Features and Results of Conducted Studies Using a Lean Management Approach in Emergency Department in Hospital: A Systematic Review

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.

Decision-maker roles in healthcare quality improvement projects: a scoping review

OBJECTIVES

Evidence suggests that healthcare quality improvement (QI) projects are more successful when decision-makers are involved in the process. However, guidance regarding the engagement of decision-makers in QI projects is lacking. We conducted a scoping review to identify QI projects involving decision-makers published in the literature and to describe the roles decision-makers played.

METHODS

Following the Joanna Briggs Institute framework for scoping reviews, we systematically searched for all types of studies in English or French between 2002 and 2023 in: EMBASE, MEDLINE via PubMed, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature. Criteria for inclusion consisted of literature describing health sector QI projects that involved local, regional or system-level decision-makers. Descriptive analysis was performed. Drawing on QI and participatory research literature, the research team developed an inductive data extraction grid to provide a portrait of QI project characteristics, decision-makers' contributions, and advantages and challenges associated with their involvement.

RESULTS

After screening and review, we retained 29 references. 18 references described multi-site projects and 11 were conducted in single sites. Local decision-makers' contributions were documented in 27 of the 29 references and regional decision-makers' contributions were documented in 12. Local decision-makers were more often active participants in QI processes, contributing toward planning, implementation, change management and capacity building. Regional decision-makers more often served as initiators and supporters of QI projects, contributing toward strategic planning, recruitment, delegation, coordination of local teams, as well as assessment and capacity building. Advantages of decision-maker involvement described in the retained references include mutual learning, frontline staff buy-in, accountability, resource allocation, effective leadership and improved implementation feasibility. Considerations regarding their involvement included time constraints, variable supervisory expertise, issues concerning centralised leadership, relationship strengthening among stakeholders, and strategic alignment of frontline staff and managerial priorities CONCLUSIONS: This scoping review provides important insights into the various roles played by decision-makers, the benefits and challenges associated with their involvement, and identifies opportunities for strengthening their engagement. The results of this review highlight the need for practical collaboration and communication strategies that foster partnership between frontline staff and decision-makers at all levels.

Indicadores de cuidado de enfermería hospitalario orientados por modelo de práctica profesional

Objetivo Diseñar y validar indicadores de cuidado de enfermería a partir de la orientación de un modelo de práctica profesional en un hospital universitario de Colombia, 2018 – 2021. Material y Método: Esta es una “Investigación metodológica en enfermería” desarrollada por fases: 1) revisión de los procesos de calidad institucional. 2) revisión de literatura sobre indicadores hospitalarios de enfermería. 3) propuesta de indicadores con orientación del modelo institucional de práctica profesional de enfermería 4) validación de los indicadores mediante criterio de expertos y 5) evaluación de la efectividad preliminar en campo durante 8 meses. Resultados: Los 21 indicadores de cuidado de enfermería propuestos presentaron alta comprensibilidad y validez facial, una razón de validez de contenido (RVC) entre .74 y .96, y un índice de validez de contenido (IVC) de 0.83. Conclusión: Los indicadores de cuidado de enfermería diseñados bajo la orientación de un modelo de práctica profesional y validados mediante el criterio de expertos, mostraron una efectividad preliminar positiva para medir y mejorar los procesos y resultado del cuidado de enfermería de acuerdo con las personas implicadas en la recepción y suministro de dicho cuidado.  Estos indicadores pueden ser empleados en hospitales con plataformas estratégicas similares.

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.

Road to Better Work-Life Balance? Lean Redesigns and Daily Work Time among Primary Care Physicians

PURPOSE

To assess the impact of Lean primary care redesigns on the amount of time that physicians spent working each day.

METHODS

This observational study was based on 92 million time-stamped Epic® EHR access logs captured among 317 primary care physicians in a large ambulatory care delivery system. Seventeen clinic facilities housing 46 primary care departments were included for study. We conducted interrupted time series analysis to monitor changes in physician work patterns over 6 years. Key measures included total daily work time; time spent on "desktop medicine" outside the exam room; time spent with patients during office visits; time still working after clinic, i.e., after seeing the last patient each day; and remote work time.

RESULTS

The amount of time that physicians spent on desktop EHR activities throughout the day, including after clinic hours, decreased by 10.9% (95% CI: -22.2, -2.03) and 8.3% (95% CI: -13.8, -2.12), respectively, during the first year of Lean implementation. Total daily work hours among physicians, which included both desktop activity and time in office visits, decreased by 20% (95% CI: -29.2, -9.60) by the third year of Lean implementation.

CONCLUSIONS

These findings suggest that Lean redesign may be associated with time savings for primary care physicians. However, since this was an observational analysis, further study is warranted (e.g., randomized trial) -to determine the impact of Lean interventions on physician work experiences.

Lean six sigma in the healthcare sector: A systematic literature review

Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.

A framework to guide the implementation of lean management in emergency department

PURPOSE

The paper aims at enriching the knowledge of the application of lean management (LM) in emergency department (ED), structuring the methodology for implementing LM projects and summarizing the relevant dimensions of LM adoption in ED.

DESIGN/METHODOLOGY/APPROACH

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, a systematic literature review has been performed, extracting a database of 34 papers. To answer the research purpose, a descriptive and content analyses have been carried out.

FINDINGS

The descriptive analysis demonstrates that the dealt topic is worldwide emerging and multidisciplinary as it arouses interest by medical and engineering communities. Despite the heterogeneity in the adopted methodology, a framework can be grasped from the literature review. It points out the phases and activities, the tools and techniques and the enablers to be considered for guiding the developing of LM project in ED.

ORIGINALITY/VALUE

This paper provides a comprehensive overview on how to adopt LM in ED, contributing to fill in the gap emerged in the literature. From a practical perspective, this paper provides healthcare managers with a synthesis of the best managerial practices and guidelines in developing a LM project in ED.

Aligning implementation science with improvement practice: a call to action

Background

In several recent articles, authors have called for aligning the fields of implementation and improvement science. In this paper, we call for implementation science to also align with improvement practice. Multiple implementation scholars have highlighted the importance of designing implementation strategies to fit the existing culture, infrastructure, and practice of a healthcare system. Worldwide, healthcare systems are adopting improvement models as their primary approach to improving healthcare delivery and outcomes. The prevalence of improvement models raises the question of how implementation scientists might best align their efforts with healthcare systems’ existing improvement infrastructure and practice.

Main body

We describe three challenges and five benefits to aligning implementation science and improvement practice. Challenges include (1) use of different models, terminology, and methods, (2) a focus on generalizable versus local knowledge, and (3) limited evidence in support of the effectiveness of improvement tools and methods. We contend that implementation science needs to move beyond these challenges and work toward greater alignment with improvement practice. Aligning with improvement practice would benefit implementation science by (1) strengthening research/practice partnerships, (2) fostering local ownership of implementation, (3) generating practice-based evidence, (4) developing context-specific implementation strategies, and (5) building practice-level capacity to implement interventions and improve care. Each of these potential benefits is illustrated in a case study from the Centers for Disease Control and Prevention’s Cancer Prevention and Control Research Network.

Conclusion

To effectively integrate evidence-based interventions into routine practice, implementation scientists need to align their efforts with the improvement culture and practice that is driving change within healthcare systems worldwide. This paper provides concrete examples of how researchers have aligned implementation science with improvement practice across five implementation projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00201-1.

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.

Lean Six Sigma methodology application in health care settings: an integrative review

OBJECTIVE

to analyze the scientific production on the results of Lean Six Sigma methodology in health care institutions.

METHODS

an integrative literature review, with the following question: what are the results in health institutions using Lean Six Sigma and Six Sigma methodology? The search was carried out at MEDLINE, LILACS, BDENF, CINAHL, Web of Science, and Scopus, with no time frame.

RESULTS

thirty-four articles were included, published between 2005 and 2019, of which 52.9% came from the United States of America. The most commonly found improvements were in hospital institutions and from the perspective of customers and internal processes.

CONCLUSION

using Lean Six Sigma methodology proved to be effective in the different health care settings, evidencing a gap in its application regarding people engagement and training.

Efficiency and Teamwork in Emergency Departments: Perception of Staff on Design Interventions

OBJECTIVES

The goal of this study is twofold: (1) identifying design strategies that enhance efficiency and support teamwork in emergency departments (EDs) and (2) identifying design features that contribute to the spread of COVID-19, based on staff perception.

BACKGROUND

Due to increasing ED visits annually, an efficient work environment has become one of the main concerns in designing EDs. According to the literature, an efficient work environment and teamwork improve healthcare outcomes and positively impact staff satisfaction. During the COVID-19 pandemic, EDs faced various changes such as workflow and space usage. Few studies explored staff perceptions about the influence of design features on efficiency, teamwork, and the COVID-19 spread.

METHOD

An online survey with 14 open- and closed-ended questions was distributed among ED staff members to collect data about unit design features that impact efficiency, teamwork, and the COVID-19 spread.

RESULTS

The central nursing station was one of the preferred configurations that increased efficiency and teamwork in EDs. Decentralizing disposal rooms in small-size EDs and decentralizing the medication room in large-size EDs with more than 65 exam rooms can decrease staff walking steps. Flexibility to expand treatment spaces on demand, one-way track circulation path, and changing the air pressure in COVID-19 treatment areas were some of the staff suggestions for future EDs.

CONCLUSION

The findings of this study contribute to the body of knowledge that EDs' physical environments can impact efficiency and teamwork among staff and, consequently, healthcare outcomes. Compartmentalization of the ED layout can reduce the spread of COVID-19.

Healthcare Engineering: A Lean Management Approach

This work tries to answer the following question: can healthcare be engineered using lean management tools? Lean is known to achieve successful results when implemented in the manufacturing sector. Typical results are operational cost reduction, cycle time reduction, and higher customer satisfaction. The service sector, however, has seen mixed results. For the last two decades, educators and healthcare professionals are trying to implement lean tools in healthcare. Some reported success and many did not, for variety of reasons. In this paper, we search the literature and reveal the special nature of healthcare services, success factors, and barriers facing implementation of lean in healthcare. We then conduct a survey of 18 elite Jordanian hospitals to study the case holistically. Statistical analysis of the survey results confirmed some of what the literature revealed; organizational leadership seems to be the most dominant factor, followed by knowledge of employees about lean, training, and patient satisfaction (customer focus). Another important finding, not captured by the literature, is that lean implementation success depends on educating physicians about continuous improvement and lean and ensuring they are part of the improvement team. Based on the revealed enablers and obstacles, we created a full lean implementation framework. This framework was then used along with selected engineering tools to implement lean in a major hospital successfully. Implementation results showed 60% of reduction in cycle time, 80% reduction in operational cost, and many other benefits.

Strategies to measure and improve emergency department performance: a scoping review

Background

Over the last two decades, Emergency Department (ED) crowding has become an increasingly common occurrence worldwide. Crowding is a complex and challenging issue that affects EDs’ capacity to provide safe, timely and quality care. This review aims to map the research evidence provided by reviews to improve ED performance.

Methods and findings

We performed a scoping review, searching Cochrane Database of Systematic Reviews, Scopus, EMBASE, CINAHL and PubMed (from inception to July 9, 2019; prospectively registered in Open Science Framework https://osf.io/gkq4t/). Eligibility criteria were: (1) review of primary research studies, published in English; (2) discusses a) how performance is measured in the ED, b) interventions used to improve ED performance and their characteristics, c) the role(s) of patients in improving ED performance, and d) the outcomes attributed to interventions used to improve ED performance; (3) focuses on a hospital ED context in any country or healthcare system. Pairs of reviewers independently screened studies’ titles, abstracts, and full-texts for inclusion according to pre-established criteria. Discrepancies were resolved via discussion. Independent reviewers extracted data using a tool specifically designed for the review. Pairs of independent reviewers explored the quality of included reviews using the Risk of Bias in Systematic Reviews tool. Narrative synthesis was performed on the 77 included reviews. Three reviews identified 202 individual indicators of ED performance. Seventy-four reviews reported 38 different interventions to improve ED performance: 27 interventions describing changes to practice and process (e.g., triage, care transitions, technology), and a further nine interventions describing changes to team composition (e.g., advanced nursing roles, scribes, pharmacy). Two reviews reported on two interventions addressing the role of patients in ED performance, supporting patients’ decisions and providing education. The outcomes attributed to interventions used to improve ED performance were categorised into five key domains: time, proportion, process, cost, and clinical outcomes. Few interventions reported outcomes across all five outcome domains.

Conclusions

ED performance measurement is complex, involving automated information technology mechanisms and manual data collection, reflecting the multifaceted nature of ED care. Interventions to improve ED performance address a broad range of ED processes and disciplines.

Wanted in health care: Lean experts with a broad perspective

AIM

To reflect on Lean experts' perspective on components of Lean management in health care and its implications for practice.

BACKGROUND

The involvement of Lean experts is one of the key succes factors of a sustainable Lean transformation in health care.

METHODS

Thirteen Lean experts participated in two focus groups. They all had experience in the implementation of Lean in healthcare organizations.

RESULTS

Lean experts all seem to have a unique perspective on Lean management in health care. Experts without a healthcare degree appear to focus more on the entire management system, where experts with a nursing degree seem to concentrate more on the soft Lean principles.

CONCLUSION

It seems plausible their professional background appears to have an influence.

IMPLICATIONS FOR NURSING MANAGEMENT

In selecting a Lean expert, nurse managers may want to gauge what elements the Lean expert tends to emphasize. It seems plausible to opt for a Lean expert without a healthcare degree to accomplish the Lean transformation as they have a broader view on Lean. It may also be useful for managers to involve several Lean experts, all with complementary perspectives and backgrounds.