In quality improvement engineering there are many tools. I would like to illustrate a few and show how they can apply to healthcare. I will be using tools taken from Lean Manufacturing, an approach used at Toyota Motor Company for many years now. These tools are easily adaptable with a bit of imagination to healthcare. I am not proposing that all healthcare should blindly adopt Lean as the new “flavor of the month,” but if some of the tools fit your site well, then use them. From my experience, the best progress in quality at a site is in the identification and use of quality improvement tools that can be mastered by the employees of the site. There is no use in being a Jack-of-all-trades and master of none.

Two tools that seem to go hand in hand are 5S and Point of Use Storage. 5S is sort, set in order, shine, standardize and sustain. In the most recent issue of Quality Progress (American Society of Quality’s magazine) these tools were applied to storage areas. A storage area should only contain items that are useful to tasks that are performed nearby. For instance in an examination room there should be a good assortment of bandages, but it probably doesn’t make sense to store printer ink in the exam room. This is an example of point of use storage. Further, any storage area no matter the size should be well ordered. You don’t want to have too many of any one item; it is better to have in stock what is needed for a day or two and restock as needed. That way, you can have a wider variety of items in the storage area and will waste less time going to look for a supply when it is needed and it isn’t nearby.

Besides having the right amount of items in a storage area, you should have it arranged so that the most frequently used items are easiest to access. A way to make sure that this order is maintained is to have a diagram in the storage area showing where things are located. That way, whenever restocking occurs, items will be placed in the right place so anyone who uses the supplies can easily find them. With a diagram of the work area a person using it for the first time will be easily able to locate an item. A good rule is that anyone should be able to find any item in 30 seconds or less.

Finally, in arranging a storage area, be sure to get rid of any outdated items. If an item is rarely used in activities near that storage area be sure to transfer it to the point where it would be most useful or if no one uses it, dispose of it. Of course, this arrangement of stored items will only be successful if most everyone will work at maintaining it.

Another useful tool in lean is to eliminate wasted effort. One glaring example that I have seen is the amount of time nurses have to expend in getting prescriptions refilled for patients at primary care sites. The nurses and other representatives from the staff should examine the process of refilling patient prescriptions by drawing a diagram of the process (value stream mapping) and measure how much time each step takes and which are really needed in the process. I bet that some steps can be eliminated and thus time saved. One suggestion that I have is for prescriptions that are used over a long period of time, such as hormone replacement medications. Why not move the patient into ordering 3 months of the prescription at a time through a mail order pharmacy? It may take a bit of effort to move a patient into this habit, but is will save a lot of time in the long run for an office and will free nurses to do much other needed tasks. The patient will also be happier as they can usually save money by ordering in this fashion. My wife and I order all our recurring prescriptions this way and easily save over $200 per year.

Many in healthcare think that these tools are not useful to them. Recently I was talking to someone about using Lean principles in their office. This person thought that because health plans had so many rules applying to such things as coding and billing and other documentation that there was little room for improvement. To me this is an illustration of lack of communication among the various people on staff. If a team was formed of representatives from the staff and the above tools examined I know that the team could find many ways to find savings in time, money and effort similar to the ones that I chose to illustrate. Once the processes are identified and standardized, then the site can continue seeking ways to further improve in a process of continuous quality improvement.

Donald Bryant helps healthcare providers meet their challenges and writes
“Making Good Healthcare Better” a free monthly ezine for healthcare
providers who want to dramatically improve patient health, improve the
bottom line, and make work more rewarding, guaranteed. Go now to
http://www.bryantsstatisticalconsulting.com to get a free article with tips you can use to start making improvements immediately and to learn more about Lean Healthcare

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The symptoms discussed here are only a selection of the more common types of thing that can cause your dog problems. If you notice these symptoms or anything else you are unsure of you should contact your vet immediately, early detection of problems will save your pet more discomfort in the long run and it is often quite astounding how quickly some diseases can take hold and cause other health problems for your dog

The Respiratory Tract: The most common problem that affects the respiratory tract is some kind of obstruction that occurs.

Watch for: Mouth breathing, Persistent sneezing accompanied by nasal discharge, Gagging, Snoring, Hacking cough, Nasal discharge, Retching, Vomiting, and Rapid and Shallow respiration.

The Urogenital System: Watch for the following symptoms and consult your veterinarian if symptoms persist.

Trouble Signs: Depression, Vomiting, Diarrhoea, Rise in temperature, Pain in the kidney region, Scanty Urine Flow, Foul Breath, Weight Loss, Digestive upsets, Nervousness, Lumbar Pain, Straining to urinate, Frequent urination becoming uncontrollable, Blood in the urine, and walking in a crouched position.
General Infection: Dogs are susceptible to a wide range of bacterial and viral infection. The best way to prevent these types of infections is to vaccinate your dog. Puppies should be fully vaccinated by 12 weeks of age, and should receive their rabies vaccination at 6 months of age, and every year thereafter. Many infections can be extremely serious and life threatening. If you see any of these warning signs, you should consult your veterinarian immediately!

Trouble Signs: Runny eyes, Runny Nose with white discharge, Coughing, Red Throat, Fever, Loss of appetite, listlessness, Enlarged Tonsils, Intense thirst, Diarrhoea, Blood in the stool, Muscle stiffness, Rigidity of the tail, Stiffness in gaiting, and Vomiting.

Please do not let this list of symptoms and problems put you off owning and loving a dog, they are a great addition to any loving family and the purpose of this article is not to scare you, it is just you are going to be spending a lot of time in close contact with a member of the family who can not tell you if they are feeling unwell. We hope that if you are able to recognise the signs of a problem then you will be able to give the dog the help he needs.

http://www.tall-indoor-dog-gates.com Tall indoor dog gates is a site dedicated to dog training and healthcare - give us a visit.

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Over the past decade, the world of pharmaceutical communications has changed significantly. In the late 1990s, drug companies spent hundreds of millions of dollars on direct-to-consumer (DTC) advertisements that made drugs like Viagra and Prilosec household names.

Today, the threat of government regulation and widespread criticism has forced the industry to change its marketing tactics. Drug companies are currently shifting marketing dollars from product promotion to education. In this article, I ask and answer five tough questions about current and future trends in pharmaceutical marketing.

Q1: Should pharmaceutical companies be allowed to market their products?

A1: Yes. Drug companies have a responsibility to deliver value to their stockholders, investors and other stakeholders. In an ideal world companies would make products that sell themselves. You don’t need an advertisement to sell a cure for cancer. However, most products are not cure-alls. Rather they represent incremental advances in a number of conditions. Companies also invest research dollars into medications that are for purely cosmetic or lifestyle uses (e.g., Viagra, Ambien). In short, drug firms have every right to promote their products. However, it should be done responsibly. This means companies should:

- Adhere to the industry trade group PhRMA’s voluntary guidelines on direct-to-consumer DTC advertising (no reminder ads, wait an appropriate period of time before starting advertising for a new medication).

- Highlight the benefits and risks of medications in ways people can understand and act on.

Q2: Should the FDA ban direct-to-consumer advertising?

A2: I don’t think that the FDA would be able to ban DTC advertising due to 1st amendment concerns. However, I do believe that the FDA can do more to regulate drug advertising. Most importantly, the agency needs to figure out a better way to monitor and regulate pharmaceutical advertising.

Although companies submit advertising to the FDA’s Division of Drug Marketing, Advertising and Communications (DDMAC) when they first appear, the agency does not vet all promotional material. In fact, a December 2005 Pharmaceutical Executive article noted that the FDA has 35 staffers in the DDMAC office who are responsible for reviewing 53,000 promotional items a year.

Perhaps one solution is to dramatically increase funding for DDMAC by implementing a user-fee system similar to the one the FDA introduced to speed approval of medications. To prevent backlogs, the agency could focus on reviewing advertisements for drugs or devices that will be used in significant numbers of patients.

Q3: Should medical journals ban advertisements from drug makers?

A3: In an article published in the June 2006 edition of PLoS, Adriane Fugh-Berman, Karen Alladin and Jarva Chow suggest that “medical journals should not accept advertisements from pharmaceutical companies, medical device companies, or other industries ‘relevant to medicine.’”

This an interesting idea, but it is neither feasible or appropriate. Journals have well-established policies governing how they handle advertising from drug companies and how to separate the marketing and editorial departments. Not all publications are perfect. Some journals are not very credible because of a weak peer-review process or a perception that they do not have the resources (or reputation) to attract excellent scholarship.

In addition, anecdotal evidence indicates that many healthcare providers learn about new medications or devices via journal advertisements. If something is not advertised, a physician won’t know about it. Rather than focusing on drug advertising, journals should continue to shore up their peer-review and editorial review processes.

Q4: Does the pharmaceutical industry engage in “disease mongering”?

A4: This is not a new complaint. Critics of the pharmaceutical industry have long maintained that companies have turned ordinary aliments into diseases in order to turn a profit. My short answer is “yes and no.” Like many others, I believe that certain conditions are more legitimate than others. I’d rather companies spend less time promoting some “cosmetic” conditions and more time focusing on life threatening conditions like diabetes, cancer, high blood pressure and drug-resistant bacterial infections.

Q5: Do we need more or less safety information in drug labels?

A5: Yes, yes, yes. In this era of “consumer-driven healthcare,” people need more information about the risks and benefits of medications. More risk information may lead to better informed patients and better decision-making.

Fard Johnmar is founder of Envision Solutions, L.L.C., a full-service healthcare
marketing communications consulting firm. Envision Solutions provides
innovative products and services to not-for-profit and for-profit
organizations. For more information and insights on pharmaceutical marketing, pick a copy of Envision Solutions’ report, “Pharmaceutical Communications: Past, Present & Future Trends.” To learn more about this valuable resource, please visit http://www.envisionsolutionsnow.com/spotlight2.

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