Quality improvement in healthcare: Six Sigma systematic review

Evidence-based assessment of the application of Six Sigma to infectious disease serology quality control

OBJECTIVES

Recently, four publications have applied Sigma metrics to infectious disease serology testing. Three studies applied Sigma metrics to assays in a blood bank setting, whereas one used anti-toxoplasma testing in a diagnostic laboratory. One of the four studies applied the approach to microtitre plate enzyme immunoassays, whereas the other three were on fully automated chemiluminescent assay. The approaches used by each study differed in the approach used to calculate imprecision, measured as a percentage coefficient of variation, and bias. All four studies used the difference between the mean of the quality control result and the assay cut-off to describe the total allowable error.

METHODS

This paper compares and critically reviews the methods used to calculate the Sigma value for each assay in the four studies and provides an evidence-based assessment of these approaches using real-world quality control data obtained from the National Serology Reference Laboratory, Australia (NRL) QConnect™ quality control program.

RESULTS

The assessment found that there was a lack of standardisation in the application of Sigma metrics for infectious disease testing, including examples of inappropriate assumptions being used. Westgard Sigma Rules suggest that assays found to have a Sigma value of six or greater can be monitored using two quality control measures and applying a single mean ± three standard deviation rule.

CONCLUSIONS

Although this approach will significantly reduce the number of false rejections generated by using the full range of Westgard rules, we provide evidence that even this approach can potentially cause true errors to be missed.

Reducing radiation exposure in pediatric cervical spine imaging for trauma: a multi-disciplinary quality improvement initiative

PURPOSE

Pediatric cervical spine injury (PCSI) can result in devastating neurologic disability. While computed tomography (CT) imaging is both sensitive and specific in detecting clinically significant injuries, indiscriminate utilization can lead to excessive ionizing radiation exposure. A routine institutional audit revealed CTs were inappropriately obtained 54% of the time. This study evaluates the effects of an updated protocol to reduce radiation exposure in pediatric trauma patients.

METHODS

Data were retrospectively analyzed from a pediatric level 1 trauma center from 2021 to 2022. The data were divided into two cohorts, pre-implementation (2021) and post-implementation (2022). Inclusion criteria were patients 0-14 years old with a Glasgow Coma Scale (GCS) ranging 9-15. Outside-hospital transfers were excluded. The primary study endpoints were guideline compliance and CT utilization.

RESULTS

A total of 82 subjects were enrolled in this study. In 2021, there were 38 subjects (female/male 15/23, mean age 5.9 years old) with an average GCS of 13.6. In 2022, there were 44 subjects (female/male 19/25, mean age 5.2 years old) with an average GCS of 14.0. In 2021, the overall protocol adherence rate was 81.6%, and post-implementation in 2022, compliance was 93.2% (p = 0.109). Following implementation, the rate of inappropriate (protocol non-adherent CT) use decreased from 58.6 to 6.8% (p < 0.05).

CONCLUSIONS

Implementation of a new evidence-based institutional protocol for PCSI was associated with improved adherence and reduction of unnecessary CT orders. Ongoing monitoring will help determine if these improvements are sustained.

How to Design and Write Your Quality Improvement Study for Publication: Pearls and Pitfalls

Objective

To describe a pragmatic process for translating quality improvement (QI) projects into published manuscripts.

Scope

Types of QI work that are generalizable and have broad relevance (to journals and readers), design principles that are important for publishable QI work, how QI manuscript organization might differ from biomedical manuscripts, how to use and not to use Standards for Quality Improvement Reporting Excellence and other guidelines, pitfalls, and how to avoid/repair them.

Reducing Emergency Department Hold Hours: A Hospital-wide Effort

ABSTRACT

Patient throughput issues are of significant concern for U.S. hospitals and have serious implications for patient care quality and safety as well as hospital finances. In 2021, leaders of a community hospital commissioned a quality improvement team to address a bottleneck of patients in the emergency department (ED). The bottleneck was causing significant increases in the number of hours patients were held in the ED because of a lack of available inpatient beds. The team used the DMAIC improvement framework to analyze patient flow challenges across the hospital, design an evidence-based set of interventions, and measure improvements. Analysis revealed problems with communication breakdowns and workflow silos, discharge predictability, readiness of patients for discharge, timeliness of discharges, and lack of standardization in patient hand-offs and documentation processes. Addressing these issues resulted in patient throughput improvements including a reduction of greater than 75% in monthly ED hold hours after implementation.

Quality improvement of magnetron in Company T based on Six Sigma

Purpose

The purpose of this study is to improve the magnetron quality in Company T by identifying the nonconforming defect, adjusting the factors affecting the leakage of the magnetron tube core, and determining the optimal parameter values of these factors.

Design/methodology/approach

A case study method is used to present the quality improvement of magnetron tube core. The define, measure, analyze, improve, and control framework is applied in the case study as well as several Six Sigma tools.

Findings

The results show that Ag–W thickness, Ag–W installation state and furnace entry interval are significant factors on the leakage of magnetron tube core, and the optimum settings for these factors are 0.055 mm, offset by 1 mm from the outer edge and 5 cm, respectively.

Research limitations/implications

The main limitation of this study is that it was carried out on a small number of production processes. The authors would like to analyze more case studies on the improvements of after-sales quality and supplier quality.

Practical implications

This research could be used in magnetron manufacturing process as a tool for managers and engineers to improve product quality, which can also be extended to similar manufacturing systems.

Originality/value

In this case study, the Six Sigma approach has been applied for the first time to solve magnetron manufacturing problems by improving the quality of magnetron production process. It can help the quality engineers be more familiar with the deployment of Six Sigma and effective tools.

Delivery of Oral Health Services at Medical Visits through 3 Medical Dental Integration Models

INTRODUCTION

The Rocky Mountain Network of Oral Health is 1 of 3 regional projects funded by the Health Resources and Services Administration (2019 to 2024) focusing on caries prevention through medical-dental integration (MDI) in community health centers (CHCs). MDI models included provision of preventive oral health services (POHS) at medical visits by the medical team (model 1), by integrated dental hygienists (DHs; model 2), or a hybrid of these models (model 3). The overarching aim is to evaluate the effectiveness of these models on 3 objectives: (1) ≥50% receive POHS, (2) ≥75% with high caries risk receives dental referral, and (3) ≥30% of parents/caregivers set an oral health goal for the child.

METHODS

Primary care association practice facilitators (PFs) recruited 22 CHCs to participate from Arizona, Colorado, Montana, and Wyoming. CHCs completed oral health needs assessments prior to participating. PFs coached CHCs using an MDI change package. CHCs submitted monthly and 6-mo, aggregated, deidentified population metrics for children aged 0 to 40 mo receiving well-child care visits. Monthly CHC-specific reports were used by PFs with teams in continuous quality improvement activities. POHS delivery trends over time were assessed using a linear mixed model, adjusting for number of eligible patients during each 6-mo reporting period.

RESULTS

Participating CHCs were urban (55%), rural (36%), and frontier (8%). Twelve (55%) had co-located dental clinics. Ten CHCs implemented model 1, 5 implemented model 2, and 7 implemented model 3. From September 2020 to August 2023, CHCs reported providing 91,604 POHS to eligible children. After adjustment, there was significant improvement over time for all objectives: objective 1: F(5, 90) = 4.66, P = 0.0008; objective 2: F(5, 90) = 2.99, P = 0.0151; objective 3: F(5, 90) = 4.56, P = 0.0009.

CONCLUSIONS

The implementation of 3 MDI models across 22 CHCs in 4 states resulted in a meaningful increase in POHS delivery. POHS delivery by both medical and embedded DHs was associated with the most substantial increase in POHS delivery.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by medical and dental providers when deciding which approach they wish to use when planning the delivery of preventive oral health services at medical visits.

New horizons in systems engineering and thinking to improve health and social care for older people

Existing models for the safe, timely and effective delivery of health and social care are challenged by an ageing population. Services and care pathways are often optimised for single-disease management, while many older people are presenting with multiple long-term conditions and frailty. Systems engineering describes a holistic, interdisciplinary approach to change that is focused on people, system understanding, design and risk management. These principles are the basis of many established quality improvement (QI) tools in health and social care, but implementation has often been limited to single services or condition areas. Newer engineering techniques may help reshape more complex systems. Systems thinking is an essential component of this mindset to understand the underlying relationships and characteristics of a working system. It promotes the use of tools that map, measure and interrogate the dynamics of complex systems. In this New Horizons piece, we describe the evolution of systems approaches while noting the challenges of small-scale QI efforts that fail to address whole-system problems. The opportunities for novel soft-systems approaches are described, along with a recent update to the Systems Engineering Initiative for Patient Safety model, which includes human-centred design. Systems modelling and simulation techniques harness routine data to understand the functioning of complex health and social care systems. These tools could support better-informed system change by allowing comparison of simulated approaches before implementation, but better effectiveness evidence is required. Modern systems engineering and systems thinking techniques have potential to inform the redesign of services appropriate for the complex needs of older people.

Applying the six-sigma methodology to determine the limits of quality control (QC) tests for a specific linear accelerator

PURPOSE

We aimed to show the framework of the six-sigma methodology (SSM) that can be used to determine the limits of QC tests for the linear accelerator (Linac). Limits for QC tests are individually determined using the SSM.

METHODS AND MATERIALS

The SSM is based on the define-measure-analyze-improve-control (DMAIC) stages to improve the process. In the "define" stage, the limits of QC tests were determined. In the "measure" stage, a retrospective collection of daily QC data using a Machine Performance Check platform was performed from January 2020 to December 2022. In the "analyze" stage, the process of determining the limits was proposed using statistical analyses and process capability indices. In the "improve" stage, the capability index was used to calculate the action limits. The tolerance limit was established using the larger one of the control limits in the individual control chart (I-chart). In the "control" stage, daily QC data were collected prospectively from January 2023 to May 2023 to monitor the effect of action limits and tolerance limits.

RESULTS

A total of 798 sets of QC data including beam, isocenter, collimation, couch, and gantry tests were collected and analyzed. The Collimation Rotation offset test had the min-Cp, min-Cpk, min-Pp, and min-Ppk at 2.53, 1.99, 1.59, and 1.25, respectively. The Couch Rtn test had the max-Cp, max-Cpk, max-Pp, and max-Ppk at 31.5, 29.9, 23.4, and 22.2, respectively. There are three QC tests with higher action limits than the original tolerance. Some data on the I-chart of the beam output change, isocenter KV offset, and jaw X1 exceeded the lower tolerance and action limit, which indicated that a system deviation occurred and reminded the physicist to take action to improve the process.

CONCLUSIONS

The SSM is an excellent framework to use in determining the limits of QC tests. The process capability index is an important parameter that provides quantitative information on determining the limits of QC tests.

A graduate medical education (GME) quality improvement curriculum leads to improved knowledge and participation in high quality improvement projects by trainees

BACKGROUND

There is increased awareness about the need for quality improvement (QI) education for trainees within clinical training programs. However, formal integration of a QI curriculum into graduate medical education (GME) remains a work-in-progress. We describe the creation and implementation of a novel, virtual QI curriculum complemented by virtual-based workshops.

OBJECTIVE

To determine the impact of a GME QI curriculum on 1) trainee QI knowledge; 2) Quality of QI projects.

METHODS

The GME Quality Improvement curriculum was transitioned to an optional formal curriculum in 2020. It is led by three faculty with expertise in QI training and education. The team developed four, web-based learning modules that focused on fundamental QI concepts. These modules are completed monthly and are paired with virtual workshops that facilitate applying learned QI concepts to project development. We evaluated the effectiveness of the curriculum by assessing participants' performance on knowledge-based quizzes before and after each online module. We used IBM SPSS (version 28), to conduct a two-sided paired samples t-test, comparing each post-session test scores with their corresponding pre-session scores. The alpha, or statistical threshold significance threshold, was 0.05. Additionally, two independent judges with expertise in QI evaluated the quality of the projects presented at the annual QI showcase using a standardized scoring rubric. The poster evaluation forms included 8 questions, rated on a scale from 1 to 5. Projects were graded into 4 quartiles (poor, fair, good, excellent).

RESULTS

In the knowledge assessment quiz, the difference between the mean pre- and post-session quiz scores was statistically significant (p < 0.01). The average score of the quality of the projects presented at the annual showcase was 31, in the fourth quartile which was graded as "excellent" quality.

CONCLUSION

A GME-led QI curriculum was effective in improving knowledge of QI concepts and producing high-quality scholarly projects.

Increasing Frequency of Hemoglobin A1c Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma

BACKGROUND

The American Diabetes Association (ADA) recommends measuring A1c in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1c measurements in hospitalized patients.

METHODS

We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1c in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1c, (2) more rapid turnaround of A1c results, and (3) an EHR glucose-management tab and insulin order set that included A1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1c measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis.

RESULTS

Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1c measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention.

CONCLUSIONS

We demonstrate a novel approach in improving A1c in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.

Diagnosing patient flow issues in the emergency department: an Australasian hospital case study

PURPOSE

This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.

DESIGN/METHODOLOGY/APPROACH

An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.

FINDINGS

High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management's commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.

RESEARCH LIMITATIONS/IMPLICATIONS

This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.

PRACTICAL IMPLICATIONS

This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.

ORIGINALITY/VALUE

This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department's value stream maturity.

Leading medical laboratory professionals toward change readiness: a correlational study

BACKGROUND

To remain effective in the dynamic health care landscape, the laboratory must embrace the continuous improvement mindset to support a culture of change, and leadership must facilitate the change process, mitigating perceived barriers of change readiness in followers.

METHODS

This quantitative study was designed to determine whether there is an association between leadership style (Multifactor Leadership Questionnaire [MLQ]) and change readiness (3-component model [TCM] commitment to change/Employee Commitment Survey, and whether leadership style predicts change readiness. Laboratory professionals (n = 718) were recruited through national societies to complete a combined MLQ-TCM survey instrument. Multivariate analysis of variance, Pearson correlations, and multiple regression analyses were performed.

RESULTS

A significant correlation between leadership style and change readiness (transformational leadership [TL] and affective commitment to change, r(716) = .12, P = .002; passive-avoidant behavior and continuance commitment to change, r(716) = .25, P < .001) and between leadership style and leadership outcomes (TL and effectiveness, r(716) = .90, P < .001) was identified. Transformational leadership was a significant predictor of change readiness (β = .17, P < .05).

CONCLUSION

It is recommended that laboratory leaders use transformational leadership or situational leadership to improve followers' affective commitment to change and reduce followers' continuance commitment to change, thus improving commitment to continuous improvement. Leaders should also limit passive-avoidant behavior.

Exploring the Role of Complexity in Health Care Technology Bottom-Up Innovations: Multiple-Case Study Using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability Complexity Assessment Tool

BACKGROUND

New digital technology presents new challenges to health care on multiple levels. There are calls for further research that considers the complex factors related to digital innovations in complex health care settings to bridge the gap when moving from linear, logistic research to embracing and testing the concept of complexity. The nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework was developed to help study complexity in digital innovations.

OBJECTIVE

This study aims to investigate the role of complexity in the development and deployment of innovations by retrospectively assessing challenges to 4 digital health care innovations initiated from the bottom up.

METHODS

A multicase retrospective, deductive, and explorative analysis using the NASSS complexity assessment tool LONG was conducted. In total, 4 bottom-up innovations developed in Region Västra Götaland in Sweden were explored and compared to identify unique and shared complexity-related challenges.

RESULTS

The analysis resulted in joint insights and individual learning. Overall, the complexity was mostly found outside the actual innovation; more specifically, it related to the organization's readiness to integrate new innovations, how to manage and maintain innovations, and how to finance them. The NASSS framework sheds light on various perspectives that can either facilitate or hinder the adoption, scale-up, and spread of technological innovations. In the domain of condition or diagnosis, a well-informed understanding of the complexity related to the condition or illness (diabetes, cancer, bipolar disorders, and schizophrenia disorders) is of great importance for the innovation. The value proposition needs to be clearly described early to enable an understanding of costs and outcomes. The questions in the NASSS complexity assessment tool LONG were sometimes difficult to comprehend, not only from a language perspective but also due to a lack of understanding of the surrounding organization's system and its setting.

CONCLUSIONS

Even when bottom-up innovations arise within the same support organization, the complexity can vary based on the developmental phase and the unique characteristics of each project. Identifying, defining, and understanding complexity may not solve the issues but substantially improves the prospects for successful deployment. Successful innovation within complex organizations necessitates an adaptive leadership and structures to surmount cultural resistance and organizational impediments. A rigid, linear, and stepwise approach risks disregarding interconnected variables and dependencies, leading to suboptimal outcomes. Success lies in embracing the complexity with its uncertainty, nurturing creativity, and adopting a nonlinear methodology that accommodates the iterative nature of innovation processes within complex organizations.

Reducing the length of stay for patients stranded in the emergency department: A single-center prospective study of 18,631 patients in China

The purpose of this study was to reduce the length of stay (LOS) for patients stranded in the emergency department (ED) of a Grade III A hospital in China, and to improve patient flow and increase bed capacity. We utilized a pre-/postintervention design and employed the Six Sigma methodology, which is based on the DMAIC cycle (define, measure, analyze, improve, and control), to evaluate and improve the existing process. Data from 18,631 patients who were stranded in the ED were collected and analyzed. The median LOS for stranded patients decreased from 17.21 (6.22, 27.36) hours to 13.45 (5.56, 25.85) hours (P < .05). Similarly, the median LOS for admitted patients decreased from 19.64 (7.77, 27.68) hours to 15.92 (6.19, 26.24) hours (P < .05). The median LOS for patients with an ED triage Level IV decreased from 16.15 (5.80, 26.62) hours to 12.59 (5.20, 24.97) hours (P < .05). In addition, the average hospitalization days of hospitalized patients decreased from 0.92 days to 0.82 days (P < .05). Furthermore, the bed utilization rate increased from 66.79% to 72.29% (P < .05). The number of bed turnovers in the ED resuscitation room increased from 20.30 to 21.96 (P < .05). We had effectively met our goal of minimizing ED patient LOS. Six Sigma method can effectively shorten patient LOS by measuring and analyzing the key factors affecting patient LOS, and by implementing measures such as strict implementation of emergency classification and triage system, establishment of multidisciplinary cooperative team, reasonable allocation of human resources, information management of bed resources, and improvement of performance appraisal scheme to improve and control the effectiveness of patient LOS.

Enhancing Hospital Pharmacy Operations Through Lean and Six Sigma Strategies: A Systematic Review

Hospital pharmacies are integral to the healthcare system, and evaluating the factors influencing their efficiency and service standards is imperative. This analysis offers global insights to assist in developing strategies for future enhancements. The objective is to identify the optimal Lean Six Sigma methodologies to improve workflow and quality of hospital pharmacy services. A strategic search, aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, encompassed an extensive range of academic databases, including Scopus, PubMed/Medline, Web of Science, and other sources for relevant studies published from 2009 to 2023. The focus was on management tactics and those examining outcomes, prioritizing publications reflecting pharmacy operations management's state. The quality of the selected articles was assessed, and the results were combined and analyzed. The search yielded 1,447 studies, of which 73 met the inclusion criteria. The systematic review found a low to moderate overall risk of bias. The number of publications rose during the coronavirus disease (COVID-19) outbreak. Among studies, research output in the United States of America represented 26% of the total. Other countries such as Indonesia, Spain, Canada, China, Saudi Arabia, the United Arab Emirates, and the United Kingdom also made significant contributions. Each country accounted for 12%, 8%, 7%, 5%, 5%, 5%, and 5%, respectively. The pharmacy journals led with 26 publications, and healthcare/medical with 14. The quality category came next with 12 articles, while seven journals represented engineering. Studies used empirical and observational methods, focusing on practice quality enhancement. The process control plan had 26 instances, and the define, measure, analyze, improve, and control (DMAIC) was identified 13 times. The sort, set in order, shine, standardize, and sustain (5S) ranked third, totaling seven occurrences. Failure mode and effects analysis (FMEA) and root cause analysis were moderately utilized, with six and four instances, respectively. Poka-Yoke (mistake-proofing measures) and value stream mapping were each counted three times. Quality improvement and workflow optimization dominated managerial strategies in 22 (30.14%) studies each, followed by technology integration in 15 (20.55%). Cost, patient care, and staffing each featured in three (4.11%) studies, while two (2.74%) focused on inventory management. One (1.37%) study each highlighted continuing education, collaboration, and policy changes. Analysis of the 73 studies on Lean and Six Sigma in hospital pharmacy operations showed significant impacts, with 26% of studies reporting decreased medication turnaround time, 15% showing process efficiency improvements, and 11% each for enhanced inventory management and bottleneck/failure mode reduction. Additionally, 9% of studies observed decreased medication errors, 8% noted increased satisfaction and cost savings, 6% identified enhancements in clinical activities, 3% improved prescription accuracy, 2% reduced workflow interruptions, and 1% reported increased knowledge. Also, this study has identified key strategies for service delivery improvement and the importance of quality practices and lean leadership. To the best of the author's knowledge, this research is believed to be the first in-depth analysis of Lean and Six Sigma in the hospital pharmacy domain, spanning 15 years from 2009 to 2023.

Cultivating an Evidence-Based Decision-Making Mindset

This is the first article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

Increasing Hospital at Home Enrollment Through Decentralization With Agile Science

LEVEL OF EVIDENCE

4, Descriptive quality improvement project.

Occupational Category and Professional Title Influencing the Knowledge, Attitudes and Practice (KAP) of Quality Training: A Cross-Sectional Survey From a Tertiary General Hospital

Quality improvement is an international priority, and quality education and training are important parts of hospital quality management. The aim of this study was to understand the knowledge, attitudes and practices (KAP) and its influencing factors related to quality training in medical staff. A questionnaire survey was conducted by convenience sampling to assess the KAP of quality training in Taizhou Enze Medical Center. Principal component analysis was used to extract factors from the questionnaire. Descriptive statistics (frequency, median, mean), Kendall grade correlation analysis, and Mann-Whitney U tests were used to analyze the data. A total of 205 staff members participated in the questionnaire survey. For the 5 factors of the KAP scale, the highest score was factor F4, recognition and support for quality training (mean = 90.55, median = 100), followed by factor F3, perceived benefits (mean = 84.46, median = 85.65). Relatively lower scores were found for factor F2, quality knowledge learning and mastery (mean = 63.09, median = 63.89), and F5, quality management practices and sharing (mean = 82.07, median = 75.00). There was a correlation between the 5 factors. The scores of F2 (quality knowledge learning and mastery) for staff with senior professional titles were higher than those for staff with intermediate professional titles or below. The score of F3 (perceived benefits of quality training) in medical technicians and nurses was higher than in doctors and administrative personnel. Our findings showed that the respondents' attitude toward quality training was positive, but their knowledge mastery and practice behaviors should be further improved. Occupational category and professional title were the influencing factors of the quality training KAP. Therefore, hospital should conduct quality management training at a wider scope according to the competency requirements of different groups, and further optimize the improvement and innovation system.

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.

"If you work alone on this project, you can't reach your target": unpacking the leader's role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

The South African National Department of Health developed a quality improvement (QI) programme to reduce maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively selected public health facilities. We conducted a process evaluation to describe the characteristics and skills of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI technical experts who supported the teams. These interviews focused on participants' experiences and perceptions of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using Atlas.ti. Variation in team performance was associated with leaders' attributes and skills. However, the COVID-19 pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19 and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility for failures, correcting members' mistakes in encouraging ways, and setting high standards of care. Moreover, they promoted programme ownership among members by delegating tasks. Given the critical role leaders play in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training, and support.

Improving Inpatient Medication Dispensing with an Automated System

Introduction

Medication inventory management and error prevention are complex issues. Single interventions are insufficient to make improvement across the spectrum. A uniform system for dispensing and distributing medications can help reduce the risk of medication errors, improve efficiency, and minimize waste. This quality improvement project aims to: 1) decrease - the time from ordering medication to administration, including delay incidents, by > 70%; and 2) decrease the inpatient monthly total medication consumption by > 20% and ward medication stock items by > 70%, including decreasing returned items and loss from in-house expired medications by > 70%.

Methods

A Six-Sigma approach was applied to eliminate deficiencies throughout the medication management process. Failure mode effect analysis and staff surveys were used to evaluate implementation of automated dispensing cabinet (ADCs) and reengineered workflows for expensive, misused, and restricted medications.

Results

After the new processes were implemented, the turnaround time from ordering medication to administration was reduced by 83%, with zero delay incidents reported. Most nurses (64%) and pharmacists (67%) stated that implementation of ADCs increased their productivity by more than 40%. Monthly medication consumption was reduced by 24%, with an estimated annual saving of $4,100,000 USD. The number of returned items per month was reduced by 72%, and the estimated annual savings from loss of in-house expired medications was $750,000 USD.

Conclusions

This quality improvement project positively impacted stock control while reducing costs and turnaround time for inpatient medication dispensing. Medication delay incidents were reduced, and staff satisfaction levels were positive. Next steps are to reengineer narcotic, anesthesia, and refrigerated products' management.

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.

Quality improvement strategies in pediatric ECMO

Pediatric extracorporeal membrane oxygenation is an increasingly utilized, life-saving technology with high mortality and morbidity. A complex technology employed urgently or emergently for some of the sickest children in the hospital by a large multidisciplinary team, ECMO is an ideal area for using quality improvement strategies to reduce the variability in care and improve patient outcomes. We review critical concepts from quality improvement and apply them to patient selection and management, staffing, credentialing and continuing education, and the variability of management among providers and institutions.

Using multi-criteria decision analysis to describe stakeholder preferences for new quality improvement initiatives that could optimise prescribing in England

Background

Hospital decision-makers have limited resources to implement quality improvement projects. To decide which interventions to take forward, trade-offs must be considered that inevitably turn on stakeholder preferences. The multi-criteria decision analysis (MCDA) approach could make this decision process more transparent.

Method

An MCDA was conducted to rank-order four types of interventions that could optimise medication use in England's National Healthcare System (NHS) hospitals, including Computerised Interface, Built Environment, Written Communication, and Face-to-Face Interactions. Initially, a core group of quality improvers (N = 10) was convened to determine criteria that could influence which interventions are taken forward according to the Consolidated Framework for Implementation Research. Next, to determine preference weightings, a preference survey was conducted with a diverse group of quality improvers (N = 356) according to the Potentially All Pairwise Ranking of All Possible Alternatives method. Then, rank orders of four intervention types were calculated according to models with criteria unweighted and weighted according to participant preferences using an additive function. Uncertainty was estimated by probabilistic sensitivity analysis using 1,000 Monte Carlo Simulation iterations.

Results

The most important criteria influencing what interventions were preferred was whether they addressed "patient needs" (17.6%)' and their financial "cost (11.5%)". The interventions' total scores (unweighted score out of 30 | weighted out of 100%) were: Computerised Interface (25 | 83.8%), Built Environment (24 | 79.6%), Written Communication (22 | 71.6%), and Face-to-Face (22 | 67.8%). The probabilistic sensitivity analysis revealed that the Computerised Interface would be the most preferred intervention over various degrees of uncertainty.

Conclusions

An MCDA was conducted to rank order intervention types that stand to increase medication optimisation across hospitals in England. The top-ranked intervention type was the Computerised Interface. This finding does not imply Computerised Interface interventions are the most effective interventions but suggests that successfully implementing lower-ranked interventions may require more conversations that acknowledge stakeholder concerns.

The Quality Management Improvement Approach: Successes and Lessons Learned From a Workforce Development Intervention in Rwanda's Health Supply Chain

BACKGROUND

Rwanda's supply chain is decentralized, with regional warehouse pharmacies and service delivery points (SDPs) ensuring a reliable health commodities supply. However, in 2016, the Rwanda Ministry of Health (MOH) identified challenges with the supply chain workforce contributing to a high stock-out rate, inventory stock inaccuracies, and underutilization of the electronic logistics management information system (e-LMIS). We aimed to document successes and lessons learned from implementing a workforce development intervention to address these challenges.

PROGRAM DESCRIPTION

Rwanda's MOH and the U.S. Agency for International Development Global Health Supply Chain Program-Procurement and Supply Management project implemented a workforce development intervention, the Quality Management Improvement Approach (QMIA), to improve and sustain Rwanda's service delivery and medicines availability. The QMIA monitors the performance of supply chain professionals while continuously building their capacity to run a smooth supply chain operation. The QMIA includes supervisory visits to measure key performance indicators and discussion sessions for experience-sharing and skill-building. The central level conducts both components, supporting regional warehouses that in turn assist SDPs through supervisory visits and discussion sessions.

RESULTS

Since 2017, the QMIA has been conducted twice a year in 596 SDPs and 30 regional warehouses and has trained 1,296 supply chain staff members. The intervention has contributed to major improvements in several key supply chain outcomes (2017 versus 2019): increased utilization of the e-LMIS (55% to 96%), higher inventory data accuracy (25% to 85%), and reduced stock-outs (10% to 1%).

CONCLUSIONS

The QMIA has proven to be a successful training and capacity-building platform for supply chain management in Rwanda, enhancing system utilization and availability of accurate data to guide decision-making. Notably, the approach fosters a positive behavioral change to build local solutions and improves communication.

Operating Room Performance Optimization Metrics: a Systematic Review

Literature proposes numerous initiatives for optimization of the Operating Room (OR). Despite multiple suggested strategies for the optimization of workflow on the OR, its patients and (medical) staff, no uniform description of 'optimization' has been adopted. This makes it difficult to evaluate the proposed optimization strategies. In particular, the metrics used to quantify OR performance are diverse so that assessing the impact of suggested approaches is complex or even impossible. To secure a higher implementation success rate of optimisation strategies in practice we believe OR optimisation and its quantification should be further investigated. We aim to provide an inventory of the metrics and methods used to optimise the OR by the means of a structured literature study. We observe that several aspects of OR performance are unaddressed in literature, and no studies account for possible interactions between metrics of quality and efficiency. We conclude that a systems approach is needed to align metrics across different elements of OR performance, and that the wellbeing of healthcare professionals is underrepresented in current optimisation approaches.

Use of a Lean Six Sigma approach to investigate excessive quality control (QC) material use and resulting costs

PURPOSE

The Eastern Health Clinical Biochemistry Laboratories cater to the province of Newfoundland and Labrador. Over the last ten years, a significant increase in annual expenses on quality control material and calibrator purchases was observed. Two major Clinical Chemistry Laboratories at the Health Sciences Centre (HSC) and St. Clare's Mercy Hospital (STC), St. John's, work as referral centers for the province. The study's design was based on the Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process and involved tests performed on ten automated Abbott Clinical Chemistry (CC) and Immunoassay (IA) analyzers. The cost of purchasing the QC material from Bio-Rad and Randox had increased due to defective QC and analyzer test assignment process design. The processes were modified. An Individualized Quality Control Plan (IQCP) was developed.

RESULTS

Modification in quality control processes helped in bringing down the cost and usage of both QC and calibrators. The cost and usage of individual control material were reduced by 25 to 52% depending on the type of quality control. Total annual expenditure on the purchase of different QC materials before modification was estimated as CAD 346,395(2019) which was reduced to CAD 255,267 with annual savings of 91,128 CAD (26%) after modification (2020). The average usage reduction for various calibrators was 40% with the highest reduction in the use of urine calibrators. The annual cost of calibrators was reduced from CAD 30,568.42 (2019-20) to CAD 17,517 (2020-21) with the saving of approximately 13,051 Canadian dollars (43 %) for the laboratory.

CONCLUSIONS

There is a constant compulsion in every industry to manage costs. Implementation of Lean and Six Sigma methodology in removing Muda of high costs in a Clinical Chemistry Laboratory is the most warranted strategy in developing a cost-effective laboratory framework.

Lean and Six Sigma as continuous quality improvement frameworks in the clinical diagnostic laboratory

Processes to enhance customer-related services in healthcare organizations are complex and it can be difficult to achieve efficient patient-focused services. Laboratories make an integral part of the healthcare service industry where healthcare providers deal with critical patient results. Errors in these processes may cost a human life, create a negative impact on an organization's reputation, cause revenue loss, and open doors for expensive lawsuits. To overcome these complexities, healthcare organizations must implement an approach that helps healthcare service providers to reduce waste, variation, and work imbalance in the service processes. Lean and Six Sigma are used as continuous process improvement frameworks in laboratory medicine. Six Sigma uses an approach that involves problem-solving, continuous improvement and quantitative statistical process control. Six Sigma is a technique based on the DMAIC process (Define, Measure, Analyze, Improve, and Control) to improve quality performance. Application of DMAIC in a healthcare organization provides guidance on how to handle quality that is directed toward patient satisfaction in a healthcare service industry. The Lean process is a technique for process management in which waste reduction is the primary purpose; this is accomplished by implementing waste mitigation practices and methodologies for quality improvement. Overall, this article outlines the frameworks for continuous quality and process improvement in healthcare organizations, with a focus on the impacts of Lean and Six Sigma on the performance and quality service delivery system in clinical laboratories. It also examines the role of utilization management and challenges that impact the implementation of Lean and Six Sigma in clinical laboratories.

Transformational Performance Improvement: Why Is Progress so Slow?

In this chapter, we identify three distinct transformational performance improvement (TPI) approaches commonly used to redesign work processes in health care organizations. We describe the unique components or tools that each approach uses to improve the delivery of health services. We also summarize what is empirically known about the effectiveness of each TPI approach according to systematic reviews and recent studies published in the peer-reviewed literature. Based on examination of this research, we discuss what knowledge is still needed to strengthen the evidence for whole system transformation. This involves the use of conceptual frameworks to assess and guide implementation efforts, and facilitators and barriers to change as revealed in a recent evaluation of one major initiative, the Lean Enterprise Transformation (LET) at the Veterans Health Administration. The analysis suggests ways in which TPI facilitators can be developed and barriers reduced to improve the effectiveness and sustainability of quality initiatives. Finally, we discuss appropriate study designs to evaluate TPI interventions that may strengthen the evidence for their effectiveness in real world practice settings.

A balanced approach involving hard and soft factors for internalizing Lean Management and Six Sigma in hospitals

Purpose

This study examines the theoretical and empirical relationships between LM&SS, human resource management (HRM), climate for LM&SS and outcomes (employee well-being and performance) in hospitals. As part of this research, the authors examine the interplay between “hard” and “soft” practices for LM&SS and “soft” HR practices.

Design/methodology/approach

A cross-sectional, multisite survey study covering all internal service units at all eight Dutch university hospitals was conducted (42 units, N = 218 supervisors, N = 1,668 employees), and multivariate multilevel regression analyses were performed.

Findings

A systems approach involving “soft” LM&SS practices that are specifically HR-related has a positive effect (β is 0.46) on a climate for LM&SS. A climate for LM&SS is not related to perceived performance or employee health. It is, however, positively related to employee happiness and trusting relationships (both βs are 0.33). We did not find that a climate for LM&SS had a mediating effect.

Research limitations/implications

This study shows that a balanced approach involving both “hard” and “soft” factors is crucial to achieving the desired breadth and depth of LM&SS adoption at the macro, meso, and micro levels. The authors found that a climate for LM&SS positively affects employee well-being in hospitals.

Practical implications

In their attempt to create mutual gains for both their organization and their employees, hospitals that adopt LM&SS should foster a climate for LM&SS by embracing a balanced approach consisting of both “hard” and “soft” practices, thereby internalizing LM&SS at the macro, meso, and micro levels.

Originality/value

This is one of the first studies to examine in-depth the impact of “hard” and “soft” LM&SS on both employee well-being (subdivided into different components) and performance in healthcare, as well as the role of “soft” HRM in this relationship. Linking LM&SS, HRM and outcomes to a climate for LM&SS is relatively a new approach and has led to a deeper understanding of the mechanisms underpinning the internalization of LM&SS in healthcare.

Six Sigma in blood transfusion services: A dream too big in a third world country?

BACKGROUND AND OBJECTIVES

Transfusion errors can occur anywhere from blood donation to final blood transfusion. They are a source of increased cost and patient mortality. Automated workflows can reduce transcription errors, but resource-poor centres still use semi-automated/manual method for testing including manual labelling of column agglutination cards/testing tubes. Missing out any details on these cards can lead to errors in reporting results, wastage and loss of resources and effort. The aim of this study was to implement Six Sigma DMAIC (Define, Measure, Analyse, Improve and Control) methodology to reduce transcription errors while labelling gel card in immunohaematology lab to zero defect.

MATERIALS AND METHODS

In this prospective study, transcription errors while manually performing 200 tests with 1400 opportunities were analysed. Baseline variables like number of errors, defects per million opportunities and sigma level in our current setup were measured. With the application of DMAIC methodology, root cause analysis for each error using Ishikawa diagram and structured Interviews were done to identify causes. A multipronged approach to deal with errors was done to improve critical areas using brainstorming sessions and developing training sheets for practice. After implementing the changes, baseline variables were reanalysed.

RESULTS

Application of DMAIC resulted in an overall reduction in defects from 34.86% to 0.56% with sigma level improvement from 1.89 to 4.08.

CONCLUSION

Six Sigma methodology can be used in a resource-poor setting even with lack of automation to ensure error-free process flow.

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.

Reduction of the Cycle Time in the Biopsies Diagnosis Through a Simulation Based on the Box Müller Algorithm

Anatomic pathology services study disease in hospitals on the basis of macroscopic and microscopic examination of organs and tissues. The focus of this research investigation was on improving clinical biopsy diagnosis times through simulation based on the Box-Muller algorithm to reduce the waiting time in the diagnosis of clinical biopsies. The data were provided by a hospital in San José (Costa Rica). They covered 5 years and showed waiting times for a pathological diagnosis that for some biopsies were close to 120 days. The correlation between the main causes identified and the cycle time in the biopsy diagnostic process was defined. A statistical analysis of the variables most representative of the process and of the waiting times was carried out. It followed the DMAIC structure (Define, Measure, Analyse, Improve, Control) for the continuous improvement of processes. Two of the activities of the process were identified as being the main bottlenecks. Their processing times had a normal distribution, for which reason a Box-Muller algorithm was used to generate the simulation model. The results showed that waiting times for a diagnosis can be reduced to 3 days, for a productive capacity of 8 000 biopsies per annum, optimizing the logistics performance of health care.

The Introduction of Robotics to an Outpatient Dispensing and Medication Management Process in Saudi Arabia: A Pharmacy-led Multidisciplinary Six Sigma Performance Improvement Project. (Preprint)

Background

Outpatient pharmacy management aims for improved patient safety, improved quality of service, and cost reduction. The Six Sigma method improves quality by eliminating variability, with the goal of a nearly error-free process. Automation of pharmacy tasks potentially offers greater efficiency and safety.

Objective

The goal was to measure the impact that integration of automation made to service, safety and efficiency, staff reallocation and reorientation, and workflow in the outpatient pharmacy department. The Six Sigma problem definition to be resolved was as follows: The current system of outpatient dispensing denies quality to patients in terms of waiting time and contact time with pharmacy professionals, incorporates risks to the patient in terms of mislabeling of medications and the incomplete dispensing of prescriptions, and is potentially wasteful in terms of time and resources.

Methods

We described the process of introducing automation to a large outpatient pharmacy department in a university hospital. The Six Sigma approach was used as it focuses on continuous improvement and also produces a road map that integrates tracking and monitoring into its process. A review of activity in the outpatient department focused on non-value-added (NVA) pharmacist tasks, improving the patient experience and patient safety. Metrics to measure the impact of change were established, and a process map analysis with turnaround times (TATs) for each stage of service was created. Discrete events were selected for correction, improvement, or mitigation. From the review, the team selected key outcome metrics, including storage, picking and delivery dispensing rates, patient and prescription load per day, average packs and lines per prescription, and lines held. Our goal was total automation of stock management. We deployed 2 robotic dispensing units to feed 9 dispensing desks. The automated units were integrated with hospital information technology (HIT) that supports appointments, medication records, and prescriptions.

Results

Postautomation, the total patient time in the department, including the time interacting with the pharmacist for medication education and counseling, dropped from 17.093 to 11.812 digital minutes, with an appreciable increase in patient-pharmacist time. The percentage of incomplete prescriptions dispensed versus orders decreased from 3.0% to 1.83%. The dispensing error rate dropped from 1.00% to 0.24%. Assessed via a “basket” of medications, wastage cost was reduced by 83.9%. During implementation, it was found that NVA tasks that were replaced by automated processes were responsible for an extensive loss of pharmacist time. The productivity ratio postautomation was 1.26.

Conclusions

The Six Sigma methodology allowed for rapid transformation of the medication management process. The risk priority numbers (RPNs) for the “wrong patient-wrong medication error” reduced by a ratio of 5.25:1 and for “patient leaves unit with inadequate counseling” postautomation by 2.5:1. Automation allowed for ring-fencing of patient-pharmacist time. This time needs to be structured for optimal effectiveness.

Consecutive Surgeon and Anesthesia Team Improve Turnover Time in the Operating Room

Efficient management of the operating room (OR) contributes to much of today's healthcare expenditure and plays a critical role in generating revenue for most healthcare systems. Scheduling of OR cases with the same team and surgeon have been reported to improve turnover time between cases which in turn, improves efficiency and resource utilization. We aim to assess different operating room procedures within multiple subspecialties and explore the factors that positively and negatively influence turnover time (TOT) in the operating room. We conducted a retrospective review of cases that were completed on weekdays between 0600 and 2359 from July 2017 through March 2018. Cases between 0000 and 0559 were excluded from this study. Of the total 2,714 cases included in our study, transplant surgery had the highest mean TOT (71 ± 48 min) with orthopedic surgery cases without robots having the lowest mean TOT. OR cases in rooms with the same specialty had significantly less mean TOT compared to rooms switching between different subspecialties (70 vs. 117 min; p < 0.0001). Similarly, cases with the same surgeon and anesthesia team had a significant lower TOT (p < 0.0001). Consecutive specialty, surgeon, anesthesiologist, and prior procedure ending before 15:00 were all independent predictors of lower TOT (p < 0.0001). Our study shows scheduling cases with the same OR team for elective cases can decrease TOT and potentially increase operating room efficiency during the day. Further studies may be needed to assess the long-term effects of such variables affecting OR TOT on healthcare expenditure.

Vertical integration in healthcare: What does literature say about improvements on quality, access, efficiency, and costs containment?

INTRODUCTION

Vertical integration models involve integrating services from different levels of care (e.g., primary care, acute care, post-acute care). Therefore, one of their main objectives is to increase continuity of care, potentially improving outcomes like efficiency, quality, and access or even enabling cost containment.

OBJECTIVES

This study conducts a literature review and aims at contributing to the contentious discussion regarding the effects of vertical integration reforms in terms of efficiency, costs containment, quality, and access.

METHODS

We performed a systematic search of the literature published until February 2020. The articles respecting the conceptual framework were included in an exhaustive analysis to study the impact of vertical integration on costs, prices of care, efficiency, quality, and access.

RESULTS

A sample of 64 papers resulted from the screening process. The impact of vertical integration on costs and prices of care appears to be negative. Decreases in technical efficiency upon vertical integration are practically out of the question. Nevertheless, there is no substantial inclination to visualise a positive influence. The same happens with the quality of care. Regarding access, the lack of available articles on this outcome limits conjectures.

CONCLUSIONS

In summary, it is not clear yet whether vertically integrated healthcare providers positively impact the overall delivery care system. Nevertheless, the recent growing trend in the number of studies suggests a promising future on the analysis of this topic.

An evaluation of Lean and Six Sigma methodologies in the national health service

Purpose

The purpose of this paper is to conduct an empirical study derived from the previous literature from the perspective of benefits, tools and techniques, continuous improvement (CI) and quality improvement (QI) methodologies and critical failure factors (CFFs) of Lean and Six Sigma (SS) in the national health service (NHS).

Design/methodology/approach

A literature review was carried out to identify previous findings, empirical data and critical variables concerning Lean and SS in healthcare for over ten years. Second, primary research in quantitative surveys and qualitative interviews was carried out with 110 participants who have experience using Lean and SS in the NHS.

Findings

Lean and SS have evolved into common practices within the NHS and now have an established list of tools and techniques frequently employed by staff. Lean and SS are considered robust CI methodologies capable of effectively delivering extensive benefits across many different categories. The NHS must overcome a sizable amount of highly important CFFs and divided organizational culture.

Originality/value

This paper has developed the most extensive empirical study ever produced on Lean and SS in the NHS and has expanded on previous works to create new and updated research. The findings produced in this paper will assist NHS medical directors and practitioners in obtaining up-to-date insight into Lean and SS status in the NHS. The paper will also guide the NHS to critically evaluate their current CI strategy to ensure long-term sustainability and deliver improved levels of service to patients.

SARS-CoV-2 driving rapid change in adult cystic fibrosis services: the role of the clinical nurse specialist

Cystic fibrosis (CF) is a genetic, life-limiting disease without a cure; treatment is complex and lifelong. Respiratory failure is the most common cause of death; however, gastrointestinal disease, diabetes and liver disease are common comorbidities. Coronavirus disease (COVID-19) rapidly changed healthcare services across the globe, including redeployment of healthcare professionals. This adult CF service was challenged to continue a patient facing service within severe staffing and structural limitations.

Not only were many members of the CF multidisciplinary team (MDT) redeployed at the start of the first wave, but also both the CF and ambulatory care wards were closed. Fortunately, the CF clinical nurse specialists (CF-CNSs) remained in their role. Rapid change and adaptation of the CF service was required to ensure that patients did not feel abandoned and access to treatment remained available. The role of the CF-CNS was therefore pivotal in this change.

The aim of this project was to use quality improvement methodology to plan an emergency service allowing a reintroduction of ambulatory care services. Success was measured by the number of patients clinically reviewed with or without intervention, and the reasons for patients contacting the CF-CNS via email and phone were recorded.

In weeks 1 and 2 of the emergency service, the CF-CNSs triaged patients by phone, then reviewed face-to-face when necessary. This first step allowed the CF-CNSs to start two patients on home intravenous antibiotics. This service continued to be developed over the following 12 weeks, leading to a total of 36 patient attendances. In March 2020, n=1187 patients made contact (mostly COVID-19, unwell and medication related), in April n=904 and May n=870 (blood test results, unwell and medication related).

The motivation of the CF-CNSs was pivotal to the success of this initiative with the CF MDT available to provide some support and advice. It concluded at week 12, which then saw the opening of the formal ambulatory care ward and returning redeployed ward staff.

Important Quality Metrics and Standardization in Endoscopy

Quality metrics and standardization has become critical as the Affordable Care Act mandates that the Center for Medicare and Medicaid Services change reimbursement from volume to a value-based system. While the most commonly used quality indicators are related to that of colonoscopy, quality metrics for other procedures and endoscopy units have been developed mainly by the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy. Data to show that these quality metrics, especially in the field of advanced endoscopy as well as in the era of COVID-19 pandemic, can improve patient outcomes, are anticipated.

Improving healthcare performance through Activity-Based Costing and Time-Driven Activity-Based Costing

Improving healthcare performance has become a need for resource optimisation in a field where they are scarce. Activity-Based Costing (ABC) has been applied for more than 30 years to allocate costs and provide information for decision-making. This paper seeks to review previous literature in the health field that analysed this cost system and its new version, TDABC (Time-Driven Activity-Based Costing). Five hundred ninety articles published from 1989 to 2019 were retrieved from Scopus and Medline. The review includes descriptive, relational and content analyses. Results show that the interest in applying these cost systems is growing, especially in journals focusing on the financial aspects of health, policy and planning, and radiology. However, there is a difference in the application of ABC and TDABC. ABC is more related to efficiency and more used in laboratories. In contrast, TDABC is primarily used in hospitals and addressing the value of health rather than cost-effectiveness. On the other hand, the findings suggest that TDABC present greater opportunities for publication compared with ABC. Its progression is higher and gets more citations. The current article contributes to broadening the field's vision and encourages authors for further research.

Six Sigma in Health Literature, What Matters?

Six Sigma has been widely used in the health field for process or quality improvement, constituting a quite profusely investigated topic. This paper aims at exploring why some studies have more academic and societal impact, attracting more attention from academics and health professionals. Academic and societal impact was addressed using traditional academic metrics and alternative metrics, often known as altmetrics. We conducted a systematic search following the PRISMA statement through three well-known databases, and identified 212 papers published during 1998–2019. We conducted zero-inflated negative binomial regressions to explore the influence of bibliometric and content determinants on traditional academic and alternative metrics. We observe that the factors influencing alternative metrics are more varied and difficult to apprehend than those explaining traditional impact metrics. We also conclude that, independently of how the impact is measured, the paper’s content, rather than bibliometric characteristics, better explains its impact. In the specific case of research on Six Sigma applied to health, the papers with more impact address process improvement focusing on time and waste reduction. This study sheds light on the aspects that better explain publications’ impact in the field of Six Sigma application in health, either from an academic or a societal point of view.

Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers

The challenges facing Quality Improvement Managers (QIMs) are often understood and addressed in isolation from wider healthcare organisation within which quality improvement initiatives are embedded. We draw on Stafford Beer's Viable System Model (VSM) to shed light on how the viability of quality improvement depends on the effective functioning of five critical quality improvement systems and the extent to which these systems are integrated within the healthcare organisation. These systems are System 1 (Operations), System 2 (Coordination), System 3 (Operational Control), System 4 (Development) and System 5 (Policy). Our analysis draws on interviews with 56 QIMs working in 15 of New Zealand's 20 District Health Boards. We use VSM to identify the sources of problems in QI implementation. These include changes in direction for QI initiatives; myopic behaviour resulting from fragmented systems of care; difficulties in managing and monitoring QI activities given variable staff engagement and inadequate resourcing; pressure for quick results rather developing QI capabilities; and a lack of strategic embeddedness. A viable QI system requires QI approaches that are (1) implemented at an organisation-wide level; (2) well-resourced and carefully monitored; (3) underpinned by a long-term vision; and (4) supported by QIMs with the necessary power and influence to integrate QI subsystem within the wider healthcare organisation.

Exploring the use of operational excellence methodologies in the era of COVID-19: perspectives from leading academics and practitioners

Purpose

This paper aims to present the results of a study carried out by the authors in the form of research interviews on the topic: “Exploring the use of operational excellence methodologies in the era of COVID-19.”

Design/methodology/approach

A qualitative interview approach was utilized by interviewing a panel of leading academics and practitioners who are familiar with operation excellence methodologies.

Findings

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Research limitations/implications

One limitation of this research was that most of the interviewees who participated in this study came from Europe, North America, South America and Asia, representing four continents. It would have been better to have different views from other continents such as Australia and Africa. Also, the interviews were short and at a high level. There is an opportunity for further study and analysis.

Practical implications

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Originality/value

The paper provides an excellent resource for those people to get an insight into the value of the application of operations excellence methodologies in pandemic situations to aid healthcare process improvement and aid public and patient safety.