Search

Objective: Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population., Methods: A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding., Results: Eight focus groups with a total of 38 participants were conducted. Participants included physicians ( n = 13), nursing/ancillary staff ( n = 14), advanced nurse practitioners ( n = 2), social worker/dietitian/pharmacist ( n = 3), and patients ( n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity., Conclusions: Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program's components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Patients with cancer having minor children experience particular burden and strains. Being patient and parent at the same time is associated with specific needs of support. Therefore, the communication of child-related and family-related issues plays an important role in patient care. This study aims at testing the feasibility of a training to improve the situation of patients with cancer having minor children and their families by enhancing the competencies of healthcare professionals (HCPs, eg, physicians, nurses, psychologists) in caring for patients with cancer having minor children. Moreover, the study aims at testing the study design and outcomes of the evaluation concept and preliminary effects of the training., Methods and Analysis: We will conduct a randomised controlled pilot trial with three arms (face-to-face training versus web-based training versus waitlist control group) to investigate the study aims. Primary outcome will be the competency to approach child-related and family-related topics in patients with cancer measured using comprehensive case vignettes. Secondary outcomes will be communication and attitudes regarding child-related and family-related topics and self-efficacy in clinical communication skills. Outcomes will be assessed prior to the training and after the training as well as 3 months after the training. Data will be analysed using descriptive analyses, group comparisons and linear mixed models., Ethics and Dissemination: The study was approved by the Local Psychological Ethics Committee of the Center for Psychosocial Medicine of the University Medical Center Hamburg-Eppendorf (LPEK-001). At the end of the study, a web-based training and a face-to-face training intervention to enhance the competencies of HCPs in caring for patients with cancer having minor children will have been systematically developed and the study design and evaluation concept will have been evaluated. The results of the study will be disseminated through peer-reviewed journals and conference presentations., Trial Registration Number: DRKS00015794., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Children and young people (CYP) in the UK have poor health outcomes, and there is increasing emergency department and hospital outpatient use. To address these problems in Lambeth and Southwark (two boroughs of London, UK), the local Clinical Commissioning Groups, Local Authorities and Healthcare Providers formed The Children and Young People's Health Partnership (CYPHP), a clinical-academic programme for improving child health. The Partnership has developed the CYPHP Evelina London model, an integrated healthcare model that aims to deliver effective, coordinated care in primary and community settings and promote better self-management to over approximately 90 000 CYP in Lambeth and Southwark. This protocol is for the process evaluation of this model of care., Methods and Analysis: Alongside an impact evaluation, an in-depth, mixed-methods process evaluation will be used to understand the barriers and facilitators to implementing the model of care. The data collected mapped onto a logic model of how CYPHP is expected to improve child health outcomes. Data collection and analysis include qualitative interviews and focus groups with stakeholders, a policy review and a quantitative analysis of routine clinical and administrative data and questionnaire data. Information relating to the context of the trial that may affect implementation and/or outcomes of the CYPHP model of care will be documented., Ethics and Dissemination: The study has been reviewed by NHS REC Cornwall & Plymouth (17/SW/0275). The findings of this process evaluation will guide the scaling up and implementation of the CYPHP Evelina London Model of Care across the UK. Findings will be disseminated through publications and conferences, and implementation manuals and guidance for others working to improve child health through strengthening health systems., Trial Registration Number: NCT03461848., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Value-based healthcare is strongly advocated to reduce the spiralling rise in healthcare expenditure. Operating room efficiency is an important focus of value-based healthcare delivery due to high costs and associated hospital revenue derived from procedural streams of care. A parallel induction design, utilising induction rooms for anesthetising patients, may improve operating room efficiency and optimise revenue. We used time-driven activity-based costing (TDABC) to model personnel costs for a high-turnover operating list to assess value of parallel induction redesign., Methods: We prospectively captured activity data from high-turnover surgery allocated to induction of anesthesia within the operating room (serial design) or within induction rooms prior to completion of preceding surgery (parallel design). Personnel costs were constructed using TDABC following assignment of a case-mix that integrated our activity data. This was contrasted against procedural revenue to assess value of projected case throughput., Results: Under a parallel induction design, projected operating list duration was reduced by 55 min at marginal increase (1.6%) in personnel costs as assessed by TDABC. This could facilitate an additional short duration surgical case (e.g. Wide Local Excision, with potential additional revenue of $2818 per day and $0.73 M per annum per operating room., Conclusions: Parallel induction design reduces non-operative time at minimal increase in personnel costs for all-day, high turnover surgery. An additional short duration surgical case is likely feasible under this model and represents a value investment with minimal requirement for additional personnel resources., Implications: A parallel induction design, within the constraints of finite healthcare funding, may help alleviate some of the global increase in demand for surgical capacity that accompanies an expanding and aging population., (Copyright © 2019. Published by Elsevier Inc.)

Introduction: Health and social care professionals (HSCPs) have increasingly contributed to enhance the care of patients in emergency departments (EDs), particularly for older adults who are frequent ED attendees with significant adverse outcomes. For the first time, the effectiveness of a HSCP team intervention for older adults in the ED has been tested in a large randomised controlled trial (Clinicaltrials.gov, NCT03739515), providing an opportunity to explore the implementation process for this type of intervention. This protocol describes a process evaluation that will to investigate the implementation, delivery and impact of an HSCP team intervention in the ED., Methods and Analysis: Using the Medical Research Council Framework for process evaluations, we will employ a mixed-methods approach to provide a description of the process of implementation and delivery of the HSCP intervention in the ED, evaluate its fidelity, dose and reach and explore the perceptions of key staff members in relations to the mechanisms and contexts of impact at the levels of individuals, physical environment, operations, communication and the broader hospital and healthcare system., Ethics and Dissemination: Ethical approval for this study was received from the HSE Mid-Western Regional Hospital Research Ethics Committee (Ref: 103/18). All participants will be invited to read and sign a written consent form prior to participation. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To identify factors that explain the observed effects of internal auditing on improving patient safety., Design Setting and Participants: A process evaluation study within eight departments of a university medical centre in the Netherlands., Intervention(s): Internal auditing and feedback for improving patient safety in hospital care., Main Outcome Measure(s): Experiences with patient safety auditing, percentage implemented improvement actions tailored to the audit results and perceived factors that hindered or facilitated the implementation of improvement actions., Results: The respondents had positive audit experiences, with the exception of the amount of preparatory work by departments. Fifteen months after the audit visit, 21% of the intended improvement actions based on the audit results were completely implemented. Factors that hindered implementation were short implementation time: 9 months (range 5-11 months) instead of the 15 months' planned implementation time; time-consuming and labour-intensive implementation of improvement actions; and limited organizational support for quality improvement (e.g. insufficient staff capacity and time, no available quality improvement data and information and communication technological (ICT) support)., Conclusions: A well-constructed analysis and feedback of patient safety problems is insufficient to reduce the occurrence of poor patient safety outcomes. Without focus and support in the implementation of audit-based improvement actions, quality improvement by patient safety auditing will remain limited., (© The Author(s) 2018. Published by Oxford University Press in association with the International Society for Quality in Health Care.)

Introduction: Osteoarthritis of the knee has been identified as the most common disability in Pakistan. Total knee replacement (TKR) surgery is the curative treatment for advanced osteoarthritis of the knee; however, cost remains one of the barriers to effective and timely service delivery., Objective: We conducted a time-driven activity-based costing (TDABC) analysis of TKR to identify major cost drivers and areas for process improvement., Methods and Analysis: We performed a prospective TDABC analysis of patients who underwent bilateral TKR at The Indus Hospital (TIH) during a 14-month period from October 2015 to December 2016. Detailed process maps were developed for each phase of the care cycle. Time durations and costs were allocated to each resource utilised and aggregated across the care cycle, including personnel, direct and indirect costs., Results: We identified seven care phases for a complete TKR care cycle and created their detailed process maps. Major time contributors were ward stay and discharge (20 160 min), TKR surgery (563 min) and surgical admission (333 min). Overall, 92.10% of time is spent during the ward stay and discharge phase of care. Patients remain hospitalised for an average of 14 days postoperatively. Overall institutional cost of a TKR at TIH was US$4360.51 (Pakistani rupees 456 981.17) per bilateral TKR surgery. The overall primary cost drivers for the full bundle of care were consumables used during TKR surgery itself, consumables utilised in the wards and personnel costs contributing 57.64%, 27.45% and 12.03% of total costs, respectively., Conclusion: Utilising TDABC allowed us to obtain a granular analysis of time and cost that was subsequently used to inform quality process improvement initiatives. In low-resource settings, such as Pakistan, TDABC has the potential to be a useful tool to guide resource allocation and process improvement., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Objectives: Acute Ischemic stroke (AIS) is a time-sensitive emergency and patients frequently present to, and are transferred from emergency departments (EDs). We sought to evaluate potential factors, particularly organizational, that may influence the timeliness of interfacility transfer for ED patients with AIS., Methods: We conducted semistructured interviews at 3 EDs that routinely transfer AIS patients. A structured interview guide was developed and piloted prior to use. Staff were asked about perceived facilitators and barriers to timely and high quality emergency care for patients with AIS who require transfer. Each interview was audio recorded, transcribed, coded, and analyzed using an iterative inductive-deductive approach to build a list of themes and subthemes, and identify supporting quotes., Results: We interviewed 45 ED staff (administrative staff, nurses, and physicians) involved in acute stroke care. We identified 4 major themes influencing the execution of interfacility transfers of AIS patients: (1) processes, (2) historical experiences; (3) communication; and (4) resources. Pre-existing protocols that standardized processes (eg, autoacceptance protocols) and reduced unnecessary communication, combined with direct communication with the neurology team at the comprehensive stroke center, and the flexibility and availability of human and physical resources (eg, staff and equipment) were commonly cited as facilitators. Lack of communication of clinical and operational outcomes back to transferring ED staff was viewed as a lost opportunity for process improvement, interorganization relationship building, and professional satisfaction., Conclusions: ED staff view the interfacility transfer of AIS patients as highly complex with multiple opportunities for delay. Coordination through the use of protocols and communication pre- and post-transfer represented opportunities to facilitate transfers. Staff and clinicians at transferring facilities identified multiple opportunities to enhance existing processes and ongoing communication quality among facilities involved in the acute management of patients with AIS., (Published by Elsevier Inc.)

Background: Checklists have been found to improve patient outcomes in a variety of health care settings, but use is rare during general pediatric rounds. We aimed to decrease length of stay (LOS) by 10% within 12 months through the standardized delivery of 8 aspects of hospital care for the general pediatric unit., Methods: For the general pediatrics unit at our freestanding children's hospital, a clinical rounding checklist was developed through a consensus of teaching faculty. Iterative plan-do-study-act cycles were conducted in a targeted medical unit over a 12-month period. We assessed change using control charts., Results: Checklist use increased from 61% to 96% early in the implementation phase. LOS (72 hours) was relatively unchanged. Cardiorespiratory monitor (CRM) duration was reduced by 28% (17.3 hours) within 4 months and was sustained for more than 12 months. A similar CRM reduction of 29% (22.5 hours) was seen in our medically complex patient subgroup. No clinically significant change was appreciated in central line, peripheral intravenous (IV) catheter, IV fluid, or IV medication duration. Thirty-day readmissions, code blue events, and rapid response team activations were not impacted., Conclusions: The use of a clinical rounding checklist on the general pediatric floor improved care in only 1 of 8 targeted domains. LOS did not change significantly over the project's duration. CRM duration was significantly reduced in both routine patients and medically complex children, and these improvements were sustained without impacting patient safety. More study is needed to determine which checklist components, if any, may prove beneficial to patient outcomes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objective: To identify and compare factors influencing the use of standardized outcome measures by neurological physical therapists working in representative developed (Canada) and developing (India) countries., Methods: A self-administered web-based questionnaire on facilitators and barriers to using neurological outcome measures was sent by email to neurological physical therapists in Canada and India. Frequencies of responses to each question were computed. Differences between countries were assessed using two-proportion z test., Results: Of 317 respondents, the use of standardized outcome measures was higher for Indian (96.7%) compared with Canadian physical therapists (89.2%). Among the most highly reported facilitators, three were common for both countries (known validity and reliability, outcome measures learned in professional training, and recommended in clinical practice guidelines). Three highly reported barriers were also common for India and Canada (lack of time, relying on judgement for clinical decisions, and unavailability of the assessment tools). Nevertheless, there were differences in the percentages of barriers and facilitators between countries., Conclusion: Understanding the factors influencing the uptake of outcome measures among neurological physical therapists working in a developed (Canada) and a developing country (India) can help identify whether strategies should or should not be modified to facilitate knowledge translation in different geographical, professional, or social contexts., (Copyright © 2018 John Wiley & Sons, Ltd.)

Introduction In 2009, the Model for Assessment of Telemedicine (MAST) was developed within the MethoTelemed project as a framework for description of the effectiveness of telemedicine applications. The goal was for the assessments to be used as basis for decision-making in healthcare systems. Since then, MAST has been used in many European telemedicine studies and is now the most widely used model for assessment of telemedicine. The aim of this study was to assess the face validity of MAST. Methods A modified Delphi process was carried out and included a workshop with a sample of healthcare decision makers. A total of 56 decision makers and experts in telemedicine were invited and 19 persons participated in the two Delphi rounds. Thirteen hospitals or regional health authorities from 12 European countries and six research organisations were represented in the final sample. The participants were asked to assess the importance of the different domains and topics in MAST on a 0-3 Likert scale. Results All respondents completed the two rounds. Based on the answers, the face validity of all MAST domains was confirmed, since all domains were considered moderately or highly important by more than 80% of the respondents. Discussion Even though the study confirmed the validity of MAST, a number of supplements and improvements regarding study design and data collection were suggested. When considering the results it should be noticed that the sample size was small and larger studies are needed to confirm the results.

Objective: Heart failure is a major cause of disease burden in sub-Saharan Africa (SSA). There is an urgent need for better strategies for heart failure management in this region. However, there is little information on the capacity to diagnose and treat heart failure in SSA. We aim to provide a better understanding of the capacity to diagnose and treat heart failure in Kenya and Uganda to inform policy planning and interventions., Methods: We analysed data from a nationally representative survey of health facilities in Kenya and Uganda (197 health facilities in Uganda and 143 in Kenya). We report on the availability of cardiac diagnostic technologies and select medications for heart failure (β-blockers, ACE inhibitors and furosemide). Facility-level data were analysed by country and platform type (hospital vs ambulatory facilities)., Results: Functional and staffed radiography, ultrasound and ECG were available in less than half of hospitals in Kenya and Uganda combined. Of the hospitals surveyed, 49% of Kenyan and 77% of Ugandan hospitals reported availability of the heart failure medication package. ACE inhibitors were only available in 51% of Kenyan and 79% of Ugandan hospitals. Almost one-third of the hospitals in each country had a stock-out of at least one of the medication classes in the prior quarter., Conclusions: Few facilities in Kenya and Uganda were prepared to diagnose and manage heart failure. Medication shortages and stock-outs were common. Our findings call for increased investment in cardiac care to reduce the growing burden of heart failure., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aim: Barriers to participation in cardiac rehabilitation (CR) may occur at three levels of the referral process (lack of information, declining to participate, and referral to appropriate CR programme). The aim is to analyse the impact of socioeconomic status on barriers to CR and investigate whether such barriers influenced the choice of referral., Methods: The Rehab-North Register, a cross-sectional study, enrolled 5455 patients hospitalised at Aalborg University Hospital with myocardial infarction (MI) during 2011-2014. Patients hospitalised with ST-elevated MI and complicated non-ST-elevated MI were to be sent to specialized CR, whereas patients with uncomplicated non-ST-elevated MI and unstable angina pectoris were to be sent to community-based CR. Detailed selected socioeconomic information was gathered from statistical registries in Statistics Denmark. Data was assessed using logistic regression., Results: Patients being retired, low educated, and/or with an annual gross income <27.000 Euro/yr were significantly less informed about cardiac rehabilitation programmes. Patients being older than 70 years, retired, low educated and/or with an annual gross income <27.000 Euro were significantly less willing to participate in CR. Further, this patient population were to a higher extent referred to community-based CR., Conclusion: Patients with low socioeconomic status received less information about and were less willing to participate in cardiac rehabilitation. The same patient population was to a higher extent referred to community-based CR. Knowledge about barriers at different levels and the impact of social inequality may help in tailoring a better approach in the referral process to CR.

Background: Several challenges presently impede the conduct of prospective clinical studies in orthopaedic oncology, including limited financial resources to support their associated costs and inadequate patient volume at most single institutions. This study was conducted to prioritize research questions within the field so that the Musculoskeletal Tumor Society (MSTS), and other relevant professional societies, can direct the limited human and fiscal resources available to address the priorities that the stakeholders involved believe will have the most meaningful impact on orthopaedic oncology patient care., Questions/purposes: The purpose of this study was to use a formal consensus-based approach involving clinician-scientists and other stakeholders to identify the top priority research questions for future international prospective clinical studies in orthopaedic oncology., Methods: A three-step modified Delphi process involving multiple stakeholder groups (including orthopaedic oncologists, research personnel, funding agency representation, and patient representation) was conducted. First, we sent an electronic questionnaire to all participants to solicit clinically relevant research questions (61 participants; 54% of the original 114 individuals invited to participate returned the questionnaires). Then, participants rated the candidate research questions using a 5-point Likert scale for five criteria (60 participants; 53% of the original group participated in this portion of the process). Research questions that met a priori consensus thresholds progressed for consideration to an in-person consensus meeting, which was attended by 44 participants (39% of the original group; 12 countries were represented at this meeting). After the consensus panel's discussion, members individually assigned scores to each question using a 9-point Likert scale. Research questions that met preset criteria advanced to final ranking, and panel members individually ranked their top three priority research questions, resulting in a final overall ranking of research priorities., Results: A total of 73 candidate research questions advanced to the consensus meeting. In the end, the consensus panel identified four research priorities: (1) Does less intensive surveillance of patients with sarcoma affect survival? (2) What are the survival outcomes over time for orthopaedic oncology implants? (3) Does resection versus stabilization improve oncologic and functional outcomes in oligometastatic bone disease? (4) What is the natural history of untreated fibromatosis?, Conclusions: The results of this study will assist in developing a long-term research strategy for the MSTS and, possibly, the orthopaedic oncology field as a whole. Furthermore, the results of this study can assist researchers in guiding their research efforts and in providing a justified rationale to funding agencies when requesting the resources necessary to support future collaborative research studies that address the identified orthopaedic oncology priorities.

Assertive Community Treatment (ACT) for people with severe mental illness is an effective approach that is increasingly implemented in rural areas. Low-cost methods of evaluating fidelity to program models are needed to assure services are delivered as intended. In 2007, the Veterans Health Administration implemented an ACT-like Mental Health Intensive Case Management (ACT/ICM) program for SMI veterans in rural areas. This study demonstrates the use of administrative data, reflecting patient characteristics and intensity of service delivery, to characterize services delivered by these programs, to compare them to general mental health programs at the same VA medical centers, and to each other. A total of 298,509 veterans received mental health services at VA medical centers that also operated a rural ACT/ICM program in FY 2012. Altogether 854 (0.29%) received ACT/ICM services for 1 year or more (long term participants) and 259 (.09%) received them for less than 1 year (new entrants). Logistic regression showed ACT/ICM patients were distinguished by diagnoses of schizophrenia, bipolar disorder, and major depression; larger numbers of psychiatric or substance abuse visits; and use of 3 or more classes of psychotropic medication. The model had a high c statistic of 0.91. Propensity scores allowed clear identification of programs most and least conforming to the profile of a "typical" rural ACT/ICM program. Low cost administrative data can be used to identify programs successfully conforming to an empirically derived rural model of ACT/ICM. Further validation of this approach is needed.

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Objective: In low income countries, deaf children are identified late due to the absence of a universal screening. Hearing impairment is a common yet neglected disability in India that leads to loss of speech and language. This qualitative study explored barriers to accessing appropriate hearing services in one city in southern India., Design: To identify the barriers in timely management of deafness, 25 semi-structured interviews were conducted. Data were examined using Applied Thematic Analysis., Study Sample: Seventeen mothers of deaf children, primarily from low socioeconomic backgrounds, and eight staff members at a charitable hearing centre in Hyderabad., Results: Barriers to accessing hearing services included failure to recognise deafness, the dominant role of elders in household decisions, belief that deafness would resolve, reassurance from a child's overall good health, lack of funds and transportation barriers to reach the centre particularly from rural areas. Parents frequently learned about services through word of mouth., Conclusions: The challenges to accessing appropriate services for deafness operate prior to presentation and include educational, cultural, navigational and financial barriers especially for those of lower socioeconomic status and residents of rural areas. The findings highlighted the need to raise awareness and implement wider screening programmes for early interventions.

Pulmonary embolism response teams (PERTs) are multidisciplinary response teams aimed at delivering a range of diagnostic and therapeutic modalities to patients with pulmonary embolism. These teams have gained traction on a national scale. However, despite sharing a common goal, individual PERT programs are quite individualized-varying in their methods of operation, team structures, and practice patterns. The tendency of such response teams is to become intensely structured, algorithmic, and inflexible. However, in their current form, PERT programs are quite the opposite. They are being creatively customized to meet the needs of the individual institution based on available resources, skills, personnel, and institutional goals. After a review of the essential core elements needed to create and operate a PERT team in any form, this article will discuss the more flexible feature development of the nascent PERT team. These include team planning, member composition, operational structure, benchmarking, market analysis, and rudimentary financial operations., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Previous research has shown the importance of urgent initiation of antiplatelet therapy after transient ischemic attack (TIA) to reduce the risk of stroke. Many hospitals in the Netherlands have therefore implemented rapid pathways for assessment of patients with TIA. Dutch stroke guidelines lack clear directives for organization of TIA assessment and thus allow for variation. The aim of this study was to investigate variation in organization of TIA assessment in Dutch hospitals., Methods: One neurologist per hospital (of 88 Dutch hospitals) with special interest in stroke was invited to participate in a web-based survey addressing the organization, content, and timing of TIA assessment., Results: Seventy (80%) neurologists completed the survey, all of whom reported performing TIA assessment in their hospital. There was considerable variation in the method of application and the location of assessment. In 10% of the hospitals, patients with TIA are always admitted to the ward. The content of diagnostics is fairly similar, but hospitals vary in the extent of cardiological workup. Almost all hospitals aim for a swift start of assessment as directed by guidelines, but access time differs. Eighty-six percent of respondents reported that antiplatelet therapy is usually initiated before assessment, based on history., Conclusions: This study showed variation in organization of TIA assessment in Dutch hospitals, especially regarding location within the hospital, time to assessment after announcement, and cardiological workup. Further research is needed to investigate implications of this variation for quality of care., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Recently, 5 randomized controlled trials confirmed the superiority of endovascular mechanical thrombectomy (EMT) to intravenous thrombolysis in acute ischemic stroke with large-vessel occlusion. The implication is that our health systems would witness an increasing number of patients treated with EMT. However, in-hospital delays, leading to increased time to reperfusion, are associated with poor clinical outcomes. This review outlines the in-hospital workflow of the treatment of acute ischemic stroke at a comprehensive stroke center and the lessons learned in reduction of in-hospital delays., Methods: The in-hospital workflow for acute ischemic stroke was described from prehospital notification to femoral arterial puncture in preparation for EMT. Systematic review of literature was also performed with PubMed., Results: The implementation of workflow streamlining could result in reduction of in-hospital time delays for patients who were eligible for EMT. In particular, time-critical measures, including prehospital notification, the transfer of patients from door to computed tomography (CT) room, initiation of intravenous thrombolysis in the CT room, and the mobilization of neurointervention team in parallel with thrombolysis, all contributed to reduction in time delays., Conclusions: We have identified issues resulting in in-hospital time delays and have reported possible solutions to improve workflow efficiencies. We believe that these measures may help stroke centers initiate an EMT service for eligible patients., (Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background: Time to treatment remains the most important factor in acute ischemic stroke prognosis. We quantified the effect of new interventions reducing in-hospital delays in acute stroke management and assessed its repercussion on door-to-imaging (DTI), imaging-to-needle (ITN), and door-to-needle (DTN) times., Methods: Prospective registry of consecutive stroke patients who were candidates for reperfusion therapy attended in a tertiary care hospital from February 1 to December 31, 2014. A series of measures aimed at reducing in-hospital delays were implemented. We compared DTI, ITN, and DTN times between patients who underwent the interventions and those who did not., Results: 231 patients. DTI time was lower when personal history was reviewed and tests were ordered before patient arrival (2.5 minutes saved, P = .016) and when electrocardiogram was not made (5.4 minutes saved, P < .001). Not performing a computed tomography angiography and not waiting for coagulation results from laboratory before intravenous thrombolysis (25.5%) reduced ITN time significantly (14 and 12 minutes saved, respectively, P < .001). These interventions remained as independent predictors of a shorter ITN and DTN time. Completing all steps resulted in the lowest DTI and ITN times (13 and 19 minutes, respectively)., Conclusions: Every measure is an important part of a chain focused on saving time in acute stroke: the lowest DTI and ITN times were obtained when all steps were completed. Measures shortening ITN time produced a greater impact on DTN time reduction; therefore, ITN interventions should be considered a critical part of new protocols and guidelines., (Copyright © 2017. Published by Elsevier Inc.)

Background: Buckinghamshire Healthcare NHS Trust (BHT) carried out a cardiac rehabilitation (CR) service redesign aimed at optimising patient recruitment and retention and decreasing readmissions., Methods: A single centre observational study and local service evaluation were carried out to describe the impact of the novel technology-enabled CR model. Data were collected for adult patients referred for CR at BHT, retrospectively for patients referred during the 12-month pre-implementation period (Cohort 1) and prospectively for patients referred during the 12-month post-implementation period (Cohort 2). The observational study included 350 patients in each cohort, seasonally matched; the service evaluation included all eligible patients. No data imputation was performed., Results: In the observational study, a higher proportion of referred patients entered CR in Cohort 2 (84.3%) than Cohort 1 (76.0%, P = 0.006). Fewer patients in Cohort 2 had ≥1 cardiac-related emergency readmission within 6 months of discharge (4.3%) than Cohort 1 (8.9%, P = 0.015); readmissions within 30 days and 12 months were not significantly different. Median time to CR entry from discharge was significantly shorter in Cohort 2 (35.0 days) than Cohort 1 (46.0 days, P < 0.001). The CR completion rate was significantly higher in Cohort 2 (75.6%) than Cohort 1 (47.4%, P < 0.001); median CR duration for completing patients was significantly longer in Cohort 2 (80.0 days) than Cohort 1 (49.0 days, P < 0.001). Overall, similar results were observed in the service evaluation., Conclusions: Introduction of the novel technology-enabled CR model was associated with short-term improvements in emergency readmissions and sustained increases in CR entry, duration and completion.

Objective: In modern health care, vascular surgeons frequently serve as a unique resource to other surgical specialties for vascular exposure, repair, reconstruction, or control. These services occur both in planned and unplanned clinical settings. We analyzed the frequency, outcomes, and value of vascular services in this setting to other surgical specialties and the hospital., Methods: Intraoperative planned and unplanned vascular surgery operative consultations were reviewed over a 3-year period (2013-2016). Patient demographics, requesting surgical specialty, indication and type of vascular intervention, and work relative value units generated were recorded. Univariate and multivariate analysis of factors affecting a composite outcome of in-hospital and 30-day mortality or morbidity, or both, was performed., Results: Seventy-six vascular surgery intraoperative consultations were performed, of which 56% of the consultations were unplanned. The most common unplanned consultation was for bleeding (33%). The aorta and lower extremity were the most common vascular beds requiring vascular services. The mean work relative value units generated per vascular surgery intervention was 23.8. In-hospital and 30-day mortality was 9.2%. No difference in mortality and morbidity was found between planned and unplanned consultations. Factors associated with the composite mortality/morbidity outcome were coronary artery disease (P = .002), heart failure (P = .02), total operative blood loss (P = .009), consultation for limb ischemia (P = .013), and vascular consultation for the lower extremity (P = .01). On multivariate analysis, high operative blood loss (>5000 mL) remained significant (P = .04), and coronary artery disease approached significance (P = .06)., Conclusions: The need for vascular surgery services is frequent, involves diverse vascular beds, and occurs commonly in an unplanned setting. When requested, vascular surgery services effectively facilitate the completion of the nonvascular procedure, even those associated with significant intraoperative blood loss. Vascular surgery services are essential to other surgical specialties and the hospital in today's modern health care environment., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

The medical community has been challenged to improve upon deficiencies in the delivery of patient care. Quality improvement methods are therefore increasingly used in everyday clinical practice. As demonstrated in this review, creative and impactful improvement projects within pediatric gastroenterology can be successfully achieved as either multicenter projects or single-center efforts. Through our willingness to accept the challenge to improve, practitioners within the pediatric gastroenterology community have become leaders in using quality improvement to change practice and improve clinical outcomes.

Aim: To test the one year-post effect of an integrated diabetes care program that includes system changes, education, registry (clinical, metabolic and therapeutic indicators) and disease management (DIAPREM), implemented at primary care level, on care outcomes and costs., Methods: We randomly selected 15 physicians and 15 nurses from primary care units of La Matanza County to be trained (Intervention-IG) and another 15 physicians/nurses to use as controls (Control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for one year; both groups use structured medical data registry. Patients in IG had quarterly clinical appointments whereas those in CG received traditional care. DIAPREM includes system changes (use of guidelines, programmed quarterly controls and yearly visits to the specialist) and education (physicians' and nurses' training courses). Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions., Results: Baseline data from both groups showed comparable values and 20-30% of them did not perform HbA1c and lipid profile measurements. Majority were obese, 59% had HbA1C ≥7%, 86% fasting blood glucose ≥100mg/dL, 45%, total cholesterol ≥200mg/dL, and 92% abnormal HDL- and LDL-cholesterol values. Similarly, micro and macroangiopathic complications had not been detected in the previous year. Most patients received oral antidiabetic agents (monotherapy), and one third was on insulin (mostly a single dose of an intermediate/long-acting formulation). Most people with hypertension received specific drug treatment but only half of them reached target values; dyslipidemia treatment showed similar data., Conclusions: Baseline data demonstrated the need of implementing an intervention to improve diabetes care and treatment outcomes., (Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Objective: This article presents a method for visualization and navigation of patient flow in outpatient eye clinics with a high level of complexity., Material and Methods: A network-based software solution was developed targeting long-term process optimization by structural analysis and temporal coordination of process navigation., Results: Each examination unit receives a separate waiting list of patients in which the patient flow for every patient is recorded in a timeline. Time periods and points in time can be executed by mouse clicks and the desired diagnostic procedure can be entered. Recent progress in any of these diagnostic requests, as well as a variety of information on patient progress are collated and drawn into the corresponding timeline which can be viewed by any of the personnel involved. The software called TimeElement has been successfully tested in the practical implemenation for several months. As an example the patient flow regarding time stamps of defined events for intravitreous injections on 250 patients was recorded and an average attendance time of 169.71 min was found, whereby the time was also automatically recorded for each individual stage., Conclusion: Recording of patient flow data is a fundamental component of patient flow management, waiting time reduction, patient flow navigation with time and coordination in particular regarding timeline-based visualization for each individual patient. Long-term changes in process management can be planned and evaluated by comparing patient flow data. As using the software itself causes structural changes within the organization, a questionnaire is being planned for appraisal by the personnel involved.

The UK has many excellent care homes that provide high-quality care for their residents; however, across the care home sector, there is a significant need for improvement. Even though the majority of care homes receive a rating of 'good' from regulators, still significant numbers are identified as requiring 'improvement' or are 'inadequate'. Such findings resonate with the public perceptions of long-term care as a negative choice, to be avoided wherever possible-as well as impacting on the career choices of health and social care students. Projections of current demographics highlight that, within 10 years, the part of our population that will be growing the fastest will be those people older than 80 years old with the suggestion that spending on long-term care provision needs to rise from 0.6% of our Gross Domestic Product in 2002 to 0.96% by 2031. Teaching/research-based care homes have been developed in the USA, Canada, Norway, the Netherlands and Australia in response to scandals about care, and the shortage of trained geriatric healthcare staff. There is increasing evidence that such facilities help to reduce inappropriate hospital admissions, increase staff competency and bring increased enthusiasm about working in care homes and improve the quality of care. Is this something that the UK should think of developing? This commentary details the core goals of a Care Home Innovation Centre for training and research as a radical vision to change the culture and image of care homes, and help address this huge public health issue we face., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Because organizational culture is increasingly understood as fundamental to achieving high performance in hospital and other healthcare settings, the ability to measure this nuanced concept empirically has gained importance. Aside from measures of patient safety culture, no measure of organizational culture has been widely endorsed in the medical literature, limiting replication of previous findings and broader use in interventional studies., Methods and Results: We sought to develop and assess the validity and reliability of a scale for assessing organizational culture in the context of hospitals' efforts to reducing 30-day risk-standardized mortality after acute myocardial infarction. The 31-item scale was completed by 147 individuals representing 10 hospitals during August and September 2014. The resulting organizational culture scale demonstrated high level of construct validity and internal consistency. Factor analyses indicated that the 31 items loaded well (loading values 0.48-0.90), supporting distinguishable domains of (1) learning environment, (2) psychological safety, (3) commitment to the organization, (4) senior management support, and (5) time for improvement efforts. Cronbach α coefficients were 0.94 for the scale and ranged from 0.77 to 0.88 for the subscales. The scale displayed reasonable convergent validity and statistically significant variability across hospitals, with hospital identity accounting for 11.3% of variance in culture scores across respondents., Conclusions: We developed and validated a relatively easy-to-administer survey that was able to detect substantial variability in organizational culture across different hospitals and may be useful in measuring hospital culture and evaluating changes in culture over time as part performance improvement efforts., (© 2017 American Heart Association, Inc.)

This article focuses on the type of problems that lead to false or nonactionable clinical alarms and the type of data that can help identify which of these alarms are most prevalent in specific units in healthcare facilities. The process of identifying necessary data is first described, as this activity will drive later choices on capturing data. This article also discusses how to use the data collected in alarm reports to help determine which alarms should be targeted first for improved management in a pilot environment. Suggestions are provided on how to reduce false and nonactionable alarm signals and how to monitor to ensure no untoward consequences occur from new alarm default settings. The information provided here can be individualized to hospitals and units to enhance alarm management with physiological monitor alarms. It also can be adapted to reduce nonactionable alarm signals occurring from other medical devices.

Aims: To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013., Methods: Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013., Results: Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low., Conclusions: Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM., (Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

This chapter discusses the importance of modelling and control in increasing food process efficiency and ensuring product quality. Various approaches to both modelling and control in food processing are set in the context of the specific challenges in this industrial sector and latest developments in each area are discussed. Three industrial case studies are used to demonstrate the benefits of advanced measurement, modelling and control in food processes. The first case study illustrates the use of knowledge elicitation from expert operators in the process for the manufacture of potato chips (French fries) and the consequent improvements in process control to increase the consistency of the resulting product. The second case study highlights the economic benefits of tighter control of an important process parameter, moisture content, in potato crisp (chips) manufacture. The final case study describes the use of NIR spectroscopy in ensuring effective mixing of dry multicomponent mixtures and pastes. Practical implementation tips and infrastructure requirements are also discussed.

Cereal processing (breadmaking, extrusion, pasting, etc.) covers a range of mechanisms that, despite their diversity, can be often reduced to a succession of two core phenomena: (1) the transition from a divided solid medium (the flour) to a continuous one through hydration, mechanical, biochemical, and thermal actions and (2) the expansion of a continuous matrix toward a porous structure as a result of the growth of bubble nuclei either by yeast fermentation or by water vaporization after a sudden pressure drop. Modeling them is critical for the domain, but can be quite challenging to address with mechanistic approaches relying on partial differential equations. In this chapter we present alternative approaches through basic knowledge models (BKM) that integrate scientific and expert knowledge, and possess operational interest for domain specialists. Using these BKMs, simulations of two cereal foods processes, extrusion and breadmaking, are provided by focusing on the two core phenomena. To support the use by non-specialists, these BKMs are implemented as computer tools, a Knowledge-Based System developed for the modeling of the flour mixing operation or Ludovic ® , a simulation software for twin screw extrusion. They can be applied to a wide domain of compositions, provided that the data on product rheological properties are available. Finally, it is stated that the use of such systems can help food engineers to design cereal food products and predict their texture properties.

Background: The Mission: Lifeline STEMI Systems Accelerator program, implemented in 16 US metropolitan regions, resulted in more patients receiving timely reperfusion. We assessed whether implementing key care processes was associated with system performance improvement., Methods and Results: Hospitals (n=167 with 23 498 ST-segment-elevation myocardial infarction patients) were surveyed before (March 2012) and after (July 2014) program intervention. Data were merged with patient-level clinical data over the same period. For reperfusion, hospitals were grouped by whether a specific process of care was implemented, preexisting, or never implemented. Uptake of 4 key care processes increased after intervention: prehospital catheterization laboratory activation (62%-91%; P<0.001), single call transfer protocol from an outside facility (45%-70%; P<0.001), and emergency department bypass for emergency medical services direct presenters (48%-59%; P=0.002) and transfers (56%-79%; P=0.001). There were significant differences in median first medical contact-to-device times among groups implementing prehospital activation (88 minutes implementers versus 89 minutes preexisting versus 98 minutes nonimplementers; P<0.001 for comparisons). Similarly, patients treated at hospitals implementing single call transfer protocols had shorter median first medical contact-to-device times (112 versus 128 versus 152 minutes; P<0.001). Emergency department bypass was also associated with shorter median first medical contact-to-device times for emergency medical services direct presenters (84 versus 88 versus 94 minutes; P<0.001) and transfers (123 versus 127 versus 167 minutes; P<0.001)., Conclusions: The Accelerator program increased uptake of key care processes, which were associated with improved system performance. These findings support efforts to implement regional ST-segment-elevation myocardial infarction networks focused on prehospital catheterization laboratory activation, single call transfer protocols, and emergency department bypass., (© 2017 American Heart Association, Inc.)

Background: understanding how best to provide palliative care for frail older people with non-malignant conditions is an international priority. We aimed to develop a community-based episodic model of short-term integrated palliative and supportive care (SIPS) based on the views of service users and other key stakeholders in the United Kingdom., Method: transparent expert consultations with health professionals, voluntary sector and carer representatives including a consensus survey; and focus groups with older people and carers were used to generate recommendations for the SIPS model. Discussions focused on three key components of the model: potential benefit of SIPS, timing of delivery and processes of integrated working between specialist palliative care and generalist practitioners. Content and descriptive analysis was employed and findings were integrated across the data sources., Findings: we conducted two expert consultations (n = 63), a consensus survey (n = 42) and three focus groups (n = 17). Potential benefits of SIPS included holistic assessment, opportunity for end of life discussion, symptom management and carer reassurance. Older people and carers advocated early access to SIPS, while other stakeholders proposed delivery based on complex symptom burden. A priority for integrated working was the assignment of a key worker to co-ordinate care, but the assignment criteria remain uncertain., Interpretation: key stakeholders agree that a model of SIPS for frail older people with non-malignant conditions has potential benefits within community settings, but differ in opinion on the optimal timing and indications for this service. Our findings highlight the importance of consulting all key stakeholders in model development prior to feasibility evaluation., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Background: The nature of teamwork in healthcare is complex and interdisciplinary, and provider collaboration based on shared patient encounters is crucial to its success. Characterizing the intensity of working relationships with risk-adjusted patient outcomes supplies insight into provider interactions in a hospital environment., Methods and Results: We extracted 4 years of patient, provider, and activity data for encounters in an inpatient cardiology unit from Northwestern Medicine's Enterprise Data Warehouse. We then created a provider-patient network to identify healthcare providers who jointly participated in patient encounters and calculated satisfaction rates for provider-provider pairs. We demonstrated the application of a novel parameter, the shared positive outcome ratio, a measure that assesses the strength of a patient-sharing relationship between 2 providers based on risk-adjusted encounter outcomes. We compared an observed collaboration network of 334 providers and 3453 relationships to 1000 networks with shared positive outcome ratio scores based on randomized outcomes and found 188 collaborative relationships between pairs of providers that showed significantly higher than expected patient satisfaction ratings. A group of 22 providers performed exceptionally in terms of patient satisfaction. Our results indicate high variability in collaboration scores across the network and highlight our ability to identify relationships with both higher and lower than expected scores across a set of shared patient encounters., Conclusions: Satisfaction rates seem to vary across different teams of providers. Team collaboration can be quantified using a composite measure of collaboration across provider pairs. Tracking provider pair outcomes over a sufficient set of shared encounters may inform quality improvement strategies such as optimizing team staffing, identifying characteristics and practices of high-performing teams, developing evidence-based team guidelines, and redesigning inpatient care processes., Competing Interests: Disclosures: None., (© 2016 American Heart Association, Inc.)

Background: Patients undergoing coronary artery bypass grafting (CABG) must often see multiple providers dispersed across many care locations. To test whether teamwork (assessed with the bipartite clustering coefficient) among these physicians is a determinant of surgical outcomes, we examined national Medicare data from patients undergoing CABG., Methods and Results: Among Medicare beneficiaries who underwent CABG between 2008 and 2011, we mapped relationships between all physicians who treated them during their surgical episodes, including both surgeons and nonsurgeons. After aggregating across CABG episodes in a year to construct the physician social networks serving each health system, we then assessed the level of physician teamwork in these networks with the bipartite clustering coefficient. Finally, we fit a series of multivariable regression models to evaluate associations between a health system's teamwork level and its 60-day surgical outcomes. We observed substantial variation in the level of teamwork between health systems performing CABG (SD for the bipartite clustering coefficient was 0.09). Although health systems with high and low teamwork levels treated beneficiaries with comparable comorbidity scores, these health systems differed over several sociocultural and healthcare capacity factors (eg, physician staff size and surgical caseload). After controlling for these differences, health systems with higher teamwork levels had significantly lower 60-day rates of emergency department visit, readmission, and mortality., Conclusions: Health systems with physicians who tend to work together in tightly-knit groups during CABG episodes realize better surgical outcomes. As such, delivery system reforms focused on building teamwork may have positive effects on surgical care., (© 2016 American Heart Association, Inc.)

Objective: To describe the measure review and evaluation process used to identify new measures of care coordination for children with behavioral health needs conducted as part of Massachusetts' Children's Health Insurance Program Reauthorization Act Quality Demonstration Grant., Method: The Massachusetts Child Health Quality Coalition identified a shortage of pediatric measures of care coordination in behavioral health. After an extensive literature review, the Measure Development Committee applied the Care Coordination Key Elements Framework (Framework), which was designed as part of the grant work, and used a modified RAND Delphi method to conduct feasibility and validity evaluation and propose the new candidate measures for further rigorous testing., Results: Thirty-two measures were evaluated. One existing Healthcare Effectiveness Data and Information Set and 8 newly proposed measures met the criteria for feasibility and reliability. These measures represented each of the key elements contained in the Framework. The measures need further testing to ensure scientific acceptability and wide usability., Conclusion: A multipronged methodology was used to propose measures of care coordination in the space of pediatric behavioral health to fill the identified gaps in existing measures.

Background: Health-related scientific discoveries are often not applied in clinical settings after publication, even when recommended by a trusted journal or professional association. This article describes an assessment tool we developed for use by primary care clinicians and practice administrators to evaluate whether to implement recommended evidence-based interventions in their practices., Methods: We used dissemination and implementation theory to develop a worksheet to guide decision making about whether interventions are suitable for implementation in primary care practice settings. We tested the tool by analyzing how members of a primary care practice-based research network rated 4 evidence-based interventions., Results: The median likelihood of implementation ranged from 2 to 3.5 on a scale of 1 (low) to 5 (high). Raters' level of agreement with statements about 3 intervention characteristics was associated (P < .05) with a higher likelihood of implementation using Spearman rank-order correlation: simple to implement, testable before fully implementing, and modifiable to meet the needs of the practice. Raters found the worksheet helpful in thinking through potential implementation, especially the prompts about modifiability and relevance to the practice's patients and priorities., Conclusions: The Decision-to-Implement Worksheet provides a new resource for primary care practices that want to assess whether evidence-based interventions are suitable to adopt or adapt to meet their needs., (© Copyright 2016 by the American Board of Family Medicine.)

Objectives: Checklists are being introduced to enhance patient safety, but the results have been mixed. The goal of this research is to understand why time-outs and checklists are sometimes not effective in preventing surgical adverse events and to identify additional measures needed to reduce these events., Methods: A total of 380 consecutive patients underwent complex cardiac surgery over a 24-month period between November 2011 and November 2013 at an academic medical center, out of a total of 529 cardiac cases. Elective isolated aortic valve replacements, mitral valve repairs, and coronary artery bypass graft surgical procedures (N = 149) were excluded. A time-out was conducted in a standard fashion in all patients in accordance with the World Health Organization surgical checklist protocol. Adverse events were classified as anything that resulted in an operative delay, nonavailability of equipment, failure of drug administration, or unexpected adverse clinical outcome. These events and their details were collected every week and analyzed using a systemic causal analysis technique using a technique called CAST (causal analysis based on systems theory). This analytic technique evaluated the sociotechnical system to identify the set of causal factors involved in the adverse events and the causal factors explored to identify reasons. Recommendations were made for the improvement of checklists and the use of system design changes that could prevent such events in the future., Results: Thirty events were identified. The causal analysis of these 30 adverse events was carried out and actionable events classified. There were important limitations in the use of standard checklists as a stand-alone patient safety measure in the operating room setting, because of multiple factors. Major categories included miscommunication between staff, medication errors, missing instrumentation, missing implants, and improper handling of equipment or instruments. An average of 3.9 recommendations were generated for each adverse event scenario., Conclusions: Time-outs and checklists can prevent some types of adverse events, but they need to be carefully designed. Additional interventions aimed at improving safety controls in the system design are needed to augment the use of checklists. Customization of checklists for specialized surgical procedures may reduce adverse events., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

We describe the development, implementation, and evaluation of a standardized clinical pathway to facilitate safe discharge home at the earliest time after transfemoral transcatheter aortic valve replacement. Between May 2012 and October 2014, the Heart Team developed a clinical pathway suited to the unique requirements of transfemoral transcatheter aortic valve replacement in contemporary practice. The components included risk-stratified minimalist periprocedure approach, standardized postprocedure care with early mobilization and reconditioning, and criteria-driven discharge home. Our aim was to reduce variation in care, identify a subgroup of patients suitable for early discharge (≤48 hours), and decrease length of stay for all patients. We addressed barriers related to historical practices, complex multidisciplinary stakeholder engagement, and adoption of length of stay as a quality indicator. We retrospectively reviewed the experiences of 393 consecutive patients; 150 (38.2%) were discharged early. At baseline, early discharge patients had experienced less previous balloon aortic valvuloplasty, had higher left ventricular ejection fraction, better cognitive function, and were less frail than the standard discharge group (>48 hours). Early discharge was associated with the use of local anesthesia, implantation of balloon expandable device, avoidance of urinary catheter, and early removal of temporary pacemaker. Median length of stay was 1 day for early discharge and 3 days for other patients; 97.7% were discharged home. There were no differences in 30-day mortality (1.3%), disabling stroke (0.8%), or readmission (10.7%). The implementation of a transcatheter aortic valve replacement clinical pathway shifted the program's approach to combine standardized processes and individual risk stratification. The Vancouver transcatheter aortic valve replacement clinical pathway requires a rigorous assessment to determine its efficacy, safety, and reproducibility., (© 2016 American Heart Association, Inc.)

Infants with single ventricle require staged cardiac surgery, with stage I typically performed shortly after birth, stage II at 4 to 6 months of age, and stage III at 3 to 5 years of age. There is a high risk of interstage mortality and morbidity after infants are discharged from the hospital between stages I and II. Traditional home monitoring requires caregivers to record measurements of weight and oxygen saturation into a binder and requires families to assume a surveillance role. We have developed a tablet PC-based solution that provides secure and nearly instantaneous transfer of patient information to a cloud-based server, with the capacity for instant alerts to be sent to the caregiver team. The cloud-based IT infrastructure lends itself well to being able to be scaled to multiple sites while maintaining strict control over the privacy of each site. All transmitted data are transferred to the electronic medical record daily. The system conforms to recently released Food and Drug Administration regulation that pertains to mobile health technologies and devices. Since this platform was developed in March 2014, 30 patients have been monitored. There have been no interstage deaths. The experience of care providers has been unanimously positive. The addition of video has added to the use of the monitoring program. Of 30 families, 23 expressed a preference for the tablet PC over the notebook, 3 had no preference, and 4 preferred the notebook to the tablet PC., (© 2016 American Heart Association, Inc.)

Background: Operational inefficiencies are ubiquitous in several healthcare processes. To improve the operational efficiency of our catheterization laboratory (Cath Lab), we implemented a lean six sigma process improvement initiative, starting in June 2010. We aimed to study the impact of lean six sigma implementation on improving the efficiency and the patient throughput in our Cath Lab., Methods: All elective and urgent cardiac catheterization procedures including diagnostic coronary angiography, percutaneous coronary interventions, structural interventions and peripheral interventions performed between June 2009 and December 2012 were included in the study. Performance metrics utilized for analysis included turn-time, physician downtime, on-time patient arrival, on-time physician arrival, on-time start and manual sheath-pulls inside the Cath Lab., Results: After implementation of lean six sigma in the Cath Lab, we observed a significant improvement in turn-time, physician downtime, on-time patient arrival, on-time physician arrival, on-time start as well as sheath-pulls inside the Cath Lab. The percentage of cases with optimal turn-time increased from 43.6% in 2009 to 56.6% in 2012 (p-trend<0.001). Similarly, the percentage of cases with an aggregate on-time start increased from 41.7% in 2009 to 62.8% in 2012 (p-trend<0.001). In addition, the percentage of manual sheath-pulls performed in the Cath Lab decreased from 60.7% in 2009 to 22.7% in 2012 (p-trend<0.001)., Conclusions: The current longitudinal study illustrates the impact of successful implementation of a well-known process improvement initiative, lean six sigma, on improving and sustaining efficiency of our Cath Lab operation. After the successful implementation of this continuous quality improvement initiative, there was a significant improvement in the selected performance metrics namely turn-time, physician downtime, on-time patient arrival, on-time physician arrival, on-time start as well as sheath-pulls inside the Cath Lab., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To detect factors contributing to variation in cataract surgery processes., Methods: A multilevel study was conducted to compare the process of cataract surgery between hospitals in Belgium. The main data were collected through non-participative observations and time measurements in four hospitals. Surgeons (n = 16) performing cataract surgery in the selected region and their patients (n = 274) undergoing cataract surgery were observed. Flow efficiency is measured in the operating room (OR) as time for preparation, surgery, exit and turnover., Results: Flow efficiency in the OR can be negatively influenced by the severity of the cataract [+2.778 (1.139) min in preparation time (p < 0.05); +4.616 (1.786) min in surgery time when severe cataract (p < 0.05)] and the presence of special-cause variation [+2.832 (1.893) min preparation time (p < 0.05); +2.503 (1.277) min surgery time (p < 0.05); +1.181 (0.350) min exit time (p ≤ 0.001)]. Administering topical analgesia instead of peribulbar [+13.548 (4.436) min preparation time (p ≤ 0.001)], retrobulbar [+3.856 (1.548) min surgery time (p ≤ 0.05)] or general analgesia [+5.617 (2.536) min surgery time (p < 0.05); +5.175 (0.817) min exit time (p ≤ 0.001)] enhances flow efficiency. The experience of surgeons (>15 years) impacts flow efficiency [+12.838 (5.922) min surgery time when low experience]. The volume of cataracts performed annually per surgeon did not have a significant impact on flow efficiency. The use of specialized scrub nurses [-7.146 (3.099) min preparation time (p ≤ 0.05); -2.116 (0.586) min turnover time (p ≤ 0.05)] and the eye clinic design [-1.742 (0.686) min exit time (p < 0.05); 2.296 (1.034) min turnover time (p ≤ 0.05)] benefit flow efficiency., Conclusion: Controllable and uncontrollable factors with clinical and organizational causes influencing flow efficiency in the cataract process were found. These factors can be taken into account in the management of the healthcare process., (© 2015 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)