BACKGROUND: Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient\'s ability to receive necessary care.
OBJECTIVE: This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives.
METHODS: An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry.
RESULTS: The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age.
CONCLUSIONS: Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

OBJECTIVE: This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector.
METHODS: An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors.
RESULTS: High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management\'s commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident.
CONCLUSIONS: This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays.
CONCLUSIONS: This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow.
CONCLUSIONS: This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department\'s value stream maturity.

An industrial-scale pharmaceutical powder blending process was studied via discrete element method (DEM) simulations. A DEM model of two active pharmaceutical ingredient (API) components and a combined excipient component was calibrated by matching the simulated response in a dynamic angle of repose tester to the experimentally observed response. A simulation of the 25-minute bin blending process predicted inhomogeneous API distributions along the rotation axis of the blending container. These concentration differences were confirmed experimentally in a production-scale mixing trial using high-performance liquid chromatography analysis of samples from various locations in the bin. Several strategies to improve the blend homogeneity were then studied using DEM simulations. Reversing the direction of rotation of the blender every minute was found to negligibly improve the blending performance. Introducing a baffle into the lid at a 45° angle to the rotation axis sped up the axial mixing and resulted in a better final blend uniformity. Alternatively, rotating the blending container 90° around the vertical axis five minutes prior to the process end was predicted to reduce axial segregation tendencies.

BACKGROUND: As of 2014, the Accreditation Council for Graduate Medical Education (ACGME) mandates initiating a Program Evaluation Committee (PEC) to guide ongoing program improvement. However, little guidance nor published reports exist about how individual PECs have undertaken this mandate.
OBJECTIVE: To explore how four primary care residency PECs configure their committees, review program goals and undertake program evaluation and improvement.
METHODS: We conducted a multiple case study between December 2022 and April 2023 of four purposively selected primary care residencies (e.g., family medicine, pediatrics, internal medicine). Data sources included semi-structured interviews with four PEC members per program and diverse program artifacts. Using a constructivist approach, we utilized qualitative coding to analyze participant interviews and content analysis for program artifacts. We then used coded transcripts and artifacts to construct logic models for each program guided by a systems theory lens.  Results: Programs adapt their PEC structure, execution, and outcomes to meet short- and long-term needs based on organizational and program-unique factors such as size and local practices. They relied on multiple data sources and sought diverse stakeholder participation to complete program evaluation and improvement. Identified deficiencies were often categorized as internal versus external to delineate PEC responsibility, boundaries, and feasibility of interventions.
CONCLUSIONS: The broad guidance provided by the ACGME for PEC configuration allows programs to adapt the committee based on individual needs. However, further instruction on program evaluation and organizational change principles would augment existing PEC efforts.

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Background Reimbursement for anesthetic services in the United States utilizes a formula that incorporates procedural and patient factors with total anesthesia time. According to the Centers for Medicare & Medicaid Services and the American Society of Anesthesiologists, the period of billable time starts when the anesthesia practitioner assumes care of the patient and may include transport to the operating room from the preoperative holding area. In this report on a quality improvement effort, we implemented a departmental education initiative aimed at improving the accuracy of anesthesia start-time documentation. Methods Utilizing de-identified, internal data on surgical procedures at Yale New Haven Hospital (YNHH), New Haven, United States, the difference between documented anesthesia start and patient in-room time was determined for all cases. Those with a difference between 0-1 minute were assumed \"likely underbilled,\" and the total revenue lost for these cases was estimated using a weighted average of institutional reimbursement per unit of time. A monthly, department-wide educational email was then introduced to inform practitioners about the guidelines around start-time documentation, and the percentage of \"likely underbilled\" cases and lost revenue estimates trended over a one-year period. Results Baseline data in December 2020 showed that of the 6,877 total surgical cases requiring anesthesia at YNHH, 55.1% (N=3,790) had an anesthesia start to in-room time of 0-1 minute, which were considered \"likely underbilled.\" The average start-to-in-room time for properly recorded cases (44.9%, N=3,087) was 4.42 minutes. The baseline revenue lost in December 2020 for underbilled cases was estimated at $52,302. Over the one-year quality improvement initiative, the proportion of underbilled cases showed a downward trend, decreasing to 29.2% of total cases by November 2021. The estimate of revenue lost due to underbilling also showed a downward trend, decreasing to $29,300 in November 2021. Conclusion This quality improvement study demonstrated that a relatively simple, department-wide educational email sent monthly correlated with an improvement in anesthesia start-time documentation accuracy and a reduction in estimated revenue lost to underbilling over a one-year period.

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the \"shock team\") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

The US health care industry is increasingly shifting to a value seeking mindset. The breast imaging value chain elucidates how breast imaging radiologists generate and deliver value to their customers, who include both patients and referring health care providers. The breast imaging value chain can be used by radiologists to improve operational effectiveness and to plan new value creation strategically. The overarching goals are increased customer satisfaction and successful practices.

OBJECTIVE: Breast imaging services often experience a significant degree of variability in patient flow, leading to delay in time to diagnostic resolution, commonly referred to as time to resolution (TTR). This study applies Lean Six Sigma Methodology (LSSM) to reduce TTR and enhance patient outcomes.
METHODS: This study was IRB-approved. A baseline audit was done using cases of mammographic recalls (BI-RADS 0) to measure baseline TTR. Multidisciplinary meetings with all members of the breast imaging service, alongside a study of patient complaint data, were utilized to identify issues that were causing prolonged TTR. Following that, possible solutions were proposed and implemented. A post-implementation audit was conducted, and the resulting TTRs were compared. Significant differences in TTR between the pre- and post-solution implementation were assessed using the Mann-Whitney U test.
RESULTS: During the baseline audit of 8 months, 589 cases of mammographic recalls (BI-RADS 0) were identified, and the resulting average TTR was 86.3 days. During the post-implementation period of 3 months, 370 mammographic recalls (BI-RADS 0) occurred, with a resulting average TTR of 36.0 days. After applying LSSM, TTR was reduced by 58.3% (P < 0.01). Some changes implemented included training the coordinators, establishing a rapid diagnostic clinic using previously underutilized equipment, and having radiologists assigned full-time to the breast imaging service.
CONCLUSIONS: Our team has successfully managed to identify various causes behind the prolonged TTR using LSSM. Team collaboration was essential to study and decide on a more achievable TTR.

Developing and improving organizational processes is an important element for staff satisfaction, effective communication, and ultimately the success of an organization (Rummler & Brache, 2013). Human-service organizations are no exception and, in fact, could greatly benefit from process improvement. This article provides guided steps for using process maps as a means for improving processes in human-service organizations.