Masters in Healthcare Leadership

A LEAN SIX SIGMA APPROACH TO IMPROVE UTILISATION OF AN
EPILEPSY MONITORING UNIT IN EPILEPSY DEPARTMENT OF A TERTIARY
CARE HOSPITAL

Background
Epilepsy Monitoring Units (EMUs) are a vital diagnostic component of epilepsy
management, enabling long-term video-electroencephalography monitoring (LTM) in an
inpatient setting (1). The LTM is the gold standard procedure used to improve the accuracy of
the diagnosing epilepsy, to classify seizures, and to complete the pre-surgical evaluation of
patients with intractable epilepsy(2). Numerous studies have demonstrated underutilization of
EMUs and its impact on epilepsy care, as well as the many challenges EMUs face
internationally, such as a lack of beds, personnel, and lengthy waiting times(3–6). In Saudi
Arabia, for example, there are only eleven EMU units with an average wait time of eleven
weeks(3). In developing countries such as India, there are just 52 EMUs, of which 70 percent
have fewer than two beds, and the average wait period is 49.9 days(5). Ultimately, safety and
quality of epilepsy care are affected by delaying accurate diagnosis and classifying seizures
and surgical intervention in potential surgical candidates(7).
An important challenge for any management to improve epilepsy care is to make better
use of the current EMUs beds by improving its capacity and throughput, as increasing the
number of beds and trained physicians for EMUs are goals that need time to be fulfilled.
Unfortunately, there is still a significant amount of variation in protocols and
guidelines among units, and studies examining standardization of practices are lacking(8).
The methods and procedures of care, as well as the monitoring and evaluation of quality and
safety in EMUs, are all diverse(4,9). However, there have been many research that seeks to
identify quality and safety indicators in EMUs(4,9). There are censuses for several metrics,
including safety indicators like intervention to stop seizures and quality indicators like
waiting time for admission and length of stay.
Despite the abundance of high-quality literature on enhancing processes and throughput of
many diagnostic procedures, there is a paucity of literature regarding the EMUs. Therefore,
the goal of this quality improvement (QI) project is to optimize processes and boost
throughput in our EMU to reduce wait times and the length of stay to ultimately improve
quality and safety of care.

LEAN SIX SIGMA AS A MODEL FOR IMPROVEMENT
Lean and Six Sigma, two well-known quality-improvement approaches, were originally
created in manufacturing sector to boost the efficiency of production processes, but have
found widespread application in healthcare over the past decade attributed to its effects on
patient safety and cost-effectiveness(10,11). The Lean concept is a quality-improvement
method that focuses on giving “value” and increasing performance by removing unnecessary
steps from a workflow process(12). Six Sigma is a quality management method that focuses
on the discovery and elimination of defects in order to enhance the quality of operations(13).
Lean Six Sigma (LSS) is a hybrid strategy that tries to break down a workflow process into
its constituent components, eliminate waste and unnecessary steps, and reduce

variability(13,14). When combined, LSS is a powerful approach that has developed into five
stages: define, measure, analyze, improve, and control (DMAIC).
LSS showed to improve efficiency and quality of diagnostic processes(15–17). In
vascular interventional radiology, a study was conducted aiming to reduce waiting time and
increase patient satisfaction(17). Lean six sigma was applied and resulted in reducing the
mean wait time from 36.89 to 20.49 minutes, and increasing patient satisfaction at different
categories including the increase in satisfaction from wait time in registration from the 17th
to the 99th percentile, test/treatment from the 19th to the 60th, and likelihood to recommend
the service from the 6th to the 97th percentile. In a laboratory setting, Inal et al. found that
improving sample labeling process reduced wasted time from 3 h 45 min to 22.5 min, daily
saving 3 h 22.5 min. In addition, medical error and biological risk samples reduced from 30%
to 3%(16).
The high rate of failure and the requirement for accurate measurement systems are two of
many growing criticisms in the literature for LSS despite its success stories(18). According to
estimates, 62% of Six Sigma projects in the health sector fail(19,20). A survey found that
54% of firms do not intend to use Six Sigma, which is likely due to a trend where quality
efforts begin well but fail to have a lasting impact(19). A plausible explanation for this is the
Hawthorne effect, which describes how participants’ actions alter after they realize they are
taking part in a new experiment(21). At first, everyone is enthusiastic, and the project has a
valuable impact until they discover later that their production process collapsed. My personal
concern with using LSS stems from its violation of some principles of systems thinking(22).
LSS is mainly directed at improving parts through eliminating defect and enhancing process.
However, improving the part doesn’t necessarily contribute to the improvement of the whole
and may interfere with and hurt other parts’ performance. Moreover, it is hard to use LSS
proactively in planning and designing a more complex system, like epilepsy care.
We will employ lean six sigma to improve EMUs utilization because it is supported by
evidence and is a relatively well-known approach in our hospital. As we adopt LSS, we’ll
attempt to address potential criticisms and challenges using a variety of approaches. First, we
will put into practice many strategies that have been shown in the literature to improve our
chances of success, including management engagement at various levels,
continuous education and training, and embracing quality as a culture change rather than a
task to be completed(18). Moreover, we will use the locally available EMU data published by
Aljafen et al. due to lack of data in our hospital(3). These are data for the entire country, and
as a public hospital, we most certainly have comparable data and challenges. LSS can be a
great place to start, but quality, in my opinion, extends beyond this strategy and need to be
deeply incorporated into the culture in our organization.

The epilepsy division assembled a team that includes representatives from every major
stakeholder group. We have contacted the quality department and made this into a genuine
initiative, with me serving as the project leader and one of our neurosurgeons taking on the
role of physician champion. We’ll have bimonthly team meetings and use the LSS five-step
process (DMAIC).
DEFINE: I have created a project charter (Table 1) with the aim of accomplishing closely
related goals of reducing waiting times and lengths of stays. Waiting time is defined as the

period from the initial order of admission to the time of the admission itself. Length of stay is
defined as the time for receiving the patient to the time of leaving the EMU.
MEASURE: As we lack benchmark data for our services, we’ll use national statistics
published by Aljafen et al(3). To avoid common mistakes in process mapping like poor
process scoping, too much complexity, inconsistency, and lack of analysis, we developed an
initial process map with the help of a senior quality officer(23). The process begins with a
neurologist order EMU admission and ended with the time patients are discharged with figure
1 showed major procedures performed at each step. An epilepsy nurse will act as a
coordinator and will create a manual log that records different predetermined parameters.
Finally, a further analysis will be conducted to determine the impact of those interventions on
pre-determined measures on care quality, safety, and patient satisfaction.
ANALYZE: From published literature about the quality indicator of EMU and the
national data, waiting times and length of stay was choosen to be continuously collected and
analyzed every three months to identify the target areas for improvement(4,9). These metrics
are closely related and interact, and any improvement in one will have a clear impact on the
other and on the overall goal of improving utilization of our EMU. For example, our national
data shows an 11-week average wait time and a 7-day average stay. It is interesting to see
how minor change can create exponential impact. For example, our 4-bed EMU can admit
208 patients (given available 1460 admission days with an average length of stay of 7 days).
Reducing length of stay by one or two days will increase admission rates by 17% and 40%,
respectively.
According to the literature, the majority of patients who come from distant regions to
Saudi hospitals may stay longer since they are unable to finish outpatient management prior
to admission, and extra time is frequently required to organize for return trips(3).
Furthermore, EMU admissions requiring neuroimaging testing or AED reduction had longer
stays. The most essential component in guiding patient discharge decisions is reviewing
EEGs. In our setting, most EEGs are read in the afternoon, and admissions after hours are not
permitted. If EEG is reviewed in the afternoon and discharge is decided, there is a risk that
beds may be empty until the next morning.
IMPROVE: After brainstorming solutions for primary causes, there are few changes for
the existing processes to be made in the next 3 months. All units will be educated about the
new work flow and intervention applied.
1- Referal and pre-admission period:
We’ll attempt to admit patients from outside Riyadh with the support of social workers, as
80% of our patients are from other regions. Arrangements include two-way trips and
outpatient management, including further investigations or other medical services(3). A wellestablished practice backed by research and professional opinion is reduction of Antiepileptic drugs (AEDs)(24). We will adopt a rapid decrease in AEDs, including daily dose
reduction by 30% to 50%, which is found to reduce long-term monitoring by 1.8 days in a
randomized control trial comparing slow and fast reduction with no significant difference in
safety factors. However, the generalizability of this trial to all EMUs is limited because openlabel design in a single site(25). Furthermore, applicability may be low in our patients
receiving polytherapy with varying half-lives.

2. During admission
Changing patient and procedure work flow has been a great intervention in reducing
diagnostic waiting time and throughput(13,14,16,17). As EEG results are key to a discharge
decision, we’ll establish a deadline of 12pm. This will allow the team to early discharge
patients and admit others during working hours. Changing admission time for surgical and
non-surgical admissions are another intervention. Surgical cases make up 36.4-54.5% of
admissions and last the longest(3). We propose to admit cases in the last 2 days on weekdays
as they have potential to extend over the weekend and with this we avoid discharge and
admission over weekends were there are limited staff coverage.
CONTROL: No process changes between March 1 and April 30, 2023. This control phase
monitors processes to ensure improvements are preserved and used as planned. Monthly,
wait times and length of stay were will be examined and team meetings will be planned to
ensure protocols are maintained and data is shared with all parties.

Limitations and Conclusion
Lack of high-quality data is a limitation that negatively impact planning and decisionmaking. We’ll utilize national data and collect prospective data throughout our endeavor to
solve this challenge. Most of our physicians are pure clinicians with little education in quality
methods. Continuous staff education, stakeholder involvement, and management support can
help. A third key limitation is the absence of well-developed protocols and guidelines, which
creates variations in practice across physicians. This absence of regularly defined and verified
quality indicators for EMUs makes it difficult to determine variables that can be monitored
for improvement.
In conclusion, underutilization of EMUs is a global concern affecting epilepsy services.
Underutilization may be due to a lack of supported services beyond physicians, however
locally we have major issues with higher wait times and duration of stay compared to
developed countries. Starting to apply LSS with the interventions outlined above can help
alleviate these challenges as expanding numbers of beds and supportive services require longterm plans. By optimizing the entire process and removing wastes, this initiative has the
short-term potential to generate high-quality data that can guide care planning and improve
timeliness in health care. In summary, the implementation of LSS principles to daily work
can shift the paradigm of how quality and patient care should be conducted, which can have a
significant and lasting effect on all of our epilepsy services.
TABLE 1: Project Charter
Project Name: Improve utilization of epilepsy monitoring unit
Problem Statement:
The underutilization of epilepsy monitoring units limits our capacity to properly prepare
patients for epilepsy surgeries and to appropriately diagnose and classify their seizures.
Project Goal:
Increase the percentage of epilepsy monitoring unit admission by 20% in 6 months (Start
date: January 2023)
Project Y:

Scope:
All epilepsy patients presenting who are candidates for epilepsy surgery or who require
seizure diagnosis and classification.
Team Members:
Project leader, Consultant of neurology and epilepsy
Physician champion, Consultant of neurosurgery and epilepsy surgery
Member, neurophysiology administrator
Member, Epilepsy monitoring unit administrator
Member, Neurology department, financial analyst
Member, Chief Resident
Member, Chairman of pediatric neurology
Member, Chairman of Adult neurology
Member, Social worker
Member, a patient representative
Benefits:
1) Optimize EMU beds in evaluation of patient
2) Reduce waiting time and length of stay
3) Reduce cost with limited charge
4) Improve quality and safety of epilepsy care
Timeline:
Define/Measure: January 24–February 1, 2023
Analyze/Improve: March 10–May 30, 2023
Control: July 1–September 1, 2023

Figure 1: SIPOC diagram

REFERENCES
1. Buelow JM, Privitera M, Levisohn P, Barkley GL. A description of current practice in
epilepsy monitoring units. Epilepsy Behav. 2009 Jul;15(3):308–13.
2. Alving J, Beniczky S. Diagnostic usefulness and duration of the inpatient long-term
video-EEG monitoring: findings in patients extensively investigated before the
monitoring. Seizure. 2009 Sep;18(7):470–3.
3. Aljafen BN, Alfayez SM, Alanazy MH, Alazwary N, Alohali SM, Muayqil T. Epilepsy
monitoring units in Saudi Arabia: Neurosciences (Riyadh). 2018 Jul;23(3):244–9.
4. Sauro KM, Macrodimitris S, Krassman C, Wiebe S, Pillay N, Federico P, et al. Quality
indicators in an epilepsy monitoring unit. Epilepsy Behav. 2014 Apr;33:7–11.
5. Baheti N, Rathore C, Bansal AR, Kannan L, Gopinath S, Pillai A, et al. Current practices
in epilepsy monitoring units (EMU) in India. Seizure. 2021 Dec;93:13–9.
6. Rubboli G, Beniczky S, Claus S, Canevini MP, Kahane P, Stefan H, et al. A European
survey on current practices in epilepsy monitoring units and implications for patients’
safety. Epilepsy Behav. 2015 Mar;44:179–84.
7. Parviainen L, Kälviäinen R, Jutila L. Impact of diagnostic delay on seizure outcome in
newly diagnosed focal epilepsy. Epilepsia Open. 2020 Dec 8;5(4):605–10.
8. O’Kula SS, Faillace L, Kulick-Soper CV, Reyes-Esteves S, Raab J, Davis KA, et al.
Developing and Implementing a Standardized Ictal Examination in the Epilepsy
Monitoring Unit. Neurol Clin Pract. 2021 Apr;11(2):127–33.
9. Sauro KM, Wiebe S, Macrodimitris S, Jetté N, EMU Quality Improvement Team.
Quality indicators for the adult epilepsy monitoring unit. Epilepsia. 2016
Nov;57(11):1771–8.
10. Vest JR, Gamm LD. A critical review of the research literature on Six Sigma, Lean and
StuderGroup’s Hardwiring Excellence in the United States: the need to demonstrate and
communicate the effectiveness of transformation strategies in healthcare. Implement Sci.
2009 Jul 1;4:35.
11. DelliFraine JL, Langabeer JR, Nembhard IM. Assessing the evidence of Six Sigma and
Lean in the health care industry. Qual Manag Health Care. 2010 Sep;19(3):211–25.
12. Karstoft J, Tarp L. Is Lean Management implementable in a department of radiology?
Insights Imaging. 2011 Jun;2(3):267–73.
13. Fairbanks CB. Using Six Sigma and Lean methodologies to improve OR throughput.
AORN J. 2007 Jul;86(1):73–82.
14. Hynes JP, Murray AS, Murray OM, Eustace SK, Gilchrist S, Dolan A, et al. Use of Lean
Six Sigma methodology shows reduction of inpatient waiting time for peripherally
inserted central catheter placement. Clin Radiol. 2019 Sep;74(9):733.e5-733.e9.

15. Tekes A, Jackson EM, Ogborn J, Liang S, Bledsoe M, Durand DJ, et al. How to Reduce
Head CT Orders in Children with Hydrocephalus Using the Lean Six Sigma
Methodology: Experience at a Major Quaternary Care Academic Children’s Center.
AJNR Am J Neuroradiol. 2016 Jun;37(6):990–6.
16. Inal TC, Goruroglu Ozturk O, Kibar F, Cetiner S, Matyar S, Daglioglu G, et al. Lean six
sigma methodologies improve clinical laboratory efficiency and reduce turnaround times.
J Clin Lab Anal. 2018 Jan;32(1).
17. Godley M, Jenkins JB. Decreasing Wait Times and Increasing Patient Satisfaction: A
Lean Six Sigma Approach. J Nurs Care Qual. 2019 Mar;34(1):61–5.
18. Sony M, Antony J, Park S, Mutingi M. Key Criticisms of Six Sigma: A Systematic
Literature Review. IEEE Transactions on Engineering Management. 2020
Aug;67(3):950–62.
19. Albliwi S, Antony J, Abdul Halim Lim S, van der Wiele T. Critical failure factors of
Lean Six Sigma: a systematic literature review. International Journal of Quality &
Reliability Management. 2014 Jan 1;31(9):1012–30.
20. Six Sigma: What Went Wrong? [Internet]. [cited 2022 Sep 29]. Available from:

21. Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ. 2015 Sep
4;351:h4672.
22. Ackoff RL. Ackoff’s best: his classic writings on management. New York: Wiley; 1999.
356 p.
23. BEM. 7 Common Process Mapping Mistakes And How To Avoid Them – BEM
[Internet]. Business Enterprise Mapping. 2019 [cited 2022 Sep 29]. Available from:

24. Kumar S, Ramanujam B, Chandra PS, Dash D, Mehta S, Anubha S, et al. Randomized
controlled study comparing the efficacy of rapid and slow withdrawal of antiepileptic
drugs during long-term video-EEG monitoring. Epilepsia. 2018 Feb;59(2):460–7.
25. Dworetzky B. Fast Tapering of AEDs in the EMU: Worth the Risk or Risky Business?
Epilepsy Curr. 2018;18(3):156–7.

Academic Presentation Guidelines

Academic
Presentations checklists

When preparing for your presentation, you
should consider the following 2 checklists:
1.

Checklist of things to remember while
preparing a presentation

2.

Signposting and Language signals

Preparing an academic presentation
1. Know the context of the presentation-who are the audience and what they want to
know? What is the time limit?
2. Think carefully about the main points-structure the content. Put your ideas into a
logical sequence.

3. Include examples, statistical data, interesting quotations (when appropriate).
4. Check overall length, and the relative weight of sections using the grading rubric.
5. Prepare visual aids in PowerPoint (6-8 slides + cover slide and reference slide)
6. Plan the exact words you will use for your opening, transition points and
conclusion.

Signposting
and Language
Signals

• Introduction/Overview/Hook.
• Theoretical Framework/Research
Question.
• Methodology/Case Selection.

Presentation
content

• Background/Literature Review.
• Discussion of Data/Results.
• Analysis.
• Conclusion.

• References.

• Check your timing- make sure you stick to your time
limit and use all your slides
• Use text sparingly. If your audience is concentrating
on written text, they are less likely to give you their
complete attention.

Visual
Aids

• The “joy of six” is a helpful rule of thumb. Use a
maximum of six points per slide and six words per
point.
• Minimize or avoid animated texts, sounds, and fancy
transitions. These can be effective in certain
situations, but most are not appropriate to
academic presentations as often distract your
audience from the main points you are trying to
make.
• Ensure all your images/graphs etc. are referenced on
the slide under the image

Referencing images

Figure 1: Bloom’s Cognitive Domain (Benitez 2012)
If you refer to the Figure in the text, also include a citation:
As can be seen from Figure 1 (Benitez 2012)
List of References
Provide full citation information:
Benitez J 2012, Blooms Cognitve Domain, digital image, ALIEM, accessed 2 August
2015, .

Background:

Online
Presentations

Your background should be appropriate for the topic of the
talk. It should be a calm and serene environment to avoid
distraction from the words of the speaker. Perhaps you can
experiment with light pastel colours. However, it should not
stand out or distract the audience from your presentation.
It should complement the tone of your presentation and
literally add a backdrop to your presentation.
Speed:
You should vary your speed and prevent yourself from
talking too fast. There is often a natural tendency to speak
faster when we are nervous or do not feel like we have the
authority to talk. As a speaker, you have a right of stage and
should use that to talk comfortably and at your own pace.

Useful tip
from tutors

Depending on the programme /
platform being used to record their
presentation, it is advisable to pause
for a second or three between slides.
E.g. if you record in PPT it cuts about
a second of the recording while
transitioning – so it is best
not to transition between slides while
talking.

References:
• Chotaliya, S. The key to delivering successful online presentations. BDJ
Student 29, 8–9 (2022).
• Harris Rollins, D. Powerpoint made perfect. Available at:

df (no date) (Accessed : 01.06 2022).
• Harries, H. (2010) Training for staff, 27 May. University of Glamorgan.
Saunders, D. (2004) Making presentations: a guide for students. Centre for
Lifelong Learning: University of Glamorgan

Student number:
Tutor:
Date Submitted:
Please keep an electronic copy of your assignment for your records.
I acknowledge that by submitting this assessment electronically via
the iheed Online Learning Environment: This assessment is my original work and
no part of it has been copied from any other source except where due
acknowledgement is made.

I understand that: Plagiarism is the presentation of the work, idea or creation of
another person as though it is your own. It is a form of cheating and is a very
serious academic offence that may lead to exclusion from the University.
Plagiarised material can be drawn from, and presented in, written, graphic and
visual form, including electronic data and oral presentations. Plagiarism occurs
when the origin of the material used is not appropriately cited.

DECLARATION
I declare that all material in this assessment is my own work and that I have given
fully documented references to the work of others.

Signed:__________________________ Date: ___________________________

References

Improving The Capacity and Throughput of Cataract Surgery Waiting Lists
in the Post Covid-19 Era in a Tertiary Eye Unit in Brunei Darussalam
Background
The latest statistics from the World Health Organization ‘World report on vision’ state that
alongside uncorrected refractive errors, cataracts account for one of the leading causes of
treatable vision impairment globally (WHO, 2019). A recent statistical analysis by the Global
Burden of Disease Study found that ‘an estimated 15.2 million people aged over 50 years were
blind and a further 78.8 million had moderate levels of vision impairment due to cataract
(Pesudovs et al, 2020). Cataract surgery itself is considered one of the oldest and most
commonly performed procedures worldwide and unnecessary delays to treatment can lead
to the development of permanent vision loss in an easily correctable eye condition (Davis,
2016).
COVID-19 was declared as a “Public Health Emergency of International Concern” by the World
Health Organization on 30 January 2020 (WHO, 2020) and during the pandemic crisis, all
elective eye operations and outpatient appointments deemed non-urgent were suspended
under the instruction of the Ministry of Health in the initial two waves of the pandemic in
Brunei Darussalam Health to allocate healthcare workers to support pandemic priority
services. Unsurprisingly, the suspension of services has caused significant disruptions to the
cataract service and resulted in an increased backlog of patients awaiting vision restoration.
Strategies suggested by Pandey and Sharma for expanding capacity in an already
oversaturated cataract service were aimed at increasing throughput to beyond pre-pandemic
production levels to meet the demand. Overall, the authors’ suggestions alluded the need
for a concerted effort by both invested government and private stakeholders to improve
system efficiency at every level from the initial referral stage right up to the postoperative
period (Pandey & Sharma, 2021).
Prior to the pandemic, several pre-existing limiting factors contributed towards a long surgical
waiting list. These included issues such as three cataract surgery lists functioning per week,
patient requirements for anaesthesia, limited surgical instrument set capacity and
sterilization turnaround time in addition to increased referrals from other peripheral
hospitals. With the resumption in elective surgery, many within the healthcare industry have
taken opportunity of this ‘pause period’ to reflect, redesign and enhance their existing
services.
This paper aims to critically appraise and formulate a quality improvement plan with the
objective of increasing capacity and throughput of the cataract surgery waiting list in a tertiary
eye unit in Brunei Darussalam in the current post pandemic era.
Quality Improvement (QI) Within Healthcare
The guiding principles from The Berwick Report, although originally formulated for the UK
National Health Service are lessons that can be applied to healthcare systems globally. In
essence, ‘placing the quality and safety of patient care above all other aims is the safest and

best route to lower cost’ (Berwick, 2013) The report emphasized the importance of patient
engagement, staff empowerment and fostering an environment of trust, transparency and
accountability between the healthcare system and the public as key catalysts in enhancing
quality improvement.
Quality improvement (QI) in itself has been defined as ‘…a broad term describing the
systematic use of a range of tools and techniques to improve patient care and associated
healthcare continuously’ (Adams, 2018). Quality improvement methods and tools used in
healthcare have been derived mainly from those systems that have long been in play in the
manufacturing industry. A systematic review carried out by Nicolay et al investigated the
effectiveness of various QI tools in surgery and concluded that these methodologies and
processes were reproducible and able to be implemented successfully within the realm of
surgical healthcare QI (Nicolay et al, 2011). However, it is important to note here that the
evidence stated by the authors was admittedly suboptimal and a randomized multicentre
study was recommended.
In approaching quality improvement, the most commonly utilized strategies are summarized
below (Adams, 2018):
a) Model for improvement and testing with plan, do, study and act (PDSA) cycles
This QI framework is generally employed for ‘developing, testing and
implementing changes leading to improvement’. The repeated use of the PDSA
cycles allow for the assessment and continual learning of implementable change
on a small scale (NHS England and NHS Improvement, 2022).
b) Lean thinking
Originally derived from the automotive industry, the Lean methodology centres
around the principles of ‘waste removal’ and ‘what the customers want’ whereby
activities identified as ‘value adding’ are promoted and those deemed as ‘nonvalue adding’ are avoided (Moraros, Lemstra & Nwankwo, 2016).
c) Six sigma methodology
The Six Sigma methodology provides a statistically robust framework that
generally follows a 5 stage approach: Define, Measure, Analyse, Improve and
Control (called the D.M.A.I.C approach). Within healthcare, the Six Sigma
methodology has been used successfully in QI projects to reduce process variation
at a single step (NHS Improvement, 2011)
d) Theory of constraints (TOC)
The Theory of Constraints is based on the concept that ‘every process has a single
constraint and that total process throughput can only be improved when the
constraint is improved’ (Tabish & Syed, 2015). The TOC is of particular applicability
when the aim is to enhance system throughput.

The above illustrates that there is a no ‘one size fits all’ QI methodology due to the complex
nature of the healthcare industry.
On encountering a potential QI project, one should ensure that QI is the most appropriate
approach to the situation and take into consideration whether other tools such as clinical
audit or service evaluation may be either a better alternative or utilized to work in parallel
with QI to improve the effectiveness of the project (Backhouse & Ogunlayi, 2020).
Aims and objectives of proposed quality improvement project
Due to the mandatory jurisdictions imposed on all elective surgeries during the Covid-19
pandemic, there now exists a backlog of patients on the cataract surgery waiting list.
With the gradual reopening of services up to full capacity, robust measures now need to be
put in place to address the patients awaiting vision restoration. Guidance from The Royal
College of Ophthalmologists emphasise the importance of ensuring that patients are
prioritized according to need for surgery and not just based on the time waited (Liu, 2021).
Bolger et al described a successful public-private partnership model during the Covid-19
pandemic whereby the Irish government leased a private hospital’s premises to ensure urgent
elective surgical cases were still able to be carried out during the crisis (Bolger et al, 2020).
This model forms the basis of the proposed QIP.
The aims and objectives of this proposed QIP are:
a) To assess the current capacity of the cataract surgery waiting list
b) To increase the current surgical capacity by 50% by leasing the operating facilities in a
government-linked private medical centre
c) To clear the current backlog of patients awaiting surgery in 6 months
Diagnosis of the current system
Aims Statement:
To clear the current backlog of patients awaiting cataract surgery in 6 months by increasing
the operating capacity by 50%
Summary of Primary and Secondary Drivers Identified:
1. Approval to utilize additional theatre space (primary driver)
a. Secondary drivers: Submission of robust business plan to the board of
directors at the government-linked private medical centre
b. Change ideas:
i. Collection of current waiting list by the nurse matron in charge
ii. Schedule team meeting with all consultants to ensure agreement with
plan

iii. Task allocation to write up business plan
2. Patient allocation (primary driver)
a. Secondary drivers: Identification of suitable patient cases for the extra
operating lists. Due to the high volume nature of the lists, these will be nontraining cases and should only be performed by an experienced surgeon.
b. Change ideas:
i. Prioritisation of the current backlog of patients using the Cataract
Patient Reported Outcome Measure questionnaire (Cat-PROM5)
ii. Identification of suitable cases for the high-volume list using a
cataract surgery risk stratification calculator.
iii. Discussion with identified patients on agreeability for their surgery to
be performed at the medical centre.
3. Staff allocation (primary driver)
a. Secondary drivers: 1 operating surgeon +/- assisting surgeon, 1 scrub nurse
and 1 operating theatre technician for instrument sterilization
b. Change ideas:
i. Creation of a staff roster to ensure clinics are either
reduced/cancelled in advance or a covering doctor can be allocated.
4. Equipment, IT support and consumables (primary driver)
a. Secondary drivers: Identification of any IT, equipment and consumables that
need to be brought over from the tertiary eye centre to the medical centre.
b. Change ideas:
i. Team meeting with all involved staff to create an item inventory and
checklist.
ii. Site visit to medical centre to ascertain what equipment and
consumables would need to be supplied by the eye centre.
iii. Ensure access to a different electronic medical record (EMR) system
could be made available for visiting staff.
Process Map Summary
Patient contacted and case notes reviewed
for suitability on extra list:
• Cat PROM-5 questionnaire
• Cataract risk stratification
• No GA or sedation required

Patient currently
on cataract
surgery waiting
list

Patient waits for
procedure
appointment in eye
centre

No

Deemed
suitable for
extra list at
medical centre?
medical?

Yes

Patient has
surgery

Patient contacted and
counselled for
agreeability

Process evaluation
Measures of improvement will take the form of:
1. Quantitative improvement measures
a. The current operating capacity for cataract surgery in our tertiary eye unit is
20 to 25 patients per week. With the lease of two extra operating sessions at
the government-linked private medical centre, this will increase the weekly
procedure capacity by 12 procedures (assuming 6 cases per list) i.e. by 50%
b. The current average waiting list time from listing of the patient to surgery is 24
weeks. With the extra capacity, we would aim to reduce the current waiting
time to 12 to 16 weeks i.e. a 30-50% reduction in waiting time experienced.
2. Qualitative improvement measures
a. For each pandemic-affected patient who have completed their patient
journey, they will be invited to completed a patient experience survey.
Feedback from this will be essential not only as a measure for improvement
but as valuable feedback on how to further enhance the cataract surgery
journey.
For the first Plan-Do-Study-Act (PDSA) cycle, the initial objective of the PDSA would be to
study the actual impact of the addition of two extra operating sessions on the waiting list
capacity and patient waiting times once the change in process has been made.
Embedding and sustaining the quality improvement project in clinical practice
Implementation of the Sustainability Model allows for identification of area of strengths and
weakness. The model was used to assess the sustainability of the proposed quality
improvement project (NHS England and NHS Improvement, 2021)
Low scores were noted in process areas of adaptability and progress monitoring. In order to
maximize the potential for sustainability beyond the QIP, the process should be improved so
that it remains as an option should there be future unexpected events causing a repeated
increased backlog of patients awaiting surgery. The integrated business plan should be robust

and appealing to the stakeholders particularly the government-linked private medical centre
who will be receiving financial compensation for the lease of their facilities.
The QIP can increase its sustainability potential by increasing the number of ‘benefits beyond
helping patients’. If high volume lists are occurring in the private medical centre, their own
nursing and operating theatre staff will benefit from the knowledge and skills transfer from
the highly trained eyecare staff. This would allow for the medical centre to further expand
their own ophthalmic services thus maximizing the potential of their own workforce.
Use of the sustainability model has also identified the necessity of a monitoring system for
both qualitative and quantitative measures of improvement. Identification of a core team to
monitor and communicate the data to both the clinical and organizational leaders needs to
be in place prior to QIP implementation. Involvement of the staff early on in addition to
organising appropriate QI training for the staff will increase their confidence in monitoring
the process and work towards embedding a QI culture within the team.
QIP Limitations and Conclusions
The actual implementation of the QIP is dependent upon the relevant organizational
approvals and a joint agreement by all involved stakeholders. An outline of the financial
implications for both parties involved needs to be ascertained and noted clearly in the
business plan. The actual implementation of the QIP could be a lengthy process and
alternative plans to address the long patient waiting list would need to be made in the interim.
A second limiting factor would be current manpower shortages. Allocating staff to the private
medical centre may lead to an increase in outpatient appointment cancellations. Measures
would need to be in place to ensure minimal disruption to the eye unit’s clinical activities such
as arranging for a covering doctor.
The proposed QIP could also be viewed merely as a ‘quick fix’ solution to a short-term
problem. However, issues with the cataract surgery waiting list existed even prior to the
pandemic owing to factors such as an increasing ageing population, improved patient
awareness and an already limited surgical list capacity.
Use of repeated PDSA cycles would allow for invaluable feedback as to how to improve the
process and patient journey not just at the current bottleneck point in question but at all
levels from the point of referral up till the postoperative period. It is hoped that this would
result in an eventual streamlining of the whole process to improve patient safety and
satisfaction.

References
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Mar;18(3)89-94.
Backhouse A, Ogunlayi F. Quality improvement into practice. BMJ. 2020;368:m865
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Bolger J, Kelly M, Whelan C, et al. Public-private partnership: strategies for continuing
urgent elective operative care during the COVID-19 pandemic. Br J Surg 2020;107:e320–e31
Davis G. The Evolution of Cataract Surgery. Mo Med. 2016 Jan-Feb;113(1):58-62
Knudsen SV et al. Can quality improvement improve the quality of care? A systematic review
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September 2022)
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Masters in Healthcare Leadership
Module 2:
Assessment Brief
There are two parts to this assessment
4 Part A is worth 80% of the grade
4 Part B is worth 20% of the grade
PART A – Written Report – 80% of the module (2000 words +/- 10%)
Task:
Critically analyse a quality or safety topic from your professional practice which could form part of a
workplace improvement plan.
As part of this analysis, draw on theories, models and methods described in the module. Embed your
critical reflection in the context of the relevant wider scientific literature.
Address the following points in your report:
1. Describe the safety/quality topic you have selected.
2. Explain the rationale for choosing this topic and why a change is needed (supported with
reference to the academic literature)
3. Describe what kinds of interventions might need to be implemented.
4. Reflect on potential barriers and how you would address these.
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