Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.
This article is a report of a study of boundary work following the introduction of an acute care nurse practitioner role in healthcare teams.
Acute care nurse practitioners enacting their roles in healthcare teams have faced a number of challenges including a mix of positive and negative views of the acute care nurse practitioner role from healthcare team members and acute care nurse practitioner roles crossing the boundaries between the medical and nursing professions. Understanding the process by which the boundaries between professions changed following the introduction of an acute care nurse practitioner role was important since this could affect scope of practice and the team's ability to give patient care.
The study was conducted in two university-affiliated teaching hospitals in Canada. A descriptive multiple case study design was used. Data were collected from March to May 2009.
Participants (N = 59) described boundary work as a process that included: (1) creating space; (2) loss of a valued function; (3) trust; (4) interpersonal dynamics; and (5) time. The development of trust among team members was essential. The co-location of team members working on common projects, and medical and nursing leadership facilitated boundary work.
The micro-level processes of boundary work in healthcare teams have important implications for the development of full scope of practice for acute care nurse practitioners, effective inter-professional teamwork and the integration of new roles in healthcare systems. Future research needs to be undertaken in different contexts, and with patients and families.
Out-patient cardiac consultation in academic group practices often lacks a coordinated intake process, making it difficult to perform prospective testing or to direct undifferentiated consultations to the cardiologist with the shortest waiting list. We created a programmatic approach, with a single point of entry to improve the efficiency of cardiology consultation, without departing from the Canada Health Act. The purpose of this paper is to describe the design of Cardiac EASE.
Cardiac rehabilitation programs develop in accordance with guidelines, but also in response to local needs and resources. This study evaluated features of Ontario cardiac rehabilitation programs in accordance with guidelines, emerging evidence and treating underserved populations.
In this cross-sectional study, all Ontario cardiac rehabilitation programs were mailed an investigator-generated survey. Responses were received from 38 of 45 (84.4%) programs.
Twenty-seven (71.1%) cardiac rehabilitation programs were located within a hospital. Twenty-four (63.2%) programs reported that they offer two sessions of exercise and education per week. Twenty-six (68.4%) programs offered an alternative model of program delivery other than on-site, with 10 (27.0%) programs reporting they tailored their programs to rural patients. Twenty-three (62.2%) programs provided services to patients with a noncardiac primary indication. Twenty-six (68.4%) programs systematically screened patients for depressive symptoms. Twenty-seven (71.1%) offered resources to patients postgraduation.
Most cardiac rehabilitation programs offered alternative models of care, such as home-based rehabilitation. Cardiac rehabilitation sites are well integrated within their community, enabling smooth postcardiac rehabilitation transitions for patients. Cardiac rehabilitation programs continue to offer proven comprehensive components, while simultaneously attempting to adapt to meet the needs of patients with other chronic diseases.
BACKGROUND: Prospective randomized trials comparing the coronary artery disease-related health status outcomes (changes in symptom grade, physical functional capacity and health-related quality of life) after percutaneous coronary intervention at hospitals with and without on-site cardiac surgical backup have not been reported earlier. METHODS: We randomly assigned 609 consecutive patients fulfilling pre-specified procedural low-risk criteria to undergo percutaneous coronary intervention at either a community hospital without or a regional hospital with on-site surgical backup. Five hundred and seventy-six patients completed the health status evaluation at baseline and at 6 months follow-up. RESULTS: At baseline, 91.4% had symptoms, and the mean (standard deviation) Canadian Cardiovascular Society's classification was 2.5 (0.9). The procedural success rates and the changes in health status measures were similar at the two hospitals. Overall there was a substantial relief of symptoms with a reduction in Canadian Cardiovascular Society's classification of 1.9 (1.2), increase in exercise time [1.4 (1.9) min] and reduction in use of antianginal drugs [0.6 (0.9) less drugs] at follow-up compared with baseline (all P
Partners for Health convened an interdisciplinary team to evaluate the quality of care received by cardiac patients. The team detailed the suboptimal postacute care of patients with ischemic heart disease. To solve the quality problems, a cross-sectoral team, using an approach that is in accordance with the American Heart Association's Scientific Statement on Pathways, systematically developed and implemented an integrated community pathway for myocardial infarction patients. The paper contributes to the literature on pathways by presenting the lessons learned from the authors' first-hand experience. The paper concludes with recommendations based on those lessons.