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Introduction: Disparate clinical outcomes have been reported for patients with Limited English Proficiency (LEP) in the emergency department setting, including increased length of stay, diagnostic error rates, readmission rates, and dissatisfaction. Our emergency department had no standard processes for LEP patient identification or interpreter encounter documentation and a higher rate of 48-hour LEP return visits (RV) than English proficient patients. The aim was to eliminate gaps by increasing appropriate interpreter use and documentation (AIUD) for Spanish-speaking LEP (LEP-SS) patients from 35.7% baseline (10/17-05/18) to 100% by October 2020. Methods: LEP-SS patient data were reviewed in the electronic medical record to determine the AIUD and RV rates. Using the Model for Improvement and multiple Plan-Do-Study-Act (PDSA) cycles, a multi-disciplinary team encouraged stakeholder engagement and identified improvement opportunities, implemented an electronic tracking board LEP icon (PDSA1), standardized documentation using an LEP Form linked to the icon (PDSA2), and included color changes to the icon for team situational awareness (PDSA3). Results: The mean of LEP-SS patients with AIUD improved from 35.7% to 64.5% without significant changes in balancing measures. During the postintervention period (6/1/2018-10/31/2020), no special cause variation was noted from the baseline 48-hour emergency department RV rates for LEP patients (3.1%) or English proficient patients (2.6%). Conclusions: While the RV rate was not affected, this project is part of a multi-faceted approach aiming to positively impact this outcome measure. Significant improvements in AIUD were achieved without affecting balancing measures.

Supplemental Digital Content is available in the text., Introduction: Improving the discharge process is an area of focus throughout healthcare organizations. Capacity constraints, efficiency improvement, patient safety, and quality care are driving forces for many discharge process workgroups. Methods: Following the Pareto principle, we focused on improving the discharge process on the medical-surgical units that received the most patients admitted from the emergency department. Increased demand for medical-surgical beds, renovations, and diminished bed capacity made it imperative to improve efficiency using quality improvement techniques. A core team of frontline staff decreased the time between computer entry of discharge orders and patient’s departure from the unit to less than 60 minutes, with 80% compliance. The team developed a daily dashboard that detailed the process and outcome measures to create situational awareness and daily visual management. Additional observations of staff workflow uncovered excessive walking for printer use. Printers were placed at the point of use to reduce transport times. Next, using survey results provided by patients on discharge quality, a Treasure Map that aided with teach-back and Team Discharge were implemented to level the staff’s workload. Finally, physicians discharged patients earlier in the day. They standardized their discharge criteria to remove subjectivity from the discharge process and enable better team involvement. Results: After implementing 4 interventions, the average time between computer entry of discharge orders and patient’s departure from the unit decreased (94.26 versus 65.98 minutes; P < 0.001), simultaneously reducing our average length of stay from 5.62 to 4.81 days (P < 0.001). Conclusions: In conclusion, hardwiring proven interventions and complementing them with daily visual management led to significant, sustained results.

Healthcare systems worldwide are seeking to drive improvement on their journey to high reliability, but are searching for validated improvement science and cultural management frameworks for assistance. Too often, large investments have been made to improve outcomes, resulting in short-lived successes when the organizational focus is on these high-value initiatives. Once the organization focus is shifted to another “flavor of the month,” the results are not sustained, or new innovative methods that have been developed fail to spread successfully to other units. Not surprisingly, healthcare has reached out to other industries for their best practices over the past 15–20 years. In 1990, James Womack and his colleagues from Massachusetts Institute of Technology (MIT) were one of the first to report about a relatively unknown (at the time) automotive manufacturer and their cultural management and improvement system, known as the Toyota Production System (TPS). They introduced the term “Lean production” to refer to TPS, an unintentional misrepresentation of TPS, which implies to some that organizations will become lean through the elimination of jobs. Actually, TPS places the utmost value on the development of an organization’s people or workforce. This focus has been emulated by other improvement frameworks. Many hospitals have tried to translate TPS to healthcare, often termed “Lean healthcare” – some have been successful, while others have struggled. Generally speaking, the application of TPS to healthcare is a relatively recent development since the early 2000s and is still evolving. In this chapter two major challenges related to building a TPS culture will be discussed: (1) clarification of the meaning of TPS as an organizational culture of highly engaged people driving performance and (2) how to build an enduring TPS culture. Successful implementation of TPS requires dedication of organizational leadership, managers, and workforce. When done properly, culture driven by TPS can be a win for patients, families, caregivers, hospitals, and communities. If it is not win, win, win, win, win…, then it is not TPS.

Supplemental Digital Content is available in the text., Introduction: Total parenteral nutrition (TPN) is one of the most frequently used pharmaceuticals administered to patients in our Neonatal Intensive Care Unit (NICU). Initially, the total interdepartmental processing time (ordering, manufacturing, and delivery between NICU and Pharmacy) averaged 15.2 hours. Inefficiencies in this process only allowed TPN to infuse 8.8 hours on average before labs were collected the next morning. Given the short administration-to-laboratory collection time, we hypothesized that laboratory samples would not adequately reflect the effect of the current TPN infusion. Furthermore, clinicians would be making decisions based on suboptimal data and ultimately nourish this patient population inadequately. Methods: The project team and the frontline staff created an efficient process for the manufacture and delivery of TPN. They removed waste in the process associated with manufacturing TPN and created capacity for change upstream (ordering process) and downstream (TPN infusion process) of the internal pharmacy process. The use of selection criteria and new standard operating procedures allowed for controlled PDSA testing of changes on a subset of patients. After we attained proven, sustainable results, we scaled the improvement efforts to the entire NICU patient population. Results: After 4 cycles of change, patients now receive TPN on average 14.2 hours before new labs are collected. The interventions over the continuum of this project yielded statistically significant results, increased infusion times to our patients by 61.4% (P < 0.001), improved glucose homeostasis, and decreased average length of stay. Conclusions: In conclusion, creating process capacity from incremental changes and iterative PDSA cycles has yielded sustained results.