Using Lean Six Sigma in a Private Hospital Setting to Reduce Trauma Orthopedic Patient Waiting Times and Associated Administrative and Consultant Caseload.

In Ireland, the extent of outpatient orthopedic waiting lists results in long waiting times for patients, delays in processing referrals, and variation in the consultant caseload. At the study site, the Define, Measure, Analyze, Improve, and Control (DMAIC) Lean Six Sigma framework was applied to evaluate sources of Non-Value-Added (NVA) activity in the process of registering and triaging patients referred to the trauma orthopedic service from the Emergency Department. A pre- (October-December 2021)/post- (April-August 2022) intervention design was employed, utilizing Gemba, Process Mapping, and the TIMWOODS tool. Embracing a person-centered approach, stakeholder Voice of Customer feedback was sought at each stage of the improvement process. Following data collection and analysis, a co-designed pilot intervention (March 2022) was implemented, consisting of a new triage template, dedicated trauma clinic slots, a consultant triage roster, and a new option to refer directly to physiotherapy services. This resulted in the total wait time of patients for review being reduced by 34%, a 51% reduction in the process steps required for registering, and an increase in orthopedic consultant clinic capacity of 22%. The reduction in NVA activities in the process and the increase in management options for triaging consultants have delivered a more efficient trauma and orthopedic pathway.

The Impact of a National Cyberattack Affecting Clinical Trials: The Cancer Trials Ireland Experience.

PURPOSE: Cyberattacks are increasing in health care and cause immediate disruption to patient care, have a lasting impact, and compromise scientific integrity of affected clinical trials. On the May 14, 2021, the Irish health service was the victim of a nationwide ransomware attack. Patient care was disrupted across 4,000 locations, including 18 cancer clinical trials units associated with Cancer Trials Ireland (CTI). This report analyses the impact of the cyberattack on the organization and proposes steps to mitigate the impact of future cyberattacks. METHODS: A questionnaire was distributed to the units within the CTI group; this examined key performance indicators for a period of 4 weeks before, during, and after the attack, and was supplemented by minutes of weekly conference call with CTI units to facilitate information sharing, accelerate mitigation, and support affected units. A total of 10 responses were returned, from three private and seven public hospitals. RESULTS: The effect of the attack on referrals and enrollment to trials was marked, resulting in a drop of 85% in referrals and 55% in recruitment before recovery. Radiology, radiotherapy, and laboratory systems are heavily reliant on information technology systems. Access to all was affected. Lack of preparedness was highlighted as a significant issue. Of the sites surveyed, two had a preparedness plan in place before the attack, both of these being private institutions. Of the eight institutions where no plan was in place, three now have or are putting a plan in place, whereas no plan is in place at the five remaining sites. CONCLUSION: The cyberattack had a dramatic and sustained impact on trial conduct and accrual. Increased cybermaturity needs to be embedded in clinical trial logistics and the units conducting them.

Using a Combined Lean and Person-Centred Approach to Support the Resumption of Routine Hospital Activity following the First Wave of COVID-19.

The unexpected advent of the COVID-19 pandemic led to a sudden disruption of routine medical care, with a subsequent reorganization of hospital structures and of care. Case studies are becoming available in the literature referring to the logistical difficulties involved in a hospital resuming normal activity following the first COVID-19 lockdown period. This paper details the experience of a study site, a private hospital in Dublin, Ireland, in the redesign of service delivery in compliance with new COVID-19 prevention regulations to facilitate the resumption of routine hospital activity following the first wave of COVID-19. The aim was to resume routine activity and optimize patient activity, whilst remaining compliant with COVID-19 guidelines. We employed a pre-/post-intervention design using Lean methodology and utilised a rapid improvement event (RIE) approach underpinned by person-centred principles. This was a system-wide improvement including all hospital staff, facilitated by a specific project team including the chief operation officer, allied therapy manager (encompassing health and social care professionals), infection prevention and control team, head of surgical services, clinical nurse managers, patient services manager and the head of procurement. Following our intervention, hospital services resumed successfully, with the initial service resumption meeting the organizational target of a 75% bed occupancy rate, while the number of resumed surgeries exceeded the target by 13%. Our outpatient visits recovered to exceed the attendance numbers pre-COVID-19 in 2019 by 10%. In addition, patient satisfaction improved from 93% to 95%, and importantly, we had no in-hospital patient COVID-19 transmission in the study period of July to December 2020.

A Case Study of a Whole System Approach to Improvement in an Acute Hospital Setting.

Changes in healthcare tend to be project-based with whole system change, which acknowledges the interconnectedness of socio-technical factors, not the norm. This paper attempts to address the question of whole system change posed by the special issue and brings together other research presented in this special issue. A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement. The approach to change was co-designed by staff and management, projects involving staff from all specialities and levels of seniority were linked to each other and to the strategic objectives of the organisation, and learnings from first-generation projects have been passed to second and third-generation process improvements. The socio-technical systems framework was used retrospectively to assess the system change but could also be used prospectively to help healthcare organisations develop approaches to whole system improvement.

Fit for life after cancer: does exercise timing matter?

OBJECTIVES: To assess the effects of a single exercise session per week for 6 weeks on quality of life (QoL), fatigue and exercise participation in male and female cancer survivors with follow-up at 6 months. A secondary aim was to identify if the timing of exercise delivery determined its effect. METHODS: An exploratory prospective cohort study design was implemented. Twenty-five patients undergoing or who had completed cancer treatment (11 active treatment; 14 completed treatment) undertook exercise and educational sessions (Fit for Life) 1×/week. The Brief Fatigue Inventory (BFI), the European Organisation for Research and Treatment of Cancer QoL C-30 (EORTC QLQ C-30) and the Godin Leisure Time Exercise Questionnaire (GLTEQ) were used to assess fatigue, QoL and exercise levels, respectively. Participants were evaluated before and after the intervention, and after 6 months. RESULTS: There was a significant group × time interaction for the GLTEQ at 6 months post in favour of exercising during active treatment (p=0.01). No other group × time interactions were observed across the EORTC QLQ C-30 or BFI. There was a significant main effect for time for EORTC QLQ C-30 Global with a significant increase observed between pre and 6 months post. CONCLUSIONS: Exercise 1×/week delivered during treatment may impact on long-term exercise participation in adult cancer survivors. This lower volume programme may improve QoL, but has minimal effect on fatigue suggesting an insufficient exercise dosage to impact this variable. This study generates interesting proof of concept results and may be helpful in the development of larger randomised controlled trials.

Redesigning the Process for Scheduling Elective Orthopaedic Surgery: A Combined Lean Six Sigma and Person-Centred Approach.

The Health Service Executive Ireland model of care for elective surgery supports the delivery of elective surgical care in achieving both process and clinical outcomes. This project was conducted in the Orthopaedic Department. Following an outpatient consultation with an orthopaedic surgeon, patients who required surgical intervention were scheduled for their intervention by the administrative team. Prior to commencing this project, the average time from patient consultation to being scheduled for surgery on the hospital system was 62 h/2.58 days. A pre- and post-team-based intervention design employing Lean Six Sigma methodology was applied to redesign the process for scheduling elective orthopaedic surgery. The project was informed by collaborative, inclusive, and participatory stakeholder engagement. The goal was to streamline the scheduling process for elective orthopaedic surgery, with a target that 90% of surgeries are scheduled "right first time" within 48 h/two working days of the outpatient consultant appointment. The main outcome measures showed that 100% of orthopaedic surgeries were scheduled successfully within 2 days of outpatient appointment. Duplication in work between patient services and scheduling teams was eliminated and facilitated a reduction in unnecessary staff workload. This project highlights the importance of collaborative interdisciplinary stakeholder engagement in the redesigning of processes to achieve sustainable outcomes, and the findings have informed further improvements across the hospital's surgical scheduling system.

The Use of Lean Six Sigma for Improving Availability of and Access to Emergency Department Data to Facilitate Patient Flow.

The aim of this study was to redesign an emergency department [ED] data management system to improve the availability of, and access to, data to facilitate patient flow. A pre-/post-intervention design was employed using Lean Six Sigma methodology with a focus on the voice of the customer, Gemba, and 5S to identify areas for improvement in ED data management processes and to inform solutions for improved ED patient flow processes. A multidisciplinary ED team includes medical consultants and registrars, nurses, patient service staff, radiology staff, as well as information technology and hospital management staff. Lean Six Sigma [LSS] diagnostic tools identified areas for improvement in the current process for data availability and access. A set of improvements were implemented to redesign the pathway for data collection in the ED to improve data availability and access. We achieved a reduction in the time taken to access ED patient flow data from a mean of 9 min per patient pre-intervention to immediate post-intervention. This enabled faster decision-making by the ED team related to patient assessment and treatment and informed improvements in patient flow. Optimizing patient flow through a hospital's ED is a complex task involving collaboration and participation from multiple disciplines. Through the use of LSS methodology, we improved the availability of, and fast access to, accurate, current information regarding ED patient flow. This allows ED and hospital management teams to identify and rapidly respond to actions impacting patient flow.

The Importance of Real-World Validation of Machine Learning Systems in Wearable Exercise Biofeedback Platforms: A Case Study.

Machine learning models are being utilized to provide wearable sensor-based exercise biofeedback to patients undertaking physical therapy. However, most systems are validated at a technical level using lab-based cross validation approaches. These results do not necessarily reflect the performance levels that patients and clinicians can expect in the real-world environment. This study aimed to conduct a thorough evaluation of an example wearable exercise biofeedback system from laboratory testing through to clinical validation in the target setting, illustrating the importance of context when validating such systems. Each of the various components of the system were evaluated independently, and then in combination as the system is designed to be deployed. The results show a reduction in overall system accuracy between lab-based cross validation (>94%), testing on healthy participants (n = 10) in the target setting (>75%), through to test data collected from the clinical cohort (n = 11) (>59%). This study illustrates that the reliance on lab-based validation approaches may be misleading key stakeholders in the inertial sensor-based exercise biofeedback sector, makes recommendations for clinicians, developers and researchers, and discusses factors that may influence system performance at each stage of evaluation.

Wearable Sensor-Based Exercise Biofeedback for Orthopaedic Rehabilitation: A Mixed Methods User Evaluation of a Prototype System.

The majority of wearable sensor-based biofeedback systems used in exercise rehabilitation lack end-user evaluation as part of the development process. This study sought to evaluate an exemplar sensor-based biofeedback system, investigating the feasibility, usability, perceived impact and user experience of using the platform. Fifteen patients participated in the study having recently undergone knee replacement surgery. Participants were provided with the system for two weeks at home, completing a semi-structured interview alongside the System Usability Scale (SUS) and user version of the Mobile Application Rating Scale (uMARS). The analysis from the SUS (mean = 90.8 [SD = 7.8]) suggests a high degree of usability, supported by qualitative findings. The mean adherence rate was 79% with participants reporting a largely positive user experience, suggesting it offers additional support with the rehabilitation regime. Overall quality from the mean uMARS score was 4.1 out of 5 (SD = 0.39), however a number of bugs and inaccuracies were highlighted along with suggestions for additional features to enhance engagement. This study has shown that patients perceive value in the use of wearable sensor-based biofeedback systems and has highlighted the benefit of user-evaluation during the design process, illustrated the need for real-world accuracy validation, and supports the ongoing development of such systems.

Clinician perceptions of a prototype wearable exercise biofeedback system for orthopaedic rehabilitation: a qualitative exploration.

OBJECTIVES: This study explores the opinions of orthopaedic healthcare professionals regarding the opportunities and challenges of using wearable technology in rehabilitation. It continues to assess the perceived impact of an exemplar exercise biofeedback system that incorporates wearable sensing, involving the clinician in the user-centred design process, a valuable step in ensuring ease of implementation, sustained engagement and clinical relevance. DESIGN: This is a qualitative study consisting of one-to-one semi-structured interviews, including a demonstration of a prototype wearable exercise biofeedback system. Interviews were audio-recorded and transcribed, with thematic analysis conducted of all transcripts. SETTING: The study was conducted in the orthopaedic department of an acute private hospital. PARTICIPANTS: Ten clinicians from a multidisciplinary team of healthcare professionals involved in the orthopaedic rehabilitation pathway participated in the study. RESULTS: Participants reported that there is currently a challenge in gathering timely and objective data for the monitoring of patients in orthopaedic rehabilitation. While there are challenges in ensuring reliability and engagement of biofeedback systems, clinicians perceive significant value in the use of wearable biofeedback systems such as the exemplar demonstrated for use following total knee replacement. CONCLUSIONS: Clinicians see an opportunity for wearable technology to continuously track data in real-time, and feel that feedback provided to users regarding exercise technique and adherence can further support the patient at home, although there are clear design and implementation challenges relating to ensuring technical accuracy and tailoring rehabilitation to the individual. There was perceived value in the prototype system demonstrated to participants which supports the ongoing development of such exercise biofeedback platforms.

Patient Involvement With Home-Based Exercise Programs: Can Connected Health Interventions Influence Adherence?

Adherence to home exercise in rehabilitation is a significant problem, with estimates of nonadherence as high as 50%, potentially having a detrimental effect on clinical outcomes. In this viewpoint, we discuss the many reasons why patients may not adhere to a prescribed exercise program and explore how connected health technologies have the ability to offer numerous interventions to enhance adherence; however, it is hard to judge the efficacy of these interventions without a robust measurement tool. We highlight how well-designed connected health technologies, such as the use of mobile devices, including mobile phones and tablets, as well as inertial measurement units, provide us with the opportunity to better support the patient and clinician, with a data-driven approach that incorporates features designed to increase adherence to exercise such as coaching, self-monitoring and education, as well as remotely monitor adherence rates more objectively.

Activating Technology for Connected Health in Cancer: Protocol for a Research and Training Program.

BACKGROUND: As cancer survival rates increase, the challenge of ensuring that cancer survivors reclaim their quality of life (QoL) becomes more important. This paper outlines the research element of a research and training program that is designed to do just that. OBJECTIVE: Bridging sectors, disciplines, and geographies, it brings together eight PhD projects and students from across Europe to identify the underlying barriers, test different technology-enabled rehabilitative approaches, propose a model to optimize the patient pathways, and examine the business models that might underpin a sustainable approach to cancer survivor reintegration using technology. METHODS: The program, funded under the European Union's Horizon 2020 research and innovation program under the Marie Sklodowska-Curie grant agreement No 722012, includes deep disciplinary PhD projects, intersectoral and international secondments, interdisciplinary plenary training schools, and virtual subject-specific education modules. RESULTS: The 8 students have now been recruited and are at the early stages of their projects. CONCLUSIONS: CATCH will provide a comprehensive training and research program by embracing all key elements-technical, social, and economic sciences-required to produce researchers and project outcomes that are capable of meeting existing and future needs in cancer rehabilitation.