Identify Performance Gaps Research Articles

Quality of clinical care provided during simulated pediatric cardiac arrest: a simulation-based study.

We sought to assess compliance to resuscitation guidelines during pediatric simulated cardiac arrests in a pediatric intensive care unit (PICU) and to identify performance gaps to target with future training. In a prospective observational study in a PICU, ten cardiac arrest scenarios were developed for resuscitation training and video recorded. The video recordings were examined for times to start cardiopulmonary resuscitation (CPR), delivery of first shock, CPR quality (rate, depth), length of pauses, chest compression fraction (CCF), ventilation, pulse/rhythm assessment, compressors' rotation, and leader's behaviours. The primary outcome was percentage of events compliant to Pediatric Advance Life Support guidelines. Compliance to guidelines was poor in the 23 simulation events studied. The median [interquartile range] time to start CPR was 29 [16-76] sec and 320 [245-421] sec to deliver the first shock. A total of 306 30-sec epochs of CPR were analyzed; excellent CPR (≥ 90% compressions in target for rate and depth) was achieved in 22 (7%) epochs. More than a quarter of the CPR pauses lasted > 10 seconds (33/127, 26%) with just one task performed in most of them; CCF was ≥ 80% in 19/23 (82.6%) events. Ventilation rate for intubated patients was greater than 10 breaths·min-1 in 15/27 (56%) of one-minute epochs observed. Review of simulated resuscitation events found suboptimal compliance with resuscitation guidelines, particularly the times to starting CPR and delivering the first shock, as well as compression rate and depth.

Surgeon Communication and Family Understanding of Patient Prognosis in Critically Ill Surgical Patients: A Qualitative Investigation Informs Resident Training

Surgeons treating critically ill patients must work with family members making medical decisions for the patient. These surrogate decision makers depend on providers' high-quality communication and empathy to facilitate medical decisions. There is growing evidence of poor quality of communication and delayed family engagement in the intensive care unit, and of a decline in empathy over the course of a surgeon's clinical training. The aims of this study were to: (1) describe family understanding of patient prognosis among those admitted to our Trauma Intensive Care Unit (TICU), compared to the surgeon's assessment, and identify factors influencing the congruity of family-surgeon understanding ("congruence"); (2) characterize resident mentoring regarding difficult healthcare discussions and suggest adaptations to our communication program to address identified performance gaps. Level I TICU in an independent academic medical center. A qualitative research approach was valuable to discern the complexities of family understanding during highly stressful conditions. We enrolled adult family members of TICU patients, life expectancy <1 year, per attending. Using in-depth interviews we explored the family's experience with providers and the hospital system, and factors influencing understanding of the patient condition and decision making. We interviewed the surgical attending and/or resident separately to ascertain their perspective of the patient's condition and their experience with the family, as well as communication style, training, and influences on their approach. Interviews were audiotaped and transcribed. Using the systematic, multistep, rigorous coding process of grounded theory, we identified a range of experiences and common themes, and developed theories and hypotheses regarding factors influencing our outcomes of interest. We enrolled, coded, and analyzed 31 interviews from 16 cases; the data painted a broad description of a complex situation. We developed a conceptual model of our hypothesized factors influencing congruence (Figure). Our data suggest that congruence varies widely, and is influenced by family-surgeon engagement quality, information accessed from other hospital and personal sources, and, significantly, hospital system factors. Family-surgeon engagement quality is influenced by family and physician factors, case complexity, and myriad hospital factors. Both "physician factors" and "family factors" include previous experience, personal history, and beliefs, as well as dynamic factors such as current experiences and stress level. We identify several opportunities to improve congruence by adapting our resident communication training program: providing practice assessing family knowledge, expectations, and current understanding of information shared, and focusing on building trust. Surgical residents receive formal communication training and focused mentoring to gain important skills; however, family members' understanding of their loved one's critical condition is influenced by myriad hospital system factors beyond case complexity and surgeon communication skills.

Benchmarking pavement practices in data-scarce regions – case of Saudi Arabia

ABSTRACT This study aims at employing the benchmarking strategy for assessing the state of the practice of the pavement industry in regions that have limited access to or lack the prerequisites for effective pavement practices. The research specifically seeks to propose a benchmark framework that identifies major categories and sub-categories necessary for effective evaluation of the state of practice of the pavement industry in data-scarce regions. The benchmark framework is developed and demonstrated for the case of Kingdom of Saudi Arabia (KSA), where pavement practices in KSA are benchmarked against those of select Gulf Cooperative Council (GCC) countries. For this purpose, data are collected based on a thorough review of literature and relevant industry documentation, as well as based on interviews with project stakeholders. Commonly adopted practices in North America, Europe, and Australia are used as a blueprint for identifying performance gaps and devising recommendations for improvement. Findings from this study would aid highway agencies and stakeholders in performing internal evaluation of their current state-of-practice and adapt the proposed framework to meet their local needs and constraints. Additionally, the paper provides a much-needed compilation of pavement-related data for the GCC countries—a data-scarce region.

InsiM: in silico Mutator Software for Bioinformatics Pipeline Validation of Clinical Next-Generation Sequencing Assays

Lack of reliable reference samples containing different mutations of interest across large sets of disease-relevant loci limits the extensive validation clinical next-generation sequencing (NGS) assays and their associated bioinformatics pipelines. Herein, we have generated a publicly available, highly flexible tool, in silico Mutator (insiM), to introduce point mutations, insertions, deletions, and duplications of any size into real data sets of amplicon-based or hybrid-capture NGS assays. insiM accepts an alignment file along with target territory and produces paired-end FASTQ files containing specified mutations via modification of original sequencing reads. Mutant signal is, thus, generated within the context of existing real-world data to most closely mimic assay performance. Resulting files may then be passed through the assay's bioinformatics pipeline to assist with assay/bioinformatics validation and to identify performance gaps in detection. To establish the basic functionality of the software, a series of simulation experiments with varying mutation types, sizes, and allele frequencies were performed across the entire clinical territory of hybrid-capture and amplicon-based clinical assays developed at The University of Chicago. This work demonstrates the utility of insiM as a supplementary tool during the validation of an NGS assay's bioinformatics pipeline.

Measuring the service quality of luxury hotel chains in the USA

In the hospitality industry, quality of services rendered to customers determines the level of business success. To sustain and improve the high level of service quality continuously, hotel management should assess how well they have served their customers and how competitive they become as a result of continuous service improvements. Such assessment begins with the identification of key service attributes that shape up the customer's perceived service quality and influence the customer's level of satisfaction with hotel services. In particular, to achieve full customer satisfaction and stay ahead of industry rivals, hotel management should gain the knowledge of a hotel's competitive position in the dynamically changing marketplace and create the opportunity for continuous service improvement. With this in mind, this paper develops service standards that help hotel managers monitor their service delivery process, identify performance gaps, and take corrective actions. Based on the exploratory study of customers who have stayed at luxury hotels in the USA, this paper identifies key success factors for luxury hotel franchises and develops service improvement plans for practising hotel managers.

Simulation-based Assessment of the Management of Critical Events by Board-certified Anesthesiologists.

We sought to determine whether mannequin-based simulation can reliably characterize how board-certified anesthesiologists manage simulated medical emergencies. Our primary focus was to identify gaps in performance and to establish psychometric properties of the assessment methods. A total of 263 consenting board-certified anesthesiologists participating in existing simulation-based maintenance of certification courses at one of eight simulation centers were video recorded performing simulated emergency scenarios. Each participated in two 20-min, standardized, high-fidelity simulated medical crisis scenarios, once each as primary anesthesiologist and first responder. Via a Delphi technique, an independent panel of expert anesthesiologists identified critical performance elements for each scenario. Trained, blinded anesthesiologists rated video recordings using standardized rating tools. Measures included the percentage of critical performance elements observed and holistic (one to nine ordinal scale) ratings of participant's technical and nontechnical performance. Raters also judged whether the performance was at a level expected of a board-certified anesthesiologist. Rater reliability for most measures was good. In 284 simulated emergencies, participants were rated as successfully completing 81% (interquartile range, 75 to 90%) of the critical performance elements. The median rating of both technical and nontechnical holistic performance was five, distributed across the nine-point scale. Approximately one-quarter of participants received low holistic ratings (i.e., three or less). Higher-rated performances were associated with younger age but not with previous simulation experience or other individual characteristics. Calling for help was associated with better individual and team performance. Standardized simulation-based assessment identified performance gaps informing opportunities for improvement. If a substantial proportion of experienced anesthesiologists struggle with managing medical emergencies, continuing medical education activities should be reevaluated.

What Do HPT Consultants Do for Performance Analysis?

This study was conducted to contribute to the field of Human Performance Technology (HPT) through the validation of the performance analysis process of the International Society for Performance Improvement (ISPI) HPT model, the most representative and frequently utilized process model in the HPT field. The study was conducted using content analysis as the research methodology to investigate thirty HPT business cases. The findings in this research indicate that the detailed processes and components as depicted in the performance analysis process in the ISPI HPT model were not fully present in the HPT business cases. Actual processes used in the business cases to identify performance gaps differed in part from the model. In addition, the procedure of analysis in the model is depicted as a logical sequence and in the cases is an actual sequence. In addition, the refined performance analysis process is proposed based on the research findings.

Factors Affecting Gender Discrepancy in Entrepreneurial Activity

In spite of rising market opportunities in new, knowledge-based economies, women’s representation in business start-ups and ownership remains remarkably low across industrialized nations (Allen et al., 2008; Kelley, et al., 2010; The´baud, 2015). This low entrepreneurial activity rate could be explained by the lack of possession of different resources that facilitate entrepreneurial activities. The existing literature on women’s entrepreneurship has often explained women’s status by examining patterns of gender inequality in the labor market, such as wage and salary differences. For example, women are less likely to have the human, social, and financial capital deemed critical for the recognition and pursuit of market opportunities, such as workplace and managerial experience, heterogeneous social networks, income, and wealth (Kim, Aldrich, and Keister, 2006; The´baud, 2015). Gender-differentiated perceptions about the activity of entrepreneurship can also contribute to gender gaps in the likelihood of being a business owner (Arenius and Minniti, 2005; Minniti and Nardone, 2007). A number of studies have identified performance gaps between men and women entrepreneurs as a global phenomenon (for example, see OECD, 2005 for OECD countries and Sabarwal and Terrell, 2008 for countries in Eastern Europe). However, most support to women entrepreneurship has focused on developing countries.

All CLEAR? Preparing for IT Downtime.

Health care information technology (IT) outages pose a threat to patient safety and patient care continuity. Organizations' downtime plans must be updated regularly and staff at the work area level should have experience with implementing IT outage operations through downtime drills. This article describes the study institution's IT Outage Toolkit, based on the acronym CLEAR, which guides the development of a downtime plan as well as design, execution, and assessment of work area downtime drills. Self-report and external audits of downtime drills help identify performance gaps and gaps in downtime plans.

Recovery environment of a sub-acute mental health service

Purpose – The purpose of this paper is to examine the recovery environment of a sub-acute residential mental health service. Such services are increasingly filling a gap in the continuum of care for people with recurrent mental illness and have a major role supporting the processes of recovery. Design/methodology/approach – A cross-sectional design was used with clients and staff completing the recovery enhancing environment measure. Nine clients who had entered the service from the community (step-up), 18 who had transferred from an inpatient unit (step-down) and ten staff completed the measure. Findings – Clients and staff rated the organisational climate of the service positively, with the role of caring staff being identified as particularly valuable. Clients and staff had similar positive views on the importance of recovery-based elements and rated the service as performing well in these areas. Step-up clients identified performance gaps in the areas of self-management, general health, personal strengths, and personal relationships. Step-down clients identified a range of gaps, including meeting basic needs, empowerment, and fundamental recovery processes. Practical implications – An assessment of the perceptions of clients and staff can allow services to identify differences in the attitudes of each group and ascertain areas in which the service can be improved to better meet the needs of individual clients. This may include being responsive to the setting from which clients have entered the service. Originality/value – This is the first study that has examined the recovery environment of a residential mental health service and how it meets the recovery needs of both step-up and step-down admissions.

The value of mentorship in medical education.

The transition from senior medical student to working safely and effectively as a new junior doctor is one of the biggest challenges that a new graduate will face. In 2014 the General Medical Council published The state of medical education and practice in the UK, reporting that some new doctors continue to struggle with increased responsibilities. We classify these instances as a 'performance gap', describing occasions in clinical practice where an individual exceeds their performance capacity. The Medical Mentorship Programme addressed identified performance gaps through a structured curriculum of simulation-based education and facilitated clinical practice. Programme content was based on the experiences of the authors and their peers in graduating from their undergraduate training programme and becoming junior doctors. A questionnaire was disseminated to junior doctors in their first clinical rotation. The questionnaire asked doctors to describe instances where they experienced a performance gap. These data informed the development of the Medical Mentorship Programme. The effect of this programme was then evaluated via focus group discussion. The Medical Mentorship Programme has been shown to be an effective conduit for supporting the transfer of learning needed to address performance gaps in students. The programme increased the confidence of students in preparation for clinical practice and allowed junior doctors to reflect on their professional development. The programme combined complementary teaching techniques - mentorship, simulation and direct clinical experience - to aid the professional development of both students and mentors. Some new doctors continue to struggle with increased responsibilities.

Model-based Approach to Automated Calculation of Key Performance Indicators for Industrial Turbines

&#x0D; &#x0D; &#x0D; In recent years, the service business of the global turbo- machinery industry has undergone important changes. Many of these changes have been motivated by an increased demand for dedicated and systematic approaches to process safety, reliability, asset integrity and the overall health of the system. This has strengthened the role of key performance indicators (KPIs) as a means of providing guidance for the system’s health state and improve risk management. In order to provide trustable and accurate calculations of these performance indicators in an automated fashion, we argue for a model-based solution that deals with the complexity of diverse configurations and interdependences between system components. This paper presents a solution for calculating KPIs by a semi-automated process based on post-data processing from the site and specific system models. The models consist of a combination of system descriptions in terms of ontologies and complex event processing models. By virtue of our models, state indicator rules for KPI calculations can be formulated at different levels, identifying performance gaps and indicating precisely where action should be taken by the service engineers. With the adopted solution, we discuss the practical implementation and present results of our success story at Siemens AG for the Industrial Gas Turbines.&#x0D; &#x0D; &#x0D;

Online CME Participation by Gastroenterologists Improves Management of Exocrine Pancreatic Insufficiency

Introduction: Management of exocrine pancreatic insufficiency (EPI) can be challenging for gastroenterologists. This study assessed the effect of online continuing medical education (CME) on clinical decision-making among participating gastroenterologists compared to non-participating matched peers. Methods: The American Gastroenterological Association Institute and Medscape, LLC identified performance gaps in management of EPI. An enduring online video-based CME expert roundtable discussion was hosted on Medscape from February 28th, 2013. Clinical case vignettes with assessment questions were administered to CME participants following the CME activity and final data for outcomes was collected by May 30th, 2013. A control group of non-participants that matched the participants' characteristics (e.g., specialty, number of EPI patients treated) was randomly selected and administered the same set of questions. The difference in responses to survey questions between the two groups were analyzed using chi-square tests (P < .05), and educational effect size was calculated using Cohen's d formula, which represented the degree of nonoverlap in answers between the CME participants and non-participants. Results: Gastroenterologist CME participants (n=100) were 37.2% more likely to make evidence-based practice choices than non-participants (n=100) (moderate educational effect size of d=0.58) in the following areas: - 28% more participants ordered a fecal elastase test to confirm EPI (75% participants vs 47% non-participants, P<0.001). - 12% more participants ruled out small bowel bacteria overgrowth in poor responders to enzyme replacement therapy (90% participants vs 78% non-participants, P=.02). - 16% more participants ordered a Vitamin D level for a patient with a history of diarrhea due to EPI (93% participants vs 77% non-participants, P=.002). - 12% more participants accurately counselled patients beginning EPI therapy (88% participants vs 76% non-participants, P=.03). - Most participants (88%) and non-participants (90%) recognized that efficacy of pancreatic enzyme supplementation is influenced by timing of consumption. Conclusion: CME participation in an online video roundtable discussion impacted clinical decisionmaking in gastroenterologists treating EPI, which may translate to improved outcomes in patients. Future education should focus on testing to confirm EPI and patient-clinician communication on treatment adherence and disease management.

Identifying Performance Gaps in Comorbidity and Risk Factor Screening, Prevention, and Counseling Behaviors of Providers Caring for Children with Psoriasis.

Comorbidities and risk factors are associated with pediatric psoriasis. It is unknown whether pediatricians and dermatologists ask about, record, or counsel on pediatric psoriasis risk factors and comorbidities. The aim of our study was to assess the rate at which pediatricians and dermatologists inquire about, counsel on, and document pediatric psoriasis risk factors and comorbidities in a stable population. This was a retrospective chart review from 2011 to 2013 in a large, rural multidisciplinary clinic, the Marshfield Epidemiologic Study Area. Participants were children ages 18 years and younger with plaque psoriasis. Rates of counseling and screening for pediatric psoriasis risk factors and comorbidities by pediatricians and dermatologists were determined. Thirty patients qualified for the study. Data were collected on body mass index (BMI) and tobacco exposure. Caregiver counseling rates on these factors were low; 66.7% and 60% did not receive counseling on BMI reduction or family member smoking cessation, respectively. Counseling on stress as a risk factor was performed at only one patient's dermatology visit (3.3%). Lipid panels were collected for 40% of patients and fasting glucose levels for 33.3% since the date of first psoriasis diagnosis. Blood pressure was collected for all patients. Only 13.3% of patients were counseled on the psoriasis comorbidity hyperlipidemia, 10% on hypertension, and 3.3% on diabetes mellitus. Dermatologists and pediatricians have a low rate of counseling, documenting, and screening for pediatric psoriasis risk factors and comorbidities, suggesting that psoriasis comorbidity education is an aspect of the patient visit that may need improvement. Pediatric psoriasis counseling and screening guidelines are needed.

Quality of Type II Diabetes Care in Primary Health Care Centers in Kuwait: Employment of a Diabetes Quality Indicator Set (DQIS).

Diabetes Mellitus is one of the major public health challenges, affecting more than 347 million adults worldwide. The impact of diabetes necessitates assessing the quality of care received by people with diabetes, especially in countries with a significant diabetes burden such as Kuwait. This paper aimed at piloting an approach for measuring Type II diabetes care performance through the use of a diabetes quality indicator set (DQIS) in primary health care. The DQIS for Kuwait was adapted from that developed by the National Diabetes Quality Improvement Alliance and the International Diabetes Federation. Five key care domains/measures were employed: (1) Blood glucose level measurement, (2) Cholesterol level measurement, (3) Blood pressure measurement, (4) Kidney function testing and (5) Smoking status check. The sample included the four major primary health care centers with the highest case load in Kuwait City, 4,241 patients in 2012 and 3,211 in 2010. Findings revealed the applicability and utility of employing performance indicators for diabetes care in Kuwait. Furthermore, findings revealed that many of the primary health care centers have achieved noteworthy improvement in diabetes care between 2010 and 2012, with the exception of smoking status check. The DQIS can help policymakers identify performance gaps and investigate key system roadblocks related to diabetes care in Kuwait.

A Systems-Based Framework to Measure, Predict, and Manage Fatigue

Transportation operator fatigue is a pervasive cross-modal risk, still largely unmitigated, costly, and underreported. Effectively predicting fatigue risk can help stem this trend and improve transportation safety, performance, and well-being. Not surprisingly, there is growing interest in applying fatigue models to support and evaluate safety-critical initiatives, such as scheduling, accident investigation, and hours-of-service rule making and compliance. Yet there is limited empirical data about whether current fatigue models are used as intended, how effectively they predict fatigue, and how they might be improved. Though current models typically focus on two or three biological processes that impact fatigue, the literature presents many internal and external variables that influence fatigue, and current models largely neglect this more comprehensive suite of contributing factors needed to assess individual employee risk across variable work environments. The U.S. Department of Transportation Safety Council has recognized the need to assess the strengths and weaknesses of existing biomathematical fatigue models and to explore how to maximize efficacy, reliability, and validity. In this chapter, we review a sample of current fatigue models, identify performance gaps, and describe an overarching framework to guide next-generation fatigue model development. The proposed eight-state model offers a novel systems-based approach to integrate contributing internal and external fatigue factors and better measure, predict, and manage fatigue risk across transportation and other safety-critical operations.

The race to the top initiative: towards excellence in health-care service delivery

Abstract Background Since 2006, Rwanda has adopted performance-based incentives to boost the motivation of health-care workers and improve Millennium Development Goal (MDG) health indicators. However, performance-based incentives will often create a focus on final outcomes rather than the improvement of processes. Furthermore, national evaluation of district health facilities uses the same indicators irrespective of district-level differences in burden of disease and health priorities. In 2013, Partners In Health, in collaboration with the Rwandan Ministry of Health, launched the “race to the top” initiative (RTT), a new district-based approach to performance incentives, which strengthens process and outcomes through engagement of community and health-care workers, the setting of priority targets, and peer-to-peer learning to speed up changes in the way care is delivered. Ongoing technical support is provided throughout RTT's action periods to foster local innovations and make the most of local resources, and support data-driven quality improvement. Here, we describe results from a health district in rural Rwanda, 18 months after implementation of the RTT initiative. Methods We did a baseline assessment of population health indicators at 13 health centres in the Kirehe district hospital catchment area between January, 2013, and June, 2014. We set ambitious targets and success required a coordinated effort by health centres, local leaders, and community. We measured progress towards targets and gave feedback to health centres 6 months, 12 months, and 18 months after implementation. Health centres were given monetary rewards (to be invested in quality improvement) on the attainment of three pre-set goals: a minimum 90% coverage of community-based health insurance (CBHI); a 70% contraceptive prevalence rate; and complete elimination of severe acute malnutrition cases. Findings At 6 months' follow up, four of 13 health centres had met one target. At 12 months, seven had met one target, and by 18 months, six centres had met two targets and two centres had achieved all three indicators. At 18 months, average performance had improved significantly across the district for all three targets. The mean CBHI coverage across facilities increased by 35% from 68% at baseline to 92%. The mean number of malnutrition cases per facility per 6 month period identified at the health centres fell by 78% from 24 at baseline to 5·2 at 18 months. Finally, the contraceptive prevalence rate increased by 55% from 42% to 65%. RTT also provided opportunity for health centres to develop innovative strategies to address identified performance gaps. Interpretation The strength of the RTT intervention resides in its combination of the performance-based incentive and provision of technical support. RTT is being implemented in a neighbouring district and ongoing efforts including site visits and district level meetings are being implemented in Kirehe to understand the challenges that these health centres are facing. Funding RTT was jointly funded by Partners In Health through Doris Duke foundation and Kirehe district.

Safe Use of Electronic Health Records and Health Information Technology Systems

We will provide a context to health information technology systems (HIT) safety hazards discussions, describe how electronic health record-computer prescriber order entry (EHR-CPOE) simulation has already identified unrecognized hazards in HIT on a national scale, helping make EHR-CPOE systems safer, and we make the case for all stakeholders to leverage proven methods and teams in HIT performance verification. A national poll of safety, quality improvement, and health-care administrative leaders identified health information technology safety as the hazard of greatest concern for 2013. Quality, HIT, and safety leaders are very concerned about technology performance risks as addressed in the Health Information Technology and Patient Safety report of the Institute of Medicine; and these are being addressed by the Office of the National Coordinator of HIT of the U.S. Dept. of Human Services in their proposed plans. We describe the evolution of postdeployment testing of HIT performance, including the results of national deployment of Texas Medical Institute of Technology's electronic health record computer prescriber order entry (TMIT EHR-CPOE) Flight Simulator verification test that is addressed in these 2 reports, and the safety hazards of concern to leaders. A global webinar for health-care leaders addressed the top patient safety hazards in the areas of leadership, practices, and technologies. A poll of 76 of the 221 organizations participating in the webinar revealed that HIT hazards were the participants' greatest concern of all 30 hazards presented. Of those polled, 89% rated HIT patient/data mismatches in EHRs and HIT systems as a 9 or 10 on a scale of 1 to 10 as a hazard of great concern. Review of a key study of postdeployment testing of the safety performance of operational EHR systems with CPOE implemented in 62 hospitals, using the TMIT EHR-CPOE simulation tool, showed that only 53% of the medication orders that could have resulted in fatalities were detected. The study also showed significant variability in the performance of specific EHR vendor systems, with the same vendor product scoring as high as a 75% detection score in one health-care organization, and the same vendor system scoring below 10% in another health-care organization. HIT safety hazards should be taken very seriously, and the need for proven, robust, and regular postdeployment performance verification measurement of EHR system operations in every health-care organization is critical to ensure that these systems are safe for every patient. The TMIT EHR-CPOE flight simulator is a well-tested and scalable tool that can be used to identify performance gaps in EHR and other HIT systems. It is critical that suppliers, providers, and purchasers of health-care partner with HIT stakeholders and leverage the existing body of work, as well as expert teams and collaborative networks to make care safer; and public-private partnerships to accelerate safety in HIT. A global collaborative is already underway incorporating a "trust but verify" philosophy.

First Steps: Exploring Use of a Prospective, Office-Based Registry as the Foundation for Quality Improvement in Cardiology Training

Teaching practice-based learning and improvement and systems-based practice are challenging. Cardiology fellows at St John Hospital & Medical Center participate in a national registry of outpatient cardiology care. We assessed the use of the registry, hypothesizing that it could serve as an effective foundation for studying ambulatory care, identifying gaps in care, and planning interventions to advance competence in practice-based learning and improvement and systems-based practice. Starting in 2009, trainees prospectively entered data for ambulatory cardiac patients into the PINNACLE Registry database where compliance with 28 performance measures was calculated and reported quarterly. Fellows met with the program director individually and in groups to identify performance gaps and to develop and implement plans for quality improvement. Cardiology fellows were surveyed annually to assess this process. Through March 2012, the fellows had completed 2400 patient visits. Participation was feasible because it was cost neutral, with data form completion averaging 5minutes. It was acceptable, with most fellows describing positive effects on practice-based learning and improvement without significant detriment to work flow. Performance achievement for drug therapies ranged from 69% (77 of 111) of the patients with atrial fibrillation receiving anticoagulation to 99% (486 of 489) of patients with coronary disease receiving lipid-lowering therapy. Gaps in system performance included low levels for diabetes screening (5%; 20 of 422) and lipid monitoring (10%; 58 of 573). Initial quality improvement projects addressed practice gaps with straightforward solutions. Improving system performance was more challenging. Using a registry in cardiology trainees' outpatient practice is feasible, acceptable, and valuable. It allows for planning and studying the effects of quality improvement projects.

An examination of key factors influencing bancassurance success – Taiwan and mainland China evidence

The aims of this paper are first, a search for the key factors that influence bancassurance operation in Taiwan and mainland China; second, explore the weight of each key success (critical) factor (KSF); and third, identify performance gaps typically measured as performance minus KSFs. This study adopts the analytical hierarchy process to construct a framework of KSFs of bancassurance. Then, the importance–performance analysis is applied to identify the performance of each KSF for bancassurance. The findings mean that the strategy maker can identify the weakness and strength of their bancassurance strategy, and allocate their resources accordingly.