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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.

Objective: The increase in the financial imposition of laboratories together with developing technology and evidence-based medicine applications increased the importance of quality and efficiency studies in laboratories. The aim of the study is to examine the processes of pathology laboratory, determine the causes of waste and select lean management techniques to eliminate the causes of waste., Material and Method: A five-phase plan was used for the application of lean management in the pathology laboratory. After a comprehensive literature review, these phases were determined as follows; the support of the senior management, observation, training of employees, drawing of value stream maps and creation of value stream plan. Gastric biopsy process was selected as product/service family when value stream maps were generated. In addition, fishbone diagram and Pareto analysis were used to determine the causes of waste., Results: In the current state, 73.6% of the time spent on a gastric biopsy sample in the pathology laboratory was wasted. The most common causes of waste were identified as problems with cleaning, equipment supply problems, lack of clinical information, equipment malfunction and errors. A value stream plan was developed with lean techniques to eliminate the causes of these wastes. In the pathology laboratory, a 4.6% improvement will be achieved with the achievement of the future stated target., Conclusion: A model for lean management techniques in a developing country that will enable the pathology laboratories to work more efficiently and with improved quality has been developed in this study.

Purpose: To evaluate sustainability of impact of rapid, focused process improvement (PI) events on process and performance within an academic radiology department., Methods: Our department conducted PI during 2011 and 2012 in CT, MRI, ultrasound, breast imaging, and research billing. PI entailed participation by all stakeholders, facilitation by the department chair, collection of baseline data, meetings during several weeks, definition of performance metrics, creation of an improvement plan, and prompt implementation. We explore common themes among PI events regarding initial impact and durability of changes. We also assess performance in each area pre-PI, immediately post-PI, and at the time of the current study., Results: All PI events achieved an immediate improvement in performance metrics, often entailing both examination volumes and on-time performance. IT-based solutions, process standardization, and redefinition of staff responsibilities were often central in these changes, and participants consistently expressed improved internal leadership and problem-solving ability. Major environmental changes commonly occurred after PI, including a natural disaster with equipment loss, a change in location or services offered, and new enterprise-wide electronic medical record system incorporating new billing and radiology informatics systems, requiring flexibility in the PI implementation plan. Only one PI team conducted regular post-PI follow-up meetings. Sustained improvement was frequently, but not universally, observed: in the long-term following initial PI, measures of examination volume showed continued progressive improvements, whereas measures of operational efficiency remained stable or occasionally declined., Conclusions: Focused PI is generally effective in achieving performance improvement, although a changing environment influences the sustainability of impact. Thus, continued process evaluation and ongoing workflow modifications are warranted., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Kaizen is a proven management technique that has a practical application for health care in the context of health care reform and the 2010 Institute of Medicine landmark report on the future of nursing. Compounded productivity is the unique benefit of kaizen, and its principles are change, efficiency, performance of key essential steps, and the elimination of waste through small and continuous process improvements. The kaizen model offers specific instruction for perioperative nurses to achieve process improvement in a five-step framework that includes teamwork, personal discipline, improved morale, quality circles, and suggestions for improvement., (Published by Elsevier Inc.)

Healthcare has long looked at decreasing risk in communication and patient care processes. Increasing the simplicity in communication and patient care process is a newer concept contained in Lean methodology. Lean is a strategy for achieving improvement in performance through the elimination of steps that use resources without contributing to customer value. This is known as cutting waste or nonvalue added steps. This article outlines how the use of Lean improved a key process that supports battlefield medical fitness.

Local public health agencies are challenged to continually improve service delivery, yet they frequently operate with constrained resources. Quality improvement methods and techniques such as statistical process control are commonly used in other industries, and they have recently been proposed as a means of improving service delivery and performance in public health settings. We analyzed a quality improvement project undertaken at a local Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic to reduce waiting times and improve client satisfaction with a walk-in nutrition education service. We used statistical process control techniques to evaluate initial process performance, implement an intervention, and assess process improvements. We found that implementation of these techniques significantly reduced waiting time and improved clients' satisfaction with the WIC service.

Background: "Lean" is a set of principles and techniques that drive organizations to continually add value to the product they deliver by enhancing process steps that are necessary, relevant, and valuable while eliminating those that fail to add value. Lean has been used in manufacturing for decades and has been associated with enhanced product quality and overall corporate success., Objectives: To evaluate whether the adoption of Lean principles by an Emergency Department (ED) improves the value of emergency care delivered., Methods: Beginning in December 2005, we implemented a variety of Lean techniques in an effort to enhance patient and staff satisfaction. The implementation followed a six-step process of Lean education, ED observation, patient flow analysis, process redesign, new process testing, and full implementation. Process redesign focused on generating improvement ideas from frontline workers across all departmental units. Value-based and operational outcome measures, including patient satisfaction, expense per patient, ED length of stay (LOS), and patient volume were compared for calendar year 2005 (pre-Lean) and periodically after 2006 (post-Lean)., Results: Patient visits increased by 9.23% in 2006. Despite this increase, LOS decreased slightly and patient satisfaction increased significantly without raising the inflation adjusted cost per patient., Conclusions: Lean improved the value of the care we delivered to our patients. Generating and instituting ideas from our frontline providers have been the key to the success of our Lean program. Although Lean represents a fundamental change in the way we think of delivering care, the specific process changes we employed tended to be simple, small procedure modifications specific to our unique people, process, and place. We, therefore, believe that institutions or departments aspiring to adopt Lean should focus on the core principles of Lean rather than on emulating specific process changes made at other institutions.

The process approach is a mode of quality improvement. It leans on the cartography's establishment, allows to redefine organization around patients trajectory, the measure of defects and their correction. The process pilot is a new actor in the management of the establishment. It is developed since 3 years in the Institute Claudius Regaud, regional cancer center treatment of Midi-Pyrénées.

By adopting a cultural transformation in its employees' approach to work and using manufacturing based continuous quality improvement methods, the surgical pathology division of Henry Ford Hospital, Detroit, MI, focused on reducing commonly encountered defects and waste in processes throughout the testing cycle. At inception, the baseline in-process defect rate was measured at nearly 1 in 3 cases (27.9%). After the year-long efforts of 77 workers implementing more than 100 process improvements, the number of cases with defects was reduced by 55% to 1 in 8 cases (12.5%), with a statistically significant reduction in the overall distribution of defects (P = .0004). Comparison with defects encountered in the pre-improvement period showed statistically significant reductions in pre-analytic (P = .0007) and analytic (P = .0002) test phase processes in the post-improvement period that included specimen receipt, specimen accessioning, grossing, histology slides, and slide recuts. We share the key improvements implemented that were responsible for the overall success in reducing waste and re-work in the broad spectrum of surgical pathology processes.

Statistical process control (SPC) can be thought of as the frequent monitoring of processes using inferential statistics. The feature that distinguishes SPC from the typical use of inferential statistics for analyzing populations is that in the former frequent samples are taken over time, whereas in inferential statistics a single sample is generaLLy taken before and after some intervention or treatment. An x-s control chart is used to monitor a continuous variable that reflects the output of a process. The x-s control chart is a graph that includes serial sample means (x) as the variables of interest, a centerline that represents the grand mean of the samples (x), and upper control limit (UCL) and lower control limit (LCL) that represent three standard errors (SEx) above and below the centerline. An x-s control chart is used to estimate with 99.7% confidence that the population mean of a continuous output variable was within the interval defined by the UCL and LCL during a period of baseline monitoring. It is further assumed that if the process remains stable, future population means wiLL remain between the control Limits for additional process outputs. Control charts allow the evaluation of both common- and special-cause variation. AnaLysis of the common-cause variation aLLows an assessment of the current process performance. Special-cause variation is identified when there is a sample mean that is beyond the UCL or LCL.

A p control chart is used to monitor a proportion from a binomial variable that reflects the output of a process. The p control chart is a graph that includes serial sample proportions (p) as the variables of interest, a centerline that represents the overall proportion of the samples (p), and upper control limits (UCLs) and Lower control Limits (LCLs) that represent three standard errors (SEp) above and below the centerline. We use a p control chart to estimate with 99.7% confidence that the population proportion of an output variable was within the interval defined by the UCLs and LCLs during a period of baseline monitoring. We further assume that if the process remains stable, the values of future population proportions will remain between the established control limits. An np control chart simply plots the numerators of the sample proportions as the variables of interest. A u control chart is used to monitor ratios. In u control charts, ratios are quantities in which the numerator can have one or more occurrences in reference to the denominator. A c control chart is analogous to an np control chart in that it graphs the numerators from the ratios.

An improvement activity involving use of real-time waiting-time data resulted in reductions in bed-assignment times and overall diversion hours.

There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.

Processes management has a positive effect in both reducing the variability of clinical practice, and increasing therapeutic effectiveness and patients' satisfaction. In this article the different types of processes and the methods used to identify and define processes and subprocesses are described. The management by processes requires to combine information of patients' needs and expectations, and the recent evidence, describing the activities' sequence that the professionals would realize in order to obtain a positive outcome. Defining quality criteria of clinical practice and monitoring if standards are achieved are critical to obtain other of its characteristic: continuous improvement (PDCA cycle). The introduction of total quality ideas in the healthcare organizations in recent years has yielded the dissemination of the advantages of management processes in health care sector.

Understanding how quality improvement affects costs is important. Unfortunately, low-cost, reliable ways of measuring direct costs are scarce. This article builds on the principles of process improvement to develop a costing strategy that meets both criteria. Process-based costing has 4 steps: developing a flowchart, estimating resource use, valuing resources, and calculating direct costs. To illustrate the technique, this article uses it to cost the care planning process in 3 long-term care facilities. We conclude that process-based costing is easy to implement; generates reliable, valid data; and allows nursing managers to assess the costs of new or modified processes.

Lean Thinking is an integrated approach to designing, doing and improving the work of people that have come together to produce and deliver goods, services and information. Healthcare Lean is based on the Toyota production system and applies concepts and techniques of Lean Thinking to hospitals and physician practices.

Decision-making body or individual a key variable in prioritization. Start with more obvious QI areas to develop a comfort level. Is it harder to motivate staff to study issues that might become problems?

To design potentially successful quality improvement (QI) interventions, it is crucial to make use of detailed breakdowns of the implementation processes of successful and unsuccessful interventions. Process evaluation can throw light on the mechanisms responsible for the result obtained in the intervention group. It enables researchers and implementers to (1). describe the intervention in detail, (2). check actual exposure to the intervention, and (3). describe the experience of those exposed. This paper presents a framework containing features of QI interventions that might influence success. Attention is paid to features of the target group, the implementers or change agents, the frequency of intervention activities, and features of the information imparted. The framework can be used as a starting point to address all three aspects of process evaluation mentioned above. Process evaluation can be applied to small scale improvement projects, controlled QI studies, and large scale QI programmes; in each case it plays a different role.

The operation of any physician practice is a complicated process with many different functions and systems. Though frequently overlooked, operations improvements and efficiencies are possible if a participative, process-oriented approach is used. An actual case study of a "hospital system-owned" primary care physician group practice is presented. The methods of analysis and specific actions for improvement in operational efficiency and quality are described in detail. Opportunities for cost reduction, increased revenues, and increased patient and physician satisfaction are identified.

The risk-adjusted and descriptive outcome report provides a foundation for Outcome-Based Quality Improvement (OBQI). This article describes the steps of the process-of-care investigation that will begin once target outcomes are selected.

Background: In February 2001 Good Samaritan Hospital in Dayton, Ohio, conducted a Failure Mode and Effect Analysis (FMEA) on the blood transfusion process to reduce the risk of problems inherent in the procedure. DEVELOPING THE FMEA: The major steps of the analysis were to identify problems (failure modes), define their causes, and surmise the effects if failures occurred. Numerical scores were assigned for the likelihood of failure occurrence, the severity of the effects, and the possibility that the failure would escape detection. These scores were multiplied and reported as a risk priority number (RPN) for each failure mode. Solutions (process redesign actions) and monitoring plans (design validation) were developed to address the failure modes with the highest RPNs. PRESENTING THE FMEA: In March 2001 the FMEA document was presented to the Safety Board, which approved design changes such as use of a blood barrier system that restricts access to the blood until a patient-specific code is dialed., Results: Measures were developed to analyze results, and rapid-cycle Plan-Do-Study-Act methodology was used to test and document redesign changes; most became the standard operating procedure. The new process accomplished its purpose of preventing serious, avoidable errors. No outcome errors occurred from March 2001 through June 2001 or in the 8 months following housewide implementation on June 18, 2001., Discussion: FMEA was a valuable tool in error-trapping the blood transfusion process. Yet the FMEA process was time-consuming, tedious, and difficult and should be reserved for an organization's highest-priority processes.

The imperative to improve both technical and service quality while simultaneously reducing costs is quite clear. The Theory of Constraints (TOC) is an emerging philosophy that rests on two assumptions: (1) systems thinking and (2) if a constraint "is anything that limits a system from achieving higher performance versus its goal," then every system must have at least one (and at most no more than a few) constraints or limiting factors. A constraint is neither good nor bad in itself. Rather, it just is. In fact, recognition of the existence of constraints represents an excellent opportunity for improvement because it allows one to focus ones efforts in the most productive area--identifying and managing the constraints. This is accomplished by using the five focusing steps of TOC: (1) identify the system's constraint; (2) decide how to exploit it; (3) subordinate/synchronize everything else to the above decisions; (4) elevate the system's constraint; and (5) if the constraint has shifted in the above steps, go back to step 1. Do not allow inertia to become the system's constraint. TOC also refers to a series of tools termed "thinking processes" and the sequence in which they are used.

Describes a process to assess facilities management (FM) process capabilities: the structured process improvement for construction environments--facilities management (SPICE FM) approach. The SPICE FM framework is a method that FM organizations can use to monitor continuously and subsequently improve their performance. The SPICE FM framework is being tested in a series of case studies to ensure that its outputs are appropriate to the FM sector and of value in the real world. Documents the outcomes of a study undertaken at a facilities directorate of a healthcare NHS trust, in searching its applicability within the NHS. Further describes the study methodology and the key activities undertaken and reviews the key communication and management processes that are in place to support the implementation of the strategic FM objectives within the specific NHS facilities directorate.

Background: Hospital environments are too often characterized by delays for patients receiving diagnostic testing and prolonged waiting times to complete needed therapy. Frequently there is confusion in scheduling, related at least in part to the complex interplay of clinical acuity and highly individualized care. Luther Midelfort recently began to change the process of patient flow to improve access to care, optimize outcomes by enabling timely intervention, and decrease the wasting of resources., Unit Assessment Tool: The hospital developed a unit assessment tool based on the traffic light concept, which consisted of an assessment of current capacity and a graded, color-coded "workload tolerance" for each hospital unit. Each unit can instantly update its own status and query those of other work environments in the hospital., Experience With the Unit Assessment Tool: For most of the January-July 2001 period, there was generally a progressive decrease in the percentage of time that the units were coded as red (unit closed to new admissions), with concurrent increases in the percentage of time that the units were coded as green (unit open). Use of the tool appears to have contributed to a dramatic increase in staff satisfaction., Summary and Conclusions: The key to regulating patient flow has been to adopt a nursing-initiated capping trust policy whereby nurses are given the authority to limit new admissions. Initiatives are now under way to provide different units with novel models of resource sharing, ranging from flexible housekeeping to "flying nurse squads" to assist units that have become red.

The RAF method for regulation, assessment, follow-up and continuous improvement of quality of care was developed in Israel in the late 1980s by the Quality of Care Unit at the JDC-Brookdale Institute. The goal of the RAF method is to continuously increase the level of quality of organizations providing any kind of a service. This article presents the developmental processes for the method's adaptation to a specific regulatory service--its structuring, implementation and assimilation--based on our experience in developing and implementing the RAF method in Israel. It describes how the RAF method encourages the development of reliable data bases, adaptation of the organizational structure, and introduction of a positive ideology that together promote changes leading to continuous improvement in quality of care.

Background: Health care organizations dedicate enormous time and resources collecting data to measure the performance of physicians, hospitals, and other medical facilities. These measures may reflect outcomes, processes of care, patient perceptions of the quality of care, and resource utilization and cost. However, less thought is given to how the performance data should be used to improve care. The data must be translated into clinically relevant terms that assess the decisions of the clinical staff and the functioning of the systems that support the delivery of care. The processes of care are identified through record review, analysis of the system of care delivery, and patient interview, and are then further assessed to determine the underlying causes., Examples: Examples, drawn from case studies, are provided to illustrate how to identify and address components of care requiring improvement., Discussion: Physician behavior is an important component of care in all performance measures. Modification of some patterns of behavior, including those of nursing and other support staff, may be needed to reduce some types of error. For this reason it is important to involve physicians in the process of discovering root causes. When the root cause involves the medical care system, an interdisciplinary approach will be needed. This may involve administrators, nurses, pharmacists, home care and discharge planners, and office personnel. One recommended approach to QI is to identify system errors and then design changes in the system to reduce that type of error., Conclusion: Performance measures must be translated into the components(s) of care that are implicated in the measure. Once this component has been identified as the reason behind the suboptimal measure, its root cause should be used to structure the most effective intervention.

The third generation cardiac institute will build on the successes of the past in structuring the service line, re-organizing to assimilate specialist interests, and re-positioning to expand cardiac services into cardiovascular services. To meet the challenges of an increasingly competitive marketplace and complex delivery system, the focus for this new model will shift away from improved structures, and toward improved processes. This shift will require a sound methodology for statistically measuring and sustaining process changes related to the optimization of cardiovascular care. In recent years, GE Medical Systems has successfully applied Six Sigma methodologies to enable cardiac centers to control key clinical and market development processes through its DMADV, DMAIC and Change Acceleration processes. Data indicates Six Sigma is having a positive impact within organizations across the United States, and when appropriately implemented, this approach can serve as a solid foundation for building the next generation cardiac institute.

Challenged with persistent specimen labeling errors that were resistant to improvement efforts, our organization selected "reducing specimen labeling errors" as an indicator for a hospital-wide error reduction goal. Modeling quality improvement guidelines published in the institute of Medicine's report "To Err is Human, Building a Safer Health System," a multidisciplinary task force "error proofed" processes. The task force created new standards and crafted an implementation plan using an internal marketing strategy to change current practices and reinforce patient safety as a core value within our institution. This unique approach reduced errors by 41% and provided learning opportunities that will be valuable in more challenging patient safety initiatives such as medication error reduction.

One of the most important instruments for gathering information and processing data relating to professional and organisational quality in health systems is "healthcare processes classification". The authors found that a typical problem of many European countries is a lack of reliable information in the field of healthcare, mainly because the development of quality instruments, including healthcare processes classification, is not a priority for medical and other health professions. Additionally, it is difficult to update this instrument coherently with organisational changes and developmental achievements. This article describes the approach used by the University Medical Centre in Ljubjana, Slovenia, to redesign its healthcare processes classification in order to improve the quality of healthcare.

This study evaluated the early phase of development of a model for quality improvement of habilitation and rehabilitation project processes. The focus of the methodologic support in habilitation and rehabilitation model was on cooperation between practice contexts and science. Habermas' theory about communicative action was a theoretical frame of reference. Three project coordinators and ten project leaders were interviewed. The results revealed different attitudes towards methodologic support activities, demonstrating the importance of acknowledging cognitive and social functions, the process of legitimization, different approaches of practice versus science, and problems regarding information and communication. The model was shown to be important in bridging the gap between practice and science. To support reflective and emancipatory cognitive learning, more efforts to foster communicative action are called for, and more attention must be paid to the importance different missions and organizational structures have for the development of the dialog between practitioners and researchers.