Applying Health-Six-Sigma Principles Helps Reducing the Variability of Length of Stay in the Emergency Department

ABSTRACT Background Reducing length of stay (LOS) is one of the urgent problems in health care systems worldwide. Popular methods that are used to reduce LOS are the Lean and the 6 Sigma, which in practice result in limited improvements. In this paper we introduce and test a tailored method for implementing the 6 Sigma principles in healthcare (we call H-6S). Methods The study took place within the emergency department (ED) of the "Josephtal Medical Center" in Eilat, Israel. Our analysis focused on the processes of examining and treating patients from admission to ED until discharge home. The analysis was done during the second quarter of 2018. The implementation of the recommendations took place during Q3 2018. The reported results are from Q3 2018 to Q2 2019, compared to the corresponding period in 2017 (experienced team). Results In Q2 2017 LOS was 2.42h ± 2.07h (experienced team, N=9928). In Q2 2018, the LOS was 2.62h± 7.04h (before the H-6S, inexperienced team, N=9484). In Q2 2019 following the intervention it reached 2.3h±1.74h (N=7647). The differences between the SDs of the three periods are significant. Conclusion Implementing H-6S dropped variance of LOS within 3 months and remained low for the whole year. Each new team of physicians who enters the emergency department should be thoroughly instructed as to the routines and expectations of the system from them, which should narrow the differences of previous education between them.

Download Full-text

Trends in Emergency Department Visits and Hospital Admissions in Health Care Systems in 5 States in the First Months of the COVID-19 Pandemic in the US

JAMA Internal Medicine ◽

10.1001/jamainternmed.2020.3288 ◽

2020 ◽

Vol 180 (10) ◽

pp. 1328 ◽

Cited By ~ 13

Author(s):

Molly M. Jeffery ◽

Gail D’Onofrio ◽

Hyung Paek ◽

Timothy F. Platts-Mills ◽

William E. Soares ◽

...

Keyword(s):

Health Care ◽

Emergency Department ◽

Hospital Admissions ◽

Health Care Systems ◽

Emergency Department Visits ◽

The Us ◽

Care Systems

Download Full-text

Rapid Process Optimization

American Journal of Medical Quality ◽

10.1177/1062860616637683 ◽

2016 ◽

Vol 32 (2) ◽

pp. 172-177 ◽

Cited By ~ 2

Author(s):

Jennifer L. Wiler ◽

Kelly Bookman ◽

Derek B. Birznieks ◽

Robert Leeret ◽

April Koehler ◽

...

Keyword(s):

Health Care ◽

Length Of Stay ◽

Process Optimization ◽

Process Improvement ◽

Care Delivery ◽

Health Care Systems ◽

Process Redesign ◽

Rapid Process ◽

Left Without Being Seen ◽

Care Systems

Health care systems have utilized various process redesign methodologies to improve care delivery. This article describes the creation of a novel process improvement methodology, Rapid Process Optimization (RPO). This system was used to redesign emergency care delivery within a large academic health care system, which resulted in a decrease: (1) door-to-physician time (Department A: 54 minutes pre vs 12 minutes 1 year post; Department B: 20 minutes pre vs 8 minutes 3 months post), (2) overall length of stay (Department A: 228 vs 184; Department B: 202 vs 192), (3) discharge length of stay (Department A: 216 vs 140; Department B: 179 vs 169), and (4) left without being seen rates (Department A: 5.5% vs 0.0%; Department B: 4.1% vs 0.5%) despite a 47% increased census at Department A (34 391 vs 50 691) and a 4% increase at Department B (8404 vs 8753). The novel RPO process improvement methodology can inform and guide successful care redesign.

Download Full-text

Outpatient Stereotactic Brain Biopsies

10.21203/rs.3.rs-419258/v1 ◽

2021 ◽

Author(s):

Bertrand MATHON ◽

Pauline MARIJON ◽

Maximilien RICHE ◽

Vincent DEGOS ◽

Alexandre CARPENTIER

Keyword(s):

Health Care ◽

Medical Center ◽

Health Care Systems ◽

Cost Savings ◽

Brain Biopsy ◽

Outpatient Setting ◽

Stereotactic Brain Biopsy ◽

Same Day Discharge ◽

Care Systems ◽

Few Data

Abstract BackgroundOutpatient neurosurgery is rising popularity leading to patients’ satisfaction and cost-savings. Although several North-American teams have shown the safety of outpatient stereotactic brain biopsies, few data from other countries with different health care systems are available. ObjectiveWe therefore conducted a feasibility and safety study on the outpatient stereotactic brain biopsies. MethodsWe prospectively examined all the consecutive stereotactic brain biopsies performed in an outpatient setting at our tertiary medical center, between June 2018 and September 2020.ResultsAmong the 437 patients who underwent stereotactic brain biopsy during the study period, 40 (9.2%) patients were enrolled for an outpatient management. The sex ratio was 1 and the median age on biopsy day was 55 [41-66] years. The median distance from patients’ home to hospital was 17 kms [3-47]. 95% of patients had prebiopsy ASA score of 1 or 2 and mRs equal to 2 or less. The rate of same-day discharge was 100%. No patient experienced post-biopsy symptomatic complication necessitating readmission within the month following the biopsy. One patient (2.5%) resorted to an unplanned consultation. Histological findings obtained from brain biopsy led to a diagnosis in all patients; the most frequently found were neoplastic lesions (77.5%)ConclusionStereotactic brain biopsies can therefore be safely achieved on an outpatient setting in carefully selected patients. This process could be more widely adopted in other neurosurgical centers, without affecting the quality of patient’s health care and safety. In this article, we propose management guidelines and pre-biopsy checklist for performing ambulatory stereotactic brain biopsies.

Download Full-text

Rapid Implementation of Video Visits in Neurology During COVID-19: Mixed Methods Evaluation (Preprint)

10.2196/preprints.24328 ◽

2020 ◽

Author(s):

Erika A Saliba-Gustafsson ◽

Rebecca Miller-Kuhlmann ◽

Samantha M R Kling ◽

Donn W Garvert ◽

Cati G Brown-Johnson ◽

...

Keyword(s):

Health Care ◽

Mixed Methods ◽

Care Delivery ◽

Medical Center ◽

Health Care Systems ◽

Clinical Care ◽

Academic Medical Center ◽

Traditional Health ◽

Traditional Health Care ◽

Care Systems

BACKGROUND Telemedicine has been used for decades. Despite its many advantages, its uptake and rigorous evaluation of feasibility across neurology’s ambulatory subspecialties has been sparse. However, the COVID-19 pandemic prompted health care systems worldwide to reconsider traditional health care delivery. To safeguard health care workers and patients, many health care systems quickly transitioned to telemedicine, including across neurology subspecialties, providing a new opportunity to evaluate this modality of care. OBJECTIVE To evaluate the accelerated implementation of video visits in ambulatory neurology during the COVID-19 pandemic, we used mixed methods to assess adoption, acceptability, appropriateness, and perceptions of potential sustainability. METHODS Video visits were launched rapidly in ambulatory neurology clinics of a large academic medical center. To assess adoption, we analyzed clinician-level scheduling data collected between March 22 and May 16, 2020. We assessed acceptability, appropriateness, and sustainability via a clinician survey (n=48) and semistructured interviews with providers (n=30) completed between March and May 2020. RESULTS Video visits were adopted rapidly; overall, 65 (98%) clinicians integrated video visits into their workflow within the first 6 implementation weeks and 92% of all visits were conducted via video. Video visits were largely considered acceptable by clinicians, although various technological issues impacted their satisfaction. Video visits were reported to be more convenient for patients, families, and caregivers than in-person visits; however, access to technology, the patient’s technological capacity, and language difficulties were considered barriers. Many clinicians expressed optimism about future utilization of video visits in neurology. They believed that video visits promote continuity of care and can be incorporated into their practice long-term, although several insisted that they can never replace the in-person examination. CONCLUSIONS Video visits are an important addition to clinical care in ambulatory neurology and are anticipated to remain a permanent supplement to in-person visits, promoting patient care continuity, and flexibility for patients and clinicians alike.

Download Full-text

Using Six Sigma and Lean Strategically for creating Integrated Health Care Systems

International Supply Chain Technology Journal ◽

10.20545/isctj.v4i06.165 ◽

2018 ◽

Vol 04 (06) ◽

Keyword(s):

Health Care ◽

Six Sigma ◽

Health Care Systems ◽

Integrated Health Care ◽

Integrated Health Care Systems ◽

Integrated Health ◽

Care Systems

Download Full-text

Emergency Medicine Pharmacy Practice

Journal of Pharmacy Practice ◽

10.1177/0897190011400549 ◽

2011 ◽

Vol 24 (2) ◽

pp. 135-145 ◽

Cited By ~ 10

Author(s):

Maria I. Rudis ◽

Ryan J. Attwood

Keyword(s):

Health Care ◽

Emergency Department ◽

Emergency Medicine ◽

Clinical Pharmacist ◽

Health Care Systems ◽

Pharmacy Practice ◽

Health Care Team ◽

The Past ◽

Care Systems

Emergency medicine (EM) pharmacy practice has existed for over 30 years. In recent years, however, the specialty has grown significantly. A large number of health care systems have either a dedicated EM pharmacist or other clinical pharmacist presence in the Emergency department (ED). Over the past decade, the role of the EM pharmacist as a critical member of the health care team has expanded significantly and many innovative practices have evolved throughout the country. There is also some heterogeneity between different EM pharmacy practice sites. This article reviews the history and general concepts of EM pharmacy practice as well as illustrate some of the established benefits of an EM pharmacist.

Download Full-text

Effects of an antipsychotic restriction policy in a veteran population

Mental Health Clinician ◽

10.9740/mhc.n161245 ◽

2013 ◽

Vol 3 (1) ◽

pp. 13-19 ◽

Cited By ~ 1

Author(s):

Nicole Cupples ◽

Cynthia A. Mascarenas ◽

Troy A. Moore

Keyword(s):

Mental Health ◽

Health Care ◽

Emergency Department ◽

Index Date ◽

Hemoglobin A1c ◽

Health Care Systems ◽

Psychotropic Medications ◽

Emergency Department Visits ◽

Care Systems ◽

Secondary Outcomes

Introduction: Recent trials have failed to demonstrate differences in efficacy between first generation antipsychotics (FGAs) and second generation antipsychotics (SGAs). To reduce costs, many health care systems have restricted the availability of SGAs through use of prior authorizations. Restrictions for the off-label use of SGAs and the use of dual-antipsychotic therapy have also been implemented in many health care systems. At the South Texas Veterans Health Care System (STVHCS), a restricted drug request (RDR) method has been implemented to manage costs and improve patient safety. Risperidone, due to its lower cost and equal efficacy, is the first-line option of SGAs. If one wishes to prescribe an SGA other than risperidone, an RDR is submitted and reviewed by Veterans Integrated Service Network (VISN) pharmacists. Since the introduction of these policies at the STVHCS, the impact of the RDR has not been assessed. Rationale: The primary aim of this study was to determine the effects of the RDR policy on the care of STVHCS veterans as evidenced by changes in hospitalization rates of veterans with a denied request for an SGA due to initial criterion failure. Secondary outcomes included: impact of antipsychotic RDR denial on mental health as evidenced by changes in no-shows and cancellations for follow-up psychiatric appointments, psychiatric emergency department visits, presence of suicidal ideation, change in weight, hemoglobin A1c, number of psychotropic medications prescribed, and extrapyramidal symptoms. Methods: A retrospective chart review of veterans denied an initial SGA request was conducted from 3 months prior to denial to 3 months post request denial (index date). Data collected included: patient demographics, indication for SGA request, reason for SGA denial, length of time for request evaluation, number of psychiatric hospitalizations, number of no-shows and cancellations for mental health appointments, number of psychiatric emergency department visits, number of reports of suicidal ideation or attempts, weight, hemoglobin A1c lab results, presence of extrapyramidal symptoms, and number of prescribed psychotropic medications. The health care utilization data collected pre- and post-index date, were compared. Results were analyzed using Fisher's Exact, 2-tailed standardized t-tests, and descriptive statistics appropriately matched to data type. Results: Results for both primary and secondary outcomes were not statistically significant. No differences were found in the number of veterans hospitalized pre- versus post-index date [0/33 (0%) versus 2/33 (6%), p=0.492.] The most requested indication for an SGA was PTSD [22/33 (66.7%)] and the most frequently denied SGA was quetiapine [16/33 (48.5%)]. Conclusions: Although outcomes were not statistically significant, several valuable conclusions were drawn from this research. Positive outcomes from a RDR policy were seen by the limitations placed on inappropriate medication prescribing. Also, it was observed that the number of approvals for SGAs was almost three times higher than denials. A subsequent finding from this research is the apparent lack of metabolic monitoring for veterans prescribed SGAs. Further research on these observations, as well as conducting a pharmacoeconomic analysis on the RDR policy, would also be beneficial information for health care providers.

Download Full-text

Seeking Care for Hyperglycemia in the Emergency Department: Through the Eyes of the Patient

10.2337/figshare.13202924 ◽

2020 ◽

Author(s):

Justin W. Yan ◽

Dimah Azzam ◽

Melanie P. Columbus ◽

Kristine Van Aarsen ◽

Selina L. Liu ◽

...

Keyword(s):

Primary Care ◽

Health Care ◽

Emergency Department ◽

Hospital Admission ◽

Health Care Systems ◽

Primary Care Providers ◽

Urgent Care ◽

Care Providers ◽

Health Care Settings ◽

Care Systems

Health care systems often provide a range of options of care for patients with illnesses who do not require hospital admission. For individuals with diabetes, these options may include primary care providers, specialized diabetes clinics, and urgent care and walk-in clinics. We explored the reasons why patients choose the Emergency Department over other health care settings when seeking care for hyperglycemia.

Download Full-text