Financial incentives for ambulatory care performance improvement.

BACKGROUND: Measuring and improving the quality of care while curtailing costs are essential objectives in capitated care. As patient care moves from the hospital to outpatient settings, quality management resources must be shifted to ambulatory care process improvement. The Quality Improvement and Efficiency Financial Incentives Program at Stanford University Medical Center was adopted to increase quality improvement efforts and contain costs. THE INCENTIVE PROGRAM: Each department's budget for care of capitated patients was reduced by 5% from the previous year. Return of a reserve fund (10% of payments for specialty care) required completion of substantive quality improvement projects and containing costs. Successful departments were also eligible for bonus funds. Implementation strategies included endorsement by clinical leaders, physician education, use of administrative data to identify project topics and support measurement of quality and cost variables, project templates and time lines, and the availability of clinical quality managers with special expertise in clinical process improvement. RESULTS: Eight of 13 clinical departments developed and implemented 19 ambulatory quality improvement projects to varying degrees. Success in the program was roughly correlated with the potential impact of the incentive on revenues and the status of the lead person selected by the department to spearhead their efforts. Only 5 departments achieved their cost containment goals. DISCUSSION: Financial incentives are one method of encouraging physicians to use clinical process improvement methods. Endorsement by clinical leaders and selection of realistic beginning projects enhance chances for success. The capitated population has attributes that make it an attractive focus for initial quality improvement efforts.     

Cooling power costs from a trigeneration system in a hospital

Hospitals with high needs for electric, heat and cooling power for the whole year seem to be a promising customer interested in introducing a so-called trigeneration system. The goal of the paper is to calculate the costs of these three energy forms produced from such a system taking the energy and exergy approach. The emphasis was placed on the costs of cooling energy and its variation during peak and off-peak periods when using different types of cooling devices.     

空压机系统挖潜改造

简介了空分设备配套空压机系统存在的问题,详细介绍了对空压机系统所进行的技术改造,效果明显。     

Life cycle environmental performance and improvement of a yogurt product delivery system

A life cycle assessment was conducted to evaluate the environmental performance of the yogurt product delivery system used by Stonyfield Farm. A life cycle model was developed which included material production, manufacturing and disposition for primary and secondary packaging, as well as the related transportation links between these stages and filling, retail and the point of consumption. Product delivery systems (PDS) that utilized 4, 6, 8 and 32 oz polypropylene (PP) cups and 2 oz linear low‐density polyethylene (LLDPE) tubes were analysed. Ten strategies for improving the environmental performance of these systems were proposed and their impacts on the total life cycle burden were analysed. The life cycle energy consumption for the 2, 4, 6, 8 and 32 oz containers was 4050, 4670, 5230, 4390 and 3620 MJ/1000 lb yogurt delivered to market, respectively. Material production of the primary packaging accounted for 58% of the life cycle energy, while Distribution 3 (yogurt delivery to distributors/retailers) alone accounted for one‐third of the life cycle total energy. The life cycle solid waste profile showed that as the container size decreased, the solid waste burden increased, from 27.3 kg (32 oz) to 42.8 kg (6 oz) per 1000 lb yogurt delivered to market. This relationship was even more pronounced for the 4 oz (47.5 kg) and 2 oz (56.2 kg) product delivery systems. The greatest potential improvements in the environmental performance of the PDS are achievable through redesigning the primary packaging and using alternative manufacturing techniques for the yogurt cups. Shifting from injection moulding to thermoforming of 32 oz container reduces the life cycle energy and solid waste by 18.6% and 19.5%, respectively, primarily due to light‐weighting. Elimination of lids for 6 oz and 8 oz containers provided similar benefits. Consumers purchasing yogurt in 32 oz instead of 6 oz containers can save 14.5% of the life cycle energy and decrease solid waste by 27.2%. Copyright © 2004 John Wiley & Sons, Ltd.     

Microfluxgate performance improvement in microtechnology

Microfluxgate sensors have been developed to measure very low magnetic fields, of about some nanotesla. This paper describes a recent integrated solution coupled with the basic microfluxgate component. The objective is to decrease the noise level of the sensor down to a few nanotesla per square root of hertz. The technological solution consists of adding coils or single layers, thanks to which the required ac transverse magnetic field can be applied. A large enhancement of the sensor sensitivity is put in evidence on output signal figures with and without stabilization signal. The specifications of the sensor connected with its electronics are also presented.     

Investigation on the performance of UPQC-Q for voltage sag mitigation and power quality improvement at a critical load point

The unified power quality conditioner (UPQC) is one of the major custom power solutions, which is capable of mitigating the effect of supply voltage sag at the load end or at the point of common coupling (PCC) in a distributed network. It also prevents the propagation of the load current harmonics to the utility and improves the input power factor of the load. The control of series compensator (SERC) of the UPQC is such that it injects voltage in quadrature advance to the supply current. Thus, the SERC consumes no active power at steady state. The other advantage of the proposed control scheme is that the SERC can share the lagging VAR demand of the load with the shunt compensator (SHUC) and can ease its loading. The UPQC employing this type of quadrature voltage injection in series is termed as UPQC-Q. The VA requirement issues of SERC and SHUCs of a UPQC-Q are discussed. A PC-based new hybrid control has been proposed and the performance of the UPQC-Q is verified in a laboratory prototype. The phasor diagram, control block diagram, simulations and experimental results are presented to confirm the validity of the theory.     

Clinical performance improvement series. Classic CQI integrated with comprehensive disease management as a model for performance improvement.

BACKGROUND: In recent years, health and disease management has emerged as an effective means of delivering, integrating, and improving care through a population-based approach. Since 1997 the University of Pennsylvania Health System (UPHS) has utilized the key principles and components of continuous quality improvement (CQI) and disease management to form a model for health care improvement that focuses on designing best practices, using best practices to influence clinical decision making, changing processes and systems to deploy and deliver best practices, and measuring outcomes to improve the process. Experience with 28 programs and more than 14,000 patients indicates significant improvement in outcomes, including high physician satisfaction, increased patient satisfaction, reduced costs, and improved clinical process and outcome measures across multiple diseases. DIABETES DISEASE MANAGEMENT: In three months a UPHS multidisciplinary diabetes disease management team developed a best practice approach for the treatment of all patients with diabetes in the UPHS. After the program was pilot tested in three primary care physician sites, it was then introduced progressively to additional practice sites throughout the health system. The establishment of the role of the diabetes nurse care managers (certified diabetes educators) was central to successful program deployment. Office-based coordinators ensure incorporation of the best practice protocols into routine flow processes. A disease management intranet disseminates programs electronically. Outcomes of the UPHS health and disease management programs so far demonstrate success across multiple dimensions of performance-service, clinical quality, access, and value. DISCUSSION: The task of health care leadership today is to remove barriers and enable effective implementation of key strategies, such as health and disease management. Substantial effort and resources must be dedicated to gain physician buy-in and achieve compliance. The challenge is to provide leadership support, to reward and recognize best practice performers, and to emphasize the use of data for feedback and improvement. As these processes are implemented successfully, and evidence of improved outcomes is documented, it is likely that this approach will be more widely embraced and that organizationwide performance improvement will increase significantly. CONCLUSIONS: Health care has traditionally invested extraordinary resources in developing best practice approaches, including guidelines, education programs, or other tangible products and services. Comparatively little time, effort, and resources have been targeted to implementation and use, the stage at which most efforts fail. CQI's emphasis on data, rapid diffusion of innovative programs, and rapid cycle improvements enhance the implementation and effectiveness of disease management.     

Developing a patient complaint tracking system to improve performance

BACKGROUND: Assessing patient satisfaction exclusively through close-ended scaled survey questions may not provide a complete picture of patients' concerns. Only recently has the role of complaint data as a management tool received attention. FORMATION OF THE TEAM AND THE DATABASE: The Complaint Management Team was created in January 1997 at Hartford Hospital (Conn) to develop a coding and reporting mechanism for complaints (negative comments) gathered from patient surveys. Developing the codebook was an evolutionary process. A database was designed to collect three separate complaints and the verbatim text associated with the code. REPORTING: Department-specific, location-specific, and organization wide reports are generated. Quarterly department-specific reports are used to trend the incidence of complaint themes, identify specific locations with problems, and initiate improvement efforts. OVERALL FINDINGS: Since March 1997, most complaints have fallen into five major categories--accommodations (environment), quality of care (care and treatment), respect and caring (humaneness or attitudes and behaviors), timeliness, and communication. The hospital's real estate department has completed a project focused on increasing patient satisfaction with parking. Two projects are still in progress; one is focused on increasing patient satisfaction with respect and staff caring attitude/behaviors, and one on improving satisfaction with the level of noise on the units. DISCUSSION: Approximately 4,000 survey complaints are coded every year. One limitation of the database is that all sources of complaints received throughout the organization are not yet captured. Another limitation is that the outcomes measurement section has exclusive access to the database. CONCLUSIONS: The patient complaint tracking system enables staff, managers, teams, and departments to develop improvement efforts based on quantitative and qualitative data.     

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.     

Integrating patient satisfaction into performance measurement to meet improvement challenges

BACKGROUND: A Value Compass has been proposed to guide health care data collection. The "compass corners" represent the four types of data needed to meet health care customer expectations: appropriate clinical outcomes, improved functional status, patient satisfaction, and appropriate costs. Collection of all four types of data is necessary to select processes in need of improvement, guide improvement teams, and monitor the success of improvement efforts. INTEGRATED DATA AT BRYANLGH: BryanLGH Medical Center in Lincoln, Nebraska, has adopted multiple performance measurement systems to collect clinical outcome, financial, and patient satisfaction data into integrated databases. Data integration allows quality professionals at BryanLGH to identify quality issues from multiple perspectives and track the interrelated effects of improvement efforts. A CASE EXAMPLE: Data from the fourth quarter of 1997 indicated the need to improve processes related to cesarean section (C-section) deliveries. An interdisciplinary team was formed, which focused on educating nurses, physicians, and the community about labor support measures. Physicians were given their own rates of C-section deliveries. RESULTS: The C-section rate decreased from 27% to 19%, but per-case cost increased. PickerPLUS+ results indicated that BryanLGH obstetric patients reported fewer problems with receiving information than the Picker norm, but they reported more problems with the involvement of family members and friends. CONCLUSIONS: The data collected so far have indicated a decrease in the C-section rate and a need to continue to work on cost and psychosocial issues. A complete analysis of results was facilitated by integrated performance management systems. Successes have been easily tracked over time, and the need for further work on related processes has been clearly identified.     

Evolution of competitive priorities towards performance improvement: a meta-analysis

Competitive priorities are critical operational dimensions that a business process must possess to satisfy its internal and external customers. The process of defining competitive priorities is evolving and changing over time according to a new business paradigm. Therefore, it is the right time to revisit the critical dimensions of competitive priority. The purpose of this study is threefold: (1) to identify and revise the critical dimensions of competitive priority; (2) to assess the quality of competitive priority measures across studies based on different criteria; (3) to confirm the relationship between several competitive priorities and organisational performance. The results show the different effects that competitive priorities have on organisational performance. Cost and quality priorities show evidence of strong effect size compared to the others.     

Manufacturing capabilities and performance: a critical analysis and review

In order to advance scientific knowledge, it is important to maintain consistency regarding the methodologies and units/levels of analysis employed to test a theory's main claims. Thus, this investigation provides a critical examination of the papers that have aimed to test the trade-off model and its competing concepts. The analysis focuses on the methodologies used to examine the validity of such models and theories, and also on the operationalisation of the variables that represent the level of analysis by which those theories are tested. To aid in the investigation, a framework to distinguish measures of performance with an internal and external reference and perspective is proposed. The results show that current methodologies, approaches and rationales used to determine the validity of the trade-off model or its rival concepts observe important limitations, as they do not address the trade-off model's core principles. Those limitations in turn make the results of those studies questionable. Consequently, it is proposed that in order to advance theory in our field, more consistent methods and approaches should be utilised.     

Towards a lessons learned system for critical software

Failure can be a major driver for the advance of any engineering discipline and Software Engineering is no exception. But failures are useful only if lessons are learned from them. In this article we aim to make a strong defence of, and set the requirements for, lessons learned systems for safety-critical software. We also present a prototype lessons learned system that includes many of the features discussed here. We emphasize that, apart from individual organizations, lessons learned systems should target industrial sectors and even the Software Engineering community. We would like to encourage the Software Engineering community to use this kind of systems as another tool in the toolbox, which complements or enhances other approaches like, for example, standards and checklists.     

RCSM: a reliable critical subsystem model in multi-agent system

针对多主体系统由其自治的软件主体构成带来的故障处理上的困难,研究了多主体系统的可靠性问题,并尝试从主体组层面出发对系统中的故障进行协调处理,提出了一个可靠关键子系统模型(RCSM).RCSM包含三类主体,即中继主体、控制中心主体以及工作主体.此模型使用中继主体封装由工作主体组成的关键子系统,使子系统的拓扑结构对外界不可见,从而避免故障的大范围传播.在子系统内部采用基于任务分配的一致性检查点设置技术实现工作主体的故障恢复.对模型中的控制中心主体则采用了复制技术与团队协作相结合的手段来提高其可靠性.通过仿真实验对RCSM的故障恢复效率及其对系统正常运行效率的影响进行分析,说明了该模型的实用价值.     

Development of a framework for sustainable improvement in performance of coal mining operations

Clean Technologies and Environmental Policy - India is a developing country, where boosting of modern energy supply is the primary requirement for economic growth. About two-thirds of this energy...     

Designing a performance measurement system to support materials management in engineer-to-order:a case study

There are many different production situations that can be employed to meet demand.In the engineer-toorder(ETO)production situation,products are manufactured to meet specific customer needs by unique engineering or significant customization.In such an environment,failing to supply the required materials in the right quantities and at the right time increases the risk of breaching due date agreements and thereby losing customer satisfaction.As such,materials management is one of the most important and critical processes within production planning and control in ETO.To bring attention and improvement to this area,ETO companies may benefit from a performance measurement system(PMS)that systematically monitors how well materials management is carded out.The design of a company's PMS varies with its production situation.Within the large body of literature on performance management and measurement,limited literature specifically addressing performance measurement in ETO has been identified.After being approached by a Norwegian ETO company requesting a PMS for materials management,the authors therefore set out to design the PMS from scratch,using literature on ETO,materials management and performance management and measurement as a starting point.The paper presents the proposed PMS.It provides a basis for further studies on the topic,and could be used by managers in ETO companies to assess and improve their materials management practice.     

Radiation dose levels during interventional cardiology procedures in a tertiary care hospital

The aim of our investigation was to prospectively measure the patient radiation exposure from different cardiological procedures performed in the Catheterisation laboratory of the University Hospital Gasthuisberg in Leuven. The following local reference values were proposed: 40, 47 and 80 Gycm2 for coronary angiography (CA) or angioplasty (PTCA and stent implantation for elective patients), radio frequency ablation with angiographic images and CA plus ad hoc PTCA, respectively.     

Improved signal averaging performance in a weighing system

Translated from Izmeritel'naya Tekhnika, No. 5, pp. 22–23, May, 1988.     

Cryptanalysis and improvement on a conference key distribution system

Abstract

In 1993, Wu and Yeh proposed a conference key distribution system based on cross product. In this paper, we will show that Wu and Yeh's system is breakable. We also propose a modified scheme for the conference key distribution system under the same assumption, which can achieve better security.