critique each artical like we did in the old assigemnt

critique each artical like we did in the old assigemnt ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON critique each artical like we did in the old assigemnt Literature Review. Objective: To prepare a review of the literature pertinent to a selected problem for healthcare research and to use that review to propose a methodology to address the problem. critique each artical like we did in the old assigemnt This assignment will be done individually Select a problem/topic Conduct a search of literature relevant to the problem/topic. Identify a minimum of 7 references, most of which are randomized clinical trials. Only one opinion articles may be included. Prepare a preliminary list of these references in an approved format. Read the articles with the focus of preparing a document that will compare and contrast the information in the articles you found. Copies of the articles used must be submitted with the final paper. The reader of your literature review should be able to clearly identify the gaps in the knowledge in the problem area as well as the purpose of the study you are proposing. The number of pages in this assignment vary according to the problem length and complexity of the articles reviewed and critiqued. You should be able to write enough to create an effective argument but not so much that the result looks padded. Due March 23 . critique each artical like we did in the old assigemnt .pdf .pdf .pdf .pdf .pdf Journal of Investigative Surgery, 29, 316–321, 2016 C 2016 Taylor & Francis Group, LLC Copyright ISSN: 0894-1939 print / 1521-0553 online DOI: 10.3109/08941939.2016.1149638 NEW METHODOLOGY Integrated Practice Improvement Solutions—Practical Steps to Operating Room Management Mikhail Chernov, MD, PhD, Janet Pullockaran, MD, Angela Vick, MD, Galina Leyvi, MD, MS, Ellise Delphin, MD, MPH Montefiore Medical Center, Weiler Hospital, New York, New York, USA ABSTRACT Perioperative productivity is a vital concern for surgeons, anesthesiologists, and administrators as the OR is a major source of hospital elective admissions and revenue. Based on elements of existing Practice Improvement Methodologies (PIMs), “Integrated Practice Improvement Solutions” (IPIS) is a practical and simple solution incorporating aspects of multiple management approaches into a single open source framework to increase OR efficiency and productivity by better utilization of existing resources. Materials and Methods: OR efficiency was measured both before and after IPIS implementation using the total number of cases versus room utilization, OR/anesthesia revenue and staff overtime (OT) costs. Other parameters of efficiency, such as the first case on-time start and the turnover time (TOT) were measured in parallel. Results: IPIS implementation resulted in increased numbers of surgical procedures performed by an average of 10.7%, and OR and anesthesia revenue increases of 18.5% and 6.9%, respectively, with a simultaneous decrease in TOT (15%) and OT for anesthesia staff (26%). The number of perioperative adverse events was stable during the two-year study period which involved a total of 20,378 patients. Conclusion: IPIS, an effective and flexible practice improvement model, was designed to quickly, significantly, and sustainably improve OR efficiency by better utilization of existing resources. Success of its implementation directly correlates with the involvement of and acceptance by the entire OR team and hospital administration. Keywords: OR management; methodology; OR efficiency; quality improvement; patients care; safety INTRODUCTION Improvement Methodologies (PIMs) (Table 1) to both healthcare management in general and to OR management in particular. In recent publications, those most often used were LEAN, Six-sigma and Critical Pass Methodologies [7–9]. Broadly based on the P-D-C-A cycle, publicized in works of William E. Deming [10] in 1950s most of these methodologies have similar core principles but vary in practices and methods of implementation [11]. critique each artical like we did in the old assigemnt Each has unique elements that are specifically applicable for improvement in different areas of OR management. However, these tools were not specifically designed for this purpose and their application to the task has often been random at best and with inconsistent results [12]. In addition, utilization of a single non-specific approach may significantly limit flexibility in management choices and affect outcomes. Therefore the authors developed and implemented a step-to-step method for OR management, utilizing elements of existing PIMs applicable to specific key practice areas (KPA) of perioperative management. More than 20 years of cost-cutting measures in healthcare have caused a significant shift in the revenueto-expense ratio primarily due to rapidly rising expenses [1–3] and corresponding shifts in our approach to medicine from “science and art” to a “business.” Medicine arrived to the business world with a significantly different concept and approach focusing on patient care rather than material management, efficiency, and profit [4, 5]. This approach created multiple challenges due to lack of an industry accepted business plan or model, quality control criteria, metrics, and formally trained managers [2]. As a result, healthcare management is, in most cases, nonscientific and based primarily on “best knowledge.” One area in which this is most evident is the perioperative environment. To improve efficiency of the operating suite—the main source of elective admissions and revenue [6], attempts have been made to apply Practice Received 20 July 2015; accepted 14 December 2015. Address correspondence to Mikhail Chernov, MD, PhD, Montefiore Medical Center, Weiler Hospital, 1825 Eastchester Avenue, New York, NY 10461, USA. E-mail: mchernovS@montefiore.org 316 Integrated Practice Improvement Solutions TABLE 1 Original areas of implementation of common practice improvement methodologies Practice Improvement Methodology PDCA—(Plan-Do-ControlAct TQM—(Total Quality Management) Lesson Study TSM—(Team Service Management) CMM—(Capability Maturity Model) LEAN 6 SIGMA CPM—(Critical Pass Methodology) Main Area of Use Manufacturing/Service Manufacturing/Service Education Finance Information Technology Manufacturing Information Technology Manufacturing / Service MATERIAL/METHODS Implementation of IPIS in the management of a 13 room operating suite at Einstein Campus of Montefiore Medical Center was initiated in 2011.critique each artical like we did in the old assigemnt The system was running at full capacity by 2013. To maximize system flexibility and applicability in the complex and fast-paced environment of the OR, we rejected a conventional approach to practice management based on a single, randomly chosen methodology, and instead incorporated unique elements of multiple PIMs into a single open-source framework. The idea to use an open-source business framework originated through a study of the Capability Matu- FIGURE 1 A-B (KPA1)—Patient is leaving initial location (home, hospital ward, etc.) and arriving to ASU. B-C (KPA2)—Patient is leaving ASU to Operating room. C-D (KPA3)—Patient is leaving OR and arrives in the PACU. D-A (KPA4)—Patient is leaving the PACU to go to designated final location. C 2016 Taylor & Francis Group, LLC 317 rity Model (CMM). This methodology can be viewed as a set of structured levels that describe how well the behaviors, practices, and processes of an organization can reliably and sustainably produce a required outcome. It consists of best practices that address development and maintenance activities that cover the product lifecycle from conception through delivery and maintenance [13]. The following features make this methodology useful in our approach to OR management: 1. Mapping—Identifying KPAs throughout the entire process and the most influential functional components within each KPA. These KPAs are then subjected to a mapping process linking them to maturity levels to develop a CMM to analyze the capability of organization. 2. Maturity levels (Initial, Repeatable, Defined, Managed, and Optimized)—to define the progression of the organization towards the ultimate goal of self-optimization and self-improvement [13]. Based on the “mapping” concept, we identified four KPAs within the entire process of Patient-to-OR interaction (from initial location—to a final destination) (Figure 1). Where: A-B (KPA1)—Patient is leaving initial location (home, hospital ward, etc.) and arriving to ASU. B-C (KPA2)—Patient is leaving ASU to Operating room C-D (KPA3)—Patient is leaving OR and arrives in the PACU D-A (KPA4)—Patient is leaving the PACU to go to designated final location. The initial step was to assemble focus groups, multidisciplinary teams representing each department and division involved in the progress of a specific KPA, i.e. surgery, anesthesia, nursing, material management, and administration. Each group was guided by a “leader”, handpicked on the basis of grounds of task-specificity. Surgeons actively participated in each group independently from the task on hand to ensure desirable outcome.critique each artical like we did in the old assigemnt The main goal of these focus groups was to identify the most influential functional components related to a specific KPA and develop possible solutions if necessary. Components delaying positive progression in each KPA were flagged as (?), and those facilitating the process—as (+). All findings and proposals were discussed at the weekly “leadership” meetings and delivered to respective divisions for implementation. Focus groups were dismantled after desirable outcome at each specific KPA was achieved and classified as sustainable. However, the leaders of each group remained responsible for the follow up and implementation of corrective actions as needed. To provide a proper supervision and guarantee consistency 318 M. Chernov et al. and a smooth progression of the entire process, positions of Site Director of the Anesthesia Department and Site Director of Perioperative services were merged. Members of the focus groups were not reimbursed for this task and were driven solely by the internal motivation and professionalism. For example, the main problem for the KPA 1 (AB) was identified as a loss of 60–80 cases/month and the goal was to minimize the loss. Among multiple reasons, significant variation in pre-operative information delivered to patients i.e. NPO status, tests and consultations, prescribed medications, and postoperative transportation, was found to be the main obstacle, leading to miscommunication, misunderstanding and case cancellation. To improve patient’s education, standardized preoperative material was developed and made readily available to all patients through different sources—on line, surgical offices, hospital pre-admitting area etc. The main problem identified at KPA 2 was a delay in first case on-time start due to lack of strict timeline for all required pre-operative procedures. As a result the following timeline [14] (Figure 2) was developed, implemented and strictly enforced by the members of the respective focus group under supervision of the “floor runner”. Excessive turnover time and significant delays between cases were named as the main problem of the KPA 3. The focus group identified the following steps as negative (?): sequential and poorly coordinated turnover process, major variations in instrument/equipment setup within the same service, and lack of availability of human and physical resources for room clean-up and turnover. The following changes were suggested to facilitate the process: 1. “Parallel” turnover processing [15] (Figure 3) 2. “critique each artical like we did in the old assigemnt Fixed” turnover time, based on the complexity of the setup, not service 3. Switching from “surgeon-specific” to a “servicebased” standard instrument trays/equipment 4. Improve communications with the auxiliary staff i.e. anesthesia technicians, transporters The “turnover time” counter was incorporated in the OR management program to improve visual control over the process. Delayed recovery/discharge was the main challenge for the KPA 4. To solve it the following steps were taken: 1. Discharge criteria based on the ASA recommendations, not time 2. Designated PACU physician 3. Daily discharge planning with the bed availability report to the PACU and floor coordinator 4. Waiting lounge for discharged patients 5. Ambulatory—PACU staff cross training In our institution most of the perioperative problems were attributed to excessive waste and artificial variations in the process (staffing, scheduling, instrumentation, lab work, EMR etc.). The focus groups proposed an application of the elements of LEAN and 6 Sigma methodologies as a best solution. Furthermore, Critical Pass Methodology was used to streamline the pre-operative process and turn over time by implementation of rigid time lines and “parallel processing”. The key to success of the entire initiative was in full transparency through “by-stream” (top to bottom/bottom to top) communication. This level of connection was achieved and maintained with the help of Lesson Study methodology in a form of interactive administrative meetings, rounds and huddles. Site Director of Anesthesia/Perioperative management was ultimately responsible for establishing, maintaining and supervising the whole process, outcome, and implementation of the appropriate corrective actions. The current approach suggests that the OR efficiency should be viewed as a difference between the revenue and the expense (profit margin). Based on this suggestion, we utilized the following metrics to assess the effect of our methodology on OR efficiency and productivity: 1. 2. 3. 4. 5. Total case load Room utilization Anesthesia revenue Operating room revenue Staff overtime/cost of labor In addition, changes in “first case on time start” and turn over time (TOT) were measured as factors of influence on overall OR efficiency. RESULTS The available data prior to implementation of IPIS revealed a steady decrease in caseload from 2010 to 2012. After implementation of the IPIS model, a significant and sustainable increase in number of cases was evident over two consecutive years. For the same period of time changes in raw room utilization remained insignificant (Table 2). Anesthesia revenue related to OR activities (excluding OB and endoscopy suite) increased by 6.9% and the overall operating room revenue increased by 18.5% (Table 2). Overtime related to anesthesia activities decrease by 26.2%—from 320 hours in 2012 to 236 hours in 2013 with no changes in staffing Journal of Investigative Surgery Integrated Practice Improvement Solutions 319 FIGURE 2 The time line for the first case on time (7:30 am) start. or rooms allocation. Percentage of cases started on time increased from 57% in 2011 to an average 76% (p = 0.02) in 2013 and 2014. Simultaneously, the average TOT decreased from 39 min to 33 min (p < 0.001) (Table 3). Anesthesia controlled time (ACT) was not calculated due to significant variations in teaching related activities. The percentage of inpatient and ambulatory cases for the entire period remained practically unchanged—43% inpatient and 57% ambulatory. For the period between 2011 and the end of 2014 all cases were performed at a single facility utilizing the same set of operating rooms. However, in November of 2014 the new ambulatory surgery center (ASC) was opened. By the end of 2014 a total 208 ambulatory cases were redirected from our facility to the ASC. This redistribution resulted in decrease in overall caseload by 74 FIGURE 3 Parallel processing. critique each artical like we did in the old assigemnt C 2016 Taylor & Francis Group, LLC cases with corresponding change in anesthesia and OR revenue (Table 2). DISCUSSION Every operating suite has a unique set of challenges determined by its size, location, demographics and type of practice. This diversity requires flexibility in the decision-making process in order to identify specific problems and implement appropriate solutions. Healthcare continues to lack a methodology designed specifically for the purpose of efficient management in the perioperative environment.. The current approach to OR efficiency is described as “. . .the ratio of an output to the necessary input where the output is considered a constant for purposes of service-specific staffing, 320 M. Chernov et al. TABLE 2 Change in caseload and corresponding revenue since implementation of IPIS in 2012 YEAR 2010 2011 2012 2013 2014 TOTAL CASE LOAD Case load% change Anesth. Revenue% change OR Revenue% change OR UTILIZATION 9,744 9,571 9,236 10,226 10,152 ?1.78 ?3.5 10.72 ?0.72 ?1.88 ?2.1 6.96 54 52.5 12.05 18.56 10.26 52.9 55.6 51.2 in that surgeons functionally have open access to OR time on any future workday. In this case maximizing “efficiency” is then achieved by minimizing the input”[16]. This approach is applicable to some very specific situations and, in our opinion, may theoretically benefit the anesthesia group and/or hospital administration. In addition, “minimizing input” may require significant flexibility in OR management in general and the staffing and scheduling process in particular. Expectation of this degree of flexibility is not always realistic. Another more practical solution is to consider” input” as a constant and to increase “output” by more effective utilization of existing resources, eliminating waste and inconsistency in the process. IPIS was created for practices with a limited ability to coordinate staff and room assignments to match short term scheduling requirements. This is typical of large academic and private practices, where booking is done off – site and staffing schedule is independent from the variation in daily caseload. Here, input is considered fixed and revenue can be increased by stimulating production – output. TABLE 3 Influence of IPIS implementation on operating room efficiency YEAR First case on-time start (%) Cases meeting specific turnover time (%) Average turnover time 2011 2012 57.2 ± 21.6 73.7 ± 5.7 2013 2014 76 ± 3.7 75.5 ± 2.9 p = 0.02 p = 0.24 p = 0.1 33.3 ± 11.3 47.2 ± 3.3 50.3 ± 4.3 51.9 ± 4.2 p < 0.001 p = 0.06 p = 0.38 39 ± 3.4 34.7 ± 0.97 33.5 ± 1.3 33.7 ± 1.4 p < 0.001 p = 0.02 p = 0.92 Most of the PIMs are designed specifically for this purpose. IPIS is a “Lego – type” model, which allows users to select and combine features they consider appropriate to build unique and useful solutions to practicespecific problems. “Mapping” allows practices to assess the entire process, understanding that all components and steps are interconnected and interdependent. The subsequent choice of each methodology or elements of a methodology is flexible and depends entirely on goals and objectives of the manager and the practice. Utilization of IPIS in our situation resulted in significant improvement of OR efficiency and productivity with sustainable increase in number of cases and corresponding revenue. Notably, there were no changes in expense, related to the number of operating rooms, staff and overtime. The increase in efficiency did not change in the number of perioperative adverse events, based on review of the anesthesiology department’s Quality Improvement and Patient Safety Reports. Though improvements in wait time, turnover time and percent of cases with “on time” start independently may have a minimal influence on overall productivity [16], together they significantly increase OR efficiency and patient, staff, and administrator satisfaction. CONCLUSION IPIS is a new and unique approach to the management of the operating room. critique each artical like we did in the old assigemnt By combining the elements of multiple methodologies in one open frame model, we encourage creativity, adaptability and flexibility in the decision-making process and ultimately improvement in OR efficiency without overreliance on rigid statistical tools and pathways. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. This study did not involve human subjects and used no identifiable private information. IRB review was not necessary. REFERENCES [1] Zwanziger J, Melnick Glen A. Can managed care plans control health care costs? Health Affairs 1996;2(15):186–99 [2] H.R.3600—Health Security Act. 1993; 3 [3] “2011 Health Care Cost and Utilization Report.” 2012; 25 [4] Freeman J, M.D. Health is not a commodity: Let us get the language right. Medicine and Social Justice. 2012; 2 [5] Vissers J, Beech, R. Health operations management: Patient flow logistics in health care. Routledge Health Management Services 2005; 15–39 [6] Carter M., Price C. Operations research: A Practical Introduction. Boca Raton, FL: CRC Press. 2001 Journal of Investigative Surgery Integrated Practice Improvement Solutions [7] Mason SE, Nicolay CR, Darzi A. The use of Lean and Six sigma methodologies in surgery: A systematic review. Surgeon. 2015 Apr;13(2):91–100. [8] McIntosh B, Sheppy B, Cohen I. Illusion or delusion—Lean management in the health sector. Int. J. Health Care Qual Assur. 2014;27(6):482–92 [9] Sloan T, Fitzgerald A, Hayes KJ, et al. Lean in healthcare—history and recent developments. J Health Organ Manag. 2014;28(2):130–4 [10] Deming, W. Edwards; … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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