Impact Of Process Improvement Research Articles

How to assess the impact of process improvement interventions with routinely collected longitudinal hospital data

Objective: To show how interrupted time series can be used to isolate and measure the impact of process improvement while accounting for confounders often present in complex hospital operations. Methods: Retrospective cohort study comparing the volume of operating room exit delays (OR holds) 52 weeks before and 62 weeks after implementation of a surgical patient throughput optimization program at a tertiary academic hospital. Time-stamped electronic medical records data were collected and analyzed using interrupted time-series design. Segmented regression and Box-Jenkins time series analysis were used to measure OR hold volume pre- and post-implementation, controlling for secular trends in surgical volume, downstream capacity, and the loss of high-volume surgeons. Results: A total of 8,983 surgical patients were discharged during the pre-intervention period and 9,855 during the post-intervention period. The median weekly discharge volume pre-intervention was 175 (interquartile range [IQR] 164–180), and the median bed occupancy was 86% (IQR 84.6–88.1%). The median weekly discharge volume post-intervention was 163 (IQR 150.5–169.8), and the median bed occupancy was 82.1% (IQR 78.9–84.7%). Post-intervention, there was an immediate 60% (95% confidence interval, 54–70%) reduction in the number of OR holds that was sustained over the 14-month post-intervention period.

Quality Improvement Initiatives in Colorectal Surgery: Value of Physician Feedback

The impact of process improvement through surgeon feedback on outcomes is unclear. We sought to evaluate the effect of biannual surgeon-specific feedback on outcomes and adherence to departmental and Surgical Care Improvement Project process measures on colorectal surgery outcomes. This was a retrospective analysis of prospectively collected 100% capture surgical quality improvement data. This study was conducted at the department of colorectal surgery at a tertiary care teaching hospital from January 2008 through December 2013. Each surgeon was provided with biannual feedback on process adherence and surgeon-specific outcomes of urinary tract infection, deep vein thrombosis, surgical site infection, anastomotic leak, 30-day readmission, reoperation, and mortality. We recorded adherence to Surgical Care Improvement Project process measures and departmentally implemented measures (ie, anastomotic leak testing) as well as surgeon-specific outcomes. We abstracted 7975 operations. There was no difference in demographics, laparoscopy, or blood loss. Adherence to catheter removal increased from 73% to 100% (p < 0.0001), whereas urinary tract infection decreased 52% (p < 0.01). Adherence to thromboprophylaxis administration remained unchanged as did the deep vein thrombosis rate (p = not significant). Adherence to preoperative antibiotic administration increased from 72% to 100% (p < 0.0001), whereas surgical site infection did not change (7.6%-6.6%; p = 0.3). There were 2589 operative encounters with anastomoses. For right-sided anastomoses, the proportion of handsewn anastomoses declined from 19% to 1.5% (p < 0.001). For left-sided anastomoses, without diversion, anastomotic leak testing adherence increased from 88% to 95% (p < 0.01). Overall leak rate decreased from 5.2% to 2.9% (p < 0.05). Concurrent process changes make isolation of the impact from individual process improvement changes challenging. Nearly complete adherence to process measures for deep vein thrombosis and surgical site infection did not lead to measureable outcomes improvement. Process measure adherence was associated with decreased rate of anastomotic leak and urinary tract infection. Biannual surgeon-specific feedback of outcomes was associated with improved process measure adherence and improvement in surgical quality.

PL003: Impact of process improvements on measures of emergency department efficiency

Introduction: The objective was to study the operational impact of an intervention comprised of simultaneous process improvements to triage, patient inflow, and physician scheduling patterns on emergency department (ED) patient flow. The intervention did not require any increase in ED resources or expenditures. Methods: A 36-month pre-/post-intervention retrospective chart review at an urban community emergency department from January 2010 to December 2012. The ED process improvements started on June 6, 2011 and involved streamlining triage, parallel processing, flexible nurse-patient ratios, flexible exam spaces, and flexible physician scheduling. The main outcomes were ED length-of-stay (LOS). Secondary outcomes included time to physician-initial-assessment (PIA), left-without-being-seen (LWBS) rates, and left-against-medical-advice (LAMA) rates. Segmented regression of interrupted time series analysis was performed on Canadian Triage and Acuity Scale (CTAS) 2 to 5 patients to quantify the immediate impact of the intervention on the outcome levels, and whether there were changes in the trend between pre-intervention and post-intervention segments. Results: 251,899 patients attended the ED during the study period. Daily patient volumes increased 17.3% during the post-intervention period. Post-intervention, for CTAS 2-5 patients, there was a reduction in average LOS by 0.64 hours (p&lt;0.001), and 90th-percentile LOS by 0.81 hours (p=0.024). When separated by acuity and disposition, there were reductions in LOS for non-admitted CTAS 2 (-0.58 hours, p &lt;0.001), 3 (-0.75 hours, p &lt;0.001), 4 (-0.32 hours, p=0.002), and 5 (-0.28 hours, p=0.008) patients. For secondary outcomes, there was a decrease in overall average PIA by 43.81 minutes (p&lt;0.001), and 90th-percentile PIA by 91.39 minutes (p&lt;0.001). LWBS and LAMA rates decreased by 35.2% (p&lt;0.001) and 61.9% (p&lt;0.001), respectively. Conclusion: A series of process improvements meant to optimize flow in the ED without the addition of resources was associated with clinically significant reductions in LOS, PIA, LWBS and LAMA rates for non-resuscitative patients.

Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care

BackgroundMost strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. ObjectivesTo compare the impact of ED expansion vs. patient flow improvement and the establishment of a rapid assessment unit (RAU) on the patient experience of care in a medium-size safety net ED. MethodsThis paper describes a study of a single ED wherein the department first undertook a physical expansion (2006 Q2 to 2007 Q2) followed by a reorganization of patient flow and establishment of an RAU (2009 Q2) by the use of an interrupted time series analysis. ResultsIn the time period after ED expansion, significant negative trends were observed: decreasing Press Ganey percentiles (−4.1 percentile per quarter), increasing door-to-provider time (+4.9 minutes per quarter), increasing duration of stay (+13.2 minutes per quarter), and increasing percent of patients leaving without being seen (+0.11 per quarter). After the RAU was established, significant immediate impacts were observed for door-to-provider time (−25.8 minutes) and total duration of stay (−66.8 minutes). The trends for these indicators further suggested the improvements continued to be significant over time. Furthermore, the negative trends for the Press Ganey outcomes observed after ED expansion were significantly reversed and in the positive direction after the RAU. ConclusionsOur results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.

Process management, innovation and efficiency performance

Purpose – Much of the practitioner literature touts the universal benefits of process management and its impact on operational performance. However, in academic literature, empirical evidence is mixed. The purpose of this study is to investigate the role of the competitive intensity on the effectiveness of process management. Design/methodology/approach – Survey data from manufacturing plants were collected from through a global research project. Regression analysis was used to test hypotheses. Findings – The influence of process design on efficiency and innovation performance is not dependent on competitive intensity; however, the impact of process improvement and process control on efficiency and innovation performance is in some instances moderated by competitive intensity. Research limitations/implications – The inclusion of competitive intensity as a contingency variable helps to explain the contextual impact of process management on efficiency and innovation. Practical implications – Process management can be an effective tool if the levels of process design, control, and improvement are customized to fit with the competitive environment. Originality/value – This is one of the few studies to empirically examine process management as three core elements. Previous studies utilized a single construct of process management or multiple manufacturing practices such as customer/supplier involvement, statistical quality control, process focus, and cross-functional teams to measure process management. Using this measurement approach demonstrates how process management can influence both efficiency and innovation.

Cost analysis of information technology‐assisted quality inspection using activity‐based costing

One of the critical factors in quality control is the efficient management of quality field inspections. A method was developed to assess the cost impact of process improvements in construction jobsite management. Through the development of a prototype quality inspection system together with project database and mobile technology, the efficiency of a quality inspection system as a pilot study is examined. A time‐driven activity‐based costing (ABC) is used in evaluating the quantifying process costs attributable to the implementation of a new field inspection system. Inspection costs were reduced when the current inspection process is replaced by a new inspection prototype process using a project database and mobile technology. The cost analysis results also show that a new approach (1) identifies the inspection activities before and after the re‐engineering process; (2) computes the cost driver rate before and after the re‐engineering process; and (3) enables the performance of the scenario analysis by manipulating the volume of cost drivers under different scenarios.

Impact of Process Improvements on Reliability of RCP Technology During Scale-up

The start-up of the 300mm RCP prototype production line using automated tools was challenged by significant differences in tool sets when compared to the manual and semi-automatic lab based equipment used to develop the baseline RCP fabrication process. Thus, process transfer to automated tools required key parameter adjustments in an attempt to match the process output and reliability performance previously achieved with the 200mm lab based flow. During reliability testing of early parts from the 300mm prototype line, failures in the build-up layers were observed after thermal cycling test. The failure mechanisms were previously observed and resolved during the technology development phase using the 200mm lab based tools. An experiment was developed to identify the root cause of the build-up failures. A single die, 9x9mm, 258 I/O, 0.5mm pitch package with 2 metal routing layers was chosen as a test vehicle for the experiment. Moisture preconditioning and air to air thermal cycling at 2 different conditions followed by electrical test and visual inspection for dielectric cracks were used to gage reliability performance. Several factors were evaluated related to the dielectric and metallization processes as well as the backend interconnect process. The results from the experiment indicated the appropriate tool parameters that allowed the 300mm prototype line process output to closely match that of the 200mm lab based tools. The optimized process combined with the use of an alternate solder material allowed the 300mm RCP prototype line to successfully achieve line certification status and demonstrated RCP reliability performance beyond standards.

Nurse Manager Perceptions of the Impact of Process Improvements by Nurses

Approaches in assessment of process improvements by nurses are a timely issue, given a growing focus on changes in care delivery. Nineteen semistructured phone interviews with nurse managers whose units participated in a process improvement intervention were completed. The most prominent among assessment strategies was observation. Other strategies included quantitative data measurement, informal and formal feedback, and auditing processes. Understanding how nurses are evaluating interventions may contribute to improved measurement in the future.

Generalized Confidence Intervals for Comparing the Capability of Two Processes

The issue of selecting suppliers or assessing the impact of process improvement has already been investigated based on several process capability indices. However, the statistical test for comparing the capability of two suppliers or processes based on the C pmk index has not been developed due to the complexity of the sampling distribution. In this article, we apply the concept of generalized pivotal quantities to derive the generalized confidence intervals (GCI) for the capability ratio and the capability difference between two given suppliers or processes. A simulation study is conducted to investigate the performance of the proposed methods and compare them with the coverage rates and the average width of confidence intervals. The numerical results indicate that the GCI method on the ratio is quite satisfactory for comparing the capability of two suppliers or processes since the attained coverage rates of the confidence interval are very close to the nominal confidence level.

An approach for relating total performance improvement with financial results

For decades, top and middle managers have been conditioned to evaluate performance mainly with financial indicators. However, for a business to survive and succeed in today's complex and uncertain environment, it is imperative to monitor performance on the basis of measures that relate to quality, response time to market changes and productivity. Such indicators are the 'vital signs' that determine competitiveness, because they reflect the effectiveness of efforts to improve the performance of business processes through total quality management or other approaches. Today, we have no methods to relate improvements in business processes to economic results. This paper proposes such an approach, to assist management in evaluating more reliably the impact of process improvements that lead to greater customer satisfaction on economic results.