The fishery performance indicators for global tuna fisheries.

We characterize the ecological, economic, and community performance of 21 major tuna fisheries, accounting for at least 77% of global tuna production, using the Fishery Performance Indicators. Our analysis reveals that the biggest variations in performance among tuna fisheries are driven by the final markets that they target: international sashimi market tuna fisheries considerably outperform a comparison set of 62 non-tuna fisheries in the Fishery Performance Indicator database, international canned tuna market fisheries perform similarly to the comparison set, and tuna fisheries supplying local markets in coastal states considerably underperform the comparison set. Differences among regional fishery management organizations primarily reflect regional species composition and market access, despite stark variation in governance, management, and other enabling conditions. With a legacy of open access, tuna's harvest sector performance is similar across all fisheries, reflecting only a normal return on the capital and skill invested: industrial vessels slightly outperform semi-industrial and artisanal vessels. Differences emerge in the post-harvest sector however, as value chains able to preserve quality and transport fish to high value markets outperform others.

Supply chain partnership assessment of a diabetes clinic.

Purpose Diabetes is one of the major healthcare challenges in India. The chronic nature of the disease makes the lifetime cost of the treatment exorbitantly high. The medicine cost contributes a major size of expense in diabetes management. To make healthcare available to poorest of the poor, it is imperative to control the rising cost of diabetes treatment. The earlier research works done in this area focuses more on inventory management techniques to control the cost of healthcare. Less interest is shown in the role of better supply chain partnership (SCP) in reducing the cost of procurement of medicine. The purpose of this paper is to develop and use the SCP assessment framework for a diabetes clinic. The approach is generalized enough to be adopted for other similar organization. Design/methodology/approach This paper adopts self-assessment criteria of the European Foundation for Quality Management (EFQM) business excellence model for analysis of SCP in the supply chain of a private diabetes clinic in Varanasi. The paper uses analytic hierarchy process (AHP) method for calculation of weights of criteria. Findings The EFQM-based framework can be adopted as easy-to-use tool to make an objective assessment of the SCP. The proposed model in the study is a balanced model between enablers and results, which includes multiple assessment dimensions. The supply chain performance score of the diabetes clinic under study was found as the Tool Pusher, which means the effort in direction of SCP is not too good. The organization needs to clearly define the SCP goal and analyze the results to identify the gap areas. Originality/value The study is first of its kind and contributes to the literature by providing non-prescriptive and easy-to-use SCP assessment framework, for chronic disease care. The case study approach provides a procedure for the healthcare organization willing to adopt this approach.

Lean Six Sigma to Reduce Intensive Care Unit Length of Stay and Costs in Prolonged Mechanical Ventilation.

OBJECTIVE: Patients with prolonged mechanical ventilation (PMV) represent important "outliers" of hospital length of stay (LOS) and costs (∼$26 billion annually in the United States). We tested the hypothesis that a Lean Six Sigma (LSS) approach for process improvement could reduce hospital LOS and the associated costs of care for patients with PMV. DESIGN: Before-and-after cohort study. SETTING: Multidisciplinary intensive care unit (ICU) in an academic medical center. PATIENTS: Adult patients admitted to the ICU and treated with PMV, as defined by diagnosis-related group (DRG). METHODS: We implemented a clinical redesign intervention based on LSS principles. We identified eight distinct processes in preparing patients with PMV for post-acute care. Our clinical redesign included reengineering daily patient care rounds ("Lean ICU rounds") to reduce variation and waste in these processes. We compared hospital LOS and direct cost per case in patients with PMV before (2013) and after (2014) our LSS intervention. RESULTS: Among 259 patients with PMV (131 preintervention; 128 postintervention), median hospital LOS decreased by 24% during the intervention period (29 vs. 22 days, p < .001). Accordingly, median hospital direct cost per case decreased by 27% ($66,335 vs. $48,370, p < .001). CONCLUSION: We found that a LSS-based clinical redesign reduced hospital LOS and the costs of care for patients with PMV.

An exploratory analysis for Lean and Six Sigma implementation in hospitals: Together is better?

BACKGROUND: Despite the increasing interest for Lean and Six Sigma implementations in hospitals, there has been little empirical evidence that goes beyond descriptive case studies to address the current status and the effectiveness of the implementations. PURPOSE: The aim of this study was to explore existing patterns of Lean and Six Sigma implementation in U.S. hospitals and compare the performance of the different patterns. METHODOLOGY/APPROACH: We collected data from 215 U.S. hospitals via a survey that includes measurement items developed from related literature. Using the cross-sectional data, we conducted a cluster analysis, followed by t tests, chi-square tests, and regression analyses for cluster verification. RESULTS: The cluster analysis identifies two clusters, a Moderate Six Sigma group and a Lean Six Sigma group. Results show that the Lean Six Sigma group outperforms the Moderate Six Sigma group across many performance dimensions: responsiveness capability, patient safety, and possibly cost saving. In addition, the Lean Six Sigma group tends to be composed of larger, private teaching hospitals located in more urban areas, and they employ more resources for quality improvement. CONCLUSION: Our research contributes to the quality management literature by supporting the possible complementary relationship between Lean and Six Sigma in hospitals. PRACTICE IMPLICATIONS: Our study encourages practitioners and managers to pay more attention to Lean implementation. Although Lean seems to be conducted in a limited fashion in many hospitals, it should be expanded and combined with Six Sigma for better results.

Assurance of Myeloid Growth Factor Administration in an Infusion Center: Pilot Quality Improvement Initiative.

PURPOSE: Four incident reports involving missed doses of myeloid growth factors (MGFs) triggered the need for an outcome-driven initiative. From March 1, 2015, to February 29, 2016, at University of California Irvine Health Chao Infusion Center, 116 of 3,300 MGF doses were missed (3.52%), including pegfilgrastim, filgrastim, and sargramostim. We hypothesized that with the application of Lean Six Sigma methodology, we would achieve our primary objective of reducing the number of missed MGF doses to < 0.5%. METHODS: This quality improvement initiative was conducted at Chao Infusion Center as part of a Lean Six Sigma Green Belt Certification Program. Therefore, Lean Six Sigma principles and tools were used throughout each phase of the project. Retrospective and prospective medical record reviews and data analyses were performed to evaluate the extent of the identified problem and impact of the process changes. Improvements included systems applications, practice changes, process modifications, and safety-net procedures. RESULTS: Preintervention, 24 missed doses (20.7%) required patient supportive care measures, resulting in increased hospital costs and decreased quality of care. Postintervention, from June 8, 2016, to August 7, 2016, zero of 489 MGF doses were missed after 2 months of intervention ( P < .001). Chao Infusion Center reduced missed doses from 3.52% to 0%, reaching the goal of < 0.5%. CONCLUSION: The establishment of simplified and standardized processes with safety checks for error prevention increased quality of care. Lean Six Sigma methodology can be applied by other institutions to produce positive outcomes and implement similar practice changes.

Improving performances of the knee replacement surgery process by applying DMAIC principles.

RATIONALE, AIMS, AND OBJECTIVES: The work is a part of a project about the application of the Lean Six Sigma to improve health care processes. A previously published work regarding the hip replacement surgery has shown promising results. Here, we propose an application of the DMAIC (Define, Measure, Analyse, Improve, and Control) cycle to improve quality and reduce costs related to the prosthetic knee replacement surgery by decreasing patients' length of hospital stay (LOS) METHODS: The DMAIC cycle has been adopted to decrease the patients' LOS. The University Hospital "Federico II" of Naples, one of the most important university hospitals in Southern Italy, participated in this study. Data on 148 patients who underwent prosthetic knee replacement between 2010 and 2013 were used. Process mapping, statistical measures, brainstorming activities, and comparative analysis were performed to identify factors influencing LOS and improvement strategies. RESULTS: The study allowed the identification of variables influencing the prolongation of the LOS and the implementation of corrective actions to improve the process of care. The adopted actions reduced the LOS by 42%, from a mean value of 14.2 to 8.3 days (standard deviation also decreased from 5.2 to 2.3 days). CONCLUSIONS: The DMAIC approach has proven to be a helpful strategy ensuring a significant decreasing of the LOS. Furthermore, through its implementation, a significant reduction of the average costs of hospital stay can be achieved. Such a versatile approach could be applied to improve a wide range of health care processes.

Incorporating Budget Impact Analysis in the Implementation of Complex Interventions: A Case of an Integrated Intervention for Multimorbid Patients within the CareWell Study.

OBJECTIVES: To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. METHODS: Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. RESULTS: Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. CONCLUSIONS: This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.

Lean Six Sigma in Health Care: Improving Utilization and Reducing Waste.

Healthcare costs have been increasing worldwide mainly due to over utilization of resources. The savings potentially achievable from systematic, comprehensive, and cooperative reduction in waste are far higher than from more direct and blunter cuts in care and coverage. At King Faisal Specialist Hospital and Research Center inappropriate and over utilization of the glucose test strips used for whole blood glucose determination using glucometers was observed. The hospital implemented a project to improve its utilization. Using the Six Sigma DMAIC approach (Define, Measure, Analyze, Improve and Control), an efficient practice was put in place including updating the related internal policies and procedures and the proper implementation of an effective users' training and competency check off program. That resulted in decreasing the unnecessary Quality Control (QC) runs from 13% to 4%, decreasing the failed QC runs from 14% to 7%, lowering the QC to patient testing ratio from 24/76 to 19/81.

[Quality Management in Medicine: What the Surgeon Needs to Know]. / Qualitätsmanagement in der Medizin. Was muss der Chirurg wissen?

Quality management (QM) is a method used in the field of economics that was adopted late by the medical sector. The coincidence of quality management and what is referred to as economisation in medicine frequently leads to QM being - incorrectly - perceived as part of the economisation problem rather than as part of its solution. Quality assurance defines and observes key performance indicators for the achievement of quality objectives. QM is a form of active management that intends to systematically exclude the effects of chance. It is supposed to enable those in charge of an institution to deal with complex processes, to influence them and achieve quality even under unfavourable circumstances. Clearly defined written standards are an important aspect of QM and allow for 80 % of patients to be treated faster and less labour-intensively and thus to create more capacity for the individual treatment of the 20 % of patients requiring other than routine care. Standards provide a framework to rely on for department heads and other staff alike. They reduce complexity, support processes in stress situations and prevent inconsistent decisions in the course of treatment. Document management ensures transparent and up-to-date in-house standards and creates continuity. Good documents are short, easy to use, and, at the same time, comply with requirements. Specifications describe in-house standards; validation documents provide a forensically sound documentation. Quality management has a broad impact on an institution. It helps staff reflect on their daily work, and it initiates a reporting and auditing system as well as the systematic management of responses to surveys and complaints. Risk management is another aspect of QM; it provides structures to identify, analyse, assess and modify risks and subject them to risk controlling. Quality management is not necessarily associated with certification. However, if certification is intended, it serves to define requirements, increase motivation for the implementation of measures to be taken, and provide long-term continuity in newly adopted processes. Specialist certificates issued by medical associations frequently emphasise an interdisciplinary treatment approach; however, their certification processes are often of poor quality. The effectiveness and efficiency is evident for individual QM instruments in medicine. It is very likely that quality management improves effectiveness in the whole field of medicine, but this has yet to be proved.

[Quality management in emergency departments: Lack of uniform standards for fact-based controlling]. / Qualitätsmanagement in der Notaufnahme: Fehlende einheitliche Standards zur kennzahlenbasierten Steuerung.

BACKGROUND: The general high occupancy of emergency departments during the winter months of 2014/2015 outlined deficits in health politics. Whether on the regional, province, or federal level, verifiable and accepted figures to enable in depth analysis and fact-based controlling of emergency care systems are lacking. OBJECTS: As the first step, reasons for the current situation are outlined in order to developed concrete recommendations for individual hospitals. METHODS: This work is based on a selective literature search with focus on quality management, ratio driven management, and process management within emergency departments as well as personal experience with implementation of a key ratio system in a German maximum care hospital. RESULTS AND CONCLUSION: The insufficient integration of emergencies into the DRG systematic, the role as gatekeeper between inpatient and outpatient care sector, the decentralized organization of emergency departments in many hospitals, and the inconsistent representation within the medical societies can be mentioned as reasons for the lack of key ratio systems. In addition to the important role within treatment procedures, emergency departments also have an immense economic importance. Consequently, the management of individual hospitals should promote implementation of key ratio systems to enable controlling of emergency care processes. Thereby the perspectives finance, employees, processes as well as partners and patients should be equally considered. Within the process perspective, milestones could be used to enable detailed controlling of treatment procedures. An implementation of key ratio systems without IT support is not feasible; thus, existing digital data should be used and future data analysis should already be considered during implementation of new IT systems.

Process-Improvement Cost Model for the Emergency Department.

The objective of this report is to present a simplified, activity-based costing approach for hospital emergency departments (EDs) to use with Lean Six Sigma cost-benefit analyses. The cost model complexity is reduced by removing diagnostic and condition-specific costs, thereby revealing the underlying process activities' cost inefficiencies. Examples are provided for evaluating the cost savings from reducing discharge delays and the cost impact of keeping patients in the ED (boarding) after the decision to admit has been made. The process-improvement cost model provides a needed tool in selecting, prioritizing, and validating Lean process-improvement projects in the ED and other areas of patient care that involve multiple dissimilar diagnoses.

'Lean' approach gives greater efficiency.

Adapting the 'Lean' methodologies used for many years by many manufacturers on the production line - such as in the automotive industry - and deploying them in healthcare 'spaces' can, Roger Call, an architect at Herman Miller Healthcare in the US, argues, 'easily remedy many of the inefficiencies' found within a healthcare facility. In an article that first appeared in the September 2013 issue of The Australian Hospital Engineer, he explains how 'Lean' approaches such as the 'Toyota production system', and 'Six Sigma', can be harnessed to good effect in the healthcare sphere.

[Economic implications of bedside communication errors]. / Ökonomische Implikationen fehlerhafter Kommunikation am Krankenbett.

Good communication can contribute significantly to avoiding expert disputes. An open and honest relationship in dealing with errors allows people to learn from them and avoid them in the future. This benefits both doctors and patients.

Cost estimates for operating a primary care practice facilitation program.

PURPOSE: Practice facilitation is widely recognized as a promising method for achieving large-scale practice redesign. Little is known, however, about the cost of providing practice facilitation to small primary practices from the prospective of an organization providing facilitation activities. METHODS: We report practice facilitation costs on 19 practices in South Texas that were randomized to receive facilitation activities. The study design assured that each practice received at least 6 practice facilitation visits during the intervention year. We examined only the variable cost associated with practice facilitation activities. Fixed or administrative costs of providing facilitation actives were not captured. All facilitator activities (time, mileage, and materials) were self-reported by the practice facilitators and recorded in spreadsheets. RESULTS: The median total variable cost of all practice facilitation activities from start-up through monitoring, including travel and food, was $9,670 per practice (ranging from $8,050 to $15,682). Median travel and food costs were an additional $2,054 but varied by clinic. Approximately 50% of the total cost is attributable to practice assessment and start-up activities, with another 31% attributable to practice facilitation visits. Sensitivity analysis suggests that a 24-visit practice facilitation protocol increased estimated median total variable costs of all practice facilitation activities only by $5,428, for a total of $15,098. CONCLUSIONS: We found that, depending on the facilitators wages and the intensity of the intervention, the cost of practice facilitation ranges between $9,670 and $15,098 per practice per year and have the potential to be cost-neutral from a societal prospective if practice facilitation results in 2 fewer hospitalizations per practice per year.