Impact of hospital-wide process redesign on clinical outcomes: a comparative study of internally versus externally led intervention

A case-based methodology for lean implementation in hospital operations

PURPOSE

Although there are general methodologies for lean implementation in manufacturing companies, a specific methodology for the implementation of lean healthcare in hospitals has not been addressed by the literature. Addressing this gap, the purpose of this paper is to develop a practice-driven methodology for implementing lean in hospital operations.

DESIGN/METHODOLOGY/APPROACH

Three case studies were conducted to collect evidence on the lean implementation process in Brazilian hospitals. From empirical evidence and literature, the implementation methodology was proposed and submitted to critical assessment by experts from the field.

FINDINGS

The process of lean implementation was very similar in all cases, triggered by strategic planning and operationalized by continuous improvement projects. On the other hand, in all cases, the lean implementation teams had to deal with employees' resistance. These findings were valuable inputs to the development of the implementation methodology. After refinement, it was proposed a feasible, useful and user-friendly methodology.

RESEARCH LIMITATIONS/IMPLICATIONS

The proposed methodology was raised from the practice through case study research. However, the proposed methodology was not fully applied, and the associated performance measures were not elaborated in this paper. Therefore, more case studies and applications will be necessary to generalize the findings.

PRACTICAL IMPLICATIONS

The methodology provides practical guidelines that support lean implementation in hospital operations. Although it demands adaptations for each specific hospital setting, this initial step may encourage hospital managers to start the lean journey.

ORIGINALITY/VALUE

This study addressed the gap in the literature regarding the lack of methodologies for implementing lean healthcare in hospital operations. The methodology synthesizes the knowledge, principles and tools of lean thinking that can be applied in hospital operations.

Exit block in emergency departments: a rapid evidence review

BACKGROUND

Exit block (or access block) occurs when 'patients in the ED requiring inpatient care are unable to gain access to appropriate hospital beds within a reasonable time frame'. Exit block is an increasing challenge for Emergency Departments (EDs) worldwide and has been recognised as a major factor in leading to departmental crowding. This paper aims to identify empirical evidence, highlighting causes, effects and strategies to limit exit block.

METHODS

A computerised literature search was conducted of English language empirical evidence published between 2008 and 2014 using a combination of terms relating to exit block in ED.

RESULTS

233 references were identified following the computerised search. Of these, 32 empirical articles of varying scientific quality were identified as relevant and results were presented under a number of headings. The majority of studies presented data relating to the impact of exit block on departments, patients and staff. A smaller number of articles evaluated interventions designed to reduce exit block. Evidence suggests that exit block is more likely to occur in more densely populated areas and less likely to occur in paediatric settings. Bed occupancy appears to be associated with exit block. Evidence supporting the impact of initiatives pointed towards increasing workforce and inpatient bed resources within the hospital setting to reduce block.

CONCLUSIONS

Further evidence is needed, especially within the NHS setting to increase the understanding around factors that cause exit block, and interventions that are shown to relieve it without compromising patient outcomes.

Evaluating the impact of the reconfiguration of gynaecology services at a University Hospital NHS trust in the United Kingdom

BACKGROUND

The project aim was to investigate the impact of reconfiguring gynaecology services on the key performance indicators of a University Hospital NHS Trust in the UK. The reconfiguration involved the centralisation of elective gynaecology on one hospital site and emergency gynaecology on the other.

METHODS

Data measuring outcomes of the Trust's performance indicators (clinical outcomes, patient experience, staff satisfaction, teaching/training, research/development and value for money) were collected. Two time periods, 12 months before and after the reconfiguration in March 2011, were compared for all outcome measures except patient experience. Retrospective data from the hospitals audit department on clinical activity/outcomes and emergency gynaecology patient's feedback questionnaires were analysed. Staff satisfaction, teaching/training and research/development were measured through an online survey of gynaecology consultants.

RESULTS

Post reconfiguration, the total number of admissions reduced by 6% (6,867 vs 6,446). There was a 14% increase in elective theatre sessions available (902.29 vs 1030.57) and an 84% increase in elective theatre sessions cancelled (44.43 vs 81.71). However, the average number of elective operations performed during each theatre session remained similar (2.63 vs 2.5). There was a significant increase in medical devices related clinical incidents (2 vs 11). With patient experience, there was a significant reduction in patient's overall length of stay on the emergency gynaecology ward and waiting times for investigations. For staff satisfaction, Consultants were significantly more dissatisfied with workload (3.45 vs 2.85) and standards of care (3.75 vs 2.93). With research and development, consultants remained dissatisfied with time/funding/opportunities for research. No significant impact on undergraduate/postgraduate teaching was found. No financial data on gynaecology was provided for the assessment of value for money.

CONCLUSIONS

Reconfiguration of gynaecology services at this Trust may have resulted in a reduction in gynaecological activity and increased cancellation of elective operations but did not significantly reduce the number of elective operations performed. Although consultants expressed increased dissatisfaction with standards of clinical care, clinical incident reports did not significantly increase apart from medical devices incidents. Patient experience of emergency gynaecology services was improved. This manuscript provides a framework for similar exercises evaluating the impact of service redesign in the NHS.

Implementation of an acute surgical admission ward

Background

The aim of the study was to assess the impact of an acute surgical admission ward on admission and discharge processes.

Methods

This prospective cohort study was conducted in a university tertiary referral centre. All acute surgical patients were clustered in the acute surgical unit (ASU) in February and March 2012, and discharged or transferred to specialized departments within 48 h. The primary outcome was length of hospital stay (LOS). Secondary outcomes were impact on emergency department waiting times, discharge home within 48 h, incorrect ward admissions, readmissions and mortality. Outcomes of the study group were compared with those of a historical reference group admitted during the same interval the year before.

Results

Some 249 patients were admitted to the ASU during the study interval. The reference group consisted of 211 patients. The total LOS decreased significantly from a median of 4·0 to 2·0 days (P = 0·004). The percentage of patients who were discharged within 48 h increased from 30·3 to 43·4 per cent (P = 0·004). The rate of incorrect ward admission decreased from 9·5 to 0 per cent. Emergency department waiting time, readmission rate and 30-day mortality did not change.

Conclusion

Introduction of an acute surgical unit-shortened length of hospital stay without comprising readmission and mortality rates.

Ten clinician-driven strategies for maximising value of Australian health care

OBJECTIVE

To articulate the concept of high-value care (i.e. clinically relevant, patient-important benefit at lowest possible cost) and suggest strategies by which clinicians can promote such care in rendering the Australian healthcare system more affordable and sustainable.

METHODS

Strategies were developed by the author based on personal experience in clinical practice, evidence-based medicine and quality improvement. Relevant literature was reviewed in retrieving studies supporting each strategy.

RESULTS

Ten strategies were developed: (1) minimise errors in diagnosis; (2) discontinue low- or no-value practices that provide little benefit or cause harm; (3) defer the use of unproven interventions; (4) select care options according to comparative cost-effectiveness; (5) target clinical interventions to those who derive greatest benefit; (6) adopt a more conservative approach nearing the end of life; (7) actively involve patients in shared decision making and self-management; (8) minimise day-to-day operational waste; (9) convert healthcare institutions into rapidly learning organisations; and (10) advocate for integrated patient care across all clinical settings.

CONCLUSIONS

Clinicians and their professional organisations, in partnership with managers, can implement strategies capable of maximising value and sustainability of health care in Australia. What is known about this topic? Value-based care has emerged as a unitary concept that integrates quality and cost, and is being increasingly used to inform healthcare policy making and reform. What does this paper add? There is scant literature that translates the concept of high value care into actionable enhancement strategies for clinicians in everyday practice settings. This article provides 10 strategies with supporting studies in an attempt to fill this gap. What are the implications for practitioners? If all practitioners, in partnership with healthcare managers, attempted to enact all 10 strategies in their workplaces, a significant quantum of healthcare resources could be redirected from low- to high-value care, culminating in much greater health benefit from the healthcare dollars currently being spent. However, such reforms will require a shift in clinician thinking and practice away from volume-based care to value-based care.