A lean approach for improving medicines management in Australia's first cardiac hospital inventory system.

BACKGROUND: Medicines are the cornerstone of healthcare. Lean methodology approach such as Value Stream Mapping (VSM) is being used in healthcare to manage resources wisely to ensure sustainability of medicines and resources. The aim of this quality improvement study was to evaluate and improve the medication management and hospital imprest supply processes in Australia's first dedicated cardiology hospital using VSM. METHOD: We conducted a review of our medicine supply processes at a 180-bed cardiology hospital in Australia. We followed a lean methodology approach over a 4-month period from February to May 2023 and evaluated the outcome of our improvements for another 4 months from July to October 2023. We used VSM to identify non-value adding activities. Cost of medicines holding was calculated, as well as time taken to complete supply processes, pre and post. RESULTS: Pharmacy department stockholdings reduced by 51%; p = 0.000121 (from $539,662 to $275,406). Time taken to manage the inventory system also reduced by 42%; p = 0.025762 (from 148 h/month to 62 h/month). Lean methodology such as VSM can facilitate cost-effective and sustainable system improvements for pharmacy procurement systems.

Comparative Study on Anti-VEGF in Wet Age-Related Macular Degeneration in the Setting Based on Lean Methodology from the Bari Intravitreal Injection Registry (BIVIR).

INTRODUCTION: Optimizing treatment protocols for wet age-related macular degeneration (wAMD) is an ongoing challenge, as it involves a delicate balance between achieving therapeutic efficacy and minimizing invasive procedures' frequency. This study aimed to apply the Lean methodology and evaluate the effectiveness of this new setting on intravitreal therapy for wAMD, employing different anti-vascular endothelial growth factors (VEGF) drugs (bevacizumab, brolucizumab, aflibercept, ranibizumab), drawing data from the Bari Intravitreal Injections Registry (BIVIR). METHODS: This was a retrospective, monocentric, nonrandomized, comparative study. Lean methodology was employed to design the new setting and the BIVIR collected information from electronic medical records. Clinical data of four groups, stratified based on the first-line anti-VEGF agents used, were compared. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) changes were compared between the four groups at 3 and 12 months. RESULTS: Out of 4990 eyes and 41,323 intravitreal injections (IVs) recorded in BIVIR, 1421 eyes of 1182 patients were included. The mean number of IVs in first year was 6.1 ± 2.5, with no significant differences among the four subgroups. The mean change in BCVA was + 6.2 letters [95% confidence interval (CI) 5.6-6.8] after two IVs, and + 5.9 (95% CI 5.1-6.8) letters after three IVs; at three months, brolucizumab was associated with a greater mean increase in BCVA than bevacizumab (p = 0.050); aflibercept (p = 0.044) and ranibizumab p = 0.047). At the 1-year follow-up, the mean change was + 6.3 letters (95% CI 5.4-7.2), brolucizumab and ranibizumab were associated with a superior improvement in BCVA compared to aflibercept (p = 0.033). Regarding the CRT, a significant reduction was observed in the subgroup treated with brolucizumab at the 3-month follow-up, compared to bevacizumab (p = 0.003), aflibercept (p = 0.015), and ranibizumab (p < 0.001); Aflibercept exhibited a superior effect than ranibizumab (p = 0.001). At 1-year follow-up, aflibercept resulted in a more significant reduction of macular thickness compared to ranibizumab (p = 0.016) while no significant differences were observed among the other drugs. CONCLUSIONS: Our practical experience showed the effectiveness of the new setting in the treatment of wAMD. This comparative study at 1 year suggested a predominant brolucizumab efficacy on functional outcomes. In addition, brolucizumab and aflibercept appeared to have similar efficacy in fluid control.

Monthly multidisciplinary complex spine conference: a cost-analysis utilizing time-driven activity-based costing.

PURPOSE: To understand costs and provide an initial framework associated with conference implementation as it pertains to complication prevention. METHODS: Team members' time spent on conference preparation, presentation, and follow-up tasks was recorded and averaged to determine the time required to prepare and present one patient. Using 2022 hourly wage rates based on our urban hospital setting, wage values were calculated for each personnel type and applied to their time spent. The total cost of the conference was annualized and calculated from the time spent in the three phases of the conference multiplied by the wage rate. Published data on complication rates and associated costs before and after conference implementation were used to calculate total cost reduction. RESULTS: With 3 active spine surgeons and 108 patients per year, the total time investment was 104.04 min per patient, costing $21,791 annually. Total RN equivalent value per patient was 5.25 for all three phases. Using a historical model, this multidisciplinary approach for adult spinal deformity reduced complications by 51% at 30 days, resulting in cost savings of $418,518 per year. Thus, the model demonstrates that implementation of this approach resulted in a potential total savings of $396,726/year. CONCLUSION: Implementing a cost-saving tool for managing complex spinal disorders is a responsibility of the spine team, who should lead a multidisciplinary conference. The combination of TDABC and lean methodology can effectively demonstrate the variable costs associated with this multidisciplinary effort and models provide evidence of potential cost-savings when applied to a multidisciplinary adult spinal deformity conference. These findings should encourage clinicians and administrators to allocate resources to improve patient care by reducing complications and costs.

Challenging Organizational Factors Associated With Admission Delay to Intensive Care Unit-A Novel Quality Indicator.

BACKGROUND: Delays in admitting patients to the intensive care unit (ICU) can defer the timely initiation of life-sustaining therapies and invasive monitoring, jeopardizing the success of the treatment. Nevertheless, the availability of research on interventions that reduce or minimize admission delays is limited. OBJECTIVES: The current study aimed to assess the factors related to delays in admission times of critically ill patients transferred to the ICU. METHODS: A software was designed to follow-up, compare and measure the defined intervals of the time to admission, implemented at the ICU for 6 months. Measurements included 5 time intervals, referral department, and work shift at admission. Data from 1004 patients admitted to the ICU between July 2017 and January 2020 were analyzed in a retrospective observational study. RESULTS: Precisely, 53.9% of total patients were referred from the hospital emergency department, and 44% were admitted during the evening shift. Significant differences were found in time intervals between shifts, showing the morning round had the longer total admission time (median: 67.8 min). Analysis showed that admission time was longer at times of full capacity compared to times of available bed (mean: 56.4 and 40.2 min, respectively; U = 68,722, p < .05). Findings demonstrated a significant shortening of time to admission after implementing a new time monitoring software by the Institutional Quality Control Commission (U = 5072, p < .001). CONCLUSIONS: Our study opens doors for potential studies on applying effective initiatives in critical care settings to improve patient care and outcomes. Additionally, it generates new insights regarding how clinicians and nursing teams can jointly develop and promote multidisciplinary interventions in intensive care work environments.

Reflexões acerca do uso da metodologia lean em serviços hospitalares / Reflections on the use of lean metodhodoly in hospital services

Introdução: A metodologia Lean é contemporânea e vem sendo utilizada em ambientes hospitalares, principalmente em serviços de urgências e emergências. Objetivo: Refletir acerca da metodologia Lean na perspectiva de suas ferramentas e estratégias, desafios, limitações e potencialidades, para a atenção hospitalar. Método: Estudo reflexivo fundamentado em base teórica e científica acerca da metodologia Lean na atenção hospitalar. Resultados: São discutidas considerações sobre a utilização da metodologia Lean com enfoque na implementação, monitoramento, potencialidades e limitações das ferramentas/estratégias utilizadas. Conclusão: Conclui-se que a implementação da metodologia Lean contribui para obtenção de melhores resultados nos principais indicadores da gestão de leitos, diminuição da superlotação nos serviços e do tempo de permanência nos leitos hospitalares, fortalece a atuação da regulação de leitos que, por sua vez, contribuem para uma melhoria da qualidade da assistência e satisfação dos usuários

Introduction: The Lean methodology is contemporary and has been used in hospital environments, especially in emergency services. Objective: To reflect on the Lean methodology from the perspective of its tools and strategies, challenges, limitations and potentialities for hospital care. Method: Reflective study based on theoretical and scientific basis about the Lean methodology in hospital care. Results: Considerations are discussed about the use of the Lean methodology focusing on the implementation, monitoring, potentialities and limitations of the tools/strategies used. Conclusion: It is concluded that the implementation of the Lean methodology contributes to obtain better results in the main indicators of bed management, reduction of overcrowding in services and length of stay in hospital beds, the regulation of beds, which in turn contribute to an improvement in the quality of care and user satisfaction

Introducción: La metodología Lean es contemporánea y ha sido utilizada en ambientes hospitalarios, principalmente en servicios de urgencias y emergencias. Objetivo: Reflexionar sobre la metodología Lean desde la perspectiva de sus herramientas y estrategias, desafíos, limitaciones y potencialidades para la atención hospitalaria. Método: Estudio reflexivo basado en bases teóricas y científicas sobre la metodología Lean en la atención hospitalaria. Resultados: Se discuten consideraciones sobre el uso de la metodología Lean, con foco en la implementación, seguimiento, potencialidades y limitaciones de las herramientas/estrategias utilizadas. Conclusión: Se concluye que la implementación de la metodología Lean contribuye a obtener mejores resultados en los principales indicadores de gestión de camas, reduciendo el hacinamiento en los servicios y el tiempo de estancia en camas hospitalarias, fortaleciendo el desempeño de la regulación de camas, que a su vez contribuyen a una mejora en la calidad de la atención y la satisfacción del usuario

Reducing Disposable Surgical Items: Decreasing Environmental Impact and Costs at a Children's Hospital, a Pilot Study.

INTRODUCTION: United States landfill waste generated in the operating room (OR) is estimated to be three billion tons per year. The goal of this study was to analyze the environmental and fiscal impact of right-sizing surgical supplies at a medium-sized children's hospital using lean methodology to reduce physical waste generated in the operating room. METHODS: A multidisciplinary task force was created to reduce waste in the OR of an academic children's hospital. A single-center case study, proof-of-concept, and scalability analysis of operative waste reduction was performed. Surgical packs were identified as a target. Pack utilization was monitored during an initial pilot analysis for 12 d then followed by a focused 3-week period, capturing all unused items by participating surgical services. Items discarded in more than 85% of cases were excluded in subsequent preformed packs. RESULTS: Pilot review identified 46 items in 113 procedures for removal from surgical packs. Subsequent 3-week analysis focusing on two surgical services, and 359 procedures identified a potential $1,111.88 savings with elimination of minimally used items. Over 1 y, removal of all minimally used items from seven surgical services diverted two tons of plastic landfill waste, saved $27,503 in surgical pack acquisition-costs, and prevented the theoretical loss of $13,824 in wasted supplies. Additional purchasing analysis has resulted in another $70,000 of savings through supply chain streamlining. Application of this process nationally could prevent >6000 tons of waste in the United States per year. CONCLUSIONS: Application of a simple iterative process to reduce waste in the OR can result in substantial waste diversion and cost savings. Broad adoption of such a process to reduce OR waste could greatly reduce the environmental impact of surgical care.

Application of lean methodology to frozen section workflow - An audit of present practices at a single large oncology center.

AIM: We conducted a pilot study to analyze the frozen section workflow in the histopathology department and to construct a future state map using Lean management for a better efficiency. METHOD: We analyzed the current state of frozen section workflow in our department, from receipt of the specimen to delivery of slides to the pathologist to communication of report to the surgeon by using value-stream mapping and spaghetti diagram. Further, with the help of the fishbone diagram and Pareto's chart, root cause analysis was done, and a future state map was created with help of a spaghetti diagram to eliminate the non-value-added steps. RESULTS: Our current value-stream map identified a total specimen processing time of 3393 min of which 2880 min were value-added, translating to a process cycle efficiency of 84.88 %. Also, with the help of tools of lean management we constructed a future state map to improve process cycle efficiency. CONCLUSION: In this study, we have attempted to use a few tools of lean management systems and suggested ways for continuous improvements that can be successfully implemented in histopathology laboratories.

Process control: simply a matter of efficiency or of survival and costs? A single-centre quality improvement project in living donor renal transplant.

BACKGROUND: Rising incidence and prevalence of end-stage renal disease is a worldwide concern for sustainability of healthcare systems and societies. Living donor renal transplant [LDRT] provides highest health achievements and cost containment than any alternative form of renal replacement therapy. Nonetheless, about 25% of potential LDRTs are missed for causes directly related with inadequate timing in donor assessment. Our quality improvement (QI) project implement process control tools and strategy aiming at reducing total evaluation time for donor candidates and minimizing dialysis exposure for intended recipients, which are the two main determinants of clinical outcomes and costs. METHODS: The study includes patients who underwent donor nephrectomy between January 1, 2017 and December 31, 2021. Six Sigma DMAIC approach was adopted to assess Base Case performance (Jan2017-Jun2019) and to design and implement our QI project. Study of current state analysis focused on distribution of time intervals within the assessment process, analysis of roles and impacts of involved healthcare providers and identification of targets of improvement. Improved Scenario (Jul2019-Dec2021) was assessed in terms of total lead time reduction, total pre-transplantation dialysis exposure and costs reduction, and increase in pre-emptive transplantations. The study was reported following SQUIRE 2.0 Guidelines for QI projects. RESULTS: Study population includes 63 patients, 37 in Base Case and 26 in Improved Scenario. Total lead time reduced from a median of 293 to 166 days and this in turn reduced pre-transplantation dialysis exposure and costs by 45%. Rate of potential pre-emptive donors' loss changes from 44% to 27%. CONCLUSIONS: Lean methodology is an effective tool to improve quality and efficiency of healthcare processes, in the interest of patients, healthcare professionals and payers.

A Regional Health System Journey from Volume to Value: Roadmap to the Recognition as a 15 Top Health System in the USA for Quality Excellence.

The 15 Top Health System program, an IBM Watson study, objectively measures health systems' performance overall on an annual basis using publicly reported data available from the Center for Medicare and Medicaid Services (CMS) and state data banks. Genesis Health System was recognized as an IBM Watson Health 15 Top Health System for two consecutive years in 2020 and 2021. A system-based approach with a "physician-lead, professionally-managed" framework, led to accomplishing the 15 Top Health System. The steps needed included adoption of the IBM Watson database to determine current status of certain key performance indicators, establishing a clinical effectiveness program and governance structure, and adopting Lean methodologies to analyze and determine appropriate interventions with long-term solution. The desire and willingness to accomplish this ambitious goal start with adoption by the Board and the administration of the health system while supplying appropriate financial and human resources that are dedicated to the success of the journey. In this manuscript, we describe the journey and steps implemented to accomplish the outcomes that led to the recognition as a 15 Top Health System for quality excellence.

Combining time-driven activity-based costing and lean methodology: an initial study of single-level lumbar fusion surgery to assess value-based healthcare in patients undergoing spine surgery.

OBJECTIVE: Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient's care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery. METHODS: This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay. RESULTS: Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians. CONCLUSIONS: In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.

Service improvement in a nurse-led clinic for extracorporeal photopheresis.

The skin tumour unit at one London hospital has been providing extracorporeal photopheresis (ECP) treatment since 2012, using an online fully integrated system. This report summarises 9 years of continuous process improvement, which has enabled the team to meet the growing demand for ECP treatments for cutaneous T-cell lymphoma (CTCL) and graft-versus-host disease (GvHD) patients. The unit formed a partnership with a lean-management company to go through the process of evaluation of capacity constraints, design layout and patient scheduling. METHODS: Increased capacity year-on-year and over the 9-year period was calculated based on data collected from records. The authors reviewed the nurse staffing resources allocated for ECP treatments over the same period, and financial value created by the continuous improvement (additional number of treatments multiplied by the national tariff for ECP treatments). RESULTS: In 2012 the average number of ECP treatments per nurse per week was 11. With the implementation of the new planning tool, and improved working practices, the average number of treatments per nurse per week has more than doubled to 23. Nurse staffing was maintained at 4 nurses per shift to deliver ECP treatments. The unit recorded additional revenue of approximately £3.2 million in 2020 compared with 2012. CONCLUSIONS: The team has successfully increased the capacity of the service to deliver treatments without incurring any additional nursing costs, resulting in more patients with CTCL and GvHD being able to access ECP treatment and a cost benefit for the Trust. The service continues in its mission to grow and provide a superior patient experience.

Lean: Introduction of a Quality Improvement Concept into Percutaneous Nephrolithotomy to Improve Efficiency while Maintaining Safety / Lean: introducción de un concepto en la nefrolitotomía percutánea para mejorar la eficiencia mientras se mantiene la seguridad

Introduction and objective Standardization of surgical interventions reduces complications and costs and positively impacts intra and postoperative outcomes. Implementation of the lean concept, initially proposed in the auto industry, now becomes an interesting approach in the surgical setting. We want to present the results of how percutaneous nephrolithotripsy (PCNL) in a high-level center can be positively impacted by implementing the lean concept. Methods We evaluated a total of 140 PCNL procedures. Group 1 included all cases operated prior to implementing the lean concept and group 2 was composed of those operated after implementing the lean concept. We looked for all seven sources of waste to identify and modify our practice to improve efficiency and safety. We then collected intraoperative times and compared the ones prior to those after the implementation. Results After implementing the lean concept, with an average of six PCNL cases per day, a comparison was made to an equivalent number of cases prior to the lean implementation (group 1). The average total operative time for PCNL preintervention was 138 (confidence interval [CI]: 79 to 170) minutes and postlean intervention was 71.1 (CI: 43 to 157) minutes. Surgical time (cystoscopy to skin closure) was 36.1 (CI: 25 to 50) minutes prelean and 50 minutes postlean (CI: 23 to 154). For this last one, bilateral procedures were performed. Operative room turnover time was 27.8 (CI: 21 to 38) minutes prelean and 5.67 (CI: 3.5 to 12) minutes postlean. Induction time was 16.5 (CI: 5 to 55) minutes prelean and 5.4 (CI: 3.5 to 7.5) minutes postlean. Conclusion Implementation of the lean concept enables optimization of the surgical procedure, allowing hospitals to reduce costs and standardization.

Introducción y objetivo La estandarización de los procedimientos quirúrgicos reduce complicaciones, costos, y mejora resultados intra y postoperatorios. El concepto lean fue utilizado por primera vez en la industria automotriz. El presente trabajo busca implementar el concepto lean para optimizar el procedimiento de nefrolitotomía percutánea (NLP) en nuestro medio. Métodos Se realizaron 140 procedimientos de nefrolitotomía percutánea, los cuales se dividieron en 2 grupos: uno en el cual se registraron los tiempos intraoperatorios, y el segundo en que se registraron los tiempos luego de la implementación del concepto lean. Resultados Durante el período estudiado, se realizaron 70 procedimientos luego de la implementación del concepto lean, y se logró realizar un promedio de 6 procedimientos por día. Se compararon los tiempos operatorios, y se encontró un tiempo operatorio total promedio de 138 (intervalo de confianza [IC]: 79 a 170) minutos pre-lean, y de 71,1 (IC: 43 a 157) minutos post-lean. El tiempo quirúrgico (cistoscopia a cierre de piel) pre-lean fue de 36,1 (IC: 25 a 50) minutos, y el post-lean fue de 50 (IC: 23 a 154) minutos. Para este último, se trató de procedimientos bilaterales. El cambio de sala fue de 27,8 (IC: 21a 38) minutos pre-lean, y de 5,67 (IC: 3.5 a 12) minutos post-lean. El tiempo de inducción fue de 16.5 (IC: 5 a 55) minutos pre-lean, y de 5.4 (IC: 3.5 a 7.5) minutos post-lean. Conclusiones La implementación del concepto lean permite optimizar el procedimiento, con reducción de costos y estandarización del modelo de atención para cualquier centro asistencial. La movilización de los especialistas en nuestro modelo de atención permite un mayor cubrimiento poblacional de alta calidad.

Lean approach to the management of patients undergoing intravitreal injections during COVID-19 pandemic.

BACKGROUND: To introduce Lean approach principles in the management of patients undergoing intravitreal injections (IVIs) for wet age-related macular degeneration. METHODS: Retrospective single-centre cohort study. Services location, IVIs scheduling, utilization of staff, data recording methods, ophthalmic examination and surgical procedures were analysed; a new Intravitreal Injection Centre (IVIC) was developed according to Lean principles. Mean number of daily IVIs performed, mean time between registration and discharge, mean turnover time in between patients, percentages of performed IVIs on the monthly scheduled IVIs and of patients rating their experience ⩾8/10 via standardized feedback questionnaires were retrospectively analysed. RESULTS: The mean IVIs number per day increased from 20 ± 4.08 to 50 ± 7.07, and the mean time between registration and discharge of a patient decreased from 240 ± 14.14 to 60 ± 8.16 min (p = 0.00057 and p < 0.00001, respectively). Mean turnover time in between patients decreased from 10 ± 1.41 to 8 ± 2 min (p = 0.055). The percentage of monthly IVIs performed on the total of scheduled IVIs increased from 60% to 100%, and the percentage of satisfied patients who rated IVIC ⩾8/10 increased from 45% to 95% (p = 0.0177 and p < 0.00105, respectively). CONCLUSION: The IVIC improved the quality, efficiency, speed of the overall procedures and clinical capacity of the IVI service through a fast one-way route for patients, limiting time wasted and total distance travelled. This model facilitates the creation of a one-stop clinic through the just-in-time management principle and may be relevant to other ophthalmology services.

Workflow optimization in a clinical laboratory using Lean management principles in the pre-analytical phase.

BACKGROUND: The application of the Lean methodology in clinical laboratories can improve workflow and user satisfaction through the efficient delivery of analytical results. The purpose of this study was to optimise delivery times of the test results at a clinical laboratory, using Lean management principles in the pre-analytical phase. METHODS: A prospective study with a quasi-experimental design was implemented. Staff functions were restructured and sample flows were modified. Delivery times of clinical results (glucose and haematocrit; 6648 data) from the Medicine and Adult Emergency services for years 2017 and 2018 were compared. RESULTS: A reduction (p < 0.05) in turnaround times in the delivery of glucose test results at the adult emergency service was observed (84 to 73 min, 13%, pre and post). In addition, there was a non-significant reduction in the turnaround times for glucose (Medicine) and haematocrit in both services. In the analytical and post-analytical phase (not intervened), an increase in turnaround times was observed in some cases. CONCLUSIONS: Other studies have indicated that the application of the Lean methodology in clinical laboratories improves workflow, increasing effectiveness and efficiency. This study showed an improvement in the delivery time of test results (glucose - Emergency), giving rise to a culture of cooperation and continuous improvement. It would, however, be essential to address the management model integrating the analytical and post-analytical phases.

Lean into Clinical Pharmacy: An Experience in Implementing Key Performance Indicators and Gemba Walks into Clinical Pharmacy Services.

Purpose: The Lean methodology was applied to clinical metrics by a critical care pharmacy team. The experiences associated with the development and implementation of clinical metrics and their impact on daily workflow are described. Summary: The Lean methodology has been introduced into the healthcare system as a means of process improvement, which can eliminate waste through appropriate medication utilization. At OhioHealth Riverside Methodist Hospital, the department of pharmacy was tasked with the development of clinical metrics after a health system wide Gemba walk was initiated. The pharmacy department's critical care team developed a strategy identifying and evaluating clinical metrics pertaining to their everyday workflow. Each clinical metric was evaluated in accordance with a pre-defined goal. Metrics requiring heavy documentation and those in which the pharmacist does not have autonomous authority to manage were often challenging to implement and were less successful. Throughout this process, the lessons learned focused on generating ideas that were easily documented, evidence-based, and department specific. The critical care team discovered that the outcome of the most successful metrics highlighted clinical pharmacist value and data generated could be used to support funding for additional resources. Conclusion: The critical care pharmacy team developed a streamlined process to implement clinical metrics as means of identifying areas for improvement using the Lean methodology.

Measuring Process Capability in a Hospital by Using Lean Six Sigma Tools-A Case Study in Bangladesh.

Bangladesh's government had been constantly conscious of its health-care system. As a result, the health-care system had seen a significant rise in quality in the past few years. The Lean Six Sigma concept is used to boost up the productivity as well as the quality of products or services. The purpose of this article was to measure the process capability in the health-care system by lean tools. In this study, we selected the dialysis unit as our investigation area where we applied the Six Sigma DMAIC (Define, Measure, Analysis, Improve, and Control) model which had been structured step by step, respectively. Furthermore, different tools of Total Quality Management, Statistical Quality Control and Lean manufacturing like SIPOC (Supplier, Input, Process, Output, and Customer) diagram, P Control chart, Fishbone diagram, and Pareto analysis had been performed in different phases of the DMAIC model. Measuring process capability using the DMAIC model helped to identify the problems associated with the dialysis unit and also recommendations were developed based on investigation and analysis. These recommendations will help the hospital management to overcome all problems and increase service rate and patient safety in the dialysis unit.

Laboratory Process Improvement: A Quality Initiative in an Outpatient Oncology Clinic.

The goal of achieving maximum productivity through process redesign and teamwork in oncology laboratory (lab) operations can be challenging in cancer care organizations. At an urban cancer center, missing lab orders occurred frequently and led to increases in lab errors, turnaround time, and patient wait times. Patient and staff satisfaction metrics were also affected, resulting in suboptimal scores. A nurse-driven practice change project was initiated after a thorough assessment in two clinic sites. The application of targeted lean methodology to redesign lab processes and workflows, in addition to engaging multiple stakeholders, was implemented to support a culture of continuous quality improvement.

Implementation of Lean healthcare methodology in designing an Intravitreal Injection Center: first Italian experience.

PURPOSE: The principles of the Lean methodology, introduced by Toyota to improve productivity, are relevant to other settings, including healthcare. We aimed to use Lean methodology to design a new setting in our ophthalmology clinic to improve the management of patients receiving an intravitreal injection for ocular diseases. METHODS: The location of services, days of operation, scheduling and processing of patients, utilization of staff, data recording methods, and examination and surgical procedures were analyzed, and a new Intravitreal Injection Center was developed according to Lean principles. RESULTS: The new setting, which is confined to a single floor, in contrast to the previous system, which necessitated that patients visit various locations spread over three floors of the hospital, demonstrated benefits for patients and improved the flow and management of patients through the system with a need for fewer team members. The intravitreal injection service improved with regard to both the quality and speed of the overall procedure and the efficient use of staff. CONCLUSION: Our aim to achieve a fast and one-way route to move patients through intravitreal injection administration was achieved, limiting any waste of time and space and improving the capacity management of the center. The system is of relevance to other ophthalmology clinic settings and facilitates the collection of valuable epidemiological and clinical information on the response of patients to different drugs and treatment regimens.

Making enhanced recovery the norm not the exception.

BACKGROUND: Enhanced Recovery After Surgery ("STAAR" in our system) is multimodal care focused on the reduction of physiological and psychological stress. While enhanced recovery is well established in colorectal surgery, and there is evidence for effectiveness in other surgical disciplines, to date widespread use is limited. METHOD: We implemented a Lean process that, within 12 months, expanded STAAR to 13 surgical services lines involving >130 surgeons, and impacting the care of >6000 surgical patients/year. RESULTS: Implementation involved educational and administrative meetings (279 in the first 6 months) and rounding. Use of STAAR was defined as >60% compliance. LOS was reduced up to 40%, mortality index and transfusion decreased 67% and 23% respectively. Case mix index increased 17%. Readmission rates, infections, ER visits were not increased. CONCLUSION: Using a Lean process focused on value, STAAR protocols became the standard rather than the exception. Time investment by senior surgical leadership was extensive.

Minimizing central line-associated bloodstream infections in a high-acuity liver transplant intensive care unit.

BACKGROUND: Increases in liver transplant patient perioperative acuity have resulted in frail immunosuppressed patients at elevated risk for nosocomial infections. Avoiding central line-associated bloodstream infections (CLABSIs) is paramount to facilitate transplantation and post-transplant recovery. In 2015, our liver transplant intensive care unit (ICU) CLABSIs accounted for more than 25% of all CLABSI at our institution. We therefore undertook a multidisciplinary collaborative among clinical epidemiology, nursing, transplant surgery, and critical care to eliminate CLABSI events. METHODS: From 2014-2016, using Lean methodology and plan-do-study-act (PDSA) cycles, 14 interventions were implemented in the liver transplant ICU. Interventions were aimed at infection prevention, care standardization, and team-based monitoring. Implementation used quality improvement methodology including audit and feedback, education, standardization, multidisciplinary stakeholder involvement, and PDSA cycles. Process measures were monitored and audited. CLABSI rates per 1,000 central venous catheter (CVC) days were tracked by clinical epidemiology. RESULTS: During the intervention, 901 CVC catheter audits were completed. Improvements were seen on all process measures, and complete compliance increased from 25%-67%. CLABSI infection rates dropped from 4.2 to 1.8 in 1,000 CVC days, with an average of less than 1 CLABSI per month. This marked a 61.2% annual reduction, which correlated with an estimated $935,000 annual savings. CONCLUSION: Concerted ongoing multidisciplinary collaboratives are essential to minimize CLABSI and optimize value and quality in a challenging, high-acuity patient population.