Harlow, UK: Financial Times Prentice Hall; 2003.

    10. Piškor M, Kondić V. Lean production kao jedan od načina povećanja konkurentnosti hrvatskih poduzeća na globalnom tržištu. Tehnički glasnik. 2010;4(1-2):37-41. [Internet]. [pristupljeno 07.07.2022.]. Dostupno na: https://hrcak.srce.hr/85887. [HTTP]

    11. Mićović, P. Mneadžment zdravstvenog sistema. Evropski centar za mir i razvoj ECPD Univerziteta za mir Ujedinjenih nacija, 2000.

    12. Bonavía T, Marín JA. An empirical study of lean production in the ceramic tile industry in Spain. Int J Oper Prod Manag. 2006 May 1;26(5):505-31. doi: 10.1108/01443570610659883. [CROSSREF]

    13. Holden RJ. Lean Thinking in emergency departments: a critical review. Ann Emerg Med. 2011 Mar;57(3):265-78. doi: 10.1016/j.annemergmed.2010.08.001. [CROSSREF]

    14. Successfully deploying Lean in healthcare. Philips Healthcare. [Internet]. [pristupljeno 18.5.2022.]. Dostupno na: https://www.philips.be. [HTTP]

    15. Mićović PM, Jakovljević Đ, Dovijanić P. Zdravstveni menadžment: menadžment zdravstvenog sistema i zdravstvenih ustanova. Beograd: Komora zdravstvenih ustanova Srbije; 2008.

    16. Jae YM, Byeong WK, Young HS, Choon SL, Hyungjoon M. An integrated Method for Business Process Improvement. Int J Innov Comput Inf Control. 2012 July 8(7(B)):5237-50.


REFERENCES

1. Brown C. Why and how to employ the SIPOC model. J Bus Contin Emer Plan. 2019 Jan 1;12(3):198-210. [HTTP]

2. Sharma P, Gupta A, Malik SC, Jha PC. Quality Improvement In Manufacturing Process Through Six Sigma: A Case Study Of Indian MSME Firm. Yugoslav Journal of Operations Research 2019; 29(4):519–37. DOI: https://doi. org/10.2298/YJOR190115007S. [CROSSREF]

3. Hadek A, Bakkali S, Ajana S. Sipoc Model In Moroccan Engineering Education Context: Lean Approach. International Journal of Education 2019;7(1):47–60. DOI: 10.5121/ije.2019.7104 47. [CROSSREF]

4. Chyon BSc FA, Ahmmed BSc MS, Shuvo BSc MKA, Suman BSc MNH, Hossain PhD MM. Measuring Process Capability in a Hospital by Using Lean Six Sigma Tools-A Case Study in Bangladesh. Glob Adv Health Med. 2020 Oct 8;9:2164956120962441. doi: 10.1177/2164956120962441. [CROSSREF]

5. Reshad AI, Rahman MM, Chowdhury NM. Performance of Epidemic Healthcare Management during COVID-19 Outbreak using LSS DMAIC Approach: A Case Study for Bangladesh. Proceedings of the 5th NA International Conference on Industrial Engineering and Operations Management, Detroit, Michigan, USA, August 10 - 14, 2020. Dostupno na: http://www.ieomsociety. org/detroit2020/papers/132.pdf

6. Dickson EW, Anguelov Z, Vetterick D, Eller A, Singh S. Use of lean in the emergency department: a case series of 4 hospitals. Ann Emerg Med. 2009 Oct;54(4):504-10. doi: 10.1016/j.annemergmed.2009.03.024. [CROSSREF]

7. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012 Feb;74(3):364-71. doi: 10.1016/j.socscimed.2011.02.011. [CROSSREF]

8. Stoiljković V. Lean u Zdravstvu Srbije. [Internet]. [pristupljeno 07.06.2022.]. Dostupno na: http://www.cimlss.rs/wp-content/uploads/2014/08/Lean-u-Zdravstvu.pdf. [HTTP]

9. Ambler T. Marketing and the Bottom Line. 2nd ed. Harlow, UK: Financial Times Prentice Hall; 2003.

10. Piškor M, Kondić V. Lean production kao jedan od načina povećanja konkurentnosti hrvatskih poduzeća na globalnom tržištu. Tehnički glasnik. 2010;4(1-2):37-41. [Internet]. [pristupljeno 07.07.2022.]. Dostupno na: https://hrcak.srce.hr/85887. [HTTP]

11. Mićović, P. Mneadžment zdravstvenog sistema. Evropski centar za mir i razvoj ECPD Univerziteta za mir Ujedinjenih nacija, 2000.

12. Bonavía T, Marín JA. An empirical study of lean production in the ceramic tile industry in Spain. Int J Oper Prod Manag. 2006 May 1;26(5):505-31. doi: 10.1108/01443570610659883. [CROSSREF]

13. Holden RJ. Lean Thinking in emergency departments: a critical review. Ann Emerg Med. 2011 Mar;57(3):265-78. doi: 10.1016/j.annemergmed.2010.08.001. [CROSSREF]

14. Successfully deploying Lean in healthcare. Philips Healthcare. [Internet]. [pristupljeno 18.5.2022.]. Dostupno na: https://www.philips.be. [HTTP]

15. Mićović PM, Jakovljević Đ, Dovijanić P. Zdravstveni menadžment: menadžment zdravstvenog sistema i zdravstvenih ustanova. Beograd: Komora zdravstvenih ustanova Srbije; 2008.

16. Jae YM, Byeong WK, Young HS, Choon SL, Hyungjoon M. An integrated Method for Business Process Improvement. Int J Innov Comput Inf Control. 2012 July 8(7(B)):5237-50.

1. Brown C. Why and how to employ the SIPOC model. J Bus Contin Emer Plan. 2019 Jan 1;12(3):198-210. [HTTP]

2. Sharma P, Gupta A, Malik SC, Jha PC. Quality Improvement In Manufacturing Process Through Six Sigma: A Case Study Of Indian MSME Firm. Yugoslav Journal of Operations Research 2019; 29(4):519–37. DOI: https://doi. org/10.2298/YJOR190115007S. [CROSSREF]

3. Hadek A, Bakkali S, Ajana S. Sipoc Model In Moroccan Engineering Education Context: Lean Approach. International Journal of Education 2019;7(1):47–60. DOI: 10.5121/ije.2019.7104 47. [CROSSREF]

4. Chyon BSc FA, Ahmmed BSc MS, Shuvo BSc MKA, Suman BSc MNH, Hossain PhD MM. Measuring Process Capability in a Hospital by Using Lean Six Sigma Tools-A Case Study in Bangladesh. Glob Adv Health Med. 2020 Oct 8;9:2164956120962441. doi: 10.1177/2164956120962441. [CROSSREF]

5. Reshad AI, Rahman MM, Chowdhury NM. Performance of Epidemic Healthcare Management during COVID-19 Outbreak using LSS DMAIC Approach: A Case Study for Bangladesh. Proceedings of the 5th NA International Conference on Industrial Engineering and Operations Management, Detroit, Michigan, USA, August 10 - 14, 2020. Dostupno na: http://www.ieomsociety. org/detroit2020/papers/132.pdf

6. Dickson EW, Anguelov Z, Vetterick D, Eller A, Singh S. Use of lean in the emergency department: a case series of 4 hospitals. Ann Emerg Med. 2009 Oct;54(4):504-10. doi: 10.1016/j.annemergmed.2009.03.024. [CROSSREF]

7. Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012 Feb;74(3):364-71. doi: 10.1016/j.socscimed.2011.02.011. [CROSSREF]

8. Stoiljković V. Lean u Zdravstvu Srbije. [Internet]. [pristupljeno 07.06.2022.]. Dostupno na: http://www.cimlss.rs/wp-content/uploads/2014/08/Lean-u-Zdravstvu.pdf. [HTTP]

9. Ambler T. Marketing and the Bottom Line. 2nd ed. Harlow, UK: Financial Times Prentice Hall; 2003.

10. Piškor M, Kondić V. Lean production kao jedan od načina povećanja konkurentnosti hrvatskih poduzeća na globalnom tržištu. Tehnički glasnik. 2010;4(1-2):37-41. [Internet]. [pristupljeno 07.07.2022.]. Dostupno na: https://hrcak.srce.hr/85887. [HTTP]

11. Mićović, P. Mneadžment zdravstvenog sistema. Evropski centar za mir i razvoj ECPD Univerziteta za mir Ujedinjenih nacija, 2000.

12. Bonavía T, Marín JA. An empirical study of lean production in the ceramic tile industry in Spain. Int J Oper Prod Manag. 2006 May 1;26(5):505-31. doi: 10.1108/01443570610659883. [CROSSREF]

13. Holden RJ. Lean Thinking in emergency departments: a critical review. Ann Emerg Med. 2011 Mar;57(3):265-78. doi: 10.1016/j.annemergmed.2010.08.001. [CROSSREF]

14. Successfully deploying Lean in healthcare. Philips Healthcare. [Internet]. [pristupljeno 18.5.2022.]. Dostupno na: https://www.philips.be. [HTTP]

15. Mićović PM, Jakovljević Đ, Dovijanić P. Zdravstveni menadžment: menadžment zdravstvenog sistema i zdravstvenih ustanova. Beograd: Komora zdravstvenih ustanova Srbije; 2008.

16. Jae YM, Byeong WK, Young HS, Choon SL, Hyungjoon M. An integrated Method for Business Process Improvement. Int J Innov Comput Inf Control. 2012 July 8(7(B)):5237-50.


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