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May 24, 2024

US Acute Care Solutions Names Dr. Shea Combs Regional Vice President of South Division

CANTON, Ohio, May 24, 2024 – US Acute Care Solutions (USACS), the nation’s largest physician-owned provider of hospital-based emergency and inpatient medicine, announced today that it has named Shea Combs, MD, FACEP, a Regional Vice President of its South Division. Most recently, Dr. Combs served as the Regional Integrated Acute Care (IAC) Medical Director of the USACS South Division and System Medical Director of Hospital Medicine. In this role she was responsible for the management of several service lines at both Cedar Park Regional Medical Center in Cedar Park, TX, and Peterson Regional Medical Center in Kerrville, TX. Dr. Combs is also an active member of the USACS South Clinical Governance Board which aims to ensure consistency and quality patient care throughout all USACS locations. “Our team is looking forward to welcoming Dr. Combs as she steps into her new leadership role within our division,” said Brandon Lewis, DO, MBA, FACOEP, FACEP, President of the USACS South Division. “Dr. Combs has proven to be an outstanding leader and we are fully confident she will continue to excel as a regional vice president.” Dr. Combs said, “Being selected to fill this role for our group is an honor and a privilege. I am ready to embrace new responsibilities with the goal of leading our division to continued success. I am grateful to our existing leadership team for their confidence and look forward to making an impact both regionally and company-wide.” A board-certified emergency physician, Dr. Combs completed her bachelor’s and master’s degrees at the University of Texas at Austin then went on to earn her medical degree at the University of Texas Health Science Center at San Antonio. She completed her emergency medicine residency at Allegheny General Hospital in Pittsburgh, PA. About USACS Founded by emergency medicine and inpatient physicians across the country, USACS is solely owned by its physicians and hospital system partners. The group is a national leader in integrated acute care, including emergency medicine, hospitalist, and critical care services. USACS provides high-quality care to approximately ten million patients annually across more than 400 programs and is aligned with many of the leading health systems in the country. Visit usacs.com for more. ### Media Contact Marty Richmond Corporate Communications Department US Acute Care Solutions 330.493.4443 x1406 [email protected]

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How Digital Transformation Can Improve Hospitals’ Operational Decisions

• Song-Hee Kim

It can help with patient flow, staffing, scheduling, and supply-chain management.

The use of digital technologies in clinical decision-making has received the most attention. But they also have the potential to help hospitals make better decisions in many areas of operations.  Research and hospitals’ experiences show that they can make a big difference in such areas as the management of the patient flow, staffing, scheduling, and the supply chain. The result can be improvements in the quality and efficiency of care and patients’ access to it.

Many companies are interested in digital transformation — using digital technologies to create or modify business processes, culture, and customer experiences — to grow and stay ahead of the competition, and hospitals are no exception.

• Song-Hee Kim is an associate professor of operations management at the SNU Business School at Seoul National University. Her research focuses on data-driven decision-making within health care systems, especially how to design human-algorithm interactions to improve quality, efficiency, and access to care in hospitals.
• Hummy Song is an assistant professor of operations, information, and decisions at the University of Pennsylvania’s Wharton School. Her research focuses on how operations can be designed to help health care providers work more efficiently and effectively.

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“Case Studies in Healthcare: Success Stories and Lessons Learned”

Table of Contents

The healthcare industry is an ever-evolving field with innovations and improvements happening daily. As healthcare providers strive to deliver the best care possible, case studies have become a valuable resource for learning and growth. In this article, we will explore various case studies in healthcare, highlighting both success stories and the lessons learned along the way. By analyzing what works and why, we can gain insight into the practices that lead to triumphs in healthcare and potentially replicate these successes in our own organizations.

Case Studies in Healthcare: A Closer Look at Triumphs and Takeaways

Healthcare case studies provide a unique opportunity to dissect real-world scenarios, understand the decisions made, and measure the outcomes of those choices. One notable success story is the implementation of telemedicine in rural areas. By leveraging technology, healthcare providers have successfully expanded access to care for patients who would otherwise have to travel long distances for treatment. Lessons learned include the importance of investing in reliable technology and training staff to effectively use telemedicine platforms.

Another critical case study involves the management of electronic health records (EHRs). When a large hospital system transitioned to a new EHR system, they faced significant resistance from physicians who were accustomed to the old way of doing things. However, by involving physicians in the planning and implementation process, the hospital successfully integrated the new system, leading to improved efficiency and patient care. This case study highlights the value of stakeholder engagement and effective change management.

In the fight against infectious diseases, case studies have shown the significance of swift and coordinated responses. An example of this is the containment of Ebola in West Africa. Through international collaboration and the rapid deployment of healthcare resources, the spread of the virus was effectively limited. This case study underscores the importance of preparedness, communication, and teamwork in tackling healthcare crises.

Success Stories in Healthcare: Analyzing What Works and Why

Understanding why certain strategies succeed is crucial for replicating positive results in the healthcare industry. For instance, one hospital’s initiative to reduce patient readmissions focused on comprehensive discharge planning and follow-up care. By ensuring patients had clear instructions and support after leaving the hospital, readmission rates dropped significantly. This case study emphasizes the role of thorough patient education and post-discharge care in improving outcomes.

In the realm of preventive care, a primary care clinic introduced a program to increase vaccination rates among its patient population. By actively reaching out to patients due for immunizations and offering flexible scheduling options, the clinic saw a dramatic increase in vaccination rates. The takeaway from this case study is the impact of proactive patient engagement and removing barriers to care.

Lastly, a healthcare organization’s embrace of continuous quality improvement (CQI) led to enhanced patient safety and satisfaction. By fostering a culture of open communication and ongoing learning, the organization identified areas for improvement and systematically implemented changes. This case study demonstrates the power of a commitment to CQI as a driver for excellence in healthcare.

The healthcare industry is rich with case studies that provide valuable insights and lessons learned. By analyzing and understanding these success stories, healthcare providers can apply similar strategies to achieve positive outcomes in their own organizations. Whether it’s through technology, stakeholder engagement, or quality improvement initiatives, these case studies offer a blueprint for triumph and provide a roadmap for future success in the ever-changing landscape of healthcare.

Why are case studies valuable in the healthcare industry, and how do they provide insights into successful decision-making and problem-solving within healthcare organizations?

Case studies are valuable as they offer real-world examples of challenges and solutions in healthcare. They provide insights into successful decision-making, problem-solving, and strategies that can be applied by healthcare professionals and organizations facing similar scenarios.

How does the article select and present case studies, and what criteria are considered to ensure the relevance and applicability of the showcased success stories to a diverse audience?

The article discusses the criteria for selecting case studies, such as their impact on healthcare outcomes, innovation, or overcoming significant challenges. It highlights the diversity of cases to ensure relevance to a broad audience, considering different healthcare settings, specialties, and contexts.

Can you provide examples of healthcare case studies featured in the article, and how do these stories illustrate successful decision-making or lessons learned that can benefit readers in the healthcare field?

Certainly! Examples may include cases where innovative technologies improved patient outcomes, or instances where strategic decisions enhanced operational efficiency. The article presents these stories to illustrate valuable lessons learned and best practices that readers can apply in their own healthcare settings.

In what ways do case studies contribute to professional development and learning opportunities for healthcare professionals, and how can organizations leverage these stories for continuous improvement and staff training?

The article explores how case studies offer learning opportunities, allowing healthcare professionals to gain insights from others’ experiences. Organizations can leverage these stories for staff training, fostering a culture of continuous improvement and encouraging employees to apply lessons learned to their daily practices.

For healthcare leaders seeking to implement successful strategies within their organizations, what recommendations and actionable insights does the article provide based on the analysis of the showcased case studies?

The article offers recommendations based on the case studies, such as the importance of collaboration, data-driven decision-making, and embracing innovation. It provides actionable insights that healthcare leaders can use to inform their decision-making processes and drive positive outcomes within their organizations.

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• v.11(2); 2022

Defining case management success: a qualitative study of case manager perspectives from a large-scale health and social needs support program

Margae knox.

1 School of Public Health, University of California, Berkeley, Berkeley, California, USA

Emily E Esteban

2 Contra Costa Health Services, Martinez, California, USA

Elizabeth A Hernandez

Mark d fleming, nadia safaeinilli, amanda l brewster, associated data.

No data are available. Data are not publicly available to protect potentially sensitive information. For data inquiries, please contact the corresponding author.

Health systems are expanding efforts to address health and social risks, although the heterogeneity of early evidence indicates need for more nuanced exploration of how such programs work and how to holistically assess program success. This qualitative study aims to identify characteristics of success in a large-scale, health and social needs case management program from the perspective of interdisciplinary case managers.

Case management program for high-risk, complex patients run by an integrated, county-based public health system.

Participants

30 out of 70 case managers, purposively sampled to represent their interdisciplinary health and social work backgrounds. Interviews took place in March–November 2019.

Primary and secondary outcome measures

The analysis intended to identify characteristics of success working with patients.

Case managers described three characteristics of success working with patients: (1) establishing trust; (2) observing change in patients’ mindset or initiative and (3) promoting stability and independence. Cross-cutting these characteristics, case managers emphasised the importance of patients defining their own success, often demonstrated through individualised, incremental progress. Thus, moments of success commonly contrasted with external perceptions and operational or productivity metrics.

Conclusions

Themes emphasise the importance of compassion for complexity in patients’ lives, and success as a step-by-step process that is built over longitudinal relationships.

What is already known on this topic?

• Case management programs to support health and social needs have demonstrated promising yet mixed results. Underlying mechanisms and shared definitions of successful case management are underdeveloped.

What this study adds?

• Case managers emphasised building trust over time and individual, patient-defined objectives as key markers of success, a contrast to commonly used quantitative evaluation metrics.

How this study might affect research, practice or policy?

• Results suggest that lighter touch case management interventions face limitations without an established patient relationship. Results also support a need for alternative definitions of case management success including patient-centered measures such as trust in one’s case manager.

Introduction

Health system efforts to address both health and social needs are expanding. In the USA, some state Medicaid programmes are testing payments for non-medical services to address transportation, housing instability and food insecurity. Medicaid provides healthcare coverage for lower income individuals and families, jointly funded by federal and state governments. Similarly, social prescribing, or the linking of patients with social needs to community resources, is supported by the UK’s National Health Service and has also been piloted by Canada’s Alliance for Healthier Communities. 1

A growing evidence base suggests promising outcomes from healthcare interventions addressing social needs. In some contexts, case managers or navigators providing social needs assistance can improve health 2 and reduce costly hospital use. 3–5 Yet systematic reviews also report mixed results for measures of health and well-being, hospitalisation and emergency department use, and overall healthcare costs. 6–9 Notably, a randomised trial of the Camden Care Coalition programme for patients with frequent hospitalisations due to medically and socially complex needs 10 found no difference in 180-day readmission between patients assigned to a care transitions programme compared with usual hospital postdischarge care. In the care transition programme, patients received follow-up from a multidisciplinary team of nurses, social workers and community health workers. The team conducted home visits, scheduled and accompanied patients to follow-up outpatient visits, helped with managing medications, coached patients on self-care and connected patients with social services and behavioural healthcare. The usual care group received usual postdischarge care with limited follow-up. 11 This heterogeneity of early evidence indicates a need for more nuanced explorations of how social needs assistance programmes work, and how to holistically assess whether programmes are successful. 12 13

Social needs case management may lead to health and well-being improvements through multiple pathways involving both material and social support. 14 15 Improvements are often a long-term, non-linear process. 16 17 At the same time, quality measures specific to social needs assistance programmes currently remain largely undefined. Studies often analyse utilisation and cost outcomes but lack granularity on interim processes and markers of success.

In order to translate a complex and context-dependent intervention like social needs case management from one setting to another, these interim processes and outcomes need greater recognition. 18–20 Early efforts to refine complex care measures are underway and call out a need for person-centred and goal-concordant measures. 21 Further research on how frontline social needs case managers themselves define successes in their work could help leaders improve programme design and management and could also inform broader quality measure development efforts.

Our in-depth, qualitative study sought to understand how case managers defined success in their work with high-risk patients. Case managers were employed by CommunityConnect, a large-scale health and social needs care management programme that serves a mixed-age adult population with varying physical health, mental health and social needs. Each case manager’s workflow includes an individualised, regularly updated dashboard of operational metrics. It is unclear, however, whether or how these operational factors relate to patient success in a complex care programme. Thus, the case managers’ perspectives on defining success are critical for capturing how programmes work and identifying essential principles.

Study design and setting

In 2017, the Contra Costa County Health Services Department in California launched CommunityConnect, a case management programme to coordinate health, behavioural health and social services for County Medicaid patients with complex health and social conditions. The County Health Services Department serves approximately 15% (180 000) of Contra Costa’s nearly 1.2 million residents. CommunityConnect enrollees were selected based on a predictive model, which leveraged data from multiple county systems to identify individuals most likely to use hospital or emergency room services for preventable reasons. Enrollees are predominantly women (59%) and under age 40 (49%). Seventy-seven per cent of enrollees have more than one chronic condition, particularly hypertension (42%), mood disorders (40%) and chronic pain (35%). 22 Programme goals include improving beneficiary health and well-being through more efficient and effective use of resources.

Each case manager interviewed in this study worked full time with approximately 90 patients at a time. Case managers met patients in-person, ideally at least once a month for 1 year, although patients sometimes continue to receive ongoing support at the case manager’s discretion in cases of continued need. Overall, up to 6000 individuals at a time receive in-person case management services through CommunityConnect, with approximately 200–300 added and 200–300 graduated per month. At the time of the study, CommunityConnect employed approximately 70 case managers trained in various public health and social work disciplines (see table 1 , Interview Sample). Case managers and patients are matched based on an algorithm that prioritises mental health history, primary language and county region.

Interview sample

Although case managers bring unique experience from their respective discipline, all are expected to conduct similar case management services. Services included discussing any unmet social needs with patients, coordinating applicable resources and partnering with the patient and patient’s care team to improve physical and emotional health. The programme tracks hospital and emergency department utilisation as well as patient benefits such as food stamps, housing or transportation vouchers and continuous Medicaid coverage on an overall basis. Each case manager has access to an individualised dashboard that includes operational metrics such as new patients to contact, and frequency of patient contacts, timeliness for calling patients recently discharged from the hospital, whether patients have continuous Medicaid coverage, and completion of social risk screenings.

Study recruitment

Semistructured interviews were conducted with 30 field-based case managers as part of the programme’s evaluation and quality improvement process. Participants included four mental health clinical specialists, five substance abuse counsellors, six social workers, nine public health nurses, four housing support specialists and two community health worker specialists. Case managers were recruited by email and selected based on purposive sampling to reflect membership across disciplines and experience working with CommunityConnect for at least 1 year. Three case managers declined to participate. Interviews ended when data saturation was achieved. 23

Interview procedures

Interviews were conducted by five CommunityConnect evaluation staff members (including EEE), who received training and supervision from the evaluation director (EH), who also conducted interviews. The evaluation staff were bachelor and masters-level trained. The evaluation director was masters-level trained and held prior experience in healthcare quality and programme planning.

The evaluation team drafted the interview guide to ask about a variety of work processes and experiences with the goal of improving programme operations including staff and patient experiences. Specific questions analysed for this study were (1) how case managers define success with a patient and (2) examples where case managers considered work with patients a success.

Interviews took place in-person in private meeting rooms at case managers’ workplace from March 2019 – November 2019. Interviews lasted 60–90 min and only the interviewer and case manager were present. All interviewers were familiar with CommunityConnect yet did not have a prior relationship with case managers. Case managers did not receive compensation beyond their regular salary for participating in the study and were allowed to opt out of recruitment or end the interview early for any reason. All interviews were audio recorded, transcribed and entered into Nvivo V.12 for analysis.

Patient and public involvement

This project focused on case manager’s perspectives and thus did not directly involve patients. Rather, patients were involved through case manager recollections of experiences working with patients.

Data analysis

We used an integrated approach to develop an initial set of qualitative codes including deductive coding of programme processes and concepts, followed by inductive coding of how case managers defined success. All interviews were coded by two researchers experienced in qualitative research (EEE and MK). Themes were determined based on recurrence across interviews and illustrative examples and being described by more than one case manager type. The two researchers identified preliminary themes independently, then consulted with one another to achieve consensus on final themes. Themes and supporting quotes were then presented to the full author team to ensure collective agreement that key perspectives had been included. Preliminary results were also shared at a staff meeting attended by case managers and other staff as an opportunity for feedback on study findings. This manuscript addresses the Standards for Reporting Qualitative Research, 24 and the Consolidated Criteria for Reporting Qualitative Research checklist is provided as an appendix. 25

All case manager participants provided informed consent. Research procedures were approved by the Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018).

Case managers frequently and across multiple roles mentioned three characteristics of success when working with patients: (1) establishing trust; (2) fostering change in patients’ mindset or initiative and (3) promoting stability and independence. Across these characteristics, case managers expressed that success is patient-defined, with individualised and often incremental progress—a contrast with external perceptions of success and common operational or productivity metrics (see figure 1 ).

Illustration of key themes.

Success is establishing trust

Trusting relationships were the most widely noted characteristic of success. Trust was described as both a product of case managers’ consistent follow-up and helpfulness over time and a foundational step to enable progress on patient-centred goals. To build trust, case managers explained, patients must feel seen and heard, and understand the case managers’ desire to help: ‘Success is to know that she knows me very well…I look for her on the streets, and I’m waiting for her to call me back. Hopefully she knows that when she’s ready I will be there at least to provide that resource for her and so it’s that personal relationship that you build’ (Case manager 11, social worker). Case managers also highlighted the longitudinal relationship required to establish trust, distinguishing success as more than one-time information delivery or navigating bureaucratic processes to procure services.

Case managers also identified trust as foundational to provide better support for patients: ‘So they’re as honest with me as they can be. That way I have a clear understanding about realistically what I can do to help them coordinate their care or link them to services.’ (Case manager 2, mental health clinician specialist). Establishing trust was essential to improve communication with patients and produced an amplifying effect. That is, a case manager’s initial help and follow-up builds trust so that patients can be more open, and open communication helps the case manager know what specific services can be most useful. This positive feedback loop further cements trust and builds momentum for a longitudinal relationship.

Permission to have a home visit was mentioned as a valuable indicator of early success in building trust: ‘(Your home is) your sanctuary’, expressed one case manager (Case manager 29, public health nurse), acknowledging the vulnerability of opening one’s home to an outsider. For another case manager, regular home visits in the context of a trusting relationship made the case manager aware of and able to address a difficult situation: ‘Every time I was going to her home, I was noticing more and more gnats flying around… She said it’s because of the garbage…’ After establishing trust, the patient allowed the case manager access to the bedroom where the case manager uncovered numerous soiled diapers. The case manager arranged professional cleaning and sanitation through CommunityConnect, after which, ‘there was room for a dance floor in her bedroom. There was so much room, and the look on her face, it was almost as if her chest got proud, just in that day. She didn’t seem so burdened…So that’s a success’ (Case manager 4, substance abuse counsellor). Across multiple examples, case managers expressed trust as a critical element for effective patient partnerships.

However, the pathways to building trust are less clear cut. Quick wins through tangible support such as a transportation voucher to a medical appointment could help engage a patient initially. Yet case managers more frequently emphasised strategies based on relationships over time. Strategies included expressing empathy (putting yourself in the patient’s shoes), demonstrating respect (especially when the patient has experienced disrespect in other health system encounters), keeping appointments, following through on what you say you will do, calling to check in and ‘being there’. Overall, case managers expressed that trust lets patients know they are not alone and sets the stage for future success.

Success is fostering a change in patients’ mindset or initiative

Case managers described a change in patients’ mindset or initiative as evidence of further success. One case manager explained, ‘Really (success) could be a switch in mind state… If I can get someone to consider addressing an issue. Or just acknowledging an issue. That’s progress’ (Case manager 24, substance abuse counsellor). Another case manager spoke to the importance of mindset by stating, ‘what I try to do is not just change the surface of life’. This case manager elaborated, ‘You help (a patient) get their housing and they’re gonna lose it again, unless they change; something changes in their mindset, and then they see things differently.’ (Case manager 6, mental health clinician specialist). Some case managers suggested that the supportive resources they provide are only band-aid solutions if unaccompanied by a changed mindset to address root causes.

Case managers reported that shared goals and plans are essential, in contrast to solutions identified by case managers without patient involvement. ‘I can’t do everything for them’, expressed one case manager (Case manager 21, public health nurse), while others similarly acknowledged that imposing self-improvement goals or providing resources for which a patient may not be ready may be counterproductive. Rather, one case manager emphasised, ‘I think it’s really important to celebrate people’s ideas, their beliefs, their own goals and values’. (Case manager 4, substance abuse counsellor). As an example, the case manager applauded a patient’s ideas of getting a driver’s license and completing an education certificate. In summary, case managers viewed success as a two-way street where patient’s own ideas and motivation were essential for long-term impact.

Success is promoting stability and independence

Case managers also identified patients’ stability and independence as a characteristic of success. One case manager stated, ‘I define success as having them be more independent in their just manoeuvring the system…how they problem solve’ (Case manager 30, public health nurse). Relative to the other characteristics of success, stability and independence more closely built on resources and services coordinated or procured by the case manager. For example, CommunityConnect provides cell phones free-of-charge to patients who do not currently have a phone or continuous service, which has helped patients build a network beyond the case manager: ‘Once we get them that cell phone then they’re able to make a lot of connections … linking to services on their own. They actually become a lot more confident in themselves is what I’ve seen’. (Case manager 23, substance abuse counsellor). In another example, a case manager helped a patient experiencing complex health issues to reconcile and understand various medications. For this patient stability means, ‘when he does go into the emergency room, it’s needed. … even though he’s taking his medication like he’s supposed to… it’s just his health gets bad. So, yea I would say that one (is a success)’ (Case manager 8, social worker). Thus, stability represents maintained, improved well-being, supported by care coordination and resources, even while challenges may still be present.

As a step further, ‘Absolute success’, according to one case manager, ‘(is when a patient) drops off my caseload and I don’t hear from them, not because they’re not doing well but because they are doing well, because they are independent’ (Case manager 12, social worker). Patients may still need periodic help knowing who to contact but can follow through on their own. This independence may arise because patients have found personal support networks and other resources that allow them to rely less and less on the case manager. While not all patients reach this step of sustained independence and stability, it is an accomplishment programmatically and for case managers personally.

Success is patient-defined, built on individualised and incremental progress

Case managers widely recognised that success comes in different shapes and sizes, dependent on their patient’s situation. Irrespective of the primary concern, many identified the patient’s own judgement as the benchmark for success. One case manager explained, ‘I define success with my patients by they are telling me it was a success. It’s by their expression, it’s just not a success until they say it’s a success for them’ (Case manager 7, social worker). In a more specific example, a case manager highlighted checking in with a patient instead of assuming a change is successful: ‘It’s not just getting someone housed or getting someone income. Like the male who we’re working towards reconciliation with his parents… that’s a huge step but if he doesn’t feel good about it… then that’s not a success.’ The same case manager elaborated, ‘it’s really engaging with the knowing where the patient him or herself is at mentally, for me. Yeah. That’s a success’ (Case manager 18, homeless services specialist). This comment challenges the current paradigm where, for example, if a patient has a housing need and is matched to housing, then the case is a success. Rather, case managers viewed success as more than meeting a need but also reciprocal satisfaction from the patient.

Often, case managers valued individualised, even if seemingly small, achievements as successes: ‘Every person’s different you know. A success could be just getting up and brushing their teeth. Sometimes success is actually getting them out of the house or getting the care they need’ (Case manager 28, social worker). Another case manager echoed, ‘(Success) depends on where they’re at … it runs the gamut, you know, but they’re all successes’ (Case manager 10, public health nurse). CommunityConnect’s interdisciplinary focus was identified as an important facilitator for tailoring support to individualised client needs. In contrast with condition-specific case management settings, for example, a case manager with substance abuse training noted, ‘whether someone wants to address their substance use or not, they still have these other needs, and (with CommunityConnect) I can still provide assistance’ (Case manager 24).

However, the individualised and incremental successes are not well captured by common case management metrics. One case manager highlighted a tension between operational productivity metrics and patient success, noting, ‘I get it, that there has to be accountability. We’re out in the field, I mean people could really be doing just a whole lot of nothing… (Yet), for me I don’t find the success in the numbers. I don’t think people are a number. Oh, look I got a pamphlet for you, I’m dropping it off… I don’t think that that is what’s really going to make this programme successful’ (Case manager 8, social worker). One case manager mentioned change in healthcare utilisation as a marker of success, but more often, case managers offered stories of patient success that diverge from common programme measures. For example, one case manager observed, ‘The clear (successes) are nice: when you apply for Social Security and they get it that’s like a hurrah. And then there’s other times it’s just getting them to the dentist’ (Case manager 28, social worker). Another case manager elaborated, ‘It’s not always the big number—the how many people did I house this year. It’s the little stuff like the fact that this 58-year-old woman who believes she’s pregnant and has been living outside for years and years, a victim of domestic violence, has considered going inside. Like that is gigantic’ (Case manager 18, homeless services specialist). Overwhelmingly, case managers defined success through the interpersonal relationship with their patients within patients’ complex, daily life circumstances.

Case managers’ definitions of success focused on establishing trust, fostering patients change in mindset or initiative, and, for some patients, achieving independence and stability. Examples of success were commonly incremental and specific to an individual’s circumstances, contrasting with programmatic measures such as reduction in hospital or emergency department utilisation, benefits and other resources secured, or productivity expectations. Study themes heavily emphasise the interpersonal relationship that case managers have with patients and underscore the importance of patient-centred and patient-defined definitions of success over other outcome measures.

Our results complement prior work on clinic-based programmes for complex patients. For example, interdisciplinary staff in a qualitative study of an ambulatory intensive care centre also identified warm relationships between patients and staff as a marker of success. 26 In another study interviewing clinicians and leaders across 12 intensive outpatient programmes, three key facilitators of patient engagement emerged: (1) financial assistance and other resources to help meet basic needs, (2) working as a multi-disciplinary care team and (3) adequate time and resources to develop close relationships focused on patient goals. 27 Our results concur on the importance of a multi-disciplinary approach, establishing trusting relationships, and pursuing patient-centred goals. Our results diverge on the role of resources to meet basic needs. Case managers in our study indicated that while connections to social services benefits and other resources help initiate the case manager-patient relationship, lasting success involved longer-term relationships in which they supported patients in developing patients’ own goal setting skills and motivation.

An important takeaway from case managers’ definitions of success is the ‘how’ they go about their work, in contrast to the ‘what’ of particular care coordination activities. For example, case managers emphasise interpersonal approaches such as empathy and respect over specific processes and resource availability. Primary care clinicians, too, have expressed how standard HEDIS or CAHPS quality metrics fail to capture, and in some cases disincentivise, the intuitions in their work that are important for high quality care. 28 29 Complex care management programmes must also wrestle with this challenge of identifying standards without extinguishing underlying quality constructs.

Strengths and limitations

This study brings several strengths, including bringing to light the unique, unexplored perspective of case managers working on both health and social needs with patients facing diverse circumstances that contribute to high-risk of future hospital or emergency department utilisation. The fact that our study explores perspectives across an array of case manager disciplines is also a strength, however a limitation is that we are unable to distinguish how success differed by discipline based on smaller numbers of each discipline in this study sample. Other study limitations include generalisability to other settings, given that all case managers worked for a single large-scale social needs case management programme. Comments around productivity concerns or interdisciplinary perspectives on ways to support patients may be unique to the infrastructure or management of this organisation. In addition, at the time of the study, all case managers were able to meet with patients in-person; future studies may explore whether definitions of success change when interactions become virtual or telephonic as occurred amidst COVID-19 concerns.

This study is the first to our knowledge to inquire about holistic patient success from the perspective of case managers in the context of a social needs case management programme. The findings offer important implications for researchers as well as policy makers and managers who are designing complex case management programmes.

Our results identify patient-directed goals, stability and satisfaction, as aspects of social needs case management which are difficult to measure but nonetheless critical to fostering health and well-being. Case managers indicated these aspects are most likely to emerge through a longer-term connection with their patients. Thus, while resource-referral solutions may play an important role in addressing basic needs, 30 our findings suggest that weak patient–referrer rapport may be a limitation for such lighter touch interventions. The need for sustained rapport building is also one explanation why longer time horizons may be necessary to show outcome improvements in rigorous studies. 16

Relatedly, results point to trusting relationships as an under-recognised and understudied feature of social needs case management. Existing research finds that patients’ trust in their primary care physician is associated with greater self-reported medication adherence 31 along with health behaviours such as exercise and smoking cessation. 32 Similar quantitative results have not yet been illuminated in social needs case management contexts, yet the prominence of trusting relationships in this study as well as other sources 26 27 33 34 suggests that measures of trust should be used to complement currently emphasised outcomes such as inpatient and outpatient utilisation. Future research and programme evaluation will need to develop new trust measurement or modify existing trust measures for the social needs case management context. 31 35

In summary, study themes provide waypoints of how to conceptualise programme design, new staff training and potential measurement development for complex case management programmes like CommunityConnect. Despite the broad swath of social needs addressed, case managers coalesced on establishing a trusting relationship as a necessary foundation to appropriately identify needs and facilitate connections. Second, fostering patients’ own ideas, including a change their mindset or initiative, was important to fully make use of programme resources. Third, supporting new-found independence or stability was a gratifying, but not universally achieved marker of success. Commonly, case managers highlighted moments of success with mindfulness toward small victories, illuminating that success is non-linear with no certain path nor single end point. Themes emphasise the importance of bringing compassion for the complexity in patients’ lives and developing collaborative relationships one interaction at a time.

Acknowledgments

The authors would like to thank the CommunityConnect evaluation team for their support conducting and transcribing interviews and applying preliminary coding, especially Gabriella Quintana, Alison Stribling, Julia Surges and Camella Taylor.

Contributors: MK coded and analysed qualitative data, identified key themes and related discussion areas, and drafted and critically revised the manuscript. EEE conducted interviews, coded and analysed qualitative data, and drafted and critically revised the manuscript. EH developed the study instrument, conducted interviews, supervised data collection, contributed to the data interpretation and critically revised the manuscript. MDF contributed to the interpretation and critically revised the manuscript. NS contributed to the interpretation and critically revised the manuscript. ALB contributed to the design and interpretation and critically revised the manuscript. All authors approve of the final version to be published.

Funding: MK was supported by the Agency for Healthcare Research and Quality (AHRQ) under the Ruth L. Kirschstein National Research Service Award T32 (T32HS022241). MDF was supported by the Agency for Healthcare Research and Quality, grant # K01HS027648.

Disclaimer: Its contents are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ. Funding had no role in the study’s design, conduct or reporting.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants and was approved by Contra Costa Regional Medical Center and Health Centers Institutional Review Committee (Protocol 12-17-2018). Participants gave informed consent to participate in the study before taking part.

• Research article
• Open access
• Published: 28 August 2021

Lean adoption in hospitals: the role of contextual factors and introduction strategy

• Angelo Rosa 1 ,
• Giuliano Marolla   ORCID: orcid.org/0000-0002-2095-8641 1 ,
• Federico Lega 2 &
• Francesco Manfredi 1  

BMC Health Services Research volume  21 , Article number:  889 ( 2021 ) Cite this article

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In the scientific literature, many studies describe the application of lean methodology in the hospital setting. Most of the articles focus on the results rather than on the approach adopted to introduce the lean methodology. In the absence of a clear view of the context and the introduction strategy, the first steps of the implementation process can take on an empirical, trial and error profile. Such implementation is time-consuming and resource-intensive and affects the adoption of the model at the organizational level. This research aims to outline the role contextual factors and introduction strategy play in supporting the operators introducing lean methodology in a hospital setting.

Methodology

The methodology is revealed in a case study of an important hospital in Southern Italy, where lean has been successfully introduced through a pilot project in the pathway of cancer patients. The originality of the research is seen in the detailed description of the contextual elements and the introduction strategy.

The results show significant process improvements and highlight the spontaneous dissemination of the culture of change in the organization and the streamlined adoption at the micro level.

The case study shows the importance of the lean introduction strategy and contextual factors for successful lean implementation. Furthermore, it shows how both factors influence each other, underlining the dynamism of the organizational system.

Peer Review reports

Over the last decade, healthcare has been called upon to respond to the increasing pressures arising from changes in demand – due to epidemiological changes and the demand for quality and safety – and increased costs due to the introduction of new technologies [ 1 , 2 ]. These major challenges are exacerbated by the shrinking resources available in health systems and, for most countries, by the principle of universal access to patient care. In order to meet the patients’ needs, a hospital must utilize a number of scarce resources at the right time: beds, technological equipment, staff with appropriate clinical skills, medical devices, diagnostic reports, etc. [ 1 , 2 ].

One of the most relevant issues for the management of a healthcare provider is the management of patient flows in order to purchase, make available, and use these scarce resources at the right time and in the right way, and to ensure the best possible care [ 3 , 4 , 5 ]. In this scenario, hospitals need to focus on the patient pathways in order to ensure fast, safe, and high-quality service [ 3 , 6 , 7 , 8 ]. The search for solutions to these challenges has extended beyond the boundaries of healthcare practices to study organizational methods and paradigms that have been successfully implemented in other sectors [ 3 , 5 ]. Among these, lean thinking has proven to be one of the most effective solutions for improving operational performance and process efficiency and for reducing waste [ 5 , 9 ]. Lean is a process-based methodology focused on improving processes to achieve a customer ideal state and the elimination of waste [ 10 ]. Waste is defined as the results of unnecessary or wrong tasks, actions or process steps that do not directly benefit the patient. The taxonomy of waste is: overproduction, defects, waiting, transportation, inventory, motion, extra-processing and unused talent [ 3 , 4 , 5 ]. In addition, lean addresses other key service issues such as continuous improvement and employee empowerment, whether healthcare professionals or managers [ 1 , 11 , 12 ]. Lean healthcare is defined as a strategic approach to increasing the reliability and stability of healthcare processes [ 7 , 13 , 14 ].

The first documented cases of lean applications in a hospital setting (HS) date back to the late 1990s. These aimed at improving patient care processes, interdepartmental interaction, and employee satisfaction [ 1 , 2 ]. The Virginia Mason Medical Center is one of the first and most emblematic examples of a successful migration of lean methodology from the manufacturing sector to healthcare. The hospital, based on the principles of the Toyota Production System, created the Virginia Mason Production System, a holistic management model in continuous evolution that not only had a strong impact on the quality of the services provided and on the reduction of lead time, but it also led to a decrease in operating costs [ 14 , 15 ]. Over time, many hospitals have followed in the footsteps of the Virginia Mason Medical Center [ 8 , 16 , 17 ]. The lean paradigm crossed the US border and spread to other countries such as Canada and England [ 5 , 12 ]. It was not until the early 2000 that the model was introduced in European hospitals [ 12 , 16 ].

The implementation of the lean paradigm in HS environments has increasingly attracted the attention of researchers and professionals. The interest in lean in HSs was fostered by the idea that the paradigm was particularly suitable for hospitals because its concepts are intuitive, compelling, and, therefore, easy for medical staff to use [ 18 , 19 ]. However, over time, alongside the evidence of successful implementation of lean in HSs, much of the research has shown failures in adopting the paradigm [ 5 , 20 , 21 ]. Moreover, a literature review showed that most of the cases were characterized by a partial implementation of lean methodologies and concerned single processes in the value chain or restricted technical applications [ 20 , 22 ]. Even today, few hospitals apply lean principles at a systemic level [ 23 , 24 ].

The failure of lean implementation is a hot topic. Many authors who have focused their studies on social and managerial issues have highlighted the existence of factors that either enable or hinder the implementation of lean. These factors are mostly related to the context and the implementation strategies [ 5 , 16 , 25 , 26 , 27 ]. Lean implementation is not self-evident, and the process of transforming an organization into a lean organization requires a long-term strategic vision, a commitment by management, and a culture of change in the entire organization [ 5 , 16 , 26 ]. Contextual factors influence successful implementation and introduction strategy; lean adoption, in turn, changes contextual factors. A lean transformation must be planned and managed; it is not a quick solution, but a strategic plan in constant evolution [ 5 , 28 , 29 ]. From this point of view, the introduction phase plays a fundamental role in implementation because it facilitates the dissemination of the lean principle in hospitals and enables the contextual elements that support change. Although most researchers have recognized the role of the introduction step, the impact of this phase on contextual factors has been poorly reported on in the literature [ 5 , 12 , 20 ]. Most of the articles have focused more on the benefits of this phase than on how to manage it.

In light of this, it is necessary to examine how hospitals introduce lean into their clinical pathways in order to explain the success of the lean implementation. Starting with an in-depth analysis of the contextual factors discussed in the literature, the document helps to clarify what drives success in lean implementation within the hospital. The research has therefore undertaken a critical study of the introduction of lean in the case study of the haematology ward at a university hospital in the south of Italy. The objective is to highlight: (a) the role of contextual factors for successful lean introduction and implementation in a hospital ward; (b) how the pilot project has improved the pathway of a cancer patient undergoing chemotherapy infusion; and, (c) how the success of the pilot project modified the contextual factors, facilitating the spread of lean within the organization.

The study has the merit of detailing all the lean introduction phases. The analysis period is about 2 years. The lean introduction started in May 2018 and lasted 7 months. The pilot project results refer to the follow-up period of December 2018 to May 2020, while the dissemination results refer to the period from December 2019 to May 2020.

The paper is structured as follows: In the following section, the theoretical background is provided. Section 3 describes the research methods, while Section 4 presents the results of the pilot project. Finally, Section 5 presents the conclusion, highlights some limitations of this study, and proposes some directions for further research.

Theoretical background

Most authors point out that the introduction phase is a crucial moment in lean implementation [ 10 , 12 , 16 ]. This phase reduces distrust of the method and organizational resistance to change. It shows the benefits of lean and assesses the organization’s ability to undertake continuous improvement. Many case studies report the success of lean in HSs by describing the use of lean instruments [ 8 , 30 , 31 ]. They offer the practitioners some methodological support, but not in a structured way since they do not provide a clear implementation roadmap [ 5 , 32 , 33 ]. Some authors have tried to fill this gap in the literature by offering guidelines for implementation. Augusto and Tortorella [ 33 ] suggests carrying out a feasibility study focused on the desired performance before implementing continuous improvement activities. The author suggests defining the techniques, roles, and results related to the improvement path. Curatolo et al. [ 5 ] argue that the improvement procedure has to take into account six core operational activities of business process improvement and five support activities. The six core operational activities are: selecting projects, understanding process flows, measuring process performance, process analysis, process improvement, and implementing of lean solutions. The five support activities are: monitoring, managing change, organizing a project team, establishing top management support, and understanding the environment. These studies, while offering further guidance on the process of introducing lean into a hospital, do not describe either the organizational context in which the method is being implemented or the strategies for its implementation [ 5 , 12 , 25 ]. The introduction of lean into a HS is not an easy task; there are many organizational issues to be addressed. Among these, the analysis of the context and the definition of the implementation strategy are the ones with the greatest impact on the success of the introduction [ 16 , 26 , 34 ].

The contextual elements are the special organizational characteristics that must be considered to understand how a set of interventions may play out [ 35 , 36 ]. They interact and influence the intervention and its effectiveness [ 34 , 36 ]. Two of the most cited contextual element are the drive to improve processes and the level of maturity [ 5 , 10 ]. The drive for improvement is represented by the exogenous and endogenous needs that act as triggers for the introduction of improvement methodologies [ 25 , 26 , 35 , 37 ]. The level of maturity refers to knowledge and experience in process improvement initiatives. It includes knowledge of methodologies and tools, experience gained, confidence, trust, and dissemination within the organization. Where the maturity is low, there is a risk of lean introduction failure in both the processes and the organization as a whole [ 5 , 16 , 38 ]. As long as the organization does not reach a fair level of maturity, the rate of change tends to be slow and sometimes frustrating. However, as the degree of maturity increases, lean implementation becomes a “day-to-day job” rather than a series of projects that take place at discreet moments [ 10 , 21 , 39 ]. Hasle et al. [ 39 ] highlighted that a high level of maturity allows for the implementation of principle-driven lean. Contextual elements include organizational and technological barriers such as resistance to change, lack of motivation, skepticism, and a lack of time and resources that inhibits the introduction and the implementation process [ 4 , 8 , 21 , 40 ]. The lean introduction process in HS is also complicated by the organizational context and the double line of clinical and management authority in hospitals [ 41 , 42 ].

With regard to internal contextual factors, many authors explored the readiness and sustainability factors influencing the adoption of lean. Readiness factors are those elements that improve the chances of lean implementation success; they provide the necessary skills and knowledge to enable organizational change [ 23 , 43 , 44 , 45 ]. The readiness and sustainability factors include any practices or characteristics that allow organizational transformation by reducing or nullifying potential inhibitors of success. High commitment and strong leadership of managers and physicians, continuous training, value flow orientation, and the hospital’s involvement in continuous improvement are just some of the most discussed topics [ 5 , 10 , 16 , 43 ]. Other examples include understanding employees needs, identifying the organization’s strategic objectives, project management, and teamwork [ 5 , 12 , 16 , 46 ].

From the study of the contextual elements described so far, some authors have developed models to assess the impact of context on the implementation of organizational improvement activities. Kaplan et al. [ 36 ] put forth the Model for Understanding Success in Quality (MUSIQ). The authors identified 25 key contextual factors at different organizational levels that influence the success of quality improvement efforts. They defined five domains: the microsystem, the quality improvement team, quality improvement support and capacity, organization, and the external environment. Kaplan et al. [ 36 ] suggest that an organization that disregards contextual factors is doomed to fail in implementing an improvement program; an organization that adopts a context-appropriate implementation strategy can change the outcome by triggering implementation enablers. Previous studies of lean adoption in HSs suggest that the fit between the approach taken and the circumstances will influence the chances of success [ 3 , 12 , 34 ].

There are two strategies for introducing lean in a HS, and they are characterized by the implementation level. The level of implementation refers to either micro or meso implementation. Brandao de Souza [ 16 ] defined meso-level implementation as the condition under which lean is spread throughout the organization and is implemented at the strategic level, while micro-level implementation is where lean is implemented at a single process level in discrete moments. Meso-level implementation is crucial for long-term success because a lack of integration in a lean system can lead to the achievement of local rather than global objectives and can also affect the sustainability of the paradigm [ 23 , 26 , 47 ]. However, organizations that want to implement lean at the strategic level often do not recognize the need for a long-term implementation program and introduce lean as a “big-bang initiative”. This leads in many cases to a failure to introduce the method [ 16 , 47 ]. Many researchers suggest introducing the lean approach through a pilot project run by a specially formed lean team [ 12 , 16 , 48 , 49 ]. The pilot project should be challenging, involve a process relevant to the organization, and require the use of a systemic approach. In particular, it should not be limited to the application of “pockets of good practice” or lean tools, but should include the systemic adoption of improvement programs such as the Plan-Do-Check-Act (PDCA) cycle [ 21 , 48 ]. Brandao de Souza [ 16 ] asserts that the first initiative should be tested on a relevant patient pathway. The lean team should be composed of clinical and non-clinical staff actively involved in the patient pathway. A pilot project that meets these conditions is a useful tool for increasing the maturity of the method within the organization [ 21 , 39 ]. It can increase the confidence of the team and staff in the lean approach and can promote the learning of lean methodologies and techniques [ 21 , 39 ]. Moreover, the pilot project activates the contextual elements, enabling the introduction of the model [ 10 , 12 ]. The successes of the pilot initiative must be celebrated and communicated within the organization [ 10 ]. When the first initiative leads to visible and easily quantifiable results, the method has a greater chance of spreading throughout the organization [ 10 , 12 , 16 ]. In light of these considerations, the lean implementation requires that the contextual elements and the introduction strategy be assessed at the same time. In addition, it would seem fair to assume that as contextual factors influence the introduction strategy, the results of the implementation strategy will influence the contextual factors.

In Fig.  1 , we propose an adaptation of the MUSIQ model [ 36 ] that shows the impact that the lean implementation strategy has on the contextual elements.

Our adaptation of the MUSIQ model

Study setting and design

This is an explanatory single-case study of the introduction of lean at a university hospital in Southern Italy. In particular, the introduction of lean in the pathway of a cancer patient undergoing infusion chemotherapy in a haematology ward will be discussed. This study was designed to evaluate how the contextual elements discussed so far have influenced the introduction of the method and how the successful pilot project has enhanced the internal context. We used the adaptation of the MUSIQ model [ 36 ] proposed in Fig. 1 to systematically trace the antecedents of the lean introduction and to explain how the success of the implementation strategy changes the contextual elements.

The work covers four periods over 2 years (Fig.  2 ). The first period concerns lean introduction and implementation strategy. The second is related to the pilot project implementation in the haematology ward. The third shows the pilot project results. The last assesses the impact of the pilot project on the dissemination of lean within the organization.

Stages of data analysis

Data collection

Different data sources and data collection methods are used with the aim of improving data validity through triangulation. The data sources are lean training documents, direct observations and nonparticipant observations, process performance reports, process data recorded by patients, and two questionnaires submitted to the hospital staff (the questionnaires assess the “pre” and “post” lean dissemination phases and the difference regards three open questions) (Fig. 2 ). The second author is the consultant who trained the lean team and coordinated the pilot project, and the first author conducted approximately 50 h of nonparticipant observations. The questionnaire was delivered to 25 medical department staff members in September 2018 and in May 2020. The first questionnaire focused on contextual factors that existed before the introduction of lean, and the second investigated changes in the contextual elements - in particular trust, maturity and lean dissemination. The semi-annual performance reports from 2017 to 2020 for the clinical pathway under examination include daily averages of the number of chemotherapies per chemo chair (MT), the patients’ length of stay (LOS), and the daily average of the percentage of patients undergoing chemotherapeutic infusion within 3 hours of hospital admission (P3). Each day, from September 2018, a document containing all the steps of the clinical pathway was given to each patient. For each activity, the patient recorded the start and end time, and a signature of the doctor or nurse was required. In the period of September 2018 – May 2020, the medical staff collected more than 1.250 reports from patients. The study also draws on 10 semi-structured interviews. The hospital CEO, the chief of the medical department, the nurse supervisor, the chief of the antiblastic chemotherapy handling units, and the chief of the clinical laboratory were interviewed in September 2018 and May 2020. The interviews focused on the contextual elements either enabling or inhibiting lean introduction or its dissemination, and ranged from 30 min to 1 hour in duration.

Data analysis

The factors described in Fig. 1 were used to systematically analyse the antecedents of the results and to understand their causal influence on the lean introduction. This data collection allows for the description of the case study. In addition, it simplifies the interpretation of the evidence that emerged through the study of the factors listed. The authors carried out a content analysis to classify the data by theme. The content analysis followed an inductive approach based on the identification of meaning units at the semantic level and the encoding of results [ 49 , 50 ]. Whenever researchers did not agree on semantic meaning, a new unit of analysis was proposed. The principle of consensus among all panel members was used to determine the interpretation, addition or deletion of elements of analysis. The discussion of the case study focuses on four themes: (a) contextual elements enabling or hindering lean introduction, (b) implementation strategy, (c) pilot project results, and (d) lean dissemination and adoption in hospital. These themes were submitted for review by the interviewees; their feedback was used to improve the accuracy of the case study description.

Case study presentation

The university hospital is a model of excellence in Italy for pre-clinical, translational, and clinical research and care activities. It is equipped with 110 beds to treat all types of oncological pathologies in adults. There are 115 researchers working there. The hospital is structured into six departments, of which three are clinical (Medical Area, Diagnosis and Imaging Therapy, Surgical Area), two are services, and one is an administrative/management department. The medical area includes four wards: medical oncology for thoracic pathology, medical oncology, haematology, medical oncology for oncology patient care. In 2015, the institute was accredited as a clinical cancer centre according to the Organization of European Cancer Institutes (OECI). Since 2015, evidence-based medicine and patient-centred care methodologies have been successfully implemented in the hospital, but no process improvement methodology has been used. In 2017, the hospital became a hub for oncological diseases, which led to an increased demand for care and services. The hospital has received national funds dedicated to hubs and has made investments in infrastructure improvements and the purchase of new innovative medical equipment.

Contextual factors enabling or hindering lean introduction

The description of the external and internal contextual factors, as revealed in the first questionnaire and the interviews, is given in Table  1 . Below is a brief description of each item.

External context and organizational elements driving lean introduction in the haematology ward

The analysis of the context revealed external and internal elements influencing the introduction of lean. Starting with the external elements, the most frequently discussed motivators that led to the search for methodologies for process improvement include the continuous increase in patient volume and the benchmark of process performance with other providers. Although the clinical results were above the national average, the increase in demand - especially in the medical area - highlighted the inability to manage the increasing flow of patients. The inability to manage the increasing number of patients also affected the performance of the process in the diagnostic area.

Internal elements driving the lean introduction were related to dissatisfaction with inefficient work practices within the medical area and the dissatisfaction of many patients who complained about long wait times and lengths of stay.

The choice of lean methodology derives from the desire to follow the example of certain Tuscan hospitals that have been using lean at a strategic level since 2015. These hospitals are considered the benchmark for continuous process improvement. One of these hospitals was already included in the 2013 OASI Report, edited by CERGAS - Bocconi, among the six Italian companies that were the first and best to successfully implement Lean Thinking in healthcare. In addition, the methodology was strongly sponsored by the clinical director and the general director of the hospital. They had participated in a 60-h regional training course on lean healthcare in the second half of 2017. During the training course, they studied case studies of excellence in lean implementation.

When, in May 2018, the hospital directorate proposed the introduction of lean methodology in the medical area, the head physicians showed strong resistance because of the resources that would need to be allocated to the implementation process. In addition, some doctors did not trust the method. This brought up some conflicts with the medical area managers. The haematology staff, represented by their head physician, were the only ones who explicitly agreed to implement the lean introduction. The department, as in most Italian hospitals, is structured as a clinical area where the physicians - in contrast to other professionals - were members of the ward organizationally. Haematology staff were strongly motivated to do research and achieve excellent process performance. They were interested in taking the opportunity to define excellent clinical pathways, as the ward was undergoing managerial and layout restructuring. In addition, the haematology staff believed that lean could further improve clinical performance and improve the patient-centred and evidence-based approach. Until mid-2017 the ward was part of oncology; afterward, it was made independent and new areas of the hospital were assigned to it. Since the ward became independent, one head physician, three doctors and four nurses have been hired. The department is equipped with the most modern medical equipment. The layout of the ward was not yet fully defined, and some rooms that could have potentially been assigned to medical, diagnostic and therapeutic activities had not been assigned to process activities. The ward shares the Antiblastic Chemotherapy Handling Unit (UMACA) and the analysis laboratory with the other four medical department wards in the hospital, so the staff needed to coordinate clinical processes so as not to create bottlenecks.

Since haematology is a strategic ward for the hospital, and in the last 2 years the demand for treatment has increased more than in other wards, the managers of the medical area have deemed it appropriate to introduce lean there. Haematology ward is considered strategic due to its high attractiveness and high immigration rates of patients from outside the region. These phenomena derive from the excellent reputation of the department in relation to the quality of care. Although the clinical pathways were characterized by excellent clinical outcomes, qualitative benchmarking activities (based on testimonials from physicians and patients) showed that the organization of the haematology patient pathway was very different compared to the benchmark (a Tuscan hospital) and that the patients’ perception of non-clinical service quality was lower. Although no investigation was carried out with respect to the ratio of equipment and personnel available per number of patients and amount of activities regarding the hospitals taken as benchmarks, the testimonials prompted management to come up with new specific, measurable, attainable, relevant and time - bound (SMART) goals (Table  2 ). The goals will be described in the next section.

Internal contextual elements enabling and hindering lean introduction in the haematology ward

At the organizational level, hospital management has strongly supported the introduction of the method. Since the haematology staff had no experience in process improvement activities, management provided the budget for an external consultant. In addition, three non-clinical personnel were allocated part-time to support the implementation of visual management systems and communication. The organizational structure of the ward has been modified to a matrix form. A team of three haematology ward physicians and two nurses was established and the ward’s head physician was elected project manager. The project manager had formal authority over the team and the personnel employed in the process to be improved; this reduced conflicts due to the double line of hierarchical authority. In this phase, the top-down decision-making approach was crucial to the successful restructuring of the organizational structure and the definition of the new organizational roles. The lean advisor supported the group for 8 months through training and project supervision. He coordinated two meetings per week and carried out Kata coaching activities. The theoretical training activity, lasting 5 week ends (in June 2018), was differentiated to accommodate technical and managerial competency needs. The team project manager and the medical area manager were trained on topics such as project management, team management, leadership, and the dissemination of lean. The members of the lean group were trained in lean techniques and tools. The key principles of lean thinking, the PDCA cycle methodology and lean assessment were taught to all participants. The most difficult barrier to overcome was the time available. The team agreed to spend 8 hours per week on training and pilot project implementation. The management of the team was facilitated by the experience gained with the implementation of the patient-centred care and evidence-based medicine. The motivation of the medical staff–microsystem element–and the focus on team management were key success factors for the involvement of team members. The culture of change introduced by patient-centred and evidence-based medicine was another enabling factor.

Implementation strategies

Pilot project definition.

Hospital managers and lean team members, who had experience in implementing patient-centred care methodologies, suggested starting a pilot project for the lean introduction. The consultant agreed. The team, with the support of the expert, analysed the clinical pathways in haematology. Six pathways emerged: a) diagnostic visits, b) biopsies, c) check-up visits, d) transfusions, e) infusion chemotherapies, and f) oral chemotherapies. Hospital managers argued that the pathway of the patient undergoing infusion chemotherapy was the most critical for patient and organization value. This process is the only one that involves several departments and requires a large amount of materials and time-consuming resources. In the first and second half of 2017 and 2018, there was a significant increase in the number of chemotherapeutic preparations. LOS, P3, and MT performance decreased during the same periods (Table  2 ). In addition, outpatient visits and the number of biopsies also increased. The medical staff stated that the increase in demand in the medical area had particularly affected the infusion therapy activities because they involved technical and instrumental resources that are shared with other departments (Table  2 ). The length of stay was analysed for patients undergoing short (LOS s ) and long-term infusion (LOS l ) chemotherapy. The first has a minimum duration of 90 min and a maximum of 180 min, and the second has a minimum duration of 181 min and a maximum of 360 min. Each patient was assigned to one of the infusion treatment classes. Process data were collected and analysed by the Department Management Control Office. The process performance data collection and reports were established in 2015 for the implementation of evidence-based medicine.

Pilot project implementation

The pilot project started in June 2018. The first month was dedicated to Gemba Walk, Methods-Time Measurement (MTM) and implementation of the 5S. In addition, the consultant trained the project manager, department managers and lean team members. There were many difficulties during the training period, especially with regard to process mapping and the concept of value, the latter being interpreted by doctors as clinical output. The non-medical staff dedicated to the project assisted the team in the drawing of the visual management material. A room in the medical department was dedicated for team meetings, and some notice boards were installed to post the materials developed during the project. The project activities were organized according to the Report A3 scheme. It followed the phases of the consolidated Deming cycle: Plan-Do-Check-Act (PDCA). Implementing the approach proposed by Deming allowed for the trial-and-error empirical method to be abandoned in favour of the “scientific” one. The PDCA allowed accurate planning of objectives and activities and their monitoring. The departmental managers and the consultant through the study of the national publications and explicit requests to colleagues in other hospitals - considered virtuous - identified the benchmark (Table  2 ). They took into account the hospital’s specific characteristics, such as the policy of not accepting haematochemical reports from outside for fragile patients. This choice is dictated by the risk management plan and affects P3 and MT performance. Time for blood sampling and haematochemical analysis is added to the cycle time; however, it eliminates many risks associated with clinical treatment.

The existing care process was mapped through Value Stream Mapping (VSM) based on the patient reports, Gemba walks, interviews, and direct observation. For instance, Fig.  3 shows the pathway of a patient undergoing short-term infusion chemotherapy. The cycle time in Fig. 3 was calculated over an observation period of 1 week and included 51 patients. In addition, the application of the Demand Map and the Spaghetti Chart were used to evaluate the ward nodes activated by the patients and the ward’s layout. These tools were useful in defining the possible sources of waste in the process. The application of these tools lasted more than 2 months and required several revisions. Once completed, the results were posted in the meeting room and were used for discussions with colleagues in the medical department. The lean team requested support from the consultant for the drafting of the VSM and for the layout analysis. In addition, the consultant was asked to simplify negotiations with staff from other departments who were reluctant to be subjected to time and method measurements. The negotiation activity required a degree of organizational effort. The facilitating elements were manifold: they enabled the involvement of staff opposed to the introduction of measuring instruments. In particular, the most effective were: the intervention of the directorate general, the delegation of hierarchical authority to the project manager and finally the endorsement of trade union committees. Moreover, during the planning phase, many difficulties emerged, including the selection of a unique and standardised measurement system, the coordination of work and meeting schedules, and the deadlines set by the project Gantt. Although the project manager was able to manage the team, he did not have enough experience in lean tools. The external consultant played a key role in managing these activities.

As-is process represented by VSM

At the end of the as-is analysis process, an Ishikawa diagram was used for the definition of root causes. Four root causes emerged from the meetings and interviews. They were patient flow management, coordination activities with other departments, layout, and Information Technology equipment (IT).

Patient flow management concerned the absence of priority in the management of patients based on the clinical path and the arrival of patients in the early hours of the morning. The lack of coordination with other departments led to delays in the preparation of infusion chemotherapy and blood test reports. The layout was such that the flow of doctors and nurses crossed the flow of patients, and this caused great inconvenience to the doctors and nurses. Also, the computer software was not compatible, which meant that the same data had to be recorded several times.

After some meetings and rigorous brainstorming, the lean team suggested changes to be made in the existing pathway. This was done by considering how patients could be divided into clusters so that the infusion activity could start as soon as possible without affecting other occurrences. Moreover, it is made possible to simplify the coordination between diagnostic units. The patient flow has been managed in such a way that long-term patients are given priority (first to be accepted and blood sampled), followed by patients needing biopsies, first visit, follow-up visit. Finally, short-term patients are treated in a way that limits waiting time and does not affect the activities of other departments. Theories of queues and operational research methodologies were implemented to address chemo chair saturation. A chemo chair activities plan was implemented through pull logic. In addition, the hospital engineer was involved in making sure the information systems were compatible. Whenever integrating the software was not possible, a data entry person was assigned to prevent medical staff from wasting their time on low-value activities. The ward layout has been modified to prevent patient flows from intersecting with the flows of doctors and nurses. In addition, the use of one room has been changed from a small warehouse to a blood collection room to increase the value of the activities carried out within it. The waiting rooms were moved outside the ward and, during the first 2 hours of the working day, the biopsy room was reassigned to blood collection activities to speed up the requests for therapies in UMACA. Patient intake, blood collection, and tube labelling activities have been paralleled to be performed simultaneously in the same room. The routes and modalities for the delivery of blood samples to the laboratories were revised in order to reduce the time and distance travelled by non-clinical staff. Tablet reporting systems were installed. Finally, a patient chemo chair allocation system was developed.

The resources needed for these changes were determined. The team tested and modified the changes during December 2018 and January 2019. The tests were evaluated based on the performance data, patient reports and the team’s expertise.

Pilot project results

In January 2019, it was decided to implement the new standard procedures that were tested in order to improve performance. The team met once a week for 6 months. On a monthly basis, performance was reviewed and new changes were tested. Clinical and nonclinical personnel from other wards and departments were invited to each weekly meeting to share with them the results of the pilot project, and to involve them in the lean methodology.

Every morning, the team leader investigated the impact of organizational changes in order to avoid conflicts. Organizational problems that emerged were discussed and resolved by consensus. In the follow-up phase, the consultant performed supervisory activities. Each week, the team leader performed the Kata coaching. During the first 6 months, the monitoring of activity was very frequent to prevent a return to old operating modes. Subsequently, when the staff had learned the new procedures, monitoring was reduced to once a month.

Table  2 and Fig.  4 shows the results achieved through the implementation of the pilot project. The objectives were not reached for all indicators; however, the results improved over time.

Figure  5 shows the to-be state of the same process analysed in Fig. 3 . From the cycle time analysis of each process step, the areas of waste eliminated are clear.

To-be process represented by VSM

The incremental improvements in process performance over time are explained by the need for staff to learn new procedures in the early period. In addition, the patients’ resistance to changing their habits also slowed down the improvement in performance. Patients have been educated over time, through an intense communication activity based on visual management systems and telephone reminders.

In addition to the results showed in Table  2 , the pilot project had a positive impact on the performance of other patient pathways in the medical department. The cycle time variability reduction and the levelling of the service demand allowed the UMACA and the analysis laboratory to better plan their activities. The new layout reduced waste due to unnecessary movement. Nurses walk 2 km less per day and doctors 1.5 km less per day. Software integration has reduced data logging time by 35 min per day for each doctor. Patients have evaluated the change positively. In particular, they have experienced a drastic reduction in wait times, and greater attention from the medical staff. Increased privacy and a precise time of service are other improvements reported by patients.

Finally, the clinical staff was satisfied with the new procedures because they reduce overloads and allowed for better planning of activities. They say that dividing patients into time slots based on clinical priority reduces stress and simplifies the coordination of activities with other departments. The success of the project was communicated internally and externally to the organization. In June 2019 the results were celebrated with a formal team award ceremony. The resulting Report A3 was posted on the bulletin boards in the hospital wards and in the reception area. By means of an internal circular sent to all medical directors, the directorate officially thanked the members of the lean team and highlighted the excellent results achieved in terms of waiting lists and process time reduction. In addition, the directorate funded the lean team’s participation to national conferences in order for the team to discuss the project. The improvement activities and results were described and summarized in an official report sent to the regional health authority and cancer patient associations (the latter were also given an evaluation form and an invitation to observe the optimised process in the field). Reporting was carried out by the hospital directorate and the project manager.

Lean dissemination and adoption in the hospital

Following several meetings between the directors and the primary doctors of the medical area, it became clear that there was a willingness to implement further improvement projects in other medical wards. The feedback from the pilot project team was a strong convincing factor. Moreover, the results of the external communication of the pilot project played a critical role in increasing the desire for emulation. The regional authorities requested for the project team to co-design the diagnostic and therapeutic care pathways (PDTA) of the haematology patient pathway inside the regional network. The patient association lobbied for similar projects to be implemented in other clinical oncology pathways. The change of internal context and enabling factors were of great importance at this stage. The drive to disseminate lean was characterized by both the need to improve process performance and to the desire to emulate the success of the project pilot. In addition, increased trust in the lean method has prompted the directors to provide a peer internal training program in the medical area. In June 2019, members of the pilot project lean team were promoted to the position of lean champions. Their role was to disseminate the lean methodology in the medical area and to train colleagues. The hospital directorate set up the Lean Support Office and assigned to it the three non-clinical resources that had already supported the pilot project. The first methodology to spread throughout the medical department was 5S. According to the lean sponsors, this methodology was a prerequisite for implementing lean methodologies in all wards and for facilitating inter-process lean implementation. Visual management systems have been implemented to facilitate changes and standardization of activities and to guide the patient through the hospital. The 5S methodology and visual management, which was initially underestimated by the medical staff, has solved many problems in the working environment. Increasing the availability of tools, simplifying the transmission of documentation, reducing errors in medical records and nursing diaries, reducing the duplication of requests and medical documentation, creating flexible workplaces, less movement and transportation in the hospital, and increasing patient autonomy are just some of the improvements achieved. However, the most important result to be achieved was an improvement in workplace wellbeing. Among the most used tools for 5S implementation and visual management are: checklists, one point lessons, kaizen forms, horizontal and vertical marking, red tags, Kanban, spaghetti charts. Finally, the demand map was implemented to trace the patient flow across the departments of the medical area and the vertical swim lanes and the resources/process matrix were utilized to identify staff involved in several processes and the potential bottlenecks (in addition to the UMACA and the blood chemistry laboratory). As of August 2019 many other lean projects have launched sometimes spontaneously and sometimes at the demand of department heads or project managers (Fig.  6 ). In August 2019, three projects were undertaken in the medical oncology for thoracic pathology and the medical oncology wards. Two of them concerned the same clinical pathway addressed in the pilot project, and the last one was the harmonization of protocols for caring for an oncological patient between departments. Each project has been implemented following the PDCA cycle (using the A3 report framework) with the support of one of the lean champions, who was assigned the role of project manager. Teams of three doctors and one nurse were dedicated to each project. In the planning phase, the tools adopted in each project were: spaghetti charts, VSM, Gemba Walk, standardized data collection sheets (both for patients and physicians), control charts, 5 Why or alternatively the Fishbone Diagram, definition of SMART objectives. In the “Do” phase, the solutions adopted for the resolution of problems are derived from Just in Time and agile approaches (especially for software’s’ integrations management). The pilot project A3 report was used as a knowledge management tool and resulted to be of great value to guide the implementation of the three projects. The members of the pilot project team supported their colleagues during the implementation of the three projects. This resulted in a positive impact on the quality and timing of the data collection activities, the drafting of the VSM, the definition of the KPIs and especially the root cause analysis. Even though the negotiation was simplified by peer training, support from more experienced colleagues and project management by a doctor, organizational and structural barriers emerged. The difficulty in getting the new procedures accepted, the impossibility of optimizing the layouts and the “not always respecting” the authority of the project manager limited the performance improvement. Although not all potential solutions have been implemented, the results obtained are evidence of the success of the projects.

Lean projects and dissemination activities

In September 2019 the diagnostic department started 5S and visual management implementation initiatives. In October 2019 the same initiatives were undertaken in the surgical department. These initiatives were spontaneously implemented. The managers of these departments have asked the hospital director to introduce lean in their departments. Given the maturity of the method and the number of doctors trained, hospital managers did not consider it possible to undertake systemic improvement pathways in all departments. However, they have changed the organizational structures of the departments into matrix structures. Two doctors with lean experience, per department, have been assigned the role of project manager. The project managers have sponsored peer training and Kaizen blitz activities throughout the hospital departments. In the period October to December 2019 more than 60 doctors and nurses were trained in 40-h courses by their colleagues (Fig. 6 ). Three Kaizen blitz projects in the diagnostic department and two Kaizen blitz projects in the surgical area were carried out (Fig. 6 ). In addition, a PDCA cycle project was implemented in the medical area for the stocking and tracking of drugs and instruments. Moreover, the two bin Kanban systems, drug tracking tools, optimisation of the position in the storage layout and systems for the analysis of consumption time series were implemented.

In December 2019, in all the departments discussed so far, doctors were involved in continuous improvement activities, with projects structured through the use of both PDCA cycle and Kaizen blitz. The activities were undertaken spontaneously without the supervision of a manager and without any impact on daily clinical activity. The maturity of the methodology, the support of colleagues, and trust were enabling elements. However, some barriers such as infrastructural constraints and coordination of doctors and nurses and information systems have frequently affected the implementation of the method and two projects failed.

Due to the success of implementations at the micro level, managers have attempted to implement the lean methodology at the meso level. Hospital managers discussed, formalized and communicate in organization the Lean Strategic Plan. In January 2020, the Lean Support Office was transformed into a lean projects control room and renamed as the Operations Management Office. The role of this office is to define lean development policies and to supervise continuous improvement activities. The office has been placed in line with the strategic direction. Two lean project managers, two hospital managers, and three administrative officers have been assigned to it. Lean assessment, to evaluate the degree of lean maturity in organization, and Honshi Kanri, to strategically govern change activities, were implemented to the organizational level. While the lean assessment revealed an increase in both advance in the use of lean tools and the principles behind them, the governance of strategic implementation through Honshi Kanri did not seem to provide the foreseen results. Operations management office project managers did not always agree with hospital directorate on project prioritization. In addition, there often were disagreements between the Operations Management Office staff and departmental project managers about when to launch a project and how to manage it and communicate project results. Although there were many process improvement projects underway, these have not always been decided harmoniously between the Operation Management Office and the hospital departments. Moreover, many projects undertaken spontaneously by lean teams were not communicated to the Operations Management Office, which was therefore unable to govern the dissemination of the method. Medical leadership in departments seemed to dominate over managerial leadership; thus, there is great difficulty in strategically governing continuous improvement.

The marked differences in the responses to the closed questions of the questionnaires submitted provide significant evidence of how lean has spread throughout the organization (Fig.  7 ).

Responses to the closed questions of the questionnaire

The marked differences in the responses to the closed questions of the questionnaires presented provide significant evidence of how lean has spread throughout the organization. In particular, the results show how standardisation, self-assessment, time for improvement and peer-to-peer training have become part of everyday working practice. Furthermore, problem solving and collaborative decision-making show significant improvements. These improvements were witnessed not only by management but also by doctors, nurses and technical staff in the medical area.

After the pilot project and the initial push for implementation by management, internal contextual factors changed radically within the organization. While initially sponsorship and management involvement were necessary for lean implementation, today the methodology is independently disseminated. In particular, small improvement groups have emerged that are able to address various challenges. Process vision and patient focus have become part of the hospital culture. Doctors claim that continuous improvements simplify daily work, save time, and increase the level of service and the number of services provided. However, although these changes occurred at the micro level, the organization failed to direct change at the strategic level. Thus, harmonization of lean projects according to the strategic direction of the facility has yet to be achieved.

In accordance with the findings of many researchers [ 10 , 16 ], this case study showed how a careful, context-driven lean introduction strategy facilitated the dissemination of lean - at micro level - within the hospital. The decision to implement lean was precipitated by external factors, including the need to improve the performance of processes in the medical area and to follow the example of other successful hospitals. The in-depth training by an external specialist and the pilot project, characterized by interdepartmental activities, the need for a systemic approach based on the Deming Cycle and the constant support of the external consultant, allowed the participants to acquire the necessary skills to support - sufficiently - the lean implementation in the clinical pathways of the medical department and to train their colleagues. The results of this project have been manifold. At the process level, there was a significant reduction in the patients’ length of stay, the wait times for haematological patients, the process time variability, and an increase in the number of daily chemotherapy therapies performed. At the medical area level, a spontaneous spread of the culture of improvement has emerged. Directorate commitment, motivation of the medical department staff and management, and the presence of a consultant were the main enabling factors for the success of the pilot project. In turn, the results of the pilot project were the trigger for the spread of lean in the hospital. The pilot project itself, and the changes made to standard procedures that were inspired by the intervention, altered the contextual elements, mirroring the MUSIQ model [ 18 , 26 , 36 ]. Moreover, as trust and maturity raised, the speed of lean dissemination increased. This confirms that knowledge of the lean method tends to reduce organizational barriers and resistance [ 5 , 21 , 51 , 52 ]. Kata training and coaching were other key elements for the dissemination of the methodology. Initially, the consultant carried out the training activity, and after the pilot project, the team members became trainers and project managers; in this way, lean spread in the organization spontaneously. Moreover, as stated by many researchers [ 12 , 21 , 46 ], the matrix structure and project managers helped the staff to support and better coordinate process improvement. The many projects activated in the period July 2019–March 2020 are the measure of the diffusion itself.

However, some issues have arisen. For the new working procedures, the willingness of and the acceptance by the staff is crucial to achieving and sustaining the results of lean initiatives; where this did not occur, conflicts arose and the speed of change slowed. In addition, although in the early stages of implementation the bottom-up approach must prevail over a top-down approach to facilitate consensus and trust among physicians, nurses, and all workers, during the dissemination phase a greater equilibrium between the two decision-making approaches must be achieved. In accordance with [ 2 , 5 , 10 ], this case study demonstrates the importance of the right balance between bottom-up and top-down approaches. Medical leadership tends to dominate managerial leadership such that continuous improvement, even though it takes place in clinical processes, does not follow the strategic organizational guidelines. This leads to conflicts between managers and medical staff. Organizational, technical and infrastructural obstacles have hindered the adoption of the methodology. It is clear from what has been found that the introduction strategy was correct, but that the implementation at the strategic level has not yet taken place. The context has changed considerably from an organizational point of view, but some barriers have not been overcome. The management, which strongly sponsored and supported the introduction and implementation of lean, was subsequently unable to guide the implementation at the strategic level.

Our adaptation to the MUSIQ model is useful for interpreting the relationship between lean introduction strategies and changing contextual elements. Looking backward through this model allows us to understand the links between contextual elements, lean implementation and outcomes.

Conclusions

This study revealed that the strategy of introducing lean has improved readiness, sustainability and confidence in the method within the organization. The growing maturity of the organization has encouraged lean dissemination. However, the choice of strategy depends heavily on contextual factors. The two factors, therefore, influence each other. Although the introduction strategy may facilitate the introduction of lean, it may be less important when certain organizational, technical and infrastructural barriers remain. This is particularly relevant for systemic implementation. Contextual elements, which changed over time, influenced the success of the implementation at micro-level. At the meso-level, however, the organization has not reached the maturity for a systemic implementation of the method.

As has already been shown in the literature, the determining factors for introducing the methodology refer to external and internal pressures. The level of commitment of both the leadership and management are decisive for the success of the implementation only if the staff is motivated. Furthermore, the analysis shows that managing lean implementation at the micro and meso-levels requires different types of efforts. While the level of maturity speeds up the adoption of lean at the clinical level, it is not true that the dissemination of lean at the operational level inevitably translates into its application at the strategic level. Medical leadership, reinforced by the success of lean project implementations, could instead undermine proper implementation at the meso-level. This experience strengthens the MUSIQ model and complements it by showing the importance of the lean introduction strategy and its impact on contextual factors.

Limitations and future research

The main limitations concern the complexity of detecting and analysing all the relevant social and organizational aspects that have characterized the introduction and dissemination phases and the observation period of the dissemination phase. Moreover, the expert content analysis could introduce opportunities for misinterpretation of the data. The relationship between the contextual elements and the pilot project results were mainly assessed through participant and patient reports, document studies, and observations. The authors used data triangulation and a review of hospital staff to overcome the limits of the content analysis. Given the specificity of the hospital’s contextual factors and strategic choices, it is also clear that the case study cannot be generalized.

The sustainability aspect of lean was not considered because the observational study was conducted over a period of only 2 years. To understand this issue, the authors will investigate the socio-technical aspects of lean and how the context supports continuous improvement over time.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Hospital Setting

Information Technology

Length of stay

Number of chemotherapies per chemo chair

Methods-Time Measurement

Model for Understanding Success in Quality

Organization of European Cancer Institutes

Patients undergoing chemotherapeutic infusion within three hours of hospital admission

Plan-Do-Check-Act

Antiblastic Chemotherapy Handling Unit

Value Stream Mapping

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Savage C, Parke L, von Knorring M, Mazzocato P. Does lean muddy the quality improvement waters? A qualitative study of how a hospital management team understands lean in the context of quality improvement. BMC Health Serv Res. 2016;16(588). https://doi.org/10.1186/s12913-016-1838-z .

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Angelo Rosa, Giuliano Marolla & Francesco Manfredi

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All authors discussed the results and contributed to the final manuscript. GM conceived and designed the analysis, AR contributed data and analysis tools, FL and FM suggested the background reference model. The authors read and approved the final manuscript.

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Rosa, A., Marolla, G., Lega, F. et al. Lean adoption in hospitals: the role of contextual factors and introduction strategy. BMC Health Serv Res 21 , 889 (2021). https://doi.org/10.1186/s12913-021-06885-4

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Hospital Case Study

Ai generator.

We can use case studies to gain an up-close and personal understanding of a subject in its natural context. Although it doesn’t hold as much evidence as empirical investigation , we can still gain insights about the perils of the medical community from hospital case studies. Because they are a method of research that concerns a small, nonrepresentative group, they are generally exhaustive in terms of details and information.

What Is a Hospital Case Study?Hospital Case Study

Case studies, in its fundamental form, is an in-depth analysis of a situation with a proposal for changes. Hospital case studies are like  medical case studies . However, instead of focusing on novel, rare, and undocumented cases of diseases and patient conditions, these case studies are about cases and propositions that will, ultimately, improve hospital operation . We need case studies because there will always be an exemption to the rule. Real experience may not always be the same for everyone. What works for nine hospitals may be inefficient for the 10th. That doesn’t mean that that one hospital will have to follow the general rule or process at the cost of service quality.

Harbinger of death

Hospitals are supposed to be where the sick regains health. However, around the 1800s, these places were home to hundreds of mysterious deaths. Mothers were dying painfully after giving birth. The alarming fact is that delivery complications did not cause mortality. The tragic thing was that infections were the ones claiming lives. After investigation, physician Ignaz Semmelweis  caught the culprit barehanded. Medical students and professors unknowingly transmitted harmful streptococci bacteria to the patients. And it wasn’t because they were purposely harming the mothers. Gloveless, the medical personnel would perform autopsies on corpses. After, they would go the wards and examine laboring women. The number of deaths declined when the doctors and students started to wash their hands as part of the hospital protocol.

Forward momentum

Our quality of health and health care has improved since the 1800s. Hospitals are still riddled with disease-causing pathogens, but because of improvement in healthcare practice, we have fewer chances of dying when we go see the doctor. Keeping the patients alive is not a paramount prerequisite of quality health care. There are aspects of the hospital that are indirect contributors to health care, but when neglected can spell disaster. These features may not be present in all hospitals or have a different derivative. Hospital case studies work best for local-scale improvements. Even though case studies are still meant to be made public for transparency and future reference. Because, like the handwashing story, a proposition can improve the entire medical practice.

Case permutations

There are different types of case studies . But because they are fruits of the same tree, they typically have the same structure. Think of it as an evolutionary descent of case studies, where though there have been multiple divergences of lineages over time to suit a situation, they contain a genetic code that remained unchanged. The mitochondrial DNA of case studies are as follows:

Title: A good title goes a long way. It informs your readers on what the study is about. It doesn’t have to be boring. You can create a catchy title that encapsulates the content of the case study in a few words.

Executive summary:  Although some people are using abstract sections, the summary is a brief about your entire case. Generally, readers refer to this section to know if they’re looking at the right case study for reference.

Background:  This section introduces the subject of your research. In clinical case studies , this page orients the readers about the patient. For hospital case studies, this can be about the institution and the case to be presented.

Evaluation:  This part explains in detail the problem that needs to be addressed. It tells how the issue came to be, its effect on the concerned department, and how it hampers the function of the institution.

Plan:  This segment provides suggested resolutions to the problem. There can be multiple solutions. The chosen solution has to be justified by feasibility , appropriateness, and efficacy.

Results:  Like any initiative, a program does not stop at the execution of the proposed strategy. This page shows the feedback and progress of the action. This serves as the basis in deciding if the solution will be fully integrated into the system.

Redefining health care

Health care providers in the United States and the rest of the world are striving to keep up with the times. They are on the lookout of ways that they can better patient care and hospital operations and processes. The following are examples of hospital case studies that investigated and presented projects and initiatives, from practice to infrastructure, on what can hospitals do to update their system.

Hospital Case Study Examples

1. patient care case study.

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2. Hospital Architecture Study

3. Hospital Layout Study

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4. Patient Care Study

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5. Rural Health Care Study

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6. Hospital Case Study

7. Medical Practice Study

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8. Hospital Improvement Study

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10. Obesity Case Study

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11. Hospital Data Management

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12. Hospital Workforce Study

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13. Process Improvement Study

14. Hospital Care Study

15. Medical Records Study

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16. Hospital Merger Study

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Use or Misuse: Case study

The usefulness of a hospital case study, despite it being about a more personal encounter than evidence-based research, lies on its effect on the institution. How do you determine if the challenge at hand requires a case study?

1. Does the Shoe Fit?

Despite the advantages of case studies in improving hospital operations, not all problems require in-depth treatment. Before spending the organization’s resources, ask yourself first if there is a need to conduct the study? There might be faster solutions. Case studies, because of their nature, takes time. Instead of helping you, making a case study might mean more losses for your institution in this case.

2. Nose in the Book

Before you spend time and resources for your case study, you have to research the subject first. A similar problem may have already been resolved. You can gain insight into how others dealt with the issue and apply their solutions to the challenge at hand. By consulting with available sources first, you save yourself and the institution from paying heftily for a reiterated solution.

3. Know your Enemy

After you decided that the issue needs to be resolved with the help of case studies, you have to determine the focus of your research. This means that you have to specify the problem and see it for what it really is. You have to zero in on the issue. If you don’t, all your succeeding efforts to find resolution wouldn’t be fruitful. To solve the problem, you have to identify it first. Determine their causes and how they affect the hospital.

4. Fairest of Them All

Too much of a good thing is bad. After you have analyzed the situation, you are stumped with an unlikely predicament. There are too many choices on how to resolve the issue at hand. You might be tempted to apply everything. This is counterintuitive. Your best approach in this scenario is ranking the choices and deciding which ones will be most appropriate for the problem. This is where tracking the initiative’s progress will help you. You can use it as a basis to integrate or scrap a project.

Text prompt

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• 11 Modules of Hospital Management System and their Benefits

Ever wondered what it is like to manage an entire hospital?  

It definitely sounds difficult.  

Well, if you’ve landed on this article, you know that efficiently running an entire hospital isn’t a walk in the park. Although it is essential, it gets overwhelming at times.  

Time is of the utmost importance when it comes to healthcare. Imagine the severity if there is even a minor delay or fault while sharing the results and diagnosis.  To simplify operations and efficiently manage patient records, leading hospitals use a hospital management system.  Employing hospital management software helps you reap the maximum benefits from your work.  

Before discussing in detail how you can leverage an HMS to the fullest, let us understand what an HMS is and why it is needed. 

What is a Hospital Management System?

A study showed that healthcare providers spend 35% of their time on documenting patient data. While paperwork is unavoidable in a hospital, you can automate the process and reduce the burden on the staff and doctors. Not just this, hundreds of other processes run parallel in a hospital. An HMS is a one-stop solution to manage all hospital processes and data transfer. You can use it to digitize and simplify activities like: 

• Patient record management 
• Tracking and managing appointments 
• Maintaining staff records 
• Billing and insurance claims 

Overall, an HMS helps you improve patient experience and the quality of service provided in the hospital.  At the same time it is also used to minimize operating expenses and improve the revenue cycle.  

In a nutshell, Hospital Management System (HMS) creates a frictionless approach to managing the entire hospital and solving operational complexities.  

However, HMS can be a complex system. For ease of understanding and implementation, it is divided into different modules. These modules are built depending on the needs of a department or a particular process. Let’s look at the 11 HMS modules that are essential for any hospital to improve end-to-end productivity. 

11 Essential Hospital Management System Modules

Below we have discussed the 11 hospital management system modules in the same order that a hospital would need them, according to a patient’s journey. 

1. Appointment Management   

Managing appointments manually is not only tedious but also increases the chances of human errors. Even patients are inclined to choose a hospital with an option to book appointments online. In a recent study, 68% of patient s said they would prefer to schedule, modify, or cancel appointments online.  

This hospital management system module enables you to add a scheduling option to your hospital’s website so that patients can easily schedule an appointment.  

Once your patient has booked an appointment, the HMS software for hospitals will match the patient’s illness to the doctor’s area of expertise. It will then assign them to the next available specialist or the one they prefer. It also updates the available slots in real-time to avoid any confusion at the hospital.    The next step in appointment booking is to collect medical documents. An HMS with a patient portal is used to collect documents and share the patient history with the doctors well in advance. If the patient requires assistance at his/her house, the system will check the doctors’ availability for the remote visit and allocate accordingly. In this way, you can create a smooth and error-free process by digitizing the appointment booking process.

2. Patient Management   

After the patient onboarding is completed, the patient is moved to an IPD or OPD. The patient management module of HMS caters to the needs of the inpatient and outpatient departments. It captures and stores the medical history, treatment required, details of their previous visits, upcoming appointments, reports, insurance details, and more.   

Patient management software also generates unique admissions numbers for each patient to easily manage admissions, discharges, and transfers. It also builds a comprehensive discharge summary to ensure smooth discharge. At the same time, it records and generates related documents, e.g., consent forms for electronic signature. 

When you start collecting and storing details on hospital software systems, by default you also eliminate the need to get these details on every visit. HMS enables doctors and staff to focus more on treatment than administrative work.  

Now, if you wish to automate other activities like patient communication, consider integrating your HMS with marketing automation software such as LeadSquared . It will enable you to automate communication with patients and doctors. You can send appointments and lab test reminders, or follow-ups, and build meaningful long-lasting relationships.  

3. Facility Management    

To provide a smooth experience for your patients, it is essential for your staff to have easy access to necessary hospital records. The facility management module of a healthcare management system helps you to maintain records of bed availability, occupancy status of rooms with specialized care, and more.  

Healthcare management systems collect all such information and make it readily available to your receptionist. 

If you have multiple facilities, then an HMS connects them to provide an overall picture. For example, doctors can access patient data from any hospital using an online hospital management system. Patients can visit any hospital according to their convenience, as all the records are available online. 

4. Staff Management    

The staff management module provides a concrete solution for the HR department. It contains records of your staff, job description, service domain, and other vital details.  

It helps you to know your staff without going through a heavy bundle of files. Additionally, it enables you to plan the hiring process based on the requirements of the hospital.   

5. Supply Management    

A hospital cannot afford to be short of medical supplies. Not having the medicine at the right time or a minor delay in refill can lead to severe results. The supply management component of the HMS tracks the availability of medical stocks. It helps you calibrate the minimum quantity of supplies required without any hassle. It records the purchase date, quantity consumed, and supplier details. This way, you can calculate or predict the next purchase and reorder before the stock falls short.  It also provides the details of the medicine available so that doctors can prescribe the ones in stock.   

6. Financial Management   

The financial management component of an HMS deals with the financial affairs of your hospital. It calculates, stores, and presents the billing information to the patients.   

Additionally, it also records the expenses incurred by the hospital, revenue data, and other financial details of the hospital.   

This consolidation saves you the trouble of analyzing a colossal pile of record books.

7. Insurance Management   

An HMS’ insurance management component records and stores patients’ insurance details. On requirement, it presents the policy number, insurance company, and other associated information.   

The hospital management software makes it easy to fetch these details, making insurance validation easier. 

8. Laboratory Management    

The laboratory management feature of hospital management software shows the details of various lab tests patients take. It furnishes reports when needed and maintains all records collectively.  The doctors can easily access it. It also notifies the doctor and the patients when the results are ready.

9. Report Management    

Report Management module, records and stores all the reports generated by the hospital.   

In the case of financial reports, it analyzes performance metrics to check the business profitability. It also provides a comparison between performance reports for different years. An authorized person can access these hospital management system reports whenever required. 

Furthermore, you can use healthcare dashboards to present these reports in an easy-to-read format. 

10. Vaccination Management  

A vaccination model of hospital management software keeps track of all the completed or upcoming vaccinations. It updates you about upcoming vaccinations and books a slot with the doctor. It also sends timely reminders to parents to ensure they don’t miss the slot. 

11. Support Management

Patient satisfaction is of utmost importance for any hospital. This segment records data like inquiries, complaints, requests, and feedback from patients. It also ensures that you handle these requests and problems appropriately and at the soonest. You can automate the feedback collection process to reduce the staff’s workload, and everyone could fill out the feedback form. 

If you are still thinking of whether or not to implement an HSM. To answer this let’s discuss the benefits you will observe after implementing an HMS. 

Benefits of a Hospital Management System

1. enhanced communication between the patient and the hospital.

59% of millennials are willing to switch doctors for better online access. An HMS will improve communication between patients and hospitals by allowing patients to access their medical records, book appointments, receive reminders, and communicate online with their doctors and nurses. You will have improved patient engagement, a reduction in waiting times, and increased patient satisfaction.   

2. Secured hospital data

Hospital management software must help you keep hospital data safe and secure. You can limit the access to authorized personnel only. Make sure to look for HIPAA Compliant software for PHI security.   

3. Improved access to patient data

You can have easy entry to all patient-related data on a system using an HMS. You can also access data such as patient history, doctors engaged, test results, billing information, and many more with just a few clicks.   

4. Reduced turnaround time

Streamline your hospital workflows by automating routine tasks like appointment or inventory management . This reduces the time and effort required to perform these tasks and the turnaround time. It also allows hospital staff to focus on more critical patient care areas.   

5. Cost-effectiveness

Implementing hospital management software can lead to significant cost savings for hospitals. It helps by reducing administrative overheads, improving resource allocation, and minimizing the wastage of medical supplies. An HMS can also optimize revenue streams by ensuring timely billing and reducing claim denials.    

6. Intelligent analytics with automatically generated reports  

An HMS can provide valuable insights regarding operations by generating real-time reports on various metrics, such as patient flow, occupancy rates, and revenue generation. This enables you to make data-driven decisions, improve processes, and optimize resources.    

7. Centralized administrative control

An HMS helps build a centralized platform for managing operations, allowing hospitals to streamline their administrative processes. It ensures consistency across departments. This can improve efficiency, reduce errors, and better overall patient care.   

8. Reduced medical errors

An HMS can help reduce medical errors by providing doctors and nurses with up-to-date patient information. It minimizes the risk of misdiagnosis, incorrect treatment, or adverse drug interactions.   

9. Reduced readmissions and rehospitalization rates  

An HMS can also reduce readmissions and rehospitalization rates by ensuring timely follow-ups. This improves patient outcomes and reduces the risk of complications.   

To get to know how effective a Hospital Management System can be for hospitals, let us have a look at the example of how Manipal Hospital benefited from it. 

How LeadSquared Helped Manipal Hospitals to Improve Reporting and Lead Management  

Manipal Hospitals is one of India’s largest healthcare providers, with over 27 multispecialty hospitals. They have multiple teams working together to enable a smooth patient experience.  

With a high patient volume and each team working on a different platform, keeping track of each patient’s journey and managing appointments became increasingly hard for Manipal Hospitals. They needed to centralize leads across India while securely managing patient information. LeadSquared provided an all-in-one solution integrated with their existing HIS. 

Key Results: 

• Zero Lead Leakage 
• 360° View Across Teams 
• Better Patient Management 

LeadSquared’s APIs and connectors help us collect detailed patient data and integrate it with our core HIS system. The dashboards and reports enable us to work with this data and derive great insights from it. Both these features help streamline processes, save time, and in turn boost team productivity. Kiran Ramakrishna, Assistant Manager, Manipal Hospitals

[Also read: Manipal Hospital Improves Reporting and Lead Management to know the complete story.]

Conclusion  

Hospital Management System (HMS) is essential to the delivery of modern healthcare. It can boost patient outcomes, lower medical errors, and improve the overall quality of care. It enables hospitals with a centralized platform to manage their operations, automate mundane processes, and enhance communication.   

Moreover, Healthcare CRM , when integrated with the Hospital Management System, helps you combine professional medical care with quality patient service.    

To experience the benefits of an integrated HMS and Healthcare CRM system, get in touch with our team today!  

Also read:   

• What is Healthcare CRM?    
• EHR integration with healthcare CRM software    
• Patient satisfaction survey questions   
• Healthcare CRM – A 61-question checklist to help you make the right decision  

There are generally two types of HMS, cloud-based and on-premises. A cloud-based or web-based hospital management software is hosted on the provider’s server. In contrast, on-premises hospital management software is hosted on the hospital’s private server and data centers.  A cloud-based hospital management system is more popular as it is cost-effective, and the provider can handle it remotely.

While implementing an HMS, you may face the following challenges:  1. Cybersecurity  2. Lack of technical team support  3. Complex interface  4. Higher initial implementation cost  To overcome these challenges, you need the right provider. They will ensure data security and support the implementation and staff training.  

An off-the-shelf CRM is popular as it is cost-effective and quick to implement. It is a great option for small to medium sized organizations looking for basic and essential features. Whereas a custom-built HMS provides more control over the usage and features.  

Awantika is a healthcare marketer with LeadSquared. She has been a part of the content and product marketing game for almost 3 years. You can connect with her on LinkedIn or write to her at [email protected].

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Top 40 Most Popular Case Studies of 2021

Two cases about Hertz claimed top spots in 2021's Top 40 Most Popular Case Studies

Two cases on the uses of debt and equity at Hertz claimed top spots in the CRDT’s (Case Research and Development Team) 2021 top 40 review of cases.

Hertz (A) took the top spot. The case details the financial structure of the rental car company through the end of 2019. Hertz (B), which ranked third in CRDT’s list, describes the company’s struggles during the early part of the COVID pandemic and its eventual need to enter Chapter 11 bankruptcy. 

The success of the Hertz cases was unprecedented for the top 40 list. Usually, cases take a number of years to gain popularity, but the Hertz cases claimed top spots in their first year of release. Hertz (A) also became the first ‘cooked’ case to top the annual review, as all of the other winners had been web-based ‘raw’ cases.

Besides introducing students to the complicated financing required to maintain an enormous fleet of cars, the Hertz cases also expanded the diversity of case protagonists. Kathyrn Marinello was the CEO of Hertz during this period and the CFO, Jamere Jackson is black.

Sandwiched between the two Hertz cases, Coffee 2016, a perennial best seller, finished second. “Glory, Glory, Man United!” a case about an English football team’s IPO made a surprise move to number four.  Cases on search fund boards, the future of malls,  Norway’s Sovereign Wealth fund, Prodigy Finance, the Mayo Clinic, and Cadbury rounded out the top ten.

Other year-end data for 2021 showed:

• Online “raw” case usage remained steady as compared to 2020 with over 35K users from 170 countries and all 50 U.S. states interacting with 196 cases.
• Fifty four percent of raw case users came from outside the U.S..
• The Yale School of Management (SOM) case study directory pages received over 160K page views from 177 countries with approximately a third originating in India followed by the U.S. and the Philippines.
• Twenty-six of the cases in the list are raw cases.
• A third of the cases feature a woman protagonist.
• Orders for Yale SOM case studies increased by almost 50% compared to 2020.
• The top 40 cases were supervised by 19 different Yale SOM faculty members, several supervising multiple cases.

CRDT compiled the Top 40 list by combining data from its case store, Google Analytics, and other measures of interest and adoption.

All of this year’s Top 40 cases are available for purchase from the Yale Management Media store .

And the Top 40 cases studies of 2021 are:

1.   Hertz Global Holdings (A): Uses of Debt and Equity

2.   Coffee 2016

3.   Hertz Global Holdings (B): Uses of Debt and Equity 2020

4.   Glory, Glory Man United!

5.   Search Fund Company Boards: How CEOs Can Build Boards to Help Them Thrive

6.   The Future of Malls: Was Decline Inevitable?

7.   Strategy for Norway's Pension Fund Global

8.   Prodigy Finance

9.   Design at Mayo

10. Cadbury

11. City Hospital Emergency Room

13. Volkswagen

14. Marina Bay Sands

15. Shake Shack IPO

16. Mastercard

17. Netflix

18. Ant Financial

19. AXA: Creating the New CR Metrics

20. IBM Corporate Service Corps

21. Business Leadership in South Africa's 1994 Reforms

22. Alternative Meat Industry

23. Children's Premier

24. Khalil Tawil and Umi (A)

25. Palm Oil 2016

26. Teach For All: Designing a Global Network

27. What's Next? Search Fund Entrepreneurs Reflect on Life After Exit

28. Searching for a Search Fund Structure: A Student Takes a Tour of Various Options

30. Project Sammaan

31. Commonfund ESG

32. Polaroid

33. Connecticut Green Bank 2018: After the Raid

34. FieldFresh Foods

35. The Alibaba Group

36. 360 State Street: Real Options

37. Herman Miller

38. AgBiome

39. Nathan Cummings Foundation

40. Toyota 2010

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CASE STUDY OF HOSPITAL MANAGEMENT SYSTEM (HMS

Related Papers

International Journal of Clinical Monitoring and Computing

International Journal for Research in Applied Science & Engineering Technology (IJRASET)

IJRASET Publication

Hospital Management System includes registration of patients, storing the details into the system and appointing doctors online. Our software has the facility to give a unique id for every patient and stores the details of every patient and list of all the doctors which work in the hospital. It includes a search availability of a doctor and the details of a patient using the id. Our system gives each doctor a unique code due to which patients can book their appointments online. The Hospital Management System can be entered using a username and a password. It is accessible by an administrator, doctor and the patient as well. Each doctor has their unique username and password which can be logged in by their correspond email-id , like the doctor patient also have their unique username and pass. But the admin has access to both the doctors and patients details and everything which would help the admin to keep an eye over its hospital management. The interface is simple and userfriendly. The data are well protected for personal use and makes the data processing very fast.

Ijaems Journal

— Health institution requires quality data and information management to function effectively and efficiently. It is an understatement to say that many organizations, institutions or government agencies have become critically dependent on the use of database system for their successes especially in the hospital. This work aims at developing an improved hospital information management system using a function-based approach. An efficient HIMS that can be used to manage patient information and its administration is presented in this work. This is with the goal of eradicating the problem of improper data keeping, inaccurate reports, wastage of time in storing, processing and retrieving information faced by the existing hospital information system in order to improve the overall efficiency of the health institution. The system was developed with Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), Hypertext Preprocessor (PHP), and My Structured Query Language (MySQL). The new system was tested using data collected from Renewal Clinic, Ibadan, Nigeria was used as case study were the data for the research was collected and the system was tested. The system provides a vital platform of information storage and retrieval in hospitals.

The paper developed an automated system that is used to manage patient information and its administration. This was with a view to eliminate the problem of inappropriate data Keeping, inaccurate reports, time wastage in storing, processing and retrieving information encountered by the traditional hospital system in order to improve the overall efficiency of the organization. The tools used to implement the system are Hypertext Markup Language (HTML), Cascading Style Sheets (CSS), Hypertext Preprocessor (PHP), and My Structured Query Language(MySQ).The Proposed system was tested using the information collected from Murab Hospital, Ilorin, kwara State , Nigeria and compared with the existing traditional hospital system. The design provides excellent patient services and improved information infrastructure.

Mohammed Aman

OBJECTIVE : Hospitals currently use a manual system for the management and maintenance of critical information. The current system requires numerous paper forms, with data stores spread throughout the hospital management infrastructure. Often information (on forms) is incomplete, or does not follow management standards. Forms are often lost in transit between departments requiring a comprehensive auditing process to ensure that no vital information is lost. Multiple copies of the same information exist in the hospital and may lead to inconsistencies in data in various data stores. A significant part of the operation of any hospital involves the acquisition, management and timely retrieval of great volumes of information. This information typically involves; patient personal information and medical history, staff information, room and ward scheduling, staff scheduling, operating theater scheduling and various facilities waiting lists. All of this information must be managed in an efficient and cost wise fashion so that an institution's resources may be effectively utilized HMS will automate the management of the hospital making it more efficient and error free. It aims at standardizing data, consolidating data ensuring data integrity and reducing inconsistencies. PROJECT OVERVIEW : The Hospital Management System (HMS) is designed for Any Hospital to replace their existing manual, paper based system. The new system is to control the following information; patient information, room availability, staff and operating room schedules, and patient invoices. These services are to be provided in an efficient, cost effective manner, with the goal of reducing the time and resources currently required for such tasks. A significant part of the operation of any hospital involves the acquisition, management and timely retrieval of great volumes of information. This information typically involves; patient personal information and medical history, staff information, room and ward scheduling, staff scheduling, operating theater scheduling and various facilities waiting lists. All of this

International Journal of Computer Theory and Engineering

Ezenwa Nwawudu

emeka ajoku

ABSTRACT This study investigated online hospital management system as a tool to revolutionize medical profession. With many writers decrying how patients queue up for hours in order to receive medical treatment, and some end-up being attended to as „spillover‟, the analyst investigated the manual system in detail with a view to finding out the need to automate the system. Subsequently, a computer-aided program was designed to bring about improvement in the care of individual patients, taking the advantage of computer speed, storage and retrieved facilities. The software designed will take care of patient‟s registration, billing, treatment and payments. The programming language employed in this work was Microsoft C#.

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• Published: 27 May 2024

A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient

• Wei Fu 1 , 2   na1 ,
• Zi Wei Deng 3   na1 ,
• Pei Wang 1 ,
• Zhen Wang Zhu 1 ,
• Zhi Bing Xie 1 ,
• Yong Zhong Li 1 &
• Hong Ying Yu 1  

BMC Infectious Diseases volume  24 , Article number:  533 ( 2024 ) Cite this article

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Hepatitis B virus (HBV) infection can cause liver failure, while individuals with Acquired Immunodeficiency Virus Disease (AIDS) are highly susceptible to various opportunistic infections, which can occur concurrently. The treatment process is further complicated by the potential occurrence of immune reconstitution inflammatory syndrome (IRIS), which presents significant challenges and contributes to elevated mortality rates.

Case presentation

The 50-year-old male with a history of chronic hepatitis B and untreated human immunodeficiency virus (HIV) infection presented to the hospital with a mild cough and expectoration, revealing multi-drug resistant pulmonary tuberculosis (MDR-PTB), which was confirmed by XpertMTB/RIF PCR testing and tuberculosis culture of bronchoalveolar lavage fluid (BALF). The patient was treated with a regimen consisting of linezolid, moxifloxacin, cycloserine, pyrazinamide, and ethambutol for tuberculosis, as well as a combination of bictegravir/tenofovir alafenamide/emtricitabine (BIC/TAF/FTC) for HBV and HIV viral suppression. After three months of treatment, the patient discontinued all medications, leading to hepatitis B virus reactivation and subsequent liver failure. During the subsequent treatment for AIDS, HBV, and drug-resistant tuberculosis, the patient developed disseminated cryptococcal disease. The patient’s condition worsened during treatment with liposomal amphotericin B and fluconazole, which was ultimately attributed to IRIS. Fortunately, the patient achieved successful recovery after appropriate management.

Enhancing medical compliance is crucial for AIDS patients, particularly those co-infected with HBV, to prevent HBV reactivation and subsequent liver failure. Furthermore, conducting a comprehensive assessment of potential infections in patients before resuming antiviral therapy is essential to prevent the occurrence of IRIS. Early intervention plays a pivotal role in improving survival rates.

Peer Review reports

HIV infection remains a significant global public health concern, with a cumulative death toll of 40 million individuals [ 1 ]. In 2021 alone, there were 650,000 deaths worldwide attributed to AIDS-related causes. As of the end of 2021, approximately 38 million individuals were living with HIV, and there were 1.5 million new HIV infections reported annually on a global scale [ 2 ]. Co-infection with HBV and HIV is prevalent due to their similar transmission routes, affecting around 8% of HIV-infected individuals worldwide who also have chronic HBV infection [ 3 ]. Compared to those with HBV infection alone, individuals co-infected with HIV/HBV exhibit higher HBV DNA levels and a greater risk of reactivation [ 4 ]. Opportunistic infections, such as Pneumocystis jirovecii pneumonia, Toxoplasma encephalitis, cytomegalovirus retinitis, cryptococcal meningitis (CM), tuberculosis, disseminated Mycobacterium avium complex disease, pneumococcal pneumonia, Kaposi’s sarcoma, and central nervous system lymphoma, are commonly observed due to HIV-induced immunodeficiency [ 5 ]. Tuberculosis not only contributes to the overall mortality rate in HIV-infected individuals but also leads to a rise in the number of drug-resistant tuberculosis cases and transmission of drug-resistant strains. Disseminated cryptococcal infection is a severe opportunistic infection in AIDS patients [ 6 ], and compared to other opportunistic infections, there is a higher incidence of IRIS in patients with cryptococcal infection following antiviral and antifungal therapy [ 7 ]. This article presents a rare case of an HIV/HBV co-infected patient who presented with MDR-PTB and discontinued all medications during the initial treatment for HIV, HBV, and tuberculosis. During the subsequent re-anti-HBV/HIV treatment, the patient experienced two episodes of IRIS associated with cryptococcal infection. One episode was classified as “unmasking” IRIS, where previously subclinical cryptococcal infection became apparent with immune improvement. The other episode was categorized as “paradoxical” IRIS, characterized by the worsening of pre-existing cryptococcal infection despite immune restoration [ 8 ]. Fortunately, both episodes were effectively treated.

A 50-year-old male patient, who is self-employed, presented to our hospital in January 2022 with a chief complaint of a persistent cough for the past 2 months, without significant shortness of breath, palpitations, or fever. His medical history revealed a previous hepatitis B infection, which resulted in hepatic failure 10 years ago. Additionally, he was diagnosed with HIV infection. However, he ceased taking antiviral treatment with the medications provided free of charge by the Chinese government for a period of three years. During this hospital visit, his CD4 + T-cell count was found to be 26/μL (normal range: 500–1612/μL), HIV-1 RNA was 1.1 × 10 5 copies/ml, and HBV-DNA was negative. Chest computed tomography (CT) scan revealed nodular and patchy lung lesions (Fig.  1 ). The BALF shows positive acid-fast staining. Further assessment of the BALF using XpertMTB/RIF PCR revealed resistance to rifampicin, and the tuberculosis drug susceptibility test of the BALF (liquid culture, medium MGIT 960) indicated resistance to rifampicin, isoniazid, and streptomycin. Considering the World Health Organization (WHO) guidelines for drug-resistant tuberculosis, the patient’s drug susceptibility results, and the co-infection of HIV and HBV, an individualized treatment plan was tailored for him. The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day) for HBV and HIV antiviral therapy, as well as linezolid (0.6 g/day), cycloserine (0.5 g/day), moxifloxacin (0.4 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for anti-tuberculosis treatment, along with supportive care.

The patient’s pulmonary CT scan shows patchy and nodular lesions accompanied by a small amount of pleural effusion, later confirmed to be MDR-PTB

Unfortunately, after 3 months of follow-up, the patient discontinued all medications due to inaccessibility of the drugs. He returned to our hospital (Nov 12, 2022, day 0) after discontinuing medication for six months, with a complaint of poor appetite for the past 10 days. Elevated liver enzymes were observed, with an alanine aminotransferase level of 295 IU/L (normal range: 0–40 IU/L) and a total bilirubin(TBIL) level of 1.8 mg/dL (normal range: 0–1 mg/dL). His HBV viral load increased to 5.5 × 10 9 copies/ml. Considering the liver impairment, elevated HBV-DNA and the incomplete anti-tuberculosis treatment regimen (Fig.  2 A), we discontinued pyrazinamide and initiated treatment with linezolid, cycloserine, levofloxacin, and ethambutol for anti-tuberculosis therapy, along with BIC/TAF/FTC for HIV and HBV antiviral treatment. Additionally, enhanced liver protection and supportive management were provided, involving hepatoprotective effects of medications such as glutathione, magnesium isoglycyrrhizinate, and bicyclol. However, the patient’s TBIL levels continued to rise progressively, reaching 4.4 mg/dL on day 10 (Fig.  3 B). Suspecting drug-related factors, we discontinued all anti-tuberculosis medications while maintaining BIC/TAF/FTC for antiviral therapy, the patient’s TBIL levels continued to rise persistently. We ruled out other viral hepatitis and found no significant evidence of obstructive lesions on magnetic resonance cholangiopancreatography. Starting from the day 19, due to the patient’s elevated TBIL levels of 12.5 mg/dL, a decrease in prothrombin activity (PTA) to 52% (Fig.  3 D), and the emergence of evident symptoms such as abdominal distension and poor appetite, we initiated aggressive treatment methods. Unfortunately, on day 38, his hemoglobin level dropped to 65 g/L (normal range: 120–170 g/L, Fig.  3 A), and his platelet count decreased to 23 × 10 9 /L (normal range: 125–300 × 10 9 /L, Fig.  3 C). Based on a score of 7 on the Naranjo Scale, it was highly suspected that “Linezolid” was the cause of these hematological abnormalities. Therefore, we had to discontinue Linezolid for the anti-tuberculosis treatment. Subsequently, on day 50, the patient developed recurrent fever, a follow-up chest CT scan revealed enlarged nodules in the lungs (Fig.  2 B). The patient also reported mild dizziness and a worsening cough. On day 61, the previous blood culture results reported the growth of Cryptococcus. A lumbar puncture was performed on the same day, and the cerebrospinal fluid (CSF) opening pressure was measured at 130 mmH 2 O. India ink staining of the CSF showed typical encapsulated yeast cells suggestive of Cryptococcus. Other CSF results indicated mild leukocytosis and mildly elevated protein levels, while chloride and glucose levels were within normal limits. Subsequently, the patient received a fungal treatment regimen consisting of liposomal amphotericin B (3 mg/kg·d −1 ) in combination with fluconazole(600 mg/d). After 5 days of antifungal therapy, the patient’s fever symptoms were well controlled. Despite experiencing bone marrow suppression, including thrombocytopenia and worsening anemia, during this period, proactive symptom management, such as the use of erythropoietin, granulocyte colony-stimulating factor, and thrombopoietin, along with high-calorie dietary management, even reducing the dosage of liposomal amphotericin B to 2 mg/kg/day for 10 days at the peak of severity, successfully controlled the bone marrow suppression. However, within the following week, the patient experienced fever again, accompanied by a worsened cough, increased sputum production, and dyspnea. Nevertheless, the bilirubin levels did not show a significant increase. On day 78 the patient’s lung CT revealed patchy infiltrates and an increased amount of pleural effusion (Fig.  2 C). The CD4 + T-cell count was 89/μL (normal range: 500–700/μL), indicating a significant improvement in immune function compared to the previous stage, and C-reactive protein was significantly elevated, reflecting the inflammatory state, other inflammatory markers such as IL-6 and γ-IFN were also significantly elevated. On day 84, Considering the possibility of IRIS, the patient began taking methylprednisolone 30 mg once a day as part of an effort to control his excessive inflammation. Following the administration of methylprednisolone, the man experienced an immediate improvement in his fever. Additionally, symptoms such as cough, sputum production, dyspnea, and poor appetite gradually subsided over time. A follow-up lung CT showed significant improvement, indicating a positive response to the treatment. After 28 days of treatment with liposomal amphotericin B in combination with fluconazole, liposomal amphotericin B was discontinued, and the patient continued with fluconazole to consolidate the antifungal therapy for Cryptococcus. Considering the patient’s ongoing immunodeficiency, the dosage of methylprednisolone was gradually reduced by 4 mg every week. After improvement in liver function, the patient’s anti-tuberculosis treatment regimen was adjusted to include bedaquiline, contezolid, cycloserine, moxifloxacin, and ethambutol. The patient’s condition was well controlled, and a follow-up lung CT on day 117 indicated a significant improvement in lung lesions (Fig.  2 D).

Upon second hospitalization admission ( A ), nodular lesions were already present in the lungs, and their size gradually increased after the initiation of ART ( B , C ). Notably, the lung lesions became more pronounced following the commencement of anti-cryptococcal therapy, coinciding with the occurrence of pleural effusion ( C ). However, with the continuation of antifungal treatment and the addition of glucocorticoids, there was a significant absorption and reduction of both the pleural effusion and pulmonary nodules ( D )

During the patient's second hospitalization, as the anti-tuberculosis treatment progressed and liver failure developed, the patient’s HGB levels gradually decreased ( A ), while TBIL levels increased ( B ). Additionally, there was a gradual decrease in PLT count ( C ) and a reduction in prothrombin activity (PTA) ( D ), indicating impaired clotting function. Moreover, myelosuppression was observed during the anti-cryptococcal treatment ( C )

People living with HIV/AIDS are susceptible to various opportunistic infections, which pose the greatest threat to their survival [ 5 ]. Pulmonary tuberculosis and disseminated cryptococcosis remain opportunistic infections with high mortality rates among AIDS patients [ 9 , 10 ]. These infections occurring on the basis of liver failure not only increase diagnostic difficulty but also present challenges in treatment. Furthermore, as the patient’s immune function and liver function recover, the occurrence of IRIS seems inevitable.

HIV and HBV co-infected patients are at a higher risk of HBV reactivation following the discontinuation of antiviral drugs

In this case, the patient presented with both HIV and HBV infections. Although the HBV DNA test was negative upon admission. However, due to the patient’s self-discontinuation of antiretroviral therapy (ART), HBV virologic and immunologic reactivation occurred six months later, leading to a rapid increase in viral load and subsequent hepatic failure. Charles Hannoun et al. also reported similar cases in 2001, where two HIV-infected patients with positive HBsAg experienced HBV reactivation and a rapid increase in HBV DNA levels after discontinuing antiretroviral and antiviral therapy, ultimately resulting in severe liver failure [ 11 ]. The European AIDS Clinical Society (EACS) also emphasize that abrupt discontinuation of antiviral therapy in patients co-infected with HBV and HIV can trigger HBV reactivation, which, although rare, can potentially result in liver failure [ 12 ].

Diagnosing disseminated Cryptococcus becomes more challenging in AIDS patients with liver failure, and the selection of antifungal medications is significantly restricted

In HIV-infected individuals, cryptococcal disease typically manifests as subacute meningitis or meningoencephalitis, often accompanied by fever, headache, and neck stiffness. The onset of symptoms usually occurs approximately two weeks after infection, with typical signs and symptoms including meningeal signs such as neck stiffness and photophobia. Some patients may also experience encephalopathy symptoms like somnolence, mental changes, personality changes, and memory loss, which are often associated with increased intracranial pressure (ICP) [ 13 ]. The presentation of cryptococcal disease in this patient was atypical, as there were no prominent symptoms such as high fever or rigors, nor were there any signs of increased ICP such as somnolence, headache, or vomiting. The presence of pre-existing pulmonary tuberculosis further complicated the early diagnosis, potentially leading to the clinical oversight of recognizing the presence of cryptococcus. In addition to the diagnostic challenges, treating a patient with underlying liver disease, multidrug-resistant tuberculosis, and concurrent cryptococcal infection poses significant challenges. It requires considering both the hepatotoxicity of antifungal agents and potential drug interactions. EACS and global guideline for the diagnosis and management of cryptococcosis suggest that liposomal amphotericin B (3 mg/kg·d −1 ) in combination with flucytosine (100 mg/kg·d −1 ) or fluconazole (800 mg/d) is the preferred induction therapy for CM for 14 days [ 12 , 14 ]. Flucytosine has hepatotoxicity and myelosuppressive effects, and it is contraindicated in patients with severe liver dysfunction. The antiviral drug bictegravir is a substrate for hepatic metabolism by CYP3A and UGT1A1 enzymes [ 15 ], while fluconazole inhibits hepatic enzymes CYP3A4 and CYP2C9 [ 16 ]. Due to the patient's liver failure and bone marrow suppression, we reduced the dosage of liposomal amphotericin B and fluconazole during the induction period. Considering the hepatotoxicity of fluconazole and its interaction with bictegravir, we decreased the dosage of fluconazole to 600 mg/d, while extending the duration of induction therapy to 28 days.

During re-antiviral treatment, maintaining vigilance for the development of IRIS remains crucial

IRIS refers to a series of inflammatory diseases that occur in HIV-infected individuals after initiating ART. It is associated with the paradoxical worsening of pre-existing infections, which may have been previously diagnosed and treated or may have been subclinical but become apparent due to the host regaining the ability to mount an inflammatory response. Currently, there is no universally accepted definition of IRIS. However, the following conditions are generally considered necessary for diagnosing IRIS: worsening of a diagnosed or previously unrecognized pre-existing infection with immune improvement (referred to as “paradoxical” IRIS) or the unmasking of a previously subclinical infection (referred to as “unmasking” IRIS) [ 8 ]. It is estimated that 10% to 30% of HIV-infected individuals with CM will develop IRIS after initiating or restarting effective ART [ 7 , 17 ]. In the guidelines of the WHO and EACS, it is recommended to delay the initiation of antiviral treatment for patients with CM for a minimum of 4 weeks to reduce the incidence of IRIS. Since we accurately identified the presence of multidrug-resistant pulmonary tuberculosis in the patient during the early stage, we promptly initiated antiretroviral and anti-hepatitis B virus treatment during the second hospitalization. However, subsequent treatment revealed that the patient experienced at least two episodes of IRIS. The first episode was classified as “unmasking” IRIS, as supported by the enlargement of pulmonary nodules observed on the chest CT scan following the initiation of ART (Fig.  2 A). Considering the morphological changes of the nodules on the chest CT before antifungal therapy, the subsequent emergence of disseminated cryptococcal infection, and the subsequent reduction in the size of the lung nodules after antifungal treatment, although there is no definitive microbiological evidence, we believe that the initial enlargement of the lung nodules was caused by cryptococcal pneumonia. As ART treatment progressed, the patient experienced disseminated cryptococcosis involving the blood and central nervous system, representing the first episode. Following the initiation of antifungal therapy for cryptococcosis, the patient encountered a second episode characterized by fever and worsening pulmonary lesions. Given the upward trend in CD4 + T-cell count, we attributed this to the second episode of IRIS, the “paradoxical” type. The patient exhibited a prompt response to low-dose corticosteroids, further supporting our hypothesis. Additionally, the occurrence of cryptococcal IRIS in the lungs, rather than the central nervous system, is relatively uncommon among HIV patients [ 17 ].

Conclusions

From the initial case of AIDS combined with chronic hepatitis B, through the diagnosis and treatment of multidrug-resistant tuberculosis, the development of liver failure and disseminated cryptococcosis, and ultimately the concurrent occurrence of IRIS, the entire process was tortuous but ultimately resulted in a good outcome (Fig.  4 ). Treatment challenges arose due to drug interactions, myelosuppression, and the need to manage both infectious and inflammatory conditions. Despite these hurdles, a tailored treatment regimen involving antifungal and antiretroviral therapies, along with corticosteroids, led to significant clinical improvement. While CM is relatively common among immunocompromised individuals, especially those with acquired immunodeficiency syndrome (AIDS) [ 13 ], reports of disseminated cryptococcal infection on the background of AIDS complicated with liver failure are extremely rare, with a very high mortality rate.

A brief timeline of the patient's medical condition progression and evolution

Through managing this patient, we have also gained valuable insights. (1) Swift and accurate diagnosis, along with timely and effective treatment, can improve prognosis, reduce mortality, and lower disability rates. Whether it's the discovery and early intervention of liver failure, the identification and treatment of disseminated cryptococcosis, or the detection and management of IRIS, all these interventions are crucially timely. They are essential for the successful treatment of such complex and critically ill patients.

(2) Patients who exhibit significant drug reactions, reducing the dosage of relevant medications and prolonging the treatment duration can improve treatment success rates with fewer side effects. In this case, the dosages of liposomal amphotericin B and fluconazole are lower than the recommended dosages by the World Health Organization and EACS guidelines. Fortunately, after 28 days of induction therapy, repeat CSF cultures showed negative results for Cryptococcus, and the improvement of related symptoms also indicates that the patient has achieved satisfactory treatment outcomes. (3) When cryptococcal infection in the bloodstream or lungs is detected, prompt lumbar puncture should be performed to screen for central nervous system cryptococcal infection. Despite the absence of neurological symptoms, the presence of Cryptococcus neoformans in the cerebrospinal fluid detected through lumbar puncture suggests the possibility of subclinical or latent CM, especially in late-stage HIV-infected patients.

We also encountered several challenges and identified certain issues that deserve attention. Limitations: (1) The withdrawal of antiviral drugs is a critical factor in the occurrence and progression of subsequent diseases in patients. Improved medical education is needed to raise awareness and prevent catastrophic consequences. (2) Prior to re-initiating antiviral therapy, a thorough evaluation of possible infections in the patient is necessary. Caution should be exercised, particularly in the case of diseases prone to IRIS, such as cryptococcal infection. (3) There is limited evidence on the use of reduced fluconazole dosage (600 mg daily) during antifungal therapy, and the potential interactions between daily fluconazole (600 mg) and the antiviral drug bictegravir and other tuberculosis medications have not been extensively studied. (4) Further observation is needed to assess the impact of early-stage limitations in the selection of anti-tuberculosis drugs on the treatment outcome of tuberculosis in this patient, considering the presence of liver failure.

In conclusion, managing opportunistic infections in HIV patients remains a complex and challenging task, particularly when multiple opportunistic infections are compounded by underlying liver failure. Further research efforts are needed in this area.

Availability of data and materials

All data generated or analyzed during this study are included in this published article.

Abbreviations

Hepatitis B virus

Acquired immunodeficiency virus disease

Immune reconstitution inflammatory syndrome

Human immunodeficiency virus

Multi-drug resistant pulmonary tuberculosis

Bronchoalveolar lavage fluid

Bictegravir/tenofovir alafenamide/emtricitabine

Cryptococcal meningitis

World Health Organization

Computed tomography

Total bilirubin

Cerebrospinal fluid

European AIDS Clinical Society

Intracranial pressure

Antiretroviral therapy

Prothrombin activity

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Acknowledgements

We express our sincere gratitude for the unwavering trust bestowed upon our medical team by the patient throughout the entire treatment process.

This work was supported by the Scientific Research Project of Hunan Public Health Alliance with the approval No. ky2022-002.

Author information

Wei Fu and Zi Wei Deng contributed equally to this work.

Authors and Affiliations

Center for Infectious Diseases, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Wei Fu, Pei Wang, Zhen Wang Zhu, Ye Pu, Zhi Bing Xie, Yong Zhong Li & Hong Ying Yu

Department of Tuberculosis, The First Affiliated Hospital of Xinxiang Medical University, XinXiang, Henan, China

Department of Clinical Pharmacy, Hunan University of Medicine General Hospital, Huaihua, Hunan, China

Zi Wei Deng

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Contributions

WF and ZWD integrated the data and wrote the manuscript, YHY contributed the revision of the manuscript, PW and YP provided necessary assistance and provided key suggestions, ZWZ, YZL and ZBX contributed data acquisition and interpretation for etiological diagnosis. All authors reviewed and approved the final manuscript.

Corresponding author

Correspondence to Hong Ying Yu .

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The study was approved by the Ethics Committee of the Hunan University of Medicine General Hospital (HYZY-EC-202306-C1), and with the informed consent of the patient.

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Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.

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Fu, W., Deng, Z.W., Wang, P. et al. A complex case study: coexistence of multi-drug-resistant pulmonary tuberculosis, HBV-related liver failure, and disseminated cryptococcal infection in an AIDS patient. BMC Infect Dis 24 , 533 (2024). https://doi.org/10.1186/s12879-024-09431-9

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How capital expenditure management can drive performance

One of the quickest and most effective ways for organizations to preserve cash is to reexamine their capital investments. The past two years have offered a fascinating look into how different sectors have weathered the COVID-19 storm: from the necessarily capital expenditure–starved airport industry to the cresting wave of public-sector investments in renewable infrastructure and anticipation of the next mining supercycle. Indeed, companies that reduce spending on capital projects can both quickly release significant cash and increase ROIC, the most important metric of financial value creation (Exhibit 1).

This strategy is even more vital in competitive markets, where ROIC is perilously close to cost of capital. In our experience, organizations that focus on actions across the whole project life cycle, the capital project portfolio, and the necessary foundational enablers can reduce project costs and timelines by up to 30 percent to increase ROIC by 2 to 4 percent. Yet managing capital projects is complex, and many organizations struggle to extract cost savings. In addition, ill-considered cuts to key projects in a portfolio may actually jeopardize future operating performance and outcomes. This dynamic reinforces the age-old challenge for executives as they carefully allocate marginal dollars toward value creation.

Companies can improve their odds of success by focusing on areas of the project life cycle— capital strategy and portfolio optimization , project development and value improvement, and project delivery and construction—while investing in foundational enablers.

Cracking the code on capital expenditure management

Despite the importance of capital expenditure management in executing business strategy, preserving cash, and maximizing ROIC, most companies struggle in this area for two primary reasons. First, capital expenditure is often not a core business; instead, organizations focus on operating performance, where they have extensive institutional knowledge. When it comes to capital projects, executives rely on a select few people with experience in capital delivery. Second, capital performance is typically a black box. Executives find it difficult to understand and predict the performance of individual projects and the capital project portfolio as a whole.

Across industries, we see companies struggle to deliver projects on time and on schedule (Exhibit 2). In fact, cost and schedule overruns compared with original estimates frequently exceed 50 percent. Notably, these occur in both the public and private sectors.

The COVID-19 pandemic has accelerated and magnified these challenges. Governments are increasingly viewing infrastructure spending as a tool for economic stimulus, which amplifies the cyclical nature of capital expenditure deployments. At the same time, some organizations have had to make drastic cutbacks in capital projects because of difficult economic conditions. The reliance on just a few experienced people when travel restrictions necessitated a remote-operating model further increased the complexity. As a result, only a few organizations have been able to maintain a through-cycle perspective.

In addition, current inflation could put an end to the historically low interest rates that companies are enjoying for financing their projects. As the cost of capital goes up, discipline in managing large projects will become increasingly important.

Improving capital expenditure management

In our experience, the organizational drivers that impede capital expenditure management affect all stages of a project life cycle, from portfolio management to project execution and commissioning. Best-in-class capital development and delivery require companies to outperform in three main areas, supported by several foundational enablers (Exhibit 3).

Recipes for capturing value

Companies can transform the life cycle of a capital expenditure project by focusing on three areas: capital strategy and portfolio optimization, project development and value improvement, and project delivery and construction. While the savings potential applies to each area on a stand-alone basis, their impact has some overlap. In our experience, companies that deploy these best practices are able to save 15 to 30 percent of a project’s cost.

Capital strategy and portfolio optimization

The greatest opportunity to influence a project’s outcome comes at its start. Too often, organizations commit to projects without a proper understanding of business needs, incurring significant expense to deliver an outcome misaligned with the overall strategy. Indeed, a failure to adequately recognize, price, and manage the inherent risks of project delivery is a recurring issue in the industry. Organizations can address this challenge by following a systematic three-step approach:

Assess the current state of capital projects and portfolio. It’s essential to identify strengths, areas of improvement, and the value at stake. To do so, organizations must build a transparent and rigorously tested baseline and capital budget, which should provide a clear understanding of the overall capital expenditure budget for the coming years as well as accurate cost and time forecasts for an organization’s portfolio of capital projects.

Ensure capital allocation is linked to overall company strategy. This step involves reviewing sources and uses of cash and ensuring allocated capital is linked to strategy. Companies must set an enterprise-wide strategy , assess the current portfolio against the relevant market with forward-looking assessments and cash flow simulation, and review sources and uses of cash to determine the amount of capital available. Particular focus should be given to environmental, social, and governance (ESG) considerations—by both proactively managing risks and capturing the full upside opportunity of new projects—because sustainability is becoming a real source of shareholder value (Exhibit 4). With this knowledge, organizations can identify internal and external opportunities to strengthen their portfolio based on affordability and strategic objectives.

Optimize the capital portfolio to increase company-wide ROIC. Executives should distinguish between projects that are existing or committed, planned and necessary (for legal, regulatory, or strategic requirements), and discretionary. They can do so by challenging a project’s justification, classifications, benefit estimates, and assumptions to ensure they are realistic. This analysis helps companies to define and calibrate their portfolios by prioritizing projects based on KPIs and discussing critical projects not in the portfolio. Executives can then verify that the portfolio is aligned with the business strategy, risk profile, and funding constraints.

For example, a commercial vehicle manufacturer recently undertook a rigorous review of its project portfolio. After establishing a detailed baseline covering several hundred planned projects in one data set, the manufacturer classified the projects into two categories: must-have and discretionary. It also considered strategic realignment in light of a shift to e-mobility and the implications on investments in internal-combustion-engine vehicles. Last, it scrutinized individual maintenance projects to reduce their scope. Overall, the manufacturer uncovered opportunities to decrease its capital expenditure budget by as much as 20 percent. This strict review process became part of its annual routine.

Project development and value improvement

While value-engineering exercises are common, we find that 5 to 15 percent of additional value is typically left on the table. Too often, organizations focus on technical systems and incremental improvements. Instead, executives should consider the full life cycle cost across several areas:

Sourcing the right projects with the right partners. Companies must ensure they are sourcing the right projects by aligning on prioritization criteria and identifying the sectors to play in based on their strategy. Once these selections are made, organizations can use benchmarking and advanced-analytics tools to accelerate project timelines and improve planning. Building the right consortium of contractors and partners at the outset and establishing governance and reporting can have a huge impact. Best-in-class teams secure the optimal financing, which can include public and private sources, by assessing the economic, legal, and operational implications for each option.

A critical success factor is a strong tendering office, which focuses on choosing better projects. It can increase the likelihood of winning through better partnerships and customer insights and enhance the profitability of bids with creative solutions for reducing cost and risk. Best-in-class tendering offices identify projects aligned with the company’s strategy, have a clear understanding of success factors, develop effective partnerships across the value chain, and implement a risk-adjusted approach to pricing.

Achieve the full potential of the preconstruction project value. Companies can take a range of actions to strengthen capital effectiveness. For example, they should consider the project holistically, including technical systems, management systems, and mindsets and behaviors. To ensure they create value across all stages of the project life cycle, organizations should design contract and procurement interventions early in the project. An emphasis on existing ideas and proven solutions can help companies avoid getting bogged down in developing new solutions. For instance, a minimum-technical-solution approach can be used to identify the highest-value projects by challenging technical requirements once macro-elements are confirmed.

Companies should also seek to formalize dedicated systems and processes to support decision making and combat bias. We have identified five types of biases to which organizations should pay close attention (Exhibit 5). For instance, interest biases should be addressed by increasing transparency in decision making and aligning on explicit decision criteria before assessing the project. Stability biases can also be harmful. We have seen it too many times: companies have a number of underperforming projects that just won’t die and that take up valuable and already limited available resources. Organizations should invest in quickly determining when to halt projects—and actually stop them.

Setting up a system to take action in a nonbiased way is a crucial element of best-in-class portfolio optimization. Changing the burden of proof can also help. One energy company counterbalanced the natural desire of executives to hang on to underperforming assets with a systematic process for continually upgrading the company’s portfolio. Every year, the CEO asked the corporate-planning team to identify 3 to 5 percent of the company’s assets that could be divested. The divisions could retain any assets placed in this group but only if they could demonstrate a compelling turnaround program for them. The burden of proof was on the business units to prove that an asset should be retained, rather than just assuming it should.

An effective governance system ensures that all ideas generated from project value improvements are subject to robust tracking and follow-up. Further, the adoption of innovative digital and technological solutions can enhance standardization, modularization, transparency, and efficiency. A power company recently explored options to phase out coal-powered energy using a project value improvement methodology and a minimum technical solution. The process helped to articulate options to maximize ROI and minimize greenhouse-gas emissions. An analysis of each option, using an idea bank of more than 2,000 detailed ideas, let the company find solutions to reduce investment on features with little value added, reallocate spending to more efficient technologies, and better adjust capacity configurations with business needs. Ultimately, the company reduced capital costs by 30 percent while increasing CO 2 abatement by the same amount.

Designing the right project organization. An open, collaborative, and result-focused environment enabled by stringent performance management processes is critical for success, regardless of the contractual arrangement between owners and contractors. Improving capital project practices is possible only if companies measure those practices and understand where they stand compared with their peers. The organization should be designed with a five-year capital portfolio in mind and built by developing structures for project archetypes and modeling the resources required to deliver the capital plan. A rigorous stage-gate process of formal reviews should also be implemented to verify the quality of projects moving forward. Too many projects are rushed through phases with no formal review of their deliverables, leading to a highly risky execution phase, which usually results in delays and cost overruns.

As successful organizations demonstrate, addressing organizational health in project teams is as important as performance initiatives. McKinsey research has found that the healthiest organizations generate three times higher returns than companies in the bottom quartile and more than 60 percent higher returns compared with companies in the middle two quartiles. 1 Scott Keller and Bill Schaninger, Beyond Performance 2.0: A Proven Approach to Leading Large-Scale Change , second edition, Hoboken, NJ: Wiley, 2019.

Project delivery and construction

Since the root causes of poor performance—project complexity, data quality, execution capabilities, and incentives and mindsets—can be difficult to identify and act on, organizations can benefit from taking the following actions across project delivery and construction dimensions.

Optimize the project execution plan. Organizations should embrace principles of operations science to develop an optimized configuration for the production system, as well as set a competitive and realistic baseline for the project. This execution plan identifies the execution options that could be deployed on the project and key decisions that need to be made. Companies should also break the execution plan into its microproduction systems and visualize the complicated schedule. Approaching capital projects as systems allows companies to apply operations science across process design, capacity, inventory, and variability.

Contract, claims, and change orders management. While claims are quite common on capital projects, proactive management can keep them under control and allow owners to retain significant value. Focusing on claims avoidance when drafting terms and conditions can head off many claims before they arise. In addition, partnering with contractors creates a more collaborative environment, making them less inclined to pursue an aggressive claims strategy. To manage change orders on a project, companies should address their contract management capability, project execution change management, and project closeout negotiation support. A European chemical company planning to build greenfield infrastructure in a new Asian geography recently employed this approach. It reduced risk on the project by bringing together bottom-up, integrated planning and performance management with targeted lean-construction interventions. By doing so, the company reduced the project’s duration by a year, achieved on-time delivery, and stayed within its €1 billion budget.

Enablers of the capital transformation

These three value capture areas must be supported by a capable organization with the right tools and processes—what we call the “transformational chassis.” To establish this infrastructure, organizations should focus on several activities.

Performance management

The best organizations institute a performance management system to implement a cascading set of project review meetings focused on assessing the progress of value-creation initiatives. Building on a foundation of quality data, the right performance conversations must take place at all levels of the organization.

Companies should also be prepared to reexamine their stage-gate governance system to shift from an assurance mindset (often drowning in bureaucracy and needless reporting) to an investor mindset. Critical value-enabling activities should be defined at each stage of the project life cycle, supported by a playbook of best practices for execution and implemented by a project review board. While governance processes exist, they often involve reporting without decision making or are not focused on the right outcomes—for example, ensuring that the investment decision and thesis remain valid through a project’s life. Quite often, companies provide incentives for project managers to execute an outdated project plan rather than deliver against the organization’s needs and goals.

Creating project transparency is also critical. Companies should establish a digital nerve center—or control tower—that collects field-level data to establish a single source of truth and implement predictive analytics. Equally important, companies must address capability building to ensure that the team has a solid understanding of the baseline and embraces data-based decision making.

Companies should stand up delivery teams that integrate owner and contractor groups across disciplines and institute a consistent and effective project management rhythm that can identify risks and opportunities over a project’s duration. Once delivery teams prioritize the biggest opportunities, dedicated capacity should be allocated to solve a project’s most challenging problems. Finally, companies should build and deploy comprehensive programs that improve culture and workforce capabilities throughout the organization, including the front line.

Capital analytics

Many organizations struggle to get a clear view of how projects are performing, which limits the possibility for timely interventions, decision making, and resource planning. By digitalizing the performance management of construction projects using timely and transparent project data, companies can track value capture and leading indicators while making data available across the enterprise. Using a single source of truth can reduce delivery risk, increase responsiveness, and enable a more proactive approach to the identification of issues and the capture of opportunities. The most advanced projects build automated, real-time control towers that consolidate information across systems, engineering disciplines, project sites, contractors, and broader stakeholders. The ability to integrate data sets speeds decision making, unlocks further insights, and promotes collaborative problem solving between the company that owns the capital project and the engineering, procurement, and construction company.

Ways of working

In many cases, executives are unwilling to engage in comprehensive capital reviews because they lack a sufficient understanding of capital management processes, and project managers can be afraid to expose this lack of proficiency. Agile practices can facilitate rapid and effective decision making by bringing together cross-functional project teams. Under this approach, organizations establish daily stand-ups, weekly showcases, and fortnightly sprints to help eliminate silos and maintain a focus on top priorities. Agility must be supported by an organizational structure, well-developed team capabilities, and an investment mindset. Organizations should also build skills and establish a culture of cooperation to optimize their capital investments.

We do recognize that getting capital expenditure management right feels like a lot to do well. And although many of these tasks are somehow done by a slew of companies, pockets of organizational excellence can be undermined instantly (and sometimes existentially) by one big project that goes wrong or a strategic misfire that pushes an organization from being a leader to a laggard in the investment cycle. In some ways, capital expenditure management leaders face similar challenges to those in other functions that have already undergone major productivity improvements: often these challenges are not technical problems but instead relate to how people work together toward a common goal.

Yet we believe organizations have a significant opportunity to fundamentally improve project outcomes by rethinking traditional approaches to project delivery. Sustainable improvements can be achieved by resizing the project portfolio, optimizing the cash flows for individual projects, and improving and reducing individual project delivery risk.

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Fats and Cholesterol

When it comes to dietary fat, what matters most is the type of fat you eat. Contrary to past dietary advice promoting low-fat diets , newer research shows that healthy fats are necessary and beneficial for health.

• When food manufacturers reduce fat, they often replace it with carbohydrates from sugar, refined grains, or other starches. Our bodies digest these refined carbohydrates and starches very quickly, affecting blood sugar and insulin levels and possibly resulting in weight gain and disease. ( 1-3 )
• Findings from the Nurses’ Health Study ( 4 ) and the Health Professionals Follow-up Study ( 5 ) show that no link between the overall percentage of calories from fat and any important health outcome, including cancer, heart disease, and weight gain.

Rather than adopting a low-fat diet, it’s more important to focus on eating beneficial “good” fats and avoiding harmful “bad” fats. Fat is an important part of a healthy diet. Choose foods with “good” unsaturated fats, limit foods high in saturated fat, and avoid “bad” trans fat.

• “Good” unsaturated fats — Monounsaturated and polyunsaturated fats — lower disease risk. Foods high in good fats include vegetable oils (such as olive, canola, sunflower, soy, and corn), nuts, seeds, and fish.
• “Bad” fats — trans fats — increase disease risk, even when eaten in small quantities. Foods containing trans fats are primarily in processed foods made with trans fat from partially hydrogenated oil. Fortunately, trans fats have been eliminated from many of these foods.
• Saturated fats , while not as harmful as trans fats, by comparison with unsaturated fats negatively impact health and are best consumed in moderation. Foods containing large amounts of saturated fat include red meat, butter, cheese, and ice cream. Some plant-based fats like coconut oil and palm oil are also rich in saturated fat.
• When you cut back on foods like red meat and butter, replace them with fish, beans, nuts, and healthy oils instead of refined carbohydrates.

Read more about healthy fats in this “Ask the Expert” with HSPH’s Dr. Walter Willett and Amy Myrdal Miller, M.S., R.D., formerly of The Culinary Institute of America

1. Siri-Tarino, P.W., et al., Saturated fatty acids and risk of coronary heart disease: modulation by replacement nutrients. Curr Atheroscler Rep, 2010. 12(6): p. 384-90.

2. Hu, F.B., Are refined carbohydrates worse than saturated fat? Am J Clin Nutr, 2010. 91(6): p. 1541-2.

3. Jakobsen, M.U., et al., Intake of carbohydrates compared with intake of saturated fatty acids and risk of myocardial infarction: importance of the glycemic index. Am J Clin Nutr, 2010. 91(6): p. 1764-8.

4. Hu, F.B., et al., Dietary fat intake and the risk of coronary heart disease in women. N Engl J Med, 1997. 337(21): p. 1491-9.

5. Ascherio, A., et al., Dietary fat and risk of coronary heart disease in men: cohort follow up study in the United States. BMJ, 1996. 313(7049): p. 84-90.

6. Hu, F.B., J.E. Manson, and W.C. Willett, Types of dietary fat and risk of coronary heart disease: a critical review. J Am Coll Nutr, 2001. 20(1): p. 5-19.

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