Dissemination of Lean Methods to Improve Pap Testing Quality and Patient Safety

Is It Still Time for Safety Walkaround? Pilot Project Proposing a New Model and a Review of the Methodology

Background and Objectives: Healthcare facilities are complex systems due to the interaction between different factors (human, environmental, management, and technological). As complexity increases, it is known that the possibility of error increases; therefore, it becomes essential to be able to analyze the processes that occur within these contexts to prevent their occurrence, which is the task of risk management. For this purpose, in this feasibility study, we chose to evaluate the application of a new safety walkaround (SWA) model. Materials and Methods: A multidisciplinary working group made up of experts was established and then the subsequent phases of the activity were divided into three stages, namely the initial meeting, the operational phase, and the final meeting, to investigate knowledge regarding patient safety before and subsequently through visits to the department: the correct compilation of the medical record, adherence to evidence-based medicine (EBM) practices, the overall health and the degree of burnout of the various healthcare professionals, as well as the perception of empathy of staff by patients. Results: This working group chose to start this pilot project in the vascular surgery ward, demonstrating the ability of the tool used to capture the different aspects it set out to collect. In detail, the new version of SWA proposed in this work has made it possible to identify risk situations and system vulnerabilities that have allowed the introduction of corrective tools; detect adherence to existing company procedures, reschedule training on these specific topics after reviewing, and possibly update the same procedures; record the patient experience about the doctor-patient relationship and communication to hypothesize thematic courses on the subject; evaluate workers' perception of their health conditions about work, and above all reassure operators that their well-being is in the interest of the management of the healthcare company, which is maintained. Conclusions: Therefore, the outcome of the present study demonstrates the versatility and ever-present usefulness of the SWA tool.

Innovative Synoptic Reporting With Seven-Point Sampling Protocol to Improve Detection Rate of Microvascular Invasion in Hepatocellular Carcinoma

Pathological MVI diagnosis could help to determine the prognosis and need for adjuvant therapy in hepatocellular carcinoma (HCC). However, narrative reporting (NR) would miss relevant clinical information and non-standardized sampling would underestimate MVI detection. Our objective was to explore the impact of innovative synoptic reporting (SR) and seven-point sampling (SPRING) protocol on microvascular invasion (MVI) rate and patient outcomes. In retrospective cohort, we extracted MVI status from NR in three centers and re-reviewed specimen sections by SR recommended by the College of American Pathologists (CAP) in our center. In prospective cohort, our center implemented the SPRING protocol, and external centers remained traditional pathological examination. MVI rate was compared between our center and external centers in both cohorts. Recurrence-free survival (RFS) before and after implementation was calculated by Kaplan-Meier method and compared by the log-rank test. In retrospective study, we found there was no significant difference in MVI rate between our center and external centers [10.3% (115/1112) vs. 12.4% (35/282), P=0.316]. In our center, SR recommended by CAP improved the MVI detection rate from 10.3 to 38.6% (P<0.001). In prospective study, the MVI rate in our center under SPRING was significantly higher than external centers (53.2 vs. 17%, P<0.001). RFS of MVI (−) patients improved after SPRING in our center (P=0.010), but it remained unchanged in MVI (+) patients (P=0.200). We conclude that the SR recommended by CAP could help to improve MVI detection rate. Our SPRING protocol could help to further improve the MVI rate and optimize prognostic stratification for HCC patients.

Implementation of a 'lean' cytopathology service: towards routine same-day reporting

OBJECTIVES

To systematically assess the effects of a Lean management intervention in an academic cytopathology service.

METHODS

We monitored outcomes including specimen turnaround times during stepwise implementation of a lean cytopathology workflow for gynaecological and non-gynaecological cytology.

RESULTS

The intervention resulted in a major reduction of turnaround times for both gynaecological (3rd quartile 4.1 vs 2.3 working days) and non-gynaecological cytology (3rd quartile 1.9 vs. 1.2 working days). Introduction of fully electronic reporting had additional effect over continuous staining of slides alone. The rate of non-gynaecological specimens reported the same day increased from 4.5% to 56.5% of specimens received before noon.

CONCLUSIONS

Lean management principles provide a useful framework for organization of a cytopathology workflow. Stepwise implementation beginning with a simplified gynaecological cytology workflow allowed involved staff to monitor the effects of individual changes and allowed for a smooth transition.

Safety improvements from health lean management implementation

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.

Improving Hospital Laboratory Performance: Implications for Healthcare Managers

Laboratory services in healthcare delivery systems play a vital role in inpatient care. Studies have shown that laboratory data affects approximately 65% of the most critical decisions on admission, discharge, and medication. Laboratory testing accounts for approximately 10% of hospital billing. Reducing laboratory costs and improving laboratory performance would contribute to reducing total healthcare cost, which is one of the major goals for the U.S. healthcare delivery system. The objective of this paper is to review and analyze the diverse research approaches applied to improve the performance of hospital laboratories in large healthcare delivery systems. The approaches reviewed include: lean, quality control, automation, and simulation modeling. In the conclusion, future research directions are presented, which include additional methods to be investigated to further improve the performance of hospital laboratories.

Investigating the connections between health lean management and clinical risk management

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.

Applying systems engineering to implement an evidence-based intervention at a community health center

Impressive results in patient care and cost reduction have increased the demand for systems-engineering methodologies in large health care systems. This Report from the Field describes the feasibility of applying systems-engineering techniques at a community health center currently lacking the dedicated expertise and resources to perform these activities.

Guidelines for overcoming hospital managerial challenges: a systematic literature review

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.

Increasing the efficiency of autopsy reporting

CONTEXT

-When autopsy reports are delayed, clinicians and families do not receive information in a timely fashion.

OBJECTIVE

-Using lean principles derived from the Toyota Production System, we set out to streamline our autopsy reporting process.

DESIGN

-In a formal workshop setting, we identified the steps involved in producing an autopsy report, then sought to eliminate, abbreviate, or reschedule them into a more efficient format. We established intermediate deadlines for each case, taking care to make them visible; we initiated a weekly quality assurance review, giving attention to both scientific issues and approaching deadlines.

RESULTS

-By adopting a more standardized approach, eliminating redundancy, and improving the visibility of tasks, we improved the mean completion time of autopsy reports from 53 days (N = 47 cases) to 25 days (N = 47 cases). Previously, 17% of reports were completed by 30 days and 71% by 60 days; in the 15 months following initiation of the program, 72% of reports were completed by 30 days and 100% by 60 days. A follow-up survey of attending physicians revealed continuing appreciation for the autopsy and timely communication, with no perceived diminution in the quality of reports.

CONCLUSIONS

-This approach was of great benefit in our laboratory and may assist others in reducing the turnaround time of their autopsy reports. It may also benefit other areas of the laboratory.

Unsatisfactory SurePath liquid-based Papanicolaou tests: causes and significance

BACKGROUND

The introduction of liquid-based Papanicolaou (Pap) tests (LBPTs) has reduced the incidence of unsatisfactory Pap tests (UPTs), but little is known about their causes and significance, especially in the case of SurePath LBPTs.

METHODS

All unsatisfactory LBPTs from January 1, 2003 to December 31, 2006 were retrieved. The characteristics of patients, providers, and LBPTs; the reason for UPTs; and any cytologic or histologic follow-up within 24 months were recorded. Negative Pap tests that were evaluated immediately after a UPT served as a control group.

RESULTS

Of 243,006 Pap tests (95.5% SurePath LBPTs), 0.23% were unsatisfactory. Scant cellularity was the primary cause of SurePath UPT. Women in this UPT group were older, had more diagnostic Pap tests taken, less frequently were taking contraceptives or were pregnant, and were more likely to be menopausal or posthysterectomy. The 278 women who had UPTs had significantly higher rates of follow-up Pap tests (65.1% vs 22.2%), abnormal Pap tests (5.4% vs 1.4%), biopsies (10% vs 1%), and abnormal biopsies (5% vs 1%) than the 284 women in the control group, including 7 women with cervical intraepithelial neoplasia 1 (CIN-1), 1 woman with CIN-2, 4 women with CIN-3, and 2 women with endometrial hyperplasia. The UPT rates varied little between provider groups (physicians vs nonphysicians and gynecologists vs nongynecologists).

CONCLUSIONS

The frequency of UPTs in a predominantly SurePath LBPT-screened population was very low and was caused mainly by low cellularity. Similar to conventional Pap smears, unsatisfactory SurePath LBPTs had a higher risk of significant histologic abnormalities on follow-up than negative satisfactory Pap tests and could have benefited from a repeat Pap test or other evaluation, according to current management guidelines.

Informatics applied to cytology

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.