scholarly journals Easier and Faster Is Not Always Better: Grounded Theory of the Impact of Large-Scale System Transformation on the Clinical Work of Emergency Medicine Nurses and Physicians

10.2196/11013 ◽  
2018 ◽  
Vol 5 (4) ◽  
pp. e11013 ◽  
Author(s):  
Elaine Zibrowski ◽  
Lisa Shepherd ◽  
Kamran Sedig ◽  
Richard Booth ◽  
Candace Gibson
Keyword(s):  
Emergency Medicine ◽  
Grounded Theory ◽  
Large Scale ◽  
Clinical Work ◽  
System Transformation ◽  
Large Scale System ◽  
Nurses And Physicians ◽  
The Impact

scholarly journals Easier and Faster Is Not Always Better: Grounded Theory of the Impact of Large-Scale System Transformation on the Clinical Work of Emergency Medicine Nurses and Physicians (Preprint)

2018 ◽  
Author(s):  
Elaine Zibrowski ◽  
Lisa Shepherd ◽  
Kamran Sedig ◽  
Richard Booth ◽  
Candace Gibson
Keyword(s):  
Health Care ◽  
Emergency Medicine ◽  
Grounded Theory ◽  
Health Care Professionals ◽  
Large Scale ◽  
Clinical Work ◽  
Well Being ◽  
Clinical Workflow ◽  
Nurses And Physicians ◽  
The Impact

BACKGROUND The effectiveness of Lean Thinking as a quality improvement method for health care has been contested due, in part, to our limited contextual understanding of how it affects the working conditions and clinical workflow of nurses and physicians. Although there are some initial indications, arising from prevalence surveys and interviews, that Lean may intensify work performed within medical environments, the evidence base still requires detailed descriptions of the changes that were actually introduced to individuals’ clinical workflow and how these changes impacted health care professionals. OBJECTIVE The aim of this study was to explore ways in which a Lean intervention may impact the clinical work of emergency medicine nurses and physicians. METHODS We used a realist grounded theory approach to explore the clinical work of nurses and physicians practicing in 2 emergency medicine departments from a single teaching hospital in Canada. The hospital has 1000 beds with 128,000 emergency department (ED) visits annually. In 2013, both sites began a large-scale, Lean-driven system transformation of their practice environments. In-person interviews were iteratively conducted with health care professionals from July to December 2017. Information from transcripts was coded into categories and compared with existing codes. With repeated review of transcripts and evolving coding, we organized categories into themes. Data collection continued to theoretical sufficiency. RESULTS A total of 15 emergency medicine nurses and 5 physicians were interviewed. Of these, 18 individuals had practiced for at least 10 years. Our grounded theory involved 3 themes: (1) organization of our clinical work, (2) pushed pace in the front cell, and (3) the toll this all takes on us. Although the intervention was supposed to make the EDs work easier, faster, and better, the participants in our study indicated that the changes made had the opposite impact. Nurses and physicians described ways in which the reconfigured EDs disrupted their established practice routines and resulted in the intensification of their work. Participants also identified indications of deskilling of nurses’ work and how the new push-forward model of patient care had detrimental impacts on their physical, cognitive, and emotional well-being. CONCLUSIONS To our knowledge, this is the first study to describe the impact of Lean health care on the working conditions and actual work of emergency medicine nurses and physicians. We theorize that rather than support health care professionals in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to further complicate their working environment. We have illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of health care professionals. We identify some areas for reconsideration by the departments and put forward ideas for future research.

scholarly journals The use tensor method of dual networks for analysis of the transport and tourist components of sustainable development of territories

2020 ◽  
Vol 208 ◽  
pp. 05012
Author(s):  
Aleksandra Volosova ◽  
Ekaterina Matiukhina ◽  
Dmitry Akimov
Keyword(s):  
Sustainable Development ◽  
Transport System ◽  
Large Scale ◽  
The Sustainable Development ◽  
Tensor Method ◽  
Large Scale System ◽  
Intelligence System ◽  
The Impact ◽  
Double Networks

The article explores the possibility of applying tensor method of dual networks for analysis of transport and tourism components in sustainable development of territories. The tensor method of dual networks, in contrast to other methods allows to consider the structure of the large-scale intelligence system and the processes occurring in it as one whole. Thus, we have the possible to complex analyze all the components of a large-scale system even when its structure, the number of its elements and the connections between them will be changed. Tensor equations make it possible to accurately calculate the parameters of a system when simulating various ways of connecting its elements. On the example of the analysis of the tourist transport system, the advantages of using the method of double networks to assess the impact of the system on the sustainable development of the territory are shown.

scholarly journals A Qualitative Study of the Theory Behind the Chairs: Balancing Lean-Accelerated Patient Flow With the Need for Privacy and Confidentiality in an Emergency Medicine Setting (Preprint)

2018 ◽  
Author(s):  
Elaine Zibrowski ◽  
Lisa Shepherd ◽  
Richard Booth ◽  
Kamran Sedig ◽  
Candace Gibson
Keyword(s):  
Emergency Medicine ◽  
Qualitative Study ◽  
Health Care Professionals ◽  
Family Members ◽  
Value Added ◽  
Clinical Work ◽  
Patient Privacy ◽  
Privacy And Confidentiality ◽  
The Impact ◽  
The Chairs

BACKGROUND Many emergency departments (EDs) have used the Lean methodology to guide the restructuring of their practice environments and patient care processes. Despite research cautioning that the layout and design of treatment areas can increase patients’ vulnerability to privacy breaches, evaluations of Lean interventions have ignored the potential impact of these on patients’ informational and physical privacy. If professional regulatory organizations are going to require that nurses and physicians interact with their patients privately and confidentially, we need to examine the degrees to which their practice environment supports them to do so. OBJECTIVE This study explored how a Lean intervention impacted the ability of emergency medicine physicians and nurses to optimize conditions of privacy and confidentiality for patients under their care. METHODS From July to December 2017, semistructured interviews were iteratively conducted with health care professionals practicing emergency medicine at a single teaching hospital in Ontario, Canada. The hospital has 1000 beds, and approximately 128,000 patients visit its 2 EDs annually. In response to poor wait times, in 2013, the hospital’s 2 EDs underwent a Lean redesign. As the interviews proceeded, information from their transcripts was first coded into topics and then organized into themes. Data collection continued to theoretical sufficiency. RESULTS Overall, 15 nurses and 5 physicians were interviewed. A major component of the Lean intervention was the construction of a three-zone front cell at both sites. Each zone was outfitted with a set of chairs in an open concept configuration. Although, in theory, professionals perceived value in having the chairs, in practice, these served multiple, and often, competing uses by patients, family members, and visitors. In an attempt to work around limitations they encountered and keep patients flowing, professionals often needed to move a patient out from a front chair and actively search for another location that better protected individuals’ informational and physical privacy. CONCLUSIONS To our knowledge, this is the first qualitative study of the impact of a Lean intervention on patient privacy and confidentiality. The physical configuration of the front cell often intensified the clinical work of professionals because they needed to actively search for spaces better affording privacy and confidentiality for patient encounters. These searches likely increased clinical time and added to these patients’ length of stay. We advocate that the physical structure and configuration of the front cell should be re-examined under the lens of Lean’s principle of value-added activities. Future exploration of the perspectives of patients, family members, and visitors regarding the relative importance of privacy and confidentiality during emergency care is warranted.

scholarly journals Hydrothermal Unit-Commitment Problem of a Large-Scale System with Representation of Forbidden Zones

Energies ◽  
2021 ◽  
Vol 15 (1) ◽  
pp. 39
Author(s):  
Bruno Colonetti ◽  
Erlon Finardi ◽  
Lucas Borges Picarelli
Keyword(s):  
Power Systems ◽  
Large Scale ◽  
Unit Commitment ◽  
Electrical Networks ◽  
Unit Commitment Problem ◽  
Large Scale System ◽  
Marginal Costs ◽  
Commitment Problem ◽  
Electrical Components ◽  
The Impact

As we move towards electrical networks with a growing presence of renewable generation, the representation of the electrical components becomes more important. In hydro-dominated power systems, modelling the forbidden zones of hydro plants becomes increasingly challenging as the number of plants increases. Such zones are ranges of generation that either should be avoided or are altogether unreachable. However, because representing the forbidden zones introduces a substantial computational burden, hydrothermal unit-commitment problems (HTUC) for large systems are usually formulated ignoring the forbidden zones. Nonetheless, this simplification may demand adjustments to the solution of the HTUC, because the generation of the hydro stations may fall in forbidden zones. In practice, the adjustments are usually performed based on the experience of system operators and, then, can be far from an optimal correction. In this paper, we study the impact of explicitly representing the hydro-generation forbidden zones in a large-scale system with more than 7000 buses, 10,000 lines, and 700 hydro units. Our findings show that the simplified model that is current used can deviate significantly from the model with forbidden zones, both in terms of the generation of hydro plants, as well as the generation of thermal plants and the system marginal costs.

Impact of COVID-19 on Nuclear Medicine in Germany, Austria and Switzerland: An International Survey in April 2020

2020 ◽  
Vol 59 (04) ◽  
pp. 294-299 ◽  
Author(s):  
Lutz S. Freudenberg ◽  
Ulf Dittmer ◽  
Ken Herrmann
Keyword(s):  
Nuclear Medicine ◽  
Health Systems ◽  
Personal Protective Equipment ◽  
Large Scale ◽  
Diagnostic Procedures ◽  
Protective Equipment ◽  
Current Crisis ◽  
Web Based ◽  
Public Versus Private ◽  
The Impact

Abstract Introduction Preparations of health systems to accommodate large number of severely ill COVID-19 patients in March/April 2020 has a significant impact on nuclear medicine departments. Materials and Methods A web-based questionnaire was designed to differentiate the impact of the pandemic on inpatient and outpatient nuclear medicine operations and on public versus private health systems, respectively. Questions were addressing the following issues: impact on nuclear medicine diagnostics and therapy, use of recommendations, personal protective equipment, and organizational adaptations. The survey was available for 6 days and closed on April 20, 2020. Results 113 complete responses were recorded. Nearly all participants (97 %) report a decline of nuclear medicine diagnostic procedures. The mean reduction in the last three weeks for PET/CT, scintigraphies of bone, myocardium, lung thyroid, sentinel lymph-node are –14.4 %, –47.2 %, –47.5 %, –40.7 %, –58.4 %, and –25.2 % respectively. Furthermore, 76 % of the participants report a reduction in therapies especially for benign thyroid disease (-41.8 %) and radiosynoviorthesis (–53.8 %) while tumor therapies remained mainly stable. 48 % of the participants report a shortage of personal protective equipment. Conclusions Nuclear medicine services are notably reduced 3 weeks after the SARS-CoV-2 pandemic reached Germany, Austria and Switzerland on a large scale. We must be aware that the current crisis will also have a significant economic impact on the healthcare system. As the survey cannot adapt to daily dynamic changes in priorities, it serves as a first snapshot requiring follow-up studies and comparisons with other countries and regions.

HOME VISITS DURING THE FIRST MONTH OF DELIVERY FOR RECENTLY DELIVERED WOMEN IN UTTAR PRADESH, INDIA

2020 ◽  
Vol 6 (5) ◽  
pp. 1183-1189
Author(s):  
Dr. Tridibesh Tripathy ◽  
Dr. Umakant Prusty ◽  
Dr. Chintamani Nayak ◽  
Dr. Rakesh Dwivedi ◽  
Dr. Mohini Gautam
Keyword(s):  
Large Scale ◽  
National Level ◽  
Uttar Pradesh ◽  
Life Time ◽  
Structured Interview ◽  
The Other ◽  
Registration System ◽  
Action Group ◽  
Current Article ◽  
The Impact

The current article of Uttar Pradesh (UP) is about the ASHAs who are the daughters-in-law of a family that resides in the same community that they serve as the grassroots health worker since 2005 when the NRHM was introduced in the Empowered Action Group (EAG) states. UP is one such Empowered Action Group (EAG) state. The current study explores the actual responses of Recently Delivered Women (RDW) on their visits during the first month of their recent delivery. From the catchment area of each of the 250 ASHAs, two RDWs were selected who had a child in the age group of 3 to 6 months during the survey. The response profiles of the RDWs on the post- delivery first month visits are dwelled upon to evolve a picture representing the entire state of UP. The relevance of the study assumes significance as detailed data on the modalities of postnatal visits are available but not exclusively for the first month period of their recent delivery. The details of the post-delivery first month period related visits are not available even in large scale surveys like National Family Health Survey 4 done in 2015-16. The current study gives an insight in to these visits with a five-point approach i.e. type of personnel doing the visit, frequency of the visits, visits done in a particular week from among those four weeks separately for the three visits separately. The current study is basically regarding the summary of this Penta approach for the post- delivery one-month period.     The first month period after each delivery deals with 70% of the time of the postnatal period & the entire neonatal period. Therefore, it does impact the Maternal Mortality Rate & Ratio (MMR) & the Neonatal Mortality Rates (NMR) in India and especially in UP through the unsafe Maternal & Neonatal practices in the first month period after delivery. The current MM Rate of UP is 20.1 & MM Ratio is 216 whereas the MM ratio is 122 in India (SRS, 2019). The Sample Registration System (SRS) report also mentions that the Life Time Risk (LTR) of a woman in pregnancy is 0.7% which is the highest in the nation (SRS, 2019). This means it is very risky to give birth in UP in comparison to other regions in the country (SRS, 2019). This risk is at the peak in the first month period after each delivery. Similarly, the current NMR in India is 23 per 1000 livebirths (UNIGME,2018). As NMR data is not available separately for states, the national level data also hold good for the states and that’s how for the state of UP as well. These mortalities are the impact indicators and such indicators can be reduced through long drawn processes that includes effective and timely visits to RDWs especially in the first month period after delivery. This would help in making their post-natal & neonatal stage safe. This is the area of post-delivery first month visit profile detailing that the current article helps in popping out in relation to the recent delivery of the respondents.   A total of four districts of Uttar Pradesh were selected purposively for the study and the data collection was conducted in the villages of the respective districts with the help of a pre-tested structured interview schedule with both close-ended and open-ended questions.  The current article deals with five close ended questions with options, two for the type of personnel & frequency while the other three are for each of the three visits in the first month after the recent delivery of respondents. In addition, in-depth interviews were also conducted amongst the RDWs and a total 500 respondents had participated in the study.   Among the districts related to this article, the results showed that ASHA was the type of personnel who did the majority of visits in all the four districts. On the other hand, 25-40% of RDWs in all the 4 districts replied that they did not receive any visit within the first month of their recent delivery. Regarding frequency, most of the RDWs in all the 4 districts received 1-2 times visits by ASHAs.   Regarding the first visit, it was found that the ASHAs of Barabanki and Gonda visited less percentage of RDWs in the first week after delivery. Similarly, the second visit revealed that about 1.2% RDWs in Banda district could not recall about the visit. Further on the second visit, the RDWs responded that most of them in 3 districts except Gonda district did receive the second postnatal visit in 7-15 days after their recent delivery. Less than half of RDWs in Barabanki district & just more than half of RDWs in Gonda district received the third visit in 15-21 days period after delivery. For the same period, the majority of RDWs in the rest two districts responded that they had been entertained through a home visit.

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