Performance Improvement Program Research Articles

81 Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations

Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite a growing evidence-base supporting clinical risk stratification and outpatient management, wide variation in syncope hospitalization rates persist. In order to address low-yield hospitalizations, we sought to develop a new quality measure for very low risk ED adult syncope patients who can be incorporated into performance improvement programs using national administrative data.

Validation of the Nelson Tool: A Scoring Tool for Nonsurgical Service Admission of Injured Patients.

Trauma performance improvement programs are required by the American College of Surgeons to review all nonsurgical admissions if the annual rate exceeds 10%. These reviews can have varying consistency between reviewers, are time consuming, and the consequent aggregate data are difficult to evaluate for trends. This study set forth to standardize nonsurgical admission review through validation of the Nelson tool, which is a published objective scoring tool to determine the appropriateness of nonsurgical admissions. We hypothesized that implementation of this tool would facilitate earlier identification of events resulting in meaningful intervention and a reduction of inappropriate nonsurgical admissions. The Nelson tool and scoring was integrated into the nonsurgical admission review process. A customized audit filter and report were built in the trauma registry. Data were reviewed with respect to scores and admitting service. Statistical analysis included using analysis of variance and t tests to examine differences between admitting services, χ2 test of independence or Fisher's exact to test the association of categorical variables, and ordinal logistic regression to test the ability of the total Nelson tool to predict appropriateness of admission. Using the Nelson tool, scores resulted in appropriate admission service in over 90% of cases. Implementation of the tool resulted in a decreased performance improvement workload with a 78% reduction in nonsurgical admission cases required to go to secondary level of review. Utilization of a validated scoring tool decreases performance improvement workload without compromising patient safety.

High achievers’ attitudes, flow experience, programming intentions and perceived teacher support in primary school: A moderated mediation analysis

To improve programming performance for a larger student population, this study shed light on the commonalities of high achievers in programming classes. To the best of our knowledge, few studies have investigated high achievers in primary school programming classes. This study adapted the hedonic-motivation system adoption model to identify high achievers' perceived attitudes, flow experience, programming intentions and perceived teacher support. With a response rate of 72%, 54 primary schools participated in the study. A survey was conducted and four hundred and thirty-two students were included in the moderated mediation analysis. The results showed that high achievers' attitudes towards programming positively related to their flow experience, which further positively associated with their programming intentions. In addition, teacher support moderated the relationship between high achievers’ attitudes and their flow experience; such that when teacher support increased, the flow experience was weaker for those with comparatively higher positive attitudes. The practical implications of the findings and future research directions are discussed.

Online Application Guidance for Heterogeneous Memory Systems

As scaling of conventional memory devices has stalled, many high-end computing systems have begun to incorporate alternative memory technologies to meet performance goals. Since these technologies present distinct advantages and tradeoffs compared to conventional DDR* SDRAM, such as higher bandwidth with lower capacity or vice versa, they are typically packaged alongside conventional SDRAM in a heterogeneous memory architecture. To utilize the different types of memory efficiently, new data management strategies are needed to match application usage to the best available memory technology. However, current proposals for managing heterogeneous memories are limited, because they either (1) do not consider high-level application behavior when assigning data to different types of memory or (2) require separate program execution (with a representative input) to collect information about how the application uses memory resources. This work presents a new data management toolset to address the limitations of existing approaches for managing complex memories. It extends the application runtime layer with automated monitoring and management routines that assign application data to the best tier of memory based on previous usage, without any need for source code modification or a separate profiling run. It evaluates this approach on a state-of-the-art server platform with both conventional DDR4 SDRAM and non-volatile Intel Optane DC memory, using both memory-intensive high-performance computing (HPC) applications as well as standard benchmarks. Overall, the results show that this approach improves program performance significantly compared to a standard unguided approach across a variety of workloads and system configurations. The HPC applications exhibit the largest benefits, with speedups ranging from 1.4× to 7× in the best cases. Additionally, we show that this approach achieves similar performance as a comparable offline profiling-based approach after a short startup period, without requiring separate program execution or offline analysis steps.

The Study of Optimal Performance Improvement Method for Aircraft of Various Variants within the Same Type

In this paper, we studied the optimal method of improving performance for aircraft having various variants within the same type. The study defined configuration of an entire fleet of aircraft being subject to a performance improvement program. And selected the most complicated aircraft configuration among them as a Standard Aircraft for modification by according to the proposed Aircraft Selection Process for developing an optimal Aircraft Performance Improvement Process. Based on the selected the Standard Aircraft, drew a system integration design result and carried out Evaluation Test and obtained Airworthiness Certification. Created the database with the design data of the Standard Aircraft, Evaluation Test, and Airworthiness Certification results, and applied it to variants of aircraft to complete the performance improvement program with optimized schedules and costs. By applying the proposed method to IFF performance improvement program, drew optimal system integration design and completed the program with minimized schedule.

The Impact of Delays in Interfaculty Transfer on Outcomes in Elderly Trauma Patients.

Delay to definitive treatment is a significant and persistent challenge to trauma systems across the United States, especially in rural communities with limited resources. We hypothesized that elderly trauma patients with delay in transfer would have increased morbidity and mortality. This study evaluates the relationship between inter-facility transfer time and outcomes in elderly trauma patients, and the validity of the 4-hour dwell time as a performance improvement benchmark. The National Trauma Registry and Emergency Medical Services Database were queried from January 2010 to January 2018. Inclusion criteria included age ≥65, blunt mechanism, and transfer from another facility. Correlation analysis was used to evaluate the association between clinical and demographic variables and transfer time. Multicollinearity was evaluated using the variance inflation factor. 1535 patients were identified. This cohort was further subdivided into 4 cohorts based on dwell time: 0-1.5 hours (n = 384), ≥1.5-1.9 hours (n = 379), 1.9-<2.5 hours (n = 383), and ≥2.5 hours (n = 388). Analysis revealed that shorter dwell time was associated with male gender (P = .0039), higher ISS (injury severity score) (P < .0001), lower RTS (revised trauma score) (P < .0001), higher pre-hospital arrest (P = .0066), lower initial GCS (Glasgow Coma Scale) (P = .0012), higher mortality, longer ICU, and ventilator length of stay (P < .0001). Longer dwell times were associated with discharge from the hospital to home or skilled nursing facility as well as lower mortality (P < .0001). Longer dwell time was inversely related to outcome. More severely injured patients were rapidly transferred. This represents a mature rural trauma system. In addition, dwell time should be scrutinized as a meaningful indicator within a performance improvement program.

Effectively use metrics as part of process safety feedback and learning systems to monitor and improve performance

AbstractWithout appropriate process safety program metrics and feedback systems, warning signs of problems may be missed and learning opportunities for improving performance can be lost. Ensuring the right things are measured and evaluated, based on process safety program goals, provides information on the current performance level and trends: is performance getting better or worsening? Learning from experience, based on effective feedback systems and the use of organizational learning approaches to collect, analyze, share, and retain critical process safety information, helps promote sensitivity to operations, a sense of vulnerability, and knowledge of past problems and successes to help maintain organizational memory and maintain or improve program performance.

The Case for Malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US Skilled Nursing Facilities.

As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.

An SLP Vectorization Method Based on Equivalent Extended Transformation

SIMD extensions provide an efficient energy consumption platform to support mobile systems. How to use SIMD instructions to improve program performance is a challenge. SLP (superword level parallelism) is an efficient solution to exploit the parallelism, oriented to SIMD, between statements in the basic blocks, and it has been widely used in almost all the mainstream compilers. SLP relies on finding isomorphic statements to pack together into vectors. However, the capability of autovectorization for nonisomorphic statements is insufficient. In this paper, we introduce SLP-E, a novel autovectorization method that can automatically vectorize the codes which contain nonisomorphic statements, translate the nonisomorphic statements into the isomorphic statements by equivalent extended transformation of expressions, and vectorize the isomorphic statements. SLP-E improves the application scope and benefits of SLP. We implement the SLP-E in LLVM and compare it with prior approaches. A set of applications that benefit from autovectorization are taken from the SPEC CPU 2017 benchmark to compare our approach and prior techniques. Experimental results show that SLP-E achieves more than 43.9% speedup, on average, over other similar methods.

Comparison of clinical competency self-assessments among Advanced Education in General Dentistry (AEGD) residents before and during COVID-19 pandemic.

Purpose/objectivesSelf‐assessment of clinical competence is an important tool for effective learning and training for some educational programs. The New York University (NYU) Langone Hospital's Advanced Education in General Dentistry (AEGD) Program has had its residents complete self‐assessment of clinical competency evaluations for many years. The evaluation is used to understand the residents’ perception of their own clinical skill upon beginning the program and to determine the necessary resources to provide to the residents for them to meet program standards. The same evaluation is completed by the residents 6 months later to determine if they perceived advancement in their clinical performance while in the program. Dental education, along with other fields of education was disrupted by the coronavirus disease 2019 (COVID‐19) pandemic. The purpose of this study was to examine the impact of COVID‐19 on clinical competency self‐assessments among the NYU Langone AEGD residents before and during the pandemic.MethodsIn this cross‐sectional study, data was collected from two AEGD cohorts representing 2019–2020 and 2020–2021 academic years; from July 2019 (n = 196) to January 2020 (n = 189) and July 2020 (n = 202) to January 2021 (n = 184). The self‐assessment evaluations were administered via an online residency management platform on the first days of July and January of the academic year. The survey consisted of 48 questions on “clinical skills and performance” as established by CODA standards for postdoctoral general dentistry programs.ResultsSurvey response rate was 100% for both cohorts. When comparing results, the findings indicate the COVID‐19 pandemic had interrupted clinical learning during dental school. However, training through the AEGD program led to improvements in perceived clinical competence by the residents in mid‐program evaluation.ConclusionThe self‐assessment evaluation can be used as a tool to enhance training as part of the AEGD program's performance improvement plan.

Human Papillomavirus Vaccination in South Africa: Programmatic Challenges and Opportunities for Integration With Other Adolescent Health Services?

Compared to other regions of the world, sub-Saharan Africa has made limited progress in the implementation and performance of nationwide human papillomavirus (HPV) vaccination programmes. Without urgent intervention, this will serve to undermine cervical cancer elimination efforts in this region. The primary intent of this narrative review is to highlight the programmatic successes and challenges of the school-based HPV vaccination programme in South Africa since its inception in 2014, with the aim of contributing to the evidence base needed to accelerate implementation and improve programme performance in other sub-Saharan African countries. As of 2020, the proportion of adolescent girls aged 15 years who had received at least one dose of the HPV vaccine at any time between ages 9–14 years was 75%, while 61% had completed the full recommended two-dose schedule. This gives some indication of the reach of the South African HPV vaccination programme over the past 6 years. Despite this, vaccine coverage and dose completion rates have persistently followed a downward trend, slowing progress toward attaining global elimination targets. There is evidence suggesting that declining public demand for the HPV vaccine may be a result of weakening social mobilization over time, inadequate reminder and tracking systems, and vaccine hesitancy. Another concern is the disproportionate burden of HPV and HIV co-infections among adolescent girls and young women in South Africa, which predisposes them to early development of invasive cervical cancer. Moving forward, national policy makers and implementers will have to explore reforms to current age eligibility criteria and vaccine dose schedules, as well as implement strategies to support vaccine uptake among populations like out-of-school girls, girls attending private schools, and HIV positive young women. Additional opportunities to strengthen the South African HPV vaccination programme can be achieved by scaling up the co-delivery of other adolescent health services such as comprehensive sexual and reproductive health and rights education, deworming, and health screening. This calls for reinforcing implementation of the integrated school health policy and leveraging existing adolescent health programmes and initiatives in South Africa. Ultimately, establishing tailored, adolescent-centered, integrated health programmes will require guidance from further operational research.

It is time to look in the mirror: Individual surgeon outcomes after emergent trauma laparotomy.

Multiple quality indicators are used by trauma programs to decrease variation and improve outcomes. However, little if any provider level outcomes related to surgical procedures are reviewed. Emergent trauma laparotomy (ETL) is arguably the signature case that trauma surgeons perform on a regular basis, but few data exist to facilitate benchmarking of individual surgeon outcomes. As part of our comprehensive performance improvement program, we examined outcomes by surgeon for those who routinely perform ETL. A retrospective cohort study of patients undergoing ETL directly from the trauma bay by trauma faculty from December 2019 to February 2021 was conducted. Patients were excluded from mortality analysis if they required resuscitative thoracotomy for arrest before ETL. Surgeons were compared by rates of damage control and mortality at multiple time points. There were 242 ETL (7-32 ETLs per surgeon) performed by 14 faculties. Resuscitative thoracotomy was performed in 7.0% (n = 17) before ETL. Six patients without resuscitative thoracotomy died intraoperatively and damage-control laparotomy was performed on 31.9% (n = 72 of 226 patients). Mortality was 4.0% (n = 9) at 24 hours and 7.1% (n = 16) overall. Median Injury Severity Score (p = 0.21), new injury severity score (p = 0.21), and time in emergency department were similar overall among surgeons (p = 0.15), while operative time varied significantly (40-469 minutes; p = 0.005). There were significant differences between rates of individual surgeon's mortality (range [hospital mortality], 0-25%) and damage-control laparotomy (range, 14-63%) in ETL. Significant differences exist in outcomes by surgeon after ETL. Benchmarking surgeon level performance is a necessary natural progression of quality assurance programs for individual trauma centers. Additional data from multiple centers will be vital to allow for development of more granular quality metrics to foster introspective case review and quality improvement. Therapeutic/care management, level III.

Enhancing and promoting data management and systematic monitoring for an improved HIV/AIDS programs in Addis Ababa, Ethiopia

BackgroundEthiopia Population-based HIV Impact Assessment findings showed that in Addis Ababa, only 65.2% of people living with HIV (PLHIV) know their status. We present the enhanced HIV/AIDS data management and systematic monitoring experience in Addis Ababa City Administration Health Bureau (AACAHB).MethodsAACAHB established a command-post with leadership and technical team members from the health bureau, 10 sub-city health offices, and non-governmental stakeholders. The command-post improved governance, standardized HIV program implementation, and established accountability mechanism. A web-based database was established at each health facility, sub-city, and AACAHB level. Performance was scored (green, ≥75%; yellow, 50–74%; red, < 50%). The command-post reviewed performance on weekly basis. A mentorship team provided a weekly site-level support at underperforming public and private health facilities. At facility level, quality of data on recording tools such as registers, and individual medical records were maintained through continued review, feedback mechanisms and regular consistency check of data. Percentage and 95% confidence interval were computed to compare the improvement in program performance over time.ResultsAfter 6 months of intervention period, the monthly New HIV case finding in 47 health facilities increased from 422 to 734 (1.7 times) and treatment initiation increased from 302 to 616 (2 times). After 6 months, the aggregate scoring for HIV testing at city level improved from yellow to green, HIV case finding improved from red to green, and treatment initiation improved from red to yellow. An increasing trend was noted in HIV positive case finding with statistically significant improvement from 43.4% [95% Confidence Interval: 40.23–46.59%] in May 2019 to 74.9% [95% Confidence Interval: 72.03–77.6%] in September 2019. Similarly, significant improvement was recorded for new HIV treatment from 30.9% [95% Confidence Interval: 28.01–33.94%] in May 2019 to 62.5% [95% Confidence Interval: 59.38–65.6%] in September 2019.ConclusionsRegular data driven HIV program review was institutionalized at city, sub-city and health facility levels which further improved HIV program monitoring and performance. The performance of HIV case finding and treatment initiation improved significantly via using intensified monitoring, data driven performance review, targeted site-level support based on the gap, and standardized approaches.

Developing Theoretical Sustainable Building Material Selection Framework for Ethiopia

The construction industry regarded as one of the pivotal aspects of achieving the objectives of sustainable development in communities. In this regard, the choice of building materials is one of the challenges in order to improve program performance with respect to sustainable development, and the use of sustainable materials is an effective step towards achieving sustainable construction. Selection of sustainable building materials represents an important strategy in the design and construction of buildings in Ethiopia. One of the principal challenges is the process of prioritizing and aggregating relevant criteria into a selection framework. Therefore, the purpose of this framework in building projects is to look at the complexity of the interactions between sustainability building materials and architects and to set up a knowledge-based decision support system. After conducting a thorough literature review, case study (BREEAM, LEED, CASBEE, LBC, and G-SEED), questionnaire, and discussion with selected experts, 27 sustainable building material selection criteria items identified based on the sustainable triple bottom line. A survey of Ethiopian architectural firms was conducted to capture their awareness of sustainable building materials. A total of 199 registered offices, based on Ethiopia's construction ministry in 2021. From among these, 51 offices chosen, as a sample size randomly. One of the study's limitations is that it excludes other stakeholders, such as the client, who may have an influence on material selection. Another drawback is that since elements are used to organize materials and components, Ratings are thus based solely on product performance within each constituent group. On the other hand, this study excluded several items. For example, "products" such as lighting, water fixtures, HVAC, and electrical fixtures are not included.

Role of machine learning in improving tourism and education sector

Tourism is viewed as a major economy booster. Although tourism has a beneficial influence on the economy in terms of national income generation, job creation, tax revenue generation and foreign exchange generation, it is a multi-segment sector. As a primary goal of higher education institutions, improving student performance is a top priority. Before a performance improvement program can be designed, it is necessary to map the students' current situation. Traditional computer techniques in the IT industry differ from machine learning. To describe or solve a problem, computers utilize a set of well-written instructions. Data inputs for factual research can be prepared using master learning approaches by computers. We'll look at how machine learning can be used in the tourist and education sectors.

Is the healthy start scheme associated with increased food expenditure in low-income families with young children in the United Kingdom?

BackgroundHealthy Start is a food assistance programme in the United Kingdom (UK) which aims to provide a nutritional safety-net and enable low-income families on welfare benefits to access a healthier diet through the provision of food vouchers. Healthy Start was launched in 2006 but remains under-evaluated. This study aims to determine whether participation in the Healthy Start scheme is associated with differences in food expenditure in a nationally representative sample of households in the UK.MethodsCross-sectional analyses of the Living Costs and Food Survey dataset (2010–2017). All households with a child (0–3 years) or pregnant woman were included in the analysis (n = 4869). Multivariable quantile regression compared the expenditure and quantity of fruit and vegetables (FV), infant formula and total food purchases. Four exposure groups were defined based on eligibility, participation and income (Healthy Start Participating, Eligible Non-participating, Nearly Eligible low-income and Ineligible high-income households).ResultsOf 876 eligible households, 54% participated in Healthy Start. No statistically significant differences were found in FV or total food purchases between participating and eligible non-participating households, but infant formula purchases were lower in Healthy Start participating households. Ineligible higher-income households had higher purchases of FV.ConclusionThis study did not find evidence of an association between Healthy Start participation and FV expenditure. Moreover, inequalities in FV purchasing persist in the UK. Higher participation and increased voucher value may help to improve programme performance and counteract the harmful effects of poverty on diet.

Building a Collaborative Framework for a Maternal Quality Assurance Performance Improvement Program

The purpose of our collaborative quality assurance performance improvement (QAPI) program is to evaluate the provision of maternal care and identify opportunities for improvement, including continuous review of aggregate patient data to identify and respond to trends. Improvement plans are developed and implemented with ongoing evaluation until a resolution is achieved.

Clinician-Directed Performance Improvement Program Transforms Care From the Bedside

Clinician-Directed Performance Improvement Program Transforms Care From the Bedside

Understanding the Role of Health Workers in the LF Elimination Program in Kenya: Challenges Faced and Suggestions for Improved Program Performance

The Kenyan Ministry of Health and its partners through the Division of Vector-Borne and Neglected Tropical Diseases, is in charge of the Lymphatic Filariasis Mass Drug Administration programme. This is implemented through the national, county, and sub-county neglected tropical diseases coordinators. The current study sought to understand the roles, challenges faced and suggestions of how program performance can be improved by the community health extension workers, county and sub-county neglected tropical diseases coordinators. Two wards of the Kaloleni sub-county; Kilifi County were purposively selected. In 2015, Kaloleni and Kayafungo wards had a treatment coverage of 58% and 54% respectively; 62% and 39% respectively in 2016, all below the recommended minimum treatment coverage of 65%. Qualitative data was collected through sixteen in-depth interviews with community health extension workers and two semi-structured interviews with the county and sub-county neglected tropical diseases coordinators. Data were analysed by QSR NVIVO version 10 according to identified themes. The study results show the various roles in planning and implementation of the program include; supply chain management; health information education communication and records management; health workforce training and management, leadership and governance, and service delivery. Challenges faced included insufficiency of drugs supplied and information education communication materials, the inadequacy of community drug distributors selected and trained, poor facilitation for training and supervision of community drug distributors, limited duration of the mass drug administration, and delayed reporting due to poor network coverage. The results of this study show that the community health extension workers, county and sub-county neglected tropical diseases coordinators are not fully involved in program leadership and governance, a role that is taken up at the national level. They should be involved in all the stages of the mass drug administration program to create ownership to improve the program performance

Improving the Delivery of High-Quality Cancer Care in Medically Underserved Communities: A Formative Evaluation Method.

In 2015, the American Society of Clinical Oncology launched a new program: Improving Quality of Care in Underserved Communities with the overarching aim of serving patients with cancer who have traditionally had difficulty accessing the care they need. Cancer care requires intense coordination of complex services to provide safe, effective, timely, and equitable care. If chemotherapy and/or radiation is needed, patients must navigate a complex system of care many times, a formidable challenge for many disadvantaged patients. Many practices believe that these patients face such significant issues that it is almost impossible to provide high-quality care. A grant from the Stavros Niarchos Foundation allowed us to select 4 oncology practices serving high proportions of racial minorities and persons of low socioeconomic status to participate in the new American Society of Clinical Oncology program. The program had 2 objectives: (1) to improve the capacity and capability of the participating practices to provide evidence-based, high-quality care; and (2) to identify and disseminate lessons learned for improving quality of care among oncology practices serving underserved patients. The program leveraged existing programs including the Quality Oncology Practice Initiative, which is a national performance measurement and improvement program that collects data about processes of care provided in the outpatient medical oncology setting, and the American Society of Clinical Oncology Quality Training Program, which provides training in how to apply the tools and methods of quality improvement in routine care settings. Training was provided in face-to-face and virtual meetings and participants were provided mentors throughout the program. At the conclusion, a formative evaluation method was used to assess whether the goals had been achieved. Objectives, activities, and desired outcomes were identified for each of the goals and thus became the framework for the evaluation. The program met the stated goals and objectives. The evaluation revealed many successes, some surprises, and a list of improvements that were incorporated in the next iteration of this program. Based on data from the evaluation, the Niarchos Foundation provided funds for an additional 10 practices to participate in a similar program in 2020. This article outlines the evaluation of a new program demonstrating that medical oncology practices can make improvements in the care of their underserved populations if provided with the proper tools, methods, and coaching. The use of formative evaluation methodology also identified opportunities for improvement and ultimately resulted in additional funding for more practices to participate in the program.