Decreasing Wait Times and Increasing Patient Satisfaction: A Lean Six Sigma Approach

Improving Outcomes in Patients Sent to the Emergency Department from Outpatient Providers: A Receiver-Driven Handoff Process Improvement

BACKGROUND

Outpatient providers refer to emergency departments (EDs) due to findings requiring assessment beyond existing capabilities. However, poor communication surrounding these transitions may hinder safety and timeliness of emergency care. Receiver-driven handoff (RDH) is a process that helps ensure that all pertinent information is shared. This quality improvement project aimed to (1) improve knowledge of RDH, (2) increase satisfaction and perceptions surrounding RDH, (3) modify behaviors in relation to RDH, and (4) decrease referred patients leaving without being seen (LWBS).

METHODS

The Iowa Model and Implementation Framework guided this evidence-based quality improvement project. A multidisciplinary team developed and implemented a standardized RDH process consisting of screening to determine whether a patient was referred to the ED, review of electronic health record (EHR), and use of EHR documentation. Process measures were collected via questionnaire pre- and postimplementation and were analyzed quantitatively. Outcome measures were trended by a statistical process control p-chart, which was developed to demonstrate changes in the percentage of patients who were referred to the ED from the outpatient setting and LWBS.

RESULTS

The average response for the question "How satisfied are you with the handoff of patient information from referring clinic providers to the ED?" increased from 1.51 preintervention to 2.04 postintervention (p = 0.005). Respondents rated the information received during handoff higher postintervention (2.12 vs. 2.52, p = 0.04). Compliance with screening for referral to the ED was 84.0%. The proportion of patients LWBS after referral decreased by 6.2 percentage points (p < 0.001).

CONCLUSION

Using RDH in conjunction with a standardized triage screening may improve quality of information shared during this vulnerable transition and may assist in reduction of referred patients LWBS. The RDH process should be adapted into everyday workflow to ensure sustainability and effectiveness.

International collaboration between low-middle-income and high-income institutions to improve radiation therapy care delivery

INTRODUCTION

The Philippines is a lower-middle-income island country with over 153 000 new cancer diagnosis each year. Despite many patients needing radiotherapy as part of disease management, there remains limitations to access. Currently, the Philippines has 50 linear accelerator facilities serving a population of 110 million. However, given the recommendation of 1 linear accelerator for every 250 thousand people, it is evident that the demand for accessible radiotherapy resources is significantly underserved in the country. This paper outlines the collaboration between GenesisCare Solutions (GCS) and Fairview Cancer Center (FCC) to address efficiency and access within the radiotherapy department at FCC.

METHODS

Through international collaboration between GCS and FCC, areas for improvement were identified and categorized into four domains: Dosimetry quality, Patient workflow, Data & Reporting, and Information Technology (IT) Infrastructure. Action plans were developed then implemented. A baseline measurement was obtained for each domain, and post-implementation evaluation undertaken at 3 months, 6 months, and 12 months. Data captured within the electronic medical record system was extrapolated, and average treatment times were established for pre- and post-engagement. A paired, 2-tailed t-test was used for statistical analysis of outcome parameters using IBM SPSS version 23 for all statistics.

RESULTS

Twelve months post-initial engagement, all four domains saw positive outcomes. Improved plan quality linked to Intensity Modulated Radiotherapy (IMRT) utilization rates saw an increase from 20% to 54%. A significant reduction in patient average wait times was also observed, from 27 to 17 min (p ≤ 0.001). Prior to engagement, tracking patient demographics and diagnosis was not prioritized, post engagement an average of 92% diagnosis entry compliance was achieved.

CONCLUSION

Through the collaboration of GCS and FCC, objectives in all action plan domains were achieved, highlighting the benefits of collaboration between low-middle-income and high-income institutions.

Revolutionising Quality Management in the Oral Pathology Laboratory: A Deep Dive Into the Six Sigma Methodology

Six Sigma Foundations is a statistical standard that indicates an exceptionally high level of quality, along with a customer satisfaction management approach that intends to lower error rates and boost process efficiency. The Define, Measure, Analyse, Improve, and Control (DMAIC) approach is a fundamental component of Six Sigma and provides an organised framework for process improvement. In contrast to conventional techniques that are more manual-based, Six Sigma emphasises and focuses on making decisions based on facts and evidence. The key to the success of Six Sigma is its reliance on statistical methods. Advanced tools like Pareto charts, histograms, regression analysis, and fishbone diagrams are used ardently for the benefit of customers and to reduce the overall error rate. To support clinical decision-making, a clinical laboratory's primary responsibility is to generate test results that are accurate, repeatable, fast, and appropriately interpreted. Ensuring desired clinical outcomes must be the ultimate objective. To accomplish this goal, laboratories must prioritise cost-effectiveness while establishing and maintaining quality in all laboratory procedures. The concept of the Lean Six Sigma (LSS) methodology, which mainly centres on efficiency by discerning and eradicating actions or operations that do not provide any benefit to the organisation, is combined with the proposition of Six Sigma, which emphasises data-driven analyses and optimization. The integration of these powerful concepts aids in the overall improvement of the organisations adopting these techniques. This review provides a brief overview of the benefits of the LSS methodology and its implementation in the oral pathology laboratory.

Implementing patient safety and quality improvement in dermatology. Part 2: Quality improvement science

Quality improvement (QI) in medicine is reliant on a team-based approach and an understanding of core QI principles. Part 2 of this continuing medical education series outlines the steps of performing a QI project, from identifying QI opportunities, to carrying out successive Plan-Do-Study-Act cycles, to hard-wiring improvements into the system. QI frameworks will be explored and readers will understand how to interpret basic QI data.

Evaluating Outcomes and Time Delays of a Non-Trainee-Driven Hospitalist Procedure Service

BACKGROUND AND OBJECTIVES

Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure.

METHODS

The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained).

RESULTS

Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service.

CONCLUSIONS

A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.

Improving Time to Diagnostic Resolution in the Breast Imaging Service: A Tertiary Center's Experience and Process of Improvement

OBJECTIVE

Breast imaging services often experience a significant degree of variability in patient flow, leading to delay in time to diagnostic resolution, commonly referred to as time to resolution (TTR). This study applies Lean Six Sigma Methodology (LSSM) to reduce TTR and enhance patient outcomes.

METHODS

This study was IRB-approved. A baseline audit was done using cases of mammographic recalls (BI-RADS 0) to measure baseline TTR. Multidisciplinary meetings with all members of the breast imaging service, alongside a study of patient complaint data, were utilized to identify issues that were causing prolonged TTR. Following that, possible solutions were proposed and implemented. A post-implementation audit was conducted, and the resulting TTRs were compared. Significant differences in TTR between the pre- and post-solution implementation were assessed using the Mann-Whitney U test.

RESULTS

During the baseline audit of 8 months, 589 cases of mammographic recalls (BI-RADS 0) were identified, and the resulting average TTR was 86.3 days. During the post-implementation period of 3 months, 370 mammographic recalls (BI-RADS 0) occurred, with a resulting average TTR of 36.0 days. After applying LSSM, TTR was reduced by 58.3% (P < 0.01). Some changes implemented included training the coordinators, establishing a rapid diagnostic clinic using previously underutilized equipment, and having radiologists assigned full-time to the breast imaging service.

CONCLUSION

Our team has successfully managed to identify various causes behind the prolonged TTR using LSSM. Team collaboration was essential to study and decide on a more achievable TTR.

Six Sigma can significantly reduce costs of poor quality of the surgical instruments sterilization process and improve surgeon and operating room personnel satisfaction

Operating room (OR) management is a complex multidimensional activity combining clinical and managerial aspects. This longitudinal observational study aimed to assess the impact of Six-Sigma methodology to optimize surgical instrument sterilization processes. The project was conducted at the operating theatre of our tertiary regional hospital during the period from July 2021 to December 2022. The project was based on the surgical instrument supply chain analysis. We applied the Six Sigma lean methodology by conducting workshops and practical exercises and by improving the surgical instrument process chain, as well as checking stakeholders' satisfaction. The primary outcome was the analysis of Sigma improvement. Through this supply chain passed 314,552 instruments in 2022 and 22 OR processes were regularly assessed. The initial Sigma value was 4.79 ± 1.02σ, and the final one was 5.04 ± 0.85σ (SMD 0.60, 95%CI 0.16-1.04, p = 0.010). The observed improvement was estimated in approximately $19,729 of cost savings. Regarding personnel satisfaction, 150 questionnaires were answered, and the overall score improved from 6.6 ± 2.2 pts to 7.0 ± 1.9 pts (p = 0.013). In our experience the application of the Lean Six Sigma methodology to the process of handling the surgical instruments from/to the OR was cost-effective, significantly decreased the costs of poor quality and increased internal stakeholder satisfaction.

Improving pain management and safe opioid use after surgery: A DMAIC-based quality intervention

Background

Multimodal perioperative patient education and expectation-setting can reduce post-operative opioid use while maintaining pain control and satisfaction. As part of a quality-improvement project, we developed a standardized model for perioperative education built upon the American College of Surgeons (ACS) Safe and Effective Pain Control After Surgery (SEPCAS) brochure to improve perioperative education regarding opioid use and pain control.

Material and methods

Our study was designed within the Define, Measure, Analyze, Improve, Control (DMAIC) quality-improvement framework. Patients were surveyed about the adequacy of their perioperative education regarding pain control and use of prescription opioid medication. After gathering baseline data, a multimodal educational intervention based on the SEPCAS brochure was implemented. Survey responses were then compared between groups.

Results

Twenty-seven subjects were included from the pre-intervention period, and thirty-nine were included from the post-intervention period (n = 66). Those in the post-intervention period were more likely to report receiving the appropriate amount of education regarding recognizing the signs of opioid overdose and how to safely store and dispose of opioid medications. The majority of patients who received the SEPCAS brochure reported that it was useful in their post-operative recovery and that it should be given to every patient undergoing surgery.

Conclusions

The ACS SEPCAS brochure is an effective tool for improving patient preparation to safely store and dispose of their opioid medication and recognize the signs of opioid overdose. The brochure was also well received by patients and perceived as an effective educational material.

Reducing Wait Times for Radiology Exams Around Holiday Periods: A Monte Carlo Simulation

Reducing patient wait times is a key operational goal and impacts patient outcomes. The purpose of this study is to explore the effects of different radiology scheduling strategies on exam wait times before and after holiday periods at an outpatient imaging facility using computer simulation. An idealized Monte Carlo simulation of exam scheduling at an outpatient imaging facility was developed based on the actual distribution of scheduled exams at outpatient radiology sites at a tertiary care medical center. Using this simulation, we examined three scheduling strategies: (1) no scheduling modifications, (2) increase imaging capacity before or after the holiday (i.e. increase facility hours), and (3) use a novel rolling release scheduling paradigm. In the third scenario, a fraction of exam slots are blocked to long-term follow-up exams and made available only closer to the exam date, thereby preventing long-term follow-up exams from filling the schedule and ensuring slots are available for non-follow-up exams. We examined the effect of these three scenarios on utilization and wait times, which we defined as the time from order placement to exam completion, during and after the holiday period. The baseline mean wait time for non-follow-up exams was 5.4 days in our simulation. When no scheduling modifications were made, there was a significant increase in wait times in the week preceding the holiday when compared to baseline (10.0 days vs 5.4 days, p < 0.01). Wait times remained elevated for 4 weeks following the holiday. Increasing imaging capacity during the holiday and post-holiday period by 20% reduced wait times by only 6.2% (9.38 days vs 10.0 days, p < 0.01). Increasing capacity by 50% resulted in a 7.1% reduction in wait times (9.28 days, p < 0.01), and increasing capacity by 100% resulted in a 13% reduction in wait times (8.75 days, p < 0.01). In comparison, using a rolling release model produced a reduction in peak wait times equivalent to doubling capacity (8.76 days, p < 0.01) when 45% of slots were reserved. Improvements in wait times persisted even when rolling release was limited to the 3 weeks preceding or 1 week following the holiday period. Releasing slots on a rolling basis did not significantly decrease utilization or increase wait times for long-term follow-up exams except in extreme scenarios where 80% or more of slots were reserved for non-follow-up exams. A rolling release scheduling paradigm can significantly reduce wait time fluctuations around holiday periods without requiring additional capacity or impacting utilization.

Process optimization for atrial fibrillation ablation

AIMS

In the light of an increasing prevalence of atrial fibrillation (AF) and growing evidence for the superiority of early invasive rhythm control, the demand for ablation therapy is rising. Accordingly, ablation centres will have to maximize their capacity by either adding electrophysiology laboratory resources or optimizing process management. In order to optimize process management, we applied "Lean Six Sigma" method to a single ablation center. We compared procedural parameters, acute efficacy and safety of cryoballoon pulmonary vein isolation (cryoPVI) before and after modifications.

METHODS AND RESULTS

Patients (n = 713) undergoing cryoPVI (108 before and 605 after process optimization) were analysed. Within 3 years of process optimization, electrophysiology laboratory occupancy time (150.7 ± 44.4 vs. 94 ± 22.1 min, P < 0.001), procedure time (84.5 ± 21-47.4 ± 12 min, P < 0.001), left-atrial dwell time (53.9 ± 18.4-31.9 ± 9.9 min, P < 0.001), and fluoroscopy time (15.8 ± 5.1 vs. 6.2 ± 2.8 min, P < 0.001) decreased. Contrast dye use (116 ± 35 vs. 27 ± 15 mL, P < 0.001) and radiation dose (893 ± 1078 vs. 253 ± 249 cGy cm2, P < 0.001) were reduced by ∼77 and ∼72%, respectively. There was no difference in safety endpoint occurrence (3.7 vs. 1.5%, P = 0.11).

CONCLUSION

The process optimization of cryoPVI for AF therapy using the 'Lean Six Sigma' method significantly increases efficiency without compromising patient safety.

Elements of patient satisfaction: An integrative review

AIM

To summarize the scientific literature on the elements essential to understanding a nursing definition of patient satisfaction.

DESIGN

Whittemore and Knafl's methodology was used for this integrative review.

METHODS

Articles were included if the studies they explored patient satisfaction in patient populations and measured patient satisfaction using standardized, validated instruments. Elements in this review were defined as the essential components that create the complex concept of patient satisfaction.

RESULTS

Thirty articles were found and analysed in full. Five definitions of patient satisfaction were used, all of which were at least 20 years old. Twenty-two different measures of patient satisfaction were used, six of which were nursing-specific. Sixty-eight elements of patient satisfaction were studied in the included articles. Forty-three elements were reported as having a significant relationship with patient satisfaction, 25 were reported as having no significant relationship. Eight elements had both significant and non-significant relationships.

Redesigning Patient Flow in Orthopedics and Radiology Clinics via a 3-Phase 'Kaizen' Improvement Approach and Interrupted Time Series Analysis

INTRODUCTION

The orthopedics clinic at an academic medical center has low patient satisfaction rates for patients that require an x-ray and have difficulty ambulating. The project aimed to reduce the 'non-value-added' time during appointments by using Lean and Six Sigma methodologies and enhance patient experience.

METHODS

An analysis of the current state was conducted using Gemba walks, interviews with subject matter experts, and an interrupted time study to assess baseline data. The project was implemented using a 3-phase Kaizen event approach.

RESULTS

Interventions implemented included: 1) re-engineering patient flow and 2) standardizing appointment scheduling guidelines. The 'non-value-added' appointment time was measured post intervention and it decreased from 17 to 8 minutes (51%) and 87% (N = 47) of patients rated the scheduling process positively.

CONCLUSION

Lean, Six Sigma and Kaizen improvement methodologies are invaluable tools to improve operational efficiency. The implemented interventions enhanced patient experience and improved clinic efficiency.

Do Patient Experiences Have Mediating Roles on Patient Loyalty?

The study aimed to evaluate the mediating roles of patient experiences on patient loyalty. The data were collected through an electronic questionnaire regarding feedback from 5732 patients received outpatient clinics. Patient loyalty was evaluated using the Net Promoter Score (NPS₁₁) that patients were asked whether they would like to recommend the hospital to their relatives or friends. Patient experiences with physicians, nurses, and waiting times were also asked in the questionnaire. After preliminary analysis, mediation analyses were performed to evaluate direct and indirect causal effects among variables for NPS_11. While patient experiences are used as possible mediators, Branch Groups in the first and Admission Time in the second model are independent variables. In the analyses, Surgical Medical Science (p = 0.019) and Day Shift (p = 0.000) have a direct mediating effect on NPS₁₁. Nursing care experiences were found to be a mediator variable for NPS₁₁ in both models (p = 0.000 for both). Patient loyalty was associated with Surgical Medical Science and Day Shift primarily whereas Nursing care experience had a mediating role.

Determinants of Out-of-Network Utilization of Care Among Insured Clients Under the National Health Insurance Fund of Sudan

Purpose

Knowledge of insured clients' utilization behavior is essential for developing evidence-based interventions for reform activities. This study explored the magnitude and determinants of voluntary out-of-network physician visit utilization among an insured population under the National Health Insurance Fund (NHIF) of Sudan.

Methods

This study was a cross-sectional survey conducted at the primary healthcare centers of NHIF in Al Jazirah state in Sudan. A structured interview questionnaire was used to collect data related to socio-economic and health insurance characteristics of NHIF clients and to assess their utilization behavior. Data were collected from September to October 2021.

Results

Of 768 NHIF clients who were interviewed (mean age 46 years, 55.1% females), 63.2% reported using out-of-network physician visits during the last six months prior to the interview. The median out-of-pocket payment for the last out-of-network physician visit was 5000 Sudanese pounds. The regression analysis revealed that clients’ gender, marital status, self-reported health, overall rating of the quality of care, rating of the general practitioner care, and ease of referral to a specialist were the significant determinants for seeking out-of-network physician care.

Conclusion

A high magnitude of out-of-network physician visit utilization was found among the insured NHIF clients of Al Jazirah state in Sudan. Policymakers should address issues identified in the current study to reduce patients’ leakage to out-of-network services.

The Impact of Diagnostic Decisions on Patient Experience in the Pediatric Emergency Department

OBJECTIVE

Patient experience serves as both a subjective measure of value-based health care delivery and a metric to inform operational decision making. The objective of this study was to determine if specific diagnostic and therapeutic interventions affect patient experience scores for children seen in the emergency department.

METHODS

We performed a retrospective observational study in the emergency department of a large quaternary care children's hospital on patients who were discharged to home and later completed a National Research Corporation Health patient experience survey. We matched the survey results to electronic health record (EHR) data and were able to extract demographics, operational metrics, and order information for each patient. We performed multiple logistic regression analyses to determine the association of image acquisition, laboratory test ordering, medication administration, and discharge prescribing with likelihood to recommend the facility as our measure of patient experience.

RESULTS

Of the 4103 patients who met inclusion criteria for the study, 75% strongly recommended the facility. Longer wait times were associated with lower patient experience scores [odds ratio (OR) per waiting room hour increase, 0.72; 95% confidence interval (CI), 0.65-0.81]. Significant diagnostic factors associated with higher patient experience included magnetic resonance imaging ordering (OR, 2.38; 95% CI, 1.00-5.67), x-ray ordering (OR, 1.19; 95% CI, 1.00-1.42), and electrocardiogram ordering (OR, 1.62; 95% CI, 1.07-2.44). Of the treatment factors studied, only antibiotic prescribing at discharge was found to have a significant positive association with patient experience (OR, 1.32; 95% CI, 1.08-1.63).

CONCLUSION

The positive association between more intensive diagnostic workups and patient experience could have implications on the utility of patient experience scores to evaluate pediatric care teams. Consideration should be taken to interpret patient experience scores in the context of compliance with approaches in evidence-based medicine.

Improving performance of the hospitalization process by applying the principles of Lean Thinking

Purpose

The goal was to improve the quality of the hospitalization process and the management of patients, allowing the reduction of costs and the minimization of the preoperative Length of Hospital Stay (LOS).

Design/methodology/approach

The methodology used to improve the quality of the hospitalization process and patient management was Lean Thinking. Therefore, the Lean tools (Value stream map and Ishikawa diagram) were used to identify waste and inefficiencies, improving the process with the implementation of corrective actions. The data was collected through personal observations, patient interviews, brainstorming and from printed medical records of 151 patients undergoing oral cancer surgery in the period from 2006 to 2018.

Findings

The authors identified, through Value Stream Map, waste and inefficiencies during preoperative activities, consequently influencing preoperative LOS, considered the best performance indicator. The main causes were identified through the Ishikawa diagram, allowing reflection on possible solutions. The main corrective action was the introduction of the pre-hospitalization service. A comparative statistical analysis showed the significance of the solutions implemented. The average preoperative LOS decreased from 4.90 to 3.80 days (−22.40%) with a p-value of 0.001.

Originality/value

The methodology allowed to highlight the improvement of the patient hospitalization process with the introduction of the pre-hospitalization service. Therefore, by adopting the culture of continuous improvement, the flow of hospitalization was redrawn. The benefits of the solutions implemented are addressed to the patient in terms of lower LOS and greater service satisfaction and to the hospital for lower patient management costs and improved process quality. This article will be useful for those who need examples on how to apply Lean tools in healthcare.

A Six Sigma DMAIC methodology as a support tool for Health Technology Assessment of two antibiotics

Health Technology Assessment (HTA) and Six Sigma (SS) have largely proved their reliability in the healthcare context. The former focuses on the assessment of health technologies to be introduced in a healthcare system. The latter deals with the improvement of the quality of services, reducing errors and variability in the healthcare processes. Both the approaches demand a detailed analysis, evidence-based decisions, and efficient control plans. In this paper, the SS is applied as a support tool for HTA of two antibiotics with the final aim of assessing their clinical and organizational impact in terms of postoperative Length Of Stay (LOS) for patients undergoing tongue cancer surgery. More specifically, the SS has been implemented through its main tool, namely the DMAIC (Define, Measure, Analyse, Improve, Control) cycle. Moreover, within the DMAIC cycle, a modelling approach based on a multiple linear regression analysis technique is introduced, in the Control phase, to add complementary information and confirm the results obtained by the statistical analysis performed within the other phases of the SS DMAIC. The obtained results show that the proposed methodology is effective to determine the clinical and organizational impact of each of the examined antibiotics, when LOS is taken as a measure of performance, and guide the decision-making process. Furthermore, our study provides a systematic procedure which, properly combining different and well-assessed tools available in the literature, demonstrated to be a useful guidance for choosing the right treatment based on the available data in the specific circumstance.

Technology-dependent pedagogical process redesign: leveraging lean methods

Purpose

This research compared the efficacy of process outcomes leveraging lean methods versus traditional pedagogy applied to dental education dependent on emerging technology. The pedagogical objective was to improve system efficiency without compromising traditional outcomes of effectiveness (quality).

Design/methodology/approach

The research team tested the efficacy of a lean A3 framework to identify, remove waste and redesign a technology-dependent simulation laboratory course (CAD/CAM/IR Restorative Dentistry). Students were also sensitized to time-in-chair to introduce a stronger patient focus. Baseline data collected from a control group were statistically compared to the research group's data after the course redesign. In addition, course time allocations were measured and then compared.

Findings

The results showed the interventions significantly reduced procedure cycle times without compromising quality. Additionally, the course was more efficiently conducted as measured by course time allocations.

Practical implications

This research demonstrated that the use of the A3 framework enhanced learning through process documentation, reengineering and systems optimization resolving issues of inefficiency associated with the CAD/CAM/IR pedagogy. This work is significant because it demonstrates the practice of using lean interventions to redesign and improve a technology-based healthcare course to maximize benefits.

Originality/value

This research is the first to examine how to leverage lean methods in a healthcare simulation laboratory, dependent on innovative technology, to educate and train future practitioners. This research applied statistical rigor in a controlled experiment to maximize its applicability and generalizability.

Applying Lean in Process Innovation in Healthcare: The Case of Hip Fracture

Academic literature and practitioners acknowledge that there is a need to improve efficiency and service quality in the healthcare industry. In Spain, osteoporotic fractures represent a great cost in socio-economic and morbi-mortality terms, hip fracture being the surgical pathology with the second highest consumption of resources. The research questions that govern this study concern the use of Lean principles to identify waste, and an evaluation of the application of an innovative approach in the hip fracture surgery process. A research design based on a case study and action research was developed. Findings relate to (i) the identification of the main types of waste or muda (being the most frequent delay, transportation, over-processing and defects); (ii) the analysis of existing processes based on a Lean approach (identifying opportunities for improvement as a reduction of the number of steps and participants, improving communication, automation, standardization, etc.); and (iii) the application of an innovative process based on the Lean approach and action research in the healthcare industry. This research provides insights for academia, practitioners, management, and society: waste identification and process redesign helps to continue the improvement of operations, increase efficiency, reduce costs, and enhance services, providing benefits to patients, families, hospital employees, and the healthcare system.

The Buffering Effect of Humanity of Care in the Relationship between Patient Satisfaction and Waiting Time: A Cross-sectional Study in an Emergency Department

This study aims to examine whether humanity of care and environmental comfort played a role in moderating the relationship between waiting time and patient satisfaction in an emergency department (ED). The study used a cross-sectional and non-randomized design. A total of 260 ED patients in two hospitals in Italy completed a self-report questionnaire. Moderated regression showed that after adjusting for control variables, waiting time was significantly and inversely associated with patient satisfaction. Humanity of care and environmental comfort showed a positive and significant association with patient satisfaction. Finally, the interaction term between waiting time and humanity of care was found to be significant, whereas the interaction effect between waiting time and environmental comfort was not significant. The conditional effect showed that when humanity of care was low, waiting time was negatively and significantly related to patient satisfaction. By contrast, when humanity of care was medium and high, the relationship between waiting time and patient satisfaction was not significant. These findings shed light on the key role of humanity of care in moderating the relationship between waiting time and patient satisfaction. The complex interrelations emerged should be carefully considered when interventions to foster patient satisfaction in an ED context are planned.

Effects of a comprehensive reservation service for non-emergency registration on appointment registration rate, patient waiting time, patient satisfaction and outpatient volume in a tertiary hospital in China

BACKGROUND

In China, a long waiting time for registration is a common occurrence in many tertiary hospitals. This study aimed to analyze the effects of a comprehensive reservation service for non-emergency registration on appointment registration rate, patient waiting time, patient satisfaction and outpatient volume at the Guangzhou Women and Children's Medical Center.

METHODS

This was a cross-sectional study. This study investigated the effects of a comprehensive reservation service for non-emergency registration in Guangzhou Women and Children's Medical Center in China starting in October 2015. In total, 2194 patients completed a satisfaction survey administered by the Guangdong Situation Research Center. The content of the questionnaire consisted of six aspects: general impression, service attitude, service quality, hospital environment, price perception and medical ethics. A Likert 5-point rating scale was used in the questionnaire; answers were classified as "very satisfied", "relatively satisfied", "neutral", "unsatisfied" and "very unsatisfied". The method of application was paper-based. T-tests were used to compare the sample means, and chi-square tests were used to compare the rates. A multiple-test procedure was performed to evaluate the differences in the reservation rates during a 12-month period.

RESULTS

After the implementation of the comprehensive reservation service for non-emergency registration in our hospital, which has an annual outpatient volume of approximately 4 million, the monthly appointment registration rate increased from (34.95 ± 2.91)% to(89.13 ± 3.12)%,P < 0.01. The patient waiting time was significantly reduced (P < 0.01), and the proportion of patients who believed that the waiting time required improvement was decreased significantly (P < 0.01). Moreover, the third-party evaluation result of outpatient satisfaction significantly improved (P < 0.01). The total hospital outpatient volume decreased(P < 0.01). The outpatient volume of the Department of General Pediatrics decreased.

CONCLUSION

The implementation of the comprehensive reservation service for non-emergency registration in the hospital shortened patient waiting time and improved patient satisfaction, and the outpatient volume was effectively controlled. These results indicated that this program obtained the desired results in a Grade 3A hospital in China.

Patient Satisfaction with Rural Medical Services: A Cross-Sectional Survey in 11 Western Provinces in China

Rural medical services play an important role in protecting and promoting the health of the rural population; however, patient satisfaction with rural medical services has been understudied in China. A better understanding of the actual situation and the determinants involved will provide evidence for health-related policy makers and hospital managers to further improve rural medical services. A total of 9811 patients (5208 outpatients and 4603 inpatients) were included in this study from a cross-sectional survey conducted in rural hospitals from 11 western provinces in China. Three in five patients (including outpatients and inpatients) were satisfied with rural medical services. The mean overall satisfaction scores were 3.61 ± 0.857 and 3.80 ± 0.829 (out of a maximum of 5) for rural outpatients and inpatients, respectively. The most satisfying domains for outpatients and inpatients were medical service attitude and illness explanation, and waiting time and medical expenses were the domains that outpatients and inpatients were least satisfied with. Satisfaction with medical technology (OR: 1.73; 95% CI: 1.57–1.92) and satisfaction with trust in physicians (OR: 2.05; 95% CI: 1.85–2.28) were identified as the strongest predictors of outpatients’ and inpatients’ overall satisfaction with rural medical services, respectively. This study might shed light on rural medical services management in China.

Improving outpatient satisfaction by extending expected waiting time

Background

Long waiting times result in low satisfaction. Although several methods are used to shorten the actual waiting time (AWT) in large hospitals of China, the outpatients still have a long actual waiting time. This study aimed to explore whether satisfaction could be improved by extending the expected waiting time (EWT) instead of shortening the AWT.

Methods

In October 2016, 257 students in grade one voluntarily participated in this study. They came from 6 classes, which were randomly divided into two groups: 3 classes comprised the control group (n = 125) and 3 classes comprised the experimental group (n = 132). Unfavorable information (UI) was given to the experimental group alone. Six distinct questionnaires were designed to explore the effects of UI on EWT and the effects of an extended EWT on satisfaction. Satisfaction scores ranged from 0 to 100: 0–25, very dissatisfied; 26–50, dissatisfied; 51–75, satisfied; 76–100, very satisfied. Each participant finished one of the 6 questionnaires online. Of the 257 questionnaires, 233 were valid.

Results

Before UI was given, the initial EWT (T₀) was similar between the control and experimental groups (Z = -1.924, P = 0.054). Under the effects of UI, individuals in the experimental group extended their EWT (T₁) from 121.0 to 180.0 min (Z = -6.367, P < 0.001). Females prolonged their EWT longer than males did (Z = -2.239, P = 0.025). Then, this study defined T₀ = 1.5 h and T₁ = 2.5 h, and compared the satisfaction scores between the control and experimental groups: a significant difference was found when AWT =2.0 h (t = − 3.568, P = 0.001), but not when AWT =3.0 h (t = − 0.718, P = 0.475) or when AWT =1.0 h (t = − 1.088, P = 0.280). When AWT =3.0 h, fewer individuals felt “very dissatisfied” in the experimental group (21.2%) than in the control group (44.7%) (χ² = 4.368, P = 0.037).

Conclusions

EWT was found to be extended greatly by UI. An extended EWT could improve satisfaction scores.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4408-3) contains supplementary material, which is available to authorized users.