Definition of strategies for the reduction of operational inefficiencies in a stroke unit

Stroke disease is the second common cause of death in the world and is then of particular concern to policy-makers. Additionally, it is a meaningful problem leaving a high number of people with severe disabilities, placing a heavy burden on society and incurring prolonged length of stay. In this respect, it is necessary to develop analytic models providing information on care system behavior in order to detect potential operational inefficiencies along the stroke patient journey and subsequently design improvement strategies. However, modeling stroke care is highly complex due to the multiple clinical outcomes and different pathways. Therefore, this paper presents an integrated approach between Discrete-event Simulation (DES) and Markov models so that integrated planning of healthcare services relating to stroke care and the evaluation of potential improvement scenarios can be facilitated, made more logically robust and easy to understand. First, a stroke care system from Colombia was characterized by identifying the exogenous and endogenous variables of the process. Afterward, an input analysis was conducted to define the probability distributions of the aforementioned variables. Then, both DES and Markov models were designed and validated to provide deeper analysis of the entire patient journey. Finally, the possible adoption of thrombolytic treatment on patients with stroke disease was assessed based on the proposed approaches within this paper. The results evidenced that the length of stay (LOS) decreased by 12,89% and the mortality ratio was diminished by 21,52%. Evaluation of treatment cost per patient is also carried out

organizational solutions to improve timeliness and effectiveness of the stroke care

Saving time means saving neurons in stroke care process. Managerial and organizational solutions that lean the processes should be considered in order to overcome the effects of stroke, which is the second worldwide cause of death. The purpose of the paper is to understand how Health Lean Management (HLM) can be adopted to achieve a more efficient stroke care process. In this peculiar context, efficiency enhancement leads to safety and effectiveness results. For this reason, the investigated projects have been recognized as Lean & Safety (L&S) projects, being HLM projects reporting patient safety improvements. Due to the peculiarity of the project to investigate, a holistic case study has been conducted in a university hospital of Tuscany region. Thanks to the research framework developed in the literature for L&S projects, data regarding motivations, objectives, organizational and managerial aspects, outcomes, enablers and obstacles of the project have been collected and analysed. A multidisciplinary team, already trained on HLM and supported by the top management, was created and the step-by-step Six Sigma approach was adopted. After a mapping phase, a value stream map was created, Key Performance Indicators were defined and, finally, the Door To Needle (DTN) times and the modified Rankin Scales (mRS) were measured. Thanks to root cause analysis, the identified wastes were analyzed and intervention actions were defined and implemented. They regarded mainly different organizational interventions and they led to a decrease of both DTN times and mRS. The analysed project has demonstrated how it is possible to obtain relevant operational and clinical outcomes through organizational solutions. The analysis of this project, in which pursuing efficiency has led to safety and effectiveness results, has demonstrated how these different performances are linked each other in some peculiar care processes, in which shorter time means more effective and safer care, as in the stroke case. The implementation of L&S projects can improve care processes, providing a contribution to realize a more efficient, effective and safer healthcare system

Steam bottoming cycle for an adiabatic diesel engine

Steam bottoming cycles using adiabatic diesel engine exhaust heat which projected substantial performance and economic benefits for long haul trucks were studied. Steam cycle and system component variables, system cost, size and performance were analyzed. An 811 K/6.90 MPa state of the art reciprocating expander steam system with a monotube boiler and radiator core condenser was selected for preliminary design. The costs of the diesel with bottoming system (TC/B) and a NASA specified turbocompound adiabatic diesel with aftercooling with the same total output were compared, the annual fuel savings less the added maintenance cost was determined to cover the increase initial cost of the TC/B system in a payback period of 2.3 years. Steam bottoming system freeze protection strategies were developed, technological advances required for improved system reliability are considered and the cost and performance of advanced systes are evaluated

Preventing Hospital Readmission In The Sepsis Patient: A Multi-Modal Discharge National Framework

Sepsis, the leading cause of hospital readmissions in the United States, accounts for $23.7 billion of aggregate costs. The Medicare Hospital Readmissions Reduction Program (HRRP) requires hospitals to provide efficient patient discharge coordination to prevent readmissions or risk financial penalties. Although a substantial value capture opportunity exists to reduce avoidable readmissions, a significant gap exists in sepsis-specific discharge interventions. The purpose of this quality improvement project was to design and evaluate an evidence-based framework for reducing sepsis readmissions in the acute care setting with national impact. The novel, multidisciplinary framework developed here integrated literature on: (1) Sepsis Nurse-Navigator driven discharge interventions; (2) Patient awareness using an expert-validated sepsis education tool; and (3) Patient-Nurse collaboration using telehealth or telephonic follow-up at critical time points. Seventy-five community hospital patients with qualifying CMS (2019) Diagnosis Related Group (DRG) 870, 871, and 872 discharging to home or an assisted living facility participated for a total of 6 months. Comparative analysis included review of 30-day readmissions pre-and post-program. Patient and nurse satisfaction as indicators of sustainability or opportunities for improvement were examined. The reduction in readmission rate after program implementation was statistically and clinically significant. Observed readmission rate fell to 17.2% after implementation of the framework (Z=37.36, p \u3c .001) vs. the 44.2% baseline rate. Intervention resulted in a large effect size of 27.0% (95% CI=25.2%, 28.0%). National outcomes of this Healthcare Leadership DNP project determine scalability across a 21-state health system, inform evidence-based discharge interventions, and contribute to best practices for sepsis readmission reduction nationally

Predicting the effectiveness of early senior decision-making in urgent internal medical care : application of a hybrid agent-based and discrete event systems simulation model to evaluate UK healthcare policy recommendations

Hospital systems face year-upon-year rises in demand for in-patient services. Moments when urgent care departments are overwhelmed with more patients than they are resourced to provide care for (overcrowding) frequently emerge due to poor availability of hospital beds. Policymakers and healthcare leaders in the UK recommend an early senior decision-making (ESDM) strategy to divert suitable patients away from in-patient services at the time of referral into urgent care. Policies also advise expert clinicians – the highest grade of clinical staff - should perform this task. This research specifically explored the effectiveness of the ESDM strategy when applied to urgent internal medical populations – the largest consumers of in-patient services – with the intention of informing a cost-effectiveness analysis of ESDM. A systems simulation model (SSM) combining agent-based and discrete event systems simulation model was created to reproduce ESDM in a representative acute medical unit in the UK. Data to inform model conceptualisation, programming, and parameter inputs was gathered via observational ethnography, analytic autoethnography of expert early decision-making in urgent care, and prospective data collection of patient-reported outcomes. Outputs aligned with the goals of patients, staff, and provider goals were defined. Upon validation, the model was used to predict how outputs could change with different configurations of expert and non-expert staffing in the decision-maker role. Staffing strategies were analysed at increasing levels of tolerated overcrowding in the department to mimic high hospital occupancies that limited transfer from the unit. Modelled outputs were analysed for meaningful differences and trends. Early senior decision-making realised meaningfully fewer moments of overcrowding and delays, but only when departmental overcrowding was enforced. This occurred via of intuitive decision-making by clinical experts - a phenomenon not previously reported in literature available at the time of writing. System-wide inefficiencies begin to emerge when experts perform decision-making for all patients referred. Impact upon patient health is unclear. The ESDM strategy has the potential to realise safer in-patient care and generate local efficiencies in hospitals that face frequent moments of overcrowding, but not in systems that maintain urgent care bed occupancy levels below 100%. Improving currently available decision-support tools to harness the decision-making of experts may deliver efficiency gains at lesser cost. Further research into the health impact of admission avoidance and overcrowding in urgent care areas outside of the ED is warranted before cost-effectiveness may be explored.Hospital systems face year-upon-year rises in demand for in-patient services. Moments when urgent care departments are overwhelmed with more patients than they are resourced to provide care for (overcrowding) frequently emerge due to poor availability of hospital beds. Policymakers and healthcare leaders in the UK recommend an early senior decision-making (ESDM) strategy to divert suitable patients away from in-patient services at the time of referral into urgent care. Policies also advise expert clinicians – the highest grade of clinical staff - should perform this task. This research specifically explored the effectiveness of the ESDM strategy when applied to urgent internal medical populations – the largest consumers of in-patient services – with the intention of informing a cost-effectiveness analysis of ESDM. A systems simulation model (SSM) combining agent-based and discrete event systems simulation model was created to reproduce ESDM in a representative acute medical unit in the UK. Data to inform model conceptualisation, programming, and parameter inputs was gathered via observational ethnography, analytic autoethnography of expert early decision-making in urgent care, and prospective data collection of patient-reported outcomes. Outputs aligned with the goals of patients, staff, and provider goals were defined. Upon validation, the model was used to predict how outputs could change with different configurations of expert and non-expert staffing in the decision-maker role. Staffing strategies were analysed at increasing levels of tolerated overcrowding in the department to mimic high hospital occupancies that limited transfer from the unit. Modelled outputs were analysed for meaningful differences and trends. Early senior decision-making realised meaningfully fewer moments of overcrowding and delays, but only when departmental overcrowding was enforced. This occurred via of intuitive decision-making by clinical experts - a phenomenon not previously reported in literature available at the time of writing. System-wide inefficiencies begin to emerge when experts perform decision-making for all patients referred. Impact upon patient health is unclear. The ESDM strategy has the potential to realise safer in-patient care and generate local efficiencies in hospitals that face frequent moments of overcrowding, but not in systems that maintain urgent care bed occupancy levels below 100%. Improving currently available decision-support tools to harness the decision-making of experts may deliver efficiency gains at lesser cost. Further research into the health impact of admission avoidance and overcrowding in urgent care areas outside of the ED is warranted before cost-effectiveness may be explored

Improving performance of the hospitalization process by applying the principles of Lean Thinking

Purpose: The goal was to improve the quality of the hospitalization process and the management of patients, allowing the reduction of costs and the minimization of the preoperative Length of Hospital Stay (LOS). Design/methodology/approach: The methodology used to improve the quality of the hospitalization process and patient management was Lean Thinking. Therefore, the Lean tools (Value stream map and Ishikawa diagram) were used to identify waste and inefficiencies, improving the process with the implementation of corrective actions. The data was collected through personal observations, patient interviews, brainstorming and from printed medical records of 151 patients undergoing oral cancer surgery in the period from 2006 to 2018. Findings: The authors identified, through Value Stream Map, waste and inefficiencies during preoperative activities, consequently influencing preoperative LOS, considered the best performance indicator. The main causes were identified through the Ishikawa diagram, allowing reflection on possible solutions. The main corrective action was the introduction of the pre-hospitalization service. A comparative statistical analysis showed the significance of the solutions implemented. The average preoperative LOS decreased from 4.90 to 3.80 days (−22.40%) with a p-value of 0.001. Originality/value: The methodology allowed to highlight the improvement of the patient hospitalization process with the introduction of the pre-hospitalization service. Therefore, by adopting the culture of continuous improvement, the flow of hospitalization was redrawn. The benefits of the solutions implemented are addressed to the patient in terms of lower LOS and greater service satisfaction and to the hospital for lower patient management costs and improved process quality. This article will be useful for those who need examples on how to apply Lean tools in healthcare

What works to increase access to assistive technology in southern Africa

Access to assistive technologies (AT) is necessary to achieving all 17 sustainable development goals. Yet for most people who need AT in Southern Africa, AT is unaffordable, unavailable, and often inappropriate. My PhD research was guided by the core question: What works to increase access to assistive technology in Southern Africa? Organized into three sub-studies, my research aimed to identify and describe the facilitators and barriers to access AT and develop a theoretical model to inform strategies to increase AT access in Southern Africa. The first two sub-studies listed below were previously published and the full manuscripts are included as separate chapters within the thesis. The three sub-studies included: • Sub-study 1: A scoping review that characterized existing evidence on AT from resource limited environments. Evidence identified was limited in quantity and quality, and primarily focused on mobility and vision types of AT. • Sub-study 2: A secondary analysis (i.e., bivariate regressions) of national survey data from Botswana and Swaziland served to examine factors associated with higher levels of AT access. The type of disability (i.e., mobility vs. non-mobility) was found to be the most important factor in determining AT access in both countries. • Sub-study 3: A regional qualitative sub-study was conducted to increase the understanding of how a multitude of interrelated factors operate to increase the supply of and access to AT. An adapted health systems framework was applied to analyse multiple data sources including stakeholder interviews, documentation review and observations. The thesis is organized into seven chapters. In Chapter 1, I provide background information and conceptual framing of the research topic, assistive technology access within Southern Africa. The research questions and overview of the three sub-studies are included in this introductory chapter. Chapter 2 covers the research methods of all three sub-studies. For the first two sub-studies, a brief overview of data collection and analysis methods are included that reference the more detailed methods presented within each published manuscript. The first two sub-studies are presented as Chapter 3 (scoping review) and Chapter 4 (secondary analysis) within the thesis. The third sub-study (qualitative) provided the most comprehensive data of the three sub-studies and comprises findings presented in Chapter 5 and Chapter 6. In the final chapter, Chapter 7, I synthesize findings from all three sub-studies to identify prominent patterns and present models that aim to explain constraints within the AT sector. The synthesis of evidence showed that AT in Southern Africa does not operate as a sector but as a constellation of uncoordinated parts. The low prioritization of AT and high level of fragmentation within the system emerged as pervasive patterns. The combination of these two patterns result in a wasteful sector. This means that the limited resources invested in funding products and services, and in strengthening the national AT procurement and provision system are not used effectively to increase the supply of and access to appropriate AT. In my further interpretation of data to respond to the core research question: What works to increase access to assistive technology in Southern Africa? I then identify strategic levers to increase AT access. Strategic levers aim to increase resources invested in the AT sector while reducing system-wide inefficiencies. Finally, study limitations and conclusions are presented at the end of this final chapter