In health care, "Timing is everything" is not just a casual aphorism. In a hospital, special scheduling requirements complicate the care of patients with diabetes. The timing of meals must be coordinated with the administration of insulin. The timing of radiology procedures can interfere with meal delivery, insulin administration, and blood glucose testing. Jonathan Jay Yamamoto, Bill Malestinic, Angela Lehman, and Rattan Juneja cite an earlier Lean Six Sigma study in which it had been found that the absence of coordination in the timing of meals and radiology tests could impede reaching optimal clinical outcomes in patients receiving insulin. The authors now report on a project in which Lean Six Sigma methodology was used to improve the clinical outcomes of patients receiving insulin by improving the coordination of meal delivery and test timing with insulin administration.
To test the premise that the patient's failure to comply with his or her visit schedule is a major obstacle to the success of the disease management plan, and that long waiting times contribute to the no-show rates, Fischman and a project team employed Lean Six Sigma methodology to determine the critical factors affecting no-show rates, scheduling efficiency, and continuity of care. Among the factors contributing to the patient's schedule compliance was his or her personal relationship with the physician-a feeling of "connectedness" with the doctor, if you will.
Widespread attention is focused on the application of Six Sigma and Lean Six Sigma methodology to improvement efforts in systems for the delivery of health care services, particularly in hospitals. Consultants are retained, workshops held, teams formed, projects launched, and reports published. However, Jami Dellifraine, James R. Langabeer, and Ingrid M. Nembhard question the quality of the evidence validating the effectiveness of Lean and Six Sigma. They carried out a comprehensive literature review, assessing the quality of the empirical evidence relating Lean and Six Sigma initiatives to observed improvements in clinical outcomes, processes of care, and financial performance of health care organizations. Their principal conclusion is that the evidence linking Six Sigma and Lean to improvements in health care quality is very weak. In particular, they point to the absence of measurable outcome evidence in many studies, the emphasis on process instead of on clinical outcomes, and the absence of well-designed statistical analysis. They attribute these omissions to bad study design. They offer a credible and intriguing theory to explain the absence of studies reporting negative results.
In situ simulation is a valuable way of analyzing and evaluating skills and performance on the basis of the team rather than on the basis of the individual. An example of the use of this intervention, drawn from the aviation industry, in a health care setting is presented by William R. Hamman and coworkers. They explain the 3 steps in an in situ simulation: creation of a realistic scenario based on the events that are within the participants' experience, enactment of the scenario, and immediate video debriefing with the participants in a "nonanxious" setting. In the study reported on, several latent threats to patient safety were revealed, and corrective measures taken.
It is old news that, to an increasing extent, physicians are engaged and involved in various sorts of practice organizations. They work in group practices, academic medical centers, or similar bodies. The totally independent solo practitioner is disappearing. To swim, thrive, and carry out their mission in this new ocean, physician leaders need to have a wide range of new skills of the kind taught in graduate schools of business management. This skill set addresses, among other things, organizing projects, managing teams, keeping the financial structure healthy, and dealing with various communities, many with their own agendas-all the while producing the desired products, healthy and satisfied patients. Nancy Gagliano and colleagues present a report about the content and outcomes of a 2-year course offered by the Massachusetts General Physicians' Organization designed to provide physicians with the desired leadership skills.
Computerized physician order entry (CPOE) systems are widely acknowledged as instrumental in supporting patient safety and clinical efficacy. However, as Stephanie M. Peshek, Kathleen Cubera, and Linda Gleespen report, incorporating the applicable protocols and best practice guidelines devised during the hardcopy days in new CPOEs and then activating the system can be a complicated project. They take the reader through the entire process in their report of the implementation of a network-wide CPOE system.
The forces that affect employees' decisions about acknowledging and reporting performance errors are addressed by Steven L. Walston and Ari Mwachofi of Oklahoma City in collaboration with Bakheet Aldosari, Badan A. Al-Omar, Asmaa Al Yousef, and Asiya Sheikh of Riyadh, Kingdom of Saudi Arabia. The hospital that was the site of their study, a major teaching institution, enjoys the advantages of having a sophisticated information system. Having such a system in place facilitates the detection and reporting of patient care errors. On the other hand, cultural and social influences frequently work in the direction of mutual protection and glossing over observed errors. The coauthors analyze the interaction between these 2 factors as it ultimately affects patient safety and the quality of care. They conclude that an organizational culture that fosters the open acknowledgment and discussion of errors will promote quality improvement.
Borrowing strategies from industry, many hospitals are adopting Red Rules to implement their patient safety programs. Basically, health care Red Rules have the following characteristics: (a) the Red Rule should demonstrably support patient safety; (b) the rule must be stated in absolute terms without exceptions, and its language must be easily understandable by all personnel; (c) anyone noticing a breach of a Red Rule is authorized and obliged to halt whatever patient care process is involved in the breach; (d) all levels of the organization support the work stoppage; (e) anyone who has broken a Red Rule is permitted to explain and defend his or her action; and (f) Red Rules are very few in number, easily understood, and easy to memorize. Sheree O'Neill, Karen Gabel Speroni, Lisa Dugan, and Marlon Daniel report a hospital's experience in implementing 2 of the hospital's Red Rules. The research objectives addressed were (a) to evaluate the success of the preparatory educational efforts and (b) to determine the factors responsible for safety-maintenance errors.
M. Thane Forthman, Robert S. Gold, Henry G. Dove, and Richard D. Henderson point to the need for an evaluation system that will enable consumers to make more informed choices when selecting health care providers. They tackle the methodological problem by developing a risk-adjusted method for assessing clinical outcomes across providers. Their plan is built on 4 indices for measuring rates of mortality, complications, readmissions, and patient safety events.
-Jean Gayton Carroll, PhD
Editor