I.M.B. Bongers

Application of lean thinking to health care: issues and observations

Background Incidents and quality problems are a prime cause why health care leaders are calling to redesign health care delivery. One of the concepts used is lean thinking. Yet, lean often leads to resistance. Also, there is a lack of high quality evidence supporting lean premises. In this paper, we present an overview of lean thinking and its application to health care. Development, theory and application of lean thinking to health care Lean thinking evolved from a tool designed to improve operational shop-floor performance at an automotive manufacturer to a management approach with both operational and sociotechnical aspects. Sociotechnical dynamics have until recently not received much attention. At the same time a balanced approach might lead to a situation where operational and sociotechnial improvements are mutually reinforcing. Application to health care has been limited and focussed mainly on operational aspects using original lean tools. A more integrative approach would be to pay more attention to sociotechnical dynamics of lean implementation efforts. Also, the need to use the original lean tools may be limited, because health care may have different instruments and tools already in use that are in line with lean thinking principles. Discussion We believe lean thinking has the potential to improve health care delivery. At the same time, there are methodological and practical considerations that need to be taken into account. Otherwise, lean implementation will be superficial and fail, adding to existing resistance and making it more difficult to improve health care in the long term.

A scenario analysis of the future residential requirements for people with mental health problems in Eindhoven

BackgroundDespite large-scale investments in mental health care in the community since the 1990 s, a trend towards reinstitutionalization has been visible since 2002. Since many mental health care providers regard this as an undesirable trend, the question arises: In the coming 5 years, what types of residence should be organized for people with mental health problems? The purpose of this article is to provide mental health care providers, public housing corporations, and local government with guidelines for planning organizational strategy concerning types of residence for people with mental health problems.MethodsA scenario analysis was performed in four steps: 1) an exploration of the external environment; 2) the identification of key uncertainties; 3) the development of scenarios; 4) the translation of scenarios into guidelines for planning organizational strategy. To explore the external environment a document study was performed, and 15 semi-structured interviews were conducted. During a workshop, a panel of experts identified two key uncertainties in the external environment, and formulated four scenarios.ResultsThe study resulted in four scenarios: 1) Integrated and independent living in the community with professional care; 2) Responsible healthcare supported by society; 3) Differentiated provision within the walls of the institution; 4) Residence in large-scale institutions but unmet need for care. From the range of aspects within the different scenarios, the panel was able to work out concrete guidelines for planning organizational strategy.ConclusionsIn the context of residence for people with mental health problems, the focus should be on investment in community care and their re-integration into society. A joint effort is needed to achieve this goal. This study shows that scenario analysis leads to useful guidelines for planning organizational strategy in mental health care.

The Impact of Smoking and Drinking on Plasma Levels of Norharman

The hypothesized role of the beta-carboline norharman in processes of drug dependence forms the basis for several studies on plasma levels of norharman among substance-using populations, particularly among alcoholics and smokers. However, it is not clear whether norharman is implicated in processes of dependence to both substances, or only to tobacco smoke. In the present study plasma concentrations of norharman were measured among four groups of participants regarding heavy smokers who do or do not drink alcohol excessively and nonsmokers who do or do not drink alcohol excessively. All measurements were conducted on three different days with an interval of 2 months in between and at three times during the day to account for possible circadian or seasonal variations. Results showed that elevated plasma levels of norharman appear only in heavy smokers regardless of their drinking profile. The norharman plasma levels of nonsmoking excessive drinkers showed a similar pattern to that of the control group. The findings indicate that elevated plasma levels of norharman are due to heavy smoking and not to excessive drinking.

Ranked motives of long‐term care providing family caregivers

Family caregivers provide long-term care to their chronically ill loved ones and as a consequence they experience physical, relational and financial problems. This study investigates how long-term family caregivers rank 12 motives for caregiving. Motives are derived from the views of four philosophical anthropologists and are related to self-reported stress and joy and to several different background characteristics of respondents. Motives that focus on feelings concerning the relationship between caregiver and care recipient are more popular as a first choice than motives stemming from feelings of obligation or a general feeling of happiness and are also more popular than more self-directed motives. An analysis of full ranking data shows that two groups can be distinguished, one group of family caregivers with mixed motives and one group of family caregivers with motives that focus on reciprocal mutually equal relationships. The latter are mainly women taking care for a partner or a child, the former report high levels of stress. Implications for intervention programmes and health policy are being discussed.

Effectiveness of an Outreach Treatment Program for Inner City Crack Abusers: Compliance, Outcome, and Client Satisfaction

In a randomized controlled trial the effectiveness of an outreach treatment program (OTP) was compared with standard addiction care services for hard-drug addicts in Rotterdam (The Netherlands). The study aimed at chronic, high-risk crack abusers who were insufficiently engaged in standard addiction treatment services. Data were collected from February 2000 to December 2001. A total of 124 subjects participated in the study at baseline. Follow-up data were available for 94 subjects. Outcome measures included treatment compliance, outcome, and satisfaction. Data were collected by means of monthly registrations, EuropAsi interviews and an evaluation form. There was a high compliance with OTP in the treatment group; the average length-of-stay was 6 months, with visits three times a week. Although both groups were well represented in standard care, participation was mainly based on methadone maintenance. Subjects treated in OTP showed significant improvements in physical health, general living conditions, and psychiatric status, but no change in employment, substance abuse, and legal status. The control group remained almost unchanged. Clients of OTP reported feeling very satisfied with their treatment. On-the-spot incentives and a positive relationship with the care provider were directly associated with treatment retention. An outreach treatment program, as conducted in this study, is associated with high compliance, general improvement, and treatment satisfaction. Characteristics of this treatment modality are (1) assertive outreach, (2) a mixed program with incentives, and (3) a strong focus on individual-bound therapy. Further research is needed with larger groups and similar conditions at baseline assessment.

Bridging the Gap between Science and Practice: Do Applied Academic Centres Contribute to a Solution? A Plea for International Comparative Research

This article refers to the worldwide gap between research and practice. The use of so-called applied academic centres as a possible way to bridge this gap is proposed. Within academic centres, the university, on the one hand, and treatment and (public) health and social welfare services, on the other, together invest in a long-term partnership. A long-term research program and a knowledge-exchange structure are developed. The authors have established these kinds of centres in different fields such as, among others, the field of public health, the field of mental health and the field of social welfare. These centres may differ in important characteristics including the number of organisations involved and the form in which the collaboration is organised. These differences make valuable comparisons possible. A plea is made for further research towards the usefulness of applied academic health centres in promoting evidence-based work within treatment and public health and social work services.

Gender differences in problems and needs among chronic, high‐risk crack abusers: Results of a randomized controlled trial

Objective: Aims of the study were to assess, among clients receiving an outpatient treatment program (OTP), whether female crack abusers have more severe problems and/or different service needs than men. Methods: A total of 63 chronic crack abusers (34 women) participated in the study at baseline. Follow‐up data were available for 33 subjects (21 women). Outcome measures included general condition at intake, and treatment compliance, outcome and satisfaction. Data were collected by means of monthly registrations, EuropAsi interviews and an evaluation form. OTP consisted of assertive outreach, a time‐out provision, and intensive case management. Results: The vast majority of women were involved in street prostitution and were extremely vulnerable to deterioration. Compared to men, women who entered treatment had poorer physical health, higher rates of previous physical/sexual abuse, and more anxiety symptoms. Women reported a longer episode of cocaine abstinence than men. At discharge from OTP men reported a significantly better treatment outcome than women. Both genders gained most improvement in general living conditions. No gender differences emerged in treatment compliance. Although both men and women were satisfied with the service items offered by OTP, an outpatient walk‐in service best served the needs of men, whereas women preferred a 24‐hour care service including medical treatment and motivational outreach. Conclusions: Due to the harshness of street prostitution, treatment for female crack abusers should address areas of severe impairment. Integrated treatment services, tailored to the lifestyle of these women, are required to improve their general situation and safety.

Can mobile skin conductance assessments be helpful in signalling imminent inpatient aggression

Background: A well-known technique to assess (psychological) arousal is to measure the skin conductance level (SCL). Although widely used in experimental psychological research, this technique has not been used often in (locked) psychiatric admission settings on patients who are at a high risk of engaging in aggressive behaviour. One of the obvious reasons for this is that measuring skin conductance, until recently, required a substantial amount of equipment. Methods: As technology developed, it became possible to develop small wearable devices in the form of regular watches to measure the SCL as well as other psycho-physiological parameters. To illustrate the potential this may have for the prevention of aggressive behaviour, a case description is provided of a patient in crisis who became physically aggressive while wearing a skin conductance measurement device. Results: Interestingly, the SCL of the patient had been rising sharply before the first signs of aggressive behaviour were visible. Conclusion: Although it concerns an anecdotal case study, this finding suggests that measuring SCL on a continuous basis in patients who are at a high risk of becoming violent, without this procedure having to interfere with their daily life, may open new avenues for preventing aggression at an earlier stage. A large-scale empirical study in a substantial number of (potentially aggressive) patients is needed, however, to investigate the predictive validity of mobile skin conductance assessments on imminent inpatient aggression in a reliable way.

Project Aanpassing landelijke informatieproducten (ALI): consequenties voor de GGZ-instellingen

SamenvattingDe brancheorganisatie GGZ Nederland heeft per 2007 afscheid genomen van de GGZ zorggegevensset en het Zorgis informatiesysteem, waarmee prestaties van GGZ- en verslavingszorg instellingen gepresenteerd en vergeleken werden. Met het project Aanpassing Landelijke Informatieproducten (ALI) wordt beoogd de informatievoorziening te verbeteren, zonder extra administratieve lasten voor de instellingen.

Literature study from a social ecological perspective on how to create flexibility in healthcare organisations

Abstract Aim: To examine (1) how flexibility is defined and described in healthcare literature and (2) which interventions are used at what organisational level to influence flexibility. Background: Flexibility is necessary in healthcare for continuous adaptation to the dynamic environment. In accordance with Social Ecological Theory, it takes the combination of all organisational levels to achieve flexibility (individual, interpersonal, organisational, community, and macro-policy). However, managing this is complex. Evaluation: Using Psychinfo and Web of Science, a systematic search was performed on flexibility in health care organisations. The 19 studies that met the selection criteria were analysed from a social ecological perspective. Eight publications described flexibility as a result of interventions, but provided little information about their evidence base. Key issues: It is difficult to achieve flexibility: a pro-active attitude and capability to adapt internal processes to the changing environment. Interventions promoting flexibility in healthcare need all organisational levels, since they mutually influence each other. Conclusion: This study shows that there is too little evidence on how to create flexibility in healthcare organisations. Implications for management: Change in healthcare is continuous. Therefore, flexibility should be a permanent pro-active attitude of both managers and professionals and should take all organisational levels into account.