Implementing Lean Quality Improvement in Primary Care: Impact on Efficiency in Performing Common Clinical Tasks.

BACKGROUND: Many primary care practices have adopted Lean techniques to reduce the amount of time spent completing routine tasks. Few studies have evaluated both immediate and sustained impacts of Lean to improve this aspect of primary care work efficiency. OBJECTIVE: To examine 3-year impacts of Lean implementation on the amount of time taken for physicians to complete common clinical tasks. DESIGN: Non-randomized stepped wedge with segmented regression and interrupted time series analysis (January 2011-December 2016). PARTICIPANTS: A total of 317 physician-led teams in 46 primary care departments in a large ambulatory care delivery system. INTERVENTION: Lean redesign was initiated in one pilot site followed by system-wide spread across all primary care departments. Redesigns included standardization of exam room equipment and supplies, streamlining of call management processes, care team co-location, and team management of the electronic inbox. MEASURES: Time-stamped EHR tracking of physicians' completion time for 4 common tasks: (1) office visit documentation and closure of patient charts; (2) telephone call resolution; (3) prescription refill renewal; and (4) response to electronic patient messages. RESULTS: After Lean implementation, we found decreases in the amount of time to complete: office visit documentation (- 29.2% [95% CI: - 44.2, - 10.1]), telephone resolution (- 22.2% [95% CI: - 38.1, - 2.27]), and renewal of prescription refills (- 2.96% per month [95% CI: - 4.21, - 1.78]). These decreases were sustained over several years. Response time to electronic patient messages did not change significantly. CONCLUSIONS: Lean redesigns led to improvements in timely completion of 3 out of 4 common clinical tasks. Our findings support the use of Lean techniques to engage teams in routine aspects of patient care. More research is warranted to understand the mechanisms by which Lean promotes quality improvement and effectiveness of care team workflows.

Experiences of primary care physicians and staff following lean workflow redesign.

BACKGROUND: In response to growing pressures on primary care, leaders have introduced a wide range of workforce and practice innovations, including team redesigns that delegate some physician tasks to nonphysicians. One important question is how such innovations affect care team members, particularly in view of growing dissatisfaction and burnout among healthcare professionals. We examine the work experiences of primary care physicians and staff after implementing Lean-based workflow redesigns. This included co-locating physician and medical assistant dyads, delegating significant responsibilities to nonphysician staff, and mandating greater coordination and communication among all care team members. METHODS: The redesigns were implemented and scaled in three phases across 46 primary care departments in a large ambulatory care delivery system. We fielded 1164 baseline and 1333 follow-up surveys to physicians and other nonphysician staff (average 73% response rate) to assess workforce engagement (e.g., job satisfaction, motivation), perceptions of the work environment, and job-related burnout. We conducted multivariate regressions to detect changes in experiences after the redesign, adjusting for respondent characteristics and clustering of within-clinic responses. RESULTS: We found that both physicians and nonphysician staff reported higher levels of engagement and teamwork after implementing redesigns. However, they also experienced higher levels of burnout and perceptions of the workplace as stressful. Trends were the same for both occupational groups, but the increased reports of stress were greater among physicians. Additionally, members of all clinics, except for the pilot site that developed the new workflows, reported higher burnout, while perceptions of workplace stress increased in all clinics after the redesign. CONCLUSIONS: Our findings partially align with expectations of work redesign as a route to improving physician and staff experiences in delivering care. Although teamwork and engagement increased, the redesigns in our study were not enough to moderate long-standing challenges facing primary care. Yet higher levels of empowerment and engagement, as observed in the pilot clinic, may be particularly effective in facilitating improvements while combating fatigue. To help practices cope with increasing burdens, interventions must directly benefit healthcare professionals without overtaxing an already overstretched workforce.

Hospital-Community Partnerships to Aid Transitions for Older Adults: Applying the Care Transitions Framework.

This study examined the implementation and hospitalwide scaling of a community-based transitional care program to reduce readmissions among adults 65 years or older. Our analysis was guided by the Care Transitions Framework and was based on semistructured interviews with program implementers to identify intervention successes, barriers, and outcomes beyond reducing readmissions. Such outcomes included the program's critical role in providing a safety net and transition to more advanced care, and redefining intervention success from more patient-centered perspectives.

Potential Risks of Ecological Momentary Assessment Among Persons Who Inject Drugs.

BACKGROUND: Ecological momentary assessment (EMA)-which often involves brief surveys delivered via mobile technology-has transformed our understanding of the individual and contextual micro-processes associated with legal and illicit drug use. However, little empirical research has focused on participant's perspective on the probability and magnitude of potential risks in EMA studies. OBJECTIVES: To garner participant perspectives on potential risks common to EMA studies of illicit drug use. METHODS: We interviewed 38 persons who inject drugs living in San Diego (CA) and Philadelphia (PA), United States. They completed simulations of an EMA tool and then underwent a semi-structured interview that systematically explored domains of risk considered within the proposed revisions to the Federal Policy for the Protection of Human Subjects or the "Common Rule." Interviews were transcribed verbatim and coded systematically to explore psychological, physical, social, legal, and informational risks from participation. RESULTS: Participants perceived most risks to be minimal. Some indicated that repetitive questioning about mood or drug use could cause psychological (i.e., anxiety) or behavioral risks (i.e., drug use relapse). Ironically, the questions that were viewed as risky were considered motivational to engage in healthy behaviors. The most cited risks were legal and social risks stemming from participant concerns about data collection and security. IMPORTANCE: Improving our understanding of these issues is an essential first step to protect human participants in future EMA research. We provide a brief set of recommendations that can aid in the design and ethics review of the future EMA protocol with substance using populations.

Antibiotic prescribing practices of medical doctors in a resource-limited setting and the influence of individual perceptions and stewardship support: a survey in three tertiary hospitals in Vietnam.

Objectives: To understand antibiotic prescribing and influencing factors to inform antimicrobial stewardship (AMS) interventions to reduce unwanted consequences of antibiotic use in hospitals in Vietnam, a lower-middle-income country in Asia. Methods: We conducted a cross-sectional study of doctors at three tertiary hospitals using non-probability convenience sampling, through a paper-based (Hospitals 1 and 2) or electronic (Hospital 3) survey. Questions included items on perceptions regarding antibiotic resistance and AMS, prescribing practices, knowledge, demographics and training. We used principal components analysis and mixed-effects models to examine practices and identify influencing factors. Results: Among 314 surveyed participants, 61%, 57% and 59% in Hospitals 1, 2 and 3, respectively, felt certain about the appropriateness of their antibiotic prescriptions. In total, 9% reported sometimes prescribing antibiotics when not needed to meet patients' expectations, and 13% reported doing so to avoid perceived complications. Higher prescribing confidence was found among those with positive perceptions about AMS (P < 0.0001), whereas negative perceptions about colleagues' practices reduced this confidence (P < 0.0001). Individual preference for branded antibiotics was associated with more unnecessary prescribing whereas having higher prescribing confidence decreased the habits of prescribing when not needed. Conclusions: This study provides important implications for design of hospital interventions to address influencing factors on antibiotic prescribing in Vietnam and similar resource-limited settings. Specific interventions should target improving knowledge through education and training for doctors, enhancing the support from the AMS team, and promoting guidelines and policies for appropriate antibiotic use in hospital.

Kinetics of Organic Biodegradation and Biogas Production in the Pilot-Scale Moving Bed Biofilm Reactor (MBBR) for Piggery Wastewater Treatment.

In this research, the kinetics of COD biodegradation and biogas production in a moving bed biofilm reactor (MBBR) at pilot scale (10 m3) for piggery wastewater treatment were investigated. Polyethylene (PE) was used as a carrying material, with organic loading rates (OLRs) of 10, 15, and 18 kgCOD/m3 day in accordance to hydraulic retention times (HRTs) of 0.56, 0.37, and 0.3 day. The results showed that a high COD removal efficiency was obtained in the range of 68-78% with the influent COD of 5.2-5.8 g/L at all 3 HRTs. About COD degradation kinetics, in comparison to the first- and second-order kinetics and the Monod model, Stover-Kincannon model showed the best fit with R 2 0.98 and a saturation value constant (K B ) and a maximum utilization rate (U max) of 52.40 g/L day and 82.65 g/L day, respectively. The first- and second-order kinetics with all 3 HRTs and Monod model with the HRT of 0.56 day also obtained high R 2 values. Therefore, these kinetics and models can be further considered to be used for predicting the kinetic characteristics of the MBBR system in piggery wastewater treatment process. The result of a 6-month operation of the MBBR was that biogas production was mostly in the operating period of days 17 to 80, around 0.2 to 0.3 and 0.15-0.20 L/gCODconverted, respectively, and then reduction at an OLR of 18 kgCOD/m3. After the start-up stage, day 35 biogas cumulative volume fluctuated from 20 to 30 m3/day and reached approximately 3500 m3 for 178 days during the whole digestive process. Methane is accounted for about 65-70% of biogas with concentration around 400 mg/L.

Contextual Conditions and Performance Improvement in Primary Care.

BACKGROUND: Although organizational context can affect the implementation of quality initiatives, we know less about the influence of contextual conditions on quality outcomes. We examined organizational features of primary care clinics that achieved greatest performance improvements after implementing Lean redesigns. METHODS: We used operational data and baseline (ie, pre-Lean implementation) surveys of 1333 physicians and staff in 43 primary care clinics located across a large ambulatory care system. Segmented regression with interrupted time series analysis was used to identify clinics with highest improvements in workflow efficiency, physician productivity, and patient satisfaction following Lean redesign. We conducted independent-samples t tests to identify contextual features of clinics that showed greatest improvements in performance outcomes. RESULTS: Clinics with highest increases in efficiency had most prior experience with quality improvement, compared with all other clinics. Efficiency gains were also found in clinics reporting highest levels of burnout and work stress prior to redesign. Highest improvements in physician productivity were associated with a history of change, staff participation, and leadership support for redesigns. Greatest improvements in patient satisfaction occurred in least stressful environments with highest levels of teamwork, staff engagement/efficacy, and leadership support. CONCLUSIONS: Our findings encourage careful evaluation of clinic characteristics and capacity to effectively implement redesigns. Such evaluations may help leaders select interventions most appropriate for certain clinics, while identifying others that may need extra support with implementing change.

Sustainment of Lean Redesigns for Primary Care Teams.

BACKGROUND: Quality improvements are notoriously followed by "backsliding" or relapse to the status quo. This mixed-methods study examined the sustainment of Lean workflow redesigns for primary care teams several years after being implemented in a large, ambulatory care delivery system. METHODS: We conducted qualitative interviews of 57 leaders and frontline providers, and fielded post-Lean implementation surveys to 1164 physicians and staff in 17 primary care clinics across the system. We analyzed interviews and conducted independent sample t tests to identify key factors that facilitated the sustainment of new workflows among primary care teams. All analyses were conducted after Lean redesigns were implemented and scaled across the system in 3 consecutive phases. RESULTS: Adherence to Lean redesigns was highest in the pilot clinic, despite having the longest postdesign measurement period. Members of the pilot clinic reported greatest participation in designing workflows, were most highly engaged in quality improvement efforts, and held most favorable beliefs about Lean changes. Adherence to redesigns was lowest among clinic members in the second phase of implementation; these members also reported highest levels of burnout. CONCLUSIONS: Staff participation in Lean redesign is a key to facilitating buy-in and adherence to changes. Change ownership and continued availability of time for improvement activities are also critical to the long-term success of Lean implementation in primary care.

Potential benefits of using ecological momentary assessment to study high-risk polydrug use.

BACKGROUND: While studies have documented both the feasibility and acceptability of using ecological momentary assessment (EMA) to study drug use, there is little empirical research assessing participants' perceptions of utilizing this technology-driven approach. METHODS: Participants were English-speaking persons ≥18 years old who reported injection drug use and sequential (e.g., alcohol followed by opioid use) or simultaneous (i.e., injecting heroin and cocaine in one shot) polydrug use within 30 days recruited in San Diego, CA and Philadelphia, PA. Participants (N=36) completed two cell phone-based EMA simulations assessing mood, drug use, HIV risk behaviors, and daily activities, followed by semi-structured interviews that probed for potential benefits of participation over time. Qualitative analysis involved an iterative process of reviewing texts from the interviews to create a coding framework, which was then applied to all transcripts to identify themes. RESULTS: Findings suggest participants may derive indirect benefits from participation in EMA studies including: improved self-worth from helping others; experiencing increased social support through utilization of the study-provided mobile device for non-research purposes; and most importantly, increased self-reflection, which could lead to therapeutic and intervention-like effects such as decreased substance use or reduced HIV risk. CONCLUSIONS: Participants identified a variety of potential benefits from participating in a study that utilizes EMA. This research suggests that benefits are highly salient for individuals involved in studies of polydrug use.

Current conservation status of Germain's langur (Trachypithecus germaini) in Vietnam.

Following the split of the silvered langurs of Indochina into two species based on molecular and phenotypic data, there is a need to reevaluate their distribution and update their conservation status. Here, we report the distribution and assess the population size of Germain's langur (Trachypithecus germaini) within its known range across Vietnam. We confirmed this species at six of seven survey sites in different habitats within three provinces in the Mekong Delta Region, including semi-evergreen forest at the Seven Mountains of An Giang Province, mangrove forest in Ngoc Hien and Nam Can Districts and Melaleuca forest in U Minh Ha National Park of Ca Mau Province, and limestone forest at Kien Luong Karst Area and semi-evergreen and evergreen forests at Phu Quoc National Park of Kien Giang Province. We found no evidence of this species in Mui Ca Mau National Park, Ca Mau Province where it was previously reported. We conservatively estimate that the total population of Germain's langurs in Vietnam consists of 362-406 individuals, with the largest population found in the Kien Luong Karst Area. Hunting and habitat loss are severely impacting Germain's langur, resulting in the extirpation of the population in Mui Ca Mau National Park and small, isolated populations in the Seven Mountains and Ngoc Hien and Nam Can Districts. However, the ability of this species to inhabit a wide range of forest types, and its increasing population sizes in Phu Quoc National Park and Kien Luong Karst Area, provide signs of hope that continued conservation actions may help in its long-term survival.

Comparison of a homogeneous assay with a precipitation method for the measurement of HDL cholesterol in diabetic patients.

OBJECTIVE: To compare direct-measured HDL cholesterol with HDL cholesterol measured by a precipitation method. RESEARCH DESIGN AND METHODS: We compared a homogeneous assay for direct HDL cholesterol analysis with the phosphotungstic acid magnesium chloride precipitation method in 55 type 1 diabetic patients, 70 type 2 diabetic patients, and 82 nondiabetic normal control subjects with plasma triglyceride levels <4.6 mmol/l. The cholesterol content of HDL determined by the direct assay was overall 0.1 mmol/l higher in all three groups than HDL cholesterol measured after precipitation, but the two methods were closely correlated (r(2) = 0.98, P < 0.001). RESULTS: HbA(1c), blood glucose, serum albumin, serum bilirubin, or triglyceride did not influence the differences of the two HDL cholesterol measurements. Because we have previously shown HDL cholesterol isolated by phosphotungstic acid precipitation to be lower than that by ultracentrifugation, the positive bias found in this study was expected. It seems that the direct HDL cholesterol assay reacts with apolipoprotein (apo) B-containing lipoproteins in the fraction with a density of >1.063; these apo B-containing lipoproteins are suggested to be coprecipitated with the phosphotungstic acid method. We also measured LDL cholesterol directly by a LDL cholesterol plus method and found no significant differences between this method and LDL cholesterol calculated from Friedewald's formula. CONCLUSIONS: Direct homogeneous assay for HDL cholesterol determination in diabetic patients seems not to exhibit a negative bias, in contrast to the precipitation method, when compared with the ultracentrifugation method. In addition, the direct assay saves time and is not influenced by type of diabetes or degree of metabolic control.

Photopatterned anisotropic swelling of dual-crosslinked hyaluronic acid hydrogels.

The purpose of a tissue engineered (TE) scaffold is to provide a support structure that can aid the regeneration of damaged tissue. Unlike native tissues, currently existing TE scaffolds are structurally simple, with homogeneous bulk properties that are unable to induce cells to regenerate architecturally complex healthy tissue. Thus, there is a need for methods that can create structural complexity within TE scaffolds to guide tissue regeneration. In this paper we have engineered novel dual-crosslinked hyaluronic acid hydrogel scaffolds with photopatterned anisotropic swelling. Anisotropic swelling can produce zonal distributions of crosslink density, water content and viscoelasticity on the macro- and micro-scales within the hydrogel scaffold. We have found that anisotropically swelling hydrogels can be obtained by a combination of chemical crosslinks and patterned photocrosslinks within a single dual-crosslinked hydrogel. According to our method an unswollen chemically crosslinked hydrogel substrate was spatially patterned with photocrosslinks that restricted swelling at selected sites. The resulting dual-crosslinked hydrogel swelled anisotropically because of differential crosslink densities between the photopatterned and non-photopatterned regions. Anisotropic swelling permitted the hydrogel to contort and evolve a shape different from that of the unswollen hydrogel. A biodegradable hydrogel with this unique swelling behavior yields a new, unexplored type of shape-changing TE scaffold.

Drug-binding hydrogels of hyaluronic acid functionalized with beta-cyclodextrin.

Hyaluronic acid (HA) hydrogels are attractive materials for biomedical applications because they are porous, water-swelling, biocompatible, biodegradable, and resistant to non-specific cell adhesion. A limitation of HA hydrogels is that incorporation of bioactive drugs can be restricted by low solubility of drug within the hydrogel environment. Our goal was to synthesize HA hydrogels that bind drug through hydrophobic interactions as a method for increasing drug loading. We functionalized photocrosslinked HA hydrogels with a methacryloyl derivative of beta-cyclodextrin (betaCD). betaCD is a molecular "basket" with a hydrophilic exterior and a hydrophobic cavity. Inclusion complexes are formed when betaCD hosts all or part of a hydrophobic drug within the cavity. HA hydrogels functionalized with methacryloyl-betaCD monomer gained the property of inclusion complexation which greatly enhanced the uptake of a model hydrophobic drug, hydrocortisone. Pre-incubation of the hydrogels with adamantane carboxylic acid (ACA) inhibited hydrocortisone uptake by competition for betaCD cavities. In addition, control hydrogels of HA functionalized with alphaCD monomer were not efficient at hydrocortisone uptake because the alphaCD cavity is too small for efficient complexation. These experiments confirmed that the betaCD monomer enhances drug loading by the mechanism of inclusion complexation. Drug-binding HA-betaCD hydrogels may be further engineered to create HA-based biomaterials with a built in drug delivery capability.