Carl Savage

Lean thinking in healthcare: a realist review of the literature

Objective To understand how lean thinking has been put into practice in healthcare and how it has worked. Design A realist literature review. Data sources The authors systematically searched for articles in PubMed, Web of Science and Business Source Premier (January 1998 to February 2008) and then added articles through a snowball approach. Review methods The authors included empirical studies of lean thinking applications in healthcare and excluded those articles that did not influence patient care, or reported hybrid approaches. The authors conducted a thematic analysis based on data collected using an original abstraction form. Based on this, they articulated interactions between context, lean interventions, mechanisms and outcomes. Results The authors reviewed 33 articles and found a wide range of lean applications. The articles describe initial implementation stages and emphasise technical aspects. All articles report positive results. The authors found common contextual aspects which interact with different components of the lean interventions and trigger four different change mechanisms: understand processes to generate shared understanding; organise and design for effectiveness and efficiency; improve error detection to increase awareness and process reliability; and collaborate to systematically solve problems to enhance continual improvement. Conclusions Lean thinking has been applied successfully in a wide variety of healthcare settings. While lean theory emphasises a holistic view, most cases report narrower technical applications with limited organisational reach. To better realise the potential benefits, healthcare organisations need to directly involve senior management, work across functional divides, pursue value creation for patients and other customers, and nurture a long-term view of continual improvement.

Pseudo-understanding: an analysis of the dilution of value in healthcare

Background Management concepts cycle through healthcare in trends lasting 3–5 years. This may hinder policy-makers, healthcare managers, researchers and clinicians from grasping the intricacies of a management concept and prevent organisations from realising the potential of these concepts. We, therefore, sought to characterise how the newest management concept, value-based healthcare (VBHC), is used and understood in the scientific literature. Methods We developed a novel five-step approach: (1) identification of a trend-starting article, (2) identification of key conceptual aspects in the trend-starting article, (3) collection of citing articles and identification of citing text, (4) categorisation of citing text to evaluate which aspects were used and (5) categorisation of citing text according to the structure of observed learning outcomes (SOLO) taxonomy to evaluate understanding. Results We identified four aspects in the trend-starting article, ‘What is value in healthcare’, of which value and outcomes were the most cited. More than one-quarter of the citing texts demonstrated no understanding of the aspect referred to; most demonstrated a superficial understanding. Level of understanding was inversely related to journal impact factor (IF), and did not change significantly over time. A deeper understanding was demonstrated in those articles that repeatedly cited the trend-starting article. Conclusions None of the four aspects were understood at a level required to develop the management concept of VBHC. VBHC may be undergoing a process of dilution rather than diffusion. To break the cycle of management trends, we encourage a deeper reflective process about the translation of management concepts in healthcare.

Time-driven activity-based costing in health care: A systematic review of the literature

Health care organizations around the world are investing heavily in value-based health care (VBHC), and time-driven activity-based costing (TDABC) has been suggested as the cost-component of VBHC capable of addressing costing challenges. The aim of this study is to explore why TDABC has been applied in health care, how its application reflects a seven-step method developed specifically for VBHC, and implications for the future use of TDABC. This is a systematic review following the PRISMA statement. Qualitative methods were employed to analyze data through content analyses. TDABC is applicable in health care and can help to efficiently cost processes, and thereby overcome a key challenge associated with current cost-accounting methods The methods ability to inform bundled payment reimbursement systems and to coordinate delivery across the care continuum remains to be demonstrated in the published literature, and the role of TDABC in this cost-accounting landscape is still developing. TDABC should be gradually incorporated into functional systems, while following and building upon the recommendations outlined in this review. In this way, TDABC will be better positioned to accurately capture the cost of care delivery for conditions and to control cost in the effort to create value in health care.

Teaching group dynamics - do we know what we are doing?: An approach to evaluation

Background: Research into the efficacy of programs of leadership and group dynamics in undergraduate medical education is sparse. Aims: The aim of this study was to apply and test a pre- post evaluation design of a one-week experiential learning based course of group dynamics. Methods: Two questionnaires were sent to 160 medical students, before and after the course. The response rate was acceptable (73%). Results: While there was a small change in attitudes towards openness in their professional role and group dynamics, there was a major change in two subgroups of students to these topics. The students who were least interested in collaborative constructivist learning and those students who mainly looked for practical value were the students who changed their attitudes most towards openness in their professional role. Conclusions: It appears that those students who would be least likely to voluntarily attend such a course were the ones who learned the most. This study does not allow for any generalizations regarding the outcome of experiential learning of group dynamics, but it is an argument for the use of systematic evaluations in order to identify students who can benefit from courses aimed at improving profound knowledge.

HIV and tuberculosis coinfection: a qualitative study of treatment challenges faced by care providers.

SETTING Infectious Diseases Department, Karolinska University Hospital, Stockholm, Sweden. OBJECTIVE To understand the challenges faced by nurses and physicians in the treatment of patients co-infected with the human immunodeficiency virus (HIV) and tuberculosis (TB), with special focus on opportunities for information and communication technology. DESIGN Using a qualitative study design, on-site observations and informal discussions were carried out to become acquainted with the clinical context. Seven nurses and six physicians were purposefully selected to participate in one-to-one in-depth interviews inspired by cognitive task analysis. Interviews were audio recorded and transcribed verbatim, and analysed using inductive thematic analysis. RESULTS Care providers faced challenges related to 1) the complexities inherent to TB-HIV co-treatment, 2) clinical knowledge and task standardisation, 3) care coordination and collaboration, 4) information management, and 5) engaging patients in their treatment. CONCLUSION Support is needed on several levels to address the emerging burden of TB-HIV coinfection in Sweden. Educational material and tools need to be further developed to support care providers in making decisions about adequate care, and to support collaborative activities and communication among patients and care providers. Information and communication technology based solutions may provide an opportunity to address some of these challenges.

Does an outcome-based approach to continuing medical education improve physicians' competences in rational prescribing?

Background: Continuing medical education (CME) is compulsory in Iran, and traditionally it is lecture-based, which is mostly not successful. Outcome-based education has been proposed for CME programs. Aim: To evaluate the effectiveness of an outcome-based educational intervention with a new approach based on outcomes and aligned teaching methods, on knowledge and skills of general physicians (GPs) working in primary care compared with a concurrent CME program in the field of “Rational prescribing”. Method: The method used was cluster randomized controlled design. All GPs working in six cities in one province in Iran were invited to participate. The cities were matched and randomly divided into an intervention arm for education on rational prescribing with an outcome-based approach, and a control arm for a traditional program on the same topic. Knowledge and skills were assessed using a pre- and post-test, including case scenarios. Results: In total, 112 GPs participated. There were significant improvements in knowledge and prescribing skills after the training in the intervention arm as well as in comparison with the changes in the control arm. The overall intervention effect was 26 percentage units. Conclusion: The introduction of an outcome-based approach in CME appears to be effective when creating programs to improve GPs’ knowledge and skills.

Does lean muddy the quality improvement waters? A qualitative study of how a hospital management team understands lean in the context of quality improvement

BackgroundHealth care has experimented with many different quality improvement (QI) approaches with greater variation in name than content. This has been dubbed pseudoinnovation. However, it could also be that the subtleties and differences are not clearly understood. To explore this further, the purpose of this study was to explore how hospital managers perceive lean in the context of QI.MethodsWe used a qualitative study design with semi-structured interviews to explore twelve top managers’ perceptions of the relationship between lean and quality improvement (QI) at a university-affiliated hospital.ResultsManagers described that QI and lean shared the same overall purpose: focus on patient needs and improve efficiency and effectiveness. Employee involvement was emphasized in both strategies, as well as the support offered by managers of staff initiatives. QI was perceived as a strategy that could support structural changes at the organizational level whereas lean was seen as applicable at the operational level. Moreover, lean carried a negative connotation, lacked the credibility of QI, and was perceived as a management fad.ConclusionsAspects of QI and lean were misunderstood. In a context where lean remains an abstract term, and staff associate lean with automotive applications and cost reduction, it may be fruitful for managers to invest time and resources to develop a strategy for continual improvement and utilize vocabulary that resonates with health care staff. This could reduce the risk that improvement efforts are rejected out of hand.

Surviving multiple obligations through stimulation, autonomy, and variation

PURPOSE Professionals in academic health centers (AMCs) face multiple obligations, such as those from research, teaching and clinical care. The purpose of this study is to explore and develop an understanding about how well findings generated from two previous studies about the influence of multiple obligations on health care personnel fit those within health care associated with academic institutions. DESIGN/METHODOLOGY/APPROACH A total of 11 professionals engaged in teaching, research, and clinical work were interviewed. Data from the open-ended interactive interviews were transcribed and compared with findings from the two previous studies, using modified analytic induction. FINDINGS Work at an AMC can entail balancing three tasks: research, education, and clinical care. These tasks as well as the different employers associated with them can be a source of conflict. For a group of committed professionals, these conflicts were accepted and balanced as long as they experienced stimulus, autonomy, and variation. RESEARCH LIMITATIONS/IMPLICATIONS Modified analytic induction, an uncommon analysis method, is useful for comparing findings from previous studies in another context and with different subjects. PRACTICAL IMPLICATIONS Stimulation, autonomy, and variation could play a vital role as driving factors in coping and dealing with the unavoidable presence of multiple obligations in todays health care systems. ORIGINALITY/VALUE Although AMCs combine clinical care, research, and teaching, the intersection of all three has in contrast not been investigated so thoroughly at the individual level.

Innovation in medical education: how Linköping created a Blue Ocean for medical education in Sweden

Background: The Linköping Health University is an example of a medical school which has succeeded, not only with a major curricular change, transforming itself into a problem-based learning school, but also in contributing to innovations in medical education. Aims: To analyse the Linköping example in order to better understand how to succeed with innovations in medical education. Method: By applying a framework developed within the strategic management literature to the case study, the authors hope to understand how this innovation was achieved. Results: Linköping Health University was able to break boundaries and create a divergent profile through eliminating, reducing, raising, and creating different aspects of the curricula. Conclusions: A strategic management framework can be applied to medical education to better understand innovation. The authors discover that many of the later innovations were in fact more aimed at sustaining the initial innovation rather than creating new trends. It remains unclear from the case study how to stimulate innovation without the use of fear or threats.

Structuring a research infrastructure: A study of the rise and fall of a large-scale distributed biobank facility

This study analyses the perceived key interests, importance, influences and participation of different actors in harmonizing the processes and mechanisms of a distributed research infrastructure. It investigates the EU-funded initiative, BioBanking and Molecular Resource Infrastructure in Sweden (BBMRI.se), which seeks to harmonize the biobanking standards. The study interviews multiple actors involved throughout the development process. Their responses are analysed via a framework based on the IIED Stakeholder Power Analysis Tool. The BBMRI.se formation was facilitated by two parallel processes, with domestic and European/foreign origin, with leading scientists becoming ‘National Champions’. The respondents joined the organization under the premise that it would be a collaborative endeavour, but they were disappointed to learn the deliberative elements were more prevalent. In conclusion, the resulting autonomous structure caused disarray, while also fuelling interpersonal differences, ultimately leading to the closure of the infrastructure. Hence, it is necessary to clearly identify potential collaborative and deliberative elements already at the outset while also securing wider forms of communication between the participating actors, when establishing distributed research infrastructures. Moreover, while prior literature suggests that research infrastructures counteracts fragmentation, these results illustrate that this is not the case for this distributed research infrastructure.