Integrated Lean Six Sigma approach for patient flow improvement in hospital emergency department

Because of increased competition between healthcare providers, higher customer expectations, stringent checks on insurance payments and new government regulations, it has become vital for healthcare organisations to enhance the quality of the care they provide, to increase efficiency, and to improve the cost effectiveness of their services. Consequently, a number of quality management concepts and tools are employed in the healthcare domain to achieve the most efficient ways of using time, manpower, space and other resources. Emergency departments are designed to provide a high-quality medical service with immediate availability of resources to those in need of emergency care. The challenge of maintaining a smooth flow of patients in emergency departments is a global problem. This study attempts to improve the patient flow in emergency departments by considering Lean techniques and Six Sigma methodology in a comprehensive conceptual framework. The proposed research will develop a systematic approach through integration of Lean techniques with Six Sigma methodology to improve patient flow in emergency departments. The results reported in this paper are based on a standard questionnaire survey of 350 patients in the Emergency Department of Aseer Central Hospital in Saudi Arabia. The results of the study led us to determine the most significant variables affecting patient satisfaction with patient flow, including waiting time during patient treatment in the emergency department; effectiveness of the system when dealing with the patient’s complaints; and the layout of the emergency department. The proposed model will be developed within a performance evaluation metric based on these critical variables, to be evaluated in future work within fuzzy logic for continuous quality improvement.

End-of-life care pathways for improving outcomes in caring for the dying (Review)

Background This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these. Search Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles.We conducted the original search in September 2009, and the updated search in June 2013. Selection Criteria All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data Collection and Analysis Two review authors assessed the results of the searches against the predetermined criteria for inclusion. Main Results The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update. Authors’ Conclusions With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

Privacy concerns and the purchasing of travel services online

The travel industry has come to rely heavily on information and communication technologies to facilitate relations with consumers. Compiling consumer data profiles has become easier and it is generally thought that this has led to an increase in consumers' privacy concerns, which may have an adverse impact on their willingness to purchase online. Three specific aspects of privacy that have received attention from researchers are unauthorized secondary use of data, invasion of privacy, and errors. A study was undertaken to examine the effects of these factors on prior purchase of travel services via the Internet and future purchase probability. No evidence was found to indicate that such privacy concerns affect online purchase behavior within the travel industry. Managerial implications are discussed.

Lung health care for Aboriginal and Torres Strait Islander Queenslanders : breathing easy is not so easy

Objectives In Aboriginal and Torres Strait Islander peoples in Queensland, to (a) determine the disease burden of common chronic lung diseases and (b) identify areas of need with respect to lung health services. Methods Literature reviews and analyses of hospitalisation and mortality data were used to describe disease epidemiology and available programs and services. Key stakeholder interviews and an online survey of health professionals were used to evaluate lung health services across the state and to identify services, needs and gaps. Results Morbidity and mortality from respiratory diseases in the Indigenous population is substantially higher than the non-Indigenous population across all age groups and regions. There are inadequate clinical services and resources to address disease prevention, detection, intervention and management in an evidence-based and culturally acceptable fashion. There is a lack of culturally appropriate educational resources and management programs, insufficient access to appropriately engaged Indigenous health professionals, a lack of multi-disciplinary specialist outreach teams, fragmented information systems and inadequate coordination of care. Conclusions Major initiatives are required at all levels of the healthcare system to adequately address service provision for Indigenous Queenslanders with lung diseases, including high quality research to investigate the causes for poor lung health, which are likely to be multifactorial.

A survey of the Queensland healthcare workforce : attitudes towards dementia care and training

Background Positive attitudes of healthcare staff towards people with dementia promote higher quality care, although little is known about important factors that underlie positive attitudes. Key aims of this project were to explore the relationships between staff attitudes towards dementia, self-confidence in caring for people with dementia, experience and dementia education and training. Method A brief online survey was developed and widely distributed to registered nurses and allied health professionals working in Queensland in 2012. Regression analyses were performed to identify important predictors of self-confidence in caring for people with dementia and positive attitudes towards people with dementia. Results Five hundred and twenty-four surveys were completed by respondents working in a range of care settings across Queensland. Respondents were predominantly female (94.1%), and most were registered nurses (60%), aged between 41 and 60 years (65.6%). Around 40% regularly worked with people with dementia and high levels of self-confidence in caring for this population and positive attitudes towards people with dementia were reported. The majority of respondents (67%) had participated in a dementia education/training activity in the past 12 months. More experience working with people with dementia predicted greater self-confidence while recent participation in a dementia education/training and higher self-confidence in caring for a person with dementia significantly predicted more positive attitudes towards people with dementia. Conclusion These results confirm the importance of self-confidence and dementia education in fostering positive attitudes and care practices towards people with dementia. Our results also indicate that the demand for ongoing dementia education is high amongst health care workers and it is recommended that regular dementia education/ training be provided and promoted for all healthcare personnel who work with people with dementia.

Implementing cognitive remediation therapy : lessons from two public mental health services

Objective: Neurocognitive deficits are a core symptom domain of schizophrenia, occurring in 75 -90 % of people with this diagnosis and influencing long term functional outcomes. This article aims to describe the pilot implementation of cognitive remediation therapy (CRT) in two large public mental health services and detail changes made to the delivery of this therapy after this trial. Conclusions: CRT provides an evidence based approach to targeting cognitive deficits but the translation of this therapy from a research setting to clinical practice has not been well evaluated.

Patients perceptions of emergency department services : better specialised staff, convenient and available services

Many factors are identified as contributing to the high demand for emergency department (ED) care. Similarly, there have been many initiatives taken to minimise the impact that is placed on EDs. Many of these, however, do not consider the patient's opinions and motivations. The aim of this cross-sectional study was to understand patients’ perspectives and reasons behind their decision to present to EDs. 911 surveys were collected from patients presenting to eight QLD EDs in 2011. Based on the Principal Component Analysis technique, a six-item scale entitled "Best services at emergency departments" was extracted (α = 0.729) measuring patients' opinions and perspectives. Further, the independent t-tests were conducted between various groups of ED users. The results suggest that multiple users more likely viewed EDs as the best place for their conditions than the first-time users (Median 10.73 v 11.56, p<0.001). Moreover, patients who made the decision to present by themselves had a more favourable perception of the ED services than those for whom the decision was made or others were involved (Median 11.38 v 10.80, p=0.003). Method of arrival did not affect the respondents’ perception of ED (11.13 v 11.00, p=0.65). The results of this research indicate that patients’ perception of ED as the best and most appropriate place for attention to their medical conditions plays an important role in their decision to present and keep returning to ED. Understanding patients’ reasons and decisions enhances the success of planning and implementing alternative services to manage the demand for ED services.

Inward internationalization of consumer services : lessons from Australian firms

Purpose - The aim of this paper is to explore the inward internationalization process of consumer services. A review of the service internationalization literature is conducted and the resource-based view of the firm is used as a theoretical approach. Design/methodology - Case study methodology is used to explore the internationalization process of five different consumer service sectors: tourism, education, accommodation, transport and entertainment. The main data collection method was interviews conducted with top managers of 12 Australian consumer service firms from these sectors. Findings - Findings of this study show that inward internationalizing services confront most of their barriers, such as immigration policies, exchange rate fluctuations, and cultural differences, in the domestic market where the service is provided. The findings also suggest that superior intentional performance for consumer service firms combines firm-specific resources and capabilities, such as market orientation, service quality, cultural sensitivity, international communicational activities, partnerships and networks, with country-specific resources and capabilities, such as country-of-origin image and government support. Research limitations/implications - This is one of the few studies in the academic literature that directly addresses the issue of inward internationalization of consumer services. Limitations derive from the qualitative nature of this study. Practical implications - The process of inward internationalization applies to a broad range of service industries and can assist firms to develop more effective international marketing strategies. Originality/value - This study contributes to the international services literature by identifying the main barriers and drivers of international performance for inward internationalizing consumer service firms, which is a topic that has been neglected in the literature.

Embedded digital creative workers and creative services in banking

This chapter explores the roles and functions of both digital creative workers and creative services firms in an industry beyond the core creative industries: banking. The chapter focuses on the design and development of apps and mobile websites for smartphones and tablet computers, with examples drawn principally from the Australian banking sector. While it might be assumed that utility and practicality are more critical and more highly valued in apps development for financial services institutions than innovation and aesthetic design, this chapter illustrates the growing importance placed on creative work in this sector.

Creative services, apps and banks in Australia

This paper is divided in to three parts. The first part discusses recent CCI research on employment in creative services, with particular focus on the 'creative trident' model, and the distinction between cultural production and creative services occupations. The second part discusses the growth of the app economy and related employment details. The third part discusses mobile banking use, financial services and mobile devices, and apps created by or for banks.

Front-line workers as intermediaries : the changing landscape of disability and employment services in Australia

Recent welfare reform in Australia has been constructed around the now-familiar principle of paid work and willingness to work as the fundamental marker of social citizenship. Beginning with the long-term unemployed in Australia in the mid 1990s, the scope of welfare reform has now extended to include people with a disability – which is a category of income support that has been growing in Australia. From the national government’s point of view this growth is a financial concern as it seeks to move as many people as possible into paid work to support the costs of an ageing population (DEWR, 2005). In doing so, the government has changed the meaning of disability in terms of eligibility for financial support from the state, and at the same time redefined the role of people with a disability with regard to work, and the role of the state with regard to the disabled. This has been a matter of some political contention in Australia.

How transit route passenger load and distance can together influence quality of service

This paper investigates quality of service and resource productivity implications of transit route passenger loading and travel distance. Weekday Automatic Fare Collection data for a premium radial bus route in Brisbane, Australia, is used to investigate correlation between load factor and distance factor. Relationships between boardings and transit work indicate that distance factor generally increases with load factor. Time series analysis is then presented by examining each direction on an hour by hour basis. Inbound correlation is medium to strong across the entire span of service and strong for daytime services up to 19:30, while outbound correlation is strong across the entire span. Passengers tend to be making longer distance, peak direction commuter trips under the least comfortable conditions under stretched peak schedules than off-peak. Therefore productivity gains may be possible by adjusting fleet utilization during off-peak times. Weekday profiles by direction are established for a composite load-distance factor. A threshold corresponding to standing passengers on the Maximum Load Segment reveals that on-board loading and travel distance combined are more severe during the morning inbound peak than evening outbound peak, although the sharpness of the former suggests that encouraging shoulder peak travel during the morning would be more effective than evening peak. Further research suggested includes: consideration of travel duration factor, relating noise within hour to Peak Hour Factor, profiling load-distance factor across a range of case studies, and relating load-distance factor threshold to line length.