The effects of a lean transition on process times, patients and employees.

Purpose Treatment delays must be avoided, especially in oncology, to assure sustainable high-quality health care and increase the odds of survival. The purpose of this paper is to hypothesize that waiting times would decrease and patients and employees would benefit, when specific lean interventions are incorporated in an organizational improvement approach. Design/methodology/approach In 2013, 15 lean interventions were initiated to improve flow in a single radiotherapy institute. Process/waiting times, patient satisfaction, safety, employee satisfaction, and absenteeism were evaluated using a mixed methods methodology (2010-2014). Data from databases, surveys, and interviews were analyzed by time series analysis, χ2, multi-level regression, and t-tests. Findings Median waiting/process times improved from 20.2 days in 2012 to 16.3 days in 2014 ( p<0.001). The percentage of palliative patients for which waiting times had exceeded Dutch national norms (ten days) improved from 35 (six months in 2012: pre-intervention) to 16 percent (six months in 2013-2014: post-intervention; p<0.01), and the percentage exceeding national objectives (seven days) from 22 to 17 percent ( p=0.44). For curative patients, exceeding of norms (28 days) improved from 17 (2012) to 8 percent (2013-2014: p=0.05), and for the objectives (21 days) from 18 to 10 percent ( p<0.01). Reported safety incidents decreased 47 percent from 2009 to 2014, whereas safety culture, awareness, and intention to solve problems improved. Employee satisfaction improved slightly, and absenteeism decreased from 4.6 (2010) to 2.7 percent (2014; p<0.001). Originality/value Combining specific lean interventions with an organizational improvement approach improved waiting times, patient safety, employee satisfaction, and absenteeism on the short term. Continuing evaluation of effects should study the improvements sustainability.

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.

Cost-Effectiveness of Reduced Waiting Time for Head and Neck Cancer Patients due to a Lean Process Redesign.

BACKGROUND: Compared with new technologies, the redesign of care processes is generally considered less attractive to improve patient outcomes. Nevertheless, it might result in better patient outcomes, without further increasing costs. Because early initiation of treatment is of vital importance for patients with head and neck cancer (HNC), these care processes were redesigned. OBJECTIVES: This study aimed to assess patient outcomes and cost-effectiveness of this redesign. METHODS: An economic (Markov) model was constructed to evaluate the biopsy process of suspicious lesion under local instead of general anesthesia, and combining computed tomography and positron emission tomography for diagnostics and radiotherapy planning. Patients treated for HNC were included in the model stratified by disease location (larynx, oropharynx, hypopharynx, and oral cavity) and stage (I-II and III-IV). Probabilistic sensitivity analyses were performed. RESULTS: Waiting time before treatment start reduced from 5 to 22 days for the included patient groups, resulting in 0.13 to 0.66 additional quality-adjusted life-years. The new workflow was cost-effective for all the included patient groups, using a ceiling ratio of €80,000 or €20,000. For patients treated for tumors located at the larynx and oral cavity, the new workflow resulted in additional quality-adjusted life-years, and costs decreased compared with the regular workflow. The health care payer benefited €14.1 million and €91.5 million, respectively, when individual net monetary benefits were extrapolated to an organizational level and a national level. CONCLUSIONS: The redesigned care process reduced the waiting time for the treatment of patients with HNC and proved cost-effective. Because care improved, implementation on a wider scale should be considered.

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.

Innovative Education Method for a More Effective, Faster, and Valued Training in Radiation Therapy Treatment Planning.

Purpose: Because of the automation of radiation therapy, competencies of radiation technologists (RTTs) change, and training methods are challenged. This study aims to develop, and pilot test an innovative training method based on lean management principles. Methods and Materials: A new training method was developed for lung cancer treatment planning (TP). The novelty is summarized by including a stable environment and an increased focus on the how and why of key decision making. Trainees have to motivate their decisions during TP process, and to argue their choices with peers. Six students and 6 RTTs completed this training for lung cancer TP. Effects of the training were measured by (1) quality of TP, using doses in organs at risk and target volumes, (2) perceived experiences (survey), measured at baseline (T0); after peer session (T1); and 6 months later (T2). Finally, training throughput time was measured. Results: At T0, RTTs showed a larger intragroup interquartile range (IIR) (2.63Gy vs 1.51Gy), but lower mean doses to heart and esophagus than students (6.79Gy vs 8.49Gy; 20.87Gy vs 24.62Gy). At T1, quality of TPs was similar between RTTs and students (IIR: 1.39Gy vs 1.33Gy) and no significant differences in mean dose to heart and esophagus (4.48Gy vs 4.69Gy; 17.75Gy vs 18.47Gy). At T2, students still performed equal to RTTs (IIR: 1.07Gy vs 1.45Gy) and achieved lower maximum dose to esophagus (44.75Gy vs 46.45Gy). The training method and peer sessions were experienced positive: at baseline (T0): 8 score on a scale 1-10, directly after the peer sessions; (T1): 8 by the students and 7 by the RTTs, after 9 months; (T2): 9 by the students and 7 by the RTTs. Training throughput time decreased from 12 to 3 months. Conclusions: This training method based on lean management principles was successfully applied to training of RTTs for lung cancer TP. Training throughput time was reduced dramatically and TP quality sustained after 6 months. This method can potentially improve training efficiency in diverse situations with complex decision-making.

Compliance to technical guidelines for radiotherapy treatment in relation to patient safety.

OBJECTIVE: To determine the compliance of radiation technologists to technical guidelines in daily practice for radiotherapy treatment and whether there are differences in compliance across organizational units. DESIGN: On the basis of consensus, radiation technologists constructed a flowchart describing the work procedure of the irradiation of patients with breast cancer. Using video recordings, technologists in two units were observed to determine whether treatment was conducted in accordance with the flowchart. SETTING: Data have been collected on one linear accelerator at the MAASTRO clinic, a radiotherapy clinic in the Netherlands. PARTICIPANTS: Fifty-six treatments for breast cancer were analyzed in two treatment units. MAIN OUTCOME MEASURE: Percentage compliance to the most important issues for patient safety. RESULTS: An overall compliance of 59% (range: 2-100%) was shown on the 18 most important tasks for patient safety. Between the two units, the compliance varied from 21% to 81%. Tasks considered important by independent assessment had higher levels of compliance. CONCLUSIONS: Video-taped observation proved to be an effective tool for determining compliance in daily practice. A large variation in practice within and across units was detected by the video observations suggesting a need for standard operating procedures to improve the safety of radiotherapy.

A Factorial Survey on Safety Behavior Providing Opportunities to Improve Safety.

OBJECTIVES: To realize safe, high-quality treatment, employees should behave according to patient safety standards. Periodic measurement of safety behavior could provide management-relevant information to adjust the implementation of interventions and maximize improvement. Therefore, we constructed a factorial survey measuring safety awareness and intentions for behavior. METHODS: Cross-sectional results of the factorial survey were compared with results from the Hospital Survey on Patient Safety Culture, distributed in MAASTRO radiotherapy in 2010 to 2011. Respondents were presented 20 scenarios about incidents, randomly varying on work pressure, person causing incident, whether patient level was reached, severity of harm, notification by patient, and management support. After each scenario, questions were asked about safety awareness and behavior. χ and multilevel regression analyses were used. RESULTS: Response rates were 64% (n = 54) for the culture survey and 62% (n = 52) for the factorial survey on intentions. The culture survey reflected positive opinions regarding nonpunitive response and incident reporting, in accordance with high scores (factorial survey) on safety awareness (9.0; scale, 1-10) and reporting intentions (8.7). Whether an incident reached the patient level predicted safety awareness and intentions for safety behavior (ß = -1.3/-3.08) most strongly. Severity of harm showed minimal additional effects (ß = -0.24/-0.42). CONCLUSIONS: The factorial survey presented practical information on safety awareness and intentions for behavior. Therefore, it created additional opportunities for improving safety interventions. Because behavior is expected to change before values, one could hypothesize that factorial surveys would be more sensitive to change than culture surveys. Longitudinal research should further study the surveys' sensitivity to measure changes.

Safer radiation therapy treatment resulting from an equipment transition: A mixed-methods study.

PURPOSE: To realize individualized safe radiation therapy, reliable treatment equipment is essential in combination with a system-level improvement approach. We hypothesized that implementation of a system that integrated all required treatment equipment would result in improved safety and stability of the irradiation treatment process. METHODS AND MATERIALS: Seven accelerators, portal imaging, and the treatment planning software were replaced by an integrated system that included 6 accelerators. The number of reported safety incidents and root causes were recorded between 2010 and 2014. Time series analysis was performed, and quantitative results were explored by structured interviews. Additionally, downtime was recorded. RESULTS: From January 2010 to July 2014, 5085 incidents were reported. Reports related to the accelerators decreased from 33% (2010) to 20% (2013-2014) of total reports, whereas the number of delivered fractions per accelerator increased by 20% (2010: 643 per month; 2013: 795 per month). Reports related to portal imaging decreased from 16.5 reports per month (2010) to 3.1 (2013-2014). Of these portal imaging reports, 316 had at least 1 technical cause in 2010, which decreased to 13 in 2013-2014. Interviewees attributed the decreased reporting to the equipment transition, not to decreased safety awareness. Downtime decreased by 46%, from 5.4% in 2010 to 2.9% in 2013. CONCLUSIONS: The number of reported accelerator- and portal imaging-related incidents decreased significantly, whereas safety awareness remained stable. In addition, accelerator downtime decreased, possibly resulting in less rescheduling of patients and fewer disruptions of work processes. Therefore, we conclude that the risk for serious safety incidents and patient harm decreased after implementation of the new integrated system.

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

OBJECTIVE: The objective of this review is to obtain a better understanding of the user-related barriers against, and facilitators for, the implementation of surgical safety checklists. METHODS: We searched MEDLINE for articles describing stakeholders' perspectives regarding, and experiences with, the implementation of surgical safety checklists. The quality of the papers was assessed by means of the Qualitative Assessment and Review Instrument. Thematic synthesis was used to integrate the emergent descriptive themes into overall analytical themes. RESULTS: The synthesis of 18 qualitative studies indicated that implementation requires change in the workflow of healthcare professionals as well as in their perception of the checklist and the perception of patient safety in general. The factors impeding or advancing the required change concentrated around the checklist, the implementation process and the local context. We found that the required safety checks disrupt operating theatre staffs' routines. Furthermore, conflicting priorities and different perspectives and motives of stakeholders complicate checklist implementation. When approaching the checklist as a simple technical intervention, the expectation of cooperation between surgeons, anaesthetists and nurses is often not addressed, reducing the checklist to a tick-off exercise. CONCLUSIONS: The complex reality in which the checklist needs to be implemented requires an approach that includes more than eliminating barriers and supporting facilitating factors. Implementation leaders must facilitate team learning to foster the mutual understanding of perspectives and motivations, and the realignment of routines. This paper provides a pragmatic overview of the user-related barriers and facilitators upon which theories, hypothesising potential change strategies and interactions, can be developed and tested empirically.

Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute.

PURPOSE: The importance of a safety culture to maximize safety is no longer questioned. However, achieving sustainable culture improvements are less evident. Evidence is growing for a multifaceted approach, where multiple safety interventions are combined. Lean management is such an integral approach to improve safety, quality and efficiency and therefore, could be expected to improve the safety culture. This paper presents the effects of lean management activities on the patient safety culture in a radiotherapy institute. METHODS: Patient safety culture was evaluated over a three year period using triangulation of methodologies. Two surveys were distributed three times, workshops were performed twice, data from an incident reporting system (IRS) was monitored and results were explored using structured interviews with professionals. Averages, chi-square, logistical and multi-level regression were used for analysis. RESULTS: The workshops showed no changes in safety culture, whereas the surveys showed improvements on six out of twelve dimensions of safety climate. The intention to report incidents not reaching patient-level decreased in accordance with the decreasing number of reports in the IRS. However, the intention to take action in order to prevent future incidents improved (factorial survey presented ß: 1.19 with p: 0.01). CONCLUSIONS: Due to increased problem solving and improvements in equipment, the number of incidents decreased. Although the intention to report incidents not reaching patient-level decreased, employees experienced sustained safety awareness and an increased intention to structurally improve. The patient safety culture improved due to the lean activities combined with an organizational restructure, and actual patient safety outcomes might have improved as well.

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.