Unpacking process improvement : in-depth studies of how lean and clinical pathways contribute to the timeliness of care

Introduction: Lean thinking and Clinical Pathways are two process improvement strategies that have gained popularity in health care. They both have the potential to improve the timeliness of care, which is an important goal shared by decisions makers, practitioners, and patients alike. Accounts of both approaches report success in terms of improved process performance but seldom explain how and why they work. Aim: To clarify how contemporary process improvement efforts, in this case lean thinking and clinical pathways, work in practice and how they relate to performance, particularly the timeliness of care. Method: The main research strategies were organizational case studies and realistic evaluation, drawing on multiple data collection methods and sources. Study I is a realist review of empirical studies of lean applications in health care. Study II and IV investi-gate a lean-inspired intervention in seven emergency care services at the Karolinska University Hospital. Study III examines a clinical pathways intervention for hip-fracture care patients at the Danderyd Hospital. Findings: All articles reviewed in Study I reported positive results from lean interven-tions, explained by how they enabled staff to: understand processes, organize and de-sign for effectiveness and efficiency, improve error detection, and collaborate to solve problems. Studies II and IV found initial improvement in the timeliness of care across all seven emergency services studied. The most common changes involved matching capacity with demand through modifications in staffing, scheduling and competency levels. Differences were observed regarding the degree of improvement, performance levels, and the sustainability of results. These differences were related to how the ser-vices adapted the intervention to the degree of complexity of their care processes and their educational commitments. Learning from daily practice proved a challenge. Study III found that extending improvement efforts beyond the hip-fracture care process re-sulted in a net reduction in lead time to surgery for all acute surgical orthopaedic pa-tients. Two key improvement mechanisms were involved: more active and centralized planning of surgery and restructuring of how resources were allocated among patient groups. Discussion: Lean and clinical pathway improvement efforts make inconsistent and in-efficient practices in health care visible. Care providers can then use a number of plan-ning activities to address those problems. This can yield improvement in the timeliness of care delivery. While these changes are not unique to lean or clinical pathways, they are triggered by these two approaches. The ability to sustain and continually improve performance depends on adapting the process improvement efforts to the specific con-text of application and on routines that support learning from daily practice. Conclusion: Practitioners, managers, and researchers should become aware of the spe-cific characteristics of their particular health care delivery systems when they develop, implement, and evaluate process improvements. Practices that foster learning from daily work, including data-driven improvement, timely feedback loops, and the in-volvement of managers in problem identification and problem solving may support adaptation and continual improvement

Team behaviors in emergency care: a qualitative study using behavior analysis of what makes team work

<p>Abstract</p> <p>Objective</p> <p>Teamwork has been suggested as a promising approach to improving care processes in emergency departments (ED). However, for teamwork to yield expected results, implementation must involve behavior changes. The aim of this study is to use behavior analysis to qualitatively examine how teamwork plays out in practice and to understand eventual discrepancies between planned and actual behaviors.</p> <p>Methods</p> <p>The study was set in a Swedish university hospital ED during the initial phase of implementation of teamwork. The intervention focused on changing the environment and redesigning the work process to enable teamwork. Each team was responsible for entire care episodes, i.e. from patient arrival to discharge from the ED. Data was collected through 3 days of observations structured around an observation scheme. Behavior analysis was used to pinpoint key teamwork behaviors for consistent implementation of teamwork and to analyze the contingencies that decreased or increased the likelihood of these behaviors.</p> <p>Results</p> <p>We found a great discrepancy between the planned and the observed teamwork processes. 60% of the 44 team patients observed were handled solely by the appointed team members. Only 36% of the observed patient care processes started according to the description in the planned teamwork process, that is, with taking patient history together. Beside this behavior, meeting in a defined team room and communicating with team members were shown to be essential for the consistent implementation of teamwork. Factors that decreased the likelihood of these key behaviors included waiting for other team members or having trouble locating each other. Getting work done without delay and having an overview of the patient care process increased team behaviors. Moreover, explicit instructions on when team members should interact and communicate increased adherence to the planned process.</p> <p>Conclusions</p> <p>This study illustrates how behavior analysis can be used to understand discrepancies between planned and observed behaviors. By examining the contextual conditions that may influence behaviors, improvements in implementation strategies can be suggested. Thereby, the adherence to a planned intervention can be improved, and/or revisions of the intervention be suggested.</p

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden

<p>Abstract</p> <p>Background</p> <p>There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.</p> <p>Methods</p> <p>We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.</p> <p>Results</p> <p>Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.</p> <p>Conclusions</p> <p>Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).</p

Lean on lean? Indagine sul perchè e come il lean management si sta diffondendo nelle aziende sanitarie italiane

Il capitolo propone uno studio empirico sullo sviluppo delle tecniche lean in sanit

Assessing the reliability and validity of the Danish version of Organizational Readiness for Implementing Change (ORIC)

Abstract Background Organizational change initiatives in health care frequently achieve only partial implementation success. Understanding an organizational readiness for change (ORC) may be a way to develop more effective and efficient change strategies. Denmark, like many countries, has begun a major system-wide structural reform which involves considerable changes in service delivery. Due to the lack of a validated Danish instrument, we aimed to translate and validate a Danish version of the Organizational Readiness for Implementing Change (ORIC) questionnaire. It measures if organizational members are confident in their collective commitment towards and ability (efficacy) to implement organizational change. ORIC is concise, grounded in theory, and designed, but not yet validated among employees in a real hospital setting. Methods The 12-item ORIC instrument was translated into Danish and back-translated to English. Employees (N = 284) at a hospital department facing a major organizational change in the Central Denmark Region completed the questionnaire. Face and content validity was ascertained. Exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) were used to assess construct validity. Reliability was assessed with Cronbach’s alpha. Item response theory (Rasch analysis) was used to determine item and person reliability. Results Response rate was 72%. A two factor (commitment and efficacy), 11-item scale, of the Danish language ORIC was shown to be valid (CFI = .95, RMSEA = .067, and CMNI/DF = 2.32) and reliable (Cronbach’s alpha 0.88) in a health care setting. Item response analysis confirmed acceptable person and item separation reliability. Conclusions Our version of ORIC showed acceptable validity and reliability as an instrument for measuring readiness for implementing organizational change in a Danish-speaking health care population. For health care managers interested in evaluating their organizations and tailor change strategies, ORIC’s brevity and theoretical underpinnings could make it an appealing and feasible tool to develop more successful change efforts

Data from: Staffs’ and managers’ perceptions of how and when discrete event simulation modeling can be used as a decision support in quality improvement: a focus group discussion study at two hospital settings in Sweden

Objective To explore healthcare staffs’ and managers’ perceptions of how and when discrete event simulation modeling can be used as a decision support in improvement efforts. Design Two focus group discussions were performed. Setting Two settings were included: a rheumatology department and an orthopedic section both situated in Sweden. Participants Healthcare staff and managers (n=13) from the two settings. Interventions Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modeling. Results from the respective simulation model were then presented and discussed in the following focus group discussion. Results Categories from the content analysis are presented according to the following research questions: how and when simulation modeling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modeling could act as a tool for support and a way to visualize problems, potential solutions and their effects. Regarding when, simulation modeling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in the improvement work. Conclusions Its potential as an information and communication tool and as an instrument for pedagogic work within healthcare improvement render a broader application and value of simulation modeling than previously reported

Staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in quality improvement : A focus group discussion study at two hospital settings in Sweden

Objective: To explore healthcare staffs' and managers' perceptions of how and when discrete event simulation modelling can be used as a decision support in improvement efforts. Design: Two focus group discussions were performed. Settings: Two settings were included: a rheumatology department and an orthopaedic section both situated in Sweden. Participants: Healthcare staff and managers (n=13) from the two settings. Interventions: Two workshops were performed, one at each setting. Workshops were initiated by a short introduction to simulation modelling. Results from the respective simulation model were then presented and discussed in the following focus group discussion. Results: Categories from the content analysis are presented according to the following research questions: how and when simulation modelling can assist healthcare improvement? Regarding how, the participants mentioned that simulation modelling could act as a tool for support and a way to visualise problems, potential solutions and their effects. Regarding when, simulation modelling could be used both locally and by management, as well as a pedagogical tool to develop and test innovative ideas and to involve everyone in improvement work. Conclusions: Its potential as an information and communication tool and as an instrument for pedagogic work with healthcare improvement render a broader application and value of simulation modelling than previously reported

Unpacking the key components of a programme to improve the timeliness of hip-fracture care : a mixed-methods case study

Background: Delay to surgery for patients with hip fracture is associated with higher incidence of post-operative complications, prolonged recovery and length of stay, and increased mortality. Therefore, many health care organisations launch improvement programmes to reduce the wait for surgery. The heterogeneous application of similar methods, and the multifaceted nature of the interventions, constrain the understanding of which method works, when, and how. In complex acute care settings, another concern is how changes for one patient group influence the care for other groups. We therefore set out to analyse how multiple components of hip-fracture improvement efforts aimed to reduce the time to surgery influenced that time both for hip-fracture patients and for other acute surgical orthopaedic inpatients. Methods: This study is an observational mixed-methods single case study of improvement efforts at a Swedish acute care hospital, which triangulates control chart analysis of process performance data over a five year period with interview, document, and non-participant observation data. Results: The improvement efforts led to an increase in the monthly percentage of hip-fracture patients operated within 24 h of admission from an average of 47 % to 83 %, with performance predictably ranging between 67 % and 98 % if the process continues unchanged. Meanwhile, no significant changes in lead time to surgery for other acute surgical orthopaedic inpatients were observed. Interview data indicated that multiple intervention components contributed to making the process more reliable. The triangulation of qualitative and quantitative data, however, indicated that key changes that improved performance were the creation of a process improvement team and having an experienced clinician coordinate demand and supply of surgical services daily and enhance pre-operative patient preparation. Conclusions: Timeliness of surgery for patients with hip fracture in a complex hospital setting can be substantially improved without displacing other patient groups, by involving staff in improvement efforts and actively managing acute surgical procedures