Support Process Improvement Research Articles

POLICY SERIES: THE MOVING FORWARD NURSING HOME COALITION: NURSING HOME REFORM AND THE RESIDENTS’ GOALS, PREFERENCES, AND PRIORITIES

Abstract The 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report called for nursing facilities to provide “care aligned to the individual’s goals and preferences.” Missing has been an efficient process to uncover the individual’s detailed goals, preferences, and priorities (GPPs). GPPs are a care planning process that translates into actionable interventions, supported by quality measurement to determine whether the care provided aligns with those GPPs, and health information technology to collect GPPs efficiently and to determine if the care provided is concordant with the individual’s GPPs. A diverse set of experts representing the Moving Forward Nursing Home Quality Coalition are collaborating to develop an integrated approach to these shortcomings and will discuss these issues in detail including new approaches to the identification and documentation of GPPs for use in a modified care planning process, the status of health information technologies (HIT) processes being developed to support these changes and the development of new quality measures. While the Moving Forward Coalition is focused on nursing facilities, the approaches being developed here to improve care and to standardize the vocabulary for GPPs are applicable to all care settings. Three committees from the Moving Forward Nursing Home Coalition will present work focused on the development of a standardized GPP care planning process to enhance the identification, documentation, communication, and implementation of resident GPPs, the measurement of the care planning process to support process improvement, and the creation of a HIT-enabled process to measure the concordance of care provided with an individual’s GPPs. This is a collaborative symposium between the Aging Workforce, Hospital Elder Life Program, Measurement, Statistics, and Research Design, Systems Research in Long Term-Care, and Technology and Aging Interest Groups.

Lean and Safety Management in Primary Care Centres: an Italian Case Study

The primary care sector is globally recognised as the pillar of an efficient and patient-centred care model. Despite its importance, many countries fail to ensure equitable access and individualised care. This problem significantly impacts the most vulnerable part of the population, such as chronic and elderly patients. In this context, considering the large number of people affected by multiple diseases, multidisciplinary and multi-organisation teamwork has become fundamental to guarantee high levels of quality, increasing patient satisfaction, and continuity of care. Furthermore, working in a multidisciplinary primary care team can improve information exchange between care providers and patients, positively impacting on clinical performance. Despite these opportunities, the primary care workforce is often overloaded in its daily activities and not adequately organised and coordinated to avoid burnout experiences and inefficient skills deployment. In this context, implementing Lean and Safety Management (L&SM) as a process improvement methodology can increase care pathways performance and integration, patient safety and satisfaction through the reduction of wastes and risks. The current study aims to implement L&SM in a primary care centre in Italy, with the final goal of increasing productivity and effectiveness in daily activities performed by primary care physicians. This project is carried out following the DMAIC cycle; a managerial approach that combines qualitative and quantitative techniques to support process improvement. The implementation roadmap will combine HLM and CRM, planning to achieve the main steps listed as follows: mapping the care demand and the available resources to define the focus of the study; identifying the most representative and critical patients; mapping the target care pathway; identifying wastes and risk and their root causes; identifying critical aspects and improvement events; implementing countermeasures; evaluating and monitoring results. The expected results of the forthcoming months consist of measurable improvements within the healthcare pathway, supporting the optimisation of the primary care centre. Moreover, this initiative may represent a pilot case for other similar projects, contributing to spread L&SM culture throughout primary care centres with benefits for both patients and clinical staff.

Improving Cancer Care Delivery: Learnings for Oncology Nurses and Patient Navigation From a National Quality Survey.

Background:Although implementation of patient navigation programs in clinical practice is widespread, heterogeneity exists in the design and delivery of these services. Greater clarity is required on competencies of personnel, delineation of their roles in multidisciplinary cancer care teams, navigation service components that positively impact patient outcomes, and associated metrics.Methods:A national, double-blind, online survey was implemented between January 24, 2019, and April 25, 2019, to investigate care coordination for advanced (stage III/IV) non–small cell lung cancer (NSCLC). Respondents included multidisciplinary team (MDT) members, such as oncologists, pathologists, oncology nurses, advanced practice nurses, and patient navigators, from US cancer programs. Customized questions covered NSCLC screening, diagnosis, treatment, and care coordination, with a focus on oncology nurses, advanced practice nurses, and patient navigation. Descriptive statistics were computed. Subanalyses examined relationships between care delivery and outcomes such as shared decision-making (SDM) through statistical testing.Results:Across programs, there was a lack of patient (nurse or lay) navigators (22.3%, 101/452) to assist patients with NSCLC. Most respondents (90.1%, 100/111) worked in programs with no formal health literacy assessments. Significantly higher mean SDM scores (p < .05) were observed in programs with patient navigators compared with programs without these specialists.Conclusion:Patient navigation is pivotal to enhancing the patient experience along the lung cancer care continuum and should be strategically integrated within lung cancer MDTs. These findings, along with survey inputs from other MDT disciplines, can help support process improvement plans for patient-centered advanced NSCLC care delivery.

Department of Defense Trauma Registry Infectious Disease Module Impact on Clinical Practice.

The Joint Trauma System (JTS) is a DoD Center of Excellence for Military Health System trauma care delivery and the DoD's reference body for trauma care in accordance with National Defense Authorization Act for Fiscal Year 2017. Through the JTS, evidence-based clinical practice guidelines (CPGs) have been developed and subsequently refined to standardize and improve combat casualty care. Data are amassed through a single, centralized DoD Trauma Registry to support process improvement measures with specialty modules established as the registry evolved. Herein, we review the implementation of the JTS DoD Trauma Registry specialty Infectious Disease Module and the development of infection-related CPGs and summarize published findings on the subsequent impact of the Infectious Disease Module on combat casualty care clinical practice and guidelines. The DoD Trauma Registry Infectious Disease Module was developed in collaboration with the Infectious Disease Clinical Research Program (IDCRP) Trauma Infectious Disease Outcomes Study (TIDOS). Infection-related information (e.g., syndromes, antibiotic management, and microbiology) were collected from military personnel wounded during deployment June 1, 2009 through December 31, 2014 and medevac'd to Landstuhl Regional Medical Center in Germany before transitioning to participating military hospitals in the USA. To support process improvements and reduce variation in practice patterns, data collected through the Infectious Disease Module have been utilized in TIDOS analyses focused on assessing compliance with post-trauma antibiotic prophylaxis recommendations detailed in JTS CPGs. Analyses examined compliance over three time periods: 6 months, one-year, and 5 years. The five-year analysis demonstrated significantly improved adherence to recommendations following the dissemination of the 2011 JTS CPG, particularly with open fractures (34% compliance compared to 73% in 2013-2014). Due to conflicting recommendations regarding use of expanded Gram-negative coverage with open fractures, infectious outcomes among patients with open fractures who received cefazolin or expanded Gram-negative coverage (cefazolin plus fluoroquinolones and/or aminoglycosides) were also examined in a TIDOS analysis. The lack of a difference in the proportion of osteomyelitis (8% in both groups) and the significantly greater recovery of Gram-negative organisms resistant to aminoglycosides or fluoroquinolones among patients who received expanded Gram-negative coverage supported JTS recommendations regarding the use of cefazolin with open fractures. Following recognition of the outbreak of invasive fungal wound infections (IFIs) among blast casualties injured in Afghanistan, the ID Module was refined to capture data (e.g., fungal culture and histopathology findings, wound necrosis, and antifungal management) needed for the TIDOS team to lead the DoD outbreak investigation. These data captured through the Infectious Disease Module provided support for the development of a JTS CPG for the prevention and management of IFIs, which was later refined based on subsequent TIDOS IFI analyses. To improve combat casualty care outcomes and mitigate high-consequence infections in future conflicts, particularly in the event of prolonged field care, expansion, refinement, and a mechanism for sustainability of the DoD Trauma Registry Infectious Disease Module is needed to include real-time surveillance of infectious disease trends and outcomes.

‘Lean 4.0’: How can digital technologies support lean practices?

Digital technologies, such as advanced analytics, autonomous vehicles or the Internet of Things, are often touted as means to substantially improve operations. While this potential has been frequently highlighted and evidenced from single case applications, we still lack a deeper theoretical understanding of the underlying mechanisms how digital technologies can support process improvement in general, and lean practices more specifically. In this paper, we use a qualitative study based on focus group design to understand how manufacturing and supply chain management professionals perceive the potential of digital technologies in support of lean practices. We identify eight digital waste reduction mechanisms that illustrate how digital technologies can support lean practices. These include a cluster of mechanisms that augment operational execution in terms of speed and precision of execution, as well as flexibility in space and time. Furthermore, we identify a second cluster of mechanisms that augment decision-making through visibility, feedback, engagement, and prevention. In terms of managerial implications, our findings provide firms with a structured approach how to identify those digital technologies that can most effectively support their respective process improvement activities.

A Sub-Analysis of U.S. Africa Command Area of Operations Transportations for Ophthalmic Concerns, 2008-2018.

American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

Integrated Pharmacy and PrEP Navigation Services to Support PrEP Uptake: A Quality Improvement Project.

Preexposure prophylaxis (PrEP) is highly effective in preventing HIV among both men and women, with the reduction in risk directly linked to medication adherence. Navigation services and other adherence interventions have demonstrated efficacy in medication uptake; however, their use may not be fully integrated into clinic operations or their roles clearly defined. This quality improvement (QI) project developed an evidenced-based PrEP Navigation (PN) tool to identify patient-reported barriers to uptake and to support process improvement at a large community health center in Washington, DC. Outcomes related to patient-reported barriers, patient demographics, and time to medication pickup from the pharmacy were measured before and after implementation. A total of 198 patients were included in this analysis. Mean days from initial prescription to medication pickup was reduced by 1.42 days (p = .030) following PN tool implementation. The evidenced-based PN tool is modifiable to the needs of the individual clinic and the patients they care for to support wide-scale PrEP uptake and continuous system process improvements.

Measuring Lipolytic Activity to Support Process Improvements to Manage Lipase-Mediated Polysorbate Degradation.

Polysorbates are critical stabilizers in biopharmaceutical protein formulations. However, they may degrade in drug substance (DS) or drug product (DP) during storage. Degradation catalyzed by lipases present in host cell proteins (HCPs) is one suspected root cause. The purpose of this study was to develop an assay to detect lipolytic activity in biopharmaceutical DS and DP formulations. The assay is based on the hydrolysis of the lipase substrate 4-methylumbelliferyl oleate to yield the fluorescent product 4-methylumbelliferone. First, the assay components and their concentrations (buffer salts and pH, solvent and inhibitor Orlistat) were established and optimized using a model lipase (Porcine pancreatic lipase) and cell culture harvest fluid that exhibited lipolytic activity. The assay was then successfully applied and thereby qualified in protein formulations and at lipase concentrations possibly encountered in actual biopharmaceutical DS and DP formulations. The lipase assay can be used to detect lipolytic activity in intermediate and final DS, for example during process optimization in downstream purification, to better and specifically reduce the level, or deplete, lipases from HCPs. The assay is also suitable to be applied during root cause investigations related to polysorbate degradation in biopharmaceutical DP.

Methodological Approaches to Support Process Improvement in Emergency Departments: A Systematic Review.

The most commonly used techniques for addressing each Emergency Department (ED) problem (overcrowding, prolonged waiting time, extended length of stay, excessive patient flow time, and high left-without-being-seen (LWBS) rates) were specified to provide healthcare managers and researchers with a useful framework for effectively solving these operational deficiencies. Finally, we identified the existing research tendencies and highlighted opportunities for future work. We implemented the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to undertake a review including scholarly articles published between April 1993 and October 2019. The selected papers were categorized considering the leading ED problems and publication year. Two hundred and three (203) papers distributed in 120 journals were found to meet the inclusion criteria. Furthermore, computer simulation and lean manufacturing were concluded to be the most prominent approaches for addressing the leading operational problems in EDs. In future interventions, ED administrators and researchers are widely advised to combine Operations Research (OR) methods, quality-based techniques, and data-driven approaches for upgrading the performance of EDs. On a different tack, more interventions are required for tackling overcrowding and high left-without-being-seen rates.

Applying clustering and classification data mining techniques for competitive and knowledge‐intensive processes improvement

Processes as one of the valuable knowledge resources can create sustainable competitive advantages in organizations. There is a large number of processes in organizations. They generate a high volume of process data that leads to the high‐dimensionality problems, complex relationships, dynamic changes, and difficulties in the understanding of the process by human resources. Traditional process improvement methodologies have weaknesses in environment with the large number of processes. Data mining techniques can support process improvement in this environment. They can recommend the improvement suggestions through extracting valuable patterns from a high volume of the process dataset. Recently, knowledge‐intensive processes have been increasingly concentrated in the field of process improvement. These types of processes can induce a competitive behavior over the other processes. The main problem is the improvement of competitive and knowledge‐intensive processes in a high volume of process dataset.The main purpose of this paper is to present a model to identify the behavior of competitive and knowledge‐intensive processes and recommend improvement suggestions. For this purpose, data mining techniques are applied to extract valuable patterns hidden in a high volume of process dataset. In this regard, K‐means clustering and C5 classification algorithms are applied to extract valuable patterns. A real process dataset was used to evaluate the effectiveness and applicability of the model. The results confirmed that the proposed model can apply data mining techniques to support competitive and knowledge‐intensive process improvement in a high volume of process dataset.

Process-Model-Driven Guidance to Reduce Surgical Procedure Errors: An Expert Opinion

This paper explains how a detailed, precise surgical process model can help reduce errors by fostering better understanding, providing guidance during surgery, helping train newcomers, and by supporting process improvement. It describes the features that a process-modeling language should have in order to support the precise specification of such models.

Benchmark-Instrument for Controlling as a Function of Higher Education-Comparative Analysis in Bosnia and Herzegovina

&lt;em&gt;Object of research is such that it is necessary to ask why even conducted “benchmark” in higher education? Analysis and comparison of the organizational units within the company itself, but also with the competition, will help in understanding the success factors, determining the problem areas of the subject and knowledge of roads to improve the current situation. Use that provides quality made “benchmark” be located in the recognition requirements of consumers, establish effective goals, development of accurate indicators of production, improve competitiveness, and the installation of the best business process. I would say that benchmark contributes to determining the best way carry out a satisfied customer, cost-efficient collection of creative ideas, knowledge of own strengths and weaknesses, and supporting process improvement of continuing action. Therefore, all the work put in relation to the Higher Education Benchmarks.&lt;/em&gt;

Improving Measurement Systems to Support Process Improvement Efforts in Health Care

Quality problem or issue: To improve the operations of one federally qualified health center, this research sought to reduce patient cycle time. However, this investigation was impeded by the health center’s lack of an accurate and reliable measurement system. Initial assessment: To address this issue, this health center undertook a process improvement project in one of their faclitites. Through process mapping and measurement activities, project team members obtained a collective understanding regarding the inner workings of their process and identified problems with their measurement system regarding missing and infeasible data. Choice of solution: Through a series of process audits, project team members identified that measurement errors were due to not having a specific staff member assigned to check-out patients; later, they found this was due to medical assistants not fully understanding how to enter patient check-out times in the electronic medical record. Implementation: The accuracy and reliability of the measurement system was improved by assigning the task of checking out patients to medical assistants, and providing them with training about how to enter patient check-out times in the electronic medical record. Evaluation: The effect of the improvements made to the measurement system are evident given the decrease in the amount of infeasible patient cycle time data recorded (34% less) and the reduction in patient cycle time variation for the improved process. Lessons learned: This case study provides an example from which others can learn regarding the importance of measurement system accuracy and reliability with respect to process improvement efforts.

Developing an integrated framework for using data mining techniques and ontology concepts for process improvement

Process, as an important knowledge resource, must be effectively managed and improved. The main problems are the large number of processes, their specific features, and the complicated relationships between them, which all lead to the increase in complexity and create a high-dimensionality problem. Traditional process management systems are unable to manage and improve processes with a high volume of data. Data mining techniques, however, can be employed to identify valuable patterns. With the aid of these patterns, suggestions for process improvement can be presented. Further, process ontology can be applied to share the process patterns between people, facilitate the process understanding, and develop the reusability of the extracted patterns for process improvement.This study presents a combined three-part, five-stage framework of data mining, process improvement, and process ontology. To evaluate the applicability and effectiveness of the proposed framework, a real process dataset is applied. Two clustering and classification techniques are used to discover valuable patterns as the process ontology. The output of these two techniques can be considered as the recommendations for improving the processes. The proposed framework can be exploited to support process improvement methodologies in organizations.

Debugging‐workflow‐aware software reliability growth analysis

SummarySoftware reliability growth models support the prediction/assessment of product quality, release time, and testing/debugging cost. Several software reliability growth model extensions take into account the bug correction process. However, their estimates may be significantly inaccurate when debugging fails to fully fit modelling assumptions. This paper proposes debugging‐workflow‐aware software reliability growth method (DWA‐SRGM), a method for reliability growth analysis leveraging the debugging data usually managed by companies in bug tracking systems. On the basis of a characterization of the debugging workflow within the software project under consideration (in terms of bug features and treatment phases), DWA‐SRGM pinpoints the factors impacting the estimates and to spot bottlenecks, thus supporting process improvement decisions. Two industrial case studies are presented, a customer relationship management system and an enterprise resource planning system, whose defects span a period of about 17 and 13 months, respectively. DWA‐SRGM revealed effective to obtain more realistic estimates and to capitalize on the awareness of critical factors for improving debugging.

Evaluating Business Process Maturity Models

Maturity models have become important aids to support process improvement. However, researchers have frequently criticized the many business process maturity models (BPMMs) for differing in quality, which creates a demand for comparing and evaluating these models. This paper describes a well-founded, ranked, and weighted set of critical criteria for BPMMs that are most important to prospective users. The paper also demonstrates how this set can serve as a standard or guideline for designing BPMMs. In evaluating the used sample of BPMMs against the set of criteria, we reveal gaps and shortcomings of current BPMMs, make suggestions for raising the quality of BPMMs, and highlight future research avenues.

An ontology-based approach for integrating tools supporting the software measurement process

Context: Software measurement is a fundamental practice to support process improvement and project management, since it provides useful data for decision making at both organizational and project levels. Due to the nature of software measurement activities, the use of computational supporting tools is essential. Software measurement can be performed in the context of various software processes and these processes generally have different supporting tools. Thus, it is common to use several tools to allow collecting data regarding the processes. Tools are usually developed at different time, by different teams and without concern for integration. As a result, organizations have to deal with integration issues to enable communication between tools and to properly support the measurement process. A key factor for integration is that tools share a common understanding regarding the meaning of the exchanged terms and services. In other words, it is important to deal with integration not only at the syntactic level, but also at the semantic level. Among the instruments used to address semantics, ontologies have been acknowledged as an important means to address semantic integration. Objective: This paper presents the Ontology-Based Approach for Measurement Systems Integration (OBA-MSI), an approach that uses ontologies as a basis to integrate tools aiming at supporting the software measurement process. Method: OBA-MSI was developed following the Design Science Research paradigm. To evaluate OBA-MSI, we carried out a case study in which we used the approach to integrate tools for a real software development organization. After that, we applied a survey to get feedback from users of the integrated solution. Results: The users stated that the integrated solution obtained from applying OBA-MSI properly supported the software measurement process and added value to the organization, providing more benefits than using the tools in isolation. Conclusions: The use of OBA-MSI to aid tools integration helps deal with semantic conflicts and contributes to obtain a proper support to the software measurement process.

Activating clinical trials: a process improvement approach.

BackgroundThe administrative process associated with clinical trial activation has been criticized as costly, complex, and time-consuming. Prior research has concentrated on identifying administrative barriers and proposing various solutions to reduce activation time, and consequently associated costs. Here, we expand on previous research by incorporating social network analysis and discrete-event simulation to support process improvement decision-making.MethodsWe searched for all operational data associated with the administrative process of activating industry-sponsored clinical trials at the Office of Clinical Research of the University of South Florida in Tampa, Florida. We limited the search to those trials initiated and activated between July 2011 and June 2012. We described the process using value stream mapping, studied the interactions of the various process participants using social network analysis, and modeled potential process modifications using discrete-event simulation.ResultsThe administrative process comprised 5 sub-processes, 30 activities, 11 decision points, 5 loops, and 8 participants. The mean activation time was 76.6 days. Rate-limiting sub-processes were those of contract and budget development. Key participants during contract and budget development were the Office of Clinical Research, sponsors, and the principal investigator. Simulation results indicate that slight increments on the number of trials, arriving to the Office of Clinical Research, would increase activation time by 11 %. Also, incrementing the efficiency of contract and budget development would reduce the activation time by 28 %. Finally, better synchronization between contract and budget development would reduce time spent on batching documentation; however, no improvements would be attained in total activation time.ConclusionThe presented process improvement analytic framework not only identifies administrative barriers, but also helps to devise and evaluate potential improvement scenarios. The strength of our framework lies in its system analysis approach that recognizes the stochastic duration of the activation process and the interdependence between process activities and entities.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1227-2) contains supplementary material, which is available to authorized users.

Functional assessment and structural basis of antibody binding to human papillomavirus capsid.

Persistent high-risk human papillomavirus (HPV) infection is linked to cervical cancer. Two prophylactic virus-like particle (VLP)-based vaccines have been marketed globally for nearly a decade. Here, we review the HPV pseudovirion (PsV)-based assays for the functional assessment of the HPV neutralizing antibodies and the structural basis for these clinically relevant epitopes. The PsV-based neutralization assay was developed to evaluate the efficacy of neutralization antibodies in sera elicited by vaccination or natural infection or to assess the functional characteristics of monoclonal antibodies. Different antibody binding modes were observed when an antibody was complexed with virions, PsVs or VLPs. The neutralizing epitopes are localized on surface loops of the L1 capsid protein, at various locations on the capsomere. Different neutralization antibodies exert their neutralizing function via different mechanisms. Some antibodies neutralize the virions by inducing conformational changes in the viral capsid, which can result in concealing the binding site for a cellular receptor like 1A1D-2 against dengue virus, or inducing premature genome release like E18 against enterovirus 71. Higher-resolution details on the epitope composition of HPV neutralizing antibodies would shed light on the structural basis of the highly efficacious vaccines and aid the design of next generation vaccines. In-depth understanding of epitope composition would ensure the development of function-indicating assays for the comparability exercise to support process improvement or process scale up. Elucidation of the structural elements of the type-specific epitopes would enable rational design of cross-type neutralization via epitope re-engineering or epitope grafting in hybrid VLPs.

Best practices and process improvement. An application for the transfer and management of knowledge to the transportation of hydrocarbons in ECOPETROL

Knowledge’s processes enrich the information bringing value to organizations. These formal or informal, processes increase the value of information and useful knowledge of people and organizations. Therefore, in order to identify good practices that promote the improvement of processes for the implementation of knowledge management in the area of transport hydrocarbon, this exploratory study it perform on ECOPETROL, Colombia's largest oil company. Due to its size, it belongs to 40 largest oil and gas companies in the world´s group and recognize as one of the four major in Latin American. The study target the workshops developed within the Operations and Maintenance teams using the methodology of the Knowledge Assurance Guide. The results show positive impacts identifying best practices that support process improvement in the tactical, strategic and operational levels.