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PubMed1999

Overcoming barriers to effectiveness in a health care operational environment: building on the lessons of American industry.

Several of the manufacturing-based philosophies, techniques and tools, such as Total Quality Management (TQM), Continuous Improvement (CI), Business Process Reengineering (BPR) and Time-based Competition (TBC) have been successfully adapted for use within the service sector. Diverse service industries including airlines, insurance, food services and hospitality have increased customer satisfaction and performance through the use of the quality driven, manufacturing-based philosophies. This article explores the reasons for the limited success of TQM/CI, BPR, TBC and benchmarking within the health care industry. Sixteen barriers to change are identified, possible counter-measures to these barriers are outlined and two conceptual frameworks are offered as possible facilitators of change for the health care industry.

Benchmarking↗
PubMed2003

Estimating the effects of 17alpha-ethinylestradiol on populations of the fathead minnow Pimephales promelas: are conventional toxicological endpoints adequate?

Environmental benchmarks have recently been proposed for several steroids including the synthetic steroid, 17alpha-ethinylestradiol (EE2). These benchmarks are based on extrapolation from studies involving long-term exposure of various fish species to EE2. One of the critical studies was a complete life-cycle experiment performed with the fathead minnow Pimephales promelas over a 289 day exposure period. The lowest observed effect concentration (LOEC) and the no observed effect concentration (NOEC) for gonad histology were 4 and 1 ng L(-1) respectively. This was because no testicular tissue could be found in any fish exposed to 4 ng L(-1). In the present paper, the survival and reproduction data from that study are reanalyzed to determine the effects of EE2 on the intrinsic rate of population growth (r = In (lambda)), a parameter of demographic importance. We estimate critical threshold concentrations with respect to r and compare these with those previously derived from conventional toxicity test summaries. Further, we assess the influence of individual variability on threshold estimates using a combination of bootstrap and regression approaches, together with a suite of perturbation analyses. These yield ErC100 values (the concentration estimated to reduce intrinsic growth rate to zero) of 3.11 ng L(-1) (linear model) and 3.41 ng L(-1) (quadratic model), comparable with a maximum acceptable toxicant concentration (MATC) of 2 ng L(-1) for feminization of exposed fish calculated by Laenge et al. Our results indicate that reduction in population growth rate with increasing concentration occurred more through EE2 acting to reduce fertility than survival rates. The significance of these summary statistics when deriving environmental benchmarks for steroid estrogens is discussed in the context of affording protection to populations following long-term exposure.

Animals↗
PubMed2006

Validation of the 2000 Bernstein-Parsonnet score versus the EuroSCORE as a prognostic tool in cardiac surgery.

BACKGROUND: Intradepartmental and interdepartmental benchmarking requires scoring systems with reliability (calibration) and stability over the complete spectrum of periprocedural risk. The aim of this single-center study was to assess the performance of the 2000 Bernstein-Parsonnet risk stratification model in cardiac surgery, by itself and against the EuroSCORE. METHODS: A prospective observational design was used. The study group consisted of 1,639 consecutive patients of mean age 64.6 +/- 12.04 years who underwent elective or emergency cardiac surgery from January 2003 to June 2004. The probabilities of hospital death were estimated with the 2000 Bernstein-Parsonnet and EuroSCORE algorithms. The correlation of predicted and observed mortality was compared between the two models, and score validity was assessed by calculating the area under the receiver operating characteristic (ROC) curve. RESULTS: The patients were stratified into five risk groups according to their scores in the two models. For the 2000 Bernstein-Parsonnet model, findings were as follows: score 0-10: predicted mortality 0%-2.2%, observed mortality 0.6%; score 10.5-20: predicted 2.3%-4.7%, observed 2.3%; score 20.5-30: predicted 4.8%-10%, observed 6.7%; score 30.5-40: predicted 10.1%-23%, observed 11.5%; and score greater than 40: predicted 23.1%-80%, observed 29.9%. For the EuroSCORE, findings were as follows: score 0%-2%: predicted mortality 1.1%, observed mortality 0.6%; score 3%-5%: predicted 2.1%, observed 3.0%; score 6%-8%: predicted 4.1%, observed 3.5%; score 9-11: predicted 7.6%, observed 6.6.%; and score greater than 12: predicted 13.8%, observed 14.0%. There was good agreement between the observed and expected number of deaths, with both models. The area under the ROC curve was higher for the Bernstein-Parsonnet model (0.83, odds ratio [OR] 2.01, 95% confidence interval [CI] 1.75-2.31, p < 0.0001) than for the EuroSCORE (0.73, OR 1.05, 95% CI 1.04-1.07, p < 0.001). CONCLUSIONS: The 2000 Bernstein-Parsonnet model is a simple, objective system for the estimation of hospital mortality in patients undergoing cardiac surgery, with slightly higher calibration and discrimination than the EuroSCORE additive model.

Aged↗
PubMedDate not supplied

National benchmarking as a support system for clinical governance.

Audit of the management of acute asthma in hospital has developed in tandem with guidelines produced and updated by the British Thoracic Society (BTS), on the principle that agreed guidelines combined with systematic review of practice by periodic audit are more likely to result in improvements in practice than guidelines alone. A short audit data set was distilled from previous experience with more elaborate tools and made available nationally to audit departments and through letters to consultant members of the BTS. Hospitals have been able to contribute since 1990. The data set reflects key items of the process of care: peak flow measured on admission and twice daily during the hospital stay; blood gases on admission; systemic corticosteroids as an inpatient; discharged with inhaled and oral corticosteroids; written self-management plans; follow-up arrangements. Data from 4,741 admissions over a seven year period are presented. The proportion of patients nationally receiving these items of asthma care is given. The median values for hospital performance improved significantly over the seven years, although there is potential for further improvement. If these data represent the national picture, they could form the basis upon which to set national standards for the care of patients with acute asthma in hospital. A further result of the developing audit has been the recognition of the value of external benchmarking in providing a context for the interpretation of local audit results. This audit system provides hospitals with a quick and easy method of obtaining an overview of local performance, with comparative national data for the same year. This has potential as a tool for clinical governance with much wider applicability, providing the data are handled carefully, particularly as the variability between hospitals diminishes over time.

Asthma↗
PubMed2006

Attitude to personality disorder among prison officers working in a dangerous and severe personality disorder unit.

BACKGROUND: It is well established that staff attitudes to personality disordered patients are commonly negative, characterised by pessimism and rejection. A recent study in forensic psychiatric hospitals has described the psychological and social factors underlying positive attitudes, and suggested that staff with more positive attitudes perform better and are less stressed. AIM: To assess whether it is possible to predict which staff will adjust positively to working with personality disordered people. More specifically to confirm links between attitude to personality disorder and: job performance; perception of managers; personal well-being; burnout; and interaction rates with inmates. METHODS: The opening of a new Dangerous and Severe Personality Disorder unit within a UK prison allowed a longitudinal study of prison officers to be performed, in which a number of measures, including the Attitude to Personality Disorder Questionnaire (APDQ), were collected at three fixed points (at baseline, eight and sixteen months after the opening of the unit). RESULTS: Attitude to Personality Disorder varied over the course of the study, and changes in attitude were linked to events experienced by individual officers. More positive attitude to personality disorder was associated with improved general health and job performance, decreased burnout, and favourable perception of managers. CONCLUSIONS: Attitude to Personality Disorder has important outcomes, and is responsive to the psychosocial environment. Its measurement is not useful for staff selection, because of low stability over lengthy time periods. The APDQ has been demonstrated to be valid measure of attitude to PD, and potentially useful for outcome studies, or benchmarking between units.

Absenteeism↗
PubMed1997

The risks of risk adjustment.

CONTEXT: Risk adjustment is essential before comparing patient outcomes across hospitals. Hospital report cards around the country use different risk adjustment methods. OBJECTIVES: To examine the history and current practices of risk adjusting hospital death rates and consider the implications for using risk-adjusted mortality comparisons to assess quality. DATA SOURCES AND STUDY SELECTION: This article examines severity measures used in states and regions to produce comparisons of risk-adjusted hospital death rates. Detailed results are presented from a study comparing current commercial severity measures using a single database. It included adults admitted for acute myocardial infarction (n=11880), coronary artery bypass graft surgery (n=7765), pneumonia (n=18016), and stroke (n=9407). Logistic regressions within each condition predicted in-hospital death using severity scores. Odds ratios for in-hospital death were compared across pairs of severity measures. For each hospital, z scores compared actual and expected death rates. RESULTS: The severity measure called Disease Staging had the highest c statistic (which measures how well a severity measure discriminates between patients who lived and those who died) for acute myocardial infarction, 0.86; the measure called All Patient Refined Diagnosis Related Groups had the highest for coronary artery bypass graft surgery, 0.83; and the measure, MedisGroups, had the highest for pneumonia, 0.85 and stroke, 0.87. Different severity measures predicted different probabilities of death for many patients. Severity measures frequently disagreed about which hospitals had particularly low or high z scores. Agreement in identifying low- and high-mortality hospitals between severity-adjusted and unadjusted death rates was often better than agreement between severity measures. CONCLUSIONS: Severity does not explain differences in death rates across hospitals. Different severity measures frequently produce different impressions about relative hospital performance. Severity-adjusted mortality rates alone are unlikely to isolate quality differences across hospitals.

Benchmarking↗
PubMed2007

Wax removal for accelerated cotton scouring with alkaline pectinase.

A rational approach has been applied to design a new environmentally acceptable and industrially viable enzymatic scouring process. Owing to the substrate specificity, the selection of enzymes depends on the structure and composition of the substrate, i.e. cotton fibre. The structure and composition of the outer layers of cotton fibre has been established on the basis of thorough literature study, which identifies wax and pectin removal to be the key steps for successful scouring process. Three main issues are discussed here, i.e. benchmarking of the existing alkaline scouring process, an evaluation of several selected acidic and alkaline pectinases for scouring, and the effect of wax removal treatment on pectinase performance. It has been found that the pectinolytic capability of alkaline pectinases on cotton pectin is nearly 75% higher than that of acidic pectinases. It is concluded that an efficient wax removal prior to pectinase treatment indeed results in improved performance in terms of hydrophilicity and pectin removal. To evaluate the hydrophilicity, the structural contact angle (theta) was measured using an auto-porosimeter.

Cellulose↗
PubMed2007

Separation of genomic DNA, RNA, and open circular plasmid DNA from supercoiled plasmid DNA by combining denaturation, selective renaturation and aqueous two-phase extraction.

In the current study we developed a process for the capture of pDNA exploiting the ability of aqueous two-phase systems to differentiate between different forms of DNA. In these systems scpDNA exhibits a near quantitative partitioning in the salt-rich bottom phase. The successive recovery from the salt rich bottom phase is accomplished by a novel membrane step. The polish operation to meet final purity demands is again based on a system exploiting a combination of the denaturation of the nucleic acids present, specific renaturation of scpDNA, and an ATP system able to differentiate between the renatured scpDNA and the denatured contaminants such as ocpDNA and genomic host DNA. This polish step thus allows a rapid and efficient separation of scpDNA from contaminating nucleic acids which up to date otherwise only can be accomplished with much more cumbersome chromatographic methods. In a benchmark comparison, it could be shown that the newly developed process exhibits a comparable yield to an industrial standard process while at the same time showing superior performance in terms of purity and process time. Additionally it could be shown that the developed polish procedure can be applied as a standalone module to support already existing processes.

Chemical Fractionation↗
PubMed1996

Simulated annealing with restrained molecular dynamics using a flexible restraint potential: theory and evaluation with simulated NMR constraints.

A new functional representation of NMR-derived distance constraints, the flexible restraint potential, has been implemented in the program CONGEN (Bruccoleri RE, Karplus M, 1987, Biopolymers 26:137-168) for molecular structure generation. In addition, flat-bottomed restraint potentials for representing dihedral angle and vicinal scalar coupling constraints have been introduced into CONGEN. An effective simulated annealing (SA) protocol that combines both weight annealing and temperature annealing is described. Calculations have been performed using ideal simulated NMR constraints, in order to evaluate the use of restrained molecular dynamics (MD) with these target functions as implemented in CONGEN. In this benchmark study, internuclear distance, dihedral angle, and vicinal coupling constant constraints were calculated from the energy-minimized X-ray crystal structure of the 46-amino acid polypeptide crambin (ICRN). Three-dimensional structures of crambin that satisfy these simulated NMR constraints were generated using restrained MD and SA. Polypeptide structures with extended backbone and side-chain conformations were used as starting conformations. Dynamical annealing calculations using extended starting conformations and assignments of initial velocities taken randomly from a Maxwellian distribution were found to adequately sample the conformational space consistent with the constraints. These calculations also show that loosened internuclear constraints can allow molecules to overcome local minima in the search for a global minimum with respect to both the NMR-derived constraints and conformational energy. This protocol and the modified version of the CONGEN program described here are shown to be reliable and robust, and are applicable generally for protein structure determination by dynamical simulated annealing using NMR data.

Computer Simulation↗
PubMed2006

Design rationale and intended use of a short optical stylet for routine fiberoptic augmentation of emergency laryngoscopy.

Patient safety in emergency airway management has traditionally relied upon prediction of difficult laryngoscopy and alternative intubation devices. Unfortunately, screening tests for difficult laryngoscopy have poor predictive value, and alternative devices are often not suitable for emergency airways. RSI performed with hit or miss repetitive laryngoscopy followed by delayed deployment of rarely used rescue devices is inherently hazardous. First pass success with laryngoscopy should be a benchmark of quality and patient safety in emergency airway management. By making a commitment to minimally modify practice and expand our skill set, fiberoptic augmentation of every laryngoscopy can promote patient safety through the avoidance of repetitive laryngoscopy and esophageal intubation. This article presents the design rationale and intended use of a new short optical stylet for the routine augmentation of emergency direct laryngoscopy.

Airway Obstruction↗
PubMed2005

Influence of time on risk of bowel resection in complete small bowel obstruction.

BACKGROUND: Little is known about the effect of passing time on risk of resection among patients with complete small bowel obstruction. We sought to provide a benchmark of the relationship of time from symptom onset to surgical treatment on the need for resection in patients with complete small bowel obstruction. STUDY DESIGN: We performed an observational study of patients with surgically treated complete small bowel obstruction at an inner-city urban tertiary referral center and a municipal hospital. Patients were sampled randomly retrospectively (n=60), and prospectively (n=81), for a final sample of 141. Detailed clinical and time data were abstracted from medical records including out-of-hospital examinations. Risk of resection was calculated using actuarial life table methods. Linear regression was used to determine factors affecting time to treatment. RESULTS: All patients were treated surgically for obstruction; 45% underwent resection. Resected patients had longer (11 days versus 8 days; p=0.01) and more complicated (31% versus 14% in ICU; p=0.01) hospital stays. The risk of resection was 4% among patients with 24 hours of unresponsive symptoms; it increased to 10% to 14% through 96 hours, then dropped slightly but did not disappear. Patients treated first with a tube had longer times between first examination and operation, system-time (40.6 hours versus 10.2 hours; p=0.0007), but this was not associated with an increased resection risk. System-times were shorter among patients seen first in the emergency department (median: 25.7 hours versus 59.7 hours; p=0.0001). CONCLUSIONS: Physicians should be cautious in postponing surgery beyond 24 hours in patients with unresponsive symptoms from complete obstruction. The risk of resection rises dramatically, remains elevated through 96 hours of unresolved symptoms, then declines but does not disappear.

Adolescent↗
PubMed2000

A simple iterative approach to parameter optimization.

Various bioinformatics problems require optimizing several different properties simultaneously. For example, in the protein threading problem, a scoring function combines the values for different parameters of possible sequence-to-structure alignments into a single score to allow for unambiguous optimization. In this context, an essential question is how each property should be weighted. As the native structures are known for some sequences, a partial ordering on optimal alignments to other structures, e.g., derived from structural comparisons, may be used to adjust the weights. To resolve the arising interdependence of weights and computed solutions, we propose a heuristic approach: iterating the computation of solutions (here, threading alignments) given the weights and the estimation of optimal weights of the scoring function given these solutions via systematic calibration methods. For our application (i.e., threading), this iterative approach results in structurally meaningful weights that significantly improve performance on both the training and the test data sets. In addition, the optimized parameters show significant improvements on the recognition rate for a grossly enlarged comprehensive benchmark, a modified recognition protocol as well as modified alignment types (local instead of global and profiles instead of single sequences). These results show the general validity of the optimized weights for the given threading program and the associated scoring contributions.

Algorithms↗
PubMed2006

Identifying cis-regulatory modules by combining comparative and compositional analysis of DNA.

MOTIVATION: Predicting cis-regulatory modules (CRMs) in higher eukaryotes is a challenging computational task. Commonly used methods to predict CRMs based on the signal of transcription factor binding sites (TFBS) are limited by prior information about transcription factor specificity. More general methods that bypass the reliance on TFBS models are needed for comprehensive CRM prediction. RESULTS: We have developed a method to predict CRMs called CisPlusFinder that identifies high density regions of perfect local ungapped sequences (PLUSs) based on multiple species conservation. By assuming that PLUSs contain core TFBS motifs that are locally overrepresented, the method attempts to capture the expected features of CRM structure and evolution. Applied to a benchmark dataset of CRMs involved in early Drosophila development, CisPlusFinder predicts more annotated CRMs than all other methods tested. Using the REDfly database, we find that some 'false positive' predictions in the benchmark dataset correspond to recently annotated CRMs. Our work demonstrates that CRM prediction methods that combine comparative genomic data with statistical properties of DNA may achieve reasonable performance when applied genome-wide in the absence of an a priori set of known TFBS motifs. AVAILABILITY: The program CisPlusFinder can be downloaded at http://jakob.genetik.uni-koeln.de/bioinformatik/people/nora/nora.html. All software is licensed under the Lesser GNU Public License (LGPL).

Algorithms↗
PubMed2003

Patients' needs for nursing care: beyond staffing ratios.

The current focus on staffing ratios as a means to assure appropriate care for patients ignores the very real differences among patients in their needs for nursing care. Implementing a system that identifies these needs provides a more accurate indication of staffing requirements. In addition, storing the raw data from the system at their most basic level provides opportunities for more extensive analyses and informed, data-driven decision-making related to resource allocation, performance improvement, and productivity enhancement.

Benchmarking↗
PubMed2006

An evidence-based virtual reality training program for novice laparoscopic surgeons.

OBJECTIVE: To develop an evidence-based virtual reality laparoscopic training curriculum for novice laparoscopic surgeons to achieve a proficient level of skill prior to participating in live cases. SUMMARY BACKGROUND DATA: Technical skills for laparoscopic surgery must be acquired within a competency-based curriculum that begins in the surgical skills laboratory. Implementation of this program necessitates the definition of the validity, learning curves and proficiency criteria on the training tool. METHODS: The study recruited 40 surgeons, classified into experienced (performed >100 laparoscopic cholecystectomies) or novice groups (<10 laparoscopic cholecystectomies). Ten novices and 10 experienced surgeons were tested on basic tasks, and 11 novices and 9 experienced surgeons on a procedural module for dissection of Calot triangle. Performance of the 2 groups was assessed using time, error, and economy of movement parameters. RESULTS: All basic tasks demonstrated construct validity (Mann-Whitney U test, P < 0.05), and learning curves for novices plateaued at a median of 7 repetitions (Friedman's test, P < 0.05). Expert surgeons demonstrated a learning rate at a median of 2 repetitions (P < 0.05). Performance on the dissection module demonstrated significant differences between experts and novices (P < 0.002); learning curves for novice subjects plateaued at the fourth repetition (P < 0.05). Expert benchmark criteria were defined for validated parameters on each task. CONCLUSION: A competency-based training curriculum for novice laparoscopic surgeons has been defined. This can serve to ensure that junior trainees have acquired prerequisite levels of skill prior to entering the operating room, and put them directly into practice.

Benchmarking↗
PubMed2004

Assessment of patient satisfaction of mentally ill patients hospitalized in Thailand.

Psychiatric patients' satisfaction with their hospital care has not been reported in the Western literature. The concept of asking psychiatric patients about their perceptions of care is relatively new. The purpose of the present investigation was to assess the satisfaction of the care received by a group of acutely mentally ill hospitalized Thai patients. This post-test design examined a random sample of 182 persons hospitalized between 1 March 2000 and 31 July 2000. Using a validated Perception of Care instrument, research assistants assessed patient satisfaction. Patients rated the care as average with none of the items achieving a very good or excellent score. The lowest scoring items were receiving information about their rights, consistency of information provided, and the ease of obtaining information. Women tended to be more satisfied with care as were patients over the age of 55 years (P = 0.02). Patients with a diagnosis of schizophrenia were more satisfied with the care than other patients (P = 0.05). It is unknown if satisfaction levels are similar in other institutions in Thailand. None of the areas received excellent or very good ratings. The findings of this study were shared with the staff at the study site. There appears to be a need to develop performance improvement activities designed to address the areas identified as needing improvement. Replication of this study in other Thailand sites would provide an opportunity for agencies to benchmark their findings. By consenting to be a part of this study the staff and patients have taken a positive step forward to improve patient satisfaction with care.

Adult↗
PubMed1991

Immobilized microbe bioreactors for waste water treatment.

The application of adapted microbial populations immobilized on a porous diatomaceous earth carrier to pre-treat and reduce toxic concentration of volatile organics, pesticides, petroleum aliphatics and aromatics has been demonstrated for several industrial sites. In the pre-treatment of industrial effluents and contaminated groundwaters, these bioreactors have been used to optimize and reduce the cost of conventional treatment systems, i.e. steam stripping, carbon adsorption and traditional biotreatment. Additionally, these systems have been employed as seeding devices for larger biotreatment systems. The cost effective utilization of an immobilized microbe reactor system for water supply regeneration in a microgravity environment is presented. The feasibility of using immobilized biomass reactors as an effluent treatment technology for the biotransformation and biodegradation of phenols, chlorinated halocarbons, residual oils and lubricants was evaluated. Primary biotransformation tests of two benchmark toxicants, phenol and ethylene dichloride at concentrations expected in life support effluents were conducted. Biocatalyst supports were evaluated for colonization potential, surface and structural integrity, and performance in continuous flow bioreactors. The implementation of such approaches in space will be outlined and specific areas for interfacing with other non-biological treatment approaches will be considered for advanced life support, tertiary waste water biotreatment.

Biodegradation, Environmental↗