A Lean Six Sigma Quality Improvement Project Improves Timeliness of Discharge from the Hospital

Driving in the Wrong Direction: Exploring the Unintended Consequences of an Early Discharge Program on Length of Stay in Hospital Setting

BACKGROUND AND OBJECTIVES

Early discharge of patients has become standard work in acute care settings to reduce inpatient length of stay (LOS), improve patient flow, and reduce boarding in the emergency department (ED).

Retrospective analysis of outcomes from a "discharge by 11 am " program at an academic medical center from January 1, 2020, to June 30, 2022. The analysis addresses the effects of a discharge by 11 am goal on time from discharge order release to patient discharge, ED boarding, LOS, and observed-to-expected LOS.

METHODS

Patient-level electronic health record data included discharge order entry time, discharge time, LOS, and diagnosis-related group geometric LOS (GMLOS). Additional unit-level data for ED boarding volumes and hours were included. Analyses were conducted at the hospital and unit levels where indicated.

RESULTS

Patients with a discharge order by 9 am have longer mean hours from order to discharge than patients without a discharge order by 9 am (9.04 vs 2.48 hours, P < .001) ED boarding total ( R2  = 46.2%, P ≤ .001), percentage ( R2  = 50.4%, P ≤ .001), median minutes ( R2  = 24.6%, P = .005), and total minutes ( R2  = 40.8%, P ≤ .001) all increased as discharge by 11 am performance improved. The mean LOS is longer for the discharge by 11 am group than the non-discharge by 11 am group -1.67; 95% CI, -2.03 to -1.28, P < .001). Discharge by 11 am patients had a LOS/GMLOS ratio 21.9% higher than the non-discharge by 11 am cohort (difference -0.31; 95% CI, -0.36 to -0.26, P < .001).

CONCLUSIONS

Discharge order entry and release by 9 am and patient physically discharged by 11 am initiatives demonstrate a statistical increase in time from discharge order to discharge time, ED boarding, LOS, and observed-to-expected LOS.

Application of a Human Factors Systems Approach to Healthcare Control Centres for Managing Patient Flow: A Scoping Review

Over the past decade, healthcare systems have started to establish control centres to manage patient flow, with a view to removing delays and increasing the quality of care. Such centres-here dubbed Healthcare Capacity Command/Coordination Centres (HCCCs)-are a challenge to design and operate. Broad-ranging surveys of HCCCs have been lacking, and design for their human users is only starting to be addressed. In this review we identified 73 papers describing different kinds of HCCCs, classifying them according to whether they describe virtual or physical control centres, the kinds of situations they handle, and the different levels of Rasmussen's [1] risk management framework that they integrate. Most of the papers (71%) describe physical HCCCs established as control centres, whereas 29% of the papers describe virtual HCCCs staffed by stakeholders in separate locations. Principal functions of the HCCCs described are categorised as business as usual (BAU) (48%), surge management (15%), emergency response (18%), and mass casualty management (19%). The organisation layers that the HCCCs incorporate are classified according to the risk management framework; HCCCs managing BAU involve lower levels of the framework, whereas HCCCs handling the more emergent functions involve all levels. Major challenges confronting HCCCs include the dissemination of information about healthcare system status, and the management of perspectives and goals from different parts of the healthcare system. HCCCs that take the form of physical control centres are just starting to be analysed using human factors principles that will make staff more effective and productive at managing patient flow.

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.

Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review

Despite the increasing utilization of lean practices and digital technologies (DTs) related to Industry 4.0, the impact of such dual interventions on healthcare services remains unclear. This study aims to assess the effects of those interventions and provide a comprehensive understanding of their dynamics in healthcare settings. The methodology comprised a systematic review following the PRISMA guidelines, searching for lean interventions supported by DTs. Previous studies reporting outcomes related to patient health, patient flow, quality of care, and efficiency were included. Results show that most of the improvement interventions relied on lean methodology followed by lean combined with Six Sigma. The main supporting technologies were simulation and automation, while emergency departments and laboratories were the main settings. Most interventions focus on patient flow outcomes, reporting positive effects on outcomes related to access to service and utilization of services, including reductions in turnaround time, length of stay, waiting time, and turnover time. Notably, we found scarce outcomes regarding patient health, staff wellbeing, resource use, and savings. This paper, the first to investigate the dual intervention of DTs with lean or lean–Six Sigma in healthcare, summarizes the technical and organizational challenges associated with similar interventions, encourages further research, and promotes practical applications.

Utilization of Lean & Six Sigma quality initiatives in Indian healthcare sector

PURPOSE

The purpose of this paper is to investigate the utilization of Lean & Six Sigma quality initiatives in healthcare sector in India.

METHODOLOGY

The survey questionnaires were sent to 454 hospitals through registered postal in all the states of India. The survey questionnaire was designed to assess different quality initiatives; currently implemented in Indian hospitals, factors align with organization's objectives, reasons for not implementing Lean & Six Sigma and contribution of Lean & Six Sigma projects in healthcare improvement projects etc. A separate section in the questionnaire provides the feedback on implementation of Lean & Six Sigma in various hospitals. The relationships between Lean & Six Sigma and healthcare performance have also been established in this paper.

FINDINGS

It is found that 15 Nos. of hospitals have implemented the Lean tools while 14 Nos. have implemented the Six Sigma tools out of 109 collected responses. This shows the utilization of Lean & Six Sigma in Indian healthcare sector. The 'Lack of knowledge' and 'Availability of resources' are the major reasons for not implementing Lean & Six Sigma. It is also observed that 22% running projects were related to Lean & Six Sigma out of various improvement projects running in various hospitals.

ORIGINALITY

There is lack of evidences of similar studies that determines the utilization of Lean & Six Sigma in Indian healthcare sector at the national level. This paper will provide important breakthrough to academicians and healthcare practitioners, who are involved in Lean & Six Sigma research.

SOCIAL IMPLICATIONS

The present study will create awareness among healthcare practitioners across India for utilization of quality tools that will provide direct benefits to the society.

Huddles and their effectiveness at the frontlines of clinical care: a scoping review

BACKGROUND

Brief, stand-up meetings known as huddles may improve clinical care, but knowledge about huddle implementation and effectiveness at the frontlines is fragmented and setting specific. This work provides a comprehensive overview of huddles used in diverse health care settings, examines the empirical support for huddle effectiveness, and identifies knowledge gaps and opportunities for future research.

METHODS

A scoping review was completed by searching the databases PubMed, EBSCOhost, ProQuest, and OvidSP for studies published in English from inception to May 31, 2019. Eligible studies described huddles that (1) took place in a clinical or medical setting providing health care patient services, (2) included frontline staff members, (3) were used to improve care quality, and (4) were studied empirically. Two reviewers independently screened abstracts and full texts; seven reviewers independently abstracted data from full texts.

RESULTS

Of 2,185 identified studies, 158 met inclusion criteria. The majority (67.7%) of studies described huddles used to improve team communication, collaboration, and/or coordination. Huddles positively impacted team process outcomes in 67.7% of studies, including improvements in efficiency, process-based functioning, and communication across clinical roles (64.4%); situational awareness and staff perceptions of safety and safety climate (44.6%); and staff satisfaction and engagement (29.7%). Almost half of studies (44.3%) reported huddles positively impacting clinical care outcomes such as patients receiving timely and/or evidence-based assessments and care (31.4%); decreased medical errors and adverse drug events (24.3%); and decreased rates of other negative outcomes (20.0%).

DISCUSSION

Huddles involving frontline staff are an increasingly prevalent practice across diverse health care settings. Huddles are generally interdisciplinary and aimed at improving team communication, collaboration, and/or coordination. Data from the scoping review point to the effectiveness of huddles at improving work and team process outcomes and indicate the positive impact of huddles can extend beyond processes to include improvements in clinical outcomes.

STUDY REGISTRATION

This scoping review was registered with the Open Science Framework on 18 January 2019 ( https://osf.io/bdj2x/ ).

Lean Healthcare Tools for Processes Evaluation: An Integrative Review

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

Six sigma approach for neonatal jaundice patients in an Indian rural hospital - a case study

PURPOSE

The purpose of this paper is to implement Six Sigma approach to decrease the length of stay (LOS) of neonatal jaundice patients in an Indian government rural hospital situated in northern hill region.

DESIGN/METHODOLOGY/APPROACH

Six Sigma's Define-Measure-Analyse-Improve-Control procedure is applied in order to decrease the LOS of neonatal jaundice patients. The mean and standard deviation have been computed as 34.53 and 20.01 h, respectively. The cause and effect diagram is used in the "Analyse" phase of the Six Sigma. The regression analysis and GEMBA observation techniques are used to validate the causes identified through cause and effect diagram.

FINDINGS

The waiting time for registration, waiting time for tests, waiting time for phototherapy and time for discharge implementation are the main factors that are responsible for longer LOS. Based on the identified root causes, some recommendations are suggested to the hospital administration and staff members in order to reduce the LOS.

RESEARCH LIMITATIONS/IMPLICATIONS

The present research is limited to provide recommendations to the hospital administration to reduce LOS and it entirely depends upon the implementation of the administration. However, target of administration is to reduce the LOS up to 24 h.

PRACTICAL IMPLICATIONS

Six Sigma model will reduce bottlenecks in LOS and enhance service quality of hospital. The developed regression model will help the doctors and staff members to assess and control the LOS by controlling and minimising the independent variables.

SOCIAL IMPLICATIONS

The project will directly provide benefits to society, as LOS will decrease and patients' satisfaction will automatically increase.

ORIGINALITY/VALUE

Six Sigma is a developed methodology, but its application in paediatric department is very limited. This is the first ever study of applying Six Sigma for neonatal jaundice patients in India.

Applying Lean Six Sigma to Reduce the Incidence of Unplanned Surgery Cancellation at a Large Comprehensive Tertiary Hospital in China

Unplanned surgery cancellation (USC) was an important quality management issue in the course of medical care for surgical patients, which caused inappropriate use of hospital resources and had negative impacts on quality and safety. This study used Lean Six Sigma to reduce the incidence of USC. Following the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process, the main factors influencing the USC were identified, such as the time of informing patient admission, the time of submitting operation notice, and the management of test report follow-up. A series of measures were implemented including improving the health education content of virtual bed patients, standardizing the way of communication between the Admission Management Center and the patients, improving the timing of anesthesia evaluation, optimizing the process of operation notice with an information system, and implementing the regulations of virtual bed management. The incidence of USC reduced from 10.21% in Jan. 2016 to 3.8% in Dec. 2016, and the Z-score increased from 1.25 to 1.68, which improved patient safety and demonstrated that Lean Six Sigma was an effective method to solve cross-department issues in hospital.

Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review

Healthcare services are facing challenges in increasing their efficiency, quality of care, and coping with surges in demand. To this end, some hospitals have implemented lean healthcare. The aim of this systematic review is to evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve. The review was performed according to PRISMA. We used six databases to search for studies published from 2002 to 2019. Out of 5732 studies, 39 measuring one or more defined outcomes were included. Hospital length of stay (LOS) was measured in 23 studies, 16 of which reported a reduction, turnover time (TOT) decreased in six out of eight studies, while the turnaround time (TAT) and on-time starts (OTS) improved in all five and seven studies, respectively. Moreover, eight out of nine studies reported an earlier discharge time, and the boarding time decreased in all four cases. Meanwhile, the readmission rate did not increase in all nine studies. Lastly, staff and patient satisfaction improved in all eight studies. Our findings show that by focusing on reducing non-value-added activities, LH contributed to improving patient flow and efficiency within inpatient care.

Improving Early Discharges With an Electronic Health Record Discharge Optimization Tool

Introduction:

Delays in hospital discharge can negatively impact patient care, bed availability, and patient satisfaction. There are limited studies examining how the electronic health record (EHR) can be used to improve discharge timeliness. This study aimed to implement an EHR discharge optimization tool (DOT) successfully and achieve a discharge before noon (DBN) percentage of 25%.

Methods:

We conducted a single-center quality improvement study of patients discharged from 3 pediatric hospital medicine teaching service teams at a quaternary care academic children’s hospital. The multidisciplinary team created a DOT centrally embedded within the care team standard workflow to communicate anticipated time until discharge. The primary outcome was the monthly percentage of patients discharged before noon. Secondary outcomes included provider utilization of the DOT, tool accuracy, and patient length of stay. Balancing measures were 7- and 30-day readmission rates.

Results:

The DBN percentage increased from 16.4% to an average of 19.3% over the 13-month intervention period (P = 0.0005). DOT utilization was measured at 87.2%, and the overall accuracy of predicting time until discharge was 75.6% (P < 0.0001). Median length of stay declined from 1.75 to 1.68 days (P = 0.0033), and there was no negative impact on 7- or 30-day readmission rates.

Conclusion:

This initiative demonstrated that a highly utilized and accurate discharge tool could be created in the EHR to assist medical care teams with improving DBN percentage on busy, academic teaching services.

Fast track surgery for knee replacement surgery: a lean six sigma approach

Purpose

The reduction of costs has a more and more relevant role in the healthcare context, therefore, a large effort is done by health providers to this aim, for example, by reducing the length of hospital stay (LOS) of patients undergoing surgery. Fast track surgery fits perfectly this issue and was applied to patients undergoing knee replacement surgery due to Osteoarthritis, one of the most common diseases of aged population. The paper aims to discuss these issues.

Design/methodology/approach

Lean six sigma was applied to analyze the implementation of fast track surgery through the define, measure, analyze, improve, control roadmap, used as a typical problem-solving approach. It is characterized by five operational phases, which make possible the achievement of fixed goals through a rigorous process of defining, measuring, analyzing, improving and controlling business problems.

Findings

The corrective action, consisting in the application of fast track surgery, improved both effectiveness and efficiency of the process of care. The average length of hospital stay (LOS) was reduced from 8.34 to 6.68 days (–19.9 percent) and its standard deviation from 2.41 to 1.99 days (–17.1 percent). The statistical significance of this decrease was verified by means of proper tests. Moreover, some variables influencing the LOS were identified.

Research limitations/implications

The follow up and the satisfaction of patients were not analyzed and could be a future development of this study.

Practical implications

Patients will experience a faster recovery while the hospital will benefit from a rise of available beds. The effect is a general improvement of hospital management.

Originality/value

The introduction of fast track surgery for patients undergoing knee replacement surgery made significantly reduce LOS and, consequently, costs’ with a money saving of more than 50,000 euro per year.

The Distributions of Weekday Discharge Times at Acute Care Hospitals in the State of Florida were Static from 2010 to 2018

When hospital capacity is near census, either due to limits on the number of physical or staffed beds, delays in patients' discharge can result in domino effects of congestion for the emergency department, the intensive care units, the postanesthesia care unit, and the operating room. Hospital administrators often promote increasing the percentage of patients discharged before noon as mitigation. However, benchmark data from multiple hospitals are lacking. We studied the time of weekday inpatient discharges from all 202 acute care hospitals in the state of Florida between 2010 and 2018 using publicly available data. Statewide, the average length of stay (4.63 days) did not change, but hospital discharges increased 6.1%. There was no change over years in the percentage of patients discharged before 12 noon (13.0% ± 0.28% standard error [SE]) or before 3 PM (42.2% ± 0.25% SE). For every year, the median hour of patient discharge was 3 PM. Only 9 of the 202 hospitals (4.5%) reliably achieved a morning weekday discharge rate ≥ 20.0%. Only 19 hospitals (9.4%) in the state reliably achieved a ≥ 50.0% weekday discharge rate before 3 PM. Hospital administrators seeking to achieve earlier patient discharges can use our provided data as realistic benchmarks to guide efforts. Alternatively, administrators could plan based on a model that beds will not be reliably available for new patients until late in the afternoon and apply other well-developed operational strategies to address bottlenecks affecting the internal transfer of patients within the hospital.

Reducing the length of clinic visits: A process analysis case report

Because the University of Houston Student Health Center often had more demand for services than available appointments, the aim of this study was to streamline their clinic visit process. While appointments were scheduled for 20 minutes, the clinic's patient visit cycle time (from check-in to check-out) averaged 70 minutes. This report demonstrats how to perform process analysis using failure modes and effects analysis in order to identify the highest priority cause of waste and how to conduct a detailed evaluation of ideas using a prioritization matrix in order to select the best solution to help streamline a process. Analysis of this clinic's visit process identified that patients (mostly international students) asking many questions during their appointment regarding issues not directly related to their care led to long clinic visits. To address this issue, the clinic recruited a team of international students to create a frequently asked questions video with answers, and the final video was then uploaded to the clinic's Facebook page. Comparing before and after the video was posted showed the clinic's average time for a clinic visit was reduced by more than 15%, and it was able to accommodate nearly 100 additional patient visits per month.