A systematic review of the evidence of how hospitals capture financial benefits of process improvement and the impact on hospital financial performance.

BACKGROUND: Governments, funders and hospital managers around the world are looking for ways to address the continual growth in expenditure by reducing the level of waste in the healthcare delivery system and improving the value of care provided to patients. Process improvement methods are applied to increase high value care, reduce low value care and remove waste from care processes. The purpose of this study is to review the literature to identify the methods used by hospitals to measure and capture financial benefits from PI initiatives to identify best practice. The review also pursues the way hospitals collate these benefits at the enterprise level to achieve improved financial performance. METHODS: A systematic review was undertaken in line with the PRISMA process and employed qualitative research methods. Databases searched were Medline, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINHAL), Web of Science and SCOPUS. The initial search was conducted in in July 2021 with a follow up search conducted in February 2023 using the same search terms and databases to identify additional studies published in the intervening period. The search terms were identified through the PICO (Participants, Interventions, Comparisons and Outcomes) method. RESULTS: Seven papers were identified that reported reduction in care process waste or improvement of the value of care using an evidence-based PI approach and included financial benefits analysis. Positive financial impact was measured for the PI initiatives but none of the studies reported how these financial benefits were captured or applied at the enterprise level. Three of the studies suggested that sophisticated cost accounting systems were required to enable this. CONCLUSION: The study demonstrates the paucity of literature in the field of PI and financial benefits measurement in healthcare. Where financial benefits are documented, they vary in terms of cost inclusions and the 'level' at which the costs were measured. Further research on best practice financial measurement methods is needed to enable other hospitals to measure and capture financial benefits arising from their PI programs.

A practical framework for achieving value creation and capture in healthcare through process improvement.

PURPOSE: The purpose of this study was to examine the concept of value in healthcare through a practical appraisal of the applicability of a conceptual framework, which is aimed at supporting the measurement and realisation of financial benefits from process improvement (PI) activities in a hospital setting. DESIGN/METHODOLOGY/APPROACH: A single case study of a hospital system in Melbourne, Victoria, Australia, was used to assess the applicability of the framework. The study sought to verify the framework's intention, that PI methods could be used to address known wastes that contribute to the cost of providing healthcare. The case study examines the current approach taken by the hospital to measure and realise financial benefits from PI activities and compares these to the components of the Strategy to Balance Cost and Quality in Health Care framework to assess its applicability in practice. FINDINGS: The case study revealed that the steps described in the framework were fundamentally in place albeit with some variation. Importantly, the case study identified an additional step that could be added into the framework to support hospitals to better define their portfolio of initiatives to deliver value. The case study also clarified three types of contributory elements that should be in place for the application of the framework to be successful. PRACTICAL IMPLICATIONS: The Framework to Achieve Value in Healthcare is offered to hospitals as a model by which they can look to reduce expenditure through the removal of non-value adding activities. The modification to the conceptual framework has arisen from a single case study and would benefit from further testing by other hospitals in other policy settings (i.e. other countries). ORIGINALITY/VALUE: This is the first paper to examine and enhance an existing framework to assist hospitals balance cost and quality through PI.

Investigation of the presence of prednisolone in bovine urine.

Over the past two years low levels of prednisolone have been reported in bovine urine by a number of laboratories in European Union member states. Concentrations vary, but are reported to be below approximately 3 µg l(-1). Forty per cent of bovine urine samples from the Dutch national control plan had concentrations of prednisolone between 0.11 and 2.04 µg l(-1). In this study the mechanism of formation of prednisolone was investigated. In vitro conversion of cortisol by bacteria from faeces and soil, bovine liver enzymes and stability at elevated temperatures were studied. In vitro bovine liver S9 incubation experiments showed a significant 20% decrease of cortisol within 6 h, and formation of prednisolone was observed from 0.2 g l(-1) at t = 0 to 0.5 g l(-1) at t = 6. Under the influence of faeces, the stability of cortisol in urine is reduced and cortisol breaks down within 50 h. Prednisolone is formed up to 4 µg l(-1) at 70°C after 15 h. However, this decreases again to zero after 50 h. With soil bacteria, a slower decrease of cortisol was observed, but slightly higher overall formation of prednisolone, up to 7 µg l(-1) at 20°C. As opposed to incurred urine, in fortified urine incubated with faeces or soil bacteria no prednisolone was detected. This difference may be explained by the presence of natural corticosteroids in the incurred sample. With UPLC-QToF-MS experiments, in urine and water samples incubated with faeces, metabolites known from the literature could be (tentatively) identified as 20ß-hydroxy-prednisolone, cortisol-21-sulfate, oxydianiline, tetrahydrocortisone-3-glucuronide and cortexolone, but for all compounds except 20ß-hydroxy-prednisolone no standards were available for confirmation. Based on the results of this study and literature data, for regulatory purposes a threshold of 5 µg l(-1) for prednisolone in bovine urine is proposed. Findings of prednisolone in concentrations up to 5 µg l(-1) in bovine urine can, most likely, originate from other sources than illegal treatment with growth promoters.

Immunofiltration as sample cleanup for the immunochemical detection of beta-agonists in urine.

Despite the ban of the European Union on use of drugs to improve animal growth, occasionally beta-agonist drugs are still found in samples from cattle. Over time, the specified limits for the detection of these illegal drugs have been lowered. To improve the immunochemical screening of urine samples to detect lower levels of several beta-agonists, immunofiltration (IF) was applied for sample cleanup in combination with a beta-agonist-ELISA. In the applied IF format, free (non-immobilised) anti-salbutamol polyclonal antibodies were mixed with the urine sample in an ultra-filtration device (cut off 30 kDa) and the sample was removed by centrifugation. The antibody bound beta-agonists were freed from the antibodies by the addition of a mixture of methanol and 0.1 M acetic acid (1:1; v/v) and centrifugation. The filtrate, containing the free beta-agonists, was evaporated to dryness and the residue dissolved in buffer, an aliquot of which was analysed with the beta-agonist ELISA. Compared with the direct beta-agonist ELISA, this IF cleanup procedure resulted in a 30-times lower limit of detection (LOD) of 0.14 ng ml(-1) (salbutamol equivalents). The anti-salbutamol antibodies recognised several beta-agonists and the combination of IF with the beta-agonist ELISA was found suitable for the detection of at least ten beta-agonists in urine with comparable LODs.