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Though lean manufacturing has been widely recognised for its effectiveness in continuously improving productivity, product quality, and on-time delivery to customers, the cost for hiring a full-time lean manufacturing engineer has kept many small businesses from implementing lean in their facilities. This paper presents a case study of lean implementation at a small manufacturer in the United States. Starting with collecting process information, a current value-stream map was created that reflected the current operation status. A future value stream map was then proposed to serve as a guide for future lean activities. Next, hurdles that kept the company from moving towards future state were identified. The '5 whys' method was employed to reveal the root cause for each hurdle, followed by kaizen events proposed as solutions. In this case study, two kaizen events were proposed. For the first kaizen event, Taguchi experiment design was used to find the optimal machining parameters that reduced variation in a plasma cutting process. It consequently eliminated rework time and improved productivity. In the second kaizen event, implementation of rabbit chasing increased the system flexibility and consequently reduced inventory levels between work stations. [ABSTRACT FROM AUTHOR]

Background: This study examined the changes in outpatient palliative care services at US cancer centers over the past decade.Methods: Between April and August 2018, all National Cancer Institute (NCI)-designated cancer centers and a random sample of 1252 non-NCI-designated cancer centers were surveyed. Two surveys used previously in a 2009 national study were sent to each institution: a 22-question cancer center executive survey regarding palliative care infrastructure and attitudes toward palliative care and an 82-question palliative care program leader survey regarding detailed palliative care structures and processes. Survey findings from 2018 were compared with 2009 data from 101 cancer center executives and 96 palliative care program leaders.Results: The overall response rate was 69% (140 of 203) for the cancer center executive survey and 75% (123 of 164) for the palliative care program leader survey. Among NCI-designated cancer centers, a significant increase in outpatient palliative care clinics was observed between 2009 and 2018 (59% vs 95%; odds ratio, 12.3; 95% confidence interval, 3.2-48.2; P < .001) with no significant changes in inpatient consultation teams (92% vs 90%; P = .71), palliative care units (PCUs; 26% vs 40%; P = .17), or institution-operated hospices (31% vs 18%; P = .14). Among non-NCI-designated cancer centers, there was no significant increase in outpatient palliative care clinics (22% vs 40%; P = .07), inpatient consultation teams (56% vs 68%; P = .27), PCUs (20% vs 18%; P = .76), or institution-operated hospices (42% vs 23%; P = .05). The median interval from outpatient palliative care referral to death increased significantly, particularly for NCI-designated cancer centers (90 vs 180 days; P = 0.01).Conclusions: Despite significant growth in outpatient palliative care clinics, there remain opportunities for improvement in the structures and processes of palliative care programs. [ABSTRACT FROM AUTHOR]

Increasing numbers of underrepresented minorities in medicine (URMM) have garnered increased attention, especially since the number of black men in medical school is lower now than in the 1970s (Association of American Medical Colleges [AAMC], 2015; Laurencin & Murray, 2017). Minorities oftentimes face discrimination and academic medicine is not an immune environment. A support for URMM individuals has been diversity offices. Many started as minority affairs offices focusing on increasing numbers of URMMs, being defined as African-Americans or Blacks, Native Americans, Mexican Americans, and mainland Puerto Ricans (AAMC, 2004). Offices have evolved to serving the entire Latino population, LGBTQ population, veterans, women of all races and others. With this evolution, racial/ethnic minority affairs offices have become diversity offices, with names and missions directed by the sponsoring medical school. [ABSTRACT FROM AUTHOR]

In light of the unprecedented terrorist assaults on September 11, 2001, this research attempts to assess their underlying impacts on travel arrangements and business practices. A questionnaire reflecting the objectives of the study is developed accordingly. To gather the empirical data, this research draws samples from an academic community consisting of faculty, staff, and students. This study first reveals that the level of perceived risk differs among the respondents; students tend to be risk-takers while faculty and stall could be considered as risk-averters. In large, respondents agree that the recovery of airline business will take at least a year. As for travel arrangements, participating in leisure activities around government buildings notably decreases. Regarding tourism practices, it indicates that both governments and businesses have taken rightful measurements against future terrorist movements. Critical marketing implications along with suggestions for future research are discussed in the conclusion section. [ABSTRACT FROM AUTHOR]

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This research delineates the change of Asian outbound travelers' consumption patterns due to the effect of the economic crisis prevailing in Asian countries since late 1997. The study populations are Japanese, Taiwanese, and South Korean travelers to the U.S. between 1997 and 1998. Four consumption patterns are examined by logit analyses. The resulting data reveal that Japanese travelers have significant changes in information acquisition; Taiwanese travelers exhibit significant change in the length of trip; and South Korean travelers show the changes of consumption patterns in three categories, including information acquisition, transportation mode, and length of trip. Tour package is the only consumption pattern that has not changed among the three groups of tourists after the crisis. In the conclusion, marketing strategies are provided for international tourism practitioners focusing on Japanese, Taiwanese, and South Korean outbound travelers to the U.S. [ABSTRACT FROM PUBLISHER]

Objectives: To compare cancer centre (CC) executives' attitudes towards palliative care between National Cancer Institute-designated CCs (NCI-CCs) and non-NCI-designated CCs (non-NCI-CCs) in 2018 and to examine the changes in attitudes and beliefs between 2009 and 2018., Methods: CC chief executives at all NCI-CCs and a random sample of non-NCI-CCs were surveyed from April to August 2018. Twelve questions examined the executives' attitudes towards palliative care integration, perceived barriers and self-assessments. The primary outcome was agreement on the statement 'a stronger integration of palliative care services into oncology practice will benefit patients at my institution.' Survey findings from 2018 were compared with data from 2009 to examine changes in attitudes., Results: 52 of 77 (68%) NCI-CCs and 88 of 126 (70%) non-NCI-CCs responded to the survey. A vast majority of executives at NCI-CCs and non-NCI-CCs endorsed palliative care integration (89.7% vs 90.0%; p>0.999). NCI-CCs were more likely to endorse increasing funding for palliative care (52.5% vs 23.1%; p=0.01) and hiring physician specialists (70.0% vs 37.5%; p=0.004) than non-NCI-CCs. The top three perceived barriers among NCI-CCs and non-NCI-CCs were limited institutional budgets (57.9% vs 59.0%; p=0.92), poor reimbursements (55.3% vs 43.6%; p=0.31), and lack of adequately trained palliative care physicians and nurses (52.6% vs 43.6%; p=0.43). Both NCI-CCs and non-NCI-CCs favourably rated their palliative care services (89.7% vs 71.8%; p=0.04) with no major changes since 2009., Conclusion: CC executives endorse integration of palliative care, with greater willingness to invest in palliative care among NCI-CCs. Resource limitation continues to be a major barrier., Competing Interests: Competing interests: DH received grants from Helsinn outside the submitted work., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: It is unclear how well palliative care teams are staffed at US cancer centers. Our primary objective was to compare the composition of palliative care teams between National Cancer Institute (NCI)-designated cancer centers and non-NCI-designated cancer centers in 2018. We also assessed changes in team composition between 2009 and 2018. Methods: This national survey examined the team composition in palliative care programs at all 61 NCI-designated cancer centers and in a random sample of 60 of 1252 non-NCI-designated cancer centers in 2018. Responses were compared to those from our 2009 survey. The primary outcome was the presence of an interprofessional team defined as a palliative care physician, nurse, and psychosocial member. Secondary outcomes were the size and number of individual disciplines. Results: In 2018, 52/61 (85%) of NCI-designated and 27/38 (71%) non-NCI-designated cancer centers in the primary outcome comparison responded to the survey. NCI-designated cancer centers were more likely to have interprofessional teams than non-NCI-designated cancer centers (92% vs 67%; P  = .009). Non-NCI-designated cancer centers were more likely to have nurse-led teams (14.8% vs 0.0%; P  = .01). The median number of disciplines did not differ between groups (NCI, 6.0; non-NCI, 5.0; P  = .08). Between 2009 and 2018, NCI-designated and non-NCI-designated cancer centers saw increased proportions of centers with interprofessional teams (NCI, 64.9% vs 92.0%, P  < .001; non-NCI, 40.0% vs 66.7%; P  = .047). Conclusion: NCI-designated cancer centers were more likely to report having an interprofessional palliative care team than non-NCI-designated cancer centers. Growth has been limited over the past decade, particularly at non-NCI-designated cancer centers.

Background: Palliative care (PC) education and research are essential to developing a skilled workforce and evidence base to support the delivery of quality cancer care. The current state of PC education and research at US cancer centers is unclear. In this national survey, the education and research programs of the National Cancer Institute (NCI)-designated and nondesignated cancer centers and the changes between 2009 and 2018 are compared., Methods: Between April and August 2018, PC program leaders at all NCI-designated cancer centers and a random sample of nondesignated centers were sent a survey to examine the structure, processes, and outcomes of their programs on the basis of questions from a 2009 national survey. This preplanned analysis focused on education and research., Results: There were 52 of 61 (85%) NCI-designated and 27 of 38 (71%) nondesignated cancer centers that responded. NCI-designated centers were more likely than nondesignated centers to have a PC fellowship program (87% vs 30%; P < .001), training for advanced practice providers (71% vs 44%; P = .03), PC research program (58% vs 15%; P < .001), peer-reviewed funding (43% vs 11%; P = .005), and philanthropic grants (41% vs 7%; P = .002). There were few significant improvements in PC education or research between 2009 and 2018 for both groups, notable exceptions include an increase in PC fellowships (38% vs 87%; P < .001) and mandatory PC rotations for medical oncology fellows (29% vs 55%; P = .02) at NCI-designated cancer centers., Conclusions: PC education and research are more developed at NCI-designated cancer centers. Despite some progress over the past decade, it is relatively slow and suboptimal., (© 2021 American Cancer Society.)

Importance: Medical device performance and safety databases can be analyzed for patterns and novel opportunities for improving patient safety and/or device design. Objective: The objective of this analysis was to use supervised machine learning to explore patterns in reported adverse events involving cochlear implants. Design: Adverse event reports for the top three CI manufacturers were acquired for the analysis. Four supervised machine learning algorithms were used to predict which adverse event description pattern corresponded with a specific cochlear implant manufacturer and adverse event type. Setting: U.S. government public database. Participants: Adult and pediatric cochlear patients. Exposure: Surgical placement of a cochlear implant. Main Outcome Measure: Classification prediction accuracy (% correct predictions). Results: Most adverse events involved patient injury ( n  = 16,736), followed by device malfunction ( n  = 10,760), and death ( n  = 16). The random forest, linear SVC, naïve Bayes and logistic algorithms were able to predict the specific CI manufacturer based on the adverse event narrative with an average accuracy of 74.8%, 86.0%, 88.5% and 88.6%, respectively. Conclusions & relevance: Using supervised machine learning algorithms, our classification models were able to predict the CI manufacturer and event type with high accuracy based on patterns in adverse event text descriptions.

The selection of appropriate endpoints in pediatric drug development trials is a critical aspect of trial design. Given the high pediatric trial failure rate, selecting optimal trial design elements, such as the primary efficacy endpoint, is essential to ensuring increased potential for trial success. The objectives of this study were to identify the primary efficacy endpoints measured in pediatric drug development trials submitted to the US Food and Drug Administration and to relate endpoint attributes to trial and label outcome. The analysis included pediatric pivotal efficacy studies submitted from September 2007 to July 2016 for which there was a corresponding adult trial for the same indication. Two hundred and thirty-four efficacy trials on 138 unique products studied in pediatric patients were assessed. The adult and pediatric endpoints were the same in 141 of the 234 trials (60.3%), and these trials succeeded in meeting their primary endpoint more often (122 of 141 [86.5%]) than when the adult and pediatric endpoints differed (57 of 93 [61.3%]; odds ratio, 4.03; 95%CI, 2.10-7.80). Trials that included both pediatric and adult patients succeeded more frequently than those trials that did not combine pediatric and adult patients (85 of 95 versus 94 of 139, respectively; odds ratio, 4.05; 95%CI, 1.94-9.31). No differences were observed in pediatric trial success between those using subjective and objective endpoints. Using the same endpoint in the pediatric trial as was measured in the corresponding adult trial and enrolling pediatric and adult patients in the same trial were attributes associated with trial success., (© 2018, The American College of Clinical Pharmacology.)

A well-managed healthcare system improves the quality of the patient experience. However, many small healthcare clinics have suboptimal systems for scheduling and locating patients and medical staff, delaying the relay of information and creating poor resource and room utilization. This paper proposes a Radio Frequency Identification (RFID)-based Real-Time Tracking (R-RTT) System for optimizing small healthcare facility operations, enabling further optimization of throughput time, room utilization, and patient flow. In the proposed scenario, RFID readers were equipped in strategic locations throughout the facility. Patients and medical staff were issued personalized RFID tags. When they pass through the reader's interrogation zone, it reads their RFID tag and sends the information to a central computer equipped with software capable of filtering the RFID data into useable information. A Visual Basic Application (VBA) program uses the information received from the ID tags to display the location of the patients and staff as they move throughout the facility. This increases their visibility within the facility by allowing medical staff to determine where their colleagues and patients are at all times. The VBA program was also able to record the data in order to track the time each stage of the appointment process takes to complete. The recorded time data can be broken into processes, making it easier to determine if it adds value. This data can then be transformed into a value stream map for further analysis and improvement.