Performance Improvement Measures Research Articles

Improving the Health System with Performance Reporting – Real Gains or Unnecessary Work?

Aim: This paper will discuss current approaches to performance reporting and whether there are real benefits to healthcare organisations or whether it is a time consuming activity that adds little to improving quality healthcare and organisational performance. Most importantly, this paper will argue that performance reporting will not prevent another major healthcare scandal, such as that seen at Bundaberg Hospital or NHS Mid Staffordshire Trust. The paper will also outline learnings for Australia from other health systems where performance reporting is part of management practice.
 Approach: While performance reporting is largely designed to increase the efficiency and effectiveness of healthcare organisations, this paper will explore the approach from a practical managerial perspective.
 Context: This paper explores performance reporting across a range of Australian healthcare organisational settings to highlight differing approaches to improving performance.
 Main findings: Performance reporting can be an effective tool to improve organisational performance. For performance reporting to be successful, managers and clinicians need to work collaboratively to identify areas for performance improvement and useful measures to address these. Additionally, organisations must choose a meaningful suite of measurements that can help drive performance improvement. Real time performance reporting, such as through performance dashboards, provides managers with the opportunity to make timely, incremental improvements. Finally, performance reporting must be done in a way that does not detract from providing safe, quality patient care.
 Conclusions: Performance reporting can be a useful management tool for healthcare organisations, however organisations must consider timeliness of performance reporting and select a number of measurements that have impact for their given facilities and avoid the wholesale analysis of data that has little opportunity to improve practice or performance.
 Abbreviations: LHN – Local Health Network; NEAT – National Emergency Access Targets; NHPA – National Health Performance Authority.

Healthcare Accreditation in Kazakhstan: Methods and Impact

In today’s health care arena, a number of issues are being raised that have received more attention either from the health care consumers or the media. Whether as a provider, a consumer or a purchaser, each was looking for ways to satisfy the other through measuring and reporting on care outcomes. All of these activities were done in the effort to measure performance. WHO organized and facilitated a number of activities related to quality assessment, performance improvement and outcome measurement. A large number of countries and institutions participated in these activities and initiatives. And at the end, all agreed that there had to be an organized mechanism to account for quality, continuous measurement and improved performance in health care organizations. In order to do this a mechanism for certification, licensure or accreditation should be put in place. In this article we will discuss the importance and the components of quality in health care and accreditation. A detailed exploration of accreditation will take the majority of discussion of this article. The process and the methodology of accreditation will be discussed and a system for its implementation is presented as a case study of Republic of Kazakhstan.

Is Management by Constraint Applicable to the Improvement of Team Performance?

In operations management, the attention of management should be focused on a constraint that limits the performance of a system. When applying the Theory of Constraints, the mistake many managers will make is to firstly focus on a productivity improvement strategy around a capacity constraint. However, it is not necessary to be considered capacity constraints preferentially, but necessary to be considered the various other constraints. This paper addresses the applicability of the theory of constraints (TOC) in improving the performance of a team organization. In particular, we discuss the performance improvement strategies policy constraints factors, discuss performance improvement measures in the case to be considered policy and strategic factors. This paper argues that it is needed to redefine the concept of constraint in order to improve the performance in a team organization. We then suggest a methodology to identify and manage ‘the constraint’ Through a hypothetical example, this paper demonstrates a three-step problem solving framework for improving the performance of a team organization.

Uncertainty evaluation of EnPIs in industrial applications as a key factor in setting improvement actions

A methodology is proposed assuming high-level Energy Performance Indicators (EnPIs) uncertainty as quantitative indicator of the evolution of an Energy Management System (EMS). Motivations leading to the selection of the EnPIs, uncertainty evaluation techniques and criteria supporting decision-making are discussed, in order to plan and pursue reliable measures for energy performance improvement. In this paper, problems, priorities, operative possibilities and reachable improvement limits are examined, starting from the measurement uncertainty assessment.Two different industrial cases are analysed with reference to the following aspects: absence/presence of energy management policy and action plans; responsibility level for the energy issues; employees’ training and motivation in respect of the energy problems; absence/presence of adequate infrastructures for monitoring and sharing of energy information; level of standardization and integration of methods and procedures linked to the energy activities; economic and financial resources for the improvement of energy efficiency.A critic and comparative analysis of the obtained results is realized. The methodology, experimentally validated, allows developing useful considerations for effective, realistic and economically feasible improvement plans, depending on the specific situation. Recursive application of the methodology allows getting reliable and resolved assessment of the EMS status, also in dynamic industrial contexts.

Optimal design of a thin-wall diffuser for performance improvement of a tidal energy system for an AUV

The study presents an energy performance improvement measure for an Autonomous Underwater Vehicle (AUV) carrying oceanographic equipment for collecting scientific data from the ocean. The required electric energy for the on-board equipment is harvested from tidal energy by using twin horizontal axis turbines which are integrated with thin-wall diffusers to enhance their energy capturing performance. The main focus and hence objective of the paper is the optimal design of the diffusers by using Reynolds Average Navier–Stokes Equations (RANSE) based Computational Fluid Dynamics (CFD) method and the validation of the design using physical model tests.A goal-driven optimisation procedure is used to achieve a higher power coefficient for the turbine while keeping the size and the drag of the diffuser as practically minimum as possible. Two main parameters of the optimisation are selected, the outlet diameter and the expansion section length of the diffusers, which are optimised for the highest flow acceleration ratio at the diffuser throat and for the minimum drag of the integrated diffuser and turbine system which is called as “Diffuser Augmented Tidal Turbine” (DATT) system.The numerical optimisation is validated by two sets of physical model tests conducted with a single turbine without diffuser and the same turbine integrated with the diffuser (DATT) in a cavitation tunnel and a circulating water channel. These tests demonstrated a performance enhancement for the turbine with the optimal diffuser by almost doubling the power coefficient of the turbine without the diffuser. However, the performance enhancement was dependent upon the pitch angle of the turbine.

Predictors of failure in the Advanced Trauma Life Support course

BackgroundOver 1 million healthcare providers have participated in the Advanced Trauma Life Support course. No studies have evaluated factors that predict course performance. This study aims to identify these predictors. MethodsAll participants taking the course at 2 centers over a 4-year period were identified. Demographics, background, and performance data were extracted. Participants who failed were compared with those who did not. Stepwise logistic regression analysis was used to identify independent risk factors for failure. ResultsSeven hundred forty-four healthcare providers participated in the course; 89.5% passed and 10.5% failed. Failure rates were lowest (.0%) among Trauma/Surgical Critical Care (SCC) providers and highest among pediatric providers (28.6%). Stepwise logistic regression identified age greater than 55, English as a second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine background as predictors of failure. ConclusionsA failure rate of 10.5% was demonstrated among the course participants. Age greater than 55, English as second language, pretest score less than 75, and non-Trauma/SCC and non-Emergency Medicine backgrounds were associated with failure. These subgroups may benefit from performance improvement measures.

Variation in performance measure criteria significantly affects cardiology practice rankings: Insights from the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry

Million Hearts is a national initiative to prevent 1 million heart attacks and strokes over 5 years by improving cardiovascular prevention. An important tool in the success of programs like Million Hearts is public ranking on the quality of practices, yet different measures may provide different rankings, so the true quality of practices is difficult to discern. We evaluated the quality of ambulatory cardiology care using performance measure metrics. We compared rankings of practices participating in the National Cardiovascular Data Registry's Practice Innovation and Clinical Excellence Registry using measures from (1) the physician quality reporting system and (2) the American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement. We compared achievement rates for measures between the 2 frameworks and determined correlations in rankings using Spearman correlation coefficients. From January 1, 2008 to December 31, 2012, there were 1,711,326 patients enrolled from 111 US practices. Among eligible patients, the physician quality reporting system and American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement measures were achieved in 76.1% versus 77.4% for antiplatelet prescription (P < .001), 68.3% versus 90.8% for blood pressure control (P < .001), 26.9% versus 43.4% for cholesterol control (P < .001), and 37.4% versus 40.6% for smoking cessation (P = .383). Practice rankings were strongly correlated for antiplatelet prescription (correlation coefficient 0.98) and cholesterol control (0.92) but poorly correlated for blood pressure control (0.39) and smoking cessation (0.22). Evaluation of preventive care and individual practice rankings vary significantly depending on how measures are defined. Publicly reported measures need to be validly associated with outcomes to avoid incorrectly evaluating practice performance and failing to achieve public health goals.

International benchmarking and best practice management: in search of health care and hospital excellence.

Hospitals worldwide are facing the same opportunities and threats: the demographics of an aging population; steady increases in chronic diseases and severe illnesses; and a steadily increasing demand for medical services with more intensive treatment for multi-morbid patients. Additionally, patients are becoming more demanding. They expect high quality medicine within a dignity-driven and painless healing environment. The severe financial pressures that these developments entail oblige care providers to more and more cost-containment and to apply process reengineering, as well as continuous performance improvement measures, so as to achieve future financial sustainability. At the same time, regulators are calling for improved patient outcomes. Benchmarking and best practice management are successfully proven performance improvement tools for enabling hospitals to achieve a higher level of clinical output quality, enhanced patient satisfaction, and care delivery capability, while simultaneously containing and reducing costs. This chapter aims to clarify what benchmarking is and what it is not. Furthermore, it is stated that benchmarking is a powerful managerial tool for improving decision-making processes that can contribute to the above-mentioned improvement measures in health care delivery. The benchmarking approach described in this chapter is oriented toward the philosophy of an input-output model and is explained based on practical international examples from different industries in various countries. Benchmarking is not a project with a defined start and end point, but a continuous initiative of comparing key performance indicators, process structures, and best practices from best-in-class companies inside and outside industry. Benchmarking is an ongoing process of measuring and searching for best-in-class performance: Measure yourself with yourself over time against key performance indicators. Measure yourself against others. Identify best practices. Equal or exceed this best practice in your institution. Focus on simple and effective ways to implement solutions. Comparing only figures, such as average length of stay, costs of procedures, infection rates, or out-of-stock rates, can lead easily to wrong conclusions and decision making with often-disastrous consequences. Just looking at figures and ratios is not the basis for detecting potential excellence. It is necessary to look beyond the numbers to understand how processes work and contribute to best-in-class results. Best practices from even quite different industries can enable hospitals to leapfrog results in patient orientation, clinical excellence, and cost-effectiveness. Despite common benchmarking approaches, it is pointed out that a comparison without "looking behind the figures" (what it means to be familiar with the process structure, process dynamic and drivers, process institutions/rules and process-related incentive components) will be extremely limited referring to reliability and quality of findings. In order to demonstrate transferability of benchmarking results between different industries practical examples from health care, automotive, and hotel service have been selected. Additionally, it is depicted that international comparisons between hospitals providing medical services in different health care systems do have a great potential for achieving leapfrog results in medical quality, organization of service provision, effective work structures, purchasing and logistics processes, or management, etc.

Health resource variability in the achievement of optimal performance and clinical outcome in ischemic heart disease.

A disparity between evidence and practice in the management of ischemic heart disease is frequently observed. Guideline adherence and clinical outcomes are influenced by system, provider, and patient factors. Recently, performance improvement measures for cardiovascular disease have gained a lot of popularity worldwide. These measures may facilitate the uptake of evidence-based recommendations and improve patient outcomes. While apparently valid as quality metrics, their impacts on clinical outcomes remain limited and are areas of further research. Several methods for optimizing performance have been instituted and essentially involve three different approaches—improvement in the reporting of data on guideline adherence, providing infrastructure and tools, and providing incentives to improve guideline adherence. Public reporting of quality metrics and "pay-for-performance" are some novel performance improvement tools. The impact of these approaches on patient outcomes will be pivotal in improving cardiovascular outcomes in the future.

A framework to study requirements-driven collaboration among agile teams: Findings from two case studies

Stakeholders’ collaboration is required to develop requirements in agile software development. Requirements engineering and agile methods share common grounds as they both focus on stakeholder collaboration. The key issue is finding a way to study collaboration driven by requirements in geographically distributed agile teams. In this paper, we aim to propose a framework to study collaboration driven by requirements among agile teams and determine the impact of their collaboration patterns on the iteration performance. We define collaboration in terms of communication as information exchange among members, and awareness knowledge of others. Two case studies were conducted to examine communication and awareness network patterns among distributed agile teams. Data were collected through questionnaires, semi-structured interviews and onsite observation. The findings revealed that the framework aids in determining the core members, collaboration trends, clustering tendency, communication and awareness reciprocity of the teams, small worldliness and centralisation behaviour of the networks and iteration performance of the agile teams. The framework has implications for the industrial practitioners, i.e. managers to learn about their team’s collaboration in order to take measures for performance improvement. At the same time, the researchers can use this framework to study other social aspects in variable settings to produce more empirical results.

Measuring and improving the efficiency and effectiveness of bus public transport systems

In this paper, Data Envelopment Analysis (DEA) is used to evaluate the performance of individual bus lines composing the public transport network in Thessaloniki, Greece. Results showed that efficiency of local bus lines is slightly better than operational effectiveness without indicating a clear positive or negative relationship between the two performance components. Traffic conditions and population density seem to be important exogenous factors influencing performance. We employed bootstrapping techniques to check robustness of DEA results and we explain that performance assessment is more reliable when correcting for bias. We found that production models we developed for evaluating performance do not always exhibit the same technology of returns to scale, indicating that comparison across ratings pertaining to different performance dimensions should be made with caution. DEA results enabled us to perform clustering of bus lines based on the derived piecewise production functions. We defined the variables of these functions so as to allow performance improvement monitoring over service design changes in any given bus public transport network. It is found that for most of the bus lines in Thessaloniki, scheduling of buses with fewer seats would be a more successful performance improvement measure than reducing their span of service.

A Delay-Oriented Prioritization Policy Based on Cooperative Lossless Buffering in PTN Domains

New kinds of services and data flows, such as cloud computing, server virtualization, or quality of service (QoS)-aware Internet services, have led to higher demands on network resources. Thus, they have also led to increased bandwidth consumption and unexpected congestion, especially in backbones. In this article a novel proposal is studied, with the aim of improving the performance of delay-sensitive flows. The congestion impact on those QoS-aware flows that require a high level of reliability and delay is analyzed. This management proposal has been implemented on multiprotocol label switching transport profile (MPLS-TP), which is a packet transport networks technology that provides QoS by means of flow differentiation in Internet backbones. In order to improve performance in congested networks, a guarantee of service is proposed. It allows local recovery of lost traffic of MPLS-TP privileged flows, and in order to fulfill the requirements for implementation on MPLS-TP, a minimum set of extensions to RSVP-TE has also been proposed to provide self-management capable routes. Finally, in this paper we have carried out a performance improvement measurement by means of an analytical model and simulations.

An OAM function to improve the packet loss in MPLS‐TP domains for prioritized QoS‐aware services

SummaryThe emergence of new kinds of applications and technologies (e.g., data‐intensive applications, server virtualization, and big data technology) has led to a higher utilization of network resources. These services imply increased bandwidth consumption and unexpected congestions, especially in backbones. In this article, a novel proposal is studied with the aim of improving the performance of prioritized forwarding equivalence classes in congested Multiprotocol Label Switching Transport Profile (MPLS‐TP) domains. The congestion impact on those QoS‐aware services that require high reliability and low delay is analyzed. A new policy has been implemented on MPLS‐TP, which is a technology that provides QoS by means of flow differentiation in the Internet backbones. The proposal is known as Gossip‐based local recovery policy and is offered as an operation, administration, and management function to allow local recovery of lost traffic for MPLS‐TP privileged forwarding equivalence classes. In order to fulfill the requirements for implementation on MPLS‐TP, a minimum set of extensions to resource reservation protocol traffic engineering has also been proposed to provide self‐management capable routes. Finally, we have carried out a performance improvement measurement by means of an analytical model and simulations. Copyright © 2014 John Wiley &amp; Sons, Ltd.

Goals and objectives: statistical techniques and measures for performance improvement of HEIs in Oman

Research has been conducted on goals, objectives and measures to assess the processes and activities of private or government higher education institutions (HEIs) in a number of countries and international bodies. This study is intended to refine the goals and objectives of HEIs for assessing the performance of higher education institutions in Oman, and as a tool for benchmarking and international comparisons. In order to assess the goals and the relevance between these goals and related objectives, two instruments were distributed to faculty members of several HEIs in the Sultanate of Oman. The respondents were requested to judge the importance of the goals set for HEIs and the relevance between the selected objectives and goals. Some statistical tests and measures were applied to the data collected. The study found out that the proposal has a considerable gain in all statistical tests and measures used therein. Conclusions and numerical results are then reported.

Abstract 93: Utility of Stress Testing in a Chest Pain Center: A Bayesian Analysis

Background: Chest pain is one of the most common reasons for Emergency Department (ED) visits and Chest pain centers (CPC) improve efficiency by triaging low and intermediate risk patients more effectively. We examined the Length of stay (LOS) in CPC and the utility of stress testing and further risk stratification during the CPC visit using a Bayesian analysis. Based on this analysis we suggest some performance improvement measures which may reduce costs and improve efficiency. Methods: We conducted a retrospective analysis of patients evaluated in our CPC in 2011. For each patient the pre and post stress test conditional probability of coronary artery disease (CAD) was calculated using Bayes Theorem. Based on the estimated pretest probability, patients were classified into low, intermediate and high risk groups. The post stress testing conditional probabilities were calculated and used to determine if results of stress testing had a significant impact on further cardiovascular risk assessment. Results: 95% of patients tested were negative for ischemia and were not admitted, reducing length of stay in ED. Stress echocardiography was the most utilized modality of stress testing, which provided additional diagnoses such as valvular heart disease in 2% of patients while avoiding radiation exposure. A Bayesian analysis indicated that in the low (pre-test) probability group consisting of young females with atypical symptoms remained in the low probability group irrespective of stress testing results. Also most intermediate risk patients remained in the intermediate risk category despite negative testing. Conclusions: CPC has improved cost-effectiveness due to reduced length of stay in ED, avoiding inpatient admissions and thereby reducing costs. As highlighted by the Bayesian analysis that most intermediate risk patients remained in the intermediate risk category despite negative testing, the need for pre-discharge testing needs to be re-examined as negative stress tests do not eliminate risk of CAD and avoiding these test can help further reduce costs and improve efficiency. Once acute coronary syndrome is ruled out, CPC visits should be more centered on establishing a primary care physician, risk factor modification, smoking cessation and promoting primary prevention.

Commoditization of PACS and the Opportunity for Disruptive Innovation

The transition from film-based (i.e., analog) to filmless (i.e., digital) medical imaging represented a radical innovation in medical imaging practice and technology, which in large part was driven by the creation of the picture archival and communication system (PACS). For the first time, medical imaging professionals could capture, archive, transmit, and display medical images digitally, thereby eliminating the inefficiencies associated with hard copy film, which had been the norm for almost a century. This radical technology innovation in turn led to a myriad of medical imaging practice innovations including the outsourcing of professional medical imaging services (i.e., teleradiology), rapid report turnaround times (through speech recognition software), and instantaneous and ubiquitous access to medical imaging data. While the early adoption of PACS in the USA was in large part restricted to the academic practicing community, its dissemination over time has effectively permeated the entire medical imaging community. The result is that the PACS market has been transformed from a new purchaser to replacement market, which has dramatically reduced economic opportunity for PACS vendors. Along with this shift in market dynamics, PACS technologic innovation has declined, which in part is attributable to its longevity. The early and mid-stages of the PACS S-curve were defined by incremental innovations leading to substantive performance gains in workflow, productivity, and operational efficiency, which effectively created a positive return on investment (ROI) for PACS vendors [1]. The late stage of the PACS S-curve has been associated with a relative dearth of innovation and lack of performance improvement measures, which has led to its commoditization. The resulting declines in PACS profit margins and new sales have in turn lead to a further decline in R&D expenditures, which perpetuates this commoditization trend and lack of innovation. While this may seem like a lost economic and technologic cause, the reality is that these market conditions have created an opportunity for disruptive innovation. If successful, this could reinvigorate the PACS marketplace and produce a new cycle of technologic and practice innovation.

Development of an Empirical Model for Selecting Accident Prevention Measures for Construction Managers

This paper investigates the association between the mindsets of construction managers on the acceptance of accident causation theories and the vigour of implementing safety measures on accident prevention in the Hong Kong construction industry. A questionnaire survey is conducted. The vigour of implementing each accident prevention measure is predicted by a combination of accident causation theories. Each measure is associated with a unique set of predictors revealing management mindsets in pursuit of accident prevention. A new model for decision making of implementing accident prevention measures is then developed and its application is also demonstrated in this paper. This paper found that Hong Kong construction managers have exhibited their commitment to safety by implementing all the accident prevention measures with above average vigour levels. Referring to the results of the correlation and linear regression between the accident causation theories and the accident prevention measures, the extent of construction managers’ acceptance of the accident causation theories do not reflect any linear correlation on their vigour of implementing the accident prevention measures for Safety pre-task planning (M5), Employee pre-qualification (M6), Safety training (M8), Smoking, alcohol and drug ban program (M10), and Safety meetings (M13). The systematic and logical based approach in mapping out the specific accident prevention measures can be adopted by the construction managers so that they can implement appropriate measures for safety performance improvement.

Combat management of splenic injury

As a performance improvement measure to optimize patient outcome, theater-wide clinical practice guidelines (CPGs) have been developed to standardize the management of many injury patterns seen during combat operations. Battle-related splenic injury presents differently from civilian practice, and a combat-related CPG was developed. The epidemiology and validation of the spleen injury CPG were analyzed. The Joint Theater Trauma Registry was queried for splenic injury from 2001 to 2010. Theater of operation (Afghanistan and Iraq), injury year, mechanism, patients' baseline characteristics, and severity were recorded. Patient charts were reviewed for management decisions and outcomes. The 10-year experience identified 393 patients who sustained splenic injury (rate of 16.1 per 1000 injuries). Most victims were men (97.5%), blunt, and severely injured (70.7%; mean Injury Severity Score, 32.5, respectively), with a mean age of 25.4 years. The prominent mechanism was explosion (62.2%), followed by vehicle crash (25.9%). The most prevalent injury was grade II (56.2%), followed by III (21.1%), IV (11.7%), and V (9.7%). More than half of patients underwent splenectomy (52.7%), most of which occurred in theater (95.1%). All nonoperative failures were treated within 4 days of injury at the role IV facility in Landstuhl. Patients who underwent splenectomy received more blood products, crystalloid, and demonstrated a longer length of stay than those treated nonoperatively. High-grade injuries treated nonoperatively were successfully managed. The overall cohort mortality was 9%, and no death was directly related to delayed diagnosis or treatment. Splenic injury has been successfully managed during combat operations through the use of a well-established CPG. The overall mortality remains low, with few delayed nonoperative failures. Refinements in this validated CPG may now address controversies in higher grade injuries.

Sustaining Disease-Specific Performance Improvement Measures for Joint Replacement

To maintain standards of excellence and continuously improve their outcomes, specialized joint replacement centers must develop, implement, and sustain specific performance improvement activities. This article describes the activities at one. Midwestern healthcare system's joint replacement center related to three disease-specific performance improvement measures: fall prevention, preoperative education, and pain management. Specific steps in the process for each measure are described. These include current-state analyses, goals established, the use of Plan-Do-Study-Act (PDSA) methodology to identify and implement appropriate interventions, and the use of the Six Sources of Influence model to promote successful change. Outcomes, lessons learned, and suggestions for replication by other institutions are discussed.

Sustaining Disease-Specific Performance Improvement Measures for Joint Replacement

Orthopaedic Nursing: May/June 2012 - Volume 31 - Issue 3 - p 151-152 doi: 10.1097/NOR.0b013e31825a1968