Teaching novice clinicians how to reduce diagnostic waste and errors by applying the Toyota Production System

Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain

OBJECTIVES

Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning.

CASE PRESENTATION

A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction.

CONCLUSIONS

An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.

Adapting lean methodology towards surgical tray rationalisation in inguinoscrotal day case surgery in the republic of Ireland

INTRODUCTION

Lean methodologies have been used successfully in both industry and healthcare to reduce waste. The operating room (OR) and central supplies department (CSD) are areas associated with high hospital costs. The aim of this study was to employ Lean methodologies to support the rationalisation of surgical trays in paediatric inguinoscrotal surgery in order to reduce instrument wastage, processing times and overall costs in a European setting.

METHODS

This was a prospective, pilot observation and implementation study using Lean methodology including DMAIC (Define, Measure, Analyse, Improve and Control) cycles. Relevant tray set-up included trays for boys ≥12 months age undergoing open elective inguinoscrotal surgery. A comparative analysis of two phases, pre and post-standardization was then carried out with respect to operating times, instrument set-up times, tray weights, and costs. Instruments that were used <40% of the time were eliminated from the surgical tray.

RESULTS

Rationalization of the inguinoscrotal tray led to a 34.7% reduction in tray size, with a concomitant time-reduction of >2 min per case. The average overall instrument utilisation rate increased from 56% to 80% across users. Cost savings were projected at €5380.40 per annum based on current changes. There were no differences in operative time, or adverse outcomes.

DISCUSSION

At the hospital level, the reduction in variation, and rationalisation of this single surgical tray could lead to both operational (Tray assembly process; Operating rooms; Ergonomic functionality) as well as economic (Sterilisation; Instrument repair; Purchases) financial and ergonomic improvements for the healthcare system. The reduction in time taken to count and sterilise instruments can lead to a potential manpower saving involving a redistribution of activities to other areas which may require them.

CONCLUSION

Surgical tray rationalisation is emerging Lean concept with overlap across a number of specialities, and represents a technique by which to manage costs, and improve supply chain efficiency without any adverse effect in patient healthcare outcomes.

Combining time-driven activity-based costing and lean methodology: an initial study of single-level lumbar fusion surgery to assess value-based healthcare in patients undergoing spine surgery

OBJECTIVE

Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient's care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery.

METHODS

This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay.

RESULTS

Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians.

CONCLUSIONS

In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.

Facilitating Development of Problem-Solving Skills in Veterinary Learners with Clinical Examples

Simple Summary

This review seeks to open discussion on the teaching of problem-solving skills in veterinary learners. Before a veterinary learn-er can solve a problem, they need to be able to recognize the problem. Then, information is gathered and economically viable solutions determined. To make problem-solving easier, we suggest a process with 5 elements: (1) define the problem list; (2) create an associated timeline; (3) describe the (anatomical) system involved or the pathophysiological principle applicable to the case; (4) propose management for the case; and (5) identify unique features of the case. In order to put the above into context, we end the review with an example case scenario showing the approach of teaching of problem-solving.

Abstract

This paper seeks to open discussion on the teaching of problem-solving skills in veterinary learners. We start by defining the term problem before discussing what constitutes problem-solving. For veterinary medical learners, problem-solving techniques are similar to those of decision-making and are integral to clinical reasoning. Problem-solving requires the veterinary learner to organize information logically to allow application of prior or new knowledge in arriving at a solution. The decision-making must encompass choices that provide the most beneficial and economical approach. In a modification of an existing protocol, we suggest the inclusion of the 5 elements: (1) define the problem list; (2) create an associated timeline; (3) describe the (anatomical) system involved or the pathophysiological principle applicable to the case; (4) propose management for the case; and (5) identify unique features of the case. During problem-solving activities, the instructor should take the role of facilitator rather than teacher. Skills utilized in the facilitation of problem-solving by learners include coaching, differential reinforcement, effective feedback, modelling and ‘think out loud’. Effective feedback must inform learners of their progress and performance, as this is fundamental to continued learning and motivation to succeed. In order to put the above into context, we end with an example case scenario showing how we would approach the teaching of problem-solving to veterinary learners.

Utilizing Lean Methodology and Time-Driven Activity-Based Costing Together: An Observational Pilot Study of Hip Replacement Surgery Utilizing a New Method to Study Value-Based Health Care

BACKGROUND

Time-driven activity-based costing (TDABC) has been suggested as the cost-accounting arm of value-based care organizations seeking to address costing challenges from the bottom up by studying the actual processes used in patient care. Lean methodology is a system in which the care pathway is understood at a granular level. In the current study, we attempt to combine these 2 methodologies, providing a robust mechanism to detect meaningful variation. First, we used data from a single surgeon and examined differences in time and cost for patients released on postoperative days 1 or 2. Next, we compared the data from patients discharged on postoperative day 1 with those of patients who underwent an operation by a different surgeon and were also discharged on postoperative day 1.

METHODS

Consecutive patients who underwent an anterior hip arthroplasty performed by 1 of 2 surgeons and who had degenerative pathology of the hip, an inpatient stay of 1 or 2 days, discharge to home, and no readmission within 30 days of the surgical procedure were identified. We obtained data on patient demographic characteristics and time spent on activities for each personnel role in 15-minute increments occurring during 4 time points of a surgical episode of care (preoperative bay, surgical procedure, post-anesthesia care unit, and inpatient). Personnel costs were set as a ratio relative to the cost of a registered nurse (RN).

RESULTS

Consistent with our hypotheses, both RNs and nursing assistants-certified (NA-Cs) spent more time with patients released on postoperative day 2 compared with those released on postoperative day 1. Also consistent with our hypotheses, we only found significant differences for the time that personnel spent in the surgical procedures.

CONCLUSIONS

For patients undergoing total hip arthroplasty for degenerative conditions, we demonstrate that, in the setting of lean methodology, TDABC can detect variability in a meaningful and predictable way. This combination may further enable clinicians and administrators to improve processes, to allocate appropriate resources to specific process steps, and to optimize various treatments across episodes of care.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV. See Instructions for Authors for a complete description of levels of evidence.