Quality Improvement Plan Research Articles

Minimalisasi Defect Produk Granite Tile Pada Proses Sorting & Polishing Dengan Pendekatan Root Cause Analysis (RCA) (Studi Kasus di PT. Niro Ceramic Nasional Indonesia, Bogor–Jawa Barat )

Competition in the industry makes manufacturing companies do continuous improvement of production in order to achieve good quality. PT. XYZ is a company engaged in the manufacturing industries that produce granite tile. The problems that often arise on the production floor, especially in the process of sorting and polishing that is, the high defect products produced in the process. The purpose of this study is to minimize damage to the product on the S & P, Useful and finished product quality improvement plans. To support solving this problem, researchers used a method approach Root Cause Analysis (RCA). In the histogram obtained from the check sheets, Pareto diagrams visible damage in the S & P damage type of disability the most dominant is the Crack (57%), followed Thick (18%), Glaze Drop (11%), Black Coring (8%), and the last is the Scraper Defect (6%). From the research, a result that most of the damage is Crack. Factors causing these defects are the factors that cause deviations quality raw materials such factors, factors working methods irregularities in the implementation of the work, a factor that is less engine preventive maintenance, factor of fewer operators do not obey the standard factory operations. From the productivity results in the S & P, generate some suggestion in terms of minimizing the product is defective is implementing kaizen. Keywords: Root Cause Analysis (RCA), Application of Process Improvement, Kaizen, 5S, Granite Tile.

International collaboration between low-middle-income and high-income institutions to improve radiation therapy care delivery.

The Philippines is a lower-middle-income island country with over 153 000 new cancer diagnosis each year. Despite many patients needing radiotherapy as part of disease management, there remains limitations to access. Currently, the Philippines has 50 linear accelerator facilities serving a population of 110 million. However, given the recommendation of 1 linear accelerator for every 250 thousand people, it is evident that the demand for accessible radiotherapy resources is significantly underserved in the country. This paper outlines the collaboration between GenesisCare Solutions (GCS) and Fairview Cancer Center (FCC) to address efficiency and access within the radiotherapy department at FCC. Through international collaboration between GCS and FCC, areas for improvement were identified and categorized into four domains: Dosimetry quality, Patient workflow, Data & Reporting, and Information Technology (IT) Infrastructure. Action plans were developed then implemented. A baseline measurement was obtained for each domain, and post-implementation evaluation undertaken at 3 months, 6 months, and 12 months. Data captured within the electronic medical record system was extrapolated, and average treatment times were established for pre- and post-engagement. A paired, 2-tailed t-test was used for statistical analysis of outcome parameters using IBM SPSS version 23 for all statistics. Twelve months post-initial engagement, all four domains saw positive outcomes. Improved plan quality linked to Intensity Modulated Radiotherapy (IMRT) utilization rates saw an increase from 20% to 54%. A significant reduction in patient average wait times was also observed, from 27 to 17 min (p≤0.001). Prior to engagement, tracking patient demographics and diagnosis was not prioritized, post engagement an average of 92% diagnosis entry compliance was achieved. Through the collaboration of GCS and FCC, objectives in all action plan domains were achieved, highlighting the benefits of collaboration between low-middle-income and high-income institutions.

Cystic fibrosis-related diabetes screening at a large pediatric center.

Cystic Fibrosis Foundation guidelines recommend annual diabetes screening by oral glucose tolerance test (OGTT) in pediatric patients with cystic fibrosis (CF) starting at the age of 10 years. Adherence to these guidelines proves to be challenging, and the nationwide screening rates are still considered suboptimal. The aim of this study was to assess and improve the screening rates at our large pediatric center. A 4-year retrospective audit of OGTT completion among pediatric patients with CF of age ≥10 years who are not yet diagnosed with diabetes was conducted. A collaborative working group was formed to identify the barriers to screening and formulate a quality improvement plan, which was monitored and evaluated for a 9-month period. Diabetes screening rates determined by OGTT completion at our center showed a gradual decline during the COVID-19 pandemic from 2019 to 2022. Following the implementation of the quality improvement plan during the summer of 2023, there was a marked increase in OGTT ordering compliance by providers as well as test completion by patients. Notably, the fractional OGTT completion rate rose from 45% during the preintervention phase (January-April 2023) to 70% during the postintervention phase (May-September 2023). Diabetes screening in pediatric patients with CF can be effectively improved by refining practices related to patient experience, care coordination, and laboratory testing strategies.

Comparative Study of Eclipse and RayStation Multi-Criteria Optimization-Based Prostate Radiotherapy Treatment Planning Quality.

Multi-criteria optimization (MCO) function has been available on commercial radiotherapy (RT) treatment planning systems to improve plan quality; however, no study has compared Eclipse and RayStation MCO functions for prostate RT planning. The purpose of this study was to compare prostate RT MCO plan qualities in terms of discrepancies between Pareto optimal and final deliverable plans, and dosimetric impact of final deliverable plans. In total, 25 computed tomography datasets of prostate cancer patients were used for Eclipse (version 16.1) and RayStation (version 12A) MCO-based plannings with doses received by 98% of planning target volume having 76 Gy prescription (PTV76D98%) and 50% of rectum (rectum D50%) selected as trade-off criteria. Pareto optimal and final deliverable plan discrepancies were determined based on PTV76D98% and rectum D50% percentage differences. Their final deliverable plans were compared in terms of doses received by PTV76 and other structures including rectum, and PTV76 homogeneity index (HI) and conformity index (CI), using a t-test. Both systems showed discrepancies between Pareto optimal and final deliverable plans (Eclipse: -0.89% (PTV76D98%) and -2.49% (Rectum D50%); RayStation: 3.56% (PTV76D98%) and -1.96% (Rectum D50%)). Statistically significantly different average values of PTV76D98%,HI and CI, and mean dose received by rectum (Eclipse: 76.07 Gy, 0.06, 1.05 and 39.36 Gy; RayStation: 70.43 Gy, 0.11, 0.87 and 51.65 Gy) are noted, respectively (p < 0.001). Eclipse MCO-based prostate RT plan quality appears better than that of RayStation.

Abstract WP93: Providing Stroke Reports to Emergency Medical Services (EMS) Agencies Improves Data Quality in Michigan's Statewide EMS Data Repository

Intro: The Michigan Stroke Program (MiSP) monitors statewide EMS stroke care performance and data quality. Starting in 2018, quarterly performance and outcome benchmark data were shared with EMS agency partners to support prehospital quality improvement (QI) for stroke patients. Objective: To improve EMS data quality and prehospital stroke care performance. Methods: This is a retrospective before and after study of the impact of tailored QI interventions to improve EMS compliance with three prehospital stroke quality metrics selected by MiSP EMS partners: (prehospital stroke scale documentation, last known well documentation, and prehospital notification). Five MiSP EMS partners participated in the intervention which consisted of provision of quarterly performance reports generated from linked data from Michigan’s EMS Information System and the Michigan Stroke Registry. The MiSP team reviewed agency performance with EMS leadership to select the target measures for intervention and then assisted in development of a QI plan to improve agency performance. Measure compliance was compared from three months prior to and six months after data quality solutions were implemented. Results: Through data sharing and communication with EMS agencies and EMS software data vendors, common themes were identified related to poor data quality beginning in January 2020. A sample of agencies and resolutions to address these issues are displayed in the Table. Compliance with the targeted metric improved significantly at each agency at three and six months following intervention. Conclusions: Analysis of EMS data and sharing performance data directly with EMS agency partners identified correctable data quality issues negatively impacting EMS quality measures. Correcting these issues led to dramatic and sustained improvement in EMS quality metric compliance. This approach may serve as a model for improving the accuracy of EMS performance data in state-level EMS registries.

Evaluation of improvements in plan quality with Photon Optimizer v16.1 for single brain lesion SRS treatment.

The purpose of this study is to compare the performance of the Photon Optimizer (PO) version 16.1 algorithm with its earlier version PO v13.6 and with Progressive Resolution Optimizer (PRO) version 13.6 algorithms. 20 patients with single brain lesions treated with the stereotactic radiosurgery (SRS) technique were retrospectively selected for this study. Initially, for all patients volumetric modulated arc therapy (VMAT) SRS plans were generated with the PRO v 13.6 algorithm. Then, all the plans were re-generated with two versions 13.6 and 16.1 of PO algorithm using the same setup and dose-volume optimization objectives as that of PRO with a similar planning approach. The quality of the generated plans was analysed using ICRU 91 plan evaluation parameters and also using dice similarity co-efficient (DSC), centre of mass distance (CMD) between target and prescription isodose line, Monitor units (MU) and brain-gross tumor volume (GTV) 12 Gy volume. Paired Student t-test was used for statistical analysis with 0.05 as a significant value. PO v16.1 improved all the dosimetric parameters studied compared to PO 13.6, the difference is statistically significant for all the parameters (p < 0.05), except for median dose and brain-GTV 12 Gy volume. PO v16.1 also showed statistically significant improvement for all the dosimetric parameters evaluated, except DSC and conformity index (CI), compared to PRO v13.6. The PO v16.1 generated plans are dosimetrically superior to PO v13.6 and PRO v13.6 in terms of target dose coverage and dose gradient with lesser beam modulation and plan complexity for single brain lesion SRS.

Developing a Quality Improvement Implementation Taxonomy for Organizational Employee Wellness Initiatives.

Standardized taxonomies (STs) facilitate knowledge representation and semantic interoperability within health care provision and research. However, a gap exists in capturing knowledge representation to classify, quantify, qualify, and codify the intersection of evidence and quality improvement (QI) implementation. This interprofessional case report leverages a novel semantic and ontological approach to bridge this gap. This report had two objectives. First, it aimed to synthesize implementation barrier and facilitator data from employee wellness QI initiatives across Veteran Affairs health care systems through a semantic and ontological approach. Second, it introduced an original framework of this use-case-based taxonomy on implementation barriers and facilitators within a QI process. We synthesized terms from combined datasets of all-site implementation barriers and facilitators through QI cause-and-effect analysis and qualitative thematic analysis. We developed the Quality Improvement and Implementation Taxonomy (QIIT) classification scheme to categorize synthesized terms and structure. This framework employed a semantic and ontological approach. It was built upon existing terms and models from the QI Plan, Do, Study, Act phases, the Consolidated Framework for Implementation Research domains, and the fishbone cause-and-effect categories. The QIIT followed a hierarchical and relational classification scheme. Its taxonomy was linked to four QI Phases, five Implementing Domains, and six Conceptual Determinants modified by customizable Descriptors and Binary or Likert Attribute Scales. This case report introduces a novel approach to standardize the process and taxonomy to describe evidence translation to QI implementation barriers and facilitators. This classification scheme reduces redundancy and allows semantic agreements on concepts and ontological knowledge representation. Integrating existing taxonomies and models enhances the efficiency of reusing well-developed taxonomies and relationship modeling among constructs. Ultimately, employing STs helps generate comparable and sharable QI evaluations for forecast, leading to sustainable implementation with clinically informed innovative solutions.

Full daily re-optimization improves plan quality during online adaptive radiotherapy

Background and purposeDaily online treatment plan adaptation requires a fast workflow and planning process. Current online planning consists of adaptation of a predefined reference plan, which might be suboptimal in cases of large anatomic changes. The aim of this study was to investigate plan quality differences between the current online re-planning approach and a complete re-optimization. Material and methodsMagnetic resonance linear accelerator reference plans for ten prostate cancer patients were automatically generated using particle swarm optimization (PSO). Adapted plans were created for each fraction using (1) the current re-planning approach and (2) full PSO re-optimization and evaluated overall compliance with institutional dose-volume criteria compared to (3) clinically delivered fractions. Relative volume differences between reference and daily anatomy were assessed for planning target volumes (PTV60, PTV57.6), rectum and bladder and correlated with dose-volume results. ResultsThe PSO approach showed significantly higher adherence to dose-volume criteria than the reference approach and clinical fractions (p < 0.001). In 74 % of PSO plans at most one criterion failed compared to 56 % in the reference approach and 41 % in clinical plans. A fair correlation between PTV60 D98% and relative bladder volume change was observed for the reference approach. Bladder volume reductions larger than 50 % compared to the reference plan recurrently decreased PTV60 D98% below 56 Gy. ConclusionComplete re-optimization maintained target coverage and organs at risk sparing even after large anatomic variations. Re-planning based on daily magnetic resonance imaging was sufficient for small variations, while large variations led to decreasing target coverage and organ-at-risk sparing.

Using the settings approach to health promotion in hospital and health services to support collaboration, engagement, and partnership in integrated care systems.

Introduction: Hospitals and health services within integrated care systems can implement the 2020 Standards for Health Promoting Hospitals and Health Services to promote the mutual values reflected in the nine pillars of integrated care, such as shared vision and multisectoral action, improving population health, people-centered care, community participation, staff health, leadership, and quality improvement. After the impact of the COVID-19 pandemic, a shift towards these shared values is needed to better address burnout and a decreasing workforce.&#x0D; Intervention: The International Network of Health Promoting Hospitals &amp; Health Services’ (HPH) 600 members from 33 countries work towards supporting the integration of health promotion into the organizational structure and culture of organizations to create health promoting settings. To operationalize this vision and guide decision makers in transforming their institutions into settings that support collaboration, engagement, and partnership, the 2020 Standards for Health Promoting Hospitals and Health Services and complimentary Self-Assessment tools were conceived. &#x0D; Five overarching standards, 18 substandards, and 86 standard statements resulted from a methodological consolidation of existing HPH standards (addressing equity, mental health, the environment, health literacy, patient-centered care, groups such as the elderly, children, and adolescents) and from two Delphi consultation rounds with HPH subject experts. The standards reflect over 30 years of knowledge and international experience in health promotion implementation across various areas of policy, practice, and evidence within the International HPH Network. Complementary self-assessment tools, developed with input from 14 countries, can be used to identify key members of multidisciplinary steering teams, to compare data and monitor progress, and develop targeted quality improvement plans based on data collected. Currently, the Standards are available in 11 languages on the HPH website.&#x0D; Outcomes: Hospitals and health services who adopt a comprehensive health promotion approach are agile, better able to respond to challenges and are receptive to change. During Delphi consultation rounds to define the standards, high ratings of relevance were given to population health needs, organizational commitment, and environmental health amongst countries contributing to the design of the Standards. The standards, therefore, strongly focus on organizational collaboration; engagement of patients, family, staff, and the community; and building alliances and partnerships between stakeholders along a patients’ care pathway. Organizations adopting this holistic approach are efficient, leading to better health outcomes, satisfaction for all involved, and lower costs, which are shared aims of integrated care. Health promoting settings are supportive of integrated care and can be implemented as a first step in a system-wide transformation. &#x0D;

East Toronto Health Partners: Collaborating on Quality Improvement

Developing a shared quality agenda has led to a new focus on population health within our community in East Toronto, Ontario, Canada. Amidst pandemic recovery, community members often struggle to access care. Health care organizations are challenged to support patient flow and mental health needs, and to catch up on preventative care and chronic disease management that was delayed due to reduced in-person care. One might think that these pressures would sideline quality improvement (QI) work, however we’ve seen new energy generated by QI capacity-building and application of rapid learning cycles to address our shared challenges. &#x0D; Ontario Health Team context&#x0D; An Ontario Health Team is “a group of collaborative partners (organizations and individuals who offer health services, social services, and other health-relevant activities) brought together under a collaborative governance framework… to work with, and be accountable for, the health and wellbeing of a well-defined Attributed Population.” This context generates motivation for organizations and stakeholders to work closely on quality initiatives. Quality improvement activities form part of a larger rapid-learning health system strategy that includes program evaluation, evidence-based best practices in frontline care, and business intelligence efforts.&#x0D; Approaches within our QI Collaboration&#x0D; -Collecting and sharing patient experience measures as part of Best Practice Guideline implementation for Person &amp; Family-Centred Care;&#x0D; -Strengthening involvement of community members; co-creating our 2022 collaborative Quality Improvement Plan with diverse partners;&#x0D; -Accessing and reflecting on baseline data for our defined population, and building capacity for local analytics. Together with other Ontario Health Teams, we have outlined requirements for data and tools to support population health management;&#x0D; -Focusing on priority neighbourhoods to improve health equity; and building QI capacity with teams of Community Health Ambassadors within those neighbourhoods.&#x0D; Key Learnings&#x0D; Patient Experience: We grounded our work in person- and family-centred care; respecting the voices of patients and caregivers in reporting their level of involvement in care plans and treatment. Collaboration among partners uncovered examples of best practice in patient experience data collection and moved us toward data collection as an integrated system of care (beyond surveys conducted within individual organizations). &#x0D; Patient Flow: Our collaboration led us to focus “upstream,” and to strengthen our ability to identify unmet needs for clients in community settings. A strengths-based assessment across collaborating organizations helped to increase awareness of diverse assets within our community and examples of leadership in Seniors-Friendly Care. We are launching transdisciplinary teams dedicated to responsive support for transitions in care. &#x0D; Preventative Care: An equity approach was key. In addition to primary care practice-based improvement initiatives (e.g. cancer screening) we prioritized efforts to reach vulnerable groups, such as individuals without a family doctor, and those with barriers to navigating health services in English. Rapid-cycle improvement and evaluation plans (co-designed with community members) are helping to ensure that service offerings are addressing the needs of the community.&#x0D; RESULT: The East Toronto Health Partners’ collaborative Quality Improvement work has helped our Ontario Health Team to align and integrate work across multiple organizations – building our capabilities for proactive population health management.

Clinician Attitudes Toward Suicide Prevention Practices and Their Implementation: Findings From the System of Safety Study.

The authors aimed to assess clinicians' attitudes toward suicide-related practices and their implementation, across roles and settings, before implementation of the Zero Suicide model in a health care system. Clinicians (N=5,559) were invited to complete a survey assessing demographic characteristics; confidence and self-reported suicide-related practice; leadership buy-in; and attitudes toward suicide prevention, safety planning, and continuous quality improvement (CQI). Of 1,224 respondents, most felt confident conducting suicide screening but less confident performing other suicide-related care. Provider role and care setting were significantly associated with confidence (p<0.001, Kruskal-Wallis H test) and practice (p<0.001, Kruskal-Wallis H test) of providing suicide prevention care, with behavioral health providers and providers in the emergency department (ED) reporting the highest confidence. Attitudes toward safety planning were more positive among women (p<0.001, t test) and behavioral health providers (p<0.001, F test) than among their counterparts or peers. Positive attitudes toward CQI were significantly associated with male sex (p=0.01), non-White race (p=0.03), younger age (p=0.02), fewer years working in health care (p<0.001), administrative role (p<0.001), working in the ED (p<0.001), outpatient settings (p<0.02), and medical provider role (p<0.001). Behavioral health providers and those in the ED reported feeling prepared to deliver suicide-related care, with nurses feeling less confident and less supported. Initiatives to improve suicide-related care should account for clinical role and care setting during planning. CQI could help engage a broader range of clinicians in suicide-related care improvements.

REDUCING UNPLANNED HOSPITALIZATIONS OF NURSING HOME RESIDENTS: A PROCESS EVALUATION OF INTERCARE

Abstract The INTERCARE study provided evidence for a complex intervention to reduce unplanned hospitalizations in 11 Swiss nursing homes. The six intervention components were strengthening of interprofessional collaboration, introduction of a nurse with in-depth geriatric training (INTERCARE nurse), comprehensive geriatric assessment, advanced care planning, evidence-based tools, and data-driven quality improvement. This process evaluation aims to describe the intervention components’ use in practice and understand the mechanisms of change to optimize intervention components for scale-up. We used qualitative data from individual and focus group interviews and meetings notes from the research team’s conversations with nursing home care workers and leadership, INTERCARE nurses and physicians from five nursing homes participating in the INTERCARE study. Data was extracted into spread sheets before starting inductive coding. Findings were summarized and consolidated in a conceptual model. In connection with the four intervention elements interprofessional collaboration, INTERCARE nurse, advanced care planning and evidence-based tools, we identified four intervention mechanisms, grouped into 1) those changing reasoning of care workers e.g., following a more structured approach to do things and 2) those enabling existing resources e.g., availability of a responsible contact person. We also identified behavior changes in care workers, including faster reaction to changes in resident situations, more comprehensive assessment of resident situations and improved communication which contributed to reductions in hospitalizations. Understanding how interventions work in practice is crucial for informing potential adaptations to the intervention and the implementation strategies. Our findings can help optimize the intervention components for scale-up, ultimately reducing unplanned hospitalizations from nursing homes.

Application research on reducing radiation-induced lung injury with a trigger operator based on overlap volume histogram (OVH) in breast cancer postoperative radiotherapy

This study aims to develop a trigger operator based on the Overlap Volume Histogram (OVH) and examined its effectiveness in enhancing plan quality to minimize radiation-induced lung injury in postoperative radiotherapy for breast cancer. This trigger operator was applied for plan re-optimization to the previous Volumetric Modulated Arc Therapy (VMAT) plans of 16 left breast conserving surgery cases. These cases were categorized into a Contiguous Group (CG) and a Separated Group (SG) based on the relative position between the target and the Left-Lung (L-Lung). We investigated the changes in Vx, mean dose, and Normal Tissue Complication Probability (NTCP) values of organs-at-risk (OARs) before and after using the trigger operator. The Pairwise Sample T test was employed to evaluate the differences in indices between the two groups before and after optimizations. The trigger operator effectively initiated plan re-optimization. The values of V5, V10, V20, V30, and V40 of the L-Lung, as well as the mean dose of the heart, all decreased after re-optimization. The Pairwise Sample T test results showed statistically significant differences in the V20, V30, and V40 of the L-Lung in the CG (P < 0.01), and in the V5, V10, V20, V30, and V40 of the L-Lung in the SG (P < 0.01). Our findings suggest that the proposed trigger operator can improve plan quality, thereby reducing radiation-induced lung injury in postoperative radiotherapy for breast cancer.

Improved Dosimetry and Plan Quality for Accelerated Partial Breast Irradiation Using Online Adaptive Radiation Therapy: A Single Institutional Study

PurposeAccelerated partial breast irradiation (APBI) is an attractive treatment modality for eligible patients as it has been shown to result in similar local control and improved cosmetic outcomes compared to whole breast radiotherapy. The use of online adaptive radiotherapy (OART) for APBI is promising as it allows for a reduction of PTV margins since breast motion and lumpectomy cavity volume changes are accounted for in daily imaging. Here we present a retrospective, single-institution evaluation on the adequacy of kV-cone beam computed tomography (CBCT) OART for APBI treatments. Methods and Materials19 patients (21 treatment sites) were treated to 30 Gy in 5 fractions between January of 2022 and May of 2023. Time between simulation and treatment, change in gross tumor (i.e. lumpectomy cavity) volume (GTV), and differences in dose volume histogram (DVH) metrics with adaption were analyzed. The Wilcoxon paired, non-parametric test was utilized to test for DVH metric differences between the scheduled plans (initial plans recalculated on daily CBCT anatomy) and delivered plans, either the scheduled or adapted plan, which was re-optimized using daily anatomy. ResultsMedian (inter-quartile range) time from simulation to first treatment was 26 days (21-32 days). During this same time, median GTV volume reduction was 16.0% (7.3-23.9%) relative to simulation volume. Adaptive treatments took 31.3 min (27.4-36.6 min) from start of CBCT to treatment session end. At treatment, the adaptive plan was selected for 86% (89/103) of evaluable fractions. In evaluating plan quality, 78% of delivered plans met all target, OAR, and conformity metrics evaluated, compared to 34% of scheduled plans. ConclusionsUse of OART for stereotactic linac-based APBI allowed for safe, high-quality treatments in this cohort of 21 treatment courses. Although treatment delivery times were longer than traditional stereotactic body treatments, there were notable improvements in plan quality for APBI using OART.

Information technology of quality improvement planning of process subsets of the spice model

The object of research is the software development process. The subject of the study is models, methods and information technology for planning quality improvement of a subset of processes of the SPICE maturity model. The aim of the work is to implement the developed models, method and technology within the framework of information technology and check its performance on test examples. Research methods: quality engineering of software systems; the theory of utility, on the basis of which the target function of the model is built; the method of options sequential analysis; the decision-making theory and modeling of business processes in the development of decision-making support information technology. Applied models: the SPICE maturity model is formalized, which is presented in the form of a hierarchical system; a model for evaluating the level of possibility of a separate process/subprocess of the SPICE model was synthesized; the quality improvement-planning model of a subset of the SPICE model processes under conditions of limited resources is synthesized. The method of options sequential analysis was applied, which was implemented on the basis of the "Kyiv Broom" algorithm. The obtained results: a technology for solving the given task was developed, which is presented in the form of a sequence of execution of individual business processes using the IDEFO standard; the requirements for software were defined; a data model of the subject area was developed; the toolkit for software development is substantiated; the software architecture was chosen; a diagram of software components placement is presented; the performance of the developed information technology was verified on test examples. The practical significance of the work lies in the fact that the obtained information technology allows the managers of IT companies within the limits of the allocated resources in a certain planning period to build the trajectory of the development of the most significant processes of software, to determine how their level of opportunity will increase in each planning sub-period in order to obtain quality software.

Impact of land use pattern on water quality under different riparian buffer zone scales in Gaya River Basin, Northeast China

River water quality is influenced by land use and landscape distribution patterns. Quantifying the relationship between land use, landscape pattern and water quality factor at different riparian buffer zone scales is of great significance for rational land use planning and water quality improvement. Based on water quality data from 91 sites in May 2021 in the Gaya River Basin, we analyzed the spatial characteristics of land use types and landscape patterns at the riparian buffer zone scales. With redundancy analysis (RDA) and generalized additive models (GAM), we examined the effects of land use and landscape patterns on river water quality. The results showed that water quality was primarily impacted by total nitrogen (TN). Farmland was the dominant land use type at riparian buffer zone of 50, 100 and 500 m. The sampling sites were classified into farmland dominant group and farmland other group. Forest was dominant at riparian buffer zone of 1000, 1500, 2000 m, and the sampling sites were classified into forest dominant group and forest other group. 100 m riparian buffer zone was the strongest scale in the Gaya River, and 1000 m was the second. Land use types in the forest dominant group were closely related with electrical conductivity, dissolved oxygen, phosphate, permanganate index and ammonium (NH4+-N) of water. NH4+-N was positively correlated with proportion of forest and farmland area. Phosphate was significantly affected by Shannon diversity index (SHDI). SHDI and largest patch index (LPI) was the key landscape indices affecting permanganate index. TN was significantly impacted by area proportion of forest, grassland and LPI in farmland dominant group, showing decreasing trend with the area proportion of forest increasing from 8% to 40%. Total suspended solids in farmland other group were significantly correlated with proportion of farmland area, while negatively correlated with proportion of forest area. Water quality in the Gaya River was mainly affected by proportion of forest area, followed by proportion of farmland area. The combined effects of LPI, SHDI and other land use types played an important role in affecting water quality.

Improvement Plan Using Fatigue Analysis Minimizes Jar Twistoff

_ This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper SPE 210723, “Service Quality Improvement Plan Using FEA Fatigue Analysis Minimizes Jar Twistoff in Challenging Applications,” by Chaouki Boufama, SPE, Baozhong Yang, and Sultan Alfaraedhi, Schlumberger, et al. The paper has not been peer reviewed. _ Jar twistoff is a well-known service quality issue for some applications, especially in relatively large borehole sizes such as 22 and 16 in. The jar is one of the weakest points in the drillstring because of moving parts, which include complex shapes, resulting in stress concentration. The complete paper presents results of a study focusing on placing the jar in the bottomhole assembly (BHA) to reduce bending moments and bending stresses on the jar connections. As a result, the risk of twistoffs during drilling is minimized, while the effectiveness of the jar is maintained if a stuck event occurs. Introduction Jars traditionally are placed between drill collars in the applications described in this study. These applications include 22- and 16-in. vertical holes with simple BHA designs, either rotary or with positive displacement motors. In cases of lateral vibration that creates high bending stress, this design is likely to cause the jar to experience extreme stress levels. The design concept of placing the jar between other components with lower weight and stiffness appears to be the most logical approach. This design would have to be validated with finite element analysis (FEA) dynamic modeling simulations to confirm lower stress at the jar and that a new weak point has not been introduced in the string. Impact and impulse also must be evaluated to confirm the effectiveness of the jar in the case of a stuck-pipe condition. The study is based on the work flow shown in Fig. 1 of the complete paper. Statement of Theory and Definitions A more in-depth analysis was performed on a 22-in. vertical drilling application with nonhomogeneous formations. A downhole real-time recording tool was added to the drillstring above the BHA to evaluate and verify the magnitude of vibration and bending moments acting on the BHA during drilling operations. The 22-in. vertical section was selected because it was determined to be the most challenging section. The following key observations were made during the drilling run when the circulation was lost to the formation: - Significant lateral vibration levels - Chaotic whirling motions - High bending moment Mechanical specific energy (MSE) and drilling parameters were controlled during the run to alleviate vibration. Vibration severity could have been influenced by the absence of the mud column as well as the borehole quality because of formation washout and an oversized hole. However, this was never verified using a caliper log. The string entered a state of chaotic whirl as the loss of circulation fluid began. The parameters, and thus the MSE, were reduced, but the severe vibrations persisted. Even though the run did not cause any jar-component failure or crack, multiple previous incidents showed similar failure modes in the same downhole conditions. These failures, which included the fractured face of each of the parted components, were analyzed and evaluated (Fig. 1). The slanted fracture indicated a high combined stress-related fracture. In addition, beach marks present near the fracture area also indicated fatigue-induced damage.

Assessing capacity for culture change in serious illness communication across McGill University cancer centers.

457 Background: Patients with advanced malignancy at McGill University’s Rossy Cancer Network (RCN) frequently die in the emergency room or hospital in the context of cancer directed therapy. Internal data indicate delayed referral to palliative care for high-risk patient groups and lack of training and physician discomfort with serious illness communication (SIC). To plan for a system-wide quality improvement (QI) initiative, we aimed to assess capacity for culture change around SIC across three university-affiliated cancer centers. Methods: Interdisciplinary oncology and palliative care leaders from the three RCN sites completed an institutional readiness survey to assess local data and QI infrastructure and potential strengths and challenges related to SIC. We conducted a retrospective chart review of patients who received care at RCN sites for advanced malignancy and who died over a 24-month period. We organized pilot three-hour multi-disciplinary training sessions in use of a Serious Illness Conversation Guide and targeted physicians, nurses, and social workers from each RCN site. Participants completed a survey upon training completion. We developed a quality improvement plan. Results: Institutional readiness surveys highlighted challenges in identifying patients who could benefit from serious illness conversations and lack of consistency and localization of electronic health record documentation of SIC. Preliminary analysis from a retrospective chart review (n=370) demonstrated that 98% of patients had documentation of some aspect of SIC. Only 38% of SIC documentation described patient goals and values, and only 23% referred to patient preferences or wishes. Most instances of SIC documentation (74%) focused on code status and orientation of treatment toward either comfort or cure. 28% of patients had first documentation of SIC within 30 days of death. Fifteen healthcare providers took part in the multidisciplinary training sessions. Training evaluation data suggest that trainees found the training acceptable and feasible, and appreciated the interprofessional nature of the sessions. Results include presentation of an implementation plan. Conclusions: Culture change initiatives related to SIC benefit from a robust assessment of existing resources and challenges. We used a multi-modal approach to assess and build capacity for a cross-institution QI initiative. This process and the resulting network and hospital-level QI plans can assist other academic institutions in leveraging SIC to transform and improve cancer care.

Treatment planning comparison for head and neck cancer between photon, proton, and combined proton–photon therapy – From a fixed beam line to an arc

Background and purposeThis study investigates whether combined proton–photon therapy (CPPT) improves treatment plan quality compared to single-modality intensity-modulated radiation therapy (IMRT) or intensity-modulated proton therapy (IMPT) for head and neck cancer (HNC) patients. Different proton beam arrangements for CPPT and IMPT are compared, which could be of specific interest concerning potential future upright-positioned treatments. Furthermore, it is evaluated if CPPT benefits remain under inter-fractional anatomical changes for HNC treatments. Material and methodsFive HNC patients with a planning CT and multiple (4–7) repeated CTs were studied. CPPT with simultaneously optimized photon and proton fluence, single-modality IMPT, and IMRT treatment plans were optimized on the planning CT and then recalculated and reoptimized on each repeated CT. For CPPT and IMPT, plans with different degrees of freedom for the proton beams were optimized. Fixed horizontal proton beam line (FHB), gantry-like, and arc-like plans were compared. ResultsThe target coverage for CPPT without adaptation is insufficient (average V95%=88.4 %), while adapted plans can recover the initial treatment plan quality for target (average V95%=95.5 %) and organs-at-risk. CPPT with increased proton beam flexibility increases plan quality and reduces normal tissue complication probability of Xerostomia and Dysphagia. On average, Xerostomia NTCP reductions compared to IMRT are −2.7 %/-3.4 %/-5.0 % for CPPT FHB/CPPT Gantry/CPPT Arc. The differences for IMPT FHB/IMPT Gantry/IMPT Arc are + 0.8 %/-0.9 %/-4.3 %. ConclusionCPPT for HNC needs adaptive treatments. Increasing proton beam flexibility in CPPT, either by using a gantry or an upright-positioned patient, improves treatment plan quality. However, the photon component is substantially reduced, therefore, the balance between improved plan quality and costs must be further determined.

The Association Between Pediatric Readiness and Mortality for Injured Children Treated at US Trauma Centers.

To use updated 2021 weighted Pediatric Readiness Score (wPRS) data to identify a threshold level of trauma center emergency department (ED) pediatric readiness. Most children in the United States receive initial trauma care at nonpediatric centers. The aim of the National Pediatric Readiness Project (NPRP) was to ensure that all EDs are prepared to provide quality care for children. Trauma centers reporting the highest quartile of wPRS on the 2013 national assessment have been shown to have lower mortality. Significant efforts have been invested to improve pediatric readiness in the past decade. A retrospective cohort of trauma centers that completed the NPRP 2021 national assessment and contributed to the National Trauma Data Bank (NTDB) from 2019 to 2021 was analyzed. Center-specific observed-to-expected mortality estimates for children (0-15 y) were calculated using Pediatric Trauma Quality Improvement Program models. Deterministic linkage was used for transferred patients to account for wPRS at the initial receiving center. Center-specific mortality odds ratios were then compared across quartiles of wPRS. A total of 66,588 children from 630 centers with a median (interquartile range) wPRS of 79 (66-93) were analyzed. The average observed-to-expected odds of mortality [1.02 (0.97-1.06)] for centers in the highest quartile (wPRS≥93) was lower than any of the lowest 3 wPRS quartiles [1.19 (1.14-1.23) (Q1), 1.29 (1.24-1.33) (Q2), and 1.28 (1.19-1.36) (Q3), all P <0.05). The presence of a pediatric-specific quality improvement plan was the domain with the strongest independent association with mortality [standardized beta -0.095 (-0.146 to -0.044)]. Trauma centers should address gaps in pediatric readiness to include a pediatric-specific quality improvement plan and aim to achieve wPRS ≥93.