Merging clinical pathway programs as part of overall health system mergers: a ten-step guide. Spectrum Health

BACKGROUND: Mergers, acquisitions, and reorganizations can be stressful and accompanied by ambivalence, confusion, and uncertainty. Providing clear and simple steps for merging clinical pathways may help organizations move through the transition process more smoothly. The ten steps according to which Spectrum Health merged its pathway program-conduct an inventory of previous efforts, plan for the ideal program, bring staff together early in the merger process, decide on a common format, standardize the development and revision process, standardize a reporting tool, create a clinical pathway manual, implement an educational plan, present the program to key customers, and appoint an advisory group-need not be done sequentially. The ten-step pathway merger program uses pathways as a means to improve the quality of the care provided, with a focus on multidisciplinary clinical pathway teamwork. Before the merger, the two hospital systems' pathway programs used different approaches to operations and pathway format. When the announcement to merge came in September 1997, steps to merge the clinical pathway programs began. DISCUSSION: More than two years into the merger, Spectrum Health continues to struggle with the evolution of the health system. Clinical pathways represent just one of the significant and extensive issues related to organizational mergers; organizational values, finances, vision, mission, customer relations, strategic priorities, and people issues are a few of the others. Focusing on merging programs such as clinical pathway programs can help put one large piece of the merger puzzle in place and reduce some of the ambiguity associated with all mergers. Executive support is critical to the success of the clinical pathway program.     

Reducing inappropriate restraint use in Colorado's long-term care facilities

BACKGROUND: Many physical and psychosocial complications arise from the use of physical restraints. Restraints in nursing homes have been estimated to cause approximately 1 in every 1,000 nursing home deaths. When restraints are removed, quality of life and functional status improve; there does not appear to be an increase in serious falls, and serious injuries may even decline. METHODS: To assess the current status in Colorado nursing homes, in 1997 the Colorado Foundation for Medical Care mailed a questionnaire to 214 nursing homes to identify remaining barriers to restraint reduction. Results were used to plan interventions to further reduce inappropriate use that met most providers' needs. Given providers' need for greater family and public awareness of the risks associated with restraints, the project team developed educational tools for distribution to families and a media campaign for the public. In addition, an assessment tool and educational materials were created to facilitate appropriate use of devices and implementation of least-restrictive interventions. Data were collected before and after the intervention phase on remaining barriers, frequency of assessment, and perceived level of success of restraint reduction. RESULTS: Most of the 175 (82%) of Colorado's 214 long-term care providers who received educational materials found them very useful and recommended expansion to other states. Facilities indicated a higher perceived level of success in reducing restraints, an increase in the frequency of assessments, and a decrease in barriers to restraint reduction. The public awareness campaign, performed in tandem with the state health department, reached more than a half-million people in Colorado, using the slogan, "Restraints Have Risks!"     

Discovery of significant pathways in breast cancer metastasis via module extraction and comparison

Discovering significant pathways rather than single genes or small gene sets involved in metastasis is becoming more and more important in the study of breast cancer. Many researches have shed light on this problem. However, most of the existing works are relying on some priori biological information, which may bring bias to the models. The authors propose a new method that detects metastasis‐related pathways by identifying and comparing modules in metastasis and non‐metastasis gene co‐expression networks. The gene co‐expression networks are built by Pearson correlation coefficients, and then the modules inferred in these two networks are compared. In metastasis and non‐metastasis networks, 36 and 41 significant modules are identified. Also, 27.8% (metastasis) and 29.3% (non‐metastasis) of the modules are enriched significantly for one or several pathways with p ‐value <0.05. Many breast cancer genes including RB1, CCND1 and TP53 are included in these identified pathways. Five significant pathways are discovered only in metastasis network: glycolysis pathway, cell adhesion molecules, focal adhesion, stathmin and breast cancer resistance to antimicrotubule agents, and cytosolic DNA‐sensing pathway. The first three pathways have been proved to be closely associated with metastasis. The rest two can be taken as a guide for future research in breast cancer metastasis.Inspec keywords: cancer, genetics, genomics, DNA, molecular biophysics, adhesion, cellular biophysicsOther keywords: breast cancer metastasis, module extraction, gene sets, metastasis‐related pathways, nonmetastasis gene coexpression networks, Pearson correlation coefflcients, breast cancer genes, RB1, CCND1, TP53, glycolysis pathway, cell adhesion molecules, focal adhesion, stathmin, breast cancer resistance, antimicrotubule agents, cytosolic DNA‐sensing pathway, breast cancer metastasis     

Providing the right infrastructure to lead the culture change for patient safety

BACKGROUND: In early 2000 the hospital leadership of Good Samaritan Hospital (GSH), a community teaching hospital in Dayton, Ohio, made patient safety a strategic priority and devoted resources to incorporate safety as a part of the hospital's culture and care processes. The vice president of clinical effectiveness and performance improvement, as a champion for safety, led a consensus-building effort to enlist the support of key physician and hospital leaders to a safety program. GSH added a Safety Board to its administrative infrastructure, which was to serve as an oversight body to ensure the advance of the safety program and to produce policies and procedures that are associated with safety. ADDRESSING PATIENT SAFETY AIMS: To assess GSH's progress toward achieving three aims--demonstrate patient safety as a top leadership priority, promote a nonpunitive culture for sharing information and lessons learned, and implement an integrated patient safety program throughout the organization--the Safety Board evaluates GSH's performance bimonthly, using a 5-point-scaled self-assessment tool. For example, for the third aim, the Safety Board oversaw the formation of three subcommittees, which were to test ideas and achieve improvements in three areas--medication, clinical, and environmental. DISCUSSION: The administrative structure provides the leadership and momentum necessary to fuel a cultural change in the way that patient safety issues are perceived and acted on throughout the organization. "To err" may be human, but so is the ability to increase patient safety awareness, to promote cultural change within existing systems, and to improve the patient care processes and outcomes.     

Discrepancy in bicycle helmet use among college students between two bicycle use purposes: Commuting and recreation

Objectives

The purpose of the study was to examine associations between bicycle helmet use and attitudes among U.S. college students. Bicycle helmet use was assessed for two different bicycle use purposes: commuting to school and recreation.

Materials and methods

Student bicycle riders were recruited on the campus of a large public university in Colorado. Questionnaire development was guided by the Theory of Reasoned Action and Health Belief Model. Bicycle use and helmet use for the two purposes, attitudes toward helmet use and bicycle helmet regulations on campus, perceived risk of bicycle-related injury, subjective norms were asked. Bicycle helmet use was defined by current behaviors and intentions for the future, based on the Stages of Change model.

Results

A total of 192 questionnaires collected from students who rode bicycles for both commuting and recreation was used for the analysis. Bicycle helmet use differed depending on purposes of bicycle riding: 9.4% of bicycle riders wore bicycle helmets every time for commuting, while 36.5% did so for recreation. Different variables were associated with bicycle helmet use for commuting and recreation in logistic regression models, suggesting that psychosocial structures behind bicycle helmet use behaviors might differ between two bicycle use purposes, commuting and recreation.     

Factors influencing the use of infant car restraints

Over a six-week period 100 mothers in Dunedin, New Zealand obtained General Motors infant car seats from a rental scheme. In interviews conducted in the maternity hospital, before the seats had been used, the mother's perceptions of the comfort and ease of use of the seat were recorded. All mothers rated the seats as very safe. From details of 2,830 car trips undertaken by these mothers while their infants were 0-3 months old and from a further 687 journeys by 85 of those mothers when their infants were 4-6 months old we found that an infant car seat was used for only 72% of journeys with the younger infant compared to 91% of journeys with the older infant. Those mothers who had rated the seat--before ever using it--as appearing uncomfortable or difficult to use were less likely to make use of it. The seat was least likely to be used when the mother was going out for more than two hours in the evening for some purpose that involved only a short car journey.     

The strategic use of outcome information

BACKGROUND: Most health care executives see outcome measurement as a technical or tactical matter rather than as a strategic tool. Accordingly, provider investment in outcome measurement and management is relatively small. Nevertheless, outcome information can be key to achieving an organization's strategic objectives. Advances in risk adjustment and improvements in technology for data collection and analysis have made outcome measurement a practical tool for individual hospital use. CASE STUDIES: Strategically integrated outcome measurement efforts can give providers a competitive advantage over organizations that only use outcomes tactically. One of the best examples of an acute care provider that has used outcome information for strategic advantage is Intermountain Health Care (IHC; Salt Lake City). In 1997 IHC made clinical quality and outcomes the primary focus of its five-year strategic plan. To support the new strategy IHC's board of trustees approved the development of an outcome information system that generated data along clinical processes of care and the creation of a new management structure to use these data to hold professionals accountable and to set and achieve clinical improvement goals. From 1996 to 1999, IHC's share of the commercial health care market in Utah increased from roughly 50% to about 62% of the market, with the result that it has stopped actively marketing its services. DISCUSSION: Health care executives will not willingly invest in outcomes until they believe that they have business value. Therefore, making the business case for outcomes can help improve the quality of health care and the lives of individuals.     

Using administrative data to improve compliance with mandatory state event reporting

BACKGROUND: The New York Patient Occurrence and Tracking System (NYPORTS) is a mandatory adverse event reporting system that was redesigned in 1998. Analysis of the first full year of its use showed large regional and hospital variation in reporting frequency not due to hospital or case mix differences. In early 2001, New York State mandated that all hospitals conduct retrospective review for unreported adverse incidents for the previous 2 years. Hospitals could submit previously unreported incidents within a defined window without penalty. The hospital used an ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) analysis to screen for missed NYPORTS cases, to assist in focusing review resources. METHODS: NYPORTS categories were matched to corresponding combinations of inpatient ICD-9-CM diagnosis and procedure codes. Other variables considered included discharge disposition, primary or secondary coding position, readmissions, and NYPORTS exclusions. RESULTS: Among more than 60,000 discharges in 2 years, 5,500 records were identified for NYPORTS review based on the ICD-9-CM criteria; 211 cases had already been reported through normal reporting processes. Thirteen of the NYPORTS codes had a 30% or greater match rate to the ICD-9-CM codes, with an average "hit rate" of 56%. Five-hundred sixty reviews identified 187 (33.4%) reportable events for the same code the case was being screened for and 26 additional reportable events for a code other than the screening code. NYPORTS categories for procedure and operative-related occurrences had the highest yields. CONCLUSIONS: This retrospective effort helped identify previously unreported occurrences, increase institutional awareness of New York State's mandatory reporting process, and stimulate the redesign of our concurrent detection process.     

Infant mortality review as a vehicle for quality improvement in a local health department

BACKGROUND: Many communities across the United States have established fetal and infant mortality review (FIMR) programs as a way of gaining insight into the causes of such deaths and of devising and implementing ways to improve the health of pregnant women and their infants. IMR PROCESS: The IMR process in the Jefferson County Department of Health in Birmingham, Alabama, evolved in a somewhat different fashion than that in other communities. A technical review team reviews all the infant deaths in the county, with particular attention to each woman's pregnancy history. A community review team reviews composite cases that illustrate some particular problem that might lead to infant mortality, such as teenage pregnancy or short intervals between pregnancies. This team provides insights into cultural patterns and a community perspective on the problems. Recommendations from the two teams are acted on by the health department, with the assistance of other agencies as needed. IMPACT OF THE IMR PROCESS: The IMR process has been used to increase community agency participation in health department activities, improve health department procedures, increase health department staff acceptance of a new and controversial program (Healthy Start), and offer services to women who need them. CONCLUSIONS: IMR has become a mechanism for CQI in the health department, embodying many of the principles of CQI, including the use of teams, focus on a team mission, and examination of processes, not individuals. The program offers a model of how to reduce rates of fetal and infant mortality.     

Injuries and use of protective equipment among college in-line skaters

In-line skating injuries and protective gear use were explored in a sample of college students (n = 217). A minority of respondents wore protective gear. One third of skaters had experienced at least one minor injury, and a smaller percentage had experienced fractures or head injuries. Most minor injuries occurred during the first 1–2 times skating, while more serious injuries tended to occur after at least 50 times on in-line skates. Psychosocial predictors of protective gear use were explored. Four major Health Belief Model constructs (perceived barriers to wearing gear, perceived susceptibility to injury, perceived severity of injury, and perceived benefits of wearing gear) were significant predictors of protective gear use. The Health Belief Model, tested using regression and structural equation modelling, predicted gear typically worn, frequency of gear use, and injuries received while in-line skating. Implications for increasing protective gear use are described.     

Signalling pathway impact analysis based on the strength of interaction between genes

Signalling pathway analysis is a popular approach that is used to identify significant cancer‐related pathways based on differentially expressed genes (DEGs) from biological experiments. The main advantage of signalling pathway analysis lies in the fact that it assesses both the number of DEGs and the propagation of signal perturbation in signalling pathways. However, this method simplifies the interactions between genes by categorising them only as activation (+1) and suppression (−1), which does not encompass the range of interactions in real pathways, where interaction strength between genes may vary. In this study, the authors used newly developed signalling pathway impact analysis (SPIA) methods, SPIA based on Pearson correlation coefficient (PSPIA), and mutual information (MSPIA), to measure the interaction strength between pairs of genes. In analyses of a colorectal cancer dataset, a lung cancer dataset, and a pancreatic cancer dataset, PSPIA and MSPIA identified more candidate cancer‐related pathways than were identified by SPIA. Generally, MSPIA performed better than PSPIA.Inspec keywords: genetics, cancer, biology computing, perturbation theory, biological organs, data analysisOther keywords: gene interaction strength, cancer‐related pathways, differentially expressed genes, biological experiments, signal perturbation propagation, signalling pathway impact analysis methods, Pearson correlation coefficient, mutual information, colorectal cancer dataset analysis, pancreatic cancer dataset, PSPIA, MSPIA     

Using data to improve medical practice by measuring processes and outcomes of care

BACKGROUND: The purpose of this article is to help clinicians expand their use of data to improve medical practice performance and to do improvement research. Clinical practices can be viewed as small, complex organizations (microsystems) that produce services for specific patient populations. These services can be greatly improved by embedding measurement into the flow of daily work in the practice. WHY DO IT?: Four good reasons to build measures into daily medical practice are to (1) diagnose strengths and weaknesses in practice performance; (2) improve and innovate in providing care and services using improvement research; (3) manage patients and the practice; and (4) evaluate changes in results over time. It is helpful to have a "physiological" model of a medical practice to analyze the practice, to manage it, and to improve it. One model views clinical practices as microsystems that are designed to generate desired health outcomes for specific subsets of patients and to use resources efficiently. This article provides case study examples to show what an office-based practice might look like if it were using front-line measurement to improve care and services most of the time and to conduct clinical improvement research some of the time. WHAT ARE THE PRINCIPLES FOR USING DATA TO IMPROVE PROCESSES AND OUTCOMES OF CARE?: Principles reflected in the case study examples--such as "Keep Measurement Simple. Think Big and Start Small" and "More Data Is Not Necessarily Better Data. Seek Usefulness, Not Perfection, in Your Measures"--may help guide the development of data to study and improve practice. HOW CAN A PRACTICE START TO USE DATA TO IMPROVE CARE AND CONDUCT IMPROVEMENT RESEARCH?: Practical challenges are involved in starting to use data for enhancing care and improvement research. To increase the odds for success, it would be wise to use a change management strategy to launch the startup plan. Other recommendations include "Establish a Sense of Urgency. (Survival Is Not Mandatory)" and "Create the Guiding Coalition. (A Small, Devoted Group of People Can Change the World)." SUMMARY: Over the long term, we must transform thousands of local practice cultures so that useful data are used every day in countless ways to assist clinicians, support staff, patients, families, and communities.     

Why are sobriety checkpoints not widely adopted as an enforcement strategy in the United States?

Sobriety checkpoints have been used by police in the United States for at least the past two decades to enforce impaired driving laws. Research has indicated that sobriety checkpoints are effective in reducing drinking and driving and alcohol-related fatal crashes. Despite this evidence, many police agencies have been unenthusiastic about using checkpoints. Information was collected from all 50 states plus the District of Columbia on the use of sobriety checkpoints. A total of 37 states and the District of Columbia reported conducting sobriety checkpoints at least once or twice during the year. Only 11 states reported that checkpoints were conducted on a weekly basis. Thirteen states do not conduct checkpoints either because of legal or policy issues. More detailed information was collected from five states that conduct checkpoints frequently and matched with information from five similar states that conduct checkpoints infrequently. States with frequent checkpoint programs had several common features such as program themes, support from task forces and citizen activist groups, use of a moderate number of police at the checkpoints, and use of all available funding mechanisms (federal, state, local) to support them. States with infrequent checkpoints claimed a lack of funding and police resources for not conducting more checkpoints, preferred saturation patrols over checkpoints because they were more “productive,” and used large numbers of police officers at checkpoints. Ways to overcome perceived barriers to checkpoint use are discussed.     

The use of finite element analysis techniques for solving rail gunproblems

The use of commercial electromagnetic finite-element programs for solving railgun problems such as inductance calculations, force evaluations, and current-density distributions is described. The first code considered, PE2D, is a program for solving the electromagnetic and electrostatic problems described by the Laplace, Poisson, Helmholz or diffusion equations in two dimensions. PE2D is limited in that only 2-D problems can be solved, and that current distributions through rail-armature configurations are not readily calculable. Hence, a three-dimensional code called MEGA is being developed. This program, has been used to calculate the 2-D current-density distributions through rails and armatures; however, it is expected that it will be used to calculate full three-dimensional problems     

Evidence-based management: using serial firm trials to improve diabetes care quality

BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.     

What happened in Finland to increase home hemodialysis?

Finland is geographically a rather large country with a relatively sparse population (5.3 million). Home hemodialysis (HHD) was started in Helsinki 40 years ago and in the early years it was only used in selected patients. However, by the late 1980s HHD almost disappeared owing to the advent of CAPD and new HD centers. Towards the end of the 1990s, it became evident that PD had limitations and new ways had to be found to individualize HD, improve the outcome, increase capacity, and limit the growth of costs of HD. After careful planning, HHD was reinstituted at the Helsinki University Hospital in 1998 and since then the program has grown steadily. By December 31, 2007, altogether 163 patients had started at home. This has required changes in the predialysis program where the "home first" policy was adopted. Other important features include close cooperation with other nephrological centers as well as centralized HHD training that also supports more remote hospitals. Since then this therapy has been started in several other academic and in some smaller hospitals, and at the end of last year about 4% of all Finnish dialysis patients (n=1.600) were on HHD (prevalence 11.8/million). In the Helsinki metropolitan area this treatment is the most economical modality (estimated annual global costs euro37.000), comparable to self-care satellite HD and CAPD. A successful HHD program requires a well-organized predialysis program, a highly motivated multidisciplinary team, and well-developed training networks.     

Primary and secondary prevention of drink driving by the use of alcolock device and program: Swedish experiences

To prevent drinking and driving, alcolock (or alcohol-interlock) devices and programs were introduced in Sweden in 1999. Two types of prevention programs were begun. A primary prevention strategy was initiated to prevent alcohol impaired driving by individuals not pre-selected for having prior DWI offences. This approach was first applied as a pilot project in three commercial transport companies (buses, trucks, taxis). Also a secondary prevention trial was begun as a voluntary 2-year program for DWI offenders involving strict medical requirements, including counseling and regular checkups by a medical doctor. The program did not require a prior period of hard suspension and focused on changing alcohol use habits.

Alcolocks in commercial vehicles have been well accepted by professional drivers, their employers, and their passengers, and the number of vehicles with alcolocks as a primary prevention measure is rapidly growing in Sweden. Three of 1000 starts in the primary prevention program were blocked by the alcolock after measuring a BAC higher than the legal limit and lock point of 0.02% (20 mg/dl).

Only 11% of eligible DWI offenders took part in the voluntary, secondary prevention program. Of these, 60% had diagnoses of alcohol dependence or abuse. During the program, alcohol consumption generally decreased significantly as measured through five biological alcohol markers, and the rate of DWI recidivism fell sharply from a yearly rate of approximately 5% to almost 0. These effects on DWI recidivism are paralleled by reduced rates of police-reported traffic accidents involving injuries and hospital admissions due to road accidents. Successful completion of the program appears to have lasting effects (even 2.5 years later) in terms of far lower rates of DWI recidivism and maybe also lower crash rates. On the other hand those being dismissed from the program appear to rapidly return to previous behaviour.

Hard suspension seems almost to have an adverse effect on DWI recidivism, but crashes resulting in injuries may be reduced during revocation.     

"镂空"设计在包装装潢中的运用

论述了镂空设计运用于包装装潢之中,主要包含2个方面的内容:一是直接在包装造型上进行开口设计;二是运用中国民间剪纸的形式进行装饰.镂空设计给现代包装装潢设计注入了新的活力,呈现出清新、典雅的民族气质.