Lean in Healthcare: Time for Evolution or Revolution?

ABSTRACT

Lean has gained recognition in healthcare as a quality improvement tool. The purpose of this research was to examine the extent to which quality improvement projects in healthcare adhered to Lean's eight-step process. We analyzed 605 publications identified through a systematic literature review following PRISMA guidelines. Each publication was coded using a structured coding sheet. The most frequent type of publication reported empirical research (48.6%) and most of these (80.3%) shared the results of the Lean projects. Of the 237 publications reporting Lean projects, more than half (71.3%) used an experimental, one-site, pre/postdesign. The impact of the project was most often measured using a single metric (59.1%) that was operational (e.g., waiting time). Although most Lean project publications reported the use of tools to "break down the problem" (84.4%, Step 2) and "see countermeasures through" (70.0%, Step 6), fewer than half described using tools associated with each of the other steps. Projects completed an average of 2.77 steps and none of the projects completed all steps. Although some may perceive low adherence to the tenets of Lean as a deficiency, it may be that Lean approaches are evolving to better meet the needs of healthcare.

Does vigilance in decision-making matter for dementia family caregivers?

OBJECTIVES

Family responsibilities and social expectations often prompt conflict in caregivers' decision-making processes. Janis and Mann's (1977) conflict model describes vigilance as high-quality decision-making resulting in optimal outcomes. The purpose of our research was threefold: (1) to describe decision styles in a population of family caregivers of persons with dementia; (2) to examine the socio-economic characteristics associated with caregivers who are more likely to be vigilant decision-makers; and (3) to assess differences in caregiving experiences between vigilant and non-vigilant caregivers.

METHOD

Our analysis was based on 639 survey respondents recruited from a university-affiliated memory disorders clinic.

RESULTS

Our typical caregiver was Caucasian non-Hispanic, was currently married, and had two children. Approximately half of our sample used a 'pure vigilant' decision style. Vigilance was associated with more positive and fewer negative caregiving outcomes.

CONCLUSION

Supporting caregivers to become vigilant decision-makers is a functionally viable intervention that could significantly improve the caregiving experience.

Age Differences in Information Use While Making Decisions: Resource Limitations or Processing Differences?

Recent research on the decision-making abilities of older adults has shown that they use less information than young adults. One explanation ascribes this age difference to reductions in cognitive abilities with age. The article includes three experimental studies that focused on determining the conditions in which older and young adults would display dissimilar information processing characteristics. Findings from Studies 1 and 2 demonstrated that older adults are not necessarily at greater disadvantage than young adults in decision contexts that demand more information processing resources. Findings from Study 3 indicated that older adults when faced with decisions that require greater processing are likely to use a strategy that reduces the amount of information needed, whereas younger adults rely on strategies that utilize more resources. Combined the findings indicate that older adults change their decision-making strategies based on the context and information provided. Furthermore, support is provided for processing difference.

The Alzheimer's Family Caregiver as Decision Maker: A Typology of Decision Styles

This study developed a typology of decision styles and discussed its usefulness for providing support to family caregivers of people with Alzheimer's disease. During semistructured interviews, 28 caregivers described making a total of 159 caregiving decisions. The analysis involved the classification of the caregivers' experiences into categories and the formation of a typology of the styles used throughout the decision-making process. Predecision styles include proactive, reactive, and inactive and are based on caregivers' tendencies to prepare for and initiate the decision. Postdecision styles include forecasting, attempting, and depending and are based on the caregivers'implementation plans. Although many (46.4%) of the caregivers tended toward a particular decision style, the majority were not consistent. Eight of the ten categories of decisions made appeared to require a particular decision style. Decision-making needs based on caregiving decision styles are presented to guide the provision of decision support to family caregivers.

Colorectal cancer screening: patients' and physicians' perspectives on decision-making factors

While patient barriers to colorectal cancer (CRC) screening have been identified, how well this knowledge is utilized during the patient-physician interaction is not fully understood. This study aims to assess among primary care physicians the degree of consensus between perceived and actual patients' CRC screening decision-making influential factors. During 2004-2006, 30 patients were interviewed to identify factors influencing screening decisions and 66 physicians were interviewed to understand what factors they thought were important to patients. The factors were categorized using the PRECEDE-PROCEED framework, and perspectives were compared. The researchers found little consensus on CRC screening decision-making influential factors between family practitioners, general internists, and patients. The recommendations to reach consensus are provided on the individual (e.g., updating the contents of a physician's screening recommendation to proactively address patients' decision-making needs) and population (e.g., providing cross-cultural training to medical students enabling them to better understand their patients) levels.

Using decision tree models to depict primary care physicians CRC screening decision heuristics

OBJECTIVE

The purpose of this study was to identify decision heuristics utilized by primary care physicians in formulating colorectal cancer screening recommendations.

DESIGN

Qualitative research using in-depth semi-structured interviews.

PARTICIPANTS

We interviewed 66 primary care internists and family physicians evenly drawn from academic and community practices. A majority of physicians were male, and almost all were white, non-Hispanic.

APPROACH

Three researchers independently reviewed each transcript to determine the physician's decision criteria and developed decision trees. Final trees were developed by consensus. The constant comparative methodology was used to define the categories.

RESULTS

Physicians were found to use 1 of 4 heuristics ("age 50," "age 50, if family history, then earlier," "age 50, if family history, then screen at age 40," or "age 50, if family history, then adjust relative to reference case") for the timing recommendation and 5 heuristics ["fecal occult blood test" (FOBT), "colonoscopy," "if not colonoscopy, then...," "FOBT and another test," and "a choice between options"] for the type decision. No connection was found between timing and screening type heuristics.

CONCLUSIONS

We found evidence of heuristic use. Further research is needed to determine the potential impact on quality of care.

Physician colorectal cancer screening recommendations: an examination based on informed decision making

OBJECTIVE

The purpose of this research was to examine the content of physicians' colorectal cancer screening recommendations. More specifically, using the framework of informed decision making synthesized by Braddock and colleagues, we conducted a qualitative study of the content of recommendations to describe how physicians are currently presenting this information to patients.

METHODS

We conducted semi-structured interviews with 65 primary care physicians. We analyzed responses to a question designed to elicit how the physicians typically communicate their recommendation.

RESULTS

Almost all of the physicians (98.5%) addressed the "nature of decision" element. A majority of physicians discussed "uncertainties associated with the decision" (67.7%). Fewer physicians covered "the patient's role in decision making" (33.8%), "risks and benefits" (16.9%), "alternatives" (10.8%), "assessment of patient understanding" (6.2%), or "exploration of patient's preferences" (1.5%).

CONCLUSION

We propose that the content of the colorectal screening recommendation is a critical determinant to whether a patient undergoes screening. Our examination of physician recommendations yielded mixed results, and the deficiencies identified opportunities for improvement.

PRACTICE IMPLICATIONS

We suggest primary care physicians clarify that screening is meant for those who are asymptotic, present tangible and intangible benefits and risks, as well as make a primary recommendation, and, if needed, a "compromise" recommendation, in order to increase screening utilization.

"Do we really need all that equipment?": factors influencing colorectal cancer screening decisions

The lifetime risk of developing colorectal cancer is 2.5 to 5% in the general population. Colorectal screening can prevent mortality, and there are a number of screening methods, ranging from noninvasive to highly invasive. Although recommendations have been widely disseminated in the media and scientific journals, screening usage is low. In this project, the authors examine the factors that influence individuals' decisions regarding colorectal screening. They conducted semistructured interviews with 30 people (13 men and 17 women) selected to provide a maximum variation sample. They categorized factors into the following themes: concern for one's personal well-being, competing demands, preparing for the procedure, the screening process, gender concerns, fear of having cancer, feeling healthy, cost, the experiences of others, and turning 50 years old.

Diagnosis-seeking at subspecialty memory clinics: trigger events

BACKGROUND

Research has shown that dementia often goes unrecognized, and diagnostic assessment is often further delayed. Understanding families' decision to seek care at memory clinics is relevant to efforts to facilitate early diagnosis.

OBJECTIVE

To examine the population seeking care at two memory clinics and the triggers causing caregivers to seek diagnostic assessment for a family member.

METHOD

We surveyed a consecutive sample of caregivers who accompanied a patient to an assessment at two university memory disorders clinics. Caregivers (n=416) described events that led them to seek a memory assessment for the patient, as well as who first suggested an assessment and diagnosis received.

RESULTS

Changes in the patient (cognitive, personality/behavioral, physical, or unspecified) accounted for 81% of 903 trigger events reported. Nearly half of the caregivers noting specific patient changes recorded some combination, rather than cognitive changes alone. Of the 338 respondents who noted a change in the patient as a trigger, 85% specified at least one cognitive change, while 40% specified at least one personality/behavioral change. Memory loss was most frequent trigger reported, followed by disorientation and recommendations (lay or professional). Caregivers themselves and non-specialist physicians were the most frequent sources of recommendations noted by all respondents.

CONCLUSION

A broad range of trigger events, beyond cognitive or symptomatic changes, caused caregivers to seek diagnosis at a memory clinic. Awareness of triggers significant to families may help physicians reduce the number and severity of events needed to convince caregivers a memory assessment is indicated.

The characteristics of dementia caregiving onset

This study examined the characteristics of entry into the caregiving role for family and friends of older adults suffering from dementia. Using data from a large community survey of informal caregivers of patients who visited the University of Kentucky's Alzheimer's Disease Research Center (n = 1055), respondents were classified into one of four onset sequences: recognition-diagnosis, care provision, recognition-care, and diagnosis dependent. A multinomial logistic regression identified several characteristics (i.e., caregiver income, time since onset, care recipient gender, care recipient living status, and primary caregiver identification) that were significantly associated with various caregiving onset patterns. The findings describe the complexity of the entry process and its potential association with health-related transitions in the caregiving career.

The carrot and the stick: benefits and barriers in getting a diagnosis

The goals of this study were to identify the benefits and barriers perceived by family caregivers of persons who have been through a diagnostic assessment for dementia symptoms and to determine which caregivers experience more benefits and barriers associated with assessments. A survey was mailed to caregivers involved in the decision to seek a diagnostic assessment for a family member at a University of Kentucky memory disorders clinic. A total of 528 family caregivers (response rate 71.7%) returned a 4-page survey designed to elicit benefits, barriers, and demographic information. Respondents delayed the diagnostic assessment for an average of 22.4 months after noticing symptoms. Perceived benefits involved confirmation of a medical condition, access to treatment, and help preparing for the caregiving role. Barriers were both emotional and pragmatic in nature. Respondents who were younger, visited the rural assessment clinic, and had less education experienced more barriers. All groups reported receiving the same number of benefits from the assessment. By incorporating these benefits and barriers, interventions can be designed to increase the likelihood of early diagnostic assessments.

Capturing the insights of family caregivers: survey item generation with a coupled interview/focus group process

The usefulness of qualitative methodologies to augment and enrich quantitative studies is often overlooked. The authors' goals are to describe the qualitative process employed to generate survey items and to compare the results to those of studies that used different methodologies for item generation. The study identified barriers to and benefits of memory assessments. The survey item generation methodology, which involved 24 key informant interviews and 3 focus groups, resulted in the identification of 31 barrier and 28 benefit items. The 34 unique items were rated among the most important by survey respondents. The authors, therefore, present a strong case for generating survey items using informant interviews as groundwork for focus groups.

Essential information and support needs of family caregivers

The purpose of this study was to identify essential information and support needs of family caregivers for individuals with Alzheimer's disease or a related dementia, and to examine the relationship between caregiver characteristics and needs. Caregivers (n=128, response rate=49.4%) returned a survey detailing information needs, support needs, and personal information. The need for information concerning diagnosis/treatment and legal/financial issues was more important than general information about the disease. Specifically, information about health plan coverage was most important. Experienced caregivers also needed legal/financial information, as well as support. Female caregivers rated needs related to support as significantly more important than male caregivers. Practitioners should realize that caregivers may have different information and support needs and these needs may change throughout the caregiving experience.

Urban-rural differences in a memory disorders clinical population

OBJECTIVES

To compare patient characteristics and family perceptions of patient function at one urban and one rural memory disorders clinic.

DESIGN

Secondary, cross-sectional data analyses of an extant clinical database.

SETTING/PARTICIPANTS

First time visits (n = 956) at two memory disorders clinics.

MEASUREMENTS

Patient and family-member demographics and assessment results for the Mini-Mental State Examination (MMSE), instrumental activities of daily living (IADLs), activities of daily living (ADLs), the Memory Change and Personality Change components of the Blessed Dementia Rating Scale, and the Revised Memory and Behavior Problems Checklist.

RESULTS

In both clinics, patients and family members were more likely female. The typical urban clinic patient was significantly more likely to be living in a facility and more educated than the typical rural patient. Urban and rural patients did not show significant differences in age- and education-adjusted MMSE scores or raw ADL/IADL ratings, but the urban family members reported more memory problems, twice as many personality changes, more-frequent behavior problems, and more adverse reactions to problems.

CONCLUSION

Physicians who practice in both urban and rural areas can anticipate differences between patients, and their families, who seek a diagnosis of memory disorders. Our most important finding is that despite similarities in reported functional abilities, urban families appear to be more sensitive to and more distressed by patients' cognitive and behavioral symptoms than rural families. These differences may reflect different underlying needs, and should be explored in further research.