Process Improvement Strategies Research Articles

Redesigning the Patient Observer Model to Achieve Increased Efficiency and Staff Engagement on a Surgical Trauma Inpatient Unit

Provision of safe and efficient observer care to inpatients whose behavior puts them at risk for injury is a clinically challenging and costly endeavor for hospitals. At Massachusetts General Hospital (MGH; Boston), process improvement strategies were deployed to provide staff with an improved clinical model for patient observation, unit-based responsibility for allocating resources, and strategies to maintain a safer environment. In a surgical trauma unit at MGH, a team of nursing leaders and clinicians created an innovative process to identify, assess, and develop best practices for ensuring patient safety in the hospital environment. Patients with delirium were identified as the most prevalent and concerning patient group, and specific interventions were developed to address their unique needs. From December 2012 through June 2014, the team successfully piloted the best practices (July 16, 2013-September 30, 2013) and implemented them. The baseline outcome metric of patient observer direct-care hours decreased from a median of 208 hours/week (January 1, 2012-July 13, 2013) to a median of 112 hours/week (July 14, 2013-June 28, 2014); a 46% decrease in utilization. Fall rate (falls per 1,000 patient-days) remained unchanged postimplementation, and staff satisfaction with the patient observer model increased from 9% to 72%, while costs associated with providing observer care remained stable. Providing the inpatient unit staff with the knowledge and tools needed to optimally manage patients with at-risk behaviors, including delirium, significantly decreased the number of staff hours spent at the bedside providing observation, did not negatively affect the unit fall rate, and increased staff engagement at no additional expense to the unit.

A Six Sigma Trial For Reduction of Error Rates in Pathology Laboratory.

A major target of quality assurance is the minimization of error rates in order to enhance patient safety. Six Sigma is a method targeting zero error (3.4 errors per million events) used in industry. The five main principles of Six Sigma are defining, measuring, analysis, improvement and control. Using this methodology, the causes of errors can be examined and process improvement strategies can be identified. The aim of our study was to evaluate the utility of Six Sigma methodology in error reduction in our pathology laboratory. The errors encountered between April 2014 and April 2015 were recorded by the pathology personnel. Error follow-up forms were examined by the quality control supervisor, administrative supervisor and the head of the department. Using Six Sigma methodology, the rate of errors was measured monthly and the distribution of errors at the preanalytic, analytic and postanalytical phases was analysed. Improvement strategies were reclaimed in the monthly intradepartmental meetings and the control of the units with high error rates was provided. Fifty-six (52.4%) of 107 recorded errors in total were at the pre-analytic phase. Forty-five errors (42%) were recorded as analytical and 6 errors (5.6%) as post-analytical. Two of the 45 errors were major irrevocable errors. The error rate was 6.8 per million in the first half of the year and 1.3 per million in the second half, decreasing by 79.77%. The Six Sigma trial in our pathology laboratory provided the reduction of the error rates mainly in the pre-analytic and analytic phases.

Contemporary 21st century therapeutic jurisprudence in civil cases: Building bridges between law and psychology

Contemporary 21st century therapeutic jurisprudence in civil cases: Building bridges between law and psychology

Development of Dynamic Lean Six Sigma Model for Enhancing Stability, Capability and Robustness Metrics in Small and Medium Enterprises and Pilot Implementation in a Plastic Industry

Lean and six sigma are key business process strategies, which are employed by companies to enhance their manufacturing performance. Lean and Six Sigma are two widely acknowledged business process improvement strategies available to manufacturing organisations today for achieving dramatic results in cost, quality and time by focusing on process performance. In the current manufacturing scenario, many of the large scale manufacturing industries are adopting the Lean Six Sigma (LSS) concepts for the sustainable development. However, the manufacturing industry belongs to small and medium enterprises (SME) are unable to effectively adopt the LSS concepts. This is due to the reason that the SME are following the stringent production orders, schedule, routing, and production deficiencies with meticulous due date requirements. There are many LSS models are already available for large scale, medium scale and small scale manufacturing industries. However, there is no exclusive integrated model for manufacturing industries of SME. This situation indicates the need for developing a dynamic model that can enable the implementation of the LSS concept for achieving prosperity in SME. Hence the main purpose of this investigation is to develop and implement a dynamic Lean Six Sigma Model (DLSS) for enhancing stability, capability and robustness metrics in a systematic and streamlined manner. Due to the response and commitment for follow up initiatives, a small scale plastic industry has been considered in this investigation. The level of response, practicality and willingness for adopting the change management with respect to LSS concepts are found to be appreciable in that small scale plastic industry. After pilot investigation, it is suggested that the advanced LSS concepts by applying certain optimization techniques can also be initiated in SME for achieving more effectiveness. Thus, the proposed framework systematically integrates the required LSS tools such as current state map, 5S System, design of experiments and Define-Measure-Analyse-Improve-Control (DMAIC) methodology to enhance the performance of the SME to enhance the overall bottom-line results and win customer loyalty progressively. In future, the developed model can be reviewed and revised suitable to face the real time difficulties.

HCP-12IMPROVING THE EFFICIENCY OF MOLECULAR TESTING FOR EXPEDITED BRAIN TUMOR PATIENT MANAGEMENT AND CLINICAL TRIAL ENROLLMENT

BACKGROUND: O6-methylguanine methyltransferase (MGMT) methylation status is prognostic in glioblastoma. It is a critical datum in optimizing care in elderly glioblastoma patients. Further, MGMT methylation status is increasingly required for clinical trial enrollment (e.g. NCT02336165, NCT02287428). As such, maximizing efficiency of molecular tumor testing is critical in order to provide the best care for glioblastoma patients. METHODS: Using the longitudinal electronic medical record and pathology sample tracking systems, we determined the turn around time (TAT) from tumor resection to MGMT methylation status reporting, along with various intermediate steps along the way. We performed interdepartmental process mapping to identify opportunities for process change, followed by 2 process interventions with follow-up tracking of TAT with statistical process control testing. RESULTS: The baseline average interval from craniotomy to MGMT methylation result was 25.1 days for the 30 weeks prior to intervention, which included ∼5 days from craniotomy to pathological diagnosis, and ∼18 days from pathological diagnosis to MGMT result. Two tests of change were implemented, including a switch from batched to daily DNA extraction and MGMT methylation testing, and implementation of a new procedure for pathology sample inventory within the molecular pathology laboratory. The median time from craniotomy to MGMT methylation status reporting was reduced to from 25.1 days to 17 days after the first intervention, and to 15 days after the second intervention, with significant TAT reduction. CONCLUSIONS: Through clinical process improvement strategies and interdepartmental collaboration, we significantly reduced the TAT from craniotomy to MGMT methylation status reporting by an average of 10 days (40%). This allows for improved patient care by accelerating the delivery of potentially treatment-altering information as well as supplying earlier eligibility information for clinical trial enrollment. We continue to study additional opportunities for intervention, as this work highlights the possibility for neuro-oncology care improvement through process improvement strategies.

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives

BackgroundThe testing and result communication process in primary care is complex. Its successful completion relies on the coordinated efforts of a range of staff in primary care and external settings...

Leadership model key to developing a successful, person-centered memory care workforce

It is imperative that long-term care begins to utilize leadership programs that espouse a person-centered approach by all staff, particularly for memory care. Staff whose needs are met are able to focus on the needs of the residents and families for whom they care. Employees who are prepared for their role - educated, supported, included in decisions, valued, cared for and nurtured - have greater job satisfaction and enhanced performance, and in turn will provide enhanced dementia care for those they serve. This session will share a “people-centered” organizational and leadership model, “SERVICE,” developed in a successful Alzheimer's facility. SERVICE is grounded in the literature and based on 25 years of operational experience, incorporating domains of practice including: Service; Education; Respect; Vision; Inclusion; Communication; and Enrichment. Specifically, this program will address components essential to a culture of staff engagement, satisfaction and retention specific to memory and dementia care, including: 1) successful staff selection; 2) interviewing strategies; 3) vision and mission; 4) staff orientation; 5) ongoing education and support; 6) providing a stimulating and motivating environment; 7) staff participation/ownership; 8) monitoring techniques; and 9) recognizing and celebrating accomplishments. Additional components to be discussed include expectations for performance, respect as a foundation, shared visioning, and creating an enriching environment for those who live and work in the community. Success is found in ongoing evaluation, process improvement strategies and collective information sharing, which will also be addressed. Attendees will learn how person-centered memory care based on the needs of residents, families and staff is addressed by the model and the impact made on resident and staff satisfaction, employee retention, facility reputation and overall quality. Research and results on the initial framework will be discussed, including a 90% employee retention rate and 98.5% family recommendation rate, multiple consecutive deficiency-free surveys, and several state and national awards. Outcomes from the replication of the model from other organizations will be shared as well as practical, effective tools and ideas for attendees to develop an effective memory care staff culture in their own environment.

Using lean principles to improve outpatient adult infusion clinic chemotherapy preparation turnaround times

The workflow and chemotherapy preparation turnaround times at an adult infusion clinic were evaluated to identify opportunities to optimize workflow and efficiency. A three-phase study using Lean Six Sigma methodology was conducted. In phase 1, chemotherapy turnaround times in the adult infusion clinic were examined one year after the interim goal of a 45-minute turnaround time was established. Phase 2 implemented various experiments including a five-day Kaizen event, using lean principles in an effort to decrease chemotherapy preparation turnaround times in a controlled setting. Phase 3 included the implementation of process-improvement strategies identified during the Kaizen event, coupled with a final refinement of operational processes. In phase 1, the mean turnaround time for all chemotherapy preparations decreased from 60 to 44 minutes, and a mean of 52 orders for adult outpatient chemotherapy infusions was received each day. After installing new processes, the mean turnaround time had improved to 37 minutes for each chemotherapy preparation in phase 2. In phase 3, the mean turnaround time decreased from 37 to 26 minutes. The overall mean turnaround time was reduced by 26 minutes, representing a 57% decrease in turnaround times in 19 months through the elimination of waste and the implementation of lean principles. This reduction was accomplished through increased efficiencies in the workplace, with no addition of human resources. Implementation of Lean Six Sigma principles improved workflow and efficiency at an adult infusion clinic and reduced the overall chemotherapy turnaround times from 60 to 26 minutes.

A unique solution for principal component analysis-based multi-response optimization problems

A procedure to find a unique solution for multi-response optimization problems based on indexing is presented. The procedure utilizes principal component analysis to map the original data to a new vector of component scores, transforming the original response variables into uncorrelated principal components. This process involves loadings that are the elements of the eigenvectors corresponding to the eigenvalues of response variables in the correlation matrix. It is shown that for a given eigenvalue λ, its corresponding eigenvectors are not unique, which could lead to different “optimal” parametric (factor-level) settings and will further mislead the process or product improvement strategy. The proposed indexing method will determine a unique optimal solution in the presence of (2p)(p!) combinations of eigenvectors.

Efficacy of a Process Improvement Intervention on Inmate Awareness of HIV Services: A Multi-Site Trial.

BackgroundThe prevalence of HIV among U.S. inmates is much greater than in the general population, creating public health concerns and cost issues for the criminal justice system. The HIV Services and Treatment Implementation in Corrections protocol of the NIDA funded Criminal Justice Drug Abuse Treatment Studies tested the efficacy of an organizational process improvement strategy on improving HIV services in correctional facilities.MethodsFor this paper, we analyzed efficacy of this strategy on improving inmate awareness and perceptions of HIV services. The study used a multi-site (n = 28) clustered randomized trial approach. Facilities randomized to the experimental condition used a coach-driven local change team approach to improve HIV services at their facility. Facilities in the control condition were given a directive to improve HIV services on their own. Surveys about awareness and perceptions of HIV services were administered anonymously to inmates who were incarcerated in study facilities at baseline (n = 1253) and follow-up (n = 1048). A series of one-way ANOVAs were run to test whether there were differences between inmates in the experimental and control facilities at baseline and follow-up.ResultsDifferences were observed at baseline, with the experimental group having significantly lower scores than the control group on key variables. But, at post-test, following the intervention, these differences were no longer significant.ConclusionsTaken in context of the findings from the main study, these results suggest that the change team approach to improving HIV services in correctional facilities is efficacious for improving inmates’ awareness and perceptions of HIV services.Electronic supplementary materialThe online version of this article (doi:10.1186/s40352-015-0023-5) contains supplementary material, which is available to authorized users.

The application of systems biology to biomanufacturing

‘omics and systems biology have led to paradigm shifts in biology and medicine. This success has drawn the attention of the bioprocessing industry where their application is increasingly more prevalent. systems biology uses system-level high dimensional data generated via ‘omics technologies to provide a holistic view of the production cell lines. We discuss how systems biology drives rational process improvement and cell engineering strategies, highlighting seminal studies in prokaryotes and mammalian cell lines that combined multi-‘omics and modeling to provide insights into the behavior of production cell lines. Despite its recognized potential, there are challenges and limitations to overcome to fully implement and realize benefits heralded by systems biology for biomanufacturing: increasing titer, yield, quality, process efficiency and stability.

Comparison of Fe–Mn enhanced coagulation and O3-BAC for removing natural organic matter from source waters: a case study

This plant-scale investigation compared two process improvement strategies for Lianyungang drinking water treatment plant (L-DWTP), a typical plant employing conventional processes to treat source water impacted by seasonal non-point pollution. Hierarchical cluster analysis grouped it into two clusters, i.e. normal period and polluted period. Originally, the L-DWTP exhibited poor organic matter removal efficiency, and 76.7% of the effluent permanganate index (CODMn) levels exceeded the state regulation requirement (<3 mg/L). In addition, chloroform concentration was observed to exceed the regulation requirement (60 μg/L) by 14.2 and 56.2% in normal and polluted periods. The combined use of FeCl3 and KMnO4 (Fe–Mn enhanced coagulation) increased the CODMn removal efficiency by 10.6%, and decreased the chloroform formation by 26.4%. It indicates that about 94.5% of effluent CODMn values and nearly all of chloroform levels may meet the standard in normal period. However, Fe–Mn enhanced coagulation shows limitation in polluted period. The advanced treatment by ozone-biological activated carbon process (O3-BAC) increases the CODMn removal efficiency by 29.5%, and decreases the chloroform formation by 43%, indicating that effluent levels may meet the standard both in normal and polluted periods. Cost was also compared, and the extra cost for Fe–Mn enhanced coagulation is only about 20% of that for O3-BAC. In conclusion, O3-BAC works well both in normal and polluted periods. Fe–Mn enhanced coagulation only shows good performance in normal period, but is more economical. Therefore, it is proposed to use Fe–Mn enhanced coagulation in normal period, while O3-BAC during polluted period. These obtained plant-scale data are valuable to optimize the operation of DWTPs with similar challenges.

Early Identification of Individuals with Poorly Controlled Diabetes Undergoing Elective Surgery: Improving A1c Testing in the Preoperative Period

To describe a process improvement strategy that increased the identification of individuals with poorly controlled diabetes (glycated hemoglobin [A1C] ≥8%) undergoing elective surgery at a major academic medical center and increased their access to specialist care. An algorithm was developed to ensure A1C measurements were obtained as per the American Association of Clinical Endocrinologists/American Diabetes Association (AACE/ADA) guidelines. The diabetes management team worked collaboratively with anesthesiologists, surgeons, and preoperative nurse practitioners to improve the glycemic control of patients with an A1C ≥8%. Before implementing the program, A1C testing was recorded in 854 out of 2,335 (37%) patients with diabetes seen in the preoperative clinic from January 1, 2011 to December 31, 2012. The program was instituted in February 2013. From February 2013 to February 2014, A1C testing occurred in 1,236 out of 1,334 (93%) patients with diabetes. After excluding those scheduled for same day surgery, 228 patients were considered high risk with A1C ≥8%, and 175 were available for endocrine preoperative consultation. The program led to significant blood glucose level improvements on the day of surgery. A process improvement strategy to evaluate and treat diabetes in the preoperative period of elective surgery patients was implemented by a multidisciplinary team (endocrinologists, nurse practitioners, anesthesiologists, and surgeons) and resulted in a substantial improvements in obtaining A1C tests, access to specialist diabetes care, and glycemic control on the day of surgery. The impact of improved glycemic control on hospital and surgical outcomes needs further evaluation.

Transforming the Patient Experience through Lean Initiatives: Improving Care for Our Brachytherapy Patients

Transforming the Patient Experience through Lean Initiatives: Improving Care for Our Brachytherapy Patients

Facilitation of Clinical Chart Audits: The Examination of a Potential Leadership Process Improvement Strategy within the Radiation Therapy Department of the R. S. McLaughlin Durham Regional Cancer Centre

Facilitation of Clinical Chart Audits: The Examination of a Potential Leadership Process Improvement Strategy within the Radiation Therapy Department of the R. S. McLaughlin Durham Regional Cancer Centre

A theoretical framework for requirements engineering and process improvement in small and medium software companies

Purpose– Requirements engineering (RE) and process improvement has been identified as one of the key factors for improving software quality. Despite this, little scholarly work has been done on developing ways to improve the RE process. The situation of RE and process improvement is even worse in small and medium enterprises that produce software. Consequently, the quality of software being produced by these companies has kept deteriorating. The purpose of this paper is to design a framework that will help small and medium software companies improve their RE processes in order to compete favorably with larger software companies, more especially in terms of software quality.Design/methodology/approach– A qualitative research approach was adapted. Four software companies in Uganda were purposively selected to participate in the study. Data were collected using questionnaires. The requirements for designing the framework were gathered and refined from both primary and secondary data.Findings– The key requirements for process improvement in small and medium software companies were identified as user involvement, use of evolutionary requirements engineering process improvement (REPI) strategy, change management, training and education, management support and commitment.Practical implications– The designed framework was validated to ensure that it can be applied in RE and process improvement in small and medium software companies. Validation results show that the proposed framework is applicable and can be used to improve RE and process improvement in small and medium software companies.Originality/value– The paper presents an improvement of the systematic approach to REPI by Kabaale and Nabukenya which is decomposed for easy understanding by non-technical readers and users.

Management of pain, agitation, and delirium in critically ill patients

Pain, agitation, and delirium (PAD) are common in critically ill patients. Consequently, analgesic and sedative medications are frequently administered to critically ill patients to treat PAD, to improve synchrony with mechanical ventilation, and to decrease the physiological stress response. However, prolonged, continuous deep sedation of intensive care unit (ICU) patients is associated with numerous adverse outcomes, including longer durations of mechanical ventilation, prolonged ICU stays, acute brain dysfunction, and an increased risk of death. The 2013 ICU PAD Guidelines were developed to provide a clear, evidence-based road map for clinicians to better manage PAD in critically ill patients. Significant knowledge gaps in these areas still remain, but if widely adopted, the PAD Guidelines can help bridge these gaps and will be transformative in terms of their impact on ICU care. Strong evidence indicates that linking PAD management strategies with ventilator weaning, early mobility, and sleep hygiene in ICU patients will result in significant synergistic benefits to patient care and reductions in costs. An interdisciplinary team-based approach, using proven process improvement strategies, and ICU patient and family activation and engagement, will help ensure successful implementation of the ICU PAD Care Bundle in ICUs. This paper highlights the major recommendations of the 2013 ICU PAD Guidelines. We hope this review will help ICU physicians and other health care providers advance the management of PAD in critically ill patients, and improve patients' clinical outcomes.

The effect of a local change team intervention on staff attitudes towards HIV service delivery in correctional settings: a randomized trial.

The National Criminal Justice Drug Abuse Treatment Studies research program conducted cluster randomized trials to test an organizational process improvement strategy for implementing evidence-based improvements in HIV services for preventing, detecting, and/or treating HIV for individuals under correctional supervision. Nine research centers conducted cluster randomized trials in which one correctional facility used a modified Network for Improvement of Addiction Treatment (NIATx) change team approach to implementing improved HIV services and the other facility used their own approach to implement the improved HIV services. This paper examines whether the intervention increased the perceived value of HIV services among staff of correctional and community HIV organizations. Baseline and follow-up measures of the perceived acceptability, feasibility, and organizational support for implementing HIV service improvements were collected from correctional, medical, and community HIV treatment staff. Results indicated that the perceived acceptability and feasibility of implementing HIV services improved among staff in the facilities using the modified NIATx change team approach as compared to staff in the comparison facilities.

Developments in the fermentation process and quality improvement strategies for mead production.

Mead is a traditional alcoholic drink derived from the fermentation of diluted honey in the presence of appropriate yeast. Its modern production, in general terms, involves the addition of nutrients to initial diluted honey, pasteurization, yeast inoculation, fermentation and removal of impurities. Undesirable events along the process have been reported; among them, we highlight: delayed or arrested fermentations, modified and unpleasant sensory and quality parameters of the final product. These problems have been linked to the inability of yeasts to accomplish their role in extreme growth conditions. Emphasis has also been placed on the long fermentation times required, ranging from weeks to months, particularly when traditional procedures are applied and when the honey concentration is low. A series of alterations to the must and technological changes have been proposed in order to optimize the mead production process. In this context, this review examines the evidence that aims to improve meads’ quality and make the production process easier and more efficient, by clarifying the source of unexpected events, describing the implementation of different fermentative microorganisms and using new methodologies.

Evolving leadership in healthcare design.

Nurses and other healthcare professionals have always had opportunities for diverse careers. Healthcare professionals can advance into management, education, specialized clinical practice, schools, sports teams, and even the movie industry. This issue of HERD discusses how healthcare professionals and those involved in healthcare design are using their art, expertise, and critical thinking skills improve both patient care and the built environment.Billions of dollars have been spent in the design and construction of healthcare facilities since the building boom of the 1990s. As a result, the healthcare design industry has had several opportunities evaluate the effectiveness of the built environment improve the patient experience and enhance the work environment for healthcare professionals. Perhaps a result of this building boom, or perhaps because of the pioneering spirit it engendered, nurses and other healthcare professionals began enter the design and construction industry integrate their perspective and expertise into the design and of healthcare facilities. Today, many healthcare professionals, especially nurses, are long-standing employees of architectural firms.A survey completed by the Nursing Institute of Healthcare Design (NIHD) found that nurses have been employed by architectural firms or the design industry since the early 1980s. The roles of physicians, nurses, and others have included visioning, strategic planning, operational improvement, space programming, team liaison, and conceptual thinking. Their roles have evolved include advising on the healthcare facility guidelines, technology and equipment development, interior design, architecture, product development and implementation, simulation modeling, and research.Those of us who work in the healthcare design industry may think of a building or a specific environment when we hear the word design. However, healthcare design encompasses so much more. The word design means to plan and fashion artistically or skillfully. Nursing is both an art and a skill. Nurses work artfully develop rapport with their patients and their families, design solutions motivate patients who are uninvolved in their care, creatively schedule analgesia manage a patient's pain, find solutions for the patient who cannot sit up by him- or herself, and create workarounds when the proper equipment or supplies are not available. Skill is related the knowledge base, training, and critical thinking required care for a myriad of disease processes that a nurse faces over the course of a day, week, or year. The right combination of art and skill cannot be readily observed or taught and the value of this insight in the design process is irreplaceable. The nurse and other healthcare professionals possess a combination of skill, knowledge, awareness, and experience that has a positive impact the design of the care delivery model as well as the design solution for the supporting environment.Today, that art and skill is being used lead the design of the future healthcare delivery model. The leadership opportunities in the domain of design are plentiful. The Spheres of Influence in Figure 1 illustrate how the healthcare professional's expertise permeates the patient care environment. The influence may or may not have a direct correlation an end-product within the environment; however, all dimensions require leadership, clinical knowledge, and advocacy for both patients as well as other staff members. The concentric circles demonstrate how the strength and influence of the clinician's leadership, knowledge, and advocacy can impact the end result of the project, both the clinical aspects as well as the design of the built environment.The first sphere (orange) demonstrates how healthcare professionals have the opportunity use their knowledge influence strategic planning within the healthcare system, collaborate with the development of patient access solutions, lead safety and quality initiatives, impact the future care delivery model, and identify and implement process improvement strategies. …