Rachel Flynn

Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol).

BackgroundLean is a set of operating philosophies and methods that help create a maximum value for patients by reducing waste and waits. It emphasizes the consideration of the customer’s needs, employee involvement and continuous improvement. Research on the application and implementation of lean principles in health care has been limited.MethodsThis is a protocol for a systematic review, following the Cochrane Effective Practice and Organisation of Care (EPOC) methodology. The review aims to document, catalogue and synthesize the existing literature on the effects of lean implementation in health care settings especially the potential effects on professional practice and health care outcomes. We have developed a Medline keyword search strategy, and this focused strategy will be translated into other databases. All search strategies will be provided in the review. The method proposed by the Cochrane EPOC group regarding randomized study designs, non-randomised controlled trials controlled before and after studies and interrupted time series will be followed. In addition, we will also include cohort, case–control studies, and relevant non-comparative publications such as case reports. We will categorize and analyse the review findings according to the study design employed, the study quality (low- versus high-quality studies) and the reported types of implementation in the primary studies. We will present the results of studies in a tabular form.DiscussionOverall, the systematic review aims to identify, assess and synthesize the evidence to underpin the implementation of lean activities in health care settings as defined in this protocol. As a result, the review will provide an evidence base for the effectiveness of lean and implementation methodologies reported in health care.Systematic review registrationPROSPERO CRD42014008853

The potential for nurses to contribute to and lead improvement science in health care

AIM A discussion of how nurses can contribute to and lead improvement science activities in health care. BACKGROUND Quality failures in health care have led to the urgent need for healthcare quality improvement. However, commonly quality improvement interventions proceed to practice implementation without rigorous methods or sufficient empirical evidence. This lack of evidence for quality improvement has led to the development of improvement science, which embodies quality improvement research and quality improvement practice. This paper discusses how the discipline of nursing and the nursing profession possesses many strengths that enable nurses to lead and to play an integral role in improvement science activities. However, we also discuss that there are insufficiencies in nursing education that require attention for nurses to truly contribute to and lead improvement science in health care. DESIGN Discussion paper. DATA SOURCES This paper builds on a collection of our previous work, a 12-month scoping review (March 2013-March 2014), baseline study on a quality improvement management system (Lean), interviews with nurses on quality improvement implementation and supporting literature. IMPLICATIONS FOR NURSING This paper highlights how nurses have the philosophical, theoretical, political and ethical positioning to contribute to and lead improvement science activities. However up to now, the potential for nurses to lead improvement science activities has not been fully used. CONCLUSION We suggest that one starting point is to include improvement science in nursing education curricula. Specifically, there needs to be increased focus on the nursing roles and skills needed to contribute to and lead healthcare improvement science activities.

Lean management in health care: effects on patient outcomes, professional practice, and healthcare systems

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess effects of Lean management in health care on patient, professional, and systems outcomes by addressing the following question. What are the effects of Lean management interventions in health care on patient outcomes, professional practice, and healthcare systems? To answer the following questions in addressing secondary objectives: What are the effects of Lean management interventions in combination with other management systems (e.g. Six Sigma) on patient outcomes, professional practice, and healthcare systems (utilisation and access, adverse effects, cost)? Is the effectiveness of Lean interventions influenced by the setting (e.g. Emergency Department, Laboratory, Pharmacy) in which they are implemented?

An evaluation of a frontline led quality improvement initiative.

Purpose The Edmonton Zone, one of five Zones in Alberta Health Services (the health system in the province of Alberta, Canada), established a quality management framework (QMF) as a means to improve the delivery of high quality health care in the spring of 2014. The purpose of this research study was to understand the factors that facilitated or hindered the implementation of a quality improvement (QI) initiative for hand hygiene led by a newly formed frontline unit quality council (UQC), a part of the QMF, based out of the pediatric intensive care unit (PICU) at the Stollery Childrens Hospital in the Edmonton Zone. This research will provide an understanding of the newly established QMF in the Edmonton Zone and the factors needed to foster the ongoing development of frontline UQC that do improvement work as part of their daily routine. Design/methodology/approach Using a qualitative case study research design data were collected using semi-structured open-ended interviews with six key stakeholders (one registered nurse, one physician, one patient case manager, medical director for QI, clinical QI consultant and director of clinical QI) involved in UQC at the PICU. Findings Individual, unit and organizational level factors were identified as influencing the function of the UQC. Leadership and work culture were the key facilitating factors to success and lack of QI training and personnel/dedicated time were perceived barriers to completing the QI initiative. Originality/value The findings from this research illustrate that frontline UQC are able to impact positive sustained change early in their establishment as part of a larger QMF. It is important, however, for the system to foster ongoing development of capacity and capability of these frontline UQC to ensure sustained success of the larger systems change.

Heart failure with preserved ejection fraction: health services implications of a stealth syndrome

Heart failure (HF) is burdensome. What is recognized far less is that HF with preserved ejection fraction (HFPEF) is even more disruptive and justifies urgent attention to understand and improve outcomes. Why? Firstly, HFPEF is the fastest growing form of HF in high-income countries.1 For example, in the United States nearly 50% of current HF patients have HFPEF.1 Originally termed diastolic heart failure, these patients have a divergent left ventricular remodelling pattern (e.g. via increased wall thickness and concomitant decreased cavity size) compared with HF patients with reduced ejection fraction (HFREF). This results in wider variations in outcomes in HFPEF patients around exercise intolerance, morbidity and mortality.2,3 Compounding these variations, while medicines continue to improve the life expectancy and quality in patients with HFREF, such therapies do not usually have the same benefits for patients with HFPEF.2 As these patients also tend to be older women with hypertension and obesity,2 to reduce the future burden of HF and improve the prospects of the sizable population with HF, better understanding and treatment of HFPEF are now urgent priorities. Yet, surprisingly basic gaps still exist in addressing HFPEF and improving outcomes. Most clinical guidelines and research studies remain focused predominantly on patients with HFREF and/or do not differentiate between patients with HFPEF and HFREF.2 Uncertainty remains regarding what constitutes a ‘normal’ ejection fraction. HFPEF raises a number of complex challenges for nursing and health services research. Ongoing uncertainty over whether HFPEF worsens prognosis, exercise capacity and life quality creates the possibility that HFPEF is a common, but usually hidden, confounding factor in pharmacological and non-pharmacological trials. This has particularly troublesome consequences because HFPEF is more common in older adults and women – the two main populations which will contribute most to the burden of heart disease in coming decades.4 Patients with HFPEF are also likely to have more co-morbidities and, thus, arguably be in greater need of beneficial and efficient therapies and health services. Yet, these patient groups also tend to be excluded from or are less likely to participate in trials.2 Ensuring that study populations contain representative populations remains a challenging but important aim to support generalizability of results to vulnerable clinical populations. Trials, especially those examining the influence of exercise, should also include mechanistic measures of heart function2 to ensure that intervention effects are not only measured but also understood. Unless study populations are adequately described and the presence of HFPEF determined, variations in outcomes may not result from chance or any intervention being evaluated but from the prevalence of HFPEF in the population being studied. As is well established in evidence-based practice: populations, the nature of interventions and comparisons, and what outcomes are studied influence the effects of interventions. However, HFPEF is difficult to diagnose, systolic and diastolic dysfunction can co-exist in the same patients and some patients with HFPEF may not even be characterized as having HF. While non-pharmacological interventions to promote HF self-care are often poorly described in studies and meta-analyses,3,5 this suggests that the characteristics of the populations in studies are also an important but potentially neglected facet.

Two Approaches to Focus Group Data Collection for Qualitative Health Research: Maximizing Resources and Data Quality

This article discusses four challenges to conducting qualitative focus groups: (1) maximizing research budgets through innovative methodological approaches, (2) recruiting health-care professionals for qualitative health research, (3) conducting focus groups with health-care professionals across geographically dispersed areas, and (4) taking into consideration data richness when using different focus group data collection methods. In light of these challenges, we propose two alternative approaches for collecting focus group data: (a) extended period of quantitative data collection that facilitated relationship building in the sites prior to qualitative focus groups and (b) focus groups by videoconference. We share our experiences on employing both of these approaches in two national research programs.

What Is Lean management in health care? development of an operational definition for a Cochrane Systematic Review

Industrial improvement approaches such as Lean management are increasingly being adopted in health care. Synthesis is necessary to ensure these approaches are evidence based and requires operationalization of concepts to ensure all relevant studies are included. This article outlines the process utilized to develop an operational definition of Lean in health care. The literature search, screening, data extraction, and data synthesis processes followed the recommendations outlined by the Cochrane Collaboration. Development of the operational definition utilized the methods prescribed by Kinsman et al. and Wieland et al. This involved extracting characteristics of Lean, synthesizing similar components to establish an operational definition, applying this definition, and updating the definition to address shortcomings. We identified two defining characteristics of Lean health-care management: (1) Lean philosophy, consisting of Lean principles and continuous improvement, and (2) Lean activities, which include Lean assessment activities and Lean improvement activities. The resulting operational definition requires that an organization or subunit of an organization had integrated Lean philosophy into the organization’s mandate, guidelines, or policies and utilized at least one Lean assessment activity or Lean improvement activity. This operational definition of Lean management in health care will act as an objective screening criterion for our systematic review. To our knowledge, this is the first evidence-based operational definition of Lean management in health care.