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This case study aims to demonstrate the strengths of the Lean Six Sigma (LSS) methodology to improve the acute ischemic stroke (AIS) treatment rates and reduce process lead time at Baruch Padeh Medical Center (BPMC), a rural hospital in the Galilee region of Northern Israel. The LSS project redefined the BPMC stroke care pathway and increased its efficacy.

The LSS methodology was implemented in September 2017 by integrating lean principles and the Six Sigma DMAIC (Define–Measure–Analyze–Improve–Control). Existing procedures, field observation, ad hoc measurement and in-depth interviews were utilized, and the GEMBA method was implemented to identify root cause and improve actions optimizing the stroke pathway.

The presented case shows the usefulness of the LSS methodology in improving quality performance in a rural hospital. The intervention allowed the BPMC to improve the intravenous tissue plasminogen activator (IV-tPA) administration rate (+15.2%), reducing the process lead time. The lead time of door-to-computer tomography decreased from 52 to 26 min, and the door-to-needle time decreased from 94 to 75 min.

The present case study shows the implementation of the LSS methodology aimed to improve the IV-tPA administration rate and reduce the stroke pathway lead time in a rural hospital. The case demonstrates the potential for the LSS methodology to support the AIS pathway optimization and represents a guide for healthcare organizations located in rural areas.

The purpose of this study had two aims: (1) to extend insight regarding the challenges of implementing standardised work, via care pathways, in a healthcare setting by considering interactions with other operational (i.e. resource sharing, portfolio alignment) and professional (i.e. autonomous expertise) dependencies and (2) to develop novel insights regarding a specific flow mechanism, the stroke nurse practitioner, a form of flow “pilo” or guide.

This was a longitudinal case study of implementing the acute stroke care pathway in a National Health Service hospital in England based on 185 hours of non-participant observations and 68 semi-structured interviews. Archival documents were also analysed.

The combined flow, operational and professional dependency lens extends operations management understanding of the challenge of implementing standardised work in healthcare. One observed practice, the process pilot role, may be particularly valuable in dealing with these dependencies but it requires specific design and continuous support, for which the authors provide some initial guidance.

The research was a single case study and was focussed on a single care pathway. The findings require replication and extension but offer a novel set of insights into the implications of standardised work in healthcare.

In addition to confirming that a multidependency lens adds conceptual and practical insight to the challenges of implementing standardised work in a healthcare setting, the findings and recommendations regarding flow “pilots” are novel. The authors' analysis of this role reveals new insights regarding the need for continued improvisation in standardised work.

The purpose of this paper is to evaluate the needs of stroke survivors and the impact of a Life After Stroke service on users, and to explore the effectiveness of a service provided by a third sector organisation working closely with other stroke service provision.

Review of management documents and reports, polling views of 128 service users through a nationally recognised survey designed to assess the service impact, and using interviews and focus groups to gain a deeper understanding of the value and impact of the service from a range of professionals involved with delivering stroke care. Survey response rates were similar to that experienced nationally and the age/gender profile of respondents suggested they were representative.

The service was highly regarded by service users as providing personal, practical and emotional support from people who were knowledgeable and accessible in acute hospitals. From the wider perspective, professionals involved in the stroke pathway saw the service as complementing the acute hospital provision and the stroke community nursing team. The organisation providing the support service worked effectively across health and social care boundaries and built on their existing links and trusted relationships.

This adds to the evidence that the personal impact of stroke is substantial, and on being discharged from acute care many survivors will still have considerable needs. For those responsible for meeting these needs, the particular model of delivering stroke support evaluated here has been found to have considerable merits and resilience in the changing landscape of tighter resources and NHS restructuring.

The purpose of this paper is to examine the suitability of current care pathway modelling techniques for supporting business improvement and the development of information systems. This is in the light of current UK government policies advocating the use of care pathways as part of the £12.4 billion programme for Information Technology and as a key strategy to reducing waiting times.

A qualitative analysis of the variety in purpose, syntax and semantics in a selection of existing care pathways is conducted.

Care pathways are typically modelled in an ad hoc manner with little reference to formal syntax or semantics.

The research reviews a small selection of existing pathways. The feature set used for evaluation could be further refined. Future research should examine the suitability of applying existing process modelling techniques to care pathways and explore the motivations for modelling care pathways in an ad hoc manner.

The development of care pathways can aid process improvement and the integration of information systems. However, while syntax and semantics are not standardised the impact of care pathways in the work of Department of Health agencies, in particular Connecting for Health, is likely to be limited.

The results provide insight into the limitations of the state of the art in care pathway models. This highlights a significant omission in the Department of Health's approach and identifies an important direction for further development that will aid Connecting for Health, healthcare organisations and healthcare professionals to deliver more effective services.

The purpose of this paper is to demonstrate that, if teams in healthcare focus on the patient using the framework of a care pathway, change can occur without the overt need to “manage” it directly.

In this paper the relevant literature is reviewed and it is demonstrated that if this approach is used it also provides a means for addressing difficult professional and organisational issues that are often unresolved in broader projects of organisational change. This is not presented as a panacea or the solution to all change projects, rather the contention here is that it is one means among many that can be used to bring about important changes in practice.

The paper finds that care pathways represent a useful tool, which teams can use to work through the contextual and practical issues involved in changing practice.

The paper describes the development of integrated care pathways, which can be regarded as a fortunate fusion of managerial and professional concerns.

Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help.

Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches.

A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement.

The authors provide a conceptual framework that requires empirically testing.

This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery.

For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

The article aims to globally illuminate and inform the healthcare delivery systems of the potential value of integrated care pathways (ICPs) application to the management and control of infection in the hospital setting

An analysis of recent pertinent literature (1993‐2004) is given, preceded by a broad overview of both the subjects of infection control and ICPs.

There are scanty examples of ICPs applied to infection control albeit successfully with demonstrable merits which include improvements in the quality and cost of care. However, there is a lack of robust studies on the subject which warrants further research.

Infection control is a major challenge to all healthcare providers seeking practical solutions. This source article may stimulate further informed debate to curb the problem of hospital acquired infection (HAI) which remains a major cause of morbidity and mortality despite all the great advancement in medicine.

Tertiary hospitals have registered an incremental rise in expenditure mostly because of the increasing demands by ageing populations. Reducing the length of stay (LOS) of patients within tertiary hospitals is one of the strategies, which has been used in the last decades to ensure health care systems’ sustainability. Furthermore, LOS is one of the key performance indicators, which is widely used to assess hospital efficiency. Hence, it is crucial that policy makers use evidence-based practices in health care to aim for optimal LOS. The purpose of this paper is to identify and summarize empirical research that brings together studies on the various variables that directly or indirectly impact on LOS within tertiary hospitals so as to develop a LOS causal systems model.

This scoping review was guided by the following research question: “What is affecting the LOS of patients within tertiary-level health care?” and by the guidelines specified by Arksey and O’Malley (2005), and by Armstrong et al. (2011). Relevant current literature was retrieved by searching various electronic databases. The PRISMA model provided the process guidelines to identify and select eligible studies.

An extensive literature search yielded a total of 30,350 references of which 46 were included in the final analysis. These articles yielded variables, which directly/indirectly are linked to LOS. These were then organized according to the Donabedian model – structure, processes and outcomes. The resultant LOS causal model reflects its complexity and confirms the consideration by scholars in the field that hospitals are complex adaptive systems, and that hospital managers must respond to LOS challenges holistically.

This paper illustrates a complex LOS causal model that emerged from the scoping review and may be of value for future research. It also highlighted the complexity of the construct under study.

The purpose of this paper is to discuss the construction of the theoretic model of systematic knowledge creation in the healthcare process according to professionals' collaboration using clinical‐pathways.

Healthcare is a knowledge‐intensive service conducted by professionals. A clinical‐pathway is an effective tool in the knowledge management aspect of this service. The theoretic model of the medical knowledge management which used the clinical‐pathway from case studies in two hospitals is constructed.

The theoretical model shows the interaction between explicit knowledge and tacit knowledge in the healthcare process using clinical‐pathways. This theoretical model is a knowledge creation model which creates new knowledge continuously. Therefore, the clinical‐pathways are suggested as an effective tool for knowledge management in healthcare.

Promotion of knowledge communication between healthcare professionals by clinical‐pathways activities is important for excellent healthcare management.

This paper will be valuable for sustained improvement of healthcare quality by knowledge management with clinical‐pathways. In this paper, the detailed theoretic model which explains medical knowledge management with clinical‐pathways has been constructed.

The best treatment for femur fractures is the surgical one within 48 h from the admission to the hospital. These fractures have serious consequences, both in terms of morbidity and socio-economic impact. In the hospital A.O.R.N. Cardarelli of Naples in Italy, the mean pre-operative length of hospital stay (LOS) was nine days and just 4 per cent of patients was operated within the suggested time. Therefore, a diagnostic-therapeutic-assistance path (DTAP) was implemented to improve the process.

This paper analyzes two groups of patients (534 and 562, respectively) before and after the introduction of DTAP, through six sigma (SS) based on define, measure, analyze, improve and control cycle. Age, gender, American Society of Anaesthesiologists (ASA) score, cardiovascular diseases, diabetes and allergies were used as independent subgrouping variables. The t-tests and chi-square were performed to compare the groups, tools of SS were used.

The analyses were conducted considering overall patients and some subgroups. The overall reduction in LOS was about 54 per cent, patients without cardiovascular diseases and with a low ASA score had the highest reduction, more than 60 per cent. All the p-values proved a high statistically significant difference between the two groups.

The influence of the Italian health-care system is a minor limitation while, unfortunately, the lack of a follow-up did not allow quantifying the real gain in health of patients. A lean thinking analysis would suit this context.

There are practical advantages for both hospital and patients: the hospital will have an increase in admissions and more beds available, while patients will benefit of a faster intervention and a shorter wait.

This is the first analysis through SS of DTAP showing its positive influences in terms of both socio-economic impact and patients’ outcome. Policy leaders could use this study as an example to evaluate the introduction of the same clinical pathway in other health facilities.