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

Endoscopic approach for paranasal sinuses osteomas: Our experience and review of literature

Osteomas are common benign bone tumors of the skull and facial structures involving primarily the cranial vault, mandible, external auditory canal, paranasal sinuses, nasal cavity, and orbit.1,2 These neoplasms are usually asymptomatic and account for 0.43% of tumor in population with an incidental finding on 1% of radiographs and on 3% of computed tomography (CT) scans. [1] These solid nodular sclerotic lesions usually arise from the outer table and are usually < 10 mm; lesions larger than 30 mm in diameter are considered giant tumors.3,4,7 Most of patients with such a diagnosis have few or no symptoms, in general only 10% is symptomatic, in the second to fifth decades of life 5,6. In literature, endoscopic endonasal approaches are mainly indicated for small ethmoidal osteomas without significant orbital or frontal extension7, while large osteomas require Caldwell-Luc surgery8 or other more aggressive approaches25. We report our experience about the treatment of paranasal sinuses osteomas treated endoscopically or by endoscope-assisted Caldwell-Luc approach, achieving total removal of the neoplasms with all the advantages deriving by endoscopic technique such as closer visualization of the anatomy, no damage to the surrounding structures, better cosmetic results, less morbidity and shorter hospitalization17

A six sigma DMAIC methodology as a support tool for health technology assessment of two antibiotics

Health Technology Assessment (HTA) and Six Sigma (SS) have largely proved their reliability in the healthcare context. The former focuses on the assessment of health technologies to be introduced in a healthcare system. The latter deals with the improvement of the quality of services, reducing errors and variability in the healthcare processes. Both the approaches demand a detailed analysis, evidence-based decisions, and efficient control plans. In this paper, the SS is applied as a support tool for HTA of two antibiotics with the final aim of assessing their clinical and organizational impact in terms of postoperative Length Of Stay (LOS) for patients undergoing tongue cancer surgery. More specifically, the SS has been implemented through its main tool, namely the DMAIC (Define, Measure, Analyse, Improve, Control) cycle. Moreover, within the DMAIC cycle, a modelling approach based on a multiple linear regression analysis technique is introduced, in the Control phase, to add complementary information and confirm the results obtained by the statistical analysis performed within the other phases of the SS DMAIC. The obtained results show that the proposed methodology is effective to determine the clinical and organizational impact of each of the examined antibiotics, when LOS is taken as a measure of performance, and guide the decision-making process. Furthermore, our study provides a systematic procedure which, properly combining different and well-assessed tools available in the literature, demonstrated to be a useful guidance for choosing the right treatment based on the available data in the specific circumstance

A health technology assessment between two pharmacological therapies through Six Sigma: the case study of bone cancer

Purpose: Head and neck cancers are multi-factorial diseases that can affect many sides of people's life and are due to a lot of risk factors. According to their characteristics, the treatment can be surgical, use of radiation or chemotherapy. The use of a surgical treatment can lead to surgical infections that are a main theme in medicine. At the University hospital of Naples “Federico II”, two antibiotics were employed to tackle the issue of the infections and they are compared in this paper to find which one implies the lowest length of hospital stay (LOS) and the reduction of infections. Design/methodology/approach: The Six Sigma methodology and its problem-solving strategy DMAIC (define, measure, analyse, improve, control), already employed in the healthcare sector, were used as a tool of a health technology assessment between two drugs. In this paper the DMAIC roadmap is used to compare the Ceftriaxone (administered to a group of 48 patients) and the association of Cefazolin plus Clindamycin (administered to a group of 45 patients). Findings: The results show that the LOS of patients treated with Ceftriaxone is lower than those who were treated with the association of Cefazolin plus Clindamycin, the difference is about 41%. Moreover, a lower number of complications and infections was found in patients who received Ceftriaxone. Finally, a greater number of antibiotic shifts was needed by patients treated with Cefazolin plus Clindamycin. Research limitations/implications: While the paper enhances clearly the advantages for patients' outcomes regarding the LOS and the number of complications, it did not analyse the costs of the two antibiotics. Practical implications: Employing the Ceftriaxone would allow the Department of Maxillofacial Surgery to obtain lower LOS and a limited number of complications/infections for recovered patients, consequently reducing the hospitalization costs. Originality/value: There is a double value in this paper: first of all, the comparison between the two antibiotics gives an answer to one of the main issues in medicine that is the reduction of hospital-acquired infections; secondly, the Six Sigma through its DMAIC cycle can be employed also to compare two biomedical technologies as a tool of health technology assessment studies

Surgical management of pleomorphic adenoma of parotid gland in elderly patients: Role of morphological features.

The neoplasms of the salivary glands account for 2% of head and neck tumors and the most common form is the Pleomorphic Adenoma (PA). Parotid gland is affected from 80% to 90% of cases. In elderly this tumors occurs mostly in females. These benign tumors are composed of epithelial and myoepithelial cells that are arranged with various morphological patterns and subtypes. The classification of these tumors is also based on the amount and nature of the stroma. In literature there is a almost complete consensus that, in the major salivary glands, PAs are enclosed by a layer of fibrous tissue often called "capsule" but there is disagreement about the form, extention and thickness of this layer. The treatment is surgical and there are two main different surgical approaches: an enucleation (local dissection) or so-called subtotal superficial parotidectomy and lateral or superficial total parotidectomy. Histopathological characteristics of PAs especially of capsular alterations such as thin capsule areas, capsule-free regions, capsule penetration, satellite nodules and pseudopodia in the different subtypes are important for the choice of surgical treatment and the first explanation for tumor recurrence. In our study we describe a morphological features of 84 cases of pleomorphic adenoma of parotid gland from elderly patients treated by a surgical "enucleation like" method called nucleoresection

Three-dimensional superimposition for patients with facial palsy: an innovative method for assessing the success of facial reanimation procedures

Facial palsy is a severe condition that may be ameliorated by facial reanimation, but there is no consensus about how to judge its success. In this study we aimed to test a new method for assessing facial movements based on 3-dimensional analysis of the facial surfaces. Eleven patients aged between 42 and 77 years who had recently been affected by facial palsy (onset between 6 and 18 months) were treated by an operation based on triple innervation: the masseteric to temporofacial nerve branch, 30% of the hypoglossal fibres to the cervicofacial nerve branch, and the contralateral facial nerve through two cross-face sural nerve grafts. Each patient had five stereophotogrammetric scans: at rest, smiling on the healthy side (facial stimulus), biting (masseteric stimulus), moving the tongue (hypoglossal stimulus), and corner-of-the-mouth smile (Mona Lisa). Each scan was superimposed onto the facial model of the "rest" position, and the point-to-point root mean square (RMS) value was automatically calculated on both the paralysed and the healthy side, together with an index of asymmetry. One-way and two-way ANOVA tests, respectively, were applied to verify the significance of possible differences in the RMS and asymmetry index according to the type of stimulus (p = 0.0329) and side (p < 0.0001). RMS differed significantly according to side between the facial stimulus and the masseteric one on the paralysed side (p = 0.0316). Facial stimulus evoked the most asymmetrical movement, whereas the masseteric produced the most symmetrical expression. The method can be used for assessing facial movements after facial reanimation