The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals’ work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.

Use of a Feedback Survey as a Part of a Wellness Champions Program to Improve Academic Faculty Satisfaction and Burnout: Implications for Burnout in Academic Health Centers

Background

Faculty and trainee well-being at academic medical centers is a nationwide concern. In response, the University of Utah Health created a system-wide provider wellness program that used individual faculty champions who were empowered to 1) examine the unique needs of their department or division using a lens of quality improvement, 2) design projects to address well-being, and 3) measure impact of projects addressing well-being. One team used a feedback tool to attempt to improve the well-being of Family Medicine faculty by better understanding challenges and developing a roadmap for action.

Objective

Evaluate the effectiveness of an anonymous feedback tool on faculty well-being.

Methods

The Division of Family Medicine developed and implemented a quarterly anonymous faculty survey to facilitate an ongoing improvement process for faculty wellness in 2016. The faculty survey identified thematic concerns, which were used to develop constructive solutions and systemic changes.

Results

A closed loop feedback structure provided rich faculty input into impacts on burnout and professional well-being. Sense of control (good to optimal) over workload among faculty increased significantly (p = 0.011) from 10% to 42% over one year exhibiting a large effect size (Cohen's h = 0.751). Faculty burnout, using a single item emotional exhaustion question validated to the Maslach Burnout Inventory, was reduced from 48% to 25% showing a medium effect size (Cohen's h = 0.490 with p = 0.097). Work related stress was reduced from 72% to 50% demonstrating clinical significance (Cohen's h = 0.465) but not statistical significance (p = 0.154)-an effect which was more noticeable when comparing means between years (Cohen's d=0.451with p = 0.068). Response rate was 100% in 2016 (29/29) and 92% (23/25) in 2017.

Conclusion

This faculty survey, which has since been adopted by other groups at the University of Utah, could help improve well-being in a variety of health care professions.

Six Sigma for workplace safety improvement: improving hazards and unsafe conditions in a metallic packaging manufacturing company

Six Sigma has been applied as a business process improvement strategy in many companies worldwide with great results. On the other hand, workplace safety constitutes a key issue for company managers due to their responsibility. The aim of this article is to demonstrate how using Six Sigma can reduce accidents. A case study is conducted on a large European metallic packaging manufacturing company. As a result, the company presented a reduction of lost time accidents from 97 to 30 that saved a lot of time and cost. The σ value achieved was 4.24. This project shows the effectiveness of Six Sigma as an improvement tool in the human resources area, despite most of the previous Six Sigma research being focused on manufacturing aspects. The case studied can be useful either for large companies or small and medium-sized companies interested in improving safety.

Evaluation of Changes in Quality Improvement Knowledge Following a Formal Educational Curriculum Within a Statewide Learning Collaborative

OBJECTIVE

Our objectives were to (1) develop a curriculum based upon participants' needs, (2) evaluate baseline QI knowledge of the Illinois Surgical Quality Improvement Collaborative (ISQIC) members, and (3) evaluate the effectiveness of the educational curriculum.

DESIGN

The Surgeon Champion (SC), Surgical Clinical Reviewer (SCR), and QI Designee at each ISQIC hospital completed a QI curriculum containing online modules and in-person trainings. A surgical adaptation of QI-KAT, a validated QI knowledge assessment with multiple-choice and free-response sections, was administered pre- and postcurriculum. Three blinded educators scored each exam using a rubric-based scoring tool (54 total points).

SETTING

The ISQIC is a 52-hospital learning collaborative. Generally, ISQIC participants had little prior formal training or experience with quality improvement.

RESULTS

Among 52 hospitals, 144 pretests and 112 post-tests were collected. Mean scores increased from 66% (35.6 points) to 77% (41.6 points; p < 0.001). Across all hospitals, all participant groups scored higher on the post-test (SCs 15%, SCRs 21%, QI Designees 17%). There was no significant difference in post-test mean scores among different team members: SCs 44 points, SCRs 42 points, QI Designees 44 points, (p = 0.76). When the post-test scores were aggregated at the hospital level, hospitals with new surgical QI programs improved more than hospitals with established programs (new 18%, established 11%, p < 0.05).

CONCLUSIONS

QI knowledge significantly improved after completion of the ISQIC curriculum. These data support the value of formalized curricula to rapidly advance QI knowledge and application skills as a foundation for implementing QI initiatives.

Bolstering clinician resilience through an interprofessional, web-based nightly debriefing program for emergency departments during the COVID-19 pandemic

The COVID-19 pandemic has instigated significant changes for health care systems. With clinician burnout rising, efforts to promote clinician resilience are essential. Within this quality improvement project, an interprofessional debriefing program (Brigham Resilience in COVID-19-pandemic Emergency Forum-BRIEF) was developed within two emergency departments (EDs). An interprofessional group of ED providers led optional, nightly debriefings using a web-based portal to connect with ED clinicians for six weeks. In total, 81 interprofessional staff participated in nightly debriefings with a 47% attendance rate. On average, three participants attended the BRIEF nightly (range = 2-8) to discuss the challenges of social distancing, scarce resources, high acuity, clinician burnout and mental health. Participation increased as rates of COVID-19 positive patients rose. Debriefing leaders provided ED leadership with summaries of clinician experiences and suggestions for improvements. Feedback supported quality improvement initiatives within the ED and greater mental health support for staff. Clinicians and administrators provided positive feedback regarding the program's impact on clinician morale, and clinical processes that promoted the safety and quality of patient care. Optional debriefing with receptive departmental leadership may be a successful tool to support clinicians and hospitals during critical events.

Mammography Adherence: Creation of a Process Change Plan to Increase Usage Rates

BACKGROUND

Mammography is the optimal tool to mitigate breast cancer morbidity and mortality; however, in many healthcare settings, mammography adherence rates are decreasing.

OBJECTIVES

This nurse-led quality improvement project was conducted to improve patient adherence to annual mammography screening.

METHODS

Data collection included clinical information from the electronic health record, chart reviews, tracking documentation used by the clinic's social worker, interviews with staff, observation of the clinical setting, creation of a process flow map to identify barriers, and identification of internal and external resources. Strategies to reduce barriers included communication with staff about problems, a streamlined referral process, a scripted message about mammography, an up-front assessment of financial and social barriers to adherence, and an early referral to resources.

FINDINGS

A pre-process change chart audit showed a 22% mammography adherence rate. The post-process change rate was 51%, representing a statistically significant difference in adherence.

X-ray tomography for the advancement of laser powder bed fusion additive manufacturing

X-ray computed tomography is a powerful tool to nondestructively inspect additively manufactured parts. Additive manufacturing of metals, especially laser powder bed fusion, is increasingly being adopted for serial production of critical components in aerospace, automotive and various other industries. The technology holds huge potential for more efficient material usage and light weighting of components, among the many advantages. As this new production method is being ramped up and refined in various industry sectors, X-ray tomography is critical to the advancement of the quality of the produced components. X-ray tomography allows the nondestructive evaluation of the structural integrity of the parts produced, which in turn provides confidence in the expected performance of the parts. Besides final inspection of parts for porosity/defects and dimensional tolerances for a pass/fail decision, X-ray tomography also has a critical role to play in advancing and improving the additive manufacturing processes. This process improvement refers to the inspection of small representative coupon samples on a microscopic scale, in order to optimize the process parameters such as laser power, speed, scan strategy and various others. In this work, we describe the evaluation of small solid cube coupon samples and lattice structure coupon samples. These examples are meant to improve the understanding of the potential of X-ray tomography in advancing additive manufacturing processes (in contrast to its usual use for nondestructive testing of final parts), thereby providing support towards qualification of these processes and the parts produced in these processes. X-ray tomography, therefore, plays a key role in the adoption and qualification of high-quality metal additive manufacturing.

Optimizing Interventions Across the HIV Care Continuum: A Case Study Using Process Improvement Analysis

UNAIDS' 90-90-90 goal for 2020 is for 90% of HIV-infected people to know their status, 90% of infected individuals to receive antiretroviral therapy (ART), and 90% of those on ART to achieve viral suppression. To achieve these ambitious goals, effective care delivery programs are needed. In this paper we present a case study showing how HIV care can be improved by viewing the patient care process as a production process and applying methods of process improvement analysis. We examine the continuum of HIV care at a hospital-based HIV clinic in Kingston, Jamaica. We perform qualitative analysis to identify key programmatic, personnel, and clinical areas for process improvement. We then perform quantitative analysis. We develop a stochastic model of the care process which we use to evaluate the effects of potential process improvements on the number of patients who receive ART and the number who achieve viral suppression. We also develop a model for optimal investment of a fixed budget among interventions aimed at improving the care cascade and we use the model to determine the optimal investment among three interventions that the clinic could invest in. By viewing the patient care process as a production process and applying qualitative and quantitative process improvement analysis, our case study illustrates how clinics can identify the best ways to maximize clinical outcomes. Our methods are generalizable to other HIV care clinics as well as to clinics that provide care for other chronic conditions (e.g., diabetes, hepatitis B, or opioid use disorder).

Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings

Objectives

Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions.

Materials and Methods

SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition.

Results

During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD.

Discussion

The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied.

Conclusion

The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review

The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.

Mobile Application for Communication Increases the Efficiency of Organ Procurement and Transplantation

Background:

Donor organ recovery is a complex process involving organ procurement organizations and multiple surgical teams from various transplant centers. Nearly 30% of discarded organs are wasted due to reasons related to improper coordination and communication.

Problem Statement:

Lack of real-time communication results in many hours of preventable delay between procurement and transplant teams resulting in the high volume of organ waste, clinical frustration, and critical delays.

Methods:

A Plan-Do-Study-Act performance improvement methodology was utilized to design and implement a dedicated mobile communication application (app). Critical time points in the organ offer, procurement, and transplant processes were analyzed from the Report of Organ Offers, and relation coordination metrics were measured.

Processes Addressed:

Members of procurement and transplant teams in Iowa were interviewed and a dedicated smartphone application was implemented to replace phone calls, e-mails, faxes, and text messages during upcoming kidney offers from July 31, 2017 to July 31, 2018.

Outcomes:

Teams reported a substantial increase in clinical productivity and case progress awareness, including a noteworthy reduction in phone calls. The relational coordination data indicated substantially higher relationship and communication quality with the app. The Report of Organ Offer data revealed a 35% increase in organs transplanted and a 50% reduction in time from initial organ offer to transplant with the use of the mobile application.

Implications for Practice:

The use of a dedicated communication application reduces clinical frustration and delays during the coordination of organ offer, procurement, and transplant. Technologies that improve communication have the potential to improve organ utilization.

A Lean Quality Improvement Initiative to Enhance Tobacco Use Treatment in a Cancer Hospital

Sustained tobacco use after cancer diagnosis decreases treatment effectiveness while increasing treatment side effects, primary cancer recurrence, and the occurrence of secondary cancers. Delivering tobacco use treatment to fewer patients due to inefficient workflow represents missed opportunities to deliver life-saving care. In 2017, the National Cancer Institute initiated the Cancer Cessation Initiative (C3I) to push new tobacco cessation resources into cancer centers across the United States. This grant allowed the University of North Carolina Tobacco Treatment Program (UNC TTP) to dramatically expand tobacco use treatment (TUT) services to patients at the North Carolina Cancer Hospital (NCCH). With this push, the team saw an opportunity to utilize Lean Six Sigma, a set of quality improvement (QI) tools, to streamline their processes and uncover the root causes of program inefficiencies. A 12-month QI project using the Lean A3 problem-solving tool was implemented to examine the team's workflow. The study team mapped out the processes and, as a result, developed multiple "experiments" to test within the NCCH to address workflow efficiency and clinical reach. Outcome measures from the baseline to follow-up included: (1) the number of new patient referrals per month, and (2) the number of counseling sessions delivered per month. From the baseline to final state, the team's referrals increased from a mean of 10 to 24 per month, and counseling sessions increased from a mean of 74 to 84 per month. This project provided a deeper understanding of how workflow inefficiencies can be eliminated in the clinical setting, how technology can be harnessed to increase reach, and finally, that soliciting and using feedback from NCCH leadership can remove barriers and improve patient care.

Benefit of Digital Tools Used for Integrated Personalized Diabetes Management: Results From the PDM-ProValue Study Program

BACKGROUND

Integrated personalized diabetes management (iPDM) is a digitally supported therapeutic concept to improve patient-physician interaction to overcome the aspects of clinical inertia. Integrated personalized diabetes management can support decision making and improve therapeutic outcomes of suboptimally controlled persons with insulin-treated type 2 diabetes (T2D). In this paper, we report the results of an analysis of the PDM-ProValue study program on the effectiveness and perceived benefit of this approach, with a focus on how physicians used and assessed the digital tools provided for the iPDM process.

MATERIALS AND METHODS

The study program included two 12-month, prospective, controlled, cluster-randomized multicenter trials. A total of 101 practices participated with 907 patients. Practices were cluster-randomized to an intervention group and a control group. Digital tools for data visualization and analysis applied were used. HCP were asked to assess the use, relevance, and usefulness of the tools.

RESULTS

A clear preference was stated for the visual overview over more statistically complex analyses. A total of 83% of the participants rated a high relevance of the "daily profile," 81% of the "total profile," and 68% the "risk illustrated by traffic light symbols" for the therapy decision. The overall iPDM process was very favorably rated with respect to structuredness and potential for personalized treatment and well accepted among health care professionals (HCP).

CONCLUSIONS

Embedding digital tools in a structured process (iPDM) were proved to provide a benefit for insulin-treated T2D patients and their physicians. These results offer insight for further development and improvement of the tools and add information on how to overcome clinical inertia.

Evaluating Radiology Result Communication in the Emergency Department

PURPOSE

To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting.

METHODS

An institutional review board-approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period.

RESULTS

A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study.

CONCLUSIONS

Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

Patient and physician perceptions of lung cancer care in a multidisciplinary clinic model

Background

Lung cancer (lc) is a complex disease requiring coordination of multiple health care professionals. A recently implemented lc multidisciplinary clinic (mdc) at Kingston Health Sciences Centre, an academic tertiary care hospital, improved timeliness of oncology assessment and treatment. This study describes patient, caregiver, and physician experiences in the mdc.

Methods

We qualitatively studied patient, caregiver, and physician experiences in a traditional siloed care model and in the mdc model. We used purposive sampling to conduct semi-structured interviews with patients and caregivers who received care in one of the models and with physicians who worked in both models. Thematic design by open coding in the ATLAS.ti software application (ATLAS.ti Scientific Software Development, Berlin, Germany) was used to analyze the data.

Results

Participation by 6 of 72 identified patients from the traditional model and 6 of 40 identified patients from the mdc model was obtained. Of 9 physicians who provided care in both models, 8 were interviewed (2 respirologists, 2 medical oncologists, 4 radiation oncologists). Four themes emerged: communication and collaboration, efficiency, quality of care, and effect on patient outcomes. Patients in both models had positive impressions of their care. Patients in the mdc frequently reported convenience and a positive effect of family presence at appointments. Physicians reported that the mdc improved communication and collegiality, clinic efficiency, patient outcomes and satisfaction, and consistency of information provided to patients. Physicians identified lack of clinic space as an area for mdc improvement.

Conclusions

This qualitative study found that a lc mdc facilitated patient communication and physician collaboration, improved quality of care, and had a perceived positive effect on patient outcomes.

Detection and Remediation of Misidentification Errors in Radiology Examination Ordering

BACKGROUND

Despite progress in patient safety, misidentification errors in radiology such as ordering imaging on the wrong anatomic side persist. If undetected, these errors can cause patient harm for multiple reasons, in addition to producing erroneous electronic health records (EHR) data.

OBJECTIVES

We describe the pilot testing of a quality improvement methodology using electronic trigger tools and preimaging checklists to detect "wrong-side" misidentification errors in radiology examination ordering, and to measure staff adherence to departmental policy in error remediation.

METHODS

We retrospectively applied and compared two methods for the detection of "wrong-side" misidentification errors among a cohort of all imaging studies ordered during a 1-year period (June 1, 2015-May 31, 2016) at our tertiary care hospital. Our methods included: (1) manual review of internal quality improvement spreadsheet records arising from the prospective performance of preimaging safety checklists, and (2) automated error detection via the development and validation of an electronic trigger tool which identified discrepant side indications within EHR imaging orders.

RESULTS

Our combined methods detected misidentification errors in 6.5/1,000 of study cohort imaging orders. Our trigger tool retrospectively identified substantially more misidentification errors than were detected prospectively during preimaging checklist performance, with a high positive predictive value (PPV: 88.4%, 95% confidence interval: 85.4-91.4). However, two third of errors detected during checklist performance were not detected by the trigger tool, and checklist-detected errors were more often appropriately resolved (p < 0.00001, 95% confidence interval: 2.0-6.9; odds ratio: 3.6).

CONCLUSION

Our trigger tool enabled the detection of substantially more imaging ordering misidentification errors than preimaging safety checklists alone, with a high PPV. Many errors were only detected by the preimaging checklist; however, suggesting that additional trigger tools may need to be developed and used in conjunction with checklist-based methods to ensure patient safety.

Crafting an Evidence-Based, Accreditation Council of Graduate Medical Education-Compliant Lactation Policy for Residents and Fellows

Background: New Accreditation Council of Graduate Medical Education (ACGME) requirements mandate lactation accommodations for resident physicians and fellows. However, to date, few training programs have developed and reported robust lactation support programs or policies. Objective: The authors aimed to develop an evidence-based, ACGME-compliant policy to optimize lactation support for residents and fellows at their institution. Methods: Six Sigma process improvement methodology was utilized to structure this 2018-2019 project. Qualitative methods included stakeholder analysis, feedback sessions, formal needs assessments, and a thorough review of breastfeeding law, societal guidelines, and best practices. Quantitative methods included use of a standardized grading tool for lactation facilities. Quality assurance efforts are ongoing to ensure successful implementation of the developed policy. Results: The authors present a framework for improving lactation support for residents and fellows and share an institutional policy suitable for implementation by other graduate medical education departments. Conclusions: To ensure compliance with ACGME requirements and address breastfeeding challenges faced by medical trainees, it is crucial that U.S. residencies and fellowships implement lactation policies to support trainees. The authors welcome the modification and utilization of the evidence-based, ACGME-compliant policy reported herein.

Streamlining an existing hip fracture patient pathway in an acute tertiary adult Irish hospital to improve patient experience and outcomes

OBJECTIVE

To improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway.

DESIGN

A pre-post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery.

SETTING

A 600-bed teaching hospital in Ireland.

PARTICIPANTS

Nursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management.

INTERVENTIONS

LSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators.

MAIN OUTCOME MEASURES

Access to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment.

RESULTS

The percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral.

CONCLUSIONS

Hip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

A multidisciplinary approach to improving process and outcomes in unscheduled cesarean deliveries

BACKGROUND

Effective communication between providers of various disciplines is crucial to the quality of care provided on labor and delivery. The lack of standardized language for communicating the clinical urgency of cesarean delivery and the lack of standardized processes for responding were identified as targets for improvement by the Obstetric Patient Safety Committee at the Hospital of the University of Pennsylvania. The committee developed and implemented a protocol aimed at improving the performance of our multidisciplinary team and patient outcomes.

OBJECTIVE

To evaluate whether implementation of a multidisciplinary protocol that standardizes the language and process for performing unscheduled cesarean deliveries had reduced the decision to incision interval and improved maternal and neonatal outcomes.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent unscheduled cesarean delivery pre- and postimplementation of a protocol standardizing language, communication, provider roles, and processes. The primary outcome was cesarean decision to incision interval overall and stratified by fetal and nonfetal indications for delivery. Secondary outcomes included decision to operating room and operating room to incision intervals, operative complications, use of general anesthesia, maternal transfusion, 5-minute Apgar score <6, and umbilical cord arterial pH <7.2. Descriptive statistics were calculated. Continuous variables were tested for normality and compared using the Student t test or Mann-Whitney U test as appropriate. Categorical variables were characterized by proportions and compared by the χ² or Fisher exact test as appropriate.

RESULTS

There were 121 and 119 subjects in the pre-and postimplementation groups respectively, collected from corresponding 3-month periods. There were no significant differences in demographics, comorbidities, or indications for cesarean delivery between groups. Overall median decision to incision interval did not differ between the pre- and postimplementation groups. There was a significant decrease in median decision to incision interval (63 versus 50 minutes, P = .02) in cesarean deliveries performed for nonfetal indications. This was driven by a shorter median decision to operating room interval (32.5 versus 23 minutes, P = .01). The incidences of operative complications (35% [19/55] versus 11% [6/53], P < .01) and cord pH <7.2 (36% [20/55] versus 17% [9/53], P = .02) were also decreased in cesarean deliveries performed for nonfetal indications. The incidences of general anesthesia, maternal transfusion, and 5-minute Apgar score <6 did not differ. Outcomes did not differ between the pre- and postimplementation groups in cesarean deliveries performed for fetal indications.

CONCLUSION

Implementation of a multidisciplinary process improvement protocol that standardizes language, roles, and processes for unscheduled cesarean deliveries was associated with a reduced decision to incision interval and improved maternal and neonatal outcomes in cesarean deliveries performed for nonfetal indications. Standardized process implementation on labor and delivery has the potential to improve patient outcomes.

The Role of the Doctor of Nursing Practice in Promoting Nonpharmacologic Pain and Comfort Management

In this article the author presents her vision for integration of nonpharmacologic treatments, many taken from whole systems of care (Verhoef et al., 2005), for both pain and comfort management. By combining the evidence-based practice expertise of the clinical nurse specialist role with the knowledge of innovation, systems thinking, health policy, and implementation science acquired in the Doctor of Nursing Practice program, she is engaging interprofessional teams to join her shared vision.

Developing and Implementing Health Information Management Document Imaging Productivity Standards: A Case Study from an Acute Care Community Hospital

As health information management (HIM) shifts from paper-based medical records to electronic medical documentation, HIM professionals must appropriately manage their resources to produce higher results for their organization's operational and financial indicators. This case study highlights the experience of the HIM department in a small Florida community hospital in analyzing existing productivity standards and developing new standards with the purpose of improving the document imaging process. The research produced new productivity standards that more accurately represent the time HIM technicians spend performing their everyday tasks. The data collected during this period indicate that the average HIM technician was prepping 844 images an hour, scanning 601 images an hour, and indexing 482 images an hour. While a trend in productivity cannot be identified because different types of data were collected, the department's standards are now based on more consistently measurable output. The data collected during this study were used to manage the continuously changing workflow processes; improve the staff's knowledge, skills, and abilities; and identify potential areas of process improvement.

Technical Tips: A Checklist for Responding to Intraoperative Neuromonitoring Changes

When changes occur in neurological responses during a surgical case, it is very important that all staff in the operating room (OR) understand their role in resolving or improving these conditions. Timely interventions are needed, and each personnel team is responsible for very specific tasks. Our intent was to cut down on confusion and delay by implementing a checklist that assigns tasks and designates a coordinator, so we incorporated the use of a checklist developed by Vitale et al. into our process for neuromonitoring cases. Staff members who used the checklist were surveyed to assess ease of use, understanding and perceptions about patient safety and case efficiency with the incorporation of the checklist. The post-implementation survey showed an increase in confidence and understanding in team responsibilities and workflow. Results showed ease of use and a perception of increased patient safety with no perceived decrease in surgery case efficiency.

Automation and Process Re-engineering Work Together to Achieve Six Sigma Quality: A 27-Year History of Continuous Improvement

BACKGROUND

In most clinical laboratories, examination quality is considered excellent, whereas pre-/postexamination quality is an area for focused improvement. In our organization, 1 pre-/postexamination quality metric, namely, lost specimens, as tracked continuously for 27 years, has demonstrated steady improvement. During this period, many of our processes transitioned to highly automated effectors. Concurrently, we implemented behavioral controls and reengineered error-prone processes. We believe that this bilateral approach has conclusively lowered our lost specimen rates.

METHODS

Using data spanning 27 years, we plotted the correlation between lost specimens and the implementation dates for 8 major phases of automation, as well as 19 process improvements and engineering controls.

RESULTS

The lost specimen rate decreased nearly 100-fold. In Six Sigma terms, the 12 month moving average for lost specimens currently hovers at approximately 5.94 sigma, with 11 months at or better than 6 sigma. Although the combination of implementation of process improvements, engineering controls, and automation contributed to the reduction, automation was the most significant contributor.

CONCLUSIONS

The custom automation in use by our laboratory has led to improved pre-/postexamination quality. Although this automation may not be possible for all laboratories, our description of 19 behavior and engineering controls may be useful to others seeking to design high quality pre-/postexamination processes.

Quantifying patient satisfaction with process metrics using a weighted bundle approach

Background

Current patient satisfaction assessment results are delayed and obtained from select patient surveys. As a result, these assessments may not represent the experience of the entire patient population. This study developed a method to measure and evaluate all patients' experiences while they are within the care episode and link it to processes within the organisation.

Methods

Using the Six Sigma methodology, sites assembled diverse teams to categorise and analyse negative experience comments from patients to understand the drivers of dissatisfaction. These customer expectations lead to the development of the four components in the Patient Experience Bundle (PEB): communication, environment, basic needs/comfort and logistics. Individual process elements were ranked to create a numerical relationship between service and the needs expressed by the voice of the customer. Sites created surveys incorporating questions that focused on the bundle elements and measured daily bundle compliance. Graphical analysis and hypothesis testing enabled sites to determine key drivers of patient dissatisfaction within the bundle elements. Improvement strategies were developed and implemented to address the key drivers of patient dissatisfaction.

Results

After implementing process improvements focused on issues identified by the PEB, bundle compliance improved from an average of 51% to an average of 82.5% and Press Ganey Likelihood to Recommend (PG LTR) scores improved from an average of 64.73% to an average 74.64%. The data demonstrated that the trends in improving PEB are followed by meaningful changes in PG LTR scores.

Conclusion

This work is built on the identification of common elements of care that impact patient satisfaction and detailed mathematical analysis of the relationship between factors. Using the bundle concept, these improvement efforts maintain highly reliable processes to drive outcomes and provide real-time feedback on patient experience.