A. Trip

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures

AIMS AND OBJECTIVES The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway. METHODS A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS. RESULTS The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days. CONCLUSION The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.

Generic Project Definitions for Improvement of Health Care Delivery: A Case-Based Approach

Background: The purpose of this article is to create actionable knowledge, making the definition of process improvement projects in health care delivery more effective. Methods: This study is a retrospective analysis of process improvement projects in hospitals, facilitating a case-based reasoning approach to project definition. Data sources were project documentation and hospital-performance statistics of 271 Lean Six Sigma health care projects from 2002 to 2009 of general, teaching, and academic hospitals in the Netherlands and Belgium. Results: Objectives and operational definitions of improvement projects in the sample, analyzed and structured in a uniform format and terminology. Extraction of reusable elements of earlier project definitions, presented in the form of 9 templates called generic project definitions. These templates function as exemplars for future process improvement projects, making the selection, definition, and operationalization of similar projects more efficient. Each template includes an explicated rationale, an operationalization in the form of metrics, and a prototypical example. Thus, a process of incremental and sustained learning based on case-based reasoning is facilitated. Conclusions: The quality of project definitions is a crucial success factor in pursuits to improve health care delivery. We offer 9 tried and tested improvement themes related to patient safety, patient satisfaction, and business-economic performance of hospitals.

Impact of 5 years of Lean Six Sigma in a university medical center

Lean Six Sigma (LSS) is an originally industry-based methodology for cost reduction and quality improvement. In more recent years, LSS was introduced in health care as well. This article describes the experiences of the University Medical Center Groningen, the second largest hospital in the Netherlands, with LSS. It was introduced in 2007 to create the financial possibility to develop innovations. In this article, we describe how LSS was introduced, and how it developed in the following years. We zoom in at the traumatology department, where all main processes have been analyzed and improved. An evaluation after 5 years shows that LSS helped indeed reducing cost and improving quality. Moreover, it aided the transition of the organization from purely problem oriented to more process oriented, which in turn is helpful in eliminating waste and finding solutions for difficult problems. A major benefit of the program is that own employees are trained to become project leaders for improvement. Several people from the primary process were thus stimulated and equipped to become role models for continuous improvement.

Quality Quandaries∗: Efficiency Improvement in a Nursing Department

In recent years, some hospitals in The Netherlands have adopted Lean Six Sigma (LSS) for quality improvement, to deal with clinical and medical issues, and for business improvement in all areas of operation. Their success motivated the University Medica..

Pain and Anxiety During Bone Marrow Biopsy

A bone marrow biopsy is considered to be painful, often causing anxiety. We observed large differences between patients and wondered which factors cause pain and anxiety. In a prospective study, 202 patients were analyzed. Experienced hematologists and fellows in training (17% of biopsies) performed bone marrow aspirates and biopsies from the posterior iliac crest. Demographics, disease category, performance score, source of information, number of previous biopsies, experience of the hematologist, and length and quality of the biopsy were recorded. Pain and anxiety were measured using a visual analog scale and verbal rating score. Data were subjected to univariate and multivariate regression. The median pain score was 1.9 (range 0-10); 21% did not experience any pain. Anxiety scored 1.8 (range 0-10), and correlated positively with pain (p = .000). By univariate analysis, young age, poor performance, the physician as source of information, and prolonged procedures were associated with more pain. In multivariate analysis, anxiety, information from the physician, and a prolonged procedure persisted. Length or artifacts of the core biopsy did not correlate with pain. In conclusion, bone marrow biopsies performed in an optimal setting by experienced hematologists cause only mild pain, with, however, some patients experienced serious problems. To reduce pain, not only careful local anesthesia, but also the addition of systemic analgesics and especially anxiety reduction seems to be useful.

Handling multivariate problems with univariate control charts

Statistical process control (SPC) is an important ingredient of quality management. SPC has evolved from a technique to a philosophy, and now includes a large number of techniques and methods directed to quality control and quality improvement. Few processes can be controlled through only one parameter. Hence research into multivariate methods applied to SPC has been undertaken already long ago. Hotelling introduced in 1947 the T2 control chart as a technique for monitoring a multivariate process, and several authors have since elaborated on this. In essence the aim to approach the problem of SPC from a multivariate perspective is to make more efficient use of the data by incorporating the covariances in the model. However, multivariate methods have not gained much popularity. This is due to two important drawbacks: interpretation of out‐of‐control situations signalled by a multivariate chart is usually difficult and involves further statistical evaluation of the data; and estimation of the process‐inherent covariance matrix is sensitive to out‐of‐control conditions. This paper illustrates some important control chart methods for multivariate problems. A real‐world case is analysed by several authors in different ways. From this case and many others we conclude that it is often sufficient to use a few univariate control charts, even though the nature of the process is multivariate. The key argument for this conclusion is that direct interpretation on the shop floor is very important. A brief introduction to the implementation of SPC is given in this paper as well. Copyright

Quality Quandaries: Reducing Overuse of Diagnostic Tests for Trauma Patients

The University Medical Center Groningen in Denmark used lean Six Sigma to reduce the amount of redundant diagnostic tests administered and increase cost awareness among medical doctors.

Quality Quandaries: Precision and Accuracy of Ear Thermometry

The subject of this quandary is the analysis of measurement systems. Measurement systems are everywhere—we find them at home (bathroom scales, thermostats), in our cars (speedometers, check engine lights), in hospitals (heart rate monitors, blood pressu..

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures: Clinical pathway for hip fractures

AIMS AND OBJECTIVES The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway. METHODS A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS. RESULTS The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days. CONCLUSION The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life.