Numerous studies have identified a relationship between staffing levels and nurse-sensitive outcomes for medical and surgical patients, but little has been published on the impact of nurse-sensitive outcomes for the childbearing family and even less that examines the relationship of intrapartum staffing on adverse perinatal outcomes.
The more cumbersome it is for someone to engage in improvement work, the less likely they are to do so. I think that the key is: People need to feel empowered, but it can't be just lip service. It has to go that extra step, where people recognize and see that they are empowered.
On July 13, 1950, Dr. Deming was invited to meet with 21 presidents of Japan's leading industries representing about 80 percent of the country's capital. Dr. Deming told the Japanese presidents many things on this day, the most important being that if the Japanese followed his teachings that the world would be screaming for protection from their quality products within five years. According to Dr. Deming, "they did it in four (years)."
Wondering how you can become a process professional with high impact in your organization? Here are ten (well, really eight) habits of successful process professionals. Spoiler Alert: Focus on listening. Listen to the business. Listen to your customers. Listen to your employees.
Process improvements have become a main goal at hospitals, particularly as demands for greater efficiency in care delivery rise alongside care costs and pressures to improve outcomes. Hospitals can facilitate these improvements by first explaining to staff why the changes are necessary, then encouraging leaders to champion the improvements by tying their evaluations to the outcome, as well as ensuring staff and leaders have the skills necessary to achieve those goals.
As many IEs in Healthcare, Mark Odom started his career in manufacturing right out of college. He has found many valuable lessons from manufacturing that he now uses as the CIO of St. Benards Healthcare.
Kaiser Health News staff writer Julie Appleby, working in collaboration with USA Today, reports: "When a car rolls off an assembly line, the automaker knows exactly what parts, labor and facilities cost. Not so in health care, and now some health executives are trying to change that. Although U.S. hospitals account for the single largest chunk of the nation's $2.7 trillion in health spending, few of them can say how much it actually costs them to care for every patient they admit. ... Today, the [University of] Utah health system is one of a handful in the nation with a data system that can track cost and quality for every one of its 26,000 patients. That data is shared with doctors and nurses for further input about ways to streamline cost and improve care."
On May 29, the President's Council of Advisors on Science and Technology (PCAST) released a report to President Barack Obama that identifies a comprehensive set of recommendations, including the implementation of systems engineering, to address cost and quality challenges in healthcare.
Dallas-based Tenet Healthcare had a nurse retention problem. Between 80 percent and 90 percent of the system's nurses left within the first year, and a growing number were leaving before the 90-day mark.
In a "Spring Break Practicum" program, industrial and systems engineering students from USC conducted an intense week of student-led projects resulting in improving efficiency in hospital operations.
Starting in 2012, Washington emergency rooms began tracking patients in a mandatory, statewide database as part of an effort to supply the necessary health information to divert patients from trips to emergency rooms for non-urgent problems. Dr. Nathan Schlicher, an ER doctor who serves on the board of the Washington State Medical Association, said the Emergency Department Information Exchange has given hospitals a way to monitor patients and keep hospitals up-to-date regarding patients' health records.
This article in JAMA describes the case for adoption of mobile health technologies (mHealth) and the potential for future application from a clinician's perspective.
New video: Understanding control charts
IHI Executive Director of Performance Improvement, Bob Lloyd, Ph.D. has been teaching the science of improvement all over the world for more than 20 years. The IHI Open School has compiled a series of short "whiteboard" videos in which Lloyd breaks down the core concepts of improvement science. The latest addition to the series is a two-part video on understanding control charts.
This article in Pharmacy Purchasing & Products describes a strategic framework for controlling and reducing costs in hospital pharmacies based on work done at Riverside Health System in Virginia.
This is a summary presentation of one-year results from a project at Mayo Clinic in Florida aimed at improving the operational performance of a hospital's operating rooms by assessing and managing variability. The changes resulted in a 5 per cent increase in OR utilization and net revenue and a 27 percent reduction in overtime. These data were also published in the June 2013 Journal of The American College of Surgeons.
Researchers applied lean and Six Sigma methodologies to improve OR efficiency. Multidisciplinary teams addressed minimizing volume variation; streamlining the preoperative process; reducing non-operative time; eliminating redundant information; and promoting employee engagement.
This article promotes using scribes as a cost-effective alternative to adding physician, nurse practitioners or physician assistant staffing in the emergency department.
This article in the Wound Care Advisor is a case study describing a cost-effective pressure-ulcer program in a 350-bed acute-care hospital. The authors report that the program they put in place is saving over $2 million annually.
This was a presentation at the 2013 SHS Healthcare Systems Process Improvement Conference
Hospitals and health systems spend millions of dollars to acquire and meaningfully use certified EMRS and EHRS nationwide. This presentation from HSPIC 2013 describes a for-profit health system's experience in deploying efficient workflows that lead to increased acceptance and usage by physicians and other stakeholders to realize many benefits including receiving CMS incentives.
Clinical Laboratory News
This article describes strategies several hospitals around the country, including Cleveland Clinic, are using to reduce over-utilization of routine lab.
There are two keys to successful cost-cutting in healthcare: the first - necessary but not sufficient - is to apply proven tools and tactics from industrial engineering, lean, Six Sigma, and business process re-engineering; the second is to align the initiative with the organization's mission and culture and engage clinical and administrative staff across the organization to collaborate in the process. This post from the HBR Blog Network describes how Banner Health, one of the nation's largest health systems, did it.
This presentation at the 2013 Healthcare Systems Process Improvement Conference provides a case study in the use of vertical value streams for large, complex improvements. Vertical value streams are a multi-layered value stream approach using rigorous project management. Boulder Community Hospital applied this methodology to the opening a Patient Centered Medical Home.
The following synthesis of performance improvement strategies is based on a case study series published on The Commonwealth Fund website, WhyNotTheBest.org. The hospitals profiled in this series were identified based on their performance on the pneumonia care improvement measures that are reported to the Centers for Medicare and Medicaid Services. Please see the case studies for a full description of the selection methodology.
This research investigates the effect of communication complexity level on patients' perceived quality. The amount of communication was measured by self reports regarding the patient's visit.
This paper and presentation at the 2013 SHS Healthcare Systems Process Improvement Conference describes efforts to optimize logistics (transportation of goods and services to and from patient care areas) in a large regional medical center. The basis of the project was the application of simulation modeling to better understand the complexity and interaction.
This study uses a highly efficient and time-economic automated computer visualization measurement technique called Discursis to analyze conversational behavior in consultations.
This paper and presentation delivered at the 2013 Healthcare Systems Process Improvement Conference describes work done in the Ochsner Health System to reduce orthopedic joint replacement costs and improve quality for the patient. High quality care at an affordable cost is an attainable goal that is both in the best interest of the patient and the healthcare system. Driving value through minimization of clinical variation enabled OHS to meet a higher standard of patient care while ensuring the long-term financial stability of the organization.
In this article, Patti Brennan, the Lillian L. Moehlman Bascom Professor in the School of Nursing and College of Engineering at the University of Wisconsin, discusses the intersecting fields of industrial engineering and clinical care with members of University of Missouri's Industrial and Manufacturing Systems Engineering Department.
Patient experience and physician productivity: Debunking the mythical divide at HealthPartners Clinics
It is a common presumption that patients satisfaction and physician productivity are somewhat exclusive. This study in the Permanente Journal helps dispel commonly held myths about the exclusivity of productivity and patient satisfaction, suggesting that 1) there are many physicians who excel in both areas simultaneously, and 2) there are different characteristics associated with varying levels of performance.
Do I want to become a consultant?
Many people consider becoming a consultant at some point in their career. Longtime SHS contributor, John Templin, shares his perspective as a person with more than 40 years consulting experience. The presentation and paper describe some of the behind-the-scenes aspects of consulting including marketing, pricing, estimating time, career options and what it takes to run a healthcare consulting business. Presentation - Financial worksheet
In an online article in Hospitals and Health Network Daily, Haydn Bush describes how Mark Chassin, M.D., president of the Joint Commission, believes it may be time for hospitals to move away from best practices and adopt comprehensive improvement methods that allow for deeper, more specific analyses of their patient safety requirements. Dr. Chassin cites examples of multiple failure modes of various processes in different facilities that can't effectively be addressed by best practices alone.
Under the New England VERC, engineering faculty and students from Northeastern University, Worcester Polytechnic Institute and Massachusetts Institute of Technology are working on projects within VA facilities. VERC members are learning firsthand about healthcare issues and developing solutions and approaches that will improve care.
Dr. John D. Evans shares his thoughts in this video presentation, at the 2011 Stanford Graduate School of Business Healthcare Summit, about the importance of leveraging systems engineering in the healthcare sector. Using intensive care units as an example, Evans points out that no one has ever really sat down with a clean sheet of paper and said, "This is the mission." He says what the intensive care unit, and the healthcare market in general, needs is for innovators to create efficient designs not just for individual technologies, but for the whole system. Evans presents a generalized model for a systems engineering that he believes should be applied to healthcare.
This presentation at the 2012 Healthcare Systems Process Improvement Conference describes how the Operational Improvement team at Nebraska Medical Center is organized for sustained improvement. The leader of the OI team describes the process to identify potential projects and prioritize centralized project leadership resources based on organizational benefits, while simultaneously developing these individuals as future organizational leaders.
A recent article in the UW-Madison College of Engineering Alumni Magazine describes ongoing research in the Department of Industrial and System Engineering to improve healthcare. One research project led by Professor Doug Wiegmann is being done to develop better methods to improve flow and communication in the operating room. Data is being collected at Cedars-Sinai Medical Center in Los Angeles, where graduate students follow trauma cases from the emergency department through surgery. The research is sponsored in part with a $1.2 million grant from the U.S. Department of Defense.
Mark Graban blogs on Steve Markovich's keynote address, "Bringing Value to Your CEO." Steve Markovich is president of Riverside Methodist Hospital in the OhioHealth System. Markovich is also a family practice physician, Brigadier General in the Ohio National Guard and an F-16 fighter pilot.
An online article in American Nurse Today, describes how Lehigh Valley Health Network (LVHN) in eastern Pennsylvania, is working to implement Lean. LVHN calls their approach the "System for Partners in Performance Improvement (SPPI)." The goal of the organization is to discover more efficient ways to provide health care by using lean tools and concepts that reduce waste and repetition. The article provides a detailed description of the five-day rapid improvement event process in use at LVHN.
In this presentation at the 2011 SHS Conference, Jonathan Flanders describes how a 400 bed hospital reduced average LOS for Hospitalist patients by 1.0 day using lean concepts applied at the service-line level. The presentation is a comprehensive case study for the application of lean and six sigma tools. The use of multi-level value stream mapping applied to an inpatient care unit will be of particular benefit for readers struggling in this area.
In this presentation at the 2011 SHS Conference, Lynn Alters describes how a system-wide performance improvement initiative improved margins by 40 percent at WellStar Health System using internal resources and fostering an environment of trust and respect. In addition to the financial benefits, the initiative created stronger leaders and will soon exceed its initial goals by three-fold.
A multidisciplinary group at Presbyterian Healthcare Services teamed together to meet the Joint Commission National Patient Safety Goal and to reduce the central line infection rate to less than 1 per 1,000 patient days. The team used a Lean Sigma improvement methodology to identify a number of countermeasures including checklists, education, defined observer, and a standardized central line kit. In the first six months of the project, the central line infection rate was reduced to .22 infections per 1,000 patient days.
Lessons learned from moving to Web-based surgical requests
The authors delivered a presentation and paper at the 2011 SHS Conference providing a comprehensive case study of how the Sir Mortimer B. Davis-Jewish General Hospital in Montreal, Quebec, moved from a paper surgical request process to a web based system. The lessons learned described by the authors will be valuable for anyone undertaking a similar large scale IT change.
Nursing leaders at Our Lady of Lourdes Medical Center in Camden, New Jersey, engaged staff to improve patient and employee satisfaction and reduce staff turnover on a medical-surgical unit using the Transforming Care at the Bedside (TCAB) model developed by Robert Woods Johnson Foundation and the Institute for Healthcare Improvement. The team focused on a set of directed methodologies and conducted a number of experiments that resulted in dramatic improvement.
A recent feature in Binghamton's Watson Review describes ongoing healthcare improvement research at the Watson Institute for Systems Excellence (WISE). Ongoing healthcare research at WISE includes research in ED throughput and supply chain. WISE researchers collaborate with a number of hospital systems including Vitua, Mayo, and Wilson and Binghamton General Hospitals. Thirteen research assistants in the WISE program have recently been placed in healthcare organizations.
In a recent New York Times article, Dr. Pauline W. Chen makes a case that organizational culture is more important than technique and technology in providing quality healthcare.
In this paper recognized at the SHS 2011 Conference, the authors from the École Polytechnique de Montréal address the difficulty and complexity of nurse scheduling. The authors developed an algorithm to optimize nurse scheduling and also a heuristic model that can be applied without complex computer analysis that results in considerable improvement over the current methodologies. The authors applied the optimization and heuristic models to two different hospitals in Montreal.
Popular author and speaker Atul Gawande challenged the 200 graduates of the 2011 Harvard Medical School to pursue a more systematic approach to delivering healthcare. He used pit crews and cowboys as examples of working as a system.
A multidisciplinary team working at the Rady Children's Hospital in San Diego, Calif., was formed to improve ED throughput. Based on comprehensive variability analysis the team implemented a number of changes including daily performance reporting, a fast track for lower acuity patients, and standardized nurse and physician rounding. The changes resulted in a 10 percent lower length of stay and a 50 percent reduction in left without being seen. These changes are planned to improve revenue by $782,000 to be budgeted in the next fiscal year.
In an article recently published in the Journal of Industrial Engineering and Management, the authors concluded that while IE students working in hospitals focused on technical approaches to improvement, mastery and application of softer skills may be more beneficial.
In this presentation at the 2011 Society for Health Systems conference, Cindy Hafer provides a comprehensive look at how Nationwide Children's Hospital in Cincinnati is moving to eliminating all preventable harm to patients through a comprehensive safety initiative.
At a recent Premier Breakthroughs Conference and Exhibition, clinical and performance improvement staff at the 370-bed Good Samaritan Hospital in Suffern, New York presented a case study of improvement on a nursing unit using the TCAB model.
Rachel Fields summarized the opinion of Dennis Patterson, chairman of The Collaborative for Healthcare Leadership, on the top ways to cut labor expenses in hospitals.
Sunnybrook Health Sciences Centre is considering implementing recommendations made by three fourth-year students at the University of Windsor Industrial and Manufacturing Systems Engineering as part of their capstone project. Ben de Mendonca, Josh Vandermeer and Andrew Phibbs, conducted an intensive examination of the system used by the emergency department to collect and label patient blood samples.
Pharmacy leaders at Elkhart General Hospital, in Elkhart, Ind., applied a number of lean concepts resulting in lower operational costs and improved patient care.
A recent study in the Annals of Surgery found that high quality hospitals deliver lower cost care to trauma patients, according to a news release by the University of Rochester Medical Center.
In a recent presentation at the 2011 SHS Conference, Brian H. Fillipo delivered a presentation on a comprehensive approach to reducing patient falls across seven Bon Secours hospitals in Virginia.
In a case study on the AHRQ website, the 340-bed Forbes Regional Campus of Western Pennsylvania Hospital developed a number of strategies to reduce delays in patient admission and discharge resulting in improved patient flow. The improvements were made during a weeklong kaizen blitz.
In an article previously published in Industrial Engineer magazine, industrial engineering researchers at Clemson University assisted Cannon Memorial Hospital in Pickens, S.C., in a number of hospital-wide and service specific improvements resulting in increased efficiency.
Discusses the increasing importance of case management in reducing costs and improving reimbursement in the current environment.
The stltoday.com website recently featured efforts at Barnes-Jewish Hospital in St. Louis to provide improved patient-centered-care using a number of lean management principles. A number of examples of process improvement in the OR and peri-operative services are discussed.
The Dartmouth Institute for Health Policy and Clinical Practice, TDI, has been selected to support a national collaboration aimed at reducing costs for high-volume, high-cost chronic and acute medical conditions that have high cost variation. Dartmouth-Hitchcock Medical Center, Cleveland Clinic, Denver Health, Geisinger Health System, Intermountain Healthcare and the Mayo Clinic have teamed together to take on such things as knee-replacement surgery where there is up to 50 percent cost variation.
Many U.S. healthcare organizations are already being exposed to Recovery Audit Contractor (RAC) reviews of Medicare and Medicaid billing as well as other third-party payor audits to assure accurate and non-fraudulent billing. In response, the authors propose an analytical approach to efficiently evaluate the accuracy of billing.
A case study of a centralized patient tracking system at Sentara Careplex Hospital in Hampton, Va. The case study shows how Sentara was able to reduce patient registration labor by over 50 percent and save over $300,000 per year.
A recent article in AORN Management Connections by Carina Stanton describes how three healthcare organizations are implementing lean.
It's time for hospital operations to be built on the back of adaptive technology instead of human performance alone. As other industry transformations have demonstrated, adaptive technology can become the engine driving sustainable performance over time.
A discussion of survey results regarding communication between providers and the patient. The visit quality as perceived by the patient increases with fewer communications.
Using Lean Six Sigma tools, a hospital redesigns its PAT department process so that all charting is completed 72 hours prior to the day of surgery.
Management Engineering: What is it?
Management engineers may need money to implement healthcare improvement. This article outlines several potential funding sources.
One hospital details improvements to their medical equipment retrieval, cleaning, and distribution process.
Using Lean Six Sigma tools, a hospital redesigns and implements new ICU protocols for patients on mechanical ventilation. The article details how the initial sustainability effort failed, but was brought back into long-run control.
A traditional process improvement methodology leads to changes within a hospital's HR department. Results from time studies, swim lanes, and simulation are used to support the proposed solutions.
Physician and Nursing roles and responsibilities within a PICU are redefined using lean tools to decrease LOS while increasing outcomes.
Using examples from several clinical lab redesigns, the sequence of steps utilized during a lean improvement effort are described.
Karen Martin describes the steps needed to ensure an improvement effort is successful at a system level, and ways for a performance improvement consultant to continuously improve their professional skills.
Four experts discuss various health care issues and potential solutions. The implementation of lean, the importance of sustainability, the necessity of crafting appropriate technology solutions, and the ultimate need for improvements to come from within an organization are covered.
A CT scan department has its demand smoothed.
5S theory and implementations are discussed
Lean tools are used to redesign processes throughout a hospital.
Discussion of applications of lean within the OR.
System-level quality and effectiveness programs are implemented using Six Sigma at a childrens' hospital in Washington DC.
Improvement projects in surgery, nursing, and the ED are discussed. The process of moving a hospital towards adoption of Lean Six Sigma is also described.
Pharmacy decision-making is discussed, with focus on controlling costs.
What are the parts of a rewarding career as an engineer in health care? This presentation proposes an answer.
A methodology for standardized evaluation of the financial impact of operational and patient care improvements is discussed.
Several change management projects are covered in brief, moving rapidly through high-level descriptions of problem / intervention / impact steps.
Detailed description of a lean project to improve TAT in the CT Scan department.
In a for-profit ambulatory surgical center, the current scheduling method often results in cases starting later than the initial plan. The presentation describes an implementation of clustering as well as multiple simulations of different possibilities.
Why do some improvement projects fail and others succeed? What are some big-picture concepts that could move organizations to success with process improvement projects? This is a big-picture discussion of several issues.
The surgical admitting process is targeted with a lean event. Current and future state is described, the process of improvement is shown, and results are discussed.
Three successful lean projects are discussed in detail. The ED, Radiology, and HR departments all show significant improvement.
Three successful lean projects are discussed in detail. Specimen Labeling, Surgery and Endoscopy Pre-Op, and Inpatient Nursing Crash Cart projects all demonstrate significant improvement.
The authors propose a methodology for shortening the time gap between discovery of new evidence-based clinical results and hospital (provider) utilization of the new practice.
Results of a hospital-wide specimen labeling lean project is discussed.
Implementation of productivity monitoring programs are discussed
Multiple projects and results are discussed in the goal to continuously improve patient flow.
A hospital implements improvements in staffing to hourly changes in RN demand.
A consulting group presented their throughput ideas, including reasons why some department-specific projects fail to realize proposed improvements.
All processes in an ED are redesigned, with multiple outcomes showing improvement.
A 100,000 annual visit hospital ED is redesigned using lean principles. Wait times decrease and pt satisfaction and revenue increases. Simulation shows further viability of new processes. This presentation is made by a MD who became a lean coach.
A systemwide linking of departmental performance to manager and employee annual pay is discussed.
A Lean Six Sigma project focusing on ICU throughput times is completed. Lessons learned and successes are shared.
A lean project is done at a cardiac clinic. Problem is to reduce wait time for an appt and cycle time of the appointment. Results are discussed.
A performance improvement team tackles a call center. Issues and lessons learned are discussed.
An OR's case scheduling process is studied; improvement projects are proposed.
A hospital undertakes a systemic improvement of their OR suite. The process and final results are detailed.
Management team-building requires careful thought and planning. The presentation goes over several common pitfalls and proposes solutions.
Replacing manual processes and disparate systems with a multi-site Gastroenterology electronic medical record system in a large multispecialty practice had many challenges.
The presentation is a discussion of change management proposals and policies.. Some are successful yet some fail miserably.
Key success factors for change as well as the keys to team dynamics are considered and explained within this paper.
Emergent Care was redesigned to decrease wait time significantly.
Methods of confronting and smoothing the variability of patient flow are discussed.
4 lean projects were performed - pharmacy, lab, outpatient clinic, and telemetry unit. Each project was meticulously documented in the presentation. Pre- and post- metrics are included, as well as a discussion of sustainability.
Lean projects at Kaiser Permanente are detailed and discussed. The report is a system-level presentation showing many departmental improvements.
A senior member of the Johnson&Johson consulting group discusses his approach to organizational culture change and the importance of sustained leadership commitment.
Root cause analysis was conducted to determine reasons for bed sores. This presentation and paper is the result of their team's effort. Sustainability and ongoing improvements are discussed.
System-wide implementation of Lean Six Sigma has resulted in many successes. This presentation discusses the rationale for their overall strategy.
The IHI Bundle was implemented; metric changes are documented and discussed. Several nursing practices were also changed.
Medicare's changes to payment require a higher degree of awareness from hospitals nationwide. This presentation addresses some of the concerns and discusses mitigation efforts currently underway.
Pressure Ulcers are a known issue with long hospitalizations. This presentation deals with several issues surrounding eliminating their occurrence.
ED charge capture is a constant problem for hospitals. This presentation covers one system-wide approach to increasing the capture rate.
HCA discusses its methodology for monitoring its usage of premium pay to ensure they use as little as possible.
A pre-registration Internet interface was successfully developed. Lessons learned and sustainability are also discussed.
This presentation motivates the approach to management of a hospital as continuous improvement of many systems.
Although healthcare is unlike any other service industry, improvement concepts are immediately applicable. This presentation teases out some specifics and attempts to answer student questions regarding the complexities of health care.
Payment denials were decreased, resulting in a cost savings of $1.6 million annually. This project steps through the list of improvements made.