Healthcare Process Improvement Research Articles

Program evaluation and healthcare process improvement focused on complex wheelchair procurement

ABSTRACT The operations of a specialty wheelchair (WC) seating center can influence the evaluation to delivery timeframe in days for a complex rehab technology (CRT) WC. Operations at one facility improved due to departmental process improvement (PI) project with evaluation of the delivery workflow and implementation of changes. A retrospective chart audit gathered baseline data on the evaluation to delivery timeframe in days of a CRT WC for 50 individuals prior to PI changes. Standard departmental workflow collected 745 individuals’ post-PI changes. The interventions took place from March 25, 2017, to April 5, 2018, and included defining and educating stakeholders on their roles and expectations, revisions of the electronic medical record, weekly and quarterly meetings with supplier leadership, paperwork completion goals, and follow-up paperwork centralization. Mean pre- and post-intervention evaluation to delivery timeframes in days was significantly different (162.2 versus 127.4 days, p < 0.0001). Overall, a reduction in the mean evaluation to delivery timeframe in days of CRT WC by 21.5% or 34.8 days occurred. Systematic change takes time as well as the commitment of all key players. PI changes resulted in evaluation to delivery timeframe reduction for patients to receive their CRT WCs.

Lean-Based Approach to Improve Emergency Department Throughput.

Objective:Lean methodology can be utilized to increase throughput in a fast-track care area without changing staffing in a busy, urban emergency department (ED). Methods: A retrospective before-and-after analysis was performed to an improvement process in a fast-track care area within an ED with a census of 100,000 patients. The intervention utilized Lean methodologies to identify inefficiencies in the throughput model set for patients triaged to fast-track. Multiple ED stakeholders were involved in formulating a more efficient framework for how patients would receive care when triaged to fast-track. Results: There was a decline in the patient's overall length of stay (-9%, p=0.08), arrival to the room (-10%, p=0.4418), and ED attending to disposition (-9%, p=0.003). Additionally, all aspects of patients leaving prior to treatment completion (against medical advice (-29.4%, p=0.006), elopement (-20.4%, p=0.049), and left without being seen (-5.3%, p=0.11)) declined. Discussion:Identifying wasted time and resources in a patient's stay in the ED allowed for a more efficient throughput model to be developed. This resulted in patients being able to be seen in a more methodical manner leading to decreased wait times and lower left without being seen rates. Conclusion: A Lean-based throughput model was implemented to improve efficiency, reducing the length of stay and increasing the volume of patients evaluated per shift without additional costs. This improvement led to fewer patients leaving before treatment and demonstrated the value of process improvement in healthcare.

How to Sustain Healthcare Process Improvement in Heterogenous Teams? Evidence from a Systems Dynamic Model

This research investigates how to sustain process improvement (PI) initiatives in healthcare. Despite the abundant knowledge on PI, we know very little on why and how PI sustains over time. This is particularly true in the context of heterogeneous frontline teams of physicians and nurses with different operational characteristics such as attrition rates, skill sets, training, and goals. Our study builds a model that simulates the mutual, dynamic interaction of these stakeholders with each other and with processes with different characteristics in the presence of endogenous management prioritization. We build confidence in the model by calibrating it to data from PI teams at several family medicine clinics at a large US Midwestern healthcare system. The computational experiments performed using data from these teams yield several important insights for theory and practice. First, we find that process metrics, which are leading metrics related to the day-to-day functioning of the units, and outcome metrics, which are lagging metrics often tied to the unit's bottom line, are both critical for the functioning of the PI teams. Emphasizing one over the other can reduce sustainability while a mixed case in which one group of employees is incentivized to leading and another group to lagging can create a regime that is more effective in many scenarios. Second, we find that management interventions that improve short-term PI gains generally also reduce the likelihood of long-run sustainment. Third, we find that attrition and turnover among the team members affect sustainability of PI initiatives and reducing turnover for one class of employee, which attends lagging metrics, facilitates sustainment while reducing it for the other class, which attends leading metrics, can hinder sustainment. We conclude by discussing these implications to the practice of PI among healthcare teams.

Using process mining algorithms for process improvement in healthcare

Healthcare professionals must provide their patients with the best possible service and be well-informed and expert at carrying out complex surgical procedures to fulfill this responsibility. The aim of the medical treatments is fewer complications, shorter hospital stays, and a better patient experience. Through continuous learning and training, medical practitioners trained in up-to-date and state-of-the-art surgical techniques and technologies make productive and effective healthcare systems possible. Healthcare systems often report on problems with surgical processes, skipped procedures, unusual activities during operations, and lengthy transition times. This event log data allows implementing process mining methods to deliver medical professionals with simple and understandable findings using Petri nets for process analysis and enhancement. This study identifies the parallels and discrepancies between the pre-and post-stages and their respective frequency on each typical Central Venous Catheter (CVC) installation activity. The Process Mining for Python (PM4Py) frameworks used four major mining algorithms to view the event log (i.e., alpha miner, directly-follows graph (DFG), heuristic miner, and inductive miner). This study's findings indicate that medical residents are more susceptible to error during pre-operative procedures.

The application of a person-centred approach to process improvement in ophthalmology services in the North East of the Republic of Ireland

Background: Ophthalmology in the Republic of Ireland has one of the longest waiting lists in healthcare, with around 44,000 people awaiting a first outpatient appointment. In the north-east region, 12,500 people are waiting. The North-Eastern Region Integrated Eye Care Service (NERIECS) was established in 2021 to improve patient care and access to services. A key driver for the team was to understand ‘how we work together’ to enable a shared vision of change within regional services. Aim: To support hospital and community ophthalmology services, which comprise eight organisations in the region, to prepare for the development of system-level integration of eyecare services. Methods: We integrated a popular process-improvement methodology, Lean Six Sigma, with a person-centred approach to support staff to develop a shared vision of change and to deliver improvements for ophthalmology services. Findings: The integrated approach enabled staff to work in ways that supported the development of good quality, person-centred care that takes account of the outcomes for and experiences of ophthalmology patients and their families, and of staff. Conclusions: Our work builds on a recent study that identified coherence in the underlying philosophy, intention, method and outcomes of Lean Six Sigma and person-centred approaches to healthcare improvement, highlighting the added value of an integrated approach in enabling improvement that positively impacts patient outcomes and healthcare culture. Implications for practice: The application of an integrated approach to process improvement in healthcare is shown to be effective beyond a single study site, having a positive impact across geographic and organisational boundaries, and across levels of care (primary, secondary, tertiary and post-acute) The integrated approach puts the focus on synergies between both methodological approaches and avoids improvement work being reduced to the use of a decontextualised toolkit

The Search for an Outcome Variable That Measures Both Quality and Processes in Cardiac Surgery: Comparing the Quality Process Index and Mortality.

The translation of a large quantity of data into valuable insights for daily clinical practice is underexplored. A considerable amount of information is overwhelming, making it difficult to distill and assess quality and processes at the hospital level. This study contributes to this necessary translation by developing a Quality Process Index that summarizes clinical data to measure quality and processes. The Quality Process Index was constructed to enable retrospective analyses of quality and process evolution from 2011 to 2021 for various surgery types in the Amsterdam Cardiosurgical Database (n = 5497). It is presented alongside mortality rates, which are the golden standard for quality measurement. The two outcome variables are compared as quality and process measurement options. Results showed that the mean Quality Process Index appeared rather stable, even though analysis of variance found that the mean Quality Process Index differed significantly over the years (p < 0.001). The 30-day and 120-day mortality rates appeared to fluctuate more, but interestingly, we failed to reject the null hypothesis of equal means. The Quality Process Index and mortality rates were statistically negatively correlated, and the extent of correlation was more pronounced with the 120-day mortality rate, as computed using the Pearson correlation coefficient r (30-day rQPI,30 = -0.07, p < 0.001 and 120-day mortality rates rQPI,120 = -0.12, p < 0.001). The Quality Process Index seeks to address the need to translate data for quality and process improvement in healthcare. While mortality remains the most impactful outcome measure, the Quality Process Index provides a more stable and comprehensive measurement of quality and process improvement or deterioration in healthcare. Therefore, the Quality Process Index as a quantification reinforces the understanding of the definition of quality and process improvement.

Evaluation of remote digital postoperative wound monitoring in routine surgical practice

Remote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. This was a single-arm pilot implementational study of remote digital postoperative wound monitoring across two tertiary care hospitals in the UK (IDEAL stage 2b, clinicaltrials.gov: NCT05069103). Adults undergoing abdominal surgery were recruited and received a smartphone-delivered wound assessment tool for 30-days postoperatively. Patients received 30-day postoperative follow-up, including the Telehealth Usability Questionnaire (TUQ). A thematic mixed-methods approach was used, according to the WHO framework for monitoring and evaluating digital health interventions. 200 patients were enroled, of whom 115 (57.5%) underwent emergency surgical procedures. Overall, the 30-day SSI rate was 16.5% (n = 33/200), with 72.7% (n = 24) diagnosed post-discharge. Usage of the intervention was 83.0% (n = 166/200), with subsequently 74.1% (n = 123/166) TUQ completion. There were no issues reported with feasibility of the technology, with the reliability (3.87, 95% CI: 3.73–4.00) and quality of the interface rated highly (4.18, 95%: 4.06–4.30). Patient acceptance was similarly high with regards to ease of use (4.51, 95% CI: 4.41–4.62), satisfaction (4.27, 95% CI: 4.13–4.41), and usefulness (4.07, 95% CI: 3.92–4.23). Despite the desire for more frequent and personalised interactions, the majority viewed the intervention as providing meaningful benefit over routine postoperative care. Remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.

Managing Through a Pandemic: A Daily Management System for COVID-19 Response and Recovery.

This study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events. We conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency. There were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages. Overall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.

Digital Transformation in Healthcare: Insights on Value Creation

ABSTRACT Current research on digital transformation in the healthcare context is limited, and doesn’t consider the patient’s definition of value, the need to support traditional healthcare process improvement in parallel with new value creation activities, nor does it clearly examine changes that occur in the structure of healthcare organizations due to technologically driven change. This research seeks to address these issues and determine the capabilities that influence the creation of new and existing value propositions and the subsequent structural changes of digital transformation in healthcare by analyzing interviews with 19 American healthcare executives. Results highlight the need for patient-focused modes of value creation necessary to improve care coordination, which is affected by the ability to integrate data and reconfigure processes. End user focused modes compel healthcare organizations to digitize their services, however, this can be hampered by difficulties with change management and enforcing IT governance processes.

Process Improvement in Surgery

Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps. This review contains 10 figures, 3 tables, and 22 references Keywords: Operating room, surgery, surgical leader, multidisciplinary team, waste, project carter, control chart, Pareto table, health care improvement

Process Improvement in Surgery

Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps. This review contains 10 figures, 3 tables, and 22 references Keywords: Operating room, surgery, surgical leader, multidisciplinary team, waste, project carter, control chart, Pareto table, health care improvement

Process Improvement in Surgery

Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps. This review contains 10 figures, 3 tables, and 22 references Keywords: Operating room, surgery, surgical leader, multidisciplinary team, waste, project carter, control chart, Pareto table, health care improvement

Process mining for healthcare: Characteristics and challenges

Process mining techniques can be used to analyse business processes using the data logged during their execution. These techniques are leveraged in a wide range of domains, including healthcare, where it focuses mainly on the analysis of diagnostic, treatment, and organisational processes. Despite the huge amount of data generated in hospitals by staff and machinery involved in healthcare processes, there is no evidence of a systematic uptake of process mining beyond targeted case studies in a research context. When developing and using process mining in healthcare, distinguishing characteristics of healthcare processes such as their variability and patient-centred focus require targeted attention. Against this background, the Process-Oriented Data Science in Healthcare Alliance has been established to propagate the research and application of techniques targeting the data-driven improvement of healthcare processes. This paper, an initiative of the alliance, presents the distinguishing characteristics of the healthcare domain that need to be considered to successfully use process mining, as well as open challenges that need to be addressed by the community in the future.

Implementation for Sustained Impact in Teleophthalmology (I-SITE): applying the NIATx Model for tailored implementation of diabetic retinopathy screening in primary care

BackgroundTeleophthalmology provides evidence-based, telehealth diabetic retinopathy screening that is underused even when readily available in primary care clinics. There is an urgent need to increase teleophthalmology use in the US primary care clinics. In this study, we describe the development of a tailored teleophthalmology implementation program and report outcomes related to primary care provider (PCP) adoption.MethodsWe applied the 5 principles and 10 steps of the NIATx healthcare process improvement model to develop and test I-SITE (Implementation for Sustained Impact in Teleophthalmology) in a rural, the US multi-payer health system. This implementation program allows patients and clinical stakeholders to systematically tailor teleophthalmology implementation to their local context. We aligned I-SITE components and implementation strategies to an updated ERIC (Expert Recommendations for Implementing Change) framework. We compared teleophthalmology adoption between PCPs who did or did not participate in various components of I-SITE. We surveyed PCPs and clinical staff to identify the strategies they believed to have the highest impact on teleophthalmology use.ResultsTo test I-SITE, we initiated a year-long series of 14 meetings with clinical stakeholders (n=22) and met quarterly with patient stakeholders (n=9) in 2017. Clinical and patient stakeholder groups had 90.9% and 88.9% participant retention at 1 year, respectively. The increase in teleophthalmology use was greater among PCPs participating in the I-SITE implementation team than among other PCPs (p < 0.006). The proportion of all PCPs who used the implementation strategy of electing diabetic eye screening for their annual performance-based financial incentive increased from 0% (n=0) at baseline to 56% (n=14) following I-SITE implementation (p = 0.004). PCPs and clinical staff reported the following implementation strategies as having the highest impact on teleophthalmology use: reminders to ask patients about diabetic eye screening during clinic visits, improving electronic health record (EHR) documentation, and patient outreach.ConclusionsWe applied the NIATx Model to develop and test a teleophthalmology implementation program for tailored integration into primary care clinics. The NIATx Model provides a systematic approach to engaging key stakeholders for tailoring implementation of evidence-based telehealth interventions into their local context.

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

PurposeThis 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/approachA qualitative interview approach was utilized by interviewing a panel of leading academics and practitioners who are familiar with operation excellence methodologies.FindingsOperational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.Research limitations/implicationsOne 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 implicationsOperational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.Originality/valueThe 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.

Recommendations for enhancing the usability and understandability of process mining in healthcare.

Healthcare organizations are confronted with challenges including the contention between tightening budgets and increased care needs. In the light of these challenges, they are becoming increasingly aware of the need to improve their processes to ensure quality of care for patients. To identify process improvement opportunities, a thorough process analysis is required, which can be based on real-life process execution data captured by health information systems. Process mining is a research field that focuses on the development of techniques to extract process-related insights from process execution data, providing valuable and previously unknown information to instigate evidence-based process improvement in healthcare. However, despite the potential of process mining, its uptake in healthcare organizations outside case studies in a research context is rather limited. This observation was the starting point for an international brainstorm seminar. Based on the seminar's outcomes and with the ambition to stimulate a more widespread use of process mining in healthcare, this paper formulates recommendations to enhance the usability and understandability of process mining in healthcare. These recommendations are mainly targeted towards process mining researchers and the community to consider when developing a new research agenda for process mining in healthcare. Moreover, a limited number of recommendations are directed towards healthcare organizations and health information systems vendors, when shaping an environment to enable the continuous use of process mining.

Análise dos incidentes relacionados à assistência à saúde no município de Porto Alegre, Rio Grande do Sul, nos anos de 2016 e 2017

Introduction: Health care incidents represent a serious public health problem since they are associated with increased mortality, length of hospitalization and treatment costs. In this context, the continuous monitoring and surveillance of incident occurrence by the health services are important prevention tools. Objective: To describe and evaluate the quality of the incident notification related to healthcare occurred in the city of Porto Alegre, RS, between 2016 and 2017. Method: A descriptive study that proposes to calculate the prevalence of notified incidents and to analyze their variables from secondary data. Results: A total of 1,059 events occurred among the studied years, most of them in hospitals, with mild damage and during healthcare. The most affected age group was the elderly and the most frequent incidents were produced by falls. The most frequent never event were pressure ulcers and the quality of the notification was generally low. Conclusions: It is important risk monitoring and incident notification to be permanent practices in health services and the notified data to be used as a tool for constant improvement of healthcare processes.

Using Business Ontology to Integrate Business Architecture and Business Process Management for Healthcare Modeling

Patient safety and quality of health care services continue to be an issue within healthcare organizations. Quality improvement of healthcare processes at a systems level requires a shared language so the system is well understood across and between business areas. Business ontology provides the ability to create a shared language which can be used to integrate business process management (BPM) and business architecture (BA) concepts to identify, prioritize, and plan system wide improvement. The effective application of this comprehensive management approach has been demonstrated using medication management services within a publicly funded Canadian healthcare organization. This article illustrates how the foundational ontology developed by the Global University Alliance and the related Business Process Management Ontology (BPMO) can be used to facilitate the integration of BA and BPM concepts to improve quality of medication management. The development of business artefacts resulted in a prioritized list of improvement initiatives and an action plan to implement and monitor the initiatives. The integration of BPM and BA using an ontology in a healthcare setting yields improved services at the systems level.

Towards KPI-Based Health Care Process Improvement

In healthcare organizations, decision making is both a crucial and a challenging task. Therefore, it’s necessary to collect all relevant indicators designed for both effective management and process improvement. These indicators need to reflect not only the performance of business process but also the satisfaction of patients toward the ED (emergency department). In this paper, we concentrate on the selection of the relevant performance measures related to health care process and illustrate the usefulness of the retained measures through a real case study in the emergency department of “Farhat Hached” hospital in Sousse (Tunisia). Thus, this work contributes to the improvement of the healthcare process and helps managers to optimize its performance.

Using Six Sigma, Lean, and Simulation to Improve the Phlebotomy Process

Six Sigma, lean, and simulation modeling are all popular methodologies, but they have rarely been used together in healthcare process improvement. This study explores how the three can be integrated together, using a process improvement effort in a large hospital to demonstrate the methodology. The system under study is the phlebotomy process in the emergency department of the St. Catharines Site of the Niagara Health System. The process starts when an order for a blood test is placed, and ends when the specimen arrives at the lab. Research outputs occur at three levels of detail. A structured framework integrating the three research methodologies is developed, which may benefit a variety of future hospital process improvement efforts, and could inform quality improvement efforts in other industries (this is the primary generalizable output from this study). In addition, insights are gained into the phlebotomy process—aspects that may benefit phlebotomy improvement efforts in other hospitals. Also, suggestions are made to reduce the flow time (by an average of seven minutes) of the process at the St. Catharines Site.