Using systems thinking to support clinical system transformation

Purpose

– The British Columbia Ministry of Health’s Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC’s health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings.

Design/methodology/approach

– Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey.

Findings

– The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system.

Research limitations/implications

– The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels – policy, management and practice – about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue.

Practical implications

– Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues.

Originality/value

– Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

Fitting Higgs data with nonlinear effective theory

In a recent paper we showed that the electroweak chiral Lagrangian at leading order is equivalent to the conventional [Formula: see text] formalism used by ATLAS and CMS to test Higgs anomalous couplings. Here we apply this fact to fit the latest Higgs data. The new aspect of our analysis is a systematic interpretation of the fit parameters within an EFT. Concentrating on the processes of Higgs production and decay that have been measured so far, six parameters turn out to be relevant: [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text]. A global Bayesian fit is then performed with the result [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text]. Additionally, we show how this leading-order parametrization can be generalized to next-to-leading order, thus improving the [Formula: see text] formalism systematically. The differences with a linear EFT analysis including operators of dimension six are also discussed. One of the main conclusions of our analysis is that since the conventional [Formula: see text] formalism can be properly justified within a QFT framework, it should continue to play a central role in analyzing and interpreting Higgs data.

Exploring distributed leadership in the BC Sepsis Network

Commissioned research was undertaken to explore the role of networks in supporting large-scale change and improvement. Participatory action research and social network analysis were used to study the BC Sepsis Network. Findings of this research include insights into distributed leadership, enablers and barriers within a network approach; the importance of relationships and trust; and the need for meaningful and timely data. Recommendations are made for health leaders who are considering utilizing networks for improving patient quality and safety.

Gamification as a strategy to engage and motivate clinicians to improve care

Approaching change through seeking commitment rather than requiring compliance is an effective way to promote desired behaviours in healthcare. Gamification was explored as a technique to engage clinicians in the adoption of sepsis identification and management tools. Positive extrinsic (eg, feedback and rewards) and intrinsic (eg, mastery, autonomy, relatedness, and purpose) motivators were integrated into a campaign to save lives, leading to a significant reduction in severe sepsis mortality and improvement in processes of care.

Improving care for British Columbians: the critical role of physician engagement

Canadian provinces are addressing quality of care and patient safety in a systemic way, but obtaining physician involvement in system improvement continues to be a challenge. To address this issue, individual physicians, physician groups, the British Columbia Medical Association, the health authorities, the BC Patient Safety & Quality Council (BCPSQC) and the Ministry of Health have come together to support physician involvement and foster physician satisfaction. Building on earlier work on patient safety, in 2010 the ministry developed a comprehensive strategy for system-wide improvement, focusing on achieving critical population, patient and sustainability outcomes. Central to this plan is the acknowledged need to involve healthcare providers of all disciplines, in particular physicians. Today, BC physicians are leading large-scale provincial clinical improvement in three interdependent areas: Clinical Care Management, Integrated Primary and Community Care, and the National Surgical Quality Improvement Program. To further physicians' key contributions to BC's healthcare system, the BCPSQC, physician-ministry committees, health authorities and the Ministry will continue to engage physicians through practice support, feedback, financial recognition and information exchange, and by supporting improvements in the care provided to patients.

High-resolution dielectric study reveals pore-size-dependent orientational order of a discotic liquid crystal confined in tubular nanopores

We report a high-resolution dielectric study on a pyrene-based discotic liquid crystal (DLC) in the bulk state and confined in parallel tubular nanopores of monolithic silica and alumina membranes. The positive dielectric anisotropy of the DLC molecule at low frequencies (in the quasistatic case) allows us to explore the thermotropic collective orientational order. A face-on arrangement of the molecular discs on the pore walls and a corresponding radial arrangement of the molecules is found. In contrast to the bulk, the isotropic-to-columnar transition of the confined DLC is continuous, shifts with decreasing pore diameter to lower temperatures, and exhibits a pronounced hysteresis between cooling and heating. These findings corroborate conclusions from previous neutron and x-ray-scattering experiments as well as optical birefringence measurements. Our study also indicates that the relative simple dielectric technique presented here is a quite efficient method in order to study the thermotropic orientational order of DLC-based nanocomposites.

EUROPattern Suite technology for computer-aided immunofluorescence microscopy in autoantibody diagnostics

Antinuclear autoantibodies (ANA) are highly informative biomarkers in autoimmune diagnostics. The increasing demand for effective test systems, however, has led to the development of a confusingly large variety of different platforms. One of them, the indirect immunofluorescence (IIF), is regarded as the common gold standard for ANA screening, as described in a position statement by the American College of Rheumatology in 2009. Technological solutions have been developed aimed at standardization and automation of IIF to overcome methodological limitations and subjective bias in IIF interpretation. In this review, we present the EUROPattern Suite, a system for computer-aided immunofluorescence microscopy (CAIFM) including automated acquisition of digital images and evaluation of IIF results. The system was originally designed for ANA diagnostics on human epithelial cells, but its applications have been extended with the latest system update version 1.5 to the analysis of antineutrophil cytoplasmic antibodies (ANCA) and anti-dsDNA antibodies.

Ultrastable low-noise current amplifier: a novel device for measuring small electric currents with high accuracy

An ultrastable low-noise current amplifier (ULCA) is presented. The ULCA is a non-cryogenic instrument based on specially designed operational amplifiers and resistor networks. It involves two stages, the first providing a 1000-fold current gain and the second performing a current-to-voltage conversion via an internal 1 MΩ reference resistor or, optionally, an external standard resistor. The ULCA's transfer coefficient is highly stable versus time, temperature, and current amplitude within the full dynamic range of ±5 nA. The low noise level of 2.4 fA/√Hz helps to keep averaging times short at small input currents. A cryogenic current comparator is used to calibrate both input current gain and output transresistance, providing traceability to the quantum Hall effect. Within one week after calibration, the uncertainty contribution from short-term fluctuations and drift of the transresistance is about 0.1 parts per million (ppm). The long-term drift is typically 5 ppm/yr. A high-accuracy variant is available that shows improved stability of the input gain at the expense of a higher noise level of 7.5 fA/√Hz. The ULCA also allows the traceable generation of small electric currents or the calibration of high-ohmic resistors.

Verhaltensauffälligkeiten mit 9 Jahren zur Vorhersage von Schulproblemen im Alter von 11 und 15 Jahren

Verhaltensauffälligkeiten im Kindesalter stellen einen Risikofaktor für psychische Auffälligkeiten und verminderte schulische Leistungsfähigkeit dar. Die Studie untersucht, ob eine geringere Funktionalität im Grundschulalter die Auftretenswahrscheinlichkeit von Schulproblemen in der Adoleszenz erhöht. Fragebogendaten der 9-, 11- und 15-Jahres Nachuntersuchungen der MAS-Geburtskohorte (N=1314 Baselineerhebung bei Geburt; 47.9 % Mädchen, 52.1 % Jungen) werden ausgewertet. Erhoben werden Funktionalität auf den Dimensionen Psychisches Wohlergehen, Körperlicher Status, Soziale Beziehungen und Alltagsfunktionsfähigkeit zu 9 Jahren sowie das Vorkommen von Schulproblemen mit 11 und 15 Jahren. Eine geringere Funktionalität im Alter von 9 Jahren geht mit einer erhöhten Auftretenswahrscheinlichkeit von Schulproblemen mit 11 (adjustierte Odds Ratio [aOR]=3.53, 95 %Konfidenzintervall [KI] 2.20 – 5.66) und 15 Jahren (aOR=3.22, 95 %KI 1.85 – 5.62) einher. Diese Effekte zeigen sich deutlicher für Jungen als für Mädchen. Bereits Grundschulkinder können Einschränkungen in ihrer Funktionalität zeigen, welche über Jahre stabil zu bleiben scheinen und mit Schulproblemen in der Adoleszenz einhergehen können.

Thermotropic orientational order of discotic liquid crystals in nanochannels: an optical polarimetry study and a Landau-de Gennes analysis

Optical polarimetry measurements of the orientational order of a discotic liquid crystal based on a pyrene derivative confined in parallelly aligned nanochannels of monolithic, mesoporous alumina, silica, and silicon as a function of temperature, channel radius (3-22 nm) and surface chemistry reveal a competition of radial and axial columnar orders. The evolution of the orientational order parameter of the confined systems is continuous, in contrast to the discontinuous transition in the bulk. For channel radii larger than 10 nm we suggest several, alternative defect structures, which are compatible both with the optical experiments on the collective molecular orientation presented here and with a translational, radial columnar order reported in previous diffraction studies. For smaller channel radii our observations can semi-quantitatively be described by a Landau-de Gennes model with a nematic shell of radially ordered columns (affected by elastic splay deformations) that coexists with an orientationally disordered, isotropic core. For these structures, the cylindrical phase boundaries are predicted to move from the channel walls to the channel centres upon cooling, and vice-versa upon heating, in accord with the pronounced cooling/heating hystereses observed and the scaling behavior of the transition temperatures with the channel diameter. The absence of experimental hints of a paranematic state is consistent with a biquadratic coupling of the splay deformations to the order parameter.

Structure-property relationship of anilino-squaraines in organic solar cells

Soluble molecular semiconductors are a promising alternative to semiconducting polymers in the field of organic photovoltaics. Here, three custom-made symmetric 1,3-bis(N,N-alkylated-2,6-dihydroxy-anilino)squaraines containing systematic variations in their molecular structures are compared regarding their applicability as donor materials in bulk-heterojunction solar cells. The terminal substitution pattern of the squaraines is varied from cyclic over linear to branched including a stereogenic center. Single crystal structures are determined, and, in the case of chiral squaraine, unusual formation of stereoisomer co-crystals is revealed. The thin film absorbance spectra show characteristic signatures of H- and J-bands or hint at the formation of tautomers. The general feasibility of these model compounds for photovoltaic applications is studied by light-induced electron spin resonance spectroscopy. The impact of the different molecular substitution patterns on aggregation behavior and, consequently, their optoelectronic solid state properties including charge carrier mobility and finally the solar cell performance are investigated.

Abstract WP399: Improving Stroke and TIA Care in the Emergency Department: Results from a Provincial Stroke Improvement Collaborative

Background: Stroke and transient ischemic attack (TIA) are common disorders cared for by emergency physicians. Best practices exist for the management of these disorders; however, these are not always followed.

OBJECTIVES: This study sought to measure the impact of a coordinated, provincial structured improvement collaborative, on care for stroke and TIA patients within emergency departments (ED’s) in British Columbia.

METHODS: This study was a qualitative and quantitative process evaluation of a provincial improvement collaborative. The collaborative followed an Institute of Healthcare Improvement (IHI) Methodology, consisting of five workshops, bi-weekly webinars, and improvement coaching and support, over a 10-month period, from Sept 2011 to June 2012. This evaluation examined process measures of success, such as self-reported improvement and adherence to certain clinical process measures (e.g. time to CT). Collaborative participants submitted monthly reports that quantified their improvement using the Self Assessment Score, which is used in IHI Collaborative Methodology.

RESULTS: 17 multidisciplinary teams participated, representing 27% of all ED’s in British Columbia (29 / 108), and all five Health Authorities. Further, all but one of the province’s tPA enabled sites were represented. 90% of teams (15 / 17) reported a median Self Assessment Score greater than 4.5/5.0, indicating significant and sustainable improvements in stroke and TIA care. No teams dropped out of the Collaborative. Teams reported a mean of 5.5 (SD 2.4) significant improvements within their ED. For example, shortened door-to-CT times, improved triage and training, and implementation of standardized swallowing screens were shown. This collaborative showed higher success rates of self-reported improvement (typically only 30% of teams achieve significant improvement) and lower rates of dropouts, than the published literature.

CONCLUSIONS: Using an IHI structured collaborative format, a provincial stroke & TIA emergency department quality improvement initiative was able to achieve significant improvements in adherence to best practices. A formal outcome evaluation is planned to measure the impact on stroke incidence, disability, and mortality.

Short term clinical efficacy of new meridol HALITOSIS tooth & tongue gel in combination with a tongue cleaner to reduce oral malodor

OBJECTIVE

This study evaluated the short term efficacy of tongue cleaning with meridol HALITOSIS tooth & tongue gel in comparison to mechanical tongue cleaning alone and untreated after five and 60 minutes in patients with an oral cause of bad breath.

METHODS

Fifty-four male and female subjects with an intra-oral cause of halitosis (organoleptic ratings > or = 2 and volatile sulphur compounds > or = 50 ppb) participated in this crossover study and were assigned to six different treatment sequences (ABC, ACB, BAC, BCA, CAB, CBA) with no treatment (A), mechanical tongue cleaning alone (B), and tongue cleaning with tooth & tongue gel applied to the tongue cleaner (C). Efficacy was assessed by organoleptic ratings and volatile sulphur compound measurements five and 60 minutes after treatment

RESULTS

Cleaning the tongue with tooth & tongue gel applied onto the tongue cleaner resulted in significantly reduced organoleptic ratings (p < 0.001 for the five-minute assessment; p = 0.001 for the 60-minute assessment) and volatile sulphur compounds (H2S + CH3SH: p = 0.005 for the five-minute assessment; p = 0.003 for the 60-minute assessment) compared to no treatment at the five- and 60-minute assessment time points, while mechanical tongue cleaning alone was less effective in reducing organoleptic ratings (p = 0.008 for the five-minute assessment; p = 0.144 for the 60-minute assessment) and volatile sulphur compounds (H2S + CH3SH: p = 0.261 for the five-minute assessment; p = 0.365 for the 60-minute assessment).

CONCLUSIONS

Single tongue cleaning with meridol HALITOSIS tooth & tongue gel had a positive effect on halitosis five and 60 minutes after treatment. Tongue cleaning with tooth & tongue gel in combination with other oral hygiene procedures is a promising approach to control halitosis.