Quality control in the Netherlands; todays practices and starting points for guidance and future research

OBJECTIVES

Adequate analytical quality of reported results is primarily ensured by performing internal quality control (iQC). Currently, several different iQC practices are in use. As a prelude to the revision of a Dutch guidance document on analytical QC, a questionnaire was sent out to gain insights in the applied practices and the need for guidance.

METHODS

A questionnaire, containing 20 multiple-choice questions with possibilities for explanation and comment on iQC practices and aspects was distributed to all clinical chemistry laboratories within the Netherlands. Results were reported descriptively.

RESULTS

Responses were received from 27 clinical laboratories (response 43 %). In 30 % the iQC was based on the analytical characteristics only, while 30 % used a 6-Sigma method, 19 % risk-based beyond 6-Sigma and 22 % used an alternative approach. 89 % of laboratories used a virtual analyzer model for iQC setup within one or more laboratory sites. Practices for determining standard deviation (SD) values included determining SD for each new iQC material (35 %), using historical SD values for new materials (35 %), and incorporating clinical tolerances into the SD value (31 %). Furthermore, 44 % of laboratories used patient moving averages for one or more tests. Daily iQC management was based on either "traffic lights" indicating in or out of control status, and review of all QC charts, often using multiple software systems.

CONCLUSIONS

A large heterogeneity of iQC practices in clinical laboratories was observed in the Netherlands. Several starting points for further research and/or guidance were identified, particularly in relation to the determination of SD values, the virtual analyzer model and methods to ensure analyzer equivalence.

Staying on track - Keeping things running in a high-end scientific imaging core facility

Modern life science research is a collaborative effort. Few research groups can single-handedly support the necessary equipment, expertise and personnel needed for the ever-expanding portfolio of technologies that are required across multiple disciplines in today's life science endeavours. Thus, research institutes are increasingly setting up scientific core facilities to provide access and specialised support for cutting-edge technologies. Maintaining the momentum needed to carry out leading research while ensuring high-quality daily operations is an ongoing challenge, regardless of the resources allocated to establish such facilities. Here, we outline and discuss the range of activities required to keep things running once a scientific imaging core facility has been established. These include managing a wide range of equipment and users, handling repairs and service contracts, planning for equipment upgrades, renewals, or decommissioning, and continuously upskilling while balancing innovation and consolidation.

A systematic review of biobanks in Latin America: Strengths and limitations for biomedical research

Biobanks are valuable tools for developing and applying scientific research and international cooperation through the collection of biological materials and their associated data. Systematic research following the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines was conducted in late 2022 in PubMed and Scopus, and generated 17 articles to be reviewed in depth and critically assessed using the Critical Appraisal Skills Programme Checklist due to the limited available data; 12 relevant health organizations and government websites outside of peer-reviewed journals were also included. Our research identified 44 biobanks in Latin America. In general, there is a lack of regulation and legislation guaranteeing the stored materials' quality and institutional collaboration. We believe a consensus needs to be reached regarding the terminology and definitions used for biobanks. The design for informed consent should also be agreed upon to ensure the privacy of the data shared among institutions. In conclusion, in Latin America, there is a clear need for government support in creating specific procedures for biobanks and providing further support for existing biobanks.

Feasibility evaluation of a blood rotation system for efficient blood product utilization in remote island settings

BACKGROUND AND OBJECTIVES

Geographical limitations in remote island medical facilities result in excessive wastage of blood products. To address this, we explored the feasibility of a novel blood rotation system, which enables the return and redelivery of blood products to/from the blood bank while ensuring the management of product quality, including temperature control. This study aimed to enhance the supply of blood products to these facilities.

MATERIALS AND METHODS

The Japan Red Cross Nagasaki Blood Center, Nagasaki Goto Chuoh Hospital (NGCH) and Nagasaki University Hospital collaborated to coordinate the transport and supply of red blood cell (RBC) products. Type O, RhD-positive, irradiated RBC products were stored at a precise 4.0 ± 2.0°C in an active transport refrigerator (ATR). After transport from the Japan Red Cross Nagasaki Blood Center to NGCH, RBC products were held for 1 week in the ATR, and unused products were returned. Eligible returned products were reissued to the Nagasaki University Hospital.

RESULTS

All the returned RBC products met the redelivery criteria. Among the 103 redelivered RBC preparations, 101 bags (98.1%) were successfully used. NGCH utilized 597 RBC products and discarded 80 samples. The ATR supplied 107 type O RBC bags without any wastage. The overall wastage rate was 10.2% during the study period compared with 24.2% in the same period in the previous year.

CONCLUSION

This innovative supply and operation system ensures a consistent and secure RBC product supply to remote islands while maximizing blood product use.

Assessing progress in managing and improving quality in nascent integrated care systems in England

OBJECTIVES

In 2022, England embarked on an ambitious reorganisation to produce an integrated health and care system, intended also to maximise population health. The newly created integrated care systems (ICSs) aim to improve quality of care, by achieving the best outcomes for individuals and populations through the provision of evidence-based services. An emerging approach for managing quality in organisations is the Quality Management System (QMS) framework. Using the framework, this study assessed how ICSs are managing and improving quality.

METHODS

Four ICSs were purposively sampled, with the data collected between November 2021 and May 2022. Semi-structured interviews with system leaders (n=60) from health and social care, public health and local representatives were held. We also observed key ICS meetings and reviewed relevant documents. A thematic framework approach based on the QMS framework was used to analyse the data.

RESULTS

The ICSs placed an emphasis on population health, reducing inequity and improving access. This represents a shift in focus from the traditional clinical approach to quality. There were tensions between quality assurance and improvement, with concerns that a narrow focus on assurance would impede ICSs from addressing broader quality issues, such as tackling inequalities and unwarranted variation in care and outcomes. Partnerships, a key enabler for integration, was seen as integral to achieving improvements in quality. Overall, the ICSs expressed concerns that any progress made in quality development and in improving population health would be tempered by unprecedented system pressures.

CONCLUSION

It is unclear whether ICSs can achieve their ambition. As they move away from an assurance-dominated model of quality to one that emphasises openness, learning and improvement, they must simultaneously build the digital infrastructure, staff expertise and culture to support such a shift.

Cardiothoracic operating room blood gas workflow performance improvement initiative

OBJECTIVES

To evaluate the current workflow of blood gas ordering and testing in a cardiothoracic operating room to identify opportunities to streamline the process, using performance improvement methodologies.

METHODS

Issues with specimen relabeling were identified that lead to delayed results and potential patient safety concerns. Blood gas specimen relabeling was evaluated for operating room cases from August 2018 to December 2022. An OpTime Epic Sidebar button for arterial blood gas and venous blood gas orders was created in January 2019 to streamline the ordering process so that laboratory barcode labels were then printed in the operating room and attached to the specimen, eliminating the need for relabeling by the technologists.

RESULTS

This Epic Sidebar intervention led to a drastic improvement of appropriate labeling, which has been sustained. From March 2019 to January 2023, with our new workflow, over 95% of blood gas specimens arrived barcode labeled compared to less than 1% in the preintervention era.

CONCLUSIONS

A multidisciplinary team with key stakeholders is important to address complex care issues. Performance improvement methodology is critical to develop interventions that hardwire the process. This intervention led to a sustained reduction in secondary relabeling of patient samples and improved timeliness of reporting of blood gas results.

A script-enabled interactive checklist document for efficient management of electronic devices in a busy multimodality radiotherapy clinic

PURPOSE

Develop an efficient, interactive, and instructive checklist document for the management of implanted electronic medical devices in a multimodality radiotherapy clinic.

METHODS

The built-in scripting and interactivity of a popular commercial word processor was used to develop an interactive document that changes the information presented to the user based on drop-down selections. The interactivity and scripting were compatible with the radiation oncology information system (ROIS) which allows the document to be accessible by all team members and serve as a permanent record in a patient's electronic chart.

RESULTS

The final interactive document, which was clinically deployed after beta testing with a group consisting of nurses and medical physicists, presents information and action plans to the user based on multiple departmental medical device decision trees that are specific to the combination of device, treatment modality, rhythm-pacing dependence for cardiac devices, and distance from the device to the treatment volume.

CONCLUSION

A script-enabled interactive document was developed for a busy multimodality clinic, condensing multiple comprehensive departmental guidelines spanning multiple device types and treatment modalities into a single interactive checklist accessible within the ROIS. Given the wide accessibility of the commercial word processor, this approach could be adopted by other clinics to streamline their own respective workflows.

Clinical implementation of failure modes and effects analysis for gynecological high-dose-rate brachytherapy

Purpose

To use failure modes and effects analysis (FMEA) to identify failure modes for gynecological high-dose-rate (HDR) brachytherapy pathway and score with severity, occurrence, and detectability.

Material and methods

A research team was organized to observe gynecological HDR brachytherapy pathway, and draw detailed process map to identify all potential failure modes (FMs). The whole team scored FMs based on three parameters, including occurrence (O), detectability (D), and severity (S), and then multiplied three scores to obtain risk priority number (RPN). All FMs were ranked according to RPNs and/or severity scores, and FMs with the highest RPN scores (> 100) and severity scores (> 8) were selected for in-depth analysis. Fault tree analysis (FTA) was applied to find progenitor causes of high-risk FMs and their propagation path, and determine which steps in the process need to be changed and optimized. Efficiency of each existing preventive methods to detect and stop FMs was analyzed, and proposals to improve quality management (QM) and ensure patient safety were suggested.

Results

The whole gynecological HDR brachytherapy pathway consisted of 5 sub-processes and 30 specific steps, in which 57 FMs were identified. Twelve high-risk FMs were found, including 7 FMs with RPNs > 100 and 5 FMs with severity scores > 8. For these FMs, 2 were in the insertion stage, 1 in the imaging stage, 4 in the treatment planning stage, and 5 in the final stage of treatment delivery. The most serious of these FMs was the change in organ at risk (OAR) during treatment delivery (RPN = 245.7). The FM that occurred most frequently was the applicator shift during patient transfer.

Conclusions

Failure modes and effects analysis is a prospective risk-based tool that can identity high-risk steps before failures occur, provide preventive measures to stop their occurrence, and improve quality management system.

Six SIGMA evaluation of 17 biochemistry parameters using bias calculated from internal quality control and external quality assurance data

Background

Six Sigma is a popular quality management system that enables continuous monitoring and improvement of analytical performance in the clinical laboratory. We aimed to calculate sigma metrics and quality goal index (QGI) for 17 biochemical analytes and compare the use of bias from internal quality control (IQC) and external quality assurance (EQA) data in the calculation of sigma metrics.

Methods

This retrospective study was conducted in Marmara University Pendik E&R Hospital Biochemistry Laboratory. Sigma metrics calculation was performed as (TEa-bias)/CV). CV was calculated from IQC data from June 2018 - February 2019. EQA bias was calculated as the mean of % deviation from the peer group means in the last seven surveys, and IQC bias was calculated as (laboratory control result mean-manufacturer control mean)/ manufacturer control mean) x100. In parameters where sigma metrics were <5; QGI=bias/1.5 CV) score of <0.8 indicated imprecision, >1.2 pointed inaccuracy, and 0.8-1.2 showed both imprecision and inaccuracy.

Results

Creatine kinase (both levels), iron and magnesium (pathologic levels) showed an ideal performance with ≥6 sigma level for both bias determinations. Eight of the 17 parameters had different sigma levels when we compared sigma values calculated from EQA and IQC derived bias% while the rest were grouped at the same levels.

Conclusions

Sigma metrics is a good quality tool to assess a laboratory's analytical performance and facilitate the comparison of the assay performances in the same manner across multiple systems. However, we might need to design a tight internal quality control protocol for analytes showing poor assay performance.

Key Factors Influencing the Operationalization and Effectiveness of Telemedicine Services in Henan Province, China: Cross-Sectional Analysis

BACKGROUND

Telemedicine has demonstrated its potential in alleviating the unbalanced distribution of medical resources across different regions. Henan, a province in China with a population of approximately 100 million, is especially affected by a health care divide. The province has taken a proactive step by establishing a regional collaborative platform for telemedicine services provided by top-tier provincial hospitals.

OBJECTIVE

We aim to identify the key factors that influence the current operationalization and effectiveness of telemedicine services in Henan province. The insights gained from this study will serve as valuable references for enhancing the efficient operation of telemedicine platforms in low- and middle-income regions.

METHODS

We analyzed service reports from the performance management system of telemedicine services in Henan province throughout 2020. Using descriptive statistics and graphical methods, we examined key influencing factors, such as management competency; device configuration; and hospital capability, capacity, and service efficacy, across hospitals at 2 different tiers. In addition, we used generalized linear models and multiple linear regression models to identify key operational factors that significantly affect the service volume and efficacy of 2 major telemedicine services, namely teleconsultation and tele-education.

RESULTS

Among the 89 tier 3 hospitals and 97 tier 2 hospitals connected to the collaborative telemedicine platform, 65 (73%) and 55 (57%), respectively, have established standardized management procedures for telemedicine services. As the primary delivery method for telemedicine services, 90% (80/89) of the tier 3 hospitals and 94% (91/97) of the tier 2 hospitals host videoconferencing consultations through professional hardware terminals rather than generic computers. Teleconsultation is the dominant service type, with an average annual service volume per institution of 173 (IQR 37-372) and 60 (IQR 14-271) teleconsultations for tier 3 and tier 2 hospitals, respectively. Key factors influencing the service volume at each hospital include available funding, management competency, the number of connected upper tiers, and the number of professional staff. After receiving teleconsultations from tier 3 (65/89, 73%) and tier 2 (61/97, 63%) hospitals, patients reported significant improvements in their medical conditions. In addition, we observed that service efficacy is positively influenced by management competency, financial incentives, the number of connected upper or lower tiers, and the involvement of participating medical professionals.

CONCLUSIONS

Telemedicine has become increasingly popular in Henan province, with a notable focus on teleconsultation and tele-education services. Despite its popularity, many medical institutions, especially tier 2 hospitals, face challenges related to management competency. In addition to enhancing the effectiveness of existing telemedicine services, health care decision-makers in Henan province and other low- and middle-income regions should consider expanding the service categories, such as including remote emergency care and telesurgery, which have promise in addressing crucial health care needs in these regions.

Segmentectomy quality remains important in ground-glass-dominant stage I lung cancer

BACKGROUND

Segmentectomy for early-stage lung cancer has benefits for survival and parenchymal preservation. However, segmentectomies are technically challenging, thereby resulting in considerable variability in the quality of resection. In this study, we aimed to review the quality of segmentectomies and analyze their clinical impact.

METHODS

This retrospective study reviewed patients diagnosed with stage I lung cancer after segmentectomies between 2013 and 2021. Segmentectomies were classified as anatomical or nonanatomical; anatomical resection included segmental bronchus and vessel (artery and/or vein) divisions; others were classified as nonanatomical. The primary outcome was recurrence-free and overall survival, and the secondary outcome was postoperative spirometry and lung plication, which is seen as a fibrotic line along the stapling site.

RESULTS

Of the 132 segmental resections included in this study, 101 (76.5%) were anatomical segmentectomies. The median consolidation-tumor ratio was 0.40, and 83.3% (110/132) had ground-glass opacities (GGOs). Compared to nonanatomical resections, more N1 and total lymph node stations were retrieved after anatomical segmentectomies. Regarding clinical outcomes, recurrence-free survival was better after anatomical segmentectomy (p = 0.049); however, overall survival was not significantly different (p = 0.064). Furthermore, at 3-6 months postoperatively, thicker lung plication at the stapling site was observed in nonanatomical resections (p < 0.001). Subgroup analysis for complex segmentectomies revealed a larger decrease in forced-expiration volume in 1 s after nonanatomical resection.

CONCLUSION

Anatomical segmentectomy resulted in better survival and a lower incidence of thick lung plication, even in GGO-dominant tumors. Therefore, further standardization and quality management of segmentectomy procedures will improve the clinical outcomes.

Review for special issue: Corneal lamellar surgery: Present outcomes and future perspectives

Since the establishment of the first eye bank in the 1940s, their role has evolved to face new challenges. With the recent development of lamellar keratoplasties, eye banks play an even bigger role in the selection and preparation of donor tissues. The increasing number of keratoplasty techniques and the high demand for "ready-to-use" tissues are challenging eye banks to improve and develop new preparation techniques. Besides necessary examinations, new approaches of tissue analysis in eye banks allow a better/optimized selection of corneal tissues. These new challenges in tissue preservation, preparation, and selection are propelling eye banks into a new era of modern eye banking.

Analysis of Factors Related to Variation in Dissolution Profiles Estimated from Continuously Conducted Dissolution Tests of Generic Products

The development of generic pharmaceuticals involves a bioequivalence study to ensure the therapeutic equivalence of the test formulation to the original innovative product. The formulation characteristics of generic products are expected to be maintained in the long term after approval. This study analyzed the factors contributing to the changes in the dissolution profiles of approved products during their life cycles. Cumulative data on the dissolution similarity of 1675 products of 127 ingredients tested by official laboratories in Japan were assessed according to Japanese bioequivalence guidelines with slight modifications. The products showing dissimilarities in dissolution profiles were analyzed for reporting year, therapeutic category, co-development, physical properties of the active pharmaceutical ingredient (API), and suspected reasons for dissolution change. The increase in the number of dissimilar products is related to the co-development of generic products. Although the solubility of the API was not associated with the dissolution change in the analysis of the total dissolution data, control of the API particle size is suggested to be important for drugs with poorly soluble APIs. Additionally, a risk factor for dissolution changes in the test solutions at a certain pH was the presence of acidic or basic residues. These results indicate the importance of proper development through a thorough evaluation of the formulation and process factors affecting the dissolution properties throughout the product lifecycle.

Revolutionising Quality Management in the Oral Pathology Laboratory: A Deep Dive Into the Six Sigma Methodology

Six Sigma Foundations is a statistical standard that indicates an exceptionally high level of quality, along with a customer satisfaction management approach that intends to lower error rates and boost process efficiency. The Define, Measure, Analyse, Improve, and Control (DMAIC) approach is a fundamental component of Six Sigma and provides an organised framework for process improvement. In contrast to conventional techniques that are more manual-based, Six Sigma emphasises and focuses on making decisions based on facts and evidence. The key to the success of Six Sigma is its reliance on statistical methods. Advanced tools like Pareto charts, histograms, regression analysis, and fishbone diagrams are used ardently for the benefit of customers and to reduce the overall error rate. To support clinical decision-making, a clinical laboratory's primary responsibility is to generate test results that are accurate, repeatable, fast, and appropriately interpreted. Ensuring desired clinical outcomes must be the ultimate objective. To accomplish this goal, laboratories must prioritise cost-effectiveness while establishing and maintaining quality in all laboratory procedures. The concept of the Lean Six Sigma (LSS) methodology, which mainly centres on efficiency by discerning and eradicating actions or operations that do not provide any benefit to the organisation, is combined with the proposition of Six Sigma, which emphasises data-driven analyses and optimization. The integration of these powerful concepts aids in the overall improvement of the organisations adopting these techniques. This review provides a brief overview of the benefits of the LSS methodology and its implementation in the oral pathology laboratory.

Trace Metal Impurities Effects on the Formation of [64Cu]Cu-diacetyl-bis(N4-methylthiosemicarbazone) ([64Cu]Cu-ATSM)

[64Cu]Cu-diacetyl-bis(N4-methylthiosemicarbazone) ([64Cu]Cu-ATSM) is a radioactive hypoxia-targeting therapeutic agent being investigated in clinical trials for malignant brain tumors. For the quality management of [64Cu]Cu-ATSM, understanding trace metal impurities' effects on the chelate formation of 64Cu and ATSM is important. In this study, we conducted coordination chemistry studies on metal-ATSM complexes. First, the effects of nonradioactive metal ions (Cu2+, Ni2+, Zn2+, and Fe2+) on the formation of [64Cu]Cu-ATSM were evaluated. When the amount of Cu2+ or Ni2+ added was 1.2 mol or 288 mol, equivalent to ATSM, the labeling yield of [64Cu]Cu-ATSM fell below 90%. Little effect was observed even when excess amounts of Zn2+ or Fe2+ were added to the ATSM. Second, these metals were reacted with ATSM, and chelate formation was measured using ultraviolet-visible (UV-Vis) absorption spectra. UV-Vis spectra showed a rapid formation of Cu2+ and the ATSM complex upon mixing. The rate of chelate formation by Ni2+ and ATSM was lower than that by Cu-ATSM. Zn2+ and Fe2+ showed much slower reactions with the ATSM than Ni2+. Trace amounts of Ni2+, Zn2+, and Fe2+ showed little effect on [64Cu]Cu-ATSM' quality, while the concentration of impurity Cu2+ must be controlled. These results can provide process management tools for radiopharmaceuticals.

Quality standards and internal quality control practices in medical laboratories: an IFCC global survey of member societies

OBJECTIVES

The trueness and precision of clinical laboratory results are ensured through total quality management systems (TQM), which primarily include internal quality control (IQC) practices. However, quality practices vary globally. To understand the current global state of IQC practice and IQC management in relation to TQM the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Task Force on Global Laboratory Quality (TF-GLQ) conducted a survey of IFCC member countries on IQC practices and management.

METHODS

The survey included 16 questions regarding IQC and laboratory TQM practices and was distributed to IFCC full and affiliate member countries (n=110). A total of 46 (41.8 %) responses were received from all regions except North America.

RESULTS

Of the responding countries, 78.3 % (n=36) had legislative regulations or accreditation requirements governing medical laboratory quality standards. However, implementation was not mandatory in 46.7 % (n=21) of responding countries. IQC practices varied considerably with 57.1 % (n=28) of respondents indicating that they run 2 levels of IQC, 66.7 % (n=24) indicating they run IQC every 24 h and 66.7 % (n=28) using assay manufacturer IQC material sources. Only 29.3 % (n=12) of respondents indicated that every medical laboratory in their country has written IQC policies and procedures. By contrast, 97.6 % (n=40) of responding countries indicated they take corrective action and result remediation in the event of IQC failure.

CONCLUSIONS

The variability in TQM and IQC practices highlights the need for more formal programs and education to standardize and improve TQM in medical laboratories.

Short Course Training on a Quality Management System for Pathologists, Trainees, and Histotechnologists During the African Pathology Assembly

OBJECTIVES

Provide quality management training in anatomic pathology so that slides are of adequate quality and can be interpreted.

METHODS

During the first African Pathology Assembly, we performed a needs assessment and knowledge quizzes, then presented 4 modules of the quality management system (personnel management, process control, sample management, and equipment) that are used to train quality in vertical programs by the World Health Organization.

RESULTS

Participants included 14 (34%) trainees, 14 (34%) pathologists, and 9 (22%) technologists from South Africa (11), Nigeria (6), Tanzania (4), and other countries (18). Thirty (73%) participants took the course because they had interest in the topic while 6 (15%) did it because it was recommended by a supervisor. Most participants thought that the quality of slides was medium to high in their institution and that clinicians trust results. The most frequent quality issues cited included problems from processing to staining, long turnaround times, and preanalytical issues (fixation, lack of clinical history). The average result of the knowledge quiz was 6.7 (range, 2-10) before (38 participants) the course and 8.3 (range, 5-10) after (30 participants) the course.

CONCLUSIONS

This assessment suggests there is a need for quality management courses in pathology in Africa.

Comparative Analysis of Patient Satisfaction Surveys-A Crucial Role in Raising the Standard of Healthcare Services

(1) Background: The study aimed to assess the patients' perception of the quality of the medical staff's care, the hotel's services, and the hospital's overall impression as well as to determine the best rating scale through a comparative analysis of patient satisfaction questionnaires. (2) Methods: A retrospective study was performed based on satisfaction questionnaires addressed to the patients hospitalized in the Orthopedics and Traumatology departments of the County Clinical Emergency Hospital Oradea between 2015 and 2019. Three different types of questionnaires were used during the study period, with the number of questions varying between 30 (variant A) and 37 (variant C). The evaluation was done using the Likert scales with three, four, or five answer variables. (3) Results: The items that we found to be present in all three categories of surveys and for which at least two different questionnaire variants used the Likert scales with various answer variables were chosen. In terms of the treatment given by the medical staff, hotel services, and the overall perception of the hospital, the patients perceive a higher level of quality. (4) Conclusions: The level of patient overall satisfaction or general impression about the hospital is strongly dependent on the quality of medical care provided by the doctors and the specific hotel conditions of the hospital. The quality assessment using the Likert rating scale with five binary variables is more accurate.

Quality Management System in Clinical Digital Pathology Operations at a Tertiary Cancer Center

Digital pathology workflows can improve pathology operations by allowing reliable and fast retrieval of digital images, digitally reviewing pathology slides, enabling remote work and telepathology, use of computer-aided tools, and sharing of digital images for research and educational purposes. The need for quality systems is a prerequisite for successful clinical-grade digital pathology adoption and patient safety. In this article, we describe the development of a structured digital pathology laboratory quality management system (QMS) for clinical digital pathology operations at Memorial Sloan Kettering Cancer Center (MSK). This digital pathology-specific QMS development stemmed from the gaps that were identified when MSK integrated digital pathology into its clinical practice. The digital scan team in conjunction with the Department of Pathology and Laboratory Medicine quality team developed a QMS tailored to the scanning operation to support departmental and institutional needs. As a first step, systemic mapping of the digital pathology operations identified the prescan, scan, and postscan processes; instrumentation; and staffing involved in the digital pathology operation. Next, gaps identified in quality control and quality assurance measures led to the development of standard operating procedures and training material for the different roles and workflows in the process. All digital pathology-related documents were subject to regulatory review and approval by departmental leadership. The quality essentials were developed into an extensive Digital Pathology Quality Essentials framework to specifically address the needs of the growing clinical use of digital pathology technologies. Using the unique digital experience gained at MSK, we present our recommendations for QMS for large-scale digital pathology operations in clinical settings.

Toward a global harmonization of service infrastructure in academic clinical trial units: an international survey

Background

Clinicians around the world perform clinical research in addition to their high workload. To meet the demands of high quality Investigator Initiated Trials (IITs), Clinical Trial Units (CTUs) (as part of Academic Research Institutions) are implemented worldwide. CTUs increasingly hold a key position in facilitating the international mutual acceptance of clinical research data by promoting clinical research practices and infrastructure according to international standards.

Aim

In this project, we aimed to identify services that established and internationally operating CTUs - members of the International Clinical Trial Center Network (ICN) - consider most important to ensure the smooth processing of a clinical trial while meeting international standards. We thereby aim to drive international harmonization by providing emerging and growing CTUs with a resource for informed service range set-up.

Methods

Following the AMEE Guide, we developed a questionnaire, addressing the perceived importance of different CTU services. Survey participants were senior representatives of CTUs and part of the ICN with long-term experience in their field and institution.

Results

Services concerning quality and coordination of a research project were considered to be most essential, i.e., Quality management, Monitoring and Project management, followed by Regulatory & Legal affairs, Education & Training, and Data management. Operative services for conducting a research project, i.e., Study Nurse with patient contact and Study Nurse without patient contact, were considered to be least important.

Conclusion

To balance the range of services offered while meeting high international standards of clinical research, emerging CTUs should focus on offering (quality) management services and expertise in regulatory and legal affairs. Additionally, education and training services are required to ensure clinicians are well trained on GCP and legislation. CTUs should evaluate whether the expertise and resources are available to offer operative services.

Best Practices for Effective Management of Point of Care Testing

With the recent COVID-19 pandemic, point-of-care testing has gained tremendous attention, particularly in acute care settings. The point-of-care testing landscape is rapidly expanding and being contemplated for any crucial test with a central laboratory turnaround time >25% of the clinical decision time. A typical point-of-care testing program within a large hospital system encompasses a multitude of operators utilizing a wide range of devices across multiple testing sites. Thus, managing a large point-of-care testing network remains a daunting task with challenges related to staffing, standardization, quality management, training and competency assessment, and data management. This review will focus on understanding the general organization as well as the roles and responsibilities of various point-of-care testing stakeholders in addressing these challenges. More importantly, it will discuss the strategies and best practices for effective point-of-care testing management based on consensus recommendations from professional societies as well as our experience at Texas Childrens Hospital.

Effect of Optimizing Medical Rehabilitation System for Patients with Coronavirus Disease 2019 Using the Functional Resonance Analysis Method

Objectives

Coronavirus infection 2019 (COVID-19) is an indication for rehabilitation medicine, especially in severe cases. However, there has been no system analysis of safe and continuous provision of medical rehabilitation for COVID-19 patients. The aim of this study was to confirm the effectiveness of rehabilitation for severe COVID-19 and to analyze the optimization of the medical rehabilitation system using the Functional Resonance Analysis Method (FRAM).

Methods

The subject of the analysis was the medical rehabilitation system itself, which had been implemented by the Rehabilitation Center of our hospital in response to the increased number of COVID-19 patients. In the FRAM analysis, Functions were identified, and their relationships were examined. Functions were established using a hierarchical cross-check by the authors. Patient outcomes resulting from optimization of the rehabilitation system were length of hospital stay, patient independence in daily living, and rehabilitation-related medical costs, and these were statistically validated.

Results

In repeated optimizations of the rehabilitation system, the main issues were "handling of infected patients and isolation of usual clinical practice," "staff rotation," and "remote consultation". The modification of the medical rehabilitation system was associated with shorter hospital stays, shorter periods of time without prescription, faster improvement in independence of daily living, and lower rehabilitation-related medical costs.

Conclusions

Optimization at each stage of medical rehabilitation resulted in positive effects on patient outcomes. FRAM is useful for identifying and the optimization of key functions.

Identifying Environmental Impact Factors for Sustainable Healthcare: A Scoping Review

The healthcare industry has a substantial impact on the environment through its use of resources, waste generation and pollution. To manage and reduce its impact, it is essential to measure the pressures of healthcare activities on the environment. However, research on factors that can support these measurement activities is unbalanced and scattered. In order to address this issue, a scoping review was conducted with the aims of (i) identifying and organizing factors that have been used to measure environmental impact in healthcare practice and (ii) analyzing the overview of impact factors in order to identify research gaps. The review identified 46 eligible articles publishing 360 impact factors from original research in PubMed and EBSCO databases. These factors related to a variety of healthcare settings, including mental healthcare, renal service, primary healthcare, hospitals and national healthcare. Environmental impacts of healthcare were characterized by a variety of factors based on three key dimensions: the healthcare setting involved, the measurement component or scope, and the type of environmental pressure. The Healthcare Environmental Impact Factor (HEIF) scheme resulting from this study can be used as a tool for selecting measurable indicators to be applied in quality management and as a starting point for further research. Future studies could focus on standardizing impact factors to allow for cross-organization comparisons and on expanding the HEIF scheme by addressing gaps.

Harnessing patient complaints to systematically monitoring healthcare concerns through disproportionality analysis

Staff observations are the most common source of data for driving improvements in care. However, the patient perspective should also be considered, and healthcare complaints offer concrete details that health organizations might otherwise overlook and that can highlight areas for learning and improvement in the healthcare system. However, because of the diverse nature of patient complaints, systematic analyses can be challenging. This study aimed to identify and prioritize areas for improvement using a data-driven approach to analysing patient complaints. The Danish version of the Healthcare Complaints Analysis Tool was used to categorize the content of complaint letters. All complaints managed by the national complaints authority, compensation claims to the Patient Compensation Association, and locally managed complaints that were filed directly at Odense University Hospital from 2017 to 2021 were included. Proportional reporting ratios (PRRs) were used to measure and display the top five signals of disproportionality and rank them by excess complaints at the hospital level and when divided into department types. The study included 6366 complaints containing 13 156 problems (on average, 2.1 problems mentioned per complaint letter). Surgical departments had the highest number of complaints (3818), followed by medical (1059), service (439), and emergency departments (239). Signal 1 of disproportionality, relating to quality problems during ward procedures, had the highest excess reporting of 1043 complaints at the hospital level and a PRR of 1.61 and was present in all department types. Signal 2, relating to safety problems during the examination and diagnosis stage, had an excess reporting of 699 problems and a PRR of 1.86 and was also present in all department types. Signal 3, relating to institutional problems during admission, had the highest PRR of 3.54 and was found in most department types. Signals 4 and 5, relating to environmental problems during ward procedures and care on the ward, respectively, had PRRs of 1.5 and 1.84 and were present in most department types. The study found that analysing patient complaints can identify potential areas for hospital improvement. The study identified recurring issues in multiple departments, including quality problems during ward procedures, safety problems during the examination, institutional problems during admission, and environmental problems on the ward. The study highlights disproportionality analysis of complaints as a valuable tool to monitor patient concerns systematically.

Laboratory Surveillance, Quality Management, and Its Role in Addressing Antimicrobial Resistance in Africa: A Narrative Review

AMR is a major public health concern that calls for extensive work and a multidisciplinary team approach. The high prevalence of infectious diseases in African nations leads to widespread antibiotic usage and eventual antimicrobial resistance, which has significant negative effects on people's health, the economy, and society. Additionally, inadequate or nonexistent antimicrobial drug regulations, inappropriate prescription practices, and restrictions on public health prevention initiatives such as immunization, water and sanitation, and sexual health may all contribute to the emergence of AMR. Despite the need for laboratory quality assurance, many African laboratories confront substantial difficulties in implementing efficient quality assurance programs. AMR surveillance in Africa is hampered by a lack of laboratory capacity, insufficient data collection and analysis, and poor stakeholder collaboration. Several initiatives and programs, including the World Health Organization's Global Antimicrobial Resistance and Use Surveillance System (GLASS), the Africa Centres for Disease Control and Prevention (Africa CDC) Antimicrobial Resistance Surveillance Network (AMRSNET), and the Fleming Fund, a UK government initiative aimed at tackling AMR in low- and middle-income countries, have been established to strengthen AMR surveillance in Africa and globally.

Applied Molecular-Based Quality Control of Biobanked Samples for Multi-Omics Approach

Biobanks are vital for high-throughput translational research, but the rapid development of novel molecular techniques, especially in omics assays, poses challenges to traditional practices and recommendations. In our study, we used biospecimens from oncological patients in Polish clinics and collaborated with the Indivumed Group. For serum/plasma samples, we monitored hemolysis, controlled RNA extraction, assessed cDNA library quality and quantity, and verified NGS raw data. Tissue samples underwent pathologic evaluation to confirm histology and determine tumor content. Molecular quality control measures included evaluating the RNA integrity number, assessing cDNA library quality and quantity, and analyzing NGS raw data. Our study yielded the creation of distinct workflows for conducting preanalytical quality control of serum/plasma and fresh-frozen tissue samples. These workflows offer customization options to suit the capabilities of different biobanking entities. In order to ensure the appropriateness of biospecimens for advanced research applications, we introduced molecular-based quality control methods that align with the demands of high-throughput assays. The novelty of proposed workflows, rooted in innovative molecular techniques, lies in the integration of these QC methods into a comprehensive schema specifically designed for high-throughput research applications.

Elaboration and implementation of a protocol for the Golden Hour of premature newborns using an Implementation Science lens

OBJECTIVE

describe the process of designing and implementing a care protocol for the first hour of life of premature newborns.

METHOD

a participatory research study using an implementation science framework, the Consolidated Framework for Implementation Research (CFIR) was employed to determine drivers and facilitators of implementation success of the Golden Hour protocol for newborns at a large university hospital in southeastern Brazil. A multi-professional team, including first line providers and managers participated in six stages of quality improvement: situational diagnosis; protocol elaboration; training protocol implementation; barrier and facilitator assessment; and protocol monitoring and review. Qualitative and monitoring data collected across these six stages were analyzed using descriptive statistics and content analysis.

RESULTS

the institution's Golden Hour protocol was organized by the multi-professional team based on a collective and dialogical approach. The protocol prioritized the infant's cardiopulmonary stability, as well as prevention of hypothermia, hypoglycemia and infection. After four months of implementation, the care team was evaluated the protocol as a good quality intervention, necessary for the service, low-cost and not very complex. One suggested improvement recommended was to carry out refresher training to address staff turnover.

CONCLUSION

implementation of the Golden Hour protocol introduced an appropriate and feasible neonatal care quality improvement process, which requires periodic refresher training to ensure greater adherence and better neonatal results.

Creating blood conservation for a cardiothoracic surgical hospital: when you have to start from scratch!

BACKGROUND

This improvement report presents a hospital blood-management programme, a hospital-specific model that differs from patient blood managment and was aimed at improving operational standards of transfusion. We identified the challenges of the transfusion process and suggest practical strategies for improving them. The aim of this article was to investigate the effect of the programme on the transfusion of blood components.

METHODS

In January 2019, the programme was started to improve the transfusion process. The data before and after the start of the programme were compared. Frequency distribution was obtained for each variable for statistical analysis and the chi-squared test with continuity correction was used to compare these variables for the years 2018 and 2019.

RESULTS

Transfusion of total blood components decreased by 23.2%, fresh whole blood by 46.7%, fresh frozen plasma by 38.4%, pooled platelets by 14.0% and red blood cells by 9.66%. Autologous transfusion increased 11.7-fold. The emergency department (76.0%) and intensive care unit transfusion rate (9.26%) decreased significantly.

CONCLUSION

This programme is an example for hospitals where patient blood management cannot be applied. The programme can be considered the first step for blood management and may be applied to blood management in institutions worldwide. The difficulty of blood supply and increased cost will increase the importance of hospital blood-management programmes in the coming years.

Quality indicators in intensive care medicine for Germany - fourth edition 2022

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

Is Our Newborn Screening Working Well? A Literature Review of Quality Requirements for Newborn Blood Spot Screening (NBS) Infrastructure and Procedures

Newborn screening using dried blood spots (NBS) is widely acknowledged as a highly successful procedure in secondary prevention. For a number of congenital disorders, severe disability or death are impressively prevented by early detection and early treatment through NBS. However, as with any other screening, NBS can also cause harm, and the principle that "the overall benefits of screening should outweigh the harms" must be considered when introducing and implementing NBS programmes. This publication compiles the results of a systematic literature research on requirements for NBS infrastructure and procedures which was conducted as part of a research project on the quality and shortcomings of the NBS pathway in Germany. The compilation contains the requirements and recommendations for realising the principle of "maximise benefits and minimise harms" in relevant NBS pathway components such as parental education and information, coverage, timeliness, laboratory quality assurance, follow-up of abnormal results, confirmatory diagnostics, documentation, and evaluation. The results reflect the complexity of NBS infrastructure, and thus, they illustrate the importance of considering and implementing NBS as a well-coordinated public health programme with continuous quality management. Special attention should be paid to the perspectives of parents and families. Some NBS issues can substantially benefit from digital instruments or international cooperation. The literature review presented here has contributed to a concept of proposals for the advancement of NBS in Germany, and despite different settings, it may as well be of interest for other countries to achieve the best possible course and outcome of NBS for each child.

Sustained agreement rates in the longitudinal assessment of lupus patients to a Broad Consent for personal data and specimen usage in the RHINEVIT biobank

Background

Biobanks are essential structures for scientific research. The RHINEVIT biobank is used to recruit biomaterials from rheumatology patients in outpatient care and to conduct clinical research studies (e.g., cohort studies) and basic research. RHINEVIT established Broad Consents (BC) to allow extensive and relevant usage of data and biospecimens without the need for specific project restrictions. For quality assurance, we compared the consent rate of individual items of the BC versions in patients with systemic lupus erythematosus (SLE) in the longitudinal study.

Methods

BCs were used for biomaterial donation. Informed consent data from RHINEVIT were analyzed. Due to the content restructuring of the BC items due to changes from the templates of the working group of the Medical Ethics Commissions in the Federal Republic of Germany and GDPR requirements, content mapping of the items was performed for the analysis.

Results

From September 2015 to March 2022, 291 SLE outpatients donated biomaterials. In 119 patients, the BC was renewed at least once in a subsequent biomaterial donation. Three biomaterial donations were obtained from 21 patients and four from six patients using the respective BC. However, one consent was later revoked. Consent to the BC topics showed consistently high rates of agreement (range 97.5%-100%), with only some patients disagreeing with individual topics. This remained stable over time (median 526 days [Q1 400, Q3 844]). None of the patients disagreed with a certain topic in two consecutive visits.

Conclusion

Modifications to the BC did not result in any relevant changes in the approval rates for SLE patients. RHINEVIT's BC is successfully used for the quality-assured handling of excellently annotated biomaterial. The long-term use of these highly valuable biospecimens for unrestricted research, also in an international context, remains assured.

Competence-based catalog of learning objectives for the subject area of quality management in medical studies - position paper of the working group Quality Management in Education, Training and Continuing Education of the Society for Quality Management in Health Care (GQMG)

Background

Traditionally, direct medical competences are taught in medical studies, whereas leadership and quality management competences are hardly taught, although graduates are already confronted with management tasks at the beginning of their clinical work. With the upcoming amendment of the Medical Licensing Regulations, this topic area will probably be addressed and must be adequately taught by the faculties. The learning objectives in the area of quality management listed in the current working version of the German National Catalogue of Learning Objectives in Medicine (NKLM) 2.0 have so far been formulated in rather general terms and need to be concretized.

Aim

To develop a competence-based learning objectives catalog for the topic area of quality management in medical studies as a structured framework recommendation for the design of faculty teaching-learning programs and as a suggestion for further development of the NKLM.

Methods

The competence-based learning objectives catalog was developed by an eight-member working group "Quality Management in Education, Training and Continuing Education" of the Gesellschaft für Qualitätsmanagement in der Gesundheitsversorgung e.V. (GQMG) within the framework of a critical synthesis of central publications. The members of the project group have many years of project experience in quality management in health care as well as in university didactics.

Results

Six basic competence goals as well as 10 specific competence goals could be formulated and consented upon. These are each flanked by a list of essential basic concepts and examples. These focus on quality improvements, including patient safety and treatment success against the background of a physician leadership role in an interprofessional context.

Discussion

A competency-based set of learning objectives has been compiled that encompasses the necessary concepts and basic knowledge of quality management required for those entering the profession to understand and actively participate in quality management after completing medical school. To the authors' knowledge, no comparable learning objectives catalog is currently available for medical studies, even internationally.

Impact of COVID-19 on cancer care pathways in a comprehensive cancer center in northern Italy

The COVID-19 pandemic burdened health care systems worldwide. Health services were reorganized with the dual purpose of ensuring the most adequate continuity of care and, simultaneously, the safety of patients and health professionals. The provision of care to patients within cancer care pathways (cCPs) was not touched by such reorganization. We investigated whether the quality of care provided by a local comprehensive cancer center has been maintained using cCP indicators. A retrospective single-cancer center study was conducted on eleven cCPs from 2019 to 2021 by comparing three timeliness indicators, five care indicators and three outcome indicators yearly calculated on incident cases. Comparisons of indicators between 2019 and 2020, and 2019 and 2021, were performed to assess the performance of cCP function during the pandemic. Indicators displayed heterogeneous significant changes attributed to all cCPs over the study period, affecting eight (72%), seven (63%) and ten (91%) out of eleven cCPs in the comparison between 2019 and 2020, 2020 and 2021, and 2019 and 2021, respectively. The most relevant changes were attributed to a negative increase in time-to-treatment surgery-related indicators and to a positive increase in the number of cases discussed by cCP team members. No variations were found attributed to outcome indicators. Significant changes did not account for clinical relevance once discussed by cCP managers and team members. Our experience demonstrated that the CP model constitutes an appropriate tool for providing high levels of quality care, even in the most critical health situations.

Conducting an Epidemiologic Study and Making It FAIR: Reusable Tools and Procedures from a Population-Based Cohort Study

Conducting large-scale epidemiologic studies requires powerful software for electronic data capture, data management, data quality assessments, and participant management. There is also an increasing need to make studies and the data collected findable, accessible, interoperable, and reusable (FAIR). However, reusable software tools from major studies, underlying such needs, are not necessarily known to other researchers. Therefore, this work gives an overview on the main tools used to conduct the internationally highly networked population-based project Study of Health in Pomerania (SHIP), as well as approaches taken to improve its FAIRness. Deep phenotyping, formalizing processes from data capture to data transfer, with a strong emphasis on cooperation and data exchange have laid the foundation for a broad scientific impact with more than 1500 published papers to date.

Evaluation of immunoglobulin replacement therapy in secondary immunodeficiency at three British Columbia hospitals

BACKGROUND AND OBJECTIVES

Immunoglobulin (Ig) usage has ongoing shortage concerns. Secondary immunodeficiencies (SIDs) account for a major proportion of usage of Igs in Canada. We audited Ig usage in patients with SID at three British Columbia hospitals to determine whether more stringent local guidelines are necessary.

MATERIALS AND METHODS

A retrospective chart review was performed for patients who had Ig ordered between 1 January 2018 and 31 December 2019 for any SID indication. Cohorts were stratified into chronic and new users, and the Australian BloodSTAR guidelines were used as the benchmark at the time of conception. Having an eligible primary diagnosis, meeting SID criteria, an appropriate dosage and follow-up immunoglobulin G (IgG) levels encompassed appropriate usage.

RESULTS

There were no demographic differences between chronic (N = 81) and new (N = 33) cohorts. The new cohort had a higher rate of appropriate usage (45.7% vs. 66.7%, p = 0.06). The most common reason for inappropriate usage in both groups was the lack of follow-up IgG level at 6 or 12 months. Factors, displayed by relative risk (RR), associated with appropriateness included the dispensing hospital (RR: 6.60), use of subcutaneous Ig (RR: 3.84), having an IgG level before starting therapy (RR: 3.51) and documentation of clinical benefit (RR: 4.70).

CONCLUSION

There are high rates of inappropriate Ig usage in SID patients in both new and chronically treated groups. More stringent local guidelines and processes for assessing initial and ongoing Ig replacement are warranted.

The estimated negative impacts on the red blood cell inventory of reducing shelf-life at two large health authorities in British Columbia, Canada, using a discrete-event simulation model

BACKGROUND AND OBJECTIVES

Reducing the maximum red blood cell (RBC) shelf-life is under consideration due to potential negative effects of older blood. An assessment of the impacts of this change on blood supply chain management is evaluated.

MATERIALS AND METHODS

We performed a simulation study using data from 2017 to 2018 to estimate the outdate rate (ODR), STAT order and non-group-specific RBC transfusion at two Canadian health authorities (HAs).

RESULTS

Shortening shelf-life from 42 to 35 and 28 days led to the following: ODRs (in percentage) in both HAs increased from 0.52% (95% confidence interval [CI] 0.50-0.54) to 1.32% (95% CI 1.26-1.38) and 5.47% (95% CI 5.34-5.60), respectively (p < 0.05). The estimated yearly median of outdated RBCs increased from 220 (interquartile range [IQR] 199-242) to 549 (IQR 530-576) and 2422 (IQR 2308-2470), respectively (p < 0.05). The median number of outdated redistributed units increased from 152 (IQR 136-168) to 356 (IQR 331-369) and 1644 (IQR 1591-1741), respectively (p < 0.05). The majority of outdated RBC units were from redistributed units rather than units ordered from the blood supplier. The estimated weekly mean STAT orders increased from 11.4 (95% CI 11.2-11.5) to 14.1 (95% CI 13.1-14.3) and 20.9 (95% CI 20.6-21.1), respectively (p < 0.001). The non-group-specific RBC transfusion rate increased from 4.7% (95% CI 4.6-4.8) to 8.1% (95% CI 7.9-8.3) and 15.6% (95% CI 15.3-16.4), respectively (p < 0.001). Changes in ordering schedules, decreased inventory levels and fresher blood received simulated minimally mitigated these impacts.

CONCLUSION

Decreasing RBC shelf-life negatively impacted RBC inventory management, including increasing RBC outdating and STAT orders, which supply modifications minimally mitigate.

Quality management, quality assurance, and quality control in medical physics

The historic and ongoing evolution of the practice, technology, terminology, and implementation of programs related to quality in the medical radiological professions has given rise to the interchangeable use of the terms Quality Management (QM), Quality Assurance (QA), and Quality Control (QC) in the vernacular. This White Paper aims to provide clarification of QM, QA, and QC in medical physics context and guidance on how to use these terms appropriately in American College of Radiology (ACR) Practice Parameters and Technical Standards, generalizable to other guidance initiatives. The clarification of these nuanced terms in the radiology, radiation oncology, and nuclear medicine environments will not only boost the comprehensibility and usability of the Medical Physics Technical Standards and Practice Parameters, but also provide clarity and a foundation for ACR's clinical, physician-led Practice Parameters, which also use these important terms for monitoring equipment performance for safety and quality. Further, this will support the ongoing development of the professional practice of clinical medical physics by providing a common framework that distinguishes the various types of responsibilities borne by medical physicists and others in the medical radiological environment. Examples are provided of how QM, QA, and QC may be applied in the context of ACR Practice Parameters and Technical Standards.

Patient Satisfaction with Healthcare Services and the Techniques Used for its Assessment: A Systematic Literature Review and a Bibliometric Analysis

Patient satisfaction with healthcare provision services and the factors influencing it are be-coming the main focus of many scientific studies. Assuring the quality of the provided services is essential for the fulfillment of patients' expectations and needs. Thus, this systematic review seeks to find the determinants of patient satisfaction in a global setting. We perform an analysis to evaluate the collected literature and to fulfill the literature gap of bibliometric analysis within this theme. This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) approach. We conducted our database search in Scopus, Web of Science, and PubMed in June 2022. Studies from 2000-2021 that followed the inclusion and exclusion criteria and that were written in English were included in the sample. We ended up with 157 articles to review. A co-citation and bibliographic coupling analysis were employed to find the most relevant sources, authors, and documents. We divided the factors influencing patient satisfaction into criteria and explanatory variables. Medical care, communication with the patient, and patient's age are among the most critical factors for researchers. The bibliometric analysis revealed the countries, institutions, documents, authors, and sources most productive and significant in patient satisfaction.

Quality management in the COVID-19 pandemic: nursing action plan

OBJECTIVES

to describe the implementation of a nursing action plan to face the pandemic of COVID 19 in a University Hospital in the state of Rio de Janeiro. Methods: this is an experience report, in which two management tools were used: the Ishikawa Diagram to identify problems and the 5W2H spreadsheet to outline the actions according to the situations presented.

RESULTS

four categories were listed in two groups: 1- Actions of the Nurse Manager in the Organization of Logistics, Infrastructure and Care: materials and environment; and 2- Nursing Human Resources Management and Continuing Education: method and human resources.

FINAL CONSIDERATIONS

the plan developed showed the role of nursing management, with the search for best care practices, development of protocols, carrying out multi-professional training and management of supplies.

Information technology improves the quality of transfusion practice in China

BACKGROUND AND OBJECTIVES

Transfusion services in China must establish a quality management system, and regular inspection of quality indicators is an important component of quality management. Although the positive role of information technology in reducing human errors has been widely reported, its role in improving transfusion quality indicators still requires further study. This study explores the role of information technology in improving the quality of transfusion practice.

MATERIALS AND METHODS

We developed an optimized blood transfusion management information system and then analysed the changes in four quality indicators before and after using the system to clarify the role of information technology in improving the quality of transfusion practice.

RESULTS

After using the optimized system, the completeness rate for transfusion request forms increased from 81.5% to 99.3%; an unqualified doctor's signature was the most common incomplete content (0.45%). The appropriate transfusion rate increased from 87% to 99.4%, and red blood cell and frozen plasma utilization in most surgical departments decreased. Although the reporting rate for adverse transfusion reactions increased from 0.22% to 0.49%, these increases might be partly due to changes in transfusion regulations. The adequacy rate of transfusion medical records increased from 74.8% to 90.4%. Overall, the inadequacy of informed consent for transfusion, pre-transfusion laboratory tests and documentation of the transfusion process were reduced from 6.4%, 6.2% and 12.6% to 1.7%, 2.0% and 5.9%, respectively.

CONCLUSION

Information technology can play an important role in improving the quality of transfusion practice, as part of a programme of medical education, regular audit and other measures.

A zlog-based algorithm and tool for plausibility checks of reference intervals

OBJECTIVES

Laboratory information systems typically contain hundreds or even thousands of reference limits stratified by sex and age. Since under these conditions a manual plausibility check is hardly feasible, we have developed a simple algorithm that facilitates this check. An open-source R tool is available as a Shiny application at github.com/SandraKla/Zlog_AdRI.

METHODS

Based on the zlog standardization, we can possibly detect critical jumps at the transitions between age groups, regardless of the analytical method or the measuring unit. Its advantage compared to the standard z-value is that means and standard deviations are calculated from the reference limits rather than from the underlying data itself. The purpose of the tool is illustrated by the example of reference intervals of children and adolescents from the Canadian Laboratory Initiative on Pediatric Reference Intervals (CALIPER).

RESULTS

The Shiny application identifies the zlog values, lists them in a colored table format and plots them additionally with the specified reference intervals. The algorithm detected several strong and rapid changes in reference intervals from the neonatal period to puberty. Remarkable jumps with absolute zlog values of more than five were seen for 29 out of 192 reference limits (15.1%). This might be attenuated by introducing shorter time periods or mathematical functions of reference limits over age.

CONCLUSIONS

Age-partitioned reference intervals will remain the standard in laboratory routine for the foreseeable future, and as such, algorithmic approaches like our zlog approach in the presented Shiny application will remain valuable tools for testing their plausibility on a wide scale.

The impact of knowledge management on the quality of services in nursing homes

Introduction

Current management strategies in nursing homes (NH) aim to ensure effective knowledge management (KM) in order to provide both best possible services to residents, and care for staff in NH. Teamwork in NH is essential for effective delivery of the highest quality of services. As a result, NH are increasingly adopting KM activities to enable knowledge creation, storage, transfer, and implementation in an environment facing many challenges such as lack of staff, increasing demands, and expectations of residents.

Methods

In our quantitative study, we examined how two Slovenian state NH that adopted the E-Qalin quality management model (European quality-improving learning model) adapted their KM, and what impact their quality management system and KM activities actually have on the quality of services. Furthermore, we examined how two Slovenian private NH that have not adopted a certified quality management program (like ISO or E-Qalin) tackle the issue of quality of services from the KM perspective. The sample consisted of 80 nursing professionals. In every NH that is part of this study, teamwork is essential and every individual that was involved in our survey is part of a team. In our study, we analyzed relationships between individual variables using linear regression.

Results

We found a significant and positive relationship between knowledge creation, transfer, and implementation in NH with and without the E-Qalin certificate. We found a significant and positive relationship between knowledge storage and the quality of services only in NH without a E-Qualin certificate. It seems that when connecting multidisciplinary fields such as NH and KM, there is still a lack of awareness and knowledge on the topic of KM, which might be one of the reasons for some bias in the answers provided by respondents. We also found different teamwork approaches in NH with and without a E-Qalin certificate. Our research results therefore emphasize the need to gain additional insight into quality management and KM in the environment of NH.

Conclusion

Teamwork based on knowledge storage, transfer, the implementation of existing knowledge, and creation of new knowledge are essential for well-trained professionals and, as a result, contribute to continuous improvement in service quality. Implementation of KM is well received by NH, and enables them to better meet the needs and expectations of residents. More importantly, nursing staff also share and pass on tacit knowledge through teamwork. Finally, all of the NH in our study that implemented quality and KM activities noted an improvement in the quality of services that are offered to residents in practice. Our results indicate that the topic of KM in NH is interesting, and it has a positive impact on the quality of services in practice. However, the problem of awareness and knowledge on the topic of KM in the environment of NH still exists, highlighting the need for further research, additional insight, and dissemination of knowledge to every interested stakeholder functioning in the field of NH. The results of the study make an important contribution to the research of KM in NH, focusing on the transfer of tacit knowledge.

A Rank Model of Casting Non-Conformity Detection Methods in the Context of Industry 4.0

In the face of ongoing market changes, multifaceted quality analyses contribute to ensuring production continuity, increasing the quality of the products offered and maintaining a stable market position. The aim of the research was to create a unified rank model for detection methods in the identification of aluminium casting non-conformities, in line with the paradigms of the fourth industrial revolution. The originality of the model enables the creation of a rank for the effectiveness of total inspection points allowing for the optimisation of detection methods. Verification of the model was carried out against the production process of aluminium casting. The model included the integration of non-destructive testing (NDT) methods and the analysis of critical product non-conformities, along with the determination of the level of effectiveness and efficiency of inspection points. The resulting ranking of detection methods indicated the NDT method as the most effective, which was influenced by the significant detection of critical non-conformities and the automation of the process. The study observed little difference in the visual inspection and measurement efficiency parameters, which was due to the identifiability of non-conformities with a lower degree of significance and the low level of inspection cost. Further research will look at the implications of the model in other production processes.

Construction of nursing care quality evaluation indicators for post-anaesthesia care unit in China

AIMS AND OBJECTIVES

To establish a set of scientific and practical nursing care quality evaluation indicators for PACU in China.

BACKGROUND

No unified nursing care quality evaluation indicators for post-anaesthesia care unit (PACU) were found in China.

DESIGN

An international literature review, domestic cross-sectional survey and two-round e-Delphi study.

METHODS

The international literature review and domestic cross-sectional survey were conducted to identify the potential nursing care quality evaluation indicators for PACU. A total of 38 and 32 indicators were extracted from 24 articles and the cross-sectional survey respectively. Two rounds of e-Delphi study were conducted to collect opinions from a panel of 20 independent experts and establish the final version of the nursing care quality evaluation indicators for PACU. A GRRAS checklist was used to guide the reporting of this study.

RESULTS

Of 20 experts, 19 completed the first round of e-Delphi study and 18 completed the second round, with a response rate of 95% and 90% respectively. The experts' authority coefficient in the two rounds of e-Delphi study was 0.91 and 0.90 respectively. The Kendall W value of the two rounds ranged between 0.108 and 0.385 (p < .01). Four structure indicators, 12 process indicators and seven outcome indicators were included in the nursing care quality evaluation indicators for PACU.

CONCLUSIONS

With the methods of literature review, cross-sectional survey and e-Delphi study, we established a set of scientific and practical nursing care quality evaluation indicators for PACU, to improve the nursing care quality, reduce incidence of complications and ensure patient safety.

RELEVANT TO CLINICAL PRACTICE

The findings from this study enable nurses and managers in PACU settings to evaluate clinical nursing care quality using a robust framework.

Stakeholder Participation and Cross-Sectoral Cooperation in a Quality Circle on Community-Based Teaching: Results of a Qualitative Interview Study

Introduction

Community-based learning in family medicine practices is an increasingly important part of the medical curriculum internationally. It is widely regarded as one solution to healthcare system needs, such as training and retaining a workforce willing to work in primary care. However, the perspectives of community-based medical educators and representatives from university-based medical education are rarely integrated. To improve teaching quality and promote exchange between those two sectors of medical education, the Institute for General Practice and Interprofessional Care at Tübingen University started a quality circle in family medicine teaching involving stakeholders from both sectors in 2018. The study aims to describe how the participants of this specific QC describe the cross-sectoral cooperation and participation of stakeholders in the quality management of community and university medical education.

Methods

After an observed meeting of the quality circle, semi-structured interviews were conducted with n=12 participants of the quality circle. Interview transcripts were analyzed using grounded theory.

Results

According to the participants, the quality circle provides a dynamic continuity which allows participants to navigate known barriers to transsectoral collaboration in the quality management of community-based medical education. The quality circle is perceived as an instrument for quality improvement that offered continuity and direction. At the same time, it allows for enough freedom and flexibility for the involved stakeholders to creatively work together on quality management and be inspired by their experiences.

Discussion

The quality circle has the potential to facilitate collaboration between the two teaching settings, form a creative community, and give medical students an active role in educational quality management.

Feedback in family medicine clerkships: a qualitative interview study of stakeholders in community-based teaching

Feedback is an important aspect of teaching and learning in medical education. Irrespective of the training environment, too little effective dialogic feedback occurs. Community-based outpatient learning environments, such as general practitioner practices, have heterogeneous framework conditions regarding feedback that decrease feedback quality. To improve feedback in this setting, characteristics of feedback in such learning environments must be considered. This study aims to reveal such characteristics from different perspectives and derive ideas for improving feedback in community-based learning environments. Three stakeholder groups in family medicine clerkships as an example of community-based learning environments (n = 15 students, n = 12 faculty and administrative staff, n = 13 general physician trainers) were interviewed for this study. Transcripts of the interviews were analysed with qualitative content analysis. All stakeholders interviewed note a lack of feedback between groups. Feedback in primary care practices takes place in specific contexts (e.g., during vs after a consultation, during vs at the end of the clerkship) and is provided in different ways (e.g., verbal vs nonverbal). Barriers of effective feedback in community-based settings are: lack of opportunity/initiation, fear of giving feedback, unawareness (of correct feedback and/or lack of prior experience with feedback), and little basis for feedback. Currently, the exchange between the university and community-based learning environments is limited to grading and report writing, with little sharing of meaningful information. The potential of a better exchange between those within community-based learning environments and the university to improve feedback processes is not reached. This exchange and the framework conditions specific for the community-based learning environment should be considered as parts of the structural dimension of feedback. Teachers and course managers of family medicine institutes are in an important position to shape these factors actively, working together with stakeholders of community-based teaching.

Analysis of risk factors for quality management to blepharoplasty based on DEMATEL-ISM

OBJECTIVE

Blepharoplasty is a typical complex structural system, which involves many factors and the interaction among them. Therefore, it is the basis of controlling the occurrence of medical complications in blepharoplasty to clarify the hierarchical relationship of various risk factors and find out the key risk factors.

METHODS

On the basis of identifying the risk factors for quality management of blepharoplasty by means of literature research, questionnaire survey and expert interview, the risk factor model of blepharoplasty quality management were analyzed and constructed. The relationship between the risk factors and the degree of influence on the risk factors was studied using Decision-Making Trialand Evaluation Laboratory and Interpretative Structural Modeling Method, and the hierarchical structure model of the risk factors for blepharoplasty quality management was obtained.

RESULTS

Six levels of risk factors in quality management of blepharoplasty were identified and classified, and the causal attributes among risk factors were determined. Six key risk factors in quality management of double eyelid surgery were determined according to centrality, and finally the above risk factors were divided into three categories: direct cause, excessive cause, and essential cause.

CONCLUSIONS

This study realizes the comprehensive risk factor analysis of the complex system of quality management of blepharoplasty, which can provide reference for plastic surgeons to make safety decisions of blepharoplasty.

Safety and Effectiveness of Endovascular Therapy for the Treatment of Peripheral Artery Disease in Patients with and without Diabetes Mellitus

This study investigated the distribution of risk factors, lesion characteristics and endovascular revascularization (EVR) strategies in patients with peripheral arterial disease (PAD) with vs without diabetes mellitus (DM). Data were collected within the RECcording COurses of vasculaR Diseases (RECCORD) registry. Demographic data, lesion localization (iliac vs femoropopliteal vs below-the-knee (BTK)) and lesion complexity score (LCS) based on number of affected segments, and lesion length (< 10 vs 10-20 vs > 20 cm), EVR strategies and peri-procedural complications were analysed in 786 patients with and 1337 without diabetes mellitus. Patients with diabetes mellitus were older (71.6 ± 9.6 vs 69.4 ± 10.5 years, P < .001) and had higher LCS and more often BTK lesions (P < .05 for all). Lesions were treated less frequently with stents (48.7 vs 59.6%, P < .001) in patients with diabetes mellitus, whereas a non-significant trend was noticed for higher DCB treatment rates (48.3 vs 44.4%, P = .07). Post-interventional ankle-brachial index (ABI) increase was similar (from .77 ± .28 to .92 ± .25 with diabetes mellitus and from .74 ± .21 to .90 ± .20 without diabetes mellitus, P < .001 for both). Peri-/post-procedural complications were low in both groups (4.6%). Patients with diabetes mellitus, who undergo endovascular revascularization are older, have more comorbidities and higher target lesion complexity. However, treatment success rates are similar and complication rates are low.

Self-help friendliness in cancer care: A cross-sectional study among self-help group leaders in Germany

BACKGROUND

Peer support is increasingly recognized as crucial for improving health and psychosocial outcomes in oncological care. The integration of cancer self-help groups (SHGs) into cancer care facilities has gained importance in recent years. Yet, there is a lack of knowledge of the extent and quality of cooperation between cancer care facilities and SHGs and their integration into routine care. The concept of self-help friendliness (SHF) provides a feasible instrument for the measurement of cooperation and integration.

METHODS

A cross-sectional study across Germany investigates the experiences of 266 leaders of cancer SHGs concerning their cooperation with cancer care facilities based on the criteria for SHF. The participatory study was developed and conducted with representatives of the House of Cancer Self-Help and the federal associations of cancer self-help.

RESULTS

According to the SHG leaders, about 80% of their members primarily find their way to an SHG via other patients and only less than 50% more or less frequently via hospitals or rehabilitation clinics. The quality of cooperation with cancer centres, hospitals and rehabilitation clinics, however, is rated as good to very good by more than 70% of the respondents. Nine out of 10 quality criteria for SHF are fully or at least partially implemented, the values vary between 53% and 87%. Overall, 58% of the SHG leaders feel well to be very well integrated into care facilities.

CONCLUSIONS

The results show a positive assessment of the involvement of SHGs in oncological care, but differences between inpatient and outpatient care and low referrals to SHGs are prominent. The concept of SHF is a feasible solution for a systematic and measurable involvement of SHGs.

PATIENT OR PUBLIC CONTRIBUTION

The perspectives and insight of patient representatives obtained through qualitative interviews were directly incorporated into this study. Representatives of cancer self-help organizations were involved in the development of the questionnaire, reviewed it for content and comprehensibility, and further helped to recruit participants.