Integrating lean thinking and mathematical optimization: A case study in appointment scheduling of hematological treatments

This paper addresses the relationship between lean thinking and mathematical optimization. We discuss the roles of the two approaches, using as a reference case study the appointment scheduling process in a hematological center of a large Italian hospital. We report on how lean tools have been deployed to improve the process, we present a mathematical optimization model and discuss its implementation. Our aim is to show that the joint use of lean thinking and mathematical optimization can disclose large benefits when they are properly integrated in the improvement process. In our case study, simulated experiments point out that the average patient lead time could be decreased by more than 30%. Keywords: Appointment scheduling, Hematological treatments, Lean thinkin

HCD-SIM: Healthcare Clinic Design Simulator With Application to a Bone Marrow Transplant Clinic

The treatment of patients in outpatient healthcare clinics is continually growing as technology improves and recovery benefits are recognized. In this thesis, a simulation framework is developed to model the operational aspects of clinics with the goal of providing a method to understand the impact of clinic design decisions relative to productivity, efficiency, and quality of patient care. The healthcare clinic design simulator (HCD-Sim) is designed to study the dynamic system behavior of clinics and to analyze alternative outpatient healthcare clinic designs. Additionally, the simulation framework is created using a data-driven structure that can represent a large class of outpatient healthcare clinics through the specification of clinic data relative to patient flows, work flows, and resource requirements. To demonstrate capability, the framework is applied to a representative general clinic to analyze capacity and investigate important resources that impact the clinic’s performance. Lastly, the framework is applied to a Bone Marrow Transplant (BMT) clinic application to examine the system and provide design recommendations

The impact of the hospital environment:Understanding the experience of the patient journey

A hospital visit is often an anxious and uncertain event for patients and their relatives. Patients are often concerned about a diagnosis and/or the treatment of their disease in an outpatient or inpatient setting. Knowledge regarding the influence of these settings on patients is essential for facilitating the quality of health care. It is expected that an understanding of the experience of patients will allow designers and decision-makers in hospitals to positively influence the well-being of patients. The aim of this thesis was to gain an improved understanding about a more holistic experience and well-being of patients at specific focal points of the entire patient journey from the arrival, to the diagnosis, and to the actual treatment in a hospital. For example, results showed that patients sometimes experience difficulties in finding their way to an outpatient clinic, that images of nature during a CT scan can reduce anxiety, and that (the opportunity of) interaction with other patients is a pleasant distraction or, on the contrary, an invasion of their own privacy. This thesis emphasizes the relations between the hospital environment and the psychosocial and physical well-being of patients. The results show that it is of great importance to listen carefully to patients’ experiences and needs when designing a hospital as many of the results showed individual differences with patients that emphasize that one size does not fit all. The well-being of patients in future hospitals can be improved by aligning the hospital environment with individual patient characteristics, needs, and preferences

The application of a human factors approach to the evaluation of a novel outpatient parenteral antimicrobial therapy service in Malta.

The application of a human factors approach to healthcare has been gaining traction ever since its first mention in the early 1960s. The need for this synergistic collaboration stems from the poor safety and quality outcomes that have been plaguing the history of healthcare, despite continuous efforts by stakeholders to offer patient-centred care at all costs. In recent years, healthcare practitioners have positively contributed to bridging the gap between clinical practices and systems-based approaches. To this end, this research project sets out to apply a human factors approach to the evaluation of a specific niche in healthcare - the newly launched Maltese OPAT service. Considering the high quality attributed to systematic literature reviews (SLRs) in evidence-based medicine, the first phase of this study featured a dual-discipline PROSPERO-registered SLR. Data were critically appraised, synthesised and presented to deduce whether human factors approaches were amenable to OPAT pathways. Data synthesis using the SEIPS 2.0 model successfully extracted facilitators and barriers to OPAT services across the globe, indicating how systems needed to be redesigned to improve service outcomes. At this point during the research journey, the absence of a singular reference source about OPAT episodes made benchmarking and auditing against international service provisions impractical. The second phase addressed this lacuna by conducting a prospective observational cohort study about OPAT episodes, whilst concomitantly compiling a repository (October 2016 to October 2019). Details about the patient cohort and OPAT episodes, completion statuses, OPAT durations and the cost to run the service were inferred. Over the study timeframe, a total of 132 episodes were rendered to 117 patients, equating to a total of 3287 hospital bed days saved. Of these, only 23 episodes resulted in a readmission and so the overall success rate was 82.6%. The OPAT duration was significantly influenced by the presenting infection (p = 0.021), VAD (p < 0.001) and occurrence of a readmission (p = 0.05). Despite the importance of these findings, they offered little knowledge about the patients' and professionals' experiences as end users of the service. This reasoning guided the pursuit of identifying facilitators and barriers attributable to the service from the perspective of these end-users. A cross-sectional questionnaire and a focus group session were conducted to gather data from patients and the OPAT team respectively. Quantitative and qualitative analysis were supplemented by human factors strategies - namely hierarchical task analysis and SEIPS-based modelling. Following quantitative data analysis, a general positive trend in patient satisfaction scores (satisfaction rate of 95.8%) was recorded, therefore favouring the service and the high standard it managed to maintain through the years of provision. Thematic analysis supported this finding and advised caution in terms of focusing on the patient's wellbeing, standardisation of practices, availability of resources and the involvement of informal caregivers. Certain themes were also reiterated from the analysis of the focus group discourse, whereby the OPAT team also stressed the importance of standardising procedures (with specific reference to the referral process and training/education methods), and the team's flexibility and adaptability prior to expanding the service further. SEIPS-based modelling conducted on data collected during the cross-sectional survey and focus group contributed to the mapping of a systems based model applicable to the local service. Comparisons between this and the model created during the SLR about global OPAT services shed light on the requirements for system redesigns of local practices. This doctoral research has contributed both to the practice of OPAT nationally and to the general application of systems-based strategies for the betterment of healthcare outcomes. Future work should focus on the use of new methods to gather more data about the local service, including more robust pharmacoeconomic studies and an in-depth ethnography study from the perspective of the end-users through fieldwork, which could then supplement further human factor approaches such as workflow analysis, thereby ensuring further triangulation of data. On a larger scale, the findings of this research shed light on the amenability of human factors approaches to healthcare practices in general and therefore should be applied across the institution beyond the boundaries set by this case study research

Psychedelic-assisted research for the treatment of drug and alcohol addiction : a scoping review

This master thesis is written as a scoping review article supplemented with a “kappe” for more extensive information, detailed explanations, and supplementary data for the article. Introduction: Psychedelic-assisted treatments are receiving renewed interest for treating a range of different mental health disorders. Among these are addiction disorders, which have limited treatment options for people who experience little effect of conventional treatments. Due to the relatively new application, this review will scope the field of relevant studies utilizing the psychedelic substances LSD, psilocybin, MDMA, and ketamine for treating addiction disorders, to map the current research situation and inform strategies for future research, using safety guidelines, standards, and strategies proposed in reviews of previously conducted psychedelic research. Method: Systematic literature searches in four databases (Ovid Medline, Embase, Scopus, and Web of Science) were performed, in addition to handpicked searches through citation tracking, additional bibliographies and online searches. All results were uploaded to EndNote 20 for screening of titles, abstracts, and lastly in full text to assess eligibility according to the eligibility criteria. The included studies were limited to those utilizing the selected psychedelic substances treating addiction disorders in a therapeutic or clinical context with a behavioral outcome or therapeutic gain. A pilot tested data charting tool was used to extract relevant data, which were presented in relevant tables. Results: Nineteen studies were identified within the limitations set for this review, one investigating LSD, one MDMA, one psilocybin, and 16 ketamine. There are noteworthy methodological differences, and the majority of studies do not provide sufficient data and materials to adequately evaluate and replicate the trials. Study and participant characteristics vary greatly, as does the different combinations of interventions and psychedelic substances applied in the studies. Overall, abstinence rates and changes in craving are significant in most studies, especially in the controlled studies. Conclusion: This review highlighted the current research status investigating psychedelic-assisted addiction treatments, identifying most research investigating ketamine. Overall, the included studies showed promising outcomes, but there are noteworthy methodological differences between the studies, and limitations that can be addressed using safety guidelines, standards, and strategies presented in this review.Denne masteroppgaven er skrevet som en scoping review artikkel med en tilhørende «kappe» for mer omfattende informasjon, detaljerte forklaringer og data som supplement for artikkelen. Introduksjon: Det har blitt økt interesse for bruk av psykedelika i behandling av en rekke ulike psykiske lidelser. Blant disse er avhengighet til alkohol eller andre narkotiske stoffer, som har begrenset med behandlingstilbud for de som opplever liten effekt av konvensjonelle behandlingsalternativer. Denne scoping review artikkelen vil kartlegge den nåværende forskningsstatusen og identifisere relevante studier som bruker de psykedeliske stoffene LSD, psilocybin, MDMA og ketamin i behandling av avhengighet til alkohol eller narkotiske stoffer. Disse vil brukes til å fremlegge strategier for fremtidig forskning basert på retningslinjer for sikkerhet, standarder og strategier som er utarbeidet etter evaluering av tidligere forskning med psykedelika. Metode: Det ble utført systematiske litteratursøk i fire databaser (Ovid Medline, Embase, Scopus og Web of Science) i tillegg til søk i ekstra bibliografier, siteringssøk og online søk. Alle resultater ble lastet opp til EndNote for gjennomgang av titler, abstrakter og avslutningsvis studier i full-tekst for å vurdere valgbarhet basert på inklusjons- og eksklusjonskriteriene. De inkluderte studiene var begrenset til de som anvendte de utvalgte psykedeliske stoffene for å behandle en avhengighet til alkohol eller narkotiske stoffer, i en terapeutisk eller klinisk setting med et adferdsrelatert studieutfall eller terapeutisk gevinst. Det ble brukt et pilot-testet skjema for ekstraksjon og kartlegging av data, som ble organisert og presentert i relevante tabeller. Resultater: Det ble identifisert 19 studier innenfor avgrensningene til denne artikkelen, en med LSD, MDMA og psilocybin, og 16 med ketamin. Det er bemerkelsesverdige metodologiske forskjeller mellom de inkluderte studiene, i tillegg til at de fleste ikke har publisert tilstrekkelig med data og materiale for å kunne evaluere eller replikere studiene. Det er stor variasjon i egenskapene til studiene og deltakerne, samt variasjon i kombinasjoner av intervensjoner og psykedeliske stoffer som er brukt i de ulike studiene. Studieutfall for avholdenhet og endringer i rus-begjær er signifikant i de fleste studiene, spesielt de kontrollerte. Konklusjon: Denne scoping review artikkelen har fremhevet den nåværende forskningsstatusen for psykedelika-assistert behandling av avhengighet. Det ble identifisert mest forskning med ketamin. De inkluderte studiene presenterte lovende resultater og positive utfall, på tross av metodologiske forskjeller mellom studier. Slike forskjeller og andre begrensninger kan minimeres ved bruk av retningslinjene, standardene og strategiene presenter i denne scoping review artikkelen.M-FO

Comprehensive Cancer Care: an outpatient treatment facility

A cancer diagnosis can result in a loss of decision-making and control for patients. The majority of clinical treatments fail to adequately address corollary symptoms and needs that arise both from treatment and from the disease itself. Thus, the architectural problem identified in this thesis inquiry is how can an outpatient cancer centre treat the whole patient comprehensively, while at the same time instilling control and re-empowering the patient? This thesis project proposes a patient-centered environment designed to support the myriad and nuanced needs of the cancer patient, as well as a site-specific proposal for a comprehensive outpatient cancer treatment centre located in Spartanburg County, South Carolina. This cancer centre is designed with the notion of patient-empowerment as a design driver, and incorporates non-traditional complementary treatments in addition to those clinical treatments typically offered in the conventional North American cancer centre. By way of supporting this topical area of inquiry, the following topics comprise the scope of inquiry undertaken in this project: Clinical Cancer Treatment Architecture: the three main facility types in which cancer treatment occurs - freestanding, aggregated, and monolithic. Complementary/Alternative Treatment Architecture: both cancer-focused and general alternative treatment centres were also investigated, in order to determine what complementary therapies might be appropriate to incorporate with a clinical cancer treatment center. Additionally, these facilities were helpful in giving cues as to what physical design drivers could help guide the subsequent thesis design proposal. The review of many personal cancer patient blogs and video diaries (all openly available online) was important in framing the experience of the patient. What therapies were commonly feared, personal aversions that developed as a result of treatment, and similar notions written or spoken about all helped to give a sense of what it might be like to be in a patient\u27s situation, and what design decisions might have been helpful in nurturing a more positive experience. Design principles were developed out of the topical inquiry and architectural investigation, with the focus of patient empowerment at hand. Similarly, site selection, programmatic development, and the final design proposal were each conducted through the lens of the patient experience, and how best to instill control before, during, and after treatment is delivered (that is to say, before the patient arrives, the experience of receiving care, and what is taken away once they leave the treatment centre). The resulting design proposal developed from this investigation is a 45,000 square foot outpatient cancer treatment centre located in Spartanburg County, South Carolina. The facility comprises a full hematology and infusion therapy suite, a radiation therapy suite, an alternative medicine suite, a physical therapy program, mind-body therapies, and a diet and nutrition area. Patients originating in the Cities of Greenville, Spartanburg, and Greer, and all surrounding areas will utilize this centre

Evaluation of Patient Throughput in an Outpatient Pediatric Hematology, Oncology, and Bone Marrow Transplant Clinic

Background: Outpatient oncology clinics are complex environments. The multi-step, sequential nature of oncology treatment contributes to delays. Prolonged wait time impacts patient compliance, satisfaction, and staff satisfaction. Objectives: To assess throughput in the outpatient pediatric oncology clinic and explore staff’s assessment of throughput and their opinions of what might be improved. Methods: Our descriptive-comparative study used retrospective reviews to measure four time intervals for 312 visits at our mid-Atlantic outpatient clinic. Patient and appointment factors were explored. Mean interval times were calculated and differences impacting throughput were analyzed using ANOVA. Prospective survey data were obtained from 22 clinic staff and themes were identified. Results: The shortest interval was check-in to triage (18.49 ± 18.21 minutes) while the longest was from receiving laboratory results to treatment initiation (136.73 ± 77.98 minutes). Throughput was significantly shorter for appointments consisting of provider visit and laboratory studies only compared to visits involving infusions and blood product transfusions (p \u3c .001). Throughput for 8:00-10:00 a.m. appointments was significantly longer than 2:01-6:00 p.m. appointments (p = .013). Staff respondents reported throughput was suboptimal. Common problems identified were appointment noncompliance, laboratory workflow, triage and front desk bottlenecks, physician timeliness, fellow workflow, and “saving seats”. Conclusions: Delays occurred at each clinic intersection but were significantly longer with early clinic appointments and infusion and transfusion visits. Staff highlighted problems at each clinic juncture and overarching problems that caused inefficiencies. We identified priority areas to be addressed via targeted interventions in a structured action plan to improve clinic efficiency and throughput