Process Improvement Methods Research Articles

Restructuring Care Teams Within a Neonatal Intensive Care Unit

Abstract BACKGROUND: Organizing care teams in a large neonatal intensive care unit (NICU) is a challenge. In our pod-based model, babies were assigned a care team based on acuity and bed location. They were frequently moved between teams to accommodate nursing assignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team. OBJECTIVES: The objective of this project was to improve consistency of patient care and to balance the workload across the three care teams in the NICU. DESIGN/METHODS: The setting is a 69 bed tertiary teaching NICU with approximately 1300 admissions a year. Three clinical teams share day to day assignment of a combination of these level III and level II pods. A multidisciplinary subgroup conducted a two hour Kaizen (brain storming) event with a larger group of stake-holders during which the decision was made to assign babies to a care team based on current workload of each team. The care teams follow each patient from admission to discharge, regardless of the baby’s location within the unit instead of moving babies between teams. Education communication, feedback strategies regarding the process change were formulated and executed by the sub-group. The new method was piloted for a period of three months. Objective data was collected regarding patient movement, patient acuity, census balance, and rounds time. Qualitative data was collected through staff and family surveys. ignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team. RESULTS: Forty percent of babies admitted to the NICU crossed care teams during their stay prior to the process change while 0.3% changed teams after the change. The number of moves per patient decreased from 1.4 to 1.27. The variability in both census and acuity was diminished following implementation of the changes. The daily average number of man-hours to complete daily rounds decreased from 47.5 before the change to 40.5 after the change. There was a 35% response rate to the staff survey with an overall positive response to the changes with regards to improving the patient and family experience. The family satisfaction survey showed a trend toward increased satisfaction following the change. CONCLUSION: Process improvement methods can be used to successfully change how care teams are structured in a tertiary NICU.

Abstract TMP84: Reducing Door to Needle and Door to Reperfusion Times: The Trim Effect

Background and Purpose: One minute of brain ischemia can kill 2 million nerve cells and 14 billion synapses. The more time that elapses before IV thrombolysis or mechanical reperfusion, the slimmer the odds of a successful outcome. Early in fiscal year 2015, the Door-To- Needle (DTN) and Door-To-Reperfusion (DTR) times at our comprehensive stroke center rose to 78 min and 165 min, respectively. Also, the rate of IV tPA administration within 60 min decreased to 17%. In January 2015, lean methodology, specifically, Teams Refocus Imagine Measure (TRIM) was used to reduce DTN and DTR times. The purpose was to achieve: DTN < 60 min, DTR < 120 min, and rate of IV tPA given within 60 min > 75%. Methods: The TRIM and the Plan-Do-Check-Act methods were used to improve outcomes. Components included value stream mapping, A3 problem solving, and real-time observations to identify barriers, duplications and wasted time. The team consisted of Neurology, Neurosurgery, Nursing, Emergency Medicine, Emergency Medical Systems (EMS), Interventional Services (IVS), Radiology, Pharmacy, Anesthesia, Laboratory, Registration, Social Work, Risk Management, Transfer Center, Research, and Performance Improvement. Median and average times and percent compliance were calculated for pre-TRIM and post-TRIM data. Some interventions included: • Designated ED trauma room for all strokes • Early entry of acute stroke orders • Use glucose and EKG from EMS for acute evaluation • One-call stroke alert • Advance tPA mixing • Advance CTA contrast preparation • Notification of parking lot arrival by on-call IVS Team • Advance anesthesia consent • Early discussion with patient and family regarding tPA • Timely communication of turnaround times for each stroke alert Results: In the first two weeks after implementing changes, 23 min was reduced from the stroke alert response. In five months, DTN decreased to 51 min and 63 min was eliminated from DTR. Conclusion: Through an organized multidisciplinary team approach using standardized process improvement methods, identified best practices, and out-of-the-box thinking, improved stroke turnaround times were achieved to provide quality patient care and improve patient outcomes.

A Directional Modifier-Adaptation Algorithm for Real-Time Optimization

The steady advances of computational methods make model-based optimization an increasingly attractive method for process improvement. Unfortunately, the available models are often inaccurate. The traditional remedy is to update the model parameters, but this generally leads to a difficult parameter estimation problem that must be solved on-line. In addition, the resulting model may not represent the plant well when there is structural mismatch between the two. The iterative optimization method called Modifier Adaptation overcomes these obstacles by directly incorporating plant measurements into the optimization framework, principally in the form of constraint values and cost and constraint gradients. However, the number of experiments required to estimate these gradients increases linearly with the number of process inputs, which tends to make the method intractable for processes with many inputs. This paper presents a new algorithm, called Directional Modifier Adaptation, that overcomes this limitation by only estimating the plant gradients in certain privileged input directions. It is proven that plant optimality with respect to these privileged directions can be guaranteed upon convergence. A novel, statistically optimal, gradient estimation technique is developed. The algorithm is illustrated through the simulation of a realistic airborne wind-energy system, a promising renewable energy technology that harnesses wind energy using large kites. It is shown that Directional Modifier Adaptation can optimize in real time the path followed by the kite.

모바일 폰 임베디드 소프트웨어 개발을 위한 식스 시그마 방법의 활용에 대한 사례 연구

The development process of Embedded Software (SW) is gathering interest due to the increased importance of SW in mobile products. According to tough competition and the growing size of the Embedded SW, there is a demand for a new effective way to improve the SW development process, based on customer and market quality aspects, rather than focusing on defect removals in individual SW modules. We review 103 SW improvement projects from the area of mobile phones in order to check the effectiveness of Six Sigma which is the standard for the process improvement statistical tools and methods.

A Critical Evaluation and Framework of Business Process Improvement Methods

The redesign of business processes has a huge potential in terms of reducing costs and throughput times, as well as improving customer satisfaction. Despite rapid developments in the business process management discipline during the last decade, a comprehensive overview of the options to methodologically support a team to move from as-is process insights to to-be process alternatives is lacking. As such, no safeguard exists that a systematic exploration of the full range of redesign possibilities takes place by practitioners. Consequently, many attractive redesign possibilities remain unidentified and the improvement potential of redesign initiatives is not fulfilled. This systematic literature review establishes a comprehensive methodological framework, which serves as a catalog for process improvement use cases. The framework contains an overview of all the method options regarding the generation of process improvement ideas. This is established by identifying six key methodological decision areas, e.g. the human actors who can be invited to generate these ideas or the information that can be collected prior to this act. This framework enables practitioners to compose a well-considered method to generate process improvement ideas themselves. Based on a critical evaluation of the framework, the authors also offer recommendations that support academic researchers in grounding and improving methods for generating process improvement ideas. Next to the framework and its critical evaluation, this review investigates the research procedures of the studies that were used to create the framework. Related to this investigation, academic researchers can find additional guidance regarding procedures for building and evaluating new methods.

Designing Simulation Model of the Production Operation for Further Decision Making

Simulation as a decision making method through its software is a supportive tool for analysis of a material flow, and it is appropriate when a performance of complex systems have to be evaluated, designed and optimized. As the behavior of complex systems is hardly predictable, simulating the existing systems’ performance is helpful in order to gain results of system performance before applying changes in a real system. A change that appears to be a best solution might, after calculation and analysis of its consequences, prove as a wrong direction lead. The more accurately is the model built, the more real results are being achieved. Decisions about the performance improvement might be intuitive as what-if analysis, or achieved by process redesign and improvement methods as Theory of Constraints, Lean Manufacturing, Six Sigma Method, some of them with slight changes in a single processes following Kaizen principles.

Applying Process Improvement Methods to Clinical and Translational Research: Conceptual Framework and Case Examples.

There is growing appreciation that process improvement holds promise for improving quality and efficiency across the translational research continuum but frameworks for such programs are not often described. The purpose of this paper is to present a framework and case examples of a Research Process Improvement Program implemented at Tufts CTSI. To promote research process improvement, we developed online training seminars, workshops, and in‐person consultation models to describe core process improvement principles and methods, demonstrate the use of improvement tools, and illustrate the application of these methods in case examples. We implemented these methods, as well as relational coordination theory, with junior researchers, pilot funding awardees, our CTRC, and CTSI resource and service providers. The program focuses on capacity building to address common process problems and quality gaps that threaten the efficient, timely and successful completion of clinical and translational studies.

A participative end-user method for multi-perspective business process elicitation and improvement

A business process can be characterized by multiple perspectives (intentional, organizational, operational, functional, interactional, informational, etc). Business process modeling must allow different stakeholders to analyze and represent process models according to these different perspectives. This representation is traditionally built using classical data acquisition methods together with a process representation language such as BPMN or UML. These techniques and specialized languages can easily become hard, complex and time consuming. In this paper, we propose ISEA, a participative end-user modeling approach that allows the stakeholders in a business process to collaborate together in a simple way to communicate and improve the business process elicitation in an accurate and understandable manner. Our approach covers the organizational perspective of business processes, exploits the information compiled during the elicitation of the organizational perspective and touches lightly an interactional perspective allowing users to create customized interface sketches to test the user interface navigability and the coherence within the processes. Thus, ISEA can be seen as a participative end-user modeling approach for business process elicitation and improvement.

Reducing intraoperative red blood cell unit wastage in a large academic medical center.

The wastage of red blood cell (RBC) units within the operative setting results in significant direct costs to health care organizations. Previous education-based efforts to reduce wastage were unsuccessful at our institution. We hypothesized that a quality and process improvement approach would result in sustained reductions in intraoperative RBC wastage in a large academic medical center. Utilizing a failure mode and effects analysis supplemented with time and temperature data, key drivers of perioperative RBC wastage were identified and targeted for process improvement. Multiple contributing factors, including improper storage and transport and lack of accurate, locally relevant RBC wastage event data were identified as significant contributors to ongoing intraoperative RBC unit wastage. Testing and implementation of improvements to the process of transport and storage of RBC units occurred in liver transplant and adult cardiac surgical areas due to their history of disproportionately high RBC wastage rates. Process interventions targeting local drivers of RBC wastage resulted in a significant reduction in RBC wastage (p < 0.0001; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.39), despite an increase in operative case volume over the period of the study. Studied process interventions were then introduced incrementally in the remainder of the perioperative areas. These results show that a multidisciplinary team focused on the process of blood product ordering, transport, and storage was able to significantly reduce operative RBC wastage and its associated costs using quality and process improvement methods.

Geometric issues in V-bending electromagnetic forming process of 2024-T3 aluminum alloy

As one of the high speed forming technologies, electromagnetic forming (EMF) has the ability to solve low formability problems in such lightweight alloys as aluminum and magnesium during the conventional forming process. However, one of the drawbacks of EMF is that shape deviation exists between the formed part and the desired part. In order to control this deviation, an in-depth study has been carried out so as to determine the causes of geometrical deviation during the EMF process and possible improvement methods. A series of V-bending electromagnetic forming experiments with rectangular samples of 2024-T3 were carried out using a flat spiral coil and V-shaped die at various voltages. Furthermore, not only the geometrical issues, especially the saddle issue, were quantitatively analyzed, but also a numerical model is established so as to analyze the origin and progression of geometric issues in the part. In the analysis, four major aspects were considered, namely the electromagnetic force distribution, the update of electromagnetic force distribution, the collision impact between sheet and die, and the duration of coil current pulse. It has been observed that electromagnetic force intensifies at the edges from which the distance to the eddy current center is shorter, and that the non-uniformity of force distribution deteriorates with increasing voltage, resulting in further non-uniformity of sheet deformation. In addition, the update of force distribution in sheet plays a useful role in obtaining the desired shape and a proper impact helps to weaken the saddle-like geometrical issue. Moreover, widening the duration of coil current pulse can suppress the rebound of the part in forming with a shallow die.

시스템 이론에 기반 한 긍정탐색(appreciative inquiry)프로세스 재구조화 : 지속가능한 학교공동체 형성을 위한 방법론으로

Abstract Appreciative inquiry is applicable to schools to minimize the resistance of the members, and the subjectof the school community Forming is suitable for the introduction of an AI program. But to become a way for a sustainable school community we must reconstruct the 4D modes of appreciative inquiry that the members can beapplied as needed. In this paper, we propose the process of seven steps core learning activities based on systems theory. Seven steps are selecting a theme, interviewing for finding success story, analyzing an organization's successstories and deriving the core values, deriving future of the organization, sharing future of the organization, designing the ideal future of the organization consist of a practice. Since the proposed seven steps process is based on the literature it is necessary to apply follow-up study is to verify the result, and a variety of research methods for processimprovement in AI. Key Words : Appreciative inquiry, Systems theory, Process, Learning process reengineering, core learning activities

Abstract W P366: Increasing Utilization of Transitional Care Management (TCM) codes for Post-acute Stroke Care

Background and Issues: Stroke patients discharged home often are medically complex with decreased functional independence, especially during the initial transitional period after discharge. The Centers for Medicare and Medicaid Services has set transitional care requirements with new TCM coding that includes a 48 hour phone call from a licensed health professional and provider visit within 14 days after discharge. Process improvement methods can help determine the necessary staffing in order to efficiently meet these guidelines and increase utilization of these codes. Purpose: To review our post stroke transitional care program for TCM code utilization before and after addition of an RN to perform the follow-up phone calls. Methods: We performed a retrospective review of our hospital-supported transitional stroke care program. Our program initially consisted of 2 NPs on rotating schedules between inpatient service and outpatient ambulatory clinics to provide continuity of care during the transitional period after discharge, followed by 2 week hospital follow up visit focused on stroke education, caregiver support, recovery, and complications. The 2 nd phase included NPs performing high risk 48 hour phone calls after discharge thus allowing utilization of TCM codes. The 3 rd phase included addition of an RN to perform 48 hour phone calls and coordinating care between discharge and the stroke NP clinic visit. To assess the increased benefit of adding an RN for phone calls, we searched our EMR for TCM codes during the 3 month period before and 3 month period after RN phone calls were performed (February 2014 through July 2014). Results: A total of 95 patients were discharged home with a stroke or TIA in 6 months. In the first 3 months, 9 TCM codes were utilized. The last 3 months after the RN focused on 48 hour calls, 20 TCM codes were utilized. Conclusions: The a ddition of an RN to help provide 48 hour phone calls to patients after discharge increased the utilization of TCM coding. Further assessment of our transitional care program and use of TCM coding will be focused on effectiveness of decreasing readmission rates and improving outcomes.

Improvement of Business Processes – A Research Study in Wood-processing Companies of Slovakia

Abstract A strong competition on the wood and furniture market forces enterprises to pay attention not only to quality of products but also to quality and performance of internal business processes. Business process is an object of the process approach to management based on investigating and analysing from the view of business activities and activities carried out by managing staff. The paper deals with issue of the improvement of internal processes in production companies, which is the last part in a life cycle of a process management. The attention is paid to initial conditions and methods for process improvement. The aim of the paper is to summarize theoretical knowledge in the area of improvement of business processes and to analyse how this issue is solved in wood-processing companies of Slovakia. A quantitative research through questionnaires was carried out to achieve the goal. The results of the research showed that process management is implemented mostly in large companies with mass and batch production.

Quasi-Feedforward and Feedback Control for Random Step Shift Disturbance Models

Process monitoring and process adjustment strategies are two important parts of the process improvement methods, and they are often considered separately but should be integrated together. Integrated moving average (IMA) model is the most common disturbance model, and step shift model is one type of more complicated disturbance model that often exists in many real applications. In this paper we investigate the case when IMA background disturbance is subject to random step shifts with a certain probability. We propose a process adjustment procedure with feedback control, together with a so-called quasi-feedforward control based on process monitoring of the output errors. This control strategy was proved to be very robust against parameter misspecifications in the disturbance model. We also further investigate the effects of type I and type II errors in process adjustment on this IMA plus random step shift disturbance model.

Application of process improvement principles to increase the frequency of complete airway management documentation.

Process improvement in healthcare delivery settings can be difficult, even when there is consensus among clinicians about a clinical practice or desired outcome. Airway management is a medical intervention fundamental to the delivery of anesthesia care. Like other medical interventions, a detailed description of the management methods should be documented. Despite this expectation, airway documentation is often insufficient. The authors hypothesized that formal adoption of process improvement methods could be used to increase the rate of "complete" airway management documentation. The authors defined a set of criteria as a local practice standard of "complete" airway management documentation. The authors then employed selected process improvement methodologies over 13 months in three iterative and escalating phases to increase the percentage of records with complete documentation. The criteria were applied retrospectively to determine the baseline frequency of complete records, and prospectively to measure the impact of process improvements efforts over the three phases of implementation. Immediately before the initial intervention, a retrospective review of 23,011 general anesthesia cases over 6 months showed that 13.2% of patient records included complete documentation. At the conclusion of the 13-month improvement effort, documentation improved to a completion rate of 91.6% (P<0.0001). During the subsequent 21 months, the completion rate was sustained at an average of 90.7% (SD, 0.9%) across 82,571 general anesthetic records. Systematic application of process improvement methodologies can improve airway documentation and may be similarly effective in improving other areas of anesthesia clinical practice.

A critical analysis of Lean approach structuring in hospitals

Purpose – As reimbursements fall and costs for services climb, organizations are forced to follow the painful motto of doing more with less. A solution could be the adaptation of industrial business process improvement (BPI) methods such as Lean to the hospital setting (HS). The purpose of this paper is to analyze if Lean approaches related in the literature provide sufficient methodological support for other practitioners to reproduce the reported results. Design/methodology/approach – The authors analyzed the published Lean literature in the HS using a methodological maturity-level framework and what the authors defined as the 11 characteristic activities of BPI. Findings – The literature analysis reveals that a Lean approach with a high-methodological maturity level that includes the 11 characteristic activities of BPI has never been reported. Considering this, the paper suggests a meta model for a high-methodological maturity-level Lean method based on the characteristic activities of BPI. Originality/value – This is the first study on the Lean approach in the HS that evidences the absence of a robust Lean methodology in the literature. For Lean to be adopted and implemented by hospital practitioners a structured robust method should be provided.

Sa1451 Systematic Process Improvement Applied to Scheduling and Performing ESWL Followed by ERCP for Large Pancreatic Duct Calculi: Waste Reduction and Quality Improvement

Aside from surgical drainage of the pancreatic duct, extracorporeal shockwave lithotripsy (ESWL) followed by ERCP is an accepted treatment modality for large pancreatic duct stones. In our institution, ESWL is performed exclusively by the Urology service. Due to the number of services and resources involved, scheduling patients for ESWL/ERCP has been difficult and has resulted in a high defect rate, long patient wait times and increased waste, all of which negatively impact quality of care. We sought to determine whether application of an institution-wide systematic method for process improvement to the entire process of scheduling and performing ERCP/ESWL could result in decreased waste and therefore higher quality of care.

What can science contribute to quality improvement in general practice?

Over many decades practitioners and academics working in general practice have built a strong reputation for their commitment to developing innovative approaches to improving the quality of patient care. The orientation of these initiatives has evolved over the years. Until the 1980s, providing high quality patient care was primarily reliant on the personal motivation of individual doctors to achieve explicit standards of practice.1 These standards were maintained through a commitment to education and training, and their attainment rewarded by peer recognition, for example by membership or fellowship of professional bodies. From the 1980s until the early part of this century, the emphasis shifted from individuals to teams and the narrative changed from the relatively static orientation of attaining standards to the more dynamic one of continuous improvement.2 Guidelines were developed that had to be delivered by multidisciplinary teams, multiprofessional audit was encouraged, team-based significant event analysis become common, methods of process improvement developed in the manufacturing sector were introduced into practices, and team-based financial incentives were designed and implemented at scale. Over the past decade the focus has shifted again, this time to levers for improvement that operate at a health system level and which place the locus of control more with policymakers and system leaders than with individual professionals or clinical teams. Performance management, competition, transparency, regulation, and legislation have been introduced as ways of potentiating the established professionally-led methods, or replacing them when they are deemed to be failing. In this article we describe what we see as the next phase of the ‘improvement journey’ for general practice, a phase that builds on the strengths of approaches currently being used, and attempts to address their deficiencies. We propose that this will place a stronger emphasis on the role of science — the science of improvement — …

Human Factors Engineering in Patient Safety

Human Factors Engineering in Patient Safety

Potential Strategies for Increasing Drug-Discovery Productivity

The productivity challenge facing the pharmaceutical industry is well documented. Strategies to improve productivity have mainly focused on enhancing efficiency, such as the application of Lean Six Sigma process improvement methods and the introduction of modeling and simulation in place of 'wet' experiments. While these strategies have their benefits, the real challenge is to improve effectiveness by reducing clinical failure rates. We advocate redesigning the screening cascade to identify and optimize novel compounds with improved efficacy against disease, not just with improved potency against the target. There should be greater use of disease-relevant phenotypic screens in conjunction with target-based assays to drive medicinal chemistry optimization. An opportunistic approach to polypharmacology is recommended. There should also be more emphasis on optimization of the molecular mechanism of action incorporating understanding of binding kinetics, consideration of covalent drug strategies and targeting allosteric modulators.