Front-line Experts Research Articles

Understanding breast cancer screening—past, present, and future

This article provides an up-to-date overview of breast cancer mammography screening and briefly discusses its history, controversies, current guidelines, practices across Asia, and future directions. An emphasis is made on shared decision-making--instead of giving just a 'yes' or 'no' answer to patients, the focus should be on providing sufficient information about the pros and cons of screening to help women make a personal, informed choice. Frontline experts, including breast surgeons, oncologists, breast radiologists, and their representative professional associations should all participate in guideline panels, with the goal of improving cancer detection, reducing mortality, and improving patient outcome.

Agent-Based Self-Service Technology Adoption Model for Air-Travelers: Exploring Best Operational Practices

The continuous development of the service economy and an aging society with fewer children is expected to lead to a shortage of workers in the near future. In addition, the growth of the service economy would require service providers to meet various service requirements. In this regard, self-service technology (SST) is a promising alternative to securing labor in both developed and emerging countries. SST is expected to coordinate the controllable productive properties in order to optimize resources and minimize consumer stress. As services are characterized by simultaneity and inseparability, a smoother operation in cooperation with the consumer is required to provide a certain level of service. This study focuses on passenger handling in an airport departure lobby with the objective of optimizing multiple service resources comprising interpersonal service staff and self-service kiosks. Our aim is to elucidate the passenger decision- making mechanism of choosing either interpersonal service or self-service as the check-in option, and to apply it to analyze several scenarios to determine the best practice. The experimental space is studied and an agent-based model is proposed to analyze the operational efficiency via a simulation. We expand on a previous SST adoption model, which is enhanced by introducing the concept of individual traits. We focus on the decision-making of individuals who are neutral toward the service option, by tracking the actual activity of passengers and mapping their behavior into the model. A new method of validation that follows a different approach is proposed to ensure that this model approximates real-world situations. A scenario analysis is then carried out with the aim of exploring the best operational practice to minimize the stress experienced by the air travelers and to meet the business needs of the airline managers at the airport. We collected actual data from the Departure Control System of an airline to map the real-world data to the proposed model. Passenger behavior was extracted by front-line service experts and clarified through consecutive on-site observations.

A Collaborative for Implementation of an Evidence-Based Clinical Pathway for Enhanced Recovery in Colon and Rectal Surgery in an Affiliated Network of Healthcare Organizations

In 2015 the Mayo Clinic Care Network (MCCN), in an effort to extend medical knowledge and share these best practices, embarked on an education mission to diffuse the clinical practice redesign involving the practice of colon and rectal surgery at Mayo Clinic (Rochester, Minnesota) to members of the MCCN. They elected to use a collaborative framework in an attempt to transfer knowledge to multiple teams in an efficient and supportive manner. Eight MCCN members assembled a multidisciplinary team, which participated in both a didactic learning session delivered by frontline experts, as well as follow-up remote sessions regarding Mayo Clinic's enhanced recovery pathway for colon and rectal surgery. Teams departed the group session with established immediate next steps, communication plans, and an awareness of potential barriers and strategies for mitigation. Monthly coaching calls followed in an effort to help all teams meet their time line and overall goals. Finally, all participants met again after six months to report their clinical outcomes, as well their unique individual organization's successes and barriers encountered. Participating teams felt overwhelmingly that the collaborative program exceeded their expectations and equipped them with the tools to be successful. They also felt that the extended support provided by the Mayo Clinic team was essential, and the collaboration with other members markedly enhanced their experience. Importantly, all teams were able to successfully reduce length of stay, which was the desired main clinical outcome. The collaborative format was instrumental in the rapid diffusion and successful implementation of a transformative practice redesign involving colorectal surgical care of patients.

How can frontline expertise and new models of care best contribute to safely reducing avoidable acute admissions? A mixed-methods study of four acute hospitals

BackgroundHospital emergency admissions have risen annually, exacerbating pressures on emergency departments (EDs) and acute medical units. These pressures have an adverse impact on patient experience and potentially lead to suboptimal clinical decision-making. In response, a variety of innovations have been developed, but whether or not these reduce inappropriate admissions or improve patient and clinician experience is largely unknown.AimsTo investigate the interplay of service factors influencing decision-making about emergency admissions, and to understand how the medical assessment process is experienced by patients, carers and practitioners.MethodsThe project used a multiple case study design for a mixed-methods analysis of decision-making about admissions in four acute hospitals. The primary research comprised two parts: value stream mapping to measure time spent by practitioners on key activities in 108 patient pathways, including an embedded study of cost; and an ethnographic study incorporating data from 65 patients, 30 carers and 282 practitioners of different specialties and levels. Additional data were collected through a clinical panel, learning sets, stakeholder workshops, reading groups and review of site data and documentation. We used a realist synthesis approach to integrate findings from all sources.FindingsPatients’ experiences of emergency care were positive and they often did not raise concerns, whereas carers were more vocal. Staff’s focus on patient flow sometimes limited time for basic care, optimal communication and shared decision-making. Practitioners admitted or discharged few patients during the first hour, but decision-making increased rapidly towards the 4-hour target. Overall, patients’ journey times were similar, although waiting before being seen, for tests or after admission decisions, varied considerably. The meaning of what constituted an ‘admission’ varied across sites and sometimes within a site. Medical and social complexity, targets and ‘bed pressure’, patient safety and risk, each influenced admission/discharge decision-making. Each site responded to these pressures with different initiatives designed to expedite appropriate decision-making. New ways of using hospital ‘space’ were identified. Clinical decision units and observation wards allow potentially dischargeable patients with medical and/or social complexity to be ‘off the clock’, allowing time for tests, observation or safe discharge. New teams supported admission avoidance: an acute general practitioner service filtered patients prior to arrival; discharge teams linked with community services; specialist teams for the elderly facilitated outpatient treatment. Senior doctors had a range of roles: evaluating complex patients, advising and training juniors, and overseeing ED activity.ConclusionsThis research shows how hospitals under pressure manage complexity, safety and risk in emergency care by developing ‘ground-up’ initiatives that facilitate timely, appropriate and safe decision-making, and alternative care pathways for lower-risk, ambulatory patients. New teams and ‘off the clock’ spaces contribute to safely reducing avoidable admissions; frontline expertise brings value not only by placing senior experienced practitioners at the front door of EDs, but also by using seniors in advisory roles. Although the principal limitation of this research is its observational design, so that causation cannot be inferred, its strength is hypothesis generation. Further research should test whether or not the service and care innovations identified here can improve patient experience of acute care and safely reduce avoidable admissions.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme (project number 10/1010/06). This research was supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

Resident Case Review at the Departmental Level: A Win-Win Scenario

Resident Case Review at the Departmental Level: A Win-Win Scenario

The development of a novel curriculum to address past sexual assault.

The development of a novel curriculum to address past sexual assault.

Improving Patient Care Through Leadership Engagement with Frontline Staff: A Department of Veterans Affairs Case Study

Leveraging Frontline Expertise (LFLE) is a patient safety intervention for engaging senior managers with the work-systems challenges faced by frontline workers and ensuring follow-up and accountability for systemic change. A study was conducted to assess the ability to refine, implement, and demonstrate the effectiveness of LFLE, which was designed for and tested in private-sector hospitals, in a Department of Veterans Affairs medical center (VAMC), typically a more hierarchical setting. LFLE was pilot tested in an urban, East coast-based VAMC, which implemented LFLE in its emergency department and operating room, with the medical/surgical ward and ICU serving as controls. A 20-month multimethod evaluation involved interviews, observation, data-tracking forms, and surveys to measure participant perceptions of the program, operational benchmarks of effectiveness, and longitudinal change in safety climate. Implementation showed fidelity to program design. Participating units identified 22 improvement opportunities, 16 (73%) of which were fully or partially resolved. Senior managers' attitudes toward LFLE were more positive than those of frontline staff, whose attitudes were mixed. Perceptions of safety climate deteriorated during the study period in the implementation units relative to controls. LFLE can be implemented in the VA, yield work-system improvements, and increase alignment of improvement aims and actions across hierarchical levels. Yet the results also warn against dangers inherent in adapting improvement programs to new settings. Findings suggest the need for active listening and learning from frontline staff by senior managers and trust building across hierarchical

How can We Enhance Productivity in Social Work? Dynamically Reflective Structures, Dialogic Leadership and the Development of Transformative Expertise

This article examines how to enhance the ability of managers to promote productivity through reflective structures and appreciatively evaluative dialogues based on front-line expertise and knowledge in social work practice. In order to discuss these ideas, we review the ideas of dialogical leadership and reflective structures, and the concept of productivity in relation to reassessing social work core tasks and the work-related well-being of social workers. We will present and reflect on our experiences and ideas generated from research that developed reflective tools, known as the Mirror method, for peer evaluation and practice development in social work. The Mirror method is designed as a tool for leaders and managers to enhance, through trialogic processes and structures, both the well-being of employees at the individual level and the productivity of social work and learning for transformation at the organizational level.

Becoming a high reliability organization

Aircraft carriers, electrical power grids, and wildland firefighting, though seemingly different, are exemplars of high reliability organizations (HROs) - organizations that have the potential for catastrophic failure yet engage in nearly error-free performance. HROs commit to safety at the highest level and adopt a special approach to its pursuit. High reliability organizing has been studied and discussed for some time in other industries and is receiving increasing attention in health care, particularly in high-risk settings like the intensive care unit (ICU). The essence of high reliability organizing is a set of principles that enable organizations to focus attention on emergent problems and to deploy the right set of resources to address those problems. HROs behave in ways that sometimes seem counterintuitive - they do not try to hide failures but rather celebrate them as windows into the health of the system, they seek out problems, they avoid focusing on just one aspect of work and are able to see how all the parts of work fit together, they expect unexpected events and develop the capability to manage them, and they defer decision making to local frontline experts who are empowered to solve problems. Given the complexity of patient care in the ICU, the potential for medical error, and the particular sensitivity of critically ill patients to harm, high reliability organizing principles hold promise for improving ICU patient care.

Affan Hamakhan Jafar: treating trauma in northern Iraq

Affan Hamakhan Jafar: treating trauma in northern Iraq

The Veterans Affairs Root Cause Analysis System in Action

The patient safety program in the Department of Veterans Affairs (VA) began in 1998, when the National Center for Patient Safety (NCPS) was established to lead the effort on a day-to-day basis. NCPS provides the structure, training, and tools, and VA facilities provide front-line expertise, feedback about the process, and root cause analysis (RCA) of adverse events and close calls. Facility patient safety managers determine the disposition of adverse events and close calls occurring at their facilities. They use a safety assessment code (SAC) to prioritize the actual and potential severity and frequency of an event. BEFORE-AND-AFTER STUDY: Before the new RCA system was implemented in 2000, the VA used another adverse event reporting system, focused review (FR). A comparison of the two processes indicates that the RCA process has shifted analyses of adverse events toward a human factors engineering approach-entailing a search for system vulnerabilities rather than human errors and other less actionable root causes. Two case examples--on hazards in the magnetic resonance imaging (MRI) room and on a cardiac pacemaker malfunction--illustrate how the RCA system works in actual operation. The cases illustrate that broadly applicable, high-impact actions can result from a thorough RCA process. NCPS monitors the quality and completeness of RCAs through the immediate review and feedback process. Still to be investigated is the effectiveness of RCA actions addressing the hypothesized root causes and contributing factors of the close calls and adverse events.

The forensic entomologist in the context of the forensic pathologist’s role

An adequate death investigation requires the combined efforts and cooperation of experts in different disciplines: crime scene technicians, death investigators, forensic pathologists, anthropologists, entomologists, other medical and non-medical professionals. These front-line experts play a crucial role in every death investigation process. The forensic pathologist normally has the legal authority to take charge of the dead body at a death scene and his primary functions are the exterior and interior examination of the cadaver by analyzing the extent of antemortem injuries and the postmortem changes and the recovery of physical evidence. He is responsible for determining how, when and why of any death which is the result of violence, suspicious or unexplained circumstances or a death which is sudden or unattended, defending and explaining the reasons for making these diagnoses in a courtroom. The forensic entomologist can provide invaluable aid in death cases where human remains are colonized by insects and in the overall investigation. His principal role is to identify the arthropods associated with such cases and to analyze entomological data for interpreting insect evidence. He is responsible for determining the period of insect activity according to all the variables affecting insect invasion of remains and their development. The major goal of medico-criminal entomology is to contribute to the determination of the time, cause, manner and place of the investigated death (especially on badly decomposed corpses or skeletonized human remains) with the support of all the elements which can be inferred from the study of insects found on the cadaver or nearby. The application of techniques devised recently in forensic entomology can allow experts in the field to collect strong entomological evidence and provide useful information not only in a death investigation including movement or storage of the remains following death, time of dismemberment, postmortem artifacts on the body but also at the scene, and even more in child neglect, sexual molestation and identification of suspects. As the role of the forensic entomologist at the death scene, at the autopsy and in the laboratory is defined and well known, this paper focuses on the difficulties that could arise if forensic pathologists and entomologists are uncertain about the procedures that they have to follow, do not realize the value of objective findings or fail to evaluate them. Although every forensic case presents a slightly different set of circumstances and has to be tackled individually, the forensic pathologist should work with the forensic entomologist from the visual observations of the cadaver on the scene, through the collection of arthropods and temperature data at the death scene and at the autopsy, up to the final report with the interpretation of entomological and other biological evidence.