The 2000 ICSI/IHI Colloquium on Clinical Quality Improvement: "Cultivating Quality--Growing and Nurturing Clinical Quality Improvement in Health Care"

BACKGROUND: Almost 300 people attended the 2000 ICSI/IHI Colloquium on Clinical Quality Improvement, "Cultivating Quality--Growing and Nurturing Clinical Quality Improvement in Health Care," May 11-12, 2000, in St Paul. Sponsored by the Institute for Clinical Systems Improvement (ICSI) and the Institute for Healthcare Improvement (IHI), the annual event featured three keynote speakers--David M. Lawrence, MD (Kaiser Foundation Health Plan, Inc, and Kaiser Foundation Hospitals, Oakland, Calif): Martin P. Eccles, MD (University of Newcastle-upon-Tyne, England); and Maureen Bisognano (IHI). PATIENT SAFETY AND THE U.S. HEALTH CARE SYSTEM: David M. Lawrence, MD, said medicine is trying to use new technologies and meet consumer expectations with a delivery system--a "chassis"--that was designed for another time and a different science. He also described the four chassis stages in medicine. GETTING EVIDENCE INTO PRACTICE: Martin P. Eccles, MD, presented a researcher's view of the reasons evidence is not used in daily practice, a range of strategies for promoting its use, and the strengths and shortcomings of this evidence base. He discussed three areas of evidence--clinical strategies, behavior change strategies--and systems for delivering these strategies--and how they can be used for implementation of practice changes. INNOVATIONS IN INTERACTION: GETTING CLOSER TO OUR PATIENTS: Maureen Bisognano outlined three methods that should be in every health care provider's improvement portfolio: reducing the defects a patient experiences, eliminating costs, and pursuing innovation. Focusing on defects and waste reduction will free up funds for innovation. It is the responsibility of leaders to push for innovation on behalf of patients, or patients will take their business elsewhere.     

Essentials of quality in "the gold standard veterinary clinical trial".

Quality Assurance (QA) has played a pivotal role within Good Laboratory Practice (GLP) since its inception in 1976. GLP is now recognized as a quality standard, as can be seen from the introductory statement of the recently issued OECD Principles of GLP (revised in 1997) that clearly state "GLP is a quality system concerned with the organisational process and the conditions under which non-clinical health and environmental safety studies are planned, performed, monitored, recorded, archived and reported". We can, therefore, see a close comparison between GLP compliance and the ISO/EN accreditation systems that have been adopted by other institutes on a worldwide basis.     

The AMA clinical quality improvement forum on addressing patient safety

BACKGROUND: More than 200 health care policy makers and researchers, clinicians, quality professionals, and other representatives of health care organizations, government, and academia attended the Division of American Medical Association Clinical Quality Improvement's conference, "Addressing Patient Safety," April 28, 2000, in Chicago--the first national conference to respond to the recent Institute of Medicine (IOM) report, To Err Is Human: Building a Safer Health System. ADDRESSING PATIENT SAFETY--PUBLIC AND PRIVATE PERSPECTIVES: John M. Eisenberg, MD, stated that research on errors is needed to describe the scope and nature of the problem, understand the barriers to and benefits of improvement, and develop and test strategies for improvement. Kenneth W. Kizer, MD, MPH, stated that the National Quality Forum will develop a compendium of best practices and will develop core measures for serious adverse events, and health care organizations and government health programs should act now to make a clear organizational commitment to patient safety, create a nonpunitive health care culture of safety, and implement known safe medication practices. Alan R. Nelson, MD, stated that the IOM report places its emphasis on continuous quality improvement and technology that can be used to mitigate the risks in a complex health system. HOSPITAL AND ACCREDITATION AGENCY ACTIVITIES ON PATIENT SAFETY ISSUES: Donald M. Nielsen, MD, discussed the American Hospital Association's (AHA's) Medication Safety Initiative, which promised to provide its members with successful practices, tools, and resources and to track progress of implementation of the recommended successful practices. Dennis S. O'Leary, MD, stated that when a hospital reports a sentinel event, the hospital is expected to implement improvements to reduce risk and monitor their effectiveness. The National Committee for Quality Assurance is considering changes to its accreditation standards to further address patient safety.     

Photoactivation at a clinical LINAC: The reaction slightly above threshold

The properties of a clinical LINAC are investigated for a study of photoactivation cross-sections slightly above the neutron threshold. As an example, the photoactivation of a tiny amount of gold by the reaction has been measured. The derived photon intensity is at least comparable to conventional and widely used photon sources. In combination with its extremely stable operation, a clinical LINAC ensures that photoactivation studies can be performed for a wide number of targets with very limited beamtime.     

Assessing "best evidence": issues in grading the quality of studies for systematic reviews.

BACKGROUND: Evidence-based medicine, clinical practice guidelines, quality and value of health services, and science-based decision making are becoming mainstays of the health care sector. As part of the evidence-based movement, systematic reviews of the literature on clinical questions are becoming increasingly common. Part of the structured approach to evaluating the literature involves assessing the quality of individual studies included in systematic reviews. REVIEW QUESTIONS: To clarify issues in this area, in 1998 the Agency for Health Care Policy and Research commissioned a small project to determine how its 12 Evidence-based Practice Centers were carrying out this part of their systematic reviews (called evidence reports). The number of potential checklists, scales, and similar tools for grading the methodology or the clinical relevance of individual reports is large; the reliability, the validity, the feasibility, and the utility of these tools are either unmeasured or quite variable. CONCLUSIONS: Numerous methodologic questions await definitive research and answers, but in the meantime teams developing authoritative systematic reviews can take certain steps to ensure that their approaches to grading the quality of articles meet applicable scientific standards. Clinicians, program administrators, and health policymakers can then be confident in the overall strength of the evidence and study conclusions.     

Assessing clinical pathways use in a community hospital: it depends on what "use" means

BACKGROUND: Many benefits have been associated with the use of clinical pathways, yet developing them can be costly, and implementing them is not always successful. A 300-bed Midwestern community hospital began a clinical pathways program in 1995, and by fall 1998, 15 pathways were in various stages of implementation, with 3 under development. Many challenges had been encountered, but hospital leaders were eager to find ways to increase pathway use. METHODS: A qualitative case study design was used to investigate four clinical pathways, two perceived as being "used" and two that were perceived as "not used". Each pathway was analyzed as a separate case, followed by cross-case analysis. Qualitative data were collected in 65 semistructured interviews with administrators, physicians, physicians' office staff, nurses, and allied health professionals at the hospital. Data were also collected through observation and document analysis. RESULTS: The two used pathways had been introduced as part of a larger change in care, whereas the two pathways not used had been introduced as stand-alone innovations. Confusing and inadequately developed aspects of the hospital's clinical pathways program included its purposes, the definition of pathway use, pathway procedures, accountability, education, and incentives. A new case management department, ongoing administrative support, and a sophisticated medical information system were viewed as supports for continued growth in the program. CONCLUSIONS: Implementation of clinical pathways was delayed and complicated by the varied perceptions of the program among stakeholders. Lack of clarity and consistency in how information about the program was communicated made it difficult for clinicians to develop a shared understanding of clinical pathways.     

Globalization at the nano frontier: The future of nanotechnology policy in the United States, China, and India

The field of nanotechnology offers the possibility of transforming the international science and technology (S&T) policy landscape and making a significant impact on the direction of research and development for a wide range of nations and companies. Nanotechnology endeavors in the United States, China, and India remain some of the most interesting because of the opportunities and challenges this field poses for future competition and collaboration between these three nations. This paper examines how nanotechnology will raise new science and policy questions—and lead to new strategic linkages—that will have a major impact on the futures of these nations for decades to come. Then the paper analyzes and compares the current state of nanotechnology in these three countries, discusses some of the main drivers of collaboration, investigates current and potential uncertainties associated with nanotechnology, and offers policy suggestions on ways that these difficulties may be addressed.     

表面粗糙度对TiAl/AgCu/TiAl钎焊质量的影响

为探究表面粗糙度对钎焊质量的影响,在优选的钎焊温度870 ℃和保温时间5 min条件下,以AgCu合金为钎料,进行TiAl合金的真空钎焊,研究了表面粗糙度与磨痕方向对钎料润湿铺展、钎焊接头界面组织、力学性能的影响.采用扫描电镜、能谱分析、光学显微镜和万能材料试验机等分析测试手段,对钎焊接头的组织与力学性能进行分析.结果表明：AgCu钎料在各向异性的TiAl基板表面润湿铺展时会受表面特征影响,沿着特定的方向优先铺展,当基板表面不具各向异性特征时,钎料润湿铺展近似为圆形;表面粗糙度S_a=0.103 μm的基板,钎焊接头的平均剪切强度最优,达到323 MPa,而表面粗糙度S_a=0.133 μm的基板,接头平均剪切强度为245 MPa,钎焊接头强度均方差最大.     

Computers: From ethos and ethics to mythos and religion: Notes on the new frontier between computers and philosophy

This essay surveys recent studies concerning the social, cultural, ethical and religious dimensions of computers. The argument is that computers have certain cultural influences which call for ethical analysis. Further suggestions are that American culture is itself reflected in new ways in the high-technology computer milieu, and that ethical issues entail religious ones which are being largely ignored.     

The influence of oxygen ambient annealing conditions on the quality of Al/SiO2/n-type 4H-SiC MOS structure

The effect of reoxidation process in O₂ on the electrical properties of metal-oxide-semiconductor (MOS) capacitors fabricated on n-type 4H-SiC (0 0 0 1) is investigated. All samples were oxidized in wet oxygen at temperature of 1175 °C. Reoxidation process was carried out on four of the five samples. Samples were annealed at temperature of 700 °C and 800 °C for different process times. The reoxidation process in oxygen improves the quality of the dielectric layer and the interface of Al/SiO₂/n-type 4H-SiC MOS structure. The best quality of the SiO₂/SiC interface can be achieved for the MOS structure annealed in O₂ at higher temperature (800 °C) for longer time. However, higher and more uniformly distributed values of breakdown voltage were obtained for MOS structures reoxidized at temperature of 700 °C.     

The influence of Graphene quality on performance of a Si/Graphene nanocomposite anode

Si/Graphene nanoparticles represent attractive alternative anode materials for Lithium-ion batteries. Graphene nanosheets with different properties, including surface area, defect distance, and charge-transfer resistance, were fabricated and characterised in Si/Graphene nanocomposites formed by static-electric self-assembly then by an in-situ reduction process. Graphene nanosheets that exhibited the highest surface area, the shortest defect distance, and the lowest charge-transfer resistance demonstrated the best overall electrochemical performance, with a high initial discharge capacity of 2692?mAh?g^?1, good cycling performance of 1135?mAh?g^?1, at the 200th cycle at the current rate of 0.5?C. This work shows the preferable graphene quality for Si/Graphene nanocomposite anode and provides insights into the design of graphene nanocomposite electrodes, regardless of the graphene synthesis method.     

The Patient Care Notebook: quality improvement on a rehabilitation unit

BACKGROUND: Shortened lengths of stay in acute and rehabilitation hospitals, continuing financial pressures on all postacute care services, and increasing out-of-pocket health care costs for patients and families challenge rehabilitation hospitals' patient education and discharge planning processes. Spaulding Rehabilitation Hospital (Boston) introduced a patient care notebook in a 15-bed satellite unit and pilot tested its contribution to the patient education and discharge planning process. DEVELOPING THE NOTEBOOK: The three-ring binder notebook included sections on medical appointments and phone numbers, understanding illness and medical care, coping with illness, physical activities, recommendations for the home, and community resources, with both standard and patient-specific information. RESULTS: Most of the patients and caregivers who received the notebooks found them to be helpful, and most staff indicated that the notebook improved the teaching process. Telephone calls to the unit after home discharges decreased form 28 calls for 11 discharges to 6 calls for 21 discharges after the notebook began to be used regularly. DISCUSSION: Staff felt that the process of using the notebook helped focus attention on teaching during the entire course of a patient's hospitalization rather than just a day or two before discharge. The patient care notebook process is being introduced to the entire hospital and to all patients, regardless of discharge location and the patient's literacy or proficiency with English. CONCLUSION: In using the notebook, the QI team, and the entire unit staff, learned about the complexities of QI, patient education, and discharge planning. The notebook process was implemented throughout the hospital a little more than a year after the completion of the pilot project.     

The special severity of occupational accidents in the afternoon: "the lunch effect"

The severity of occupational accidents suffered by construction workers at different hours of the day is analyzed in this study. It may be seen that the interval of time between 13:00 and 17:00 has incomprehensibly high rates of severe and fatal accidents in comparison with any other. We associate this higher accident rate with what we have termed the “lunch effect”. We studied 10,239,303 labor accidents in Spain over the period 1990–2002. The relationships between potential risk factors for occupational accidents around lunch in Spain, especially alcohol consumption are studied, using two methods: analysis of national archival data of 2,155,954 occupational accidents suffered by workers in the construction sector over the period 1990–2002 and a survey study. This study also seeks to contribute the opinions of the workers themselves regarding the causes that might explain this situation.     

基于化学成分临床利用量的不同产地黄柏质量评价

采用小檗碱临床利用量对黄柏药材的质量进行再评价研究。通过正交试验优选黄柏小檗碱最佳临床提取工艺,根据最佳提取工艺采用HPLC法测定5批不同产地黄柏小檗碱含量,然后计算其临床利用量。黄柏小檗碱最佳临床提取工艺为加药材10倍量的水提取3次,每次1.5 h。贵州、陕西、湖北、天津、新疆的小檗碱临床利用量(g/100 g)分别为11.10,7.30,1.35,1.30,1.40 g。该文建立的方法将中药材中的有效成分与临床实际利用情况相联系,为黄柏及其他的中药材品质评价提供新思路。     

The "music" of core-shell spheres and hollow capsules: influence of the architecture on the mechanical properties at the nanoscale

We report on the first measurement of elastic vibrational modes in core-shell spheres (silica-poly(methyl methacrylate), SiO2-PMMA) and corresponding spherical hollow capsules (PMMA) with different particle size and shell thickness using Brillouin light scattering, supported by numerical calculations. These localized modes allow access to the mechanical moduli down to a few tens of nanometers. We observe reduced mechanical strength of the porous silica core, and for the core-shell spheres a striking increase of the moduli in both the SiO2 core and the PMMA shell. The peculiar behavior of the vibrational modes in the hollow capsules is attributed to antagonistic dependence on overall size and layer thickness in agreement with theoretical predictions.     

Effective quality factors for neutrons based on the revised ICRP/ICRU recommendations

The quality factor (Q) is intended to relate the biological effectiveness of a radiation to the absorbed dose delivered in tissue. Quality factors are defined as a function of the unrestricted linear energy transfer (L) relationship in water and are used with operational quantities. Radiation weighting factors (wR) are used in protection quantities to take into account total radiation detriment. While the International Commission on Radiological Protection (ICRP) defines the Q(L) relationship, the International Commission on Radiation Units and Measurements (ICRU) recommends the charged particle stopping power and range data. If either of these data recommendations change, the quality factors must be recomputed. The latest guidance from both organisations applicable to neutron quality factors are the ICRP Publication 60 (Q(L) relationship) and the ICRU Report 49 (stopping power and range data). In the present study, absorbed dose conversion coefficients (pGy cm2) were calculated for two operational quantities defined by the ICRU--the ambient absorbed dose and the personal absorbed dose. Dose-equivalent (pSv cm2) conversion coefficients were also computed using mean quality factors based on ICRP 60 and ICRU 49 recommendations. Effective quality factors were then calculated from the ratio of the dose-equivalent to the absorbed dose conversion coefficients for both the personal dose-equivalent and ambient dose-equivalent and compared to values reported in the literature.     

走向“新活字”——汉字设计的未来图景

从毕达哥拉斯提出“万物皆数”、柏拉图以“数”来构建“理念世界”开始，到古希腊、古罗马建筑中普遍反映的“数”之美，再到意大利文艺复兴时期人文主义者以数值化、几何化的方法解剖古罗马碑文，西文字体设计正根植于“自然世界研究的数学化”这一西方文明大传统中，近代以来席卷了世界。在这里，字体所反映的不仅是审美趣味，而是西方人对于自然世界的认知方法这一根本性问题。那么，汉字设计在未来人工智能等技术的变革中，是否也可能找到一条根植于自身文明的道路？古昔与未来之间是否存在着一条贯通的脉络？对于这些问题，希望站在思想史的角度加以讨论，厘清汉字设计的特殊性和未来可能展现出的全新发展路径。