Using practical quality improvement approaches and tools in reproductive health services in east Africa.

BACKGROUND: A nonprofit, nongovernment organization, AVSC International provides technical assistance worldwide, including a range of reproductive health services and quality improvement (QI) approaches and tools. Current activities in East Africa involve several hundred sites, including referral hospitals, district-level hospitals, and individual family planning clinics. THE QI PACKAGE: AVSC and its local partners developed Client-Oriented, Provider-Efficient Services (COPE), a problem-solving process and set of tools to involve all levels of site staff members in assessing and improving the services. The COPE tools--self-assessment guides, client interview guides, client flow analyses, and action plans--promote involvement, ownership, and commitment to the QI process. Facilitative supervision and whole-site training complemented AVSC's traditional approaches of medical monitoring and informed choice. Facilitative supervision encourages supervisors and managers to consider staff members as internal customers, whose needs they must meet for staff to be able to meet the needs of external customers (clients). Whole-site training was developed to meet the needs of staff members and providers, who needed to function as a team responsible for providing high-quality services. CASE STUDY: A government hospital that has adopted the entire package of QI approaches, has used the Quality Improvement Quotient self-assessment surveys to track its progress in several elements of high-quality care, including management and supervision, safety, and information and client--provider interactions. For example, maternity ward staff learned how to pass on to their clients information about clients' rights and family planning methods through posters, pamphlets, sample contraceptives, and health talks. LESSONS LEARNED: AVSC's work with local organizations suggests a number of lessons learned, including the following: easy-to-use tools that promote staff involvement and ownership are essential in the QI process, QI requires considerable staff development and capacity building at all levels, and although the QI approaches were initially introduced for a relatively narrow field of services, they are applicable to and have increasingly been used in other departments and wards. (It is difficult, may be impossible, and certainly undesirable, to limit QI activities to one ward or service.) CONCLUSION: Activities in East Africa have shown that QI is possible even in very resource-poor settings. The same principles have guided the process in all the different programs, with some adaptation of the tools used. AVSC program activities are to continue to disseminate the experiences of sites implementing the package of tools and approaches, to advocate for investment in supervision and management capacity building as a means to support continuous quality improvement, and to further study the impact of the QI approaches on service quality.     

Measurement of light absorption by aquatic particles: improvement of the quantitative filter technique by use of an integrating sphere approach

Determination of particulate absorption in natural waters is often made by measuring the transmittance of samples on glass-fiber filters with the so-called quantitative filter technique (QFT). The accuracy of this technique is limited due to variations in the optical properties of the sample/filter composite, and due to uncertainties in the path-length amplification induced by multiple scattering inside the filter. Some variations in the optical properties of the sample/filter composite can be compensated by additional measurements of the filter's reflectance (transmittance-reflectance method [T-R] [S. Tassan and G. M. Ferrari, Limnol. Oceanogr. 40, 1358 (1995)]). We propose a different, rarely used approach, namely to measure the filter's absorptance in the center of a large integrating sphere, to avoid problems with light losses due to scattering. A comparison with other QFTs includes a sensitivity study for different error sources and determination of path-length amplification factors for each measurement technique. Measurements with a point-source integrating-cavity absorption meter were therefore used to determine the true absorption. Filter to filter variability induced a much lower error in absorptance compared to a measured transmittance. This reduced error permits more accurate determination of the usually low absorption coefficient in the near IR spectral region. The error of the T-R method was lower than that of the transmittance measurement but slightly higher than that of an absorptance measurement. The mean path-length amplification was much higher for the absorptance measurement compared to the T-R method (4.50 versus 2.45) but was found to be largely independent of wavelength and optical density. With natural samples the path-length amplification was less variable for the absorptance measurement, reducing the overall error for absorption to less than ±14%, compared to ±25% for the T-R method.     

Integrating baseline health status data collection into the process of care.

BACKGROUND: Health status data are an increasingly important component of outcomes assessment and can be used to facilitate quality assessment and improvement efforts. An enormous challenge to the use of health status data among hospitalized patients, however, is collecting baseline data at the time of treatment, an essential component for risk-adjusting subsequent outcomes. The Mid America Heart Institute of Saint Luke's Hospital (Kansas City, Mo), attempted to integrate the collection of health status assessments within the process of performing coronary revascularization. THE DATA COLLECTION STRATEGY: The data collection strategy was developed for each admission portalelective outpatients (admissions for same-day procedures), inpatients, and emergent cases. Health status data were collected on all patients with coronary artery disease who were receiving a percutaneous coronary intervention or coronary artery bypass graft with no disruption to physician scheduling or nursing staff. RESULTS: In general, patients were agreeable to completing the health status survey. Despite initial efforts to educate the hospital staff about the goal and purpose of health status assessment, staff members who were unaware of the uses of these data seemed to minimize their value. Providing examples of how to use these data relative to the staff member's specific occupational role facilitated buy-in for this project. EPILOGUE: After the pilot study, which lasted until June 1999, data were continually collected for 18 months, through August 2000, even with the cessation of external grant funding for this project. Baseline data collection finally stopped, primarily because of a failure to accommodate data collection into the routine flow of patient care by existing nursing staff.     

Detection of interferences in an additive manufacturing process: an experimental study integrating methods of feature selection and machine learning

Additive manufacturing becomes a more and more important technology for production, mainly driven by the ability to realise extremely complex structures using multiple materials but without assembly or excessive waste. Nevertheless, like any high-precision technology additive manufacturing responds to interferences during the manufacturing process. These interferences – like vibrations – might lead to deviations in product quality, becoming manifest for instance in a reduced lifetime of a product or application issues. This study targets the issue of detecting such interferences during a manufacturing process in an exemplary experimental setup. Collection of data using current sensor technology directly on a 3D-printer enables a quantitative detection of interferences. The evaluation provides insights into the effectiveness of the realised application-oriented setup, the effort required for equipping a manufacturing system with sensors, and the effort for acquisition and processing the data. These insights are of practical utility for organisations dealing with additive manufacturing: the chosen approach for detecting interferences shows promising results, reaching interference detection rates of up to 100% depending on the applied data processing configuration.     

Practice issues for integrating strategic social assessment into the setting of environmental limits: insights from Canterbury,New Zealand

Abstract

There is mounting concern in New Zealand and worldwide about the impacts of current and projected land-use activities on freshwater quality. In 2011, the New Zealand government effected the National Policy Statement for Freshwater Management, requiring all regional councils to establish freshwater nutrient loads and water allocation measures in their land and water regional plans. These ‘limits’ must achieve locally defined social, economic and cultural outcomes while, as a minimum, halting any decline in water quality. The authors have participated in the Canterbury region’s strategic land and water planning activities. This has involved strategically assessing the social impacts of ‘limit options’ on aspects of catchment life and then integrating them into official reports and community deliberations, which ultimately inform the development of rules for catchment land use. This paper highlights practice issues which were confronted in the process and how they were managed.     

Quality improvement initiatives in Brazil: a progress report.

BACKGROUND: In 1994 Brazil's Ministry of Health (MOH) introduced a program to provide a supporting environment for quality improvement (QI) initiatives. Yet the five-track QI strategy, which included moving toward outcome indicators, establishing a national accreditation program, emphasizing QI tools, establishing basic clinical guidelines, and enhancing community control, was discontinued in 1998, following the dismissal of the minister of health. The QI program retained only its accreditation activities. ACCREDITATION: The Consortium for Brazilian Accreditation (CBA) began in 1994 to establish an accreditation process compatible with international initiatives. Both the MOH and the CBA have developed standards for hospitals. The Brazilian Manual for the Accreditation of Hospitals is available on the Internet. The CBA has developed a set of standards by adapting the 1996 hospital standards from the Joint Commission on Accreditation of Healthcare Organizations. To developing CBA's role as an accrediting organization, administrative and technical supporting structures were created within the Cesgranrio Foundation and a Joint Commission for Accreditation was established. QUALITY MANAGEMENT INITIATIVES: A growing number of hospitals, clinical laboratories, blood banks, health plans, and other health care services and organizations are seeking International Organization for Standardization (Geneva) certification. Consulting firms in the field of quality management continue to increase the number of their clients in the health sector. CONCLUDING REMARKS: Current QI initiatives represent only a minority of health care services and organizations in the country. Strong efforts need to be made by both the private and public sectors to expand such initiatives throughout Brazil.     

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative

BACKGROUND: Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. STRUCTURE AND PROCESS OF THE COLLABORATIVE: The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. SUCCESS: Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26 teams have made significant improvement in 17 different topic areas. In addition, each organization has been able to successfully spread tested improvements to other individuals, teams, or locations, and the improvement work has become easier and more rapid with each successive cycle. CONCLUSIONS: The learning process initiated by this project will continue for at least another year in the VHA Upper Midwest region and will be expanded as participating organizations in other regions enroll in the VHA's national effort.     

Beyond the joint-venture: knowledge sourcing in Chinese automotive events

Abstract

This article analyses how firms use events and trade fairs for external knowledge sourcing, which barriers emerge and how event organisers strategically mediate and influence those processes. The research setting focuses on two major automotive events in Shanghai, highlighting that knowledge sourcing in these events do complement other types of knowledge accessed in permanent ‘sites’ and organisational configurations, such as in clusters and through joint-ventures. Firms use automotive events to access buzz, to monitor other firms and to explore options for new collaborations. Yet, it is also argued that a focus on existing relations, the defensive strategies deployed by lead firms and the intrinsic complexity of exhibited technologies hinder the process of knowledge sourcing that is influenced by event organisers’ content, matchmaking and access policies.     

Education for sustainable development: integration of sustainable development into engineering education in Ukraine

Kofi Annan, Secretary General of the United Nations.

The use of non-traditional approaches is suggested for engineering education, where the concept of SD is integrated with a systematic approach to be used not only as the theoretic foundation and philosophy of engineering education but also as a basis for future strategies and tactics. The essence of our approach not only consists of the knowledge to be obtained by the future experts of sustainable development, but the concept also became the basis of all basic disciplines and courses in the system of continuous education.     

Embracing complexity: a sociotechnical systems approach for the design and evaluation of higher education learning environments

ABSTRACT

Higher education institutions (HEI) have undergone fundamental changes driven by ICT developments, globalisation, and the advent of socio-constructivist pedagogic approaches. As a result, within the UK, capital investment in new and retrofitted facilities has reached a record expenditure. Recent research on user-related evaluations of facilities, particularly in HEI learning spaces, highlights the prevalence of evaluations dominated by reductionist approaches focused on measuring outcomes, on users, such as satisfaction, learning outcomes or engagement. These approaches have a major pitfall, neglecting the complexity of the dynamic relationships between people, spaces, technology, institutional structure and pedagogic practices. In response, this paper aims to propose a shift on current approaches by exploring the application of sociotechnical systems theory to learning space design and evaluation. Amid these, it is argued that Cognitive Work Analysis (CWA) offers promising alternatives to inform design and management of higher education learning spaces. Finally, within the paper, three CWA interventions are proposed and discussed, focusing on how these address previously identified shortcomings of predominant approaches used in HEI learning space design and evaluation.     

Crisis communication: learning from the 1998 LPG near miss in Stockholm.

The authors examine current trends in urban risks and resilience in relation to hazardous material transports in general, and crisis communication and the Stockholm liquefied petroleum gas (LPG) near miss in 1998 in particular. The article discusses how current dynamics affecting urban areas, such as the decay in terms of increased condensation and limited expansion alternatives combined with industry site contamination and transports of hazardous materials on old worn-out physical infrastructure, work together to produce high-risk factors and increase urban vulnerability in large parts of the world today. Crisis communication takes a particularly pronounced role in the article as challenges in communication and confidence maintenance under conditions of information uncertainty and limited information control are explored. The LPG near miss case illustrates a Swedish case of urban risk and the tight coupling to hazardous material transports. The case also serves as a current example of Swedish resilience and lack of preparedness in urban crises, with particular observations and lessons learned in regards to crisis communication.     

Flashed stimuli and the suppression of flicker response from long-wavelength-sensitive cones: integrating two separate approaches.

The selective suppression of flicker response from LWS cones has been investigated with two approaches. One approach has emphasized the use of light-adaptation conditions, and the other has emphasized the use of dark-adaptation conditions. In both cases, stimuli are arranged to restrict or exceed the ability of adaptation processes to maintain an afferent flicker response, and long-wavelength stimuli are used to overload spectrally opponent processes. By integrating these two approaches, this study shows that diverse manifestations of flicker response suppression can be closely related mechanistically. For instance, the steep flicker TVI slopes that resulted from superimposing temporally modulated (100% contrast) test stimuli on flashed backgrounds corresponded to the disappearance of flicker that resulted from increasing the time-averaged illuminance of temporally modulated stimuli (contrast x < 100%) that were flashed alone in an otherwise dark field. For the stimulus parameters of this study, flicker response suppression was more evident for small (19' diameter) than for large (1 degree diameter) stimuli. However, flicker response suppression was elicited reliably for both sizes by adding a spatially coincident short-wavelength stimulus to the interstimulus interval between presentations of the long-wavelength stimuli. By showing that temporal contrast can be treated as an independent variable for an important set of test/background stimulus combinations, the results of this study make it possible to investigate the means by which changes of contrast gain help to maintain flicker response as assessed in a conventional flicker TVI paradigm. The reduced degree of suppression for relatively large stimuli probably is related to the increased action of spatially extensive contrast gain-control processes. These contrast gain-control processes might not act independently of spectrally opponent processes.     

Beyond the concept: characterisations of later-stage creative behaviour in design

As a mechanism through which better solutions are developed, creativity is well-recognised as an important part of the engineering design process, but has to date largely only been studied in general or in early design process stages. This paper aims to study the occurrence of creative behaviour in engineering design with a particular focus on the later design process stages. Through the application of a detailed coding scheme to two studies of engineers’ work, this paper identifies patterns in creative behaviour through the design process stages, creative approaches employed by engineers, typical types of creative task, and fundamental differences within creative behaviour between early- and late-stage design. This understanding is then used to form ten characterisations of engineer behaviour within late-stage design, early-stage design, and throughout the design process. These characterisations can be used to direct future research and to improve the design process and output through development of specific, effective design support methods, selected to be appropriate to the design stage and type of creative behaviour that occurs within.     

Measuring antidepressant prescribing practice in a health care system using administrative data: implications for quality measurement and improvement

BACKGROUND: Up to one in eight Americans experiences an episode of depression that requires treatment in his or her lifetime. The direct and indirect costs associated with major depression are high but may be reduced with appropriate treatment. To decrease the probability of relapse, guidelines specify that treatment with antidepressant medications should continue for at least 4 months after symptom remission and that adequate doses of antidepressants be used. A study was conducted in 1997-1999 to examine how different specifications in the construction of quality of care measures for depression treatment influence conclusions about the adequacy of antidepressant prescribing practices. METHODS: Subjects were all adult members of two United Healthcare plans who each had at least one outpatient or inpatient claim with a diagnosis of depression during the years 1993-1995 and were continuously enrolled for 12 months. Pharmacy claims data were used to construct measures of duration of treatment, dose, and type of antidepressant. The effects of two different definitions of a new episode (4-month versus 9-month clean period) and two different ways of identifying an episode of depression (one visit versus two visits with a code for depression) were examined on conclusions about adequacy of antidepressant prescribing practices (dose and duration). Whether antidepressant type was related to the likelihood that antidepressants were prescribed at therapeutic doses was also examined. RESULTS: Patients with two or more visits with depression diagnosis codes were significantly more likely to receive antidepressants than those with only one visit, and were more likely to receive therapeutic doses at each time period (1-5 months). The duration of the clean period was not related to conclusions about therapeutic dosing. Among persons receiving antidepressants, those receiving selective serotonin reuptake inhibitors (SSRIs) were more likely to receive therapeutic doses and to continue treatment for at least 5 months than were those prescribed other classes of antidepressants. In multivariate analysis, being prescribed an SSRI versus another class of antidepressants was significantly associated with receiving both 1 month (OR = 7.3 [5.7-9.3]) and 5 months (OR = 2.0 [1.6-2.5]) of therapeutic treatment. DISCUSSION: Conclusions regarding the appropriateness of antidepressant prescribing can vary markedly, depending on how the quality measure is specified. Given that administrative data are and will continue to be used for both monitoring and quality improvement purposes in the short run, it is critical that we understand how variations in measurement specifications influence the conclusions that are drawn about treatment of depression in health plans.     

Quality assurance education and training in the U.K.

This paper deals with the part that education and training plays in the achievement of quality. The initial section examines the role of the Government sponsored Directory of Quality Training and Education in the U.K. and the aims of the National Quality Campaign. It assesses how successful the courses outlined in the Directory might be in providing sufficient stimulus for a change in attitude towards quality within industry particulraly with regard to satisfying the identified aims of the campaign. The conclusions that are drawn as a result indicate that there are several problems that need to be resolved before progress can be assured. The final section details what progress has already been made in the pursuit of improved quality and looks at various alternative methods of education and training that have been proposed to aid the process of change.