From advanced hydraulic modelling to performance indicator for the efficiency of investments in leakage management of pressurized water systems

INTRODUCTION

The digital transition is meant as the review of processes using digital technologies and strategies to increase efficiency based on a simpler collection of representative data. The process of interest here is the leakage management in systems distributing water.

OBJECTIVE

To develop a novel key performance indicator (KPI) for leakage management considering the needs of ongoing digital transition in the water sector, which is opening a new era in the management of drinking water infrastructures.

METHODOLOGY

The novel KPI, named Asset Management Support Indicator, is developed starting from advanced hydraulic modelling and the physical laws governing leakage outflows, in order to be physically based and rational for increasing the efficiency of leakage management activities using representative process data.

RESULTS

The Asset Management Support Indicator supports effective leakage management strategies by driving towards efficiency, as discussed and demonstrated using several real case studies.

CONCLUSION

The novel indicator is consistent with the digital transition perspective and current need of increasing the efficiency of water utilities, and it is also suitable to be adopted by water authorities to benchmark their performances, because it overcomes the weaknesses of traditional KPIs.

[Reliability of peer review-like dialogue in the German statutory quality assurance program]

BACKGROUND

Quality measurement in the German statutory program for quality in health care follows a two-step process. For selected areas of health care, quality is measured via performance indicators (first step). Providers failing to achieve benchmarks in these indicators subsequently enter into a peer review process (second step) and are asked by the respective regional authority to provide a written statement regarding their indicator results. The statements are then evaluated by peers, with the goal to assess the provider's quality of care. In the past, similar peer review-based approaches to the measurement of health care quality in other countries have shown a tendency to lack reliability. So far, the reliability of this component of the German statutory program for quality in health care has not been investigated.

METHOD

Using logistic regression models, the influence of the respective regional authority on the peer review component of health care quality measurement in Germany was investigated using three exemplary indicators and data from 2016.

RESULTS

Both the probability that providers are asked to provide a statement as well as the results produced by the peer review process significantly depend on the regional authority in charge. This dependence cannot be fully explained by differences in the indicator results or by differences in case volume.

CONCLUSIONS

The present results are in accordance with earlier findings, which show low reliability for peer review-based approaches to quality measurement. Thus, different results produced by the peer review component of the quality measurement process may in part be due to differences in the way the review process is conducted. This heterogeneity among the regional authorities limits the reliability of this process. In order to increase reliability, the peer review process should be standardized to a higher degree, with clear review criteria, and the peers should undergo comprehensive training for the review process. Alternatively, the future peer review component could be adapted to focus rather on identification of improvement strategies than on reliable provider comparisons.

Tensions experienced by case managers working in home care for older adults in Quebec: first level analysis of an institutional ethnography

BACKGROUND

Case managers play a vital role in integrating the necessary services to optimise health-related goals and outcomes. Studies suggest that in home care, case managers encounter tensions in their day-to-day work, that is, disjuncture between what they should do, in theory, and what they actually do, in practice. However, direct exploration of these tensions is lacking. As such, this study aimed to describe the tensions encountered by case managers in public home care for older adults in Quebec and their influence on day-to-day work.

METHODS

An institutional ethnography was conducted through observations of work, interviews and a survey with case managers working in home care in Quebec. Data were analysed using institutional ethnography first-level analysis procedures. This included mapping the work sequences as well as identifying the tensions experienced by case managers through the words they used.

RESULTS

Three main tensions were identified. First, case managers perceive that, despite working to return hospitalised older adults at home safely, their work also aims to help free up hospital beds. Thus, they often find themselves needing to respond quickly to hospital-related inquiries or expedite requests for home care services. Second, they are supposed to delegate the care to "partners" (e.g., private organisations). However, they feel that they are in effect managing the quality of the services provided by the "partners." Consequently, they go to great lengths to ensure that good care will be provided. Finally, they must choose between meeting organisational requirements (e.g., reporting statistics about the work, documenting information in the older adults' file, doing mandatory assessments) and spending time providing direct care. This often leads to prioritising direct care provision over administrative tasks, resulting in minimal reporting of essential information.

CONCLUSION

The results are discussed using the three lenses of professional practice context analyses (i.e., accountability, ethics, and professional-as-worker) to formulate recommendations for practice and research. They suggest that, despite their important role, case managers have limited power in home care (e.g., with partners, with the hospital).

Introducing the f0% method: a reliable and accurate approach for qPCR analysis

BACKGROUND

qPCR is a widely used technique in scientific research as a basic tool in gene expression analysis. Classically, the quantitative endpoint of qPCR is the threshold cycle (CT) that ignores differences in amplification efficiency among many other drawbacks. While other methods have been developed to analyze qPCR results, none has statistically proven to perform better than the CT method. Therefore, we aimed to develop a new qPCR analysis method that overcomes the limitations of the CT method. Our f0% [eff naught percent] method depends on a modified flexible sigmoid function to fit the amplification curve with a linear part to subtract the background noise. Then, the initial fluorescence is estimated and reported as a percentage of the predicted maximum fluorescence (f0%).

RESULTS

The performance of the new f0% method was compared against the CT method along with another two outstanding methods-LinRegPCR and Cy0. The comparison regarded absolute and relative quantifications and used 20 dilution curves obtained from 7 different datasets that utilize different DNA-binding dyes. In the case of absolute quantification, f0% reduced CV%, variance, and absolute relative error by 1.66, 2.78, and 1.8 folds relative to CT; and by 1.65, 2.61, and 1.71 folds relative to LinRegPCR, respectively. While, regarding relative quantification, f0% reduced CV% by 1.76, 1.55, and 1.25 folds and variance by 3.13, 2.31, and 1.57 folds regarding CT, LinRegPCR, and Cy0, respectively. Finally, f0% reduced the absolute relative error caused by LinRegPCR by 1.83 folds.

CONCLUSIONS

We recommend using the f0% method to analyze and report qPCR results based on its reported advantages. Finally, to simplify the usage of the f0% method, it was implemented in a macro-enabled Excel file with a user manual located on https://github.com/Mahmoud0Gamal/F0-perc/releases .

Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries

BACKGROUND

Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability.

METHODS

The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries.

RESULTS

Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care.

CONCLUSIONS

This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

Learning from intermittent water supply schedules: Visualizing equality, equity, and hydraulic capacity in Bengaluru and Delhi, India

Intermittent distribution affects one in five piped water users, threatens water quality, and magnifies inequity. Research and regulations to improve intermittent systems are hindered by system complexity and missing data. We created four new methods to visually harness insights from intermittent supply schedules and demonstrate these methods in two of the world's most complicated intermittent systems. First, we created a new way to visualize the varieties of supply continuities (hours/week of supply) and supply frequencies (days between supplies) within complicated intermittent systems. We demonstrated using Delhi and Bengaluru, where 3278 water schedules vary from continuous to only 30 min/week. Second, we quantified equality based on how uniformly supply continuity and frequency were divided between neighbourhoods and cities. Delhi provides 45 % more supply continuity than Bengaluru, but with similar inequality. Bengaluru's infrequent schedules require consumers to store four times more water (for four times longer) than in Delhi, but Bengaluru's storage burden is more equally shared. Third, we considered supply inequitable where affluent neighbourhoods (using census data) received better service. Neighbourhood wealth was inequitably correlated with the percent of households with piped connections. In Bengaluru, supply continuity and required storage were also inequitably divided. Finally, we inferred hydraulic capacity from the coincidence of supply schedules. Delhi's highly coincident schedules result in city-wide peak flows 3.8 times their average - sufficient for continuous supply. Bengaluru's inconvenient nocturnal schedules may indicate upstream hydraulic limitations. Towards improved equity and quality, we provided four new methods to harness key insights from intermittent water supply schedules.

Clinical and laboratory key performance indicators in IVF: A consensus between the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR) and the Italian Society of Embryology, Reproduction and Research (SIERR)

PURPOSE

Infertility is increasing worldwide, and many couples seek IVF. Clinical management and laboratory work are fundamental in the IVF journey. Therefore, the definition of reliable key performance indicators (KPIs) based on clinical and laboratory parameters, is essential for internal quality control (IQC). Laboratory performance indicators have been identified and a first attempt to also determine clinical ones has been recently published. However, more detailed indicators are required.

METHODS

An Italian group of experts in Reproductive Medicine from both public and private clinics on behalf of SIFES-MR and SIERR was established to define IVF indicators to monitor clinical performance.

RESULTS

The working group built a consensus on a list of KPIs, performance indicators (PIs) and recommendation indicators (RIs). When deemed necessary, the reference population was stratified by woman age, response to ovarian stimulation and adoption of preimplantation genetic testing for aneuploidies (PGT-A). Each indicator was scored with a value from 1 to 5 and a weighted average formula - considering all the suggested parameters-was defined. This formula generates a center performance score, indicating low, average, good, or excellent performance.

CONCLUSION

This study is intended to provide KPIs, PIs and RIs that encompass several essential aspects of a modern IVF clinic, including quality control and constant monitoring of clinical and embryological features. These indicators could be used to assess the quality of each center with the aim of improving efficacy and efficiency in IVF.

Development of performance indicators for hepatitis countermeasures as a tool for the assessment and promotion of liver cancer prevention in Japan

BACKGROUND

Hepatitis countermeasures are being promoted by governments in Japan. We aimed to develop performance indicators (PIs) to assess the process and outcome of such countermeasures implemented for the prevention of viral hepatitis-related liver cancer at the national and prefectural government levels.

METHODS

We developed 19 PIs for hepatitis countermeasures implemented by local governments, covering the morbidity and mortality of liver cancer, hepatitis testing, subsidy programs for examinations and antiviral treatment, and education on hepatitis patient care to healthcare workers. We analyzed the PIs for each prefecture from Fiscal Year (FY) 2018-2020.

RESULTS

The morbidity and mortality of liver cancer significantly decreased in the study period. The percentage of municipalities conducting hepatitis screening was already high at 95% in FY2017. The usage rate of government-subsidized screenings did not change. The subsidy usage rate for periodic viral hepatitis examination significantly increased. Meanwhile, the subsidy usage rate for antiviral treatment of hepatitis B increased, whereas that for hepatitis C decreased. The number of certified healthcare workers providing care for hepatitis patients increased significantly, and these workers were efficiently placed at regional core centers, institutions specialized in liver diseases, health care centers, and municipal governments. Liver cancer mortality was positively correlated with hepatitis screening, subsidies for periodic examinations, and the number of hepatitis medical care coordinators but was negatively correlated with subsidies for anti-HCV therapy, suggesting that rigorous countermeasures were implemented in prefectures with high liver cancer mortality.

CONCLUSIONS

The developed PIs could be a useful tool for monitoring government efforts and achievements, thereby providing basic data for setting practical goals in liver cancer prevention.

Overordering of tumor marker for outpatients revealed by performance indicators and the impact of a health policy intervention: An observational study using administrative records

PURPOSE

The overuse of laboratory tests contributes to impair health systems effectiveness, tumor markers (TMs) being a paradigmatic example. In the present study we applied indicators of TMs appropriateness developed from administrative datasets to appraise regionwide overordering in the clinical practice.

PATIENTS AND METHODS

TMs ordered to outpatients in the Veneto Region over 6 years were obtained from the eletronic Outpatients' Records of Diagnostic and Therapeutic Procedures. TMs orders were examined as aggregated data or stratified according to disease codes, gender, age, and requests per patient. TMs recommended only for specific malignancies were examined using epidemiological data obtained from Veneto Tumor Registry.

RESULTS

A total of 5,821,251 TMs were ordered in 4,382,159 patients over 6 years. Overall, 3,252,389 (55.9%) TMs were ordered without appropriate disease codes (ranging from 77.0% for PSA to 17.5% for CA15.3). TM orders declined over 6 years (-13.4%), with a noticeable reduction of orders without appropriate disease codes (-21.3%). Orders decreased sharply from 2015 to 2016, after the enactment of a national Decree-Law aimed at improving appropriateness, and remained stable thereafter. However, the rate of inappropriate TMs requests still remained elevated (44.4%) in the last year of observation, with orders of TMs being much higher than expected on the basis of prevalence and incidence figures of specific malignancies.

CONCLUSIONS

Indicators developed from administrative datasets were effective in assessing the overordering of TMs and the impact of interventions to improve appropriateness. The developed indicators could be considered for other diagnostic tests.

Artificial intelligence and machine learning-based monitoring and design of biological wastewater treatment systems

Artificial intelligence (AI) and machine learning (ML) are currently used in several areas. The applications of AI and ML based models are also reported for monitoring and design of biological wastewater treatment systems (WWTS). The available information is reviewed and presented in terms of bibliometric analysis, model's description, specific applications, and major findings for investigated WWTS. Among the applied models, artificial neural network (ANN), fuzzy logic (FL) algorithms, random forest (RF), and long short-term memory (LSTM) were predominantly used in the biological wastewater treatment. These models are tested by predictive control of effluent parameters such as biological oxygen demand (BOD), chemical oxygen demand (COD), nutrient parameters, solids, and metallic substances. Following model performance indicators were mainly used for the accuracy analysis in most of the studies: root mean squared error (RMSE), mean square error (MSE), and determination coefficient (DC). Besides, outcomes of various models are also summarized in this study.

The influence of removing home advantage on the Chinese Football Super League

BACKGROUND

Due to the COVID-19 pandemic, the 2020 season Chinese Super League (CSL) was held in neutral venues, this study aims to analyse the impact of removing home advantage (HA) in CSL.

METHOD

240 games of the CSL 2019 season (home and away double round-robin system) and 160 games of the 2020 season (in neutral venues) were analysed. 27 technical and tactical performance indicators were involved as dependent variables. A multiple linear regression model was established to analyse the influence of removing HA on the performance indicators.

RESULTS

After moving from home stadium to neutral venue in 2020 season, goal, shot, shot on target, shot from outside box, shot from inside box, shot on target from inside box, corner kick, key pass, cross, breakthrough, tackle decreased significantly (p < 0.05), while yellow card and foul increased steeply (p < 0.05). Comparing with playing away match, in neutral venue, free kicks and pass accuracy enhanced radically (p < 0.05), while tackle, clearance and block shot dropped noticeably (p < 0.05).

CONCLUSION

When removing HA and playing in the neutral venue, teams' performance dropped significantly. This study confirmed the positive impact of HA on the teams' performance and may help elite football teams make proper playing strategies regarding different match locations.

Material flow analysis and recycling performance of an improved mechanical recycling process for post-consumer flexible plastics

Increasing the recycling rates for post-consumer flexible plastics (PCFP) waste is imperative as PCFP is considered a difficult-to-recycle waste with only 17 % of PCFP effectively recycled in Europe. To tackle this pressing issue, improved mechanical recycling processes are being explored to increase the recycling rates of PCFP. One interesting option is the so-called quality recycling process (QRP) proposed by CEFLEX, which supplements more conventional mechanical recycling of PCFP with additional sorting, hot washing, improved extrusion, and deodorization. Material flow analysis (MFA) model is applied to assess the performance of QRP. Four performance indicators related to quantity (process yield and net recovery) and quality (polymer grade and transparency grade) are applied to measure the performance of three PCFP mechanical recycling scenarios. The results are compared against the conventional recycling of PCFP, showing that QRP has a similar process yield (64 % - 66 %) as conventional recycling (66 %). The net recovery indicator shows that in QRP higher recovery rates are achieved for transparent-monolayer PCFP (>90 %) compared to colored-multilayer PCFP (51 % - 91 %). The quality indicators (polymer and transparency grades) demonstrate that the regranulates from QRP have better quality compared to the conventional recycling. To validate the modeling approach, the modeled compositional data is compared with experimental compositional analyses of flakes and regranulates produced by pilot recycling lines. Main conclusions are: (i) although yields do not increase significantly, extra sorting and recycling produces better regranulates' quality (ii) performing a modular MFA gives insights into future recycling scenarios and helps in decision making.

On the Construction of Pareto-Compliant Combined Indicators

The most relevant property that a quality indicator (QI) is expected to have is Pareto compliance, which means that every time an approximation set strictly dominates another in a Pareto sense, the indicator must reflect this. The hypervolume indicator and its variants are the only unary QIs known to be Pareto-compliant but there are many commonly used weakly Pareto-compliant indicators such as R2, IGD+, and ε+. Currently, an open research area is related to finding new Pareto-compliant indicators whose preferences are different from those of the hypervolume indicator. In this article, we propose a theoretical basis to combine existing weakly Pareto-compliant indicators with at least one being Pareto-compliant, such that the resulting combined indicator is Pareto-compliant as well. Most importantly, we show that the combination of Pareto-compliant QIs with weakly Pareto-compliant indicators leads to indicators that inherit properties of the weakly compliant indicators in terms of optimal point distributions. The consequences of these new combined indicators are threefold: (1) to increase the variety of available Pareto-compliant QIs by correcting weakly Pareto-compliant indicators, (2) to introduce a general framework for the combination of QIs, and (3) to generate new selection mechanisms for multiobjective evolutionary algorithms where it is possible to achieve/adjust desired distributions on the Pareto front.

The performance evaluation of wastewater service: a protocol based on performance indicators applied to sewer systems and wastewater treatment plants

This research aimed to identify a tool to objectively analyse the performance and the environmental contextualisation of sewer systems (SwSs) and wastewater treatment plants (WWTPs). This procedure performs assessment by calculating performance indices which could be subsequently applied to SwSs and WWTPs with different characteristics. The proposed tool can be applied conveniently over the years by managers of integrated urban water management systems for the analysis of different realities also allowing the evaluation of the effects of upgrades carried out during the management phases. The proposed analysis allows the optimisation of SwSs and can profitably guide the choice and the priority among possible interventions for the sewerage infrastructure and WWTPs providing a verification and evaluation protocol as well as a financial planning tool.

The contribution of benchmarking to quality improvement in healthcare. A systematic literature review

BACKGROUND

Benchmarking has been recognised as a valuable method to help identify strengths and weaknesses at all levels of the healthcare system. Despite a growing interest in the practice and study of benchmarking, its contribution to quality of care have not been well elucidated. As such, we conducted a systematic literature review with the aim of synthesizing the evidence regarding the relationship between benchmarking and quality improvement. We also sought to provide evidence on the associated strategies that can be used to further stimulate quality improvement.

METHODS

We searched three databases (PubMed, Web of Science and Scopus) for articles studying the impact of benchmarking on quality of care (processes and outcomes). Following assessment of the articles for inclusion, we conducted data analysis, quality assessment and critical synthesis according to the PRISMA guidelines for systematic literature review.

RESULTS

A total of 17 articles were identified. All studies reported a positive association between the use of benchmarking and quality improvement in terms of processes (N = 10), outcomes (N = 13) or both (N = 7). In the majority of studies (N = 12), at least one intervention, complementary to benchmarking, was undertaken to stimulate quality improvement. The interventions ranged from meetings between participants to quality improvement plans and financial incentives. A combination of multiple interventions was present in over half of the studies (N = 10).

CONCLUSIONS

The results generated from this review suggest that the practice of benchmarking in healthcare is a growing field, and more research is needed to better understand its effects on quality improvement. Furthermore, our findings indicate that benchmarking may stimulate quality improvement, and that interventions, complementary to benchmarking, seem to reinforce this improvement. Although this study points towards the benefit of combining performance measurement with interventions in terms of quality, future research should further analyse the impact of these interventions individually.

Suitability of different precipitation data sources for hydrological analysis: a study from Western Ghats, India

For hydrological analysis, it is essential to have continuous and long-term precipitation data. However, the precipitation data from rain gauge stations are often insufficient and not continuous. At present, ground-based gridded data and satellite-based gridded data are often used as an alternative. However, these data sets have to be evaluated for their suitability in hydrological studies. The current study compared three different rainfall data sources with the observed station data for the Kallada River basin of Kerala, India. The ground-based gridded rainfall data from the India Meteorological Department (IMD), the high-resolution satellite product Tropical Rainfall Measuring Mission (TRMM 3B43, version 7), and the reanalysis data Modern-Era Retrospective Analysis for Research and Applications (MERRA) are used in the analysis. The correlation coefficient, normalized root mean square error, Nash-Sutcliffe efficiency, modified index of agreement, and volumetric efficiency are used as performance indicators. The performance indicator's weights are based on the entropy method. The multi-criteria decision-making techniques like compromise programming and Preference Ranking Organization Method (PROMETHEE II) are used for ranking the precipitation data sources. It is found that IMD ground-based gridded data is ranked 1 among the three data sets. The IMD ground-based gridded data are not homogeneous based on the absolute homogeneity test, even though they had the highest rank. The IMD gridded data are further corrected based on double mass curve analysis. The corrected data were analyzed using the precipitation concentration index (PCI) to assess the temporal variation in precipitation, and it was found that the location falls under a uniform distribution zone.

Evaluation of the CORDEX regional climate models (RCMs) for simulating climate extremes in the Asian cities

This study evaluates the ability of 21 Regional Climate Models (RCMs) from the Coordinated Regional Climate Downscaling Experiment (CORDEX) in simulating climate extremes in the fast growing Asian cities which are highly vulnerable to climate change. The three Asian cities have two different climate characteristics, namely Bangkok and its vicinity and Ho Chi Minh City in tropical climate region and Kathmandu in sub-tropical and temperate climate region. The RCMs were evaluated to simulate the six climate indices; Consecutive Dry Days (CDD), Simple Daily Intensity Index (SDII), Number of extremely heavy precipitation days (R50mm), Maximum 1-day precipitation amount (RX1day), Mean of daily maximum temperature (TX mean) and Mean of daily minimum temperature (TN mean). The performance indicators used were correlation coefficient, normalized root mean square deviation, absolute normalized root mean square deviation and average absolute relative deviation. The Entropy method was endorsed to acquire weights of these four indicators and weightage average techniques were used for ranking of 21 RCMs. The result demonstrated that the best model for one climate index is not the same best model for other climate indices. The 3 RCMs; WAS44_SMHI_RCA4_IPSL_CM5A_MR, WAS44_SMHI_RCA4_MIROC5, and WAS44_IITM_REGCM4-4_CSIRO_MK3-6-0 are the best performing RCMs for simulating future climate extremes in Bangkok and its vicinity, Ho Chi Minh city and Kathmandu valley, respectively. Therefore, they are recommended to use for climate change impact and adaptation studies in water resources management in the selected cities.

Assessment of performance indicators for different sizes of water supply systems in Minas Gerais, Brazil

Indicators are important tools to improve the efficiency of water supply systems. Considering that the performance could vary according to the systems' sizes, this research proposed financial, operational, and water quality indicators for water supply systems of municipalities with different populations in Minas Gerais, Brazil. The organisation and selection of the sample were based on available information in the National Sanitation Data System of 2014. We selected 363 municipalities of Minas Gerais and 56 predictors. Through multiple linear regression (MLR), we found that the commitment of revenues with expenditures and the ratio among revenues and expenses are the most relevant variables to describe the financial performance. Furthermore, water loss per connection and water-billing index were the most important to describe the operational performance. Finally, models related to water quality performance could not be established due to the low value of the coefficient of determination. We observed that supply systems have distinct variables to describe their financial and operational performance, according to their sizes. Small municipalities have a strong relationship with financial performance and expenses. Large counterparts have their performance related to the collection, which can be explained by the economy of scale. Considering the operational performance, we observed that larger municipalities have a strong relationship between their operational performance and water loss. These models are potential tools in the decision-making processes, which can be used to promote improvements in water supply systems.

Evaluation validation of a qPCR curve analysis method and conventional approaches

BACKGROUND

Reverse Transcription quantitative polymerase chain reaction (RT-qPCR) is a sensitive and reliable method for mRNA quantification and rapid analysis of gene expression from a large number of starting templates. It is based on the statistical significance of the beginning of exponential phase in real-time PCR kinetics, reflecting quantitative cycle of the initial target quantity and the efficiency of the PCR reaction (the fold increase of product per cycle).

RESULTS

We used the large clinical biomarker dataset and 94-replicates-4-dilutions set which was published previously as research tools, then proposed a new qPCR curve analysis method--CqMAN, to determine the position of quantitative cycle as well as the efficiency of the PCR reaction and applied in the calculations. To verify algorithm performance, 20 genes from biomarker and partial data with concentration gradients from 94-replicates-4-dilutions set of MYCN gene were used to compare our method with various publicly available methods and established a suitable evaluation index system.

CONCLUSIONS

The results show that CqMAN method is comparable to other methods and can be a feasible method which applied to our self-developed qPCR data processing and analysis software, providing a simple tool for qPCR analysis.

Key Performance Indicators in Claims Management: Definition of a Set of Indicators for the Evaluation of the Medico-Legal Activity

BACKGROUND

In recent decades, in the field of healthcare, awareness of the problems inherent to the quality has steadily increased. Currently, the evaluation of healthcare activities is one of the ways in which health systems regulate internal relationships and define strategic decisions.

OBJECTIVE

The study aims to describe in detail the entire process of developing a group of Key Performance Indicators for monitoring and implementing the management of litigation due to medical liability. Particularly, the objective is to centralize and standardize the indicators to provide scientifically reliable data on claims management to hospital professionals responsible for strategic choices.

METHODS

The study was conducted to analyze data relating to the claims management at Umberto I General Hospital in Rome from 2012 to 2018. All claims reported were classified according to a selection of the categories coded in the International Classification for Patient Safety system, the economic features, and the chronological references of the main management extrajudicial and judicial phases. The Process Analysis Method was followed to develop significant indicators for measuring the performance and the quality of claims management.

RESULTS AND CONCLUSION

The results obtained demonstrate how the assessment of performance in claims management can potentially lead to greater risk control with significant repercussions in terms of reduction of disputes, speed in settling claims, reduction of management times, planning of loss prevention measures, and implementation of quality of care.

Decentralized management of sewage using septic tanks and anaerobic filters and its potential to comply with required standards in a developing country: a case study in Brazil

To investigate the feasibility of implementing decentralized sewage treatment systems aiming to meet environmental standards, the performance of three decentralized wastewater treatment plants (WWTPs) comprising septic tanks and anaerobic filters (ST+AF) was evaluated. The ability of the WWTPs to comply with the provisions of the legislation and the technical literature was investigated by monitoring physical and chemical parameters at the entrance and exit of the WWTPs, from May 2017 to August 2018. Considering that factors such as operational routine, design of treatment systems, and the existence of pluvial contributions to the sewage network can influence the performance of WWTPs, an investigation of these factors was conducted. The results show that the ST+AF systems can meet the requirements of the legislation. The hypothesis raised in this study is that factors such as cleaning routine and dimensioning of the treatment units can influence the performance of the systems. The best performance was found in the WWTP submitted to frequent cleaning and whose ST dimensions were closest to those recommended by technical standards. The average annual efficiencies of removal of biochemical oxygen demand (BOD) and chemical oxygen demand (COD) in this WWTP assumed values of 93 and 89%, while its solid effluents presented concentrations 82% below the limit established in legislation. Finally, no rainwater contributions were found in the WWTPs, which may be associated with the use of short collection networks in decentralized systems.

The current and potential uses of Electronic Medical Record (EMR) data for primary health care performance measurement in the Canadian context: a qualitative analysis

BACKGROUND

Electronic Medical Records (EMRs) are a rich data source to measure and improve quality of care. As Canadian primary health care (PHC) EMRs mature, there is increasing potential use of EMR data for performance measurement. This study identifies and describes current uses of EMR data for performance measurement and considerations to further its potential in the Canadian context.

METHODS

We applied a qualitative case study design and descriptive assessment in three phases, consulting multiple data sources including scientific and grey literature, system leaders (n = 41), and clinician/researchers (n = 20). Phases included a multimethod approach to identify initiatives using EMR data for performance measurement across Canadian jurisdictions; in-depth review of current initiatives identified from a healthcare performance intelligence lens; and triangulation and thematic analysis across data sources to explore considerations for advancing performance measurement uses of EMR data in the Canadian context.

RESULTS

Six initiatives of EMR data use for performance measurement were identified: one multi-jurisdictional; five jurisdiction-specific in the provinces of British Columbia, Manitoba and Ontario. EMR data uses were predominately for micro-level PHC physician and team performance improvement, with some use for meso-level organization/network-wide improvement. Indicator sets varied in number, though shared emphasis on chronic disease management and prevention/screening and to a lesser extent medication management. Key considerations for governing, resourcing and implementing EMR data for performance measurement were identified.

CONCLUSIONS

The extent of EMR data use for performance measurement varies across Canada. To further its potential, pan-Canadian data and privacy standards, performance intelligence competencies and renewed core PHC indicators should be prioritized. Experiences across countries, coupled with increasing momentum for performance measurement using real-world data, should be leveraged to avoid unnecessarily slow progress in Canada and abroad.

Assessment of leakage management in small water supplies using performance indicators

The revision of the Drinking Water Directive (DWD), which the process of consultation by the European Parliament is coming to the end, includes a commitment for all Member States to assess the level of water leakage. The overarching aim of this action is to reduce water loss through leaks. In regard to this, use of performance indicators as suitable to enable assessment of water utility performance with regard to leakage reduction, including impacts on environment and cost-efficiency, is recommended. The paper provides results from water losses evaluation with the set of performance indicators (PI), considering dependence on the availability of resources and specific operating conditions. An analysis of different PI that are necessary to evaluate in most of leakage reduction methods was conducted considering step-by-step approach. Furthermore, the most relevant data for leakage analysis and management on a network level was determined. Presented PI can be used to improve leakage management of small water supply system. Similarly as in the Deming cycle, the described tool provides for planning activities, executing activities in accordance with the plan, checking the degree of execution of objectives included in the plan, and on the basis of conducted analyses and lessons learned, the so-called improvement. The results of the analysis lead to the conclusion that through a comprehensive, systematically improved strategy, the high effectiveness of the system could be reach. The reliable monitoring does not have to be based on advanced technological methods, which are often unavailable for small water supply system, due to high investment and operating costs. The results indicate that integrated IT systems, as SCADA, might not be directly beneficial to water loss management in small networks with moderate leakage levels.

Integrated membrane bioreactors modelling: A review on new comprehensive modelling framework

Integrated Membrane Bioreactor (MBR) models, combination of biological and physical models, have been representing powerful tools for the accomplishment of high environmental sustainability. This paper, produced by the International Water Association (IWA) Task Group on Membrane Modelling and Control, reviews the state-of-the-art, identifying gaps for future researches, and proposes a new integrated MBR modelling framework. In particular, the framework aims to guide researchers and managers in pursuing good performances of MBRs in terms of effluent quality, operating costs (such as membrane fouling, energy consumption due to aeration) and mitigation of greenhouse gas emissions.

Implementation of circular economy in the management of municipal solid waste in an Italian medium-sized city: A 30-years lasting history

The Circular Economy model is gaining attention as a key factor for boosting sustainable development. Reducing the consumption of raw materials, as well as increasing the amount of recycled waste, are the current challenges the municipal solid waste management system is called for. In this study, the evolution of the municipal waste management strategies in the city of Brescia was analysed, covering a period of 30 years. The results obtained by a) progressively extending the separate collection with street containers, b) building a Waste to Energy plant, and c) moving to a door to door collection system, were assessed via numerical indicators and mass balances. In order to highlight the complexity of the system, the waste flow, from collection to the achievement of the "end of waste" attribute, was followed. Separate collection with street containers came to a saturation percentage around 40%. The realization of the incineration plant eliminated the direct disposal of waste to landfills. With the introduction of the new collection system, the separately collected waste increased up to over 73%, the per capita amount of collected waste decreased from 685.3 kg/(in y) to 579.6 kg/(in y), and a significant reduction of recyclable materials in the unsorted waste was gained. In the paper, these achievements and their affecting factors are analysed. Moreover, criticalities in the calculation of material recovery indices due to the complexity of the system (72 transformation sites were identified) are discussed.

Performance indicators for aquatic centres in Canada: Identification and selection using fuzzy based methods

Aquatic centres (ACs) are becoming exceedingly popular in the urban agglomerations of cold climate countries like Canada but functioning without assessing the state of their sustainability performance. Previous studies examined health and safety, water and indoor air quality, and energy consumption aspects without aiming at the holistic sustainability performance assessment. The present research is the first systematic effort for benchmarking of ACs. A hierarchical-based framework arranged 81 performance indicators to appraise the key components, including water management, indoor environment, personnel, service quality, energy, social, and operations. Fuzzy AHP and fuzzy mean clustering methods evaluated the identified PIs based on the opinion of experts (from Canadian aquatic centres) on their importance, measurability, and understandability. Finally, the selection process ranked a set of 63 most suitable PIs under 14 sub-criteria. Fuzzy-based methods efficiently handled the subjective scoring process and the difference of opinion among the experts. The criteria performance indices inform the top-level management while the sub-indices stipulate the operations management for honing in the lacking indicators. Using the selected PIs, the AC's management can allocate the available resources for both the short-term (e.g., efficient response to complaints) and long-term (e.g., replacing failed manually operated fixtures with the sensor-operated ones) improvement actions. The selected PIs will enhance the sustainability of ACs in Canada and other cold regions around the globe through a structured benchmarking process.

Could health information systems enhance the quality of Aboriginal health promotion? A retrospective audit of Aboriginal health programs in the Northern Territory of Australia

BACKGROUND

In Australia, health services are seeking innovative ways to utilize data stored in health information systems to report on, and improve, health care quality and health system performance for Aboriginal Australians. However, there is little research about the use of health information systems in the context of Aboriginal health promotion. In 2008, the Northern Territory's publicly funded healthcare system introduced the quality improvement program planning system (QIPPS) as the centralized online system for recording information about health promotion programs. The purpose of this study was to explore the potential for utilizing data stored in QIPPS to report on quality of Aboriginal health promotion, using chronic disease prevention programs as exemplars. We identify the potential benefits and limitations of health information systems for enhancing Aboriginal health promotion.

METHODS

A retrospective audit was undertaken on a sample of health promotion projects delivered between 2013 and 2016. A validated, paper-based audit tool was used to extract information stored in the QIPPS online system and report on Aboriginal health promotion quality. Simple frequency counts were calculated for dichotomous and categorical items. Text was extracted and thematically analyzed to describe community participation processes and strategies used in Aboriginal health promotion.

RESULTS

39 Aboriginal health promotion projects were included in the analysis. 34/39 projects recorded information pertaining to the health promotion planning phases, such as statements of project goals, 'needs assessment' findings, and processes for consulting Aboriginal people in the community. Evaluation findings were reported in approximately one third of projects and mostly limited to a recording of numbers of participants. For almost half of the projects analyzed, community participation strategies were not recorded.

CONCLUSION

This is the first Australian study to shed light on the feasibility of utilizing data stored in a purposefully designed health promotion information system. Data availability and quality were limiting factors for reporting on Aboriginal health promotion quality. Based on our learnings of QIPPS, strategies to improve the quality and accuracy of data entry together with the use of quality improvement approaches are needed to reap the potential benefits of future health promotion information systems.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design is a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology, enabling local contextual interpretations of the indicators while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia, the Pacific and South Africa has also showed the potential of the WSC Index internationally.

Assessment of electronic disease early warning system for improved disease surveillance and outbreak response in Yemen

BACKGROUND

Diseases Surveillance is a continuous process of data collection, analysis interpretation and dissemination of information for swift public health action. Recent advances in health informatics have led to the implementation of electronic tools to facilitate such critical disease surveillance processes. This study aimed to assess the performance of the national electronic Disease Early Warning System in Yemen (eDEWS) using system attributes: data quality, timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility, and representativeness, based on the Centres for Disease Control & Prevention (US CDC) standard indicators.

METHODS

We performed a mixed methods study that occurred in two stages: first, the quantitative data was collected from weekly epidemiological bulletins from 2013 to 2017, all alerts of 2016, and annual eDEWS reports, and then the qualitative method using in-depth interviews was carried out in a convergent strategy. The CDC guideline used to describe the following system attributes: data quality (reporting, and completeness), timeliness, stability, simplicity, predictive value positive, sensitivity, acceptability, flexibility and representativeness.

RESULTS

The finding of this assessment showed that eDEWS is a resilient and reliable system, and despite the conflict in Yemen, the system is still functioning and expanding. The response timeliness remains a challenge, since only 21% of all eDEWS alerts were verified within the first 24 h of detection in 2016. However, identified gaps did not affect the system's ability to identify outbreaks in the current fragile situation. Findings show that eDEWS data is representative, since it covers the entire country. Although, eDEWS covers only 37% of all health facilities, this represents 83% of all functional health facilities in all 23 governorates and all 333 districts.

CONCLUSION

The quality and timeliness of responses are major challenges to eDEWS' functionality, the eDEWS remains the only system that provides regular data on communicable diseases in Yemen. In particular, public health response timeliness needs improvement.

Water Sensitive Cities Index: A diagnostic tool to assess water sensitivity and guide management actions

Cities are wrestling with the practical challenges of transitioning urban water services to become water sensitive; capable of enhancing liveability, sustainability, resilience and productivity in the face of climate change, rapid urbanisation, degraded ecosystems and ageing infrastructure. Indicators can be valuable for guiding actions for improvement, but there is not yet an established index that measures the full suite of attributes that constitute water sensitive performance. This paper therefore presents the Water Sensitive Cities (WSC) Index, a new benchmarking and diagnostic tool to assess the water sensitivity of a municipal or metropolitan city, set aspirational targets and inform management responses to improve water sensitive practices. Its 34 indicators are organised into seven goals: ensure good water sensitive governance, increase community capital, achieve equity of essential services, improve productivity and resource efficiency, improve ecological health, ensure quality urban spaces, and promote adaptive infrastructure. The WSC Index design as a quantitative framework based on qualitative rating descriptions and a participatory assessment methodology enables local contextual interpretations of the indicators, while maintaining a robust universal framework for city comparison and benchmarking. The paper demonstrates its application on three illustrative cases. Rapid uptake of the WSC Index in Australia highlights its value in helping stakeholders develop collective commitment and evidence-based priorities for action to accelerate their city's water sensitive transition. Early testing in cities in Asia and the Pacific has also showed the potential of the WSC Index internationally.

Operating room efficiency and timing during coronavirus disease 2019 outbreak in a referral orthopaedic hospital in Northern Italy

Purpose

The SARS-CoV-2 outbreak affected health care systems at different levels with important consequences on health, economy, and social structures. This paper aims to analyse the impact on surgical block utilisation and efficiency in an orthopaedics reference centre in Northern Italy.

Methods

The timeframe chosen for the current analysis was April 2020, to be compared with the corresponding period in 2019. Number and type of procedures, first case delay, occupancy rate, and turnover time were used as indicators to benchmark the activities.

Results

The overall number of surgical procedures decreased by 57%, from 537 in 2019 to 230 in the same timeframe in 2020. Orthopaedic procedures predominated in 2019, with 434 cases (80.8%), while in 2020, trauma was the leading activity, with 200 cases (86.9%). Orthopaedic surgery had a relative decrement of 93% while trauma has relatively increased by 94%. Mean first case delay in orthopaedic room (OR) was two hours and 36 minutes (SD 01:40:21) in 2020 compared with only 19 minutes (SD 00:02:15) in 2019. OR occupancy rate was 59% in 2020 compared with 89% in 2019. Turnover time raised from 21 minutes in 2019 to 53 min in 2020.

Conclusions

These data clearly show the deep impact of COVID-19 pandemic on OR facilities. Efficiency indicators fell dramatically in April 2020 compared with the corresponding period in 2019. This scenario will deeply affect both the waiting lists and the economic burden of the hospital. Regaining efficiency and maintaining the quality and safety of the process while restoring elective orthopaedic surgery are among the main challenges that surgeons will face in the next time.

Hospital incident command groups' performance during major incident simulations: a prospective observational study

BACKGROUND

Hospital incident command groups' (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group.

METHODS

This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and staff procedure skills during major incident simulations were assessed using measurable performance indicators.

RESULTS

Decision-making skills are correlated to staff procedure skills and overall HICG performance. Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to staff procedure skills.

CONCLUSION

There is a significant correlation between decision-making skills and staff procedural skills. Hospital incident command groups' proactive decision-making abilities tended to be less developed than reactive decision-making abilities. These proactive decision-making skills may be a predictive factor for overall hospital incident command group performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident.

Performance Analysis in Rugby Union: a Critical Systematic Review

BACKGROUND

Performance analysis in rugby union has become an integral part of the coaching process. Although performance analysis research in rugby and data collection has progressed, the utility of the insights is not well understood. The primary objective of this review is to consider the current state of performance analysis research in professional rugby union and consider the utility of common methods of analysing performance and the applicability of these methods within professional coaching practice.

METHODS

SPORTDiscus electronic database was searched for relevant articles published between 1 January 1997 and 7 March 2019. Professional, male 15-a-side rugby union studies that included relevant data on tactical and performance evaluation, and statistical compilation of time-motion analysis were included. Studies were categorised based on the main focus and each study was reviewed by assessing a number of factors such as context, opposition analysis, competition and sample size.

RESULTS

Forty-one studies met the inclusion criteria. The majority of these studies measured performance through the collection and analysis of performance indicators. The majority did not provide context relating to multiple confounding factors such as field location, match location and opposition information. Twenty-nine performance indicators differentiated between successful match outcomes; however, only eight were commonly shared across some studies. Five studies considered rugby union as a dynamical system; however, these studies were limited in analysing lower or national-level competitions.

CONCLUSIONS

The review highlighted the issues associated with assessing isolated measures of performance, lacking contextual information such as the opposition, match location, period within match and field location. A small number of studies have assessed rugby union performance through a dynamical systems lens, identifying successful characteristics in collective behaviour patterns in attacking phases. Performance analysis in international rugby union can be advanced by adopting these approaches in addition to methods currently adopted in other team sports.

Are municipal waste utilities becoming sustainable? A framework to assess and communicate progress

A framework of indicators to assess the progress towards sustainability of municipal waste management utilities is developed. Its purpose is to fulfil the need for assessing the performance of municipal waste (MW) management in a simple but comprehensive way-unlike indicators based on individual aspects such as recycling-and including aspects not well considered before, such as waste prevention. The framework is composed of a set of six single indicators, concerning the three dimensions of sustainability: reduction of effectively landfilled MW and reduction of MW generation (environmental component), balance between expenses and revenues and reduction of costs (economic component), accessibility to separate collection and number of complaints (social component). Each indicator consists of an evaluation of the current status of the variable in contrast to a previous situation, with a positive value in case of improvement or negative in case of decline. Then, the values of the individual indicators are combined to obtain a global result. This approach focuses on dynamic progress towards sustainability, complementing the common static indicators. Contrarily to the existing performance indicator schemes, the proposed framework aims at measuring the progress and not the absolute or relative achievement of a waste management utility. The framework was tested on two Portuguese municipalities, proving to be a straightforward application and reliable in guiding stakeholders. Results for the case study showed good performance on economic sustainability, while environmental and social performance were lower due to a lack of strategies for waste prevention and low source separation, affected by poor accessibility to separate collection.

Ranking hospital performance based on individual indicators: can we increase reliability by creating composite indicators?

BACKGROUND

Report cards on the health care system increasingly report provider-specific performance on indicators that measure the quality of health care delivered. A natural reaction to the publishing of hospital-specific performance on a given indicator is to create 'league tables' that rank hospitals according to their performance. However, many indicators have been shown to have low to moderate rankability, meaning that they cannot be used to accurately rank hospitals. Our objective was to define conditions for improving the ability to rank hospitals by combining several binary indicators with low to moderate rankability.

METHODS

Monte Carlo simulations to examine the rankability of composite ordinal indicators created by pooling three binary indicators with low to moderate rankability. We considered scenarios in which the prevalences of the three binary indicators were 0.05, 0.10, and 0.25 and the within-hospital correlation between these indicators varied between - 0.25 and 0.90.

RESULTS

Creation of an ordinal indicator with high rankability was possible when the three component binary indicators were strongly correlated with one another (the within-hospital correlation in indicators was at least 0.5). When the binary indicators were independent or weakly correlated with one another (the within-hospital correlation in indicators was less than 0.5), the rankability of the composite ordinal indicator was often less than at least one of its binary components. The rankability of the composite indicator was most affected by the rankability of the most prevalent indicator and the magnitude of the within-hospital correlation between the indicators.

CONCLUSIONS

Pooling highly-correlated binary indicators can result in a composite ordinal indicator with high rankability. Otherwise, the composite ordinal indicator may have lower rankability than some of its constituent components. It is recommended that binary indicators be combined to increase rankability only if they represent the same concept of quality of care.

Can public-private partnership (PPP) improve hospitals' performance indicators?

Background: This study was conducted to compare the main performance indicators of Hasheminejad hospital before and after implementing PPP model.

Methods: This cross sectional study was conducted in Iran in 2015. Performance indicators of Hasheminejad hospital, the only Iranian unit that implemented PPP model, were applied. Data were collected based on a researcher-designed checklist after ensuring its validity and reliability. Data were analyzed applying SPSS21, and the Shapiro-Wilk test was used to examine the relevant data normalization. After confirming the normality of the data, descriptive statistics and paired t test were used to analyze the data at a significant level of 0.05.

Results: Dramatic variations were observed in the status of the studied indicators after the implementation of PPP in Hasheminejad hospital, and the changes were statistically significant in all these indicators (p<0.05).

Conclusion: It seems that implementing PPP in Hasheminejad hospital can be considered as a successful experience in Iran’s health sector. The significant improvement in this hospital’s performance indicators can emphasize the effective role of PPP in administration of this hospital. However, service quality and patient satisfaction should be considered as qualitative indicators, along with the present quantitative indicators because better judgment about the changes was achieved in this hospital after implementing PPP.

Influence of scope definition in recycling rate calculation for European e-waste extended producer responsibility

Efficiency indicators have been frequently used to assess end-of-life chain performance, mostly. In terms of the percentage of mass sent to re-use, recycling, and/or energy recovery facilities. While legislation gives a standard definition for recycling and recovery rates, stakeholders sometimes redefine them to better fit their own scopes and objectives. Therefore, to accurately interpret the results of an efficiency indicator, during a decision-making process, it's necessary to fully understand the scope definition used to calculate it. This work discusses the influence of scope definition when establishing performance rates. It does this by introducing further alternative scope definitions and comparing them to those defined by legislation and stakeholders. As a case study, the proposed complementary scopes are applied to the recycling chain of flat panel displays in France.

Development of quality outcome indicators to improve the quality of urinary and faecal continence care

Introduction and hypothesis

Despite the range of treatment options available, relatively few people with incontinence find a total cure. The importance of daily management with toileting and containment cannot be underestimated. To our knowledge, there are no outcome measures to benchmark good care. The aim of this study was to create a set of key performance indicators (KPIs) to measure outcomes for toileting and containment.

Methods

An expert panel (EP) defined a set of KPIs using evidence from a scoping review, stakeholder engagement, and expert consensus. Peer reviewed articles, high-quality grey literature and international and national standards were reviewed to identify existing measures for management. These findings were augmented by an exercise involving patients, caregivers, nurses, clinicians, payers, policy makers and care providers to prioritise the findings and identify additional areas of interest.

Results

The final set of 14 KPIs includes quality indicators of process and outcome for those managed with a toileting and containment strategy and is relevant for both care-independent and -dependent persons. Rates of assessment, days waiting for specialist assessment, rates of return to work and those rating their quality of life as good or acceptable are captured. An indicator of well-being for caregivers and the economic costs of poor care are also defined.

Conclusions

The set of KPIs to measure outcomes from toileting and containment strategies describes the components of each to encourage integration into existing quality frameworks. Each KPI has been refined and detailed to encourage this. If implemented, resulting benchmarking data will facilitate care quality improvement and inform value-based care procurement and provision of toileting and containment strategies.

Electronic supplementary material

The online version of this article (10.1007/s00192-018-3768-2) contains supplementary material, which is available to authorized users

Would program performance indicators and a nationally coordinated response accelerate the elimination of tuberculosis in Canada?

Twenty years ago, a National Consensus Conference on Tuberculosis (TB) recommended that the provinces and territories of Canada jointly declare a commitment to TB elimination with national coordination and assured funding, executed by a committee of federal and provincial/territorial representatives. Canada has committed to the global TB elimination targets set forth by the World Health Organization but lacks a coordinated response. In particular, with the exception of one published and implemented by Indigenous Services Canada, there has been no national monitoring and performance framework. Herein, we provide a commentary on the importance, to TB elimination in Canada, of developing such a framework. We invite a debate about whether more can and should be done to monitor and report for action at every jurisdictional level. Of utmost importance will be the need to achieve consensus from stakeholders about what is measured, among whom, how often, who collects and processes data, and how to respond to the successes and failures those data indicate. Insofar, as performance targets are well defined and implemented, national progress towards tuberculosis elimination should accelerate.

Validity of police contacts as a performance indicator for the public mental health care system in Amsterdam: an open cohort study

PURPOSE

The Public Mental Health Care (PMHC) system is a network of public services and care- and support institutions financed from public funds. Performance indicators based on the registration of police contacts could be a reliable and useful source of information for the stakeholders of the PMHC system to monitor performance. This study aimed to provide evidence on the validity of using police contacts as a performance indicator to assess the continuity of care in the PMHC system.

METHODS

Data on services received, police contacts and detention periods of 1928 people that entered the PMHC system in the city of Amsterdam were collected over a period of 51 months. Continuity of care was defined as receiving more than 90 days of uninterrupted service. The associations between police contacts and continuity were analyzed with multilevel Poisson and multivariate linear regression modeling.

RESULTS

Clients had on average 2.12 police contacts per person-year. Clients with police contacts were younger, more often single, male, and more often diagnosed with psychiatric or substance abuse disorders than clients without police contacts. Incidence rates of police contacts were significantly lower for clients receiving continuous care than for clients receiving discontinuous care. The number of police contacts of clients receiving PMHC coordination per month was found to be a significant predictor of the percentage of clients in continuous care.

CONCLUSION

The number of police contacts of clients can be used as a performance indicator for an urban PMHC system to evaluate the continuity of care in the PMHC system.

A Preceptor competency framework for pharmacists. Part 2 of a 3-part series

BACKGROUND

Pharmacy faculties in Canada are transitioning to the doctor of pharmacy degree which will require approximately one-third of curricula contact time in experiential education. Preceptors will be responsible for delivering this experiential component and many have received little or no training in how to be an effective educator. Although training is mandated through accreditation standards, competencies to serve as a foundation for preceptor development have yet to be created. The objectives of this review were to develop core competencies of an effective preceptor and to identify performance indicators to guide preceptor growth METHODS: A literature review of teaching competencies from pharmacy, medicine, nursing, and higher education was completed. Competencies and performance indicators were extracted and analyzed for recurring themes. A framework was proposed and refined through consultation with Canadian and United States pharmacy stakeholder groups.

RESULTS

Six-hundred and thirty-nine articles were identified through the review, of which only eight articles directly addressed preceptor competencies and/or related performance indicators. These articles were reviewed in detail. Regardless of discipline, several recurring themes emerged. Themes were collated and culminated in nine competencies and supporting performance indicators for preceptors. Competencies address important interpersonal, professional, and educational knowledge, skills, and attitudes of an effective educator.

IMPLICATIONS

Defining competence and its performance indicators is essential to help preceptors effectively fulfill their professional responsibility of developing competent graduates. The competencies and performance indicators should be further refined through stakeholder engagement. This framework could be foundational to national preceptor development program, preceptor recruitment, and quality assurance programs.

Proceedings of resources for optimal care of acute care and emergency surgery consensus summit Donegal Ireland

BACKGROUND

Opportunities to improve emergency surgery outcomes exist through guided better practice and reduced variability. Few attempts have been made to define optimal care in emergency surgery, and few clinically derived key performance indicators (KPIs) have been published. A summit was therefore convened to look at resources for optimal care of emergency surgery. The aim of the Donegal Summit was to set a platform in place to develop guidelines and KPIs in emergency surgery.

METHODS

The project had multidisciplinary global involvement in producing consensus statements regarding emergency surgery care in key areas, and to assess feasibility of producing KPIs that could be used to monitor process and outcome of care in the future.

RESULTS

Forty-four key opinion leaders in emergency surgery, across 7 disciplines from 17 countries, composed evidence-based position papers on 14 key areas of emergency surgery and 112 KPIs in 20 acute conditions or emergency systems.

CONCLUSIONS

The summit was successful in achieving position papers and KPIs in emergency surgery. While position papers were limited by non-graded evidence and non-validated KPIs, the process set a foundation for the future advancement of emergency surgery.

[Identification of health outcome indicators in Primary Care. A review of systematic reviews]

INTRODUCTION

Outcome measures are being widely used by health services to assess the quality of health care. It is important to have a battery of useful performance indicators with high validity and feasibility. Thus, the objective of this study is to perform a review of reviews in order to identify outcome indicators for use in Primary Care.

METHODOLOGY

A review of systematic reviews (umbrella review) was carried out. The following databases were consulted: MedLine, EMBASE, and CINAHL, using descriptors and free terms, limiting searches to documents published in English or Spanish. In addition, a search was made for free terms in different web pages. Those reviews that offered indicators that could be used in the Primary Care environment were included.

RESULTS

This review included a total of 5 reviews on performance indicators in Primary Care, which consisted of indicators in the following areas or clinical care processes: in osteoarthritis, chronicity, childhood asthma, clinical effectiveness, and prescription safety indicators. A total of 69 performance indicators were identified, with the percentage of performance indicators ranging from 0% to 92.8%. None of the reviews identified performed an analysis of the measurement control (feasibility or sensitivity to change of indicators).

CONCLUSIONS

This paper offers a set of 69 performance indicators that have been identified and subsequently validated and prioritised by a panel of experts.

Operating Room Efficiency before and after Entrance in a Benchmarking Program for Surgical Process Data

Operating room (OR) efficiency continues to be a high priority for hospitals. In this context the concept of benchmarking has gained increasing importance as a means to improve OR performance. The aim of this study was to investigate whether and how participation in a benchmarking and reporting program for surgical process data was associated with a change in OR efficiency, measured through raw utilization, turnover times, and first-case tardiness. The main analysis is based on panel data from 202 surgical departments in German hospitals, which were derived from the largest database for surgical process data in Germany. Panel regression modelling was applied. Results revealed no clear and univocal trend of participation in a benchmarking and reporting program for surgical process data. The largest trend was observed for first-case tardiness. In contrast to expectations, turnover times showed a generally increasing trend during participation. For raw utilization no clear and statistically significant trend could be evidenced. Subgroup analyses revealed differences in effects across different hospital types and department specialties. Participation in a benchmarking and reporting program and thus the availability of reliable, timely and detailed analysis tools to support the OR management seemed to be correlated especially with an increase in the timeliness of staff members regarding first-case starts. The increasing trend in turnover time revealed the absence of effective strategies to improve this aspect of OR efficiency in German hospitals and could have meaningful consequences for the medium- and long-run capacity planning in the OR.

Assessment of performance indicators of a radiotherapy department using an electronic medical record system

AIM

To retrospectively assess the performance indicators of our radiotherapy department and their temporal trends, using a commercially available electronic-medical-record (EMR) system.

BACKGROUND

A recent trend in healthcare quality is to define and evaluate performance indicators of the service provided.

MATERIALS AND METHODS

Patient and external-beam-radiotherapy-treatments data were retrieved using the Mosaiq EMR system from 1-January-2012 till 31-December-2015. Annual performance indicators were evaluated as: productivity (number of new cases/year and diagnosis distribution); complexity (ratio of Volumetric-Modulated-Arc-Therapy (VMAT) courses, average number of imaging procedures/patient); and quality (average, median and 90th percentile waiting times from admission to first treatment). The temporal trends of all performance indicators were assessed by linear regression.

RESULTS

Productivity: the number of new cases/year increased with an average rate of 4%. Diagnosis distribution showed that breast is the main pathology treated, followed by gastro-intestinal and head-and-neck. Complexity: the ratio of VMAT courses increased from 13% to 35%, with an average rate of 7% per year. The average number of imaging procedures/patient increased from 8 to 11. Quality: the waiting times from admission to treatment remained stable over time (R² ≤ 0.1), with average, median and 90th percentile values around 20, 15, and 31 days, respectively.

CONCLUSIONS

An EMR system can be used to: monitor the performance indicators of a radiotherapy department, identify workflow processes needing attention and improvement, estimate future demands of resources. Temporal analysis of our data showed an increasing trend in productivity and complexity paired with constant waiting times.

The case of the breast-conserving surgery indicator

Background

The evolution in the surgical and diagnostic procedures, the attention to women’s preferences, the case mix, and differences in professional practices may lead to a variability in the quality of breast cancer clinical pathway. To catch and manage this variability it is important to use valid measures. The aim of this paper is to examine the concurrent validity of the breast-conserving surgery (BCS) indicator and to provide evidence to guide the quality improvement process.

Methods

The BCS indicator was calculated using hospital discharge records (HDRs) and was validated against surgical registry (SR) data in a random sample of 336 women undergoing breast cancer surgery in 2012 in two Tuscan teaching hospitals. The concurrent validity of BCS was examined by cross-tabulating patients using the ICD-9 CM codes for breast surgery obtained from the two data sources.

Results

The analysis, carried out involving breast cancer professionals, highlighted that the large majority of interventions coded as “mastectomies” in HDRs are in fact reconstructing procedures, including nipple-sparing, skin-sparing and skin-reducing mastectomies in SR. These results led us to refine the old algorithm, that calculates the proportion of breast-conserving surgery over the total number of breast interventions, and reclassify breast cancer surgical procedures into three categories: conservative, reconstructive and traditional mastectomy. Based on this new classification algorithm, the percentages of (I) reconstructive interventions were 16% at Florence TH and 38.3% at Pisa TH; (II) breast-conserving interventions were respectively 72.8 and 52.1%; and (III) mastectomies 11.2 and 9.6%. After adjusting for age in a logistic regression model, the percentages of reconstructive interventions at Florence and Pisa were respectively 22 and 34% and those of breast-conserving interventions 63 and 53%.

Conclusions

Our results indicate that breast cancer care indicators should be refined by distinguishing reconstructive procedures (nipple/skin-sparing surgery with implant or breast tissue expander insertion) from traditional mastectomy. The involvement of breast care professionals in the choice of indicators proved to be crucial to capture the up-to-date breast cancer surgical practice and inform the quality improvement process.

How different is cancer control across Canada? Comparing performance indicators for prevention, screening, diagnosis, and treatment

Meaningful performance measures are an important part of the toolkit for health system improvement. The Canadian Partnership Against Cancer has been reporting on pan-Canadian cancer system performance indicators since 2009-work that has led to the availability of standardized measures that can help to shed light on the extent of variation and opportunities for quality improvement across the country. Those measures include a core set of system indicators ranging from prevention and screening, through diagnosis and treatment, to survivorship and end-of-life care. Key indicators were calculated and graphed, showing the range from worst to best result for the provinces and territories included in the data. There were often significant differences in cancer system performance between provinces and territories. For example, smoking prevalence rates ranged from 14% to 62%. The 90th percentile wait times from an abnormal breast screen to resolution (without biopsy) ranged from 4 weeks to 8 weeks. The percentage of breast cancer resections that used breast-conserving surgery rather than mastectomy ranged from 38% to 75%. Clinical trial participation rates for adults ranged from 0.2% to 6.6%. Variations in performance indicators between Canadian jurisdictions suggest potential differences in the planning and delivery of cancer control services and in clinical practice patterns and patient outcomes. Understanding sources of variation can help to identify opportunities for improvements in the quality and outcomes of cancer control service delivery in each province and territory.

Tools for evaluating environmental performance at Brazilian public ports: Analysis and proposal

The port sector critically needs improved management techniques to evaluate its environmental performance. In the present study, we conducted an exploratory research to understand the metrics used in the Brazilian public ports to assess their environmental performance. We considered two state agencies and two port authorities of southern Brazil. As preliminary results, we found that economic factors are excluded in the tools for measuring environmental performance. A system of indicators to address this shortcoming was then proposed, but it could not be applied because of data deficiencies. Thus, the system was divided into two parts: a simplified system with 7 indicators (measuring costs related to criteria were measured only technically) and an advanced system with 5 indicators (approaching costs were currently difficult to measure). Thus, the proposed indicators can be applied by port authorities to facilitate decision-making related to environmental management. As suggestions for further work, we propose research that includes more ports, both public and private, to provide an overview at the national level.

Hypertension management in rural primary care facilities in Zambia: a mixed methods study

BACKGROUND

Improved primary health care is needed in developing countries to effectively manage the growing burden of hypertension. Our objective was to evaluate hypertension management in Zambian rural primary care clinics using process and outcome indicators to assess the screening, monitoring, treatment and control of high blood pressure.

METHODS

Better Health Outcomes through Mentoring and Assessment (BHOMA) is a 5-year, randomized stepped-wedge trial of improved clinical service delivery underway in 46 rural Zambian clinics. Clinical data were collected as part of routine patient care from an electronic medical record system, and reviewed for site performance over time according to hypertension related indicators: screening (blood pressure measurement), management (recorded diagnosis, physical exam or urinalysis), treatment (on medication), and control. Quantitative data was used to develop guides for qualitative in-depth interviews, conducted with health care providers at a proportional sample of half (20) of clinics. Qualitative data was iteratively analyzed for thematic content.

RESULTS

From January 2011 to December 2014, 318,380 visits to 46 primary care clinics by adults aged ≥ 25 years with blood pressure measurements were included. Blood pressure measurement at vital sign screening was initially high at 89.1% overall (range: 70.1-100%), but decreased to 62.1% (range: 0-100%) by 48 months after intervention start. The majority of hypertensive patients made only one visit to the clinics (57.8%). Out of 9022 patients with at least two visits with an elevated blood pressure, only 49.3% had a chart recorded hypertension diagnosis. Process indicators for monitoring hypertension were <10% and did not improve with time. In in-depth interviews, antihypertensive medication shortages were common, with 15/20 clinics reporting hydrochlorothiazide-amiloride stockouts. Principal challenges in hypertension management included 1) equipment and personnel shortages, 2) provider belief that multiple visits were needed before official management, 3) medication stock-outs, leading to improper prescriptions and 4) poor patient visit attendance.

CONCLUSIONS

Our findings suggest that numerous barriers stand in the way of hypertension diagnosis and management in Zambian primary health facilities. Future work should focus on performance indicator development and validation in low resource contexts, to facilitate regular and systematic data review to improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier NCT01942278 . Date of Registration: September 2013.

Assessment strategies for municipal selective waste collection schemes

An important strategy to promote a strong sustainable growth relies on an efficient municipal waste management, and phasing out waste landfilling through waste prevention and recycling emerges as a major target. For this purpose, effective collection schemes are required, in particular those regarding selective waste collection, pursuing a more efficient and high quality recycling of reusable materials. This paper addresses the assessment and benchmarking of selective collection schemes, relevant to guide future operational improvements. In particular, the assessment is based on the monitoring and statistical analysis of a core-set of performance indicators that highlights collection trends, complemented with a performance index that gathers a weighted linear combination of these indicators. This combined analysis underlines a potential tool to support decision makers involved in the process of selecting the collection scheme with best overall performance. The presented approach was applied to a case study conducted in Oporto Municipality, with data gathered from two distinct selective collection schemes.