Developing a questionnaire to evaluate an automated audit & feedback intervention: a Rand-modified Delphi method.

BACKGROUND: Audit and feedback (A&F) is a widely used implementation strategy to evaluate and improve medical practice. The optimal design of an A&F system is uncertain and structured process evaluations are currently lacking. This study aimed to develop and validate a questionnaire to evaluate the use of automated A&F systems. METHODS: Based on the Clinical Performance Feedback Intervention Theory (CP-FIT) and the REFLECT-52 (REassessing audit & Feedback interventions: a tooL for Evaluating Compliance with suggested besT practices) evaluation tool a questionnaire was designed for the purpose of evaluating automated A&F systems. A Rand-modified Delphi method was used to develop the process evaluation and obtain validation. Fourteen experts from different domains in primary care consented to participate and individually scored the questions on a 9-point Likert scale. Afterwards, the questions were discussed in a consensus meeting. After approval, the final questionnaire was compiled. RESULTS: A 34-question questionnaire composed of 57 items was developed and presented to the expert panel. The consensus meeting resulted in a selection of 31 questions, subdivided into 43 items. A final list of 30 questions consisting of 42 items was obtained. CONCLUSION: A questionnaire consisting of 30 questions was drawn up for the assessment and improvement of automated A&F systems, based on CP-FIT and REFLECT-52 theory and approved by experts. Next steps will be piloting and implementation of the questionnaire.

Pericardial Effusion Detection on Post-Mortem Computed Tomography Images Using Convolutional Neural Networks.

Pericardial effusion can be a sign of significant underlying diease and, in some cases, may lead to death. Post-mortem computed tomography (PMCT) is a well-established tool to assist death investigation processes in the forensic setting. In practice, the scarcity of well-trained radiologists is a challenge in processing raw whole-body PMCT images for pericardial effusion detection. In this work, we propose a Pericardial Effusion Automatic Detection (PEAD) framework to automatically process raw whole-body PMCT images to filter out the irrelevant images with heart organ absent and focus on pericardial effusion detection. In PEAD, the standard convolutional neural network architectures of VGG and ResNet are carefully modified to fit the specific characteristics of PMCT images. The experimental results prove the effectiveness of the proposed framework and modified models. The modified VGG and ResNet models achieved superior detection accuracy than the standard architecture with reduced processing speed.

The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise.

BACKGROUND: Delays in the pathway from first symptom to treatment of chronic limb-threatening ischaemia (CLTI) are associated with worse mortality and limb loss outcomes. This study examined the processes used by vascular services to provide urgent care to patients with suspected CLTI referred from the community. METHODS: Vascular surgery units from various regions in England were invited to participate in a process mapping exercise. Clinical and non-clinical staff at participating units were interviewed, and process maps were created that captured key staff and structures used to create processes for referral receipt, triage and assessment at the units. RESULTS: Twelve vascular units participated, and process maps were created after interviews with 45 participants. The units offered multiple points of access for urgent referrals from general practitioners and other community clinicians. Triage processes were varied, with units using different mixes of staff (including medical staff, podiatrists and s) and this led to processes of varying speed. The organisation of clinics to provide slots for 'urgent' patients was also varied, with some adopting hot clinics, while others used dedicated slots in routine clinics. Service organisation could be further complicated by separate processes for patients with and without diabetes, and because of the organisation of services regionally into vascular networks that had arterial and non-arterial centres. CONCLUSIONS: For referred patients with symptoms of CLTI, the points of access, triage and assessment processes used by vascular units are diverse. This reflects the local context and ingenuity of vascular units but can lead to complex processes. It is likely that benefits might be gained from simplification.

Kenya's Experience: Factors Enabling and Impeding the COVID-19 Response.

This case study describes the country-level response to the COVID-19 pandemic in Kenya between February 2020 and May 2021. We organize the presentation of COVID-19 response strategies across the five stages of (a) engagement, (b) assessment, (c) planning, (d) action/implementation, and (e) evaluation. We describe the participatory monitoring and evaluation (M&E) process implemented in collaboration with the WHO Regional Office for Africa Monitoring and Evaluation Team. The M&E system was used to organize and make sense of emerging data regarding specific response activities and changing COVID incidence. We share the results of that collaborative sensemaking, with particular attention to our analysis of the factors that facilitated and those that impeded our pandemic response. We conclude with lessons learned and practical implications from Kenya's experience to help guide future country-level responses to rapidly changing public health crises.

Development and evaluation of the Family Needs Questionnaire for Pediatric Rehabilitation.

PURPOSE: To develop the Family Needs Questionnaire-Pediatric Rehabilitation (FNQ-PR) version and evaluate the reliability and concurrent validity of this self-report measure for caregivers of children with disabilities who receive pediatric rehabilitation services. MATERIALS/METHODS: The 39-item FNQ-PR was developed through a modified Delphi Technique. For test-retest evaluation, parents completed the FNQ-PR twice through an online REDCap survey, 1-3 weeks apart. Concurrent validity data (parent-report Impact on Family Scale [IFS-15] and Measure of Processes of Care [MPOC-20]) were collected at baseline. Reliability analyses included ICCs (95%CI) and internal consistency evaluation. RESULTS: Twenty-five caregivers of children ages 2-18 years (mean age 12.2 years) with a disability completed the FNQ-PR at baseline, and 21 completed the retest. FNQ-PR total score demonstrated excellent test-retest reliability (ICC = 0.84); internal consistency was high. The FNQ-PR total score was strongly negatively associated with IFS-15 total score (r = -0.62) and showed fair to strong association with MPOC subscale scores (0.45 ≤ r ≤ 0.70). Participants did not identify issues with the online format or FNQ-PR item rating. CONCLUSIONS: The FNQ-PR demonstrated excellent overall reliability and strong evidence of validity. It fills a gap in clinical care of families of children with disabilities, providing a systematic way for families to identify the extent to which their needs are perceived to have been met. Clinicians can use this tool to target unmet needs that are most important to families. FNQ-PR use in future research will support exploration of the impact of specific child and family factors on family needs.

Systematic review: What is the impact of triage implementation on clinical outcomes and process measures in low- and middle-income country emergency departments?

INTRODUCTION: Triage is widely regarded as an essential function of emergency care (EC) systems, especially in resource-limited settings. Through a systematic search and review of the literature, we investigated the effect of triage implementation on clinical outcomes and process measures in low- and middle-income country (LMIC) emergency departments (EDs). METHODS: Structured searches were conducted using MEDLINE, CENTRAL, EMBASE, CINAHL, and Global Health. Eligible articles identified through screening and full-text review underwent risk-of-bias assessment using the Newcastle-Ottawa Scale. The quality of evidence for each effect measure was summarized using GRADE. RESULTS: Among 10,394 articles identified through the search strategy, 58 underwent full-text review and 16 were included in the final synthesis. All utilized pre-/postintervention methods and a majority were single center. Effect measures included mortality, waiting time, length of stay, admission rate, and patient satisfaction. Of these, ED mortality and time to clinician assessment were evaluated most frequently. The majority of studies using these outcomes identified a positive effect, namely a reduction in deaths and waiting time among patients presenting for EC. The quality of the evidence was moderate for these measures but low or very low for all other outcomes and process indicators. CONCLUSIONS: There is moderate quality of evidence supporting an association between the introduction of triage and a reduction in deaths and waiting time. Although the available data support the value of triage in LMIC EDs, the risk of confounding and publication bias is significant. Future studies will benefit from more rigorous research methods.

Improving personalised care, through the development of a service evaluation tool to assess, understand and monitor delivery.

Systematically implementing personalised care has far reaching benefits to individuals, communities and health and social care systems. If done well, personalised care can result in better health outcomes and experiences, more efficient use of health services and reduced health inequalities. Despite these known benefits, implementation of personalised care has been slow. Evaluation is an important step towards achieving the ambition of universally delivered personalised care. There are currently few comprehensive assessments or tools that are designed to understand the implementation of personalised care at a service or system level, or the cultural, practical and behavioural factors influencing this. The aim of this paper is to describe the development and testing of a system-wide evaluation tool. The tool offers a process through which healthcare systems can better understand the current delivery of personalised care and the factors influencing this. With a focus on implementation, the development of the tool was informed by the Consolidated Framework for Implementation Research, and its content is structured using behaviour change theory (COM-B Theory of Behaviour Change Model). The tool consists of four mirrored surveys, which were developed using an iterative exploratory design. This included a series of testing cycles, in which its structure and content were continually refined. To date, it has been used by 24 clinical services, involving 397 service users, 313 front-line practitioners, 73 service managers and 40 commissioners. These services have used the evaluation process to initiate quality improvement, targeted at one of the more aspects of personalised care. The use of the COM-B model increases the likelihood of those improvements being sustained, through identification of the core factors that enable or limit personalised care behaviours among healthcare staff. We have shown this process to be applicable in a wide range of settings, thus it potentially has broad applicability as a tool for cultural change and quality improvement. The next stage of this work will focus on implementation and evaluation, to fully understand if and how the tool can be used to drive improvements in personalised care delivery.

How much convergence exists between registered process measures and patient reported experience measures? A study on Catalan primary healthcare.

The use of quality measures is important for transparency and the continuous improvement of performance. However, we do not know enough about the relationship between registered process measures and patient reported experience measures (PREMs) in primary healthcare. Recent studies point to areas of convergence that run contrary anticipated trends. This is a relevant question for healthcare management and governments as their position is stronger when system's guidelines and targets also matter to patients or, vice versa, when patient-centered measures are used to develop new process measures. Our aim is to study both type of measures, their logic and their level of convergence. We also assess the relationship between PREMs, patients' demographic characteristics and area socioeconomic level. We estimated pairwise correlations with patient experience aggregated at the health-center level and a series of multilevel regression models to assess the adjusted effect of four registered process measures on ratings of patient experience at the patient level. We use patient experience as measured by survey data, two composite quality indices and two single indicators regularly computed by the Catalan Health Service. Continuity of care with the same doctor and accessibility are positively associated with patient experience. No relationship was observed in the index created to measure quality of assistance. The index measuring the quality of prescriptions was positively associated with patient experience but only when analyzed separately. We conclude that registered process measures and PREMs are not entirely independent, hence improvements of the management side have the potential to impact patient experience.

Assessment of the Psychosocial Care Center multidisciplinary team from users' and family members' perspective.

OBJECTIVES: to assess the multidisciplinary team of a Psychosocial Care Center I from users' and family members' perspective. METHODS: an evaluative study, anchored in the fourth generation evaluation theoretical-methodological framework, carried out in a Psychosocial Care Center I, from September 2021 to March 2022. Eleven users and 06 family members participated. Data were collected through non-participant observation, individual interviews and negotiation sessions, and analyzed using the Constant Comparative Method, using the MAXQDA software. RESULTS: the team develops its care based on individual and collective care, with integrated and complementary work by professionals. They seek to facilitate treatment initiation and continuation, considering health needs and offering support, understanding and guidance to users and their families. FINAL CONSIDERATIONS: the multidisciplinary team's work is based on the psychosocial paradigm, which can qualify care and strengthen the service role in the mental health network.

An "Engage to Sustain" Intervention to Improve Process Performance Measures in Ambulatory Care.

In ambulatory care, monitoring process performance measures (PPMs) is essential to meet regulatory requirements, establish targets for care, seek reimbursement, and evaluate patient care responsibilities. We implemented a comprehensive program, "Engage to Sustain," for licensed practical nurses (LPNs) and certified medical assistants (CMAs) to practice at the top of their licensure/certification. Screening rates for 4 key PPMs (depression screening, fall risk screening, and tobacco use screening and counseling) markedly increased following this intervention across 18 ambulatory departments with more than 2 million patient visits. These results suggest that shifting responsibilities for patient screening from physicians and advanced practitioners to LPNs and CMAs may improve screening rates.

Measure of Processes of Care (MPOC-56 and 20): Turkish adaptation, reliability, and validity study.

BACKGROUND: The purpose of this study was to investigate the validity and reliability of the Turkish versions of the Measure of Processes of Care, MPOC-56 and MPOC-20, in children with disability aged 5-17 years. METHODS: A total of 290 parents of children with disability due to various disorders were evaluated with the MPOC-56 and MPOC-20. Internal consistency was determined with Cronbach`s alpha, and test-retest reliability with the intraclass correlation coefficient (ICC). Confirmatory factor analysis was performed to investigate the factor structure of the Turkish MPOC-56 and -20. RESULTS: Cronbach`s alpha values for the MPOC-56 and MPOC-20 ranged between 0.84-0.97 and 0.87-0.92, respectively. Test-retest ICC values were 0.96-0.99 for MPOC-56 and 0.94-0.98 for MPOC-20. The correlations of the subscale scores of MPOC- 56 and MPOC-20 were shown to be at very good to excellent levels for reliability. Factor structure for MPOC-20 and MPOC-56 were found to be acceptable. CONCLUSIONS: This study has shown that the Turkish versions of MPOC-56 and MPOC-20 are valid, reliable, and applicable for the evaluation of parents` experiences of processes of care for children with disability aged 5-17 years.

A deep memory bare-bones particle swarm optimization algorithm for single-objective optimization problems.

A deep memory bare-bones particle swarm optimization algorithm (DMBBPSO) for single-objective optimization problems is proposed in this paper. The DMBBPSO is able to perform high-precision local search while maintaining a large global search, thus providing a reliable solution to high-dimensional complex optimization problems. Normally, maintaining high accuracy while conducting global searches is an important challenge for single-objective optimizers. Traditional particle swarms optimizers can rapidly lose the diversity during iterations and are unable to perform global searches efficiently, and thus are more likely to be trapped by local optima. To address this problem, the DMBBPSO combines multiple memory storage mechanism (MMSM) and a layer-by-layer activation strategy (LAS). The MMSM catalyzes a set of deep memories to increase the diversity of the particle swarm. For every single particle, both of the personal best position and deep memories will be used in the evaluation process. The LAS enables the particle swarm to avoid premature convergence while enhancing local search capabilities. The collaboration between MMSM and LAS enhances the diversity of the particle swarm, which in turn enhances the robustness of the DMBBPSO. To investigate the optimization ability of the DMBBPSO for single-objective optimization problems, The CEC2017 benchmark functions are used in experiments. Five state-of-the-art evolutionary algorithms are used in the control group. Finally, experimental results demonstrate that the DMBBPSO can provide high precision results for single-objective optimization problems.

Relationships Between EHR-Based Audit Log Data and Physician Burnout and Clinical Practice Process Measures.

OBJECTIVE: To explore the relationship of electronic health record (EHR)-based audit log data with physician burnout and clinical practice process measures. METHODS: From September 4 to October 7, 2019, we surveyed physicians in a larger academic medical department and matched responses to August 1 through October 31, 2019, EHR-based audit log data. Multivariable regression analysis evaluated the relationship between log data and burnout and the interrelationship between log data and turnaround time for In Basket messages and percentage of encounters closed within 24 hours. RESULTS: Of the 537 physicians surveyed, 413 (77%) responded. On multivariable analysis, number of In Basket messages received per day (each additional message: odds ratio, 1.04 [95% CI, 1.02 to 1.07]; P<.001) and time spent in the EHR outside scheduled patient care (each additional hour: odds ratio, 1.01 [95% CI, 1.00 to 1.02]; P=.04) were associated with burnout. Time spent doing In Basket work (each additional minute: parameter estimate, -0.11 [95% CI, -0.19 to -0.03]; P=.01) and in the EHR outside scheduled patient care (each additional hour: parameter estimate, 0.04 [95% CI, 0.01 to 0.06]; P=.002) were associated with turnaround time (days per message) for In Basket messages. None of the variables explored were independently associated with percentage of encounters closed within 24 hours. CONCLUSION: Electronic health record-based audit log data of workload relate to odds of burnout and responsiveness to patient-related inquiries and results. Further study is needed to determine whether interventions that reduce the number of and time spent doing In Basket messages or time spent in the EHR outside scheduled patient care reduce physician burnout and improve clinical practice process measures.

Design and Implementation of a Chain-Type Direct Push Drilling Rig for Contaminated Sites.

For sites where volatile organic compounds are present, the direct push method, in combination with other sensors for investigation, is a powerful method. The investigation process is an integrated drilling and sensing process, but the trajectory of the probe carrying the sensor is ambiguous. This paper explores and introduces the application of a chain-type direct push drilling rig by designing and building a chain-type direct push miniature drilling rig. This rig allows for indoor experimental studies of direct push trajectories. The chain-type direct push drilling model is proposed based on the mechanism of chain transmission. The drilling rig provides a steady direct thrust through the chain, which is driven by a hydraulic motor. In addition, the drilling tests and results described prove that the chain could be applied to direct push drilling. The chain-type direct push drilling rig can drill to a depth of 1940 mm in single-pass and up to 20,000 mm in multiple passes. The test results also indicate that it drills a total length of 462.461 mm and stops after 87.545 s of operation. The machine can provide a drilling angle of 0-90° and keep the borehole angle fluctuating within 0.6° with the characteristics of strong adjustability, flexibility, continuity, stability, and low disturbance, which is of great value and significance for studying the drilling trajectory of direct push tools and obtaining more accurate investigation data.

Truth of Colorectal Enhanced Recovery Programs: Process Measure Compliance in 151 Hospitals.

BACKGROUND: Commonly cited studies have reported substantial improvements (defined as >20%) in process measure compliance after implementation of colorectal enhanced recovery programs (ERPs). However, hospitals have anecdotally reported difficulties in achieving similar improvement gains. This study evaluates improvement uniformity among 151 hospitals exposed to an 18-month implementation protocol for 6 colorectal ERP process measures (oral antibiotics, mechanical bowel preparation, multimodal pain control, early mobilization, early liquid intake, and early solid intake). STUDY DESIGN: One hundred fifty-one hospitals implemented a colorectal ERP with pathway, educational and supporting materials, and data capture protocols; 906 opportunities existed for process compliance improvement across the cohort (151 hospitals × 6 process measures). However, 240 opportunities were excluded due to high starting compliance rates (ie compliance >80%) and 3 opportunities were excluded because compliance rates were recorded for fewer than 2 cases. Thus, 663 opportunities for improvement across 151 hospitals were studied. RESULTS: Of 663 opportunities, minimal improvement (0% to 20% increase in compliance) occurred in 52% of opportunities, substantial improvement (>20% increase in compliance) in 20%, and worsening compliance occurred in 28%. Of the 6 processes, multimodal pain control and use of oral antibiotics improved the most. CONCLUSIONS: Contrary to published ERP literature, the majority of study hospitals had difficulty improving process compliance with 80% of the opportunities not achieving substantial improvement. This discordance between ERP implementation success rates reported in the literature and what is observed in a large sample could reflect differences in hospitals' culture or characteristics, or a publication bias. Attention needs to be directed toward improving ERP adoption across the spectrum of hospital types.

The Value of Clock Drawing Process Assessment in Screening for Mild Cognitive Impairment and Alzheimer's Dementia.

Many clock drawing test (CDT) scoring systems focus on drawing results and lack drawing process assessments. This study created a CDT scoring procedure with drawing process assessment and explored its diagnostic value in screening for mild cognitive impairment (MCI) and early Alzheimer's disease (AD) from normal control (NC). We used logistic regression and receiver operating characteristic (ROC) curves to determine a new, sensitive scoring system for AD and MCI patients in a derivation cohort. The new scoring method was then compared to two common scoring systems and externally validated in a second cohort. We developed a new scoring system named CDT5, which contained one process assessment item: remember setting time without asking. Compared with two published scoring systems, CDT5 had better discriminatory power in distinguishing AD patients from NCs in derivation (area under the ROC curve [area under the curve, AUC] = .890) and validation (AUC = .867) cohorts. Three scoring systems had poor diagnostic accuracy at discriminating MCI patients from controls, with CDT5 being the most sensitive (78.57%). Adding the drawing process in CDT helps accurately detect patients with early AD, but its role in identifying patients with MCI needs to be further explored.

A Review of Quality Improvement Process Measures for Colorectal Surgery in the United States Using the American College of Surgeons National Surgical Quality Improvement Program Database - Have We Made Progress?

Numerous guidelines have been published regarding Enhanced Recovery Programs (ERP) following colorectal surgery over the past decade. Participation in these guidelines at a national level is unclear. We hypothesize that the adaptation of ERP for patients undergoing elective colorectal surgery is limited but the use of quality improvement measures has increased and while outcomes have improved over the past several years. A total of 86 402 patients were evaluated undergoing elective colectomy between 2013-2018 using the ACS-NSQIP database. Over a 5-year period, there was a significant increase in the use of quality improvement process measures: mechanical and oral bowel preparation and minimally invasive approach. During this time, there was a significant decrease in overall perioperative morbidities (P <.001). These encouraging results from a large national database suggest that evidence-based, quality improvement guidelines are being embraced and that overall outcomes for patients undergoing elective colectomy are improving.

Contexts of Concealment: Initial Validation of Three Disclosure Avoidance Process Measures.

The choice to withhold subjective distress reflects a multifactorial decision highly sensitive to context. Unfortunately, existing measures are built on unidimensional models (i.e., concealment-disclosure as a single, bipolar dimension) and operationalize the construct as a stable trait. In this article, we outline the development and initial validation of a self-report inventory that accounts for problem-context and assesses multiple processes central to both the concealment and disclosure of emotional distress. Exploratory analysis of pilot items in Study 1 (male student sample; N = 373) guided subsequent item development and revisions to our conceptual model. In Study 2 (mixed-gender community sample; N = 297), we refined the item-pool based on additional tests of latent scale structure and associations with concurrent criteria. In a final validation sample (Study 3; international community participants; N = 978), confirmatory factor analyses corroborated our hypothesized three-factor model (Privacy Management, Disclosure Desire, and Social Fear) and supported measurement invariance by sex. The three Contexts of Concealment Scales (CCS) were internally consistent and associated in expected directions with external indices of concurrent concealment, disclosure, depression, anxiety, loneliness, experiential avoidance, and self-stigma.

Creating a Rapid Assessment Zone with Limited Emergency Department Capacity Decreases Patients Leaving Without Being Seen: A Quality Improvement Initiative.

INTRODUCTION: Patients leaving the emergency department before treatment (left without being seen) result in increased risks to patients and loss of revenue to the hospital system. Rapid assessment zones, where patients can be quickly evaluated and treated, have the potential to improve ED throughput and decrease the rates of patients leaving without being seen. We sought to evaluate the impact of a rapid assessment zone on the rate of patients leaving without being seen. METHODS: A pre- and post-quality improvement process was performed to examine the impact of implementing a rapid assessment zone process at an urban community hospital emergency department. Through a structured, multidisciplinary approach using the Plan, Do, Check, Act Deming Cycle of process improvement, the triage area was redesigned to include 8 rapid assessment rooms and shifted additional ED staff, including nurses and providers, into this space. Rates of patients who left without being seen, median arrival to provider times, and discharge length of stay between the pre- and postintervention periods were compared using parametric and nonparametric tests when appropriate. RESULTS: Implementation of the rapid assessment zone occurred February 1, 2021, with 42,115 ED visits eligible for analysis; 20,731 visits before implementation and 21,384 visits after implementation. All metrics improved from the 6 months before intervention to the 6 month after intervention: rate of patients who left without being seen (5.64% vs 2.55%; c2 = 258.13; P < .01), median arrival to provider time in minutes (28 vs 11; P < .01), and median discharge length of stay in minutes (205 vs 163; P < .01). DISCUSSION: Through collaboration and an interdisciplinary team approach, leaders and staff developed and implemented a rapid assessment zone that reduced multiple throughput metrics.

What do we want to get out of this? a critical interpretive synthesis of the value of process evaluations, with a practical planning framework.

BACKGROUND: Process evaluations aim to understand how complex interventions bring about outcomes by examining intervention mechanisms, implementation, and context. While much attention has been paid to the methodology of process evaluations in health research, the value of process evaluations has received less critical attention. We aimed to unpack how value is conceptualised in process evaluations by identifying and critically analysing 1) how process evaluations may create value and 2) what kind of value they may create. METHODS: We systematically searched for and identified published literature on process evaluation, including guidance, opinion pieces, primary research, reviews, and discussion of methodological and practical issues. We conducted a critical interpretive synthesis and developed a practical planning framework. RESULTS: We identified and included 147 literature items. From these we determined three ways in which process evaluations may create value or negative consequences: 1) through the socio-technical processes of 'doing' the process evaluation, 2) through the features/qualities of process evaluation knowledge, and 3) through using process evaluation knowledge. We identified 15 value themes. We also found that value varies according to the characteristics of individual process evaluations, and is subjective and context dependent. CONCLUSION: The concept of value in process evaluations is complex and multi-faceted. Stakeholders in different contexts may have very different expectations of process evaluations and the value that can and should be obtained from them. We propose a planning framework to support an open and transparent process to plan and create value from process evaluations and negotiate trade-offs. This will support the development of joint solutions and, ultimately, generate more value from process evaluations to all.