Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

Towards a home-grown approach to strategic environmental assessment: adapting practice and participation in Kenya

Abstract

Kenya is among the first countries in sub-Saharan Africa to formally require the assessment of public policies, plans and programs. National strategic environmental assessment (SEA) guidelines were finalized in 2012 to adapt and enhance SEA practice in the Kenyan context. The purpose of this research was to examine recent Kenyan SEA, with a particular emphasis on public participation, by developing and applying an analysis framework that both incorporates commonly accepted SEA principles and approaches and is cognizant of the national context in shaping SEA practice. Results reveal that a number of SEA practices are consistent with the framework in the nine cases considered, such as containing standard SEA components and developing monitoring plans. A requirement that each SEA must include educating the public about SEA is an innovative local adaptation. Results also show a number of practices that are still emerging, such as initiating SEA early and disseminating results to the participants. We conclude that SEA is still developing in Kenya, but processes for conducting it are slowly adapting to the Kenyan context.     

Assessment of scientific profiles and capabilities of Ph.D. programs in Chile: A scientometric approach

It is well known that the quality of a doctorate program is related to the level of involvement of its faculty in research. Thus, we worked with the hypothesis that postulates that if the in-house scientific output of the core faculty involved in a Ph.D. program can be appraised in such a manner that the achievements render quantitative and qualitative indicators, it is possible to depict profiles amenable for comparisons. We describe the methodology, that uses performance scientometric indicators, and results obtained after studying five Ph.D. programs in the field of Cell and Molecular Biology/Biochemistry in three different Chilean universities and show that the approach serves to portray the in-house capacity of each programvis a vis national and international standards.     

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.     

Issues in the development, dissemination, and effect of an evidence-based guideline for managing sore throat in adults

BACKGROUND: In October 1995 the University of Michigan Healthcare System initiated a program to develop and implement guidelines for primary care in an effort to improve the quality and cost-effectiveness of care for common conditions associated with wide variations in clinical practice. One of these conditions was Group A beta-hemolytic streptococcus (GABHS), present in 5% to 20% of adults complaining of sore throat. METHODS: A draft guideline was developed on the basis of a theoretical model of sore throat management, local data, and research evidence. The guideline was revised to reflect physicians' beliefs and practices regarding sore throat management. Guideline recommendations depended only on the number of clinical signs experienced by the patient and included testing only if it was likely to provide additional information about the probability of GABHS. Data on pre- and postdissemination data on patients presenting with sore throat were collected. RESULTS: When physicians believed testing or antibiotics were unnecessary, only 7% of patients demanded screening and only 6% of patients wanted antibiotics. Physician beliefs about a patient's need for testing agreed with guideline recommendations in 63% of patients both before and after guideline dissemination. DISCUSSION: Disseminating locally modified, evidence-based guidelines may not be sufficient to produce practice changes. If the guideline had been followed, the amount of testing would have been reduced by 17% and the appropriateness of testing improved for 32% of sore throat patients. The results indicate the need for implementation efforts that go beyond presenting evidence, even when that evidence is from both the literature and the local practice setting.     

Regulating research: a tale of two technologies

This paper challenges the widely held view that research activities are impaired by the imposition of any form of governmental regulation. Research on topics which raise ethical concerns requires guidelines or rules along with an administrative apparatus in order for significant levels of research activity to be undertaken. This regulatory framework can emerge only after the ethical issues are addressed. Thus, there is a direct connection between the resolution of ethical issues and the production of new scientific information. Two research areas which have strong ethical overtones are compared. In the case of recombinant DNA technology, consideration of ethical issues has led to the establishment guidelines and a regulatory apparatus and has made possible the vigorous development of this field. In the reproductive technologies, such as in vitro fertilization, the failure to confront the ethical dilemmas in the US has prevented guidelines from being established and has severely handicapped the development of research programs. Other countries, such as the UK, by taking account of the ethical issues have been able to create policies thatpermit research to proceed.     

Interlaboratory comparisons for passive radon measuring devices at BfS

Since 2003, the German Federal Office for Radiation Protection (BfS) has conducted annual interlaboratory comparisons for passive radon measuring devices in order to ensure the quality of these measurements. Passive radon devices which use solid state nuclear track detectors, electrets or activated charcoal can be tested. The exposures of radon devices are carried out in the radon calibration laboratory at BfS. Radon activity concentrations are traced back to the national standard, being established at the National Institute of Physics and Metrology (PTB). According to the national guideline, radon services which offer radon monitoring at workplaces have to participate in the intercomparisons and prove the suitability of their radon devices for the measurements.     

《环境管理建立防治土地退化和荒漠化良好实践的指南第1部分:良好实践框架》国际标准分析研究

2017年10月,国际标准化组织ISO/TC 207环境管理标准化技术委员会正式发布了ISO 14055-1《环境管理建立防治土地退化和荒漠化良好实践的指南第1部分:良好实践框架》国际标准。本文对该项国际标准所提出的关键术语和定义、良好实践指南原则、确定造成土地退化和荒漠化的因素,以及建立良好实践并监测其实施等核心内容进行分析研究,旨在为我国土地退化和荒漠化防治与管理工作提供国际标准化经验和实践指引。     

Developing global supply chain quality management systems

This paper presents a global supply chain quality management (SCQM) framework as an extension of the traditional supply chain operations and quality management. Three distinct groups of variables are adopted in this study to illustrate the conceptual framework: a hierarchy of design variables, a hierarchy of system variables, and a hierarchy of problem solving methods. The aim of this theoretical framework is to offer practical guidelines to global business leaders and their value chain partners. This study also involves interviews with senior executives from a multinational enterprise in Taiwan. Four major SCQM themes are identified – design for six sigma (DFSS); international standards; supply chain management (SCM); global leadership and human resource management. In this study, we also view the cycle of decision making as an integral part of any global SCQM strategy. The analytic hierarchy process (AHP) is used to develop priority indices for the following three hierarchical levels: environmental scanning, strategic choice, and tactical choice. The presented framework adopts a systems approach and ensures that quality conscious products are designed, manufactured, and distributed.     

Prognostic implications of clinical practice guidelines among hemodialysis patients

Although the National Kidney Foundation (NKF) has published clinical practice guidelines for the management of risk factors for cardiovascular disease, these guidelines have not been tested rigorously for their effectiveness. We conducted an observational study among patients with end-stage kidney disease to examine the prognostic impact of threshold levels recommended by the NKF for blood pressure, hemoglobin, calcium-phosphate product, parathyroid hormone, low-density lipoprotein, and glycosylated hemoglobin. The study population (N = 197) was assembled from a previously completed randomized trial examining arteriovenous graft thrombosis. Cox proportional hazard analysis was used to calculate hazard ratios for the association of levels outside guideline recommended targets and death, adjusting for age, comorbidity, race, and albumin. The proportion of patients outside guideline targets ranged from 33% to 81%, and the impact of levels outside guideline targets on mortality varied substantially. Elevated calcium-phosphate product and glycosylated hemoglobin had harmful effects, with adjusted hazard ratios of 1.58 (95% CI 1.00-2.50; p = 0.050) and 2.21 (95% CI 0.99-4.97; p = 0.054), respectively. Nontarget levels for blood pressure, hemoglobin, and parathyroid hormone had little effect, with adjusted hazard ratios of 1.15 (95% CI 0.74-1.78; p = 0.542), 1.04 (95% CI 0.65-1.68; p = 0.866), and 0.90 (95% CI 0.50-1.61; p = 0.722), respectively. Elevated low-density lipoprotein had a paradoxically beneficial effect, with an adjusted hazard ratio of 0.48 (95% CI 0.23-1.00; p = 0.049). These results suggest that the prognostic impact of current threshold levels recommended by select NKF guidelines on mortality is variable. Accordingly, the development and implementation of clinical practice guidelines should be accompanied by corresponding efforts to confirm their impact on patient outcomes. Such efforts are essential for the improvement of guidelines and to inform health policy optimally.     

Best Practice Guidelines for Pre-Launch Characterization and Calibration of Instruments for Passive Optical Remote Sensing

The pre-launch characterization and calibration of remote sensing instruments should be planned and carried out in conjunction with their design and development to meet the mission requirements. The onboard calibrators such as blackbodies and the sensors such as spectral radiometers should be characterized and calibrated using SI traceable standards. In the case of earth remote sensing, this allows inter-comparison and intercalibration of different sensors in space to create global time series of climate records of high accuracy where some inevitable data gaps can be easily bridged. The recommended best practice guidelines for this pre-launch effort is presented based on experience gained at National Institute of Standards and Technology (NIST), National Aeronautics and Space Administration (NASA) and National Oceanic and Atmospheric Administration (NOAA) programs over the past two decades. The currently available radiometric standards and calibration facilities at NIST serving the remote sensing community are described. Examples of best practice calibrations and intercomparisons to build SI (international System of Units) traceable uncertainty budget in the instrumentation used for preflight satellite sensor calibration and validation are presented.     

Guideline implementation: what the literature doesn't tell us

BACKGROUND: Despite large numbers of studies and literature reviews about guideline implementation, it remains unclear whether and how clinical guidelines can be used to improve the quality of medical care. This study sought to learn whether these studies and reviews have recognized the importance of systems thinking and organizational change for implementation. METHODS: A literature search was conducted for systematic reviews of guideline implementation or practice improvement studies. Each review was studied for the extent to which it identified or discussed the value of systems changes, organizational support, practice environmental factors, and use of a change process. RESULTS: Forty-seven good-quality systematic reviews were found. They largely concurred that using reminders and perhaps using feedback in the course of clinical encounters were the most effective ways of implementing guidelines. However, these same reviews rarely identified these strategies as systems changes, and there was little discussion about any need for organizational support or attention to various environmental variables that might affect implementation. The change process required to introduce a new or changed practice system received even less attention. CONCLUSION: Reviews of guideline implementation trials have focused on how to change the behavior of individual clinicians. There has been little attention to the impact of practice systems or organizational support of clinician behavior, the process by which change is produced, or the role of the practice environmental context within which change is being attempted. New attention to these issues may help us to better understand and undertake the process of improving medical care delivery.     

Evidence-based medicine: is translating evidence into practice a solution to the cost-quality challenges facing medicine?

BACKGROUND: Evidence-based medicine (EBM) and practice guidelines have been embraced by increasing numbers of scholars, administrators, and medical journalists as an intellectually attractive solution to the dilemma of improving health care quality while reducing costs. However, certain factors have thus far limited the role that EBM might play in resolving cost-quality trade-offs. FACTORS FOR SUCCESS OF EBM RECOMMENDATIONS AND GUIDELINES: Beyond the quality of the guideline and the evidence base itself, critical factors for success include local clinician involvement, a unified or closed medical staff, protocols that minimize use of clinical judgment and that call for involvement of so-called physician extenders (such as nurse practitioners and physician assistants), and financial incentive. TROUBLESOME ISSUES RELATED TO COST-QUALITY TRADE-OFFS: Rationing presents many dilemmas, but for physicians one critical problem is determining what is the physician's responsibility. Is the physician to be the patient's advocate, or should the physician be the advocate of all patients (the patients' advocate)? How do we get physicians out of potentially conflicted roles? EBM guidelines are needed to help minimize the number of instances physicians are asked to ration care at the bedside. If the public can decide to share and limit resources--presumably based on shared priorities--physicians would have a basis to act as advocates for all patients. CONCLUSIONS: Although EBM alone is not a simple solution to the problems of increasing costs and public expectations, it can be an important source of input and information in relating the value of service and medical technology to public priorities.     

基于工作分析的绩效考核体系研究

根据某企业的需求,应用工作分析的原理和先期研究得出的“业绩 表现”的绩效考核模式,构建了基于客观化业绩考核的绩效考核体系。业绩考核分为可量化工作和不可量化工作考核,对于可量化工作从工作定额的角度考核,对于不可量化工作从时间进度的角度考核,并设计了相应的考核标准和考核方法。为了使不同的工作岗位之间具有可比性,设置了业绩考核的岗位系数。通过案例研究,说明了该绩效考核体系的应用,表明该体系具有很强的可操作性。     

A note on 'Some models for understanding the cooperation between the supplier and the buyer'

Concern has been expressed that UK organizations are lagging behind their competitors in the adoption of advanced manufacturing technology. It has been suggested that it is not the shortcomings of the technology that is resulting in the rejection of AMT projects but possibly the inappropriateness of the economic evaluation methods used in its appraisal, the difficulties in evaluating the potential benefits and the criteria used to assess management performance. A postal survey, addressed to large UK manufacturing organizations, into the ‘state of the art’ of investment appraisal of AMT projects has identified that there is concern that the traditional financial appraisal techniques may be inappropriate for appraising long-term projects. This research also identified the concern over the difficulties experienced in appraising AMT projects and supports the argument that a short-term business philosophy may exist in some major UK manufacturing companies. Areas for further academic research are highlighted.     

SNT-TC-1A within a UK quality assurance system

Training and certification of ndt personnel is discussed within the framework of an overall system of quality assurance in industry. The authors argue that SNT-TC-1A, a Recommended Practice for inspection and testing with guidelines laid down by ASNT, should be integrated into the quality system of individual companies to assure customers of the quality of inspection personnel. The requirements of SNT-TC-1A are outlined and compared with other operator certification schemes.     

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.     

中国第二代法定证件及防伪技术

证件防伪是关系到维护国家利益、保障社会秩序、建立公开公正和谐社会的一个重要基础。当前世界，和平和发展是社会发展主题。但是我们也必须看到，影响和平发展的不确定因素也在日益增加，这个使我们感到越来越小的地球，由于恐怖活动，由于局部战争等等因素，仍然处在深深的不安动荡之中。因此，证件证卡防伪对反恐、对跨国性的安全防范日显重要。国际国内的复杂形势，给证件证卡领域的研究者提出了众多新的研究课题。我今天主要就中国第二代居民身份证的问题谈一下自己的观点，并简单介绍一下公安部第一研究所在证件领域的工作．