Process Improvement Principles Research Articles

Reducing Erythrocyte Sedimentation Rate Ordering: De-implementation and Diagnostic Stewardship.

The Choosing Wisely campaign recommends against the routine use of erythrocyte sedimentation rate (ESR) for the assessment of acute undiagnosed inflammation or infection. We examined ESR and C-reactive protein (CRP) ordering practices at a large, freestanding children's hospital. We found that 80% of ESR orders were placed concurrently with a CRP order. We aimed to reduce the ESR testing rate by 20% within 6 months in both inpatient and emergency department (ED) settings. Applying Lean process improvement principles, we interviewed stakeholders from multiple subspecialties and engaged the institutional laboratory stewardship committee to identify the root causes of ESR ordering and design interventions. We conducted provider education (November 2020) and employed clinical decision support through an order panel in the electronic health record (April 2021). The outcome measures were monthly ESR testing rate per 1000 patient days (inpatient) and per 1000 ED visits, analyzed using statistical process control charts. CRP testing rate was a balancing measure. After intervention implementation, the ESR testing rate decreased from 11.4 to 8.9 tests per 1000 inpatient patient days (22% decrease) and from 49.4 to 29.5 tests per 1000 ED visits (40% decrease). This change has been sustained for >1 year postintervention. Interventions were effective even during the coronavirus disease 2019 pandemic when there was a rise in baseline ED ESR ordering rate. CRP testing rates did not increase after the interventions. Education and clinical decision support were effective in reducing the ESR ordering rate in both inpatient and ED settings.

Using a Cascading Approach to Improve Multisite Study Procedures.

Multisite studies offer larger, more diverse samples to successfully capture populations and clinical practices of interest at the point of care. However, investigators face challenges with site recruitment and sampling, differences in clinical practices across sites, and data integrity. Addressing these issues a priori can improve the rigor and reproducibility of the research. This article aims to describe a cascading approach to multisite research. An exemplar is provided of a study using this approach, which aimed to evaluate the prevalence of pain and the pain management practices provided to critically ill children in pediatric intensive care units in the United States. The cascading approach includes two or more pilot study procedures with a progressively increasing number of sites prior to a full-scale study. Following each pilot, study procedures are evaluated; feedback was obtained from site personnel and content experts; procedures were revised accordingly; approvals were obtained; sites were trained; and the revised procedures are repeated with a larger, more diverse number of sites. In the exemplar provided, improvements in the efficiency and integrity of data collection were noted for the full-scale study following the pilots. All sites that completed the agreements and approvals for study participation were retained for the duration of the two pilots and full-scale study. Borrowing from principles of process improvement, the cascading approach allows knowledge to be gained regarding site differences and informs the revision of study procedures while potentially maximizing efficiency and data integrity, minimizing site burden, and maintaining site engagement for multisite studies.

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Utilizing process improvement strategies to generate clinic templates and improve patient flow in pediatric otolaryngology

ObjectivesTo examine outcomes from process improvement strategies aimed to: 1) develop computer generated physician clinic templates using captured and historic clinical data, and, 2) introduce said new template designs while maintaining historic daily patient volumes. MethodsAn Institutional Review Board approved retrospective review of time stamped data collection in a tertiary facility pediatric otolaryngology clinic. ResultsA discrete-event simulation was built from timestamps associated with clinic interaction milestones. The data were analyzed to develop standard clinic templates with the goal to reduce patient overall visit length by 10%. A total of 12,052 clinic visits were analyzed, 8,045 before (avg. of 62.9 visits/day) and 4,007 after (avg. of 65.7 visits/day) template standardization. The change led to a 10.5% (5.5 min, p < 0.001) decrease in total clinic visit time from 52.3 ± 25.9 min to 46.8 ± 25.0 min. This data extrapolated over a year is estimated to save 1,567 clinic hours. Secondarily, it was found that patient experience was not affected as a result of this change. ConclusionDiscrete-event simulation, using the principles of process improvement, is effective in guiding clinic operational redesign. This quality improvement project decreased the average length of clinic visit by 10% with no impact on historic high clinic volumes. Patient flow can improve in high volume pediatric otolaryngology practices by using process improvement strategies and discrete-event simulations to create standardized provider templates. Theoretically, this strategy can lead to improved patient and physician experiences along with an increase in patient visits over time.

Why Orthopaedic Residents Must Be Exposed to and Taught Value-Based Care

Abstract: The shift to value-based care is changing the practice of medicine. In order to prepare our orthopaedic trainees to survive in a value-based health-care environment, we must expose them to and educate them about value-based programs. This creates both challenges and opportunities for training programs. Academic medical centers (AMCs) will need to carefully consider how to adopt value-based programs and agreements, and assess whether they need alternative facilities, partnerships, or processes in order to be successful. Process improvement principles to adapt physician behavior, the introduction of outcome metrics into the surgical decision-making process, and the development of team-based care can greatly enhance the likelihood of success. AMCs should embrace these challenges to ensure that their residents are well-prepared for the future.

Developing and operationalizing a safety culture across a hematology/oncology ambulatory network.

250 Background: The “Safety Belongs to Me” (SBTM) campaign is an initiative that evaluates safety systems utilized by the Medical Oncology ambulatory network. The SBTM project aims to identify, report, and resolve current and future safety risks by implementing weekly interdisciplinary conference calls across the network. In addition it deploys a highly reliable reporting structure for departmental stakeholders (i.e. Administration, Nursing Administration, Materials Operations, Laboratory, and Pharmacy.) Thereby increasing situational awareness, and prevention of complacency as it relates to patient and employee safety risks. Methods: Methodologies utilized include six sigma tools (Kano analysis, etc.) improvement science tools (PDSA, process maps, and driver diagrams), and surveys. These were used to illustrate how principles of process improvement can be utilized to provide an effective framework for systematic innovation in healthcare. Weekly safety calls were started March 2019 after clinical and administrative leadership completed IHI safety culture training. Results: Since implementation of weekly safety calls, an average 13.2 safety issues identified/week with 3.6 issues/week needing follow up for resolution. There has been an increasing trend in safety issues identified and decreasing trend in new safety issues for follow up. Conclusions: The development of a reporting platform augmented a pre-existing process to escalate safety concerns and events within the medical oncology network. This collaborative has facilitated a formalized safety culture that has increased the identification of both potential and existing safety concerns.

Workplace violence prevention standardization using lean principles across a healthcare network

PurposeThe purpose of this paper is to describe the process used to standardize a Workplace Violence Prevention Program (WVPP) within a five-hospital healthcare system in Veterans Health Administration (VHA).Design/methodology/approachA description of the lean process improvement principles, used to bring the WVPP into compliance with Occupational Safety and Health Administration (OSHA) and other agencies through streamlining/standardizing processes.FindingsThere was significant standardization in both the threat assessment and education arms of the WVPP. Compliance with all major US Department of Labor OSHA requirements, as well as substantial time savings, were realized as part of this process improvement.Originality/valueVHA is leading the way in inter/multidisciplinary assessment and mitigation of workplace violence, however, there are significant competing demands on staff time. This first ever use of lean principles to streamline processes around workplace violence prevention freed up clinician time for care while improving internal and external customer satisfaction, representing a major step forward in workplace violence risk mitigation.

Utilization of Lean Techniques in Pharmacy Residency Training: Modifying the PGY1 Management and Leadership Experience.

Purpose: The purpose of this study was to utilize lean process improvement principles to enhance the health-system pharmacy administration learning experience within a postgraduate year 1 (PGY1) residency program. Summary: The Richard L. Roudebush VA Medical Center adopted the use of lean to improve customer service and workplace efficiency. The Residency Advisory Council, overseeing the 6 pharmacy residency programs, felt that training residents in a proven process improvement technique would benefit the service and assist in developing problem-solving skills. Yellow Belt training was incorporated into the residency programs in 2012, and the Yellow Belt project for the 2014-2015 residency class was the modification of the PGY1 Health-System Pharmacy Administration learning experience. Residents focused on a few key areas as part of their completion plan: educating residents and preceptors on the importance of leadership activities, establishing a list of consistent topic discussions to be held during the administration learning experience, confirming a topic list for the pharmacy practice management and leadership seminars, piloting collaborative precepting for the administration experience, revising the staff development program, and increasing resident involvement in the PGY1 interview process. Two portions of the project lacked effective and timely communication, and as a result, those areas were not fully implemented. The remainder of the items achieved 100% completion. Conclusion: Lean techniques were effectively utilized within a residency program to enhance the health-system pharmacy administration learning experience. Successful implementation of lean requires engagement of stakeholders within the health-system, timely communication, frequent reassessments, and accountability.

Increasing Therapist Productivity: Using Lean Principles in the Rehabilitation Department of an Academic Medical Center.

The Department of Rehabilitation Services, within the University of Maryland Medical Center's 650-bed academic medical center, was experiencing difficulty in meeting productivity standards. Therapists in the outpatient division believed they were not spending enough time performing billable patient care activities. Therapists in the inpatient division had difficulty keeping pace with the volume of incoming referrals. Collectively, these issues caused dissatisfaction among referral sources and frustration among the staff within the rehabilitation department. The department undertook a phased approach to address these issues that included examining the evidence, using Lean process improvement principles, and employing transformational leadership strategies to drive improvements in productivity and efficiency. The lessons learned support the importance of having meaningful metrics appropriate for the patient population served, the use of Lean as an effective tool for improving productivity in rehabilitation departments, the impact of engaging staff at the grassroots level, and the importance of having commitment from leaders. The study findings have implications for not only rehabilitation and hospital leadership, but CEOs and managers of any business who need to eliminate waste or increase staff productivity.

Risk based uncertainty quantification to improve robustness of manufacturing operations

The cyber-physical systems of Industry 4.0 are expected to generate vast amount of in-process data and revolutionise the way data, knowledge and wisdom is captured and reused in manufacturing industries. The goal is to increase profits by dramatically reducing the occurrence of unexpected process results and waste. ISO9001:2015 defines risk as effect of uncertainty. In the 7Epsilon context, the risk is defined as effect of uncertainty on expected results. The paper proposes a novel algorithm to embed risk based thinking in quantifying uncertainty in manufacturing operations during the tolerance synthesis process. This method uses penalty functions to mathematically represent deviation from expected results and solves the tolerance synthesis problem by proposing a quantile regression tree approach. The latter involves non parametric estimation of conditional quantiles of a response variable from in-process data and allows process engineers to discover and visualise optimal ranges that are associated with quality improvements. In order to quantify uncertainty and predict process robustness, a probabilistic approach, based on the likelihood ratio test with bootstrapping, is proposed which uses smoothed probability estimation of conditional probabilities. The mathematical formulation presented in this paper will allow organisations to extend Six Sigma process improvement principles in the Industry 4.0 context and implement the 7 steps of 7Epsilon in order to satisfy the requirements of clauses 6.1 and 7.1.6 of the ISO9001:2015 and the aerospace AS9100:2016 quality standard.

Abstract TP405: Raising the Bar, Lowering the Target

Background: In 2013 our growing regional stroke referral center was not meeting Target Stroke® best practice recommendations for door to needle times within 60 minutes. A Rapid Improvement Event (RIE) was held to decrease process waste and therefore improve treatment times. Process changes were implemented in January 2014. Twelve months of monitoring identified sustained improvement and evidence that the process could continue to improve therefore a second rapid improvement event was held in January 2015 targeting door to needle times within 45 minutes. Purpose: The purpose of the process improvement event was to decrease treatment times below 60 minutes targeting 45 minutes. Methods: The RIE was utilized as the platform to incorporate process improvement principles and evidence based practice in order to elevate the standard of care for patients experiencing ischemic stroke. A multidisciplinary team including pre-hospital and hospital staff met to develop a care model that would impact patients presenting with stroke like symptoms. Lean tools were used to capture waste and bring transparency to the process. A standardized pathway and standard work for each role were developed. Huddles to debrief on successes and barriers from each case were implemented as a way to increase staff engagement and familiarize them with the new process. Results: Significant improvement was achieved. Median door to needle treatment times decrease from 86 minutes to 49 minutes, a 43% improvement. Treatment within 60 minutes improved from 23% of eligible patient to 67% of eligible patients, this was an improvement of 66%. Treatment within 45 minutes improved from 6% of eligible patients to 45% of eligible patients, this was an improvement of 87%. Conclusion: Lean principles proved to be an effective tool for improving the thrombolytic delivery process for acute ischemic stroke patients.

Process improvement in the banking sector

Six sigma, operational excellence and lean are very popular tools, but their use in worldwide banking remains limited today. These tools are mostly used in other industries, and banking experts often question the value they hold to the banking sector. Process improvement is not industry-dependent, but it is not easy to translate production methods from manufacturing to services. Nevertheless, the results can be similar. Consistency is required in the application of process improvement principles, even if the economy is changing and senior managers are forced to adapt their business strategy. Flexibility in the implementation process is needed to find the best way in response to different market and economic conditions. When K&amp;H; Bank in Hungary started its business improvement journey in 2005 it began as a rather bureaucratic institution that had paper-based process descriptions for its rules, more than 300 active IT systems, a functional organisational structure working in ‘silos’, complex end-to-end processes lacking sufficient cooperation and risk avoidance as the bank’s main target. The organisation was neither customer-friendly nor efficient. Changing the corporate culture has been a ten-year journey, using business-as-usual operational excellence and lean tools for process improvement, and continuously measure and manage process performance. Today, all internal staff communication from the CEO contains the same final key message, repeated for years as the most important cultural principles for all employees: ‘be the reference’ (meaning that all employees should work and act as part of the best bank in the market), ‘serve your customer’ and ‘simplify’. These messages are not empty words, the whole organisation is working on these goals every day. To achieve this result K&amp;H; Bank needed to change its process strategy several times to enable it to adapt to the changing market requirements. This paper summarises the key drivers of the market and the different implementation strat­egies of the bank, including the toolkits, results and challenges at each stage, and the increasing levels of process management and improvement that were achieved.

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.

AGIS: Towards an ISO9001 based Tool for Measuring Agility

ISO9001:2008 is probably the most widely adopted process improvement model in the world. ISO9001:2008 is a general purpose standard for service and production organizations, which established the groundwork for improving system processes in an enterprise. This standard has also been widely adopted in the software industry. On the other hand, agile development methodologies have been steadily gaining acceptance and popularity in the past decade. At a first glance, these two approaches are opposite. While agility preaches interaction above processes, ISO is a process-oriented approach to improvement. Nonetheless, both approaches share the same conundrum: both hold claims of compliance but there have been few data-backed-up success case studies. However, since ISO is a general purpose standard, its achievement is fairly attainable. In contrast, the agile development ecosystem is full of false positives that claim agility without achieving project success. This paper presents an assessment tool to measure agility based on ISO 9001:2008 process improvement principles. Our tool is capable of measuring a degree of agility aligned with the agile manifesto values. Its goal is to provide an objective measurement of agility that avoids false positives on both sides.

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.

Four archetypes of process improvement: a Q-methodological study

This paper explores the process improvement approaches of organisations. It seeks to identify process redesign principles and the combinations of these principles that are used successfully in industry. We use Q-methodology to explore the viewpoints of a range of highly experienced process experts about the success of 16 improvement practices. Q-methodology enables the examination of the similarities and differences in the success of the improvement principles used by organisations in order to inform archetypes of process improvement. Overall, our findings suggest that process improvement is determined through the application of two foundational principles combined with one of four archetypes. ‘Remove non-value-adding tasks’ and ‘re-sequence tasks’ are described as foundational principles of process improvement, whilst outsourcing needs to be approached with caution. Furthermore, we articulate four distinctive archetypes comprising unique configurations of improvement principles that can be used to redesign operational processes. Based on this evidence we propose a typology of process improvement. This work suggests that rather than adopting generic improvement frameworks, managers should consult the typology to determine the archetype in closest proximity to their specific requirements. This study has several limitations including the small number of items populating the concourse and the fact that implementation problems are not taken into account.

Lean implementation of electronic health records (EHR).

211 Background: The Palo Alto Medical Foundation (PAMF), an integrated multispecialty physician group and one of five regions of Sutter Health in Northern California, is converting from an electronic chemotherapy ordering and administration system, Intellidose, to Epic Beacon to achieve full EHR integration. As chemotherapy workflows are complex with multiple interactions between providers and high potential for patient harm, we adopted a novel approach of incorporating Lean process improvement principles in advance of our Beacon deployment to improve the design of our software build and increase operational safety and efficiency. Methods: Two multi-disciplinary teams including oncologists, pharmacists, nurses, administrative and technical support staff were deployed; a Sutter Beacon team responsible for technical design and build of the Sutter Beacon standard and a second PAMF team to evaluate workflow variation among PAMF chemotherapy infusion centers, identify best practices, engage the Sutter Beacon Build team around system design and institute rapid cycle process improvement in partnership with the PAMF Lean Promotion Office. Results: Visio maps of current state workflows were constructed to reflect oncologist, pharmacy and nursing workflows from medication ordering to chemotherapy administration and billing submission. Two Rapid Process Improvement Workshops designed future state workflows and identified key areas requiring re-engineering. Lean rapid cycle improvement strategies will be leveraged to improve clinical workflows prior to Beacon implementation. To support the 40% of infusion treatments that are for non-oncology patients, a second process was designed as an important patient safety initiative to avoid discordant nursing administration workflows. Conclusions: Successful design, build and implementation of EHR require achieving consensus-driven work processes that maximize patient safety, eliminate workflow redundancies and maximizes the value-added component. It requires coordination between the EHR technical build team who design the system and the implementation team who integrate it with re-engineered workflows. Lean methodology provides the conceptual framework to achieve a successful EHR deployment.

Practice Policy and Quality Initiatives Quality Improvement and Confirmation Projects: Facilitating Rapid, Measurable Performance Improvement

As radiology departments continue to increase in size and complexity, the process of improving and maintaining excellent performance is becoming increasingly challenging. In response, a systematic process for efficiently implementing and sustaining measurable improvement in our radiology department has been developed, which targets focused aspects of individual performance that contribute to overall departmental quality. Projects designed to achieve such improvements have been called quality improvement and confirmation (QuIC) projects. The QuIC project process involves a project champion, medical expert, technical expert, quality improvement technologist specialist, and appropriate leaders, managers, and support personnel. The project champion conducts a preliminary investigation and organizes team members, who define the desired performance through consensus, establish data collection and analysis procedures, and prepare to launch the project. Once launched, the QuIC project process follows an execution period that is divided into four phases: (a) project launch phase, (b) support phase, (c) transition phase, and (d) maintenance phase. The first three phases focus on education, group-level feedback, and individual feedback, respectively. Weekly audits are performed to track performance improvement. Data collection, analysis, and dissemination processes are automated to the extent possible. To date, four such projects have been successfully conducted. The QuIC project concept is an attempt to apply the principles of process improvement to the process of process improvement by enabling any member of a radiology department to efficiently and reliably spearhead a quality improvement project. We consider this to be a work in progress and continue to refine the process with the goal of eventually being able to conduct many projects simultaneously.

Quality Improvement and Confirmation Projects: Facilitating Rapid, Measurable Performance Improvement.

As radiology departments continue to increase in size and complexity, the process of improving and maintaining excellent performance is becoming increasingly challenging. In response, a systematic process for efficiently implementing and sustaining measurable improvement in our radiology department has been developed, which targets focused aspects of individual performance that contribute to overall departmental quality. Projects designed to achieve such improvements have been called quality improvement and confirmation (QuIC) projects. The QuIC project process involves a project champion, medical expert, technical expert, quality improvement technologist specialist, and appropriate leaders, managers, and support personnel. The project champion conducts a preliminary investigation and organizes team members, who define the desired performance through consensus, establish data collection and analysis procedures, and prepare to launch the project. Once launched, the QuIC project process follows an execution period that is divided into four phases: (a) project launch phase, (b) support phase, (c) transition phase, and (d) maintenance phase. The first three phases focus on education, group-level feedback, and individual feedback, respectively. Weekly audits are performed to track performance improvement. Data collection, analysis, and dissemination processes are automated to the extent possible. To date, four such projects have been successfully conducted. The QuIC project concept is an attempt to apply the principles of process improvement to the process of process improvement by enabling any member of a radiology department to efficiently and reliably spearhead a quality improvement project. We consider this to be a work in progress and continue to refine the process with the goal of eventually being able to conduct many projects simultaneously. © RSNA, 2013.

Management of the Complex Trauma Patient With Limited Resources

Trauma systems provide lifesaving care for complex trauma patients but at a significant cost. With both government and private funding sources becoming scarce, the business principles of process improvement and control have been applied to health care, simultaneously shifting the focus to quality and profit. Expenses are decreased by limiting costs for materials, limiting unnecessary training, and reducing both variability and complications. Training requirements for any particular task or patient care activity are reduced by establishing routine protocols to enable physician assistants and nurse practitioners to perform duties that at one time were performed only by physicians. Routine algorithms for items such as ICU and postoperative management all reduce variability and result in standardized care. This permits analysis and performance improvement within a hospital and across hospitals nationally. To this end, the American College of Surgeons National Surgical Quality Improvement Project is a risk-adjusted outcomes-based program created to provide tools and data to hospitals for quality improvement in surgical care. The analogy for trauma care is the Trauma Quality Improvement Program. Trauma Quality Improvement Program and other quality improvement strategies are increasingly being applied to trauma systems and programs to provide higher quality care, greater standardization, fewer complications for patients, and reduced costs.