THE LEAN SIX SIGMA IN A PUBLIC HOSPITAL

The hospital can be likened to an industrial enterprise with a high level of security expected. Indeed, the patient has particularities: it is a living being brought to the hospital in an uncontrolled manner and diffi cult to regulate or anticipate accurately. In addition, the constraint in the public hospital is fi nancial: It is to treat a maximum of patients, the best possible, with limited fi nancial resources. Despite this constraint, patient demands are high in terms of quality of treatment and medical innovations. Hence the interest of using the methods used in the industrial management of high security environments namely Lean management to adequately meet the constraints of economic and societal effi ciency, fl exibility and security imposed by the hospital stakeholders. In this article, we will try to defi ne the concept of Lean six sigma in care institutions, then we will describe the methodology adopted that of the DMAIC method and in the end to implement the fi rst 3 steps of this method. in a public hospital.


INTRODUCTION
Like an industrial enterprise, the current hospital has the following characteristics, whatever its status or location [01]: • It consists of a set of scarce and limited resources, of which it must justify an effi cient use; • It must coordinate management of multiple fl ows (patient fl ows, fl ows of medicines and treatments, information fl ows, fi nancial fl ows) in a permanent concern of multiple effi ciency: to guarantee the good care of the right patient at the right moment with suffi cient information, medicines and adequate infrastructure, all at the lowest cost. • It must motivate the main critical resource, all collaborators (medical, nursing, support technician, management support body), by continuously solving the daily challenges of good interpersonal communication and communication and a perfect coordination with the patient's expectations. • It must deploy a clear, consistent and effective strategy on a daily basis with regard to the expectations and objectives of the organization's stakeholders and the opportunities offered by its competitive and technological environment. As a result, the hospital can be likened to an industrial enterprise with a high level of security expected. Indeed, the patient presents particularities: it is a living being brought to the hospital in an uncontrolled and diffi cult to regulate or anticipate accurately. Thus, the constraint in the public hospital is fi nancial (state budget). It is a question of treating as many patients as possible, with the best possible fi nancial resources. Despite this constraint, patient demands are high in terms of quality of treatment and medical innovations [02].
Hence the interest of using the methods used in the industrial management of high security environments namely Lean management to adequately meet the constraints of economic and societal effi ciency, fl exibility and security imposed by the hospital stakeholders. In this article, we will try to defi ne the concept of Lean six sigma in care institutions, then we will describe the methodology adopted that of the DMAIC method and in the end to implement the fi rst 3 steps of this method. in a public hospital.

LEAN SIX SIGMA IN CARE INSTITUTIONS
First, service companies, such as those providing health care, would benefi t from adopting the Lean Six sigma for the following three reasons [03]: 1. Processes in services are generally slow, so costly, 2. Processes in services are slow because there is far too much work going on, which is often too complex 3. In any slow process, 80% of the waiting time is attributable to less than 20% of the activities.

METHODOLOGY ADOPTED: THE DMAIC METHOD
The best-known method of Lean Six Sigma is DMAIC ("Defi ne, Measure, Analyze, Improve, Control," meaning "defi ne, measure, analyze, improve and control"). This method is a problem-solving approach that combines qualitative and quantitative tools to improve the processes in place [06] and [09]. These tools help to defi ne the scope and objectives of the project (to defi ne), to outline potential problems hindering the processes in place Kenza Tadlaoui -The Lean Six Sigma in a public hospital (to measure), and then to identify and analyze the root causes of the time required to grant leave (to analyze), undertake the improvement and control stages [06]. It has been successfully used in many care hospital settings and has reduced the length of hospital stays for almost half of trauma patients [10]. In this paper, we will focus on the fi rst 3 steps of DMAIC method namely: Defi ne, Measure and Analyze. Table 1 explains our adopted methodology.

IMPLEMENTATION OF THE DMAIC METHOD
Step 1: DEFINE

THE SCOPE OF THE STUDY
This is a descriptive, exploratory retrospective mixed study. It took place over a 4-month period from February to April 2016, with a two-month data collection period. The appropriate quote is the case study, unique case type hospital Sidi Lahcen with nested analysis levels, this quote allows us to analyze in depth.

Presentation of the PHC
The Sidi Lahcen Hospital is a prefectural hospital center of Skhirat-Temara, was inaugurated on May 20, 1995. It was erected in autonomous state service (ASS) on the 01/07/1998, it is the only hospital of the prefecture. It is part of the Skhirat-Temara delegation and is aimed at a population of more than 539,000 inhabitants for an operating budget of around 8,000,000DH. It is a suburban hospital with a litter capacity of 59 beds is 1 bed / 9135 inhabitants

DATA COLLECTION PLAN
The data was collected through fi ve methods: document consultation, observation, semi-structured interviews, focus group and questionnaire. The questionnaire was fi rst pre-tested and then rectifi ed.

The consultation of documents
Determined the proportion of the pharmaceutical budget in the hospital's operating budget to determine the amount of resources allocated to the purchase of pharmaceuticals. Consultation of the management tools: the delivery notes, the inventory sheets, the reception notes, the order forms and the inventory were made in order to: • Recognize the availability and correct use of management tools; • Calculate and analyze some important management data and indicators: the expiry rate of pharmaceutical products (PP), the duration of stockouts, and the percentage of leftovers to be delivered for pharmaceutical products (PP).

Observation using a grid
It was conducted at the pharmacy of the hospital to see the compliance of the latter with the standards of storage, organization and conservation of PP. We also checked the availability and qualifi cation of staff of the hospital pharmacy employed in their management.

Semi structured interviews
Semi-structured interviews were used to identify and describe the PP circuit. They were carried out on the basis of a personal interview guide, with the chiefs of services, the pharmacist and head of administrative and economic service.

The question sheet
The questionnaire was administered to the nurse heads of services to assess the management mode of PP at the level of care services.

The group focus
We have been able to identify the causes of stock outs of pharmaceuticals and suggest suggestions for improving the availability of pharmaceuticals.

DEFINITION OF PERFORMANCE INDICATORS
The availability of pharmaceutical products is the result of the performance of the supply system but also of the suppliers and recipients who place their orders [11]. Thus the performance of the supply system is conditioned by a good stock management, and an optimization in the order, in other words, the effi cient supply is that which makes it possible to buy the right product, in necessary quantity, the right moment. We refer to the models of indicators proposed by the French Society of Clinical Pharmacy in 2015. This organization was asked to develop and validate activity indicators in the fi eld of hospital pharmacy. We focus on the indicators of the purchase and logistics and distinguish in the Table 2 the indicators of the production, the quality as well as the tasks and the designations: It is considered that it is necessary to add an important indicator that of the rupture rate which is equal to (Sum of unmet drug requests / total amount of drug requests); Step 2: MEASURE First, before modeling pharmaceutical management processes, we will begin with the presentation of Pharmaceutical Logistics Chain within the Hospital (PLCH) Sidi Lahcen. PP supply is carried out according to two main processes " Figure 1 • The quantifi cation of pharmaceutical needs is done at the level of each service, estimated using the annual consumption method. It is not based on treatment regimens. A meeting is organized between the pharmacist and the department head to validate the order. Then, the pharmacist regroups the needs of the services and readjust the quantities to be ordered according to the remains to be delivered from previous years and the available stock, then recalculates the total amount and returns the order form of the PP duly informed to the SD. • The acquisition of PP is done exclusively by the SD.
For example, PP are purchased from national suppliers (drug laboratories and medical device suppliers), except for the purchase of vaccines at UNICEF. The acquisition is made by launching tenders in accordance with the provisions of decree no. 2-12-349 of 08 joumada I 1434 (20 March 2013) relating to public procurement. • Receipt and storage by the SD of the products ordered from the suppliers. The SD then ensures the partial delivery of the PP ordered by the hospital according to a schedule. • The receipt and storage of PP by the hospital in 2 premises, one for drugs and one for medical devices. • The distribution of pharmaceutical products to care units according to three distribution modes: • The global distribution: This is the most used at the hospital. The products are delivered on the basis of a PP delivery note drawn from a voucher book. The products are then stored in wardrobes and delivered as and when to the nursing staff who administers them following a medical prescription. The vouchers are of two types: The monthly delivery slip that allows the service to order the products it needs for a period of one month. Delivery notes duly signed by the heads of services and the head nurses must reach the pharmacy at least 48 hours in advance to allow the pharmacy to prepare the delivery in time and avoid delays and delivery expectations. Orders are not systematically analyzed by the pharmacist. The determination of the quantities to be delivered is made according to the available stock. The pharmacy does not impose a limit, in quantity or value, for the orders of the services. The voucher for supplement or for an urgent order allows to order the drugs which the service needs and which are not available any more. • The individual dispensing to hospitalized patients for expensive drugs. This type of dispensing consists in delivering the Drugs to a patient on presentation of a prescription bearing the name, the admission number, the product designation, the dosage, the duration of treatment, dated and signed by the attending physician. • Prescription by registered prescription of implantable medical devices • The dispensing by prescription of methotrexate to the Ramed patients followed by the rheumatologists of the hospital but not hospitalized.

Supply of non-nomenclature PP:
This purchase is made directly from wholesalers either by: • The launch of the order forms for the non-nomenclature PP at break-up and close-break, or the PP which are also at the SD level; • or through the launch of the call for tenders for non-nomenclature medical devices or the PP out of the SD.

Modeling by SCOR
Our approach is a hybrid approach that combines the SCOR and ARIS models. The choice of the SCOR model is justifi ed by the fact that it allows: • -to represent any type of company, a macro identification of the key processes of the supply chain, • -develop a dashboard of each process activity. The ARIS formalism is a concise and effi cient simple formalism to model in detail the information fl ow of the supply chain. The proposed model represents an integration of the ARIS model into the SCOR model. From the analysis of the overall scheme described in Figure 1, it turned out that the modeling of the Pharmaceutical Logistics (PL) goes beyond the limits of pharmacy. It requires the involvement upstream of certain actors from the Ministry of Public Health, who play the role of internal suppliers and planners. These are the Directorate of Planning and Financial Resources (DPFR) and the Supply Division (SD). Downstream, care units are internal clients that use pharmaceuticals. The patient is, in our case, assimilated to the fi nal consumer.

Modeling by the ARIS tool
We modeled the globalized and nominative PP distribution process at Sidi Lahcen Hospital using the Aris-Express tool. Indeed, these processes include the main tasks of the hospital pharmacy (logistic vision), in order to compare the new organization with the old one

Organizational chart
The aim is to formalize the organization chart corresponding to the functions of the PLCH. The goal is to isolate the actors who intervene during this chain. The fl owchart " Figure 3 "shows that the PLCH is the business of four organizational units namely: the hospital pharmacy, the care unit, the administrative and economic affairs and the management of the hospital.

Value Chain
The value chain (VC) is composed of a set of processes (represented by arrows) connected by precedence or superiority relationships. " Figure 4" presents the VC of the pharmaceutical supply chain according to the adapted SCOR model.

Event Process Chain
The event process chain (EPC) is a diagram detailing a process (an element of a value chain). EPC is a set of events and functions that follow a specifi ed logical fl ow through the use of logical operators, such as OR, AND, and XOR. In this framework, the EPC diagram allows us to describe processes by showing how events trigger activities. We also included the information fl ows (incoming and outgoing data), as well as the actors in each step of the PP distribution process to care units within Sidi Lahcen Hospital " Figure 5".  [12] 65 Kenza Tadlaoui -The Lean Six Sigma in a public hospital Figure 6: Rate of service of SD at Sidi Lahcen Hospital

Reliability of stocks
The concept of stock reliability refers to all existing discrepancies between computerized or administrative stocks and the physical state of stocks; We used the inventory result from the pharmacy team to determine the percentage of items whose physical inventory is different from the administrative stock. The result that traces the reliability of the stock is 14.83% or 50 out of 337 products.

Expiry rate
The dates of expiry are systematically recorded at the time of receipt on the inventory sheets with the respect of the rule of First Expiration First Out (FEFO) at each exit, When the pharmacy of the hospital cannot consume the articles of which the remaining validity period is lower or equal to 6 months before expiry, she tries to give them away as an exchange or donation.
The analysis of the activity report in 2015 showed that the expiry rate is equal to 0.25% for drugs, and 1.2% for medical devices. So the expiry rate for 2015 is 0.72%;

Replenishment of a care unit
Monthly orders are developed by service majors. Sometimes there is the dispatch to the pharmacy of urgent orders. These are estimated at about 4 to 5 per month according to the questionnaire sent to the head nurses, especially for the maternity ward, the emergency department and the operating theater. The Replenishment of a unit of care refl ects the number of times / week, the pharmacy replenishes the service units. In our case, it is equal to 1, ie on average once a week.
Step 3: ANALYZE According to Figure 1 and Figure 5, as well as the survey conducted at Sidi Lahcen Hospital, we were able to develop the SWOT matrix to identify the strengths and weaknesses of the FP supply system. one side, as well as the opportunities and threats of this system " Figure 7".

CONCLUSION
Through this communication, we adopted the most famous Lean Six sigma method, that of the DMAIC method. By following the fi rst 3 steps of this method, we were able to model the PP supply system using the SCOR model, to have a macroscopic view of the system, and then to refi ne the modeling using the ARIS tool. Then we were able to propose performance indicators that were measured and valued. We then analyzed the system using the SWOT matrix. In perspective, we will continue the steps of DMAIC to propose actions of improvement, then to make the classifi cation of these actions by the method PROMOTHEE and in the end, to make the simulation of the process of management of the pharmaceutical products to compare the current situation with the optimized one by integrating the proposed improvement solutions.