Effect of Lean Processes on Surgical Wait Times and Efficiency in a Tertiary Care Veterans Affairs Medical Center

Importance There are an increasing number of veterans in the United States, and the current delay and wait times prevent Veterans Affairs institutions from fully meeting the needs of current and former service members. Concrete strategies to improve throughput at these facilities have been sparse. Objective To identify whether lean processes can be used to improve wait times for surgical procedures in Veterans Affairs hospitals. Design, Setting, and Participants Databases in the Veterans Integrated Service Network 11 Data Warehouse, Veterans Health Administration Support Service Center, and Veterans Information Systems and Technology Architecture/Dynamic Host Configuration Protocol were queried to assess changes in wait times for elective general surgical procedures and clinical volume before, during, and after implementation of lean processes over 3 fiscal years (FYs) at a tertiary care Veterans Affairs medical center. All patients evaluated by the general surgery department through outpatient clinics, clinical video teleconferencing, and e-consultations from October 2011 through September 2014 were included. Patients evaluated through the emergency department or as inpatient consults were excluded. Exposures The surgery service and systems redesign service held a value stream analysis in FY 2013, culminating in multiple rapid process improvement workshops. Multidisciplinary teams identified systemic inefficiencies and strategies to improve interdepartmental and patient communication to reduce canceled consultations and cases, diagnostic rework, and no-shows. High-priority triage with enhanced operating room flexibility was instituted to reduce scheduling wait times. General surgery department pilot projects were then implemented mid-FY 2013. Main Outcomes and Measures Planned outcome measures included wait time, clinic and telehealth volume, number of no-shows, and operative volume. Paired t tests were used to identify differences in outcome measures after the institution of reforms. Results Following rapid process improvement workshop project rollouts, mean (SD) patient wait times for elective general surgical procedures decreased from 33.4 (8.3) days in FY 2012 to 26.0 (9.5) days in FY 2013 (P = .02). In FY 2014, mean (SD) wait times were half the value of the previous FY at 12.0 (2.1) days (P = .07). This was a 3-fold decrease from wait times in FY 2012 (P = .02). Operative volume increased from 931 patients in FY 2012 to 1090 in FY 2013 and 1072 in FY 2014. Combined clinic, telehealth, and e-consultation encounters increased from 3131 in FY 2012 to 3460 in FY 2013 and 3517 in FY 2014, while the number of no-shows decreased from 366 in FY 2012 to 227 in FY 2014 (P = .02). Conclusions and Relevance Improvement in the overall surgical patient experience can stem from multidisciplinary collaboration among systems redesign personnel, clinicians, and surgical staff to reduce systemic inefficiencies. Monitoring and follow-up of system efficiency measures and the employment of lean practices and process improvements can have positive short- and long-term effects on wait times, clinical throughput, and patient care and satisfaction

A multidisciplinary approach to improving women’s health in semi‐urban Ecuador

ObjectiveTo examine women’s reasons for seeking care at The Quito Project (TQP), a student‐led organization that aims to improve the health, education, and well‐being of a semi‐urban community in Quito, Ecuador, and to explore the need for additional preventative interventions.MethodsAn oral survey was administered to 86 adult patients in 2008. We also completed a chart review to evaluate patient demographics and medical conditions.ResultsSixty‐three (73.3%) survey respondents were female. Nearly three‐quarters of the women reported an income below the minimum wage; 60% reported that the cost of medical care posed a burden. Fifty‐two percent sought care at TQP because the services were free. Additionally, 77% of women reported going to the doctor only when ill and did not access preventative services.ConclusionsBy offering medical, dental, and tutoring services, along with preventative health workshops, TQP addresses established barriers to achieving adequate women’s health. Survey results have reinforced TQP’s focus on prevention.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135173/1/ijgo70.pd

Consensus-based approach to develop a measurement framework and identify a core set of indicators to track implementation and progress towards effective coverage of facility-based Kangaroo Mother Care.

BACKGROUND: As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus-based approach to develop a measurement framework and identify a core set of indicators for monitoring facility-based KMC that would be feasible to measure within existing systems. METHODS: The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face-to-face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. RESULTS: The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow-up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility-based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow-up (according to country-specific protocol). CONCLUSIONS: These core KMC indicators, identified with input from a wide range of global and country-level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country-led data systems

Impact of Gleason pattern up gradation after radical prostatectomy for carcinoma prostate patients with low biopsy score (≤ 6)

Context: Biopsy Gleason score (b-GS) is often different from the Gleason score obtained after analysis of radical prostatectomy (RP) specimen (rp-GS). Upgradation has an important implication in decision making for cancer prostate management, and is the focus of this study. Aim: To evaluate Gleason score upgradation after radical prostatectomy with low biopsy score (≤ 6) and its correlation to pathological findings and outcome. Settings and Design: This was a retrospective analysis of 257 cases of prostate cancer patients with initial b-GS ≤ 6, over a period of 14 years. Materials and Methods: Data were divided into two groups according to (rp- GS) as 1) Group A (n=151; rp-GS ≤ 6 ) 2) and Group B(n=106; rp-GS ≥7). Both groups were compared in terms of the following: 1) preoperative variables e.g. age, PSA, transurethral resection of prostate (TURP) status, clinical T stage; 2) pathological features - rp GS, pathological stage (pT), capsular penetration, cut margin, seminal vesicle and lymph node status; 3) biochemical recurrence, overall and cancer specific mortality. Statistical Analysis Used: Student's t test and Chi-square test. Results: Group B had worse pathological features, except lymph node invasion, and they received significantly more adjuvant hormonal/local radiotherapy and had higher recurrence rate. However, the overall and cancer-specific mortality were similar in both the groups. Conclusions: b-GS upgradation after radical prostatectomy is frequent and correlates with adverse pathological features, higher use of adjuvant therapy and higher recurrence rate. In Group B, adjuvant therapy delays the biochemical or clinical relapse and controls mortality in short-term follow up. Group A had favorable pathological findings and less recurrence rate

Predictors of no-scalpel vasectomy acceptance in Karimnagar district, Andhra Pradesh

Introduction: Karimnagar District has consistently achieved highest rates of no-scalpel vasectomy (NSV) in the past decade when compared to state and national rates. This study was conducted to elucidate the underlying causes for higher acceptance of NSV in the district. Materials and Methods: A community-based, case control study was conducted. Sampling techniques used were purposive and simple random sampling. A semi-structured questionnaire was used to evaluate the socio-demographic, family characteristics, contraceptive history and predictors of contraceptive choice in 116 NSV acceptors and 120 other contraceptive users (OCUs). Postoperative complications and experiences were ascertained in NSV acceptors. Results: Age (χ2 =11.79, P value = 0.008), literacy (χ2 =17.95, P value = 0.03), duration of marriage (χ2 =14.23, P value = 0.008) and number of children (χ2 =10.45, P value = 0.01) were significant for acceptance of NSV. Among the predictors, method suggested by peer/ health worker (OR = 1.5, P value = 0.01), method does not require regular intervention (OR = 1.3, P value = 0.004) and permanence of the method (OR = 1.2, P value = 0.031) were significant. Acceptors were most satisfied with the shorter duration required to return to work and the most common complication was persistent postoperative pain among 12 (10.34%) of the acceptors. Conclusion: Advocating and implementing family planning is of high significance in view of the population growth in India and drawing from the demographic profile, predictors, pool of trainers and experiences in Karimnagar District, a similar achievement of higher rates of this simple procedure with few complications can be replicated

Utility of numerical and visual analog scales for evaluating the post-operative pain in rural patients

Background: Visual analog scales (VAS) and numeric analog scales (NAS) are used to assess post-operative pain, but few studies indicate their usefulness in rural illiterate population in India. Aims: This study was designed to 1) Compare the impact of literacy on the ability to indicate pain rating on VAS and NAS in post-operative rural patients. 2) Assess the level of agreement between the pain scales. Setting and Design: Cross sectional, hospital based study. Methods: Informed consent was obtained from patients prior to undergoing surgical procedures in a teaching hospital. Post surgery, patients who were conscious and coherent, were asked to rate pain on both VAS and NAS. The pain ratings were obtained within 24 hours of surgery and within 5 minutes of each other. Statistical Methods: Percentages, chi square test, regression analysis. Results: A total of 105 patients participated in the study. 43 (41%) of the sample was illiterate. 82 (78.1%) were able to rate pain on VAS while 81 (77.1%) were able to rate pain on NAS. There was no significant association between pain ratings and type of surgery, duration of surgery and nature of anaesthesia. In multivariate analysis, age, sex and literacy had no significant association with the ability to rate pain on VAS (P value 0.652, 0.967, 0.328 respectively). Similarly, no significant association was obtained between age, sex and literacy and ability to rate pain on NAS (P value 0.713, 0.405, 0.875 respectively). Correlation coefficient between the scales was 0.693. Conclusion: VAS and NAS can be used interchangeably in Indian rural population as post-operative pain assessment tools irrespective of literacy status

SOCIAL CLASS DIFFERENTIATION AND ITS IMPACT ON QUALITY OF LIFE AMONG DIABETIC PATIENTS

ABSTRACT Social class is a significant modifier of quality of life in diabetic patients which we sought to measure in this study. A hospital based, cross sectional descriptive was conducted in diabetic patients using a semi structured questionnaire. A total of 103 diabetic patients consented and participated in the study. The sample consisted of 58 males and 45 females and most respondents had a duration of onset of diabetes between 1-5 yrs (47%). 68 (66%) of the respondents belonged to lower class, 27 (26%) to the middle class and 8 (8%) to the upper class. 92 (89.32%) of the respondents were using oral hypoglycemic agents and 11 (10.68%) used injectable insulin. Socioeconomic status was significant for the number of missed doses (P < 0.04). The mean scores for upper, middle and lower class on the items of financial burden were 3.99 ± 0.906, 3.37 ± 1.079, 3.00 ± 0.756, for general health were 3.49 ± 0.837, 2.96 ± 0.706, 2.63 ± 0.744 and for psychological distress were 3.56 ± 0.835, 2.70 ± 0.609 and 2.75 ± 0.707 respectively. Social class has a significant impact on quality of life and therapy compliance and measures to address this must be undertaken while providing comprehensive healthcare in diabetes for an optimal outcome

The Dynamics of Suspended Sediment in a Typical Alpine Alluvial River Reach: Insight From a Seasonal Survey

International audienceThe transport of suspended sediment is associated with important social, economic, and environmental issues. It is still unclear, however, how suspended sediments eroded on hillslopes are transferred downstream through the river system. In this study, we aimed to investigate this process by applying a sediment budget approach to a typical 3.5-km-long Alpine braided reach. Using high-frequency suspended load measurements combined with Monte Carlo simulations for uncertainty propagation, we observed a significant buffering behavior of the reach studied. Thirty-two of the 48 events observed during the 2-month campaign showed significant differences between upstream and downstream mass transported as suspension, despite the reach studied was short compared to the upstream drainage area (130 km(2)). These differences at the event scale varied widely within an envelope comprised between a net erosion equivalent to 74% of upstream suspended mass and a net deposition equivalent to 71%. Budgets were found to be controlled at a nearly instantaneous time scale by the liquid discharges and the suspended sediment concentrations in an opposite way: for low upstream concentrations, net erosion increased when the discharges increased, while above a certain concentration, net deposition increased when the concentrations increased. Moreover, coarse particles mobility in the reach (characterized via bedload transport measurements) appeared to have a strong influence on the availability of suspended particles as both quantities evolved concomitantly through time. These observations have important implications for our understanding and modeling of the transfer of suspended particles in gravel bedded streams