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Article ; Online: Sustainability of performance improvements after 26 Kaizen events in a large academic hospital system: a mixed methods study.

Haapatalo, Erik / Reponen, Elina / Torkki, Paulus

2023 Volume 13, Issue 8, Page(s) e071743

Abstract: Introduction: Implementing Kaizen can improve productivity in healthcare but maintaining long-term results has proven challenging. This study aimed to assess improved performance achieved and sustained by Kaizen events and find explanatory factors for ... ...

Abstract	Introduction: Implementing Kaizen can improve productivity in healthcare but maintaining long-term results has proven challenging. This study aimed to assess improved performance achieved and sustained by Kaizen events and find explanatory factors for the persistence or decline of long-term results. Methods: Kaizen events were conducted in 26 specialised healthcare units in a large academic hospital system in southern Finland. Primary data for mixed methods analysis was collected from each unit with 21 semi-structured interviews, Kaizen report files and performance metrics. Results: Fifteen explanatory factors were found in this study. Work culture and motivation for continuous improvement stood out as the most important explanatory factor for the persistence of long-term results-lack of time for improvement activities and high workload for the decline. Success in preparation and follow-up was associated with sustained long-term results. Thirteen units achieved long-term results, three units could not sustain the performance improvements and five units struggled to make any improvements. Conclusions: This study explains the long-term sustainability of performance improvements, bringing new insights to Kaizen research. Our findings can guide organising successful Kaizen events. The events can be worth organising even though long-term performance improvements are not guaranteed. Units with supportive working culture and motivation for the Kaizen event will likely succeed. A unit should aim to create a supportive foundation for Kaizen before organising a Kaizen event. Units that lack the foundation can be identified, trained and guided to increase their chances of success. Pitfalls like high workload and insufficient follow-up should be proactively identified and appropriately managed by allocating the required time and resources for the development work.
MeSH term(s)	Humans ; Hospitals ; Health Facilities ; Benchmarking ; Finland ; Motivation
Language	English
Publishing date	2023-08-28
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2599832-8
ISSN	2044-6055 ; 2044-6055
ISSN (online)	2044-6055
ISSN	2044-6055
DOI	10.1136/bmjopen-2023-071743
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Associations Between Lean IT Management and Financial Performance in US Hospitals.

Lee, Justin / Hung, Dorothy Y / Reponen, Elina / Rundall, Thomas G / Tierney, Aaron A / Fournier, Pierre-Luc / Shortell, Stephen M

Quality management in health care

2023 Volume 33, Issue 2, Page(s) 67–76

Abstract: Background and objectives: To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes.: Methods: Primary data were ... ...

Abstract	Background and objectives: To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes. Methods: Primary data were sourced from 1222 hospitals that responded to the National Survey of Lean (NSL)/Transformational Performance Improvement, which was fielded to 4500 general medical-surgical hospitals across the United States. Secondary sources included hospital performance data from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). We performed 2 sets of multivariable regressions using data gathered from US hospitals, linked to AHRQ and CMS performance outcomes. We examined 10 different outcomes measuring financial performance, quality of care, and patient experience, and their associations with Lean adoption within hospital IT departments. We then focused only on those hospitals that adopted Lean in IT to identify specific practices associated with performance. Results: Controlling for other factors, adoption of Lean IT management was associated with lower length of stay ( b = -0.098, P = .018) and inpatient expense per discharge ( b = -0.112, P = .090). Specifically, use of visual management tools (eg, A3 storyboards, status sheets) was associated with lower adjusted inpatient expense per discharge ( b = -0.176, P = .034) and higher earnings before interest, taxes, depreciation, and amortization margin ( b = 0.124, P = .042). Such tools were also associated with hospital participation in bundled payment programs (odds ratio = 2.326; P = .046; 95% confidence interval, 0.979-5.527) and percentage of net revenue paid on a shared risk basis ( b = 0.188, P = .031). Conclusions: Lean IT management was associated with positive financial performance, particularly with hospital participation in value-based payment. More detailed study is needed to understand other influential factors and types of work processes, activities, or mechanisms by which high-functioning IT can contribute to financial outcomes.
MeSH term(s)	Aged ; Humans ; United States ; Information Technology ; Medicare ; Hospitals
Language	English
Publishing date	2023-10-11
Publishing country	United States
Document type	Journal Article
ZDB-ID	1162319-6
ISSN	1550-5154 ; 1063-8628
ISSN (online)	1550-5154
ISSN	1063-8628
DOI	10.1097/QMH.0000000000000440
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Article: Classification of Electronic Health Record-Related Patient Safety Incidents: Development and Validation Study.

Palojoki, Sari / Saranto, Kaija / Reponen, Elina / Skants, Noora / Vakkuri, Anne / Vuokko, Riikka

JMIR medical informatics

2021 Volume 9, Issue 8, Page(s) e30470

Abstract: Background: It is assumed that the implementation of health information technology introduces new vulnerabilities within a complex sociotechnical health care system, but no international consensus exists on a standardized format for enhancing the ... ...

Abstract	Background: It is assumed that the implementation of health information technology introduces new vulnerabilities within a complex sociotechnical health care system, but no international consensus exists on a standardized format for enhancing the collection, analysis, and interpretation of technology-induced errors. Objective: This study aims to develop a classification for patient safety incident reporting associated with the use of mature electronic health records (EHRs). It also aims to validate the classification by using a data set of incidents during a 6-month period immediately after the implementation of a new EHR system. Methods: The starting point of the classification development was the Finnish Technology-Induced Error Risk Assessment Scale tool, based on research on commonly recognized error types. A multiprofessional research team used iterative tests on consensus building to develop a classification system. The final classification, with preliminary descriptions of classes, was validated by applying it to analyze EHR-related error incidents (n=428) during the implementation phase of a new EHR system and also to evaluate this classification's characteristics and applicability for reporting incidents. Interrater agreement was applied. Results: The number of EHR-related patient safety incidents during the implementation period (n=501) was five-fold when compared with the preimplementation period (n=82). The literature identified new error types that were added to the emerging classification. Error types were adapted iteratively after several test rounds to develop a classification for reporting patient safety incidents in the clinical use of a high-maturity EHR system. Of the 427 classified patient safety incidents, interface problems accounted for 96 (22.5%) incident reports, usability problems for 73 (17.1%), documentation problems for 60 (14.1%), and clinical workflow problems for 33 (7.7%). Altogether, 20.8% (89/427) of reports were related to medication section problems, and downtime problems were rare (n=8). During the classification work, 14.8% (74/501) of reports of the original sample were rejected because of insufficient information, even though the reports were deemed to be related to EHRs. The interrater agreement during the blinded review was 97.7%. Conclusions: This study presents a new classification for EHR-related patient safety incidents applicable to mature EHRs. The number of EHR-related patient safety incidents during the implementation period may reflect patient safety challenges during the implementation of a new type of high-maturity EHR system. The results indicate that the types of errors previously identified in the literature change with the EHR development cycle.
Language	English
Publishing date	2021-08-31
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2798261-0
ISSN	2291-9694
ISSN	2291-9694
DOI	10.2196/30470
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Article ; Online: Examining the Relationship Between the Lean Management System and Quality Improvement Care Management Processes.

Tierney, Aaron A / Shortell, Stephen M / Rundall, Thomas G / Blodgett, Janet C / Reponen, Elina

Quality management in health care

2021 Volume 31, Issue 1, Page(s) 1–6

Abstract: Background and objectives: The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the ... ...

Abstract	Background and objectives: The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean Management System based on the Shingo principles originally developed by Toyota in Japan. Our objective was to examine the association between hospital use of the Lean Management System and evidence-based or recommended quality improvement care management processes. Methods: A cross-sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals was conducted. Results: Controlling for hospital organizational and market characteristics, the number of years using Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the P < .05 level. The degree of education and training in Lean methods and processes was also positively associated ( P < .05) with greater support for care transitions. The number of years using Lean was marginally associated with screening for clinical conditions at the P < .10 level. There was an unexpected negative association between education and training scores and screening for clinical conditions. Conclusions: Greater experience in using the Lean Management System is positively associated with several evidence-based and/or recommended quality improvement care management processes.
Language	English
Publishing date	2021-08-26
Publishing country	United States
Document type	Journal Article
ZDB-ID	1162319-6
ISSN	1550-5154 ; 1063-8628
ISSN (online)	1550-5154
ISSN	1063-8628
DOI	10.1097/QMH.0000000000000318
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Article ; Online: Lean Management and Hospital Performance: Adoption vs. Implementation.

Shortell, Stephen M / Blodgett, Janet C / Rundall, Thomas G / Henke, Rachel Mosher / Reponen, Elina

Joint Commission journal on quality and patient safety

2021 Volume 47, Issue 5, Page(s) 296–305

Abstract: Background: The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance.: Methods: A multivariate analysis was performed of the ... ...

Abstract	Background: The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance. Methods: A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures. Results: Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures. Conclusion: Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.
MeSH term(s)	Aged ; Hospitals ; Humans ; Inpatients ; Medicare ; Patient Satisfaction ; Surveys and Questionnaires ; United States
Language	English
Publishing date	2021-02-05
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	1189890-2
ISSN	1938-131X ; 1549-425X ; 1553-7250 ; 1070-3241 ; 1549-3741
ISSN (online)	1938-131X ; 1549-425X
ISSN	1553-7250 ; 1070-3241 ; 1549-3741
DOI	10.1016/j.jcjq.2021.01.010
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Article ; Online: Quality of British and American Nationwide Quality of Care and Patient Safety Benchmarking Programs: Case Neurosurgery.

Reponen, Elina / Tuominen, Hanna / Korja, Miikka

Neurosurgery

2018 Volume 85, Issue 4, Page(s) 500–507

Abstract: Background: Multiple nationwide outcome registries are utilized for quality benchmarking between institutions and individual surgeons.: Objective: To evaluate whether nationwide quality of care programs in the United Kingdom and United States can ... ...

Abstract	Background: Multiple nationwide outcome registries are utilized for quality benchmarking between institutions and individual surgeons. Objective: To evaluate whether nationwide quality of care programs in the United Kingdom and United States can measure differences in neurosurgical quality. Methods: This prospective observational study comprised 418 consecutive adult patients undergoing elective craniotomy at Helsinki University Hospital between December 7, 2011 and December 31, 2012.We recorded outcome event rates and categorized them according to British Neurosurgical National Audit Programme (NNAP), American National Surgical Quality Improvement Program (NSQIP), and American National Neurosurgery Quality and Outcomes Database (N2QOD) to assess the applicability of these programs for quality benchmarking and estimated sample sizes required for reliable quality comparisons. Results: The rate of in-hospital major and minor morbidity was 18.7% and 38.0%, respectively, and 30-d mortality rate was 2.4%. The NSQIP criteria identified 96.2% of major but only 38.4% of minor complications. N2QOD performed better, but almost one-fourth (23.2%) of all patients with adverse outcomes, mostly minor, went unnoticed. For NNAP, a sample size of over 4200 patients per surgeon is required to detect a 50.0% increase in mortality rates between surgeons. The sample size required for reliable comparisons between the rates of complications exceeds 600 patients per center per year. Conclusion: The implemented benchmarking programs in the United Kingdom and United States fail to identify a considerable number of complications in a high-volume center. Health care policy makers should be cautious as outcome comparisons between most centers and individual surgeons are questionable if based on the programs.
MeSH term(s)	Adult ; Benchmarking/standards ; Craniotomy/adverse effects ; Databases, Factual ; Elective Surgical Procedures/adverse effects ; Female ; Humans ; Male ; Middle Aged ; Neurosurgery/standards ; Neurosurgical Procedures/adverse effects ; Patient Safety/standards ; Postoperative Complications/epidemiology ; Postoperative Complications/etiology ; Prospective Studies ; Quality Improvement/standards ; Registries ; United Kingdom ; United States
Language	English
Publishing date	2018-09-18
Publishing country	United States
Document type	Journal Article ; Observational Study
ZDB-ID	135446-2
ISSN	1524-4040 ; 0148-396X
ISSN (online)	1524-4040
ISSN	0148-396X
DOI	10.1093/neuros/nyy380
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Article: Lifetime Cannabis Use Is Not Associated With Negative Beliefs About Medication in Patients With First Treatment Psychosis.

Gjerde, Priyanthi B / Steen, Synne W / Vedal, Trude S J / Steen, Nils Eiel / Reponen, Elina J / Andreassen, Ole A / Steen, Vidar M / Melle, Ingrid

Frontiers in psychiatry

2022 Volume 13, Page(s) 824051

Abstract: Objective: Cannabis use is common among patients with psychosis, and along with negative beliefs about medication, it has been found to predict poor adherence to antipsychotic drug treatment. Such lack of adherence to antipsychotic drug treatment ... ...

Abstract	Objective: Cannabis use is common among patients with psychosis, and along with negative beliefs about medication, it has been found to predict poor adherence to antipsychotic drug treatment. Such lack of adherence to antipsychotic drug treatment increases the risk of poor clinical outcomes and relapse in patients with first treatment for psychosis (FTP). However, to date, it is unclear whether cannabis use may be related to negative perceptions about antipsychotic drug treatment. Methods: A cross-sectional sample of 265 FTP patients with schizophrenia spectrum disorder underwent extensive clinical assessments. Three measures of cannabis use were obtained: lifetime, current and meeting diagnostic criteria for abuse or addiction. For the primary analyses we focused on lifetime cannabis use. The Beliefs about Medication Questionnaire (BMQ) was employed to assess the patients' specific concerns and perceptions of antipsychotic medications, as well as general beliefs about pharmacotherapy. The relationship between lifetime cannabis use and BMQ scores was investigated with general linear model (GLM) analyses, controlling for age and sex. Results: Patients with lifetime use of cannabis ≥10 times were more likely to be male, younger at the age of onset of psychosis and with higher levels of alcohol use and daily tobacco smoking, as compared to the non-users ( Conclusion: Use of cannabis is not linked to negative perceptions about antipsychotic medicines in patients with FTP. Other reasons for poor compliance to antipsychotic drug treatment in cannabis users need to be further investigated.
Language	English
Publishing date	2022-03-29
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2564218-2
ISSN	1664-0640
ISSN	1664-0640
DOI	10.3389/fpsyt.2022.824051
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Article ; Online: Expert-Identified Practices for Achieving Measurable Performance Improvements With Lean Implementation.

Reponen, Elina / Rundall, Thomas G / Shortell, Stephen M / Blodgett, Janet C / Jokela, Ritva / Mäkijärvi, Markku / Torkki, Paulus

Quality management in health care

2022 Volume 32, Issue 1, Page(s) 1–7

Abstract: Background and objectives: Despite the rapid spread of Lean management in health care, few organizations have achieved measurable overall performance improvements with Lean. What differentiates these organizations from those that struggle with realizing ...

Abstract	Background and objectives: Despite the rapid spread of Lean management in health care, few organizations have achieved measurable overall performance improvements with Lean. What differentiates these organizations from those that struggle with realizing the potential benefits of Lean management is unclear. In this qualitative study we explore measuring the impact of Lean and the recommended practices for achieving measurable performance improvements with Lean in health care organizations. Methods: Informed by preliminary quantitative results from analyses of high- and low-performing Lean hospitals, we conducted 17 semi-structured interviews with Lean health care experts on the Lean principles and practices associated with better performance. We conducted qualitative content analyses of the interview transcripts based on grounded theory and linking to core principles and practices of the Lean management system. Results: The qualitative data revealed 3 categories of metrics for measuring the impact of Lean: currently used institutional measures, measures tailored to Lean initiatives, and population-level measures. Leadership engagement/commitment and clear organizational focus/prioritization/alignment had the highest weighted averages of success factors. The lack of these 2 factors had the highest weighted averages of biggest barriers for achieving measurable performance improvements with Lean implementation. Conclusions: Leadership engagement and organizational focus can facilitate achieving the organization's performance improvement goals, whereas their absence can considerably hinder performance improvement efforts. Many different approaches have been used to quantify the impact of Lean, but currently used institutional performance measures are preferred by the majority of Lean experts.
MeSH term(s)	Humans ; Delivery of Health Care ; Hospitals ; Leadership ; Benchmarking ; Qualitative Research
Language	English
Publishing date	2022-04-06
Publishing country	United States
Document type	Journal Article
ZDB-ID	1162319-6
ISSN	1550-5154 ; 1063-8628
ISSN (online)	1550-5154
ISSN	1063-8628
DOI	10.1097/QMH.0000000000000349
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Article ; Online: Lean Management and Breakthrough Performance Improvement in Health Care.

Ahn, Christie / Rundall, Thomas G / Shortell, Stephen M / Blodgett, Janet C / Reponen, Elina

Quality management in health care

2020 Volume 30, Issue 1, Page(s) 6–12

Abstract: Background and objectives: Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health ... ...

Abstract	Background and objectives: Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health care organizations to substantially improve quality of care and patient outcomes while containing costs in the relatively short term, many health care leaders are looking for ways to achieve large breakthrough improvements in their organization's performance. The objective of this research is to understand whether and how Lean management can be used to achieve breakthrough improvements in performance. Methods: This study used grounded theory and content analysis of in-depth, semistructured interviews with 10 nationally recognized experts in the use of Lean management in health care organizations. The 10 participants constitute a purposive sample of experts with in-depth understanding of the strengths and limitations of Lean management in health care organizations. Results: Two out of 10 participants defined breakthrough improvement as a major change in a performance metric; 2 participants defined it as a fundamental redesign in a process or service; the remaining 6 participants defined breakthrough improvement as having both these characteristics. The extent to which participants believed Lean was an effective means for achieving breakthrough improvement in performance was related to how they defined breakthrough improvement. The 2 participants who defined breakthrough improvement as a significant change in a performance metric believed Lean methods alone were sufficient. The 2 participants who defined breakthrough improvement to be a fundamental redesign tended not to view Lean alone as an effective approach. Rather, they, and the 6 participants who defined breakthrough improvement as having both change-in-metric and process redesign characteristics, viewed human-centered design thinking as the primary or important complementary approach to achieving breakthrough improvement. Participants identified resources, culture change, and leadership commitment beyond what would be required to achieve incremental improvement as the main facilitators and barriers to achieving breakthrough improvements. Conclusion: This research reveals some differences in experts' definitions of breakthrough improvement, and illuminates the value of human-centered design thinking, alone or as a complement to Lean management, in achieving breakthrough improvement in health care organizations. Most of our expert participants agreed that supplementing Lean management methods with the contributions of innovation design and investing significant resources, strengthening the organizational culture to support the necessary changes, and providing stronger leadership commitment to the effort are important facilitators for achieving breakthroughs in organizational performance.
MeSH term(s)	Delivery of Health Care ; Health Facilities ; Humans ; Leadership ; Organizational Culture ; Quality Improvement
Language	English
Publishing date	2020-11-09
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1162319-6
ISSN	1550-5154 ; 1063-8628
ISSN (online)	1550-5154
ISSN	1063-8628
DOI	10.1097/QMH.0000000000000282
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Article ; Online: Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery.

Reponen, Elina / Korja, Miikka / Tuominen, Hanna

Neurosurgery

2017 Volume 83, Issue 2, Page(s) 197–202

Abstract: Background: Patient-reported preoperative factors hold promise in improving the prediction of postoperative adverse events, but they have been poorly studied.: Objective: To study the role of patient-reported factors in the preoperative risk ... ...

Abstract	Background: Patient-reported preoperative factors hold promise in improving the prediction of postoperative adverse events, but they have been poorly studied. Objective: To study the role of patient-reported factors in the preoperative risk stratification of elective craniotomy patients. Methods: A prospective, unselected cohort of 322 adult patients underwent elective craniotomy in Helsinki, Finland. We preoperatively recorded the American Society of Anesthesiologists (ASA) score, Helsinki ASA score, and 3 questionnaire-based patient-reported factors including overall health status, ability to climb 2 flights of stairs, and cognitive function (Test Your Memory test). Outcome measures comprised in-hospital major and overall morbidity. Receiver-operating characteristic curves served to calculate area under the curve (AUC) values for a composite score of patient-reported factors and both ASA scores with regard to outcomes. Results: In-hospital major and overall morbidity rate was 15.2%. Only preoperatively diminished cognitive function remained a significant predictor of major morbidity after multivariable logistic regression analysis (P < .001, odds ratio 1.1, confidence interval 1.0-1.1). A composite score of our 3 patient-reported factors had a higher AUC (0.675) for major morbidity than original ASA score (0.543) or Helsinki ASA score (0.572). In elderly patients, the composite score had an AUC of 0.726 for major morbidity. Conclusion: Preoperative patient-reported factors had higher sensitivity for detecting major morbidity compared to the ASA scores in this study. Particularly, the simple composite score seems to predict adverse outcomes in elective cranial surgery surprisingly well, especially in the elderly. These results are interesting and worth confirming in other centers.
MeSH term(s)	Adult ; Aged ; Cohort Studies ; Craniotomy/adverse effects ; Elective Surgical Procedures/adverse effects ; Female ; Finland ; Health Status ; Humans ; Male ; Middle Aged ; Patient Reported Outcome Measures ; Postoperative Complications/etiology ; Prospective Studies ; Risk Assessment/methods ; Risk Factors ; Sensitivity and Specificity
Language	English
Publishing date	2017-09-24
Publishing country	United States
Document type	Journal Article
ZDB-ID	135446-2
ISSN	1524-4040 ; 0148-396X
ISSN (online)	1524-4040
ISSN	0148-396X
DOI	10.1093/neuros/nyx385
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