Dirk F. de Korne

Diffusing Aviation Innovations in a Hospital in the Netherlands

BACKGROUND Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation. METHODS A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews. INNOVATIONS Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened. CONCLUSION A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety.

Evaluation of an international benchmarking initiative in nine eye hospitals.

Background: Benchmarking has become very popular among managers to improve quality in the private and public sector, but little is known about its applicability in international hospital settings. Purpose: The purpose of this study was to evaluate the applicability of an international benchmarking initiative in eye hospitals. Methodology: To assess the applicability, an evaluation frame was constructed on the basis of a systematic literature review. The frame was applied longitudinally to a case study of nine eye hospitals that used a set of performance indicators for benchmarking. Document analysis, nine questionnaires, and 26 semistructured interviews with stakeholders in each hospital were used for qualitative analysis. Findings: The evaluation frame consisted of four areas with key conditions for benchmarking: purposes of benchmarking, performance indicators, participating organizations, and performance management systems. This study showed that the international benchmarking between eye hospitals scarcely met these conditions. The used indicators were not incorporated in a performance management system in any of the hospitals. Despite the apparent homogeneity of the participants and the absence of competition, differences in ownership, governance structure, reimbursement, and market orientation made comparisons difficult. Benchmarking, however, stimulated learning and exchange of knowledge. It encouraged interaction and thereby learning on the tactical and operational levels, which is also an incentive to attract and motivate staff. Practice Implications: Although international hospital benchmarking seems to be a rational process of sharing performance data, this case study showed that it is highly dependent on social processes and a learning environment. It can be useful for diagnostics, helping local hospitals to catalyze performance improvements.

Safety by design: effects of operating room floor marking on the position of surgical devices to promote clean air flow compliance and minimise infection risks

Objective To evaluate the use of floor marking on the positioning of surgical devices within the clean air flow in an operating room (OR) to minimise infection risk. Laminar flow clean air systems are important in preventing infection in ORs but, for optimal results, surgical devices must be correctly positioned. Methods The authors evaluated floor marking in four ORs at an eye hospital using time series analysis. Through observations during 829 surgeries over a 20-month period, the positions of surgical devices were determined. Eight semistructured interviews with surgical staff were conducted to assess user experiences and team dynamics. Results Before marking, the instrument table was positioned completely within the laminar flow in only 6.1% of the cases. This increased to 36.1% and finally 53.8%. Mayo stands were increasingly positioned within the laminar flow: from 74.2% to 84.7%. The surgical lamp decreasingly obstructed flow: from 41.8% to 28.7%. At T3 (20 months), however, in 48.6% of the applicable cases the lamp was positioned in the flow again. Discussions and site visits between airside operators and surgical staff resulted in increasing awareness of specific risk areas in the OR. Conclusions OR floor markings facilitated and stimulated safety awareness and resulted in significantly increased compliance with the positioning of surgical devices in the clean air flow. Safety and quality approaches in hospital care, therefore, should include a human factors approach that focuses on system design in addition to teaching clinical and non-technical skills.

A RFID Specific Participatory Design Approach to Support Design and Implementation of Real-Time Location Systems in the Operating Room

Information technology, such as real-time location (RTL) systems using Radio Frequency IDentification (RFID) may contribute to overcome patient safety issues and high costs in healthcare. The aim of this work is to study if a RFID specific Participatory Design (PD) approach supports the design and the implementation of RTL systems in the Operating Room (OR). A RFID specific PD approach was used to design and implement two RFID based modules. The Device Module monitors the safety status of OR devices and the Patient Module tracks the patients’ locations during their hospital stay. The PD principles ‘multidisciplinary team’, ‘participation users (active involvement)’ and ‘early adopters’ were used to include users from the RFID company, the university and the hospital. The design and implementation process consisted of two ‘structured cycles’ (‘iterations’). The effectiveness of this approach was assessed by the acceptance in terms of level of use, continuity of the project and purchase. The Device Module included eight strategic and twelve tactical actions and the Patient Module included six strategic and twelve tactical actions. Both modules are now used on a daily basis and are purchased by the hospitals for continued use. The RFID specific PD approach was effective in guiding and supporting the design and implementation process of RFID technology in the OR. The multidisciplinary teams and their active participation provided insights in the social and the organizational context of the hospitals making it possible to better fit the technology to the hospitals’ (future) needs.

Hospital benchmarking: Are U.S. eye hospitals ready?

Background: Benchmarking is increasingly considered a useful management instrument to improve quality in health care, but little is known about its applicability in hospital settings. Purpose: The aims of this study were to assess the applicability of a benchmarking project in U.S. eye hospitals and compare the results with an international initiative. Methodology: We evaluated multiple cases by applying an evaluation frame abstracted from the literature to five U.S. eye hospitals that used a set of 10 indicators for efficiency benchmarking. Qualitative analysis entailed 46 semistructured face-to-face interviews with stakeholders, document analyses, and questionnaires. Findings: The case studies only partially met the conditions of the evaluation frame. Although learning and quality improvement were stated as overall purposes, the benchmarking initiative was at first focused on efficiency only. No ophthalmic outcomes were included, and clinicians were skeptical about their reporting relevance and disclosure. However, in contrast with earlier findings in international eye hospitals, all U.S. hospitals worked with internal indicators that were integrated in their performance management systems and supported benchmarking. Benchmarking can support performance management in individual hospitals. Having a certain number of comparable institutes provide similar services in a noncompetitive milieu seems to lay fertile ground for benchmarking. International benchmarking is useful only when these conditions are not met nationally. Practice Implications: Although the literature focuses on static conditions for effective benchmarking, our case studies show that it is a highly iterative and learning process. The journey of benchmarking seems to be more important than the destination. Improving patient value (health outcomes per unit of cost) requires, however, an integrative perspective where clinicians and administrators closely cooperate on both quality and efficiency issues. If these worlds do not share such a relationship, the added “public” value of benchmarking in health care is questionable.

Benchmarking operating room departments in the Netherlands: Evaluation of a benchmarking collaborative between eight university medical centres

Purpose – Benchmarking is increasingly considered a useful management instrument to improve performance in healthcare. The purpose of this paper is to assess if a nationwide long-term benchmarking collaborative between operating room (OR) departments of university medical centres in the Netherlands leads to benefits in OR management and to evaluate if the initiative meets the requirements of the 4P-model. Design/methodology/approach – The evaluation was based on the 4P-model (purposes, performance indicators, participating organisations, performance management system), developed in former studies. A mixed-methods design was applied, consisting of document study, observations, interviews as well as analysing OR performance data using SPSS statistics. Findings – Collaborative benchmarking has benefits different from mainly performance improvement and identification of performance gaps. It is interesting that, since 2004, the OR benchmarking initiative still endures after already existing for ten years. A ke...

Tracking surgical day care patients using RFID technology

Objective Measure wait times, characterise current information flow and define requirements for a technological information system that supports the patients journey. Design First, patients were observed during eight random weekdays and the durations of actions performed at each phase of the surgical trajectory were measured. Patients were grouped into patients receiving general anaesthesia or local (or topical) anaesthesia. Second (active) Radio Frequency IDentification (RFID) technology was installed and patients were tracked during 52 weekdays. Length of hospital stay, length of stay and wait times per phase, and differences in wait times between the two types of administered anaesthesia were analysed. Third, interviews were conducted to characterise the current information flow between staff, and between staff and escorts (patients’ family/friends escorting them throughout their journey). Results Observations (198 patients) showed that the average duration of actions for general anaesthesia patients took longer than for local anaesthesia patients, especially at the recovery phase (general anaesthesia: 0h16, local anaesthesia: 0h01). RFID tracking (622 patients): Significant differences were seen for wait times between general and local anaesthesia patients at: preoperative ward (p=0.014), recovery (p<0.001) and postoperative ward (p<0.001). The average percentage of wait time during the entire hospital stay ranged from 64% to 68% (with variation in groups being substantial). Interviews (30 escorts, 9 ward nurses and 8 holding/recovery nurses): Escorts did not use the current information system and ward nurses indicated problems with exchanging information concerning bringing/picking up patients to/from the holding/recovery that resulted in unnecessary wait times for some patients (mainly local anaesthesia patients). Conclusions Most time spent in hospital is wait time. A Patient Tracking System was designed to automatically display the phase in which a patient is in. It provides transparency for patients and staff in the surgical trajectory and is expected to reduce intermittent communication, improve patient flow, reduce wait times and improve patient and staff satisfaction.

Human Factors and Operating Room Design Challenges

Diffusing innovations from other industries have been suggested as a source to improve safety and quality of surgical patient care. Operating rooms are high-risk areas for preventable patient harm. Many studies focus on teaching, training, and changing staff behaviour as an approach to improvement. Most safety improvements in other high-risk industries, however, first focus on work area design before attempting to change behaviour. Design can purposefully shape behaviour towards more sustainable practices and improve teamwork dynamics and situational awareness. Human factor engineering, concerned with the understanding of interactions among humans and other elements of a system, can help in ‘mistake proofing’ by changing designs to make processes more reliable and effective. The field of design and human factor engineering can assist improving safety in the operating room. The application of these principles will be demonstrated in two case studies: Effects of operating floor marking on the position of surgical devices to promote clean air flow compliance and minimize infection risks, and use of video feedback and computer-assisted systems using video imaging technology to improve sensomotor and non-technical skills.

Effects of a portion design plate on food group guideline adherence among hospital staff

Food group guideline adherence is vital to prevent obesity and diabetes. Various studies have demonstrated that environmental variables influence food intake behaviour. In the present study we examined the effect of a portion design plate with food group portion guidelines demarcated by coloured lines (ETE Plate™). A two-group quasi-experimental design was used to measure proportions of carbohydrate, vegetable and protein portions and user experience in a hospital staff lounge setting in Singapore. Lunch was served on the portion design plate before 12.15 hours. For comparison, a normal plate (without markings) was used after 12.15 hours. Changes in proportions of food groups from 2 months before the introduction of the design plate were analysed in a stratified sample at baseline (859 subjects, all on normal plates) to 1, 3 and 6 months after (in all 1016 subjects on the design plate, 968 subjects on the control plate). A total of 151 participants were asked about their experiences and opinions. Between-group comparisons were performed using t tests. Among those served on the portion design plate at 6 months after its introduction, the proportion of vegetables was 4·71 % (P < 0·001) higher and that of carbohydrates 2·83 % (P < 0·001) lower relative to the baseline. No significant change was found for proteins (−1·85 %). Over 6 months, we observed different change patterns between the different food group proportions. While participants were positive about the portion design plate, they did not think it would influence their personal behaviour. A portion design plate might stimulate food group guideline adherence among hospital staff and beyond.

From Volume to Value: Prospects and Pitfalls in Organising Integrated Dry Eye Practice Units

With the advent of aging populations, chronic multifactorial diseases will dominate and strain existing models of health care. A model of healthcare delivery that emphasizes seamless, integrated, team-based care and remuneration for patient outcomes, have proven advantageous in diseases like diabetes mellitus, compared to systems based on isolated medical services. It is, however, unclear whether major chronic ophthalmic diseases including dry eye are also suitable for this model. Multiple co-morbidities such as depression, anxiety, postmenopausal mood swings, sleep disorders, and chronic neuropathic pain in dry eye greatly and unexpectedly increase its healthcare burden, and also produce high levels of patient and physician frustration. Many patients benefit from counseling, social support, and psychological management, but are frustrated by multiple referrals and inefficiency in care coordination. With the new model, patients may have a seamless transition between care settings, better experience and improved outcomes, and likely attain added value per unit cost.