Multimodal Quality Research Articles

Probabilistic combination of local independent component regression model for multimode quality prediction in chemical processes

In this paper, a probabilistic combination form of the local independent component regression (ICR) model is proposed for quality prediction of chemical processes with multiple operation modes. Through the introduction of the Bayesian inference strategy, the posterior probabilities of the data sample in different operation modes are calculated upon two monitoring statistics of the independent component analysis (ICA) model. Then, based on the combination of local ICR models in different operation modes, a probabilistic multiple ICR (MICR) model is developed. Meanwhile, the operation mode information of the data sample is located through posterior analysis of the new model. To evaluate the multimode quality prediction performance of the proposed method, two case studies are provided.

Panama Canal Expansion Illustrates Need for Multimodal Near-Source Air Quality Assessment

Panama Canal Expansion Illustrates Need for Multimodal Near-Source Air Quality Assessment

A Resident-Led Quality Improvement Program for Increasing Documentation of Advance Care Planning Discussions (FR407-C)

1.Describe the design of a resident-led quality improvement program that included a financial incentive to increase rates of documentation of advance care planning discussions in the medical record.2.Detail the effects of the intervention on rates of documentation of advance care planning discussions.3.Identify key components that contributed to the program's success. Advance care planning (ACP) discussions ensure that end of life care is in accord with patients’ preferences. Inconsistent documentation of inpatient discussions puts patients at risk for unwanted interventions after discharge. To design and implement a resident-led quality improvement program including a financial incentive to ensure that the results of inpatient ACP discussions are available across care transitions. In response to frustration about inconsistent documentation of ACP discussions, two internal medicine residents, in coordination with program faculty, designed a multimodal quality improvement project to encourage residents to assess and document patients’ wishes for end of life care. A field was incorporated into the electronic discharge summary template for residents to document details of ACP discussions occurring during admission. We set a goal for residents to document discussions in the template for 75% of discharged patients. The program included: 1) financial incentive of $400 dollars per resident if goal reached from July 1st, 2011 to May 31st, 2012; 2) providing real time biweekly email feedback about individual rates of completion; 3) monthly education at chief resident orientations and quality improvement conferences. Rates of successful completion increased from 21% to around 90% over the course of the program. Key factors contributing to program success included the resident-led nature of the project, frequent audit and feedback, and the financial incentive. Assessment of sustainability is ongoing. A resident-led quality improvement program including a financial incentive resulted in significant increases in the documentation of ACP discussions in an easy location for outpatient and inpatient providers to locate across care transitions.

Non-technical skills training to enhance patient safety: a systematic review

Many quality improvement education programmes have been introduced over the last decade with the purpose of enhancing patient safety. The importance of non-technical skills training is becoming increasingly prominent, but the extent to which educational interventions have been used and the theoretical underpinnings of such interventions remain unclear. These issues were investigated through a systematic review of the literature. Any studies involving an educational intervention to improve non-technical skills amongst undergraduate or postgraduate staff in an acute health care environment were considered. A standardised search of online databases was carried out independently by two authors and consensus reached on the inclusion of studies. Data extraction and multimodal quality assessment were completed independently, followed by a content analysis of interventions and the extraction of key themes. A total of 22 studies met the inclusion criteria. Measured outcomes were variable, as was the strength of conclusions. Theoretical underpinning of interventions was not described in any studies. Content analysis revealed reasonable consistency with the emergence of five key themes: error; communication; teamwork and leadership; systems, and situational awareness. Teaching was often multidisciplinary and methods used included simulation and role-play exercises, and observation. The methodological quality of published studies is reasonable, although the reporting of specific interventions is poor. Although a recognised model to support the design of patient safety education is lacking, a number of theories have been applied to guide educators in future instructional design. Further published work should clearly describe interventions and their theoretical underpinnings, and should aim to further explore which specific aspects of interventions are effective and why. Such research should also try to assess whether such interventions can impact patient outcomes.

Republished: Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach

BackgroundEffective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence...

Improving hand hygiene in a paediatric hospital: a multimodal quality improvement approach

BackgroundEffective hand hygiene has long been recognised as an important way to reduce the transmission of bacterial and viral pathogens in healthcare settings. However, many studies have shown that adherence...

The MAURO study: baseline characteristics and compliance with guidelines targets

The Multiple Intervention and Audit in Renal Diseases to Optimize Care (MAURO) study was a cluster randomized controlled trial in 22 renal clinics which aimed to assess the efficacy of a multimodal quality improvement intervention to increase compliance with guideline recommendations for prevention of chronic kidney disease (CKD) progression and cardiovascular (CV) complications. The trial aimed to test whether this multimodal intervention improved adherence to recommended targets for a series of surrogate indicators relevant to blood pressure (BP) control, sodium intake, proteinuria, dyslipidemia, anemia and calcium-phosphate alterations. The trial also tested whether the same intervention slowed CKD progression and prevented CV complications in CKD patients. Twenty-two renal clinics were randomized to 2 arms: an intervention arm applying a multimethod quality improvement intervention and a control arm providing standard care. Surrogate indicators were measured to evaluate blood pressure (BP) control, sodium intake, proteinuria, dyslipidemia, anemia and calcium-phosphate alterations. Notwithstanding the fact that the vast majority of patients enrolled in this study (95%) were being treated with antihypertensive drugs, BP goals at baseline (specific for proteinuria level and diabetes) were met only in 45% of nonproteinuric patients and in just 14% and 18% of proteinuric and diabetic patients, respectively. The use of diuretics in hypertensive patients was less than what was needed, and about 80% of patients showed a salt excretion >100 mmol/24 hours. Total and low-density lipoprotein cholesterol levels were out of target in over 40% of patients, but only about 60% of these were on statins. A large majority of CKD patients were obese or overweight. The proportion of smokers was relatively small (13%), and 37% of patients had quit smoking, indicating patients' awareness of the health risks of smoking. In our cohort, management of modifiable risk factors for CKD progression and CV disease could be substantially improved.

Discharge Documentation of Patients Discharged to Subacute Facilities: A Three-Year Quality Improvement Process Across an Integrated Health Care System

Effective communication among physicians during hospital discharge is critical to patient care. Partners Healthcare (Boston) has been engaged in a multi-year process to measure and improve the quality of documentation of all patients discharged from its five acute care hospitals to subacute facilities. Partners first engaged stakeholders to develop a consensus set of 12 required data elements for all discharges to subacute facilities. A measurement process was established and later refined. Quality improvement interventions were then initiated to address measured deficiencies and included education of physicians and nurses, improvements in information technology, creation of or improvements in discharge documentation templates, training of hospitalists to serve as role models, feedback to physicians and their service chiefs regarding reviewed cases, and case manager review of documentation before discharge. To measure improvement in quality as a result of these efforts, rates of simultaneous inclusion of all 12 applicable data elements ("defect-free rate") were analyzed over time. Some 3,101 discharge documentation packets of patients discharged to subacute facilities from January 1, 2006, through September 2008 were retrospectively studied. During the 11 monitored quarters, the defect-free rate increased from 65% to 96% (p < .001 for trend). The largest improvements were seen in documentation of preadmission medication lists, allergies, follow-up, and warfarin information. Institution of rigorous measurement, feedback, and multidisciplinary, multimodal quality improvement processes improved the inclusion of data elements in discharge documentation required for safe hospital discharge across a large integrated health care system.

Multimodal Quality Assessment of Compressed Television Material for Portable and Mobile Devices

Portable and mobile multimedia production faces special challenges posed by transmission bandwidth limitations. This paper describes experimental studies of the multimodal quality of compressed television materials for mobile and portable devices, discusses required optimizations and proposes a mathematical model for content adaptive bit rate allocation. Study results are used to discuss the characteristics of multimodal quality and support the proposition that, if multimodal audiovisual perceptual quality is taken into account, it will improve the quality of new portable and mobile multimedia applications.

Author reply to the letter to the editor “Surgeon’s volume and lymph nodes number in assessing colorectal cancer surgery and multimodal treatment quality”

We thank Dr. Hottenrott for interest in our paper. We absolutely agree that the surgeon plays a central role in the operative and oncological safety during laparoscopic colorectal cancer surgery. Several studies have shown the learning curve for laparoscopic colorectal surgery [1–5]. Most of the studies have reported that the learning curve shows a ‘‘plateau’’ reaching adequate experience at some number of cases and suggest a certain number of cases to achieve a ‘‘plateau.’’ To date, however, there have not been a sufficient number of studies on the oncological learning curve. Therefore, the number of cases required to achieve sufficient experience continues to be debated. In the April issue of Surgical Endoscopy, we addressed the changes in the personal learning curve for laparoscopic colorectal cancer surgery with the accumulation of experience, and its impact on the oncological and surgical outcomes. As we mentioned in our study, the learning curve for laparoscopic colorectal resection showed a gradual change over all time periods. Although, our study did not address the role of the surgeon’s volume of cases on safety and effectiveness of the laparoscopic procedure, the volume of cases that a surgeon treats changes as the level of experience increases. Similar to open surgery, the surgeon’s volume of cases is associated with the safety and effectiveness of laparoscopic surgery and perhaps more important in cases of rectal cancer surgery. For rectal cancer surgery, the surgeon’s proficiency was one of the determining factors associated with the oncological outcomes. Analysis of the surgeon’s volume and its influence on surgical outcomes is important and a necessary feature of training for laparoscopic colorectal surgery [6, 7]. In addition, the ‘‘long-term progression’’ of surgery also is important to consider; we found that the retrieved lymph node number was decreased and anastomotic leakage was increased after accumulation of a sufficient number of cases to achieve sufficient learning experience for the procedure. Therefore, some skills may appear to have improved outcomes while others may be associated with poorer outcomes due to, in part, the expansion of the indications for the surgery. Therefore, as surgical indications are extended so too is the learning curve for the procedure.

Open Profiling of Quality: A Mixed Method Approach to Understanding Multimodal Quality Perception

To quantify the excellence of multimedia quality, subjective evaluation experiments are conducted. In these experiments, the tradition of quantitative assessment is the most dominating, but it disregards the understanding of participants' interpretations, descriptions, and the evaluation criteria of quality. The goal of this paper is to present a new multimedia quality evaluation method called Open Profiling of Quality (OPQ) as a tool for building a deeper understanding on subjective quality. OPQ is a mixed method combining a conventional quantitative psychoperceptual evaluation and qualitative descriptive quality evaluation based on the individual's own vocabulary. OPQ is targeted for naïve participants applicable to experiments with heterogeneous and multimodal stimulus material. The paper presents the theoretical basis of the development of OPQ and overviews the methods for audiovisual quality research. We present three extensive quality evaluation studies where OPQ has been used with 120 participants. Finally, we conclude further recommendations of use of the method in quality evaluation research.

Making Sense of Places

This paper explores the connections between whose representation of space, and whose modalities are “desirable” as part of the design of public spaces. Drawing on the theoretical framework of Henri Lefebvre, we reiterate the importance of “spatial practice” as a key tenet running right through the urban “design control” process. Second, we examine the ways in which subsequent multi-modal representations of urban space might act as a rejoinder to questions raised by the “moral geographies” literature, concluding that a consideration of “moral geographies” offers one way to unlock the multi-modal qualities associated with a progressive sensory urbanism.

Randomized Trial to Improve Fracture Prevention in Nursing Home Residents

Background Interventions to improve the fracture prevention in nursing homes are needed. Methods Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n = 67) with ≥10 residents with a diagnosis of osteoporosis or recent hip fracture (n = 606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering. Results No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant ( P = .72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models. Conclusions Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

Effectiveness of a Practice-Based, Multimodal Quality Improvement Intervention for Gastroenteritis Within a Medicaid Managed Care Network

Acute gastroenteritis results in 220,000 hospitalizations yearly in the United States. The substantial geographic variation in gastroenteritis care, coupled with the evidence of effective treatment of dehydration in nonhospital settings, suggests that the majority of these hospitalizations are avoidable. We sought to decrease hospitalizations for gastroenteritis by using practice-based, multimodal quality improvement methods that target multiple care processes to make them consistent with evidence-based guidelines. We used a controlled before/after study design to evaluate a quality improvement intervention in a 20-practice Medicaid network. All 20 practices participated in continuing education sessions; received free oral rehydration solution, patient education materials, and performance feedback; and participated in a follow-up conference call. Three practices were chosen to develop and pilot office-process changes. These practices formed interdisciplinary teams to develop and test changes and collaborated with project faculty and each other. They shared their learning with the other 17 practices via a conference call and toolkit. We compared before/after gastroenteritis hospital admissions for children <5 years old covered by Medicaid in the intervention practices with all other Medicaid recipients in North Carolina using claims data from 2000-2002. The 3 high-intensity practices all made numerous changes to care processes. Most of the 17 low-intensity practices reported changes in their gastroenteritis care processes. Gastroenteritis admission rates declined 45% in high-intensity practices and 44% in low-intensity practices during the study compared with 11% in the control practices. A practice-based, multimodal quality improvement intervention that targets multiple care processes on the basis of evidence-based guidelines lowered rates of gastroenteritis hospitalization in a Medicaid network. This approach could lower costs attributable to gastroenteritis for Medicaid programs.

A Cluster-Randomized Trial of Benchmarking and Multimodal Quality Improvement to Improve Rates of Survival Free of Bronchopulmonary Dysplasia for Infants With Birth Weights of Less Than 1250 Grams

We tested whether NICU teams trained in benchmarking and quality improvement would change practices and improve rates of survival without bronchopulmonary dysplasia in inborn neonates with birth weights of <1250 g. A cluster-randomized trial enrolled 4093 inborn neonates with birth weights of <1250 g at 17 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Three centers were selected as best performers, and the remaining 14 centers were randomized to intervention or control. Changes in rates of survival free of bronchopulmonary dysplasia were compared between study year 1 and year 3. Intervention centers implemented potentially better practices successfully; changes included reduced oxygen saturation targets and reduced exposure to mechanical ventilation. Five of 7 intervention centers and 2 of 7 control centers implemented use of high-saturation alarms to reduce oxygen exposure. Lower oxygen saturation targets reduced oxygen levels in the first week of life. Despite these changes, rates of survival free of bronchopulmonary dysplasia were all similar between intervention and control groups and remained significantly less than the rate achieved in the best-performing centers (73.3%). In this cluster-randomized trial, benchmarking and multimodal quality improvement changed practices but did not reduce bronchopulmonary dysplasia rates.

Measuring Pedestrian Quality of Service for Midblock Street Crossings: Selection of Potential Determinants

The Florida Department of Transportation is in the process of developing a statistically estimated model of pedestrian quality of service for midblock street crossings as part of its Multimodal Quality of Service Program. This model is to be used in evaluating the level of service of street segments for pedestrian street crossing. The actual development of the model, including methodological issues explored, data collection, and model calibration and validation, is reported separately. A process was used to select potential determinants of perceived pedestrian quality of service for midblock street crossings. This process is structured and involves two steps. The first step involves the selection of a set of potential determinants through a theoretical analysis of pedestrian behavior for street crossing. The theoretical consideration ensures that these potential determinants have a sound behavioral foundation. The second step involves narrowing down this theoretical set through a practical analysis of planning needs and data requirements by an advisory committee. This practical consideration ensures that the final set of potential determinants and the model both are practically relevant.

Imagery in multi-modal object learning

Spatial objects may not only be perceived visually but also by touch. We report recent experiments investigating to what extent prior object knowledge acquired in either the haptic or visual sensory modality transfers to a subsequent visual learning task. Results indicate that even mental object representations learnt in one sensory modality may attain a multi-modal quality. These findings seem incompatible with picture-based reasoning schemas but leave open the possibility of modality-specific reasoning mechanisms.

Patient and Family Support Organization Services Should Be Included As Part of Treatment for the Severely Mentally Ill

Patient and family support organizations for Axis I disorders have grown exponentially and expanded their services over the past two decades. However, psychiatrists generally have not referred patients and families to these organizations. The goal of this paper is to change clinicians' behavior so that they more commonly include support organization services in treatment plans for patients and families. We performed a literature review focusing on the changing needs of patients and their families as they relate to mental health teams, changes in the family therapy field, and concerns of both healthcare providers and related organizations about referral. Abundant anecdotal evidence and some scientific data suggest that patients and families are satisfied with these support organizations and the services they provide. However, support organizations need clinician referrals in order for their services to be integrated into a multi-modal quality treatment plan to achieve full treatment efficacy.

How Is a Trumpet Known? The "Basic Object Level" Concept and Perception of Musical Instruments

What are the object properties that serve as a basis for the musical instrument classification system, and how do general and specific experience affect knowledge of these properties? In the first study, the multimodal quality of properties underlying children's and adults' perception was investigated. Subjects listened to solos and identified instruments producing the sounds. Even children who did not have experience with all the instruments correctly identified the family of instruments they were listening to. The hypothesis of the second study, that musical instrument families function as a "basic level" in the instrument taxonomy, was confirmed. Variation in the basic level with varying expertise was documented in the third study with musicians. In the fourth study, children and adults identified the source of sounds from unfamiliar objects, Chinese musical instruments. It is suggested that the concept of affordances may be relevant for understanding the importance for behavior of different levels of abstraction of category systems.

The Basis of Stroop Interference Involving the Multimodal Correlates of Auditory Pitch

A pure auditory tone has a range of multimodal qualities that are determined by its pitch. A reaction-time task was used to demonstrate that subjects respond immediately and automatically to these qualities. Subjects were required to press one of two keys depending on which word, from a limited set, appeared on a microcomputer screen. The words were antonyms that represented multimodal stimulus qualities, and they were assigned to alternative responses so that the two words that shared the same response were correlated in the same way with pitch. As an incidental stimulus, either a 50 Hz tone or a 5500 Hz tone accompanied the presentation of each word. Subjects were found to respond more slowly when the multimodal qualities of the tone were incongruent with the qualities represented by the test word. When the stimulus-response mapping rules were changed, however, the Stroop effect did not occur; suggesting that a polarised semantic code of the incidental tone, that embraces its multimodal features, accesses the same semantic register as the equivalent code for the test word itself.