Iterative Improvement Research Articles

Peer learning in abdominal radiology: iterative process improvements over a 20-year experience.

After a slow and challenging transition period, peer learning and improvement (PLI) is now being more widely adopted by practices as an option for continuous personal and practice performance improvement. In addition to gaps that exist in the understanding of what PLI is and how it should be practiced, wide variation exists in how the process is implemented, administered, how outcomes are measured, and what strategies are employed to engage radiologists. This report aims to describe lessons learned from our 20-year experience with the design, implementation, and continuous improvements of a PLI program in a large academic program. Since initial implementation in 2004, an oversight team prospectively documented iterative process improvements and data submission trends in our PLI process. Process data included strategies for engaging radiologists in the PLI process (fostering case submission, PLI meeting participation), steps for achieving regulatory compliance, and template content for facilitating the value and impact of PLI meetings (case analysis, review of contributing factors, identification of improvement opportunities). Submission trends, submitted case content, and improvement opportunities varied by clinical section. Process improvements that fostered engagement included closing the loop with participants, expanding criteria for case submission beyond interpretive disagreements (e.g., great pickups, near misses), minimizing impacts to workflow, and using evidence-based templates for case and contributor categorization, bias analysis, and identification of improvement opportunities. Implementing an effective PLI program requires sustained communication, education, and continuous process improvement. While PLI can certainly lead to process and individual performance improvement, the program requires trained champions, designated time, effort, resources, education, and patience to be effectively implemented.

Mitigating the Effects of Design for Manufacturability on Design Iteration Cycles in Advanced Integrated Circuit Design

In integrated circuit (IC) design for advanced manufacturing processes, iterative improvement processes are an approach commonly used for improving design quality, particularly for low-energy, high-frequency circuits. Layout-dependent effects (LDEs) affect IC design and fabrication, resulting in differences in circuit functionality and performance in presimulation versus postsimulation. These differences can greatly increase the length of design iteration cycles. Foundries have attempted to accelerate the iterative design process by providing process design kit libraries to IC designers. However, these kits can neither fully mitigate the negative affect of LDEs on design for manufacturability (DFM) nor eliminate the difference between presimulation and postsimulation results. To address this problem, this study proposed a novel algorithm-based design process in which an IC designer can use layout parasitic extraction to extract the DFM parameters of all components in a circuit prior to the routing process; these parameters include netlists that describe the internal connectivity of components as well as their interconnectivity with other components. Accordingly, the IC designer can determine the effects of DFM parameters on the circuit and modify them in advance if necessary. When the LDEs generated by device placement have been confirmed to not affect circuit properties, physical verification of the routing of metal wires in the IC layout can be performed. In this verification, postsimulations only need to focus on problems regarding the wire loading and timing effects of metal routing. The proposed design process is useful for mitigating LDEs in IC design and considerably reduces the time required for iterative improvement processes. Specifically, this study provides a method of enhancing design iteration cycles and provides guidelines for analyzing factors that hinder IC device functionality and performance. In sum, various problems can be resolved by separately extracting the DFM parameters associated with LDEs and parasitic parameters associated with routing.

STRATEGY DEVELOPMENT OF SALES ORGANIZATION USING FUZZY AHP: DIGITAL TRANSFORMATION OF FMCG

A clear understanding of internal strength allows the company to innovate and adapt in a highly competitive Fast-moving consumer goods market. Therefore, the company's ability to oversee risk and opportunities determines the company's resilience. By employing homogeneous purposive sampling, which focused on the member population of 11 FMCG companies, the present study processed quantitative data from a questionnaire using a Likert scale and qualitative data through in-depth interviews with stakeholders. The data was collected through one-on-one in-depth interviews with 11 respondents online and offline in 12 major cities from August to November 2022. Later, questionnaires were processed using AHP Fuzzy to explain and take into account the role of decision-makers resembling FMCG leaders by defining interactive factors, actors, objectives, and strategies. Factor-actor analysis found that the sales director was the actor with the most influential role in the leadership factor, the sales manager was influential in the Organizational Citizenship Behavior factor, and the sales director was a prominent actor in sales management control. The main goal of the president director, IT/Digital director, supply chain director, and sales director in digital transformation is increasing effectiveness/efficiency in business processes. Besides, the sales manager and sales supervisor aspire to achieve sales targets or sales growth set by the company. In increasing effectiveness/efficiency and achieving sales targets/sales growth set by the company, prioritized strategy can be done through the development of leadership, capability, and human resource capacity. Besides, customer/business partner-oriented digitalization is vital for increasing customer/business partner satisfaction with the company's services/business processes. Furthermore, the present study found leadership models as critical for digital transformation with the realistic scenario (iterative improvement) in all likelihood. Sales organizations are expected to consistently and continuously conduct experiments to find new ways of working and produce digital initiatives that companies need to answer customer/consumer demands. Those strategies can be done by clearly identifying factors, actors, objectives, and strategies for better business execution in digital transformation.

Abstract C115: Framework for a community-based multiple myeloma screening program

Abstract Purpose: We develop a framework for a community-based screening program for multiple myeloma (MM). MM is known to be twice as common in Black/African American (B/AA) persons compared to white persons and B/AA patients have a higher risk of delay in initial treatment compared to white patients. Therefore, we developed a community-wide screening program for B/AA persons 50 years and older. As the first of these programs, we reveal an organizational framework that prioritizes engagement with key community partners who address barriers to cancer screening. Experimental Procedures: We expand organizational development knowledge about how to implement community-based MM screening and address barriers. The study uses an iterative and qualitative continuous improvement process. The study draws on literature review and multi-disciplinary team collaboration among clinicians, researchers, administrators, and the Cleveland Clinic Community Outreach Program (Cleveland Outreach). Data Summary: Our framework includes three interrelated partners and each address barriers to MM screening: 1) Cleveland Clinic Cancer Center. The multi-disciplinary team designs an educational brochure, secures pilot grant funding, plans for insurance/financial assistance as needed, develops care algorithms, and evaluates the impact of the program. Cleveland Outreach, a department within the Cancer Center, uses the Harold Freeman model as its foundational approach, which includes patient navigators and community outreach managers who are culturally/linguistically matched to medically underserved communities. The Cancer Center addresses barriers including program implementation despite a lack of national screening guidelines, insurance/financial barriers, and patient navigation to address fears and health literacy. 2) Faith-based organizations. Church leaders committed to cancer prevention participate in Cleveland Outreach’s faith-based outreach model. Faith-based partners address barriers of trust and fear. Also, by providing space at churches for on-site screening blood draws, they address transportation barriers. 3) Clinicians at Federally Qualified Health Centers (FQHC’s). Providers and nurses at FQHC’s receive a Continuing Medical Education program about MM screening designed/funded by the Cancer Center. From within the community, providers notify medically underserved patients about the screening. With their primary care patient population, FQHC partners address barriers such as trust, health literacy, and fear of blood draws. They facilitate on-site screening at FQHC’s and health fairs, which addresses transportation barriers. Conclusions: Given that there are no universal guidelines for MM screening, we develop a novel approach to early disease detection in B/AA patients. Our framework is a partnership between the Cancer Center, faith-based organizations, and FQHC’s. Collaboratively, we address barriers to screening including fear, trust, insurance/financial, health literacy, transportation, and patient navigation if abnormal results suggest the need for further testing. Citation Format: Heather McKee Hurwitz, Kimberly Bell, Diana Basali, Raymond D. Jackson II, Jason Valent. Framework for a community-based multiple myeloma screening program [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr C115.

Gene therapy for adenosine deaminase severe combined immune deficiency-An unexpected journey of four decades.

Severe combined immune deficiency due to adenosine deaminase deficiency (ADA SCID) is an inborn error of immunity with pan-lymphopenia, due to accumulated cytotoxic adenine metabolites. ADA SCID has been treated using gene therapy with a normal human ADA gene added to autologous hematopoietic stem cells (HSC) for over 30 years. Iterative improvements in vector design, HSC processing methods, and clinical HSC transplant procedures have led nearly all ADA SCID gene therapy patients to achieve consistently beneficial immune restoration with stable engraftment of ADA gene-corrected HSC over the duration of observation (as long as 20 years). One gene therapy for ADA SCID is approved by the European Medicines Agency (EMA) in the European Union (EU) and another is being advanced to licensure in the U.S. and U.K. Despite the clear-cut benefits and safety of this curative gene and cell therapy, it remains challenging to achieve sustained availability and access, especially for rare disorders like ADA SCID.

Facility-Based Audit System With Integrated Community Engagement to Improve Maternal and Perinatal Health Outcomes in Rural Pakistan: Protocol for a Mixed Methods Implementation Study.

Maternal and newborn mortality in Pakistan remains as a major public health challenge. Pakistan faces significant infrastructure challenges and inadequate access to quality health care, exacerbated by sociocultural factors. Facility-based audit systems coupled with community engagement are key elements in achieving improved health system performance. We describe an implementation approach adapted from the World Health Organization audit cycle in real-world settings, with a plan to scale-up through mixed methods evaluation plan. This study aims to implement a locally acceptable and relevant audit system and evaluate its feasibility within the rural health system of Pakistan for scale-up. The implementation of the audit system comprises six phases: (1) identify facility and community leadership through consultative meetings with government district health offices, (2) establish the audit committee under the supervision of district health officer, (3) initiate audit with ongoing community engagement, (4) train the audit committee members, (5) launch the World Health Organization audit cycle (monthly meetings), and (6) quarterly review and refresher training. Data from all deliveries, live births, maternal deaths, maternal near misses, stillbirths, and neonatal deaths will be identified and recorded from four sources: (1) secondary-level care rural health facilities, (2) lady health workers' registers, (3) community representatives, and (4) project routine survey team. Concurrent quantitative and qualitative data will be drawn from case assessments, process analysis, and recommendations as components of iterative improvement cycles during the project. Outcomes will be the geographic distribution of mortality to measure the reach, proportion of facilities initiated to implement an audit system for measuring the adoption, proportion of audit committees with community representation, and proportion of audit committee members' sharing feedback regularly to measure acceptability and feasibility. In addition, outcomes of effectiveness will be measured based on data recording and reporting trends, identified modifiable factors for mortality and morbidity as underpinned by the Three Delays framework. Qualitative data will be analyzed based on perceived facilitators, barriers, and lessons learned for policy implications. Results will be summarized in frequencies and percentages and triangulated by the project team. Data will be analyzed using Stata (version 16; StataCorp) and NVivo (Lumivero) software. The study will be implemented for 20 months, followed by an additional 4-month period for follow-up. Initial results will be presented to the district health office and the District Health Program Management Team Meeting in the districts. This study will generate evidence about the feasibility and potential scale-up of a facility-based mortality audit system with integrated community engagement in rural Pakistan. Audit committees will complete the feedback loop linking health care providers, community representatives, and district health officials (policy makers). This implementation approach will serve decision makers in improving maternal and perinatal health outcomes. DERR1-10.2196/49578.

Effective Targeting of Evolutions in Concerns Underpinning COVID Vaccine Hesitancy in Patients with Sickle Cell Disease across the Lifespan of the COVID19 Pandemic

COVID vaccine hesitancy among patients with sickle cell disease (SCD) was prevalent during the pandemic. This subset of vaccine hesitancy within the SCD population is of particular concern due to the elevated risk of severe illness associated with COVID-19 in individuals with SCD. Numerous factors contribute to vaccine hesitancy in this context, including concerns specific to SCD, such as potential interactions with disease-modifying therapies, uncertainty regarding vaccine efficacy in this population, mistrust in healthcare systems, and historical disparities in healthcare access and delivery. Underlying psychological factors, such as fear and anxiety, may also influence vaccine hesitancy in patients with SCD. We sought to survey our patients' feelings towards the COVID19 vaccination in the peak of the pandemic (Sept-Dec 2021), as we had noted that some patients had declined the offer of vaccination and others had had a one or two doses, then stopped. 54 patients with SCD were surveyed anonymously and data analysed in excel and NVivo. 27.8% had had no doses and only 14.8% had had the 3 doses as recommended at that time leaving 57.4% partially vaccinated. Breaking this down by age, the younger patients (<16y) were more likely to have had no doses (0%) with progressive rise in uptake to the older age group (>35) where 13.9% had had no doses. Even in this older age group, only 19.4% were fully vaccinated however (A). Qualitative analysis of text responses (B) revealed themes of concern regarding: Lack of trust in the new and ‘untested’ vaccine:Fear of side effects and complications, particularly concerns about the vaccine's compatibility with their conditions and medications.Mistrust in the vaccine's efficacy and necessityLack of long-term research and unknown effectsInfluence of social media and misinformationPersonal choice and autonomyDesire for more information and communication We then undertook semi structured interviews with volunteers to understand these concerns in greater depth and progressively developed a toolkit of resources around commonly reported concerns to inform shared decision making. Discussion of these resources with patients increased our understanding of the concerns in greater depth and permitted iterative improvements to the resource such that it reduced hesitancy in all respondents, garnering a self-reported reduction of 61% on a 1 to 5 Likert scale. More recently, we have noted a significant cohort of patients who, although they were happy to accept the initial offer of 2-3 doses, have not assented to have further booster doses. We therefore re-surveyed (July 2023). 44 patients replied. 20.5% had had no doses and only 11.4% had had the 5 doses recommended leaving 68.2% partially vaccinated (C). A similar age dependent increase in acceptance was seen (60% of under 16s unvaccinated vs.16.7% of 35 & overs). Only 36.4% had accepted the offer of a broader coverage booster (D). There was an evolution in qualitative themes (E) Mistrust in/scepticism about vaccine technologyDoubts about vaccine efficacySide effects experiencedAnger at being singled out/‘forced’ to get boostersBoosters reminding of the pandemic's impact on mental health Most worryingly, there are statements regarding dissatisfaction with healthcare providers' responses regarding the vaccine and suggestions that continuing to promote the vaccine in the face of deep-rooted objections is eroding the doctor-patient relationship and level of trust and confidence in the team which is frequently hard won and highly prized by patients with SCD. Appreciating the causes of the underlying concerns and development of tailored interventions are necessary to develop targeted educational campaigns that address SCD-specific concerns, effective communication strategies that involve healthcare providers and patient advocacy groups, and the provision of accurate and transparent information. The more recent set of themes are more challenging to develop targeted resources towards, but they contain critical learning for physicians regarding the potential damage caused by promoting the vaccine too strongly to those who remain sceptical. By more fully understanding the sources of ongoing vaccine hesitancy among patients with SCD we can best support our patients to mitigate the potentially devastating consequences of the disease in this vulnerable population whilst maintaining the fragile therapeutic alliance.

A Virtual Pilot of a Multispecialty Group Mentoring Program for Underrepresented in Medicine (URiM) Trainees and Faculty

Background: Underrepresented in medicine (URiM) trainees and faculty often face limited mentorship and an increased sense of isolation in academic medicine. The objective of this pilot study was to determine if transitioning the Mentoring in Inclusion and Diversity program, a group mentoring model for URiM physicians spanning career levels and specialties, from an in-person to a virtual format during the COVID-19 pandemic was feasible and acceptable. Methods: MIND involves mentoring within multispecialty “families” composed of URiM medical students, residents, fellows, and faculty. A series of workshops comprises the formal program, which in 2020, transitioned to a virtual format. We applied the Context, Input, Process and Product (CIPP) evaluation model for continuous improvement of workshops. Through surveys, we elicited participants’ perceptions of engagement and helpfulness for each workshop, general feedback, and suggestions for improvement. Survey responses were analyzed descriptively, and open-ended comments were content-analyzed. Results: For the 2020-2021 academic year, the authors grouped 111 participants across 10 families and organized 6 virtual workshops on the following topics: How to be a Mentor, Meeting your MIND Family, Imposter Syndrome, Microaggressions, two Career Mentor Spotlights, and a book club. The CIPP model facilitated iterative improvements. Participants viewed workshops, on average, as being helpful (87%) and engaging (88%). Participants reported enjoyment of small groups, connecting with other URiM physicians, and desire for increased time for family discussions. Conclusions: The MIND group mentoring model was feasible and acceptable in a virtual format.

The development of a novel decision support system for regional land use planning for brownfield land

Digital tools, particularly specialised decision support systems (DSSs), can be utilized to assist in the complex process of brownfield redevelopment. Existing brownfield DSSs typically focus on site-specific, late-stage applications, and socioeconomic factors are often overlooked. In this paper, we present a novel DSS aimed at providing support for early-stage, city region-scale brownfield land use planning and redevelopment. The proposed DSS is a prototype WebGIS application that enables land use planners and other brownfield regeneration professionals to examine a region and a set of sites during the initial planning phase for brownfield redevelopment. The DSS includes three bespoke modules comprising: (1) Land Use Potential (residential, commercial, and public open space), (2) risks posed by contamination and geotechnical hazards, (3) data pertinent to brownfield economic viability assessments. We outline a use case for this DSS, developed through comprehensive user-requirements gathering, and subsequently describe the techniques employed to construct the DSS modules and user interface. Finally, we present the results of user testing, wherein case-study stakeholders assessed the DSS. The feedback obtained during user testing aided in the identification of areas for improvement with regard to the functionality, usability, and effectiveness of the DSS in supporting decision-makers. The feedback was utilized to implement iterative improvements to the DSS and to plan future developments for the prototype DSS.

Digital Tool-Assisted Hospitalization Detection in the Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention Study Compared to Traditional Site-Coordinator Ascertainment: Intervention Study.

Accurate, timely ascertainment of clinical end points, particularly hospitalizations, is crucial for clinical trials. The Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention (TAILOR-PCI) Digital Study extended the main TAILOR-PCI trial's follow-up to 2 years, using a smartphone-based research app featuring geofencing-triggered surveys and routine monthly mobile phone surveys to detect cardiovascular (CV) hospitalizations. This pilot study compared these digital tools to conventional site-coordinator ascertainment of CV hospitalizations. The objectives were to evaluate geofencing-triggered notifications and routine monthly mobile phone surveys' performance in detecting CV hospitalizations compared to telephone visits and health record reviews by study coordinators at each site. US and Canadian participants from the TAILOR-PCI Digital Follow-Up Study were invited to download the Eureka Research Platform mobile app, opting in for location tracking using geofencing, triggering a smartphone-based survey if near a hospital for ≥4 hours. Participants were sent monthly notifications for CV hospitalization surveys. From 85 participants who consented to the Digital Study, downloaded the mobile app, and had not previously completed their final follow-up visit, 73 (85.8%) initially opted in and consented to geofencing. There were 9 CV hospitalizations ascertained by study coordinators among 5 patients, whereas 8 out of 9 (88.9%) were detected by routine monthly hospitalization surveys. One CV hospitalization went undetected by the survey as it occurred within two weeks of the previous event, and the survey only allowed reporting of a single hospitalization. Among these, 3 were also detected by the geofencing algorithm, but 6 out of 9 (66.7%) were missed by geofencing: 1 occurred in a participant who never consented to geofencing, while 5 hospitalizations occurred among participants who had subsequently turned off geofencing prior to their hospitalization. Geofencing-detected hospitalizations were ascertained within a median of 2 (IQR 1-3) days, monthly surveys within 11 (IQR 6.5-25) days, and site coordinator methods within 38 (IQR 9-105) days. The geofencing algorithm triggered 245 notifications among 39 participants, with 128 (52.2%) from true hospital presence and 117 (47.8%) from nonhospital health care facility visits. Additional geofencing iterative improvements to reduce hospital misidentification were made to the algorithm at months 7 and 12, elevating the rate of true alerts from 35.4% (55 true alerts/155 total alerts before month 7) to 78.7% (59 true alerts/75 total alerts in months 7-12) and ultimately to 93.3% (14 true alerts/5 total alerts in months 13-21), respectively. The monthly digital survey detected most CV hospitalizations, while the geofencing survey enabled earlier detection but did not offer incremental value beyond traditional tools. Digital tools could potentially reduce the burden on study coordinators in ascertaining CV hospitalizations. The advantages of timely reporting via geofencing should be weighed against the issue of false notifications, which can be mitigated through algorithmic refinements.

Design and fabrication of a wrist splint for burn patient rehabilitation using 3D printing technologies.

Severe and common injuries involving burns to the hands and wrists can often lead to permanent loss of motion. The issue is exacerbated by the delicate nature of tendons and muscles in the hands, along with the formation of scar tissue. While rehabilitation exercises can help improve the range of motion, early-stage recovery requires additional tension on the affected areas. To address this concern, a novel project was initiated, aiming to develop a specialized splint for later-stage rehabilitation. This innovative splint allows users to carry out their daily tasks while wearing it, constantly applying a beneficial load on the wrist, hand, and digits to enhance range of motion. The development of the splint involved leveraging Fused Deposition Modelling (FDM) 3D printing and medically safe materials for the initial prototype. Finite Element Analysis (FEA) was employed to analyze the design. The process underwent iterative design improvements and parameter adjustments, ultimately resulting in the final prototype. The FEA analysis confirmed the strength and durability of the PLA components, while the TPU digit resistance bands were evaluated using a hyper-elastic model. As a result, the final design effectively applies tension to the digits without compromising day-to-day tasks’ usability and wearer’s comfort. Future iterations of the splint could focus on enhancing fastening methods, reducing brace movement during usage, creating various sizes to accommodate different arm/hand dimensions, and optimizing mass-manufacturing processes.

Interdisciplinary implementation of a synoptic reporting template for melanoma nodal surveillance ultrasound.

35 Background: As nodal surveillance is increasingly used for sentinel lymph node positive (SLN+) melanoma following the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II), availability of high-quality nodal surveillance ultrasonography (U/S) has become a critical need. Based on MSLT-II, U/S criteria concerning for nodal recurrence should be evaluated to determine indication for lymph node (LN) biopsy. We previously demonstrated low utilization of MSLT-II criteria for reporting nodal U/S at our tertiary cancer center, diminishing the clinical utility of these reports. Working in an interdisciplinary team of surgeons and radiologists, we aimed to implement and evaluate a synoptic reporting template for melanoma nodal ultrasound at our institution. Methods: Patients undergoing melanoma nodal surveillance at a tertiary cancer center from July 2017 to June 2023 who received at least one nodal U/S were identified retrospectively. Reporting language from each U/S was analyzed for number of MSLT-II criteria reported and presence of clinically actionable recommendations for the referring surgical team (e.g. normal LN appearance or abnormal LN with recommendation for biopsy or observation). The synoptic report was designed collaboratively by a group of radiologists and surgical oncologists to include MSLT-II U/S criteria and thresholds for biopsy versus continued surveillance, with the institutional U/S dictation template revised accordingly. Dissemination to clinical teams was conducted and utilization was monitored in the course of clinical care. Following implementation of the synoptic template in January 2023, post-implementation adherence and outcomes were reviewed. Descriptive statistics and bivariate analysis were performed. Results: 337 nodal U/S studies were performed on 94 SLN+ melanoma patients, with a median of 2.5 U/S per patient (range 1 to 12). Forty-two U/S (12.5%) were performed in the post-implementation period and eligible for synoptic reporting; of these, 32 (76.0%) were reported with the synoptic template. The mean number of MSLT-II criteria reported was greater post-implementation (Pre 0.5 ± 0.8 vs Post 2.5 ± 1.0, p<0.001). Abnormal findings were reported in 73 U/S (21.7%), with a significant increase in the proportion of clinically actionable recommendations for abnormal findings reported in the Post versus Pre group (93.0% vs 64.0%, p=0.037). Conclusions: Following the implementation of a collaboratively designed synoptic reporting template for melanoma nodal U/S, reports were much more likely to have MSLT-II criteria reported in addition to an actionable recommendation. There was notable improvement when ultrasounds had abnormal findings, when the application of these reporting criteria is most crucial. Further iterative improvement to increase adherence to the synoptic report and dissemination to other cancer centers is ongoing.

Regional public health staff workplace psychosocial risk assessment and health promotion initiative

Abstract Psychosocial work conditions can be detrimental to worker wellbeing with 70% of healthcare workers reporting work related stress, which may lead to burnout. Despite European health and safety legislation, managers rarely assess and manage workplace psychosocial risks. The Public Health workforce in Ireland, already impacted by the pandemic, is currently experiencing major organisational change as a result of the ongoing Public Health Reform Process. This paper describes the structures, processes and outcomes involved in a Public Health staff (n = 56) workplace psychosocial risk assessment, guided by the European Framework for Psychosocial risk Management: PRIMA-EF, using the HSE Work Positive CI psychosocial risk assessment survey. The establishment of a multidisciplinary Health & Wellbeing (H&W) group, under the governance of the Area Senior Management Team, was key to guide the process, including a workplace health promotion initiative, influenced by Positive Psychology framework (PERMA). The response rate to the survey was 70% (n = 40), with half of staff reporting psychological distress. Work stressors included role clarity, demand, change and control, scoring below average compared to Irish organisational norms. Relationships and manager support scored highly. The H&W group shared results promptly with all staff and formulated iterative mitigation measures, including HSE Change Management and HSE Health & Wellbeing consultants, based on the survey action plan and staff feedback. Five months later a repeat survey revealed continuing issues around role clarity and demands, with change and control showing an improvement. Further exploration of these results, and an evaluation, informed by staff feedback is ongoing and iterative. Lessons learnt include the importance of embedding a dedicated H&W multidisciplinary group to lead the continuous process; senior management support; employee involvement and effective utilisation of existing organisational tools and supports. Key messages • It is a public health imperative to promote risk assessment and mitigation of healthcare workplace stressors to safeguard employee wellbeing and ensure health service resilience and patient safety. • Effective workplace psychosocial risk assessment and implementation of targeted mitigation measures requires management support and a continuous iterative collaborative quality improvement process.

The 3Ranker: An AI-based Algorithm for Finding Non-animal Alternative Methods.

The search for existing non-animal alternative methods for use in experiments is currently challenging because of the lack of both comprehensive structured databases and balanced keyword-based search strategies to mine unstructured textual databases. In this paper we describe 3Ranker, which is a fast, keyword-independent algorithm for finding non-animal alternative methods for use in biomedical research. The 3Ranker algorithm was created by using a machine learning approach, consisting of a Random Forest model built on a dataset of 35 million abstracts and constructed with weak supervision, followed by iterative model improvement with expert curated data. We found a satisfactory trade-off between sensitivity and specificity, with Area Under the Curve (AUC) values ranging from 0.85-0.95. Trials showed that the AI-based classifier was able to identify articles that describe potential alternatives to animal use, among the thousands of articles returned by generic PubMed queries on dermatitis and Parkinson's disease. Application of the classification models on time series data showed the earlier implementation and acceptance of Three Rs principles in the area of cosmetics and skin research, as compared to the area of neurodegenerative disease research. The 3Ranker algorithm is freely available at www.open3r.org; the future goal is to expand this framework to cover multiple research domains and to enable its broad use by researchers, policymakers, funders and ethical review boards, in order to promote the replacement of animal use in research wherever possible.

Cerner Millennium's Care Pathways for Specialty Care Referrals: Provider and Nurse Experiences, Perceptions, and Recommendations for Improvements.

Using structured templates to guide providers in communicating key information in electronic referrals is an evidence-based practice for improving care quality. To facilitate referrals in Veterans Health Administration's (VA) Cerner Millennium electronic health record, VA and Cerner have created "Care Pathways"-templated electronic forms, capturing needed information and prompting ordering of appropriate pre-referral tests. To inform their iterative improvement, we sought to elicit experiences, perceptions, and recommendations regarding Care Pathways from frontline clinicians and staff in the first VA site to deploy Cerner Millennium. Qualitative interviews, conducted 12-20months after Cerner Millennium deployment. We conducted interviews with primary care providers, primary care registered nurses, and specialty providers requesting and/or receiving referrals. We used rapid qualitative analysis. Two researchers independently summarized interview transcripts with bullet points; summaries were merged by consensus. Constant comparison was used to sort bullet points into themes. A matrix was used to view bullet points by theme and participant. Some interviewees liked aspects of the Care Pathways, expressing appreciation of their premise and logic. However, interviewees commonly expressed frustration with their poor usability across multiple attributes. Care Pathways were reported as being inefficient; lacking simplicity, naturalness, consistency, and effective use of language; imposing an unacceptable cognitive load; and not employing forgiveness and feedback for errors. Specialists reported not receiving the information needed for referral triaging. Cerner Millennium's Care Pathways, and their associated organizational policies and processes, need substantial revision across several usability attributes. Problems with design and technical limitations are compounding challenges in using standardized templates nationally, across VA sites having diverse organizational and contextual characteristics. VA is actively working to make improvements; however, significant additional investments are needed for Care Pathways to achieve their intended purpose of optimizing specialty care referrals for Veterans.

Telehealth-Based Contingency Management Targeting Stimulant Abstinence: A Case Series From the COVID-19 Pandemic.

Contingency management (CM) is the gold standard treatment for stimulant use disorder but typically requires twice- to thrice-weekly in-person treatment visits to objectively verify abstinence and deliver therapeutic incentives. There has been growing interest in telehealth-based delivery of CM to support broad access to this essential intervention--a need that has been emphatically underscored by the COVID-19 pandemic. Herein, we present observations from initial efforts to develop and test a protocol for telehealth-based delivery of prize-based CM treatment incentivizing stimulant abstinence. Four participants engaged in hybrid courses of CM, including one or more telehealth-based treatment sessions, involving self-administered oral fluid testing to confirm abstinence. Observations from initial participants informed iterative improvements to telehealth procedures, and a 12-week course of telehealth-based CM was subsequently offered to two additional participants to further evaluate preliminary feasibility and acceptability. In most cases, participants were able to successfully join telehealth treatment sessions, self-administer oral fluid testing, and share oral fluid test results to verify stimulant abstinence. However, further improvements in telehealth-based toxicology testing may be necessary to interpret test results accurately and reliably, especially when colorimetric immunoassay results reflect substance concentrations near the cutoff for point-of-care testing devices. Preliminary findings suggest that telehealth-based CM is sufficiently feasible and acceptable to support future development, in particular through improved methods for remote interpretation and verification of test results. This is especially important in CM, wherein accurate and reliable detection of both early and sustained abstinence is crucial for appropriate delivery of therapeutic incentives.

Applying automated machine translation to educational video courses

We studied the capability of automated machine translation in the online video education space by automatically translating Khan Academy videos with state-of-the-art translation models and applying text-to-speech synthesis and audio/video synchronization to build engaging videos in target languages. We also analyzed and established two reliable translation confidence estimators based on round-trip translations in order to efficiently manage translation quality and reduce human translation effort. Finally, we developed a deployable system to deliver translated videos to end users and collect user corrections for iterative improvement.

Utilizing the RE-AIM framework for a multispecialty Veterans Affairs Extension for Community Healthcare Outcomes (VA-ECHO) program 2018-2022.

VA-ECHO (Veterans Affairs -Extension for Community Healthcare Outcomes) provides live, synchronous, continuing education accredited, case-based learning. Sessions deliver up-to-date, evidence-based, practice-relevant, Veteran-focused learning to healthcare team members. The primary goal of VA-ECHO is to increase Veterans' access to high quality care by improving knowledge and skills among VA care providers. Utilizing the RE-AIM framework, descriptive statistics for 23 VA-ECHO programs regarding program effectiveness, adoption, implementation, and maintenance during a five-year period (2018-2022) are reported. VA-ECHO offered 1,462 sessions and 157,238 contact hours, engaging 17,642 participants from 837 VA-based sites (20% rural-based sites). Effectiveness includes information on number and diversity of programs, as well as reported impact on participants' practice. Adoption includes descriptive statistics, including comparison of growth and change compared to prior years. Implementation describes change in the program over time, including the number of specialties offered, and types of continuing education offered. Maintenance includes a narrative regarding sustainability. The discussion focuses on implementation and maintenance strategies the program has used to address participant and VA needs within the RE-AIM framework, including adjustments to the program, iterative qualitative improvement, sustainment strategies, and opportunities for future evaluation.

Implementing One-at-a-Time Therapy in community addiction and mental health centres: a retrospective exploration of the implementation process and initial outcomes

BackgroundThe Department of Health of the Government of New Brunswick and Regional Health Authorities elected to implement Stepped Care 2.0 (SC2.0) in 2021, and began with One-at-a-Time (OAAT) therapy in Community Addiction and Mental Health Centres (CAMHCs) to facilitate rapid access to addiction and mental healthcare. This study: 1) explicated the process of implementing OAAT therapy as it aligned to evidence-based implementation frameworks and strategies; 2) assessed readiness for change among providers during the implementation; and 3) evaluated initial client and system outcomes.MethodsThe process of implementing OAAT therapy within CAMHCs was documented and retrospectively aligned with the Active Implementation Frameworks-Stages of Implementation, Consolidated Framework for Implementation Research, and incorporated strategies endorsed by the Expert Recommendations for Implementing Change. Providers working in CAMHCs completed online asynchronous courses in OAAT therapy and SC2.0, and were recruited to participate in research on perceptions of organizational readiness. Initial outcomes of the implementation were evaluated through client satisfaction surveys administered in CAMHCs and system performance indicators.ResultsAligning with implementation stages, key strategies included: 1) continuously monitoring readiness and soliciting stakeholder feedback for iterative improvement; 2) building a representative implementation team with engaged leaders; 3) creating a comprehensive implementation plan on staff training, communication, and system changes; and 4) supporting sustainability. Providers who participated in research (N = 170, ~ 50% response rate) agreed that their organization was ready for implementation, and that OAAT therapy delivered within a SC2.0 framework was acceptable, appropriate, and feasible. More than 3,600 OAAT therapy sessions were delivered during the initial implementation stage, and waitlists were reduced by 64.1%. The majority of clients who completed surveys (N = 1240, ~ 35% response rate) reported that their OAAT therapy session was helpful, with a minority reporting that additional intervention was needed.ConclusionsThoughtful planning and execution, aligned with evidence-based implementation frameworks and strategies, played an important role in this provincial change initiative. Implementation steps outlined can help inform others looking to enact large-scale change.

Design and Analysis of Self-Energising Unmanned Underwater Vehicle (UUV)

This research focuses on the development of a self-energizing underwater vehicle that utilizes wave energy to power its circuit. The objective of the research work is to demonstrate the feasibility of harnessing renewable energy sources in an underwater environment and showcase the potential for sustainable power generation. To ensure the structural integrity of the vehicle under water, rigorous simulation analysis has been conducted using ANSYS software. The hull design has undergone thorough scrutiny to determine its ability to withstand water pressure at depths of up to 5 meters. The simulation results confirm that the submarine's hull design is robust and capable of withstanding the expected operating conditions. This study holds great significance in the field of marine engineering as it explores alternative energy sources for underwater applications. By harnessing wave energy, this work contributes to the development of sustainable technologies that can potentially revolutionize underwater operations. The use of renewable energy sources minimizes environmental impact and reduces reliance on traditional power sources. Throughout this research, challenges were encountered, including optimizing the turbine system efficiency, ensuring reliable power transfer, and maintaining the structural integrity of the submarine. These challenges were addressed through careful design considerations and iterative improvements. The knowledge gained from this study can be applied to various underwater applications such as marine exploration, environmental monitoring, and data collection. Future research and development should focus on enhancing the turbine design, integrating advanced power management systems, and conducting field tests to validate the system's performance in real-world-scenarios.