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Business Process Redesign in Health Care IT

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1 Business Process Redesign in Health Care IT
Types of BPR Project Management Implications Examples from the Field Lee Farabaugh, Susan John, Larry Katzovitz, Eric Lott, Ashwini Patki, Jessica Pearce, Josh Snow 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

2 Group 4: Project Agenda Overview of Business Process Redesign models used in healthcare. Applicability of principles of Business Process redesign related to overall Project Management methodologies. Effectiveness of such models as part of a Healthcare IT initiative. Examples where organizations have used such a model as part of a Healthcare IT initiative. Class exercise and questions.

3 Project Management Methodologies (Traditional)
Waterfall Spiral Build and Fix

4 Traditional Methodology Model
Identify Deficiencies Define Specific Proposals for Improvement Proposed System is Designed New System is Developed System is Implemented System is Continuously Evaluated and Maintained

5 Traditional Methodologies Characteristics
Looked to improve existing systems or implement new systems Task oriented Processed based Step-by-step approach

6 Business Process Redesign Characteristics
“Clean Slate” Outcomes oriented Priority based Cyclical approach

7 Business Process Redesign Model
Envision New Processes Initiate Change Diagnosis Process Process Redesign Reconstruction Process Monitoring

8 Agile Principles Projects built around self-organized teams
Rapid adaptation to changing circumstances Continuous attention to technical design Working product is the measure of progress

9 Health Care Challenges that encourage use of BPR
Medical errors and high costs of healthcare Underinsured or uninsured population Increasing number of heterogeneous and older population, Globalization/ medical outsourcing, Maintaining quality for given cost and cost minimization for given quality Shortage of clinical and nursing staff

10 Expectations from BPR models
Increase in efficiency Reduce medical and medication errors Health care cost reduction Better access and quality in healthcare Procedure optimization Time effectiveness Customer and health care provider satisfaction

11 Highlighted solutions
Automating and monitoring processes in healthcare Redesigning or improving clinical processes where necessary and possible Identifying patient expectations and improving patient care processes for better customer services.

12 HELPS AN ORGANIZATION STAY COMPETITIVE
BPR – What & Why? Business Process Redesign is a set of activities undertaken to make sustained improvements in the … SPEED (lead time) QUALITY COST OF PROCESS HELPS AN ORGANIZATION STAY COMPETITIVE IN THE MARKETPLACE

13 BPR – How? NEW PRODUCT REDESIGN HIGH LEVEL ASSESSMENT RESULTS IN
(FOR EFFICIENCY & ALIGNMENT OF MUTUAL GOALS) BUSINESSS MISSION GOALS CUSTOMER NEEDS STRUCTURED ORDERING OF WORKSTEPS MEASURED IMPROVED (OR) ELIMINATED

14 BPR - Methods LEAN SIX SIGMA TOTAL QUALITY MANAGEMENT (TQM) KAIZEN
PLAN, DO, STUDY ACT (PDSA) CLINICAL MICROSYSTEM MODEL TALENT PROFILING

15 LEAN – What? RETHINKING & REDESIGN OF BUSINESS PROCESS
EFFICIENCY IMPROVEMENTS PROCESS COST REDUCTION REVENUE INCREASE SHORTENED LEAD TIMES REDUCED PROCESS WASTES IMPROVED CUSTOMER SATISFACTION

16 LEAN – How? HIGH LEVEL ASSESSMENT WHO ? PRODUCT DELIVERED ?

17 Improving Processes by eliminating…
LEAN – How? Improving Processes by eliminating… STEPS THAT HAVE NO VALUE PROCESS WASTE WAITING TIME

18 LEAN – How? (Six Concepts)
Value Value Stream Flow Pull Perfection Replication 6 steps to think Lean. 1.Value- Ex: Who is the customer? 2. Value Stream – Ex:What is the service or product being provided to customer? 3. Flow- Ex: Did the team identify the non- value added distances traveled by parts. 4. Pull- Ex: Waste elimination steps identified at every step of the process, to produce more than before in a way that is valued added at time of delivery. Example: Dell Computers. 5. Perfection - Ex: Optimize your process for what your tring to achieve. 6. Replication- Ex: Can this process improvement be replicated in other parts of the business.

19 LEAN – What helps? LEAN IMPLEMENTATIONS
STRONG MANAGEMENT SUPPORT & SPONSORSHIP COMMUNICATION OF SHARED GOALS LEAN IMPLEMENTATIONS

20 TO GAIN COMPETITIVE ADVANTAGE OVER OTHER COMPANIES
LEAN - Conclusion Can be applied to any business process or service industry. Can be used to dramatically reduce lead times HR recruitment New product development Customer development TO GAIN COMPETITIVE ADVANTAGE OVER OTHER COMPANIES

21 Six Sigma (Six sigma was invented by Motorola in the 1980s)
Analytical approach to indentify the inefficiencies and inadequacies in the process and provide a step by step solution based on analysis of real time data. Process must have < 3.4 defects per million occurrences (Carrigan, 2006) Statistical calculation that suggests customer needs /satisfaction to meet % or 6-Sigma level. (Caldwell 2006) Focuses on customer satisfaction, process improvement and cost reduction. (Breyfogle, 2003) Uses structured methodology and powerful statistical tools that provide a scientific approach to process improvement and patient safety. (http://www.medscape.com) Six sigma was invented by Motorola in the 1980s. Although Lean and Six Sigma are originally business management models, in recent years the potential of these techniques in health care and in software development is been recognized. (Schweikhart et al 2009)

22 Six Sigma Sub methodologies
DMAIC: Define, Measure, Analyze, Improve, and Control; (improve existing processes ) DMADV: Define, Measure, Analyze, Design, Verify; (develop new processes or products at Six Sigma quality levels) (http://www.isixsigma.com/sixsigma/six_sigma.asp) Implementing 6sigma: “Black Belt” = organize of Six Sigma project “Green belt” = implement and monitor the project. Define and describe the potential critical processes. Determine measures such as accuracy standards, reproducibility of each process, idendify and verify cause effect relationship between variables, implement the improvement design and establish control over new system via policies/ regulations and document to prevent recurring issues. DMADV has last 2 steps different: Design new process and verfy that the solution fits the problem. People in an organization are certified to implement Six Sigma by allotting them “Black Belt” or “Green belt” status. Black belts organize the Six Sigma project and green belts implement and monitor the project. Sigma is a statistical calculation that suggests customer needs /satisfaction to meet % or 6-Sigma. Majority of the times healthcare processes rarely go beyond 93% or 3 sigma.

23 Applications of BPR BPR Obstacles
4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

24 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
What is TQM? Total Quality Management (TQM) is a philosophy that says uniform commitment to quality in all areas of an organization promotes an organizational culture that meets consumers' perceptions of quality. TQM philosophy focuses on teamwork, increasing customer satisfaction, and lowering costs. The concept of TQM rests largely on five principles: 1. Produce quality work the first time Focus on the customer Have a strategic approach to improvement Improve continuously Encourage mutual respect and teamwork. To be effective in improving quality, Organizations implement TQM by encouraging managers and employees to collaborate across functions/departments, as well as with customers and suppliers, to identify areas for improvement, no matter how small. Teams of workers are trained and empowered to make decisions that help their organization achieve high standards of quality. Organizations shift responsibility for quality control from specialized departments to all employees. Thus, total quality management means a shift from a bureaucratic to a decentralized approach to control. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

25 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
TQM Process/Benefits Process begins by listening to customers' wants and needs and then delivering goods and services that fulfill these desires. An effective TQM program has numerous benefits: Financial benefits (lower costs, higher returns on sales and investment, and the ability to charge higher rather than competitive prices) Improved access to global markets Higher customer retention levels Less time required to develop new innovations Reputation as a quality firm Only a small number of companies use TQM because implementing an effective program involves much time, effort, money, and patience. However, firms with the necessary resources may gain major competitive advantages in their industries by implementing TQM. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

26 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
What is Kaizen? Philosophy/practices focusing on continuous improvement in manufacturing activities, business activities, & life in general. Refers to activities that continually improve all functions of a business, Manufacturing to management CEO to assembly line workers Kaizen aims to eliminate waste. ( Japanese for "improvement") By improving standardized activities and processes, aims to eliminating waste Kaizen was first implemented in several Japanese businesses during the country's recovery after World War II and has since spread to businesses throughout the world. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

27 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Kaizen Cycle The cycle of kaizen activity can be defined as: Standardize an operation Measure the standardized operation Gauge measurements against requirements Innovate to meet requirements and increase productivity Standardize the new, improved operations Continue cycle ad infinitum (find cycle time and amount of in-process inventory) 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

28 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Kaizen Elements Teamwork Personal discipline Improved morale Quality circles Suggestions for improvement Results Elimination of waste (muda) and incorporation of efficiency The kaizen five - S framework Seiri - tidiness Seiton - orderliness Seiso - cleanliness Seiketsu - standardized clean-up Shitsuke - discipline Standardization 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

29 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Other BPR Methods PDSA – Plan, Do, Study, Act Clinical Microsystem Model Talent Profiling 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

30 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
PDSA – Plan, Do, Study, Act Three Questions What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

31 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
The PDSA Cycle 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

32 PDSA – UW Rheumatology Office Visit Data Collection
Cycle 1 – Standardized Database & Dictation Template Cycle 2 – Disease Activity Scoring Cycle 3 – CPT Visit Coding Level Cycle 4 – Full Implementation 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

33 PDSA – UW Rheumatology Office Visit Data Collection
Improvements More Complete Data 40% Time Savings More Effective Patient/Physician Visit Improved Therapeutic Decision Making Research Study Revenue 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

34 Clinical Microsystem Method
Smallest Replicable Unit Building Blocks to Larger System 5 P’s - Purpose, Patients, Processes, Professionals, and Patterns   Improvements – Transformation of Workforce and Culture Hospital Quality = Quality of Microsystem 1 + Quality of Microsystem 2 + Quality of Microsystem 3 and Microsystem (n) 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

35 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Talent Profiling Worker rather than Process Right Person – Right Job Important Characteristics to be Successful 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

36 Business Process Reengineering and Health Care IT
IT often plays a support role in BPR in health care “What has to happen when you design the new process, you find how information technology is going to be used to support that new process, and if you don’t have that technological capability, you’re going to have to go and get it.” (George W. Whetsell) We’ve seen in our research that IT mostly plays a supportive role in BPR in healthcare. Often, the redesign initiatives focus around physical processes, such as duplication of effort or wasted steps, and IT can help in the effort to reduce waste, but it isn’t the central player. The CIO’s role is to understand BPR as it applies to his or her specific organization and be innovative in applying that understanding to the IT function within the organization, especially if technology needs to be created or implemented to achieve the process redesign goals. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

37 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Denver Health (Lean) Pure IT project: patient scheduling application development Project timeline reduced 50%, outside consulting cost reduced 36%. IS had previously sat “on the sidelines” in lean initiatives, but sought to use lean to make the department more efficient Challenge was to fit lean concepts to a longer term IT project. This first case, however, is a pure IT project within a healthcare organization. What’s interesting about this one is that the team had to redefine some of the BPR components to fit a purely IT project. Denver Health is a large U.S. integrated-delivery system with more than 5,000 employees, and it is Colorado's primary "safety net" health system. The IT department had participated in previous lean initiatives at the hospital, but in a support role. When they started the patient scheduling application development project, they wanted to see if lean could be useful in shortening development time and curbing costs paid to vendors and outside consultants, as well as internal resource time. Also, because patient scheduling is so vital to the hospital’s function, the team wanted to ensure a smooth transition to the new system. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

38 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Denver Health (Lean) Rapid Improvement Event (RIE) model was tweaked to fit this specific project Embedded into project cycle, redefining how project was managed Custom templates created Special attention given to lean tools, activity flow, and frequency of RIE events Involvement of end users “Red phone” mentality The team had to make some tweaks to the Lean model to make it fit a longer development cycle. The Rapid Improvement Events are usually focused around a short cycle of process scrutiny. However, the team was creative, and built 4 RIEs over 3 months into the development cycle, and allowed development to be somewhat redefined by the RIEs. They had to customize some of the RIE templates to fit a complex design/build project, and make some new ones such as daily report-outs. They also adopted the Vertical Value Stream Analysis (VVSA) event, which identified key players required for major work efforts, including end users. This involved scheduling and defining entry and exit criteria. They used MS Sharepoint to bring stakeholders up to speed with 15 mins of relevant information at their fingertips instead of monthly steering committee meetings Delta team of 3 individuals (IT, owning department, and vendor) replaced project governance and took day-to-day responsibility for decision making. Red phone empowered the group to have decision-making authority and cut out a lot of scheduled meetings. 25% reduction in internal resource time spent on the project Training time reduced because trainers were involved from the beginning and became application experts. Training materials were available before launch, and 80-90% of users were trained ahead of time. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

39 BayCare Health & Blue Cross
Optimize Electronics Claims Processing Understand Sub-processes in claims processing Blackbelts held team meetings Six page swim lane process map Results Reduced processing time Fewer denied claims $500,000 annual savings 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

40 VA’s VistA QUERI system (TQM)
Quality Improvement initiative within the VA, where data from the organization’s nationwide interoperable VistA EMR system is integral to the total process of improving patient outcomes. The Veterans Administration, or VA, is a unique healthcare entity in the US. It comprises over 1500 facilities service 7.84 million patients, utilizing one EHR system, called the Computerized Patient Record System, built on the VistA architecture. The VA’s QUERI system, or Quality Enhancement Research Initiative uses data from CPRS and VistA to improve patient outcomes through 6 steps. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

41 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
First, a disease is identified that is especially burdensome to the veteran population. The system is helpful in this step by providing data about disease burden and helping to identify issues that are good candidates for the process. Next, best practices are identified for addressing this disease. Third, existing practice patterns and outcomes from across the VA are collected, and deviation from best practices is identified. Again, the system provides data about these patterns and about outcomes. Sometimes the data are readily available, and sometimes new queries or applications have to be created to get the necessary data. Next, interventions are identified to promote best practices. This might come from inside or outside the organization. The human-technology interface is really important here, because if it’s not easy for the clinicians to adopt the intervention, it probably won’t be effective. The best practices that actually improve outcomes are identified, again through system data. Special attention is paid to patient quality of life and patient satisfaction, not just positive clinical outcome. The structure of the VA and the access to data provided by VistA make it a natural fit for research activities seeking to improve quality, clinical outcomes, and patient satisfaction. As Kizer et al state, “The VHA’s unique portfolio of providing patient care, teaching, conducting research, and continuously measuring outcomes, combined with its large size and national presence, provide for a broad and stable patient base for taking research discoveries and quickly putting them to work, either to improve patient care or to enhance system efficiency. QUERI attempts to purposely link research activities (which generate scientific evidence) to clinical care in as close to real time as possible, thereby leading to rapid adoption of best clinical practices and improvement in patient outcomes.” (Kizer, Demakis, & Feussner, 2000). Hynes, D. M., Perrin, R. A., Rappaport, S., Stevens, J. M., & Demakis, J. G. Informatics Resources to Support Health Care: Quality Improvement in the Veterans Health Administration. Journal of the American Medical Informatics Association. 2(5), 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

42 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Virginia Mason (Lean) IT served as a support role to improve areas identified as cost-centers Provided feedback to individual clinicians on cost performance Implementation of CPOE to reduce unnecessary prescriptions and reduce ER visits due to low refill allowances Implementation of decision support to alert clinicians when tests fall into the “not useful” category And last, we have a case where IT plays more of a support role. At Virginia Mason, they identified the problem: high cost for treating migraines and GERD, which was initially attributed to specialists, but through process scrutiny, later attributed to primary care docs and ED docs. What they found was that patients made ED visits for migraines when they lacked emergency meds, physicians prescribed too many pills for trial medications, and they prescribed the most expensive GERD medicine, among other things. IT’s role in reducing costs involved implementation of Computerized Provider Order Entry to automate fewer pills on initial prescription, and more pills on refills. They alsp initially tried educating physicians on appropriateness of tests, but found this wasn’t effective, so they created clinical decision support to tell physicians when tests were not useful. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

43 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
BPR Recap Methods How different from traditional Variety of methods Application Seen how BPR models differ from traditional project management methods Lean Six Sigma Total Quality Management (TQM) Kaizen Plan, Do, Study, Act, Clinical Microsystem Model Talent Profiling Application: IT development project Reducing wait time in rheumatology Veterans Administration Claims processing Reducing costs and wait time in ED 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

44 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Q&A Questions? 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

45 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow
Class Exercise 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

46 Business Process Redesign: Jeopardy
Lean Six-Sigma Total Quality Management (TQM) Kaizen Plan, Do, Study, Act (PDSA) 25 Points 50 Points 100 Points Subject – Methods of Business Process Reengineering 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

47 Jeopardy Questions (Modified Version)
Lean Six-Sigma Total Quality Management (TQM) Kaizen Plan, Do, Study, Act (PDSA) Name 1 of the 3 improvements that can be expected with ‘Lean’ The acronym “DMAIC” stands for what? What area of an organization does TQM focus its efforts? What is the aim of Kaizen? Name 1 of the 3 questions that should be asked before implementing PDSA Lean improves processes by eliminating what? (name 2 of the 3) What are the two types of “belts” that can be received if an org. implements six-sigma? The TQM process first begins by what? “Muda” stands for what? The “Do” stage of PDSA involves a number of duties, name 2. Lean can be applied to what business or industry? What organization invented the six-sigma methodology? Name 2 of the 5 benefits that can be expected with TQM? Name 2 of the 5 elements of Kaizen Name 2 elements involved with the “Act” cycle of PDSA? Relative to the traditional Jeopardy format, the questions will be asked first, followed by the answers. 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

48 Total Quality Management (TQM) Plan, Do, Study, Act (PDSA)
Jeopardy Answers Lean Six-Sigma Total Quality Management (TQM) Kaizen Plan, Do, Study, Act (PDSA) Shortened lead times Reduction in process waste Improved customer satisfaction DMAIC = Define, Measure, Analyze, Improve, and Control All areas of an organization Eliminate waste What are we trying to accomplish? How will we know that change is an improvement? What changes can we make that will be an improvement? Steps that have no value Process waste Waiting time Black Belt and Green Belt Listening to customers’ wants and needs Elimination of waste and incorporation of efficiency Carry out the plan Document observations Record Data Any process or industry! Motorola Financial Benefits Improved access High customer retention Less time for R&D Improved Reputation Teamwork Personal discipline Improved morale Quality circles Suggestions for improvement Asking “what changes are to be made?” Asking “what is the next cycle?” 4/6/2017 Group 4: Farabaugh, John, Katzovitz, Lott, Patki, Pearce, Snow

49 Bibliography Alexandrou, Marios (2009). Methodologies. Retrieved from Beck, K., Beedle M., Bennekum, A., et al. (2001), The Agile Manifesto. Retrieved from Caldwell, C., Lean-Six Sigma tools for rapid cycle cost reduction, Healthcare Financial Management. Oct 2006, 60 (10) CliffsNotes.com. Total Quality Management (TQM). 24 Nov Retrieved from Corn, J. B., Six Sigma in Health Care, Radiologic Technology. September/October 2009; 81(1): 92-95 Bergman, R. (1994). Reengineering Healthcare. Hospitals & Health Networks. 5 February, 1994, Breyfogle, F. W., Implementing Six Sigma: Smarter Solutions Using Statistical Methods, 2nd ed. 2003, Wiley, New York, NY. Carrigan M. D., Kujawa D. Six Sigma in health care management and strategy. Health Care Management. 2006;25(2): Davenport, D. and Short, J. The New Industrial Engineering: Information Technology and Business Process Redesign. Retrieved from Guha, S., Kettinger, W., & Teng, T. (1993) “Business Process Reengineering: Building a Comprehensive Methodology”, Information Systems Management, Summer 1993, Vol 10 (3), 13-22

50 Harrington, T. J. , Newman, E. D. (2007)
Harrington, T. J., Newman, E. D. (2007). Redesigning the care of rheumatic diseases at the practice and system levels. Clinical and Experimental Rheumatology, 25, S55-S63. Improvement Methods. Institute of Healthcare Management. Retrieved from Lanham, B., Maxson-Cooper, P. Is Six Sigma the Answer for Nursing to Reduce Medical Errors...: Implementing Six Sigma in Health Care. MedScape Today. Retrieved from Mahalik, P. Learning to Think Lean: Six Steps with Review Points. Retrieved from McQueen, H. E. (1993). The healthcare CIO’s role in business process redesign. Computers in Healthcare. February, 1993, Mohr, J, Batalden, P., Barach, P. (2004). Intergrating patient safety into the clinical microsystem. Qual Saf Health Care, 13,34-38. Plan-Do-Study-Act (PDSA) Cycle (2008). AHRQ Healthcare Innovations Exchange. Retrieved from Schweikhart S. A., Dembe A. E. J Investigative Medicine Sep 2 Shaffer, Vi. (2008). Case Study: Denver Health Leverages ‘Lean’ for a Breakthrough in Enterprise Patient Scheduling Implementation. Gartner Industry Research. 17 December, 2008. Six Sigma. Retrieved from Six Sigma - What is Six Sigma? Retrieved from ValueBasedManagement.com. Kaizen Philosophy and Kaizen Method. Retrieved from:


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