Preservation of phenolic compounds on dried leaf infusion of Bauhinia forficata Link

Abstract Bauhinia forficata Link aqueous extract is usually recommended as a phytomedicine to reduce blood glucose levels and its biological activity has been linked to the presence of phenolic compounds from B. forficata preparations. Several drying processes are used in the production of dry herbal extracts, which may influence the chemical composition and efficacy of final herbal medicines. Due to significant chemical changes, defining appropriate drying processes is essential for phytopharmaceutical drug development. In view of this, we analyzed dried B. forficata leaf infusion (BFLI) extracts by HPLC-UV-MSn, followed by molecular networking analysis to evaluate the chemical profiles from dried extracts yielded by freeze-and spray-drying processes. The main metabolites detected included 11 ferulic/isoferulic acid derivatives and 13 glycosylated flavonoids. The qualitative chemical profiles were alike for both drying processes, whereas the relative abundance of some flavonoids was higher using spray-drying. Taken together, our results showed that freeze-and spray-drying preserved the phenolic profile of BFLI and suggested that spray-drying may be the most suitable to obtain its dried products. Along with studying the chemical profiles of dried herbal extracts, evaluating the influence of drying processes on the quality and chemical profiles of final products is pivotal and may benefit future research.

Six sigma approach for neonatal jaundice patients in an Indian rural hospital - a case study.

PURPOSE: The purpose of this paper is to implement Six Sigma approach to decrease the length of stay (LOS) of neonatal jaundice patients in an Indian government rural hospital situated in northern hill region. DESIGN/METHODOLOGY/APPROACH: Six Sigma's Define-Measure-Analyse-Improve-Control procedure is applied in order to decrease the LOS of neonatal jaundice patients. The mean and standard deviation have been computed as 34.53 and 20.01 h, respectively. The cause and effect diagram is used in the "Analyse" phase of the Six Sigma. The regression analysis and GEMBA observation techniques are used to validate the causes identified through cause and effect diagram. FINDINGS: The waiting time for registration, waiting time for tests, waiting time for phototherapy and time for discharge implementation are the main factors that are responsible for longer LOS. Based on the identified root causes, some recommendations are suggested to the hospital administration and staff members in order to reduce the LOS. RESEARCH LIMITATIONS/IMPLICATIONS: The present research is limited to provide recommendations to the hospital administration to reduce LOS and it entirely depends upon the implementation of the administration. However, target of administration is to reduce the LOS up to 24 h. PRACTICAL IMPLICATIONS: Six Sigma model will reduce bottlenecks in LOS and enhance service quality of hospital. The developed regression model will help the doctors and staff members to assess and control the LOS by controlling and minimising the independent variables. SOCIAL IMPLICATIONS: The project will directly provide benefits to society, as LOS will decrease and patients' satisfaction will automatically increase. ORIGINALITY/VALUE: Six Sigma is a developed methodology, but its application in paediatric department is very limited. This is the first ever study of applying Six Sigma for neonatal jaundice patients in India.

Waste in health information systems: a systematic review.

Purpose The purpose of this paper is to discuss a systematic review on waste identification related to health information systems (HIS) in Lean transformation. Design/methodology/approach A systematic review was conducted on 19 studies to evaluate Lean transformation and tools used to remove waste related to HIS in clinical settings. Findings Ten waste categories were identified, along with their relationships and applications of Lean tool types related to HIS. Different Lean tools were used at the early and final stages of Lean transformation; the tool selection depended on the waste characteristic. Nine studies reported a positive impact from Lean transformation in improving daily work processes. The selection of Lean tools should be made based on the timing, purpose and characteristics of waste to be removed. Research limitations/implications Overview of waste and its category within HIS and its analysis from socio-technical perspectives enabled the identification of its root cause in a holistic and rigorous manner. Practical implications Understanding waste types, their root cause and review of Lean tools could subsequently lead to the identification of mitigation approach to prevent future error occurrence. Originality/value Specific waste models for HIS settings are yet to be developed. Hence, the identification of the waste categories could guide future implementation of Lean transformations in HIS settings.

Incorporating Budget Impact Analysis in the Implementation of Complex Interventions: A Case of an Integrated Intervention for Multimorbid Patients within the CareWell Study.

OBJECTIVES: To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. METHODS: Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. RESULTS: Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. CONCLUSIONS: This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.

Applying Lean Six Sigma methodology to reduce cesarean section rate.

OBJECTIVES: This study aims to reduce cesarean section rate and increase rate of vaginal delivery. METHODS: By using Lean Six Sigma (LSS) methodology, the cesarean section rate was investigated and analyzed through a 5-phase roadmap consisting of Define, Measure, Analyze, Improve, and Control. The principal causes of cesarean section were identified, improvement measures were implemented, and the rate of cesarean section before and after intervention was compared. RESULTS: After patients with a valid medical reason for cesarean were excluded, the main causes of cesarean section were maternal request, labor pain, parturient women assessment, and labor observation. A series of measures was implemented, including an improved parturient women assessment system, strengthened pregnancy nutrition guidance, implementation of painless labor techniques, enhanced midwifery team building, and promotion of childbirth-assist skills. Ten months after introduction of the improvement measures, the cesarean section rate decreased from 41.83% to 32.00%, and the Six Sigma score (ie, Z value) increased from 1.706 to 1.967 (P < .001). CONCLUSION: LSS is an effective way to reduce the rate of cesarean section.

[Integrated Quality Management System (IQMS): a model for improving the quality of reproductive health care in rural Kenya]. / Integrated Quality Management System (IQMS): ein Modell zur Förderung der Qualität der reproduktiven Gesundheitsversorgung im ländlichen Kenia.

OBJECTIVES: To develop a model aiming to improve the quality of services for reproductive health care in rural Kenya and designed to measure the quality of reproductive health services in such a way that allows these services to identify measures for improving their performance. METHODS: The Integrated Quality Management System (IQMS) was developed on the basis of a pre-existing and validated model for quality promotion, namely the European Practice Assessment (EPA). The methodology for quality assessment and feedback of assessment results to the service teams was adopted from the EPA model. Quality assessment methodology included data assessment through staff, patient surveys and service visitation. Quality is assessed by indicators, and so indicators had to be developed that were appropriate for assessing reproductive health care in rural Kenya. A search of the Kenyan and international literature was conducted to identify potential indicators. These were then rated for their relevance and clarity by a panel of Kenyan experts. RESULTS: 260 indicators were rated as relevant and assigned to 29 quality dimensions and 5 domains. The implementation of IQMS in ten facilities showed that IQMS is a feasible model for assessing the quality of reproductive health services in rural Kenya. IQMS enables these services to identify quality improvement targets and necessary improvement measures. Both strengths and limitations of IQMS will be discussed.

An EFQM excellence model for integrated healthcare governance.

PURPOSE: The purpose of this paper is to account for a ten-year experience with the European Foundation for Quality Management (EFQM) Excellence Model implemented in the Trento Healthcare Trust. DESIGN/METHODOLOGY/APPROACH: Since 2000, the EFQM Excellence Model provided an overarching framework to streamline business process governance, to support and improve its enablers and results. From 2000 to 2009, staff performed four internal (self) and four external EFQM-based assessments that provided guidance for an integrated management system. Over the years, key controls and assurances improved service quality through business planning, learning and practice cycles. FINDINGS: Rising assessment ratings and improving results characterized the journey. The average self-assessment score (on a 1,000 points scale) was 290 in 2001, which increased to 610 in 2008. Since 2006, the Trust has been Recognized for Excellence (four stars). The organization improved significantly on customer satisfaction, people results and key service delivery and outcomes. PRACTICAL IMPLICATIONS: The EFQM Model can act as an effective tool to meet governance demands and promote system-level results. The approach to integrated governance discussed here may support similar change processes in comparable organizations. ORIGINALITY/VALUE: The paper describes a unique experience when implementing EFQM within a large Italian healthcare system, which had a broader reach and lasted longer than any experience in Italian healthcare.

The power of nursing peer review.

This article describes how an integrated healthcare system created a nursing peer-review structure to empower nurses to make practice changes and enhance professional accountability. A nursing peer-review committee and tools supporting the process were developed and implemented.

Why TQM does not work in Iranian healthcare organisations.

PURPOSE: Despite the potential benefits of total quality management (TQM), many healthcare organisations encountered difficulties in its implementation. The purpose of this paper is to explore the barriers to successful implementation of TQM in healthcare organisations of Iran. DESIGN/METHODOLOGY/APPROACH: This study involved a mixed research design. In-depth interviews were conducted with TQM practitioners to explore TQM implementation obstacles in Iranian healthcare organisations. In addition, this study involved survey-based research on the obstacles associated with successful TQM transformation. FINDINGS: TQM implementation and its impact depend on the ability of managers to adopt and adapt its values and concepts in professional healthcare organisations. Unsuccessful TQM efforts in Iranian healthcare organisations can be attributed to the non-holistic approach adopted in its implementation, inadequate knowledge of managers' about TQM implementation, frequent top management turnover, poor planning, vague and short-termed improvement goals, lack of consistent managers' and employees' commitment to and involvement in TQM implementation, lack of a corporate quality culture, lack of team orientation, lack of continuous education and training and lack of customer focus. Human resource problems, cultural and strategic problems were the most important obstacles to TQM successful implementation, respectively. PRACTICAL IMPLICATIONS: Understanding the factors that are likely to obstruct TQM implementation would enable managers to develop more viable strategies for achieving business excellence. ORIGINALITY/VALUE: Understanding the factors that are likely to obstruct TQM implementation will help organisations in planning better TQM models.

[Quality management in intensive care medicine]. / Qualitätsmanagement in der Intensivmedizin.

Treatment of critical ill patients in the intensive care unit is tantamount to well-designed risk or quality management. Several tools of quality management and quality assurance have been developed in intensive care medicine. In addition to extern quality assurance by benchmarking with regard to the intensive care medicine, peer review procedures have been established for external quality assurance in recent years. In the process of peer review of an intensive care unit (ICU), external physicians and nurses visit the ICU, evaluate on-site proceedings, and discuss with the managing team of the ICU possibilities for optimization. Furthermore, internal quality management in the ICU is possible based on the 10 quality indicators of the German Interdisciplinary Society for Intensive Care Medicine (DIVI, "Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin"). Thereby every ICU has numerous possibilities to improve their quality management system.

The design, implementation, and operational management of a comprehensive quality management program to support national telehealth networks.

The Veterans Health Administration (VHA) is a large integrated healthcare system with a mission to care for over 5.6 million Veteran patients annually. VHA, like other healthcare organizations, is challenged with providing access to care to those it serves when they live at a distance from a physical site of care. VHA has embraced telehealth as a way of delivering care at a distance and increase access to specialty care services. Since 2003 VHA has developed large national telehealth networks that provided care to 497,342 patients in fiscal year 2012, who received 1,429,424 episodes of care, and is recognized as a national leader in this field. To ensure the safety and effectiveness of its telehealth networks in their delivery of care VHA has implemented a dedicated quality management (QM) program for telehealth. QM data for telehealth are reviewed at 3-month intervals, and the procedures and processes in place to support telehealth in VHA are assessed biannually in an internal accreditation process called "Telehealth Conditions of Participation." This collegial, nonadversarial process has ensured that all designated telehealth programs meet minimal standards and disseminate best practice. As a result of VHA's QM program, telehealth services in VHA meet consistently high clinical outcomes and have received no adverse Joint Commission citations. The Joint Commission regularly assesses patients managed via telehealth under its tracer methodology reviews.

An integrated methodology for process improvement and delivery system visualization at a multidisciplinary cancer center.

Multidisciplinary cancer centers require an integrated, collaborative, and stream-lined workflow in order to provide high quality of patient care. Due to the complex nature of cancer care and continuing changes to treatment techniques and technologies, it is a constant struggle for centers to obtain a systemic and holistic view of treatment workflow for improving the delivery systems. Project management techniques, Responsibility matrix and a swim-lane activity diagram representing sequence of activities can be combined for data collection, presentation, and evaluation of the patient care. This paper presents this integrated methodology using multidisciplinary meetings and walking the route approach for data collection, integrated responsibility matrix and swim-lane activity diagram with activity time for data representation and 5-why and gap analysis approach for data analysis. This enables collection of right detail of information in a shorter time frame by identifying process flaws and deficiencies while being independent of the nature of the patient's disease or treatment techniques. A case study of a multidisciplinary regional cancer centre is used to illustrate effectiveness of the proposed methodology and demonstrates that the methodology is simple to understand, allowing for minimal training of staff and rapid implementation.

[Quality management in implementing specialist pediatric palliative home care in Lower Saxony, Germany]. / Qualitätsmanagement bei der Einführung der Spezialisierten Ambulanten Pädiatrischen Palliativversorgung in Niedersachsen.

BACKGROUND: To provide comprehensive high-quality health care is a great challenge in the context of high specialisation and intensive costs. This problem becomes further aggravated in service areas with low patient numbers and low numbers of specialists. Therefore, a multidimensional approach to quality development was chosen in order to optimise the care of children and adolescents with life-limiting conditions in Lower Saxony, a German federal state with a predominantly rural infrastructure. METHODS: Different service structures were implemented and a classification of service provider's specialisation was defined on the basis of existing references of professional associations. Measures to optimise care were implemented in a process-oriented manner. RESULTS: High-quality health care can be facilitated by carefully worded requirements concerning the quality of structures combined with optimally designed processes. Parts of the newly implemented paediatric palliative care structures are funded by the statutory health insurance.

[Quality management in intensive care medicine. Indispensable for daily routine]. / Qualitätsmanagement in der Intensivmedizin : Unverzichtbar in der täglichen Routine.

In areas requiring maximum safety like intensive care units or operating room departments, modern quality management and risk management are essential. Treatment of critically ill patients is associated with high risk and, therefore, demands risk management and quality management. External quality assessment in intensive care medicine has been developed based on a core data set and quality indicators. A peer review procedure has been established. In addition, regional networks of intensive care physicians result in improved local networking. In intensive care medicine, this innovative modular system of quality management and risk management is pursued more consequently than in any other specialty.