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Lu KK, Zhang MM, Zhu YL, Ye C, Li M. Improving the Quality of Emergency Intrahospital Transport for Critically Ill Patients by Using Toyota Production System Methods. J Multidiscip Healthc 2022; 15:1111-1120. [PMID: 35607363 PMCID: PMC9123905 DOI: 10.2147/jmdh.s360261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Ke-Ke Lu
- Emergency Department, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Miao-Miao Zhang
- Emergency Department, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Yue-Li Zhu
- Department of Nursing, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
- Correspondence: Yue-Li Zhu, Department of Nursing, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China, Email
| | - Chen Ye
- Emergency Department, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Min Li
- Department of Infectious Diseases, Hangzhou Linping Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, Zhejiang Province, People’s Republic of China
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2
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Mahmoud Z, Angelé-Halgand N, Churruca K, Ellis LA, Braithwaite J. Access to surgical care as an efficiency issue: using lean management in French and Australian operating theatres. J Health Organ Manag 2021; ahead-of-print. [PMID: 34032110 DOI: 10.1108/jhom-08-2020-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Millions around the world still cannot access safe, timely and affordable surgery. Considering access as a function of efficiency, this paper examines how the latter can be improved within the context of operating theatres. Carried out in France and Australia, this study reveals different types of waste in operating theatres and a series of successful tactics used to increase efficiency and eliminate wastefulness. DESIGN/METHODOLOGY/APPROACH Data for this qualitative study were collected through 48 semi-structured interviews with operating theatre staff in France (n = 20) and Australia (n = 28). Transcripts were coded using a theory-driven thematic analysis to characterise sources of waste in operating theatres and the tactics used to address them. FINDINGS The study confirmed the prominence of seven types of waste in operating theatres commonly found in industry and originally identified by Ohno, the initiator of lean: (1) underutilised operating rooms; (2) premature or delayed arrival of patients, staff or equipment; (3) need for large onsite storage areas and inventory costs; (4) unnecessary transportation of equipment; (5) needless staff movements; (6) over-processing and (7) quality defects. The tactics used to address each of these types of waste included multiskilling staff, levelling production and implementing just-in-time principles. ORIGINALITY/VALUE The tactics identified in this study have the potential of addressing the chronic and structurally embedded problem of waste plaguing health systems' operating theatres, and thus potentially improve access to surgical care. In a global context of resource scarcity, it is increasingly necessary for hospitals to optimise the ways in which surgery is delivered.
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Affiliation(s)
- Zeyad Mahmoud
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.,LEMNA, Université de Nantes, Nantes, France
| | - Nathalie Angelé-Halgand
- LEMNA, Université de Nantes, Nantes, France.,University of New Caledonia, Noumea, New Caledonia
| | - Kate Churruca
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Louise A Ellis
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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The impact of lean management on frontline healthcare professionals: a scoping review of the literature. BMC Health Serv Res 2021; 21:383. [PMID: 33902552 PMCID: PMC8074224 DOI: 10.1186/s12913-021-06344-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 04/03/2021] [Indexed: 12/20/2022] Open
Abstract
Background Lean management practices are increasingly used in hospitals. However, their impacts on staff have not been systematically synthesised. This scoping review aims to synthesise the evidence on the effects of Lean Management practices on frontline healthcare professionals. Methods A search was conducted in February 2020 on multiple databases to identify relevant sources. Studies had to satisfy the following inclusion criteria to be considered: published in English or French, peer-reviewed, empirical, studied the use of Lean in a healthcare setting and focused on its impacts on frontline workers. The studies included were heterogeneous in terms of participants. Findings were coded and classified using a thematic analysis. The quality and methodological rigour of the reviewed articles were assessed to establish a level of confidence in their findings. Results Of 998 identified articles, 17 were included in the review. The findings were coded into four themes: (1) Morale, motivation and job satisfaction (n = 9, 2) work intensification, job strain, anxiety, stress and dehumanisation (n = 7, 3) teamwork, communication and coordination (n = 6); and (4) learning, innovation and personal development (n = 3). Overall, the articles reported positive (n = 11), negative (n = 3) and mixed (n = 3) impacts of Lean on frontline healthcare professionals. Conclusion This review is the first to synthesise and highlight the gaps in the existing literature examining the impacts of Lean on frontline health professionals. The review revealed a range of both positive, negative and mixed effects, and points to the need for more empirical research to identify the underlying reasons leading to these outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06344-0.
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Sharma G, Prasad C, Srinivasa Rao M. Industrial engineering into healthcare – A comprehensive review. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2020. [DOI: 10.1080/20479700.2020.1757874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- G.V.S.S. Sharma
- Mechanical Engineering Department, GMR Institute of Technology, Rajam, India
| | - C.L.V.R.S.V. Prasad
- Mechanical Engineering Department, GMR Institute of Technology, Rajam, India
| | - M. Srinivasa Rao
- Mechanical Engineering Department, GMR Institute of Technology, Rajam, India
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Improta G, Romano M, Di Cicco MV, Ferraro A, Borrelli A, Verdoliva C, Triassi M, Cesarelli M. Lean thinking to improve emergency department throughput at AORN Cardarelli hospital. BMC Health Serv Res 2018; 18:914. [PMID: 30509286 PMCID: PMC6276250 DOI: 10.1186/s12913-018-3654-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 10/26/2018] [Indexed: 11/14/2022] Open
Abstract
Background Throughout the world, emergency departments (ED) are characterized by overcrowding and excessive waiting times. Furthermore, the related delays significantly increase patient mortality and make inefficient use of resources to the detriment of the satisfaction of employees and patients. In this work, lean thinking is applied to the ED of Cardarelli Hospital of Naples with the aim of increasing patient flow, improving the processes that contribute to facilitating the flow of patients through the various stages of medical treatment and eliminating all bottlenecks (queue) as well as all activities that generate waste. Methods This project was performed at National Hospital A.O.R.N. A. Cardarelli of Naples. The historical times of access to the ED were analysed from January 2015 to June 2015, for a total of 16,563 records. Subsequently, starting in November 2015, corrective actions were implemented according to the Lean Approach. Data collected after the introduced improvements were collected from April 2016 to June 2016 and compared to those collected during the starting period. Results The results acquired before application of the Lean Thinking strategy illustrated the as-is process with its drawbacks. An analysis of the non-added value activities was performed to identify the procedures that need to be improved. After implementation of the corrective actions, we observed a positive increase in the performance of the ED, quantified as percentages of hospitalized patients according to triage codes and waiting times. Conclusion This work demonstrates the applicability of Lean Thinking to ED processes and its effectiveness in terms of increasing the efficiency of services and reducing waste (waiting times).
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Affiliation(s)
- Giovanni Improta
- Department of Public Health, School of Medicine and Surgery, University of Naples 'Federico II', Naples, Italy.
| | - Maria Romano
- Department of Medical and Surgical Sciences, University 'Magna Graecia' of Catanzaro, Catanzaro, Italy.,Scientific Clinical Institutes Maugeri IRCCS, Telese, Italy
| | - Maria Vincenza Di Cicco
- Department of Public Health, School of Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Anna Ferraro
- Department of Public Health, School of Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Anna Borrelli
- Responsible for the Programming and Health Planning Unit, Hospital "Antonio Cardarelli", Naples, Italy
| | | | - Maria Triassi
- Department of Public Health, School of Medicine and Surgery, University of Naples 'Federico II', Naples, Italy
| | - Mario Cesarelli
- Department of Electrical Engineering and Information Technology (DIETI), University of Naples 'Federico II', Naples, Italy.,Scientific Clinical Institutes Maugeri IRCCS, Telese, Italy
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Burckhardt I. Laboratory Automation in Clinical Microbiology. Bioengineering (Basel) 2018; 5:bioengineering5040102. [PMID: 30467275 PMCID: PMC6315553 DOI: 10.3390/bioengineering5040102] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/16/2018] [Accepted: 11/19/2018] [Indexed: 01/21/2023] Open
Abstract
Laboratory automation is currently the main organizational challenge for microbiologists. Automating classic workflows is a strenuous process for the laboratory personnel and a huge and long-lasting financial investment. The investments are rewarded through increases in quality and shortened time to report. However, the benefits for an individual laboratory can only be estimated after the implementation and depending on the classic workflows currently performed. The two main components of automation are hardware and workflow. This review focusses on the workflow aspects of automation and describes some of the main developments during recent years. Additionally, it tries to define some terms which are related to automation and specifies some developments which would further improve automated systems.
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Affiliation(s)
- Irene Burckhardt
- Department for Infectious Diseases, Microbiology and Hygiene, Heidelberg University Hospital, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany.
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Liu JJ, Raskin JS, Hardaway F, Holste K, Brown S, Raslan AM. Application of Lean Principles to Neurosurgical Procedures: The Case of Lumbar Spinal Fusion Surgery, a Literature Review and Pilot Series. Oper Neurosurg (Hagerstown) 2018; 15:332-340. [DOI: 10.1093/ons/opx289] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 02/18/2018] [Indexed: 01/17/2023] Open
Abstract
AbstractBACKGROUNDDelivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed.OBJECTIVETo apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases.METHODSProcess maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability.RESULTSTemporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively.CONCLUSIONThis pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.
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Affiliation(s)
- Jesse J Liu
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey S Raskin
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Fran Hardaway
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Katherine Holste
- School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sarah Brown
- School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Ahmed M Raslan
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
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Does lean cure variability in health care? INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2017. [DOI: 10.1108/ijopm-07-2015-0452] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to investigate the roles that employee-initiated Lean improvement projects play in health care. Lean ideas are introduced to improve flow in health care. Although variability is detrimental to flow performance, it is unclear whether Lean initiatives set out to reduce this variability and the associated buffers.
Design/methodology/approach
Longitudinal field research is combined with an exploratory field-quasi-experiment. First, a large set of Lean interventions were explored and their focus classified. Semi-structured interviews with practitioners supported the initial findings regarding the focus. Second, this study investigated whether a knowledge deficiency could explain the identified focus through a quasi-experiment in which the authors’ stimulated knowledge on the roles of variability and buffers and then classified subsequent interventions.
Findings
The results reflected a narrow application of Lean, with most interventions directed at reducing direct waste. A quasi-experiment demonstrated that a small investment in knowledge enables the focus to shift toward buffers and variability issues – i.e. toward a more complete Lean approach.
Research limitations/implications
This research supports the commonly held view that there is a tendency to focus on waste. Furthermore, a lengthy experience of Lean does not guarantee interventions will focus on buffers and variability, issues with arguably a higher complexity compared to obvious waste. However, small investments in knowledge can broaden the focus of practitioners’ interventions.
Originality/value
This study is one of the first to research the focus of Lean interventions through a data set spanning several years. The results are based on a unique data set covering a large number of documented Lean interventions.
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Crema M, Verbano C. Safety improvements from health lean management implementation. INTERNATIONAL JOURNAL OF QUALITY & RELIABILITY MANAGEMENT 2016. [DOI: 10.1108/ijqrm-11-2014-0179] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
In a context where healthcare systems have to face multiple challenges, the development of a methodology that combines new managerial approaches could contribute to pursue and achieve multiple objectives. Inside the research stream that intends to combine health lean management (HLM) and clinical risk management (CRM), the purpose of this paper is to study the significant features that characterize HLM projects obtaining patient safety improvements (L&S projects).
Design/methodology/approach
The novelty of the research implies to adopt qualitative research methodology, analyzing in-depth case studies. L&S projects at different organizational levels have been selected from the same hospital. Following a research protocol, data have been collected through semi-structured interviews and they have been triangulated studying reports and archival documentation.
Findings
Comparing the three cases, it emerges that HLM can be a support for CRM since safety improvements can be achieved solving organizational issues. Analyzing the significant features of the three cases, relevant differences have been highlighted among them. At the end, first indications useful for achieving safety improvements from lean project implementation have been grasped.
Originality/value
This research provides a preliminary contribution to a new research stream that aims to develop a synergic methodology combining HLM and CRM. The first provided indications can be followed by hospital managers who wish to learn how to implement projects achieving patient safety improvements besides efficiency enhancement. After testing and exploiting the obtained results, a new methodology should be developed moving toward a safer and more sustainable healthcare system.
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Poksinska BB, Fialkowska-Filipek M, Engström J. Does Lean healthcare improve patient satisfaction? A mixed-method investigation into primary care. BMJ Qual Saf 2016; 26:95-103. [PMID: 26864659 DOI: 10.1136/bmjqs-2015-004290] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Lean healthcare is claimed to contribute to improved patient satisfaction, but there is limited evidence to support this notion. This study investigates how primary-care centres working with Lean define and improve value from the patient's perspective, and how the application of Lean healthcare influences patient satisfaction. METHODS This paper contains two qualitative case studies and a quantitative study based on results from the Swedish National Patient Survey. Through the case studies, we investigated how primary-care organisations realised the principle of defining and improving value from the patient's perspective. In the quantitative study, we compared results from the patient satisfaction survey for 23 primary-care centres working with Lean with a control group of 23 care centres not working with Lean. We also analysed changes in patient satisfaction over time. RESULTS Our case studies reveal that Lean healthcare implementations primarily target efficiency and little attention is paid to the patient's perspective. The quantitative study shows no significantly better results in patient satisfaction for primary-care centres working with Lean healthcare compared with those not working with Lean. Further, care centres working with Lean show no significant improvements in patient satisfaction over time. CONCLUSIONS Lean healthcare implementations seem to have a limited impact on improving patient satisfaction. Care providers need to pay more attention to integrating the patient's perspective in the application of Lean healthcare. Value needs to be defined and value streams need to be improved based on both the knowledge and clinical expertise of care providers, and the preferences and needs of patients.
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Affiliation(s)
| | | | - Jon Engström
- Department of Management and Engineering, Linköping University, Linköping, Sweden
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van Leijen-Zeelenberg JE, Elissen AMJ, Grube K, van Raak AJA, Vrijhoef HJM, Kremer B, Ruwaard D. The impact of redesigning care processes on quality of care: a systematic review. BMC Health Serv Res 2016; 16:19. [PMID: 26782132 PMCID: PMC4717535 DOI: 10.1186/s12913-016-1266-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 01/12/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This literature review evaluates the current state of knowledge about the impact of process redesign on the quality of healthcare. METHODS Pubmed, CINAHL, Web of Science and Business Premier Source were searched for relevant studies published in the last ten years [2004-2014]. To be included, studies had to be original research, published in English with a before-and-after study design, and be focused on changes in healthcare processes and quality of care. Studies that met the inclusion criteria were independently assessed for excellence in reporting by three reviewers using the SQUIRE checklist. Data was extracted using a framework developed for this review. RESULTS Reporting adequacy varied across the studies. Process redesign interventions were diverse, and none of the studies described their effects on all dimensions of quality defined by the Institute of Medicine. CONCLUSIONS The results of this systematic literature review suggests that process redesign interventions have positive effects on certain aspects of quality. However, the full impact cannot be determined on the basis of the literature. A wide range of outcome measures were used, and research methods were limited. This review demonstrates the need for further investigation of the impact of redesign interventions on the quality of healthcare.
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Affiliation(s)
- Janneke E. van Leijen-Zeelenberg
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Arianne M. J. Elissen
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Kerstin Grube
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Arno J. A. van Raak
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hubertus J. M. Vrijhoef
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Scientific Center of Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands
- Department of Family Medicine, Free University of Brussels, Brussels, Belgium
| | - Bernd Kremer
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Crema M, Verbano C. Investigating the connections between health lean management and clinical risk management. Int J Health Care Qual Assur 2015; 28:791-811. [DOI: 10.1108/ijhcqa-03-2015-0029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The purpose of this paper is to investigate connections and overlaps between health lean management (HLM) and clinical risk management (CRM) understanding whether and how these two approaches can be combined together to pursue efficiency and patient safety improvements simultaneously.
Design/methodology/approach
– A systematic literature review has been carried out. Searching in academic databases, papers that focus not only on HLM, but also on clinical errors and risk reduction, were included. The general characteristics of the selected papers were analysed and a content analysis was conducted.
Findings
– In most of the papers, pursing objectives of HLM and CRM and adopting tools and practices of both approaches, results of quality and, particularly, of safety improvements were obtained. A two-way arrow between HLM and CRM emerged but so far, none of the studies has been focused on the relationship between HLM and CRM.
Originality/value
– Results highlight an emerging research stream, with many useful theoretical and practical implications and opportunities for further research.
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Papalexi M, Bamford D, Dehe B. A case study of kanban implementation within the pharmaceutical supply chain. INTERNATIONAL JOURNAL OF LOGISTICS-RESEARCH AND APPLICATIONS 2015. [DOI: 10.1080/13675567.2015.1075478] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Implementing lean in knowledge work: Implications from a study of the hospital discharge planning process. OPERATIONS MANAGEMENT RESEARCH 2015. [DOI: 10.1007/s12063-015-0103-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Curatolo N, Lamouri S, Huet JC, Rieutord A. [Improvement approaches in the hospital setting: From total quality management to Lean]. ANNALES PHARMACEUTIQUES FRANÇAISES 2015; 73:245-56. [PMID: 25558800 DOI: 10.1016/j.pharma.2014.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 11/30/2014] [Accepted: 12/04/2014] [Indexed: 10/24/2022]
Abstract
Hospitals have to deal strong with economic constraints and increasing requirements in terms of quality and safety of care. To address these constraints, one solution could be the adoption of approaches from the industry sector. Following the decree of April 6, 2011 on the quality management of the medication use process, some of these approaches, such as risk management, are now part of the everyday work of healthcare professionals. However, other approaches, such as business process improvement, are still poorly developed in the hospital setting. In this general review, we discuss the main approaches of business process improvements that have been used in hospitals by focusing specifically on one of the newest and most currently used: Lean.
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Affiliation(s)
- N Curatolo
- Arts et métiers ParisTech, 152, boulevard de l'Hôpital, 75013 Paris, France.
| | - S Lamouri
- Arts et métiers ParisTech, 152, boulevard de l'Hôpital, 75013 Paris, France.
| | - J-C Huet
- Université Paris Grand Ouest, EPMI, 13, boulevard Hautil, 95000 Cergy, France.
| | - A Rieutord
- Hôpital Antoine-Beclère, AP-HP, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France.
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Abstract
PURPOSE The purpose of this paper is to contribute toward a deeper understanding of the new roles, responsibilities, and job characteristics of employees in Lean healthcare organizations. DESIGN/METHODOLOGY/APPROACH The paper is based on three cases studies of healthcare organizations that are regarded as successful examples of Lean applications in the healthcare context. Data were collected by methods including interviews, observations, and document studies. FINDINGS The implementation of Lean in healthcare settings has had a great influence on the roles, responsibilities, and job characteristics of the employees. The focus has shifted from healthcare professionals, where clinical autonomy and professional skills have been the guarding principles of patient care, to process improvement and teamwork. Different job characteristics may make it difficult to implement certain Lean practices in healthcare. Teamwork and decentralization of authority are examples of Lean practices that could be considered countercultural because of the strong professional culture and uneven power distribution, with doctors as the dominant decision makers. PRACTICAL IMPLICATIONS Teamwork, value flow orientation, and company-wide involvement in CI were associated with positive effects on the organizations' working environment, staff development, and organizational performance. ORIGINALITY/VALUE In order to succeed with Lean healthcare, it is important to understand and recognize the differences in job characteristics between Lean manufacturing and healthcare. This paper provides insights into how Lean implementation changes the roles, responsibilities, and job characteristics of healthcare staff and the challenges and implications that may follow from this.
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Doğan NÖ, Unutulmaz O. Lean production in healthcare: a simulation-based value stream mapping in the physical therapy and rehabilitation department of a public hospital. TOTAL QUALITY MANAGEMENT & BUSINESS EXCELLENCE 2014. [DOI: 10.1080/14783363.2014.945312] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Crema M, Verbano C. Guidelines for overcoming hospital managerial challenges: a systematic literature review. Ther Clin Risk Manag 2013; 9:427-41. [PMID: 24307833 PMCID: PMC3845536 DOI: 10.2147/tcrm.s54178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The need to respond to accreditation institutes' and patients' requirements and to align health care results with increased medical knowledge is focusing greater attention on quality in health care. Different tools and techniques have been adopted to measure and manage quality, but clinical errors are still too numerous, suggesting that traditional quality improvement systems are unable to deal appropriately with hospital challenges. The purpose of this paper is to grasp the current tools, practices, and guidelines adopted in health care to improve quality and patient safety and create a base for future research on this young subject. METHODS A systematic literature review was carried out. A search of academic databases, including papers that focus not only on lean management, but also on clinical errors and risk reduction, yielded 47 papers. The general characteristics of the selected papers were analyzed, and a content analysis was conducted. RESULTS A variety of managerial techniques, tools, and practices are being adopted in health care, and traditional methodologies have to be integrated with the latest ones in order to reduce errors and ensure high quality and patient safety. As it has been demonstrated, these tools are useful not only for achieving efficiency objectives, but also for providing higher quality and patient safety. Critical indications and guidelines for successful implementation of new health managerial methodologies are provided and synthesized in an operative scheme useful for extending and deepening knowledge of these issues with further studies. CONCLUSION This research contributes to introducing a new theme in health care literature regarding the development of successful projects with both clinical risk management and health lean management objectives, and should address solutions for improving health care even in the current context of decreasing resources.
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Affiliation(s)
- Maria Crema
- Department of Management and Engineering, University of Padova, Vicenza, Italy
| | - Chiara Verbano
- Department of Management and Engineering, University of Padova, Vicenza, Italy
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Raab SS, Swain J, Smith N, Grzybicki DM. Quality and patient safety in the diagnosis of breast cancer. Clin Biochem 2013; 46:1180-6. [DOI: 10.1016/j.clinbiochem.2013.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 04/21/2013] [Accepted: 04/24/2013] [Indexed: 11/25/2022]
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Smith ML, Wilkerson T, Grzybicki DM, Raab SS. The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. Am J Clin Pathol 2012; 138:367-73. [PMID: 22912352 DOI: 10.1309/ajcp3yxid2uhzpht] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Few reports have documented the effectiveness of Lean quality improvement in changing anatomic pathology patient safety. We used Lean methods of education; hoshin kanri goal setting and culture change; kaizen events; observation of work activities, hand-offs, and pathways; A3-problem solving, metric development, and measurement; and frontline work redesign in the accessioning and gross examination areas of an anatomic pathology laboratory. We compared the pre- and post-Lean implementation proportion of near-miss events and changes made in specific work processes. In the implementation phase, we documented 29 individual A3-root cause analyses. The pre- and postimplementation proportions of process- and operator-dependent near-miss events were 5.5 and 1.8 (P < .002) and 0.6 and 0.6, respectively. We conclude that through culture change and implementation of specific work process changes, Lean implementation may improve pathology patient safety.
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Calhoun BC, Goode J, Simmons K. Process improvement of pap smear tracking in a women's medicine center clinic in residency training. J Healthc Qual 2012; 33:25-32. [PMID: 22103702 DOI: 10.1111/j.1945-1474.2011.00129.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Application of Six-Sigma methodology and Change Acceleration Process (CAP)/Work Out (WO) tools to track pap smear results in an outpatient clinic in a hospital-based residency-training program. Observational study of impact of changes obtained through application of Six-Sigma principles in clinic process with particular attention to prevention of sentinel events. Using cohort analysis and applying Six-Sigma principles to an interactive electronic medical record Soarian workflow engine, we designed a system of timely accession and reporting of pap smear and pathology results. We compared manual processes from January 1, 2007 to February 28, 2008 to automated processes from March 1, 2008 to December 31, 2009. Using the Six-Sigma principles, CAP/WO tools, including "voice of the customer" and team focused approach, no outlier events went untracked. Applying the Soarian workflow engine to track prescribed 7 day turnaround time for completion, we identified 148 pap results in 3,936, 3 non-gynecological results in 15, and 41 surgical results in 246. We applied Six-Sigma principles to an outpatient clinic facilitating an interdisciplinary team approach to improve the clinic's reporting system. Through focused problem assessment, verification of process, and validation of outcomes, we improved patient care for pap smears and critical pathology.
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Affiliation(s)
- Byron C Calhoun
- Department of Obstetrics andGynecology, West Virginia School of Medicine, 830 Pennsylvania Ave., Charleston, WV 25302, USA.
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Wong R, Levi AW, Harigopal M, Schofield K, Chhieng DC. The Positive Impact of Simultaneous Implementation of the BD FocalPoint GS Imaging System and Lean Principles on the Operation of Gynecologic Cytology. Arch Pathol Lab Med 2012; 136:183-9. [DOI: 10.5858/arpa.2011-0139-oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Our cytology laboratory, like many others, is under pressure to improve quality and provide test results faster while decreasing costs. We sought to address these issues by introducing new technology and lean principles.
Objective.—To determine the combined impact of the FocalPoint Guided Screener (GS) Imaging System (BD Diagnostics–TriPath, Burlington, North Carolina) and lean manufacturing principles on the turnaround time (TAT) and productivity of the gynecologic cytology operation.
Design.—We established a baseline measure of the TAT for Papanicolaou tests. We then compared that to the performance after implementing the FocalPoint GS Imaging System and lean principles. The latter included value-stream mapping, workflow modification, and a first in–first out policy.
Results.—The mean (SD) TAT for Papanicolaou tests before and after the implementation of FocalPoint GS Imaging System and lean principles was 4.38 (1.28) days and 3.20 (1.32) days, respectively. This represented a 27% improvement in the average TAT, which was statistically significant (P < .001). In addition, the productivity of staff improved 17%, as evidenced by the increase in slides screened from 8.85/h to 10.38/h. The false-negative fraction decreased from 1.4% to 0.9%, representing a 36% improvement.
Conclusions.—In our laboratory, the implementation of FocalPoint GS Imaging System in conjunction with lean principles resulted in a significant decrease in the average TAT for Papanicolaou tests and a substantial increase in the productivity of cytotechnologists while maintaining the diagnostic quality of gynecologic cytology.
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Smith ML, Raab SS. Assessment of Latent Factors Contributing to Error: Addressing Surgical Pathology Error Wisely. Arch Pathol Lab Med 2011; 135:1436-40. [DOI: 10.5858/arpa.2011-0334-oa] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Methods to improve surgical pathology patient safety include measuring the frequency of error in specific steps of the surgical pathology testing process, root cause analysis of active and latent components, and implementation of quality improvement initiatives.
Objective.—To determine the frequency and cause of near-miss events in the specimen accessioning, setup, and biopsy-only gross examination testing steps of anatomic pathology.
Design.—We used an observational checklist method to identify near-miss events. We performed root cause analysis to determine latent factors contributing to near-miss events. We conducted observations for 45 hours during 5 days, involving the accessioning and processing of 335 specimens.
Results.—We detected a total of 2310 process-dependent and 266 operator-dependent near-miss events, resulting in a near-miss–event frequency of 5.5 per specimen. Root cause analysis showed that all process and operator near-miss events were associated with multiple system latent factors, including lack of standardized protocols, appropriate knowledge transfer, and focus on safety culture.
Conclusion.—We conclude that the increased focus on surgical pathology near-miss events will reveal latent factors that may be targeted for improvement.
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Raab SS, Grzybicki DM. Cytologic-histologic correlation. Cancer Cytopathol 2011; 119:293-309. [DOI: 10.1002/cncy.20165] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2011] [Revised: 04/14/2011] [Accepted: 04/13/2011] [Indexed: 11/06/2022]
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Calhoun BC, Goode J, Simmons K. Process Improvement of Pap Smear Tracking in a Women's Medicine Center Clinic in Residency Training. J Healthc Qual 2011. [DOI: 10.1111/j.1945-1474.2010.00129.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kneeland PP, Kneeland C, Wachter RM. Bleeding talent: a lesson from industry on embracing physician workforce challenges. J Hosp Med 2010; 5:306-10. [PMID: 20533581 DOI: 10.1002/jhm.594] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Shortages of both generalist and specialist physicians are intensifying as the US healthcare system confronts an unprecedented confluence of demographic pressures, including an aging population, the retirement of thousands of baby-boomer physicians, the growth of nonpractice opportunities for MDs, and physician demands for greater work-life balance. This work posits that the medical profession might benefit from recognizing how progressive nonmedical companies systematically approach similar "talent shortages" through a recruiting and retention strategy called "talent facilitation." It highlights the 4 actions of talent facilitation (attract, engage, develop, and retain) and provides examples of how each action might be utilized to address medicine's recruitment and retention challenges. Although other policy maneuvers are needed to address overall physician workforce shortages (such as the planned opening of more medical schools and changes in the payment system to promote primary care), the talent facilitation approach can help individual organizations meet their needs and those of their patients.
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Affiliation(s)
- Patrick P Kneeland
- Department of Medicine, University of California, San Francisco, San Francisco, California 94143-0131, USA.
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Al-Araidah O, Momani A, Khasawneh M, Momani M. Lead-Time Reduction Utilizing Lean Tools Applied to Healthcare: The Inpatient Pharmacy at a Local Hospital. J Healthc Qual 2010; 32:59-66. [DOI: 10.1111/j.1945-1474.2009.00065.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Armah H, Austin RM, Dabbs D, Zhao C. Follow-up findings for women with human papillomavirus-positive and atypical squamous cells of undetermined significance screening test results in a large women's hospital practice. Arch Pathol Lab Med 2009; 133:1426-30. [PMID: 19722749 DOI: 10.5858/133.9.1426] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Reflex human papillomavirus (HPV) testing has been designated in consensus guidelines as "preferred" for women with atypical squamous cells of undetermined significance (ASC-US) liquid-based cytology (LBC) results, and colposcopy is currently recommended for patients with HPV-positive ASC-US results. Data from large clinical practices using newer screening methods and current cytology terminology are limited. OBJECTIVES We analyzed data from patients with ASC-US LBC and positive HPV test results. We also assessed the impact of the presence or absence of an endocervical cell/ transformation zone sample (EC/TZS) on biopsy diagnoses. DESIGN The information system of a large women's hospital serving an older-than-average population was searched over a 21-month period between July 1, 2005, and March 31, 2007, for HPV-positive cases interpreted as ASC-US (Bethesda System 2001) using computer-imaged LBC. Histologic diagnoses, patient ages, and presence or absence of an EC/TZS were analyzed. The average follow-up period was 7.5 months. RESULTS Among 4273 women with HPV-positive ASC-US results, the cumulative cervical intraepithelial neoplasia 2 or 3 (CIN 2/3) and CIN 1 rates for 2192 women with available biopsies were 5.1% and 43.6%, respectively. Cervical intraepithelial neoplasia 2/3 and CIN 1 rates for women with HPV-positive ASC-US results were not significantly different for women with and without an EC/TZS. CONCLUSIONS The risk of CIN 2/3 in the study population was significantly lower than reported in widely cited trial data. Neither presence nor absence of an EC/TZS, nor the age of the patient, had a statistically significant impact on the likelihood of biopsy diagnoses of CIN 2/3 and CIN 1 for patients with HPV-positive ASC-US test results.
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Affiliation(s)
- Henry Armah
- Department of Pathology, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and StuderGroup's Hardwiring Excellence in the United States: the need to demonstrate and communicate the effectiveness of transformation strategies in healthcare. Implement Sci 2009; 4:35. [PMID: 19570218 PMCID: PMC2709888 DOI: 10.1186/1748-5908-4-35] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 07/01/2009] [Indexed: 11/10/2022] Open
Abstract
Background U.S. healthcare organizations are confronted with numerous and varied transformational strategies promising improvements along all dimensions of quality and performance. This article examines the peer-reviewed literature from the U.S. for evidence of effectiveness among three current popular transformational strategies: Six Sigma, Lean/Toyota Production System, and Studer's Hardwiring Excellence. Methods The English language health, healthcare management, and organizational science literature (up to December 2007) indexed in Medline, Web of Science, ABI/Inform, Cochrane Library, CINAHL, and ERIC was reviewed for studies on the aforementioned transformation strategies in healthcare settings. Articles were included if they: appeared in a peer-reviewed journal; described a specific intervention; were not classified as a pilot study; provided quantitative data; and were not review articles. Nine references on Six Sigma, nine on Lean/Toyota Production System, and one on StuderGroup meet the study's eligibility criteria. Results The reviewed studies universally concluded the implementations of these transformation strategies were successful in improving a variety of healthcare related processes and outcomes. Additionally, the existing literature reflects a wide application of these transformation strategies in terms of both settings and problems. However, despite these positive features, the vast majority had methodological limitations that might undermine the validity of the results. Common features included: weak study designs, inappropriate analyses, and failures to rule out alternative hypotheses. Furthermore, frequently absent was any attention to changes in organizational culture or substantial evidence of lasting effects from these efforts. Conclusion Despite the current popularity of these strategies, few studies meet the inclusion criteria for this review. Furthermore, each could have been improved substantially in order to ensure the validity of the conclusions, demonstrate sustainability, investigate changes in organizational culture, or even how one strategy interfaced with other concurrent and subsequent transformation efforts. While informative results can be gleaned from less rigorous studies, improved design and analysis can more effectively guide healthcare leaders who are motivated to transform their organizations and convince others of the need to employ such strategies. Demanding more exacting evaluation of projects consultants, or partnerships with health management researchers in academic settings, can support such efforts.
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Affiliation(s)
- Joshua R Vest
- Department of Health Policy and Management, School of Rural Public Health, Texas A&M Health Science Center, College Station, Texas, USA.
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Pantanowitz L, Hornish M, Goulart RA. Informatics applied to cytology. Cytojournal 2008; 5:16. [PMID: 19495402 PMCID: PMC2669683 DOI: 10.4103/1742-6413.44773] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Accepted: 12/01/2008] [Indexed: 11/17/2022] Open
Abstract
Automation and emerging information technologies are being adopted by cytology laboratories to augment Pap test screening and improve diagnostic accuracy. As a result, informatics, the application of computers and information systems to information management, has become essential for the successful operation of the cytopathology laboratory. This review describes how laboratory information management systems can be used to achieve an automated and seamless workflow process. The utilization of software, electronic databases and spreadsheets to perform necessary quality control measures are discussed, as well as a Lean production system and Six Sigma approach, to reduce errors in the cytopathology laboratory.
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Affiliation(s)
- Liron Pantanowitz
- Department of Pathology, Division of Cytopathology, Baystate Medical Center, Tufts School of Medicine, MA, USA.
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Shah R, Goldstein SM, Unger BT, Henry TD. Explaining Anomalous High Performance in a Health Care Supply Chain*. DECISION SCIENCES 2008. [DOI: 10.1111/j.1540-5915.2008.00211.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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McKinlay J, Marceau L. When there is no doctor: reasons for the disappearance of primary care physicians in the US during the early 21st century. Soc Sci Med 2008; 67:1481-91. [PMID: 18701201 PMCID: PMC2757942 DOI: 10.1016/j.socscimed.2008.06.034] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Indexed: 11/18/2022]
Abstract
Primary care doctoring in the USA today (2007) bears little resemblance to what existed just 25 years ago. We focus on what is likely to unfold in the U.S. over the next several decades and suggest that by about 2025, primary care doctoring in the U.S. could be rare, possibly unrecognizable and even nonexistent. Seven reasons for the probable disappearance of primary care doctoring are identified. The most important reason is medicine's loss of state sponsorship: the U.S. state has shifted from a pluralistic orientation to a New Right approach. With less state protection medicine has become even more attractive for private interests. Six additional reasons include: (1) the epidemiologic transition (chronic diseases reduce doctors to a palliative role and monitoring of incurable conditions); (2) the overcrowded health care playing field (non-physician clinicians are supplanting primary care doctors); (3) the unintended consequences of clinical guidelines (the art of doctoring is reduced to formulaic tasks, easily codified and performed by non-physician clinicians); (4) the demise of the in-person examination (in-person examination is being replaced by impersonal testing); (5) primary care doctoring is becoming unattractive (physicians are dissatisfied, alienated and experiencing income declines. Applications by U.S. graduates to primary care programs continue to decline); (6) patients are not what they used to be (Internet access and Direct to Consumer advertising are changing the doctor-patient relationship). By 2025, many everyday illnesses in the U.S. will be managed via the Internet or by non-physician clinicians working out of retail clinics. Some medical problems will still require a physician's attention, but this will be provided by specialists rather than by primary care doctors (general practitioners).
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Affiliation(s)
- John McKinlay
- New England Research Institutes, Watertown, MA 02472, United States.
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Zhao C, Austin RM. Adjunctive high-risk human papillomavirus DNA testing is a useful option for disease risk assessment in patients with negative Papanicolaou tests without an endocervical/transformation zone sample. Cancer 2008; 114:242-248. [DOI: 10.1002/cncr.23598] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Dissemination of Lean Methods to Improve Pap Testing Quality and Patient Safety. J Low Genit Tract Dis 2008; 12:103-10. [DOI: 10.1097/lgt.0b013e31815ae9a1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Currently, tort reform is not a major priority in either the Congress of the United States or in state legislatures. Thus, it is fortunate that medical negligence claims against pathologists are relatively infrequent, at 8.3% per year per 100 insured pathologists (data from the Doctors' Company, 2000-2003). However, claims for "missed" cervical cytology specimens rank third, behind those for alleged misinterpretation of breast biopsies and pigmented skin lesions. The severity of cervical cytology errors is high, at almost $700,000 per claim, surpassed only by those concerning melanoma. There are common threads that appear consistently in the analysis of slides from allegedly misdiagnosed cervical cytology cases, including small-cell variants of high-grade squamous intraepithelial neoplasia (HGSIL), present in small numbers; hyperchromatic crowded cell groups; atypical squamous cells of undetermined significance (ASCUS); smears taken during menses; other bloody smears, particularly with degenerative features or excessive inflammation; others showing atypical repair; and unsatisfactory samples. It is important for pathologists to spend time with cytotechnologists to emphasize the patterns of abnormal smears at low microscopic magnification and those backgrounds featuring blood and inflammation which require particular attention. Managing the "look-back" requirement of the Clinical Laboratory Amendments of 1988 (CLIA88) is also crucial; the need to issue amended reports as a consequence of that provision is quite rare. Procedures for administrating and reporting retrospective reviews under the CLIA88 should be clearly outlined in a peer-reviewed procedure document in each laboratory. They should be reviewed and approved by risk managers or insurance carriers, and documented in such a manner that one obtains maximal protection from legal discovery. Consumer education is particularly important in maintaining laboratory performance and reducing risk from error in cytology. Periodic feedback to clinicians on the quality of their smear preparations, the use of ancillary techniques (eg, human papillomavirus testing), and discussion of reporting terminology are important. Moreover, one should stress the need for pertinent clinical history that is often required to initiate quality control measures for evaluation and reporting of cervical cytology specimens. The incidence of cervical cancer in the United States, at only 9700 new cases per year, is low, emphasizing the need for clinical vigilance, attention to unexplained symptoms and signs, and biopsies of any cervical abnormality. These and other efforts may assist in reducing the risk of litigation attached to allegedly false-negative gynecologic and nongynecologic cytology samples.
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Affiliation(s)
- William J Frable
- Department of Pathology, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0662, USA.
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Raab SS, Grzybicki DM, Vrbin CM, Geisinger KR. Urine cytology discrepancies: frequency, causes, and outcomes. Am J Clin Pathol 2007; 127:946-53. [PMID: 17509992 DOI: 10.1309/xuvxfxmfpl7telce] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Although urine cytology is used for the early detection and surveillance of urothelial carcinoma, there has been little study of the frequency, causes, and outcomes of cytologic-histologic discrepancies. We obtained histologic follow-up in 361 (6.2%) of 5,785 voided, 124 (19.5%) of 636 lower tract instrumented, and 23 (33%) of 69 upper tract urinary cytologic specimens from 1 institution during a 2-year timeframe to determine diagnostic discrepancy frequency and outcomes. Cytologic-histologic discrepancies were observed in 208 (40.9%) cases with histologic followup, and the cause of discrepancy was interpretation and sampling in 35.1% and 63.0%, respectively. Of all discrepancies, 101 (48.6%) resulted in minimal or mild harm, consisting mainly of repeated testing and/or diagnostic delays. Severe harm never was observed. We conclude that current screening and surveillance methods that incorporate urine cytology are accurate in diagnosing urothelial cancer. However, the current protocols result in potentially reducible errors that lead to unnecessary testing and diagnostic delays.
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Affiliation(s)
- Stephen S Raab
- Departments of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA
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Spear SJ. Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2006; 81:S144-9. [PMID: 17001126 DOI: 10.1097/00001888-200610001-00034] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
There is a marked gap between the potential of medical science to treat illness and injury and the performance of the health care system in which hard-working, intelligent, well-trained people put that science to work. Care is available to too few, and costs and risks of injury are too high. This is avoidable. Experience in Boston, Pittsburgh, Salt Lake City, Seattle, and elsewhere indicates that quality can be raised-while risks and costs are dramatically reduced-by applying lessons from the highest-performing industrial organizations to designing, operating, and improving health care processes. What are these lessons? Improve sick processes with the same approaches used to treat patients. Specify "normal." When problems in quality, safety, efficiency, responsiveness, and the like occur, quickly determine exactly what is abnormal and determine what might be causing them. Develop a "treatment plan"-process changes that will eliminate or counteract the causal factors. Run the process (or a facsimile) with a modified, watching for gaps between actual and expected outcomes. When gaps occur, do a new work-up, diagnosis, treatment plan, and test. Lessons in designing, operating, and improving processes can be taught just as medical expertise is developed. Teach basic frameworks didactically; then, provide hands-on experience in applying those principles to real problems. Start with simple well-bounded situations that can be practiced frequently, with rapid feedback and close mentoring before advancing to more complex, less well bounded situations that occur less frequently and provide less immediate feedback between action and outcome. Incorporate development of process improvement skills into residency training so that deepening expertise within specialties is complemented by greater skill at integrating functional knowledge into well-integrated care processes.
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Affiliation(s)
- Steven J Spear
- Massachusetts Institute of Technology, Institute for Healthcare Improvement, 10 Milton Road, Brookline, MA 02445, USA.
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Raab SS, Grzybicki DM, Sudilovsky D, Balassanian R, Janosky JE, Vrbin CM. Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. Am J Clin Pathol 2006; 126:585-92. [PMID: 16938657 DOI: 10.1309/njq1l7ka10ukv93q] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Our objective was to determine whether the Toyota Production System process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules. In this longitudinal, nonconcurrent cohort study, we compared the diagnostic error frequency of a thyroid aspiration service before and after implementation of error reduction initiatives consisting of adoption of a standardized diagnostic terminology scheme and an immediate interpretation service. A total of 2,424 patients underwent aspiration. Following terminology standardization, the false-negative rate decreased from 41.8% to 19.1% (P = .006), the specimen nondiagnostic rate increased from 5.8% to 19.8% (P < .001), and the sensitivity increased from 70.2% to 90.6% (P < .001). Cases with an immediate interpretation had a lower noninterpretable specimen rate than those without immediate interpretation (P < .001). Toyota process change led to significantly fewer diagnostic errors for patients who underwent thyroid fine-needle aspiration.
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Affiliation(s)
- Stephen S Raab
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15232, USA
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Raab SS, Vrbin CM, Grzybicki DM, Sudilovsky D, Balassanian R, Zarbo RJ, Meier FA. Errors in thyroid gland fine-needle aspiration. Am J Clin Pathol 2006; 125:873-82. [PMID: 16690487 DOI: 10.1309/7rqe-37k6-439t-4pb4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Scant published data exist on redesigning pathology practice based on error data. In this first step of an Agency for Healthcare Research and Quality patient safety project, we measured the performance metrics of thyroid gland fine-needle aspiration, performed root cause analysis to determine the causes of error, and proposed error-reduction initiatives to address specific errors. Eleven cytologists signed out 1,543 thyroid gland aspirates in 2 years, and surgical pathology follow-up was obtained in 364 patients. Of the 364 patients, 91 (25.0%) had a false-negative diagnosis and 36 (9.9%) a false-positive diagnosis. Root cause analysis showed that major sources of error were pre-analytic (poor specimen quality) and analytic (interpretation of unsatisfactory specimens as nonneoplastic and lack of diagnostic category standardization). We currently are evaluating the effectiveness of error reduction initiatives that target pre-analytic and analytic portions of the diagnostic pathway.
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Affiliation(s)
- Stephen S Raab
- Department of Pathology, University of Pittsburgh, School of Medicine, Pittsburgh, PA 15232, USA
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Raab SS, Vrbin CM, Grzybicki DM, Sudilovsky D, Balassanian R, Zarbo RJ, Meier FA. Errors in Thyroid Gland Fine-Needle Aspiration. Am J Clin Pathol 2006. [DOI: 10.1309/7rqe37k6439t4pb4] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Abstract
Context.—Anatomic pathology laboratories use several quality assurance tools to detect errors and to improve patient safety.
Objective.—To review some of the anatomic pathology laboratory patient safety quality assurance practices.
Design.—Different standards and measures in anatomic pathology quality assurance and patient safety were reviewed.
Main Outcome Measures.—Frequency of anatomic pathology laboratory error, variability in the use of specific quality assurance practices, and use of data for error reduction initiatives.
Results.—Anatomic pathology error frequencies vary according to the detection method used. Based on secondary review, a College of American Pathologists Q-Probes study showed that the mean laboratory error frequency was 6.7%. A College of American Pathologists Q-Tracks study measuring frozen section discrepancy found that laboratories improved the longer they monitored and shared data. There is a lack of standardization across laboratories even for governmentally mandated quality assurance practices, such as cytologic-histologic correlation. The National Institutes of Health funded a consortium of laboratories to benchmark laboratory error frequencies, perform root cause analysis, and design error reduction initiatives, using quality assurance data. Based on the cytologic-histologic correlation process, these laboratories found an aggregate nongynecologic error frequency of 10.8%. Based on gynecologic error data, the laboratory at my institution used Toyota production system processes to lower gynecologic error frequencies and to improve Papanicolaou test metrics.
Conclusion.—Laboratory quality assurance practices have been used to track error rates, and laboratories are starting to use these data for error reduction initiatives.
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Affiliation(s)
- Stephen S Raab
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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