Exploring the relation between process design and efficiency in high-volume cataract pathways from a lean thinking perspective.

OBJECTIVE To compare process designs of three high-volume cataract pathways in a lean thinking framework and to explore how efficiency in terms of lead times, hospital visits and costs is related to process design. DESIGN International retrospective comparative benchmark study with a mixed-method design. SETTING Three eye hospitals in the UK, the USA and the Netherlands participated in this study. All are major international tertiary care and training centres in ophthalmology. PARTICIPANTS Data on all patients who underwent first eye cataract surgery in 2006 were used. INTERVENTIONS The study related six operational aspects of lean thinking in the process design to efficiency. MAIN OUTCOME MEASURES Measures of lean aspects were operational focus, autonomous work cell, physical lay-out of resources, multi-skilled team, pull planning and elimination of wastes. Efficiency was measured with lead times (access time plus waiting time for surgery), hospital visits and direct costs. RESULTS Operational focus was influenced by external circumstances leading to different orientations on efficiency. Pull planning with integrating activities in one-stop procedures conducted by multi-skilled nurses as well as eliminating wastes reduced both the number of hospital visits and costs. Short lead times were associated with the use of a general outpatient clinic and a high-volume cataract surgery clinic. CONCLUSIONS The environmental context and operational focus primarily influenced process design of the cataract pathways. When pressed to further optimize their processes, hospitals can use these systematic benchmarking data to decrease the frequency of hospital visits, lead times and costs.

[1]  S. A. Fisher Essentials of Cost Accounting for Health Care Organizations , 1996 .

[2]  N. Powe,et al.  Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team. , 1994, Archives of ophthalmology.

[3]  Sally McClean,et al.  Some challenges facing Lean Thinking in healthcare , 2009, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[4]  Paul Lillrank,et al.  Standard, routine and non-routine processes in health care. , 2004, International journal of health care quality assurance incorporating Leadership in health services.

[5]  A. Sommer,et al.  Variation in cataract surgery practice and clinical outcomes. , 1994, Ophthalmology.

[6]  C. Keyes Coordination of care provision: the role of the 'handoff'. , 2000, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[7]  N. Roos,et al.  Standard cost lists for healthcare in Canada. Issues in validity and inter-provincial consolidation. , 1999, PharmacoEconomics.

[8]  A Hofman,et al.  Age-specific prevalence and causes of blindness and visual impairment in an older population: the Rotterdam Study. , 1998, Archives of ophthalmology.

[9]  S I McClean,et al.  A critical look at Lean Thinking in healthcare , 2008, Quality & Safety in Health Care.

[10]  Jeffrey K. Liker,et al.  The Toyota way : 14 management principles from the world's greatest manufacturer , 2004 .

[11]  P. Ewings,et al.  Is visual outcome compromised when next day review is omitted after phacoemulsification surgery? A randomised control trial , 2003, The British journal of ophthalmology.

[12]  J. Ellis All inclusive benchmarking. , 2006, Journal of nursing management.

[13]  Gregory H. Watson,et al.  Strategic Benchmarking: How to Rate Your Company's Performance against the World's Best , 1993 .

[14]  Jaakko Kujala,et al.  Time-based analysis of total cost of patient episodes: a case study of hip replacement. , 2006, International journal of health care quality assurance incorporating Leadership in health services.

[15]  J Zuckerman,et al.  Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. , 2000, Medical care.

[16]  Takahiro Fujimoto,et al.  Evolution of Manufacturing Systems and Ex Post Dynamic Capabilities: A Case of Toyota's Final Assembly Operations , 2001 .

[17]  J. Katz,et al.  The value of routine preoperative medical testing before cataract surgery. Study of Medical Testing for Cataract Surgery. , 2000, The New England journal of medicine.

[18]  Jaakko Kujala,et al.  Time-based management of patient processes. , 2006, Journal of health organization and management.

[19]  James P. Womack,et al.  Lean Thinking: Banish Waste and Create Wealth in Your Corporation , 1996 .

[20]  Stephen S. Raab,et al.  Dissemination of Lean Methods to Improve Pap Testing Quality and Patient Safety , 2008, Journal of lower genital tract disease.

[21]  Matthias Holweg,et al.  The genealogy of lean production , 2007 .

[22]  Takahiro Fujimoto,et al.  Lean and reflective production: the dynamic nature of production models , 2007 .

[23]  A. Reidy,et al.  National cataract surgery survey 1997–8: a report of the results of the clinical outcomes , 1999, The British journal of ophthalmology.

[24]  Walter Sermeus,et al.  Efficacy and efficiency of a lean cataract pathway: a comparative study , 2010, Quality and Safety in Health Care.

[25]  D. King,et al.  Redesigning emergency department patient flows: Application of Lean Thinking to health care , 2006, Emergency medicine Australasia : EMA.

[26]  Debbie Andalo,et al.  Innovation and improvement. , 2006, Nursing management.

[27]  J. Diamond,et al.  ‘One-stop’ cataract surgery: The Bristol Eye Hospital experience 1997-1999 , 2001, Eye.

[28]  Daniel T. Jones,et al.  From lean production to the lean enterprise , 1994 .

[29]  J. J. Dahlgaard,et al.  Measuring lean initiatives in health care services: issues and findings , 2006 .

[30]  H. Takeuchi The contradictions that drive Toyotas success , 2008 .

[31]  Tanya Horsley,et al.  The consequences of waiting for cataract surgery: a systematic review , 2007, Canadian Medical Association Journal.

[32]  I. Durand-zaleski,et al.  Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. , 2000, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[33]  Richard Janssen,et al.  Application of lean thinking to health care: issues and observations , 2009, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[34]  Durward K. Sobek,et al.  Reducing waste and errors: piloting lean principles at Intermountain Healthcare. , 2005, Joint Commission journal on quality and patient safety.

[35]  Taiichi Ohno,et al.  Toyota Production System : Beyond Large-Scale Production , 1988 .

[36]  M. Carter,et al.  Global cost-effectiveness of cataract surgery. , 2007, Ophthalmology.

[37]  R. Resar,et al.  Patient Flow in Hospitals: Understanding and Controlling It Better , 2004, Frontiers of Health Services Management.

[38]  The value of routine preoperative medical testing before cataract surgery , 2000 .

[39]  H. Taylor,et al.  Cataract blindness--challenges for the 21st century. , 2001, Bulletin of the World Health Organization.