Additional Opportunities For Improvement Research Articles

Primary care provider perceptions of an asthma home visiting program

Introduction Pediatric asthma home visiting programs have improved clinical outcomes, but little is known about how providers perceive these programs. The purpose of this study was to understand how primary care providers and their colleagues in a medical home perceive an asthma home visiting program that is available at no cost to their patients. Methods After several years of running an asthma home visiting program using community health workers (CHW) in 10 pediatric primary care offices in the South Coast of Massachusetts, we surveyed the providers of patients who had enrolled in the program. An anonymous online survey was developed by the program leaders, the program analytics team, and the CHWs for quality improvement purposes. Survey domains included the perceived utility of various aspects of the program, impact on patients, and interaction with CHWs, as well as demographic information about the providers. Results Of the 24 providers asked to complete the survey from eight primary care practices, 21 completed the survey (88%). Respondents perceived that the most beneficial aspects were environmental assessment (95%), asthma education (91%), and addressing environmental issues (86%). In addition to numerous positive free-text responses, suggestions for improvement were in the areas of referral completion, post-visit communication, and patient identification in the medical record. All respondents would continue to refer to the program. Conclusions Primary care providers and medical home staff perceived an asthma home visiting program to have high utility, particularly the environmental assessment, asthma education, and mitigation of environmental issues. Additional opportunities for improvement were identified.

Multi-Modality Non-rigid Image Registration Using Local Similarity Estimations

In this study, we focus on improving the efficiency and accuracy of nonrigid multi-modality registration of medical images. In this regard, we analyze the potentials of using the point similarity measurement approach as an alternative to global computation of mutual information (MI), which is still the most renown multi-modality similarity measure. The improvement capabilities are illustrated using the popular B-spline transformation model. The proposed solution is a combination of three related improvements of the most straightforward implementation, i.e., efficient computation of the voxel displacement field, local estimation of similarity and usage of a static image intensity dependence estimate. Five image registration prototypes were implemented to show contribution and dependence of the proposed improvements. When all the proposed improvements are applied, a significant reduction of computational cost and increased accuracy are obtained. The concept offers additional improvement opportunities by incorporating prior knowledge and machine learning techniques into the static intensity dependence estimation.

Abstract P818: Increased Eligibility for Endovascular Therapy Following Intensive Door-To-Transfer Improvement Project

Background and Purpose: Early EVT for large vessel acute ischemic stroke is associated with reduced disability and mortality. Longer transfer times from the sending facility contribute to poorer EVT outcomes, and in some circumstances, patient ineligibility for EVT due to a completed stroke on arrival to the endovascular site. Reducing avoidable delays will result in overall improved EVT outcomes and reduce the frequency of completed stroke upon arrival. Methods: A multidisciplinary group utilized the Lean A3 process and PDCA improvement cycle to reduce transfer times. Avoidable delays and resources to expedite the transfers were identified. A standardized plan with defined roles and responsibilities, communication pathways, early transport team activation, and robust staff education were implemented. The PI team met weekly for 3 months to review each individual transfer, determine what went well and what did not, and to identify additional improvement opportunities. A weekly summary with feedback was provided to front line staff and managers. Staff involved in patient transfers that had a DIDO of 90 min or less were recognized with a “Brain Pin” and staff recognition certificate. Results: Since its implementation, 23 patients were transferred for potential EVT. Compared with 12 months prior to implementation, the DIDO median time was reduced from 119 minutes to 80.5 minutes, transfers were achieved in 90 min or less 61% (n=15) of the time vs. 27.2%, and percentage of EVT eligible patients increased from 58.3 to 78.3%. Conclusion: In conclusion, rapid reduction of DIDO times and increased patient eligibility for thrombectomy is attainable through an intensive multidisciplinary process improvement project. Implementing a standardized workflow that includes rapid identification of potential EVT transfers, early activation of the transport team, development of clear pathways of communication, defined roles and responsibilities within the team, and regular staff feedback are essential.

Mortality review of US Special Operations Command battle-injured fatalities.

Comprehensive analyses of battle-injured fatalities, incorporating a multidisciplinary process with a standardized lexicon, is necessary to elucidate opportunities for improvement (OFIs) to increase survivability. A mortality review was conducted on United States Special Operations Command battle-injured fatalities who died from September 11, 2001, to September 10, 2018. Fatalities were analyzed by demographics, operational posture, mechanism of injury, cause of death, mechanism of death (MOD), classification of death, and injury severity. Injury survivability was determined by a subject matter expert panel and compared with injury patterns among Department of Defense Trauma Registry survivors. Death preventability and OFI were determined for fatalities with potentially survivable or survivable (PS-S) injuries using tactical data and documented medical interventions. Of 369 United States Special Operations Command battle-injured fatalities (median age, 29 years; male, 98.6%), most were killed in action (89.4%) and more than half died from injuries sustained during mounted operations (52.3%). The cause of death was blast injury (45.0%), gunshot wound (39.8%), and multiple/blunt force injury (15.2%). The leading MOD was catastrophic tissue destruction (73.7%). Most fatalities sustained nonsurvivable injuries (74.3%). For fatalities with PS-S injuries, most had hemorrhage as a component of MOD (88.4%); however, the MOD was multifactorial in the majority of these fatalities (58.9%). Only 5.4% of all fatalities and 21.1% of fatalities with PS-S injuries had comparable injury patterns among survivors. Accounting for tactical situation, a minority of deaths were potentially preventable (5.7%) and a few preventable (1.1%). Time to surgery (93.7%) and prehospital blood transfusion (89.5%) were the leading OFI for PS-S fatalities. Most fatalities with PS-S injuries requiring blood (83.5%) also had an additional prehospital OFI. Comprehensive mortality reviews of battlefield fatalities can identify OFI in combat casualty care and prevention. Standardized lexicon is essential for translation to civilian trauma systems. Epidemiological, level IV.

A comparative chemogenic analysis for predicting Drug-Target Pair via Machine Learning Approaches

A computational technique for predicting the DTIs has now turned out to be an indispensable job during the process of drug finding. It tapers the exploration room for interactions by propounding possible interaction contenders for authentication through experiments of wet-lab which are known for their expensiveness and time consumption. Chemogenomics, an emerging research area focused on the systematic examination of the biological impact of a broad series of minute molecular-weighting ligands on a broad raiment of macromolecular target spots. Additionally, with the advancement in time, the complexity of the algorithms is increasing which may result in the entry of big data technologies like Spark in this field soon. In the presented work, we intend to offer an inclusive idea and realistic evaluation of the computational Drug Target Interaction projection approaches, to perform as a guide and reference for researchers who are carrying out work in a similar direction. Precisely, we first explain the data utilized in computational Drug Target Interaction prediction attempts like this. We then sort and explain the best and most modern techniques for the prediction of DTIs. Then, a realistic assessment is executed to show the projection performance of several illustrative approaches in various situations. Ultimately, we underline possible opportunities for additional improvement of Drug Target Interaction projection enactment and also linked study objectives.

Abstract 232: Minimizing Bleeding Complications in the Cardiac Catheterization Lab

Background: Bleeding complications related to invasive procedures significantly increase costs, length of stay, morbidity and mortality risk. The cardiac catheterization lab [CCL] is a high risk, high volume center requiring continuous monitoring to minimize the incidence of vascular injury, hematomas/ hemorrhage, blood transfusions. Oversight extends beyond the CCL to concerns regarding post procedure access management, appropriate medication administration, ambulation, threshold for transfusion, vascular diagnostics/consultation. Based on best practices a multidisciplinary team has developed and implemented a risk stratification tool, encourages best practices, and continues to collect data to provide feedback and process improvement. Methods: The Stony Brook U Hospital CCL serves a Suffolk Co population of >1.5 million and provides 7x24 coverage for STEMI interventions over 912 square miles. Data post implementation of a bleeding risk stratification and optimal practices tool was collected from September of 2014 through September of 2015 to assess bleeding complication incidence [NCDR criteria], associations, and implementation of suggested practice improvements [radial access, bivalirudin, vascular closure). Results: A total of 1770 angioplasty procedures were performed during the monitored period [485 radial (27%), 1285 femoral (73%) approach]. In the femoral access group a total of 485 vascular closure devices (38%) were deployed. Bivalirudin [Angiomax] was used in 1,304 cases (74%); UFH was used in 466 cases (26%). Bleeding complications were identified in 69 patients during the monitored period [3.9% incidence]. Preprocedure risk screening identified 50 [72%] patients with bleeding complications as high risk and 19 [28%] patients as intermediate risk. In the patients with bleeding complications: Radial artery access was used in 16 (23%), bivalirudin in 63 (91%), vascular closure devices in 19 of appropriate femoral candidates (48%) with 12 femoral access patients (23%) receiving an Impella or IABP. Monthly case review has identified additional opportunities for improvement including: preprocedure optimization where possible, establishing transfusion thresholds, post procedure large sheathe/device management, and antithrombotic/antiplatelet medication administration. Conclusions: A bleeding complication task force developed a PCI bleeding risk assessment tool to identify patients at high risk of bleeding complications by NCDR criteria. Routine implementation accurately identifies high risk patients and encourages the use of best practices designed to reduce complications. Continued feedback, education and encouragement of practitioners and support staff in implementing best practices continues to improve implementation. Focused case review has provided additional opportunities for continued quality improvement.

Evaluation of NALDN performance characteristics in the vicinity of the CN Tower based on tall-structure lightning

The North American Lightning Detection Network has been providing lightning data since 1998. Important applications, such as detection of lightning-caused forest fires, power line fault location and aviation safety procedures, have triggered a number of hardware and software upgrades for improvement of the network performance characteristics, including its detection efficiency and location accuracy. The performance characteristics of the network have been here evaluated by examining the reported North American Lightning Detection Network (NALDN) return-stroke data based on the lightning current measured at CN Tower during three major storms (2005, 2011 and 2014). Each of these three storms followed a substantial network upgrade in 2003–2004, 2010–2011 and 2013–2014, respectively. The objective of this investigation is to outline the evolution of the network and determine where there may be opportunities for additional improvements. (It is important to stress that the evaluation of NALDN in the vicinity of the tower is mainly based on tall-structure lightning, which is upward-initialed, due to the rarity of recording downward-initiated lightning at the extremely tall tower.) Since 1990, the CN Tower has been equipped to measure the lightning current derivative signals. Its 553-m height has allowed the recording of many hundreds of current derivative signals, mostly resulting from return strokes. Also, image recording systems have been used to capture images of strikes to the tower. The evaluation of the NALDN performance characteristics includes polarity, flash and stroke detection efficiency, location accuracy and peak current estimation. The 2013 deployment of LS7002 digital sensors with the enhanced embedded software has substantially improved the sensitivity of the sensors leading to greater flash and return-stroke detection efficiencies. Furthermore, the 2014 total lightning processor (TLP100), well designed with new algorithm and techniques, provides smaller time-of-arrival errors and better location accuracy. Based on this investigation, following the latest network upgrade, the polarities of the NALDN-detected return strokes were perfectly matched with the polarities of the corresponding return-stroke currents measured at the tower. In 2014, the NALDN detected every flash that contained at least one return stroke, as well as all recorded CN Tower return strokes, resulting in 100% flash- and stroke-detection efficiencies. The perfect stroke-detection efficiency in 2014 confirms a significant network improvement in comparison with the assessment in 2005 (55.3%) and 2011 (53.8%). In the 2014 evaluation, relative to the location of the tower, the NALDN is found to have a median absolute location error of 119m and an average absolute location error of 129m. The 2014 median absolute location error is found to be significantly lower than those for 2005 (289m) and 2011 (199m). Based on 2014 evaluation, the NALDN is found to overestimate the current peak measured at the tower by a factor of 3.89, which is due to field enhancement effect resulting from high speed propagation of the current within the tall tower. The presented analysis shows that the latest NALDN upgrade (2013–2014) following the 2003–2004 and 2010–2011 upgrades, has substantially improved the NALDN performance characteristics, especially in terms of stroke-detection efficiency and location accuracy.

Cost Estimating - Make or Buy?

Determining how a corporate real estate organization estimates its project costs is a big decision that impacts budgets, customers, and the bottom line. Our next management meeting is only a few days away. What recommendations should we make for improvement of cost estimating? Troy Montgomery, a consultant at Humana in April of 2015, was tasked with providing leaders of Humana’s corporate real estate group, Workplace Solutions (WPS), with an answer to how to provide early cost estimates on large construction projects. Should they create a solution internally, outsource development of a solution, or look to an existing solution to provide a “cost calculator”? There was so much variation in the types of projects WPS worked on, not to mention an assortment of internal clients they served. Such complexity made it virtually impossible to come to a straight forward recommendation. Humana was a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. When Humana needed a new or renovated office building, call center, pharmacy, or medical center they engaged the WPS team to manage the start to finish solution. Similar to any other large project, the end user was concerned with three things: time, cost, and quality. The initial questions from WPS internal clients were typically “How long is this project going to take and how much will it cost?” WPS managers believed they provided sufficient cost estimates once all of the planning activities were completed, contracts selected, and construction drawings finalized. However, they were curious if could provide better estimates at the initial onset of a new project, before all of the planning is complete. In late 2014 and early 2015 Montgomery led a small, cross-functional team of WPS associates through process improvement initiatives. The team had only been commissioned for six months and due to their success, WPS leaders challenged the team to identify additional improvement opportunities. Determining a solution to an issue like cost estimating would not only build the credibility of Montgomery’s team, but it would also open up new opportunities for additional improvements in the future. First, the team identified the current methodology for cost estimating within WPS. In parallel they researched cost estimating tools on the market and investigated best practices within the industry. Based on the team’s analysis, WPS leaders recognized they needed a solution in a short period of time. Should they task internal resources, purchase an out-of-the-box IT tool, or commission an external vendor to create a solution?

An overview of radioisotope separation technologies for development of 188W/188Re radionuclide generators providing 188Re to meet future research and clinical demands

Separation technologies for 188W/188Re radionuclide generators.

Improving chronic care delivery and outcomes: the impact of the cystic fibrosis Care Center Network

Cystic fibrosis (CF) is a multisystem, life-shortening genetic disease that requires complex care. To facilitate this expert, multidisciplinary care, the CF Foundation established a Care Center Network and accredited the...

Climate adaptation imperatives: global sustainability trends and eco-efficiency metrics in four major crops – canola, cotton, maize, and soybeans

Supplying our world's growing nutrition needs in more sustainable ways has become an urgent global imperative, given the constraints of finite resources and the challenges of accelerating climate change. We present national-level eco-efficiency metrics in several representative production countries during the most recent decade (2000–2010) for four important crops: canola, cotton, maize, and soybeans. The metrics address greenhouse gas emissions and the utilization of land, water, and energy – all calculated per unit of production. We group countries based on their level of agricultural intensification and find that high-intensification countries are achieving the highest and yet still increasing levels of eco-efficiency, with these decadal gains: canola (26%), cotton (23%), maize (17%), and soybeans (18%). By stark contrast, low-intensification countries had no change in eco-efficiency during this same decade. Overall, our results suggest large opportunities for additional improvements in the developing world, and that cumulative resource savings through intensification have been significant. For instance, in the case of irrigated maize, if the high- and medium-intensification production countries had only achieved the same irrigation water-use efficiency as in the low-intensification countries, approximately 4 quadrillion (4×1015) more litres of irrigation water would have been consumed during the period 2000–2010.

Abstract TP336: Sustaining Excellence in Alteplase Administration in the Emergency Department: Staying Lean

Background: Identification and treatment of acute ischemic stroke (AIS) patients in the emergency department (ED) was reorganized in January 2011 using Lean Methodologies. The team achieved initial success post implementation in March 2011 of median time to treatment of 34 minutes. Sustaining the improvements required a shift in paradigm of the ED Acute Stroke Committee (EDASC) and the front line staff caring for the patients. Pre-Lean door to treatment time was 60 minutes (N=132). Methods: Lean methodologies were chosen as a process improvement strategy. Initial implementation demonstrated immediate success of reaching 34 minutes; however in the first quarter following the implementation, the team identified drift in the process and increased numbers of stroke activation evaluations. Individual case review at monthly meetings demonstrated intermittent role confusion, complex patient presentations, inconsistency in process for alteplase preparation and patient preparation. While the team historically discussed these issues, the expectations had been raised to sustain the critical changes. Identification of individuals in each case for role clarification, general nursing education regarding alteplase preparation, reinforcement of bolus administration as a priority and the addition of point of care testing to decrease barriers enabled the front line staff to receive timely feedback and rapid practice corrections. Results: The initial protocol changes were implemented in March 2011. Team reviews with rapid (less than 48 hour) feedback were implemented in April 2011. Point of care testing was implemented in September 2011 for PT/INR testing. Median time to treatment increased to 51 and 48 minutes in April and May 2011. Through drill down review, communication of expectations and progress, and addition of point of care testing the post implementation median time is currently 39 minutes (N=120) for 2011 and 2012. Conclusions: Rapid process improvement using lean tools creates opportunities to radically alter a process of care. Sustaining the changes requires rapid attention to process defects, identification of additional opportunities for improvement and individual accountability to the process.

The Leadership Continuum: A Framework for Organizational and Individual Assessment Relative to the Advancement of Women Physicians and Scientists

In the United States, women have attained near gender equity at the entry stages in academic medicine; however, progress has been much slower at senior leadership levels. The paucity of women leaders inhibits the ability of academic medicine to adequately meet the needs of an increasingly diverse body of students, faculty, staff, and patients. Research indicates that until a critical mass of women with sustained success as leaders is achieved, it is unlikely that this deficit will be corrected. To promote the attainment of a critical mass of women leaders, the authors integrate two approaches to advancing women--the concept of a leadership continuum and a framework of practical approaches for moving toward gender equity at all ranks. An institutional guide is presented that can be used to promote dialogue about gender equity, noting areas of success and opportunities for additional improvement as well as an assessment of progress. A corresponding checklist has been developed that women faculty can use as a reflection guide for their career planning and to assess their position and progress along the leadership continuum. Proactive, ongoing use of these frameworks can promote reflective dialogue and provide direction and accountability for institutions working to advance women into leadership positions.

The asthma emergency department visit: treating a crisis in the midst of uncontrolled disease

Patients with asthma who require emergency department (ED) care are burdened with asthma symptoms, are at risk for hospitalization, and use expensive resources. To examine whether an ED-based surveillance system that characterized asthma symptoms and care before, during, and after an ED visit enhances our understanding of the natural history of asthma exacerbations. This cross-sectional follow-up enrolled 225 adult patients who presented to 1 of 6 Illinois EDs for asthma care. Clinical characteristics before ED presentation, care provided in the EDs, and 1-month follow-up status were assessed by self-administered questionnaire, medical record review, and telephone interview, respectively. Persistent asthma symptoms were reported by 85.8% and 84.9% (P = .37) of patients before their ED visit and follow-up call, respectively. For patients with persistent symptoms before the ED visit and follow-up call, 54.4% and 73.8% (P = .02) reported using an inhaled corticosteroid, respectively. Inhaled corticosteroids were recommended for 49.4% of discharged patients with persistent symptoms. Relapse rates for return ED visits and return hospitalizations were 26.4% and 9.6%, respectively. Patients had low asthma-specific and general quality-of-life scores at follow-up. Patients with asthma exacerbations most often had uncontrolled asthma before the ED visit that subsequently deteriorated, temporarily improved with ED treatment, and continued as uncontrolled asthma after the ED visit. Although improvements in care were reported 1 month after the ED visit, opportunities for additional improvement were observed.

A New Quality Approach to Wellsite Safety

Summary Total quality management and the team approach can help improve safety performance. In a thorough review of wellsite safety practices, an in-house quality action team made up of drilling engineers and safety personnel examined all safety aspects of our worldwide wellsite operations. personnel examined all safety aspects of our worldwide wellsite operations. This paper describes the methods, tools. and diagnostic procedures used, as well as the recommendations made by the team. Introduction Concern for safety and the environment has always been a top priority at Phillips Petroleum Co. In March 1990, a cross-functional priority at Phillips Petroleum Co. In March 1990, a cross-functional team of professionals was charged (1) to examine current practices as they relate to safety in drilling, completions, and workovers; (2) to identify areas of opportunity for improvement; (3) to present recommendations for enhancement of safety practices at the present recommendations for enhancement of safety practices at the wellsite; and (4) to propose a plan for implementation of the recommendations. The team, called the drilling quality action team (DQAT) under the newly instituted Total Quality Program, included 28 representatives from the company's six regions, the central Drilling and Production Branch, and other organizational units (Safety, Reservoir Engineering, Geology. etc.) A management consulting firm assisted the DQAT through the quality review process and provided facilitators for the team's meetings. A turnkey drilling-contractor/consultant firm assisted by providing input on industry safety practices and reviewing current wellsite safety performance. DQAT Process The DQAT based its work on a series of diagnostic surveys and studies conducted by the management consultants. The results of these surveys helped the DQAT members to focus quickly on the major areas needing improvement. In its first full membership meeting held May 9–11, 1990, the DQAT reviewed the diagnostic surveys, elaborated on the issues behind the findings, and formulated ideas on how to address the issues or opportunities. In 3 days of intense meetings, the DQAT identified 79 issues affecting the four principal phases of the drilling cycle: planning, preparation, drilling, and postwell analysis. The DQAT split into four "mini-QAT's," each dealing with one of these drilling-cycle phases. The mini-QAT's submitted their preliminary recommendations to the DQAT for approval. At its second meeting, held June 9–12, 1990, the DQAT reviewed the recommendations, obtained feedback, solidified the details of each recommendation, discussed additional opportunities for improvement, and began the transition to the implementation phase. phase. The mini-QAT's finalized their recommendations and began to develop an implementation plan for each region. The regional representatives assisted in adapting and "customizing" the plan to meet specific needs of the individual regions. At the third and final meeting, held Aug. 1–4, 1990, the DQAT approved the recommendations and the overall implementation plan. Responsibilities for implementing the plan in each region and division were defined. By the conclusion of the meetings, the DQAT had developed a cooperative and integrated approach toward improving wellsite safety in worldwide operations. On Aug. 31, 1990, the DQAT presented its recommendations to the executive management and began implementation of the recommendations.