Search

Introduction: Waste in medical research is a relatively well-known issue. However, only a few initiatives exist to address this issue. Lean Management methods (Lean) were developed in industrial manufacturing and later applied within healthcare improvement. Overall, the results from studies of the application of Lean to healthcare appear to be positive in terms of greater efficiency regarding treatment outcomes and patient care. Nevertheless, the application of Lean to improve research processes is not well studied and, given that research alongside clinical practice and experiential knowledge provides the foundation for the treatment and care of patients, it is paramount to identify approaches and review the degree to which they increase efficiency within research procedures. Therefore, this review will scope the landscape of studies that investigated Lean and how to implement Lean in research processes, particularly regarding healthcare research., Methods and Analysis: Our approach follows the methodological framework of Arksey and O'Malley for conducting scoping reviews (PRISMA-ScR). The search strategy for this scoping review was developed using the PCC model. We will identify the relevant literature by searching four search databases: Scopus, Web of Science, Academic Search Premier and Business Source Complete. Next, we will use citation pearl growing to identify all relevant published literature. The data charting process will follow the PRISMA-ScR checklist and will be organised using NVivo. We will generate qualitative and quantitative assessments of the extracted data by using NVivo, RStudio and Excel. We will follow the PRISMA-ScR guideline when reporting the results., Ethics and Dissemination: The review will comprise existing published studies and no primary data will be collected. Our findings will be shared through open access peer-reviewed journals, national and international conferences and emails to all relevant collaborative relationships. We plan to disseminate our findings via academic social media platforms, newspaper articles and blogposts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: to investigate the contributions of applying the Lean methodology to improve work processes in health and nursing and its impact on associated financial aspects., Method: an integrative review, carried out in six databases, whose sample of ten (100.0%) studies was analyzed and summarized descriptively., Results: the outcomes obtained were stratified into: benefits/barriers to Lean Healthcare implementation; economic aspects involving Lean Healthcare implementation; and process improvements through Lean Healthcare implementation. The majority of studies (60.0%) were carried out in university hospitals, contexts that need to continually improve the quality of services provided, generally with scarce and limited resources, which support the viability of maintaining the teaching, research and extension tripod., Conclusion: three (30.0%) studies highlighted the financial aspects associated with Lean methodology application. The others only mentioned the possibility of financial gains through improving processes and reducing waste.

Objective: This study aims to examine how we can effectively and affordably evaluate the impact of design concepts such as Lean-Led Hospital Design (LLHD) on the allocation of nurses' time spent at different locations. Particularly in patient rooms, as this can be seen as value-adding time., Background: LLHD aims to create a hospital environment that supports value creation for patients and reduces waste. However, only a few studies measure its' effects. One of the reasons for this absence is the lack of an adequate and affordable way to evaluate., Method: Nurses' time spent in patient rooms was used as a proxy for value-adding time. Through studying a pioneering case of LLHD, and drawing on a pre-/postoccupancy evaluation approach, this study used an innovative methodology utilizing mobile tracking devices to adequately provide reliable data about the time nurses spend at specific locations., Results: Our analysis reveals that the answer to the question concerning the impact of LLHD, as advocated by its proponents, on nurses' allocation of time for value-adding activities versus waste time remains inconclusive. Our findings indicate no discernible difference in the amount of value-adding time nurses spent in the old facility compared to the new one., Conclusion: Our experience suggests that mobile tracking devices offer an affordable, efficient means of collecting data that produces objective measurements. Nevertheless, the interpretation of this time-based data necessitates the inclusion of supplementary qualitative information., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: In this study, we applied a six sigma model to examine cerebrospinal fluid (CSF) biochemical analytes for the first time. Our goal was to evaluate the analytical performance of various CSF biochemical analytes, design an optimized internal quality control (IQC) strategy, and formulate scientific and reasonable improvement plans., Methods: The sigma values of CSF total protein (CSF-TP), albumin (CSF-ALB), chloride (CSF-Cl), and glucose (CSF-GLU) were calculated using the following formula: sigma = [TEa(%)-|bias(%)|]/CV(%). The analytical performance of each analyte was shown using a normalized sigma method decision chart. Individualized IQC schemes and improvement protocols for CSF biochemical analytes were formulated using the Westgard sigma rule flow chart with batch size and quality goal index (QGI)., Results: The distribution of sigma values for CSF biochemical analytes ranged from 5.0 to 9.9, and the sigma values varied for different concentrations of the same analyte. The analytical performance of the CSF assays at the two QC levels is displayed visually in normalized sigma method decision charts. Individualized IQC strategies for CSF biochemical analytes were as follows: for CSF-ALB, CSF-TP and CSF-Cl, use 1 3s with N = 2 and R = 1000; for CSF-GLU, use 1 3s /2 2s /R 4s with N = 2 and R = 450. In addition, priority improvement measures for analytes with sigma values less than 6 (CSF-GLU) were formulated based on the QGI, and their analytical performance was improved after the corresponding improvement measures were taken., Conclusions: The six sigma model has significant advantages in practical applications involving CSF biochemical analytes and is highly useful for quality assurance and quality improvement., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

When increasing the quality in clinical laboratories by decreasing measurement uncertainty, reliable methods are needed not only to quantify the performance of measuring systems, but also to set goals for the performance. Sigma metrics used in medical laboratories for documenting and expressing levels of performance, are evidently totally dependent on the "total permissible error" used in the formulas. Although the conventional biological variation (BV) based model for calculation of the permissible (or allowable) total error is commonly used, it has been shown to be flawed. Alternative methods are proposed, mainly also based on the within-subject BV. Measurement uncertainty models might offer an alternative to total error models. Defining the limits for analytical quality still poses a challenge in both models. The aim of the present paper is to critically discuss current methods for establishing performance specifications by using the measurement of sodium concentrations in plasma or serum. Sodium can be measured with high accuracy but fails by far to meet conventional performance specifications based on BV. Since the use of sodium concentrations is well established for supporting clinical care, we question the concept that quality criteria for sodium and similar analytes that are under strict homeostatic control are best set by biology., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: Liquid chromatography-tandem mass spectrometry (LC-MS/MS) has become a common technique in clinical laboratories in recent years. Because most methods are laboratory-developed tests (LDTs), their reproducibility and quality control (QC) have been controversial. In this study, Westgard Sigma Rules were used to evaluate the analytical performance and establish an individualised internal QC (IQC) strategy for these LDTs., Methods: Taking the LC-MS/MS LDT method for homocysteine (Hcy) as an example, the 'desirable specifications' from the Biological Variation Database were used as quality goals. Based on the external quality assessment (EQA) samples, bias was calculated and the coefficient of variation (CV) was also calculated by IQC measurements for six consecutive months. The analytical performance was evaluated by calculated sigma metrics and an IQC strategy was designed using the Westgard Sigma Rules with run size., Results: Over 116 days within 6 months, a total of 850 data points were collected for each of IQC 1 and IQC 2. The monthly coefficient of variation CV% was 2.57-4.01%, which was non-significant (p-value: 0.75). The absolute bias% for IQC1 and IQC2 was 1.23 and 1.87%, respectively. The allowable total error (TEa) was selected as 15.5%, Sigma metrics were 4.02 and 4.30, and the analytical performance was 'Good'. The 1 3s /2 2s /R 4s /4 1s multi rules (n=4, r=1) with a run size of 200 samples were suggested for the Hcy IQC scheme. The quality goal index (QGI) values were over 1.2, indicating that trueness needed to be improved., Conclusions: The analytical performance of the Hcy LC-MS/MS LDT conformed to the Six Sigma rating level, achieving 'good' (four Sigma). Clinical practice indicated that calibration bias was the primary factor affecting trueness., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Background and Aim: Sigma metrics are applied in clinical laboratories to assess the quality of analytical processes. A parameter associated to a Sigma > 6 is considered "world class" whereas a Sigma < 3 is "poor" or "unacceptable". The aim of this retrospective study was to quantify the impact of different approaches for Sigma metrics calculation., Material and Methods: Two IQC levels of 20 different parameters were evaluated for a 12-month period. Sigma metrics were calculated using the formula: (allowable total error (TEa) (%) - bias (%))/(coefficient of variation (CV) (%)). Method precision was calculated monthly or annually. The bias was obtained from peer comparison program (PCP) or external quality assessment program (EQAP), and 9 different TEa sources were included., Results: There was a substantial monthly variation of Sigma metrics for all combinations, with a median variation of 32% (IQR, 25.6-41.3%). Variation across multiple analyzers and IQC levels were also observed. Furthermore, TEa source had the highest impact on Sigma calculation with proportions of Sigma > 6 ranging from 17.5% to 84.4%. The nature of bias was less decisive., Conclusion: In absence of a clear consensus, we recommend that laboratories calculate Sigma metrics on a sufficiently long period of time (>6 months) and carefully evaluate the choice of TEa source., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Introduction: The modern approach to quality control (QC) in medical laboratories implies the development of a risk-based control plan. This paper aims to develop a risk-based QC plan for a laboratory with a small daily testing volume and to integrate the already optimized moving average (MA) control procedures into this plan., Materials and Methods: A multistage bracketed QC plan for ten clinical chemistry analytes was made using a Westgard QC frequency calculator. Previously, MA procedures were optimized by the bias detection simulation method., Results: Aspartate aminotransferase, HDL-cholesterol and potassium had patient-risk sigma metrics greater than 6, albumin and cholesterol greater than 5, creatinine, chlorides, calcium and total proteins between 4 and 5, and sodium less than 4. Based on the calculated run sizes and characteristics of optimized MA procedures, for 6 tests, it was possible to replace the monitoring QC procedure with an MA procedure. For the remaining 4 tests, it was necessary to keep the monitoring QC procedure and introduce MA control for added security., Conclusion: This study showed that even in a laboratory with a small volume of daily testing, it is possible to make a risk-based QC plan and integrate MA control procedures into that plan., Competing Interests: Potential conflict of interest None declared., (Croatian Society of Medical Biochemistry and Laboratory Medicine.)

Process improvement methodology minimizes barriers to implementing new knowledge., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: The objective of this paper is to propose a systematic application of Lean Healthcare in the hospitalization activity in the medical clinic entry process., Design/methodology/approach: The methodology used is established in three stages: the first aims to map the process in which the focus activity is inserted, using lean tools, as well as integrating the employees involved in the application. The second is the proposal to apply the systematic, together with the employees, using the A3 tool step by step. Finally, the third stage confirms the applied systematic, collecting the results and analyzing the initial situation with those reached., Findings: As a result, improvements were made in the medical clinic entry process, such as reduced waiting time for patients, at approximately 53.8%, with a decrease in the standard deviation of the times - of approximately 79.14%, and displacement of those involved, of 72%, in addition to eliminating unnecessary activities for the process. Furthermore, the empirical results on the efficiency of this systemic application in medical clinic enable the replication of this proposal, generating a systematic., Research Limitations/implications: Despite establishing a systematic proposal with real results, it is focused on only one application, due to time limitations, may generate a subjective evaluation of the systematic. Thus, for future research, it is recommended to expand this systemic application in other activities of different processes., Practical Implications: The practical implications of this paper are precisely related to the data obtained with the application made, developing a Lean Healthcare systematic not previously seen, which is strategic, systemic and has a roadmap to assist in its application and, in addition, brings with it practical results that prove their efficiency., Social Implications: The social implications of this paper are presented in its empirical results, considering that the study hospital serves, in addition to its host city, 28 other smaller municipalities around it, improving the flow of processes, ensuring better management of the clinic doctor. In addition, the results can assist the processes flow of other medical clinics in hospitals around the world, especially at critical moments, such as pandemics or epidemics., Originality/value: Due to the positive results obtained in the systematic application, this paper fills a gap identified in the literature, proposing a systematic application of Lean Healthcare that is systemic and strategic, in addition to including a roadmap and analysis of data applied in a medium-sized Brazilian hospital, presenting positive practical results exposed in the paper., (© Emerald Publishing Limited.)

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.)

Since it is an important human need and many organizations are involved in the value chain, the agricultural food supply chain is exposed to various risks that arise naturally or through human actions. This study aims to develop the application of a quality function deployment approach to increase the resilience of the food supply chain by understanding customer needs and logistical risks in the food supply chain. In-depth studies with empirical analysis were conducted to determine the importance of customer needs, food supply chain risks, and actions to improve supply chain resilience of SMEs in the agri-food industry. The result shows that the top three customer needs are "attractive, bright color", "firm texture" and "fresh smell". The top three risks in the agri-food supply chain are "improper storage," "Harvest Failure" and "Human Resource Risks" and the top three resilience actions are "continuous training," "preventive maintenance," and "supply chain forecasting." The implications of this study are to propose an idea that broadens the perspective of supply chain resilience in the agri-food industry by incorporating the needs of customers in considering how to mitigate the existing risks to the satisfaction of customers, and it also highlights the relatively low skill and coordination of the workforce in agri-food supply chains., Competing Interests: The authors have declared that no competing interests exist.

Background: Sigma metrics are commonly used to evaluate laboratory management. In this study, we aimed to evaluate the analytical performance of cystatin C using sigma metrics and to develop an individualized quality control scheme for cystatin C concentrations., Methods: Bias was calculated based on the samples used for the external quality assessment. The coefficient of variation was calculated using six months of internal quality control measurements at two levels, and desirable specification derived from biological variation was used as the quality goal. The sigma value for cystatin C was calculated using the above data. The internal quality control scheme and improvement measures were formulated according to the Westgard sigma standards for batch size and quality goal index., Results: The sigma values for cystatin C, for quality control levels 1 and 2, were 3.04 and 4.95, respectively. The 1 3s /2 2s /R 4s /4 1s /6 x multirules ( n  = 6, R = 1), with a batch size of 45 patient samples, were selected as the internal quality control schemes for cystatin C. With different concentrations of cystatin C, the power function graph showed a probability for error detection of 94% and 100% and a probability for false rejection of 4% and 2%, respectively. According to the quality goal index of cystatin C, its precision needs to be improved., Conclusions: With a 'desirable' biological variation of 6.50%, the Westgard rule 1 3s /2 2s /R 4s /4 1s /6 x ( n  = 6, R = 1, batch size of 45) with high efficacy for determining the detection error is recommended for individualized quality control schemes of cystatin C.

In the broadest sense, a quality management system (QMS) runs by continuous interaction of elements based on processes, procedures, policies, guidelines, and resources that are compiled to guide an organization under the scope of its operational mission, vision, and objectives. QMSs in the biopharmaceutical sector defines a written and applied set of rules which aids in improvement of the quality of biopharmaceutical process engineering, while primarily assuring human tissue- and cell-based starting material and end product safety and minimizing the risk of human medicinal product recall, in the most cost-effective ways possible. This chapter aims to outline the crucial position of a QMS under the scope of good practices (GxPs) in the biopharmaceutical industry, as regards human tissue- and cell-based products.

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.

Purpose: Several authors have examined the lean healthcare literature, but besides all efforts made, articles comparing conceptual and analytical studies were not found. Thus, a systematic review is conducted aiming to understand the state of the art of lean healthcare by investigating and comparing how conceptual and analytical articles address tools/methods, application fields, implementation barriers and facilitators and positive and negative impacts., Design/methodology/approach: Articles in English about lean healthcare, published in journals in the last ten years (2009-2018) and indexed in Web of Science (WoS) or Scopus were examined and assessed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) protocol. A qualitative content analysis on the eligible articles was conducted, and results from the conceptual and analytical studies were compared., Findings: There is a literature gap regarding tools/methods in both conceptual and analytical approaches once they prioritize for different items. Barriers, facilitators and negative impacts are perceived differently within both categories and might require more extensive analysis. The same items prevail in both conceptual and analytical categories when analyzing healthcare fields and positive impacts., Originality/value: There is a lack of articles comparing conceptual and analytical studies concerning lean healthcare. So, this study's relevance is in identifying theoretical and applied research gaps to strengthen the lean healthcare state of the art and to integrate theoretical-applied knowledge. For healthcare professionals, it might provide an overview of the key factors that can promote lean implementation., (© Emerald Publishing Limited.)

Making a business case to match staffing-to-patient care needs sometimes requires new approaches. Partnering with departments outside of nursing proved successful in one acute hemodialysis department. Working with Lean Six Sigma teammates to define our workflow processes and utilizing the resulting data led to developing a business case, which gained the department 2.5 additional full-time equivalent registered nurses. A staffing template was created to evaluate ongoing patient volumes against current staffing. This staffing template can be used by any hemodialysis unit to aid in determining ongoing staffing requirements., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Background: Korea has achieved health policy objectives in pandemic management so far, namely minimizing mortality, flattening the epidemic curve, and limiting the socio-economic burden of its measures. The key to the Korean government's success in combating COVID-19 lies with the latest digital technologies (DTs). The prompt and effective application of DTs facilitates both containment as well as mitigation strategies and their sub-policy measures., Methods: This article uses an experiential analysis based on an exploratory case study - analysis on field applications of the government's interventions. Information is collected by qualitative methods such as literature analysis, meeting materials, and a review of various government reports (including internal ones) along with academic and professional experiences of the authors., Findings: The article presents the unique Korean health policy approaches in the COVID-19 crisis. First, DTs allow the Korean government to embrace various policy measures together listed in containment strategy, namely altering and warning, epidemiological investigation, quarantine of contacts, case-finding, social distancing, and mask-wearing. Second, DTs allow Korea to integrate containment and mitigation strategies simultaneously. Along with the above measures in containment, healthcare service, medical treatment, and prophylaxis (presymptomatic testing) within mitigation are utilized to prevent a COVID-19 spread., Conclusions: Korea develops DTs in an integrated manner in the early pandemic stage under strong and coordinated government leadership. Above all, the DTs' functions in each pandemic developmental stage are continuously upgraded. Instead of prioritizing policy measures or strategies, therefore, Korea can implement diverse policies simultaneously by integrating DTs effectively. During the COVID-19 outbreak, DTs work as the enablers to connect these two strategies and their measures in Korea., Recommendations: DTs should be at the center of the disaster management paradigm, especially during a pandemic. DTs are facilitators and integrators of containing and mitigating strategies and their policy measures., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2020 The Author(s).)

Continuous, safely managed water is critical to health and development, but rural service delivery faces complex challenges in low- and middle-income countries (LMICs). We report the first application of continuous quality improvement (CQI) methods to improve the microbial quality of household water for consumption (HWC) and the functionality of water sources in four rural districts of northern Ghana. We further report on the impacts of interventions developed through these methods. A local CQI team was formed and trained in CQI methods. Baseline data were collected and analyzed to identify determinants of service delivery problems and microbial safety. The CQI team randomized communities, developed an improvement package, iteratively piloted it in intervention communities, and used uptake survey data to refine the package. The final improvement package comprised safe water storage containers, refresher training for community WaSH committees and replacement of missing maintenance tools. This package significantly reduced contamination of HWC (p<0.01), and significant reduction in contamination persisted two years after implementation. Repair times in both intervention and control arms decreased relative to baseline (p<0.05), but differences between intervention and control arms were not significant at endline. Further work is needed to build on the gains in household water quality observed in this work, sustain and scale these improvements, and explore applications of CQI to other aspects of water supply and sanitation., Competing Interests: The authors have declared that no competing interests exist.

Background and objectives: Psoriasis (Pso) is a common skin condition characterized by a strong psychosocial impact, and is nowadays accepted as a systemic immune-mediated inflammatory disease. Diagnostic-Therapeutic Care Pathways (DTCPs) represent a predefined sequence of diagnostic, therapeutic, and assistance activities that integrate the participation of several specialists to obtain, for each patient, the correct diagnosis and thus the most appropriate therapy. A DTCP was validated in our dermatology clinic (AOU Maggiore della Carità, Novara, Italy). The validation process included the detailed elaboration of a protocol of diagnosis, staging of care, therapies, and follow-up of the patient with Pso. The formalization and adaptation of our DTCP resulted in ISO 9001: 2015 certification in May 2019. Materials and methods: This process involved several stages, including analysis of context and the identification of (i) targets, (ii) indicators, and (iii) service providers. The evaluation was based on a cohort of over 200 patients affected by moderate to severe Pso, who were treated and followed-up at our institution from September 2017 to April 2019. Results: The ISO 9001:2015 quality certification process allowed us to identify our weaknesses, i.e., the long waiting times for the first visit and the reduced physician-patient ratio, but also our strengths, such as the commitment to clinical research, effective collaboration with other specialists, the efficient use of technological and human resources, and attention to ensuring patient follow-up. Conclusions: In qualifying for and achieving the ISO Quality Management System (QMS) certification we were heartened to realize that our basic methodology and approach were fit for purpose. The implementation of the ISO QMS helped us to reorganize our priorities by placing the patient at the center of the process and raising awareness that Pso is not just a skin disease.

Unintended omission of warfarin, an anticoagulant used to prevent and treat thromboembolic events, can lead to serious medical complications. These complications include increased medical costs, hospitalisations and significant patient harm, including increased risk of thrombosis and mortality. Chart review of discharged patients at our institution revealed an average of one patient/month with warfarin omitted from the discharge plan despite intention to continue therapy. Lean Six Sigma methodology was used to improve the process. A system alert was implemented in the electronic health record to alert providers of patients who received warfarin during admission, the discharge medication reconciliation was complete, and there was no prescription for warfarin. Date and time of last warfarin dose and international normalised ratio were included in the alert. Providers had the option to return to the chart to update the discharge medication plan and add the warfarin prescription or to choose an appropriate over-ride reason. The number of patients discharged without an intended warfarin prescription following alert implementation was reduced from 10.5% (4/38) to 0% (0/40) (two proportion test, p=0.03). Alert tracking enhanced the ability to identify patients at risk for warfarin omissions. Process sustainability has been achieved by embedding system alerts in the electronic health record to trigger process steps., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: This study explores the perceptions and experiences of nurse managers involved in implementing the Lean management system in a Western Canadian province., Background: The provincial government of Saskatchewan, Canada, implemented a multimillion-dollar investment in the Lean management system to transform health care delivery by reducing waste and increasing efficiency of processes and outcomes., Methods: This qualitative exploratory study employed semi-structured interviews with 14 nurse managers in urban and rural health regions in one Canadian province., Results: Six themes outline the difficulties nurse managers experienced in juggling role responsibilities alongside a poorly implemented change system with scarce resources., Conclusion: The results showed tensions in the implementation of a Lean model adapted in the context of health care organisations. The expectations for nurse managers to be pivotal players in the implementation of transformative health care practices that promote and sustain strategies to reduce waste, improve coordination and increase patient safety require investment in leadership development., Implications for Nursing Management: Lean management systems significantly impact the roles of nurse managers who require adequate resources and training to successfully adapt. The results of this study may be used for more effective support mechanisms for nurse managers., (© 2019 John Wiley & Sons Ltd.)

Healthcare professionals and managers in hospitals are frequently suggested to learn from industry and business to improve quality and efficiency. However, evidence that the implementation of industrial techniques and business methods has a meaningful effect on patient outcomes is often lacking. An explanation for this phenomenon is thought to be the complexity of the hospital organisation and the diversity of patients. In this article, we use the practice approach to discuss the application of industrial techniques and business methods in healthcare. We employ a practice model that offers three perspectives to understand professional practices: Identity and intrinsic values, Interests of stakeholders, and Ideals and basic beliefs (Triple I). This model demonstrates that the nature of healthcare practices differs strongly from the nature of industrial and business practices. Healthcare has a moral nature that does not let itself be easily organised along technological or business categories. This may provide a fundamental explanation of why industrial techniques and business methods in general will be less successful in healthcare. At the same time, this model invites hospitals to develop innovative approaches that do justice to the identity and intrinsic values of healthcare. In this process, insights from industry and business cannot be copied but have to be used as sources of inspiration., (© 2020 Royal Australasian College of Physicians.)

Objective: To improve the number of patients receiving annual computed tomography (CT) scan and tumour markers, who are diagnosed with low-grade mucinous neoplasms (LAMN)., Design: A pre-/post-intervention design was employed using Lean Six Sigma methods to identify gaps in the screening system and to develop and implement solutions for a more robust, auditable screening programme., Setting: The patients diagnosed with LAMN of the appendix referred to the acute hospital and are enrolled in the screening service., Participants: Consultant colorectal surgeons, cancer nurse specialist, colorectal medical team and quality improvement staff., Interventions: Diagnostic tools identified gaps in the current process. A set of improvements were implemented to standardize the pathway for referral and surveillance of patients, provide information on the condition and treatment and standardize and track information received by patients and their referring hospital., Main Outcome Measure(s): Pre and post-intervention outcome measures were taken for the number of patients who receive an annual CT of thoracic, abdomen and peritoneum and tumour markers and number of patients who receive information and contact details., Results: At baseline, of the 28 patients that met the inclusion criteria only 61% had a correct follow-up. Following the implementation of improvements, 78% of patients had correct follow-up and 90% had received information., Conclusions: Gaps in the current cancer screening system were identified and improvements implemented a reduced number of patients having an incorrect follow-up. Findings are applicable across all precancerous screening systems irrespective of the type of malignancy. The methods used empowered patients and fostered an interdisciplinary team approach to care., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To improve access for hip fracture patients to surgery within 48 h of presentation to the Emergency Department, and to increase the number of patients receiving pre-operative orthogeriatric review, through streamlining an existing hip fracture patient pathway., Design: A pre-post design involving a multi-disciplinary team use of the Define, Measure, Analyse, Improve and Control framework integral to Lean Six Sigma (LSS) methodology, to assess and adapt the existing hip fracture pathway from presentation to Emergency Department to the initiation of surgery., Setting: A 600-bed teaching hospital in Ireland., Participants: Nursing, medical, administrative and physiotherapy staff working across Emergency Medicine, Orthogeriatrics and Orthopaedic Specialities and Project management., Interventions: LSS methodology was used to redesign an existing pathway, improving patient access to ortho-geriatrician assessment, pain relief and surgery in line with the Irish Hip Fracture Data Base Key performance indicators., Main Outcome Measures: Access to pain relief, access to surgery and volume of patients receiving ortho-geriatric assessment., Results: The percentage of patients undergoing surgery within 48 h of presentation to Emergency Department increased from 55% to 79% at 3 months, and to 85% at 6 months. Improvements were also achieved in the secondary performance metrics relevant to quality of patient care. All care pathway changes were cost neutral., Conclusions: Hip fracture surgery within 48 h of presentation to hospital is a recognized standard of hip fracture care associated with decreased length of stay and decreased mortality. With respect to this performance metric, this intervention has contributed to improved patient outcomes., (© The Author(s) 2019. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The study aim was to test the intra-assessor and interassessor reliability of the Healthcare Complaints Analysis Tool (HCAT) for categorising the information in the claim letters in a sample of Danish patient compensation claims., Design, Setting and Participants: We used a random sample of 140 compensation cases completed by the Danish Patient Compensation Association that were filed in the field of acute medicine at Danish hospitals from 2007 to 2018. Four assessors were trained in using the HCAT manual before assessing the claim letters independently., Main Outcome Measures: Intra-assessor and interassessor reliability was tested at domain, problem category and subcategory levels of the HCAT. We also investigated the reliability of ratings on the level of harm and of the descriptive details contained in the claim letters., Results: The HCAT was reliable for identifying problem categories, with reliability scores ranging from 0.55 to 0.99. Reliability was lower when coding the 'severity' of the problem. Interassessor reliability was generally lower than intra-assessor reliability. The categories of 'quality' and 'safety' were the least reliable of the seven HCAT problem categories. Reliability at the subcategory level was generally satisfactory, with only a few subcategories having poor reliability. Reliability was at least moderate when coding the stage of care, the complainant and the staff group involved. However, the coding of 'level of harm' was found to be unreliable (intrareliability 0.06; inter-reliability 0.29)., Conclusion: Overall, HCAT was found to be a reliable tool for categorising problem types in patient compensation claims., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

Purpose: The purpose of this study is to assess the state at which lean and six sigma (LSS) are used as a management system to improve the national health system national health system of Mexico., Design/methodology/approach: Cross-sectional survey-research. The survey was administered at 30 different hospitals across six states in Mexico. These were selected using convenience sampling and participants ( N  = 258) were selected through random/snowball sampling procedures, including from top managers down to front-line staff., Findings: Only 16 per cent of respondents reported participation in LSS projects. Still, these implementations are limited to using isolated tools, mainly 5s, failure mode and effects analysis (FMEA) and Fishbone diagram, with the lack of training/knowledge and financial resources as the top disabling factors. Overall, LSS has not become systematic in daily management and operations., Research Limitations/implications: The sampling procedure was by convenience; however, every attempt was made to ensure a lack of bias in the individual responses. If still there was a bias, it is conjectured that this would likely be in overestimating the penetration of LSS., Practical Implications: The penetration of LSS management practices into the Mexican health system is in its infancy, and the sustainability of current projects is jeopardized given the lack of systematic integration. Hence, LSS should be better spread and communicated across healthcare organizations in Mexico., Originality/value: This is the first research work that evaluates the use of LSS management practices in a Latin American country, and the first journal paper that focuses on LSS in healthcare in Mexico.

Purpose: Although there are general methodologies for lean implementation in manufacturing companies, a specific methodology for the implementation of lean healthcare in hospitals has not been addressed by the literature. Addressing this gap, the purpose of this paper is to develop a practice-driven methodology for implementing lean in hospital operations., Design/methodology/approach: Three case studies were conducted to collect evidence on the lean implementation process in Brazilian hospitals. From empirical evidence and literature, the implementation methodology was proposed and submitted to critical assessment by experts from the field., Findings: The process of lean implementation was very similar in all cases, triggered by strategic planning and operationalized by continuous improvement projects. On the other hand, in all cases, the lean implementation teams had to deal with employees' resistance. These findings were valuable inputs to the development of the implementation methodology. After refinement, it was proposed a feasible, useful and user-friendly methodology., Research Limitations/implications: The proposed methodology was raised from the practice through case study research. However, the proposed methodology was not fully applied, and the associated performance measures were not elaborated in this paper. Therefore, more case studies and applications will be necessary to generalize the findings., Practical Implications: The methodology provides practical guidelines that support lean implementation in hospital operations. Although it demands adaptations for each specific hospital setting, this initial step may encourage hospital managers to start the lean journey., Originality/value: This study addressed the gap in the literature regarding the lack of methodologies for implementing lean healthcare in hospital operations. The methodology synthesizes the knowledge, principles and tools of lean thinking that can be applied in hospital operations.

Lean management is a set of principles aimed at improving processes by identifying and eliminating steps that do not add value to the consumer. Such steps lead to wasted time, resources, and expenses and result in customer and employee dissatisfaction. Although initially invented and perfected for factory assembly lines in the automobile industry, it has since disseminated extensively and has repeatedly proven a powerful "engine" for improving quality and quantity in the health-care setting. Lean implementation benefits include improved safety, reduced waiting times, increased patient satisfaction, and cost reduction. Nevertheless, it appears to be less familiar and appreciated in ophthalmology and more specifically as a tool for managing an efficient eye care clinic. In this review, we explain what "Lean" and Six Sigma are and highlight their implementation in settings such as cataract surgery, laser capsulotomy, an ophthalmic emergency room and its role as a powerful tool for improving clinic patient flow. We discuss basic principles of Lean management, review examples of implementing these principles in an ophthalmology practice, and finally, offer physicians practical tools for identifying "wasteful" processes and ways to eliminate them., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background New moving average quality control (MA QC) optimization methods have been developed and are available for laboratories. Having these methods will require a strategy to integrate MA QC and routine internal QC. Methods MA QC was considered only when the performance of the internal QC was limited. A flowchart was applied to determine, per test, whether MA QC should be considered. Next, MA QC was examined using the MA Generator (www.huvaros.com), and optimized MA QC procedures and corresponding MA validation charts were obtained. When a relevant systematic error was detectable within an average daily run, the MA QC was added to the QC plan. For further implementation of MA QC for continuous QC, MA QC management software was configured based on earlier proposed requirements. Also, protocols for the MA QC alarm work-up were designed to allow the detection of temporary assay failure based on previously described experiences. Results Based on the flowchart, 10 chemistry, two immunochemistry and six hematological tests were considered for MA QC. After obtaining optimal MA QC settings and the corresponding MA validation charts, the MA QC of albumin, bicarbonate, calcium, chloride, creatinine, glucose, magnesium, potassium, sodium, total protein, hematocrit, hemoglobin, MCH, MCHC, MCV and platelets were added to the QC plans. Conclusions The presented method allows the design and implementation of QC plans integrating MA QC for continuous QC when internal QC has limited performance.

Passage of the Patient Protection and Affordable Care Act triggered 2 successive grant initiatives from the Agency for Healthcare Research and Quality, allowing for the evolution of health extension models among 20 states, not limited to support for in-clinic primary care practice transformation, but also including a broader concept incorporating technical assistance for practices and their communities to address social determinants of health. Five states stand out in stretching the boundaries of health extension: New Mexico, Oklahoma, Oregon, Colorado, and Washington. Their stories reveal lessons learned regarding the successes and challenges, including the importance of building sustained relationships with practices and community coalitions; of documenting success in broad terms as well as achieving diverse outcomes of meaning to different stakeholders; of understanding that health extension is a function that can be carried out by an individual or group depending on resources; and of being prepared for political struggles over "turf" and ownership of extension. All states saw the need for long-term, sustained fundraising beyond grants in an environment expecting a short-term return on investment, and they were challenged operating in a shifting health system landscape where the creativity and personal relationships built with small primary care practices was hindered when these practices were purchased by larger health delivery systems., (© 2019 Annals of Family Medicine, Inc.)

For many years the concept of patient-based quality control (QC) has been discussed and implemented in hematology laboratories; however, the techniques have not been widely implemented in clinical chemistry. This is mainly because of the complexity of this form of QC, as it needs to be optimized for each population and often for each analyte. However, the clear advantages of this form of QC, together with the ongoing realization of the shortcomings of "conventional" QC, have driven a need to provide guidance to laboratories to assist in deploying patient-based QC. This overview describes the components of a patient-based QC system (calculation algorithm, block size, truncation limits, control limits) and the relationship of these to the analyte being controlled. We also discuss the need for patient-based QC system optimization using patient data from the individual testing laboratory to reliably detect systematic errors while ensuring that there are few false alarms. The term patient-based real-time quality control covers many activities that use data from patient samples to detect analytical errors. These activities include the monitoring of patient population parameters such as the mean or median analyte value or using single within-patient changes such as the delta check. In this report, we will restrict the discussion to population-based parameters. This overview is intended to serve as a guide for the implementation of a patient-based QC system. The report does not cover the clinical evaluation of the population., (© 2019 American Association for Clinical Chemistry.)

This article discusses performance improvement (PI) and the various methods that PI teams can use to provide a framework for improvement. Teams that complete successful PI projects use a systematic methodology that guides them through the process in a step-by-step manner, with each step building upon the previous one using data collection methods and analytics. Personnel involved with PI projects may need to use various methodologies to achieve improvement. These tools range from Plan-Do-Study-Act cycles to more complex methods such as Six Sigma, which uses a define, measure, analyze, improve, and control process as its foundation. This article includes examples of how PI project team members can implement various methodologies and analysis tools to improve processes across the PI project continuum. After reviewing this article, the reader should have a better understanding of the systematic methodologies supporting the PI process. This is the third article of a six-part series about performance improvement., (© AORN, Inc, 2019.)

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.

This integrative conceptual review is based on a critical need in the area of performance management (PM), where there remain important unanswered questions about the effectiveness of PM that affect both research and practice. In response, we create a theoretically grounded, comprehensive, and integrative model for understanding and measuring PM effectiveness, comprising multiple categories of evaluative criteria and the underlying mechanisms that link them. We then review more than 30 years (1984-2018) of empirical PM research vis-à-vis this model, leading to conclusions about what the literature has studied and what we do and do not know about PM effectiveness as a result. The final section of this article further elucidates the key "value chains" or mediational paths that explain how and why PM can add value to organizations, framed around three pressing questions with both theoretical and practical importance (How do individual-level outcomes of PM emerge to become unit-level outcomes? How essential are positive reactions to the overall effectiveness of PM? and What is the value of a performance rating?). This discussion culminates in specific propositions for future research and implications for practice. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Purpose: This scoping review aimed to generate an overview of existing quality management (QM) models for inpatient healthcare published in peer-reviewed literature., Data Sources: Peer-reviewed publications published until June 2016 were retrieved from the databases Medline, PubMed, CINAHL and Cochrane Library using search terms related to QM and models., Study Selection: Publications mentioning a QM model for general application in healthcare or inpatient care in their title or abstract were included. Languages considered were: English, French, German, Italian and Spanish., Data Extraction: Data extraction was 3-fold. First, publication characteristics were summarized. Second, the frequency of each identified model was documented and the publications were divided into conceptual and implementation publications. Third, relevant QM models were identified and information regarding the model, including content and relationship with other models, was extracted., Results of Data Synthesis: Of 925 retrieved publications, 213 were included. The included publications reported on 64 different QM models that were suitable for or used in inpatient care. Seventeen models were identified as being relevant. The 17 models were then categorized into three different levels: conceptual quality improvement models, concrete application models and country specific adaptations., Conclusion: This scoping review provides an overview of 17 existing QM models for inpatient care and their relationships with each other. Various types of models with differing aspects and components exist. In searching for QM models, many different concepts like QM system, accreditation or methodologies appeared. For future investigation, concepts of interest should be clarified., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Six Sigma is used heavily in various industrial sectors, yet no noticeable applications are seen in healthcare logistics. This paper reveals the special case of healthcare logistics where cost reduction is not the only factor considered in project selection; performance and criticality of each item in the logistics system are of high importance as well. This paper provides a proposed framework to apply Six Sigma in the area of healthcare logistics. It also presents a case study implementing the proposed framework at a Jordanian hospital. In the case study, the paper reveals how the modifications of the define phase to take into consideration the criticality, cost, and performance of items make typical Six Sigma methodology very beneficial for healthcare logistics. In addition, it shows how the Six Sigma project selection can be done to deal effectively with healthcare logistics issues. This paper paves the road for research to elaborate on ways to use Six Sigma in the area of improving healthcare logistics.

Context: The results of detection assays for the same specimen are usually quite different in different laboratories or when tested with different detection systems., Objective: This study was designed to investigate the value of applying sigma metrics derived from different standards for allowable total error (TEa) in evaluating the analytical quality of tumor marker assays., Methods: Assays were evaluated for these six tumor markers: total prostate-specific antigen (tPSA), carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), carbohydrate antigen 199 (CA199), carbohydrate antigen 125 (CA125), and carbohydrate antigen 153 (CA153). Sigma values were calculated for two concentrations of quality control products to assess differences in quality of tumor marker assays. Improvement measures were recommended according to the quality goal index, and appropriate quality control rules were selected according to the sigma value., Results: The sigma value was highest using the higher biological variation-derived "appropriate" TEa standard: it was sigma ≥6 or higher in 16.7% of tumor markers. Sigma was below 6 for all tumor markers using the other three TEa. CEA, AFP, CA199, CA125, and CA153 required improved precision. The marker tPSA required improve precision and accuracy. According to sigma values by using China's external quality assessment standards, CEA, AFP, CA125, and CA153 require 1 3s /2 2s /R 4s /4 1s multirules for internal quality control, CA199 requires use of 1 3s /2 2s /R 4s /4 1s /8 x multirules, and tPSA requires maximum quality control rules., Conclusion: Six Sigma is useful for evaluating performance of tumor markers assays and has important application value in the quality control of these assays., (© 2018 The Authors Journal of Clinical Laboratory Analysis Published by Wiley Periodicals, Inc.)

Objective: To identify the nonconformities of the enteral diet therapy process., Method: Exploratory case study, using as a theoretical framework the philosophy of Lean Healthcare in an inpatient unit of a large hospital in Minas Gerais State. The sample consisted of 19 professionals from the multidisciplinary team involved in the enteral nutritional therapy process and the unit's documentary sample. For the data collection, we used a semi-structured script, participant observation and documentary analysis., Results: There were eight nonconformities related to enteral diet therapy. During the participant observation, there was a lack of a management model that seeks the continuous improvement of the process, as well as resistance to change., Conclusion: Although enteral diet therapy is important in the patient's evolution, there are adverse events that could be prevented and the Lean philosophy assists in the identification of process nonconformities.

Background: Garment manufacturers have been adopting lean manufacturing in order to increase productivity and competitiveness. However, the effects of lean on occupational health and safety (OHS) of the workers are not clear. In the literature, there is an ongoing debate about whether lean and OHS are complementary or contradictory., Objective: The goal of this study was to contribute to the knowledge base about the relationship between lean and OHS in garment manufacturing., Methods: The study follows an action research methodology including an intervention aimed at improving productivity and OHS in six garment manufacturers in Bangladesh. Both quantitative and qualitative methods were used for investigating the effect of lean tools on productivity and subsequently on OHS., Results: We observed instances of improvements of OHS related to the application of three lean tools (VSM, 5 S, Time and Motion Study) in the factories. Furthermore, our results do not indicate negative health effect on workers' short-term muscular pain, but rather show a statistically significant improvement of workers' health., Conclusions: The results suggest that it is possible to apply lean without adverse effects for workers, if OHS risks are taken into consideration. However, possible long-term effects on workers' health need to be further investigated.

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.

The purpose of this study was to improve the organization of work, reduce physical effort, and obtain greater satisfaction of workers in the Pre-analytical Area of the Clinical Biochemistry Service at the Miguel Servet University Hospital of Zaragoza, in Spain, by applying Lean techniques. Such techniques were applied in two steps to obtain a final situation where the reduction of the space occupied, the required physical effort, and the work time is clear. The satisfaction of the workers was analyzed during the whole process by means of surveys, concluding that the sum of all the improvements managed to increase the satisfaction of the professionals. One key aspect to get these results was to use always the information and opinions of the staff making them feel the protagonists of the process. For that, it was essential the role of the agent of change that fundamentally sought the involvement of professionals in the improvement processes. Another key point was the careful application of Lean techniques always little by little, by applying small changes that became habits and achieved permanent results. In conclusion, in this work, a methodology to improve involvement and satisfaction of workers in health care has been presented and validated., (© 2018 John Wiley & Sons, Ltd.)

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: To identify and eliminate steps that do not add value for customers in the disinfection center., Method: We applied the Lean tool: Value Flow Map, using the concepts of gemba and kaizen in the work process of the disinfection unit for ventilatory care materials, aiming at improving such process. After performing a training with the team on the Lean concepts described above, applying the Value Flow Map in the gemba, analyzing the opportunities for improvement, and approving the changes, the Value Flow Map of the future state was devised and changes were implemented., Result: The time of the disinfection process was reduced in 2h37 and the financial resources required also decreased, in R$ 809.08/month., Conclusion: The application of Lean concepts presented positive results for the elimination of wastages in the disinfection center.