Using Lean Six Sigma to Improve Delayed Intracranial Hemorrhage Screening in a Geriatric Trauma Population

Reducing surgical cancellations: a successful application of Lean Six Sigma in healthcare

OBJECTIVE

The COVID-19 pandemic emphasises the need to use healthcare resources efficient and effective to guarantee access to high-quality healthcare in an affordable manner. Surgical cancellations have a negative impact on these. We used the Lean Six Sigma (LSS) methodology to reduce cardiac surgical cancellations in a University Medical Center in the Netherlands, where approximately 20% of cardiac surgeries were being cancelled.

METHOD

A multifunctional project team used the data-driven LSS process improvement methodology and followed the 'DMAIC' improvement cycle (Define, Measure, Analyse, Improve, Control). Through all DMAIC phases, real-world data from the hospital information system supported the team during biweekly problem-solving sessions. This quality improvement study used an 'interrupted time series' study design. Data were collected between January 2014 and December 2016, covering 20 months prior and 16 months after implementation. Outcomes were number of last-minute coronary artery bypass graft cancellations, number of repeated diagnostics, referral to treatment time and patient satisfaction. Statistical process control charts visualised the change and impact over time. Students two-sample t-test was used to test statistical significance. A p<0.05 was considered as statistically significant.

RESULTS

Last-minute cancellations were reduced by 50% (p=0.010), repeated preoperative diagnostics (X-ray) declined by 67% (p=0.021), referral to treatment time reduced by 35% (p=0.000) and patient Net Promoter Score increased by 14% (p=0.005).

CONCLUSION

This study shows that LSS is an effective quality improvement approach to help healthcare organisations to deliver more safe, timely, effective, efficient, equitable and patient-centred care. Crucial success factors were the use of a structured data-driven problem-solving approach, focus on patient value and process flow, leadership support and engagement of involved healthcare professionals through the entire care pathway. Ongoing monitoring of key performance indicators is helpful in engaging the organisation to maintain continuous process improvement and sustaining long-term impact.

Lean Healthcare Tools for Processes Evaluation: An Integrative Review

Several health services have used lean healthcare to seek continuous improvement of their processes. Therefore, it is important to investigate the evidence available in the literature about the most used lean tools in the health area to review processes and the main results achieved by the researchers. As an integrative literature review methodology was used, it was conducted in five databases, using the descriptor "quality improvement" and the keyword "Lean Healthcare". A total of 33 complete articles were selected for analysis. The most recurrent tools were: define, measure, analyze, improve and control (DMAIC); value stream map (VSM); suppliers, inputs, process, outputs, customers analysis (SIPOC), Ishikawa Diagram and 5S. Through the analysis of waste, different interventions were implemented and the main results achieved were reduction in times (processing, waiting, cycle and total), costs, workload and increase in the number of calls. The findings enabled the identification of the main lean tools used in the health area to achieve better results. In particular, we highlight recent studies that have explored the lean six sigma healthcare approach. The results, in addition to contributing to the literature, will also assist managers in choosing the best tool to achieve continuous improvement in hospitals and other health services.

Addressing Behavioral Health Concerns in Trauma: Using Lean Six Sigma to Implement a Depression Screening Protocol in a Level I Trauma Center

BACKGROUND

Patients with physical injuries or chronic conditions may be impacted by mental health conditions, which significantly affect their participation and progress in treatment. The Patient Health Questionnaire-2 (PHQ-2) depression screening can identify patients who are at greatest risk for depression to provide better whole-person care.

OBJECTIVE

The quality improvement project objective was to identify and design a process that would result in the PHQ-2 depression screening for admitted trauma patients with a minimum 75% completion rate.

METHODS

Lean Six Sigma (LSS) process design methodology, DMADV (define, measure, analyze, design, and verify), drove process improvement. Medical records from before (December 2018 through February 2019) and after (March 2019 through May 2019) the intervention were evaluated using frequencies, percentages, χ, and multivariable logistic regression to determine the effectiveness of the intervention.

RESULTS

PHQ-2 document location was imperative to successful compliance, which increased from 60.74% (78 of 128) to 80.56% (87 of 108). Specifically, weekend compliance increased from 42.9% (18 of 42) to 82.8% (24 of 29).

CONCLUSION

LSS DMADV methodology helped health care professionals design a process to facilitate compliance with the PHQ-2 depression screening protocol in trauma patients. Adherence with this screening can help increase the number of behavioral health consultations, which in turn improves the treatment of traumatic injury survivors.

Complementing Root Cause Analysis With Improvement Strategies to Optimize Venous Thromboembolism Prophylaxis in Patients With Epidural Catheters

BACKGROUND AND OBJECTIVES

High reliability organizations in health care must identify defects and systematically approach causal factors with subsequent process redesign to achieve goals important to patients, families, and staff. Root cause analysis (RCA) is a commonly leveraged strategy for reviewing adverse events and can yield immense benefits toward patient safety when applied alongside complementary change management strategies such as Lean and Six Sigma. We performed an RCA in response to a hospital-acquired venous thromboembolism (VTE) event in a postoperative patient for which pharmacologic VTE prophylaxis was not appropriately resumed following removal of an epidural catheter.

METHODS

A multidisciplinary stakeholder team was assembled to further understand the details of the event. A current process map was created and non-value-added steps were identified. Causal analysis revealed that frequent staff turnover, variable methods of communication between stakeholders, inconsistent responsibilities with respect to ordering and administering pharmacologic VTE prophylaxis, and lack of an established standard work process were key contributors toward the defect of concern. Several countermeasures were introduced to combat these identified root causes, including shifting responsibility for managing VTE prophylaxis orders periepidural catheter removal from the surgical house staff to our regional anesthesia service, and creation of an epidural catheter heparin restart order set, which in one step places an order to resume prophylaxis following catheter removal at a specific time. Recommendations from this session were disseminated to staff through previously established huddles that are a component of our daily management system.

RESULTS

Postintervention, review of our updated process demonstrated a reduction in variability through establishment of standard work that is primarily owned by a constant factor in this care pathway (our regional anesthesia team). On review of the subsequent 10 cases of patients with epidural catheters, all patients receiving pharmacologic VTE prophylaxis had a maximum of 1 dose stopped for epidural catheter removal, therefore minimizing time without VTE prophylaxis.

CONCLUSIONS

RCA can be utilized in the aftermath of an adverse event to establish causal factors and identify countermeasures to prevent recurrence of such an event. It can be further augmented with additional change management strategies including Lean, Six Sigma, the Model for Improvement, and failure modes and effects analysis. These strategies allowed us to design effective error-reducing strategies to achieve a more reliable process, which yielded reduced VTE prophylaxis administration defects that in turn has prevented recurrence of hospital-acquired VTE in patients with epidural catheters.