Quality Management Department Research Articles

Does the ESC chronic coronary syndrome pre-test probability score assist coronary artery disease diagnosis in an advanced nurse practitioner led integrated community chest pain clinic?

Abstract Background The Advanced Nurse Practitioner (ANP) led integrated community chest pain clinic provides an alternative avenue to which GPs can refer patients with non-acute chest pain providing emergency dept. avoidance. The role of the ANP is to differentiate between a non-anginal versus anginal cause. In addition to taking a clinical history, physical assessment and ECG the ANP utilises the 2019 ESC guidelines for chronic coronary syndromes pre-test-probability (PTP) score, to judge if invasive investigation is required. Purpose ANP assessment of chest pain in a community clinic is unique in the Irish healthcare setting. The aim was to assess if angina characteristics & allocated ESC PTP were predictive of coronary artery disease (CAD) diagnosis in a community chest pain cohort. Method A retrospective audit of 144 patients assessed by the ANP in the ICCPC and subsequently referred for coronary angiography was performed. Final diagnosis of was analysed by i. anginal characteristic, ii. ESC PTP, iii. age and sex. Approval was given by the department of quality, safety and risk management. Results The average combined age was 61 years in n=92 Male, and n=51 Female patients. Coronary Artery Disease was diagnosed in 92% (n= 132) of those referred for angiography; obstructive CAD in 38% (n=55) and non-obstructive CAD (NOCAD) in 54% (n=77). The ANP allocated the angina characteristic ‘typical’ in 31% (n=45) cases and 58% (n=26) were diagnosed with obstructive CAD, average PTP of 20%, and 38% (n=17) were diagnoses with NOCAD. In those with ‘typical’ symptoms only two cases resulted in normal coronary arteries. Conversely 34% (n=49) were allocated ‘non-anginal’ symptoms, in whom 28% (n=14) obstructive CAD was detected; 12 cases had an intermediate to high PTP due to age and clinical likelihood. The majority of referrals (57%) were ‘high’ PTP of CAD (≤16%-52%), average 22%. The average PTP was 27% (High) in those diagnosed with CAD versus a PTP of 11% (Intermediate) in those with normal coronaries (n=12). The new category of ‘dyspnoea’ was allocated to 14% (n=20) and resulted in diagnosis of NOCAD (n=12) and (n=5) CAD. Those with dyspnoea as a presenting symptom of CAD were all male with high PTP. Conclusion Pre-test-probability and age are highly correlated, rising with age and defined by sex. The main variable is the ‘angina’ characteristic allocated by the ANP. In this community-based cohort, ‘typical’ symptom allocation by the ANP resulted in a higher PTP and subsequent CAD diagnosis. Clinical suspicion in the ‘low-intermediate risk’ can be further adjusted using the clinical likelihood ratio. The value of the PTP score in predicting CAD is as useful as the ‘angina’ characteristic and clinical likelihood allocated, requiring expert health history taking. This retrospective analysis of coronary angiogram results in this community cohort evidences that the ANP is skilled in utilising the ESC PTP score to assist in the diagnosis of CAD.

Professional perceptions of right-first-time and quality management in construction projects through open-ended feedback

PurposeThe construction industry has struggled to deliver schemes on time to budget and right-first-time (RFT). There have been many studies into nonconformance and rework through quantitative research over the years to understand why the industry continues to see similar issues of failure. Some scholars have reported rework figures as high as 12.6% of total contract value, highlighting major concerns of the sustainability of construction projects. Separately, however, there have been few studies that explore and detail the views of industry professions who are caught in the middle of quality issues, to understand their perceptions of where the industry is failing. As such, this paper interrogates qualitative data (open-ended questions) on the topic of nonconformance and rework in construction to understand what industry professionals believe are the causes and suggested improvement areas.Design/methodology/approachA qualitative approach is adopted for this research. An industry survey consisting of seven open-ended questions is presented to two professional working groups within a Tier 1 contractor, and outputs are analysed using statistic software (NVivo 12) to identify prominent themes for discussion. Inductive analysis is undertaken to gain further insight into responses to yield recurrent areas for continuous improvement.FindingsQualitative analysis of the survey reveals a persistent prioritisation of cost and programme over quality management in construction project. Furthermore, feedback from construction professionals present a number of improvement areas that must be addressed to improve quality. These include increased training and competency investment, overhauling quality behaviours, providing greater quality leadership direction and reshaping the way clients govern schemes.Research limitations/implicationsThere are limitations to this paper that require noting. Firstly, the survey was conducted within one principal contractor with varying levels of knowledge across multiple sectors. Secondly, the case study was from one major highways scheme; therefore, the generalisability of the findings is limited. It is suggested that a similar exercise is undertaken in other sectors to uncover similar improvement avenues.Practical implicationsThe implications of this study calls for quality to be re-evaluated at project, company, sector and government levels to overhaul how quality is delivered. Furthermore, the paper identifies critical learning outcomes for the construction sector to take forward, including the need to reassess projects to ensure they are appropriately equip with competent personnel under a vetted, progressive training programme, share collaborative behaviours that value quality delivery on an equal standing to safety, programme and cost and tackle the inappropriate resource dilemmas projects finding themselves in through clear tendering and accurate planning. In addition, before making erratic decisions, projects must assess the risk profiling of proceed without approved design details and include the client in the decision-making process. Moreover, the findings call for a greater collaborative environment between the construction team and quality management department, rather than being seen as obstructive (i.e. compliance based policing). All of these must be driven by leadership to overhaul the way quality is managed on schemes. The findings demonstrate the importance and impact from open-ended survey response data studies to enhance quantitative outcomes and help provide strengthened proposals of improvement.Originality/valueThis paper addresses the highly sensitive area of quality failure outcomes and interrogates them via an industry survey within a major UK contractor for feedback. Unique insights are gained into how industry professionals perceive quality in construction. From previous research, this has been largely missing and offers a valuable addition in understanding the “quality status quo” from those delivering schemes.

Presenting The Role Of CPOE Incorporating With CDSS In Decreasing The Costs Of TPN In ICU

Total parenteral nutrition (TPN) is the treatment modality of providing intravenous nutrition for patients who cannot get oral feeding. Physicians use standard scales, such as NRS-2002 and NUTRIC, for TPN orders. The usage of NRS-2002 in public hospitals has been mandatory in Turkey since 2015. The quality management department of Izmir Tire Public Hospital recognized that TPN consumption increased dramatically since 2015. The orders, which increased in direct proportion to the number of patients, showed that it should be investigated by evaluating their necessity according to nutritional practice standards. The objective of this study is to research the effect of e-orders incorporated with a clinical decision support system on TPN consumption. We digitalized the NRS-2002 form and added a clinical decision support system to calculate the score and calorie requirements. We found that the total number of NRS-2002 forms completed by physicians increased by 95%, the number of TPN orders decreased by 41%, and the cost decreased by 38% in 2018. This study showed that e-ordering of TPN combined with a clinical decision support system is beneficial for decreasing costs.

Measuring the association between temperature and heart rate in children: be aware of the uncertainties.

aDepartment of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Kyoto bClinical Research Support Center, Tokyo Metropolitan Children’s Medical Center, Tokyo, Japan Received 28 December 2022 Accepted 4 January 2023 Correspondence to Osamu Matsumura Momo, MD, Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto 606-8501, Japan, Tel: +81 75 753 4454; fax: +81 75 753 4455; e-mail: [email protected]

How did healthcare professionals define patient engagement in quality management? A survey study

BackgroundPatient and family engagement (PFE) can positively impact the patient experience and care process outcomes. There is no unique type of PFE, and the process is usually defined by the quality management department or professionals responsible for this process in the hospital. The objective of this study is to define PFE in quality management based on the professional’s perspective.MethodA survey was carried out with 90 professionals from Brazilian hospitals. There were two questions aimed at understanding the concept. The first was a multiple-choice question to identify synonyms. The second was an open-ended question to develop the definition. A content analysis methodology was employed by applying techniques for thematic and inferential analysis.ResultsThree words were classified as synonyms by more than 60% of respondents: involvement, participation, and centered care. The participants described patient participation at both the individual (related to the treatment) and organizational levels (related to quality improvement). The PFE in the treatment is related to the development, discussion and decision-making about the therapeutic plan, participation in each step of care, and knowledge of the institution's quality and safety processes. At the organizational level, engagement in quality improvement includes the involvement of the P/F in all processes of the institution, from strategic planning to the design or improvement processes, as well as active participation in institutional committees or commissions.ConclusionThe professionals defined engagement in two levels (individual and organizational) and the results suggest that their point of view can influence the practice in the hospitals. Professionals of hospitals that implemented mechanisms of consult defined PFE more in the individual level. On the other hand, professionals of hospitals that implemented mechanisms of involvement considered PFE more focus in the organizational level.

Evaluating The Performance of People in the Central Bank of Iraq (Cbi) According to the European Excellence Model

Purpose: This research seeks to measure the possibility of applying People Standards (enabling factors) and people results in Standard (results) in the Central Bank of Iraq (CBI), by the EFQM Excellence Model. Theoretical framework: The purpose of applying the EFQM Excellence Model standard in this investigation is to present a self-evaluation framework, allowing strength determination for each organization and establishing those areas where additional enhancements need to be made. Many recommendations are found in the literature concerning the application of the EFQM Excellence Model standard to identify and resolve issues and problem areas within organizational management. Design/methodology/approach: We analysed the data for the year (2021) checklist that is collected through visits and meetings with the Total Quality Management Department in the bank, where the bank is working to implement standards for evaluating institutional performance in the bank’s departments, in accordance with international standards and experiences, including the (EFQM) model, and is also working to develop standards for evaluating individual performance. Findings: The volume of research has been increasing over the past nineteen years, although there are only a few authors, institutions and reference journals contributing to the topic’s consolidation and the countries conducting the most joint research in co-authoring EFQM for the largest volume of publications, authors and impact journals. Research, Practical & Social implications: We used the suggested model to evaluate people's performance and to investigate the existing gaps between the desired and current situation of human resources within the Central Bank of Iraq. Within the People axis, two of the derived scores met EFQM standards as very excellent. Researchers found that the People Results axis had the lowest score, which indicates that the distance between these regions and the ideal condition is considerable. Originality/value: The results confirm the People Standard who got (86%) to be superior to that of the People results Standard who got (36%). The People Standard will contribute in the same way to improving people results; therefore, a balanced approach to developing the people results criterion will allow for the CBI to achieve the best competitive advantage from the EFQM Excellence Model.

Prediction modelling framework comparative analysis of dissolved oxygen concentration variations using support vector regression coupled with multiple feature engineering and optimization methods: A case study in China

Dissolved oxygen (DO) is an essential indicator for assessing water quality and managing aquatic environments, but it is still a challenging topic to accurately understand and predict the spatiotemporal variation of DO concentrations under the complex effects of different environmental factors. In this study, a practical prediction framework was proposed for DO concentrations based on the support vector regression (SVR) model coupling multiple intelligence techniques (i.e., four data denoising techniques, three feature selection rules, and four hyperparameter optimization methods). The holistic framework was tested using a data matrix (17,532 observation data in total) of 12 indicators from three vital water quality monitoring stations of the longest inter-basin water diversion project in the world (i.e., the Middle-Route of the South-to-North Water Diversion Project of China), during the year 2017 to 2020 period. The results showed that the framework we advocated for could successfully and accurately predict DO concentration variations in different geographical locations. The model used the “wavelet analysis–LASSO regression–random search–SVR” combination of the Waihuanhe station has the best prediction performance, with the Root Mean Square Error (RMSE), Mean Square Error (MSE), Mean Absolute Error (MAE), and coefficient of determination (R2) values of 0.251, 0.063, 0.190, and 0.911, respectively. The combined methods using feature selection and hyperparameter optimization techniques can significantly promote the robustness and accuracy of the prediction model and can provide a new universal and practical way of investigating and understanding the environmental drivers of DO concentration variations. For the water quality management department, this proposed comprehensive framework can also identify and reveal the key parameters that should be concerned and monitored under different environmental factors change. More studies in terms of assessing potential integrated water quality risk using multi-indicators in mega water diversion projects and/or similar water bodies are required in the future.

A MODEL FOR MONITORING OF THE 8D AND FMEA TOOLS INTERDEPENDENCE IN THE ERA OF INDUSTRY 4.0

The application of Industry 4.0 technologies is a goal that, sooner or later, all manufacturers will achieve. The implementation process of these technologies involves establishing strategies at the level of each department. In this paper we propose a model and its implementation that improves communication between the quality management department and the manufacturing and logistics departments by using specific Industry 4.0 technologies: business flow automation and communication between equipment. This is an improvement of the 8D methodology flow. Upon receipt of a customer claim, the Failure Modes and Effects Analysis (FMEA risk analysis) must be updated with the new failure mode that occurred - resulting from the claim - so there is a centralized database with the claims that occur and from which the failure modes are automatically populated. On the other hand, the claim triggers a signal flow at the level of all departments and workstations in a factory: the sending of emails to decision makers, alerts and impressions for operators in the workstations (at the level of billboards or on tablets). The proposal uses the following technologies: business flow automation using specialized software tools (middleware business process management solutions), central server communications - mobile terminal clients, server communications - equipment, IoT systems. The paper presents the implementation of the model with a case study in which its impact on the departments involved in an automotive enterprise is studied.

ОБЕСПЕЧЕНИЕ КАЧЕСТВА ОБРАЗОВАНИЯ В ВУЗЕ НА ОСНОВЕ ПРИМЕНЕНИЯ AGILE-ПРАКТИК

One of the goals of sustainable development is quality education, which meets the needs of the economy in highly qualified personnel, thereby contributing to the socio-economic development of countries. The article considers the possibilities of introducing a project approach to quality assurance of education: in the management system of a higher educational institution and in the educational process. On the basis of existing technologies in education using Agile tools, and the classical elements of the Agile approach, the components of Agile practices in the educational process are formulated. The study presents an approbation of the use of Agile practices on the basis of training courses of the Department of Project Management and Quality Management of St. Petersburg State University of Economics.

Reducing Central-Line-Associated Bloodstream Infections (CLABSI): An Improvement Project in a Specialized Tertiary Hospital.

Central-line-associated bloodstream infections (CLABSI) are preventable hospital-acquired infections that harm and prolong a patient's hospital stay and increase unnecessary hospital expenditure. In collaboration with infection control and hospital epidemiology, the quality management department initiated a performance improvement project to address 144 CLABSI events in 2017. The performance improvement project team used brainstorming to create change ideas presented in a driver diagram. The team then applied plan-do-study-act (PDSA) cycles to implement and monitor the improvements. Finally, the team applied a bundle of interventions that included the following: (a) policies and procedures for central line insertion, maintenance and removal processes standardization, (b) physicians training for line insertion by simulation, (c) an awareness campaign that included recognizing healthcare workers and enhancing patient engagement, (d) performing root cause analysis for the CLABSI events, and (e) automation of central line insertion, and (f) maintenance bundles documentation in the hospital information system. The CLABSI rate per 1000 patient days dropped from 1.5 per 1000 device days to 1.03 per 1000 device days. In addition, CLABSI events reduction was 24% by 2018. Then further reduction of 15% occurred by the end of 2019. Thus, the overall decrease in CLABSI events was 35% from the baseline number of events (i.e., 144 events) in 2017. Another achievement of the project is that 10 units reported zero CLABSI events in 2018 and 2019, of which four units had a high central line utilization rate, more than 40%. The implemented interventions effectively reduced the CLABSI events in the hospital. The project team will continue implementing more interventions with monitoring, aiming to achieve zero CLABSIs over time in all the hospital units.

ВЫЯВЛЕНИЕ АКТУАЛЬНЫХ ИССЛЕДОВАТЕЛЬСКИХ ПРОБЛЕМ ЭКОНОМИКИ И МЕНЕДЖМЕНТА КАЧЕСТВА НА ОСНОВЕ КОНТЕНТ-АНАЛИЗА НАУЧНЫХ ПУБЛИКАЦИЙ

The article is devoted to the analysis of the publication activity of scientists affiliated with scientific and educational institutions of China and India, as well as the comparison of their areas of interest with those in the publications of domestic authors. The data on the latest publications of authors from China, India and Russia are presented. The authors' thematic preferences are analyzed, on the basis of which the areas of economics and quality management that generate the greatest research activity are highlighted. A number of institutions where affiliated authors have several articles on the subject under consideration are identified. The information base of the research are the papers available in the ScienceDirect scientific publications system. The selection of topics was made on the basis of the of the St. Petersburg State Electrotechnical University’ Quality Management and Systems Department’ interest areas. The results of the conducted research can be used for possible cooperation and exchange of knowledge in the field of economics and quality management and are already being used by the administration of the LETI Quality Management and Systems Department to form a development strategy.

Development of Data-Driven Machine Learning Models for the Prediction of Casting Surface Defects

This paper presents an approach for the application of machine learning in the prediction and understanding of casting surface related defects. The manner by which production data from a steel and cast iron foundry can be used to create models for predicting casting surface related defect is demonstrated. The data used for the model creation were collected from a medium-sized steel and cast iron foundry in which components ranging from 1 to 100 kg in weight are produced from wear and heat resistant cast iron and steel materials. This includes all production-relevant data from the melting and casting process, as well as from the mold production, the sand preparation and component quality related data from the quality management department. The data are tethered together with each other, the information regarding the identity and number of components that resulted in scrap due to the casting surface defect metal penetrations was added to the dataset. Six different machine learning algorithms were trained and an interpretation of the models outputs was accomplished with the application of the SHAP framework.

"Kaizen Concept or Methodology to Improve the Performance in the Health Care and Patient Safety Business and its Advantages"

Ahsan Siddiqui* Author Affiliations Quality Management & Patient Safety Department, General Directorate of Health, Riyadh, Saudi Arabia Received: November 25, 2021 | Published: December 03, 2021 Corresponding author: Ahsan Siddiqui, Quality Management & Patient Safety Department, General Directorate of Health, Riyadh, Saudi Arabia DOI: 10.26717/BJSTR.2021.40.006439

"Comparing the Workplace Organization Method 5s with the 7 Wastes (Muda) in Waste and Failure Management Tool, in the Health Care Quality Management"

Ahsan Siddiqui* Author Affiliations Quality Management & Patient Safety Department, General Directorate of Health, Riyadh, Saudi Arabia Received: November 08, 2021 | Published: November 15, 2021 Corresponding author: Ahsan Siddiqui, Quality Management & Patient Safety Department, General Directorate of Health, Riyadh, Saudi Arabia DOI: 10.26717/BJSTR.2021.40.006387

The Impact of CBAHI Accreditation on Efficiency Rate and Patient’ Safety: Makkah Experience, KSA

Background: Understanding the effect of accreditation on healthcare outputs and outcomes and the cost savings associated with accreditation is valuable for policymakers as well as hospitals facing the decision to commit potentially limited resources to the accreditation process. Literature reviews on the effects of accreditation on the quality of care do not deliver strong evidence due to limitations of the studies. Aim of the study: The aim of the current study is to determine the impact of the CBAHI accreditation on efficiency rate and patient's safety measures on three different hospitals in Makkah city. Subjects and Methods: A retrospective cohort research design was utilized to achieve the aim of the study. Data required for this study was obtained from available electronic medical records and quality management departments data base from three different hospitals in Makkah city that has different functions and sectors. Data which has been collected concerning bed occupancy rate, bed turnover rate, average length of stay and cancellation rate as variables to measure the efficiency rate in addition to rate of medication errors/ 1000 dispensed doses, rate of patient falls, mortality rate, hospital acquired pressure ulcer and surgical site infection as variables to measure the patients safety profile in the involved hospitals after getting the approval from the quality department seniors that those factors are reflecting both efficiency and patients safety status. Data was collected the data from January 2016 to March 2020 which has the data of 15 months before the accreditation, and we will compare it with the data of 36 months after the accreditation for the same variables and monitor the progression of those variables after accreditation. Results: No statistically significant differences were found related to efficiency rate and patient safety before and after CBAHI accreditation 2017. Also, no statistically significant differences found related to efficiency rate and patient safety before and after CBAHI reaccreditation 2020 except bed turnover rate. Conclusion: Research measuring the impact of CBAHI accreditation on efficiency rate and patient's safety measures using methodologically strong designs is lacking So, more rigorous designs are needed to establish causal links between the accreditation and outcomes.

Based on the Public Quality Perception Satisfaction Evaluation Theory System Research and Yunnan Province Application Practice

Survey on public satisfaction of quality work is one of the effective methods for connecting the quality management department with the public. In this paper, the application of techniques and methods of survey on public satisfaction of quality work is studied and explored from the aspects of the design of survey content index system, data collection, and statistical result analysis based on the survey on public satisfaction of quality work in Yunnan Province, so as to provide enlightenment and reference for the relevant research work in the field of quality.

The study of risk management activities for quality of medicines at the wholesale stage

Aim. To analyze the state of implementation of risk management activities for quality in domestic organizations for wholesale trade of medicines.Materials and methods. The works of domestic and foreign authors, international professional websites, methods of survey (questionnaire), analysis, systematization, generalization were used.Results. During 2019-2020, the sociological study was carried out among the drug distribution organizations on the activities of risk management (RM) for quality. The survey showed that 78 % of employees involved in RM activities in the distribution organizations of medicines of Ukraine were specialists in quality management (assurance) subdivisions. 17 % of the respondents were employees of various departments. 5 % of the respondents stated that RM was performed jointly by quality management (assurance) departments and other divisions of the enterprise. More than 70 % of the respondents stated that when organizing RM activities they faced the problem of insufficient information on the methodology and practical aspects of RM in the drug distribution. 33 % of the respondents believed that they received the most important information about RM during thematic workshops, trainings and from external experts, consultants. 16 % of the respondents found the useful information on RM in guidelines and methodological materials, and 11 % of the respondents - in periodicals. Accordingly, 55 % of the respondents considered it necessary to develop comprehensive guidelines for RM methodology, and 28 % of the respondents agreed that these recommendations would be useful. According to 55 % of the respondents, the greatest problems in the implementation and operation of RM procedures were related to the training of the relevant specialists. When asked about the compliance of RM results with the expectations of management 88 % of the respondents answered that management was generally skeptical about this activity, perceiving RM only as a formal job, which presence was required by regulatory requirements.Conclusions. The main problems with the effectiveness of RM activities are related to the lack of competence of the relevant specialists and their number, the lack of time to perform procedures to identify, analyze, assess and manage risks to the quality of drugs. Based on the data obtained we plan to form a set of proposals for the optimal organization of activities with RM of medicines in the drug distribution organization, in particular, to substantiate the set of competencies of RM specialists, as well as determine scientific and methodological approaches to the regulation and documentation of RM activities.

Verbesserung der Ausfüllqualität der OP-Sicherheits-Checkliste durch inhaltliche und strukturelle Optimierung sowie compliancefördernde Maßnahmen

Complications occur in 3 to 16% of surgical procedures. According to experts, about 50% of these adverse events are avoidable. It is empirically proven that mortality and complication rates can be reduced by introducing checklists. In this study, the quality of completion of the new checklist, which has already been used for several years, was compared with a checklist optimised by the Quality and Clinical Risk Management Department. The new surgical checklist was introduced at the beginning of January 2017 in a hospital providing primary and regular care. In addition, compliance-promoting measures (training, etc.) were carried out to encourage the use of the new checklist. A total of 293 surgical safety checklists each (pre and post) were evaluated. With the introduction of the new checklist for a total of 8 items, the quality of the surgical safety checklists consisting of 11 items improved. In the course of the implementation of the new surgical safety checklist, there was no item for which the quality of completion was reduced compared to the old list. It was proven that the introduction of these optimised surgical safety checklists in connection with compliance promoting measures resulted in a significantly improved quality of completion. However, in view of the literature on this topic, it can also be stated that the compliance-promoting measures made an important contribution to this result.

Advancement in Medical Sciences to Treat Medical and Surgical Diseases including Prevention, Treatment and Vaccine Development of COVID-19 in Pandemic

Ahsan Siddiqui, M.D, M.S.P.H (UK)* Author Affiliations Department of Quality Management & Patient Safety, General Directorate of Health, Riyadh Saudi Arabia Received: June 25, 2020 | Published: July 08, 2020 Corresponding author: Ahsan Ali Siddiqui, Consultant Epidemiologist, Quality Management & Patient Safety, Department, General Directorate of Health, Riyadh Saudi Arabia DOI: 10.26717/BJSTR.2020.28.004695

Covid-19 Proposed Treatment and other Medical Diseases Prevention and Treatment as Modern Medical Sciences is Beneficial for All of Us

Ahsan Siddiqui, M.D, M.S.P.H (UK)* Author Affiliations Department of Quality Management & Patient Safety, General Directorate of Health, Saudi Arabia Received: June 25, 2020 | Published: July 08, 2020 Corresponding author: Ahsan Ali Siddiqui, Consultant Epidemiologist, Quality Management & Patient Safety, Department, General Directorate of Health, Riyadh Saudi Arabia DOI: 10.26717/BJSTR.2020.28.004696