Improving Patient Care in Cardiac Surgery Using Toyota Production System Based Methodology

Understanding the Patient Experience: Analysis of 2-Word Assessment and Its Relationship to Likelihood to Recommend in Outpatient Hand Surgery

BACKGROUND

Actionable feedback from patients after a clinic visit can help inform ways to better deliver patient-centered care. A 2-word assessment may serve as a proxy for lengthy post-visit questionnaires. We tested the use of a 2-word assessment in an outpatient hand clinic.

METHODS

New patients were asked to provide a 2-word assessment of the following: (1) their physician; (2) their overall experience; and (3) recommendations for improvement and their likelihood to recommend (LTR) after their clinic visit. Sentiment analysis was used to categorize results into positive, neutral, or negative sentiment. Recommendations for improvement were classified into physician issue, system issue, or neither. We evaluated the relationship between LTR status, sentiment, actionable improvement opportunities, and classification (physician issue, system issue, or neither). Recommendations for improvement were classified into themes based on prior literature.

RESULTS

Sixty-seven (97.1%) patients noted positive sentiment toward their physician; 67 (97.1%) noted positive sentiment toward their overall experience. About 31% of improvement recommendations were system-based, 5.9% were physician-based, and 62.7% were neither. Patients not LTR were more likely to leave actionable opportunities for improvement than those LTR (P = .01). Recommendations for improvement were classified into predetermined themes relating to: (1) physician interaction; (2) check-in process; (3) facilities; (4) unnecessary visit; and (5) appointment delays.

CONCLUSION

Patients not likely to recommend provided actionable opportunities for improvement using a simple 2-word assessment. Implementation of a 2-word assessment in a hand clinic can be used to obtain actionable, real-time patient feedback that can inform operational change and improve the patient experience.

Lean Management Systems in Health Care: A Review of the Literature

BACKGROUND AND OBJECTIVES

Many health care organizations now employ Lean tools to improve value in health care, yet reports of their effectiveness vary. This variation may be explained by the context in which Lean is implemented, whether as a tool or as a management system. This article reports on a structured literature review conducted to understand the evidence base for the impact of Lean Management System implementation in health care.

METHODS

A search of PubMed, Scopus, Emerald, EMBASE, CINAHL, and Business Source Complete databases was conducted in November 2017 and repeated in July 2020 to assess the evidence for the impact of Lean Management Systems in health care from 2000 to July 2020. Articles were included if they (1) reported on a Lean Management System or (2) reported on Lean Management System components as described by Mann 1 (ie, leader standard work, visual controls, daily accountability process, and discipline).

RESULTS

A total of 52 articles met the inclusion criteria. Although all articles described some combination of leader standard work, visual management, and daily accountability as part of their Lean Management System, only a handful described use of all 3 components together. Only one explicitly mentioned the fourth component, discipline, required to consistently apply the first 3. The majority reported on single-unit or department implementations and most described daily huddles at the unit level that included review of key performance indicators, identification of improvement opportunities, and problem solving. The role of the leader in a Lean Management System was described a coach and a mentor. Barriers to adoption such as insufficient training and increased workload for nurses were noted along with the importance of relevance to the local context for unit teams to find value in huddle boards and huddles. As yet, evidence of Lean Management System effectiveness in driving health care improvement is absent due to weak study designs and lack of statistical rigor.

CONCLUSION

Well-designed research on Lean Management Systems in health care is lacking. Despite increasing adoption of Lean Management Systems over the past 10 years and anecdotal reports of its effectiveness, very few articles provide quantitative data. Those that do report unit-level implementation only, little use of a comprehensive package of Lean Management Systems elements, and weaker study designs and statistical methods. More rigorous study designs and robust statistical analysis are needed to evaluate effectiveness of Lean Management Systems in health care. This represents a rich area for future health care management research.

Can Quality Improvement Methodologies Derived from Manufacturing Industry Improve Care in Cardiac Surgery? A Systematic Review

Objectives: Healthcare is required to be effectively organised to ensure that growing, aging and medically more complex populations have timely access to high-quality, affordable care. Cardiac surgery is no exception to this, especially due to the competition for and demand on hospital resources, such as operating rooms and intensive care capacity. This is challenged more since the COVID-19 pandemic led to postponed care and prolonged waiting lists. In other sectors, Quality Improvement Methodologies (QIM) derived from the manufacturing industry have proven effective in enabling more efficient utilisation of existing capacity and resources and in improving the quality of care. We performed a systematic review to evaluate the ability of such QIM to improve care in cardiac surgery. Methods: A literature search was performed in PubMed, Embase, Clarivate Analytics/Web of Science Core Collection and Wiley/the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. Results: Ten articles were identified. The following QIM were used: Lean, Toyota Production System, Six Sigma, Lean Six Sigma, Root Cause Analysis, Kaizen and Plan-Do-Study-Act. All reported one or more relevant improvements in patient-related (e.g., infection rates, ventilation time, mortality, adverse events, glycaemic control) and process-related outcomes (e.g., shorter waiting times, shorter transfer time and productivity). Elements to enhance the success included: multidisciplinary team engagement, a patient-oriented, data-driven approach, a sense of urgency and a focus on sustainability. Conclusions: In all ten papers describing the application of QIM initiatives to cardiac surgery, positive results, of varying magnitude, were reported. While the consistency of the available data is encouraging, the limited quantity and heterogenous quality of the evidence base highlights that more rigorous evaluation, including how best to employ manufacturing industry-derived QIM in cardiac surgery is warranted.

The impact of lean management on frontline healthcare professionals: a scoping review of the literature

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.

Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

BACKGROUND

Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists.

METHODS

We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare.

RESULTS

We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality.

CONCLUSIONS

When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

Cardiothoracic Critical Care

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.

The Use of Operational Excellence Principles in a University Hospital

The introduction of Operational Excellence in the Maastricht University Medical Center (MUMC+) has been the first of its kind and scale for a university hospital. The policy makers of the MUMC+ have combined different elements from various other business, management, and healthcare philosophies and frameworks into a unique mix. This paper summarizes the journey of developing this system and its most important aspects. Special attention is paid to the role of the operating rooms and the improvements that have taken place there, because of their central role in the working of the hospital. The MUMC+ is the leading tertiary healthcare center for the South-East region of The Netherlands and beyond. Regional, national, and international developments encouraged the MUMC+ to start significantly reorganizing its care processes from 2009 onward. First experiments with Lean Six Sigma and Business Modeling were combined with lessons learned from other centers around the world to form the MUMC+’s own type of Operational Excellence. At the time of writing, many improvement projects of different types have been successfully completed. Every single department in the hospital now uses Operational Excellence and design thinking in general as a method to develop new models of care. An evaluation in 2014 revealed several opportunities for improvement. A large number of projects were in progress, but 75% of all projects had not been completed, despite the first projects being initiated back in 2012. This led to a number of policy changes, mainly focusing on more intensive monitoring of projects and trying to do more improvement projects directly under the responsibility of the line manager. Focusing on patient value, continuous improvement, and the reduction of waste have proven to be very fitting principles for healthcare in general and specifically for application in a university hospital. Approaching improvement at a systems level while directly involving the people on the work floor in observing opportunities for improvement and realizing these has shown itself to be essential.

Prophylactic antibiotics in interventional paediatric cardiac catheterisation: old habits die hard?

Antibiotic prophylaxis in congenital cardiac disease has long been a topic of debate. Although there is little dispute around antibiotic cover for surgical procedures and catheter interventions where foreign material is being inserted, there are little data specific to non-device-placement procedures such as atrial septostomy or balloon valvotomy. We sought to assess the effect of routine prophylaxis on post-interventional infections via a retrospective pseudo-randomised analysis, and an online survey on paediatric interventional cardiologists in the United Kingdom and United States.

[Improvement approaches in the hospital setting: From total quality management to Lean]

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.

Quality, patient safety, and the cardiac surgical team

After more than a decade of attention, the risks inherent in cardiac surgery have been well documented, but examples of effective interventions to reduce this risk remain scarce. The need is great, because the patient population is vulnerable and the potential consequences of poor outcomes are ever present and significant. This article reviews a decade of discussion surrounding quality and safety issues in cardiac surgery, and concludes with examples of strategies that have shown great promise for improving cardiac surgery quality and safety.

Ventilator-associated complications, including infection-related complications: the way forward

Acute respiratory failure represents the most common condition requiring admission to an adult intensive care unit. Ventilator-associated pneumonia (VAP) has been used as a marker of quality for patients with respiratory failure. Hospital-based process-improvement initiatives to prevent VAP have been successfully used. The use of ventilator-associated complications (VACs) has been proposed as an objective marker to assess the quality of care for this patient population. The use of evidence-based bundles targeting the reduction of VACs, as well as the conduct of prospective studies showing that VACs are preventable complications, are reasonable first-steps in addressing this important clinical problem.