Process Improvement Interventions Research Articles

Determinants of door-in-door-out time in patients with ischaemic stroke transferred for endovascular thrombectomy.

Long door-in-door-out (DIDO) times are an important cause of treatment delay in patients transferred for endovascular thrombectomy (EVT) from primary stroke centres (PSC) to an intervention centre. Insight in causes of prolonged DIDO times may facilitate process improvement interventions. We aimed to quantify different components of DIDO time and to identify determinants of DIDO time. We performed a retrospective cohort study in a Dutch ambulance region consisting of six PSCs and one intervention centre. We included consecutive adult patients with anterior circulation large vessel occlusion, transferred from a PSC for EVT between October 1, 2019 and November 31, 2020. We subdivided DIDO into several time components and quantified contribution of these components to DIDO time. We used univariable and multivariable linear regression models to explore associations between potential determinants and DIDO time. We included 133 patients. Median (IQR) DIDO time was 66 (52-83) min. The longest component was CTA-to-ambulance notification time with a median (IQR) of 24 (16-37) min. DIDO time increased with age (6 min per 10 years, 95% CI: 2-9), onset-to-door time outside 6 h (20 min, 95% CI: 5-35), M2-segment occlusion (15 min, 95% CI: 4-26) and right-sided ischaemia (12 min, 95% CI: 2-21). The CTA-to-ambulance notification time is the largest contributor to DIDO time. Higher age, onset-to-door time longer than 6 h, M2-segment occlusion and right-sided occlusions are independently associated with a longer DIDO time. Future interventions that aim to decrease DIDO time should take these findings into account.

Implementing process improvements to enhance distress screening and management

While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer (eDT) and shares the process for deploying the (eDT) across a cancer institute by highlighting improvements at the provider, system, and clinic levels. Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. Technical EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic workflows were adapted to improve screening and distress management using the eDT. Stakeholder focus group participants (n=17) and survey respondents (n=13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management, and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 85% to 96% over a 1-year period. An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.

Reduction of Patient Harm Through Decreasing Urine Culture Contamination in an Emergency Department Using Multiple Process Improvement Interventions

BACKGROUND: From August 2018 to January 2019, the baseline urine sample contamination rate at an acute care hospital emergency department (ED) was 51%. Urine culture contamination is associated with unnecessary antibiotic use, repeat culture costs, and unnecessary inpatient admissions. These outcomes can lead to additional cost to the patient and healthcare system while leading to additional poor outcomes. METHODS: Culture results were reviewed and the project definition of contamination was applied. Contaminated cultures were reviewed further via manual electronic health record review of ED notes to determine documentation of collection source, education prior to clean catch collection, the cognitive and physical documented descriptions of the patient, and the name of the staff member who collected the sample. INTERVENTION: Staff were educated on appropriate midstream and straight catheter collection techniques, verbal along with picture education for patients, and appropriate identification of patients who may benefit from straight catheterization instead of clean catch. RESULTS: The combined interventions resulted in a six-month decrease of contaminated urine samples from the initial 51% to <10%, resulting in an 80% decrease. CONCLUSION: Urine culture contamination in an acute care ED was sustainably decreased through multiple process improvement interventions. Secondary outcomes included reduction in unnecessary antibiotic use, repeat urine cultures, and unnecessary admissions.

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A Model to Improve Care and Enhance the Physician-Patient Relationship for Hospitalized Patients With Opioid Use Disorder.

Opioid-related morbidity and mortality continues to accelerate, with increasing acute care events for opioid-related causes. Most patients do not receive evidence-based treatment for opioid use disorder (OUD) during acute hospitalizations despite this being an invaluable moment to initiate substance use treatment. Inpatient addiction consult services can bridge this gap and improve patient engagement and outcomes, but varying models and approaches are needed to match institutional resources. To improve care for hospitalized patients with OUD, a work group was formed at the University of Chicago Medical Center in October 2019. An OUD consult service, run by generalists, was created as part of a series of process improvement interventions. Important collaborations with pharmacy, informatics, nursing, physicians, and community partners have occurred over the last 3 years. The OUD consult service completes 40-60 new inpatient consults monthly. Between August 2019 and February 2022, the service completed 867 consults from across the institution. Most consult patients were started on medications for opioid use disorder (MOUD), and many received MOUD and naloxone at discharge. Patients who were treated by our consult service experienced lower 30-day and 90-day readmission rates compared with patients who did not receive a consult. Length of stay for patients receiving a consult was not increased. Adaptable models of hospital-based addiction care are needed to improve care for hospitalized patients with OUD. Continued work to reach a higher percentage of hospitalized patients with OUD and to improve linkage to care with community collaborators are important steps to strengthen the care received by individuals with OUD in all clinical departments.

Nursing Workforce Optimization Study: A Multi-method Evaluation and Process Improvement Intervention for HIV Service Delivery in Tanzania and Zambia.

Nurses are often suboptimally used in HIV care, due to misalignment of training and practice, workflow inefficiencies, and management challenges. We sought to understand nursing workforce capacity and support implementation of process improvement strategies to improve efficiency of HIV service delivery in Tanzania and Zambia. We conducted time and motion observations and task analyses at 16 facilities followed by process improvement workshops. On average, each nurse cared for 45 clients per day in Tanzania and 29 in Zambia. Administrative tasks and documentation occupied large proportions of nurse time. Self-reported competency was low at baseline and higher at follow-up for identifying and managing treatment failure and prescribing antiretroviral therapy. After workshops, facilities changed care processes, provided additional training and mentorship, and changed staffing and supervision. Efficiency outcomes were stable despite staffing increases. Collaborative approaches to use workforce data to engage providers in improvement strategies can support roll-out of nurse-managed HIV treatment.

Implementation Strategy Fidelity and Organizational Outcomes in a Randomized Trial: Implications for Reentry from Corrections to Community Treatment

Background: This study examined fidelity of implementation strategies used in an organizational process improvement intervention (OPII) designed to improve evidence-based practices related to assessments for drug-involved clients exiting incarceration. Leadership was studied as a moderating factor between fidelity and outcomes. Methods: A mixed-method cluster randomized design was used to randomize 21 sites to early- or delayed-start within 9 research centers. Parent study protocol was reviewed to develop fidelity constructs (i.e., responsiveness, dose, quality, adherence). Outcomes were site-level success in achieving goals and objectives completed during the OPII (e.g., percent goals achieved). Correlations, analyses of covariance, regressions and moderation analyses were performed. Qualitative interviews assessed facilitators/barriers to implementation. Results: Fidelity constructs related to outcomes. No differences were found in fidelity by early or delayed condition. At low levels of leadership, high staff responsiveness (i.e., engagement in the OPII) related to poorer outcome. Conclusions: It is important to consider contextual factors (e.g., leadership) that may influence implementation strategy fidelity when deploying evidence-based practices. Findings are relevant to researchers, clinicians, administrators and policy makers, and suggest that goal completion during implementation of evidence-based practices requires monitoring of leadership competence, fidelity to implementation strategies (i.e., staff responsiveness to strategies) and attendance to goal importance.

Creating conditions for effective knowledge brokering: a qualitative case study

BackgroundProcess improvement in healthcare is informed by knowledge from the private sector. Skilled individuals may aid the adoption of this knowledge by frontline care delivery workers through knowledge brokering. However, the effectiveness of those who broker knowledge is limited when the context they work within proves unreceptive to their efforts. We therefore need greater insight into the contextual conditions that support individuals to broker process improvement knowledge to the frontline of care delivery, and how policy makers and organizations might generate such conditions.MethodsOur research took place in a healthcare system within an Australian State. We undertook a qualitative, embedded single case study over the four year period of a process improvement intervention encompassing 57 semi-structured interviews (with knowledge brokers, policy makers, and executive sponsors), 12 focus groups, and 137 h of observation, which included the frontline implementation of actual process improvement initiatives, where knowledge brokering took place.ResultsWe identified four phases of the process improvement intervention that moved towards a more mature collaboration within which knowledge brokering by improvement advisors began to emerge as effective. In the first phase knowledge brokering was not established. In the second phase, whilst knowledge brokering had been initiated, the knowledge being brokered lacked legitimacy amongst frontline practitioners, resulting in resistance. Only in the fourth and final phase of the intervention did the collective experience of policy makers result in reflections on how they might engender a more receptive context for knowledge brokering.ConclusionWe highlight a number of suggested actions that policy makers might consider, if they wish to engender contextual conditions that support knowledge brokering. Policy makers might consider: ensuring they respect local context and experience, by pulling good ideas upward, rather than imposing foreign knowledge from on high; facilitating the lateral diffusion of knowledge by building cultural linkages between people and organizations; strengthening collaboration, not competition, so that trans-organisational flow of ideas might be encouraged; being friend, not foe, to healthcare organizations on their knowledge integration journey. In sum, we suggest that top-down approaches to facilitating the diffusion and adoption of new ideas ought to be reconsidered.

Strategic team engagement for successful documentation of pain management.

53 Background: Pain is experienced by a majority of cancer patients, often having a significant negative impact on their quality of life. Effective documentation of pain scores and plan of care provide care teams with data for decision-making to improve pain management. In Q2 of 2021 documentation deficiencies were identified. Process improvement interventions were initiated through the remainder of 2021 to support clinical teams. Methods: Over the course of twelve months our practice sought to improve documentation of pain management through a multi-pronged approach. Execution began with initiation of the Quality and Safety Committee early in 2021 to engage key stakeholders. Our Chain of Command Project identified strategic members of the administrative and clinical leadership teams at the individual clinic level who initiated monthly meetings to promote quality awareness and engagement. Quality measures associated with pain management, MIPS 143 and 144, were examined with assistance from our Value Based Care Transformation Team. Monthly provider scorecard distribution commenced Q2 to identify documentation inconsistencies related to pain management. Providers, medical assistants, and scribes were provided education and training related to appropriate pain management documentation workflows. Follow up audits were performed by the Quality team. In Q3 and Q4 the Quality team collaborated with Human Resources to identify new employees and facilitate education on quality metric capture within a month of hire. Results: The data above is a representation of all clinics and patients treated. The interventions resulted in improved metrics from 2020 to 2022 YTD: MIPS 143 +5.5%, MIPS 144 +27.3%, and PIMSH4 +6.3%. Conclusions: Effective change management occurred from the top down with additional engagement of administrative and clinical members. Analysis of the internal structure and deficiencies was needed with implementation of metric training. Data transparency helped with engagement and managing documentation of MIPS 143 and 144. Next steps include leveraging the current documentation processes to improve PIMSH4, ultimately improving the quality of life for patients.[Table: see text]

Implementing process improvements to enhance distress screening and management.

352 Background: While distress is prevalent among individuals living with cancer, distress management has not been optimized across cancer care delivery despite standards for screening. This manuscript describes the development of an enhanced Distress Thermometer(eDT) and shares the process for implementing the (eDT) across a cancer institute by highlighting process changes and improvements at the provider, system, and clinic levels. Methods: Focus groups and surveys were used at the provider-level to outline the problem space and to identify solutions to improve distress screening and management. Through stakeholder engagement, an eDT was developed and rolled out across the cancer institute. The eDT included pull down menus for each of the DT problem areas to provide detailed context of the specific issue. EHR infrastructure changes were implemented at the system-level to improve the use of the distress screening findings and generate automated referrals for specialty services. Clinic-level workflows were adapted to improve screening and distress management using the eDT. Patient-level data was collected to examine severity of distress and referral pathway utilization comparisons between original DT and eDT. Results: Stakeholder focus group participants (n = 17) and survey respondents (n = 13) found the eDT to be feasible and acceptable for distress identification and management. System-level technical EHR changes resulted in high accuracy with patient identification for distress management and 100% of patients with moderate to severe distress were connected directly to an appropriate specialty provider. Clinic-level workflow changes to expand eDT use improved compliance rates with distress screening from 86% to 98% over a 1 year period. We are currently analyzing utilization data based on distress screening at the patient level and will provide these results in the final presentation. Conclusions: An eDT that provides more context to patient-reported problems improved identification of referral pathways for patients experiencing moderate to high distress during cancer treatment and enhanced overall clinical use of the eDT. Combining process improvement interventions across multiple levels in the cancer care delivery system enhanced the success of this project. These processes and tools could support improved distress screening and management across cancer care delivery settings.

Interventions in the diagnosis and adoption of pacemaker therapy in sinus node dysfunction patients: Results from the IMPROVE Brady study

AimsIMPROVE Brady assessed whether a process improvement intervention could increase adoption of guideline-based therapy in sinus node dysfunction (SND) patients. Methods/Results: IMPROVE Brady was a sequential, prospective, quality improvement initiative conducted in India and Bangladesh. Patients with symptomatic bradycardia were enrolled. In Phase I, physicians assessed and treated patients per standard care. Phase II began after implementing educational materials for physicians and patients. Primary objectives were to evaluate the impact of the intervention on SND diagnosis and pacemaker (PPM) implant. SF-12 quality of life (QoL) and Zarit burden surveys were collected pre- and post-PPM implant.A total of 978 patients were enrolled (57.7 ± 14.8 years, 75% male), 508 in Phase I and 470 in Phase II. The diagnosis of SND and implantation of PPM increased significantly from Phase I to Phase II (72% vs. 87%, P < 0.001 and 17% vs. 32%, P < 0.001, respectively). Pacemaker implantation was not feasible in 41% of patients due to insurance/cost barriers which was unaltered by the intervention. Both patient QoL and caregiver burden improved at 6-months post-PPM implant (P < 0.001). ConclusionsA process improvement initiative conducted at centers across India and Bangladesh significantly increased the diagnosis of SND and subsequent treatment with PPM therapy despite the socio-economic constraints.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Advancing Nursing Science Through Site-Based Clinical Inquiry: Designing Problem Pyramids.

Resident-Driven Dysphagia Screening Protocol for Expedited Antithrombotic Delivery in Acute Ischemic Stroke.

We implemented a multi-disciplinary process improvement intervention at our Comprehensive Stroke Center with speech/language pathologists to expedite oral medication delivery in stroke patients. Following a failed nursing dysphagia screen, trained neurology physicians screened dysphagia further to approve use of oral medications. We analyzed the safety and efficacy of this intervention. We analyzed retrospectively collected data for hospital course, timing of first screen, first oral medication use, and complications (e.g., aspiration pneumonia) in consecutive ischemic stroke patients (9/2019-07/2021). Patients were included if they passed a dysphagia assessment by physicians (Ph), nurses (RN), or speech/language pathologists (SLP). Arrival-to-dysphagia screen and arrival-to-antithrombotic were assessed using restricted mean survival time (RMST). Of the 789 included patients, 673 were passed by RN, 104 by SLP, and 12 by Ph. Compared to patients passed by SLP, those passed by Ph were younger and had less severe deficits (P < .01 for both). Patients were screened more quickly by Ph than RN or SLP (median 38 vs 182 vs 1330-min post-arrival, P = .0001; 299-min RMST difference vs RN [95%CI 22-575, P = .03]; 470-min RMST difference vs SLP [95%CI 175-765, P = .002]). This translated to faster oral antithrombotic use for Ph-passed patients (138-min RMST difference vs RN [95%CI 59-216]; 332-min RMST difference vs SLP [95%CI 253-411]). No patients passed by Ph experienced aspiration pneumonia (0%). We safely conducted a physician-driven dysphagia screening paradigm which led to faster oral antithrombotic delivery without signal of patient harm. Physician availability to complete dysphagia screens in acute stroke patients was a limitation.

Abstract TP29: Physician-driven Dysphagia Screening Protocol For Expedited Medication Delivery In Acute Ischemic Stroke

Background: We implemented a multi-disciplinary process improvement (PI) intervention at a Comprehensive Stroke Center in cooperation with speech/language pathology in order to expedite oral medication delivery in patients with dysphagia. Following a failed nurse dysphagia screen, trained neurology providers were able to evaluate dysphagia further and approve the use of oral medications. Methods: We analyzed prospectively collected data from the PI intervention for timing of dysphagia screen, first oral antithrombotic, and aspiration pneumonia in ischemic stroke patients (9/2019-07/2021). Patients were included if they passed a dysphagia assessment by any provider, with comparisons made between patients who passed by physicians (Ph), nurses (RN) or speech/language pathologists (SLP). Results: Of the 789 included patients, 673 were passed by RN, 104 by SLP, and 12 by Ph. Compared to patients passed by SLP, those passed by Ph were younger and had less severe deficits (Table). Patients passed by Ph were screened more quickly than those screened by RN or SLP (median 38 vs. 182 vs. 1330 min after arrival, p=0.0001), and received first oral antithrombotic far more quickly (median 335 vs. 774 vs. 1409 min, p=0.0001). No patients passed by Ph experienced an aspiration pneumonia (0%), although there were non-significantly more pneumonias among patients passed by SLP (5%) and RN (2%, p=0.11). Conclusions: We safely conducted a physician-driven dysphagia screening paradigm which led to faster oral medication delivery, and no signal of patient harm.

Process Improvement Approaches for Increasing the Response of Emergency Departments against the COVID-19 Pandemic: A Systematic Review.

The COVID-19 pandemic has strongly affected the dynamics of Emergency Departments (EDs) worldwide and has accentuated the need for tackling different operational inefficiencies that decrease the quality of care provided to infected patients. The EDs continue to struggle against this outbreak by implementing strategies maximizing their performance within an uncertain healthcare environment. The efforts, however, have remained insufficient in view of the growing number of admissions and increased severity of the coronavirus disease. Therefore, the primary aim of this paper is to review the literature on process improvement interventions focused on increasing the ED response to the current COVID-19 outbreak to delineate future research lines based on the gaps detected in the practical scenario. Therefore, we applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform a review containing the research papers published between December 2019 and April 2021 using ISI Web of Science, Scopus, PubMed, IEEE, Google Scholar, and Science Direct databases. The articles were further classified taking into account the research domain, primary aim, journal, and publication year. A total of 65 papers disseminated in 51 journals were concluded to satisfy the inclusion criteria. Our review found that most applications have been directed towards predicting the health outcomes in COVID-19 patients through machine learning and data analytics techniques. In the overarching pandemic, healthcare decision makers are strongly recommended to integrate artificial intelligence techniques with approaches from the operations research (OR) and quality management domains to upgrade the ED performance under social-economic restrictions.

A Multi-Component Transition of Care Improvement Project to Reduce Hospital Readmissions Following Ischemic Stroke.

Ischemic stroke (IS) is a common cause of hospitalization which carries a significant economic burden and leads to high rates of death and disability. Readmission in the first 30 days after hospitalization is associated with increased healthcare costs and higher risk of death and disability. Efforts to decrease the number of patients returning to the hospital after IS may improve quality and cost of care. Improving care transitions to reduce readmissions is amenable to quality improvement (QI) initiatives. A multi-component QI intervention directed at IS patients being discharged to home from a stroke unit at an academic comprehensive stroke center using IS diagnosis-driven home care referrals, improved post-discharge telephone calls, and timely completion of discharge summaries was developed. The improvement project was implemented on July 1, 2019, and evaluated for the 6 months following initiation in comparison to the same 6-month period pre-intervention in 2018. Following implementation, a statistically significant decrease in 30-day all-cause same-hospital readmission rates from 7.4% to 2.8% (p = .031, d = 1.61) in the project population and from 6.6% to 3% (p = .010, d = 1.43) in the overall IS population was observed. Improvement was seen in all process measures as well as in patient satisfaction scores. An evidence-based bundled process improvement intervention for IS patients discharged to home was associated with decreased hospital readmission rates following IS.

Rural Residence and Factors Associated with Attendance at the Second High-Risk Infant Follow-up Clinic Visit for Very Low Birth Weight Infants in California.

This study was aimed to determine factors associated with attendance at the second high-risk infant follow-up (HRIF) visit (V2) by 20 months of corrected age after a successful first visit (V1), and the impact of rural residence on attendance rates in a statewide population of very low birth weight (VLBW; <1,500 g) infants. Data linked from the California Perinatal Quality of Care Collaborative (CPQCC) Neonatal Intensive Care Unit (NICU) database and CPQCC-California Children's Services (CCS) HRIF database. Multivariable logistic regression evaluated independent associations of sociodemographic, maternal, family, neonatal clinical, and individual HRIF program differences (factors) with successful V2 in VLBW infants born in 2010 to 2012. Of 7,295 eligible VLBW infants, 75% (5,475) attended V2. Sociodemographic factors independently associated with nonattendance included maternal race of Black (adjusted odds ratio [aOR] = 0.61; 95% confidence interval [CI]: 0.5-0.75), public insurance (aOR = 0.79; 95% CI: 0.69-0.91), and rural residence (aOR = 0.74; 95% CI: 0.61-0.9). Factors identified at V1that were associated with V2 attendance included attending V1 within the recommended window (aOR = 2.34; 95% CI: 1.99-2.75) and early intervention enrollment (aOR = 1.39; 95% CI: 1.12-1.61). Neonatal factors associated with attendance included birth weight ≤750 g (aOR = 1.83; 95% CI: 1.48-2.5). There were significant program differences with risk-adjusted rates ranging from 43.7 to 99.7%. Sociodemographic disparities and HRIF program factors are associated with decreased attendance at V2 among VLBW infants. These findings highlight opportunities for quality and process improvement interventions starting in the NICU and continuing through transition to home and community to assure participation in HRIF. · Only 75% of VLBW infants attended the second HRIF visit.. · Those less likely to attend were Black or had rural residence.. · Infants in early intervention or attending first visit within recommended ages were more likely to attend..

Assessing the functionality of an emergency obstetric referral system and continuum of care among public healthcare facilities in a low resource setting: an application of process mapping approach

BackgroundWeak referral systems remain a major concern influencing timely access to the appropriate level of care during obstetric emergencies, particularly for Low-and Middle-Income Countries, including Ghana. It is a serious factor threatening the achievement of the maternal health Sustainable Development Goal. The objective of this study is to establish process details of emergency obstetric referral systems across different levels of public healthcare facilities to deepen understanding of systemic barriers and preliminary solutions in an urban district, using Ablekuma in Accra, Ghana as a case study.MethodsThe study is an analytical cross-sectional study. Nine [1] targeted interviews were carried out for a three-week period in June and July 2019 after informed written consent with two [2] Obstetrics & Gynaecology consultants, two [2] Residents, one family physician, and four [3] Midwives managing emergency obstetric referral across different levels of facilities. Purposeful sampling technique was used to collect data that included a narration of the referral process, and challenges experienced with each step. Qualitative data was transcribed, coded by topics and thematically analysed. Transcribed narratives were used to draft a process map and analyze the defects within the emergency obstetric referral system.ResultsOut of the 34 main activities in the referral process within the facilities, the study identified that 24 (70%) had a range of barriers in relation to communication, transport system, resources (space, equipment and physical structures), staffing (numbers and attitude), Healthcare providers (HCP) knowledge and compliance to referral policy and guideline, and financing for referral. These findings have implication on delay in accessing care. HCP suggested that strengthening communication and coordination, reviewing referral policy, training of all stakeholders and provision of essential resources would be beneficial.ConclusionOur findings clearly establish that the emergency obstetric referral system between a typical teaching hospital in an urban district of Accra-Ghana and peripheral referral facilities, is functioning far below optimum levels. This suggests that the formulation and implementation of policies should be focused around structural and process improvement interventions, strengthening collaborations, communication and transport along the referral pathway. These suggestions are likely to ensure that women receive timely and quality care.

A Plan-Do-Check-Act Based Process Improvement Intervention for Quality Improvement

Waste from raw materials has a direct influence on the final price of a product. However, since waste has no added value to products, customers are unwilling to pay for it. Reducing waste along the production process and supply chain allows companies to decrease costs and remain competitive in product prices. This research is conducted in a medical device manufacturing company located in Tijuana (Mexico). The company found a negative variation in part number 9540, a metallic foil used for hot stamping. During inventory cycle counts, the company found that they were purchasing rawer material than necessary due to a 50% of waste generated along the production process. We implemented two process improvement methodologies, namely Practical Process Improvement (PPI) and the Plan-Do-Check-Act model, to eliminate 100% of the raw material waste, specifically regarding the foil’s waste. The improvement project comprised two phases: a) adjusting the parameters of the hot foil stamping machine and b) replacing the hot foil stamping machine with a pad printing machine. In our research, the PPI methodology is presented in 8 detailed stages as a simple problem-solving method, in contrast with five stages reported in other documented cases. This case study presents how a company can apply continuous improvement programs and its managerial implications, even without having a structured and defined systems for quality, such as Six Sigma or Lean Manufacturing implemented. After the two implementation phases, the improvement project led to economic savings of $\$ $ 165,000 in a year.

1045: A Process Improvement Intervention to Decrease Cardiac Thrombi During Liver Transplantation

1045: A Process Improvement Intervention to Decrease Cardiac Thrombi During Liver Transplantation