Lean in healthcare: A comprehensive review

Application of Lean Principles to Neurosurgical Procedures: The Case of Lumbar Spinal Fusion Surgery, a Literature Review and Pilot Series

BACKGROUND

Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed.

OBJECTIVE

To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases.

METHODS

Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability.

RESULTS

Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively.

CONCLUSION

This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.

Lean for airport services: a systematic literature review and agenda for future research

Purpose

The purpose of this paper is to present the key findings of a systematic literature review (SLR) on Lean for services and, in particular, airport services.

Design/methodology/approach

The authors have utilised an SLR methodology proposed by Denyer and Tranfield (2009). A total of 23 papers published in 18 scientific journals have been systematically reviewed for evaluating and establishing the current status of Lean for airport services.

Findings

It was observed that there are no journal publications on the use of Lean in UK airport services. Although value stream mapping has been widely accepted as a powerful Lean tool across many service organisations, its applications in airport services is in its early stages. One of the biggest challenges in the implementation of Lean for airport services is about maintaining the level of service standards. The most common barriers in the implementation of Lean for airport services may include: resistance to change, varied definitions of the term Lean for different people across the business and understanding the need for Lean in airport services as there is a misconception that Lean is confined to manufacturing.

Research limitations/implications

This paper seeks to contribute to and broaden the limited body of evidence of the applicability of Lean to airport services and identify areas for further research and review.

Originality/value

This paper makes an attempt to demonstrate the use of Lean thinking for service industries and, in particular, airport services. The authors have identified less than five papers on the use of Lean thinking in airport services and this paper sets the foundation for future research on the use of process excellence methodologies such as Lean. Moreover, the authors firmly believe that the results of this SLR can be extremely beneficial to many managers working in Airport Service contexts, irrespective of the country and culture of the organisation.

Nurses' Perspectives on Lean Redesigns to Patient Flow and Inpatient Discharge Process Efficiency

As hospitals around the world increasingly face pressure to improve efficiency, "Lean" process improvement has become a popular approach to improving patient flow. In this article, we examine nurses' perspectives on the implementation of Lean redesigns to the inpatient discharge process. We found that nurses experienced competing demands and tensions related to their time and professional roles and responsibilities as a result of Lean. Four main themes included (a) addressing the needs of individual patients, while still maintaining overall patient flow; (b) meeting discharge efficiency targets while also achieving high patient satisfaction scores; (c) "wasting time" to save time; and (d) the "real" work of providing clinical care versus the "Lean" work of process improvement. Our findings highlight the importance of soliciting hospital nurses' perspectives when implementing Lean process improvements to improve efficiency and patient flow.

Relationship-centered health care as a Lean intervention

Continuous improvement efforts, recognized in much literature as Lean management techniques have been used in efforts to improve efficiency in democratic health care contexts for some time to varying degrees of success. The complexity of the health care system is magnified by the sheer number of processes and sub processes required to deliver value within a bureaucratic environment, while maintaining some level of compassionate and personalized care. There is inherent tension between what is required to be efficient and what is required to be caring and this conflict presses against Lean practice at the level of delivery.Administration and care intersect at the point of the patient's experience. In order to achieve the dual goals of improved value and lower costs, the application of Lean thinking for meaningful health care reform must acknowledge the fundamental dichotomy between the impersonal tasks required to provide health services, and human interactions. Meaningful health care reform requires an acknowledgement of this distinction, currently not recognized in literature. While administrative process improvements are necessary, they are insufficient to achieve a sustainable and caring health care system. Lean thinking must be applied differently for administrative processes and patient care encounters, because these are fundamentally different processes. In this way, Lean principles will effectively contribute to sustainable health system improvements.

Lean management in health care: effects on patient outcomes, professional practice, and healthcare systems

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess effects of Lean management in health care on patient, professional, and systems outcomes by addressing the following question.

What are the effects of Lean management interventions in health care on patient outcomes, professional practice, and healthcare systems?

What are the effects of Lean management interventions in health care on patient outcomes, professional practice, and healthcare systems?

To answer the following questions in addressing secondary objectives:

What are the effects of Lean management interventions in combination with other management systems (e.g. Six Sigma) on patient outcomes, professional practice, and healthcare systems (utilisation and access, adverse effects, cost)? Is the effectiveness of Lean interventions influenced by the setting (e.g. Emergency Department, Laboratory, Pharmacy) in which they are implemented?

What are the effects of Lean management interventions in combination with other management systems (e.g. Six Sigma) on patient outcomes, professional practice, and healthcare systems (utilisation and access, adverse effects, cost)? Is the effectiveness of Lean interventions influenced by the setting (e.g. Emergency Department, Laboratory, Pharmacy) in which they are implemented?

Does Value Stream Mapping affect the structure, process, and outcome quality in care facilities? A systematic review

BACKGROUND

Quality improvement within health and social care facilities is needed and has to be evidence-based and patient-centered. Value Stream Mapping, a method of Lean management, aims to increase the patients' value and quality of care by a visualization and quantification of the care process. The aim of this research is to examine the effectiveness of Value Stream Mapping on structure, process, and outcome quality in care facilities.

METHODS

A systematic review is conducted. PubMed, EBSCOhost, including Business Source Complete, Academic Search Complete, PSYCInfo, PSYNDX, SocINDEX with Full Text, Web of Knowledge, and EMBASE ScienceDirect are searched in February 2016. All peer-reviewed papers evaluating Value Stream Mapping and published in English or German from January 2000 are included. For data synthesis, all study results are categorized into Donabedian's model of structure, process, and outcome quality. To assess and interpret the effectiveness of Value Stream Mapping, the frequencies of the results statistically examined are considered.

RESULTS

Of the 903 articles retrieved, 22 studies fulfill the inclusion criteria. Of these, 11 studies are used to answer the research question. Value Stream Mapping has positive effects on the time dimension of process and outcome quality. It seems to reduce non-value-added time (e.g., waiting time) and length of stay. All study designs are before and after studies without control, and methodologically sophisticated studies are missing.

CONCLUSIONS

For a final conclusion about Value Stream Mapping's effectiveness, more research with improved methodology is needed. Despite this lack of evidence, Value Stream Mapping has the potential to improve quality of care on the time dimension. The contextual influence has to be investigated to make conclusions about the relationship between different quality domains when applying Value Stream Mapping. However, for using this review's conclusion, the limitation of including heterogeneous and potentially biased results has to be considered.

Medical and scientific writing: Time to go lean and mean

The Lean Six Sigma methodology for process improvements and driving efficiency is old, but lean writing was adopted late by the pharmaceutical world in terms of size of the documents. The documents were lean earlier, and then became voluminous, and now we are about to complete a full circle in this regard, i.e., coming back to the lean documents again using e-formats and hyperlinking. Furthermore, writing has become more and more precise over time. The need for this lean and mean medical and scientific writing arose from voluminous research globally, both industry and academia which are abuzz with skyrocketing regulatory and scientific submission volumes. The quantum of literature is so much that reviewers or information seekers firmly believe that going through even selected and relevant literature has become highly challenging. Considering this, there has been much insistence on downsizing the medical writing documents, which could be tempting enough to be leveraged for scientific publications as well. Here, we present the need for lean and mean medical writing, discuss this concept in relation to the pharmaceutical industry, and how to apply this to key documents. Furthermore, presented is the proposed algorithm for lean and mean clinical study reports and manuscripts. These thoughts are aligned to the recently established concept of data transparency, and can be easily achieved by web links between the protocols and clinical trial results disclosed publicly, and the corresponding manuscripts.

Making care organizations great again? A comparison of Care Pathways, Lean Thinking, Relational Coordination, and Modern Sociotechnical Design

Introduction

Care organizations are often not well equipped to the increasing complexity and chronicity of diseases. Several organizational redesign models propose interventions that may help organizations adapt to this new reality. The objective of this study is to describe the redesign models in a uniform manner and to offer conceptual clarity.

Methods

This study presents a systematic comparison of the problem definition and proposed interventions of four redesign models: Care Pathways, Lean Thinking, Relational Coordination, and Modern Sociotechnical Design. Data were collected through a critical and thematic review of selected literature. Data were analyzed using a priori deducted coding derived from a theoretical framework based on Mintzberg. The COREQ checklist was used to minimize bias.

Results

Twenty conceptual documents and practical guidelines were included for data analysis. The problem definition of the four redesign models is largely similar and suggests that fragmented task division and centralized coordination hinder the delivery of complex and chronic care. The proposed interventions differ between the redesign models, but in general more attention is given to the coordination of tasks than to task division, and interventions are mainly situated at the micro (workplace) and meso (work unit) levels of the organization.

Discussion

The systematic comparison clarifies the similarities and differences between the analyzed redesign models, which can be useful for improving studies on redesign model effectiveness. Additionally, systematic comparison supports care organizations in selecting appropriate redesign models. Future studies may involve a larger selection of redesign models as well as the redesign of inter-organizational networks.

Reported implementation lessons from a national quality improvement initiative; Productive Ward: Releasing Time to Care™. A qualitative, ward-based team perspective

AIM

To explore the experiences of participants involved in the implementation of the Productive Ward: Releasing Time to Care™ initiative in Ireland, identifying key implementation lessons.

BACKGROUND

A large-scale quality improvement programme Productive Ward: Releasing Time to Care™ was introduced nationwide into Ireland in 2011. We captured accounts from ward-based teams in an implementation phase during 2013-14 to explore their experiences.

METHODS

Semi-structured, in-depth interviews with a purposive sample of 24 members of ward-based teams from nine sites involved in the second national phase of the initiative were conducted. Interviews were analysed and coded under themes, using a seven-stage iterative process.

RESULTS

The predominant theme identified was associated with the implementation and management of the initiative and included: project management; training; preparation; information and communication; and participant's negative experiences. The most prominent challenge reported related to other competing clinical priorities.

CONCLUSIONS

Despite the structured approach of Productive Ward: Releasing Time to Care™, it appears that overstretched and busy clinical environments struggle to provide the right climate and context for ward-based teams to engage and interact actively with quality improvement tools, methods and activities.

IMPLICATIONS FOR NURSING MANAGEMENT

Findings highlight five key aspects of implementation and management that will help facilitate successful adoption of large-scale, ward-based quality improvement programmes such as Productive Ward: Releasing Time to Care™. Utilising pre-existing implementation or quality frameworks to assess each ward/unit for 'readiness' prior to commencing a quality improvement intervention such as Productive Ward: Releasing Time to Care™ should be considered.

Budget impact analysis of a breast rapid diagnostic unit

BACKGROUND

The Odette Cancer Centre's recent implementation of a rapid diagnostic unit (rdu) for breast lesions has significantly decreased wait times to diagnosis. However, the economic impact of the unit remains unknown. This project defined the development and implementation costs and the operational costs of a breast rdu in a tertiary care facility.

METHODS

From an institutional perspective, a budget impact analysis identified the direct costs associated with the breast rdu. A base-case model was also used to calculate the cost per patient to achieve a diagnosis. Sensitivity analyses computed costs based on variations in key components. Costs are adjusted to 2015 valuations using health care-specific consumer price indices and are reported in Canadian dollars.

RESULTS

Initiation cost for the rdu was $366,243. The annual operational cost for support staff was $111,803. The average per-patient clinical cost for achieving a diagnosis was $770. Sensitivity analyses revealed that, if running at maximal institutional capacity, the total annual clinical cost for achieving a diagnosis could range between $136,080 and $702,675.

CONCLUSIONS

Establishment and maintenance of a breast rdu requires significant investment to achieve reductions in time to diagnosis. Expenditures ought to be interpreted in the context of institutional patient volumes and trade-offs in patient-centred outcomes, including lessened patient anxiety and possibly shorter times to definitive treatment. Our study can be used as a resource-planning tool for future rdus in health care systems wishing to improve diagnostic efficiency.

Can lean contribute to work intensification in healthcare?

Purpose

The purpose of this paper is to review and discuss the effects of the introduction of lean into healthcare workplaces, phenomena that have not been widely investigated.

Design/methodology/approach

The paper draws on discussions and findings from the literature. It seeks to bring the few geographically dispersed experiences and case studies together to draw some conclusions regarding lean’s negative effects.

Findings

Two recurring themes emerge. The first is there is little evidence of Lean’s impact on work and the people who perform it. The literature therefore suggests that we understand very little about how work conditions are changed and how Lean’s negative effects arise and may be managed in healthcare workplaces. A second observation is that Lean’s effects are ambiguous. For some Lean seems to intensify work, while for others it leads to improved job satisfaction and productivity. Given this variety, the paper suggests a research emphasis on Lean’s socio-cultural side and to derive more data on how work and its processes change, particularly in the context of healthcare team-working.

Originality/value

The paper concludes that without improved understanding of social contexts of Lean interventions its value for healthcare improvement may be limited. Future research should also include a focus on how the work is changed and whether high-performance work system practices may be used to offset Lean’s negative effects.

Trends in the supply of California's emergency departments and inpatient services, 2005-2014: a retrospective analysis

OBJECTIVES

Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014.

DESIGN

Retrospective analysis.

SETTING

Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014.

PARTICIPANTS

Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period.

OUTCOME MEASURES

We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED).

RESULTS

Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p<0.001). ED beds also increased (by 29.8%, p<0.001), with an average annual increase of 195.4 beds. Despite this growth, ED beds per visit decreased by 3.9%, from 6.0 ED beds per 10 000 ED visits in 2005 to 5.8 beds in 2014 (p=0.01). While overall admission numbers declined by 4.9% (p=0.06), inpatient medical/surgical beds per visit grew by 11.3%, from 11.6 medical/surgical beds per 1000 admissions in 2005 to 12.9 beds in 2014 (p<0.001). However, there were reductions in psychiatric and chemical dependency beds per admission, by -15.3% (p<0.001) and -22.4% (p=0.05), respectively.

CONCLUSIONS

These trends suggest that, in its current state, inadequate supply of ED and specific inpatient beds cannot keep pace with growing patient demand for acute care. Analysis of ED and inpatient supply should capture dynamic variations in patient demand. Our novel 'beds pervisit' metric offers improvements over traditional supply measures.

Using Lean to Rapidly and Sustainably Transform a Behavioral Health Crisis Program: Impact on Throughput and Safety

BACKGROUND

Lean has been increasingly applied in health care to reduce waste and improve quality, particularly in fast-paced and high-acuity clinical settings such as emergency departments. In addition, Lean's focus on engagement of frontline staff in problem solving can be a catalyst for organizational change. In this study, ConnectionsAZ demonstrates how they applied Lean principles to rapidly and sustainably transform clinical operations in a behavioral health crisis facility.

METHODS

A multidisciplinary team of management and frontline staff defined values-based outcome measures, mapped the current and ideal processes, and developed new processes to achieve the ideal. Phase I was implemented within three months of assuming management of the facility and involved a redesign of flow, space utilization, and clinical protocols. Phase II was implemented three months later and improved the provider staffing model. Organizational changes such as the development of shift leads and daily huddles were implemented to sustain change and create an environment supportive of future improvements.

RESULTS

Post-Phase I, there were significant decreases (pre vs. post and one-year post) in median door-to-door dwell time (343 min vs. 118 and 99), calls to security for behavioral emergencies (13.5 per month vs. 4.3 and 4.8), and staff injuries (3.3 per month vs. 1.2 and 1.2). Post-Phase II, there were decreases in median door-to-doctor time (8.2 hours vs. 1.6 and 1.4) and hours on diversion (90% vs. 17% and 34%).

CONCLUSIONS

Lean methods can positively affect safety and throughput and are complementary to patient-centered clinical goals in a behavioral health setting.

A questionnaire measuring staff perceptions of Lean adoption in healthcare: development and psychometric testing

BACKGROUND

During the past decade, the concept of Lean has spread rapidly within the healthcare sector, but there is a lack of instruments that can measure staff's perceptions of Lean adoption. Thus, the aim of the present study was to develop a questionnaire measuring Lean in healthcare, based on Liker's description of Lean, by adapting an existing instrument developed for the service sector.

METHODS

A mixed-method design was used. Initially, items from the service sector instrument were categorized according to Liker's 14 principles describing Lean within four domains: philosophy, processes, people and partners and problem-solving. Items were lacking for three of Liker's principles and were therefore developed de novo. Think-aloud interviews were conducted with 12 healthcare staff from different professions to contextualize and examine the face validity of the questionnaire prototype. Thereafter, the adjusted questionnaire's psychometric properties were assessed on the basis of a cross-sectional survey among 386 staff working in primary care.

RESULTS

The think-aloud interviews led to adjustments in the questionnaire to better suit a healthcare context, and the number of items was reduced. Confirmatory factor analysis of the adjusted questionnaire showed a generally acceptable correspondence with Liker's description of Lean. Internal consistency, measured using Cronbach's alpha, for the factors in Liker's description of Lean was 0.60 for the factor people and partners, and over 0.70 for the three other factors. Test-retest reliability measured by the intra-class correlation coefficient ranged from 0.77 to 0.88 for the four factors.

CONCLUSIONS

We designed a questionnaire capturing staff's perceptions of Lean adoption in healthcare on the basis of Liker's description. This Lean in Healthcare Questionnaire (LiHcQ) showed generally acceptable psychometric properties, which supports its usability for measuring Lean adoption in healthcare. We suggest that further research focus on verifying the usability of LiHcQ in other healthcare settings, and on adjusting the instrument if needed.

Patient safety improvement interventions in children's surgery: A systematic review

BACKGROUND

Adult surgical patient safety literature is plentiful; however, there is a disproportionate paucity of published safety work in the children's surgical literature. We sought to systematically evaluate the nature and quality of patient safety evidence pertaining to pediatric surgical practice.

METHODS

Systematic search of MEDLINE and EMBASE databases and gray literature identified 1399 articles. Data pertaining to demographics, methodology, interventions, and outcomes were extracted. Study quality was assessed utilizing formal criteria.

RESULTS

20 studies were included. 14 (70%) comprised peer-reviewed articles. 18 (90%) were published in the last 4years. 13 (65%) described a novel intervention, and 7 (35%) described a modification of an existing intervention. Median patient sample size was 79 (29-1210). A large number (n=55) and variety (n=35) of measures were employed to evaluate the effect of interventions on patient safety. 15 (75%) studies utilized a checklist tool as a component of their intervention. 9 (45%) studies [comprising handoff tools (n=7); checklists (n=1); and multidimensional quality improvement initiatives (n=1)] reported a positive effect on patient safety. Quality assessment was undertaken on 14 studies. Quantitative studies had significantly higher quality scores than qualitative studies (61 [0-89] vs 44 [11-78], p=0.03).

CONCLUSIONS

Pediatric surgical patient safety evidence is in its early stages. Successful interventions that we identified were typically handoff tools. There now ought to be an onus on pediatric surgeons to develop and apply bespoke pediatric surgical safety interventions and generate an evidence base to parallel the adult literature.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

LEAN thinking in Finnish healthcare

Purpose - The purpose of this study is to evaluate how LEAN thinking is used as a management and development tool in the Finnish public healthcare system and what kind of outcomes have been achieved or expected by using it. The main focus is in managing and developing patient and treatment processes. Design/methodology/approach - A mixed-method approach incorporating the Webropol survey was used. Findings - LEAN is quite a new concept in Finnish public healthcare. It is mainly used as a development tool to seek financial savings and to improve the efficiency of patient processes, but has not yet been deeply implemented. However, the experiences from LEAN initiatives have been positive, and the methodology is already quite well-known. It can be concluded that, because of positive experiences from LEAN, the environment in Finnish healthcare is ready for the deeper implementation of LEAN. Originality/value - This paper evaluates the usage of LEAN thinking for the first time in the public healthcare system of Finland as a development tool and a management system. It highlights the implementation and achieved results of LEAN thinking when used in the healthcare environment. It also highlights the expectations for LEAN thinking in Finnish public healthcare.

Operationalising the Lean principles in maternity service design using 3P methodology

The last half century has seen significant changes to Maternity services in England. Though rates of maternal and infant mortality have fallen to very low levels, this has been achieved largely through hospital admission. It has been argued that maternity services may have become over-medicalised and service users have expressed a preference for more personalised care. NHS England's national strategy sets out a vision for a modern maternity service that continues to deliver safe care whilst also adopting the principles of personalisation. Therefore, there is a need to develop maternity services that balance safety with personal choice.

To address this challenge, a maternity unit in North East England considered improving their service through refurbishment or building new facilities. Using a design process known as the production preparation process (or 3P), the Lean principles of understanding user value, mapping value-streams, creating flow, developing pull processes and continuous improvement were applied to the design of a new maternity department. Multiple stakeholders were engaged in the design through participation in a time-out (3P) workshop in which an innovative pathway and facility for maternity services were co-designed. The team created a hybrid model that they described as “wrap around care” in which the Lean concept of pull was applied to create a service and facility design in which expectant mothers were put at the centre of care with clinicians, skills, equipment and supplies drawn towards them in line with acuity changes as needed.

Applying the Lean principles using the 3P method helped stakeholders to create an innovative design in line with the aspirations and objectives of the National Maternity Review. The case provides a practical example of stakeholders applying the Lean principles to maternity services and demonstrates the potential applicability of the Lean 3P approach to design healthcare services in line with policy requirements.

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.

Rapid Process Optimization

Health care systems have utilized various process redesign methodologies to improve care delivery. This article describes the creation of a novel process improvement methodology, Rapid Process Optimization (RPO). This system was used to redesign emergency care delivery within a large academic health care system, which resulted in a decrease: (1) door-to-physician time (Department A: 54 minutes pre vs 12 minutes 1 year post; Department B: 20 minutes pre vs 8 minutes 3 months post), (2) overall length of stay (Department A: 228 vs 184; Department B: 202 vs 192), (3) discharge length of stay (Department A: 216 vs 140; Department B: 179 vs 169), and (4) left without being seen rates (Department A: 5.5% vs 0.0%; Department B: 4.1% vs 0.5%) despite a 47% increased census at Department A (34 391 vs 50 691) and a 4% increase at Department B (8404 vs 8753). The novel RPO process improvement methodology can inform and guide successful care redesign.

Has Lean improved organizational decision making?

Purpose

– Sustainable improvement is likely to be hampered by ambiguous objectives and uncertain cause-effect relations in care processes (the organization’s decision-making context). Lean management can improve implementation results because it decreases ambiguity and uncertainties. But does it succeed? Many quality improvement (QI) initiatives are appropriate improvement strategies in organizational contexts characterized by low ambiguity and uncertainty. However, most care settings do not fit this context. The purpose of this paper is to investigate whether a Lean-inspired change program changed the organization’s decision-making context, making it more amenable for QI initiatives.

Design/methodology/approach

– In 2014, 12 professionals from a Dutch radiotherapy institute were interviewed regarding their perceptions of a Lean program in their organization and the perceived ambiguous objectives and uncertain cause-effect relations in their clinical processes. A survey (25 questions), addressing the same concepts, was conducted among the interviewees in 2011 and 2014. The structured interviews were analyzed using a deductive approach. Quantitative data were analyzed using appropriate statistics.

Findings

– Interviewees experienced improved shared visions and the number of uncertain cause-effect relations decreased. Overall, more positive (99) than negative Lean effects (18) were expressed. The surveys revealed enhanced process predictability and standardization, and improved shared visions.

Practical implications

– Lean implementation has shown to lead to greater transparency and increased shared visions.

Originality/value

– Lean management decreased ambiguous objectives and reduced uncertainties in clinical process cause-effect relations. Therefore, decision making benefitted from Lean increasing QI’s sustainability.

Continuous improvement, burnout and job engagement: a study in a Dutch nursing department

Continuous improvement (CI) programs are potentially powerful means to improve the quality of care. The more positive nurses perceive these programs' effects, the better they may be expected to cooperate. Crucial to this perception is how nurses' quality of working life is affected. We studied this in a nursing department, using the job demands-resources model. We found that two job demands improved, and none of the job resources. Job engagement did not change significantly, while the burnout risk decreased slightly. Overall, the nurses felt the impact to be small yet the changes were in a positive direction. CI can thus be used to improve nurses' working lives and, by restructuring the work processes, the quality of care. Copyright © 2016 John Wiley & Sons, Ltd.

Population Health: A New Paradigm for Medicine

Healthcare delivery system reform has become a dominant topic of conversation throughout the United States. Driven in part by ever-higher national expenditures on health, an increasing number of payers and provider organizations are working to reduce the costs and improve the quality of healthcare. In this article, we demystify the term "Population Health," review some of the larger payer initiatives currently in effect and discuss specific provider group efforts to improve the quality and cost of healthcare for patients.

Application of Lean Sigma to the Audiology Clinic at a Large Academic Center

Objective

To apply Lean Sigma—a quality improvement strategy to eliminate waste and reduce variation and defects—to improve audiology scheduling and utilization in a large tertiary care referral center. The project goals included an increase in utilization rates of audiology block time and a reduction in appointment lead time.

Study Design

Prospective quality improvement study.

Setting

Academic tertiary care center.

Subjects

All patients scheduling audiology clinic visits July 2013 to July 2014.

Methods

Value stream mapping was performed for the audiology scheduling process, and wasteful steps were identified for elimination. Interventions included a 2-week block release, audiology template revision, and reduction of underutilized blocks. Schedule utilization and lead time for new patient diagnostic audiogram were measured for 5 months postintervention and compared with 5 months preintervention. Overall, 2995 preintervention and 3714 postintervention booked appointments were analyzed.

Results

Block utilization increased from 77% to 90% after intervention ( P < .0001). Utilization of joint-with-provider visits increased from 39% to 67% ( P < .0001). Booked appointments increased from 2995 to 3714, with joint-with-provider booked appointments increasing from 317 to 1193. Appointment lead time averaged 24 days postintervention, compared with 29 days preintervention ( P = .06). Average monthly relative value units measured 13,321 preintervention and 14,778 postintervention ( P = .09).

Conclusion

Lean Sigma techniques were successfully used to increase appointment block utilization and streamline scheduling practices.

An introduction to implementation science for the non-specialist

BACKGROUND

The movement of evidence-based practices (EBPs) into routine clinical usage is not spontaneous, but requires focused efforts. The field of implementation science has developed to facilitate the spread of EBPs, including both psychosocial and medical interventions for mental and physical health concerns.

DISCUSSION

The authors aim to introduce implementation science principles to non-specialist investigators, administrators, and policymakers seeking to become familiar with this emerging field. This introduction is based on published literature and the authors' experience as researchers in the field, as well as extensive service as implementation science grant reviewers. Implementation science is "the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services." Implementation science is distinct from, but shares characteristics with, both quality improvement and dissemination methods. Implementation studies can be either assess naturalistic variability or measure change in response to planned intervention. Implementation studies typically employ mixed quantitative-qualitative designs, identifying factors that impact uptake across multiple levels, including patient, provider, clinic, facility, organization, and often the broader community and policy environment. Accordingly, implementation science requires a solid grounding in theory and the involvement of trans-disciplinary research teams. The business case for implementation science is clear: As healthcare systems work under increasingly dynamic and resource-constrained conditions, evidence-based strategies are essential in order to ensure that research investments maximize healthcare value and improve public health. Implementation science plays a critical role in supporting these efforts.