System-wide Improvement Research Articles

Epidemiology of Early-onset Colorectal Cancer in a Safety-net Hospital System in Texas

Goals: We aimed to characterize risk factors for early versus advanced-stage early-onset colorectal cancer (eoCRC) at our safety-net hospital system. Background: Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Rates of CRC diagnosis in young adults (age below 50) have been rising despite an overall decrease in CRC. CRC in this group is often detected late due to screening historically being for persons 50 years and older. Etiologies for the increase in rates of eoCRC remain unclear, as do the risk factors for advanced-stage, defined as stage III or IV, at presentation. Study: We conducted a retrospective cohort study of 556 adults younger than 50 years of age with an ICD-10 diagnosis of malignant neoplasm of the colon or rectum within a 10-year span. Data collected included demographics, age at diagnosis, time to diagnosis, and cancer stage at diagnosis. Multivariable analysis was used to determine factors associated with advanced-stage CRC. Results: A total of 279 patients met the inclusion criteria. Most were Hispanic (67.03%), followed by non-Hispanic Black (NHB, 24.01%). Most had advanced-stage CRC at diagnosis (85.7%, n=239), despite 67.7% (n=189) being diagnosed within 3 months of symptom onset. When compared with non-Hispanic White (NHW) patients, NHB (OR: 2.02, CI: 0.59-6.96) and Hispanic (OR: 1.68, CI: 0.57-4.95) patients had higher odds of advance-stage CRC, albeit not statistically significant. Conclusions: Most patients were diagnosed with advanced-stage disease. NHB and Hispanic patients had a nonstatistically significant higher odds of presenting at advanced-stage CRC compared with NHW patients. System-wide quality improvement interventions may be needed to screen for eoCRC in safety-net hospital systems.

Leading Systemwide Improvement in Elementary Science Education: Managing Dilemmas of Education System Building

Reforming instruction is challenging. In this comparative case study of 12 school districts, we investigated the dilemmas that emerged for system leaders as they engaged in system building for elementary science and the approaches leaders took in managing them. We found that system leaders’ efforts to manage their environments contributed to the preferential treatment of literacy and mathematics relative to science. Leaders managed this dilemma using three strategies: (a) integration of science with other subjects, (b) specialization of teachers, and (c) adopting curriculum materials. This study contributes to literature on dilemma management by showing that dilemmas in education system building are school-subject sensitive, emerge in relation to system building for other subjects, and are embedded in school and education systems’ structural/organizational arrangements.

Overtriage of transfers to the pediatric trauma center: the importance of minor head injury.

Accurate triage of minor head injuries remains a challenge for mature trauma systems. More than one-third of trauma transfers are overtriaged, and minor head injuries predominate. Overtriage is inefficient, wasteful of resources, and burdensome for families. The authors studied overtriage at the sole level I pediatric trauma center (PTC) in a small state with a view toward improvement of processes. Data on transfer patients were extracted from an institutional trauma registry over an 8-year period. Three definitions of overtriage were examined: one based on transfer criteria from the American College of Surgeons Committee on Trauma, one based on resource utilization, and one adapted to the regional environment of the PTC. Associations of demographic, geographic, clinical, and social factors with overtriage were examined. There were 1754 unique patients transferred from the emergency departments (EDs) of other institutions to the PTC. Thirty-six percent of transfers were overtriaged by all 3 criteria, and 23% of all transfers were minor head injuries overtriaged by all criteria. Infants were more likely to be overtriaged than other age groups. Among racial categories, Black patients were least likely to be overtriaged. Patients with commercial insurance were more likely to be overtriaged. Overtriaged patients averaged shorter trips from the referring ED to the PTC, even though the PTC was farther from their homes. These observations suggest a sensitivity to social expectations in the exercise of ED physician judgments about transfer. More than one-third of all transfers to the study PTC were overtriaged, and almost one-quarter of all transfers were overtriaged minor head injuries. Minor head injuries are a potentially rewarding focus for system-wide quality improvement, but the interplay of social factors with ED physician judgments must be recognized.

Emission abatement in low-carbon supply chains with government subsidy and information asymmetry

Governmental subsidy policy and channel information structure have substantial effects on supply chain emission reduction, operations and marketing decisions. In this paper, we use game theory to study the interplay of government subsidizing arrangement and information asymmetry on manufacturers' emission reduction and retailers' low-carbon promotion. Suppose realistically that the investment coefficients for manufacturers' emission reduction levels and retailer' low-carbon promotion levels are their respective private information. Among diverse governmental subsidy schemes, we find dual subsidizing are the best choice for the defined level of total subsidy under information asymmetry, while it is not always the best choice if the total subsidy level is uncertain. Under information asymmetry, the results show that manufacturer have no incentive to lie under any subsidy policy. However, the retailer has incentive to misrepresent individual information and its misreporting behaviour is related to the coefficient and allocation ratio of governmental subsidies. On this basis, we illustrate that a screening model can be deployed to reduce the negative effects of information asymmetry on supply chain operations. We therefore propose the method of improving the performance of low-carbon supply chains under various situations of information asymmetry and governmental subsidizing schemes to achieve system-wide Pareto improvement.

The impact of referring hospital resources on interfacility overtriage: A population-based analysis

BackgroundNearly half of patients transferred from non-trauma to trauma centres have minor injuries. The transfer of patients with minor injuries to trauma centres is not associated with any known patient benefit and represents an opportunity to reduce healthcare costs and improve patient experience. In this study, we evaluated the relationship between hospital resources and overtriage, with the objective of identifying targets for system-level intervention. MethodsWe conducted a population-based cohort study of adults, age ≥ 16, presenting with minor injuries to non-trauma centres in Ontario, Canada (2009–2020). The primary outcome was overtriage, defined as transfer to a trauma centre. Hierarchical logistic regression was used to evaluate the association between hospital resources and a patient's likelihood of being overtriaged, adjusting for case-mix. Resultsamongst 165,302 patients with minor injuries, 15,641 (9.5 %) were transferred to a trauma centre (overtriage). Presence of a CT scanner, surgical support, or intensive care unit had no impact on a patient's likelihood of overtriage. Relative to community hospitals, presentation to a teaching hospital was independently associated with greater odds of overtriage (OR 2.97, 95 % CI: 1.26–7.00). Accounting for case-mix and resources, the median difference in a patient's odds of overtriage varied 3.7-fold across non-trauma centres (MOR 3.76). ConclusionsThere is significant variability in overtriage across non-trauma centres, even after adjusting for case-mix and hospital resources. These finding suggests that some centres have developed processes to minimize overtriage independent of available resources. Broad implementation of these processes may represent an opportunity for system-wide quality improvement.

Prospective Study of a System-Wide Adrenal Incidentaloma Quality Improvement Initiative.

Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs. This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral. The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517). This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs.

Santeon’s Lessons from a Decade of Implementing Value-Based Health Care

Summary Despite growing global support for value-based health care (VBHC), there is no consensus on the best approach for the identification of improvement potential nor on the selection and implementation of improvement initiatives. In addition, varying frames of reference shape how individuals interpret the concept of value and how they implement VBHC. As a result, it is often implemented in various and fragmented ways. Santeon, a nonprofit formal alliance of seven Dutch teaching hospitals, has been working on VBHC since 2012. In this article, intended to address gaps in the literature regarding the implementation of VBHC, the authors use the new strategic agenda for value transformation to share more than 10 years of Santeon’s VBHC implementation experience. The authors provide an overview of Santeon’s implementation methods; describe challenges and lessons learned; and demonstrate how value transformation was achieved with tangible examples from birth care, chronic kidney disease care, and breast cancer care. In breast cancer care, for example, system-wide improvement initiatives resulted in an increase in breast-conserving surgeries on an outpatient basis (from 391 in 2014 and 2015 to 458 in 2016), and a reduction in reoperation rates owing to positive tumor margins (from 39 in 2014 and 2015 to 33 in 2016). These results were subsequently used to negotiate a collective value-based reimbursement model with insurance companies.

Pukekauri farm – snapshots from a sustainability journey

Pukekauri Farm is a 295 ha mixed livestock hill country property in the western Bay of Plenty. Over the last 20+ years the owners have been on a development journey with a focus on the multiple dimensions of sustainability – economic, environmental, and social. This paper seeks to document that journey, with supporting resource, production, financial and environmental data to quantify progress. Some of the most useful tools have included high quality forage crops, deferred grazing, sheep genetics, accounting software and paddock-scale soil and water resource maps. Key lessons include the value of knowledge networks and modelling tools, the power of a farm plan for optimising land use and management, the importance of both profitability and grants to underwrite development investment, and the emergence of secondary benefits from decisions focused on system-wide improvement. Over 20 years, despite areduction in grazed area of 20%, meat production has increased by 16%, EBITR/ha has increased by 6%, modelled net greenhouse gas emissions have declined by 60% and modelled N leaching has declined by 29%. Overall, the farm is easier to manage and more pleasant to dwell in.

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.

Perioperative Team-Based Morbidity and Mortality Conferences: A Systematic Review of the Literature.

This systematic review aimed to identify key elements of perioperative team-based morbidity and mortality conferences (TBMMs) and their impact on patient safety, education, and quality improvement outcomes. Patient safety in the perioperative period is influenced by system, team, and individual behaviors. However, despite this recognition, single-discipline morbidity and mortality conferences remain a mainstay of educational and quality improvement efforts. A structured search was conducted in MEDLINE Complete, Embase, Web of Science, ClinicalTrials.gov, Cochrane CENTRAL, and ProQuest Dissertations and Theses Global in July 2022. Search results were screened, and the articles meeting inclusion criteria were abstracted. Seven studies were identified. Key TBMM elements were identified, including activities done before the conference-case selection and case investigation; during the conference-standardized presentation formats and formal moderators; and after the conference-follow-up emails and quality improvement projects. The impacts of TBMMs on educational, safety, and quality improvement outcomes were heterogeneous, and no meta-analysis could be conducted; however, improvement was typically shown in each of these domains where comparisons were made. Recommendations for key TBMM elements can be drawn from the reports of successful perioperative TBMMs. Possible benefits of structured TBMMs over single-discipline conferences were identified for further exploration, including opportunities for rich educational contributions for trainees, improved patient safety, and the potential for system-wide quality improvement. Design and implementation of TBMM should address meticulous preparation of cases, standardized presentation format, and effective facilitation to increase the likelihood of realizing the potential benefits.

Pediatric Advance Care Planning: A Scoping Review.

To assess current practice and provide a basis for a provincial template, clinicians at a Canadian pediatric hospice reviewed the literature surrounding pediatric advance care planning (pACP) documentation, process, and implementation for children/youth. The scoping review protocol was developed in accordance with the Joanna Briggs Institute methodology for scoping reviews, and was prospectively registered on the Open Science Framework. MEDLINE, Embase, CINAHL, the Web of Science Core Collection, and Google Scholar, as well as sources of unpublished studies and grey literature, were reviewed. Sixty-four articles met the criteria. Fifteen pACP documentation forms/tools were also identified. Overall, the included articles highlighted that pACP should be a structured, collaborative and iterative process between the family and a trusted or relevant healthcare provider, encompassing medical and non-medical issues. Few articles provided insights into specific elements recommended for advance directive forms. Identified strategies for implementation included a structured, step-by-step pACP interventional tool along with ongoing training, mentorship, and defined organizational structures for the clinician. No single specific ACP tool was acknowledged as the gold standard. Use of a pACP tool, along with ongoing provider education and communication skill development, standardized/accessible documentation, and system-wide quality improvement support, were noted as integral components of pACP.

Implementing an intervention to improve leadership/management of public healthcare services in the Free State Province, South Africa: lessons learned.

Based on the World Health Organization's health systems strengthening framework, the Health Systems Governance and Accountability (HSGA) intervention to strengthen public health leadership/management, service integration and outcomes was developed in the Free State. This study describes the process to implement and measure the effects of the HSGA intervention for system-wide improvement of leadership/management under routine conditions in a resource-constrained setting. Based on normalisation process theory, participatory discussions were held with health managers, staff and local stakeholders to attain buy-in. Evaluation of the implementation process considered progress in improving leadership/management through application of the Balanced Scorecard (BSC). All provincial reporting units were assessed during 2014/15 and again during 2015/16. The mean scores on three BSC perspectives improved statistically significantly from 2014/15 to 2015/16: customer (p=0.0085), internal business processes (p=0.0008) and finance (p=0.0001). Overall leadership/management also improved significantly (p=0.0007). Improvement in leadership/management resulting from implementation of the HSGA intervention was observed during the two years under study. From this experience, successful implementation of a health systems strengthening intervention hinges on a participatory design, appropriate use of theory, as well as application of an evaluation approach to assess the success of implementation.

Premium power investment strategy utilizing the economy of scale of custom power devices

The possible existence of ‘economy of scale’ in manufacturing poor power quality (PQ) mitigation devices motivates customers to participate in a common mitigation solution. A custom power park (CPP) is an option where the CPP operator offers a set of custom solutions to a group of customers. Given that these custom solutions comprise one or many custom power devices, both CPP operators and the customers are expected to coordinate to obtain individual mitigation device ratings while maximizing the overall utility of customers. Here, CPP operators would calculate ratings of custom solutions and associated unit cost for the minimal total cost, while the customers are expected to select custom solutions to maximize their overall benefit. Furthermore, the customers utilize their willingness-to-pay function in this process and strictly participate in this arrangement if the utility received is more than their self-generated non-negative utility. Without the CPP operator, customers would form a CPP-like arrangement to recover the cost of investment and operation and maintenance. This combinatorial problem has been solved in two stages, involving the calculation of independently generated utility in the first stage and the overall CPP designing problem in the second stage. While customer and operator-side nonlinearities in the cost functions have been suitably discretized, the proposed methodology ensures that the solution space remains intact. The proposed method is illustrated using three devices, three custom solutions, and three customers. • Existence of economy of scale is a motivating factor for common mitigation solution. • A system-wide PQ improvement might not lead to a socially justifiable outcome. • Customers participate if utility received is more than self-generated utility. • Proposed method converts the MINLP problem into MIP. • Proposed methodology could be used for complex problems with similar structure.

Understanding the Impact of Medicaid-Serving Primary Care Team Functioning and Clinical Context on Cancer Care Treatment Quality: Implications for Addressing Structural Inequities.

Primary care factors related to Medicaid enrollees' receipt of guideline concordant cancer treatment is understudied; however, team structure and processes likely affect care disparities. We explore Medicaid-serving primary care teams functioning within multiteam systems to understand performance variations in quality of breast and colorectal cancer care. We conducted a comparative case study, using critical case sampling of primary care clinics in New Jersey, to provide maximum variation on clinic-level care performance rates (Medicaid enrollees' receipt of guideline-concordant treatment). Site evaluations, conducted from 2019 to 2020, included observation (2-3 days) and interviews. Using a multistep analytic process, we explored contextual factors within primary care that may contribute to cancer care performance variations. We identified performance variations stemming from adaptations of multiteam system inputs and processes on the basis of contextual factors (ie, business model, clinic culture). Team 1 (average performer), part of a multisite safety-net clinic system, mainly teamed outside their organization, relying on designated roles, protocol-based care, and quality improvement informed by within-team metrics. Team 2 (high performer), part of a for-profit health system, remained mission-driven to improve urban health, teamed exclusively with internal teams through electronically enabled information exchange and health system-wide quality improvement efforts. Team 3 (low performer), a physician-owned private practice with minimal teaming, accepted Medicaid enrollees to diversify their payer mix and relied on referral-based care with limited consideration of social barriers. Primary care team structures and processes variations may (in part) explain performance variations. Future research aiming to improve care quality for Medicaid populations should consider primary care teams' capacity and context in relation to composite teams to support care quality improvements in subsequent prospective trials.

Creation of a quality improvement collaborative to address adolescent and young adult cancer clinical trial enrollment: ATAQI (AYA trial access quality initiative)

Adolescent and young adult (AYA) participation in cancer clinical trials (CCTs) is suboptimal, hindering further improvements in survival, quality of life, and basic understanding of cancer pathophysiology in this population. Prior studies have identified barriers and facilitators to AYA CCT enrollment; however, few interventional studies have attempted to address these barriers and measure tangible changes. In September 2020, a task force was established to address CCT enrollment barriers at a multi-institutional level utilizing a quality improvement collaborative model for improvement. The AYA Trial Access Quality Initiative was developed with the goal of bring multidisciplinary teams together across multiple sites to learn, apply and share their methods of improvement. It uses a structured process of learning sessions lead by quality improvement and clinical experts who help facilitate learning and problem solving which are followed by action phases. During the pilot phase of the collaboration, one key driver of CCT enrollment in AYA's will be addressed: communication between adult and pediatric oncology by implementation of various interventions at sites. The number of AYAs screened for and enrolled on CCTs will be tracked over the course of the collaborative along with the process measures. It is expected that the interventions will promote engagement of stakeholders in the process of screening AYA oncology patients for eligibility on CCTs. This will hopefully create a favorable environment conducive for increasing enrollment on CCTs and lead to the development of a system-wide quality improvement framework to improve AYA CCT enrollment.

Evaluation of Systemwide Improvement Programs to Optimize Time to Surgery for Patients With Hip Fractures

Longer time to surgery (TTS) for hip fractures has been associated with higher rates of postoperative complications and mortality. Given that more than 300 000 adults are hospitalized for hip fractures in the United States each year, various improvement programs have been implemented to reduce TTS with variable results, attributed to contextual patient- and system-level factors. To catalog TTS improvement programs, identify their results, and categorize program strategies according to Expert Recommendations for Implementing Change (ERIC), highlighting components of successful improvement programs within their associated contexts and seeking to guide health care systems in implementing programs designed to reduce TTS. A systematic review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Three databases (MEDLINE/PubMed, EMBASE, and Cochrane Trials) were searched for studies published between 2000 and 2021 that reported on improvement programs for hip fracture TTS. Observational studies in high-income country settings, including patients with surgical, low-impact, nonpathological hip fractures aged 50 years or older, were considered for review. Improvement programs were assessed for their association with decreased TTS, and ERIC strategies were matched to improvement program components. Preliminary literature searches yielded 1683 articles, of which 69 articles were included for final analysis. Among the 69 improvement programs, 49 were associated with significantly decreased TTS, and 20 programs did not report significant decreases in TTS. Among 49 successful improvement programs, the 5 most common ERIC strategies were (1) assess for readiness and identify barriers and facilitators, (2) develop a formal implementation blueprint, (3) identify and prepare champions, (4) promote network weaving, and (5) develop resource-sharing agreements. In this systematic review, certain components (eg, identifying barriers and facilitators to program implementation, developing a formal implementation blueprint, preparing intervention champions) are common among improvement programs that were associated with reducing TTS and may inform the approach of hospital systems developing similar programs. Other strategies had mixed results, suggesting local contextual factors (eg, operating room availability) may affect their success. To contextualize the success of a given improvement program across different clinical settings, subsequent investigation must elucidate the association between interventional success and facility-level factors influencing TTS, such as hospital census and type, teaching status, annual surgical volume, and other factors.

Reflections on the implementation and evaluation of a system-wide improvement programme based on the fundamentals of care: Lessons learned.

To demonstrate how implementing a system-wide measurement and improvement programme can make the delivery of the Fundamentals of Care visible in practice. Discussion paper. A retrospective evaluation of the experience of implementing a system-wide peer review programme using the Promoting Action on Research Implementation in Health Services framework. Implementing this programme engages nursing leaders at all levels in fundamental care delivery, evaluation and improvement. It positions nursing leaders as accountable for and champions of fundamental care. The peer review programme offers a solution to the complex challenge of measuring the fundamentals of care in practice. Successful implementations of this programme at two New Zealand inpatient sites have shown positive results in improved care and patient experience. This makes it worthy of consideration for other health organizations. Nursing leadership has proven to be critical to success. The Promoting Action on Research Implementation in Health Services framework highlights the components that assist with successful implementation and assists in presenting a case for change. This paper addressed the problem of the lack of action and dearth of quality, integrated data, visibility of the patient experience and the contribution of nursing leadership in an inpatient setting. Findings indicate that the peer review programme is translatable, modifiable and sensitive to ethnicity and disability. Using the implementation framework to evaluate the process has provided a guide for future implementations.

Increasing Naloxone Co-Prescribing Among At-Risk Individuals: Evaluation of a Quality Improvement Project in a Large Health System

Background: Naloxone availability and early administration is key in preventing death following opioid overdose. The CDC advises that naloxone should be made available to all at-risk individuals. In 2017, providers at Maine Medical Center noted that only 6% of at-risk patients had naloxone prescriptions Methods: Included in this study were all patients of MaineHealth, a health system comprising 9 hospitals and 30 primary care practices, serving approximately 1.1 million patients. Between 2017 and 2020, we implemented several system-wide quality improvement interventions to increase rates of naloxone co-prescribing among at-risk individuals. Risk factors included prescribed opioids ≥50 morphine milligram equivalents, concurrent prescriptions for opioids and benzodiazepines or sedative/hypnotics, a diagnosis of substance use disorder, or a history of opioid overdose. Our interventions included (1) a standing order for naloxone in the hospital pharmacy, (2) in-person naloxone trainings for all clinical and non-clinical primary care staff, (3) online training modules, (4) guidelines on naloxone co-prescribing sent via email, and (5) automated alerts in the electronic medical record (EMR). To evaluate these interventions, the EMR for, was queried for patients with one or more risk factors for opioid overdose, and whether they had naloxone on their medication list between 2017 and 2020. Results: Over the course of the study period, overall rate of naloxone co-prescribing system-wide increased from 0.4% to 26% of patients. Automatic EMR alerts were associated with an increase of 4.5%, the largest single-quarter increase. Online education modules and guideline dissemination were associated with smaller increases of 0.9% and 3% in the two quarters following their implementation. In-person trainings and making naloxone available without a prescription were followed by Conclusions: Our most effective intervention was automatic alerts in the EMR, while e online trainings and guidelines produced modest effects. A notable increase was also seen in one hospital system whose entire leadership and staff deliberately prioritized increasing naloxone access. Even with these gains, we have not yet achieved adequate co-prescribing across our system.

The perception of health care quality by primary health care managers in Ukraine

BackgroundUkraine is reforming its health care system to improve quality of health care. Insight into how primary health care managers perceive quality is important for the ongoing reform as well as for the improvement of medical services.MethodsAn online survey was conducted as part of the Ukrainian-Swiss project “Medical Educational Development” in April–May 2019 based on the contact list of USAID project “Health Reform Support”, and additionally on the database of the National Health Service of Ukraine and other channels. Data were analyzed using descriptive statistics and qualitative data analysis.ResultsIn total, 302 health care managers took part in the study. The majority of primary health care managers perceive quality in health care as process quality. They associate quality mostly with compliance to standards. At the same time, primary health care managers prefer to assess outcome quality via a system of indicators and feedback. There appears to be a lack of consensus about health care quality. This may be due to a lack of awareness of the national strategy for better quality of health care service.ConclusionsOur study provides new insights into primary care managers' perceptions of health care quality in Ukraine. The absence of a clear consensus about quality complicates the discussion about quality and how to measure quality in health care. This appears to be one of the obstacles to system-wide quality improvement.

MIMO architecture for fast convergence of distributed online optimization in smart grids

This paper proposes an architectural solution to enhance the resilience of distributed decision-making and control in microgrids and smart grids with respect to communication delays. The paper develops a resource allocation framework to optimally place the multiple-input multiple-output (MIMO) communication technology on critical channels to reduce the communication bottle neck and expedite the convergence speed of distributed online optimization algorithms, which require convergence in the cyber network before the solution can be implemented on the physical grid. The paper shows that optimal placement of the MIMO technology can decrease communication transmission delays, which in turn improves the reliability of power system operational protocols, such as distributed frequency regulation. Illustrative case studies using data from real-world power systems show that only upgrading the critical communication channels is sufficient to achieve system-wide performance improvement.