Joanie Ching, RN MN, Administrative Director of Quality and Safety, blogs about how Virginia Mason Hospital in Seattle is abandoning batch administration of medications to improve patient safety. By going to just-in-time medication administration, nursing workload has been leveled, medication errors have been reduced, and nurses are better able to respond to patient needs.
Editor's note: Workload leveling and smaller batch size, like many other "lean tools," are industrial engineering concepts that have been well understood for many decades. It appears that a lean approach has helped Virginia Mason to discover the benefits in this novel application.
The authors of this presentation describe how industrial engineering research improved patient access and reduced cost by applying a machine learning simulation approach at Grady Health System in Atlanta.
This article describes best practices for setting up a productive internal medicine clinic. Many of the practices described in this article can be applied for improved throughput and patient satisfaction in other types of ambulatory clinics.
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 online article describes capacity improvement at the University of Pittsburgh Medical Center (UPMC) catheterization lab. The cath lab is a particularly challenging environment because of high-volume, high-mix, and the need to meet scheduled, emergent, and urgent patient needs.
Dr. Stephen Feagins, vice president of medical affairs, describes how ER wait times were reduced by 70 percent at Mercy Health's Anderson Hospital in an interview with the Cincinnati Business Courier.
Dr. Crane addresses a host of issues in this article for improving ED performance including the application of queuing theory, demand matching, and more frequent budgeting.
Have you lost that disk from your college days that had a queuing theory calculator on it? There is at least one online queuing theory calculator that may meet your needs in your next queuing analysis.
Much attention is given to RN and other support staffing in the Emergency Department while neglecting to look at ED provider staffing. This article in ACEP news gives some recommendations for provider staffing that may be the most important driver of patient throughput in your ED.
This guest post in the Harvard Business Review describes how the Minneapolis Heart Institute has started to use a validated risk-prediction tool to distinguish between patients who require an extended hospital stay after a severe heart attack and those who can safely go home within 48 hours. Shortening hospital stays for lower-risk patients after a severe heart attack.
Managing patients in nuclear medicine departments is a very challenging problem with limited research reported in the literature. The complexity involved in this healthcare setting makes this problem unique. In this paper, the authors derive and implement algorithms for scheduling nuclear medicine patients and resources.
This presentation covers many aspects of quality improvement in the pharmacy with a focus on improving flow. This presentation covers the project from the lean aspect as well as information technology, facility redesign and human factors.
An improvement team at Advocate Trinity Hospital in Chicago addressed the issue of a high rate of "left without being seen." This presentation at the 2012 Healthcare Systems Improvement Conference describes how an improvement team used information systems and analytical approaches to gather information on the root causes for problems and potential solutions in the ED. Leadership rounding throughout the ED, establishing effective treatment protocols and finally, front loading medical orders to help expedite patient treatment and prompt patient disposition. After implementation of the above planned measures, the LWOT percentage reduced from the highest rate of 12.4 percent in July 2009 to 1.1 percent in June 2011.
Management systems focused on standardization strategies like lean result in better health outcomes and lower mortality rates, according to a new JAMA report based on a study from the Oregon Health and Science University.
A lean look at hospital readmissions
Physicians at Denver Health provide a presentation on reducing readmissions using a lean approach. Denver Health has been applying lean methods to clinical and nonclinical improvement for more than seven years and is nationally recognized for performance in patient safety and outcomes among large teaching institutions.
Real-time forecasting of pediatric intensive care unit length of stay using computerized provider orders
The authors conducted a retrospective cohort study to describe a model to provide real-time, updated forecasts of patients' intensive care unit length of stay using naturally generated provider orders. The study was based on more than 2,000 admissions to a pediatric intensive care unit. The model was designed to be integrated within a computerized decision support system to improve patient flow management.
Surviving the global healthcare perfect storm
The authors describe the application of operational planning and capacity management methods to improve patient care, improve revenue, and lower costs. Article
The Urgent Matters e-Newsletter breaks down how hospitals will be impacted by the new Joint Commission patient flow standards being put into effect in 2013 and 2014. The major focus of the new standards is to demonstrate systems for improving flow in emergency departments.
The online journal, Circulation: Cardiovascular Quality and Outcomes, describes a multi-year effort at the Mayo Clinic to meet the American College of Cardiology/American Heart Association guidelines for door-to-balloon time (DTB) < 90 minutes for non-transferred patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention.
In this presentation the authors provide a case study of the need to coordinate with departments outside of the ED to improve ED patient flow. Some of the results reported include eliminating 16 process steps for bed assignment, reducing admit order to patient orders by more than 50 percent and increasing the number of before noon discharges by more than 70 percent.
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.
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.
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.
Students at Worcester Polytechnic Institute and in coordination with UMass' Center for Innovation and Transformational Change examined how lean tools can eliminate non-value added work, improve resource management, and create lean flow at the UMass Memorial Hospital. After implementing a number of changes, the team saw a reduction in patient throughput time, elimination of defects in the chart tracking process, and a decrease in stocked inventory.
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 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.
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.
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.
In a presentation at the 2010 SHS/ASQ Healthcare Division Conference, Matthew Pierce, Nursing Manager, and Joseph Swartz, Director of Business Transformation, presented on improving hospital-wide patient flow using a Define Measure Analyze Improve and Control (DMAIC) framework. Among many of the improvements cited was a 60% reduction in delays for critical care admissions from the ED.
Hospital Operating System Unleashing Throughput Potential
The fragmentation of a hospital’s activities across departmental operational silos propagates waste, compromising throughput. The assertion of this white paper is that a hospital will not be able to manage throughput for the achievement of its purpose until it becomes a system of interconnected activities. Executive Summary | Full white paper
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.
Physician and Nursing roles and responsibilities within a PICU are redefined using lean tools to decrease LOS while increasing outcomes.
When applying value stream mapping, don't forget that sometimes patients will need to be grouped just like part families - and each of those may need a unique VSM.
A CT scan department has its demand smoothed.
Discussion of applications of lean within the OR.
An ED is redesigned after patient flows were modelled using queuing theory.
The process of creating and achieving approval of an ED simulation is discussed.
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.
Improvements to a provider appointment-making system are motivated, tested, and sustained
Improvements to a pediatric OR are proposed and tested with simulation.
An ED lean project is discussed, highlighting some advantages that undergraduates can bring when partnered with professionals in the field.
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.
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.
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.
A lean event focused on patient flow out of the ED was conducted, and results are discussed
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.
This is an overview of several lean redesign projects in the ED with overall solutions discussed and analyzed.
ED throughput process improvement projects are discussed. The presenter is a MD. Several changes are shown with great results.
Multiple projects are performed to improve an ED. Problems are stated and results are given.
A Lean Six Sigma project focusing on ICU throughput times is completed. Lessons learned and successes are shared.
A discussion of the importance of metric and measurement accuracy during execution of improvement projects.
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.
An OR's case scheduling process is studied; improvement projects are proposed.
A program is proposed that effectively confronts a majority of the issues with scheduling patient surgeries.
The author facilitates a lean educational journey through an ED.
A Premier consultant discusses lessons learned from performing many Lean ED projects during her career.
Emergent Care was redesigned to decrease wait time significantly.
Methods of confronting and smoothing the variability of patient flow are discussed.
A 848-bed hospital is experiencing long LOS and targets ancillary service availability as one potential source of improvement. The project discussed tracks the data, demonstrates immediate results, and suggests future improvements.
A lean project generated proposals for rescheduling the providers' workload. During testing of the proposals, daily departmental volume was completed significantly earlier in the day.
Lean projects at Kaiser Permanente are detailed and discussed. The report is a system-level presentation showing many departmental improvements.
Lean improvements within the radiology suite and laboratory workspace yield notable improvements. Project benefits are discussed.
A pre-registration Internet interface was successfully developed. Lessons learned and sustainability are also discussed.
Turnarounds and first case starts are improved using a variety of lean techniques. Sustainability, achievement of buy-in and metric details are also discussed.
Lean improvement projects are performed within the supplies delivery function of a surgical services suite.