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Background: Delayed discharges can be a systemic issue. Understanding the systemic factors that contribute to discharge inefficiencies is essential to addressing discharge inefficiencies., Purpose: This article reports on a Lean Six Sigma approach and the process to identifying inefficiencies and systemic barriers to early discharge in a large US academic medical center., Methods: A qualitative methodology guided this project. In particular, direct observation methods were used to help the project team identify factors contributing to discharge inefficiencies., Results: Overall, findings suggest that establishing consistent multidisciplinary team communication processes was a contributing factor to reducing the inefficiencies around discharges. On a more granular level, key barriers included disparate communication systems, disruptors (specifically Kaizen bursts), and unique role challenges., Conclusions: This article provides a framework for addressing discharge inefficiencies. Because the output of the process, a critical contributor to the overall outcome, is often not analyzed, this analysis provides value to others contemplating the same or similar process toward discharge efficiency., Competing Interests: Sue Feldman is a consultant with Guideway Care. Her work there has no relation to the content in this article. The other authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Streamlining patient pathways within health care systems is a complex and challenging process. While frontline clinicians often have an abundance of ideas, these rarely translate into real-world change due to nonadoption or early abandonment., Objectives: The aim of this article is to provide frontline clinicians with a blueprint for developing a business case for a streamlined pathway while guiding the practical implementation of this blueprint., Methods: The key steps outlined in streamlining a patient pathway are as follows: step 1-identify problems with the patient pathway; step 2-identify the potential to streamline; step 3-forecast the benefits of the streamlined pathway; step 4-gain approvals; step 5-plan the practicalities; step 6-implement and monitor the streamlined pathway; and step 7-monitor the streamlined pathway. Within these steps, Lean management techniques are introduced (including value stream mapping, Pareto charts, Ishikawa diagrams, demand and capacity calculations, role lane mapping) and strengthened by other methods (retrospective audit, systematic review, patient questionnaires, and cost analysis)., Results: This roadmap is contextualized using a case study, demonstrating how streamlining pathways can result in statistically significant reductions in referral to treatment time, the number of steps in the pathway, lead time (pathway duration), and handoff (transfer of patients between health care professionals). This can be achieved while increasing patient contact time, improving patient satisfaction, and reducing costs., Conclusion: This blueprint demonstrates a comprehensive method for streamlining patient pathways, using Lean management techniques complemented by additional methods. This approach was developed by frontline clinicians and can be replicated by others, translating quality improvement ideas into sustainable change in practice. It enables the design of streamlined pathways that confer significant benefits to patients, health care service providers, and the health economy.

Alabama's Maternal, Infant, and Early Childhood Home Visiting-funded program was one of 10 state teams accepted to participate in the first wave of the Federal Home Visiting Program State and Territory Continuous Quality Improvement Practicum. This article reports methods and results of Alabama's continuous quality improvement (CQI) project and lessons learned in developing CQI capabilities among state and local public health practitioners. The Alabama team tracked CQI data weekly for the duration of the practicum using an annotated run chart. Participants included 20 identified tobacco users in 2 participating LIAs. This article highlights specific CQI tools to achieve the project aim. On the basis of CQI interventions, Alabama reached its goal; 12 of 20 primary caregivers in 2 home visiting programs made quit attempts. Alabama utilized multiple CQI tools to reach an ambitious, behavior-based aim; these same concepts could be broadly applied to quality improvement initiatives in any federal or state public health program to guide process- and outcomes-based improvement efforts.

Background and Objectives: The mission of nonprofit health care clinics is particularly challenging to fulfill given the large number of uninsured and underinsured people they serve. In addition, these clinics feel pressure to provide services in an efficient manner to prevent patient no-shows and encourage the continuation of medical care. These challenges tend to increase further when clinics feel they have exhausted their internal resourcefulness relative to their effort to improve patient care. Without additional guidance, it can be difficult for organizations to achieve additional performance improvements. To address this problem, a case example is presented that demonstrates how one nonprofit health care clinic used the Lean Six Sigma methodology to help them further improve the efficiency of their clinic visit process., Methods: This research focused specifically on the use of process analysis tools/methods to map the clinic visit process, collect and analyze process performance data, analyze the process to identify and prioritize causes of waste, and develop and implement solutions., Results: The clinic's use of this structured improvement approach contributed to reducing patient cycle time by more than 20% and increasing patient visit capacity., Conclusions: This research provides a rich example from which other health care facilities can learn to enhance their process improvement capabilities.

Background: Hospital controlled drug processes are established to adhere to legislation, with little consideration of efficiency of processes., Local Problem: A controlled drug process existed, where nurses requested a porter to collect a hand-written order; however, only 19% of drug orders were processed this way. Instead, an unscheduled, ad hoc process led to an average of 17 nurse journeys to pharmacy daily. We aimed to reduce nurse journeys to the pharmacy by 25% to release nursing time., Methods: A pre-/postintervention design was used with Lean Six Sigma methods., Interventions: A multifaceted intervention involved process redesign, increasing the frequency of a porter-led delivery service, amending delivery times to reflect times of greatest need, and streamlining checking requirements., Results: Following implementation, there was a statistically significant 44% decrease in nurse journeys to pharmacy for drug collections, which was maintained after 18 months., Conclusions: Interprofessional collaboration improving hospital-wide processes can have significant benefits for the release of nursing time.

Background: In this article, we propose a method that integrates systematic layout planning techniques to lean health care practices aided by multicriteria decision analysis that could be applied to reformulate the layout of health care facilities., Methods: We analyze a high-variety sterilization unit of a large public hospital located in Brazil. The unit is currently implementing lean practices, and layout changes are required to provide more efficient materials and information flows., Results: Traditional design of health care facilities is not aligned with lean implementation and its underlying practices and principles. We propose the integration of such approaches to enhance their benefits. To rank and select the best layout alternative, a multicriteria decision analysis method (analytic hierarchy process) is adopted., Conclusions: There are 3 contributions here: the integration of lean principles into traditional health care facility design practices, the use of multicriteria decision analysis to refine the determination of the best layout solution, and the application of our propositions in a real case study.

Background: Patient satisfaction scores in the vascular interventional radiology department were low, especially related to wait times in registration and for tests/treatments, with low scores for intentions to recommend., Purpose: The purpose of our quality improvement project was to decrease wait times and improve patient satisfaction using Lean Six Sigma's define, measure, analyze, improve, and control (DMAIC) framework with a pre-/postintervention design., Results: There was a statistically significant decrease in wait times (P < .0019) and an increase in patient satisfaction scores in 3 areas: registration wait times (from 17 to 99 percentiles), test/treatment (from 19 to 60 percentiles), and likelihood to recommend (from 6 to 97 percentiles)., Conclusions: Lean Six Sigma was an effective framework for use in decreasing wait times and improving patient satisfaction.

Background: Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system., Methods: We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases., Results: Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout., Conclusions: Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Objective: The Veterans Health Administration (VHA) is adapting to meet the changing needs of our Veterans. VHA leaders are promoting quality improvement strategies including Lean Six Sigma (LSS). This study used LSS tools to evaluate the Veterans Choice Program (VCP), a program that aims to improve access to health care services for eligible Veterans by expanding health care options to non-VHA providers., Research Design: LSS was utilized to assess the current process and efficiency patterns of the VCP at 3 VHA Medical Centers. LSS techniques were used to assess data obtained through semistructured interviews with Veterans, staff, and providers to describe and evaluate the VCP process by identifying wastes and defects., Results: The LSS methodology facilitated the process of targeting priorities for improvement and constructing suggestions to close identified gaps and inefficiencies. Identified key process wastes included inefficient exchange of clinical information between stakeholders in and outside of the VHA; poor dissemination of VCP programmatic information; shortages of VCP-participating providers; duplication of appointments; declines in care coordination; and lack of program adaptability to local processes. Recommendations for improvement were formulated using LSS., Conclusions: This evaluation illustrates how LSS can be utilized to assess a nationally mandated health care program. By focusing on stakeholder, staff, and Veteran perspectives, process defects in the VCP were identified and improvement recommendations were made. However, the current LSS language used is not intuitive in health care and similar applications of LSS may consider using new language and goals adapted specifically for health care.

Background: Lean is a leading change strategy used in health care to achieve short-term efficiency and quality improvement while promising longer-term system transformation. Most research examines Lean intervention to address isolated problems, rather than to achieve broader systemic changes to care delivery. Moreover, no studies examine contextual influences on system-wide Lean implementation efforts in primary care., Purpose: The aim of this study was to identify contextual factors most critical to implementing and scaling Lean redesigns across all primary care clinics in a large, ambulatory care delivery system., Methodology/approach: Over 100 interviews and focus groups were conducted with frontline physicians, clinical staff, and operational leaders. Data analysis was guided by a modified Consolidated Framework for Implementation Research (CFIR), a popular implementation science framework. On the basis of expert recommendations, the modified framework targets factors influencing the implementation of process redesigns. This modified framework, the CFIR-PR, informed our identification of contextual factors that most impacted Lean acceptance among frontline physicians and staff., Findings: Several domains identified by the CFIR-PR were critical to acceptance of Lean redesigns. Regarding the implementation process acceptance was influenced by time and intensity of exposure to changes, "top-down" versus "bottom-up" implementation styles, and degrees of employee engagement in developing new workflows. Important factors in the inner setting were the clinic's culture and style of leadership, along with availability of information about Lean's effectiveness. Last, implementation efforts were impacted by individual and team characteristics regarding changed work roles and related issues of professional identity, authority, and autonomy., Practice Implications: This study underscores the need for change leaders to consider the contextual factors that surround efforts to implement Lean in primary care. As Lean redesigns are scaled across a system, special attention is warranted with respect to the implementation approach, internal clinic setting, and implications for professional roles and identities of physicians and staff.

Six Sigma and Lean methodologies are effective quality improvement tools in many health care settings. We applied the DMAIC methodology (define, measure, analyze, improve, control) to address deficiencies in our pediatric anesthesia supply chain. We defined supply chain problems by mapping existing processes and soliciting comments from those involved. We used daily distance walked by anesthesia technicians and number of callouts for missing supplies as measurements that we analyzed before and after implementing improvements (anesthesia cart redesign). We showed improvement in the metrics after those interventions were implemented, and those improvements were sustained and thus controlled 1 year after implementation.

Objective: The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%., Background: A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques., Methods: The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics., Results: The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable., Conclusions: Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.

In this study, a measure of Lean management was developed and tested. Items were identified using the Delphi technique with literature review and expert responses. Twenty-five nurses pilot-tested the instrument and then 212 nurses in 5 hospitals completed the instrument, and their responses were subjected to exploratory factor analysis. The 75-item instrument includes 12 factors describing Lean management conceptualization. Reliability and validity are acceptable for a new instrument.

Background: Although Lean management techniques are increasingly used in health care to improve quality and reduce costs, lessons about how to successfully implement this approach on the front lines of care delivery are not well documented. In this study, we highlight key facilitators and barriers to implementing Lean among frontline primary care providers., Methods: This case study took place at a large, ambulatory care delivery system serving nearly 1 million patients. In-depth interviews were conducted with primary care physicians, staff, and administrators to identify key factors impacting Lean redesigns in primary care., Results: Overall, staff engagement and performance management, sensitivity to the professional values and culture of medicine, and perceived adequacy of organizational resources were critical when introducing Lean changes. Specific drivers of change included empowerment of staff at all levels, visual display of performance metrics, and a culture of innovation and collaboration. Barriers included physician resistance to standardized work, difficulty transferring management responsibilities to non-physician staff, and time and staffing required for participating in improvement efforts., Conclusion: Although Lean offers a new approach to delivering care, the implementation process itself is both complex and crucial to success. Understanding early facilitators and barriers can maximize Lean's, potential to improve health care delivery.

Lean Six Sigma is a well-proven methodology to enhance the performance of any business, including health care. The strategy focuses on cutting out waste and variation from the processes to improve the value and efficiency of work. This article walks through the journey of "green belt" training using a Lean Six Sigma approach and the implementation of a process improvement project that focused on wait time for patients to be examined in an urban academic primary care clinic without requiring added resources. Experiences of the training and the project at an urban paper-based satellite clinic have informed the planning efforts of a data and performance team, including implementing a 15-minute nurse "pre-visit" at primary care sites of an accountable care organization.

Popular quality improvement tools such as Six Sigma (SS) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether this quality improvement tool is being used correctly and improves health care quality. The authors conducted a comprehensive literature review to assess the correct use and implementation of SS and the empirical evidence demonstrating the relationship between SS and improved quality of care in health care organizations. The authors identified 310 articles on SS published in the last 15 years. However, only 55 were empirical peer-reviewed articles, 16 of which reported the correct use of SS. Only 7 of these articles included statistical analyses to test for significant changes in quality of care, and only 16 calculated defects per million opportunities or sigma level. This review demonstrates that there are significant gaps in the Six Sigma health care quality improvement literature and very weak evidence that Six Sigma is being used correctly to improve health care quality.

Lean Six Sigma (LSS) is an originally industry-based methodology for cost reduction and quality improvement. In more recent years, LSS was introduced in health care as well. This article describes the experiences of the University Medical Center Groningen, the second largest hospital in the Netherlands, with LSS. It was introduced in 2007 to create the financial possibility to develop innovations. In this article, we describe how LSS was introduced, and how it developed in the following years. We zoom in at the traumatology department, where all main processes have been analyzed and improved. An evaluation after 5 years shows that LSS helped indeed reducing cost and improving quality. Moreover, it aided the transition of the organization from purely problem oriented to more process oriented, which in turn is helpful in eliminating waste and finding solutions for difficult problems. A major benefit of the program is that own employees are trained to become project leaders for improvement. Several people from the primary process were thus stimulated and equipped to become role models for continuous improvement.

Purpose: The purpose of the study was to show how a different collaborative relationship with family doctors and increasingly specialized diabetologists could lead to a 50% reduction in recurrent appointments due to procedural errors and a 50% reduction in the average waiting times for a specialist medical visit., Methods: A qualitative and quantitative definition of the problem was made using the Lean Six Sigma method: (Define); process indicators were observed that might interfere with the objectives of this study (Measure); descriptive statistics were used to confirm the validity and significance of the results (Analyze); and finally strategies were established to intervene on these variables (Improve)., Results: Four groups of action led to optimization of the objectives: (1) establishing clinical protocols for primary care physicians for treating hospitalized patients with type 2 diabetes and hyperglycemia; (2) increasing the autonomy of nursing care staff; (3) reorganizing the appointments booking office; and (4) making diabetes clinics more specialized., Conclusions: Thanks to this project, primary care physicians have rediscovered their role and defined their diagnostic-therapeutic function under a shared scientific protocol. The model presented in this study provides scope for reflection on the role of the diabetologist, proposing an "alternative" that concerns only the care of patients with metabolic decompensation.

In this department, the authors highlight hot topics in nursing outcomes, research, and evidence-based practice relevant to the nurse administrator. The goal is to discuss the practical implications for nurse leaders in diverse healthcare settings. Content includes evidence-based projects and decision making, locating measurement tools for quality improvement and safety projects, using outcome measures to evaluate quality, practice implications of administrative research, and exemplars of projects that demonstrate innovative approaches to organizational problems. In this article, the authors describe the intersection of various quality improvement methodologies with the evidence-based practice process. Five quality improvement approaches, plan-do-check-act, Six Sigma, Lean, root cause analysis, and failure mode effects analysis, are described and are used to frame examples.

Standardized work is the foundation of continuous improvement. Documenting standard processes is a precursor to problem solving and allows an organization to understand work flow, measure performance, and identify opportunities for improvement. Environmental health is an important function of public health departments but is rarely studied systematically. This article describes documentation of standard processes, identification of improvement opportunities, and lessons learned for environmental health processes at the Iowa Department of Public Health, using a pilot group of 3 local county offices. The approach described in this article can serve as a template for other states to follow in their quality improvement journeys.

This article describes the Nursing Works program at Flinders Medical Centre, South Australia. Program goals were to use lean principles to increase the time direct care nurses spent at the bedside, improve patient outcomes, and make nursing work more efficient and satisfying for staff. Steps incorporating lean methodology are described. Outcomes indicate that lean thinking is an effective improvement methodology and a framework for change management of nursing work.

Objective: To share our experience on how we used simple but detailed processes and deployed a management information system on a new HIV counseling and testing (HCT) project in Nigeria., Design: The procedures used in this study were adopted for their strength in identifying areas of continuous improvement as the project was implemented., Methods: We used an iterative brainstorming technique among 30 participants (volunteer counselors and project management staff) as well as iterative quality audits to identify several limitations to the success of the project and to propose solutions. We then implemented the solutions and reevaluated for performance. Findings from the evaluations were then reintroduced into the brainstorming and planning sessions., Results: Several limitations were identified with the most prominent being the poor documentation of records at the site and the lack of a document transfer trail for audit purposes., Conclusion: Communication, cohesion and team focus are necessary to achieve success on any new project. Institutionalizing routine HIV behavioral surveillance using data collected at HCT will help in streamlining interventions that will be evidence-based., (2011 Wolters Kluwer Health | Lippincott Williams & Wilkins)

Transforming Care at the Bedside program was developed as a way to improve care on medical-surgical units, patients' and family members' experience of care, and teamwork among care team members and to increase satisfaction and retention of nurses. Average turnover rates for this program's RNs decreased to about 3%, a 58% reduction in rate. The time RNs spent in direct patient care increased 10% compared to the control unit, and value-added care also increased from 10% to 15% over baseline. Patient and staff satisfaction improved.

Background: The aim of this article is to propose a new model called Healthcare Lean Six Sigma System that integrates Lean and Six Sigma methodologies to improve workflow in a postanesthesia care unit., Methods: The methodology of the proposed model is fully described. A postanesthesia care unit case study is also used to demonstrate the benefits of using the Healthcare Lean Six Sigma System model by combining Lean and Six Sigma methodologies together., Results: The new model bridges the service gaps between health care providers and patients, balances the requirements of health care managers, and delivers health care services to patients by taking the benefits of the Lean speed and Six Sigma high-quality principles., Conclusions: The full benefits of the new model will be realized when applied at both strategic and operational levels. For further research, we will examine how the proposed model is used in different real-world case studies.

A study of the uncertainty of dosimeter results is required by the national accreditation programs for each dosimeter model for which accreditation is sought. Typically, the methods used to determine uncertainty have included the partial differentiation method described in the U.S. Guide to Uncertainty in Measurements or the use of Monte Carlo techniques and probability distribution functions to generate simulated dose results. Each of these techniques has particular strengths and should be employed when the areas of uncertainty are required to be understood in detail. However, the uncertainty of dosimeter results can also be determined using a Model II One-Way Analysis of Variance technique and accreditation testing data. The strengths of the technique include (1) the method is straightforward and the data are provided under accreditation testing and (2) the method provides additional data for the analysis of long-term uncertainty using Statistical Process Control (SPC) techniques. The use of SPC to compare variances and standard deviations over time is described well in other areas and is not discussed in detail in this paper. The application of Analysis of Variance to historic testing data indicated that the accuracy in a representative dosimetry system (Panasonic® Model UD-802) was 8.2%, 5.1%, and 4.8% and the expanded uncertainties at the 95% confidence level were 10.7%, 14.9%, and 15.2% for the Accident, Protection Level-Shallow, and Protection Level-Deep test categories in the Department of Energy Laboratory Accreditation Program, respectively. The 95% level of confidence ranges were (0.98 to 1.19), (0.90 to 1.20), and (0.90 to 1.20) for the three groupings of test categories, respectively.

Background: Popular quality improvement tools such as Six Sigma and Lean Systems (SS/L) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether these 2 quality improvement tools actually improve health care quality., Methods: The authors conducted a comprehensive literature review to assess the empirical evidence relating SS/L to improved clinical outcomes, processes of care, and financial performance of health care organizations., Results: The authors identified 177 articles on SS/L published in the last 10 years. However, only 34 of them reported any outcomes of the SS/L projects studied, and less than one-third of these articles included statistical analyses to test for significant changes in outcomes., Conclusions: This review demonstrates that there are significant gaps in the SS/L health care quality improvement literature and very weak evidence that SS/L improve health care quality.

Histology and anatomic pathology have historically been slow to accept many of the process changes that have been widely accepted in the clinical laboratory. In this article, we describe the application of the Toyota Production System (LEAN) to histology and anatomic pathology as implemented at the Avera McKennan Hospital laboratory. Avera McKennan is the flagship hospital of the Avera Health System, a faith based, not for profit healthcare system based in South Dakota. Comprised of 235 hospitals, clinics, and physicians, with over 12,000 employees, Avera Health is one of the largest healthcare systems in the region. Beginning in 2004, Avera McKennan's laboratory began its "LEAN journey" and in the intervening years has expanded it throughout all areas of the laboratory. Following the example set by the laboratory, many other areas of the hospital have joined in the LEAN Process Improvement journey. In January 2009, the Avera McKennan Laboratory became the first hospital laboratory in the US to achieve the CAP ISO-15189 accreditation in both clinical and anatomic pathology.

Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.

Aim: The purpose of this study was to quantify the difference between the current process flow model for a typical patient workup for chest pain and development of a new process flow model that incorporates DMAIC (define, measure, analyze, improve, control) Six Sigma and evidence-based medicine in a best practices model for diagnosis and treatment., Methods: The first stage, DMAIC Six Sigma, is used to highlight areas of variability and unnecessary tests in the current process flow for a patient presenting to the emergency department or physician's clinic with chest pain (also known as angina). The next stage, patient process flow, utilizes DMAIC results in the development of a simulated model that represents real-world variability in the diagnosis and treatment of a patient presenting with angina. The third and final stage is used to analyze the evidence-based output and quantify the factors that drive physician diagnosis accuracy and treatment, as well as review the potential for a broad national evidence-based database., Results: Because of the collective expertise captured within the computer-oriented evidence-based model, the study has introduced an innovative approach to health care delivery by bringing expert-level care to any physician triaging a patient for chest pain anywhere in the world. Similar models can be created for other ailments as well, such as headache, gastrointestinal upset, and back pain., Conclusions: This updated way of looking at diagnosing patients stemming from an evidence-based best practice decision support model may improve workflow processes and cost savings across the health care continuum.

The complexity of the operating room (OR) requires that both structural (eg, department layout) and behavioral (eg, staff interactions) patterns of work be considered when developing quality improvement strategies. In our study, we investigated how these contextual factors influence outpatient OR processes and the quality of care delivered. The study setting was a German university-affiliated hospital performing approximately 6000 outpatient surgeries annually. During the 3-year-study period, the hospital significantly changed its outpatient OR facility layout from a decentralized (ie, ORs in adjacent areas of the building) to a centralized (ie, ORs in immediate vicinity of each other) design. To study the impact of the facility change on OR processes, we used a mixed methods approach, including process analysis, process modeling, and social network analysis of staff interactions. The change in facility layout was seen to influence OR processes in ways that could substantially affect patient outcomes. For example, we found a potential for more errors during handovers in the new centralized design due to greater interdependency between tasks and staff. Utilization of the mixed methods approach in our analysis, as compared with that of a single assessment method, enabled a deeper understanding of the OR work context and its influence on outpatient OR processes.

Health coaching, its origin from motivational interviewing, enhances patient self-management of chronic conditions by improving patient compliance and outcomes, and reducing costs. How health coaching has achieved this success and why traditional patient teaching has fallen short is explored. Dr. William Miller, an originator of the motivational interviewing concept, also shares his insights and thoughts in a brief question and answer session with the author.

Hospital unit staff scheduling continues to be a critical challenge directly impacting unit and facility performance. The creation of a quality future work schedule that balances unit needs (providing adequate staff across multiple skills) versus employee needs (honoring as many employee requests as feasible) is the first step toward ensuring the most efficient and effective use of staff resources. As an alternative to the use of expensive computer scheduling systems, this article sets forth a set of easy-to-understand and easy-to-measure schedule quality metrics that can be used via any basic spreadsheet application. The use of these metrics allows unit leaders to assess the "goodness" of a schedule and focus on identified opportunities toward improving the schedule resulting in a better match to the unit plan of expected volume/census. Higher quality schedules lead to more efficient use of staff resources by ensuring that resources are fully scheduled before reaching out to more expensive premium labor such as overtime or agency and to more effective use of resources by ensuring that schedules are as complete as possible to cover expected volumes. Resulting decreases in last-minute staff adjustments via better planning contribute to higher staff satisfaction and better patient care.

Background: The proliferation of efforts to assess physician performance underscore the need to improve the reliability of physician-level quality measures., Objective: Using diabetes care as a model, to address 2 key issues in creating reliable physician-level quality performance scores: estimating the physician effect on quality and creating composite measures., Design: Retrospective longitudinal observational study., Subjects: A national sample of physicians (n = 210) their patients with diabetes (n = 7574) participating in the National Committee on Quality Assurance-American Diabetes Association's Diabetes Provider Recognition Program., Measures: Using 11 diabetes process and intermediate outcome quality measures abstracted from the medical records of participants, we tested each measure for the magnitude of physician-level variation (the physician effect or "thumbprint"). We then combined measures with a substantial physician effect into a composite, physician-level diabetes quality score and tested its reliability., Results: We identified the lowest target values for each outcome measure for which there was a recognizable "physician thumbprint" (ie, intraclass correlation coefficient > or =0.30) to create a composite performance score. The internal consistency reliability (Cronbach's alpha) of the composite score, created by combining the process and outcome measures with an intraclass correlation coefficient > or =0.30, exceeded 0.80. The standard errors of the composite case-mix adjusted score were sufficiently small to discriminate those physicians scoring in the highest from those scoring in the lowest quartiles of the quality of care distribution with no overlap., Conclusions: We conclude that the aggregation of well-tested quality measures that maximize the "physician effect" into a composite measure yields reliable physician-level quality of care scores for patients with diabetes.

Background: Casemix-based inpatient prospective payment systems allocate payments for acute care based on what is done within an episode of care without regard for the outcome. To date, they have provided little incentive to improve quality. The Centers for Medicare & Medicaid Services have recently excluded 8 avoidable complications from their payment system., Objective: This study models an inpatient prospective payment system that comprehensively excludes not-present-on-admission and other complication diagnoses from the entire funding process, effectively adding a diagnosis-related group (DRG)-specific average complication payment across all discharges., Research Design: Complication-averaged cost weights were estimated using the same patient level cost dataset used for estimating the relative resource weights for Victorian public hospitals in 2006-07. All codes with a "C" prefix (secondary diagnoses that are coded as having arisen after admission) and codes that define a condition that prima facie represent a specific complication of care were excluded from the code string. The episodes were then regrouped to DRGs and new complication-averaged cost weights were developed., Results: When complication codes were excluded across 1.2 million discharges, 1.37% became ungroupable, 14.86% included at least one complication diagnosis code, and 1.56% grouped to another DRG. Modeled funding for individual metropolitan hospitals in Victoria, Australia, was redistributed by -2.5% to 1.8%., Conclusions: The cost weights reflect the average cost of preventable and unpreventable complications and have the potential to drive improvements in clinical care. This study is in contrast to previous studies estimating the funding impact of preventing all complications.

This qualitative study reviews and analyzes quality improvement (QI) techniques in police departments as a background for assessing ways to introduce QI into public health departments. Police departments and public health departments have many elements in common. These findings provide some understanding of how public health departments can incorporate QI methods as well as learn about the potential barriers to implementing QI projects that are inherent in government agencies. The study consists of extensive interviews of informants from academic settings and police departments across the nation. The findings describe (1) the extent of QI diffusion into police departments, (2) barriers and enablers of QI diffusion in police departments, (3) a typology of QI diffusion, and (4) the metrics and incentives to promote QI in the absence of profit motives. Seven specific recommendations are made to promote the application and adoption of QI in public health: (1) implement QI as a comprehensive management approach, (2) top official involvement, (3) a broad focus on mission and vision, (4) lessons for overcoming barriers, (5) how to find resources, (6) how to integrate proven methods, and (7) how to build on existing capabilities.

Background: This article examines the development of transformation initiatives-deliberate attempts to achieve systemic changes and rapid performance improvements. Accounts of transformation initiatives often reveal little about past organizational and contextual conditions that contributed to success. Instead, these accounts concentrate on change barriers., Purpose: We seek to restore balance to this field by examining how antecedent system capacities contributed to a successful transformation initiative., Methodology: This article presents a case study of the first 2 years of a system redesign initiative at an integrated safety-net health system and provides a historical analysis of developments during the decade preceding the redesign., Findings: Beginning in the mid-1990 s, Denver Health benefited from strong municipal support for its development and expansion. Gradually, it developed its financial and human resources, organizational structure, change strategy, change-management capabilities, information technology, and physical plant. These antecedent capacities all contributed to the implementation of the 2004 system redesign and helped Denver Health overcome several constraints., Implications: Transformation initiatives may build on existing features and resources, even as they overcome or depart from others. The Denver Health case study helps researchers identify positive antecedents to transformation initiatives, assess the success of such initiatives in terms of implementation progress and outcomes, and recognize complementary contributions of incremental and episodic changes. The study alerts practitioners to the importance of assuring that change efforts rest on solid organizational foundations.

Background: Hospitals around the world dedicate increasing attention and resources to innovation. However, surprisingly little is known about the nature of hospital innovativeness and its relationship with organizational performance. Given both the specific characteristics of the hospital sector and the rather mixed evidence from other industries, a positive innovation-performance link should not be taken for granted but requires empirical examination., Purposes: The purposes of this study were to introduce a perspective of hospitals as vital generators of innovation, to unpack the concept of innovativeness, to propose a measurement model for hospital innovativeness, and to empirically investigate the innovativeness-performance relationship., Methodology: We conducted a large-scale empirical study among the entire population of public hospital organizations that are part of the English National Health Service (n = 173) and analyzed the data using exploratory factor and regression analyses., Findings: Our analyses suggest a significant positive relationship between science- and practice-based innovativeness and clinical performance but provide less unambiguous support for the existence of such a relationship between innovativeness and administrative performance. In particular, we find that higher levels of innovativeness are rather associated with superior quality of care than with measurable bottom-line financial benefits., Practice Implications: Hospitals investing in innovation-generating activities might find their efforts well rewarded in terms of tangible clinical performance improvements. However, to achieve measurable financial benefits, numerous hospitals have yet to discover and capture the commercial value of some of their innovations-a challenging task that requires a holistic innovation management and an effective network of complementary partners.

This manuscript describes a scholarly approach to peer case review that identifies and analyzes quality-of-care issues in response to a question about nursing care of a specific patient. The comprehensive method provides a structured format that critically examines untoward patient events, generates an awareness of gaps in care from a systems perspective, ensures action planning focused on legitimate root causes, stimulates performance improvement initiatives, and provides a forum to share learning throughout the organization.

Background: Despite the prevalence of evidence-based interventions to improve quality in health care systems, there is a paucity of documented evidence of a financial return on investment (ROI) for these interventions from the perspective of the investing entity., Purposes: To report on a demonstration project designed to measure the business case for selected quality interventions in high-risk high-cost patient populations in 10 Medicaid managed care organizations across the United States., Methodology/approach: Using claims and enrollment data gathered over a 3-year period and data on the costs of designing, implementing, and operating the interventions, ROIs were computed for 11 discrete evidence-based quality-enhancing interventions., Findings: A complex case management program to treat adults with multiple comorbidities achieved the largest ROI of 12.21:1. This was followed by an ROI of 6.35:1 for a program which treated children with asthma with a history of high emergency room (ER) use and/or inpatient admissions for their disease. An intervention for high-risk pregnant mothers produced a 1.26:1 ROI, and a program for adult patients with diabetes resulted in a 1.16:1 return. The remaining seven interventions failed to show positive returns, although four sites came close to realizing sufficient savings to offset investment costs., Practice Implications: Evidence-based interventions designed to improve the quality of patient care may have the best opportunity to yield a positive financial return if it is focused on high-risk high-cost populations and conditions associated with avoidable emergency and inpatient utilization. Developing the necessary tracking systems for the claims and financial investments is critical to perform accurate financial ROI analyses.

As noted in the introductory editorial by Moeller and Toohey, the Energy Employees Occupational Illness Compensation Program Act (EEOICPA) was passed by the U.S. Congress in October 2000 and became effective on 31 July 2001. The Act provides a lump-sum compensation of $150,000 to workers who contracted certain diseases due to exposures to beryllium, silica, or radiation while working for the U.S. Department of Energy (DOE), its contractors, or subcontractors, in the nuclear weapons industry. The Secretaries of DOE, the U.S. Department of Health and Human Services (HHS), and the U.S. Department of Labor (DOL) share responsibilities for administering this program. In accordance with the provisions of EEOICPA, the President, in October 2001, appointed an Advisory Board on Radiation and Worker Health. The work of the Board, which began in January 2002, is conducted with staff support provided by the National Institute for Occupational Safety and Health (NIOSH). NIOSH is responsible for establishing scientific guidelines for determining whether a worker's cancer is "at least as likely as not" related to occupational exposure to radiation (probability of causation) and developing methods to estimate worker exposure to radiation (dose reconstruction). During its first 5 years of operation, the Board has provided substantial input on the rulemaking activities of NIOSH. It also is establishing methodologies for auditing the validity and quality of the dose estimates. The Board expects to sample and examine approximately 2-3% of the completed dose reconstructions. Random audits of approximately 1% of these are now underway.

Approximately two years after promulgation of the Energy Employees Occupational Illness Compensation Program Act, the National Institute for Occupational Safety and Health Office of Compensation and Analysis Support selected a contractor team to perform many aspects of the radiation dose reconstruction process. The project scope and schedule necessitated the development of an organization involving a comparatively large number of health physicists. From the initial stages, there were many technical and managerial challenges that required continuous planning, integration, and conflict resolution. This paper identifies those challenges and describes the resolutions and lessons learned. These insights are hopefully useful to managers of similar scientific projects, especially those requiring significant data, technical methods, and calculations. The most complex challenge has been to complete defensible, individualized dose reconstructions that support timely compensation decisions at an acceptable production level. Adherence to applying claimant-favorable and transparent science consistent with the requirements of the Act has been the key to establishing credibility, which is essential to this large and complex project involving tens of thousands of individual stakeholders. The initial challenges included garnering sufficient and capable scientific staff, developing an effective infrastructure, establishing necessary methods and procedures, and integrating activities to ensure consistent, quality products. The continuing challenges include maintaining the project focus on recommending a compensation determination (rather than generating an accurate dose reconstruction), managing the associated very large data and information management challenges, and ensuring quality control and assurance in the presence of an evolving infrastructure. The lessons learned concern project credibility, claimant favorability, project priorities, quality and consistency, and critical path project activities.

Quality control is important in many fields, especially industrial production. Major research has been developed with regard to industrial quality control to ensure reliable and consistent products. We adapt and develop methodology in quality control to monitor data collection in epidemiologic studies. There are no procedures currently used by epidemiologists to evaluate quality control during the actual process of data collection; methods are implemented only after the data have been collected. We focus on procedures that can be used during data collection: instrument calibration and population sampling. For the first, we propose methods utilizing Shewhart control charts and Westgard stopping rules. For evaluating population sampling, we present methods utilizing regression analysis. We provide a motivating example to highlight the utility of these methods. The proposed methodology may help investigators to identify data quality problems that can be corrected while data are still being collected, and also to identify biases in data collection that might be adjusted later.

Background: Work-arounds are work procedures that are undertaken to address a block in work flow. Although there has been extensive interest in the health care literature concerning work-arounds, there is a dearth of literature exploring the factors that predict work-arounds., Purpose: The purpose of this article is to examine the role of continuous quality improvement and psychological safety as predictors of work-arounds in health care organizations. Specifically, we hypothesized that continuous quality improvement and psychological safety predicted work-arounds such that psychological safety mediated the relationship between continuous quality improvement and work-arounds., Methodology: This study was part of a larger cross-sectional field study exploring workforce issues among cancer registrars working in acute care hospitals who report tumor data to a state cancer registry in the Midwest. Eighty-three employees of cancer registries responded to telephone survey items assessing continuous quality improvement (personal influence and management style), psychological safety, and work-arounds., Findings: Using mediated multiple regression (with findings confirmed with a Sobel test), we found partial support for the hypothesized mediated relationship between personal influence, management style, psychological safety, and work-arounds. The exception to this pattern concerned personal influence. Because personal influence is a dimension of continuous quality improvement, it would be negatively associated with work-arounds; we found the opposite to be true in this study., Practice Implications: To avoid problems with work-arounds, our findings suggest that organizations need to commit to continuous improvement at a strategic level. In addition, culture and management behaviors need to shift away from reinforcement of individual first-order problem solving (manifest as work-arounds) toward second-order problem-solving approaches.

This study provides evidence for reliability (the Cronbach alpha of .76-.94) and construct validity of the Patient-Family-Centered Care Survey developed by the researchers in collaboration with FKP Architects, used to measure and benchmark practice within pediatric institutions. The survey evaluates progress of integrating patient-family-centered care over time and can be triangulated with measurements of desired patient and institutional outcomes.

The Prospective Payment System had significant impact on home healthcare agencies throughout the nation. Virtua Home Care, located in Southern New Jersey, realized the need for process improvement in order to remain viable. Six Sigma was introduced to the agency and the Define, Measure, Analyze, Improve, and Control processes were initiated to achieve sustainable results, and within 9 months, Virtua Home Care improved regulatory compliance, experienced a deficiency-free survey, and recognized a 1.2 million dollars financial gain.