Background
Methods
Information sources and search strategy
Inclusion criteria | Exclusion criteria |
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Participants: organizations with a primary focus on healthcare provision | Articles published before 2003 |
Intervention: either changes in or redesigns of processes in healthcare organizations or healthcare innovations with a clearly described objective to improve quality of care | Articles in which the intervention, data collection methods, data analysis or research context is not described |
Outcome measures: quality of care, changeability, process efficiency, patient satisfaction, employee satisfaction, costs of care, facilitators or barriers to implementation, equity, timeliness of care, patient safety, effectiveness. | Articles published in languages other than English. |
Outcome measures should be clearly described and be consistent before and after intervention | |
Types of studies: RCTs, controlled before-and-after studies, before-and-after studies, interrupted time series, case studies (if using before-and-after measures), mixed methods studies (if using before-and-after measures), observational studies (if using before-and-after measures) | Articles without abstract, articles without before-and-after measurement |
Editorials, viewpoints, non-articles, interviews |
Critical appraisal
Data extraction and analysis
Results
Reporting excellence
Reference | Introduction | Methods | Results | Conclusion & discussion | Total # SQUIRE components mentioned | |||
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Intervention | Methods of evaluation | Analysis | Setting | Changes in process | ||||
1. Pennell, et al. (2005) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 3/10 components (indicated main factors contributing to choice of intervention; study design for measuring its impact; explains how method was applied) | Describes 2/5 components (instruments to measure effectiveness of implementation, primary and secondary outcomes) | Describes 1/4 components (details of qualitative and quantitative methods) | Describes 2/4 components (documents degree of success in implementation; describes how and why the initial plan evolved) | Describes 4/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 3/5 components (summary, interpretations, conclusions) | 19/38 |
2. King, Ben-Tovim, Bassham (2006) | Describes 3/5 components (local problem; intended aim; and who, what and why of intervention) | Describes 4/10 components (setting, intervention and components /parts; indicated main factors contributing to choice of intervention, implementation plan) | Describes 1/5 components (primary and secondary outcomes) | Describes 2/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention) | Describes 3/4 components (relevant elements of setting or settings; explains the actual course of the intervention; describes how and why the initial plan evolved) | Describes 3/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; presents evidence on strength of association between intervention and changes) | Describes 3/5 components (summary; limitations; conclusions) | 19/38 |
3. Raab, Andrew-JaJa, Condel, et al.(2006) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 5/10 components (setting; intervention and components/ parts; indicated main factors contributing to choice of intervention; study design for measuring impact intervention; explains how method was applied) | Describes 1/5 components (methods used to assure data quality and adequacy) | Describes 3/4 components (details of qualitative and quantitative methods; specifies degree of expected variability; describes analytic method used to demonstrate effects of time) | Describes 2/4 components (explains the actual course of the intervention; documents degree of success in implementation) | Describes 2/5 components (considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 3/5 components (relation to other evidence, limitations, interpretations) | 19/38 |
4. Raab, et al. (2006) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 6/10 components (setting; intervention and components/ parts; indicated main factors contributing to choice of intervention; expected change mechanisms; study design for measuring impact intervention; explains how method was applied) | Describes 0/5 components | Describes 1/4 components (describes analytic method used to demonstrate effects of time) | Describes 0/4 components | Describes 1/5 components (presents evidence regarding strength of association between intervention and changes) | Describes 4/5 components (relation to other evidence; limitations; interpretations; conclusions) | 15/38 |
5. Shannon, et al. (2006) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 4/10 components (ethical issues; setting; intervention and components/ parts; Implementation plan) | Describes 1/5 components (primary and secondary outcomes) | Describes 2/4 components (aligns unit of analysis with the intervention; describes analytic method used to demonstrate effects of time) | Describes 2/4 components (explains the actual course of the intervention; documents degree of success in implementation) | Describes 4/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 4/5 components (summary; relation to other evidence; limitations; interpretations) | 20/38 |
6. Kelly, Bryant, Cox et al. (2007) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 5/10 components (setting; intervention and components/parts; implementation plan; study design for measuring impact intervention; explains how method was applied) | Describes 3/5 components (instruments to measure effectiveness of implementation; contribution of components of intervention to effectiveness; primary and secondary outcomes) | Describes 1/4 components (aligns unit of analysis with the intervention) | Describes 2/4 components (explains the actual course of the intervention; documents degree of success in implementation) | Describes 2/5 components (presents data on changes observed in care delivery process; includes summary of missing data) | Describes 5/5 components (summary; relation to other evidence; limitations; interpretations; conclusions) | 22/38 |
7. Kim, et al. (2007) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 5/10 components (ethical issues; setting; intervention and components/ parts; indicated main factors contributing to choice of intervention; study design for measuring impact intervention; explains how method was applied; internal and external validity) | Describes 2/5 components (instruments to measure effectiveness of implementation; contribution of components of intervention to effectiveness) | Describes 1/4 components (aligns unit of analysis with the intervention) | Describes 2/4 components (explains the actual course of the intervention; documents degree of success in implementation) | Describes 2/5 components (presents data on changes observed in care delivery process; includes summary of missing data) | Describes 4/5 components (summary; relation to other evidence; limitations; interpretations) | 20/38 |
8. Raab, Grzybicki, Condel, et al. (2007) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 6/10 components (setting; intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; study design for measuring impact intervention; explains how method was applied) | Describes 1/5 components (instruments to measure effectiveness of implementation) | Describes 1/4 components (describes analytic method used to demonstrate effects of time) | Describes 1/4 components (documents degree of success in implementation) | Describes 2/5 components (presents data on changes observed in care delivery process; considers benefits, harms, unexpected results, problems, failures) | Describes 3/5 components (summary; limitations; interpretations) | 17/38 |
9. Shendell-Falik, Feinson, Mohr (2007) | Describes 4/5 components (background knowledge,; local problem; intended aim; and who, what and why of intervention) | Describes 4/10 components (setting; intervention; components/parts; indicated main factors contributing to choice of intervention; expected change mechanisms) | Describes 3/5 components (instruments to measure effectiveness of implementation; contribution of components of intervention to effectiveness; primary and secondary outcomes) | Describes 0/4 components | Describes 4/4 components (relevant elements of setting or settings; explains the actual course of the intervention; documents degree of success in implementation; describes how and why the initial plan evolved) | Describes 3/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; presents evidence regarding strength of association between intervention and changes) | Describes 2/5 components (summary; conclusions) | 20/38 |
10. Wood, Brennan, Chaudhry, et al. (2008) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 2/10 components (setting; intervention and components/parts) | Describes 1/5 components (primary and secondary outcomes) | Describes 0/4 components | Describes 1/4 components (actual course of the intervention) | Describes 1/5 components (evidence regarding strength of association between intervention and changes) | Describes 3/5 components (summary; relation to other evidence; conclusions) | 11/38 |
11. Reid, et al. (2009) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 7/10 components (ethical issues; setting; intervention and components/parts; indicated main factors contributing to choice of intervention; study design for measuring impact of intervention; explains how method was applied; internal and external validity) | Describes 3/5 components (instruments to measure effectiveness of implementation; primary and secondary outcomes; methods used to assure data quality and adequacy) | Describes 3/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention; describes analytic method used to demonstrate effects of time) | Describes 0/4 components | Describes 3/5 components (presents data on changes observed in measures of patient outcome; presents evidence regarding strength of association between intervention and changes; includes summary of missing data) | Describes 5/5 components (summary; relation to other evidence; limitations; interpretations; conclusions) | 25/38 |
12. Auerbach, et al. (2010) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 8/10 components (setting; intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; plan for assessment of implementation; study design for measuring impact of intervention; explains how method was applied; internal and external validity) | Describes 2/5 components (instruments to measure effectiveness of implementation; primary and secondary outcomes) | Describes 3/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention; describes analytic method used to demonstrate effects of time) | Describes 2/4 components (relevant elements of setting or settings; documents degree of success in implementation) | Describes 5/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes; includes summary of missing data) | Describes 4/5 components (summary; relation to other evidence; limitations; interpretations) | 27/38 |
13. Ravikumar, et al. (2010) | Describes 3/5 components (background knowledge; intended aim; and who, what and why of intervention) | Describes 7/10 components (setting; intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; study design for measuring impact of intervention; explains how method was applied; internal and external validity) | Describes 1/5 components (primary and secondary outcomes) | Describes 3/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention; describes analytic method used to demonstrate effects of time) | Describes 4/4 components (relevant elements of setting or settings; explains the actual course of the intervention; documents degree of success in implementation; describes how and why the initial plan evolved) | Describes 3/5 components (presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 4/5 components (relation to other evidence; limitations; interpretations; conclusions) | 25/38 |
14. Hwang, Lee, Shin (2011) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 4/10 components, (setting; intervention and components parts; indicated main factors contributing to choice of intervention; study design for measuring intervention) | Describes 2/5 components (primary and secondary outcomes; methods used to assure data quality and adequacy) | Describes 0/4 components | Describes 0/4 components | Describes 3/5 components (data on changes observed in the care delivery process; data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures) | Describes 5/5 components (summary; relation to other evidence; limitations; interpretations; conclusions) | 18/38 |
15. Collar, et al. (2012) | Describes 1/5 components (intended aim) | Describes 6/10 components (intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; study design for measuring impact of intervention; explains how method was applied; internal and external validity) | Describes 2/5 components (primary and secondary outcomes; reports validity and reliability of instruments) | Describes 2/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention) | Describes 0/5 components | Describes 4/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 4/5 components (relation to other evidence; limitations; interpretations; conclusions) | 19/38 |
16. Krening, Rehling-Anthony, Garko (2012) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 5/10 components (setting; intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; expected change mechanisms) | Describes 3/5 components (instruments to measure effectiveness of implementation; primary and secondary outcomes; explains methods used to assure data quality and adequacy) | Describes 0/4 components | Describes 4/4 components (relevant elements of setting or settings; explains the actual course of the intervention; documents degree of success in implementation; describes how and why the initial plan evolved) | Describes 4/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; considers benefits, harms, unexpected results, problems, failures; presents evidence regarding strength of association between intervention and changes) | Describes 4/5 components summary; limitations; interpretations; conclusions) | 20/38 |
17. Murray, Christen, Marsh, et al.(2012) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 6/10 components (setting; intervention and components/parts; indicated main factors contributing to choice of intervention; implementation plan; expected change mechanisms; internal and external validity) | Describes 3/5 components (instruments to measure effectiveness of implementation; primary and secondary outcomes; methods used to assure data quality and adequacy) | Describes 2/4 components (details of qualitative and quantitative methods; aligns unit of analysis with the intervention) | Describes 2/4 components (relevant elements of setting or settings; describes how and why the initial plan evolved) | Describes 4/5 components (presents data on changes observed in the care delivery process; presents data on changes observed in measures of patient outcome; presents evidence regarding strength of association between intervention and changes; includes summary of missing data) | Describes 5/5 components (summary; relation to other evidence; limitations; interpretations; conclusions) | 23/38 |
18. Liss, et al. (2013) | Describes 4/5 components (background knowledge; local problem; intended aim; and who, what and why of intervention) | Describes 4/10 components, (setting; indicated main factors contributing to choice of intervention; study design for measuring intervention; internal and external validity) | Describes 3/5 components (primary and secondary outcomes; validity and reliability of instruments; explains methods used to assure data quality and adequacy) | Describes 1/4 components (details of qualitative and quantitative methods) | Describes 1/4 components (characterizes relevant elements of setting or settings) | Describes 2/5 components (presents data on changes observed in measures of patient outcome; presents evidence regarding strength of association between intervention and changes) | Describes 5/5 components (summary; relation to other evidence; limitations; interpretations; conclusions) | 20/38 |
Types of redesign interventions
Reference (author names, publication year, country) | Intervention | Methods | ||||
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Objectives | Type of intervention | Study design | Unit of analysis (project sample size), study sample size | Intervention components | Length of follow-up | |
1. Pennell, et al. (2005) USA | To produce substantiated practice changes in glycemic management and improved outcomes for coronary artery bypass surgery patients | NP-led practice redesign | Before-and-after study | N = 103 (Before group = 41; After group = 62). | 1. New cardiothoracic team established, including advanced practice nurses; 2. 2. Implementation of new tools and guidelines | Not mentioned |
2. King, Ben-Tovim, Bassham (2006) Australia | Streamlining patient care at the ED to reduce overcrowding | Lean thinking | Before-and-after study | Before: N = 49075 presentations to the ED; After: N = 50337 presentations to the ED. | 1. Process mapping (incl. value stream map); 2. Restructuring of patient flow; streamlining in relation to predicted outcome | 12 months |
3. Raab, Andrew-JaJA, Condel, et al. (2006) USA | Improving Papanicolaou test quality and reducing medical errors by using Toyota production system methods | Toyota production system | Non-concurrent cohort study with control-group and comparison of retrospective consecutive case data from previous year for same time frame | Women with ASC US (atypical squamous cells of undetermined significance) diagnosis | 1. Choosing a target for improvement; 2. Problem Analysis; 3. Intervention design; 4. Pretest; 5. Implementation; 6. Evaluation | Not mentioned |
4. Raab, et al. (2006) USA | Determine whether the Toyota production system process redesign resulted in diagnostic error reduction for patients who underwent cytologic evaluation of thyroid nodules | Toyota production system | Longitudinal before-and-after, non-concurrent cohort study | 2,424 patients with thyroid gland nodule | 1. Development and use of a standardized diagnostic terminology scheme; 2. Expansion of an immediate interpretation service | Not mentioned |
5. Shannon, et al. (2006) USA | Eliminating central line-associated bloodstream (CLAB) infections in ICUs by employing the principles of Toyota production system adapted to health care | (Lean thinking) Toyota production system | Before-and-after study | 49 patients with CLAB admitted to medical intensive care unit and coronary care unit between July 2002 and June 2003. 10 residents, 10 fellows, 8 attending physicians, 16 nurses, 6 nurse aides and 5 personnel | Real-time problem-solving with help of the Toyota production system | 34 months |
6. Kelly, Bryant, Cox, et al. (2007) Australia | Analyze ED patient flow processes using task analysis and lean thinking; re-engineer these processes to improve flow through the ED for all groups of patients | Lean thinking | Before-and-after study | 31570 patients admitted to emergency department | Choosing a target for improvement; problem analysis; intervention design; pretest; implementation; and evaluation | Not mentioned |
7. Kim, et al. (2007) USA | Implement a lean project to improve patient care access and reduce excess work in providing palliative radiation therapy to patients referred for bone or brain metastases | Lean thinking | Before-and-after study | 1600 patients in total/year, 15 % have bone or brain metastases | Applied the principles and tools of lean thinking | Not mentioned |
8. Raab, Grzybicki, Condel, et al. (2007) USA | To measure the effect of implementation of a lean quality improvement process on the efficiency and quality of a histopathology lab section | Lean thinking | Non-concurrent interventional cohort study with control group and pre-post measurement | One histopathology section of anatomical pathology laboratory | 1. Education of staff; 2. Determining current condition; 3. Designing and implementing multiple (200) interventions; 4. Sustaining the “perfecting patient care” learning line | Not mentioned |
9. Shendel-Falik, Feinson, Mohr (2007) USA | Develop and implement a standardized approach to “hand-off” communications, including an opportunity to ask and respond to questions | Appreciative inquiry | Before-and-after study | Patients being transitioned from the ED to the telemetry unit and the associated care providers involved in the handoff | A 5D cycle of appreciative inquiry (definition, discover, dream, design, destiny) with 5 improvement projects: 1. A welcome script,; 2. Safety assessments; 3. Standardized transfer report; 4. Low-risk cardiac transport protocol; 5. Interpersonal relationships | 6 months |
10. Wood, Brennan, Chaudhry, et al. (2008) USA | To improve the quality and safety of patient care and to improve the efficiency and satisfaction of all team members, including physicians | Lean thinking | Before-and-after study | 1157 consecutive clinical notes before and 257 clinical notes after implementation; 137 physicians and 12 allied health staff members | Standardized process of patient care that included collaborative work between physicians and appropriately trained clinical assistants; the rooming process | Not mentioned |
11. Reid, et al. (2009) USA | 1. Maintain or enhance patient care experiences; 2. Reduce physician and care team burnout; 3. Improve clinical quality scores; 4. Reduce emergency, specialty and avoidable hospitalization use and costs | Patient-centered medical home | Before-and-after study | One intervention clinic and 19 control clinics; 8094 patients were included at the PCMH clinic and 228,510 patients were included at the control clinics | 1. Structural changes; 2. Point-of-care process changes; 3. Patient outreach changes; 4. Management process changes | 12 months |
12. Auerbach, et al. (2010) USA | The co-management neurosurgery service (CNS) was implemented in response to changes in care—primarily reducing availability of physicians for ward patients—which resulted from resident duty hour reductions | Hospitalist-led co-management neurosurgery service (CNS) | Before-and-after study with control group | A total of 7596 patients were admitted to the neurosurgery service during the study period: 4203 (55.3 %) before July 1, 2007, and 3393 (44.7 %) after CNS implementation | Co-management: shared management of surgical patients between surgeons and hospitalists | 18 months |
13. Ravikumar, et al. (2010) USA | Reduce mortality by enhancing continuity and co-management throughout hospital stay; minimize errors at transition points; increase throughput; reduce length of stay | Continuum of care | Before-and-after study with control group | Pilot study: one intervention and one control hospital. Validation study: one hospital department as intervention group and the entire hospital as control cohort CoC study: one hospital | 1. Surgical Continuum of Care (SCoC); 2. Continuum of Care (CoC) | Pilot study: 3 years; Validation study: 3 years; CoC study: 6 months |
14. Hwang, Lee, Shin (2011) South Korea | To shorten processing time and improve service quality | Structure redesign vs. process redesign | Before-and-after study | Two teaching hospitals. At Guro hospital (layout redesign) the final sample sizes were 291 patients at baseline and 170 patients at follow-up. At Anam hospital (critical pathway implementation) the final sample sizes were 273 patients at baseline and 125 patients at follow-up | 1. Structure-oriented approach: improvement of the physical structure of the ER operations by remodeling the hospital’s layout; 2. Process-oriented approach: implementation of critical pathways and protocols | 12 months |
15. Collar, et al. (2012) USA | To determine whether systematic implementation of lean thinking in an academic otolaryngology operating room improves efficiency and profitability and preserves team morale and educational opportunities; all staff working at one surgeon’s operating room | Lean thinking | Before-and-after study (18-month prospective quasi-experimental study) | 144 cases were included in the baseline period and 55 cases in the intervention period (follow-up) | 1. Visualization of the current state of the perioperative work process in the form of a swim lane diagram; 2. Identification of waste; 3. Root cause analysis for key waste items; 4. Creation of new swim lanes and a standard work matrix | 6 months |
16. Krening, Rehling-Anthony, Garko (2012) USA | To decrease risk exposure in the use of oxytocin administration hospitals of Centura Health | A process improvement project; standardized evidence-based protocol and processes across the healthcare system | Before-and-after study | Nine hospitals of Centura Health, delivering obstetric care | 1. A standardized oxytocin mixture; 2. Low-dose administration guidelines; 3. Utilization of safety checklists to assure fetal and maternal well-being before initiation of oxytocin and increases in oxytocin dosages; 4. A standardized order set; 5. An educational handout for pregnant woman on oxytocin usage | 12 months |
17. Murray, Christen, Marsh, et al. (2012) Scotland | Redesign of the new-patient fracture clinic, with the objective of: improving patient care, trainee education, interprofessional relations and clinic efficiency | Evidence-based redesign | Not mentioned | 301 consecutive patients attending the new-patient fracture clinic over a 3-week period in the summer of 2010, compared to 346 consecutive patients during a 3-week period exactly one year previously. Adequate data available for 240 patients (80 %) in 2010 and 296 patients (86 %) in 2009 | 1. Investigate existing conditions before introducing the new clinic model; 2. identify problems and delineate potential improvements; 3. Redesigned the new-patient fracture clinic; 4. Implemented change; 5. Documented outcomes | 3 months |
18. Liss, et al. (2013) USA | Providing patients with a continuous source of whole-person primary care; increasing patient access and satisfaction with care and reducing total costs | Patient-centered medical home | Controlled before-and-after study | One Group Health clinic as intervention site and 19 Group Health Clinics as controls. The final study population included 37,930 adults with diabetes, hypertension and/or CHD, with 1181 patients paneled to the PCMH prototype clinic and 36,757 patients paneled to other clinics | 1. Increased primary care staffing; 2. Physicians paired in dyads with medical assistants; 3. Standard in-person primary care office visits lengthened to 30 min; 4. Virtual medicine contacts; 5. Rerouting patients’ calls; 6. Creation of collaborative care plans; 7. Provider outreach to manage monitoring tests | 21 months |
Effects of redesign on quality of care
Study reference (author names, publication year) | Quality of care | Other outcomes | |||||
---|---|---|---|---|---|---|---|
Effectiveness | Efficiency | Timeliness | Patient-centeredness | Safety | Equity of care | ||
1. Pennell, et al. (2005) | - Improved basal diabetes medications being ordered prior to discontinuing the IV insulin infusion (0 % → 76.9 %) - Use of sliding scale insulin increased in undiagnosed patients (16 % → 21 %) - Use of basal medications while on sliding scale insulin improved for diagnosed patients (56.3 % → 69 %) - Increased number of documented blood glucose tests ordered for undiagnosed patients (2.8/day → 4.3/day) - Improved diabetic patients’ blood glucose test values (88 % → 71 % range 140 to 299 mm/dL) | - The Average Length Of Stay (ALOS) for the overall population was reduced by 1.2 days - The ALOS for diagnosed patients increased by 2.6 days - The ALOS for undiagnosed patients decreased by 4.6 days - The ALOS for diagnosed patients for the year was shorter than for undiagnosed patients - Patients with a primary diagnosis of coronary artery bypass with cardiac cath with complications had a significantly longer ALOS at 12.9 days - The ALOS of undiagnosed patients with coronary bypass with cardiac cath dropped after implementation | n/a | n/a | - Percentage of undiagnosed patients with postoperative infection dropped (16 % → 9.1 %) - Percentage of diagnosed patients with a postoperative infection increased (0 % → 10 %) - Diagnosed patients had fewer postoperative infections than undiagnosed patients (6.7 % vs. 12 %) | n/a | n/a |
2. King, Ben-Tovim, Bassham (2006) | n/a | - Flattening of the review times - Marked reduction in the variability of time spent waiting for review - Time to initiation of meaningful treatment significantly decreased - Time to see a doctor decreased - A slight increase in overall compliance to meeting triage waiting times - Percentage of all patients attending but not waiting to be seen after initial triaging fell significantly - Decrease in patients presenting to the ED and waiting for more than 8 h before being admitted or discharged - Significant decrease in mean time spent in the ED - Significant decrease in time spent in the ED of patients being admitted - Significant decrease in time spent in the ED of patients being discharged - Decrease of overall time spent in the department - - Decrease of time spent in the department before discharge | n/a | n/a | - No incidents of concerns associated with practice change - Overall sense of a greater degree of patient safety, and sense of control among staff | n/a | n/a |
3. Raab, Andrew-JaJA, Condel, et al. (2006) | - Significant decrease of Papanicolaou tests lacking a transformation zone component (9.9 % → 4.7 %) | - Reduced number of equivocal Papanicolaou test diagnoses (7.8 % → 3.9 %) - Decreased costs - Less additional testing (76 % → 29.4 %) - Decreased laboratory - time and effort in the screening of slides | n/a | n/a | - More women being diagnosed with appropriate categories - - Decrease of error frequency per correlating cytologic-histologic specimen pair (9.52 % → 7.84 %) | n/a | n/a |
4. Raab, et al. (2006) | - Improvement: - Significantly higher diagnostic accuracy (70.2 % → 90.6 %). - Decrease of Fine Needle Aspiration (FNA) (1543 → 1176 cases) - Significant decrease in repeated FNA rate (12.7 % → 7.7 %) - Significant decrease in non-interpretable rate for immediate interpretation service (23.8 % → 7.8 %) - Deteriorations: - Significant increase in non-interpretable rate (5.8 → 19.8 %) at terminology standardization | n/a | n/a | n/a | - Significantly fewer false-negative diagnoses (4.8 % → 19.1 %) - Significantly fewer patients had surgery (23.6 % → 19.9 %) - Deteriorations: - - No significant increase in false-positive rate (22.6 → 26.3 %) | n/a | n/a |
5. Shannon, et al. (2006) | - -Significant increase in line days (4,687 days → 7,716 days) | - Increase in admissions (11 %) - Increased acuity - Near doubling of line use without adding new staff or more beds - - Reduced need to compensate for ineffective processes | n/a | n/a | - Reduced line infection rates after intervention (10.5/1000 → 0.39/1000 line days) - - Significantly reduced line infection associated mortalities (51 % → 0 %) | n/a | - More time to be involved in direct patient care - - More time for staff to solve problems |
6. Kelly, Bryant, Cox, et al. (2007) | - Increased and sustained proportion of discharged patients (92 %) | - Improvements: - Significant reduction of overall total ED department time (12 min) - Significant reduction of total ED time for triage category 4 and 5 patients (14 and 18 min respectively) - Deteriorations: - Significant (*) increase in total ED time for category 1, 2 and 3 patients (9, 13 and 7* minutes respectively) | Significant reduction in waiting time, overall and in triage categories 2–5 (3, 2, 5, 7 and 11 min respectively) Increased bed requests within target time (73 %) | n/a | - Episodes of ambulance bypass significantly decreased (120 → 54) | n/a | - - 90 % of staff reported that they believed the ED ran better after the change |
7. Kim, et al. (2007) | n/a | - Reduction of process steps (16) to treatment - Decrease of variability | Increase of percentage of new patients with brain or bone metastases receiving consultation, simulation, and treatment on the same day (43 % → 94 %) - Process time remained stable (225 min) while wait time decreased (1 week → 1 day) | n/a | - Fewer process errors in routing patient to appointment times | n/a | - n/a |
8. Raab, Grzybicki, Condel, et al. (2007) | n/a | - Significantly increased productivity (3439 to 4047 work units/FTE) - Decrease of expenditure - Decreased specimen Turn Around Time (TAT) (9.7 h → 9.0 h) | n/a | n/a | n/a | n/a | n/a |
9. Shendel-Falik, Feinson, Mohr (2007) | - Nutritional assessment improved by 11 % - Completion of skin assessment in the ED improved by 70 % - - Compliance with cardiac enzyme regimen improved by 9.2 % | - Percentage of telemetry patients able to be transported without a cardiac monitor increased by 60 % - 67.5 h of nursing time per month were saved. | n/a | - Overall patient satisfaction improved on nursing issues (10.2 %) - Satisfaction with personal issues improved (9 %) - ED rating improved (23.3 %) | n/a | n/a | - - Improved nurse satisfaction and teamwork |
10. Wood, Brennan, Chaudhry, et al. (2008) | n/a | - Shift from clinical notes dictated by physicians to clinical notes written by clinical assistants - 21 % of the note was authored by clinical assistants and 79 % by physicians | n/a | n/a | - Significant improvements: - Increased physician identification (from 57 % to 88 %) - Increased allergy documentation (from 52 % to 70 %) - Increased advance directives documentation (from 2 % to 83 %) - Improved medication list completeness (from 32 % to 91 %) | n/a | - - Improved physician satisfaction |
11. Reid, et al. (2009) | - PCMH patients had significantly better performance on - each of the composite measures compared with 19 other clinics at baseline - Significant improvement of composite quality of care at the PCMH compared to baseline (4 %) and control groups (1.4 %) | - Improvements - PCMH patients received fewer in-person primary care visits (6 %) - PCMH patients had significantly fewer ED visits (29 %) - PCMH patients had significantly fewer hospitalizations for ambulatory care-sensitive conditions (11 %) - PCMH patients had lower ED costs ($54 per patient per year) - Deteriorations: - PCMH patients had significantly more specialty care visits (8 %) - PCMH patients had higher primary care costs per patient per year ($16 per patient per year) - PCMH patients had higher specialty care costs ($37 per patient per year) | n/a | - PCMH patients reported significantly better experience with their care - PCMH patients reported significantly higher scores on quality of doctor-patient interactions, coordination of care, patient activation/involvement and goal setting/tailoring - Patients in the control groups reported significantly higher scores for patient activation/involvement and goal setting/tailoring. - Patients at the PCMH clinic reported significantly higher scores on quality of doctor-patient interaction, shared decision making, coordination of care, access, patient activation/involvement and goal setting/tailoring | n/a | n/a | - Emotional exhaustion among physicians and physician assistants was reported significantly less frequently (20 %) at the PCMH clinic |
12. Auerbach, et al. (2010) | - No significant differences in mortality rate - No significant differences in readmission after 30 days | - Moderate decrease in adjusted hospital cost equivalent to a savings of $1439 per admission | n/a | - Statistically significant increases in the odds for a higher score in the co-management cohort for 3 questions: degree to which staff responded to concerns; cheerfulness of the hospital; and degree to which staff addressed patients’ emotional needs. - - No significant differences in overall rating of the hospital experience and likelihood of recommending the hospital | n/a | n/a | - Non-nursing professionals support CNS; significantly improved attention to medical issues during hospitalization and at discharge - - Nursing perceptions of the CNS’s effect on patient care were uniformly positive, with strongest positive change again being seen on questions regarding treatment of medical issues during hospitalization |
12. Ravikumar, et al. (2010) | - - Significant improvement of readmission rates | - Significant reduction of total hospital patient days for patients being discharged from SICU to the regular beds or to PCU - Net cost savings - Decreased SICU Length Of Stay (LOS) - Decreased PCU LOS: - Decreased total hospital LOS SICU - Decreased total hospital LOS PCU - Cost savings: $851,511 to $2,007,388 per year. - For DRG 148, reduction of variable cost was $452,000 per year | n/a | n/a | - Overall surgical mortality significantly decreased, with a corresponding improvement in mortality index for surgical DRGs | n/a | n/a |
13. Hwang, Lee, Shin (2011) | n/a | - Improvement hospital layout remodeling: - Significant (*) decrease of the mean time for the five processes: registration (7.78 %); CT/MRI enrollment (8.75 %); Complete Blood Count (CBC) sample collection (5.98 %); Prothrombin Time (PT)/Partial Thromboplastin Time (PTT) sample collection (19.73 %*); and CBC report (21.63 %*) - Time reduction in PT/PTT sample collection process - Significant reduction of total time from arrival to treatment (10.37 %) - Significant decrease in length of stay (from 10.02 to 8.6 days) - Significantly lower hospital charges (10.25 %) - Deterioration hospital layout remodeling: - Significant increase of CT/MRI and PT/PTT reporting process time (from 29.6 to 64.81 min; 28.99 %*) - Improvement process redesign: - Significant (*) decrease in process times: registration (22.76 %); CT/MRI enrollment (18.29 %); CBC sample collection (10.28 %); PT/PTT sample collection (14.32 %*); CT/MRI scan report (15.71 %*); PT/PTT report (3.59 %) - Significant decrease in time from arrival to treatment (15.75 %) - Significant decrease in LOS (from 12.98 to 9.25 days) - Significantly lower hospital charges (16 %) - Deterioration process redesign: - - Increase in CBC report time (67.96 %) | n/a | n/a | n/a | n/a | n/a |
14. Collar, et al. (2012) | n/a | - No significant difference in case length - Mean Turn Over Time (TOT) was significantly shortened - Turn Around Time (TAT) was significantly shortened - Percentage of TOTs of 30 min increased - Percentage of TATs of 60 min increased - Approximately 4,500 min of added capacity yielded - - Annual opportunity revenue for a single OR used twice weekly is approximately $330,000 | n/a | n/a | n/a | n/a | - Significantly improved team morale - - Operating Room Environment Measure did not change significantly |
15. Krening, Rehling-Anthony, Garko (2012) | - Decrease in average length of labor on oxytocin for both primigravidas (10 h → 9.5 h) and multigravidas (8 h → 6.5 h). - Significant decrease in hours receiving oxytocin for both primigravidas (9.9 h → 8.78 h) and multigravidas (7.8 h → 6.22 h) - Decrease in primary cesarean rate (61 % → 56 %) | - A theoretical saving of at least $173,000 per year if volume remains constant, caused by reduced labor length - A theoretical saving of approximately $286,000 per year, caused by reduced primary cesareans | n/a | n/a | - Significant decrease in overall incidence of tachysystole (54 % → 20 %) | n/a | n/a |
16. Murray, Christen, Marsh, et al. (2012) | - Significant decrease in overall ‘return rates’ (162 → 97 patients) - Discharge rate improved (22 % → 25 %) | - Significant decrease in proportion of patients requiring additional physical review by a consultant (89 → 22 patients) - Significant improvement in utilization of the nurse-led fracture clinic (38 → 55 referrals) | n/a | n/a | - Significant increase in proportion of cases receiving primary consultant input (98 → 202 patients) | n/a | - Significant improvements in median scores of staff perception of education, provision of senior support, morale and overall perception of patient care. - ER staff said the new style clinic was educational, practice-changing and improved interdisciplinary relations - - Reduction of official incidence rates IR1 reports |
17. Liss, et al. (2013) | - Significantly improved disease conditions for patients with diabetes; 4 % more likely to have A1C under 9.0 %, mean A1C 0.20 % lower - Significant improved follow-up and disease conditions for patients with CHD; 11 % more likely to have LDL below 100 mg/dL at follow-up, mean LDL was 2.20 mg/dL lower - Improved disease conditions for patients with hypertension; 5 % more likely to have blood pressure below 140/90 mmHg, not significant | - Significant decrease (23 %) in ambulatory care sensitive hospitalizations for patients at the PCMH - Significant decrease (4 %) in inpatient admissions for patients at the PCMH - Significant decrease (18 %) in ED and urgent care contacts | n/a | n/a | n/a | n/a | n/a |