Performance Improvement Measures Research Articles

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

Adaptation of the patient feedback survey at a community treatment setting.

The Patient Feedback Survey is a performance improvement measure designed to assess the quality of outpatient substance abuse treatment. We modified and administered this measure to 500 individuals at a multisite treatment provider. Although the feedback scores were high in general, analyses of variance showed score variability in relation to type and length of treatment. Moreover, respondents who reported any use of marijuana, cravings for substances, or mutual-support group attendance (ie, Alcoholics Anonymous or Narcotics Anonymous) had lower feedback scores than respondents without these experiences. We highlight the importance of investigating treatment evaluations in the context of other recovery experiences.

First and second law investigation of waste heat based combined power and ejector-absorption refrigeration cycle

In the proposed cogeneration cycle, a LiBr–H 2O absorption refrigeration system is employed to the combined power and ejector refrigeration system which uses R141b as a working fluid. Estimates for irreversibilities of individual components of the cycle lead to possible measures for performance improvement. Results of exergy distribution of waste heat in the cycle show that around 53.6% of the total input exergy is destroyed due to irreversibilities in the components, 22.7% is available as a useful exergy output, and 23.7% is exhaust exergy lost to the environment, whereas energy distribution shows 44% is exhaust energy and 19.7% is useful energy output. Results also show that proposed cogeneration cycle yields much better thermal and exergy efficiencies than the previously investigated combined power and ejector cooling cycle. Current investigation clearly show that the second law analysis is quantitatively visualizes losses within a cycle and gives clear trends for optimization.

Impact of Systems of Care and Blood Pressure Management on Stroke Outcomes

Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.

Performance Improvement: A Topic Whose Time Has Come—Again

In the last “Accreditation News & Views” column, I wrote about the priorities of elements of performance (EPs) that were unique to medical equipment management. In this column, I’m writing about a small group of standards that are in common to all functions in a hospital—performance improvement (PI). The Joint Commission (JC) added PI standards to their accreditation manuals quite a few years ago. When they initially did this, PI became a major theme. Over the years, there have been relatively minor changes to the wording and the placement of the PI requirements, but their essence has remained the same: collect and analyze data, plan and take action, evaluate, and report results. Then do it again, in a perpetual, performance improvement cycle. When PI standards were added to JC accreditation manuals, they made a big splash. The hospital staff who oversaw JC standards compliance put major effort into training and motivating departmental leadership into doing PI projects. How many of you remember “story boards?” In those days, a JC survey looked like show and tell day in elementary school. In the years since, however, there have been other, newer “initiatives” from the JC, and PI standards have become second tier. Perhaps this is because hospitals do a good job with PI and it no longer requires special attention. Perhaps it’s because the JC realizes that they, and hospitals, can only concentrate on a limited number of high priority standards at a time, and other issues have become more important (analogous to the way that National Patient Safety Goals come and go). For whatever reason, I believe that clinical engineering departments never put the emphasis on PI that the rest of the hospital did—even when PI was in its heyday. Now that it is not emphasized in the hospital as a whole, it appears to me that most CE departments barely even pay PI lip service anymore. Putting PI on the back burner may not be hazardous to your standards compliance health, but it definitely leads to a missed opportunity. A couple of well-chosen PI projects can pay huge dividends to your relationships with your staff, your boss, and your customers. PI projects deserve to be a favorite tool in your management tool box.

Improving Infrared Images for Standoff Object Detection

The ability to detect dangerous objects (such as improvised explosive devices) from a distance is important in security and military environments. Standoff imaging can produce images that have been degraded by atmospheric turbulence, movement, blurring and other factors. The number and size of pixels in the imaging sensor can also contribute to image degradation through under-sampling of the image. Establishing processes that enhance degraded or under-sampled infrared images so that objects of interest can be recognised with more certainty is important. Super-resolution image reconstruction and deconvolution methods are explored, as well as performance improvement measures.

Preventability Classification in Mortality Cases: A Reliability Study

The Pennsylvania Trauma Systems Foundation ad hoc Outcomes Committee developed the Pennsylvania Outcomes and Performance Improvement Measurement System (POPIMS) software program that provided a consistent outcomes reporting template for trauma centers in the state. This study was performed to evaluate inter-rater reliability of POPIMS software for mortality classification. All trauma centers in the state were instructed to submit one preventable (P), one potentially preventable (PP), and one nonpreventable (NP) POPIMS mortality report to the Pennsylvania Trauma Systems Foundation office. The reports were blinded, an equal number of P, PP, and NP classified mortalities were randomly selected, and a meeting of trauma directors who submitted cases was convened. Institutional classification (IC) was compared with reviewing trauma directors (reviewer classification [RC]) to evaluate inter-rater reliability of software. Chi-square test was used to analyze differences. Inter-rater reliability among reviews was assessed using Cronbach's alpha coefficient. Twenty-eight trauma surgeons reviewed 34 cases (11 preventable, 12 PP, 11 nonpreventable), each having a minimum of 10 reviews. When compared with IC, RC was significantly different (p < 0.001). In addition, factors contributing to mortality were different when comparing IC and RC reviews of different mortality preventability classes. There was a moderate level of inter-rater reliability among reviewers as measured by Cronbach's alpha coefficient of 0.64. POPIMS is the first statewide PI reporting system to share outcomes information between trauma centers. Significant differences between IC of mortality and that provided by reviewers suggest that more objective criteria for mortality classification are needed. Realizing limitations of preventability classification, additional outcomes parameters should be pursued.

Performance Improvement Measures in Achieving Glycemic Control in the Acute Brain Injury Population

Glycemic control is becoming a standard practice in the intensive care environment because it has been shown to produce positive patient outcomes and benefits. A 14-bed neurointensive care unit initiated a strict glycemic protocol and evaluated the results over a 1-year period through a performance improvement initiative. Results indicated that tight glycemic control could be achieved safely by adhering to an evidence-based established protocol. The average blood glucose level for all patients was between 90 and 130 mg/dl by Day 2 after the implementation of the glycemic control protocol. The purpose of this article was to explain how a strict glycemic protocol was safely implemented. Further research is necessary to determine long-term benefits of glycemic control in the population with neurocritical illness.

Performance Improvement Measures in Achieving Glycemic Control in the Acute Brain Injury Population

Performance Improvement Measures in Achieving Glycemic Control in the Acute Brain Injury Population

A comparative analysis ISO 14000 performance in Taiwan and China

ISO 14000 arose out of the push towards effective implementation of environmental policies among developed nations in recent years. To help traditional industries remain competitive, it encourages businesses to examine their operations to find ways to prevent pollution and help the environment. It also defines a basic set of common international standards that eliminate invisible technical obstacles to international trade and commerce caused by regional and cultural differences in each country’s environmental management standards. For this study, we began by collecting information and literature on the development of the traditional industries in Taiwan and China (Note. In this study, Chinese traditional industries refer to those operated in China by Taiwanese businessmen.). A questionnaire was then designed for businesses in the traditional industry that passed ISO 14000 certification to determine how they fared and the collected data was analyzed using the Performance Evaluation Matrix. According to the modified version of the performance evaluation matrix proposed by D. M. Lambert and A. Sharma, developed by Hung and Huang et al., two or more indices may be substituted into the performance matrix in order to determine the level of satisfaction and importance associated with the implementation of ISO 14000. A performance matrix may also be defined as the introduction of a standardized system to determine a business’ environmental performance. By examining where a task places in terms of satisfaction and importance within the performance matrix, a manager may assess its effectiveness and draw up performance improvement measures for the implemented system. Finally, tasks that fall into the “Inappropriate Performance Zone” are expanded to two levels using Quality Function Deployment (QFD) to determine the critical tasks. Through these analyses, this study hopes to identify the optimal measures for improving business environmental performance and establish the foundations of a sustainable business. These will serve as a useful guide for businesses seeking to enhance their corporate image through ISO 14000.

Focus on Alcohol &amp; Drug Abuse: Improving Service Delivery for Individuals With Co-occurring Disorders: New Perspectives on the Quadrant Model

Focus on Alcohol &amp; Drug Abuse: Improving Service Delivery for Individuals With Co-occurring Disorders: New Perspectives on the Quadrant Model

Measuring the Results of Performance Improvement Interventions

In this study, a web-based questionnaire was used to measure attitudes of members of a professional performance improvement organization relative to adoption and implementation of Level 4 or results-oriented evaluation. Participants were 274 members of the International Society for Performance Improvement (ISPI). It was expected that frequency of Level 4 evaluation use could be explained by innovation diffusion or change variables. Findings suggest that the adoption of effective performance improvement measurement systems and processes at the organizational level is relatively low compared to other types of evaluation. This level of adoption is impacted by a complex array of factors. Stakeholder participation in the adaptation of evaluation systems to increase their compatibility with current practices, and experimentation with this type of evaluation on a limited or trial basis may increase the rate of adoption. Management support of the development and adaptation of a results-oriented evaluation system is seen as providing the opportunity for the change process to move forward. Implications for diffusion of this type of evaluation within organizations will be discussed within the context of a HPT Change framework.

Osteoporosis: Evaluation of Screening Patterns in a Primary-Care Group Practice

An estimated half of all women aged older than 50 yr will have an osteoporosis-related fracture in their lifetime. National osteoporosis clinical guidelines for screening recommend measurement of bone mineral density in average risk women beginning at age 65 yr. Little data are available regarding compliance with this recommendation. The objective of this study was to evaluate osteoporosis screening rates in a random sample of women, aged 66 yr or older, in a large multisite primary-care group practice. The study was conducted in a primary-care group practice serving over 180,000 patients in the Denver metropolitan area. Medical records of a random sample of 833 female patients aged 66 yr or older were reviewed retrospectively. Patients were seen at 1 of 13 practice locations, by 1 of 34 physicians, who practiced either family medicine or internal medicine. The frequency of osteoporosis screening was calculated. Accepted methods of screening include peripheral bone density measurement by ultrasound or dual-energy X-ray absorptiometry (DXA), or central DXA. The physician-specific osteoporosis screening rates varied widely, ranging from 19% to 97%. The practice-specific osteoporosis screening rates ranged from 26% to 91%. Overall, the mean rate of osteoporosis screening among all physicians was 56%. Despite improvements in osteoporosis screening, there continues to be a gap in the quality of care provided compared to national recommended guidelines. Policy changes, performance improvement measures, and interventions are needed to improve screening rates in primary-care practices.

A Roadmap to the Disease Specific Care Certification Process

The Joint Commission's Disease Specific Care Certification (DSC) recognizes disease management programs for superior quality. Programs are awarded DSC that meets established criteria for managing chronic conditions. Awarding of DSC is based on a program's compliance with disease-specific standards, evidence-based clinical practice guidelines, and performance improvement measures. Programs will be evaluated during a site visit by a Joint Commission reviewer; once certification is awarded, it is valid for 2 years. Programs are required to submit an Intra-Cycle Evaluation Report after 1 year.

Actuator and controller scheduling in nonlinear transport-reaction processes

The objective of the present manuscript is to examine the performance improvement of a class of nonlinear transport processes subject to spatiotemporally varying disturbances through the employment of a comprehensive and systematic actuator activation and controller scheduling policy. To attain this objective, it is assumed that multiple groups of actuators are available with only one such actuator group being active over a time interval of fixed length while the remaining actuator groups are kept dormant. Using well-established enhanced controllability and performance improvement measures, the candidate actuator groups are first placed at locations that individually provide certain robustness with respect to an appropriately defined “worst” spatial distribution of disturbances. Once the multiple actuator groups are in place, a switching scheme that dictates the switching of a different actuator group at different time intervals, as well as the corresponding control signal supplied to it while being active, is developed. Embedded in the decision policy is the activation of actuators that lie spatially closer to the spatiotemporal disturbances, thereby improving the control authority of the actuators and enhancing the ability of the system to minimize the effects of this class of disturbances. Indeed, entering disturbances that excite different system modes at different time intervals are best handled by employing the actuators that have increased spatial controllability for the above disturbance modes while simultaneously satisfy certain performance measures. In this manner, the control system designed engages the actuators that are better suited to efficiently perform spatiotemporal disturbance compensation over the duration of certain time intervals. The proposed method is demonstrated through simulations using two typical quasi-linear highly dissipative partial differential equation examples.

Performance Assessment/Enhancement Methodology for Supply Chains

A well-coordinated supply chain is characterized by a harmonious balance between inbound logistics, production scheduling and product distribution. In multi-echelon decentralized supply chains, distribution logistics play a leading part in helping a supply chain gain advantage over competitors. Besides the uncertain consumer demand, the nonoptimal internal strategy practiced by the distribution nodes is a major problem that a supply chain must contend with. The performance of a supply-chain network that is controlled in a decentralized manner can be improved by reorganizing the operational aspects of the problematic nodes in the network. Our work is focused on (i) using time series obtained from an existing supply chain to determine the bottlenecks (poorly performing nodes) and (ii) suggesting performance improvement measures, such as retuning the reordering parameters or even changing the ordering policy itself. Simulation-based optimization of the supply-chain network model is used to achieve these objectives and compute benchmark performance standards. The concepts presented are complemented by realistic simulation examples.

Internal Audits: Setting the Stage for Joint Commission Surveys

For biomedical and clinical engineering (CE) departments looking for another way to get ready for Joint Commission unannounced surveys, internal audits or mock surveys can be used as a dress rehearsal. Done with or without the assistance of an outside consultant, these dry runs can identify defi ciencies before a surveyor does, and give all staff a chance to prepare for the Joint Commission’s visit. “The key is to make sure you’re doing the equipment testing to ensure that you have a safe environment for patients and the hospital,” says Gary Slack, president of Healthcare Engineering Consultants in Springfi eld, OH. This involves two steps: regulatory compliance and “moving beyond the requirements,” he says. “To impress the surveyor, be prepared to discuss some performance improvement measures that demonstrate you’re in an ongoing quest to improve your department.” This may include shortening turnaround time for service requests, improving customer satisfaction with the departments you’re serving, or reducing costs, Slack says. According to George Mills, senior engineer in the Joint Commission’s standards interpretations group, there are three reasons someone might want to do an internal audit: to get ready for a survey by identifying gaps and weaknesses in their program as they relate to the Joint Commission standards; as a new department manager, to assess the state of the department; or to rehearse for surveys done by the state or other agencies, such as the Centers for Medicare and Medicaid Services.

Development of an Evidence-Based Policy for the Prevention of Ventilator Associated Pneumonia by Building on Existing Systems

ISSUE: Evidence-based guidelines were well established for the prevention of ventilator associated pneumonia (VAP). All major interventions were in place for patients requiring mechanical ventilation; however there was no set protocol or policy for grouping interventions for the care of the patient requiring mechanical ventilation. PROJECT: Critical Care Unit (CCU) Nursing Staff, CCU Physician Director, and Pulmonary Care Staff collaborated to develop a policy specific to the care of the ventilated patient including prevention measures for VAP. Performance improvement measures were also included in the policy to increase awareness of staff to expectations. Literature review was conducted; incorporating Institute for Healthcare Improvement "ventilator bundle." Data collection continued by Pulmonary Care to assist in identification of VAP. A data collection tool was attached to each ventilator to make readily available when the ventilator was put into use. Once the ventilator was taken out of service, the form was sent to infection control. Additional cases were identified via traditional surveillance, Staff and Physicians reports. Mouth care protocols were outlined and a standard product selected, making all supplies readily available. We replaced non-covered oral suction devices with one with a resheathing cover. Staff education was conducted on proper mouth care. Laminated signs were implemented to place over the head of the bed to keep head elevated at least 30 degrees at all times. Staff was provided with immediate feedback when surveillance rounds were conducted for compliance with the IHI Bundle components by the use of a bulletin board with results posted as the rounds are conducted. RESULTS: There is one policy that includes all interventions for the prevention of VAP, allowing easier reference and review with staff. VAP rate decreased from 1.9/1000 ventilator days in 2004 to 0 in 2005. LESSONS LEARNED: Consolidation of expected interventions, process and outcomes measures into one document increases staff awareness and compliance resulting in improved patient outcomes.

Standards for Specialized Nutrition Support: Home Care Patients

Standards for Specialized Nutrition Support: Home Care Patients

Usefulness of the Human Activity Profile, a Functional Performance Measure, in People With Chronic Obstructive Pulmonary Disease

To further evaluate the usefulness of the Human Activity Profile (HAP) as a functional performance measure for those with chronic obstructive pulmonary disease (COPD). Phase 1. The sample consisted of 53 outpatients (51 male) with stable COPD (forced expiratory volume in 1 second% predicted (FEV1% pred) = 38 +/- 14 (mean +/- standard deviation) at a university-affiliated veterans affairs medical center. Variables were functional performance (HAP Maximal Activity Score [MAS], HAP Adjusted Activity Score [AAS]), dyspnea (modified Borg category-ratio scale and Shortness of Breath Questionnaire [SOBQ]), and exercise capacity (6-minute walk distance [6MWD]). Phase 2. The HAP was administered pre-post pulmonary rehabilitation in 48 (14 male) outpatients with stable COPD (FEV1% pred = 35 +/- 15) at an outpatient pulmonary rehabilitation program at a large private hospital. Phase 1. Scores for MAS and AAS were, respectively, 62 +/- 12 and 44 +/- 15. The 6MWD, modified Borg, and SOBQ were, respectively, 1055 +/- 372 ft, 4.1 +/- 1, and 64.4 +/- 22 ft. Correlations of the 6MWD and dyspnea scores with the AAS were strong and explained 40% of the AAS variation. Phase 2. The baseline MAS and AAS scores were 55 +/- 14 and 42 +/- 15, respectively, with 29/48 (60%) classified as "low fitness" on the basis of the AAS. Post-rehabilitation, there was significant improvement in the AAS score (48 +/- 13) and significant reduction for those classified as "low fitness." The utility of the HAP as a measure of functional performance improvement in COPD is supported by its relationship with both 6MWD and dyspnea and its responsiveness to pulmonary rehabilitation.