Improving value-add work and satisfaction in medical residents training: a resident-led quality improvement project employing the lean method to improve hospital supply usage.

PURPOSE: Our hospital has a Housestaff Quality Council that fosters education and mentorship of medical residents for quality improvement methodologies. Medical residents on our council identified non-standardised storage rooms as a source of medical resident inefficiency and dissatisfaction. To improve value-add work, medical residents implemented and evaluated a quality improvement project of storage room supplies using the lean method. METHODS: Using 5S principle and lean methodology, we designed and implemented a standardised supply cart with physician specific supplies. Between April 2014 and April 2015, 40 random observations (20 residents and 20 nurses) both before and after the standardised supply cart implementation were made. The duration time to locate an item was measured in seconds. The paths taken to locate items were drawn as spaghetti diagrams. Nurses served as our control group given that their supplies were not moved in the implementation. Fifty residents were surveyed to assess their satisfaction. RESULTS: Implementation of the standardised supply cart reduced the time for residents to locate an item per visit from 50.8 to 30.2 s in one unit (p<0.05) and 127 to 28.3 s in the second unit (p<0.05). Mean time savings per day per resident were 5 min. The spaghetti diagrams indicated that finding supplies became more efficient after the intervention for residents. After the intervention, 92% of residents reported finding supplies more rapidly and 86% reported less frustration with finding supplies. CONCLUSIONS: Residents applied the 5S principles and lean methodology to identify and solve a problem that created inefficiency and dissatisfaction.

Costs Associated with Anesthesia-Related Adverse Events During Labor and Delivery in New York State, 2010.

BACKGROUND: The safety of anesthetic care provided during childbirth has improved during the past 2 decades in the United States, with a marked decrease in the rate of anesthesia-related adverse events (ARAEs). To date, there is little research on the costs of ARAEs in obstetrics. This study aims to assess the excess cost and cost per admission associated with ARAEs during labor and delivery. METHODS: Data came from the New York State Inpatient Database 2010. Discharge records indicating labor and delivery and ARAEs were identified with International Classification of Diseases, Ninth Revision, Clinical Modification codes. ARAEs were defined as minor if not associated with maternal death, cardiac arrest, or severe morbidity. Costs were calculated as the product of hospital charges and the group average all-payer inpatient charge-to-cost conversion ratio. Excess cost was calculated as the difference between the mean cost of discharges with and without ARAEs. The cost per admission was calculated as the product of the excess cost and ARAE incidence. Excess costs and cost per admission were also calculated for 2 pregnancy-related complications: postpartum hemorrhage and preeclampsia/eclampsia. RESULTS: There were 228,104 delivery-related discharges in the study; of these, 1053 recorded at least 1 ARAE (4.6 per 1000), with 1034 (98.2%) of the ARAEs being minor. The adjusted excess cost associated with ARAEs was $1189 (95% confidence interval [CI], 1033-1350) and the cost per admission $5.49 (95% CI, 4.77-6.23). The incidence of postpartum hemorrhage and preeclamspia/eclampsia was 25.1 and 43.8 per 1000, respectively. The adjusted excess cost was $679 (95% CI, 608-748) and $1328 (95% CI, 1272-1378), respectively; the cost per admission was $17.07 (95% CI, 15.27-18.81) and $58.16 (95% CI, 55.72-60.34), respectively. CONCLUSIONS: ARAEs during labor and delivery are associated with significant excess cost. However, the excess cost per admission for ARAEs is significantly less compared with the excess cost per admission for preeclampsia/eclampsia and postpartum hemorrhage.

Photoactivation of endogenous latent transforming growth factor-ß1 directs dental stem cell differentiation for regeneration.

Rapid advancements in the field of stem cell biology have led to many current efforts to exploit stem cells as therapeutic agents in regenerative medicine. However, current ex vivo cell manipulations common to most regenerative approaches create a variety of technical and regulatory hurdles to their clinical translation, and even simpler approaches that use exogenous factors to differentiate tissue-resident stem cells carry significant off-target side effects. We show that non-ionizing, low-power laser (LPL) treatment can instead be used as a minimally invasive tool to activate an endogenous latent growth factor complex, transforming growth factor-ß1 (TGF-ß1), that subsequently differentiates host stem cells to promote tissue regeneration. LPL treatment induced reactive oxygen species (ROS) in a dose-dependent manner, which, in turn, activated latent TGF-ß1 (LTGF-ß1) via a specific methionine residue (at position 253 on LAP). Laser-activated TGF-ß1 was capable of differentiating human dental stem cells in vitro. Further, an in vivo pulp capping model in rat teeth demonstrated significant increase in dentin regeneration after LPL treatment. These in vivo effects were abrogated in TGF-ß receptor II (TGF-ßRII) conditional knockout (DSPP(Cre)TGF-ßRII(fl/fl)) mice or when wild-type mice were given a TGF-ßRI inhibitor. These findings indicate a pivotal role for TGF-ß in mediating LPL-induced dental tissue regeneration. More broadly, this work outlines a mechanistic basis for harnessing resident stem cells with a light-activated endogenous cue for clinical regenerative applications.