M. P. Kossovsky, P. Chopard, et al. (2002). "Evaluation of quality improvement interventions to reduce inappropriate hospital use." International Journal for Quality in Health Care 14(3): 227-232.

http://intqhc.oupjournals.org/cgi/content/abstract/14/3/227

Objectives. To assess the impact of process analyses and modifications on inappropriate hospital use.

Design. Pre-post comparison of inappropriate hospital use after process modifications.

Setting. The Department of Internal Medicine of the Geneva University Hospitals, Switzerland.

Participants. A random sample of 498 patients.

Interventions. Two processes of care (i.e. non-urgent admissions and transfer to a rehabilitation hospital), which influenced inappropriate hospital use, were identified and modified. The impact of these modifications was then assessed.

Main outcome measures. The proportion of inappropriate hospital admissions and inappropriate hospital days.

Results. As a baseline assessment before quality improvement interventions, the appropriateness of hospital use (admissions and hospital days) was evaluated using the Appropriateness Evaluation Protocol (AEP) in a sample of 500 patients (5665 days). After modification of the two processes through a quality improvement program, inappropriate hospital use was reassessed in a sample of 498 patients (6095 days). Inappropriate hospital admissions decreased from 15 to 9% (P = 0.002) and inappropriate hospital days from 28 to 25% (P = 0.12).

Conclusion. Using the AEP as a criterion, the quality improvement interventions significantly reduced inappropriate hospital use due to the process of non-urgent admissions, but the reduction of inappropriate hospital days specifically attributed to the transfer to the rehabilitation hospital did not reach statistical significance.

D. W. Spaite, F. Bartholomeaux, et al. (2002). "Rapid process redesign in a university-based emergency department: Decreasing waiting time intervals and improving patient satisfaction." Annals of Emergency Medicine 39(2): 168-77.

http://www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=a121215&nav=abs

Academic emergency departments are traditionally associated with inefficiency and long waits. The academic medical model presents unique barriers to system changes. Several non-university-based EDs have undertaken process redesign, with significant decreases in patient waiting time intervals. This is the presentation of a rapid process redesign in a university-based ED to reduce waiting time intervals. We present the application of a process-improvement team approach to evaluate and redesign patient flow. As a result of this effort, the median waiting room time interval (triage to patient room) decreased from 31 minutes in January 1998 to 4 minutes in July 1998. ED throughput times also decreased, from 4 hours, 21 minutes in January 1998 to 2 hours, 55 minutes in July 1998. Urgent care waiting room time intervals decreased from 52 minutes to 7 minutes and throughput times from 2 hours, 9 minutes to 1 hour, 10 minutes. Patient satisfaction evaluations by an independent institute demonstrated dramatic improvement and establishment of a new benchmark for academic EDs. Process redesign is possible in a busy, complex, tertiary-care ED, with decreases in waiting time intervals and improvement in patient satisfaction. Major sustained support from top-level hospital administrators and physician leadership are fundamental prerequisites. With these in place, a process improvement team approach for evaluating and redesigning the patient care system can be successful.