Development of a centralized progress management system using lean thinking and efforts to improve operations

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Utilizing information and communication technology, we considered improving and increasing the utilization rate of magnetic resonance imaging (MRI) examination reservation slots, reducing the number of days waiting for reservations, and reducing examination reservations to other facilities. We visualized the workflow using four tools: Value Stream Map, Standard work, Spaghetti chart, and root cause analysis. Brainstorming was implemented to formulate an improvement plan, which a weekly 15-min meeting was held to discuss daily management and further improvement plans. The number of examination reservations and examinations performed increased by 26% and 19%, respectively, after implementing the improvement plans than before. Furthermore, as detailed improvements continued through daily management, the number of examination reservations s and examinations performed increased by 34% and 28%, respectively, compared with before implementing the improvement plans. The number of waiting days for reservations decreased from an average of 45 days to an average of 5 days, and the number of examination reservations to other facilities reduced from 300 per month to 50 per month. Lean Thinking improves and increases the utilization rate of MRI examination reservation slots, reduces the number of waiting days for reservations, and reduces examination reservations to other facilities. Therefore, it could be applied to improve the throughput in the daily work of medical institutions and the work of the operation system. In addition, using daily management to turn the cycle of Lean Thinking is an important factor in improving operations. Lean Thinking MRI Quality improvement Kaizen radiology Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Introduction Lean Thinking is a method of operational improvement based on the Toyota Production System. In 2016, Klein et al. investigated the utilization of Lean Thinking to improve the throughput of computed tomography (CT) scans in emergency medical care, and its application in the healthcare field began [ 1 , 2 ]. Klein et al. implemented a behavioral analysis and improvement plan using Lean Thinking regarding the operating system (from ordering a non-contrast-enhanced CT scan in emergency medical care until the patient underwent a CT scan and returned to the examination room) to improve the throughput [ 1 ]. In the present study, we thought that Lean Thinking could be applied not only to the operating system in emergency medical care but also to improve the throughput and operating system in the daily work accounting for most medical institutions’ work. The magnetic resonance imaging (MRI) examination department of the Tokyo Women's Medical University Hospital, which had problems with work efficiency, was the target for considering operational improvement. The MRI examination department operated with four units in the outpatient center and two units in the ward examination room, making six units in total. Therefore, it was impossible to conduct examinations at the necessary time. In addition, when examinations were urgent, outsourcing them to other facilities are often necessary. This increased the number of examinations outsourced to other facilities, which has burdened the institution’s management. In the present study, we initially investigated previous studies that examined facility operation systems and throughput improvement using Lean Thinking in the MRI examination department. However, we found no related study. Therefore, we initiated this study because we believe that improving operations and throughput using Lean Thinking, even in the daily examination operation of the MRI department, is possible. In addition, we believe that using Information and Communication Technology (ICT) is key to improving daily operations using Lean Thinking; therefore, we developed a new ICT system to improve daily operations and efficiency. Based on this background, behavioral analysis and improvement plans were performed in the present study using Lean Thinking in the daily work of the MRI examination room to improve and increase the utilization rate of MRI examination reservation slots, reduce the number of waiting days for reservations, and reduce the examination to other facilities. Materials and Methods Conventional operations improvement methods and Lean Thinking Lean Thinking is based on the "Toyota Production System, " which was launched by Toyota Motor Corporation. This method was proposed by J. P. Womack in 1990 and classified all work processes from the perspective of value (whether they add value). The aim is to eliminate waste thoroughly and improve productivity. In the field of healthcare, this concept can be used to improve patient waiting time, treatment delays, operational efficiency, cost, processing capacity, quality of medical care, and work environment [3]. Conventional operation improvement methods focus on reducing the operation time, which is a part of value-adding. However, in a typical job, value-adding work usually accounts for <5% of the total work time; therefore, reducing this time by 50% will only slightly reduce the overall work time [4] (Fig. 1). Lean Thinking focuses on reducing wasteful activities (non-value-adding work time). Therefore, the overall operation time can be dramatically reduced, making it possible to provide quality service, and performance can be greatly improved [5]. Lean Thinking Cycle Diagram and Action Plan The concept of Lean Thinking is shown in Fig. 2. It consists of five steps: 1) determining the evaluation index, 2) visualizing the workflow, 3) creating a flow diagram and an improvement plan, 4) implementing the improvement plan, and 5) evaluating and repeating the Lean Thinking cycle. Based on this cycle, we will create an action plan, as shown in Table 1, and improve our operation. In addition, in Lean Thinking, it is important not only to implement the improvement plan once but also to evaluate the implemented improvement and to continue the evaluation and improvement repeatedly. By evaluating the improvements made, discovering new areas for improvement and achieving more efficient operations are possible. The details of the specific methods for each step of Lean Thinking are described in the next section. Operation improvement method based on Lean Thinking Determination of evaluation indexes Determining the evaluation index is very important in determining the direction of operational improvement and quantifying and understanding the progress of the improvement. First, in formulating an operational improvement plan, the following indices were set to evaluate the current problems and matters most desired to be improved at the initial stage. (1) The actual number of examinations, reservation slots, and operating rate. (2) Number of waiting days for examination. (3) Number of examination orders for other facilities. Improvement induced by Lean Thinking continues even if the first operational improvement plan is implemented. At the operation stage of the lean cycle, in addition to the initial evaluation indices, we could "visualize" the issues broken down one step at a time and make continuous improvements by setting more detailed evaluation indices. The details of this process are described later. Visualization of workflow After determining the evaluation indices, we could objectively understand the problems by visualizing the workflow. We used the following four tools to visualize the workflow in this study. 1) Value Stream Map Value Stream Map, also known as "value flow chart,” is a diagram that describes the activities of all processes and workflows in the hospital, including reception, examination, and accounting, after a patient arrives at the hospital, and clarifies the situation, such as cycle time, patient flow, and information flow. Using the value stream map, as shown in Fig. 3, we visualized the processes and workflows in the hospital and identified the current problems [4, 5]. 2) Standard work Standard work refers to standard work processes. By decomposing the current standard work into each element, the work processes can be understood, and the standard work processes can be visualized. Standard work includes many factors, including work process steps, operator and staff procedures, work location, equipment or technology used, safety, patient guidance, and cycle time. By incorporating patient and staff timetables into the standard work, as shown in Fig. 4, we could understand the timing of delays, work content, and wasted time. 3) Spaghetti chart A Spaghetti chart is a diagram showing staff flow lines on the drawing of the examination room and backyards. Plotting the flow lines and distances of all staff involved in the operation process on the actual floor plan allows unnecessary and dangerous flow lines can be visualized. Using the Spaghetti chart, as shown in Fig. 5, we put the flow line for each medical staff member into the facility diagram and could understand the places where delays occurred and which flow lines were unnecessary. 4) Root cause analysis Root cause analysis is a method of analyzing a problem or event and identifying the root cause. Therefore, it is a cause-solving process that focuses on identifying root causes and solutions to obstacles and problems rather than looking at them superficially. It is used in aviation, medical, and industrial fields, where high safety is required. Fig. 6 shows an example of the results of the root cause analysis. We investigated these problems and issues in depth and analyzed their root causes. Planning and implementation of operational improvement measures Planning of operational improvement measures Regarding problems in the MRI examination department, brainstorming was performed based on the analysis results obtained using the four tools mentioned above: the Value Stream Map, Standard work, Spaghetti chart, and root cause analysis. We exchanged ideas to improve operational efficiency and planned improvement measures consisting of the following five items: Increase in examination reservations Rebuilding the team structure Development of a progress management system Development of a mirror monitor that allows mutual confirmation of scanning progress Other operational efficiency improvements Details of the improvement plan The details of the operational improvement measures planned and implemented in this study are as follows: (1) A 34% increase in examination reservation slots. By investigating the actual state of the examinations and identifying those with vacant time, the number of examination reservation slots increased by 34%. The number of weekly reservation slots was 505 (2020/month) before the operation improvement in 2016, whereas it was 635 (2540/month) after the operation improvement in 2018, indicating an increase of 26%. In 2019, there were 678 cases (2712 cases/month), indicating an increase of 34%. In this manner, the number of reservation slots increased in stages. The specific steps for increasing the number of reservation slots are shown below: I. Previously, one examination reservation slot was uniformly 30 min for all examinations; however, considering the actual examination time, the brain/spine/plain examination reservation slots were changed to 20 min, and whole-body scan slots were changed to 30 min, resulting in an increase of 61 slots weekly. II. Before the review, there was one patient per slot. However, some patients did not visit the hospital at the scheduled time. Therefore, the slots were changed to one per hour, enabling two patients to fit in one slot. In this manner, we set the timeslots to minimize vacant examination rooms as much as possible, increasing the number of slots to 92 weekly. III. By moving the examination start time forward by 30 min, the examination work time per day increased by 30 min, resulting in an increase of 20 slots per week. IV. The fixed reservation slots for specific clinical departments have been reduced to 1/3. Simultaneously, by releasing fixed slots for which reservations were not made by the deadline, the number of regular reservation slots increased, and conditions for releasing vacant slots were set. By eliminating the fixed reservation slots for specific departments other than health checkups, pediatric sedation examinations, and preoperative examinations on the same day, the average daily number of fixed reservation slots was reduced from 15 to 5. In addition, reservation slots for health checkups that have not been booked 1 week in advance, pediatric sedation examinations that have not been booked by 9:00 on the previous day, and preoperative examination slots on the exact day had been released. (2) Productivity improvement by rebuilding the team structure Actively utilizing information technology (IT) through brainstorming, as mentioned above, has improved individuals’ productivity, even if the number of radiological technicians is reduced and more examinations can be completed during the same working hours. Therefore, we reduced the number of radiological technicians from 12 to 9 and transferred them to other examination sections to improve the vacation utilization rate and strengthen the education system by assigning a person in charge of educational guidance. Specific measures for staff reduction are shown below: I. We used IT tools such as a centralized progress management system and a mirror monitor, which will be described later. Therefore, we rebuilt the system to include two radiological technologists per MRI unit. As shown in Table 2, the system has been changed to consist of an examination operator in charge of each MRI examination and a controller who understands the entire MRI examination area and provides instructions to the staff. Based on this measure, productivity per person has improved significantly, and the number of radiological technicians has reduced from 12 to 9. (3) Development of a centralized progress management system We developed a centralized progress management system to improve the productivity of the radiological technician team in the MRI department. With conventional radiological information systems, it was unable to check detailed information such as how many patients have already completed the reception process, who is undergoing pre-examination interviews, who is available for examination, and how long it will take for patients undergoing examinations to complete. Therefore, it was difficult to understand how work progressed across the entire examination room, and the time from examination preparation to the end of the examination was unnecessarily long. Therefore, we have newly developed a centralized progress management system that receives information from the radiology information system in real-time and confirms in detail the status from reception to the start and end of the examination. The system extracts the necessary data from database columns in the radiology information system, converts it into information, and displays the information on the screen using a web browser. In addition to understanding the detailed status of each MRI by utilizing the centralized progress management system, it is possible to understand the patient's preparation status in detail from interviews before injection and completion of examination preparation. Therefore, an optimal patient allocation for MRI examination based on the situation is possible. As a result, we could shorten patient waiting times, improve patient satisfaction, and improve the efficiency of the overall operations, thereby creating an optimal examination environment. Details and screens of the centralized progress management system are presented in Table 3. And Fig. 7. (4) Development of a mirror monitor to check the examination status Under the new team structure of radiological technologists, as shown in Table 2, we developed a mirror monitor, as shown in Fig. 8, to show the operation screen regardless of which device the controller uses to ensure the same medical safety and quality of examination as before. The operation monitor screen of each MRI system was distributed and installed next to the monitoring monitor of another MRI system to confirm both operation monitor screens. This makes it possible for the controller to check the operation monitor screen from the MRI room and to check the progress, sequence, and operation status remotely. In addition, depending on the personnel assignment, operators who are unfamiliar with MRI operations or operators in the MRI training process may be assigned. Even operators at a distance can now check for incorrect operations, missing MRI sequences, or missing clinical findings. (5) Other operational efficiency improvements To reduce the workload per person owing to the increase in examination reservation slots and the reduction in staff, various efficiency measures, other than the first to fourth described so far, have been developed and implemented. The specific measures are as follows: I. A manual was created to standardize the pre-examination interview to ensure all examination staff was in charge of the pre-examination interview before entering the room. The training was conducted using a manual that summarizes how to use the pre-examination interview form, the order of interview, important points during the interview, and how to communicate to ensure that not only radiological technicians but also nurses and nursing assistants can conduct pre-examination interviews in the same manner. In addition, the pre-examination interview is important to confirm that you can enter the MRI room. Considering this opportunity, we examined whether there were any ambiguous expressions or missing necessary items and revised the pre-examination interview form. II. The emergency examination coordinator changed from a radiological technologist to an emergency radiologist. Previously, when an emergency examination was required, the clinical department staff would call the radiology department directly, and the radiological technologist would have to spend time on coordination tasks, thus delaying overall examination operations. By setting up an emergency radiologist and changing the response to take charge of coordinating emergency examinations, radiological technologists' time is no longer considered, and examinations are not delayed. III. We increased the number of daily examinations by approximately five using vacant slots because of reliable cancellation notifications. Previously, examination cancellation notifications were stopped at the hospital reception desk, and the radiology department could not capture them; therefore, the vacant slots due to cancellations could not be used effectively. By making it a rule that when a cancellation is received at the reception desk of the hospital, the receptionist will contact the examination room, and it is possible to perform examinations ahead of schedule for the waiting patients and to accept emergency examinations, making it possible to increase the number of examinations by approximately five daily by effectively utilizing the cancellation slots. Daily Management After implementing the improvement plan, the process should not be completed. Instead, daily management should be implemented, which is a key activity to continue evaluation and review, identify further problems and areas for improvement, and continue repeating the lean thinking cycle. In the present study, we held a weekly 15-min meeting (Daily Management) and used a dedicated sheet (Action Tracker), as shown in Fig. 9, to discuss daily management and further improvement plans. In addition to the evaluation indices set at the initial stage, the following indices were added to identify detailed problems, and evaluation and analysis were continuously performed. Total number of examinations per week Number of examinations per week based on modality Examination time based on anatomical parts Results Number of examination reservation slots and examinations performed The improvement plan mentioned above was implemented, as shown in Fig 10. In 2016, before the operational improvement plan was implemented, the number of reservation slots was 2,020/month, whereas it was 2,540/month after the implementation, indicating an increase of 26%t. Furthermore, by continuing improvements through daily management, the number of reservations increased by 34% (2,712 cases/month) in 2019 compared with before the improvement. As shown in Fig. 11, the number of examinations performed was 1,850 per month in 2016 before the operational improvement, whereas it was 2,210 per month after implementing the improvement plan in 2018, indicating an increase of 19%. Furthermore, in 2019, there were 2,360 cases/month, indicating an increase of 28% compared with before the improvement. Waiting days for reservation Implementing the improvement plan significantly increased the number of examination reservations and examinations performed. As shown in Fig. 12, the number of waiting days for reservations in 2018 decreased from an average of 45 days to an average of 10 days, approximately 1/5. Furthermore, by continuing to make detailed improvements through daily management, it decreased to an average of five days in 2019, approximately 1/9. In particular, for brain MRI, brain MRI + MR- angiography (MRA), contrast MRI, gallbladder pancreatic Magnetic Resonance Cholangiopancreatography (MRCP), and whole-body MRI, which all account for >70% of the reservation slots, it is possible to reserve and perform examinations the next business day at the earliest. Consequently, the number of waiting days decreases significantly. Number of examination orders to other facilities Because of the decrease in the number of waiting days for reservations and the significant increase in the number of examination reservation slots and examinations performed, we could reduce the number of outsourced tests from an average of 300 per month to 50 per month, approximately 1/6, as shown in Fig. 13. Discussion The increase in the number of examination reservation slots and examinations performed By implementing an operational improvement plan using Lean Thinking, we could increase the number of reservations and examinations performed by 26% and 19%, respectively, in 2018 than before operation improvement. In 2019, further improvements were made compared with 2018, and we could increase the number of reservation slots and examinations performed by 34% and 28%, respectively. The key feature of Lean Thinking is that operational improvement is not completed once implemented but is continued by repeating the cycle of Lean Thinking. In 2019, it was possible to further increase the number of reservation slots and examinations performed by eight and nine points, respectively. The key to continuous operational improvement is daily management, which will be detailed later. Number of waiting days for reservations and outsourcing Owing to operational improvements, the number of waiting days for reservations decreased significantly, and in 2018, the average number of waiting days for reservations was 10. The main reason for the significant reduction in the number of waiting days is that it is now possible to reserve and perform examinations on the next business day at the earliest, including brain MRI, brain MRI + MRA, contrast MRI, gallbladder pancreatic MRCP, and whole-body MRI. Considering further improvements through Daily Management, it became clear that the increase in the number of waiting days was due to the limited reservation slots for breast MRI and pediatric sedation MRI examinations. By increasing the number of breast MRI reservation slots, investigating the use of pediatric sedation MRI examination slots and reassigning appropriate slots, and increasing the reservation slots during times of demand, it was possible to reduce the waiting time to an average of 5 days in 2019. Given the above operation improvements, we could reduce the number of waiting days for reservations to 5 days compared with that before the improvement; however, not all problems were resolved. For example, if there is no reservation for examination slots limited to any given day of the week, the next reservation will be made for the following week. In addition, there are still problems, such as extended waiting times when holidays and other vacations overlap. Regarding the number of outsourced examinations, because of the significant increase in the number of examination reservations and examinations performed in our hospital, the number of outsourced examinations reduced from an average of 300 per month to 50 per month, approximately 1/6. Furthermore, most of the 50 outsourced monthly examinations were performed at affiliated hospitals; therefore, the possibility of outsourcing to unaffiliated hospitals to our hospital was approximately zero. In addition, the number of waiting days for reservations and outsourced examinations has been greatly reduced through the above operation improvements. Therefore, the satisfaction level of each clinical department has improved. Productivity in MRI departments Owing to the operational improvement using Lean Thinking, the number of examinations performed in the MRI department increased by 28% compared with that before the improvement. Therefore, the productivity of the MRI department increased by 28%. In addition, the number of radiological technologists reduced from 12 to 9, owing to the rebuilding of the team structure described earlier. The productivity improvement effect of the reduction in personnel can be considered to be 33%. Considering this decrease in the number of radiological technicians, overall productivity improved by 71%. Usually, a reduction in staff would result in a decrease in productivity; however, the key factor not only compensated for the decrease in productivity but also led to a significant increase in the number of examinations performed. In particular, the centralized progress management system developed in the present study enables centralized monitoring of patient preparation progress and progress in other MRI rooms, which was difficult to monitor using the radiological information system. It also enables the optimal assignment of patients according to the situation. In addition, the installation of mirror monitors has enabled skilled staff in both MRI rooms to monitor the progress of examinations and provide support to operators with varying degrees of skill, creating a support system for performing examinations safely, thus improving productivity and significantly contributing to medical safety. Daily management In the present study, we held a weekly meeting (Daily Management) for approximately 15 min to repeat the cycle of Lean Thinking, evaluated and investigated the current status after the implementation of the operation improvement, and identified further problems and possible areas for improvement. In daily management, in addition to the evaluation indices mentioned earlier, to understand the total number of examinations performed in the MRI department, the total number of examinations per week, the total number of examinations performed in the MRI room per week, and the examination time based on anatomical parts, we constructed a graph of these indices and identified the problems. The details of each index are presented below: The graph of the total number of examinations in 1 week, as shown in Fig. 14, represents the number of examinations performed for the number of scheduled reservation slots. If the number of examinations is clearly lower than the total number of reservations, we compare it with another index and identify the root cause of the decrease in the total number of examinations. It has become possible to quickly determine whether the problem is due to a sudden cause or requires a permanent solution and to make further improvements. The graph of the number of examinations per week in the MRI room for 42 weeks in 2018, as shown in Fig. 15, shows the number of examinations performed by each MRI room against the number of scheduled reservation slots. It is possible to understand the operation status of each MRI room for 1 week, compare it with other indexes such as equipment failure, protocol change, operator's skill level, and extension due to special action at the time of examination, and perform composite analysis. This makes it possible to identify root causes. In the 42nd week of 2018, as shown in Fig. 15, because the number of examinations performed by the C/D/F MRI room was lower than the planned number of examinations, C, D, and F MRI modality-specific causes that led to a lower number of inspections were suspected. Fig. 16 shows the graph of the examination time for each anatomical part. An increase in the examination time was observed on brain MRI at 43 weeks. When we checked what had caused the increase in examination time during that week, we found that it was the week when a new protocol requested by the clinical department was started and that the examination time had been extended due to inexperienced operators and improper protocol settings. By reviewing the protocol, setting the appropriate protocol for all MRIs, and informing the operators of the protocol, the examination time was greatly improved in the next week, resulting in the examination being performed within the normal time frame. Positioning of Lean Thinking in Japan’s Healthcare In 2015, the Ministry of Health, Labour and Welfare issued a proposal titled "Healthcare 2035." The proposal’s content is not a generalized list of existing initiatives but a vision 20 years into the future. To achieve this objective, the basic principles and values that should be respected in healthcare and the direction of change required are discussed from the perspective of 2035 [6]. Within this "Healthcare 2035 Proposal,” "Lean Healthcare: Enhancing the Value of Health Care" is listed as the core pillar [6]. This “lean healthcare” is a way of thinking that applies the concept of lean thinking to healthcare. Therefore, providing high-value services at lower costs is necessary, and this is positioned as lean healthcare” [6]. The Ministry of Health, Labor, and Welfare aims to build a world-class sustainable healthcare system by 2035. Based on the idea of "better medical care at a lower price,” the concept of "lean healthcare" is expected to become an important initiative in Japan's healthcare in the future. Conclusions In this study, we examined the possibility of improving the operation of an MRI room by performing behavior analysis and operation improvement using Lean Thinking, which was based on the Toyota production system. Notably, we could increase the number of examination reservation slots and examinations performed by 26% and 19%, respectively, after implementing the improvement plan than before. Furthermore, by continuing to make detailed improvements through daily management, the number of reservation slots and examinations performed increased by 34% and 28%, respectively, compared with those before the operation improvements. We could reduce the average number of waiting days to five and the number of examination orders to other facilities to 50 per month, contributing to the satisfaction of each clinical department. Lean Thinking is useful for improving and increasing the utilization rate of MRI examination reservation slots, reducing the number of waiting days, and reducing the examination orders to other facilities. Furthermore, repeating the cycle of Lean Thinking using Daily Management is an important factor in improving operations. Lean Thinking can be applied to improve throughput in the daily operations of medical institutions and to improve operational systems. Declarations Ethics approval and consent to participate : Not applicable Consent for publication : Not applicable Availability of data and materials : The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests : The authors declare that they have no competing interests Funding : Not applicable Authors' contributions : All authors read and approved the final manuscript. Acknowledgemen We wish to thank everyone at the Tokyo Women's Medical University Hospital, the Department of Imaging and Nuclear Medicine, and the Central Radiology Department for their constant support and guidance in this research. The abstract of this study was presented at the 76th Annual Scientific Meeting of the Japanese Society of Radiological Technology (2020, held online), and the chairperson's recommendations were received. References Klein D, Khan V. Utilizing Six Sigma Lean Strategies to Expedite Emergency Department CT Scan Throughput in a Tertiary Care Facility. J Am Coll Radiol. 2017;14:78–81. https://doi.org/10.1016/j.jacr.2016.06.032 . Özçelik TÖ, Güleryüz D. Lean Service and Application of MRI-Tomography Imaging Center. TOJSAT. 2016;3:102–8. The Machine That Changed the World. The Story of Lean Production. James P. Womack. Dowell JD, Makary MS, Brocone M, Sarbinoff JG, Vargas IG, Gadkari M. Lean Six Sigma Approach to Improving Interventional Radiology Scheduling. J Am Coll Radiol. 2017;14:1316–21. https://doi.org/10.1016/j.jacr.2017.02.017 . Agarwal S, Gallo JJ, Parashar A, Agarwal KK, Ellis SG, Khot UN, Spooner R, Murat Tuzcu E, Kapadia SR. Impact of lean six sigma process improvement methodology on cardiac catheterization laboratory efficiency. Cardiovasc Revasc Med. 2016;17:95–101. https://doi.org/10.1016/j.carrev.2015.12.011 . Health and Medical Care. 2035 Proposal: Health and Medical Care 2035 Advisory Panel, Ministry of Health, Labor and Welfare 2015. 6. Tables Table 1 Lean Thinking Action Plan Step 1 Step 2-3 Step 4 Step 5 Assessment Current Survey and Improvement Plan Implementation of improvement plans Post-improvement plan evaluation and review Action plan Evaluation indices Grasping the problem Current situation survey and improvement plan. Investigate problems and root causes to gain common understanding. Consider an improvement plan for the obtained problems. Implement the resulting improvement plan. Perform post-improvement plan evaluation and review. [Daily Management] Create an evaluation board that serves as an index. Execution of daily management. Output data Value stream map (Current) Current problem Request Tools used for the 5 visualizations. Value stream map (Future) Standard work Spaghetti chart Root cause analysis Brain storming Environmental improvement Evaluation board that serves as an index Sustainable improvement plan Table 2 Radiological technologist team structure and role changes ・Conventional Team Structure (12 radiological technologists in total) General Outpatient Center (4 MRI units): 8 radiological technologists (2 radiological technologists/unit) Central Ward (2 MRI units): 4 radiological technologists (2 radiological technologists/unit) ・Team Structure After Improvement(12 radiological technologists in total) General Outpatient Center (4 MRI units): 6 radiological technologists (4 operators, 1 controller, 1 libero) Central Ward (2 MRI units): 3 radiological technologists (2 operators, 1 controller) Operator: Responsible for MRI examination operations Controller: Understands the entire examination room and issues instructions to staff Libero: Assists the operator Table 3 Functions of the centralized progress management system [Functions of the centralized progress management system ] Overview: Receive information from the radiology information system in real time. •Information such as medical interview, preparation status of MRI examination, and examination in progress can be viewed at a glance. Upper half of the screen: Displays the progress of MRI examinations currently being performed． •Used for the purpose of sharing information from the operator to the controller. •Displays the progress of the examination, remaining time, physical information, patients scheduled for the next examination. •The remaining time for MRI imaging can be changed in 5-minute increments. The exact remaining time can be shared with the controller. •Displays the next patient name indicated by the controller. Lower half of the screen: Displays a list of patients currently waiting for examination •Used by controllers to give instructions to operators and other staff. •Displays waiting time, preparation status, next inspection device, etc. As for the waiting time, it is possible to grasp both the elapsed time from the reservation time and the elapsed time from the reception. •The preparation status can be set as interviewing, before needle insertion, preparation completed, or absent, and the controller can grasp the patient's preparation status at a glance. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Dec, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 22 May, 2024 Editor assigned by journal 22 May, 2024 Submission checks completed at journal 20 May, 2024 First submitted to journal 06 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4377997","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":305378795,"identity":"2b136d91-b1e8-4a89-84fd-59d9af8a5b4f","order_by":0,"name":"Seiji Yahata","email":"","orcid":"","institution":"Tokyo Women’s Medical University, Adachi Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Seiji","middleName":"","lastName":"Yahata","suffix":""},{"id":305378796,"identity":"949fa544-b6d1-4e97-b203-36ccb9630798","order_by":1,"name":"Isao Tanaka","email":"","orcid":"","institution":"Tokyo Women's Medical University 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Hospital","correspondingAuthor":false,"prefix":"","firstName":"Isao","middleName":"","lastName":"Shiina","suffix":""},{"id":305378800,"identity":"e33c26ee-b0e5-471b-a062-3a1bc3436148","order_by":5,"name":"Satoshi Nakayama","email":"","orcid":"","institution":"Philips Japan, Ltd","correspondingAuthor":false,"prefix":"","firstName":"Satoshi","middleName":"","lastName":"Nakayama","suffix":""},{"id":305378801,"identity":"66aabe20-4e2c-4667-bf8a-9cc895c792b3","order_by":6,"name":"Kazuo Shimura","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACCcYGECUngSbORlCLMSlaIFTiDKLdJT+7uXUz7x679Jnt3Ykff9QclmeQSGD88IOBLw+XFoM7B9tu8zxLzp3Nc3azhMSxw4YNEgnMkj0MbMU4tUgkArUcYM6dJ5G7QcKA7Tbj/hsJDNJAvyQ24HLYDLCW+nQ5idzNPxL+3bYH2fIbnxaGG2AthxOkJXK3SQAdmQjUwobXFgOglptzDhw3nNlzdptlY9//5Aaeh22WPQa4/SI/I/3ZjTcHquUljvduvvnjW5ptA3vy4Rs/Ko7hDDFsABS5BscSSNECBjWkaxkFo2AUjILhCgDZF1nY4ude5QAAAABJRU5ErkJggg==","orcid":"","institution":"Komazawa University","correspondingAuthor":true,"prefix":"","firstName":"Kazuo","middleName":"","lastName":"Shimura","suffix":""}],"badges":[],"createdAt":"2024-05-06 15:45:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4377997/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4377997/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-13644-2","type":"published","date":"2025-12-24T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57729351,"identity":"cf438e78-e60e-481f-b9df-4e5de47182d2","added_by":"auto","created_at":"2024-06-04 21:52:28","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":160586,"visible":true,"origin":"","legend":"\u003cp\u003eLean Thinking and conventional operations improvement\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/c7fd55e189292320b321df59.png"},{"id":57729355,"identity":"492f6e63-6e89-487e-b487-3a4e8d6b98fe","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":209529,"visible":true,"origin":"","legend":"\u003cp\u003eLean Thinking Cycle Diagram\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/031b5ddac98bfff5bc7770db.png"},{"id":57729367,"identity":"d90cabff-8ea2-4d68-9190-160b3b94dcc1","added_by":"auto","created_at":"2024-06-04 21:52:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":967080,"visible":true,"origin":"","legend":"\u003cp\u003eValue Stream Map\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/415ce674fa71f64c8c8bbbe1.png"},{"id":57730197,"identity":"eed5c3a7-2f9c-46c0-b274-d274550a5478","added_by":"auto","created_at":"2024-06-04 22:00:28","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":646096,"visible":true,"origin":"","legend":"\u003cp\u003eStandard work\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/b214b1e398ba41e515a7f3b1.png"},{"id":57729353,"identity":"9e093536-d533-4ed8-b8bd-734835deae44","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":251907,"visible":true,"origin":"","legend":"\u003cp\u003eSpaghetti chart\u003c/p\u003e","description":"","filename":"Fig5.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/c3a87a4d49eb7dbae3cc57fd.png"},{"id":57729356,"identity":"484594c8-b251-4c31-a768-dcd2f7b6be81","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":654947,"visible":true,"origin":"","legend":"\u003cp\u003eRoot cause analysis\u003c/p\u003e","description":"","filename":"Fig6.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/5036aca6bd7505e8634c0aaa.png"},{"id":57730200,"identity":"78219128-5f8e-4fc7-a3ec-bcd0a1198e17","added_by":"auto","created_at":"2024-06-04 22:00:29","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":374179,"visible":true,"origin":"","legend":"\u003cp\u003eCentralized progress management system screen\u003c/p\u003e","description":"","filename":"Fig7.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/9688f93b43e4adaea485ffde.png"},{"id":57729364,"identity":"96d78589-cf20-4f9d-a91a-664db2d3e4fb","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":1294303,"visible":true,"origin":"","legend":"\u003cp\u003eMirror monitor configuration diagram\u003c/p\u003e","description":"","filename":"Fig8.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/bf6491dc53cf72abe6a26bde.png"},{"id":57729361,"identity":"5810a884-3d21-485e-8b19-bce4329f010c","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":342258,"visible":true,"origin":"","legend":"\u003cp\u003eAction Tracker\u003c/p\u003e","description":"","filename":"Fig9.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/aa22e11af4c14e47b836253e.png"},{"id":57730199,"identity":"306a76c8-a768-4532-93d4-d4ed9d26e156","added_by":"auto","created_at":"2024-06-04 22:00:29","extension":"png","order_by":10,"title":"Figure 10","display":"","copyAsset":false,"role":"figure","size":149803,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of reservation slots per month\u003c/p\u003e","description":"","filename":"Fig10.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/55182dcb9d8fa270675d91c9.png"},{"id":57730198,"identity":"2e3a7653-5fb3-44c6-8f68-ed79d99a0ab6","added_by":"auto","created_at":"2024-06-04 22:00:29","extension":"png","order_by":11,"title":"Figure 11","display":"","copyAsset":false,"role":"figure","size":143042,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of examinations performed monthly\u003c/p\u003e","description":"","filename":"Fig11.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/c6d09800458ac376f99a1206.png"},{"id":57729358,"identity":"b6d00f45-cf54-4a89-87c9-f0365403d293","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":12,"title":"Figure 12","display":"","copyAsset":false,"role":"figure","size":165090,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of waiting days for reservation\u003c/p\u003e","description":"","filename":"Fig12.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/e3e84591748f650d6d78d9d0.png"},{"id":57729359,"identity":"8dcbeaad-f9da-4af0-8f4f-529d442ef8d8","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":150807,"visible":true,"origin":"","legend":"\u003cp\u003eThe number of examination orders to other facilities\u003c/p\u003e","description":"","filename":"Fig13.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/3517ec10ca59afa97e36828e.png"},{"id":57729362,"identity":"f420be70-5fba-4993-839b-dc79a6bac362","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":161961,"visible":true,"origin":"","legend":"\u003cp\u003eTotal number of examinations per week (2018)\u003c/p\u003e","description":"","filename":"Fig14.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/6c3ac249dd9ff1b79edc4b32.png"},{"id":57729363,"identity":"d623cf6f-5c3f-4085-a727-f800ebb57d21","added_by":"auto","created_at":"2024-06-04 21:52:29","extension":"png","order_by":15,"title":"Figure 15","display":"","copyAsset":false,"role":"figure","size":157213,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of weekly examinations performed by MRI room (42 weeks in 2018)\u003c/p\u003e","description":"","filename":"Fig15.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/598f9b43c025cd69f0f39085.png"},{"id":57729366,"identity":"e5d130ca-2bbe-4fec-9a62-dcdfcf29e299","added_by":"auto","created_at":"2024-06-04 21:52:30","extension":"png","order_by":16,"title":"Figure 16","display":"","copyAsset":false,"role":"figure","size":733930,"visible":true,"origin":"","legend":"\u003cp\u003eExamination time according to site (2018)\u003c/p\u003e","description":"","filename":"Fig16.png","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/f692b0ee23427442470191b2.png"},{"id":99172804,"identity":"e653bfbe-4932-4bd4-86c9-bc0429d3076a","added_by":"auto","created_at":"2025-12-29 16:11:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":8225595,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4377997/v1/55677c77-6c97-44e0-8356-36997a47fbb0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of a centralized progress management system using lean thinking and efforts to improve operations","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLean Thinking is a method of operational improvement based on the Toyota Production System. In 2016, Klein et al. investigated the utilization of Lean Thinking to improve the throughput of computed tomography (CT) scans in emergency medical care, and its application in the healthcare field began [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Klein et al. implemented a behavioral analysis and improvement plan using Lean Thinking regarding the operating system (from ordering a non-contrast-enhanced CT scan in emergency medical care until the patient underwent a CT scan and returned to the examination room) to improve the throughput [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, we thought that Lean Thinking could be applied not only to the operating system in emergency medical care but also to improve the throughput and operating system in the daily work accounting for most medical institutions\u0026rsquo; work. The magnetic resonance imaging (MRI) examination department of the Tokyo Women's Medical University Hospital, which had problems with work efficiency, was the target for considering operational improvement.\u003c/p\u003e \u003cp\u003eThe MRI examination department operated with four units in the outpatient center and two units in the ward examination room, making six units in total. Therefore, it was impossible to conduct examinations at the necessary time. In addition, when examinations were urgent, outsourcing them to other facilities are often necessary. This increased the number of examinations outsourced to other facilities, which has burdened the institution\u0026rsquo;s management.\u003c/p\u003e \u003cp\u003eIn the present study, we initially investigated previous studies that examined facility operation systems and throughput improvement using Lean Thinking in the MRI examination department. However, we found no related study. Therefore, we initiated this study because we believe that improving operations and throughput using Lean Thinking, even in the daily examination operation of the MRI department, is possible. In addition, we believe that using Information and Communication Technology (ICT) is key to improving daily operations using Lean Thinking; therefore, we developed a new ICT system to improve daily operations and efficiency.\u003c/p\u003e \u003cp\u003eBased on this background, behavioral analysis and improvement plans were performed in the present study using Lean Thinking in the daily work of the MRI examination room to improve and increase the utilization rate of MRI examination reservation slots, reduce the number of waiting days for reservations, and reduce the examination to other facilities.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConventional operations improvement methods and Lean Thinking\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLean Thinking is based on the \u0026quot;Toyota Production System, \u0026quot; which was launched by Toyota Motor Corporation. This method was proposed by J. P. Womack in 1990 and classified all work processes from the perspective of value (whether they add value). The aim is to eliminate waste thoroughly and improve productivity. In the field of healthcare, this concept can be used to improve patient waiting time, treatment delays, operational efficiency, cost, processing capacity, quality of medical care, and work environment [3].\u003c/p\u003e\n\u003cp\u003eConventional operation improvement methods focus on reducing the operation time, which is a part of value-adding. However, in a typical job, value-adding work usually accounts for \u0026lt;5% of the total work time; therefore, reducing this time by 50% will only slightly reduce the overall work time [4] (Fig. 1). Lean Thinking focuses on reducing wasteful activities (non-value-adding work time). Therefore, the overall operation time can be dramatically reduced, making it possible to provide quality service, and performance can be greatly improved [5].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eLean Thinking Cycle Diagram and Action Plan\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe concept of Lean Thinking is shown in Fig. 2. It consists of five steps: 1) determining the evaluation index, 2) visualizing the workflow, 3) creating a flow diagram and an improvement plan, 4) implementing the improvement plan, and 5) evaluating and repeating the Lean Thinking cycle. Based on this cycle, we will create an action plan, as shown in Table 1, and improve our operation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, in Lean Thinking, it is important not only to implement the improvement plan once but also to evaluate the implemented improvement and to continue the evaluation and improvement repeatedly. By evaluating the improvements made, discovering new areas for improvement and achieving more efficient operations are possible.\u003c/p\u003e\n\u003cp\u003eThe details of the specific methods for each step of Lean Thinking are described in the next section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOperation improvement method based on Lean Thinking\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDetermination of evaluation indexes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDetermining the evaluation index is very important in determining the direction of operational improvement and quantifying and understanding the progress of the improvement.\u003c/p\u003e\n\u003cp\u003eFirst, in formulating an operational improvement plan, the following indices were set to evaluate the current problems and matters most desired to be improved at the initial stage.\u003c/p\u003e\n\u003cp\u003e(1) The actual number of examinations, reservation slots, and operating rate.\u003c/p\u003e\n\u003cp\u003e(2) Number of waiting days for examination.\u003c/p\u003e\n\u003cp\u003e(3) Number of examination orders for other facilities.\u003c/p\u003e\n\u003cp\u003eImprovement induced by Lean Thinking continues even if the first operational improvement plan is implemented. At the operation stage of the lean cycle, in addition to the initial evaluation indices, we could \u0026quot;visualize\u0026quot; the issues broken down one step at a time and make continuous improvements by setting more detailed evaluation indices. The details of this process are described later.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVisualization of workflow\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter determining the evaluation indices, we could objectively understand the problems by visualizing the workflow. We used the following four tools to visualize the workflow in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1) Value Stream Map\u003c/p\u003e\n\u003cp\u003eValue Stream Map, also known as \u0026quot;value flow chart,\u0026rdquo; is a diagram that describes the activities of all processes and workflows in the hospital, including reception, examination, and accounting, after a patient arrives at the hospital, and clarifies the situation, such as cycle time, patient flow, and information flow. Using the value stream map, as shown in Fig. 3, we visualized the processes and workflows in the hospital and identified the current problems [4, 5].\u003c/p\u003e\n\u003cp\u003e2)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eStandard work\u003c/p\u003e\n\u003cp\u003eStandard work refers to standard work processes. By decomposing the current standard work into each element, the work processes can be understood, and the standard work processes can be visualized. Standard work includes many factors, including work process steps, operator and staff procedures, work location, equipment or technology used, safety, patient guidance, and cycle time.\u003c/p\u003e\n\u003cp\u003eBy incorporating patient and staff timetables into the standard work, as shown in Fig. 4, we could understand the timing of delays, work content, and wasted time.\u003c/p\u003e\n\u003cp\u003e3)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eSpaghetti chart\u003c/p\u003e\n\u003cp\u003eA Spaghetti chart is a diagram showing staff flow lines on the drawing of the examination room and backyards. Plotting the flow lines and distances of all staff involved in the operation process on the actual floor plan allows unnecessary and dangerous flow lines can be visualized.\u003c/p\u003e\n\u003cp\u003eUsing the Spaghetti chart, as shown in Fig. 5, we put the flow line for each medical staff member into the facility diagram and could understand the places where delays occurred and which flow lines were unnecessary.\u003c/p\u003e\n\u003cp\u003e4)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eRoot cause analysis\u003c/p\u003e\n\u003cp\u003eRoot cause analysis is a method of analyzing a problem or event and identifying the root cause. Therefore, it is a cause-solving process that focuses on identifying root causes and solutions to obstacles and problems rather than looking at them superficially. It is used in aviation, medical, and industrial fields, where high safety is required.\u003c/p\u003e\n\u003cp\u003eFig. 6 shows an example of the results of the root cause analysis. We investigated these problems and issues in depth and analyzed their root causes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePlanning and implementation of operational improvement measures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePlanning of operational improvement measures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRegarding problems in the MRI examination department, brainstorming was performed based on the analysis results obtained using the four tools mentioned above: the Value Stream Map, Standard work, Spaghetti chart, and root cause analysis. We exchanged ideas to improve operational efficiency and planned improvement measures consisting of the following five items:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eIncrease in examination reservations\u003c/li\u003e\n \u003cli\u003eRebuilding the team structure\u003c/li\u003e\n \u003cli\u003eDevelopment of a progress management system\u003c/li\u003e\n \u003cli\u003eDevelopment of a mirror monitor that allows mutual confirmation of scanning progress\u003c/li\u003e\n \u003cli\u003eOther operational efficiency improvements\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cem\u003eDetails of the improvement plan\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe details of the operational improvement measures planned and implemented in this study are as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(1) A 34% increase in examination reservation slots.\u003c/p\u003e\n\u003cp\u003eBy investigating the actual state of the examinations and identifying those with vacant time, the number of examination reservation slots increased by 34%.\u003c/p\u003e\n\u003cp\u003eThe number of weekly reservation slots was 505 (2020/month) before the operation improvement in 2016, whereas it was 635 (2540/month) after the operation improvement in 2018, indicating an increase of 26%. In 2019, there were 678 cases (2712 cases/month), indicating an increase of 34%. In this manner, the number of reservation slots increased in stages.\u003c/p\u003e\n\u003cp\u003eThe specific steps for increasing the number of reservation slots are shown below:\u003c/p\u003e\n\u003cp\u003eI. Previously, one examination reservation slot was uniformly 30 min for all examinations; however, considering the actual examination time, the brain/spine/plain examination reservation slots were changed to 20 min, and whole-body scan slots were changed to 30 min, resulting in an increase of 61 slots weekly.\u003c/p\u003e\n\u003cp\u003eII. Before the review, there was one patient per slot. However, some patients did not visit the hospital at the scheduled time. Therefore, the slots were changed to one per hour, enabling two patients to fit in one slot. In this manner, we set the timeslots to minimize vacant examination rooms as much as possible, increasing the number of slots to 92 weekly.\u003c/p\u003e\n\u003cp\u003eIII. By moving the examination start time forward by 30 min, the examination work time per day increased by 30 min, resulting in an increase of 20 slots per week.\u003c/p\u003e\n\u003cp\u003eIV. The fixed reservation slots for specific clinical departments have been reduced to 1/3. Simultaneously, by releasing fixed slots for which reservations were not made by the deadline, the number of regular reservation slots increased, and conditions for releasing vacant slots were set. By eliminating the fixed reservation slots for specific departments other than health checkups, pediatric sedation examinations, and preoperative examinations on the same day, the average daily number of fixed reservation slots was reduced from 15 to 5.\u003c/p\u003e\n\u003cp\u003eIn addition, reservation slots for health checkups that have not been booked 1 week in advance, pediatric sedation examinations that have not been booked by 9:00 on the previous day, and preoperative examination slots on the exact day had been released.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(2) Productivity improvement by rebuilding the team structure\u003c/p\u003e\n\u003cp\u003eActively utilizing information technology (IT) through brainstorming, as mentioned above, has improved individuals\u0026rsquo; productivity, even if the number of radiological technicians is reduced and more examinations can be completed during the same working hours.\u003c/p\u003e\n\u003cp\u003eTherefore, we reduced the number of radiological technicians from 12 to 9 and transferred them to other examination sections to improve the vacation utilization rate and strengthen the education system by assigning a person in charge of educational guidance.\u003c/p\u003e\n\u003cp\u003eSpecific measures for staff reduction are shown below:\u003c/p\u003e\n\u003cp\u003eI. We used IT tools such as a centralized progress management system and a mirror monitor, which will be described later. Therefore, we rebuilt the system to include two radiological technologists per MRI unit. As shown in Table 2, the system has been changed to consist of an examination operator in charge of each MRI examination and a controller who understands the entire MRI examination area and provides instructions to the staff.\u003c/p\u003e\n\u003cp\u003eBased on this measure, productivity per person has improved significantly, and the number of radiological technicians has reduced from 12 to 9.\u003c/p\u003e\n\u003cp\u003e(3) Development of a centralized progress management system\u003c/p\u003e\n\u003cp\u003eWe developed a centralized progress management system to improve the productivity of the radiological technician team in the MRI department.\u003c/p\u003e\n\u003cp\u003eWith conventional radiological information systems, it was unable to check detailed information such as how many patients have already completed the reception process, who is undergoing pre-examination interviews, who is available for examination, and how long it will take for patients undergoing examinations to complete. Therefore, it was difficult to understand how work progressed across the entire examination room, and the time from examination preparation to the end of the examination was unnecessarily long. Therefore, we have newly developed a centralized progress management system that receives information from the radiology information system in real-time and confirms in detail the status from reception to the start and end of the examination.\u003c/p\u003e\n\u003cp\u003eThe system extracts the necessary data from database columns in the radiology information system, converts it into information, and displays the information on the screen using a web browser.\u003c/p\u003e\n\u003cp\u003eIn addition to understanding the detailed status of each MRI by utilizing the centralized progress management system, it is possible to understand the patient\u0026apos;s preparation status in detail from interviews before injection and completion of examination preparation. Therefore, an optimal patient allocation for MRI examination based on the situation is possible.\u003c/p\u003e\n\u003cp\u003eAs a result, we could shorten patient waiting times, improve patient satisfaction, and improve the efficiency of the overall operations, thereby creating an optimal examination environment.\u003c/p\u003e\n\u003cp\u003eDetails and screens of the centralized progress management system are presented in Table 3. And Fig.\u0026nbsp;7.\u003c/p\u003e\n\u003cp\u003e(4) Development of a mirror monitor to check the examination status\u003c/p\u003e\n\u003cp\u003eUnder the new team structure of radiological technologists, as shown in Table 2, we developed a mirror monitor, as shown in Fig. 8, to show the operation screen regardless of which device the controller uses to ensure the same medical safety and quality of examination as before.\u003c/p\u003e\n\u003cp\u003eThe operation monitor screen of each MRI system was distributed and installed next to the monitoring monitor of another MRI system to confirm both operation monitor screens. This makes it possible for the controller to check the operation monitor screen from the MRI room and to check the progress, sequence, and operation status remotely.\u003c/p\u003e\n\u003cp\u003eIn addition, depending on the personnel assignment, operators who are unfamiliar with MRI operations or operators in the MRI training process may be assigned. Even operators at a distance can now check for incorrect operations, missing MRI sequences, or missing clinical findings.\u003c/p\u003e\n\u003cp\u003e(5) Other operational efficiency improvements\u003c/p\u003e\n\u003cp\u003eTo reduce the workload per person owing to the increase in examination reservation slots and the reduction in staff, various efficiency measures, other than the first to fourth described so far, have been developed and implemented. The specific measures are as follows:\u003c/p\u003e\n\u003cp\u003eI. A manual was created to standardize the pre-examination interview to ensure all examination staff was in charge of the pre-examination interview before entering the room. The training was conducted using a manual that summarizes how to use the pre-examination interview form, the order of interview, important points during the interview, and how to communicate to ensure that not only radiological technicians but also nurses and nursing assistants can conduct pre-examination interviews in the same manner.\u003c/p\u003e\n\u003cp\u003eIn addition, the pre-examination interview is important to confirm that you can enter the MRI room. Considering this opportunity, we examined whether there were any ambiguous expressions or missing necessary items and revised the pre-examination interview form.\u003c/p\u003e\n\u003cp\u003eII. The emergency examination coordinator changed from a radiological technologist to an emergency radiologist.\u003c/p\u003e\n\u003cp\u003ePreviously, when an emergency examination was required, the clinical department staff would call the radiology department directly, and the radiological technologist would have to spend time on coordination tasks, thus delaying overall examination operations.\u003c/p\u003e\n\u003cp\u003eBy setting up an emergency radiologist and changing the response to take charge of coordinating emergency examinations, radiological technologists\u0026apos; time is no longer considered, and examinations are not delayed.\u003c/p\u003e\n\u003cp\u003eIII. We increased the number of daily examinations by approximately five using vacant slots because of reliable cancellation notifications.\u003c/p\u003e\n\u003cp\u003ePreviously, examination cancellation notifications were stopped at the hospital reception desk, and the radiology department could not capture them; therefore, the vacant slots due to cancellations could not be used effectively. By making it a rule that when a cancellation is received at the reception desk of the hospital, the receptionist will contact the examination room, and it is possible to perform examinations ahead of schedule for the waiting patients and to accept emergency examinations, making it possible to increase the number of examinations by approximately five daily by effectively utilizing the cancellation slots.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDaily Management\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter implementing the improvement plan, the process should not be completed. Instead, daily management should be implemented, which is a key activity to continue evaluation and review, identify further problems and areas for improvement, and continue repeating the lean thinking cycle. In the present study, we held a weekly 15-min meeting (Daily Management) and used a dedicated sheet (Action Tracker), as shown in Fig. 9, to discuss daily management and further improvement plans.\u003c/p\u003e\n\u003cp\u003eIn addition to the evaluation indices set at the initial stage, the following indices were added to identify detailed problems, and evaluation and analysis were continuously performed.\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eTotal number of examinations per week\u003c/li\u003e\n \u003cli\u003eNumber of examinations per week based on modality\u003c/li\u003e\n \u003cli\u003eExamination time based on anatomical parts\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNumber of examination reservation slots and examinations performed\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe improvement plan mentioned above was implemented, as shown in Fig 10. In 2016, before the operational improvement plan was implemented, the number of reservation slots was 2,020/month, whereas it was 2,540/month after the implementation, indicating an increase of 26%t. Furthermore, by continuing improvements through daily management, the number of reservations increased by 34% (2,712 cases/month) in 2019 compared with before the improvement.\u003c/p\u003e\n\u003cp\u003eAs shown in Fig. 11, the number of examinations performed was 1,850 per month in 2016 before the operational improvement, whereas it was 2,210 per month after implementing the improvement plan in 2018, indicating an increase of 19%. Furthermore, in 2019, there were 2,360 cases/month, indicating an increase of 28% compared with before the improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eWaiting days for reservation\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImplementing the improvement plan significantly increased the number of examination reservations and examinations performed. As shown in Fig. 12, the number of waiting days for reservations in 2018 decreased from an average of 45 days to an average of 10 days, approximately 1/5. Furthermore, by continuing to make detailed improvements through daily management, it decreased to an average of five days in 2019, approximately 1/9. In particular, for brain MRI, brain MRI + MR- angiography (MRA), \u0026nbsp;contrast MRI, gallbladder pancreatic Magnetic Resonance Cholangiopancreatography (MRCP), and whole-body MRI, which all account for \u0026gt;70% of the reservation slots, it is possible to reserve and perform examinations the next business day at the earliest. Consequently, the number of waiting days decreases significantly.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNumber of examination orders to other facilities\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause of the decrease in the number of waiting days for reservations and the significant increase in the number of examination reservation slots and examinations performed, we could reduce the number of outsourced tests from an average of 300 per month to 50 per month, approximately 1/6, as shown in Fig. 13.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe increase in the number of examination reservation slots and examinations performed\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy implementing an operational improvement plan using Lean Thinking, we could increase the number of reservations and examinations performed by 26% and 19%, respectively, in 2018 than before operation improvement. In 2019, further improvements were made compared with 2018, and we could increase the number of reservation slots and examinations performed by 34% and 28%, respectively. The key feature of Lean Thinking is that operational improvement is not completed once implemented but is continued by repeating the cycle of Lean Thinking. In 2019, it was possible to further increase the number of reservation slots and examinations performed by eight and nine points, respectively. The key to continuous operational improvement is daily management, which will be detailed later.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNumber of waiting days for reservations and outsourcing\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOwing to operational improvements, the number of waiting days for reservations decreased significantly, and in 2018, the average number of waiting days for reservations was 10.\u003c/p\u003e\n\u003cp\u003eThe main reason for the significant reduction in the number of waiting days is that it is now possible to reserve and perform examinations on the next business day at the earliest, \u0026nbsp;including brain MRI, brain MRI + MRA, contrast MRI, gallbladder pancreatic MRCP, and whole-body MRI.\u003c/p\u003e\n\u003cp\u003eConsidering further improvements through Daily Management, it became clear that the increase in the number of waiting days was due to the limited reservation slots for breast MRI and pediatric sedation MRI examinations. By increasing the number of breast MRI reservation slots, investigating the use of pediatric sedation MRI examination slots and reassigning appropriate slots, and increasing the reservation slots during times of demand, it was possible to reduce the waiting time to an average of 5 days in 2019.\u003c/p\u003e\n\u003cp\u003eGiven the above operation improvements, we could reduce the number of waiting days for reservations to 5 days compared with that before the improvement; however, not all problems were resolved. For example, if there is no reservation for examination slots limited to any given day of the week, the next reservation will be made for the following week. In addition, there are still problems, such as extended waiting times when holidays and other vacations overlap.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the number of outsourced examinations, because of the significant increase in the number of examination reservations and examinations performed in our hospital, the number of outsourced examinations reduced from an average of 300 per month to 50 per month, approximately 1/6. Furthermore, most of the 50 outsourced monthly examinations were performed at affiliated hospitals; therefore, the possibility of outsourcing to unaffiliated hospitals to our hospital was approximately zero.\u003c/p\u003e\n\u003cp\u003eIn addition, the number of waiting days for reservations and outsourced examinations has been greatly reduced through the above operation improvements. Therefore, the satisfaction level of each clinical department has improved.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eProductivity in MRI departments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOwing to the operational improvement using Lean Thinking, the number of examinations performed in the MRI department increased by 28% compared with that before the improvement. Therefore, the productivity of the MRI department increased by 28%. In addition, the number of radiological technologists reduced from 12 to 9, owing to the rebuilding of the team structure described earlier. The productivity improvement effect of the reduction in personnel can be considered to be 33%. Considering this decrease in the number of radiological technicians, overall productivity improved by 71%.\u003c/p\u003e\n\u003cp\u003eUsually, a reduction in staff would result in a decrease in productivity; however, the key factor not only compensated for the decrease in productivity but also led to a significant increase in the number of examinations performed. In particular, the centralized progress management system developed in the present study enables centralized monitoring of patient preparation progress and progress in other MRI rooms, which was difficult to monitor using the radiological information system. It also enables the optimal assignment of patients according to the situation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition, the installation of mirror monitors has enabled skilled staff in both MRI rooms to monitor the progress of examinations and provide support to operators with varying degrees of skill, creating a support system for performing examinations safely, thus improving productivity and significantly contributing to medical safety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDaily management\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn the present study, we held a weekly meeting (Daily Management) for approximately 15 min to repeat the cycle of Lean Thinking, evaluated and investigated the current status after the implementation of the operation improvement, and identified further problems and possible areas for improvement.\u003c/p\u003e\n\u003cp\u003eIn daily management, in addition to the evaluation indices mentioned earlier, to understand the total number of examinations performed in the MRI department, the total number of examinations per week, the total number of examinations performed in the MRI room per week, and the examination time based on anatomical parts, we constructed a graph of these indices and identified the problems. The details of each index are presented below:\u003c/p\u003e\n\u003cp\u003eThe graph of the total number of examinations in 1 week, as shown in Fig. 14, represents the number of examinations performed for the number of scheduled reservation slots. If the number of examinations is clearly lower than the total number of reservations, we compare it with another index and identify the root cause of the decrease in the total number of examinations. It has become possible to quickly determine whether the problem is due to a sudden cause or requires a permanent solution and to make further improvements.\u003c/p\u003e\n\u003cp\u003eThe graph of the number of examinations per week in the MRI room for 42 weeks in 2018, as shown in Fig. 15, shows the number of examinations performed by each MRI room against the number of scheduled reservation slots. It is possible to understand the operation status of each MRI room for 1 week, compare it with other indexes such as equipment failure, protocol change, operator\u0026apos;s skill level, and extension due to special action at the time of examination, and perform composite analysis. This makes it possible to identify root causes. In the 42nd week of 2018, as shown in Fig. 15, because the number of examinations performed by the C/D/F MRI room was lower than the planned number of examinations, C, D, and F MRI modality-specific causes that led to a lower number of inspections were suspected.\u003c/p\u003e\n\u003cp\u003eFig. 16 shows the graph of the examination time for each anatomical part. An increase in the examination time was observed on brain MRI at 43 weeks. When we checked what had caused the increase in examination time during that week, we found that it was the week when a new protocol requested by the clinical department was started and that the examination time had been extended due to inexperienced operators and improper protocol settings. By reviewing the protocol, setting the appropriate protocol for all MRIs, and informing the operators of the protocol, the examination time was greatly improved in the next week, resulting in the examination being performed within the normal time frame.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePositioning of Lean Thinking in Japan\u0026rsquo;s Healthcare\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 2015, the Ministry of Health, Labour and Welfare issued a proposal titled \u0026quot;Healthcare 2035.\u0026quot; The proposal\u0026rsquo;s content is not a generalized list of existing initiatives but a vision 20 years into the future. To achieve this objective, the basic principles and values that should be respected in healthcare and the direction of change required are discussed from the perspective of 2035 [6].\u003c/p\u003e\n\u003cp\u003eWithin this \u0026quot;Healthcare 2035 Proposal,\u0026rdquo; \u0026quot;Lean Healthcare: Enhancing the Value of Health Care\u0026quot; is listed as the core pillar [6]. This \u0026ldquo;lean healthcare\u0026rdquo; is a way of thinking that applies the concept of lean thinking to healthcare. Therefore, providing high-value services at lower costs is necessary, and this is positioned as lean healthcare\u0026rdquo; [6].\u003c/p\u003e\n\u003cp\u003eThe Ministry of Health, Labor, and Welfare aims to build a world-class sustainable healthcare system by 2035. Based on the idea of \u0026quot;better medical care at a lower price,\u0026rdquo; the concept of \u0026quot;lean healthcare\u0026quot; is expected to become an important initiative in Japan\u0026apos;s healthcare in the future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this study, we examined the possibility of improving the operation of an MRI room by performing behavior analysis and operation improvement using Lean Thinking, which was based on the Toyota production system.\u003c/p\u003e \u003cp\u003eNotably, we could increase the number of examination reservation slots and examinations performed by 26% and 19%, respectively, after implementing the improvement plan than before. Furthermore, by continuing to make detailed improvements through daily management, the number of reservation slots and examinations performed increased by 34% and 28%, respectively, compared with those before the operation improvements.\u003c/p\u003e \u003cp\u003eWe could reduce the average number of waiting days to five and the number of examination orders to other facilities to 50 per month, contributing to the satisfaction of each clinical department. Lean Thinking is useful for improving and increasing the utilization rate of MRI examination reservation slots, reducing the number of waiting days, and reducing the examination orders to other facilities. Furthermore, repeating the cycle of Lean Thinking using Daily Management is an important factor in improving operations. Lean Thinking can be applied to improve throughput in the daily operations of medical institutions and to improve operational systems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate :\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication :\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials :\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests :\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003eFunding :\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions :\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgemen \u003c/p\u003e\n\u003cp\u003eWe wish to thank everyone at the Tokyo Women\u0026apos;s Medical University Hospital, the Department of Imaging and Nuclear Medicine, and the Central Radiology Department for their constant support and guidance in this research. The abstract of this study was presented at the 76th Annual Scientific Meeting of the Japanese Society of Radiological Technology (2020, held online), and the chairperson\u0026apos;s recommendations were received.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKlein D, Khan V. Utilizing Six Sigma Lean Strategies to Expedite Emergency Department CT Scan Throughput in a Tertiary Care Facility. J Am Coll Radiol. 2017;14:78\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jacr.2016.06.032\u003c/span\u003e\u003cspan address=\"10.1016/j.jacr.2016.06.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Ouml;z\u0026ccedil;elik T\u0026Ouml;, G\u0026uuml;lery\u0026uuml;z D. Lean Service and Application of MRI-Tomography Imaging Center. 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Cardiovasc Revasc Med. 2016;17:95\u0026ndash;101. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.carrev.2015.12.011\u003c/span\u003e\u003cspan address=\"10.1016/j.carrev.2015.12.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHealth and Medical Care. 2035 Proposal: Health and Medical Care 2035 Advisory Panel, Ministry of Health, Labor and Welfare 2015. 6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Lean Thinking Action Plan\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.415300546448087%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.51366120218579%\" valign=\"top\"\u003e\n \u003cp\u003eStep 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eStep 2-3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eStep 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003eStep 5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.58233890214797%\" valign=\"top\"\u003e\n \u003cp\u003eAssessment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.178997613365155%\" valign=\"top\"\u003e\n \u003cp\u003eCurrent Survey and Improvement Plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.178997613365155%\" valign=\"top\"\u003e\n \u003cp\u003eImplementation of improvement plans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.05966587112172%\" valign=\"top\"\u003e\n \u003cp\u003ePost-improvement plan evaluation and review\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.415300546448087%\" valign=\"top\"\u003e\n \u003cp\u003eAction plan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.51366120218579%\" valign=\"top\"\u003e\n \u003cp\u003eEvaluation indices\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;Grasping the problem\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eCurrent situation survey and improvement plan.\u003cbr\u003e\u0026nbsp;Investigate problems and root causes to gain common understanding.\u003cbr\u003e\u0026nbsp;Consider an improvement plan for the obtained problems.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eImplement the resulting improvement plan.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003ePerform post-improvement plan evaluation and review.\u003cbr\u003e\u0026nbsp;[Daily Management]\u003cbr\u003e\u0026nbsp;Create an evaluation board that serves as an index.\u003cbr\u003e\u0026nbsp;Execution of daily management.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"8.415300546448087%\" valign=\"top\"\u003e\n \u003cp\u003eOutput data\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.51366120218579%\" valign=\"top\"\u003e\n \u003cp\u003eValue stream map (Current)\u003cbr\u003e\u0026nbsp;Current problem\u003cbr\u003e\u0026nbsp;Request\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eTools used for the 5 visualizations.\u003cbr\u003e\u0026nbsp;Value stream map (Future)\u003cbr\u003e\u0026nbsp;Standard work\u003cbr\u003e\u0026nbsp;Spaghetti chart\u003cbr\u003e\u0026nbsp;Root cause analysis\u003cbr\u003e\u0026nbsp;Brain storming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.060109289617486%\" valign=\"top\"\u003e\n \u003cp\u003eEnvironmental improvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.950819672131146%\" valign=\"top\"\u003e\n \u003cp\u003eEvaluation board that serves as an index\u003cbr\u003e\u0026nbsp;Sustainable improvement plan\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Radiological technologist team structure and role changes\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e・Conventional Team Structure (12 \u0026nbsp; \u0026nbsp; radiological technologists in total)\u003cbr\u003e\u0026nbsp; \u0026nbsp; General Outpatient Center (4 MRI units): 8 radiological technologists (2 \u0026nbsp; \u0026nbsp; radiological technologists/unit)\u003cbr\u003e\u0026nbsp; \u0026nbsp; Central Ward (2 MRI units): 4 radiological technologists (2 radiological technologists/unit)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e・Team Structure After Improvement(12 \u0026nbsp; \u0026nbsp; radiological technologists in total)\u003cbr\u003e\u0026nbsp; \u0026nbsp; General Outpatient Center (4 MRI units): 6 radiological technologists (4 operators, 1 controller, 1 libero)\u003cbr\u003e\u0026nbsp; \u0026nbsp; Central Ward (2 MRI units): 3 radiological technologists (2 \u0026nbsp; \u0026nbsp; operators, 1 controller)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eOperator: Responsible for MRI examination operations\u003cbr\u003e\u0026nbsp;Controller: Understands the entire examination room and issues instructions to staff\u0026nbsp;\u003cbr\u003e\u0026nbsp;Libero: Assists the operator\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Functions of the centralized progress management system\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e[Functions of the centralized progress management system\u003c/strong\u003e]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eOverview: Receive information from the radiology \u0026nbsp;information system in real time.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Information such as medical interview, preparation status of MRI examination, and examination in progress can be viewed at a glance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eUpper half of the screen: Displays the progress of MRI examinations currently being performed．\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Used for the purpose of sharing information from the operator to the controller.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Displays the progress of the examination, remaining time, physical information, patients scheduled for the next examination.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;The remaining time for MRI imaging can be changed in 5-minute increments. The exact remaining time can be shared with the controller.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Displays the next patient name indicated by the controller.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003eLower half of the screen: Displays a list of patients currently waiting for examination\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Used by controllers to give instructions to operators and other staff.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;Displays waiting time, preparation status, next inspection device, etc. As for the waiting time, it is possible to grasp both the elapsed time from the reservation time and the elapsed time from the reception.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026bull;The preparation status can be set as interviewing, before needle insertion, preparation completed, or absent, and the controller can grasp the patient\u0026apos;s preparation status at a glance.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lean Thinking, MRI, Quality improvement, Kaizen, radiology","lastPublishedDoi":"10.21203/rs.3.rs-4377997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4377997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIn this study, behavioral analysis and improvement plans were performed using Lean Thinking. Utilizing information and communication technology, we considered improving and increasing the utilization rate of magnetic resonance imaging (MRI) examination reservation slots, reducing the number of days waiting for reservations, and reducing examination reservations to other facilities. We visualized the workflow using four tools: Value Stream Map, Standard work, Spaghetti chart, and root cause analysis. Brainstorming was implemented to formulate an improvement plan, which a weekly 15-min meeting was held to discuss daily management and further improvement plans. The number of examination reservations and examinations performed increased by 26% and 19%, respectively, after implementing the improvement plans than before. Furthermore, as detailed improvements continued through daily management, the number of examination reservations s and examinations performed increased by 34% and 28%, respectively, compared with before implementing the improvement plans. The number of waiting days for reservations decreased from an average of 45 days to an average of 5 days, and the number of examination reservations to other facilities reduced from 300 per month to 50 per month. Lean Thinking improves and increases the utilization rate of MRI examination reservation slots, reduces the number of waiting days for reservations, and reduces examination reservations to other facilities. Therefore, it could be applied to improve the throughput in the daily work of medical institutions and the work of the operation system. In addition, using daily management to turn the cycle of Lean Thinking is an important factor in improving operations.\u003c/p\u003e","manuscriptTitle":"Development of a centralized progress management system using lean thinking and efforts to improve operations","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-04 21:52:23","doi":"10.21203/rs.3.rs-4377997/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-22T08:28:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-22T04:40:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-20T13:27:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-05-06T15:43:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a2b233c1-1f2b-4953-ae0c-4d3134445a89","owner":[],"postedDate":"June 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-29T16:08:05+00:00","versionOfRecord":{"articleIdentity":"rs-4377997","link":"https://doi.org/10.1186/s12913-025-13644-2","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-12-24 15:58:05","publishedOnDateReadable":"December 24th, 2025"},"versionCreatedAt":"2024-06-04 21:52:23","video":"","vorDoi":"10.1186/s12913-025-13644-2","vorDoiUrl":"https://doi.org/10.1186/s12913-025-13644-2","workflowStages":[]},"version":"v1","identity":"rs-4377997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4377997","identity":"rs-4377997","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}