Jami L. DelliFraine

Assessing the evidence of Six Sigma and Lean in the health care industry.

Background Popular quality improvement tools such as Six Sigma and Lean Systems (SS/L) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether these 2 quality improvement tools actually improve health care quality. Methods The authors conducted a comprehensive literature review to assess the empirical evidence relating SS/L to improved clinical outcomes, processes of care, and financial performance of health care organizations. Results The authors identified 177 articles on SS/L published in the last 10 years. However, only 34 of them reported any outcomes of the SS/L projects studied, and less than one-third of these articles included statistical analyses to test for significant changes in outcomes. Conclusions This review demonstrates that there are significant gaps in the SS/L health care quality improvement literature and very weak evidence that SS/L improve health care quality.

Growth in percutaneous coronary intervention capacity relative to population and disease prevalence.

Background The access to and growth of percutaneous coronary intervention (PCI) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care. Methods and Results Geospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction (MI) prevalence at the state level. Longitudinal data were obtained for 2003–2011 from the American Hospital Association, the U.S. Census, and the Centers for Disease Control and Prevention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and MI prevalence rates have decreased from 4.0% to 3.7%. The most densely concentrated states have a ratio of 8.1 to 12.1 PCI facilities per million of population with significant variability in both MI prevalence and average distance between PCI facilities. Conclusions Over the last decade, the growth rate for PCI centers is 1.5× that of the population growth, while MI prevalence is decreasing. This has created geographic imbalances and access barriers with excess PCI centers relative to need in some regions and inadequate access in others.

The use of six sigma in health care management: are we using it to its full potential?

Popular quality improvement tools such as Six Sigma (SS) claim to provide health care managers the opportunity to improve health care quality on the basis of sound methodology and data. However, it is unclear whether this quality improvement tool is being used correctly and improves health care quality. The authors conducted a comprehensive literature review to assess the correct use and implementation of SS and the empirical evidence demonstrating the relationship between SS and improved quality of care in health care organizations. The authors identified 310 articles on SS published in the last 15 years. However, only 55 were empirical peer-reviewed articles, 16 of which reported the correct use of SS. Only 7 of these articles included statistical analyses to test for significant changes in quality of care, and only 16 calculated defects per million opportunities or sigma level. This review demonstrates that there are significant gaps in the Six Sigma health care quality improvement literature and very weak evidence that Six Sigma is being used correctly to improve health care quality.

Cost Comparison of Baby Friendly and Non–Baby Friendly Hospitals in the United States

OBJECTIVES: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Childrens Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non–baby-friendly hospitals. METHODS: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non–baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non–baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis–related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non–baby-friendly hospitals. RESULTS: Nursery plus labor-and-delivery costs for the baby-friendly sites were

Developing an ST-elevation myocardial infarction system of care in Dallas County

2205 per delivery, compared with

Emergency Medical Services as a Strategy for Improving ST-Elevation Myocardial Infarction System Treatment Times

2170 for the non–baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non–baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05). CONCLUSIONS: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non–baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.

Building the case for quality improvement in the health care industry: a focus on goals and training.

BACKGROUND The American Heart Association Caruth Initiative (AHACI) is a multiyear project to increase the speed of coronary reperfusion and create an integrated system of care for patients with ST-elevation myocardial infarction (STEMI) in Dallas County, TX. The purpose of this study was to determine if the AHACI improved key performance metrics, that is, door-to-balloon (D2B) and symptom-onset-to-balloon times, for nontransfer patients with STEMI. METHODS Hospital patient data were obtained through the National Cardiovascular Data Registry Action Registry-Get With The Guidelines, and prehospital data came from emergency medical services (EMS) agencies through their electronic Patient Care Record systems. Initial D2B and symptom-onset-to-balloon times for nontransfer primary percutaneous coronary intervention (PCI) STEMI care were explored using descriptive statistics, generalized linear models, and logistic regression. RESULTS Data were collected by 15 PCI-capable Dallas hospitals and 24 EMS agencies. In the first 18 months, there were 3,853 cases of myocardial infarction, of which 926 (24%) were nontransfer patients with STEMI undergoing primary PCI. D2B time decreased significantly (P < .001), from a median time of 74 to 64 minutes. Symptom-onset-to-balloon time decreased significantly (P < .001), from a median time of 195 to 162 minutes. CONCLUSION The AHACI has improved the system of STEMI care for one of the largest counties in the United States, and it demonstrates the benefits of integrating EMS and hospital data, implementing standardized training and protocols, and providing benchmarking data to hospitals and EMS agencies.

Improving Capacity Management in the Emergency Department: A Review of the Literature, 2000-2012

BACKGROUND Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. STUDY OBJECTIVE We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. METHODS We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics-hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. RESULTS We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). CONCLUSION Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

An institutional perspective on quality initiatives: evidence beyond manufacturing

Health care organizations are under intense pressure to improve the efficiency and effectiveness of care delivery and, increasingly, they are using quality improvement teams to identify and target projects to improve performance outcomes. This raises the question of what factors actually drive the performance of these projects in a health care environment. Using data from a survey of health care professionals acting as informants for 244 patient care, clinical-administrative, and nonclinical administrative quality improvement project types in 93 health care organizations, we focus on 2 factors—goal setting and quality training—as potential drivers of quality improvement project performance. We find that project-level goals and quality training have positive associations with process quality, while organizational-level goals have no impact. In addition, the relationship between project-level goals and process quality is stronger for patient care projects than for administrative projects. This indicates that the motivational and cognitive effects of goal setting are greater for projects that involve interactions with clinicians than for ones that involve interactions with other staff. Although project-level goal setting is beneficial for improving process quality overall, our findings suggest the importance of being especially attentive to goal setting for projects that impact direct patient care.

Barriers and Disparities in Emergency Medical Services 911 Calls for Stroke Symptoms in the United States Adult Population: 2009 BRFSS Survey

EXECUTIVE SUMMARY Capacity management (CM) is a critical component of maintaining and improving healthcare quality and patient safety. One particular area for concern has been the emergency department and the growing issues of patient overcrowding, boarding, and ambulance diversion, which can result in poor patient care and less efficient operations. This study provides a review of the current and most relevant academic literature on capacity management directly related to hospital emergency departments, identifies strengths and weaknesses of the approaches discussed in the literature, and provides practical recommendations for health services administrators implementing CM in their organizations. An extensive literature search was conducted using several search engines and scholarly databases. Articles were identified based on a combination of keywords and then were reviewed and selected for inclusion in the study in adherence to specified criteria. The CM literature includes a great divergence of themes, topics, and definitions. Twenty‐two articles were selected for their relevance to emergency department CM with a focus on operations management concepts. A categorization scheme was used, resulting in four thematic groups of articles: problems, solutions, outcomes, and metrics. Healthcare managers wishing to implement solutions to CM problems have a wide variety of operations literature to draw on that can address scheduling and patient throughput, but there are also a number of studies that consider electronic and technological solutions to CM problems. All of these solutions have the potential to positively influence the quality of patient care, including satisfaction.