Inbound hospital material logistics - goederenlogistiek naar ziekenhuizen

Delft University of Technology

FACULTY MECHANICAL, MARITIME AND MATERIALS ENGINEERING

Department Marine and Transport Technology Mekelweg 2 2628 CD Delft the Netherlands Phone +31 (0)15-2782889 Fax +31 (0)15-2781397 www.mtt.tudelft.nl

This report consists of 29 pages and 4 appendices. It may only be reproduced literally and as a whole. For commercial purposes only with written authorization of Delft University of Technology. Requests for consult are only taken into consideration under the condition that the applicant denies all legal rights on liabilities concerning the contents of the advice.

Specialization: Transport Engineering and Logistics

Report number: 2015.TEL.7917

Title:

Inbound hospital material

logistics

Author:

B.R.E. Rinsma

Title (in Dutch) Goederenlogistiek naar ziekenhuizen

Assignment: Design assignment

Confidential: no

Initiator (university): prof.dr.ir. G. Lodewijks Initiator (company): E. Raap (DENC)

Supervisor: Dr. W.A.A. Beelaerts van Blokland

Delft University of Technology

FACULTY OF MECHANICAL, MARITIME AND MATERIALS ENGINEERING

Department of Marine and Transport Technology Mekelweg 2 2628 CD Delft the Netherlands Phone +31 (0)15-2782889 Fax +31 (0)15-2781397 www.mtt.tudelft.nl

Student: Bart Rinsma Assignment type: Research

Supervisor: Dr. W.W.A. Beelaerts van Blokland

Report number: 2015.TEL.7917

Specialization: TEL Confidential: No

Creditpoints (EC): 15

Subject: Inbound hospital material logistics

Within health care logistics a lot of improvement is possible according to a report published 10 years ago: “Het kan echt: zorg voor minder geld” (Bakker, 2004). Two of the most important improvements can be made by distributing the supplies in a central distribution center by a specialized company and by combining purchase volumes.

This assignment is a research prior to a master thesis project about the optimization of the distribution location(s) for articles such as medicines, medical supplies, medical instruments, food and personal hygiene, office supplies and laundry. This research assignment is done in collaboration with DENC (distribution logistics) and RedOrange (specialist in purchasing).

The focus of this assignment is about understanding the inbound hospital logistic process and the opportunities in this process. Inbound hospital logistics in this research is bounded to the actual material transport.

The following steps must be addressed in this research:

 Gather information and data about inbound hospital material flows;

 Information and data study, create flow charts and determine opportunities;  Design a future materials supply and demand model to hospitals;

 Apply the future inbound hospital material logistics model to a case;

It is expected that you conclude with recommendations for future applicable opportunities based on the results of this study.

This report should be arranged in such a way that all data is structurally presented in graphs, tables, and lists with belonging descriptions and explanations in text.

The report should comply with the guidelines of the section. Details can be found on the website. The supervisor,

S

UMMARY

In the Netherlands there are a lot of opportunities for improvement in the health care industry. This indus-try must improve, because health insurers (patients), nowadays, have higher demands from hospitals. News feeds are often about hospital money issues for their main tasks, curing and caring people. The material lo-gistic process towards hospitals is not a main task for hospitals, but is required to support their main task. By improving hospital material logistic processes, hospitals can reduce costs at the inbound process and im-prove their main tasks.

Previously, hospitals have their own central storage areas. Hospitals nowadays still use central storage areas. The focus of this research is the opportunity of outsourcing the hospitals central storage area for multiple hospitals on a central location. This research includes only instruments, linen, food, medical and office sup-plies.

Four different inbound hospital material logistic processes are often found. Each material category has it’s own material logistic process.

• Direct delivery from supplier to hospital.

• Delivery from supplier via distribution centre (DC) to hospital.

• Material recycling at hospital.

• Material recycling outsourced to specialized company.

Each process has it’s own advantages and disadvantages over other processes. Optimal transportation meth-ods must be determined by certain case studies. There are some improvement opportunities not directly related to a certain case and are used to determine a general future material logistic process. These improve-ments are based on the current process and material supplies to hospitals

• Use tier-one suppliers to supply the majority of materials instead of a lot of different suppliers.

• Sort materials at the start of the process instead of in-between or at the end.

• Standardize materials. Use less different brands, but keep the required variety of types.

• Create partnerships between hospitals to increase purchase volumes and decrease transport kilome-tres.

• Use different truck sizes and types.

Decreasing transport is not only based on above mentioned improvements, but is also related to the central location from where hospitals are supplied. This central location can be calculated by using the number of supplies for a certain hospital as a weight factor. Material consumption information from a couple different hospitals can be used to determine a correlation between hospital characteristics and the number of sup-plies. This correlation can be used to estimate the number of supplies for hospitals that have no information available.

There is still a lot of research to be done in the health care industry, but it is certain there are a lot of im-provement opportunities in inbound hospital material logistic processes.

C

ONTENTS

3 Methodology & literature 7 3.1 Delft Systems Approach. . . 7

3.2 The Toyota way of lean organizing . . . 8

3.3 Distribution centres & warehouses . . . 8

3.4 Importance of partnerships. . . 9

4 Material logistic model 11 4.1 Different flows . . . 11

4.2 Different models . . . 11

4.2.1 Direct delivery. . . 11

4.2.2 Delivery via distribution centre (DC). . . 12

4.2.3 Recycle material . . . 12

4.3 Hagaziekenhuis. . . 13

4.4 Opportunities. . . 14

5 Material standardization & delivery opportunities 15 5.1 Data. . . 15

5.2 Different suppliers . . . 16

5.3 Opportunities. . . 18

6 Future material logistic model 19 6.1 Analysis. . . 19

6.1.1 Toyota . . . 19

6.1.2 Importance of partnerships . . . 19

6.1.3 Analysis conclusion and new general model. . . 20

6.2 Case. . . 20

6.2.1 Relations. . . 21

6.2.2 Hospital locations . . . 21

6.2.3 Case model . . . 22

7 Conclusion & recommendations 25

Bibliography 29 A Appendix A 31 B Appendix B 35 C Appendix C 37 D Appendix D 49 2015.TEL.7917 iii

1

I

NTRODUCTION

Health care industry in the Netherlands is a very premature industry, which means there is a lot of room for improvement. This industry is undergoing tremendous transformations, because health insurers (patients) are not quiet any more [1]. Health insurers choose hospitals, doctors treatments and healthcare institutions. More and more the health care institutions need to meet health insurers requirements. According [2], which was published 10 years ago there are, out of all improvement possibilities, two important opportunities in the material inbound section:

• Supply distribution from a central distribution centre for multiple clients

• Standardized goods

The health care industry can be distinguished into two different branches, cure and care. The focus of this research is the cure industry, which means hospitals. The main research question is based on these two important improvements in the cure industry.

How is a future inbound hospital material logistic process organized when looking at current inbound hospital material logistics opportunities?

To answer this research question, a set of sub-questions have been formulated and must be awnsered. The following four sub-questions have been formulated:

Question 1 How are the inbound hospital logistics organized nowadays and are hospitals working together? Question 2 Is it possible to standardize materials used by the hospitals?

Question 3 What is the effect of using tier-one suppliers on the inbound hospital logistics? Question 4 How will the location a distribution centre for hospitals be determined?

Within the cure industry, a lot of materials are used. To answer these questions the focus will be on a couple of inbound hospital material flow categories.

• Medical supplies (disposables)

• Instruments

• Linen

• Food

• Office supplies

In the next chapter, background information and literature, relevant for this research project, is discussed. The first research chapter is about material flow processes nowadays, which are discussed and evaluated. The next step is to analyse more detailed data about material and suppliers. This will be used to determine supplier opportunities and material standardization opportunities. These chapters will both cover the sup-porting questions and the outcomes of the questions will be used to determine a general future material logistic model. The general future material logistic model will be applied to a case with 5 hospitals to explain the general future material logistic model in more detail. It also provides a specific future material logistic model for a specific situation.

2

B

ACKGROUND INFORMATION

This chapter provides relevant background information for the research. First the project approach is de-scribed, which contains company names and congresses, who played a big role in gathering information for the research. Then the hospital types are discussed to set the hospital scope. Within suppliers there are al-ready some organisations distinguishing their supply method from others. Such an organization (Zorgservice XL) plays a role in the case study (section 6.2).

2.1.

P

ROJECT APPROACH

The hospital material logistic process is a relative unexplored topic, which made industry visits obligatory. Companies, related to hospital logistics, visited are:

• DENC • RedOrange • Mediq/Medeco • TU Delft • Zorgservice XL • Combi-Ster • Hagaziekenhuis

• De Boer Logistic Solutions

• Leiden University Medical Centre (LUMC)

These companies provided information about their processes and the relation between their processes and hospital processes. Each company was visited with the question lists inAppendix C. These question lists was used as a conversation guideline. Within Hagaziekenhuis a logistics manager and a cardiologist where consulted. The cardiologist was consulted to explain his opinion on material standardization.

Different supply chain and health care specialists attend at events. Events are the opportunity to gather in-formation and opinions from a lot of different people in a short time. The visited events are:

• International Supply Management Congress 2014 (ISMC) (November, 11th)

• Logiz networking event (Rivas/King) "Kruispunt van stromen: Integratie van cure en care, patient, client- en goederenprocessen." (November, 20th)

Both events where very different. The ISMC was an event with a lot of supply chain managers of big compa-nies all over the world, e.g. ASML, Shell, Unilever, Mars and a lot more. This event was about partnerships and the importance of partnerships for sustainable process improvements, which will be discussed more detailed inchapter 3. The Logiz networking event was an event with the focus on health care logistics. The people who attended this event where more specialized in health care logistics and provided more detailed information about current care industry process and improvements.

2.2.

H

OSPITALS

There are different hospital types in the Netherlands, to provide cure and care for patients. Common hospital types are general hospitals, academical hospitals, outpatient clinics and private hospitals. In the Netherlands

4 2.BACKGROUND INFORMATION

there are 131 hospitals (general and academical) and 112 outpatient clinics [3]. The scope of the research is limited to the bigger hospital groups:

• General hospitals

• Academical hospitals

These hospitals are organized in 85 organisations of which 8 academical organisations. Multiple hospitals in a single organization often have commonalities in suppliers and in their processes. Figure 2.1shows the location of all hospitals in the Netherlands.

Figure 2.1: Hospitals in the Netherlands

This figure does not contain hospital names and other hospital details. Appendix Bcontains a detailed lo-cation pictures of the hospitals by their labels. InAppendix Aa table is provided with all the general and academical hospitals in the Netherlands, with labels and year figures. These labels are related to the picture inAppendix A.

2.3.

Z

ORGSERVICE

XL

Zorgservice XL is owned by 5 hospitals, working together in decreasing material transport and storage costs [4]. There are currently 5 hospitals working together with Zorgservice XL, which each have their share in the organization:

• Sint Franciscus Gasthuis

• Reinier de Graaf Gasthuis

• Hagaziekenhuis

• IJseland ziekenhuis

• Vlietland ziekenhuis

2.3.ZORGSERVICEXL 5

These hospitals do not have to sign multiple contracts, but they can sign one contract with Zorgservice XL to provide long shelf life food, medical, household and office supplies (disposables). Zorgservice XL does not only supply materials (logistics), but also covers purchasing and invoicing.

Because Zorgservice XL is owned by the 5 different hospitals, they have low VAT (6%) for hospitals instead of 21% applicable to other companies [5].

3

M

ETHODOLOGY

&

LITERATURE

This chapter will give insight in the methodology and literature used to analyse the current state and the future state inbound hospital logistics model.

• Delft Systems Approach (DSA)

• The Toyota way of lean organizing

• Distribution centres & warehouses

• Importance of partnerships

Delft Systems Approach (DSA) is used to create a schematic presentation of the flow dimensions and

orien-tation in a system. In a system there are value-add, business value-add and non value-add processes, where non value-add processes can be related to the "types of waste" described by the Toyota way of lean organizing. Literature about distribution centres & warehouses, is related to the main research question about outsourcing and merging storage. The last topic is about partnership, which is not frequently mentioned but developing term. This is not scientific, but a supported term by multiple supply chain managers.

3.1.

D

ELFT

S

YSTEMS

A

PPROACH

The DSA is a way of thinking, to see systems and processes in a structured way and understand valuable steps. A process is defined, in order to define what happens in a specific function. A system or process (often) has multiple levels with sub-systems and sub-processes. There is no fixed number of levels, but this method allows zooming in on the features of a system, while other sub-systems (sub-processes) could be considered as a black box. The result is simple: a scheme of black-boxes positioned in the order of the flows and steps in the main system. [6]Figure 3.1is a scheme zoomed in on the inbound material logistic process box, with their own black-boxes.

Figure 3.1: Start hospital model

This scheme is used as a standard process model and shows the flows entering and exiting the system. Each material category, mentioned inchapter 1, has it’s own process which can be modelled by using this model as a basis model.

According to In ’t Veld ([7]), the DSA is limited to the capabilities of the modeller and thus modelling com-plex systems, Bounding class 4 or higher. This means that this method can not be used for modelling the behaviour of groups, organizations or even complex systems [8].

8 3.METHODOLOGY&LITERATURE

3.2.

T

HE

T

OYOTA WAY OF LEAN ORGANIZING

The book The Toyota Way by Jeffrey K. Liker, explains 14 principles of Toyota’s way of lean organizing. These principles are about long term philosophy, reducing/eliminating waste, excel people and solving problems [9]. The two principles mentioned below are applicable to this research.

• The long term philosophy, improving for a longer term instead of small short term improvements.

• Decrease waste by using TIMWOOD (section 3.2) and pull by hospitals instead of push by suppliers. The first principle is a principle which needs to be taken into account making choices. This principle is taken into account, but is not mentioned during the research. The second principle, about waste and pull, is used and mentioned in this research.

Toyota uses a third to an eighth of the suppliers a traditional U.S. car manufacturer uses [10]. Toyota is sup-plied by tier-one suppliers, who deliver all products required. Behind tier-one suppliers are tier-two suppli-ers, who deliver products to tier-one supplier. Behind tier-two suppliers are also different supplisuppli-ers, so a tree model is created. The trunk (Toyota) is supplied by the big branches (tier-one suppliers) which are supplied by the smaller branches (tier-two suppliers) etcetera.

T

According Lean theories, several types of "waste" can be distinguished. "Waste" is any step or action in a process that is not required to complete a process (called “Non Value-Adding”) successfully. When "waste" is removed, only the steps that are required (called “Value-Adding”) to deliver a satisfactory product or service to the customer remain in the process [11]. The types of waste are combined in one word "TIMWOOD".

• Transportation • Inventory • Motion • Waiting • Over-production • Over-processing • Defects

"Skill" is a waste, mentioned more and more nowadays [11]. Underutilizing people’s talents, skills and knowl-edge is a waste. Also people doing jobs which they are not educated and trained for can be a waste, mistakes are made and process times can be longer.

During the research multiple types of waste are identified, which being present in the current system. They come back during the rest of the report and an explanation is given for why they are applicable to the problem.

3.3.

D

ISTRIBUTION CENTRES

&

WAREHOUSES

DCs and warehouses can full-fill multiple tasks, e.g. storage and cross-docking, but are not always necessary. There are different reasons to use DCs and there are different types.

DCs and warehouses are used for the following reasons [12]:

• To better match supply with customer demand.

The demand of customers changes and a DC where products are stored, can still deliver when de-mand rises.

• To consolidate product.

When shipments are small they can be consolidated at a warehouse to reduce the number of ship-ments and create larger shipship-ments to hospitals.

• To provide value-added processing.

Value can be added in warehouses e.g. adding identification to products from different suppliers, so they can be tracked and traced through the system. But also assembly can be done in this process to create a whole system out of subsystems.

The different reasons mentioned above are used during the research to explain why DCs are preferred. Also what types of DCs are preferred is discussed, but are explained below first.

Different types of DCs:

3.4.IMPORTANCE OF PARTNERSHIPS 9

• Retail DC.

This type of DC has as immediate customer retail stores. Shipments leave these DCs daily and con-tain multiple different products.

• Service parts DC.

They are used to store spare parts for very expensive equipment e.g. AMSLs DCs all over the world. They store spare parts for equipment, because when their machines are down it costs hundreds of Euros per second.

• Catalogue fulfilment or e-commerce DC.

These DCs receive small orders from individuals by webshop order, mail or phone. The orders are send to individuals by own courier or a third party courier.

• 3PL DC

A 3PL DC might service different customers from one DC and is not owned by the one selling the products.

There are different combinations possible, e.g. PostNL. PostNL has e-commerce DCs but they are not selling their own products from these DCs. This means these DCs are combinations of e-commerce and 3PL DCs.

3.4.

I

MPORTANCE OF PARTNERSHIPS

As mentioned earlier, the ISMC 2014 was about partnerships. Multiple different companies e.g. Unilever, Mars, Shell, ASML and a lot more, explained their thoughts about partnerships. Chief Sustainability Officer from Mars and managing director from Cargill talked about problems because of low and decreasing supply of cocoa in the world. Mars (recipient) is starting a programme with competitors e.g. Nestlé (recipient com-petitor) to make cocoa more sustainable, by investing in cocoa farmers (first supplier) and creating the will to be a cocoa farmer by supporting them. Also Cargill (second supplier) is involved in this process, because they are the supplier (actual transporter) of cocoa to the rest of the world.

Nowadays partnerships become more and more important. This means partnerships between suppliers and recipients, but also between suppliers and recipients themselves. Working as partners instead of as competi-tors by squeezing every last penny out of suppliers, requires a mindset change. Frequent occurring obstacles in partnerships, which are related to the mindset change are:

• Trust

• Understanding

The will to work together is there most of the time, but there must be trust between (potential) partners and understanding about what (potential) partners desire.

Between Toyota and their tier-one suppliers, as explained insection 3.2, there is a partnership. This means that the importance of partnership also is a part of the Toyota way of lean organizing.

Although importance of partnership is not scientific substantiated (in this report), there are a lot of supply chain experts who confirm that partnership is important. Because the hospital industry, especially procure-ment, is about relations with their suppliers, the importance of partnerships is kept in mind throughout this research.

4

M

ATERIAL LOGISTIC MODEL

In the Netherlands there are different material supply chain models for hospitals. Some hospitals have differ-ent logistical suppliers and others use one logistical supplier to transport materials from multiple suppliers. In the following sections different process maps, which apply, will be addressed.

4.1.

D

IFFERENT FLOWS

There are a lot of different articles delivered to a hospital every day, which is addressed inchapter 5in detail. As mentioned earlier the articles can be categorized.

• Medical supplies (disposables)

• Instruments

• Linen

• Food

• Office supplies

Different flow models can be created for each category. Each flow model is explained insection 4.2.

4.2.

D

IFFERENT MODELS

A lot of different material logistic processes exist for hospitals, because of the large variety of hospitals and hospital organisations. A lot of hospitals have their own processes, which are different from other hospitals. Four different processes are used often and are explained with flow models.

• Direct delivery

• Delivery via DC

• Internal material recycling

• External material recycling

These four flow models are discussed in the following subsections.

4.2.1.

D

A couple of years ago, a lot of hospitals had direct delivery from their suppliers, as shown inFigure 4.1. These suppliers delivered to a central storage area in the hospital where everything was stored and sorted for the different hospital departments [13].

Figure 4.1: Direct delivery material logistic model

12 4.MATERIAL LOGISTIC MODEL

This means a lot of different trucks, each from a different supplier, arrived at the hospital. Still a lot of hospitals have their material logistic process organized this way, but more and more hospitals are using an external hub. This flow model applies to multiple categories: medical supplies (disposables), office, facility supplies and food. The external hub flow model will be further addressed insubsection 4.2.2.

4.2.2.

D

(DC)

Nowadays the number of hospitals having a DC in the chain, between them and their supplier, is growing. This gives the flow model as present inFigure 4.2.

Figure 4.2: Material logistic with DC model

Multiple hospitals have a common DC in the chain for different materials and goods. Materials to which this model applies are medical supplies (disposables), office, facility supplies and food. Medical supplies, office supplies, facility supplies and long shelf life food can be stored at a DC. Fresh and frozen food are delivered directly to hospitals, because it must be cooled or/and it must be consumed in a short time. Category deliver-ies are consolidated in DCs to decrease transport to hospitals. There are still direct deliverdeliver-ies from suppliers to hospitals for emergencies and short shelf life food.

4.2.3.

R

Linen and medical instruments are cleaned and reused. This requires a different process, because less waste (worn out linen or instruments) leaves the process. For instruments, most hospitals have their material flow as shown inFigure 4.3[14]. Some hospitals tried to outsource instrument cleaning as shown inFigure 4.4, but ended up doing it themselves. The main reason for hospitals, to do cleaning themselves, is because they want full control over their instruments. Doctors and surgeons need their instruments to cure people and safe lives. Missing instruments can cost lives, which should be avoided at all times.

Figure 4.3: Intern recycle materials

Linen cleaning is almost always outsourced, which results in the process flow shown inFigure 4.4. This flow model also applies to instruments, for some hospitals, but this requires for a certain amount of instruments for hospitals [14]. Hospitals outsourcing instrument cleaning, require more instruments than when they clean it themselves.

Figure 4.4: External recycle materials

Instruments are packed per net. Each net contains certain instruments for a certain procedure. Instrument 2015.TEL.7917

4.3.HAGAZIEKENHUIS 13

net cleaning takes around 3 hours and 30 minutes at a hospital, but around 7 hours and 30 minutes when outsourced. This is because at a hospital, dirty nets can be cleaned almost directly. When outsourced nets require transport and waiting time for an available spot in the system. Used nets still must be cleaned after a certain amount of time, because dirt residues cure to instruments.

To get a better understanding about the material flow quantities to hospitals, some information was provided by the Hagaziekenhuis [15].section 4.3shows the flows to a specific hospital.

4.3.

H

AGAZIEKENHUIS

The Hagaziekenhuis is located in The Hague at Leyweg and Sportlaan. The hospital at the Leyweg is bigger and consumes most materials [15]. Because of low material consumption at Sportlaan and reorganization (merging) of both hospitals, the Hagaziekenhuis will be taken as one hospital.

M

As mentioned earlier insection 2.3, Hagaziekenhuis has a share in Zorgservice XL. Zorgservice XL supplies a large variety and quantity of materials to the hospital. Figure 4.5shows the numbers of roll containers provided per supplier [15].

Figure 4.5: Material flow in and out of Hagaziekenhuis

The Hagaziekenhuis is major consumer of linen and medical, facalitair & office supplies. Food and medical instruments also contribute significantly to the hospitals consumption. Printables are delivered once a week and therefore considered not significant. Printables are mentioned in this section, but will be neglected in the following chapters.

Figure 4.6: Material and good flow for Hagaziekenhuis (larger figure inAppendix D)

14 4.MATERIAL LOGISTIC MODEL

Figure 4.6shows the main suppliers and how the material flow is organized. Flow models, explained in sec-tion 4.1, are combined into one flow model applicable to the Hagaziekenhuis.

Some materials, supplied by Zorgservice XL, are stored at Zorgservice XL and others cross docked. Cross docking means materials delivered by different suppliers and merged with other flows (consolidation) to a certain destination. Zorgservice XL has, as explained earlier insection 2.3, multiple suppliers to provide all materials for the hospitals. Deli XL and Ricoh also have different suppliers to produce and provide materials. Combi-Ster and A.W. Rentex clean materials used by the hospital. Sometimes more or different materials are required, which are borrowed from different suppliers.

The Hagaziekenhuis previously used multiple suppliers to meet demands, but nowadays has less suppliers [15]. Zorgservice XL plays a big role in the supplier reduction.

4.4.

O

PPORTUNITIES

Hospitals have or had central storage areas for multiple reasons. A couple of very important reasons are:

• Goods and materials must be on location in time because hospitals are dealing with lives.

• Sorting materials per department.

Having a central storage area in a hospital means a hospital has inventory. Inventory must be minimized, but the two above mentioned reasons for having a central storage area must be kept in mind. When outsourcing the central storage area and sharing it with multiple hospitals, the total inventory will decrease.

Having a DC (central storage area) for multiple hospitals also decreases transport distances. Suppliers deliver products to one DC and do not have to transport to every hospital. If suppliers deliver materials and goods sorted per hospital and per department, the DC only has to merge roll containers from different suppliers (consolidation). This means less motion, because it is already sorted at the beginning of the process. If materials and goods are sorted at the DC, all materials and goods must be taken of roll containers. After taking of the materials, it must be sorted and placed back on roll containers again. This is excessive motion. If materials sorted at the supplier, only material batches must be sorted in the DC, which is easier and faster than sorting all materials. Sorted roll containers are transported to the hospitals and can directly be moved to the departments. Less trucks deliver to the hospitals, because one organization delivers materials from multiple suppliers. This means shipment consolidation at the DC.

Linen and instruments are often owned by hospitals. When cleaning is outsourced for multiple hospitals, washing machines are active more. This means less downtime in the cleaning process.

Outsourcing logistical processes and cleaning process to specialized organizations, often means outsourcing to skilled people. It is assumed that skilled people are trained for specific tasks, which improves processes and process outcomes. Hospitals can focus more on their main task, curing and caring for people.

The types of waste mentioned above are:

• Transport

• Inventory

• Motion

• Waiting

• Skill

These types of waste will be mentioned in further detail with solutions insection 6.1, where a general future material logistic model is introduced.

Not only the processes can be improved, but also improvements can be made in the materials hospitals use. The next chapter is about materials supplied to hospitals and the number of suppliers. This provides a more detailed view of the current state and opportunities.

5

M

ATERIAL STANDARDIZATION

&

DELIVERY

OPPORTUNITIES

To determine if materials entering a hospital can be standardized, the meaning of "material standardization" must be explained and data or information must be gathered.

Material standardization means decreasing the number of brands but keeping a certain required amount of material types. To determine material standardization and delivery opportunities, data was provided by RedOrange.

5.1.

D

ATA

The data provided by RedOrange had no hospital identification information, because it is sensitive infor-mation. It contained material flow information about 11 general hospitals, big, small and located in the Netherlands. The dataset contained data about orders for medical disposables, food, office supplies, medical equipment and implants for the years 2012 and 2013.

The data provided by RedOrange was already cleansed, but not structured and contained not reliable data. In order to use the dataset it was handled according the method shown inFigure 5.1.

Figure 5.1: Data handling model

First the data was structured and the AS IS state was studied. Then the data was filtered to set the scope and identify material standardization and delivery opportunities. This reduced the amount of data which made it possible to analyse and conclude with opportunities and recommendations.

16 5.MATERIAL STANDARDIZATION&DELIVERY OPPORTUNITIES

5.2.

D

IFFERENT SUPPLIERS

Before analysing the data, a distinction between suppliers and logistic distributor must be made. Suppliers are the different companies selling materials. Logistic distributor is the organization transporting materials. In some cases the supplier is also the logistic distributor, but this is mentioned clearly in this study if it is applicable.

Company visits and interviews already made clear; some hospitals still have a lot of suppliers. The data about the eleven hospitals confirms this statement. These hospitals together have 9799 different suppliers. Some hospitals in this data have one logistic distributor for multiple suppliers, but there are also suppliers delivering materials to hospitals.

Figure 5.2: Number of suppliers per hospital for 2012 and 2013

Figure 5.2shows that almost each hospital has over 1000 different suppliers, which is a large amount of dif-ferent suppliers. Not all suppliers provide a large number of materials to hospitals. Figure 5.3andTable 5.1

provide a better understanding about the quantities provided per number of suppliers.

Figure 5.3: Supplier delivery percentage

Table 5.1: Number of deliveries related to number of suppliers Different suppliers Article top percentage 9799 100% 210 90% 89 80% 46 70% 26 60% 16 50% 10 40% 6 30% 3 20% 1 10%

The figure and table above shows that only 210 (of the 9799) suppliers provide 90% of the total materials, which is a supplier decrease of almost 98%. This means there are a lot of suppliers which do not deliver a significant amount of materials.

The top 30 suppliers cover between 60% and 70% of the materials supplied to hospitals. Suppliers are plotted on the x-axis against the number of articles supplied on the y-axis, as shown inFigure 5.4. It is clear there is still a big difference between the number 30 supplier and the number 1 supplier.

5.2.DIFFERENT SUPPLIERS 17

Figure 5.4: Top 30 suppliers to the hospitals and the number of materials and goods delivered

There are two top suppliers, Deli XL (food) and Medeco (medical supplies). InFigure 5.4the number of sup-plies per supplier is decreasing from left to right with the factor ex. This means the top suppliers provide a large, significant amount of materials for hospitals.

Each supplier delivers their own material categories.Table 5.2shows the suppliers and the number of suppli-ers (out of the top 30) per category.

Table 5.2: Categorized top 30 suppliers

Medical equipment and implants are out of scope and will not be further addressed. Multiple companies have multiple material categories they can provide, e.g. M3 and Medeco. They both provide in medical supplies and instruments. Linen and pharmaceutics are not present in the data. The two main suppliers for linen are Clean Lease and Lips [5]. The top 10 suppliers provide a significant number of materials and is discussed more detailed in the next subsection.

T

10

To determine if one or multiple suppliers are in the overall top 10 because they provide a large amount for one hospital and do not provide for other hospitals,Table 5.3is created. This table is also a way to ensure the data used is reliable and conclusions can be made from this dataset.

18 5.MATERIAL STANDARDIZATION&DELIVERY OPPORTUNITIES Table 5.3: Top 10 suppliers per hospital compared to overall top 10 suppliers

The most right column shows the overall top 10 suppliers, which are coloured. The other columns show the top 10 suppliers per hospital in which the overall top 10 suppliers are highlighted with the corresponding colour of the supplier in the overall top 10. The table below (Table 5.4) shows how many hospitals a supplier provide materials for.

Table 5.4: The number of hospitals the suppliers do provide materials and goods for

Suppliers Number of hospitals DELI XL 8 MEDECO 8 B. BRAUN MEDICAL 4 v. Hoeckel 6 BSN MEDICAL 8 MEDLINE 3 MEDICA EUROPE 2 LYRECO 7 Becton Dickinson BV 3 BUNZL KING 4

With this table can be concluded that every supplier provides materials for multiple hospitals. This means there are no suppliers in the overall top 10 because they provide a large amount of materials to a single hos-pital.

5.3.

O

PPORTUNITIES

There are a lot of different suppliers, but 98% of the suppliers provide the bottom 10% products and 99,1% deliver the bottom 20% products. This clearly indicates that the Toyota way of choosing suppliers is possible. This means tier-one suppliers deliver all products required for hospitals. Each tier-one supplier has their own suppliers (tier-two) to provide all other products tier-one suppliers do not have, but must supply.

Insection 4.4is stated that a DC decreases transport distances and motion. A DC can also be owned by the tier-one supplier. A tier-two supplier only has to deliver from a central location to DC, from where it can be picked, sorted and supplied to hospitals. This also ensures faster emergency deliveries, which are not uncommon for hospitals.

Table 5.3andTable 5.4indicate that the overall top 10 suppliers supply to multiple hospitals. This means hospitals are already familiar with the suppliers when choosing tier-one suppliers and combining purchase volumes for multiple hospitals.

6

F

UTURE MATERIAL LOGISTIC MODEL

chapter 4andchapter 5explained how the current logistics are organized and the opportunities. There are four hospital material logistic models for the material categories in scope. To determine a general future material logistic model, the opportunities mentioned earlier will be discussed in more depth insection 6.1.

6.1.

A

NALYSIS

In this section an analysis is done on the current situations and earlier mentioned opportunities in relation with the theory explained inchapter 3.

6.1.1.

T

Toyota literature applicable to the current material logistic model is about using tier-one suppliers instead of multiple different suppliers and reducing types of waste.

Hospitals use a lot of different suppliers for a lot of different materials. This indicates that a lot of differ-ent trucks arrive at hospitals and a lot of transport kilometres. Trucks not loaded to their maximum capacity, transport a lot of air, which means high kilometre costs per roll container. By reducing the number of different suppliers (per category) and using only tier-one suppliers the number of trucks arriving at hospitals reduce. Using more of the trucks capacity, reduces transport costs per roll container. The waste factor "transport" is reduced, by reducing the total kilometres and utilizing more of the trucks capacity. Another advantage of using tier-one suppliers is reduction in costs per material.

Hospitals reducing inventory and outsourcing their central storage area, also reduce motion. Hospitals used to sort all materials, on department, in their central storage area. Tier-one suppliers sorting materials at the beginning of the transport process, reduces sorting time later in the process (at hospitals or DCs). Using tier-one suppliers also has the advantage of more standardized materials. It is possible for hospitals to standardize materials and reduce the number of different article brands. Gloves, for surgeons in operating rooms, are a good example. Choosing three different types of gloves, normal, thick and latex, from one brand should be sufficient in most cases [16]. Normal gloves can be used for normal procedures, thick gloves are required for bone operations and latex gloves provide enough feeling (second skin).

Cleaning equipment in hospitals, especially for instrument sterilization, are often in idle mode. This means they are waiting for materials and goods which need to be cleaned. When cleaning is outsourced to an orga-nization with multiple clients, their machines can be used more optimal. Hospitals do not have to invest in expensive equipment and do not have to train or hire specialized people. Hospitals rely on the skill of people at the organization and the skill of the organization.

6.1.2.

I

Partnerships are very briefly mentioned in the subsection above and can really have impact on reducing types of waste.

Hospitals working together and having the same tier-one suppliers can even reduce the number of wastes further. Less transport and motion because of good planning, lower idle time at cleaning facilities and less inventory because there is an overlap in materials between hospitals. Hospitals do not always need the same

20 6.FUTURE MATERIAL LOGISTIC MODEL

amount of materials, some hospitals need more and others need less. This means materials are more bal-anced against each other. For manufactures it also means there is less over-production, because they know better what will be ordered.

Hospitals using one suppliers, also have a partnership relation with thier one suppliers. These tier-one suppliers create partnerships with tier-two suppliers, which creates a chain of partnerships. Hospitals need suppliers doing their job right and efficient, because this also benefits hospitals. When only hospital processes are optimized, a not adjusted supplier process creates inefficiencies in hospitals processes. This means hospitals and suppliers must work together to create efficient and optimized processes, which can handle irregularities.

6.1.3.

A

There are two changes for improving hospital material logistic processes, visual inFigure 6.1.

• The Toyota preferred supplier system.

• Cooperation between hospitals and purchasing from the same suppliers.

As shown inFigure 6.1, hospital groups have the same suppliers. These suppliers have their own suppliers to meet the hospitals demand fully. Linen and instrument cleaning facilities are in a cycle process. This makes their process different from other one-way processes.

Figure 6.1: Future general hospital logistic model (larger figure inAppendix D)

This model is a general model to visualize the optimization changes. Each hospital needs materials, one more than the other. This means further optimization must be done in depth for each hospital group, which results in different models for different groups. In order to create a specific hospital logistic model a case with 5 hospitals is done insection 6.2.

6.2.

C

ASE

Five hospitals in the South-Holland region are used to determine a specific future material handling model. Some assumptions are made, which are clarified throughout this section.

One of the five hospitals has provided information about the number of roll containers received per certain amount of time. For the other hospitals a number of roll containers supplied is estimated. This is done according a correlation between hospital characteristics and materials used by these hospitals.

6.2.CASE 21

6.2.1.

R

There is a relation between hospitals characteristics (Appendix A) and the number of materials delivered to hospitals [15]. The exact correlations must be determined with more hospital materials and goods data. In this research obvious correlations will be used.

An assumption is made that there is a relation between the number of medical & office supplies and medical instruments used by hospitals and the number of total outpatient visits. More outpatient visits might also require more medical supplies, office supplies and medical instruments. Not all patients require a bed, so for linen and food an other correlation is more obvious. For linen and food the assumption is that there is a relation between the amount of linen and food required and the number of beds occupied. The exact relation between hospital characteristics and number of materials used must be determined in further research and verified and validated with more information and data about other hospitals.

Table 6.1shows the number of beds, bed occupancy, total outpatient visits and the number of containers per hospital (rounded up). Printables is not considered in this research, because 2 roll containers per week not significant compared to other flows inFigure 4.5.

Table 6.1: Relation between hospital beds and number of containers

Number of containers per day

# Hospital Number of beds Bed occu-pancy Total out-patient visits Medical & office supplies Medical instruments Linen Food

1 Sint Franciscus Gasthuis 472 84% 181.459 23 7 47 8

2 Reinier de Graaf Gasthuis 881 41% 412.489 52 15 43 7

3 Hagaziekenhuis 803 80% 510.000 64 18 75 12

4 IJseland ziekenhuis 390 83,4% 176.926 23 7 38 7

5 Vlietland ziekenhuis 270 87% 308.058 39 11 28 5

6.2.2.

H

The five hospitals are located close to each other, as shown inFigure 6.2. During the next part of this section, general hospital names are used instead of the real hospital names.

Figure 6.2: Hospital locations geographically

The hospitals are located close to each other; the biggest straight line distance between Hospital 3 and Hospi-tal 4 is 24 km (36 km by road). The geographical location must be used to determine the optimal distribution 2015.TEL.7917

22 6.FUTURE MATERIAL LOGISTIC MODEL

centre location to obtain the smallest transport distance per roll container.

Each hospital gets a certain amount of roll containers delivered. To determine the central location, the amount of roll containers per hospital must be taken into account. The total number of roll containers is used as weight factor to obtain the optimal distribution centre location for the least overall transport kilo-metres. By using the hospitals longitude and latitude (Appendix A) a two dimensional map is created with coordinates.Equation 6.1is used to determine the central locations coordinates [17]. The sum of the number of roll containers supplied to a hospital (mi) multiplied by the coordinates of the hospital (~ri) must de divided

by the total number of roll containers.

~rc= 1 M n X i =1 mi~ri (6.1)

The resulting coordinates (~rc) are the central locations coordinates, with taking into account the number of

roll containers supplied. The central locations coordinates are (51,98778 ; 4,373366) and shown geographi-cally inFigure 6.3.

Figure 6.3: Hospital locations and central location

The central location is the optimal location for a DC to supply materials to hospitals.

6.2.3.

C

There are a lot of different truck types with different load capacities, reaching from 15 roll containers in small trucks, up to 59 roll containers in trucks with trailers [18,19].

Figure 6.4: Truck types, with small truck left and trailer truck right.

Apart from the sizes of trucks and trailers, there are also different types of trucks and trailers [20]:

• not cooled

• cooled up to 7°C

• cooled up to -20°C

6.2.CASE 23

Trucks with different storage zones for each, above mentioned, type exist and are used to reduce transport [20]. These types of trucks must also be used in the new model to maximize the roll container number trans-ported per truck. Using different types of trucks, tier-one suppliers can supply to one DC to merge small truck content into big trucks. DCs are used as storage for tier-one suppliers and cross-dock materials not possible to be store. The advantages of having a DC for multiple tier-one suppliers is shipment consolida-tion, value adding by sorting shipments per hospital and optimize delivery patterns. This means a 3PL type DC in combination with a retail DC is used as shown in the new case model inFigure 6.5.

Figure 6.5: Future general hospital logistic model (larger figure inAppendix D)

Linen is shipped directly, because the loads are large and transport via the DC increases waste (motion). The medical instruments process is a more difficult process, because cleaning of instruments takes time and cleaning must start shortly after use. This means constant/more frequent transport is required for instru-ments.

7

C

ONCLUSION

&

RECOMMENDATIONS

This research aims to answer the following main research question and determine a future inbound hospital material logistic model, based on this research question:

How is a future inbound hospital material logistic process organized when making use of the opportunities in the current inbound hospital material logistics?

And to answer this research question, the following set of sub-questions have been formulated:

1. How are the inbound hospital logistics organized nowadays and are hospitals working together?

Hospitals nowadays change their processes to reduce costs and become more efficient, but still have differ-ent material logistic processes. Some hospitals are more efficidiffer-ent than others, by reducing waste from past processes. Different material logistic processes for hospitals are:

• Direct delivery (Figure 4.1)

• Delivery via distribution centre (DC) (Figure 4.2)

• Internal material recycle (Figure 4.3)

• External material recycle (Figure 4.4)

More and more hospitals want delivery via DC to reduce the number of trucks arriving at the hospital, be-cause roll containers can be consolidated. This also gives the opportunity to remove their internal storage area and order materials just in time (JIT).

Linen and instruments are cleaned and used again. Linen cleaning is often outsourced, but instruments is of-ten cleaned at the hospital. One of the reasons for cleaning the instruments at the hospital is that instruments are needed to operate and safe lives. If emergencies occure and hospitals do not have their instruments peo-ple can die and the reason can not be that there where no clean instruments.

Some hospitals already work together and order materials in one bill from the same supplier. An organi-zation that does that already is Zorgservice XL, which does it for 5 hospitals in the same region. This gives the opportunity to increase the amount of materials ordered, increase shipment volume, decrease transport kilometers and decrease cost.

Also sorting of materials is an important topic for this sub-question. Hospitals who get materials from a lot of different suppliers, often have a central storage area. At this central storage area materials are stored and sorted on hospital department. Some hospitals, e.g. hospitals cooperating with Zorgservice XL, already outsourced their central storage area and recieve materials sorted on department. The process of hospitals without central storage area has less motion than hopitals with central storage area. Also inventory is out-sourced and when hospitals work together, the total inventory can also be decreased.

Hospitals need to cooperate with each other, but also with their suppliers. It is also required for suppliers to cooperate with each other for entire supply chain improvement. By changing hospital material logistic processes and decreasing waste, material logistic processes will become more efficient.

26 7.CONCLUSION&RECOMMENDATIONS

2. What is the effect of using tier-one suppliers on the inbound hospital logistics?

Based on the results inchapter 5, hospitals have a lot of different suppliers. The hospitals mentioned in this chapter have over 1000 different suppliers each. Using tier-one suppliers increases the material amount de-livered by per shipment and decreases transport kilometers. This means roll containers can be filled more efficiently and can be sorted on hospital department from the start, to reduce motion.

Processes at suppliers, especially for instruments, are more constant and have higher flow rates, which im-proves efficiency at suppliers and reduces waiting time. Waiting time is a disadvantage, because people still must be paid and equipment which is not running does not add value to the process.

3. Is it possible to standardize materials used by the hospitals?

The analysis inchapter 5not only concludes that hospitals have a lot of different suppliers, but also confirms that hospitals get a lot of different materials. Standardizing materials used by hospitals means using less different brands and types of the same material, but still being able to do the same tasks and handlings as when a lot of different brands and types are used. According the persons interviewed, [5,13–16,21], it is possible to standardize materials used by hospitals, but hospitals do not succeed in standardizing materials. The reason for this is that doctors prefer certain brands and do not want to use other brands they do not favour.

Standardizing materials used by hospitals also makes it easier to use tier-one suppliers, which was in sub-question 2.

4. How will the location a distribution centre for hospitals be determined?

This question is relevant for determining the location from where must be distributed to decrease overall transport per roll container. Not every hospitals requires the same amount of materials (on roll containers), so it is not optimal to just locate the DC in the center of the hospitals. By mapping the hospitals on a 2-dimensional map and giving them a weight factor corresponding with the number of roll containers they get delivered, a weighted center location is calculated.Equation 6.1is used to determine the center coordinates of all hospitals included.

Because it was not possible to gather a lot of data of hospital material supplies in the given amount of time, it was also not possible to determine the exact relation between hospital characteristics and the number of roll containers (materials) supplied to hospitals. As mentioned earlier insubsection 6.2.1, there is a relation. This relation can be used to determine the number of roll containers supplied to hospitals of which no such data is available.

Main research question: How is a future inbound hospital material logistic process organized when looking

at current inbound hospital material logistics opportunities?

With all the sub-questions answered, it becomes possible to answer the main question. At first the opportu-nities will be extracted out of the answers of the subquestions.

• Use tier-one suppliers to supply the majority of materials instead of a lot of different suppliers.

• Sort materials at the start of the process instead of in-between or at the end.

• Standardize materials. Use less different brands and types, but keep the required variety of brands and types.

• Create partnerships between hospitals to increase purchase volumes and decrease transport kilome-tres.

• Use different truck sizes and types, to transport fresh and long shelf-life materials.

Applying these improvement opportunities in an future inbound hospital material logistic model a general model is created inFigure 6.1. Tier-one suppliers provide materials to multiple hospitals and tier-two suppli-ers provide materials to tier-one supplisuppli-ers. Using tier-one supplisuppli-ers makes it also easier to standardize ma-terials and sort mama-terials earlier in the process. A group of hospitals ordering at one supplier also increases the order quantity, which reduces the price per unit. Another advantage of having a group of hospitals, in the same region and with the same suppliers, is that the supplier can transport matials more efficiently to the hospitals by creating an optimal routing plan. To utilize more of trucks capacity, different types of trucks can be used to transport materials which require different temperatures at the same time.

Applying the general future inbound hospital logistic model to certain hospitals (in the same region), the 2015.TEL.7917

27

model changes because it is adjusted to hospital demand. Figure 6.5, shows the future inbound hospital material logistic model. When a specific group of hospitals is used, the central distribution location can be determined by applying the answer of question 4. Applying this method, the coordinate of the central loca-tion is determined, which is shown inFigure 6.3.

There are a lot of opportunities within the hospital material industry. This research above does not cover all the opportunities, because there are a lot more. A couple of recommendations for further research are mentioned in below. These recommendations are based on opportunities noticed during this research and heared during company visits.

R

ECOMMENDATIONS

Because this research is a preliminary study for the master thesis which is about optimizing DC locations for hospitals, there are some recommendations towards the master thesis.

More material information from different hospitals is required to obtain a better relation between hospital characteristics and materials used by hospitals. This makes it possible to study the relation between mate-rials and hospital characteristics based on figures instead of peoples opinions. The relations can be used to determine the inbound volumes for other hospitals.

The hospitals are distributed in the Netherlands with different distances between the hospitals. With the Voronoi cell method areas around hospitals are be created, which can be used to determine clusters of hos-pitals and an optimal location for cluster DCs.

There is still a lot of research required to determine the relations, which would make it possible to determine inbound volumes for hospitals on their characteristics (year figures). These inbound volumes can then be used to determine optimal locations for hospitals.

Most patients in hospitals have appointments and often indicate their health issues in advance. It is pos-sible to make an estimation of the required materials to provide the best help to patients. Creating a link between the hospital database (with anonymous patients) and suppliers, suppliers can anticipate on the ma-terial supplies. Hospital department storage area with a storage database and a counting system might make it possible for suppliers to obtain minimum material levels in these storage areas. More detailed research is required for these opportunities and optimizing the future material logistic model further.

An material category not taken into account is pharmaceuticals. With pharmaceuticals come a lot of reg-ulations, which must be taken into account. This was also the reason to keep it out of scope for this research. A preliminary literature study on pharmaceuticals creates a good basis for a detailed study about pharma-ceutical logistics for opportunities.

B

IBLIOGRAPHY

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A

A

PPENDIX

A

On next page a table is presented with the available information about the general and academic hospitals. This table is a combination of the following sources: [3,22–25].