Process Improvement Cycle Research Articles

Implementing PDSA Cycles to Expand Reach of Self-Management Education in the Post-COVID Era

ABSTRACT Background COVID-19 reduced participation in our region’s evidence-based chronic disease self-management program (SMP), despite having expanded offerings to include diverse delivery modes (e.g. virtual, mailed toolkit, phone-based group support). Purpose The purpose was to test various approaches of disseminating the mailed toolkit (an independent study version of the SMP) to expand reach of the program. Methods We ran three process improvement (PDSA) cycles. We used electronic health record data, a participant survey, and implementer feedback to guide our decision-making process throughout the iterations. Results Toolkits reached populations that had not previously been exposed to SMPs: individuals with type 2 diabetes who did not attend diabetes education in the past year; individuals being discharged from acute care with an admitting diagnosis related to a chronic disease; and individuals referred by their provider to the program. Discussion Toolkit utilization will remain low for those who are not ready to make a behavior change. Running PDSA cycles provided the necessary information for our team to make decisions about future dissemination of the mailed toolkits. Translation to Health Education Practice Engaging in PDSA cycles can be a helpful tool for health educators when considering how to expand reach or engage new populations of interest.

Optimizing electronic blood ordering and supporting administration workflows to improve blood utilization in the pediatric hospital setting.

Red blood cell wastage occurs when blood is discarded rather than transfused, and ineffective ordering results in unnecessary crossmatch procedures. We describe how a multimodal approach to redesigning electronic ordering tools improved blood utilization in a pediatric inpatient setting and how using innovative application of time series data analysis provides insights into intervention effectiveness, which can guide future process improvement cycles. A multidisciplinary team used best practices and Toyota Production System methodology to redesign electronic blood ordering and improve administration processes. We analyzed crossmatch to transfusion ratio and red blood cell wastage time series data extracted from our laboratory information system and electronic health record. We used changepoint analysis to identify statistically discernible breaks in each time series, compatible with known interventions. We performed causal impact analysis on red blood cell wastage time series data to estimate blood wastage avoided due to the interventions. Changepoint analysis estimated an 11% decrease in crossmatch to transfusion ratio and a 77% decrease in red blood cell monthly wastage rate during the intervention period. Causal impact analysis estimated a 61% reduction in expected wastage compared to the scenario if the interventions had not occurred. Our results show that electronic health record design is an important factor in reducing waste and preventing unnecessary crossmatching, and that time series analysis can be a useful tool for evaluating the long-term impact of each stage of intervention in a longitudinal process redesign effort for the purpose of effectively targeting future improvement efforts.

Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients

Background/Purpose“Pan-scanning” pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. MethodsIn July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016–06/2017) and post-implementation (07/2017–08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. ResultsDuring the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. ConclusionsQuality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.

Abstract P818: Increased Eligibility for Endovascular Therapy Following Intensive Door-To-Transfer Improvement Project

Background and Purpose: Early EVT for large vessel acute ischemic stroke is associated with reduced disability and mortality. Longer transfer times from the sending facility contribute to poorer EVT outcomes, and in some circumstances, patient ineligibility for EVT due to a completed stroke on arrival to the endovascular site. Reducing avoidable delays will result in overall improved EVT outcomes and reduce the frequency of completed stroke upon arrival. Methods: A multidisciplinary group utilized the Lean A3 process and PDCA improvement cycle to reduce transfer times. Avoidable delays and resources to expedite the transfers were identified. A standardized plan with defined roles and responsibilities, communication pathways, early transport team activation, and robust staff education were implemented. The PI team met weekly for 3 months to review each individual transfer, determine what went well and what did not, and to identify additional improvement opportunities. A weekly summary with feedback was provided to front line staff and managers. Staff involved in patient transfers that had a DIDO of 90 min or less were recognized with a “Brain Pin” and staff recognition certificate. Results: Since its implementation, 23 patients were transferred for potential EVT. Compared with 12 months prior to implementation, the DIDO median time was reduced from 119 minutes to 80.5 minutes, transfers were achieved in 90 min or less 61% (n=15) of the time vs. 27.2%, and percentage of EVT eligible patients increased from 58.3 to 78.3%. Conclusion: In conclusion, rapid reduction of DIDO times and increased patient eligibility for thrombectomy is attainable through an intensive multidisciplinary process improvement project. Implementing a standardized workflow that includes rapid identification of potential EVT transfers, early activation of the transport team, development of clear pathways of communication, defined roles and responsibilities within the team, and regular staff feedback are essential.

Rapid Implementation and Adaptation of a Telehospitalist Service to Coordinate and Optimize Care for COVID-19 Patients.

Background/Introduction: The COVID-19 pandemic poses enormous resource challenges to hospitals. Telemedicine is increasingly recognized as an attractive tool to alleviate resource strains. Herein we describe the rapid implementation and sequential process improvement (PI) of a centralized telehospitalist service to coordinate and optimize management of large number of COVID-19 patients in a tertiary and quaternary care hospital very close to the New York City epicenter. Methods: Prospective multidisciplinary PI meetings were held weekly between March 23 and May 10, 2020, and consensus service modifications were implemented for the following week. Inpatient census data, telehospitalist intervention volumes, and service utilization statistics were collected. Results/Discussion: Between March 23 and May 10, 2020, a total of 745 COVID-19 patients were admitted to the general medical wards. The telehospitalist service performed 1,136 audiovisual (AV) patient assessments, 379 best practice interventions, cohorted 108 patients, and conducted 170 remote family conversations. During the consecutive PI cycles, a number of adaptations in AV setup, care standardization, patient logistics, communication, and consultative functions were made to load balance the bedside hospitalist teams. As the COVID-19 hospital census increased to peak levels, the most value was added through facilitation of communication and collaboration between the bedside clinical teams, the infection prevention and control teams, and patient logistics team. Conclusions: A telehospitalist service can be rapidly implemented with basic telemedicine equipment. Processes/this functions can be sequentially adapted to quickly changing needs during conditions such as the COVID-19 pandemic that very quickly can place extraordinary strains on hospital resources.

IMPLEMENTATION OF INTERNATIONAL STANDARDS AS THE WAY TO ENSURE THE SAFETY OF FOOD PRODUCTS

The article declares that the implementation of new international standards ISO 22000 on Food Safety Management Systems can help to solve the problem of food safety, which will allow facilitating the integration of HACCP and ISO 9001.&#x0D; The essence, features, and differences of ISO 22000: 2018, which provides for the usage of the PDCA cycle, which can be used to manage the quality management system on a systematic basis effectively, are considered. The content of the PDCA methodology is defined, and the components of the process improvement cycle are analyzed.&#x0D; It has been defined that the РDCА methodology is based on the risk-based thinking, enabling the enterprise to identify factors that may cause deviations from the planned results of its processes and to develop prevention measures to minimize their negative impact and to maximize the opportunities that arise. The risk management process, as well as the risk response and opportunity activities, are presented.&#x0D; It is emphasized that within management systems business risk can be perceived as an influence not only of a negative direction, but also a positive one, and perceived as an "opportunity". It is justified that risk and opportunity accounting creates the basis for improving the efficiency of all processes, achieving higher results and preventing negative consequences.&#x0D; Outlined is the role of management, as long as their new responsibilities emerge that demonstrate leadership. It is emphasized that the identification of all stakeholders and their expectations will help the organization to adjust its overall strategic development orientation.

Improved medical-alert ID ownership and utilization in youth with congenital adrenal hyperplasia following a parent educational intervention.

Classical congenital adrenal hyperplasia (CAH) is a potentially life-threatening condition, and adrenal crisis is a major cause of morbidity and mortality in affected children. Medical-alert identification (ID) could prevent complications of adrenal crisis by identifying the need for time-sensitive, critical treatment. Our objectives were to evaluate usage of medical-alert IDs by CAH youth, ownership and awareness of IDs amongst their parents, and the effect of an in-clinic educational intervention on ID utilization. Fifty families of youth with classical CAH secondary to 21-hydroxylase deficiency (11.2±5.0 years old, 58% female) were prospectively studied. An in-clinic needs assessment survey was administered at baseline to parents, paired with an educational intervention, and a follow-up needs assessment phone survey 1 month post-intervention. A quality improvement (QI) framework was utilized with plan-do-study-act (PDSA) process-improvement cycles. At baseline, 20/50 (40%) CAH families owned a medical-alert ID, of which only 10/20 (50%) of ID owners reported usage >3 days per week. Only 26/50 (52%) parents were aware of ID options. Post-intervention, ID ownership doubled to 39/50 (78%; p<0.05), usage amongst ID owners reached 100% (39/39), and awareness increased to 42/50 (84%; p<0.05). A surprising barrier reported by five Spanish-speaking families was the inability to order medical-alert IDs online. Only a small percentage of CAH youth frequently wear a medical-alert ID, but utilization can be effectively improved with an in-clinic educational intervention. Further study is merited to assess a potential reduction in morbidity and mortality of adrenal crisis with increased medical-alert ID utilization.

The Data-Driven Process Improvement Cycle: Using Digitalization for Continuous Improvement

Industry 4.0 is the first industrial revolution to be announced a priori, and there is thus a significant ambiguity surrounding the term and what it actually entails. This paper aims to clearly define digitalization, a key enabler of Industry 4.0, and illustrate how it can be used for improvement through proposing an improvement cycle and an associated digitalization typology. These tools can be used by organizations to guide improvement processes, focusing on the new possibilities introduced by the enormous amounts of data currently available. The usage of the tools is illustrated by presenting four scenarios from Kanban control, where each scenario is mapped according to their digitalization level.

Lean thinking in the highways construction sector: motivation, implementation and barriers

The interest in lean thinking in the UK’s civil construction industry is on the rise. The research presented in the paper evaluates the adoption of lean thinking in the highways construction sector by investigating 7 motivation factors, 20 lean techniques and 16 barriers through in-depth interviews with 20 sector managers and a questionnaire survey of 110 responses. The findings show the existence of strong external motivational factors for lean thinking such as clients’ push and companies’ expectation of winning more contracts alongside lean’s operational benefits. Limited adoptions of the lean techniques, mostly in the stepwise process improvement cycle, the Last Planner System and Visual Management, were determined. This raises concerns about ‘pseudo-lean’ practices in the sector. Lack of standardisation, insufficient benefit capturing, insufficient know-how, insufficient control of the entire value stream and limited view to the techniques were found as the top barriers.

Colorectal cancer screening in a rural US population

Purpose Colorectal cancer (CRC) screening saves patient suffering and health system expenses if the pathology is found in its early stages. Utilizing rapid process improvement cycles, the purpose of this paper is to improve the rate of CRC screening in a rural community in the USA. Design/methodology/approach Data were gathered from the authors’ electronic medical record. Non provider staff were trained to do the majority of the work utilizing population health, clinic visit checklists, and standard work. The two tests used were colonoscopy and fecal immunochemical test testing. Findings Dramatic improvement in the rates of colorectal screening were achieved. The base rate of documented CRC screening was 22 percent, with the rate two years later being 62.7 percent. Originality/value This work is of interest to those working in primary care, gastroenterology, general surgery, or if interested in designing standard work.

Interdisciplinary Public Health Intervention in a Multigenerational Tuberculosis (TB) Outbreak in Harris County, Texas: A Case Study with Implications for Disease Control Process Improvement and Transmission Cycle Interruption

BackgroundHarris County Public Health (HCPH) is the health department for Harris County, Texas jurisdiction. Harris County as a whole is the nation’s third most populous county, with 4.3 million residents, and a TB case rate more than double that of the USA. (7.6 cases per 100,000 pop). A total, 327 individuals were diagnosed with TB in Harris County during 2015, over two-thirds occurring in foreign-born individuals. In 2016, HCPH treated an immigrant female with active TB. Initial contact investigation (CI) yielded five household contacts (HHC). Two tested positive, but refused subsequent clinical evaluation by HCPH. Two months later, HCPH was notified of a HHC hospitalized with TB. After hospital discharge, the sick HHC moved into a motel in attempts to self-isolate, but refused evaluation of additional HHC in the home, and banned home access, precluding adequate CI. After numerous phone calls, visits to motel and home, and multiple rescheduled appointments, legal action appeared inevitable. Days later, HCPH was notified of another HHC diagnosed with active TB.MethodsWith alarm regarding the family’s adherence to control orders, TB staff implemented an innovative multidisciplinary team-based intervention in hopes of avoiding legal action. A site visit was paid to the motel by a local health authority, two TB staff, a county public investigator, and a refugee clinic outreach worker fluent in the family’s language. Patients were presented with letters requesting immediate cooperation to avoid court filings. Questions were answered, misinformation corrected, and education provided.ResultsIntermediary on-site intervention using a compassionate, firm multidisciplinary team approach resulted in 16 additional family members tested, yielding an infant with active TB (Case 4) and 8 with TB Infection (TBI). Isolation breaches were also discovered. Most importantly, TB transmission cycle was interrupted. Cultural and economic barriers hindering successful interaction with family were addressed, TB misconceptions corrected, and trusting relationship developed.ConclusionThis innovative multidisciplinary intervention avoided court proceedings and curtailed the TB transmission cycle. HCPH improved its non-adherence intervention process, and modified TB control orders for infectious patients residing in congregate settings.Disclosures All authors: No reported disclosures.

Implementasi Konsep A3 Untuk Mengurangi Reject Proses Assembly

The A3 concept is one of the Toyota tools to propose problem-solving solutions. A3 provides status reports of ongoing activities. This research applies A3 concept to solve reject problem in plastic company assembling process. The reject rate in the assembly process is 15.6%. The implementation stage of A3 concept is identification of problem, targeting, root cause, goal setting, countermeasure, implementation plan, action and follow up. The A3 concept is in line with the Plan-Do-Check-Act (PDCA) process improvement cycle. The results show that using the concept of A3 can reduce the reject Assembly effectively and precisely.

Implementing a 4C Approach to Quality Improvement.

Designing a quality improvement activity can be labor intensive and intimidating to facilitators who have not been specially trained in process improvement methodologies. To simplify the process, a team was formed with the specific task of developing a basic model that addresses key concepts in change theory. The 2010 Institute of Medicine report stresses the importance of health care professionals working together, collaboratively, to use data to improve patient outcomes and improve care nationally. In addition, as noted in Quality and Safety Education for Nurses (2013), competencies have been developed to promote frontline problem solving including using data for quality improvement, providing safe care, functioning in collaborative teams, respecting and addressing patient and family concerns, applying evidence-based practice, and using informatics to make decisions. The team completed a search of the literature on change theory to identify the factors that are imperative to address when initiating a process improvement cycle. Kotter's Model of Change provided direction and guidance on the creation of the 4C model, which involves centering on issue, collaborating with team members, using the change process, and celebrating successes. This model has been implemented in a multihospital system as a framework for process improvement with such initiatives as preventing hospital-acquired infections, implementing patient safety initiatives, and addressing human resource concerns such as turnover and patient satisfaction.

What does it take to make integrated care work?

Within the EU, there are 10 million people with chronic heart failure (CHF), 20 million people with chronic obstructive pulmonary diseases (COPD), and 60 million people with diabetes (DM). These three conditions alone cost the EU healthcare systems around €125 billion a year. Care coordination and telehealth (CC&TH) services are an effective way to treat these patients in their homes. However, the adoption of these services is relatively slow. A primary reason that is hindering the adoption is the integration of these services into the care delivery structures of exiting routine care practices. So far, CC&TH has been directed at improving health outcomes, administrative efficiency and cost effectiveness. The Advancing Care Coordination & Telehealth Deployment (ACT) Programme is the first to explore the organisational and structural processes needed to successfully implement care CC&TH services on a large scale. This EU-funded programme includes a consortium of clinical experts, universities, industry partners, and authorities from 5 leading healthcare EU regions. The objective of the ACT programme is to analyse what needs to be done to effectively integrate CC&TH services and identify best practices in Europe. Five leading EU healthcare regions with broad experience in CC&TH care delivery have shared their experiences of program deployment and provided data for the assessment. Each region has a population of at least 3000 patients (CHF, COPD and DM). The participating regions are Lombardy (IT), Basque Country (ES), Catalonia (ES), Northern Netherlands (NL), and Scotland (UK). The ACT evaluation framework considers final outcomes on efficiency and efficacy, as well as process outcomes to measure the integration of the CC&TH deployment into routine care with respect to stratification, care coordination and workflow optimization, patient adherence, and staff engagement. Data (qualitative and quantitative) were collected at baseline (month 6) and during several iterations (month 14, 18 and 24). Data collection, storage, analysis and visualization is supported an evaluation engine. There are yet no generally accepted indicators for measuring the successful deployment of CC&TH at European level. Hence, such data is not easily shared or compared. Such limitations need to be acknowledged when interpreting results. Despite marked differences between participating programmes (e.g. target population, maturity level, funding schemes), a common way to present and evaluate these programmes with the terminology, data models and its evaluation framework and engine was developed during the ACT programme. This allowed the presentation and comparison of programmes in a common framework, where (relative) differences were highlighted, and enabled generalization of findings and knowledge transfer. Over 2500 survey responses and more than 90 datasets were collected and analysed. The insights, conclusions, recommendations and best practices were then incorporated into a ‘cookbook’ for large-scale deployment of CC&TH, from which some high level examples are given below. Our findings suggest that for staff engagement it is necessary to provide interventions in training, early engagement of staff, communication feedback loops, and recognition of professional expertise. Tailored adherence strategies that address the patient’s needs are required to achieve adherence, not only for clinical needs, but also social support and socio-economic needs. Furthermore, health risk assessment should employ a population-based approach. Although some of these findings may be appear intuitive or self-evident, it is important to stress that there actually is evidence for these findings. They are based on data from various operational deployments across Europe. Further details and examples are available in the cookbook and online (www.act-programme.eu). The assessment process using the evaluation framework and engine in the regions has been useful for the regions. Some examples of their practical impact are: - demonstration of good program outcomes to policy makers, - evidence of shifts towards primary care in utilization, but not in resources, - knowledge transfer between regions after highlighting relative strengths and weaknesses, and - benchmarking of programs within a region. Due to their complexity, each CC&TH deployment is unique. Despite the differences, the methodology and tools to assess these deployments, and a common way to present their relative strengths and weaknesses was successfully developed within the ACT programme. This approach has proven to be effective in creating knowledge transfer within and across the regions. As a next step, the ACT consortium intends to apply the framework and tools to monitor progress of deployment performance during iterative process improvement cycles. In addition, the consortium seeks to promote the structured development of generally accepted quality indicators for successful deployment of care strategies across Europe.

Improving Initiation and Tracking of Research Projects at an Academic Health Center: A Case Study

Research service cores at academic health centers are important in driving translational advancements. Specifically, biostatistics and research design units provide services and training in data analytics, biostatistics, and study design. However, the increasing demand and complexity of assigning appropriate personnel to time-sensitive projects strains existing resources, potentially decreasing productivity and increasing costs. Improving processes for project initiation, assigning appropriate personnel, and tracking time-sensitive projects can eliminate bottlenecks and utilize resources more efficiently. In this case study, we describe our application of lean six sigma principles to our biostatistics unit to establish a systematic continual process improvement cycle for intake, allocation, and tracking of research design and data analysis projects. The define, measure, analyze, improve, and control methodology was used to guide the process improvement. Our goal was to assess and improve the efficiency and effectiveness of operations by objectively measuring outcomes, automating processes, and reducing bottlenecks. As a result, we developed a web-based dashboard application to capture, track, categorize, streamline, and automate project flow. Our workflow system resulted in improved transparency, efficiency, and workload allocation. Using the dashboard application, we reduced the average study intake time from 18 to 6 days, a 66.7% reduction over 12 months (January to December 2015).

Elimination of waste: creation of a successful Lean colonoscopy program at an academic medical center.

Lean processes involve streamlining methods and maximizing efficiency. Well established in the manufacturing industry, they are increasingly being applied to health care. The objective of this study was to determine feasibility and effectiveness of applying Lean principles to an academic medical center colonoscopy unit. Lean process improvement involved training endoscopy personnel, observing patients, mapping the value stream, analyzing patient flow, designing and implementing new processes, and finally re-observing the process. Our primary endpoint was total colonoscopy time (minutes from check-in to discharge) with secondary endpoints of individual segment times and unit colonoscopy capacity. A total of 217 patients were included (November 2013-May 2014), with 107 pre-Lean and 110 post-Lean intervention. Pre-Lean total colonoscopy time was 134min. After implementation of the Lean process, mean colonoscopy time decreased by 10% to 121min (p=0.01). The three steps of the process affected by the Lean intervention (time to achieve adequate sedation, time to recovery, and time to discharge) decreased from 3.7 to 2.4min (p<0.01), 4.0 to 3.4min (p=0.09), and 41.2 to 35.4min (p=0.05), respectively. Overall, unit capacity of colonoscopies increased from 39.6 per day to 43.6. Post-Lean patient satisfaction surveys demonstrated an average score of 4.5/5.0 (n=73) regarding waiting time, 4.9/5.0 (n=60) regarding how favorably this experienced compared to prior colonoscopy experiences, and 4.9/5.0 (n=74) regarding professionalism of staff. One hundred percentage of respondents (n=69) stated they would recommend our institution to a friend for colonoscopy. With no additional utilization of resources, a single Lean process improvement cycle increased productivity and capacity of our colonoscopy unit. We expect this to result in increased patient access and revenue while maintaining patient satisfaction. We believe these results are widely generalizable to other colonoscopy units as well as other process-based interventions in health care.

Developing an ERP Triggered Business Process Improvement Cycle from a Case Company

ERP (enterprise resource planning) systems offer tremendous opportunities to more consistently provide information to organizations in a standardized, centralized, and cost efficient manner. One of the primary objectives for installing ERP is the ability to integrate business processes. After a period of ERP use, key users try to bring improvements in their areas. These improvements are also related with business processes. So, to collect the improvements also to check the systems functions are needed. To prevent ERP system from the containing disconnects in the processes, an audit cycle integrated with on-going reengineering of the business processes is necessary. In this article, we have examined the user request types and the structure of a case company. And developed a model that analysis and ERP request and integrates into a BPR (Business process reengineering) project and check the system's sustainability depending on an audit cycle.

A green productivity based process planning system for a machining process

In the metal cutting industry, manufacturers have strived to increase energy efficiency and to reduce environmental burdens through the use of dust collectors and waste disposers. It is more beneficial and efficient to apply the front-of-pipe technology that prevents the sources of pollutants and minimises energy use through the redesign of products and the change of process planning and machining operations. In particular, process planning for the environment, called eco-process planning, is central to increasing energy efficiency and reducing environmental burdens because process planning decisions greatly influence machining performance. At present, greenability, a term used to indicate environmental friendliness, has been little considered as a major concern in the process planning stage because process planning decisions have focused on improving productivity aspects that include speed, cost and quality. Thus, it is essential to develop an eco-process planning approach that enables the harmonisation and enhancement of greenability performance while improving productivity performance, termed green productivity (GP). This paper presents the development of a GP-based process planning algorithm that enables the derivation of process parameters for improving GP in machining operations. The core mechanism of the algorithm is the realisation of the process improvement cycle that measures GP performance by the collection of machining data, quantifies this performance by categorical representation and predicts the performance through prediction models. To show the feasibility and applicability of the proposed algorithm, we have conducted an experiment and implemented a prototype system for a turning machining process.

Iterative development of visual control systems in a research vivarium.

The goal of this study was to test the hypothesis that reintroduction of Continuous Performance Improvement (CPI) methodology, a lean approach to management at Seattle Children’s (Hospital, Research Institute, Foundation), would facilitate engagement of vivarium employees in the development and sustainment of a daily management system and a work-in-process board. Such engagement was implemented through reintroduction of aspects of the Toyota Production System. Iterations of a Work-In-Process Board were generated using Shewhart’s Plan-Do-Check-Act process improvement cycle. Specific attention was given to the importance of detecting and preventing errors through assessment of the following 5 levels of quality: Level 1, customer inspects; Level 2, company inspects; Level 3, work unit inspects; Level 4, self-inspection; Level 5, mistake proofing. A functioning iteration of a Mouse Cage Work-In-Process Board was eventually established using electronic data entry, an improvement that increased the quality level from 1 to 3 while reducing wasteful steps, handoffs and queues. A visual workplace was realized via a daily management system that included a Work-In-Process Board, a problem solving board and two Heijunka boards. One Heijunka board tracked cage changing as a function of a biological kanban, which was validated via ammonia levels. A 17% reduction in cage changing frequency provided vivarium staff with additional time to support Institute researchers in their mutual goal of advancing cures for pediatric diseases. Cage washing metrics demonstrated an improvement in the flow continuum in which a traditional batch and queue push system was replaced with a supermarket-type pull system. Staff engagement during the improvement process was challenging and is discussed. The collective data indicate that the hypothesis was found to be true. The reintroduction of CPI into daily work in the vivarium is consistent with the 4P Model of the Toyota Way and selected Principles that guide implementation of the Toyota Production System.

The A3 Problem Solving Report: A 10-Step Scientific Method to Execute Performance Improvements in an Academic Research Vivarium

The purpose of this study was to illustrate the application of A3 Problem Solving Reports of the Toyota Production System to our research vivarium through the methodology of Continuous Performance Improvement, a lean approach to healthcare management at Seattle Children's (Hospital, Research Institute, Foundation). The Report format is described within the perspective of a 10-step scientific method designed to realize measurable improvements of Issues identified by the Report's Author, Sponsor and Coach. The 10-step method (Issue, Background, Current Condition, Goal, Root Cause, Target Condition, Countermeasures, Implementation Plan, Test, and Follow-up) was shown to align with Shewhart's Plan-Do-Check-Act process improvement cycle in a manner that allowed for quantitative analysis of the Countermeasure's outcomes and of Testing results. During fiscal year 2012, 9 A3 Problem Solving Reports were completed in the vivarium under the teaching and coaching system implemented by the Research Institute. Two of the 9 reports are described herein. Report #1 addressed the issue of the vivarium's veterinarian not being able to provide input into sick animal cases during the work day, while report #7 tackled the lack of a standard in keeping track of weekend/holiday animal health inspections. In each Report, a measurable Goal that established the basis for improvement recognition was present. A Five Whys analysis identified the Root Cause for Report #1 as historical work patterns that existed before the veterinarian was hired on and that modern electronic communication tools had not been implemented. The same analysis identified the Root Cause for Report #7 as the vivarium had never standardized the process for weekend/holiday checks. Successful outcomes for both Reports were obtained and validated by robust audit plans. The collective data indicate that vivarium staff acquired a disciplined way of reporting on, as well as solving, problems in a manner consistent with high level A3 Thinking.