Health System Quality Research Articles

"Give me five" ultra-hypofractionated radiotherapy for localized prostate cancer: non-invasive ablative approach.

Ultra-hypofractionated radiotherapy (RT) is given over a shorter time with larger doses with respect to conventional fractionation in patients with localized prostate cancer (PCa). The use of hypofractionation is supported both from the radiobiological point of view (the low α/β-ratio in PCa and dose escalation) and from the rising number of clinical evidences. The aim of this study is to review our data regarding oncological outcomes, namely biochemical progression-free survival (b-PFS) and clinical progression-free survival (c-PFS), acute and long-term toxicities in patients treated with a ultra-hypofractionated RT. A series of 194 patients with clinically localized PCa treated primarily with ultra-hypofractionated RT using image-guided intensity modulated RT (IG-IMRT) at our Institute from 2012 to 2015 was included in this analysis. According to NCCN risk group classification, 65 (33.5%) patients were low risk, 101 (52.1%) intermediate risk, and 28 (14.4%) high risk. Androgen deprivation therapy (ADT) was given to 61 patients (31.4%). A 169 patients (87.1%) received 35Gy in 5 fractions, while 25 patients (13%) received 32.5Gy in 5 fractions (usually given in patients with comorbidity). The median duration of the treatment was 10 days (IQR 9-12). Biochemical relapse was defined as a rise of prostate specific antigen (PSA) > 2ng/ml above nadir. b-PFS, c-PFS, and freedom from gastro-intestinal (GI) and genito-urinary (GU) toxicity curves were calculated by the Kaplan-Meier method. Log-rank test and multivariate Cox models were used to investigate the role RT dose and heterogeneity by NCCN risk groups adjusting for prognostic factors. Data on acute and late term toxicities were collected according to RTOG/EORTC grading system. With a median follow-up of 30 months, 17 patients experienced PSA failure (9%). The 3-year b-PFS was 87% for all patients and rates stratified for the NCCN risk were 94, 82, and 66% for low-, intermediate-, and high-risk groups, respectively. Log-rank tests indicate that biochemical progression was significantly greater for patients with initial PSA (iPSA) greater than 7ng/ml (P = 0.04), high- and intermediate-risk groups (P = 0.002), low total dose (P = 0.02) and Gleason score (GS) equal or greater than 7 (P = 0.04). No statistically significant association was found with T stage nor ADT. In multivariate analyses, total dose (P = 0.03) and risk groups (P = 0.03) remained significantly associated with recurrence. Acute and late GI and GU toxicity were acceptable. The toxicity of ultra-hypofractionated IG-IMRT in a large clinical cohort of PCa patients was tolerable and confirmed that this treatment is safe and offers excellent tumor control. Moreover, the hypofractionated RT allows to deliver the whole RT over 10 days with a sensible impact in patients' quality of life and potential overall health system and social benefits.

Focus Group in Community Mental Health Research: Need for Adaption.

The article presents an analysis of the use of focus groups in researching community mental health users, starting with the reasons for using them, their implementation in mental health service users' research, and the adaptations of focus group use when researching the experiences of users. Based on personal research experience and a review of scientific publications in the Google Scholar, Web of Science, ProQuest, EBSCOhost, and Scopus databases, 20 articles published between 2010 and 2016 were selected for targeted content analysis. A checklist for reporting on the use of focus groups with community mental health service users, aiming to improve the comparability, verifiability and validity was developed. Adaptations of the implementation of focus groups in relation to participants' characteristics were suggested. Focus groups are not only useful as a scientific research technique, but also for ensuring service users' participation in decision-making in community mental health and evaluating the quality of the mental health system and services .

Implementation and quality assessment of a pharmacy services call center for outpatient pharmacies and specialty pharmacy services in an academic health system.

The implementation and quality assessment of a pharmacy services call center (PSCC) for outpatient pharmacies and specialty pharmacy services within an academic health system are described. Prolonged wait times in outpatient pharmacies or hold times on the phone affect the ability of pharmacies to capture and retain prescriptions. To support outpatient pharmacy operations and improve quality, a PSCC was developed to centralize handling of all outpatient and specialty pharmacy calls. The purpose of the PSCC was to improve the quality of pharmacy telephone services by (1) decreasing the call abandonment rate, (2) improving the speed of answer, (3) increasing first-call resolution, (4) centralizing all specialty pharmacy and prior authorization calls, (5) increasing labor efficiency and pharmacy capacities, (6) implementing a quality evaluation program, and (7) improving workplace satisfaction and retention of outpatient pharmacy staff. The PSCC centralized pharmacy calls from 9 pharmacy locations, 2 outpatient clinics, and a specialty pharmacy. Since implementation, the PSCC has achieved and maintained program goals, including improved abandonment rate, speed of answer, and first-call resolution. A centralized 24-7 support line for specialty pharmacy patients was also successfully established. A quality calibration program was implemented to ensure service quality and excellent patient experience. Additional ongoing evaluations measure the impact of the PSCC on improving workplace satisfaction and retention of outpatient pharmacy staff. The design and implementation of the PSCC have significantly improved the health system's patient experiences, efficiency, and quality.

Hospitalist Value in an ACO World.

The accountable care organization (ACO) concept is advocated as a promising value-based payment model that could successfully realign the current payment system to financially reward improvements in quality and efficiency. Focusing on the care of hospitalized patients and controlling a substantive portion of variable hospital expenses, hospitalists are poised to play an essential role in system-level transformational change to achieve clinical integration. Especially through hospital and health system quality improvement (QI) initiatives, hospitalists can directly impact and share accountability for measures ranging from care coordination to implementation of evidence-based care and the patient and family caregiver experience. Regardless of political terrain, financial constraints in healthcare will foster continued efforts to promote formation of ACOs that aim to deliver coordinated, evidence-based, and patient-centered care. Hospitalists possess the clinical experience of caring for complex patients with multiple comorbidities and the QI skills needed to lead efforts in this new ACO era.

Quality Assessment of the Oncology Health Service in a Public Hospital

Quality assessment is a crucial issue in the strategic management of the public health sector. The objective of this study is to investigate the patients’ perception of the health system quality and explore the relationships between doctors and long-term cancer patients. The data under study have been collected during a survey conducted with long-term cancer patients who follow an oncological therapy in a Public Hospital. In the study, exploratory factorial analysis is developed and two structural equation models are proposed. The first model describes the service quality as perceived by the patients, which is influenced by four important factors, namely tangible aspects, reliability, empathy (doctor–patient human relations) and hospital organization. The second model describes the relationship between doctors and long-term cancer patients, which is influenced by three factors, that is reliability, empathy and hospital organization. The discussion highlights the contribution that the results of the study may make to the investigation of the possible strategies for improving health care service quality.

The Quality of Health System in Mexico and the Professional Nursing act before the Prescription of Medicines

The Quality of Health System in Mexico and the Professional Nursing act before the Prescription of Medicines

LEAN INTEGRATED MANAGEMENT SYSTEM: A MODEL FOR SUSTAINABILITY IMPROVEMENT

This paper presents an innovative model to improve corporate sustainability via the integration of Quality, Environment, Social Responsibility and Occupational Health and Safety Management Systems with the Lean Manufacturing System; this may help organizations to improve corporate sustainability in a structured manner. This research introduces the Lean-Integrated Management System for Sustainability Improvement - LIMSSI, which is based on the rational use of resources and energy, while engaging and empowering people. It was structured considering the difficulties of organizations in performing sustainability-improvement activities, avoiding loss of organizational efficiency due to waste, duplication, and increments of bureaucratic processes, to generate synergies. The LIMSSI may improve corporate sustainability performance, rendering companies more sustainable and competitive.

Hospital Mortality \u2013 a neglected but rich source of information supporting the transition to higher quality health systems in low and middle income countries

BackgroundThere is increasing focus on the strength of primary health care systems in low and middle-income countries (LMIC). There are important roles for higher quality district hospital care within these systems. These hospitals are also sources of information of considerable importance to health systems, but this role, as with the wider roles of district hospitals, has been neglected.Key messagesAs we make efforts to develop higher quality health systems in LMIC we highlight the critical importance of district hospitals focusing here on how data on hospital mortality offers value: i) in understanding disease burden; ii) as part of surveillance and impact monitoring; iii) as an entry point to exploring system failures; and iv) as a lens to examine variability in health system performance and possibly as a measure of health system quality in its own right. However, attention needs paying to improving data quality by addressing reporting gaps and cause of death reporting. Ideally enabling the collection of basic, standardised patient level data might support at least simple case-mix and case-severity adjustment helping us understand variation. Better mortality data could support impact evaluation, benchmarking, exploration of links between health system inputs and outcomes and critical scrutiny of geographic variation in quality and outcomes of care. Improved hospital information is a neglected but broadly valuable public good.ConclusionAccurate, complete and timely hospital mortality reporting is a key attribute of a functioning health system. It can support countries’ efforts to transition to higher quality health systems in LMIC enabling national and local advocacy, accountability and action.

A roadmap to advance dementia research in prevention, diagnosis, intervention, and care by 2025.

ObjectiveNational and global dementia plans have focused on the research ambition to develop a cure or disease‐modifying therapy by 2025, with the initial focus on investment in drug discovery approaches. We set out to develop complementary research ambitions in the areas of prevention, diagnosis, intervention, and care and strategies for achieving them.MethodsAlzheimer's Society facilitated a taskforce of leading UK clinicians and researchers in dementia, UK funders of dementia research, people with dementia, and carer representatives to develop, using iterative consensus methodology, goals and recommendations to advance dementia research.ResultsThe taskforce developed 5 goals and 30 recommendations. The goals focused on preventing future cases of dementia through risk reduction, maximising the benefit of a dementia diagnosis, improving quality of life, enabling the dementia workforce to improve practice, and optimising the quality and inclusivity of health and social care systems. Recommendations addressed gaps in knowledge and limitations in research methodology or infrastructure that would facilitate research in prioritised areas. A 10‐point action plan provides strategies for delivering the proposed research agenda.ConclusionsBy creating complementary goals for research that mirror the need to find effective treatments, we provide a framework that enables a focus for new investment and initiatives. This will support a broader and more holistic approach to research on dementia, addressing prevention, surveillance of population changes in risk and expression of dementia, the diagnostic process, diagnosis itself, interventions, social support, and care for people with dementia and their families.

Novel Approach to Emergency Departments' Pediatric Readiness Across a Health System.

A gap analysis of emergency departments' (EDs') pediatric readiness across a health system was performed after the appointment of a service line health system pediatric emergency medicine (PEM) quality director. A 55-question survey was completed by each eligible ED to generate a weighted pediatric readiness score (WPRS). The survey included questions regarding volume, ED configuration, presence of a pediatric emergency care coordinator (PECC), quality initiatives, policies and procedures, and equipment. Surveys were completed from June 1 to November 12, 2016.Analysis of variance was used to compare the 4 groups of EDs based upon their annual pediatric volume as a continuous measure (low, <1800 visits; medium, 1800-4999 visits; medium-high, 5000-9999 visits; high, >10,000 visits). The Fisher exact test was used to compare the 4 groups for the remaining categorical variables represented as frequencies and percentages. A result was considered statistically significant at the P < 0.05 level of significance. There were a total of 16 hospitals (after the exclusion of the children's hospital, the hub for pediatric care in the health system, and 1 adult-only hospital) with the following pediatric capability: 7 basic (no inpatient pediatrics), 7 general (inpatient pediatrics, with/without a neonatal intensive care unit), and 2 comprehensive (inpatient pediatrics, pediatric intensive care unit, and a neonatal intensive care unit). In 12 EDs, adults and children are treated in the same space. These EDs see a total of 800,000 annual visits including 120,000 pediatric visits. Two low pediatric volume EDs had a median WPRS of 69, range of 62 to 76 (national median, 61.4); 6 medium pediatric volume EDs had a median WPRS of 51, range of 42 to 81 (national median, 69.3); 4 medium-high pediatric volume EDs had a median WPRS of 69.3, range of 45 to 98 (national medium, 74.8); 4 high pediatric volume EDs had a WPRS score of 84.5, range of 58 to 100 (national medium, 89.8). There were 4 sites with PECCs: 1 medium-high volume and 3 high volume, with a median WPRS of 98.5, range of 81 to 100 (national medium, 89.8). Two low-volume EDs have Neonatal Resuscitation Program training for nurses (P < 0.0083). One medium-high volume ED requires specific pediatric competency evaluations for advanced level practitioners staffing the ED. Pediatric-specific quality programs are present in the 2 low volume EDs, 3 of the 6 EDs in the medium group, 3 of 4 EDs in the medium-high group, and all 4 high volume hospitals. After the implementation of the health system PEM quality director, all EDs have a doctor and nurse PECC with a median WPRS of 81. In additiona, a committee was formed with the following key stakeholders: PECCs, pediatric nursing educators, pediatric quality, pharmacy, obstetrics, behavioral health, and neonatology. The committee is part of the health system quality program within both pediatrics and emergency medicine and is spearheading the standardization of code carts and medications, dissemination of pediatric clinical guidelines, and the development of a pediatric quality program across the health system. Pediatric emergency care coordinators play an important role in ED readiness to care for pediatric patients. In a large health system, a service line PEM quality director with the support of emergency medicine and pediatrics, a committee with solid frontline ED base, and a diverse array of stakeholders can foster the engagement of all EDs and improve compliance with published guidelines.

Investigating the Relationship between Nurses’ Moral Sensitivity and Patients’ Satisfaction with the Quality of Nursing Care

Patient satisfaction is considered as an important indicator of the quality and effectiveness of health system. Moral sensitivity plays an important role in how professional responsibilities and moral decisions are made by nurses. This study aims to investigate the relationship between nurses' moral sensitivity and patients' satisfaction with quality of nursing care. This study is descriptive and analytic. First, nurses in internal, surgical and special wards were selected through census method. Then, patients were selected using quota sampling to the ratio of nurses from each section. Data were collected through Demographic Questionnaires, Patient Satisfaction Instrument and Moral Sensitive Questions. Data were analyzed using SPSS 23. There was a significant positive correlation between nurses' moral sensitivity and patients' satisfaction with quality of nursing care (P < 0.05). The majority of patients (70.5) had moderate level of satisfaction with quality of nursing care. 93.5 of nurses had high moral sensitivity. There was no statistically significant relationship between nurses' moral sensitivity and variables of sex, location of work, marital status, type of responsibility and work shift. Relationship between patient satisfaction and type of admission ward was significant (P = 0.03). Increased moral sensitivity in nurses is effective on improving patients' satisfaction with the quality of nursing care. It is suggested to conduct further research with larger sample size and investigate other factors affecting patient satisfaction in order to ensure the generalizability of research results.

What is changed in the diagnosis of osteoporosis: the role of radiologists

Osteoporosis (OP) is a very common condition with several repercussions on patients’ quality of life and health systems (1). OP is secondary to changes in normal bone turnover for decreased activity of osteoblasts (which produce bone matrix) or increased osteoclastic activity (2,3). These changes determine variation in bone mineral content (BMC) and then bone mineral density (BMD); thus, quantification of BMD correlate to changes in bone matrix.

A fuzzy set qualitative comparative analysis of 131 countries: which configuration of the structural conditions can explain health better?

BackgroundAccording to the recommendations of the World Health Organization Commission On Social Determinants of Health (CSDH) for intersectoral action on health, the well-being of and equity in health within a population are achieved via a complex fusion of policies and actions. In this study, following the CSDH’s approach and considering set-theoretic relations, we aimed to unravel this complexity and answer the kinds of questions that are outside the scope of conventional variable-oriented approach.MethodsA fuzzy-set qualitative comparative analysis of 131 countries was conducted to examine the configurational effects of five macro-level structural conditions on life expectancy at birth. The potential causal conditions were level of country wealth, income inequality, quality of governance, education, and health system. The data collected from different international data sources were recorded during 2004–2015.ResultsThe intermediate solution of the truth table analysis indicated a configuration of conditions including high level of governance, education, wealth, and affluent health system to be consistently sufficient for high life expectancy. On the other hand, four configurations, each containing two or three conditions, were consistent with being usually sufficient to cause low life expectancy.ConclusionsWe were able to configurationally explore the cases and specify the combinations of potentially causal conditions which were usually sufficient to explain high or low life expectancy in different countries. As a result, particular cases were identified for further research. In addition, research may provide support for the CSDH’s recommendations emphasizing the importance of intersectoral action for health.

PP22 How Do Health System Leaders Use Evidence To Inform Action?

Introduction:The US Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program sponsors the development of systematic reviews to inform clinical policy and practice. The EPC program sought to better understand how health systems identify and use this evidence.Methods:Representatives from eleven EPCs, the EPC Scientific Resource Center, and AHRQ developed a semi-structured interview script to query a diverse group of nine Key Informants (KIs) involved in health system quality, safety and process improvement about how they identify and use evidence. Interviews were transcribed and qualitatively summarized into key themes.Results:All KIs reported that their organizations have either centralized quality, safety, and process improvement functions within their system, or they have partnerships with other organizations to conduct this work. There was variation in how evidence was identified, with larger health systems having medical librarians and central bureaus to gather and disseminate information and smaller systems having local chief medical officers or individual clinicians do this work. KIs generally prefer guidelines, especially those with treatment algorithms, because they are actionable. They like systematic reviews because they efficiently condense study results and reconcile conflicting data. They prefer information from systematic reviews to be presented as short digestible summaries with the full report available on demand. KIs preferred systematic reviews from reputable entities and those without commercial bias. Some of the challenges KIs reported include how to resolve conflicting evidence, the generalizability of evidence to local needs, determining whether the evidence is up-to-date, and the length of time required to generate reviews. The topics of greatest interest included predictive analytics, high-value care, advance care planning, and care coordination. To increase awareness of AHRQ EPC reviews, KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available and making reports easier to find in common search engines.Conclusions:Systematic reviews are valued by health system leaders. To be most useful they should be easy to locate and available in different formats targeted to the needs of different audiences.

Anthropological analysis of cultural representations of Serbia and the European Union by EU female citizens living in Belgrade

This article researches Europeanization of everyday life in Serbia on a micro level. Itcombines cultural representations approach from cognitive theory with an analysis of lifestories from migration studies. Thus, the paper analyses the results of in-depth semistructuredinterviews with eight EU female citizens from Austria, Estonia, France, Finland,Great Britain, Greece, Germany, and Slovenia. They have chosen to live in Serbia, moreprecisely in Belgrade from the end of 1999. The aim of the paper is to point out differentcultural values and the use of diverse cultural strategies which EU female citizens utilize intheir everyday life in Serbia. In the light of the “brain drain” issue in Serbia, the reasons ofinterlocutors to live in Serbia may represent the subject of new cultural and migratorypolicies in Serbia. The most significant advantage of living in Serbia for the interlocutors isthe high quality of life: the possibility to have free and unorganized time which allows themto socialize more than it would be possible in the EU. However, many see benefits in theEU-integration process of Serbia, such are introduction of regulations of the environment,higher quality of health, legislative and educational system, and more efficient fight againstcorruption. On the other hand, as possible disadvantages of the EU-integrations, they stressthe exploitation of domestic market, the loss of freedom of decision-making or rise ofcorruption among domestic politicians. Key words: Europeanization of everyday life in Serbia, cultural representations, EU femalecitizens, European Union

Effects of physical exercise on beta cells of the pancreas: a systematic review

Background: Diabetes mellitus is a chronic disease that is rising in many parts of the world causing damage to functionality, quality of life and public health system. Objective: Verify the effects of physical exercise on beta cells of the pancreas in diabetic subjects. Methods: The database Cochrane Library via Wiley – CENTRAL, Pubmed, LILACS, SCIELO, Web of Science, Scopus, CINAHL were used to search the articles. The descriptors and synonyms of this topic were used in the search strategy. Controlled randomized clinical trials and quasi-randomized studies, which included in their samples diabetic humans undergone any type of physical exercise were included. The Cochrane collaboration bias risk tool was used to assess the risk of bias. Results: A total of 3.133 articles were initially identified and after reading the titles/abstracts and the full text 6 articles were selected for the qualitative evaluation. Most of the studies showed positive results of physical exercise on pancreatic beta cells, insulin secretion, insulin resistance and insulin sensitivity. The main limitations were the number of studies, few, and their methodological qualities. Conclusions: Physical exercises have beneficial effects on pancreatic beta cells, insulin resistance and insulin sensitivity; however better studies designs, with fewer biases and larger samples are needed so that the results presented do not be overestimated. This review is recorded in the Prospective Register of Systematic Reviews with registration number 42017054213

Association between infrastructure and observed quality of care in 4 healthcare services: A cross-sectional study of 4,300 facilities in 8 countries.

BackgroundIt is increasingly apparent that access to healthcare without adequate quality of care is insufficient to improve population health outcomes. We assess whether the most commonly measured attribute of health facilities in low- and middle-income countries (LMICs)—the structural inputs to care—predicts the clinical quality of care provided to patients.Methods and findingsService Provision Assessments are nationally representative health facility surveys conducted by the Demographic and Health Survey Program with support from the US Agency for International Development. These surveys assess health system capacity in LMICs. We drew data from assessments conducted in 8 countries between 2007 and 2015: Haiti, Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda. The surveys included an audit of facility infrastructure and direct observation of family planning, antenatal care (ANC), sick-child care, and (in 2 countries) labor and delivery. To measure structural inputs, we constructed indices that measured World Health Organization-recommended amenities, equipment, and medications in each service. For clinical quality, we used data from direct observations of care to calculate providers’ adherence to evidence-based care guidelines. We assessed the correlation between these metrics and used spline models to test for the presence of a minimum input threshold associated with good clinical quality. Inclusion criteria were met by 32,531 observations of care in 4,354 facilities. Facilities demonstrated moderate levels of infrastructure, ranging from 0.63 of 1 in sick-child care to 0.75 of 1 for family planning on average. Adherence to evidence-based guidelines was low, with an average of 37% adherence in sick-child care, 46% in family planning, 60% in labor and delivery, and 61% in ANC. Correlation between infrastructure and evidence-based care was low (median 0.20, range from −0.03 for family planning in Senegal to 0.40 for ANC in Tanzania). Facilities with similar infrastructure scores delivered care of widely varying quality in each service. We did not detect a minimum level of infrastructure that was reliably associated with higher quality of care delivered in any service. These findings rely on cross-sectional data, preventing assessment of relationships between structural inputs and clinical quality over time; measurement error may attenuate the estimated associations.ConclusionInputs to care are poorly correlated with provision of evidence-based care in these 4 clinical services. Healthcare workers in well-equipped facilities often provided poor care and vice versa. While it is important to have strong infrastructure, it should not be used as a measure of quality. Insight into health system quality requires measurement of processes and outcomes of care.

Mentorship and coaching to support strengthening healthcare systems: lessons learned across the five Population Health Implementation and Training partnership projects in sub-Saharan Africa

BackgroundDespite global efforts to increase health workforce capacity through training and guidelines, challenges remain in bridging the gap between knowledge and quality clinical practice and addressing health system deficiencies preventing health workers from providing high quality care. In many developing countries, supervision activities focus on data collection, auditing and report completion rather than catalyzing learning and supporting system quality improvement. To address this gap, mentorship and coaching interventions were implemented in projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) as components of health systems strengthening (HSS) strategies funded through the Doris Duke Charitable Foundation’s African Health Initiative. We report on lessons learned from a cross-country evaluation.MethodsThe evaluation was designed based on a conceptual model derived from the project-specific interventions. Semi-structured interviews were administered to key informants to capture data in six categories: 1) mentorship and coaching goals, 2) selection and training of mentors and coaches, 3) integration with the existing systems, 4) monitoring and evaluation, 5) reported outcomes, and 6) challenges and successes. A review of project-published articles and technical reports from the individual projects supplemented interview information.ResultsAlthough there was heterogeneity in the approaches to mentorship and coaching and targeted areas of the country projects, all led to improvements in core health system areas, including quality of clinical care, data-driven decision making, leadership and accountability, and staff satisfaction. Adaptation of approaches to reflect local context encouraged their adoption and improved their effectiveness and sustainability.ConclusionWe found that incorporating mentorship and coaching activities into HSS strategies was associated with improvements in quality of care and health systems, and mentorship and coaching represents an important component of HSS activities designed to improve not just coverage, but even further effective coverage, in achieving Universal Health Care.

Lean-integrated management system: A model for sustainability improvement

There is an unprecedented demand for sustainability incorporation; however, a significant gap exists in sustainability management systems. We considered this gap as well as the fact that organizations mainly face difficulties in managing sustainability using integrated management systems.Here, we propose an innovative model to improve corporate sustainability aimed at cleaner production; we develop this model by integrating quality, environmental, social responsibility, and occupational health and safety management systems with the lean manufacturing system. The proposed model is expected to aid organizations in improving corporate sustainability in a structured manner. This research introduces the Lean-Integrated Management System for Sustainability Improvement (LIMSSI), which is based on the rational use of resources and energy while engaging and empowering people. The LIMSSI provides an innovative description of correlations of the quality, environmental, occupational health and safety, and social responsibility requirements with the principles and tools of lean manufacturing; it also includes a description of their integration to create synergies. It was structured considering the difficulties faced by organizations in performing sustainability-improvement activities, and aim to avoid loss of organizational efficiency due to waste, duplication, and increments of bureaucratic processes. The LIMSSI is expected to improve corporate sustainability performance and thereby render companies more sustainable and competitive.

Medical student healthcare consulting groups: A novel way to train the next generation of physician-executives

Meeting the challenges of the evolving healthcare environment requires leadership of physicians well-trained in clinical medicine and healthcare management. However, many physicians lack training in business and leadership. While some residency programs have management tracks, training at the medical school level is currently lacking. We developed the Hopkins Health Management Advisory Group, an extracurricular program at Johns Hopkins University School of Medicine that exposes medical students to healthcare management and fosters development of leadership skills. Teams of students work directly with health system executives on 3–6 month-long projects using management consulting principles to address problems spanning health system domains, including strategy, operations, and quality improvement. Since the program’s inception, 23 students have completed seven projects, with 13 additional students currently working on three more projects. Sponsors leading six out of seven completed projects have implemented recommendations. Qualitative survey respondents have found the program beneficial, with students frequently describing how the program has helped to develop professional skills and foster knowledge about healthcare management. These early assessments show positive impact for both students and the institution, and suggest that such programs can train students in management early and concurrently in their medication education by immersing them in team-based health system projects.