Quality Improvement Regulation Research Articles

Linking resilience and regulation across system levels in healthcare \u2013 a multilevel study

BackgroundThe Quality Improvement Regulation was introduced to the Norwegian healthcare system in 2017 as a new national regulatory framework to support local quality and safety efforts in hospitals. A research-based response to this, was to develop a study with the overall research question: How does a new healthcare regulation implemented across three system levels contribute to adaptive capacity in hospital management of quality and safety? Based on development and implementation of the Quality Improvement Regulation, this study aims to synthesize findings across macro, meso, and micro-levels in the Norwegian healthcare system.MethodsThe multilevel embedded case study collected data by documents and interviews. A synthesizing approach to findings across subunits was applied in legal dogmatic and qualitative content analysis. Setting: three governmental macro-level bodies, three meso-level County Governors and three micro-level hospitals. Participants: seven macro-level regulators, 12 meso-level chief county medical officers/inspectors and 20 micro-level hospital managers/quality advisers.ResultsBased on a multilevel investigation, three themes were discovered. All system levels considered the Quality Improvement Regulation to facilitate adaptive capacity and recognized contextual flexibility as an important regulatory feature. Participants agreed on uncertainty and variation to hamper the ability to plan and anticipate risk. However, findings identified conflicting views amongst inspectors and hospital managers about their collaboration, with different perceptions of the impact of external inspection. The study found no changes in management- or clinical practices, nor substantial change in the external inspection approach due to the new regulatory framework.ConclusionsThe Quality Improvement Regulation facilitates adaptive capacity, contradicting the assumption that regulation and resilience are “hopeless opposites”. However, governmental expectations to implementation and external inspection were not fully linked with changes in hospital management. Thus, the study identified a missing link in the current regime. We suggest that macro, meso and micro-levels should be considered collaborative partners in obtaining system-wide adaptive capacity, to ensure efficient risk regulation in quality improvement and patient safety processes. Further studies on regulatory processes could explore how hospital management and implementation are influenced by regulators’, inspectors’, and managers’ professional backgrounds, positions, and daily trade-offs to adapt to changes and maintain high quality care.

Investigating Hospital Supervision: A Case Study of Regulatory Inspectors' Roles as Potential Co-creators of Resilience.

ObjectivesThe aim of this study was to explore if, and in what ways, there has been changes in the supervisory approach toward Norwegian hospitals due to the implementation of a new management and quality improvement regulation (Regulation on Management and Quality Improvement in the Healthcare Services, hereinafter referred to as “Quality Improvement Regulation”). Moreover, we aimed to understand how inspectors’ work promotes or hampers resilience potentials of adaptive capacity and learning in hospitals.MethodsThe study design is a case study of implementation and impact of the Quality Improvement Regulation. We performed a document analysis, and conducted and analyzed 3 focus groups and 2 individual interviews with regulatory inspectors, recruited from 3 county governor offices who are responsible for implementation and supervision of the Quality Improvement Regulation in Norwegian regions.ResultsData analysis resulted in 5 themes. Informants described no substantial change in their approach owing to the Quality Improvement Regulation. Regardless, data pointed to a development in their practices and expectations. Although the Norwegian Board of Health Supervision, at the national level, occasionally provides guidance, supervision is adapted to specific contexts and inspectors balance trade-offs. Informants expressed concern about the impact of supervision on hospital performance. Benefits and disadvantage with positive feedback from inspectors were debated. Inspectors could nurture learning by improving their follow-up and add more hospital self-assessment.ConclusionsA nondetailed regulatory framework such as the Quality Improvement Regulation provides hospitals with room to maneuver, and self-assessment might reduce resource demands. The impact of supervision is scarce with an unfulfilled potential to learn from supervision. The Government could contribute to a shift in focus by instructing the county governors to actively reflect on and communicate positive experiences from, and smart adaptations in, hospital practice.

Hospital managers’ perspectives with implementing quality improvement measures and a new regulatory framework: a qualitative case study

A new regulatory framework to support local quality and safety efforts in hospitals was introduced to the Norwegian healthcare system in 2017. This study aimed to investigate hospital managers’ perspectives...

Ectopic expression of apple hexose transporter MdHT2.2 reduced the salt tolerance of tomato seedlings with decreased ROS-scavenging ability

Salt is one of the main stresses that limit plant growth, especially at the seedling stage, reducing crop production and severely impacting food security. However, the relationship between salt stress and sugar content regulated by sugar transporters remains unknown. Here, we investigated the salt tolerance of transgenic tomato seedlings ectopically expressing MdHT2.2, which is a fructose and glucose/H+ symporter located on the plasma membrane in apple. Although the contents of fructose, glucose and sucrose in the leaves of seedlings ectopically expressing MdHT2.2 obviously increased compared with those of WT seedlings, the transgenic seedlings were significantly less tolerance to salt stress. Under salt stress, the SlSOS1/2 and SlNHX1 genes were highly expressed, and the accumulation of Na+ was lower in the transgenic seedlings than in WT, however, ROS accumulated to a greater degree in the former, and the ROS-scavenging-related enzyme activities and AsA content were lower in the transgenic seedlings than WT. Taken together, these results indicated that the relatively low salt tolerance of the MdHT2.2 transgenic seedlings was related with the accumulation of ROS, which was caused by reduced ROS-scavenging ability. Our results offer proof that changes in sugar content caused by sugar transporters are related to salt tolerance, and provide new insight into the regulation of sugar content, quality improvement and stress tolerance.

Exploring links between resilience and the macro-level development of healthcare regulation- a Norwegian case study

BackgroundThe relationship between quality and safety regulation and resilience in healthcare has received little systematic scrutiny. Accordingly, this study examines the introduction of a new regulatory framework (the Quality Improvement Regulation) in Norway that aimed to focus on developing the capacity of hospitals to continually improve quality and safety. The overall aim of the study was to explore the governmental rationale and expectations in relation to the Quality Improvement Regulation, and how it could potentially influence the management of resilience in hospitals. The study applies resilience in healthcare and risk regulation as theoretical perspectives.MethodsThe design is a single embedded case study, investigating the Norwegian regulatory healthcare regime. Data was collected by approaching three regulatory bodies through formal letters, asking them to provide internal and public documents, and by searching through open Internet-sources. Based on this, we conducted a document analysis, supplemented by interviews with seven strategic informants in the regulatory bodies.ResultsThe rationale for introducing the Quality Improvement Regulation focused on challenges associated with implementation, lack of management competencies; need to promote quality improvement as a managerial responsibility. Some informants worried that the generic regulatory design made it less helpful for managers and clinicians, others claimed a non-detailed regulation was key to make it fit all hospital-contexts. The Government expected hospital managers to obtain an overview of risks and to adapt risk management and quality improvement measures to their specific context and activities.ConclusionsBased on the rationale of making the Quality Improvement Regulation flexible to hospital context, encouraging the ability to anticipate local risks, along with expectations about the generic design as challenging for managers and clinicians, we found that the regulators did consider work as done as important when designing the Quality Improvement Regulation. These perspectives are in line with ideas of resilience. However, the Quality Improvement Regulation might be open for adaptation by the regulatees, but this may not necessarily mean that it promotes or encourages adaptive behavior in actual practice. Limited involvement of clinicians in the regulatory development process and a lack of reflexive spaces might hamper quality improvement efforts.

Ethical frameworks for quality improvement activities: an analysis of international practice.

To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. Data were extracted from 19 documents using an a priori framework developed from the published literature. We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.

Genome-wide identification of Diacylglycerol Acyltransferases (DGAT) family genes influencing Milk production in Buffalo

BackgroundThe diacylglycerol acyltransferases (DGAT) are a vital group of enzymes in catalyzing triacylglycerol biosynthesis. DGAT genes like DGAT1 and DGAT2, have been identified as two functional candidate genes affecting milk production traits, especially for fat content in milk. Buffalo milk is famous for its excellent quality, which is rich in fat and protein content. Therefore, this study aimed to characterize DGAT family genes in buffalo and to find candidate markers or DGAT genes influencing lactation performance.ResultsWe performed a genome-wide study and identified eight DGAT genes in buffalo. All the DGAT genes classified into two distinct clades (DGAT1 and DGAT2 subfamily) based on their phylogenetic relationships and structural features. Chromosome localization displayed eight buffalo DGAT genes distributed on five chromosomes. Collinearity analysis revealed that the DGAT family genes were extensive homologous between buffalo and cattle. Afterward, we discovered genetic variants loci within the genomic regions that DGAT genes located in buffalo. Seven haplotype blocks were constructed and were associated with buffalo milk production traits. Single marker association analyses revealed four most significant single nucleotide polymorphisms (SNPs) mainly affecting milk protein percentage or milk fat yield in buffalo. Genes functional analysis indicated that these DGAT family genes could influence lactation performance in the mammal through regulating lipid metabolism.ConclusionIn the present study, we performed a comprehensive analysis for the DGAT family genes in buffalo, which including identification, structural characterization, phylogenetic classification, chromosomal distribution, collinearity analysis, association analysis, and functional analysis. These findings provide useful information for an in-depth study to determine the role of DGAT family gens play in the regulation of milk production and milk quality improvement in buffalo.

Neural Network Based Control for Power Quality Improvement and Voltage Regulation in Multi Output Switched Mode Power Supply

Medical electronic equipments and personal computers stand in need of switched mode power supplies (SMPS) with isolated and regulated voltages of ± 12V, ± 5V and + 3.3 V. In this paper a neural network controlled forward boost converter based SMPS of 175 W rating is proposed. The SMPS is designed to have isolated and regulated voltages of ± 12V and ± 5V suitable for PC power supply. Power quality in terms of, total harmonic distortion (THD) and input power factor and output voltage regulation are analyzed for variation in supply voltage and load conditions by simulating the proposed circuit in MAT LAB/Simulink software. To highlight the performance of the proposed multi output SMPS, it is compared with that of conventional controller. Simulation results prove the efficacy of the proposed neural network based control for multi output SMPS. Improved power quality in terms of THD, almost unity power factor and voltage regulation are achieved for varying source and load condition.

Influence of relative humidity on aerosol composition: Impacts on light extinction and visibility impairment at two sites in coastal area of China

Investigation on the aerosol characteristics, surface visibility (Vis) and meteorology at BGS (Baguanshan, Qingdao) and LNA (Lin'an, Zhejiang) shows that the ambient aerosol chemical composition and light extinction are relative humidity (RH) dependent. At higher RH, both the strengthened hygroscopic growth and the more efficient oxidization (of the precursor gases and formation of the secondary sulfate and nitrate) contribute to the increase of the mass fraction of the hygroscopic species, which consequently results in the increase of the aerosol mass extinction efficiency (MEE) and Vis reduction at the two Chinese coastal sites. MEE and chemical composition of the aerosol vary significantly under different regional transport ways; the airmasses from the ocean directions are associated with higher RH, higher sulfate mass fraction and greater MEE at BGS, while MEEs are smaller and associated with lower RH and lower sulfate fraction for the airmasses from the continent directions. Vis shows better correlation with PM2.5 and PM10 mass concentrations when RH effect on aerosol hygroscopic growth is considered. At BGS, the sulfate mass fraction in PM2.5 and PM10 (in average 32.4% and 27.4%) can explain about 60.7% and 74.3% of the variance of the aerosol MEE, respectively; sulfate and nitrate contribute to about 61% of the light extinction. RH plays a key role in aerosol extinction and visibility variation over this coastal area of China. Formation of the secondary aerosol (especially sulfate and nitrate) as well as hygroscopic growth under favorable (more stable and humid) meteorological conditions should be paid adequate attention in regulation of air quality and Vis improvement over eastern China in addition to the routine emission control measurements.

Molecular Cloning and Single Nucleotide Polymorphism Detection of Buffalo DGAT1 Gene

We report molecular cloning and single nucleotide polymorphism detection of the buffalo DGAT1 gene. Diacylglycerol acyltransferase (DGAT1) is considered the key enzyme in controlling the rate of synthesis of triglycerides. The DGAT1 gene was recently identified as a strong functional candidate gene affecting milk yield and composition in cattle. A full-length buffalo DGAT1 genomic DNA was amplified by iterative PCR based on homolog cloning. The buffalo DGAT1 gene comprises 17 exons and spans approximately 8.3 kb. The genomic structures of DGAT1 are highly conserved among mammal species. The deduced protein of buffalo DGAT1 contains 489 amino acids, showing high-sequence similarity with mammal homologs. Through PCR-SSCP analysis and sequencing, seven polymorphic positions were detected in the complete genomic region of buffalo DGAT1, and their frequencies were observed from a collection of 117 buffalo. The SNP (C/T) detected at position 11785 in exon 17 creates a substitution change for the amino acid sequence, resulting in an Ala residue (GCG) transition to a Val residue (GTG) in position 484 of buffalo DGAT1 protein. Information provided in this study will be useful in further studies to determine the role DGAT1 plays in the regulation of milk fat synthesis and quality improvement for milk in buffalo.