This review demonstrates that there are significant gaps in the SS/L health care quality improvement literature and very weak evidence that SS/L improve health care quality.

IntroductionEmergency medical services (EMS) agencies transport a significant majority of patients with low acuity and non-emergent conditions to local emergency departments (ED), affecting the entire emergency care system’s capacity and performance. Opportunities exist for alternative models that integrate technology, telehealth, and more appropriately aligned patient navigation. While a limited number of programs have evolved recently, no empirical evidence exists for their efficacy. This research describes the development and comparative effectiveness of one large urban program.MethodsThe Houston Fire Department initiated the Emergency Telehealth and Navigation (ETHAN) program in 2014. ETHAN combines telehealth, social services, and alternative transportation to navigate primary care-related patients away from the ED where possible. Using a case-control study design, we describe the program and compare differences in effectiveness measures relative to the control group.ResultsDuring the first 12 months, 5,570 patients participated in the telehealth-enabled program, which were compared against the same size control group. We found a 56% absolute reduction in ambulance transports to the ED with the intervention compared to the control group (18% vs. 74%, P<.001). EMS productivity (median time from EMS notification to unit back in service) was 44 minutes faster for the ETHAN group (39 vs. 83 minutes, median). There were no statistically significant differences in mortality or patient satisfaction.ConclusionWe found that mobile technology-driven delivery models are effective at reducing unnecessary ED ambulance transports and increasing EMS unit productivity. This provides support for broader EMS mobile integrated health programs in other regions.

Organizational quality improvement practices have gained wide acceptance in manufacturing industries over the last several decades. A substantial number of books have been written on Lean and Six Sigma alone, which today are the leading improvement initiatives. The healthcare industry however has been slower to adopt these methods, although anecdotal evidence suggests they are now being gradually diffused throughout hospitals on an increasing basis. Yet, these new practices have been developed substantially without a theoretical foundation (Linderman et al. J Oper Manag 21:193-203, 2003) and the question of industry "fit" is the topic of debate for many physicians and administrators (Kassirer N Engl J Med 339: [1543][1544][1545] 1998). This article provides the descriptive results from our mixed methods research, combining survey questionnaire with semi-structured interviews, that examines implementation of two quality improvement initiatives (Lean and Six Sigma) in a cross-sectional sample of hospitals. We used correlations and non-parametric tests to examine relationships between goal attainment and quality management, and present descriptive findings about reported usage and adoption of quality initiatives. Importantly, we find that the efficacy of quality improvement initiatives in healthcare may be impeded by the lack of goal clarity and measurement. We build on these initial results by offering recommendations to improve results in practice, as well as an agenda for further research of quality initiatives in healthcare. The objectives of our research are to better understand how Lean and Six Sigma fit in the healthcare industry and to explore goal and value attainment from these projects.

Objective There has been very little use of telehealth in pre-hospital emergency medical services (EMS), yet the potential exists for this technology to transform the current delivery model. In this study, we explore the costs and benefits of one large telehealth EMS initiative. Methods Using a case-control study design and both micro- and gross-costing data from the Houston Fire Department EMS electronic patient care record system, we conducted a cost-benefit analysis (CBA) comparing costs with potential savings associated with patients treated through a telehealth-enabled intervention. The intervention consisted of telehealth-based consultation between the 911 patient and an EMS physician, to evaluate and triage the necessity for patient transport to a hospital emergency department (ED). Patients with non-urgent, primary care-related conditions were then scheduled and transported by alternative means to an affiliated primary care clinic. We measured CBA as both total cost savings and cost per ED visit averted, in US Dollars ($USD). Results In total, 5570 patients were treated over the first full 12 months with a telehealth-enabled care model. We found a 6.7% absolute reduction in potentially medically unnecessary ED visits, and a 44-minute reduction in total ambulance back-in-service times. The average cost for a telehealth patient was $167, which was a statistically significantly $103 less than the control group ( p < .0001). The programme produced a $928,000 annual cost savings from the societal perspective, or $2468 cost savings per ED visit averted (benefit). Conclusion Patient care enabled by telehealth in a pre-hospital environment, is a more cost effective alternative compared to the traditional EMS 'treat and transport to ED' model.

BackgroundThe access to and growth of percutaneous coronary intervention (PCI) has not been fully explored with regard to geographic equity and need. Economic factors and timely access to primary PCI provide the impetus for growth in PCI centers, and this is balanced by volume standards and the benefits of regionalized care.Methods and ResultsGeospatial and statistical analyses were used to model capacity, growth, and access of PCI hospitals relative to population density and myocardial infarction (MI) prevalence at the state level. Longitudinal data were obtained for 2003–2011 from the American Hospital Association, the U.S. Census, and the Centers for Disease Control and Prevention (CDC) with geographical modeling to map PCI locations. The number of PCI centers has grown 21.2% over the last 8 years, with 39% of all hospitals having interventional cardiology capabilities. During the same time, the US population has grown 8.3%, from 217 million to 235 million, and MI prevalence rates have decreased from 4.0% to 3.7%. The most densely concentrated states have a ratio of 8.1 to 12.1 PCI facilities per million of population with significant variability in both MI prevalence and average distance between PCI facilities.ConclusionsOver the last decade, the growth rate for PCI centers is 1.5× that of the population growth, while MI prevalence is decreasing. This has created geographic imbalances and access barriers with excess PCI centers relative to need in some regions and inadequate access in others.