Using a Person-centred model of Lean Six Sigma to support process improvement within a paediatric primary eye care clinic

Using a Person-centred model of Lean Six Sigma to support process improvement within a paediatric primary eye care clinic | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using a Person-centred model of Lean Six Sigma to support process improvement within a paediatric primary eye care clinic Christine Bourke, Aaron Mulaniff, Bobby Tang, Oriyomi Waya, Sean Paul Teeling This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4228153/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Process improvement methodologies such as Lean Six Sigma are increasingly being deployed to address inefficiencies in healthcare. Simultaneously policy and strategy development globally stress the value of person-centredness as the preferred approach in healthcare. This paper addresses the use of a Person-centred Lean Six Sigma Model (PCLSSM) to support process improvement in the study site, a paediatric eye care clinic. Methods Within the study site the referral process of children by relevant clinicians to the specialist clinic was experienced by referrers, parents of referred children and clinic staff as not fit for purpose. We applied the PCLSSM to improved the patient experience and efficiency of the clinic. Results Application of the PCLSSM to manage improvement resulted in five key outcomes: a 46% percentage increase in right first time accuracy of children’s referrals to the service, with a corresponding a 20% percentage decrease in time spent managing referrals, a 13% percentage increase in staff confidence in the referral system and 158% percentage increase in staff satisfaction with workload. Importantly there was a 104% percentage increase in child and parent satisfaction with their clinic experience. Conclusions This study will assist healthcare professionals understand the work involved in the successful deployment of a PCLSSM in paediatric healthcare settings, in order to improve operational efficiency and promote enhanced patient and staff satisfaction. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Ophthalmic care in Ireland is delivered in both the community and the acute care setting encompassing a range of clinical, technical and rehabilitative services. The availability of services and referral policies vary nationwide. Paediatric eye care services are delivered from acute hospitals and community clinics and include school vision screening, assessment diagnosis and treatment of visual impairment and the provision of glasses for correction of refractive error [1]. In Ireland, over 5100 children are suffering with visual impairment. Most of this is preventable but requires timely access to ophthalmic care. Like many other hospital specialties, paediatric ophthalmology services are under pressure as evidenced by long waiting lists [2]. Amblyopia is a common disorder presenting in children, which represents decreased vision occurring during the years of visual development [3]. This is secondary to abnormal visual stimulation or abnormal binocular interaction. Timely treatment of amblyopia improves vision and decreases the likelihood of severe visual handicap if vision loss occurs in the fellow eye later in life [4]. This can have long-lasting employment and socioeconomic repercussions. Up to 60% of amblyopia patients can be managed effectively in the community [5]. In Ireland, amblyopia is managed in both community ophthalmic clinics and tertiary hospitals. In treating amblyopia, transitioning less acute cases from tertiary to primary care settings can reduce the waiting lists in tertiary clinics. This study was set in a paediatric community eye care clinic in North Dublin, Ireland. The clinic provides ophthalmic care to children aged from two to twelve years of age. The clinic is publicly funded by the Irish Health Services Executive (HSE). The ophthalmology staff/stakeholders included a consultant ophthalmologist, a community ophthalmic physician, a specialist registrar in ophthalmology, an orthoptist, three optometrists and five administrative staff. The facility runs 9 clinics per week. In Ireland, the majority of paediatric ophthalmic care is carried out in the public sector. There are approximately 2,400 new referrals to the tertiary centre’s paediatric ophthalmology clinics per year. At the commencement of this study, the ophthalmology team working in the study site clinic anticipated that the current referral situation to the clinic would continue to increase, as there is a predicted 15% increase in demand for paediatric ophthalmology services in line with the opening of a new national children’s hospital in Ireland [5] which will amalgamate the current children’s hospitals and increase capacity. 1.2 The project team The project team came together when undertaking a specialist university qualification in Process Improvement in Health Systems within University College Dublin, Ireland, designed to support staff in implementing person-centered service improvements as part of the curriculum [6]. The team included two ophthalmology Specialist Registrars working between the tertiary hospital and community eye clinic, the Chief Services Officer of Vision Ireland and a data analytics manager working in a tertiary adult hospital. Our team mentor was a Lean Six Sigma Master Black Belt with a healthcare background, a lecturer in process improvement in healthcare, working with our academic partner. Thus, three group members were deeply involved in ophthalmic care in Dublin, with the fourth and final members of the group bringing a fresh perspective and further insight into the improvement process. The team members working within pediatric ophthalmology services were aware of a pressing need to streamline the referral process for children to ophthalmology clinics, the booking process for their appointments, and the need to quantify and understand the impact of the current configuration of these processes on paediatric clinics in the study site. They had been approached by a key stakeholder in the clinic in North Dublin and asked to oversee this process improvement as an improvement project within the timeline of their university qualification (September 2022-May 2023). 1.3 Problem statement Prior to our improvement project, clinics within the study site used a paper-based referral process from referrer sites to the paediatric ophthalmology service. This paper-based system took the form of a referral letter rather than a specified referral form and therefore contained no specified minimum data set. Quality of referral letters to paediatric services are frequently shown to contain inadequate information related to the referred patient [7]. Within the study site, 33% of referrals were not right first time, missing key pieces of information required to process a booking. Administrative staff advised that this was leading to a large amount of follow up work to gather the missing information, with an average of 20 minutes required to triage and process patient referrals and schedule their appointments for the clinic. This in turn was detracting from administrative staffs’ ability to focus on the operations of the actual live clinic sessions and respond to the needs of attending children and their families. Additionally, with little free time for staff to focus on the environment of care, the clinic environment itself was visibly orientated toward an adult rather than paediatric customer base. Studies have shown that children report feeling afraid or anxious as they anticipate and engage in healthcare settings with medical professionals [8], and when healthcare space is not intentionally designed for paediatric care, both children, their parents and staff safety may be negatively impacted, and they may have a poor care experience [9]. The problems identified informed the project team’s goals. 1.4 Project team goals In response to the problem statement, the project team determined the following high-level goals: Improve the Right First Time statistics on referrals received (baseline 67% of referrals were right first time) to minimize administrative staff time spent in triaging for missing data. Reduce administrative staff time spent on the referral management process (baseline average of 20 minutes to process a single patient referral) to release their time to focus on the operation of the actual clinics. Collaborate with clinic staff and attending children and their families to co-design a more person-centred, appropriate child-friendly environment. Use person-centred principles to inform how we worked as a team, and how we engaged with customers, both service providers (the clinic staff) and service users (children and their parents). 1.5 Project team principles The use of quality and process improvement (QI) initiatives in healthcare organisations continues to increase, as organisation seek to improve services and redesign pathways to improve the quality, experiences and safety of care [10, 11]. Lean Six Sigma QI initiatives have been used successfully in healthcare to deliver improvements in patient outcomes and experiences of care [12-13]. However, whilst previous studies have shown these initiatives can result in improvements in care, the sustainability of improvement efforts is often questioned [14,15]. Person-centred approaches to care, with an emphasis on the experiences of both patients and service providers taken into account, and the promotion of their involvement in decision making, have been demonstrated as contributing to the sustainability of improvement initiatives [13]. McCance and colleagues [16] suggest that the focus on person-centredness in healthcare reflects society's need to address ongoing issues of service delivery imbalance, and the requirement to move from a medical ethos to a more holistic and collaborative one. Within paediatrics, collaborative care has been shown to effectively provide high-quality care while creating capacity for increased primary care treatment [17]. The project team therefore decided that their project work would be supported by a person-centred methodological approach that would support the team in working together, to enable and support staff, children and their families in the redesign of ophthalmology clinic processes were necessary, through a collaborative, inclusive and participatory process [13]. Methods 2. Materials and Methods 2.1 Theoretical Framework The framework for this improvement work was a quasi-experimental, single-study site, pretest-posttest study which was conducted from September 2022 to May 2023. Quasi experimental refers to a design type used to evaluate interventions [18]. Quasi-experimental design facilitates the use of both preintervention and postintervention measurements within process improvement studies, to measure the occurrence of an outcome before and after a particular intervention is implemented [18]. We were aware that pre and post-intervention design has the limitation of ascribing with certainty results to an intervention [19], but it has been used widely to evaluate Lean Six Sigma improvement projects in healthcare [20-22]. We therefore felt it suitable to use Lean Six Sigma methodology within a quasi-experimental pre-and post-intervention study design framework. It was explicit in our study design that any outcomes from redesigning the referral process could then be extrapolated and applied to other clinics as necessitated. 2.2 Use of a Person-centred Lean Six Sigma model As outlined, the project team had decided to underpin their improvement work with person-centred principles (section 1.5). Person-centred approaches have an explicit focus on ensuring the client or patient is at the center of care delivery but are also concerned with every person involved in the patient’s care, including their families and the staff providing the care [23]. More recent studies have demonstrated that Lean Six Sigma and Person-centred care have been shown to be synergistic in their approach to eliciting the customer voice, understanding and delivering on customer needs [24,25]. These studies have led to the development of a combined model of both Person-centred and Lean Six approaches for use in healthcare [26] which acts as a guide for improvement practitioners in delivering Person-centred Lean Six Sigma improvement [23]. In use the model has shown to have contributed positively to solving problems in both inpatient and outpatient settings [27, 28] and more recently in both acute hospital and community ophthalmology services in Ireland [13]. The model pays particular attention to the synergistic elements of both Person-centred approaches and Lean Six Sigma, in particular: Voice of the Customer Observational Studies Respect for Person Staff empowerment Our work was therefore informed and underpinned by the use of a combined Person-centered Lean Six Sigma approach [13,23] using the Person-centred Lean Six Sigma model [26.] Specific examples of Lean Six Sigma improvements in healthcare include: Reduced wait times and faster access to treatment in Emergency Departments [29]; Improved patient outcomes in Cardiac Units [30]; Streamlined nursing drug rounds on wards [31]; 2.2 Design Lean Six Sigma methodology [32] was used within the quasi-experimental design to support the redesign the referral management system and improve the patient environment at the study site clinic. The methodology was applied using the DMAIC (Define, Measure, Analyze, Improve, Control) improvement framework [33] which consists of five distinct phases: Define the problem, identify required improvement activity, the opportunities for improvement, the project goals, and customer requirements. Measure process performance current process capabilities and identify the most important service parameters; Analyze the current process to determine root causes of unwanted variation and NVA (non-value add) activity; Improve process performance by piloting solutions to address and eliminate the root causes of NVA; Control the improved process and future process performance through measurement of key process performance metrics. Where the Lean Six Sigma DMAIC framework has been utilized in healthcare settings, it has demonstrated successful outcomes [30, 34, 35] which have been categorized as delivering positive outcomes for the organization, patients, their families, and staff [23]. Additionally, Lean Six Sigma has been shown to streamline outpatient services [36]. 2.3 Lean Six Sigma Toolkit Within the Lean Six Sigma DMAIC improvement framework used for this study, we utilised appropriate Lean Six Sigma tools within the relevant phase/s of the DMAIC framework (table 1). The table classifies the Lean tools according to their purpose (table 1, column 2) and stage of use (table 1, column 3) within the DMAIC process. The effective deployment of these Lean Six Sigma tools contributed to the team’s ability to achieve their goals. Table 1. Lean Six Sigma tools used in this study. 1.Improvement Tool 2.Purpose 3.DMAIC Phase Use Project Charter The main problem statement is defined in the project charter. It is used to identify the aims and scope of the project [37] Define SMART SMART is used to manage those goals, the acronym stands for Specific, Measurable, Achievable, Relevant and Timebound (SMART) [38] Define SIPOC A SIPOC (Supplier, Input, Process, Output and Customer) defines the customers and stakeholders and shows the process steps [39] Define VOC The Voice of Customer (VOC) tool gathers customers feedback about their experiences [40] Throughout all stages, iteratively seeking customer feedback Gemba Observation of the actual process taking place [41] Define, Measure, Control Ishikawa/Fishbone Identifies root causes, representing the effect and the factors or causes influencing it [42] Measure,Analyze,Improve FMEA Failure Mode and Effect Analysis is a risk analysis tool. It highlights the areas of process that require improvement [43] Measure, Analyze, Improve, Control Process map Process mapping increases understanding of complex systems [44] Throughout all stages, from initial development, current state to future state development. TIMWOODS A useful tool wherein each letter stands for one of eight potential wastes: Transport, Inventory, Motion, Waiting time, Over-processing, Overproduction, Defects and Skills [45] Measure, Analyse, Improve 2.4 Data Gathering A Project Charter [37] was developed by the Project team, discussed with staff working in the study site clinic, and the use of the SMART assessment [38] identified the following issues as key areas for data collection: Referral process (from writing of referral to its triage and apportionment date): this was facilitated by VOC, Process mapping and Gemba. System of tracking and triaging referrals: this was facilitated by VOC, Gemba, patient chart audit. Communication back to the referrer: this was facilitated by VOC, Gemba, records of mode of communication back to referral source. Time taken to register a referral; triage a referral; and book the patient's appointment: this was facilitated by VOC, Gemba, patient chart audit. Environment of clinic: this was facilitated by VOC and Gemba. Accessibility audit concerning seating and carpark signage: this was facilitated by audit, VOC, Gemba, and process mapping of current access and egress patterns. Within the Person-centred Lean Six Sigma model [26], the Lean Six Sigma voice of the customer approach to understanding customers’ requirements has been shown to be synergistic with person-centred care practices, which utilize observations, narratives, conversations, focus groups and workshops [13]. The project team therefore understood and appreciated the value of spending time in authentic customer engagement through extensive voice of the customer sessions with the clinic staff and with patients. 2.5 Data relating to the referral process Referral letters to paediatric ophthalmology services in Dublin come from a variety of sources (Table 2.) Any attempt to improve the referral process therefore had to account for all individual referral groups. To effectively implement and sustain change it is necessary to involve all stakeholders, and in the case of this study, extensive VOC engagement with the referrers to the paediatric ophthalmology service were key to the success of the improvement. VOC sessions with referrer groups sought to understand what, from a referrer’s point of view, worked well and what didn’t work well with the current referral system. Table 2. Referral Sources. REFERRAL SOURCE TOTAL REFERRALS N=173 COMPLETE N = 173 School Screening 99 93 GP 27 4 Opticians 5 5 Tertiary Hospital 19 14 Public Health Nurse 22 1 Ophthalmologist 1 0 TOTAL 173 117 Following an audit of referral letters from referring sources (table 2), we were able to establish that they were often lacking the basic clinical information (Figure 2) required for the triaging of patients to categorize them based on the severity of their presenting complaint [46]. Triaging referral letters is an integral part of the outpatient clinic operation. Inadequate information in the referral letter adversely affects the triaging of the child which ultimately deems how quickly they are seen by the relevant clinician. When the project team began their improvement work, 33% of referrals were not right the first time. This meant that administrative staff had to repeat review the referral and triage details before they could schedule a child to the appropriate clinic and clinician. Referrers, during VOC sessions were shown the audit data, and whilst recognizing the problems inherent in the current open nature of a referral letter, voiced concerns about any new referral form or system containing too many mandatory data sets and advised that these should be kept to an agreed minimum essential criteria. Referrers also asked that any new system should enable them to receive feedback confirming receipt of the referral and its current status so that they could update patients /carers. 2.6 Use of Gemba Gemba is effectively a real-time observational study of a person in the place where the work or activity occurs, mirroring the Japanese concept of Kaizen (change for the better) [41]. This form of non-judgmental observational study is not unique to Lean, with the Person-centred Lean Six Sigma model highlighting the use of workplace observations in Person-centred work to measure and evaluate ‘where we are now ’ [47]. To support our data collection, we completed three Gemba walks, carried out at intervals by different members of the team to remove any potential of a singular viewpoint. From a child and family perspective, children were observed sliding off unsuitable seating designed for adults, and with no access to tables, completing their schoolwork on the clinic floor. Clinic administrative staff were observed spending an average of 20 minutes per triage letter gathering missing information. The Gemba gave the project team an overview of the clinic activity and assisted in the development of a process map (Figure 3). The process map was a product of collective intelligence and was validated by all stakeholders involved in the process. Process mapping is not simply about drawing the map itself but is also a process of building trust and consensus showing respect for those who carry out the actual work and empowering staff by involving them in co-designing any new process [44]. 2.7 Consolidated data analysis Gemba observations validated areas of NVA that had been highlighted by stakeholders within the clinic. The current patient management system was underpinned by the largely paper-based process which was human resource-heavy and according to the administrative team ‘not fit for purpose’. This equated to a staff confidence in the accuracy of the current referral management system of 70% but a satisfaction rating of 38% with the process workload. Within this paper-based process, during one Gemba, referral letters were noted as missing necessary patient information in 90% of cases. This was far above the average noted in the baseline data of 33% of referrals not being Right First Time (RFT), indicating potential for wide variation within the referral process, and enforcing the need for referrals to have minimum data requirements that were easy to monitor. Administrative staff manually received referrals, triaged them and managed the clinics using this paper-based approach. The project team made use of the TIMWOODS tool [45] to further classify the NVA identified by the VOC, Gemba and process maps. Table 3 gives an overview of NVA that patients, their families, administrative staff and clinicians experienced due to the existing processes within the clinics. Table 3. TIMWOODS analysis. Waste Impact on child and family Impact on staff T Transport Delay in arrival due to poor directional signage to clinic Transporting paperwork Excessive movement of staff, forms/patient files between rooms. I Inventory Adult orientated furniture and fittings Paper based referral process M Motion Lack of motion due to clinic flow Excessive motion gathering paperwork W Waiting Times Waiting times for appointment Waiting time within clinic Waiting time for queries to referrers to be answered O Over-Production Unclear about appointment and its purpose-leading to multiple non attendances Follow up queries on referrals O Over- Processing Appointments rescheduled Adding pre-check phone calls for all patients to avoid DNA D Defects Poor environment of care Missing information in referral forms S Skills Clinicians follow up with referral sources Further discussion of our TIMWOODS analysis with stakeholders revealed the following: Gemba observations evidenced up to four staff involved in the processing of one standard referral received. There was excessive movement of staff and patient files between rooms. An absence of any referral management system produced excessive motion for administrative staff. Patient flow within the clinic was heavily influenced by administrative staff processing arriving referrals. Administrative staff were observed contacting patients' parents/families in advance to mitigate against DNA. Clinical staff following up with referrers and patients were missed appointments had occurred. Administrative staff spending time on processing referrals and offsetting DNAs, and not developing solutions. When staff were unable to contact patients' parents to follow up on referrals via SMS (text message) or phone, it often resulted in non-attendance (Do Not Attend/DNA) which averaged at 20% per clinic. This increased the time children were waiting to be seen by the appropriate clinician. The time spent by administrative staff trying to contact these parents had a corresponding impact on clinic flow with administrative staff diverted to follow up calls increasing waiting times for children and their families in terms of their actual waiting time in the clinic on the day of their appointments. VOC sessions with the children, their parents, and staff showed consensus that the clinic environment itself was not fit for purpose and was not designed with the child in mind. Families interviewed were struggling to find the clinic, consequently arriving late to their appointments. There was poor seating, no stroller parking, limited signage, poor contrast sensitivity and a poorly illuminated environment. All of these issues impacted on visually impaired children. These themes representing NVA were then further evaluated with clinic staff in a further series of workshops facilitated by the project team, using an Ishikawa diagram (Figure 3) enabling identification of potential root causes of the issues to be considered [42] to facilitate solution generation within the clinic. After brainstorming solutions with the clinic staff, a second modified Ishikawa Diagram was developed in collaboration with them (Figure 4). The potential highest impact solutions to the root causes identified were the implementation of a standardized referral management system, an online patient appointment system, in addition to a review of the current physical layout of the clinic to enhance the environment of care. Following the development of the Ishikawa diagrams, the team made use of a Failure Modes and Effects Analysis (FMEA), which is a systematic method to identify where and how a process might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change [43]. Working with staff, building on our collected data and our process maps, we identified potential failure modes for each of the co-designed solutions of an online referral form, online patient management system and child-friendly environment, identified within the Ishikawa exercise (figure 4). Potential failure modes for an online referral form were: incomplete referral forms and referral duplication as well as referrals sent to the wrong person and not being triaged on time. Potential failure modes for an online management system were: software malfunction amending templates which required external support inadequate staff training resulting in an inability to operate the system Potential failure modes for implementation of the child-friendly environment were: potential budgeting issues and problems with procuring stock. The use of the FMEA in conjunction with the use of the Ishikawa tool (figures 3-4) enabled us to collaborate with and codesign solutions with the staff working within the clinic. 2.6 Improvement/solutions The co-designed solutions focused on the main failure modes as outlined below. 2.6.1 Incomplete referral forms In order to improve the statistics on right-first-time referrals, both staff at the study site, and referrers agreed that a move to an electronic online referral form was the best option. This would enable patient status check at a glance and comprise compulsory fields to obviate NVA in follow up activity for administrative staff. The following fields were considered the minimum compulsory data required for any new online referral form: Name DOB, address, gender Visual acuity measurement Date referral Name of referrer Additional needs 2.6.2 Electronic referral system Staff reached consensus that the referral management system process should move from a manual paper-based system, and proposed using the project findings to support a business case to implement a new electronic system and move to electronic online referrals. 2.6.3 Implementation of a child-friendly environment. It was agreed there was a need to procure appropriate children's chairs and tables with associated accessories (coloring books and crayons) for the waiting area (figure 5). In addition to this, we conducted an access improvement audit with the help of design specialists already working within the ophthalmology service to generate recommendations for signage and colors suitable for visually impaired children. Following the outcomes of the access audit, we implemented a Wayfinding Strategy, including Assistive Technologies to positively impact the safety and psychological wellbeing of clinic attendees. This took the form of the provision of new accessible signage, inclusive of patient and family approach to the clinic, the lift/elevator access and a means to easily locate the Eye Clinic reception to ensure it is accessible to everyone. We also ensured that all pre-visit correspondence and information relating to access and wayfinding was consistent with on-site directional information. Upon review of internal environments, it was noted that backgrounds, color contrast and lighting were completely inadequate for people with visual impairment. To ensure safety during navigation we worked to ensure legibility of signage and adequate illuminance throughout. 2.6.4 Funding the improvement The problem statement, collected data, findings of the root cause analysis and potential solutions generated by the staff working within the clinic were presented to the ophthalmology service management team. The average time spent on incomplete referrals at 20 minutes, and the 33% of referrals that were not right first time, alongside staff, referrer and patient voice of the customer data were seen as a compelling case for change. Funding for the online referral system was successfully secured from the annual allocated Health Services Executive budget for the locality. The ophthalmology service was familiar with online providers of a scheduled booking system, that was currently in use in phlebotomy services, and were able to leverage existing agreements to secure an extension of the online scheduled booking system to the ophthalmic clinic. Furniture suitable for the demographic of a paediatric clinic was secured from existing stock within the wider service, and the access and wayfinding strategies were cost neutral as part of an ongoing review of signage overall. Results Following the approval and implementation of the co-designed solutions, the project team achieved the following results. 3.1 Improved staff satisfaction The staff feedback was predominantly ‘very satisfied’ with the implementation of the new electronic online referral management system showing staff confidence with the accuracy of the referral management system increased from 70 to 79%. A post-implementation survey of clinic staff showed an improvement in satisfaction with the referral process workload from 38% to 98% positive post improvement. A post implementation survey of attending children and families indicated an improvement in satisfaction with the clinic experience overall from 38% to 98% positive. Staff evidenced they were ‘very satisfied’ with the induction to and training on the new electronic referral system and expressed confidence in tracking referrals across the system. Post implementation Gemba illustrated that staff now have demonstrably less manual paperwork to complete and more efficient clinic throughput due to released time to concentrate on the clinic flow rather than referrals. 3.2 Improved patient satisfaction Patients and their families are moving through an environment more conducive to care with an improved user experience due to user friendly signage and a child appropriate environment of care. Staff time released through the use of the electronic referral management system means they are available to answer patient and family queries and assist them through their clinic journey. Within the study site clinics are finishing on time and running more efficiently. Post implementation patient satisfaction with their clinic experience has increased from a pre intervention satisfaction rate of 48% to 98 %. Parents feedback indicated that the new wayfinding strategy and child-friendly environment made visiting the clinic less stressful for both them and their children. 3.3 Patient treatment in the appropriate setting Streamlined processes within the referral system have enabled increased capacity for patients within the clinic, facilitating the local paediatric hospital in its ability transfer the less complex paediatric ophthalmology cases to the community. 3.4 Time saved in the referral process Pre-intervention patient record data on wait times for what specify was recorded over three months between September – November 2022 and post-intervention in April 2023. It indicated the following: Introduction of the electronic referral management systems to manage online referrals from pre-referral triage to allocation of available time slots lead to 4 minutes saved per each individual patient referral. The service has achieved a right first-time referral status of 98% from a baseline of 67% for referrals to the service, following the implementation of the mandatory data set in the new electronic referral form. This eliminates the issues identified within our TIMWOOD analysis (table 3) with a marked reduction in follow-up phone calls to patients or referring clinicians for missing information. The combination of increased accuracy of referrals and corresponding reduction of rework/follow up on referrals, enable a prompt clinician triage of the referrals and facilitates earlier patient scheduling for treatment. In summary, the improved efficiency of the referral and triage process means patients are seeing an appropriate medical professional at the right time in accordance with their clinical needs. Streamlining the work process, and cutting down non-value-added tasks, has freed up staff to carry out more value-add functions. Discussion The goal of this study was to improve the Right First Time statistics on referrals received, reduce administrative staff time spent on the referral management and to collaborate with clinic staff and attending children and their families to co-design a more person-centred, appropriate child-friendly environment. To do this we utilized a Person-centred Lean Six Sigma model, developed in healthcare and currently in use in healthcare settings in 6 countries [26]. Table 4 gives a high level overview of the achieved goals. Table 4: Summary of results Goal Pre-intervention Post intervention % increase/decrease Improve the Right First Time (RFT) statistics on referrals received 67% RFT 98% RFT 46% percentage increase in RFT referrals Reduce administrative staff time spent on the referral management process Average 20 minutes per single referral Average 16 minutes per single referral 20% percentage decrease in time spent per single referral Co-design solutions with staff: Staff confidence in accuracy of child referral to clinic process 70% positive 79% positive 13% percentage increase in confidence in the referral system accuracy Co-design solutions with staff: Staff satisfaction with workload involved in the child referral to clinic process 38% positive 98% positive 158% percentage increase in satisfaction with workload involved in process Co-design solutions with patients: Child and family satisfaction with clinic experience 48% positive 98% positive 104% percentage increase in patient satisfaction Use person-centred principles to inform how we worked as a team Person-centred principles used throughout intervention. We now discuss key success factors which enabled improvement within the study site. 4.1 Key success factors 4.1.1 Motivated and engaged project team and stakeholders The success of the project was enabled by motivated project team members and clinical staff in the community paediatric eye clinic with senior management support. As outlined, our project team consisted of process owners (those working within the process to be improved) two paediatric ophthalmology doctors working in the community clinic, the Chief Services Officer at Vision Ireland, a data analytic manager from the nearby tertiary hospital, and our team mentor. The fundamental desire of all team members and healthcare professionals involved was to improve user experience of the clinic and reduce time from referral to appointment to ultimately prevent visual impairment in children, a vulnerable group of patients who cannot advocate for themselves. 4.1.2 Co-designed solutions The solutions were co-designed with the project team and were fully inclusive of child and family voice. The problem statement was explored and solutions were incrementally developed using the DMAIC framework, allowing for authentic engagement with all stakeholders. The timeframe of the project allowed for critical reflection about the insights provided by our data collection and root cause analysis and ensured that the clinic staff and the children and families were active partners in redesigning the process. We took the approach that rather than merely capturing patient experience data, we should be embedding co-design practices and values in our project, avoiding tokenistic patient involvement and making sure they had meaningful involvement in the process redesign. 4.1.3 A person-centred approach The Person-centred Lean Six Sigma model emphasizes the development of person-centred improvement through the use of collaborative, inclusive and participatory (CIP) principles [13,23,26]. As discussed, as a project team we wanted to collaborate authentically with the staff and patients involved in the paediatric ophthalmology clinic, enabling us to draw on their extensive knowledge [48]. The Person-centred Lean Six Sigma model [26] outlines the factors that staff consider respectful when participating in Lean Six Sigma interventions included [13]: • Well organized and timely communication • Openness to new ways of working • Management actively and visibly supporting and leading on improvement culture • An explicit focus on staff experience in addition to that of patients • Staff respect and support for each other when involved in process improvement Throughout the project timeline, we focused on timeliness, clarity and conciseness of communication both within the project team and with our stakeholders. Staff expressed an openness and willingness to change, and senior management within the service were supportive of the project from the outset. We were clear that we would focus on the impact of the improvement project on patients, but also consider the needs of staff. The project team feedback on the project was overall very positive. As a team we felt that we had achieved outcomes by working together as an empowered and valued team of healthcare practitioners in collaborative, inclusive and participatory ways to plan and deliver on improvement [49]. We felt that the Lean Six Sigma education and training program enabled us as practitioners using both Lean Six Sigma and person-centred methodologies to promote person-centred, holistic and individualized care [50]. 4.1.4 Empowerment In creating conditions to empower individuals to voice concerns and seek solutions, our person-centred approach drew on the collective leadership pillars of performance, safety, wellbeing, team process and sustaining improvement [51] which we encapsulated by our ways of working together as a project team. This collective approach, which is synonymous with Lean Improvement acknowledged the essential requirements of active stakeholder engagement and empowerment in any quality-improvement strategy. To further involve children and their parents in the ongoing development of the ophthalmology service, the access audit results led to a follow up recommendation to the clinic management team for consideration of a patient advisory group to ensure a quality and customer focus and ascertain rich feedback. The purpose would be to empower children and families accessing primary eye care services to be involved as active and equal partners to inform and contribute to the ongoing design of the service. This recommendation has been carried forward to management for discussion and action. 4.1.5 Looking forward The solutions implemented in this study have positively affected the paediatric eye clinic in the community clinic by improving patient both child, family and staff experiences of the service. The primary goals of an improved right first time referral accuracy (post intervention 98%), releasing staff time from processing referrals (3-4 minutes per referral post intervention) and improving the environment of care, have been achieved. The ease of access to referral data from the new electronic system facilitates oversight of referral sources and the clinician referred to, strengthening newly established links between tertiary services and the community in ophthalmology. These channels of communication are important to protect, nurture and maintain these links and networks Much of the literature on community paediatric clinics highlights that they increase parental choice and access to paediatric services, increasing service flexibility and reducing unnecessary hospital visits [17]. Looking forward, the improved speed of the referral process has enabled the generation of more appointments, meaning the clinic will have the capacity to see more patients and to potentially review suitable cases that are on the waiting list in nearby tertiary hospitals. However, we note that this also has the potential for increased pressure on ophthalmologists in the community meaning more ophthalmology consultant support may be required. Our project has in effect highlighted the recommendations within the Primary Care Eye Services Review [1] to move less complex paediatric ophthalmic cases to the community. Conclusions Within this study we highlighted the importance of the correct choice and use of Lean Six Sigma tools, however we have also demonstrated that Lean Six Sigma as an improvement methodology is about more than, and should not be reduced to, a decontextualized toolkit [6,13,25,26]. Rather we have highlighted the importance of engagement with all those involved in the process of care, both recipients of care (patients and their families) and providers of care (healthcare staff). Our work in implementing a Person-centred Lean Six Sigma redesign of outpatient scheduling provides valuable insights and learning for others relating to the focused use of Lean Six Sigma principles on improving efficiency, reducing waste, and enhancing overall process performance. A key learning from this improvement project for other outpatient services is that implementing a systematic approach to clinic scheduling can be applied to multiple types of clinics within both paediatric and adult settings. Future studies in the ophthalmology service intend to look at if the process redesign has impacted on non-attendance rates in the clinic and if the capacity created by timely appointments has had any impact on waiting lists for paediatric ophthalmology clinics in the nearby tertiary center. A limitation of this study was the extensive time that was required for stakeholder engagement, which is essential for any improvement initiative. Whilst Lean Six Sigma improvement efforts may require a significant time investment, the potential benefits, as demonstrated in this study, such as increased efficiency, customer satisfaction, and overall clinic effectiveness, often outweigh the initial time and resource costs. An important lesson we learned as a team is that it is important to approach quality improvement with a long-term perspective, recognizing that the time spent upfront can lead to lasting positive changes. Another limitation was that this was a study within a single site location, and as a pilot study, we could only examine the feasibility of the intervention topic (paediatric ophthalmic outpatient clinics) included in this study. However, we believe it has implications for other hospital sites seeking to improve their outpatient scheduling processes. We contend that underpinning our Lean Six Sigma framework with a person-centred approach supported our team formation, building consensus on the project direction and facilitating our working together with stakeholders to deliver on improvement. Our approach aimed to support staff and patients through mutual respect and empowerment [52]. Our collaborative practice in this project recognized the value of and respected stakeholders diverse perspectives, skills, knowledge, and experiences. It enabled us to develop a consensus that our work was based on an understanding that Lean Six Sigma is more than a set of quality-improvement tools and techniques [6,53] but values people and their beliefs and values [54] The use of Lean Six Sigma methodologies allowed the team to quantify the existing process, identify problem areas and provide a suitable solution, whilst person-centred principles underpinned how we engaged with staff, children and their families, and how we worked together as a team. The improvement project has resulted in long-term changes with an improved referral system to facilitate timely triage of children for the community ophthalmic pathway and future-proofed the system for audit, by implementing an electronic referral management system that allows for rapid real time and retrospective data collection. We purport that this study, to our knowledge, the first of its kind in paediatric ophthalmology, will assist healthcare professionals understand the work involved in the successful deployment Lean Six Sigma model in paediatric healthcare settings, underpinned by Person-centred principles, in order to improve operational efficiency and promote enhanced patient and staff satisfaction. Abbreviations Person-centred Lean Six Sigma Model (PCLSSM) DMAIC-Define, Measure, Analyze, Improve Control FMEA-Failure Modes and Effects Analysis NVA-Non-Value Add QI-Quality Improvement VOC-Voice of the Customer DNA-Did Not Attend Declarations Ethical Approval: Not applicable Consent for publication: Those involved in the study give their consent for publication Data Availability: All data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing Interests: The authors declare no conflict of interest. Funding: This research received no external funding Author Contributions: Conceptualization CB, AM, OY and BT; methodology CB, AM, OY, BT; formal analysis CB, AM, BT and OY.; investigation CB, AM , BT and OY data curation CB, AM, OY, BT writing—original draft preparation CB writing—review and editing, CB SPT visualization SPT supervision SPT, All authors have read and agreed to the published version of the manuscript Acknowledgements: the authors would like to acknowledge all the staff at Grangegorman Community eye clinic, Dublin Ireland. References HSE Primary Care Eye Services Review Group Report 2017; Accessed online [https://www.hse.ie/eng/services/publications/primary/eye-services-review-group-report.pdf] National Treatment Purchase Fund 2023. Birch EE. Amblyopia and binocular vision. Prog Retin Eye Res. 2013 Mar;33:67-84. doi: 10.1016/j.preteyeres.2012.11.001. Epub 2012 Nov 29. PMID: 23201436; PMCID: PMC3577063. McConaghy JR, McGuirk R. Amblyopia: Detection and Treatment. 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(2018) The sustainability of Lean in paediatric healthcare: a realist review. Systematic Reviews. Vol. 7. No. 1. Article 137. https://doi.org/10.1186/s13643-018-0800-z ., 17 Williams, S. (2015) Lean and Person-centred Care: Are they at Odds? Retrieved from: tinyurl.com/Williams-lean. (Last accessed 27th November 2022) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4228153","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289874102,"identity":"0dddb887-3702-4f46-b010-c44ef12280f9","order_by":0,"name":"Christine 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15:44:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4228153/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4228153/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54515197,"identity":"a33bb4bf-0c27-4a5f-ad98-cf0147986d45","added_by":"auto","created_at":"2024-04-11 16:23:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":142701,"visible":true,"origin":"","legend":"\u003cp\u003eEssential clinical data that was missing from referral letters received at the clinic.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/1a56e2d4c4b2dd285542e15f.png"},{"id":54515198,"identity":"d92bdec1-bd40-457e-bcf1-5c4d1ed2bda6","added_by":"auto","created_at":"2024-04-11 16:23:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":329015,"visible":true,"origin":"","legend":"\u003cp\u003eThe Process Flow Map showing the end to end referral management process in the community eye clinic\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/6d15ae9201ba4321a76f1387.png"},{"id":54515199,"identity":"9c8c8851-00f0-4d2c-93cd-907e1ad691ac","added_by":"auto","created_at":"2024-04-11 16:23:14","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":75842,"visible":true,"origin":"","legend":"\u003cp\u003eIshikawa Fishbone Diagram showing the causal factors responsible for the outcome/problem.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/857848d719d5fc6172137fe4.png"},{"id":54515196,"identity":"cdb85533-7ca3-4fc9-a3c7-2888dcc55db0","added_by":"auto","created_at":"2024-04-11 16:23:14","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":88693,"visible":true,"origin":"","legend":"\u003cp\u003eModified Ishikawa diagram with solutions.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/8b726f427458b7cbacc4d24b.png"},{"id":54515200,"identity":"69289283-0ba1-453b-a849-079e8f0771d8","added_by":"auto","created_at":"2024-04-11 16:23:14","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":843553,"visible":true,"origin":"","legend":"\u003cp\u003eThe new child-friendly environment of care at the clinic with chairs suitable for toddlers and small children.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/545bc8be1c54ba57ec159713.png"},{"id":61172481,"identity":"34660f78-4a5f-466d-9af4-8e34a422b14b","added_by":"auto","created_at":"2024-07-26 14:47:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2072882,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4228153/v1/3e101723-0a5f-4257-99e2-ae4abff4755f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using a Person-centred model of Lean Six Sigma to support process improvement within a paediatric primary eye care clinic","fulltext":[{"header":"Background","content":"\u003cp\u003eOphthalmic care in Ireland is delivered in both the community and the acute care setting encompassing a range of clinical, technical and rehabilitative services. \u0026nbsp;The availability of services and referral policies vary nationwide. Paediatric eye care services are delivered from acute hospitals and community clinics and include school vision screening, assessment diagnosis and treatment of visual impairment and the provision of glasses for correction of refractive error [1].\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eIn Ireland, over 5100 children are suffering with visual impairment. \u0026nbsp;Most of this is preventable but requires timely access to ophthalmic care. Like many other hospital specialties, paediatric ophthalmology services are under pressure as evidenced by long waiting lists\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003e[2].\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAmblyopia is a common disorder presenting in children, which represents decreased vision occurring during the years of visual development [3]. This is secondary to abnormal visual stimulation or abnormal binocular interaction. \u0026nbsp;Timely treatment of amblyopia improves vision and decreases the likelihood of severe visual handicap if vision loss occurs in the fellow eye later in life [4]. This can have long-lasting employment and socioeconomic repercussions. \u0026nbsp;Up to 60% of amblyopia patients can be managed effectively in the community [5]. In Ireland, amblyopia is managed in both community ophthalmic clinics and tertiary hospitals. In treating amblyopia, transitioning less acute cases from tertiary to primary care settings can reduce the waiting lists in tertiary clinics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was set in a paediatric community eye care clinic in North Dublin, Ireland. The clinic provides ophthalmic care to children aged from two to twelve years of age. The clinic is publicly funded by the Irish Health Services Executive (HSE). The ophthalmology staff/stakeholders included a consultant ophthalmologist, a community ophthalmic physician, a specialist registrar in ophthalmology, an orthoptist, three optometrists and five administrative staff. The facility runs 9 clinics per week.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn Ireland, the majority of paediatric ophthalmic care is carried out in the public sector. There are approximately 2,400 new referrals to the tertiary centre\u0026rsquo;s paediatric ophthalmology clinics per year. At the commencement of this study, the ophthalmology team working in the study site clinic anticipated that the current referral situation to the clinic would continue to increase, as there is a predicted 15% increase in demand for paediatric ophthalmology services in line with the opening of a new national children\u0026rsquo;s hospital in Ireland [5] which will amalgamate the current children\u0026rsquo;s hospitals and increase capacity. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.2 The project team\u003c/p\u003e\n\u003cp\u003eThe project team came together when undertaking a specialist university qualification in Process Improvement in Health Systems within University College Dublin, Ireland, designed to support staff in implementing person-centered service improvements as part of the curriculum [6]. \u0026nbsp;The team included two ophthalmology Specialist Registrars working between the tertiary hospital and community eye clinic, the Chief Services Officer of Vision Ireland and a data analytics manager working in a tertiary adult hospital. \u0026nbsp;Our team mentor was a Lean Six Sigma Master Black Belt with a healthcare background, a lecturer in process improvement in healthcare, working with our academic partner. \u0026nbsp; Thus, three group members were deeply involved in ophthalmic care in Dublin, with the fourth and final members of the group bringing a fresh perspective and further insight into the improvement process. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe team members working within pediatric ophthalmology services were aware of a pressing need to streamline the referral process for children to ophthalmology clinics, the booking process for their appointments, and the need to quantify and understand the impact of the current configuration of these processes on paediatric clinics in the study site. They had been approached by a key stakeholder in the clinic in North Dublin and asked to oversee this process improvement as an improvement project within the timeline of their university qualification (September 2022-May 2023). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.3 Problem statement\u003c/p\u003e\n\u003cp\u003ePrior to our improvement project, clinics within the study site used a paper-based referral process from referrer sites to the paediatric ophthalmology service. \u0026nbsp; This paper-based system took the form of a referral letter rather than a specified referral form and therefore contained no specified minimum data set. Quality of referral letters to paediatric services are frequently shown to contain inadequate information related to the referred patient [7]. \u0026nbsp;Within the study site, \u0026nbsp;33% of referrals were not right first time, missing key pieces of information required to process a booking. \u0026nbsp;Administrative staff advised that this was leading to a large amount of follow up work to gather the missing information, with an average of 20 minutes required to triage and process patient referrals and schedule their appointments for the clinic. This in turn was detracting from administrative staffs\u0026rsquo; ability to focus on the operations of the actual live clinic sessions and respond to the needs of attending children and their families. Additionally, with little free time for staff to focus on the environment of care, the clinic environment itself was visibly orientated toward an adult rather than paediatric customer base.\u003cem\u003e\u0026nbsp; \u0026nbsp;\u003c/em\u003eStudies have shown that children report feeling afraid or anxious as they anticipate and engage in healthcare settings with medical professionals [8], and when healthcare space is not intentionally designed for paediatric care, both children, their parents and staff safety may be negatively impacted, and they may have a poor care experience [9]. \u0026nbsp;The problems identified informed the project team\u0026rsquo;s goals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.4 Project team goals\u003c/p\u003e\n\u003cp\u003eIn response to the problem statement, the project team determined the following high-level goals:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eImprove the Right First Time statistics on referrals received (baseline 67% of referrals were right first time) to minimize administrative staff time spent in triaging for missing data.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eReduce administrative staff time spent on the referral management process (baseline average of 20 minutes to process a single patient referral) to release their time to focus on the operation of the actual clinics.\u003c/li\u003e\n \u003cli\u003eCollaborate with clinic staff and attending children and their families to co-design a more person-centred, appropriate child-friendly environment.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eUse person-centred principles to inform how we worked as a team, and how we engaged with customers, both service providers (the clinic staff) and service users (children and their parents).\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003e1.5 Project team principles\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe use of quality and process improvement (QI) initiatives in healthcare organisations continues to increase, as organisation seek to improve services and redesign pathways to improve the quality, experiences and safety of care [10, 11]. \u0026nbsp;Lean Six Sigma QI initiatives have been used successfully in healthcare to deliver improvements in patient outcomes and experiences of care [12-13]. However, whilst previous studies have shown these initiatives can result in improvements in care, the sustainability of improvement efforts is often questioned [14,15].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePerson-centred approaches to care, with an emphasis on the experiences of both patients and service providers taken into account, and the promotion of their involvement in decision making, have been demonstrated as contributing to the sustainability of improvement initiatives [13]. \u0026nbsp;McCance and colleagues [16] suggest that the focus on person-centredness in healthcare reflects society\u0026apos;s need to address ongoing issues of service delivery imbalance, and the requirement to move from a medical ethos to a more holistic and collaborative one. \u0026nbsp;Within paediatrics, collaborative care has been shown to effectively provide high-quality care while creating capacity for \u0026nbsp; increased primary care treatment [17]. \u0026nbsp; The project team therefore decided that their project work would be supported by a person-centred methodological approach that would support the team in working together, to enable and support staff, children and their families in the redesign of ophthalmology clinic processes were necessary, through a collaborative, inclusive and participatory process [13].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e2. \u0026nbsp;Materials and Methods\u003c/p\u003e\n\u003cp\u003e2.1 Theoretical Framework\u003c/p\u003e\n\u003cp\u003eThe framework for this improvement work was a quasi-experimental, single-study site, pretest-posttest study which was conducted from September 2022 to May 2023. \u0026nbsp;Quasi experimental refers to a design type used to evaluate interventions [18].\u003cem\u003e\u0026nbsp;\u003c/em\u003eQuasi-experimental design facilitates the use of both preintervention and postintervention measurements within process improvement studies, to measure the occurrence of an outcome before and after a particular intervention is implemented [18]. \u0026nbsp;We were aware that pre and post-intervention design has the limitation of ascribing with certainty results to an intervention [19], but it has been used widely to evaluate Lean Six Sigma improvement projects in healthcare [20-22]. \u0026nbsp; \u0026nbsp;We therefore felt it suitable to use\u003cem\u003e\u0026nbsp;\u003c/em\u003eLean Six Sigma methodology within a quasi-experimental pre-and post-intervention study design framework. \u0026nbsp;It was explicit in our study design that any outcomes from redesigning the referral process could then be extrapolated and applied to other clinics as necessitated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.2 Use of a Person-centred Lean Six Sigma model\u003c/p\u003e\n\u003cp\u003eAs outlined, the project team had decided to underpin their improvement work with person-centred principles (section 1.5). \u0026nbsp;Person-centred approaches have an explicit focus on ensuring the client or patient is at the center of care delivery but are also concerned with every person involved in the patient\u0026rsquo;s care, including their families and the staff providing the care [23]. More recent studies have demonstrated that Lean Six Sigma and Person-centred care have been shown to be synergistic in their approach to eliciting the customer voice, understanding and delivering on customer needs [24,25]. These studies have led to the development of a combined model of both Person-centred and Lean Six approaches for use in healthcare [26] which acts as a guide for improvement practitioners in delivering Person-centred Lean Six Sigma improvement [23]. \u0026nbsp;In use the model has shown to have contributed positively to solving problems in both inpatient and outpatient settings [27, 28] and more recently in both acute hospital and community ophthalmology services in Ireland [13]. \u0026nbsp; \u0026nbsp;The model pays particular attention to the synergistic elements of both Person-centred approaches and Lean Six Sigma, in particular:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eVoice of the Customer\u003c/li\u003e\n \u003cli\u003eObservational Studies\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eRespect for Person\u003c/li\u003e\n \u003cli\u003eStaff empowerment\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eOur work was therefore informed and underpinned by the use of a combined Person-centered Lean Six Sigma approach [13,23] using the Person-centred Lean Six Sigma model [26.]\u003c/p\u003e\n\u003cp\u003eSpecific examples of Lean Six Sigma improvements in healthcare include:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eReduced wait times and faster access to treatment in Emergency Departments [29];\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImproved patient outcomes in Cardiac Units [30];\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStreamlined nursing drug rounds on wards [31];\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e2.2 Design\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLean Six Sigma methodology [32] was used within the quasi-experimental design to support the redesign the referral management system and improve the patient environment at the study site clinic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe methodology was applied using the DMAIC (Define, Measure, Analyze, Improve, Control) improvement framework [33] which consists of five distinct phases:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eDefine the problem, identify required improvement activity, the opportunities for improvement, the project goals, and customer requirements.\u003c/li\u003e\n \u003cli\u003eMeasure process performance current process capabilities and identify the most important service parameters;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAnalyze the current process to determine root causes of unwanted variation and NVA\u0026nbsp;(non-value add)\u0026nbsp;activity;\u003c/li\u003e\n \u003cli\u003eImprove process performance by piloting solutions to address and eliminate the root causes of NVA;\u003c/li\u003e\n \u003cli\u003eControl the improved process and future process performance through measurement of key process performance metrics.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eWhere the Lean Six Sigma DMAIC framework has been utilized in healthcare settings, it has demonstrated successful outcomes [30, 34, 35] which have been categorized as delivering positive outcomes for the organization, patients, their families, and staff [23]. Additionally, Lean Six Sigma has been shown to streamline outpatient services [36].\u003c/p\u003e\n\u003cp\u003e2.3 Lean Six Sigma Toolkit\u003c/p\u003e\n\u003cp\u003eWithin the Lean Six Sigma DMAIC improvement framework used for this study, we utilised appropriate Lean Six Sigma tools within the relevant phase/s of the DMAIC framework (table 1). The table classifies the Lean tools according to their purpose (table 1, column 2) and stage of use (table 1, column 3) within the DMAIC process. The effective deployment of these Lean Six Sigma tools contributed to the team\u0026rsquo;s ability to achieve their goals.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eLean Six Sigma tools used in this study.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"736\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.005434782608695%\"\u003e\n \u003cp\u003e1.Improvement Tool\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"35.19021739130435%\" colspan=\"4\"\u003e\n \u003cp\u003e2.Purpose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.804347826086957%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.DMAIC Phase Use\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.005434782608695%\"\u003e\n \u003cp\u003eProject Charter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.06521739130435%\" colspan=\"3\"\u003e\n \u003cp\u003eThe main problem statement is defined in the project charter. It is used to identify the aims and scope of the project [37]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.929347826086957%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDefine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.005434782608695%\"\u003e\n \u003cp\u003eSMART\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.06521739130435%\" colspan=\"3\"\u003e\n \u003cp\u003eSMART is used to manage those goals, the acronym stands for Specific, Measurable, Achievable, Relevant and Timebound (SMART) [38]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.929347826086957%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDefine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"36.005434782608695%\"\u003e\n \u003cp\u003eSIPOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.06521739130435%\" colspan=\"3\"\u003e\n \u003cp\u003eA SIPOC (Supplier, Input, Process, Output and Customer) defines the customers and stakeholders and shows the process steps [39]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.929347826086957%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eDefine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eVOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.097826086956523%\"\u003e\n \u003cp\u003eThe Voice of Customer (VOC) tool gathers customers feedback about their experiences [40]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.51086956521739%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eThroughout all stages, iteratively seeking customer feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eGemba\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.097826086956523%\"\u003e\n \u003cp\u003eObservation of the actual process taking place [41]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.51086956521739%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eDefine, Measure, Control\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eIshikawa/Fishbone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.097826086956523%\"\u003e\n \u003cp\u003eIdentifies root causes, representing the effect and the factors or causes influencing it [42]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.51086956521739%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eMeasure,Analyze,Improve\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eFMEA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.097826086956523%\"\u003e\n \u003cp\u003eFailure Mode and Effect Analysis is a risk analysis tool. It highlights the areas of process that require improvement [43]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.51086956521739%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eMeasure, Analyze, Improve,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eControl\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eProcess map\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.804347826086957%\" colspan=\"3\"\u003e\n \u003cp\u003eProcess mapping increases understanding of complex systems \u0026nbsp;[44]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.804347826086957%\" valign=\"top\"\u003e\n \u003cp\u003eThroughout all stages, from\u0026nbsp;\u003c/p\u003e\n \u003cp\u003einitial development, current state to future state development.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.391304347826086%\" colspan=\"2\"\u003e\n \u003cp\u003eTIMWOODS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.804347826086957%\" colspan=\"3\"\u003e\n \u003cp\u003eA useful tool wherein each letter stands for one of eight potential wastes: Transport, Inventory, Motion, Waiting time, Over-processing, Overproduction, Defects and Skills [45]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"28.804347826086957%\" valign=\"top\"\u003e\n \u003cp\u003eMeasure, Analyse, Improve\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e2.4 Data Gathering\u003c/p\u003e\n\u003cp\u003eA Project Charter [37] was developed by the Project team, discussed with staff working in the study site clinic, and the use of the SMART assessment [38] identified the following issues as key areas for data collection:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eReferral process (from writing of referral to its triage and apportionment date): this was facilitated by VOC, Process mapping and Gemba.\u003c/li\u003e\n \u003cli\u003eSystem of tracking and triaging referrals: this was facilitated by VOC, Gemba, patient chart audit.\u003c/li\u003e\n \u003cli\u003eCommunication back to the referrer: this was facilitated by VOC, Gemba, records of mode of communication back to referral source.\u003c/li\u003e\n \u003cli\u003eTime taken to register a referral; triage a referral; and book the patient\u0026apos;s appointment: this was\u0026nbsp;facilitated by VOC, Gemba, patient chart audit.\u003c/li\u003e\n \u003cli\u003eEnvironment of clinic: this was facilitated by VOC and Gemba.\u003c/li\u003e\n \u003cli\u003eAccessibility audit concerning seating and carpark signage: this was facilitated by audit, VOC, Gemba, and process mapping of current access and egress patterns.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWithin the Person-centred Lean Six Sigma model [26], the Lean Six Sigma voice of the customer approach to understanding customers\u0026rsquo; requirements has been shown to be synergistic with person-centred care practices, which utilize observations, narratives, conversations, focus groups and workshops [13]. \u0026nbsp;The project team therefore understood and appreciated the value of spending time in authentic customer engagement through extensive voice of the customer sessions with the clinic staff and with patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.5 Data relating to the referral process\u003c/p\u003e\n\u003cp\u003eReferral letters to paediatric ophthalmology services in Dublin come from a variety of sources (Table 2.) Any attempt to improve the referral process therefore had to account for all individual referral groups. To effectively implement and sustain change it is necessary to involve all stakeholders, and in the case of this study, extensive VOC engagement with the referrers to the paediatric ophthalmology service were key to the success of the improvement. \u0026nbsp;VOC sessions with referrer groups sought to understand what, from a referrer\u0026rsquo;s point of view, worked well and what didn\u0026rsquo;t work well with the current referral system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eReferral Sources.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"698\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eREFERRAL SOURCE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eTOTAL REFERRALS N=173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003eCOMPLETE N = 173\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eSchool Screening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e99\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eGP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eOpticians\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eTertiary Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003ePublic Health Nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eOphthalmologist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"33.55525965379494%\"\u003e\n \u003cp\u003e173\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.88948069241012%\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eFollowing an audit of referral letters from referring sources (table 2), we were able to establish that they were often lacking the basic clinical information (Figure 2) required for the triaging of patients to categorize them based on the severity of their presenting complaint [46]. Triaging referral letters is an integral part of the outpatient clinic operation. Inadequate information in the referral letter adversely affects the triaging of the child which ultimately deems how quickly they are seen by the relevant clinician. When the project team began their improvement work, 33% of referrals were not right the first time. This meant that administrative staff had to repeat review the referral and triage details before they could schedule a child to the appropriate clinic and clinician.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReferrers, during VOC sessions were shown the audit data, and whilst recognizing the problems inherent in the current open nature of a referral letter, \u0026nbsp;voiced concerns about any new referral form or system containing too many mandatory data sets and advised that these should be kept to an agreed minimum essential criteria. Referrers also asked that any new system should enable them to receive feedback confirming receipt of the referral and its current status so that they could update patients /carers.\u003c/p\u003e\n\u003cp\u003e2.6 Use of Gemba\u003c/p\u003e\n\u003cp\u003eGemba is effectively a real-time observational study of a person in the place where the work or activity occurs, mirroring the Japanese concept of Kaizen (change for the better) [41]. This form of non-judgmental observational study is not unique to Lean, with \u0026nbsp;the Person-centred Lean Six Sigma model highlighting the use of workplace observations in Person-centred work to measure and evaluate \u0026lsquo;where we are now \u0026rsquo; [47]. To support our data collection, we completed three Gemba walks, carried out at intervals by different members of the team to remove any potential of a singular viewpoint. From a child and family perspective, children were observed sliding off unsuitable seating designed for adults, and with no access to tables, completing their schoolwork on the clinic floor. Clinic administrative staff were observed spending an average of 20 minutes per triage letter gathering missing information. The Gemba gave the project team an overview of the clinic activity and assisted in the development of a process map (Figure 3). \u0026nbsp; The process map was a product of collective intelligence and was validated by all stakeholders involved in the process. Process mapping is not simply about drawing the map itself but is also a process of building trust and consensus showing respect for those who carry out the actual work and empowering staff by involving them in co-designing any new process [44].\u003c/p\u003e\n\u003cp\u003e2.7 Consolidated data analysis\u003c/p\u003e\n\u003cp\u003eGemba observations validated areas of NVA that had been highlighted by stakeholders within the clinic. \u0026nbsp; The current patient management system was underpinned by the largely paper-based process which was human resource-heavy and according to the administrative team \u0026lsquo;not fit for purpose\u0026rsquo;. \u0026nbsp; This equated to a staff confidence in the accuracy of the current referral management system of 70% but a satisfaction rating of 38% with the process workload. Within this paper-based process, during one Gemba, referral letters were noted as missing necessary patient information in 90% of cases. This was far above the average noted in the baseline data of 33% of referrals not being Right First Time (RFT), indicating potential for wide variation within the referral process, and enforcing the need for referrals to have minimum data requirements that were easy to monitor.\u003c/p\u003e\n\u003cp\u003eAdministrative staff manually received referrals, triaged them and managed the clinics using this paper-based approach. \u0026nbsp;The project team made use of the TIMWOODS tool [45] to further classify the NVA identified by the VOC, Gemba and process maps.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 gives an overview of NVA that patients, their families, administrative staff and clinicians experienced due to the existing processes within the clinics. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eTIMWOODS analysis.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWaste\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact on child and family\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact on staff\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eTransport\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003eDelay in arrival due to poor directional signage to clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eTransporting paperwork Excessive movement of staff, forms/patient files between rooms.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eInventory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003eAdult orientated furniture and fittings\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003ePaper based referral process\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eM\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eMotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003eLack of motion due to clinic flow\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eExcessive motion gathering paperwork\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eWaiting Times\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003eWaiting times for appointment\u003c/p\u003e\n \u003cp\u003eWaiting time within clinic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eWaiting time for queries to referrers to be answered\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eOver-Production\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003eUnclear about appointment and its purpose-leading to multiple non attendances\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eFollow up queries on referrals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eOver- Processing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Appointments rescheduled\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eAdding pre-check phone calls for all patients to avoid DNA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eDefects\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\n \u003cp\u003ePoor environment of care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eMissing information in referral forms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"5.980528511821975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.769123783031988%\" valign=\"top\"\u003e\n \u003cp\u003eSkills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.39221140472879%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"57.85813630041724%\" valign=\"top\"\u003e\n \u003cp\u003eClinicians follow up with referral sources\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFurther discussion of our TIMWOODS analysis with stakeholders revealed the following:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eGemba observations evidenced up to four staff involved in the processing of one standard referral received. There was excessive movement of staff and patient files between rooms.\u003c/li\u003e\n \u003cli\u003eAn absence of any referral management system produced excessive motion for administrative staff.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePatient flow within the clinic was heavily influenced by administrative staff processing arriving referrals.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAdministrative staff were observed contacting patients\u0026apos; parents/families in advance to mitigate against DNA.\u003c/li\u003e\n \u003cli\u003eClinical staff following up with referrers and patients were missed appointments had occurred.\u003c/li\u003e\n \u003cli\u003eAdministrative staff spending time on processing referrals and offsetting DNAs, and not developing solutions.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWhen staff were unable to contact patients\u0026apos; parents to follow up on referrals via SMS (text message) or phone, it often resulted in non-attendance (Do Not Attend/DNA) which averaged at 20% per clinic. \u0026nbsp;This increased the time children were waiting to be seen by the appropriate clinician. \u0026nbsp;The time spent by administrative staff trying to contact these parents had a corresponding impact on clinic flow with administrative staff diverted to follow up calls increasing waiting times for children and their families in terms of their actual waiting time in the clinic on the day of their appointments.\u003c/p\u003e\n\u003cp\u003eVOC sessions with the children, their parents, and staff showed consensus that the clinic environment itself was not fit for purpose and was not designed with the child in mind. Families interviewed were struggling to find the clinic, consequently arriving late to their appointments. There was poor seating, no stroller parking, limited signage, poor contrast sensitivity and a poorly illuminated environment. All of these issues impacted on visually impaired children.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese themes representing NVA were then further evaluated with clinic staff in a further series of workshops facilitated by the project team, using an Ishikawa diagram (Figure 3) enabling identification of potential root causes of the issues to be considered [42] to facilitate solution generation within the clinic.\u003c/p\u003e\n\u003cp\u003eAfter brainstorming solutions with the clinic staff, a second modified Ishikawa Diagram was developed in collaboration with them (Figure 4). The potential highest impact solutions to the root causes identified were the implementation of a standardized referral management system, an online patient appointment system, in addition to a review of the current physical layout of the clinic to enhance the environment of care.\u003c/p\u003e\n\u003cp\u003eFollowing the development of the Ishikawa diagrams, the team made use of a Failure Modes and Effects Analysis (FMEA), which is a systematic method to identify where and how a process might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change [43].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWorking with staff, building on our collected data and our process maps, we identified potential failure modes for each of the co-designed solutions of an online referral form, online patient management system and child-friendly environment, identified within the Ishikawa exercise (figure 4).\u003c/p\u003e\n\u003cp\u003ePotential failure modes for an online referral form were:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eincomplete referral forms and referral duplication as well as referrals sent to the wrong person and not being triaged on time.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePotential failure modes for an online management system were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003esoftware malfunction\u003c/li\u003e\n \u003cli\u003eamending templates which required external support\u0026nbsp;\u003c/li\u003e\n \u003cli\u003einadequate staff training resulting in an inability to operate the system\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003ePotential failure modes for implementation of the child-friendly environment were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003epotential budgeting issues and problems with procuring stock.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe use of the FMEA in conjunction with the use of the Ishikawa tool (figures 3-4) enabled us to collaborate with and codesign solutions with the staff working within the clinic.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6 Improvement/solutions\u003c/p\u003e\n\u003cp\u003eThe co-designed solutions focused on the main failure modes as outlined below.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6.1 Incomplete referral forms\u003c/p\u003e\n\u003cp\u003eIn order to improve the statistics on right-first-time referrals, both staff at the study site, and referrers agreed that a move to an electronic online referral form was the best option. \u0026nbsp;This would enable patient status check at a glance and comprise compulsory fields to obviate NVA in follow up activity for administrative staff. The following fields were considered the minimum compulsory data required for any new online referral form:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eName DOB, address, gender\u003c/li\u003e\n \u003cli\u003eVisual acuity measurement\u003c/li\u003e\n \u003cli\u003eDate referral\u003c/li\u003e\n \u003cli\u003eName of referrer\u003c/li\u003e\n \u003cli\u003eAdditional needs\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e2.6.2 Electronic referral system\u003c/p\u003e\n\u003cp\u003eStaff reached consensus that the referral management system process should move from a manual paper-based system, and proposed using the project findings to support a business case to implement a new electronic system and move to electronic online referrals. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6.3 Implementation of a child-friendly environment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt was agreed there was a need to procure appropriate children\u0026apos;s chairs and tables with associated accessories (coloring books and crayons) for the waiting area (figure 5). In addition to this, we conducted an access improvement audit with the help of design specialists already working within the ophthalmology service to generate recommendations for signage and colors suitable for visually impaired children. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the outcomes of the access audit, we implemented a Wayfinding Strategy, including Assistive Technologies to positively impact the safety and psychological wellbeing of clinic attendees. This took the form of the provision of new accessible signage, inclusive of patient and family approach to the clinic, the lift/elevator access and a means to easily locate the Eye Clinic reception to ensure it is accessible to everyone. We also ensured that all pre-visit correspondence and information relating to access and wayfinding was consistent with on-site directional information. Upon review of internal environments, it was noted that backgrounds, color contrast and lighting were completely inadequate for people with visual impairment. To ensure safety during navigation we worked to ensure legibility of signage and adequate illuminance throughout.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.6.4 Funding the improvement\u003c/p\u003e\n\u003cp\u003eThe problem statement, collected data, findings of the root cause analysis and potential solutions generated by the staff working within the clinic were presented to the ophthalmology service management team. The average time spent on incomplete referrals at 20 minutes, and the 33% of referrals that were not right first time, alongside staff, referrer and patient voice of the customer data were seen as a compelling case for change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding for the online referral system was successfully secured from the annual allocated Health Services Executive budget for the locality. The ophthalmology service was familiar with online providers of a scheduled booking system, that was currently in use in phlebotomy services, and were able to leverage existing agreements to secure an extension of the online scheduled booking system to the ophthalmic clinic. Furniture suitable for the demographic of a paediatric clinic was secured from existing stock within the wider service, and the access and wayfinding strategies were cost neutral as part of an ongoing review of signage overall.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFollowing the approval and implementation of the co-designed solutions, the project team achieved the following results.\u003c/p\u003e\n\u003cp\u003e3.1 Improved staff satisfaction\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe staff feedback was predominantly \u0026lsquo;very satisfied\u0026rsquo; with the implementation of the new electronic online referral management system showing\u0026nbsp;staff confidence with the accuracy of the referral management system increased from 70 to 79%.\u003c/li\u003e\n \u003cli\u003eA post-implementation survey of clinic staff showed an improvement in satisfaction with the referral process workload from \u0026nbsp;38% to \u0026nbsp;98% positive post improvement.\u003c/li\u003e\n \u003cli\u003eA post implementation survey of attending children and families indicated an improvement in satisfaction with the clinic experience overall from 38% to 98% positive.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;Staff evidenced they were \u0026lsquo;very satisfied\u0026rsquo; with the induction to and training on the new electronic referral system and expressed confidence in tracking referrals across the system.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePost implementation Gemba illustrated that staff now have demonstrably less manual paperwork to complete and more efficient clinic throughput due to released time to concentrate on the clinic flow rather than referrals. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e3.2 Improved patient satisfaction\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePatients and their families are moving through an environment more conducive to care with an improved user experience due to user friendly signage and a child appropriate environment of care.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eStaff time released through the use of the electronic referral management system means they are available to answer patient and family queries and assist them through their clinic journey. Within the study site clinics are finishing on time and running more efficiently.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePost implementation patient satisfaction with their clinic experience has increased from a pre intervention satisfaction rate of 48% to 98 %. Parents feedback indicated that the new wayfinding strategy and child-friendly environment made visiting the clinic less stressful for both them and their children. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e3.3 Patient treatment in the appropriate setting\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eStreamlined processes within the referral system have enabled increased capacity for patients within the clinic, facilitating the local paediatric hospital in its ability transfer the less complex paediatric ophthalmology cases to the community.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e3.4 Time saved in the referral process\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre-intervention patient record data on wait times for what specify was recorded over three months between September \u0026ndash; November 2022 and post-intervention in April 2023. It indicated the following:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIntroduction of the electronic referral management systems to manage online referrals from pre-referral triage to allocation of available time slots lead to \u0026nbsp;4 minutes saved per each individual patient referral.\u003c/li\u003e\n \u003cli\u003eThe service has achieved a right first-time referral status of 98% from a baseline of 67%\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003efor referrals to the service, following the implementation of the mandatory data set in the new electronic referral form.\u0026nbsp;This eliminates the issues identified within our TIMWOOD analysis (table 3) with a marked reduction in follow-up phone calls to patients or referring clinicians for missing information.\u003c/li\u003e\n \u003cli\u003eThe combination of increased accuracy of referrals and corresponding reduction of rework/follow up on referrals, enable a prompt clinician triage of the referrals and facilitates earlier patient scheduling for treatment.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn summary, the improved efficiency of the referral and triage process means patients are seeing an appropriate medical professional at the right time in accordance with their clinical needs. Streamlining the work process, and cutting down non-value-added tasks, has freed up staff to carry out more value-add functions.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe goal of this study was to improve the Right First Time statistics on referrals received,\u0026nbsp;reduce administrative staff time spent on the referral management and to collaborate with clinic staff and attending children and their families to co-design a more person-centred, appropriate child-friendly environment. \u0026nbsp;To do this we utilized a Person-centred Lean Six Sigma model, developed in healthcare and currently in use in healthcare settings in 6 countries [26]. Table 4 gives a high level overview of the achieved goals.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 4: Summary of results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGoal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% increase/decrease\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eImprove the Right First Time (RFT) statistics on referrals received\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003e67% RFT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003e98% RFT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e46% percentage increase in RFT referrals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eReduce administrative staff time spent on the referral management process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003eAverage 20 minutes per single referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003eAverage 16 minutes per single referral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e20% percentage decrease in time spent per single referral\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eCo-design solutions with staff: Staff confidence in accuracy of child referral to clinic process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003e70% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003e79% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e13% percentage increase in confidence in the referral system accuracy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eCo-design solutions with staff: Staff satisfaction with workload involved in the child referral to clinic process\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003e38% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003e98% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e158% percentage increase in satisfaction with workload involved in process\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eCo-design solutions with patients: Child and family satisfaction with clinic experience\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.299145299145298%\" valign=\"top\"\u003e\n \u003cp\u003e48% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.28205128205128%\" valign=\"top\"\u003e\n \u003cp\u003e98% positive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.88888888888889%\" valign=\"top\"\u003e\n \u003cp\u003e104% percentage increase in patient satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.52991452991453%\" valign=\"top\"\u003e\n \u003cp\u003eUse person-centred principles to inform how we worked as a team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"60.47008547008547%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003ePerson-centred principles used throughout intervention.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;We now discuss key success factors which enabled improvement within the study site.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.1 Key success factors\u003c/p\u003e\n\u003cp\u003e4.1.1 Motivated and engaged project team and stakeholders\u003c/p\u003e\n\u003cp\u003eThe success of the project was enabled by motivated project team members and clinical staff in the community paediatric eye clinic with senior management support. As outlined, our project team consisted of process owners (those working within the process to be improved) two paediatric ophthalmology doctors working in the community clinic, the Chief Services Officer at Vision Ireland, a data analytic manager from the nearby tertiary hospital, and our team mentor. \u0026nbsp; The fundamental desire of all team members and healthcare professionals involved was to improve user experience of the clinic and reduce time from referral to appointment to ultimately prevent visual impairment in children, a vulnerable group of patients who cannot advocate for themselves. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.1.2 Co-designed solutions\u003c/p\u003e\n\u003cp\u003eThe solutions were co-designed with the project team and were fully inclusive of child and family voice. The problem statement was explored and solutions were incrementally developed using the DMAIC framework, allowing for authentic engagement with all stakeholders. \u0026nbsp;The timeframe of the project allowed for critical reflection about the insights provided by our data collection and root cause analysis and ensured that the clinic staff and the children and families were active partners in redesigning the process. \u0026nbsp;We took the approach that rather than merely capturing patient experience data, we should be embedding co-design practices and values in our project, avoiding tokenistic patient involvement and making sure they had meaningful involvement in the process redesign.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.1.3 A person-centred approach\u003c/p\u003e\n\u003cp\u003eThe Person-centred Lean Six Sigma model emphasizes the development of person-centred improvement through the use of collaborative, inclusive and participatory (CIP) principles [13,23,26]. As discussed, as a project team we wanted to collaborate authentically with the staff and patients involved in the paediatric ophthalmology clinic, enabling us to draw on their extensive knowledge [48]. The Person-centred Lean Six Sigma model [26] outlines the factors that staff consider respectful when participating in Lean Six Sigma interventions included [13]:\u003c/p\u003e\n\u003cp\u003e\u0026bull; Well organized and timely communication\u003c/p\u003e\n\u003cp\u003e\u0026bull; Openness to new ways of working\u003c/p\u003e\n\u003cp\u003e\u0026bull; Management actively and visibly supporting and leading on improvement culture\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026bull; An explicit focus on staff experience in addition to that of patients\u003c/p\u003e\n\u003cp\u003e\u0026bull; Staff respect and support for each other when involved in process improvement\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThroughout the project timeline, we focused on timeliness, clarity and conciseness of communication both within the project team and with our stakeholders. Staff expressed an openness and willingness to change, and senior management within the service were supportive of the project from the outset. \u0026nbsp;We were clear that we would focus on the impact of the improvement project on patients, but also consider the needs of staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe project team feedback on the project was overall very positive. \u0026nbsp;As a team we felt that we had achieved outcomes by working together as an empowered and valued team of healthcare practitioners in collaborative, inclusive and participatory ways to plan and deliver on improvement [49]. We felt that the Lean Six Sigma education and training program enabled us as practitioners using both Lean Six Sigma and person-centred methodologies to promote person-centred, holistic and individualized care [50].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.1.4 Empowerment\u003c/p\u003e\n\u003cp\u003eIn creating conditions to empower individuals to voice concerns and seek solutions, our person-centred approach drew on the collective leadership pillars of performance, safety, wellbeing, team process and sustaining improvement [51] which we encapsulated by our ways of working together as a project team. This collective approach, which is synonymous with Lean Improvement acknowledged the essential requirements of active stakeholder engagement and empowerment in any quality-improvement strategy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo further involve children and their parents in the ongoing development of the ophthalmology service, the access audit results led to a follow up recommendation to the clinic management team for consideration of a patient advisory group to ensure a quality and customer focus and ascertain rich feedback. The purpose would be to empower children and families accessing primary eye care services to be involved as active and equal partners to inform and contribute to the ongoing design of the service. This recommendation has been carried forward to management for discussion and action.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e4.1.5 Looking forward\u003c/p\u003e\n\u003cp\u003eThe solutions implemented in this study have positively affected the paediatric eye clinic in the community clinic by improving patient both child, family and staff experiences of the service. \u0026nbsp;The primary goals of an improved right first time referral accuracy (post intervention 98%), releasing staff time from processing referrals (3-4 minutes per referral post intervention) and improving the environment of care, have been achieved. \u0026nbsp;The ease of access to referral data from the new electronic system facilitates oversight of referral sources and the clinician referred to, strengthening newly established links between tertiary services and the community in ophthalmology. These channels of communication are important to protect, nurture and maintain these links and networks\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMuch of the literature on community paediatric clinics highlights that they increase parental choice and access to paediatric services, increasing service flexibility and reducing unnecessary hospital visits [17]. Looking forward, the improved speed of the referral process has enabled the generation of more appointments, meaning the clinic will have the capacity to see more patients and to potentially review suitable cases that are on the waiting list in nearby tertiary hospitals. \u0026nbsp;However, we note that this also has the potential for increased pressure on ophthalmologists in the community meaning more ophthalmology consultant support may be required. Our project has in effect highlighted the recommendations within the Primary Care Eye Services Review [1] to move less complex paediatric ophthalmic cases to the community.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWithin this study we highlighted the importance of the correct choice and use of Lean Six Sigma tools, however we have also demonstrated that Lean Six Sigma as an improvement methodology is about more than, and should not be reduced to, a decontextualized toolkit [6,13,25,26]. Rather we have highlighted the importance of engagement with all those involved in the process of care, both recipients of care (patients and their families) and providers of care (healthcare staff). Our work in implementing a Person-centred Lean Six Sigma redesign of outpatient scheduling provides valuable insights and learning for others relating to the focused use of Lean Six Sigma principles on improving efficiency, reducing waste, and enhancing overall process performance. \u0026nbsp;A key learning from this improvement project for other outpatient services is that implementing a systematic approach to clinic scheduling can be applied to multiple types of clinics within both paediatric and adult settings. Future studies in the ophthalmology service intend to look at if the process redesign has impacted on non-attendance rates in the clinic and if the capacity created by timely appointments has had any impact on waiting lists for paediatric ophthalmology clinics in the nearby tertiary center.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA limitation of this study was the extensive time that was required for stakeholder engagement, which is essential for any improvement initiative. Whilst Lean Six Sigma improvement efforts may require a significant time investment, the potential benefits, as demonstrated in this study, such as increased efficiency, customer satisfaction, and overall clinic effectiveness, often outweigh the initial time and resource costs. An important lesson we learned as a team is that it is important to approach quality improvement with a long-term perspective, recognizing that the time spent upfront can lead to lasting positive changes. \u0026nbsp; Another limitation was that this was a study within a single site location, and as a pilot study, we could only examine the feasibility of the intervention topic (paediatric ophthalmic outpatient clinics) included in this study. However, we believe it has implications for other hospital sites seeking to improve their outpatient scheduling processes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe contend that underpinning our Lean Six Sigma framework with a person-centred approach supported our team formation, building consensus on the project direction and facilitating our working together with stakeholders to deliver on improvement. \u0026nbsp;Our approach aimed to support staff and patients through mutual respect and empowerment [52]. Our collaborative practice in this project recognized the value of and respected stakeholders diverse perspectives, skills, knowledge, and experiences. It enabled us to develop a consensus that our work was based on an understanding that Lean Six Sigma is more than a set of quality-improvement tools and techniques [6,53] but values people and their beliefs and values [54]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of Lean Six Sigma methodologies allowed the team to quantify the existing process, identify problem areas and provide a suitable solution, whilst person-centred principles underpinned how we engaged with staff, children and their families, and how we worked together as a team. The improvement project has resulted in long-term changes with an improved referral system to facilitate timely triage of children for the community ophthalmic pathway and future-proofed the system for audit, by implementing an electronic referral management system that allows for rapid real time and retrospective data collection. We purport that this study, to our knowledge, the first of its kind in paediatric ophthalmology, will assist healthcare professionals understand the work involved in the successful deployment Lean Six Sigma model in paediatric healthcare settings, underpinned by Person-centred principles, in order to improve operational efficiency and promote enhanced patient and staff satisfaction.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePerson-centred Lean Six Sigma Model (PCLSSM)\u003c/p\u003e\n\u003cp\u003eDMAIC-Define, Measure, Analyze, Improve Control\u003c/p\u003e\n\u003cp\u003eFMEA-Failure Modes and Effects Analysis\u003c/p\u003e\n\u003cp\u003eNVA-Non-Value Add\u003c/p\u003e\n\u003cp\u003eQI-Quality Improvement\u003c/p\u003e\n\u003cp\u003eVOC-Voice of the Customer\u003c/p\u003e\n\u003cp\u003eDNA-Did Not Attend\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Those involved in the study give their consent for publication\u003c/p\u003e\n\u003cp\u003eData Availability: All data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no external funding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Conceptualization CB, AM, OY and BT; methodology CB, AM, OY, BT; formal analysis CB, AM, BT and OY.; investigation CB, AM , BT and OY \u0026nbsp;data curation CB, AM, OY, BT \u0026nbsp;writing\u0026mdash;original draft preparation CB writing\u0026mdash;review and editing, CB SPT visualization SPT supervision SPT, All authors have read and agreed to the published version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003ethe authors would like to acknowledge all the staff at Grangegorman Community eye clinic, Dublin Ireland.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHSE Primary Care Eye Services Review Group Report 2017; Accessed online [https://www.hse.ie/eng/services/publications/primary/eye-services-review-group-report.pdf]\u003c/li\u003e\n\u003cli\u003eNational Treatment Purchase Fund 2023.\u003c/li\u003e\n\u003cli\u003eBirch EE. 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(Last accessed 27th November 2022)\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4228153/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4228153/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eProcess improvement methodologies such as Lean Six Sigma are increasingly being deployed to address inefficiencies in healthcare. Simultaneously policy and strategy development globally stress the value of person-centredness as the preferred approach in healthcare. This paper addresses the use of a Person-centred Lean Six Sigma Model (PCLSSM) to support process improvement in the study site, a paediatric eye care clinic.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWithin the study site the referral process of children by relevant clinicians to the specialist clinic was experienced by referrers, parents of referred children and clinic staff as not fit for purpose. We applied the PCLSSM to improved the patient experience and efficiency of the clinic.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eApplication of the PCLSSM to manage improvement resulted in five key outcomes: a 46% percentage increase in right first time accuracy of children\u0026rsquo;s referrals to the service, with a corresponding a 20% percentage decrease in time spent managing referrals, a 13% percentage increase in staff confidence in the referral system and 158% percentage increase in staff satisfaction with workload. Importantly there was a 104% percentage increase in child and parent satisfaction with their clinic experience.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study will assist healthcare professionals understand the work involved in the successful deployment of a PCLSSM in paediatric healthcare settings, in order to improve operational efficiency and promote enhanced patient and staff satisfaction.\u003c/p\u003e","manuscriptTitle":"Using a Person-centred model of Lean Six Sigma to support process improvement within a paediatric primary eye care clinic","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-11 16:23:09","doi":"10.21203/rs.3.rs-4228153/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cee53135-4056-471f-9b9c-caeb87706ad0","owner":[],"postedDate":"April 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-26T14:39:45+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-11 16:23:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4228153","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4228153","identity":"rs-4228153","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}