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The aim of this study was to map a patient's journey along all stages of his daily care path in an Oncology outpatient department, to identify and eliminatequot;bottleneckquot; situations that interfere with the patient's flow of care. The main key performance indicators used in the study were: waiting times for each stage of the care process, time required for each activity, and resources used.The study was conducted from 17-30 January 2018 at the medical oncology clinic of a large university teaching and research hospital in Italy. We analyzed all the healthcare services provided during the monitoring period, dividing them into: first appointments, therapy, visits for adjustments of the therapeutic plan, visits for i.v. therapy, visits for oral therapy, follow-up visits, other visits (e.g. for positioning of peripherally inserted central catheter). Data collection was performed by administering two questionnaires: a Patient Journey (PJ) questionnaire to patients and a Medical Journey (MJ) questionnaire to clinicians. This project employed Lean principles in order to: view the process and specify value through the patient's point of view, identify waste in processes and eliminate any steps lacking any added value, reduce variation of and leveling workload to improve quality and ?ow of care, engage patients and staff to redesign the process.The response rate in 1351 outpatients who were invited to participate was 63%; for doctors it was 81%. The mean waiting time for first visits and follow up visits performed in a single day was 50 minutes. An audit process was thus performed and a series of quality improvement measures were defined and shared with health professionals.The Lean methodology could provide a robust framework for improved understanding and management of complex system constraints in outpatient oncology clinics, and could result in improved access to treatment and reduced waiting times for patients.

A Surgical Suite (SS) is a complex system in which different healthcare professionals work. Inefficient management could lead to waste of money and time and reduce quality of care. The aim of the study was to carry out an organizational assessment of a SS in northern Italy, in order to identify weaknesses and inadequacies related to its performance and promote strategies to increase efficiency. The study was conducted by process mapping of the working context, qualitative and quantitative analysis of patient documents and an evaluation of the critical issues using the root cause analysis (RCA) tool. The Plan Do Check Act (PDCA) method was used to implement the necessary changes. A detailed description of the staff involved, medical devices available, organization and timing of the SS was performed. Inefficiencies in the unit were caused mainly by insufficient medical devices and underusage of the radiological software Picture Archiving and Communication System (PACS). Root causes of inefficiencies were identified and classified into four areas: organization/structure, personnel, technologies and methods. In particular, critical issues were identified in: the planning processes, the heterogeneity of technical and Information technology skills and educational background of nursing staff, the presence of several computerized information systems and lack of a connection interface between the different software, the lack of internal procedures and paths and lack of continuing professional education opportunities. Two multidisciplinary working tables were launched by the hospital management in order to identify improvement strategies. The evaluation allowed us to define the root causes of SS inefficiency in this hospital, leading to a reorganization with a view to continuous improvement. An innovative aspect of the present study was the use of RCA to perform an organizational assessment in healthcare, rather than as a reactive risk management tool.

Health impact assessment (HIA) is a multidisciplinary tool aimed at assessing the effects of policies, programs and projects on health. It comprises five phases: screening, scoping, appraisal, reporting and monitoring. A review of the literature was performed on the subject which allowed us to describe good practices for each phase and show that the method is applied in a heterogeneous manner. Despite the correct application of the tool, especially of appraisal and reporting, the evaluation phase should be more widely used.