Opportunities For Improvement Research Articles

North Carolina Caregiver Listening Study: Caregiver Experiences and Perspectives on Services and Supports in an Aging U.S. State

ABSTRACT Family caregivers experience health, financial, and social burdens related to caregiving responsibilities. North Carolina has an estimated 1.3 million caregivers, equating to a value of $13.1 billion per year. Caregiving demands warrant additional understanding of the caregiver lived experiences. Our objective was to document these North Carolina caregiver experiences during the era of COVID-19 through focus groups. Participants were recruited through diverse community organizations. All 44 caregivers who completed interest solicitation surveys were invited to participate; 29 caregivers participated across 11 groups. Thematic analysis was used to code and synthesize transcripts from each participant using Dedoose software and guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ). Caregiver routines (caregiving as an all-encompassing role; dimensions of support); most challenging parts (exhaustion and defeat; lacking support; evolving relationships); most rewarding parts (care recipient resilience; quality time; sense of purpose); social service and healthcare system interactions (positive interactions; negative interactions; inaccessible services); COVID-19 impacts on caregiving (opportunities; challenges); and caregiver suggestions for system improvements (increasing financial support; improved coordination; ideological shifts). Caregivers shared unmet needs, challenges, and opportunities for improvement. Examining these needs and experience-informed recommendations can help advance additional caregiving research, policy-making, and program development.

Assessments and observations of infection prevention and control practices in US outpatient hemodialysis facilities, 2015-2018: important opportunities for improvement.

Infections cause substantial morbidity and mortality among patients receiving care in outpatient hemodialysis facilities. We describe comprehensive infection prevention assessments by US public health departments using standardized interview and observation tools. Results demonstrated how facility layouts can undermine infection prevention and that clinical practices often fall short of policies.

Emergency department pediatric readiness of United States trauma centers in 2021: Trauma center facility characteristics and opportunities for improvement.

Emergency department (ED) pediatric readiness has been associated with lower mortality for injured children but has historically been suboptimal in non-pediatric trauma centers. Over the past decade, the National Pediatric Readiness Project (NPRP) has invested resources in improving ED pediatric readiness. This study aimed to quantify current trauma center pediatric readiness and identify associations with center-level characteristics to target further efforts to guide improvement. The study cohort included all centers that responded to the 2021 NPRP national assessment and contributed data to the National Trauma Databank (NTDB) the same calendar year. Center characteristics and pediatric (0-15y) volume from the NTDB were linked to weighted pediatric readiness scores (wPRS) obtained from the NPRP assessment. Univariate and multivariable analyses were used to determine associations between wPRS and trauma center type as well as center-level facility characteristics. The wPRS was reported for 77% (749/973) of centers that contributed to the NTDB. ED Pediatric Readiness was highest in ACS level one pediatric trauma centers (PTCs), but wPRS in the highest quartile was seen among all adult and pediatric trauma center types. Independent predictors of high wPRS included ACS level one PTC verification, pediatric trauma volume, and the presence of a PICU. Higher-level adult trauma centers and pediatric trauma centers were more likely to have pediatric-specific physician requirements, pediatric emergency care coordinators, and pediatric quality improvement initiatives. ED pediatric readiness in trauma centers remains variable and is predictably lower in centers that lack inpatient resources. There is, however, no aspect of ED pediatric readiness that is constrained to high-level pediatric facilities, and a highest quartile wPRS was achieved in all types of adult centers in our study. Ongoing efforts to improve pediatric readiness for initial stabilization at non-pediatric centers are needed, particularly in centers that routinely transfer children out. Epidemiologic, Level III.

Patient experiences of interprofessional collaboration and intersectoral communication in rare disease healthcare in Germany – a mixed-methods study

BackgroundRare diseases are often complex, chronic and many of them life-shortening. In Germany, healthcare for rare diseases is organized in expert centers for rare diseases. Most patients additionally have regional general practicioners and specialists for basic medical care. Thus, collaboration and information exchange between sectors is highly relevant. Our study focuses on the patient and caregiver perspective on intersectoral and interdisciplinary care between local healthcare professionals (HCPs) and centers for rare diseases in Germany. The aims were (1) to investigate patients’ and caregivers’ general experience of healthcare, (2) to analyse patients’ and caregivers’ perception of collaboration and cooperation between local healthcare professionals and expert centers for rare diseases and (3) to investigate patients’ and caregivers’ satisfaction with healthcare in the expert centers for rare diseases.ResultsIn total 299 individuals of whom 176 were patients and 123 were caregivers to pediatric patients participated in a survey using a questionnaire comprising several instruments and constructs. Fifty participants were additionally interviewed using a semistructured guideline. Most patients reported to receive written information about their care, have a contact person for medical issues and experienced interdisciplinary exchange within the centers for rare diseases. Patients and caregivers in our sample were mainly satisfied with the healthcare in the centers for rare diseases. The qualitative interviews showed a rather mixed picture including experiences of uncoordinated care, low engagement and communication difficulties between professionals of different sectors. Patients reported several factors that influenced the organization and quality of healthcare e.g. engagement and health literacy in patients or engagement of HCPs.ConclusionsOur findings indicate the high relevance of transferring affected patients to specialized care as fast as possible to provide best medical treatment and increase patient satisfaction. Intersectoral collaboration should exceed written information exchange and should unburden patients of being and feeling responsible for communication between sectors and specialists. Results indicate a lack of inclusion of psychosocial aspects in routine care, which suggests opportunities for necessary improvements.

Evaluation of the barriers to organizational learning in a port sector company

Competitive advantage is an essential factor for the development and longevity of businesses. It is associated with companies' ability to learn, manage their knowledge, and recognize and accurately interpret opportunities and barriers to learning processes. This work aimed to identify the barriers to organizational learning in a company in the port sector. For this, an instrument was used, such as an interview script composed of 27 questions, grouped by model learning process: Intuition, interpretation, integration and institutionalization (4I) and subgrouped by influencing factors, with semi-structured questions aimed at identifying the barriers to organizational learning present in the company. The results were analyzed based on the recordings of the interviewees' speeches. The main results showed 28 of the 80 barriers listed in the adopted model, highlighting those related to the intuition process, especially those with a personal action factor, revealing opportunities for improvement in actions and mechanisms to promote the creation of knowledge and the generation of innovative ideas.

Environmental, social, and governance (ESG) acquisitions: Deal structure and outcome

AbstractEnvironmental, social, and governance (ESG) expectations from stakeholders affect firm decisions. We investigate ESG acquisitions with a focus on how a pre‐deal ESG gap influences how acquirers' structure ESG deals strategically and their outcomes in terms of combined ESG performance post‐acquisition. Drawing on relative capabilities and signaling research, with an international sample of 340 ESG deals, we find that acquirers with a higher ESG score relative to the target (i.e., low‐ESG acquisitions) are more likely to target smaller firms, use cash as method of payment, and complete deals faster. We also show that low‐ESG deals lead to an average increase in the combined entity's ESG performance in the 3 years after the acquisition, thus indicating ESG corrective acquisitions as an opportunity for ESG capabilities transfer and improvement. However, effects are influenced by an acquirer's embeddedness in the European institutional context where ESG stakeholder expectations are more developed.

Impact of pandemic mobility restrictions on kidney transplant patients' experience: lessons on quality of care.

Patient perspectives on their post-operative health are acknowledged as valuable healthcare outcomes and should be scrupulously considered when designing interventions for patient-centered healthcare. Yet, following the COVID-19 lockdown and in the absence of standardized guidelines on how to best provide virtual chronic care to kidney transplant recipients, little is known about how this unique population coped and managed to comply with public health indications during confinement. This study addresses this shortcoming by examining the experiences of patients from a tertiary hospital in Spain during the initial weeks of the lockdown decreed by the national government. Specifically, we focus our attention on the perceptions and experiences of these patients by retrieving robust qualitative and quantitative data: the former based on a thematic analysis of focus group transcripts, the latter obtained from a large-scale survey. Our findings identify opportunities for improvement in the quality of care and point to the provisions that might be made when facing future pandemics or lockdown-requiring situations. As healthcare services navigate evolving landscapes, our findings on the experience of kidney transplant recipients should enable hospital services to improve the quality of care they are able to provide to such patients during periods of restricted mobility, especially those associated with future disease emergencies, and considering that home confinement is often part of the natural course of post-operative care of these patients.

Synthesis of the European ALARA network 20th workshop ‘ALARA for interventional radiology and nuclear medicine’

The European as low as reasonably achievable(ALARA) network regularly organises workshops on topical issues in radiation protection (RP). The topic of the 20th workshop was: ‘ALARA for interventional radiology (IR) and nuclear medicine (NM)’. The objective was to examine the challenges faced when applying the optimisation principle (ALARA) in IR and NM and to consider how ALARA could be better implemented for patient and staff exposures. This memorandum provides a synthesis of the workshop sessions, and recommendations coming from the working groups discussion. Parallels are drawn with the recommendations arising from the 13th EAN workshop on ‘ALARA and the medical sector (2011)’ to consider how the optimisation challenges in IR and NM have evolved over the past decade. Current levels of exposure are presented along with operational practice and the challenges and opportunities for improvement, both in monitoring and practice. Whilst RP challenges remain, the application of ALARA appears more established in IR compared with experiences reported in 2011. The application of ALARA to emerging technologies in the NM setting is in need of further development to ensure that RP is considered at all stages in the development process of new radiopharmaceuticals. Besides the obvious technical and operational aspects, the importance of education and training, human factors and broadly the RP ‘culture’ were deemed fundamental to the success of the application of ALARA and where further emphasis is needed. All concerned parties, medical physics experts (MPEs), radiation protection experts, clinical staff, manufacturers and regulators have a role to play in the application of ALARA and this is discussed in the memorandum. Many of the recommendations from the 13th EAN workshop remain applicable today and overlap with the recommendations arising from the 20th workshop. This should prompt attention given that the use of IR and the development of novel radiopharmaceuticals for NM is only anticipated to increase with time.

“I don’t know if I can keep doing this”: a qualitative investigation of surgeon burnout and opportunities for organization-level improvement

IntroductionBurnout is a pressing issue within surgical environments, bearing considerable consequences for both patients and surgeons alike. Given its prevalence and the unique contextual factors within academic surgical departments, it is critical that efforts are dedicated to understanding this issue. Moreover, active involvement of surgeons in these investigations is critical to ensure viability and uptake of potential strategies in their local setting. Thus, the purpose of this study was to explore surgeons’ experiences with burnout and identify strategies to mitigate its drivers at the level of the organization.MethodsA qualitative case study was conducted by recruiting surgeons for participation in a cross-sectional survey and semi-structured interviews. Data collected were analyzed using reflexive thematic analysis, which was informed by the Areas of Worklife Model.ResultsOverall, 28 unique surgeons participated in this study; 11 surgeons participated in interviews and 22 provided responses through the survey. Significant contributors to burnout identified included difficulties providing adequate care to patients due to limited resources and time available in academic medical centers and the moral injury associated with these challenges. The inequitable remuneration associated with education, administration, and leadership roles as a result of the Fee-For-Service model, as well as issues of gender inequity and the individualistic culture prevalent in surgical specialties were also described as contributing factors. Participants suggested increasing engagement between hospital leadership and staff to ensure surgeons are able to access resources to care for their patients, reforming payment plans and workplace polities to address issues of inequity, and improving workplace social dynamics as strategies for addressing burnout.DiscussionThe high prevalence and negative sequalae of burnout in surgery necessitates the formation of targeted interventions to address this issue. A collaborative approach to developing interventions to improve burnout among surgeons may lead to feasible and sustainable solutions.

Ionic Liquid-Based Green Solvents for Extraction and Purification of Natural Plant Products

Introduction: This research paper explores the environmental sustainability of ionic liquid-based green solvents in the extraction and purification of natural plant products, with a focus on their entire life cycle. The objectives of the study were to assess the environmental impact of ionic liquid synthesis, energy consumption, water usage, emissions, recycling rates, policy effects, and stakeholder perceptions. Method: Methodologically, we conducted a comprehensive Life Cycle Assessment (LCA) that involved primary data collection through field surveys and interviews with key stakeholders in the ionic liquid production and usage industry across various regions in India. The data were analyzed using specialized LCA software tools to quantify environmental impacts. Key findings include the identification of synthesis as a major contributor to environmental impact, emphasizing the need for greener synthesis methods. Result: The study revealed the significant carbon footprint, energy consumption, and water usage during production, highlighting opportunities for improvement. Emissions data underscored the importance of emission control measures, particularly for greenhouse gases and volatile organic compounds. Recycling and reuse were identified as environmentally friendly disposal methods. Policy compliance varied among stakeholders, indicating room for stricter regulations. Stakeholder perceptions varied, with researchers having the most positive outlook. Implications of the findings extend to sustainable chemistry practices, emphasizing interdisciplinary collaboration and the importance of considering the entire life cycle of chemical processes. Conclusion: This research contributes to a deeper understanding of green solvents and provides a foundation for promoting sustainable practices in industrial processes in India and globally

OPT-In; Optimized Patient Treatment Outcomes in Plaque Psoriasis: A 3-Year State-Transition Treatment-Sequencing Model in the Italian Setting.

There are several treatment options for plaque psoriasis (PsO), but uncertainty remains around the optimal sequencing of treatments. The aims of this study were to investigate how adopting a best-treatment-first treatment sequence impacts patient outcomes and healthcare systems and to quantify the cost of treatment failure to the healthcare system. A 3-year state-transition treatment-sequencing model which identifies all possible treatment sequences in PsO was adapted to the Italian healthcare setting. Treatments considered in the model are those with European Medicines Agency marketing authorization and reimbursement in Italy as of December 2022. Italian market share data (2019-2021) and list prices (2022) informed the current prescribed sequences; these sequences were compared against all possible sequences to determine opportunities for improvement. Both the national perspective in Italy as well as the local perspective from seven regions were considered. The cost of treatment failure was informed through a questionnaire circulated to Italian dermatologists. Overall, 1284 possible treatment sequences are possible when four lines of treatment are considered for patients with moderate-to-severe PsO in Italy. Within the estimated range of treatment failures across those sequences (0.97-2.56 per patient over 3 years), current prescribing behavior from the national perspective suggests patients will face 1.44 failures on average; this highlights the potential for improvement. For every treatment failure, the cost borne by the Italian National Healthcare Service (NHS) is €676.80. Overall, prescribing more optimized treatment sequences results in a 22.95% reduction in failures with a 2.27% increase in costs. The regional analyses found similar trends. Results suggest that selecting the most effective treatment sequences for incident patients provides the greatest opportunity to reduce treatment failures and maximize patient outcomes with a modest impact on costs. While regional variations exist, there is room for improvement across the board, which could translate to more efficient local healthcare systems.

Congressional Apportionment: A Multiobjective Optimization Approach

Two events, with major implications for U.S. voters, occur after each decennial census. First, congressional “apportionment” takes place, followed by congressional “districting.” Apportionment determines how to allocate the 435 seats in the House of Representatives across the 50 states, whereas districting determines the geographic boundaries assigned to representatives within each state. Although districting and the practice of gerrymandering often receive great attention in the media and courts, the best way to apportion representatives across states has been debated for nearly 250 years. Historical methods (including the current method) each satisfy some desirable optimality criteria that the others are not guaranteed to satisfy. Moreover, none are guaranteed to optimize certain reasonable fairness measures (e.g., minimum range, minimum bias). To our knowledge, we are the first to formulate and analyze a multiobjective optimization approach to apportionment, allowing policymakers to identify Pareto-optimal allocations and quantify their trade-offs between several competing criteria. Some of these models can be formulated and solved as mixed-integer linear programs, whereas others require the solution of mixed-integer, nonconvex, quadratically constrained quadratic programs. We take advantage of recent software advances that allow one to solve these problems with optimality guarantees. Policy implications of our work include Pareto curves from historical censuses and simulations, which suggest opportunities for improvement in some objectives at little sacrifice to others. This paper was accepted by David Simchi-Levi, operations management. Supplemental Material: The online appendix and data files are available at https://doi.org/10.1287/mnsc.2023.02472 .

INSIGHTS INTO CUSTOMER PERCEPTIONS: COMMERCIAL VEHICLE LOAN OFFERINGS IN A SELECTED NON-BANKING FINANCIAL INSTITUTION

Commercial vehicle financing is crucial for supporting the transportation sector, a cornerstone of any economy. This study aims to explore patterns, challenges, and opportunities in commercial vehicle financing at a Non-banking financial institution, offering insights for stakeholders and contributing to existing knowledge frameworks. Using a descriptive research design, primary data will be gathered through surveys, interviews, and focus groups involving stakeholders like customers, employees, and management. Secondary data from market studies and industry publications will supplement the analysis. Data analysis will employ both quantitative and qualitative techniques, identifying opportunities for improvement and positive changes in services. This research aims to inform decision-making and drive positive change in commercial vehicle financing operations, benefiting industry players, policymakers, and future research endeavours.

Artificial Intelligence-Based Quality Assessment of Histopathology Whole-Slide Images within a Clinical Workflow: Assessment of ‘PathProfiler’ in a Diagnostic Pathology Setting

Digital pathology continues to gain momentum, with the promise of artificial intelligence to aid diagnosis and for assessment of features which may impact prognosis and clinical management. Successful adoption of these technologies depends upon the quality of digitised whole-slide images (WSI); however, current quality control largely depends upon manual assessment, which is inefficient and subjective. We previously developed PathProfiler, an automated image quality assessment tool, and in this feasibility study we investigate its potential for incorporation into a diagnostic clinical pathology setting in real-time. A total of 1254 genitourinary WSI were analysed by PathProfiler. PathProfiler was developed and trained on prostate tissue and, of the prostate biopsy WSI, representing 46% of the WSI analysed, 4.5% were flagged as potentially being of suboptimal quality for diagnosis. All had concordant subjective issues, mainly focus-related, 54% severe enough to warrant remedial action which resulted in improved image quality. PathProfiler was less reliable in assessment of non-prostate surgical resection-type cases, on which it had not been trained. PathProfiler shows potential for incorporation into a digitised clinical pathology workflow, with opportunity for image quality improvement. Whilst its reliability in the current form appears greatest for assessment of prostate specimens, other specimen types, particularly biopsies, also showed benefit.

Unraveling the synergy: how organizational intelligence fuel soft skills and nurses’ thriving: a cross-sectional study

AimInvestigate the influence of organizational intelligence on the development of soft skills and the overall thriving of nurses at Alexandria Main University Hospital in Egypt.DesignA cross-sectional descriptive design following STROBE guidelines examined the relationship between organizational intelligence, soft skills, and nurses’ thriving.Methods and toolsData were collected from 740 nurses working across critical care units using structured questionnaires. The questionnaires assessed organizational intelligence, soft skills, and thriving at work. Sociodemographic characteristics, including age, gender, education, and nursing experience, were also collected. Statistical analyses were used to analyze the data, including ANOVA, t-tests, Pearson correlation, and stepwise regression.ResultsThe findings revealed nurses’ positive perceptions of organizational culture and documentation skills. However, areas such as measures and rewards and staff relations and communication indicated opportunities for improvement. Nurses reported high vitality levels but needed more learning opportunities at work. Significant correlations were found between demographic variables, organizational intelligence, soft skills, and thriving. Organizational intelligence demonstrated a robust positive relationship with both soft skills and thriving. Age, gender, education, and experience significantly influenced nurses’ soft skills and thriving.ConclusionThe study highlights the importance of organizational intelligence in enhancing nurses’ professional capabilities and well-being. Addressing demographic factors and fostering a supportive work environment is crucial for optimizing nursing practice and organizational effectiveness.Nursing implicationsInsights from this study can inform targeted interventions and policy decisions to enhance nursing practice, organizational development, and healthcare outcomes in Egypt. Fostering organizational intelligence and soft skills among nurses can improve patient care, increase job satisfaction, and overall organizational success.

Automatic Reconstruction of 3D Models from 2D Drawings: A State-of-the-Art Review

Among the methods of 3D reconstruction, the automatic generation of 3D models from building documentation is one of the most accessible and inexpensive. For 30 years, researchers have proposed multiple methods to automatically generate 3D models from 2D drawings. This study compiles this research and discusses the different methods used to generate 3D models from 2D drawings. It offers a critical review of these methods, focusing on the coverage and completeness of the reconstruction process. This review allows us to identify the research gaps in the literature, and opportunities for improvement are identified for future research.

Posting sensitive personal data in social media: opportunities for improvement

Posting sensitive personal data in social media: opportunities for improvement

Assessing the Progress toward a Water-Efficient Economy in the United States from 1985 to 2015.

United Nations Sustainable Development Goal 6 tackles the long-neglected economic dimension of water utilization by monitoring nations' water use efficiency (WUE). However, it is imperative to emphasize the need for consistent spatial-temporal subnational WUE estimates, rather than relying solely on recent national trends, which can obscure crucial water use concerns and improvement opportunities. Here, a time series analysis of national, state, and sectoral (e.g., industrial, service, and agriculture) WUE from 1980 to 2015 was developed by compiling the most comprehensive and disaggregated water and economic data from 3243 US counties and 50 US states. The US total WUE increased by 181% from 16.2 (1985) to 45.6 USD/m3 (2015), driven by service sector WUE enhancements. The increased industry and service WUEs in most states were more strongly correlated with decreased per capita water withdrawal than with economic growth. Simultaneously, reductions in agriculture WUE were observed in 18 states potentially because of the complicated interaction of diverse factors specific to local communities. Expanding WUE gaps between affluent and less affluent states, and persisting WUE gaps between water-abundant andwater-scarce states highlight the need to advance policies to support under-resourced communities in effective water planning and water pricing for advancing equitable development.

Variability in antivenom neutralization of Mexican viperid snake venoms.

Each year, 3,800 cases of snakebite envenomation are reported in Mexico, resulting in 35 fatalities. The only scientifically validated treatment for snakebites in Mexico is the use of antivenoms. Currently, two antivenoms are available in the market, with one in the developmental phase. These antivenoms, produced in horses, consist of F(ab')2 fragments generated using venoms from various species as immunogens. While previous studies primarily focused on neutralizing the venom of the Crotalus species, our study aims to assess the neutralization capacity of different antivenom batches against pit vipers from various genera in Mexico. We conducted various biological and biochemical tests to characterize the venoms. Additionally, we performed neutralization tests using all three antivenoms to evaluate their effectiveness against lethal activity and their ability to neutralize proteolytic and fibrinogenolytic activities. Our results reveal significant differences in protein content and neutralizing capacity among different antivenoms and even between different batches of the same product. Notably, the venom of Crotalus atrox is poorly neutralized by all evaluated batches despite being the primary cause of envenomation in the country's northern region. Furthermore, even at the highest tested concentrations, no antivenom could neutralize the lethality of Metlapilcoatlus nummifer and Porthidium yucatanicum venoms. These findings highlight crucial areas for improving existing antivenoms and developing new products. Our research reveals variations in protein content and neutralizing potency among antivenoms, emphasizing the need for consistency in venom characteristics as immunogens. While Birmex neutralizes more LD50 per vial, Antivipmyn excels in specific neutralization. The inability of antivenoms to neutralize certain venoms, especially M. nummifer and P. yucatanicum, highlights crucial improvement opportunities, given the medical significance of these species.

Comprehensive assessment of pediatric acute and inpatient care at a tertiary referral hospital in Malawi: opportunities for quality improvement

BackgroundDespite the reduction in global under-5 mortality over the last decade, childhood deaths remain high. To combat this, there has been a shift in focus from disease-specific interventions to use...