Starting continuous improvement; creating a common understanding of stroke care delivery in a general hospital.

BACKGROUND: Continuous improvement is based on fostering practitioners' suggestions to modify their own work processes This improvement strategy is widely applied in healthcare but difficult to maintain. The cross-disciplinary nature of many care processes constitutes an extra impediment. METHODS: The study had an explorative design with a qualitative single-case approach. The case presents a project to improve the treatment of patients with thrombotic stroke. Data was obtained via hands on involvement, documents, observations, and interviews with participants in a cross-functional improvement group. A thematic analysis method was employed. RESULTS: Through learning how tasks were carried out in other disciplines, the participants developed a common understanding of why it took so long to provide treatment to stroke patients. These insights were used to implement practical changes, leading to immediate improvements in stroke care delivery. The results were fed back so that successes became visible. Participants' understandings of the local context enabled them to convince peers of the rationale of changes, setting in motion a permanent improvement structure. The participants considered that mapping and then assessing the entire workflow across disciplines were relevant methods for improving the quality of patient care. CONCLUSION: Starting an improvement project in a cross disciplinary environment requires deep engagement on the part of professionals. A quintessential prerequisite is therefore the realization that the quality of care depends on cross-disciplinary cooperation. A facilitated learning arena needs to (1) create insights into each other's colleagues' tasks and process interdependencies, (2) increase understanding of how the distribution of tasks among specialist units affects the quality of care, and (3) frequently report and provide feedback on results to keep the process going.

Pioneering the Use of Tracker Data to Evaluate Lean-Led Hospital Design.

OBJECTIVE: This study aims to examine how we can effectively and affordably evaluate the impact of design concepts such as Lean-Led Hospital Design (LLHD) on the allocation of nurses' time spent at different locations. Particularly in patient rooms, as this can be seen as value-adding time. BACKGROUND: LLHD aims to create a hospital environment that supports value creation for patients and reduces waste. However, only a few studies measure its' effects. One of the reasons for this absence is the lack of an adequate and affordable way to evaluate. METHOD: Nurses' time spent in patient rooms was used as a proxy for value-adding time. Through studying a pioneering case of LLHD, and drawing on a pre-/postoccupancy evaluation approach, this study used an innovative methodology utilizing mobile tracking devices to adequately provide reliable data about the time nurses spend at specific locations. RESULTS: Our analysis reveals that the answer to the question concerning the impact of LLHD, as advocated by its proponents, on nurses' allocation of time for value-adding activities versus waste time remains inconclusive. Our findings indicate no discernible difference in the amount of value-adding time nurses spent in the old facility compared to the new one. CONCLUSION: Our experience suggests that mobile tracking devices offer an affordable, efficient means of collecting data that produces objective measurements. Nevertheless, the interpretation of this time-based data necessitates the inclusion of supplementary qualitative information.

'Bringing the Covert into the Open': A Case Study on Technology Appropriation and Continuous Improvement.

As end-users, employees appropriate technologies. Technology appropriation is generally conceived as a covert phenomenon. In particular, alternative ways and new purposes for which employees deploy technologies tend to remain hidden. Therefore, the potential of technologies as a source of organizational improvements may remain undisclosed. Continuous improvement (CI) programs, in contrast, are explicitly oriented at disclosing organizational improvements. In essence, CI programs encourage employees to openly discuss how to improve their work practices. Such continuous movements towards novel, often better, ways of working may be perfectly suited to bring the covert nature of technology appropriation into the open. Based on a case study on a personal digital assistant (PDA) in a Belgian nursing home with such a CI program in place, we document and analyze to what extent and why functionalities of the PDA were discussed and further developed. We distinguish between the functionalities that, upon implementation, intended to improve particular work practices, and those that surfaced after the technology had been introduced. To conclude, we point at employees' perceived usefulness of their work practices and their willingness to improve these, rather than only the technology itself, to further the debate on technology appropriation.

Head-worn displays and job content: A systematic literature review.

Despite the emergence of head-worn displays at work around forty years ago, few studies have appeared about their impact on job content. To investigate this, a systematic literature review was conducted on these devices and job content, defined as job demands and controls. In total, 3481 studies were identified using five scientific databases. After applying selection criteria, reference searches, citation tracking and an in-depth reading, 28 studies were selected for review. Remarkably, the findings of these studies showed contrasting results. Both increases and decreases in job demands and controls were identified. We distinguished across studies two opposite approaches for the deployment of these devices, i.e. a supportive and a directive approach.

Implementing lean-led hospital design; lessons gained at a pioneer.

PURPOSE: The aim of this study is to document and analyze experiences with building a new hospital guided by lean-led hospital design (LLHD) (Grunden and Hagood, 2012) and to investigate key mechanisms enhancing healthcare professionals' participation and collaboration in implementing this innovative approach. DESIGN/METHODOLOGY/APPROACH: An in-depth case study of the implementation of LLHD in a Dutch hospital was performed based on multiple data sources. The case hospital presented a unique opportunity since there was embedded access to the data by the first author. FINDINGS: Three mechanisms supporting participation and collaboration of staff for implementing LLHD were identified. (1) Freedom in translating a concept enables managers to balance it with variations in practice at the organizational level. (2) A set of key principles governing the design process appeared an important anchor on a managerial level in a changing environment. (3) Creation of a supportive attitude toward lean and lean facility design, with co-creation as a key element of LLHD. PRACTICAL IMPLICATIONS: By using the emerging mechanisms, managers/change agents can enlarge collaboration and participation of hospital staff when implementing organization-wide innovations. ORIGINALITY/VALUE: This case study delivers a unique inside view on the dynamics evolving in the complex change processes at organizational, managerial and personal levels involved in implementing LLHD.

A comparison of working in small-scale and large-scale nursing homes: A systematic review of quantitative and qualitative evidence.

BACKGROUND AND OBJECTIVE: Ongoing shortages of care workers, together with an ageing population, make it of utmost importance to increase the quality of working life in nursing homes. Since the 1970s, normalised and small-scale nursing homes have been increasingly introduced to provide care in a family and homelike environment, potentially providing a richer work life for care workers as well as improved living conditions for residents. 'Normalised' refers to the opportunities given to residents to live in a manner as close as possible to the everyday life of persons not needing care. The study purpose is to provide a synthesis and overview of empirical research comparing the quality of working life - together with related work and health outcomes - of professional care workers in normalised small-scale nursing homes as compared to conventional large-scale ones. DESIGN: A systematic review of qualitative and quantitative studies. DATA SOURCES: A systematic literature search (April 2015) was performed using the electronic databases Pubmed, Embase, PsycInfo, CINAHL and Web of Science. References and citations were tracked to identify additional, relevant studies. REVIEW METHODS: We identified 825 studies in the selected databases. After checking the inclusion and exclusion criteria, nine studies were selected for review. Two additional studies were selected after reference and citation tracking. Three studies were excluded after requesting more information on the research setting. RESULTS: The findings from the individual studies suggest that levels of job control and job demands (all but "time pressure") are higher in normalised small-scale homes than in conventional large-scale nursing homes. Additionally, some studies suggested that social support and work motivation are higher, while risks of burnout and mental strain are lower, in normalised small-scale nursing homes. Other studies found no differences or even opposing findings. The studies reviewed showed that these inconclusive findings can be attributed to care workers in some normalised small-scale homes experiencing isolation and too high job demands in their work roles. CONCLUSION: This systematic review suggests that normalised small-scale homes are a good starting point for creating a higher quality of working life in the nursing home sector. Higher job control enables care workers to manage higher job demands in normalised small-scale homes. However, some jobs would benefit from interventions to address care workers' perceptions of too low social support and of too high job demands. More research is needed to examine strategies to enhance these working life issues in normalised small-scale settings.

Continuous improvement, burnout and job engagement: a study in a Dutch nursing department.

Continuous improvement (CI) programs are potentially powerful means to improve the quality of care. The more positive nurses perceive these programs' effects, the better they may be expected to cooperate. Crucial to this perception is how nurses' quality of working life is affected. We studied this in a nursing department, using the job demands-resources model. We found that two job demands improved, and none of the job resources. Job engagement did not change significantly, while the burnout risk decreased slightly. Overall, the nurses felt the impact to be small yet the changes were in a positive direction. CI can thus be used to improve nurses' working lives and, by restructuring the work processes, the quality of care. Copyright © 2016 John Wiley & Sons, Ltd.

Has Lean improved organizational decision making?

Purpose - Sustainable improvement is likely to be hampered by ambiguous objectives and uncertain cause-effect relations in care processes (the organization's decision-making context). Lean management can improve implementation results because it decreases ambiguity and uncertainties. But does it succeed? Many quality improvement (QI) initiatives are appropriate improvement strategies in organizational contexts characterized by low ambiguity and uncertainty. However, most care settings do not fit this context. The purpose of this paper is to investigate whether a Lean-inspired change program changed the organization's decision-making context, making it more amenable for QI initiatives. Design/methodology/approach - In 2014, 12 professionals from a Dutch radiotherapy institute were interviewed regarding their perceptions of a Lean program in their organization and the perceived ambiguous objectives and uncertain cause-effect relations in their clinical processes. A survey (25 questions), addressing the same concepts, was conducted among the interviewees in 2011 and 2014. The structured interviews were analyzed using a deductive approach. Quantitative data were analyzed using appropriate statistics. Findings - Interviewees experienced improved shared visions and the number of uncertain cause-effect relations decreased. Overall, more positive (99) than negative Lean effects (18) were expressed. The surveys revealed enhanced process predictability and standardization, and improved shared visions. Practical implications - Lean implementation has shown to lead to greater transparency and increased shared visions. Originality/value - Lean management decreased ambiguous objectives and reduced uncertainties in clinical process cause-effect relations. Therefore, decision making benefitted from Lean increasing QI's sustainability.

Workshops as a useful tool to better understand care professionals' views of a lean change program.

PURPOSE: For change programs to succeed, it is vital to have a detailed understanding of employees' views regarding the program, especially when the proposed changes are potentially contested. Gaining insight into employee perceptions helps managers to decide how to proceed. The authors conducted two workshops in a radiotherapy institute to assess the benefits and drawbacks, as well as their underlying causes, of a proposed Lean change program. Managers' views on the workshops' usefulness were charted. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: Two workshops were organized in which employees predicted positive and negative effects of a Lean program. The workshops combined a structured brainstorm (KJ-technique) and an evaluation of the expected effects. Eight top managers judged the workshops' value on supporting decision making. FINDINGS: In total, 15 employees participated in the workshops. Participants from workshop 2 reported more expected effects (27 effects; 18 positive) than from workshop 1 (14 effects; six positive). However, when effects were categorized, similar results were shown. Three from eight managers scored the results relevant for decision making and four neutral. Seven managers recommended future use of the instrument. Increased employee involvement and bottom-up thinking combined with relatively low costs were appreciated most. PRACTICAL IMPLICATIONS: The workshop could serve as a simple instrument to improve decision making and enhance successful implementation of change programs, as it was expected to enhance employees' involvement and was relatively easy to conduct and cheap. ORIGINALITY/VALUE: The workshop increased insight into employee views, facilitating adaptive actions by healthcare organization managers.

Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized?

PURPOSE: To realize safe radiotherapy treatment, processes must be stabilized. Standard operating procedures (SOP's) were expected to stabilize the treatment process and perceived task importance would increase sustainability in compliance. This paper presents the effects on compliance to safety related tasks of a process redesign based on lean principles. METHOD: Compliance to patient safety tasks was measured by video recording of actual radiation treatment, before (T0), directly after (T1) and 1.5 years after (T2) a process redesign. Additionally, technologists were surveyed on perceived task importance and reported incidents were collected for three half-year periods between 2007 and 2009. RESULTS: Compliance to four out of eleven tasks increased at T1, of which improvements on three sustained (T2). Perceived importance of tasks strongly correlated (0.82) to compliance rates at T2. The two tasks, perceived as least important, presented low base-line compliance, improved (T1), but relapsed at T2. The reported near misses (patient-level not reached) on accelerators increased (P < 0.001) from 144 (2007) to 535 (2009), while the reported misses (patient-level reached) remained constant. CONCLUSIONS: Compliance to specific tasks increased after introducing SOP's and improvements sustained after 1.5 years, indicating increased stability. Perceived importance of tasks correlated positively to compliance and sustainability. Raising the perception of task importance is thus crucial to increase compliance. The redesign resulted in increased willingness to report incidents, creating opportunities for patient safety improvement in radiotherapy treatment.