Decreasing inpatient chemotherapy initiation delays at Memorial Regional Hospital.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 225-225
Author(s):  
Michel Vulfovich ◽  
Matthew Philip Salzberg ◽  
Marie Louis-Jeune ◽  
Khang Pham ◽  
Kelly King ◽  
...  
Keyword(s):  
Healthcare System ◽  
Time Lapse ◽  
Regional Hospital ◽  
Statistical Process ◽  
Pareto Chart ◽  
Patient Dissatisfaction ◽  
Chemotherapy Administration ◽  
Pdsa Cycle ◽  
Chemotherapy Initiation ◽  
Data Collections

225 Background: Between June and December 2019, hematology-oncology patients admitted for elective chemotherapy at Memorial Regional Hospital had a median delay of 10 hours to initiate chemotherapy infusion from time of admission. This contributes to increased cost to the healthcare system and patient dissatisfaction. By September 2020, elective inpatient median time from admission to chemotherapy initiation at Memorial Regional Hospital will be reduced by 20%. Methods: Multidisciplinary team formed to evaluate the time from admission to initiation of chemotherapy for patients who are electively admitted for chemotherapy in 8 Central based on time stamps available in the electronic health records. Patients electively admitted by a non MCI oncologist were excluded. Data collections included time stamp between each process from admission to administration of 1st chemotherapy. Longest time lapse between each process was counted as an occurrence/contributor to delay. Top 80% contributors identified from Pareto chart allowed team to identify countermeasures. Priority Matrix of implementation in PDSA cycle based on highest impact and ease of implementation. Statistical process control chart was developed. Results: (see table). Conclusions: PDSA Cycle 1, obtaining labs 24-48 hours prior to admission, resulted in a 10% reduction in chemotherapy initiation time. PDSA Cycle 2, enhancing “ok to treat” communication, resulted in a further reduction of time to treatment. The combination of PDSA Cycle 1 & 2 resulted in a 40% reduction in time to chemotherapy initiation, exceeding the planned aim of 20%. Balance measures reflected no reduction in the mean number of overnight stays between baseline and PDSA Cycle 2 (4 nights) that could contribute to a decreased cost. Results and recommendations to adopt at all inpatient oncology departments within the healthcare system will be presented to leadership for support. Data automation through collaborative efforts with information technology is in process to assist with continuous monitoring. Future state, the quality improvement tools gained from ASCO QTP will be utilized to evaluate and improve workflow issues in the outpatient oncology setting. Nationally recognized organizations are encouraged to propose a benchmark for admission time to first chemotherapy administration based on the evaluation of current available data. Additional studies are needed to evaluate chemotherapy treatment delays in other settings.[Table: see text]

scholarly journals PREDICTABILITY IN THE PRODUCTIVE PROCESS OF THINNING AND CLEARCUTTING MECHANIZED OPERATIONS IN Pinus taeda L.

FLORESTA ◽  
2019 ◽  
Vol 50 (1) ◽  
pp. 933
Author(s):  
Bruna Martins Garcia ◽  
Philipe Ricardo Casemiro Soares ◽  
Jean Alberto Sampietro ◽  
Caroline Fernandes
Keyword(s):  
Critical Points ◽  
Control Charts ◽  
Timber Harvesting ◽  
Statistical Process ◽  
Pareto Chart ◽  
Clear Cut ◽  
Forestry Sector ◽  
Productive Process ◽  
Harvesting Process ◽  
Pinus Taeda L

Some organizations in the Brazilian forestry sector, especially in the activities carried out in forest stands, do not follow the development pace of other industries and the adoption rate of management and quality methodologies and tools. This study aimed to evaluate the predictability of timber harvesting process based on critical points identified in the selective thinning and clear cut operations. Interviews and Pareto chart were used, for the identification and evaluation of the critical points, respectively, and for the evaluation of the process, it was used the Statistical Process Control (SPC) by attributes and variables in the main failures. In the interviews conducted with workers, seven critical points were identified. The evaluation with Pareto chart showed that 80% of the failures identified during harvest are attributed to the damage to the remaining trees, sorting (measures of length and diameter of the product) and stump height. Among the possible causes of the critical points are problems with employees’ training, regular maintenance of machinery and operations planning. In the evaluation with the CEP, the control charts indicated that the sorting and stump height, although within the limits specified by the company, was considered unstable and unpredictable

scholarly journals Using a network organisational architecture to support the development of Learning Healthcare Systems

2018 ◽  
Vol 27 (11) ◽  
pp. 937-946 ◽  
Author(s):  
Maria T Britto ◽  
Sandra C Fuller ◽  
Heather C Kaplan ◽  
Uma Kotagal ◽  
Carole Lannon ◽  
...  
Keyword(s):  
Healthcare System ◽  
Point Of Care ◽  
Data Entry ◽  
Regulatory Compliance ◽  
Clinical Encounter ◽  
Learning System ◽  
National Academy Of Sciences ◽  
Statistical Process ◽  
Learning Healthcare System ◽  
Communication Policies

The US National Academy of Sciences has called for the development of a Learning Healthcare System in which patients and clinicians work together to choose care, based on best evidence, and to drive discovery as a natural outgrowth of every clinical encounter to ensure innovation, quality and value at the point of care. However, the vision of a Learning Healthcare System has remained largely aspirational. Over the last 13 years, researchers, clinicians and families, with support from our paediatric medical centre, have designed, developed and implemented a network organisational model to achieve the Learning Healthcare System vision. The network framework aligns participants around a common goal of improving health outcomes, transparency of outcome measures and a flexible and adaptive collaborative learning system. Team collaboration is promoted by using standardised processes, protocols and policies, including communication policies, data sharing, privacy protection and regulatory compliance. Learning methods include collaborative quality improvement using a modified Breakthrough Series approach and statistical process control methods. Participants observe their own results and learn from the experience of others. A common repository (a ‘commons’) is used to share resources that are created by participants. Standardised technology approaches reduce the burden of data entry, facilitate care and result in data useful for research and learning. We describe how this organisational framework has been replicated in four conditions, resulting in substantial improvements in outcomes, at scale across a variety of conditions.

scholarly journals LO33: Sharing and teaching electrocardiograms to minimize infarction

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S19-S19
Author(s):  
J. McLaren ◽  
A. Taher ◽  
L. Chartier
Keyword(s):  
Educational Strategy ◽  
Statistical Process ◽  
Process Measures ◽  
Web Based ◽  
Pareto Chart ◽  
Quality Metric ◽  
Root Cause ◽  
Local Feedback ◽  
One Year ◽  
The One

Background: Every 30-minute delay to ST-Elevation Myocardial Infarction (STEMI) reperfusion increases one-year mortality by 7.5%. A local audit found that the third of patient electrocardiograms (ECGs) not initially meeting classic STEMI criteria had an ECG-to-Activation (ETA) time of over 90 minutes, more than five times that of classic STEMIs. However, three quarters of “STEMI negative” ECGs met STEMI-equivalent patterns or rules for subtle occlusion, uncovering an opportunity for improvement. Aim Statement: We aimed to reduce ETA time, from initial emergency department (ED) ECG to activation of the cath lab, for patients whose ECGs did not meet classic STEMI criteria, by 30 minutes within one year (i.e. by Dec 2019). Measures & Design: We reviewed all ED Code STEMIs over a 35-month pre-intervention period. Root Cause analyses, including Ishikawa diagram and Pareto chart, led to our Plan-Do-Study-Act cycles: 1) a survey to engage our team; 2) a Grand Rounds presentation as an educational strategy; and 3) weekly web-based feedback to all ED physicians on STEMI-equivalents and subtle occlusions, using recent local cases. Our outcome measures were ETA times, stratified by ECGs not initially meeting STEMI criteria (primary) and those that did (secondary). Our process measures were the number of website visits and page views. Our balancing measure was the proportion of Code STEMIs without culprit lesion. We used Statistical Process Control (SPC) charts with usual special cause variation rules. Evaluation/Results: ETA time for the 37.5% of 56 ECGs that did not meet classic STEMI criteria decreased from 97.5 to 53.7 minutes (min), a 43.8-min absolute decrease (p = 0.037), while those meeting STEMI criteria remained the same (16.5 to 18.2min, p = 0.75). SPC charts did not show special cause variation. There were 2,634 page views (65.9/week) and 1,092 visits (27.3/week), in a group of 80 physicians—i.e. a third of the group each week. There was no change in Code STEMIs without culprit lesions (28.0 % to 23.3%, p = 0.41). Discussion/Impact: We reduced ETA time by 43.8min for the one third of patients with culprit lesions not initially meeting classic STEMI criteria, a magnitude associated with mortality impact. To do so, we used a multi-modal educational strategy including a novel web-based feedback approach to all ED physicians. Local feedback and education on this challenging-to-diagnose subgroup, guided by ETA time as a quality metric, could be replicated in other centres.

scholarly journals LO86: Improving time to analgesia administration for musculoskeletal injuries in the emergency department.

CJEM ◽  
2019 ◽  
Vol 21 (S1) ◽  
pp. S39
Author(s):  
V. Woolner ◽  
R. Ahluwalia ◽  
H. Lum ◽  
K. Beane ◽  
J. De Leon ◽  
...  
Keyword(s):  
Medication Administration ◽  
Statistical Process ◽  
Process Measures ◽  
Pareto Chart ◽  
Root Cause ◽  
Included Patient ◽  
Number Of Patients ◽  
Before And After ◽  
Medical Directives ◽  
Clinician Assessment

Background: Greater than 80% of patient visits to emergency departments (EDs) are for a pain-related concerns. Approximately 38,000 patients per year have such complaints in our academic hospital ED. 3,300 (8.6%) of those visits are for musculoskeletal (MSK) pain (i.e. back or extremity injury/pain), which are typically triaged as low-acuity presentations, leading to longer times to clinician assessment. Delays to adequate analgesia result in unnecessary suffering, worse patient care and satisfaction, and increased patient complaints. Aim Statement: We aimed to reduce the time-to-analgesia (TTA; time from patient triage to receipt of analgesia) for patients with MSK pain in our ED by 55% (to under 60 minutes) in 9 months’ time (May 2018). Measures & Design: Our outcome measures were TTA (in minutes) and ED length of stay (LOS; in minutes). Process measures included nurses’ use of medical directive and rate of analgesia administration. Balancing measures included patient adverse events and time spent triaging for nurses. We utilized weekly data capture for the Statistical Process Control (SPC) chart, and we used Mann-Whitney U test for our before-and-after evaluation. Utilizing the Model for Improvement, we performed wide stakeholder engagement and root cause analyses, and we created a Pareto chart. This led to our Plan-Do-Study-Act (PDSA) cycles: 1) nurse-initiated analgesia (NIA) at triage; 2) new triage documentation aid for medication administration; 3) quick reference medical directive badge tag for nurses; 4) weekly targeted feedback of the project's progress at clinical team huddle. Evaluation/Results: TTA decrease from 129 minutes (n = 153) to 100 minutes (22.5%; n = 87, p < 0.05). ED LOS decreased from 580 minutes (n = 361) to 519 minutes (10.5%; n = 187; p = 0.77). Special cause variation was identified on the ED LOS SPC chart with eight consecutive points below the midline, after PDSA 1. The number of patients who received any analgesia increased from 42% (n = 361) to 47% (n = 187; p = 0.13). The number of patients who received medications via medical directives increased from 22% (n = 150) to 44% (n = 87; p < 0.001). Balancing measures were unchanged. Discussion/Impact: The significant reduction in the TTA and increase in the use of medical directives in the before-and-after analyses were likely due to our front-line focused improvements and deliberate nursing engagement. With continued success and sustainable processes, we are planning to spread our project to other EDs and broaden our initiative to all pain-related concerns.

Decreasing initiation of chemotherapy time in elective patients admitted to an inpatient hematology malignancy unit.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 120-120
Author(s):  
Jose Nahun Galeas ◽  
Stuart H. Packer ◽  
Susan Sakalian ◽  
Royston Browne ◽  
Adam Binder
Keyword(s):  
Performance Improvement ◽  
Median Time ◽  
Interim Analysis ◽  
Vital Signs ◽  
Patient Admission ◽  
Process Measures ◽  
Pareto Chart ◽  
Chemotherapy Administration ◽  
Measured Time ◽  
Admission Planning

120 Background: At our institution, we observed that 86% (n = 25) of patients admitted for elective chemotherapy experienced a delay (greater than 6 hours) in initiating their treatment. Methods: We measured time from admission to chemotherapy administration (Defined from time of vital signs taken at admission until time of chemotherapy administration) in patients admitted for elective chemotherapy. Key process measures were identified and monitored (i.e, time from admission to laboratory exam results, time from admission to chemotherapy signed, time from chemotherapy signed to chemotherapy released by nurse from the EMR). We collected data every two weeks. After collecting data and utilizing performance improvement tools such as a pareto chart and PICK chart, we developed multiple PDSA cycles as described in Table 1. Results: At the time of interim analysis, we observed a median decrease in time to chemotherapy administration from 25 hours to 8.85 hours. Median time to lab draws decreased from 2.33 hours to -0.63 hours. There was no change in time from signature to nurse releasing the chemotherapy. We noticed more providers were signing the chemotherapy prior to patient admission and more patients were receiving pre-admission alkalinization strategies. Conclusions: By implementing new admission workflows, optimizing our use of the EMR to communicate among providers, and improving pre-admission planning we were able to reduce our time to chemotherapy for elective admissions by 64.6%. Improvement still needed to meet our goals and fully standardize the processes as part of our daily workflow.[Table: see text]

Optimization of inpatient chemotherapy administration utilizing evaluation intervals.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 75-75
Author(s):  
Sabarina Ramanathan ◽  
Avani Yenamandra ◽  
Aparna Vuppala ◽  
Khine Shan ◽  
Hugo R. Lara-Martinez ◽  
...  
Keyword(s):  
Interdisciplinary Approach ◽  
Primary Outcome Measure ◽  
University Hospital ◽  
Post Intervention ◽  
Improvement Project ◽  
Equal Distribution ◽  
Chemotherapy Administration ◽  
Time Stamps ◽  
Patient Arrival ◽  
Chemotherapy Initiation

75 Background: Inpatient chemotherapy requires an interdisciplinary approach to achieve shorter hospital stays and decrease cost. A quality improvement project at Hahnemann University Hospital was undertaken to identify delays in the process from admission to chemotherapy initiation in this population. Methods: Time stamps were recorded for patient arrival (door to floor), order placement (floor to order), and administration (order to chemo) to establish a baseline. A multidisciplinary team of pharmacy, nursing, and physicians was developed to address inefficiencies. There were three evaluation intervals: May - October 2015 (Part I), January 2017 - October 2018 (Part II) and October - December 2018 (Part III). Data collected from Part I established a baseline door-to-chemo time (DTC) of 7.2 hrs. Post Part I, prompt communication of patient arrival and delays in chemotherapy hanging were addressed. Part II interventions were outpatient consents and labs, timely order placement, and utilization of order sets. Pharmacy-nurse communication and equal distribution of patients through the week was implemented in Part III. The primary outcome measure was difference in DTC. Results: 200 admissions were reviewed. Results of the evaluation intervals are shown in Table. After the first evaluation interval, DTC improved from 7.18 to 5.96 hrs. DTC further decreased to 5.78 hrs post intervention II. The longest delay was between chemotherapy order and administration. Conclusions: DTC significantly improved between intervals with the above interventions. Utilizing a standardized nursing checklist and biweekly multidisciplinary meetings to emphasize prioritization will further decrease DTC. DTC reduction will decrease cost and increase patient satisfaction. [Table: see text]

Improving the Care of Patients With Regard to Chemotherapy-Induced Nausea and Emesis: The Effect of Feedback to Clinicians on Adherence to Antiemetic Prescribing Guidelines

2003 ◽  
Vol 21 (7) ◽  
pp. 1373-1378 ◽  
Author(s):  
Wilson C. Mertens ◽  
Donald J. Higby ◽  
David Brown ◽  
Regina Parisi ◽  
Janice Fitzgerald ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Practice Guidelines ◽  
Practice Guidelines ◽  
Guideline Development ◽  
Outcome Measurement ◽  
Statistical Process ◽  
Chemotherapy Administration ◽  
Physician Participation ◽  
Delayed Nausea ◽  
Nausea And Emesis

Purpose: To evaluate the effect of performance and outcomes feedback on adherence to clinical practice guidelines regarding chemotherapy-induced nausea and emesis (CINE). Methods: Institutional CINE clinical practice guidelines were developed based on American Society of Clinical Oncology guidelines. Consecutive administrations of moderately/highly emetogenic chemotherapy were assessed for errors. Baseline statistical process control (SPC) charts were created and mean errors per administration were calculated. Prospective SPC charts were used to measure the effect of guideline development and distribution, a visiting lecturer, and ongoing feedback regarding compliance with guidelines employing SPC charts. Patients were surveyed regarding the extent and severity of CINE for 5 days postadministration. These outcomes were then shared with physicians. Results: Baseline compliance was poor (mean, 0.87 omissions per chemotherapy administration), largely because of inadequate adherence to recommendations for delayed CINE management. Most patients experienced delayed nausea, particularly on day 3 postchemotherapy. Physician prescribing performance did not undergo sustained improvement despite guideline development or distribution, a lecture by a visiting expert, or sharing of adherence data with clinicians. Once patient outcomes were shared, physicians accepted the need for compliance and instituted nurse practitioner antiemetic prescribing, with almost complete compliance and concurrent measurable reduction in day 3 nausea. SPC charts documented improvements in both outcomes. Conclusions: SPC charts effectively monitor ongoing compliance and patient symptoms and represent appropriate outcome measurement and change facilitation tools. However, physician participation in guideline development and evidence of poor compliance alone did not improve prescribing performance. Only evidence of patient CINE experience coupled with noncompliance improved results.

Strategies for reducing grade 2 and 3 adverse events due to immunotherapy in a Spanish university hospital.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 288-288
Author(s):  
Ana Gomez ◽  
Paloma Gómez Solana ◽  
Elena Ruiz ◽  
Antonio Anton ◽  
Enrique Aranda ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Adverse Events ◽  
Questionnaire Development ◽  
University Hospital ◽  
Improvement Project ◽  
Pareto Chart ◽  
Lung Cancer Patients ◽  
Patient Dissatisfaction ◽  
American Society ◽  
Ramón Y Cajal

288 Background: To develop an improvement project, the Lung Cancer Unit of Ramón y Cajal Hospital (Madrid) analyzed 45 patients treated with immunotherapy in 2017 and detected that 55% presented moderate-to-severe Adverse Events (AEs). Consequently, a specialized team from Ramon y Cajal Hospital and ECO Foundation proposed to identify improvement areas that reduce grade 2 (G2) and 3 (G3) AEs. ECO is a collaboration of experts representing the major Spanish hospitals in the pursuit of excellence in cancer treatment. Methods: The team used as an instrument the American Society of Clinical Oncology (ASCO) Quality Training Program (QTP). A data collection process was conducted before attending the first out of three sessions of the QTP with the revision of medical records from lung cancer patients. The goal for the final QTP session in late-June 2018 was to reduce G2 and G3 AEs by 25%, by standardizing patient education sessions using ASCO guidelines for the management of immune-related AEs. Results: The data collected showed that G2 and G3 AEs had an impact on quality of care, specifically a treatment delay in 31% of patients, unscheduled visits in 19%, serious complications in 11% and patient dissatisfaction with the reporting system. The team created a cause and effect diagram, in which the most relevant causes were inadequate patient knowledge and a lack of communication with patients between visits, in addition to a Pareto chart, in which the more frequent AEs were asthenia, respiratory infection, cough, among others. A run chart of percentage of G2 and G3 AEs during 2017 displayed that G2 AEs were higher during January and August; and G3 AEs in February and December. The team, including patient advocates, prioritized the implementation of these short-term measures for patients: improvement of education, education follow-up, satisfaction questionnaire development and AE knowledge test. By mid-June 2018, new data will be collected to determine the effectivity of these measures. Conclusions: This improvement approach indicates the need to continue further quality projects in healthcare. Broader participation of Spanish hospitals in improvement initiatives will enhance the goal of a quality-oriented health care system.

Application of statistical process control in service industry

2016 ◽  
Vol 11 (3) ◽  
pp. 763-782 ◽  
Author(s):  
Nima Mirzaei ◽  
Sadegh Niroomand ◽  
Rahim Zare
Keyword(s):  
Process Control ◽  
Statistical Process Control ◽  
Control Charts ◽  
Service Sector ◽  
Service System ◽  
Statistical Process ◽  
Pareto Chart ◽  
Content Type ◽  
Number Of Customers

Purpose This study aims to apply statistical process control (SPC) techniques to improve the quality and efficiency of the processes in a restaurant. Design/methodology/approach SPC tools such as check sheet, cause-and-effect analysis, Pareto chart, control charts and SERVQUAL methodology is adapted to measure and improve the quality of the system. Findings At the end, some suggestions for improving the quality of service system are proposed in this study to complete the research. Research limitations/implications The most difficult part of this study was data collection. Because of the situation of the restaurant, the number of customers does not exceed 60 every day. Another limitation of this study is that the samples have been collected from the same population each day, and it may affect the final result. Practical implications The research is based on the present service system at a restaurant, located at a university campus in Cyprus. Social implications A similar study can be applied in the social sector to evaluate and improve service quality. Originality/value In this paper, for the first time, SPC and SERVQUAL are used to evaluate and improve quality in the service sector.

A multidisciplinary effort to decrease time from admission to chemotherapy on an inpatient oncology unit.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 96-96
Author(s):  
Louise Ming-Wai Man ◽  
Jeremy Sen ◽  
Jeanne Cahan ◽  
Kathlene Degregory ◽  
Tanya Thomas ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Census Data ◽  
Medical Center ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Retrospective Data ◽  
Post Intervention ◽  
Pareto Chart ◽  
Pdsa Cycle ◽  
Oncology Unit

96 Background: Patients with established cancer diagnoses often experience delays in starting scheduled inpatient chemotherapy (CTX) after arrival on the University of Virginia (UVA) Medical Center oncology unit. These delays negatively impact hospital resource utilization. We formed a multidisciplinary team of physicians, nurses, and pharmacists to investigate these delays. We aim to decrease time-to-CTX (TTC) by 30% from baseline. Methods: From 340 planned inpatient CTX encounters in calendar year 2015, 100 were randomly reviewed to establish baseline retrospective data. The following were collected for each encounter: patient demographics; oncologic diagnosis; admitting team; CTX regimen and cycle; procedures and urinary parameters required prior to CTX start; times of lab orders and results, CTX signature and release, and start of intravenous fluid (IVF), premedications, and CTX; unit census data; available nursing staff; and length of stay. With guidance from ASCO’s Quality Training Program, we constructed a process map of the current state, an Ishikawa cause-and-effect diagram, a Pareto chart to assess causes of delays, and a priority matrix of potential interventions. XmR charts compared baseline and post-intervention data. Results: Baseline median TTC was 6.7 hours (range 1.5-105.3 h). Patients with pre-admission outpatient appointments started CTX 2.4 h earlier than those without appointments. Patients without urine parameters for treatment started CTX 3 h earlier than those with parameters. The Pareto chart indicated the longest delays occurred in pre-medicating patients, starting IVF, and signing CTX orders. In the first Plan-Do-Study-Act (PDSA) cycle, the CTX consent process was reformed. Post-intervention data showed no change in median TTC (7.2 h). Other PDSA cycles (setting patient arrival times and pre-admission pharmacy review of treatment plans) are ongoing; prospective data collection is pending. Conclusions: Retrospective data validate concerns that delays in starting inpatient CTX are longer than acceptable. They affect hospital length of stay, cost, and patient satisfaction. Our first PDSA cycle showed no change in TTC but additional interventions are ongoing.

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