Can Quality Improvement Methodologies Derived from Manufacturing Industry Improve Care in Cardiac Surgery? A Systematic Review.

OBJECTIVES: Healthcare is required to be effectively organised to ensure that growing, aging and medically more complex populations have timely access to high-quality, affordable care. Cardiac surgery is no exception to this, especially due to the competition for and demand on hospital resources, such as operating rooms and intensive care capacity. This is challenged more since the COVID-19 pandemic led to postponed care and prolonged waiting lists. In other sectors, Quality Improvement Methodologies (QIM) derived from the manufacturing industry have proven effective in enabling more efficient utilisation of existing capacity and resources and in improving the quality of care. We performed a systematic review to evaluate the ability of such QIM to improve care in cardiac surgery. METHODS: A literature search was performed in PubMed, Embase, Clarivate Analytics/Web of Science Core Collection and Wiley/the Cochrane Library according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis methodology. RESULTS: Ten articles were identified. The following QIM were used: Lean, Toyota Production System, Six Sigma, Lean Six Sigma, Root Cause Analysis, Kaizen and Plan-Do-Study-Act. All reported one or more relevant improvements in patient-related (e.g., infection rates, ventilation time, mortality, adverse events, glycaemic control) and process-related outcomes (e.g., shorter waiting times, shorter transfer time and productivity). Elements to enhance the success included: multidisciplinary team engagement, a patient-oriented, data-driven approach, a sense of urgency and a focus on sustainability. CONCLUSIONS: In all ten papers describing the application of QIM initiatives to cardiac surgery, positive results, of varying magnitude, were reported. While the consistency of the available data is encouraging, the limited quantity and heterogenous quality of the evidence base highlights that more rigorous evaluation, including how best to employ manufacturing industry-derived QIM in cardiac surgery is warranted.

Measuring healthcare quality: the challenges.

PURPOSE: Current health care quality performance indicators appear to be inadequate to inform the public to make the right choices. The aim of this paper is to define a framework and an organizational setting in which valid and reliable healthcare information can be produced to inform the general public about healthcare quality. DESIGN/METHODOLOGY/APPROACH: To improve health care quality information, the paper explores the analogy between financial accounting, which aims to produce valid and reliable information to support companies informing their shareholders and stakeholders, and healthcare aiming to inform future patients about healthcare quality. Based on this analogy, the authors suggest a measurement framework and an organizational setting to produce healthcare information. FINDINGS: The authors suggest a five-quality element framework to structure quality reporting. The authors also indicate the best way to report each type of quality, comparing performance indicators with certification/accreditation. Health gain is the most relevant quality indicator to inform the public, but this information is the most difficult to obtain. Finally, the organizational setting, comparable to financial accounting, required to provide valid, reliable and objective information on healthcare quality is described. PRACTICAL IMPLICATIONS: Framework elements should be tested in quantitative studies or case studies, such as a performance indicator's relative value compared to accreditation/certification. There are, however, elements that can be implemented right away such as third party validation of healthcare information produced by healthcare institutions. ORIGINALITY/VALUE: Given the money spent on healthcare worldwide, valid and reliable healthcare quality information's value can never be overestimated. It can justify delivering "expensive healthcare, but also points the way to savings by stopping useless healthcare. Valid and reliable information puts the patient in the driver's seat and enables him or her to make the right decision when choosing their healthcare provider.

Generic project definitions for improvement of health care delivery: a case-based approach.

BACKGROUND: The purpose of this article is to create actionable knowledge, making the definition of process improvement projects in health care delivery more effective. METHODS: This study is a retrospective analysis of process improvement projects in hospitals, facilitating a case-based reasoning approach to project definition. Data sources were project documentation and hospital-performance statistics of 271 Lean Six Sigma health care projects from 2002 to 2009 of general, teaching, and academic hospitals in the Netherlands and Belgium. RESULTS: Objectives and operational definitions of improvement projects in the sample, analyzed and structured in a uniform format and terminology. Extraction of reusable elements of earlier project definitions, presented in the form of 9 templates called generic project definitions. These templates function as exemplars for future process improvement projects, making the selection, definition, and operationalization of similar projects more efficient. Each template includes an explicated rationale, an operationalization in the form of metrics, and a prototypical example. Thus, a process of incremental and sustained learning based on case-based reasoning is facilitated. CONCLUSIONS: The quality of project definitions is a crucial success factor in pursuits to improve health care delivery. We offer 9 tried and tested improvement themes related to patient safety, patient satisfaction, and business-economic performance of hospitals.

Implementing Six Sigma in The Netherlands.

BACKGROUND: Six Sigma, a process-focused strategy and methodology for business improvement, can be used to improve care processes, eliminate waste, reduce costs, and enhance patient satisfaction. EXPERIENCE WITH SIX SIGMA IN THE NETHERLANDS: Six Sigma was introduced in 2001 at the 384-bed Red Cross Hospital (Beverwijk). During the Green Belt training, every participant was required to participate in at least one Six Sigma project. The hospital's total savings in 2004 amounted to 1.4 million dollars, for an average savings of 67,000 dollars for each of the completed 21 projects. THREE EXAMPLES OF SUCCESSFUL PROJECTS: In one project, the team designed a new admission process for the operating rooms, resulting in an average starting time nine minutes earlier. This relatively minor improvement made it possible to operate on an additional 400 patients a year and to achieve a net savings of >273,000 dollars. A second project reduced the number of patients receiving intravenous (IV) antibiotics by switching to oral administration, yielding annual savings, based on medication costs alone, of >75,000 dollars. A third project reduced the length of stay in the delivery room from 11.9 to 3.4 hours, yielding an annual savings of 68,000 dollars. The "Ultimate Cure?": Six Sigma, which entails involvement of health care workers; use of improvement tools (from industry); creation of trained project teams to tackle complex, often cross-departmental processes; data analyses; and investment in quality improvement may prove the "ultimate cure" to the current cost, quality, and safety issues that challenge health care.

Quality management: does it pay off?

Health care today is facing serious quality problems while costs are exploding. Quality management therefore becomes a major strategic challenge. In this article, we go through the strategy deployment and quality management process of the Red Cross Hospital in the Netherlands. Growth, efficiency improvement, and optimizing quality of care were chosen as our main strategic goals. To enable achievement of these goals, we implemented and integrated an ISO 9001:2000 quality management system with Six Sigma, a quality improvement approach from industry. The results of 5 years of quality management illustrated by the scores of a number of performance indicators clearly show that we were able to achieve all our strategic goals. On the basis of our findings, we believe that the combination of ISO 9000 and Six Sigma provides the proper tools to bring health care organizations to a higher level of performance.

Lean six sigma in healthcare.

Healthcare, as with any other service operation, requires systematic innovation efforts to remain competitive, cost efficient, and up-to-date. This article outlines a methodology and presents examples to illustrate how principles of Lean Thinking and Six Sigma can be combined to provide an effective framework for producing systematic innovation efforts in healthcare. Controlling healthcare cost increases, improving quality, and providing better healthcare are some of the benefits of this approach.

An ISO 9001 quality management system in a hospital: bureaucracy or just benefits?

PURPOSE: To describe how The Red Cross Hospital in Beverwijk, The Netherlands implemented an ISO 9000 quality management system throughout the entire organisation, obtained an ISO 9002:1994 and subsequently an ISO 9001:2000 certificate. DESIGN/METHODOLOGY/APPROACH: First, a global implementation plan was written concerning the process obtaining in each department. Once improved, each process was subjected to a procedure, and specific protocols effected. On completion the Quality Manual was put together. Quality management was completed by implementing an internal audit system involving 50 co-workers. FINDINGS: A number of advantages are found from using ISO. The focus on patients has been re-established. All processes are identified and subject to continuous improvement. Performance measurements were introduced and give an integrated picture of results. Measurements subsequently lead to improvement of quality of care and to quality system improvements. The documentation system serves the organization's needs without leading to bureaucracy. Positive effects on patient safety could be demonstrated compared with ten other hospitals. ORIGINALITY/VALUE: Given the need for adequate quality management tools in health care and the need for demonstrating quality, the positive effects reported in this article show how ISO is expected to become more prevalent in health-care organisations.