Slack Is Needed to Solve the Shortage of Nurses.

Healthcare systems are facing a shortage of nurses. This article identifies some of the major causes of this and the issues that need to be solved. We take a perspective derived from queuing theory: the patient-nurse relationship is characterized by a scarcity of time and resources, requiring comprehensive coordination at all levels. For coordination, we take an information-theoretic perspective. Using both perspectives, we analyze the nature of healthcare services and show that ensuring slack, meaning a less than exhaustive use of human resources, is a sine qua non to having a good, functioning healthcare system. We analyze what coordination efforts are needed to manage relatively simple office hours, wards, and home care. Next, we address the level of care where providers cannot themselves prevent the complexity of organization that possibly damages care tasks and job quality. A lack of job quality may result in nurses leaving the profession. Job quality, in this context, depends on the ability of nurses to coordinate their activities. This requires slack resources. The availability of slack that is efficient depends on a stable inflow and retention rate of nurses. The healthcare system as a whole should ensure that the required nurse workforce will be able to coordinate and execute their tasks. Above that, workforce policies need more stability.

Comparison of cataract surgery outcomes between a secondary and a tertiary eye hospital in Tamil Nadu, India.

PURPOSE: To examine the difference in post-operative visual outcomes of cataract surgeries between a tertiary and secondary centre at Aravind Eye Hospitals in Tamil Nadu, India. METHODS: Our retrospective cross-sectional study analysed cataract surgeries at a secondary centre and its associated tertiary centre in 2021. Our main outcome measures were postoperative best corrected visual acuity (BCVA), spherical equivalent, and intraoperative and postoperative complications. Two-sample proportion tests and logistic regression analyses were performed. RESULTS: The analysis of 32,302 cataract surgeries in 2021 of which 4357 were performed at the secondary centre and 27,945 were performed at the tertiary centre showed that the tertiary centre operated on more advanced cataract condition (p < 0.001). Intraoperative (p < 0.001) and post-operative complication rates (p < 0.001) were higher in the tertiary centre. The odds of effective outcomes (BCVA > = 6/12) controlling for all covariates are poorer (p < 0.0001) in the tertiary centre for both phacoemulsification (phaco) and manual small incision cataract surgeries (MSICS). CONCLUSION: World Health Organization recommendations for the effective outcome of cataract surgery are met by both the tertiary and secondary centres, but the odds of effective outcomes in the tertiary centre was lower after adjusting for all known factors. Further investigations of the causes of poor vision in both phaco and MSICS in the tertiary centre are needed to improve the situation.

Entropy Optimization by Redesigning Organization in Hospital Operations.

A redesign of hospitals (i.e., partitioning departments and delegating decision authority) may be needed to deal with variable demand. Uncertain demands and throughput times often need short reaction times. In this study, we develop quantitative methods to guide a redesign through an information-processing approach. To demonstrate how the methods can be used in practice, we tested them by applying them to a large perinatology care system in the Netherlands. We used the following two methods: 1. portfolio optimization and 2. efficient coordination of workload and reallocation of nurses. Our case study of a large perinatology care system showed that several designs of clustered units minimized the demand uncertainty in the perinatology care system. For the coordination strategy, the information and decision uncertainty is minimized when the decision power is positioned at the operation level and with the help of a centralized information system. When the operation decision-making power is not supplemented with the centralized and system-wide information system, hospitals can better use the hierarchy model, where the manager holds decision-making power with a system-wide overview. We also found that the speed of decision-making in real-time depends on the level of information aggregation set up by the system. We conclude that combining the correlation perspectives and the entropy theory is a way of quantifying how organizations can be (re)designed.

How to Use Lean Thinking for the Optimization of Clinical Pathways: A Systematic Review and a Proposed Framework to Analyze Pathways on a System Level.

Lean Thinking and clinical pathways are commonly used concepts to improve healthcare. However, little is known on how to use Lean Thinking for the optimization of pathways or the quantification of both concepts. This study aims to create a framework to analyze pathways with Lean Thinking on a system level, by quantifying the seven wastes, flow and pull. A systematic literature review was performed. Inclusion criteria were the focus of the article on a well-defined group of patients and studied a pathway optimization with Lean Thinking. Data were extracted on measured outcomes, type of intervention and type of researched pathway. Thirty-six articles were included. No articles described the implementation of the Lean Thinking philosophy or studied the development of their people and partners ("4 P" model). Most articles used process optimization tools or problem-solving tools. The majority of the studies focused on process measures. The measures found in the review were used as input for our suggested framework to identify and quantify wastes, flow, and pull in a clinical pathway. The proposed framework can be used to create an overview of the improvement potential of a pathway or to analyze the level of improvement after an enhancement is introduced to a pathway. Further research is needed to study the use of the suggested quantifications.

Causes for Medical Errors in Obstetrics and Gynaecology.

Background: Quality strategies, interventions, and frameworks have been developed to facilitate a better understanding of healthcare systems. Reporting adverse events is one of these strategies. Gynaecology and obstetrics are one of the specialties with many adverse events. To understand the main causes of medical errors in gynaecology and obstetrics and how they could be prevented, we conducted this systematic review. Methods: This systematic review was performed in compliance with the Prisma 2020 guidelines. We searched several databases for relevant studies (Jan 2010-May 2023). Studies were included if they indicated the presence of any potential risk factor at the hospital level for medical errors or adverse events in gynaecology or obstetrics. Results: We included 26 articles in the quantitative analysis of this review. Most of these (n = 12) are cross-sectional studies; eight are case-control studies, and six are cohort studies. One of the most frequently reported contributing factors is delay in healthcare. In addition, the availability of products and trained staff, team training, and communication are often reported to contribute to near-misses/maternal deaths. Conclusions: All risk factors that were found in our review imply several categories of contributing factors regarding: (1) delay of care, (2) coordination and management of care, and (3) scarcity of supply, personnel, and knowledge.

Impact of practicing internal benchmarking on continuous improvement of cataract surgery outcomes: a retrospective observational study at Aravind Eye Hospitals, India.

OBJECTIVE: We aim to assess the effectiveness of a cataract surgery outcome monitoring tool used for continuous quality improvement. The objectives are to study: (1) the quality parameters, (2) the monitoring process followed and (3) the impact on outcomes. DESIGN AND PROCEDURES: In this retrospective observational study we evaluated a quality improvement (QI) method which has been practiced at the focal institution since 2012: internal benchmarking of cataract surgery outcomes (CATQA). We evaluated quality parameters, procedures followed and clinical outcomes. We created tables and line charts to examine trends in key outcomes. SETTING: Aravind Eye Care System, India. PARTICIPANTS: Phacoemulsification surgeries performed on 718 120 eyes at 10 centres (five tertiary and five secondary eye centres) from 2012 to 2020 were included. INTERVENTIONS: An internal benchmarking of surgery outcome parameters, to assess variations among the hospitals and compare with the best hospital. OUTCOME MEASURES: Intraoperative complications, unaided visual acuity (VA) at postoperative follow-up visit and residual postoperative refractive error (within ±0.5D). RESULTS: Over the study period the intraoperative complication rate decreased from 1.2% to 0.6%, surgeries with uncorrected VA of 6/12 or better increased from 80.8% to 89.8%, and surgeries with postoperative refractive error within ±0.5D increased from 76.3% to 87.3%. Variability in outcome measures across hospitals declined. Additionally, benchmarking was associated with improvements in facilities, protocols and processes. CONCLUSION: Internal benchmarking was found to be an effective QI method that enabled the practice of evidence-based management and allowed for harnessing the available information. Continuous improvement in clinical outcomes requires systematic and regular review of results, identifying gaps between hospitals, comparisons with the best hospital and implementing lessons learnt from peers.

The Intervention Selection Toolbox to improve patient-relevant outcomes: an implementation and qualitative evaluation study in colorectal cancer surgery.

BACKGROUND: The concept of value-based healthcare is being used worldwide to improve healthcare. The Intervention Selection Toolbox was developed to bridge the gap of value-based healthcare, between insights in outcomes and actual quality improvement initiatives. In this study we aimed to evaluate the use of the Intervention Selection Toolbox in daily practice of a quality improvement team in a hospital setting. METHODS: A methodological triangulation design was used. The Intervention Selection Toolbox was used by a multidisciplinary quality improvement team for colorectal cancer care in a large teaching hospital. In-depth semi-structured interviews, focusing on the key elements of process evaluation, were conducted after implementation with representatives of the quality improvement team to evaluate the use of the Intervention Selection Toolbox. Quantitative data regarding improvement initiatives and degree of implementation was also collected. RESULTS: The use of the Intervention Selection Toolbox initially resulted in 80 potential quality improvement initiatives. Eventually, two high potential improvement initiatives were selected. Some components of the toolbox were successfully implemented in daily practice, although 'standard monitoring' and 'causal chain analysis' proved more difficult to implement. Qualitative analysis was performed with ten members of the multidisciplinary team before thematic saturation occurred. Interviewed members had a wide range in characteristics: age 28-61 years, clinical experience 6-38 years and educational attainment from vocational program to academic doctorate. The Interviews showed added value in the use of the toolbox, but identified time and organizational management as restricting factors. CONCLUSIONS: The Intervention Selection Toolbox is useful to systematically identify improvement initiatives with impact on health outcomes that matter to patients. However, before implementation organizational structure should be optimized to maximize success and efficiency on integration of the Intervention Selection Toolbox.

Hospital Organizational Structure and Information Processing: An Entropy Perspective.

Organizational structure enables organizations to achieve their goals. The chosen organizational structure determines, to a large extent, the flow of information streams and the manner and extent to which roles, power, and responsibilities are delegated and coordinated to achieve the organization's goals. In this study, we applied information theory with entropy as the central concept to assess the effectiveness and costs of an organizational structure and its coordination processes. Entropy was used to measure the amount of uncertainty associated with probabilistic events. In the context of organizational design, entropy values can be assigned to specific organizational structures to gain insights into the factors that lead to delays in decision-making. We used Shannon's entropy theory to quantify Galbraith's organizational structure and coordination process as applied to the perinatology care system of Radboud University Medical Centre in the Netherlands. Our entropy analysis provided insights into how departments should be partitioned and which coordination mechanisms should be used to achieve organizational goals, such as minimizing delays in decision-making. Particularly, two types of entropy appear to be important: positional entropy and task allocation entropy. These are different dependent variables on the organizational design scenarios. Our analysis shows that entropy is one method to determine optimal organizational structures and coordination processes. Entropy can be used as a concrete way of assessing the effectiveness of organizational design given the level of uncertainty of the environment and the required speed of decision-making.

Managing Outpatient Cycle Times in Hospitals Using Integrated Closed-Loop Approaches.

Long waiting times in outpatient clinics have multiple adverse effects on patients and their attendants, staff and hospital management. Several approaches practiced to manage the cycle time have been proposed. The purpose of this study was to evaluate the impact of implementing closed-loop based multiple approaches together. This study was conducted in Aravind Eye Hospital (AEH), Madurai, India where several approaches to manage cycle times have been implemented over the years. Scheduling system was introduced to manage COVID-19 specific norms. We compared the cycle times in general outpatient clinics in a regime in which multiple approaches were practiced together before and after introducing scheduling to regimes in which individual approaches were practiced. We analysed how the cycle time varied by patient load. Cycle time for all patient days when the combined approach was used was 19% lower than baseline, and better than under each of the individual approaches. The outcome sustained even during the COVID-19 pandemic that necessitated additional processes and procedures. Therefore, implementing multiple approaches can be more effective to reduce the cycle time than implementing individual approaches.

Barriers to cervical cancer and breast cancer screening uptake in low- and middle-income countries: a systematic review.

There is an alarmingly high growth in breast and cervical cancers in low- and middle-income countries. Due to late presentation to doctors, there is a lower cure rate. The screening programmes in low- and middle-income countries are not comprehensive. In this paper, we systematically analyse the barriers to screening through an accessibility framework. We performed a systematic literature search in PubMed, Mendeley and Google Scholar to retrieve all English language studies (quantitative, qualitative and mixed-methods) that contained information on breast and cervical cancer screening in low- and middle-income countries. We only considered publications published between 1 January 2016 and 31 May 2021. The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension (PRISMA-S), an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews. The search yielded a total of 67 articles from low- and middle-income countries in this review. We used a framework on accessibility known as the 5A framework, which distinguishes five aspects of access: approachability, acceptability, availability, affordability and appropriateness, to classify the screening barriers. We added two more aspects: awareness and angst, as they could explain other important barriers to screening. They confirmed how the lack of awareness, cost of the screening service and distance to the screening centre act as major impediments to screening. They also revealed how embarrassment and fear of screening and cultural factors such as lack of spousal or family support could be obstacles to screening. We conclude that more needs to be done by policymakers and governments to improve the confidence of the people in the health systems. Women should be made aware of the causes and risk factors of cancer through evidence-based strategies so that there is an increased adherence to screening.

Quantifying the Resilience of a Healthcare System: Entropy and Network Science Perspectives.

In this study, we consider the human body and the healthcare system as two complex networks and use theories regarding entropy, requisite variety, and network centrality metrics with resilience to assess and quantify the strengths and weaknesses of healthcare systems. Entropy is used to quantify the uncertainty and variety regarding a patient's health state. The extent of the entropy defines the requisite variety a healthcare system should contain to be able to treat a patient safely and correctly. We use network centrality metrics to visualize and quantify the healthcare system as a network and assign the strengths and weaknesses of the network and of individual agents in the network. We apply organization design theories to formulate improvements and explain how a healthcare system should adjust to create a more robust and resilient healthcare system that is able to continuously deal with variations and uncertainties regarding a patient's health, despite possible stressors and disturbances at the healthcare system. In this article, these concepts and theories are explained and applied to a fictive and a real-life example. We conclude that entropy and network science can be used as tools to quantify the resilience of healthcare systems.

Trends and Developments in Medical Liability Claims in The Netherlands.

Recent data on number of claims, final judgement of claims and their costs are scarce. This study analyzes 15 years of malpractice claims in the Netherlands. All claims filed, and all claims closed by two insurance companies (which insure approximately 95% of all hospitals in the Netherlands) between 2007-2021 are included. Trends in number of claims, medical specialties involved, final judgements and costs from malpractice claims are analyzed, as well as the impact of COVID-19 on malpractice claims. In total, 20,726 claims were filed and 21,826 claims were closed. Since 2013, the number of claims filed decreased. Of all claims filed, 64% were aimed at surgical specialties and 18% at contemplative specialties. Of all claims closed, 24.49% were accepted, 19.26% were settled and 48.94% got rejected. The financial burden of all claims closed quadrupled between 2007 and 2021; this increase was caused by rare cases with excessively high costs. Since the COVID-19 pandemic, we observed a decrease in the number of claims filed, and the number of incidents reported. This study provides valuable insights into trends and developments in the number and costs of liability claims, which is the first step towards improving patient safety and preventing incidents and malpractice claims.

Mapping the extent, range and nature of research activity on value-based healthcare in the 15 years following its introduction (2006-2021): a scoping review.

OBJECTIVES: We aimed to systematically map the extent, range and nature of research activity on value-based healthcare (VBHC), and to identify research gaps. DESIGN: A scoping review with an additional cited reference search was conducted, guided by the Joanna Briggs Institute methodology. DATA SOURCES: The search was undertaken in PubMed, Embase and Web of Science. ELIGIBILITY CRITERIA: Eligible articles mentioned VBHC or value with reference to the work of Porter or provided a definition of VBHC or value. DATA EXTRACTION AND SYNTHESIS: Data were independently extracted using a data extraction form. Two independent reviewers double extracted data from 10% of the articles. Data of the remaining articles (90%) were extracted by one reviewer and checked by a second. The strategic agenda of Porter and Lee was used to categorise the included articles. RESULTS: The searches yielded a total of 27,931 articles, of which 1,242 were analysed. Most articles were published in North America. Most articles described an application of VBHC by measuring outcomes and costs (agenda item 2). The other agenda items were far less frequently described or implemented. Most of these articles were conceptual, meaning that nothing was actually changed or implemented. CONCLUSION: The number of publications increased steadily after the introduction of VBHC in 2006. Almost one-fifth of the articles could not be categorised in one of the items of the strategic agenda, which may lead to the conclusion that the current strategic agenda could be extended. In addition, a practical roadmap or guideline to implement VBHC is still lacking. Future research could fill this gap by specifically studying the effectiveness of VBHC in day-to-day clinical practice.

Creating Coherence-Based Nurse Planning in the Perinatology Care System.

The combination of increasing demand and a shortage of nurses puts pressure on hospital care systems to use their current volume of resources more efficiently and effectively. This study focused on gaining insight into how nurses can be assigned to units in a perinatology care system to balance patient demand with the available nurses. Discrete event simulation was used to evaluate the what-if analysis of nurse flexibility strategies and care system configurations from a case study of the Perinatology Care System at Radboud University Medical Center in Nijmegen, the Netherlands. Decisions to exercise nurse flexibility strategies to solve supply-demand mismatches were made by considering the entire patient care trajectory perspective, as they necessitate a coherence perspective (i.e., taking the interdependency between departments into account). The study results showed that in the current care system configuration, where care is delivered in six independent units, implementing a nurse flexibility strategy based on skill requirements was the best solution, averaging two fewer under-/overstaffed nurses per shift in the care system. However, exercising flexibility below or above a certain limit did not substantially improve the performance of the system. To meet the actual demand in the studied setting (70 beds), the ideal range of flexibility was between 7% and 20% of scheduled nurses per shift. When the care system was configured differently (i.e., into two large departments or pooling units into one large department), supply-demand mismatches were also minimized without having to implement any of the three nurse flexibility strategies mentioned in this study. These results provide insights into the possible solutions that can be implemented to deal with nurse shortages, given that these shortages could potentially worsen in the coming years.

Exploring changes in integration, differentiation, rules, coordination and performance following the introduction of a hospital planning centre: a case study.

PURPOSE: This study explores how a hospital works, which is important for further enhancing hospital performance. Following the introduction of a Hospital Planning Centre (HPC), changes are explored in a hospital in terms of integration (the coordination and alignment of tasks), differentiation (the extent to which tasks are segmented into subsystems), rules, coordination mechanisms and hospital performance. DESIGN/METHODOLOGY/APPROACH: A case study was conducted examining the hospital's social network, rules, coordination mechanisms and performance both before and after the introduction of the HPC. All planning and execution tasks for surgery patients were studied using a naturalistic inquiry and mixed-method approach. FINDINGS: After the introduction of the HPC, the overall network structure and coordination mechanisms and coordination mechanisms remained largely the same. Integration and certain rules changed for specific planning tasks. Differentiation based on medical discipline remained. The number of local rules decreased and hospital-wide rules increased, and these remained largely in people's minds. Coordination mechanisms remained largely unchanged, primarily involving mutual adjustment and standardization of work both before and after the introduction of the HPC. Overall, the hospital's performance did not change substantially. The findings suggest that integration seems to "emerge" instead of being designed. Hospitals could benefit, we argue, from a more conscious system-wide approach that includes collective learning and information sharing. ORIGINALITY/VALUE: This exploratory study provides in-depth insight into how a hospital works, yielding important knowledge for further research and the enhancement of hospital performance.

Multidimensional outcome assessment of pulmonary rehabilitation in traits-based clusters of COPD patients.

BACKGROUND: Clusters of COPD patients have been reported in order to individualize the treatment program. Neither co-morbidity clusters, nor integrated respiratory physiomics clusters contributed to a better prediction of outcomes. Based on a thoroughly assessed set of pulmonary and extra-pulmonary traits at the start of a pulmonary rehabilitation (PR) program, we recently described seven clusters of COPD patients. The aims of this study are to confirm multidimensional differential response and to assess the potential of pulmonary and extra-pulmonary traits-based clusters to predict this multidimensional response to PR pulmonary in COPD patients. METHODS: Outcomes of a 40-session PR program for COPD patients, referred by a chest physician, were evaluated based on the minimal clinically important difference (MCID) for 6-minute walk distance (6MWD), cycle endurance time, Canadian Occupational Performance Measure performance and satisfaction scores, Hospital Anxiety and Depression Scale anxiety and depression scores, MRC dyspnea grade and St George's Respiratory Questionnaire. The aforementioned response indicators were used to calculate the overall multidimensional response and patients were grouped in very good, good, moderate and poor responders. In the same way, responses to pulmonary rehabilitation were compared based on seven previously identified pulmonary and extra-pulmonary traits-based clusters. RESULTS: Of the whole sample, drop out was 19% and 419 patients (55.4% males, age: 64.3 ± 8.8, FEV1% of predicted: 48.9 ± 20) completed the pulmonary rehabilitation program. Very good responders had significantly worse baseline characteristics with a higher burden of disease, a higher proportion of rollator-users, higher body mass index (BMI), more limitations of activities in daily life, emotional dysfunction, higher symptoms of dyspnea and worse quality of life. Of the seven pre-identified clusters, 'the overall best functioning cluster' and 'the low disease burden cluster' both including the best 6MWD, the lowest dyspnea score and the overall best health status, demonstrated attenuated outcomes, while in 'the cluster of disabled patients', 76% of the patients improved health status with at least 2 times MCID. This 'cluster of disabled patients' as well as 'the multimorbid cluster', 'the emotionally dysfunctioning cluster', 'the overall worst-functioning cluster' and 'the physically dysfunctioning cluster' all demonstrated improvements in performance and satisfaction for occupational activities (more than 65% of patients improved with > 1MCID), emotional functioning (more than 50% of patients improved with > 1 MCID) and overall health status (more than 58%). CONCLUSION: The current study confirms the differential response to pulmonary rehabilitation based on multidimensional response profiling. Cluster analysis of baseline traits illustrates that non-linear, clinically important differences can be achieved in the most functionally and emotionally impaired clusters and that 'the overall best functional cluster' as well as 'the low disease burden cluster' had an attenuated outcome.

Explaining integration and differentiation by identifying the rules and coordination mechanisms in a hospital's logistical system.

PURPOSE: Integration, that is, the coordination and alignment of tasks, is widely promoted as a means to improve hospital performance. A previous study examined integration and differentiation, that is, the extent to which tasks are segmented into subsystems, in a hospital's social network. The current study carries this research further, aiming to explain integration and differentiation by studying the rules and coordination mechanisms that agents in a hospital network use. DESIGN/METHODOLOGY/APPROACH: The current case study deepens the analysis of the social network in a hospital. All planning tasks and tasks for surgery performance were studied, using a naturalistic inquiry approach and a mixed method. FINDINGS: Of the 314 rules found, 85% predominantly exist in people's minds, 31% are in documents and 7% are in the information system. In the early planning stages for a surgery procedure, mutual adjustment based on hospital-wide rules is dominant. Closer to the day of surgery, local rules are used and open loops are closed through mutual adjustment, thus achieving integration. On the day of surgery, there is mainly standardization of work and output, based on hospital-wide rules. The authors propose topics for future research, focusing on increasing the hospital's robustness and stability. ORIGINALITY/VALUE: This exploratory case study provides an overview of the rules and coordination mechanisms that are used for organizing hospital-wide logistics for surgery patients. The findings are important for future research on how integration and differentiation are effectively achieved in hospitals.

Identifying integration and differentiation in a Hospital's logistical system: a social network analysis of a case study.

BACKGROUND: Integration, the coordination and alignment of tasks, has been promoted widely in order to improve the performance of hospitals. Both organization theory and social network analysis offer perspectives on integration. This exploratory study research aims to understand how a hospital's logistical system works, and in particular to what extent there is integration and differentiation. More specifically, it first describes how a hospital organizes logistical processes; second, it identifies the agents and the interactions for organizing logistical processes, and, third, it establishes the extent to which tasks are segmented into subsystems, which is referred to as differentiation, and whether these tasks are coordinated and aligned, thus achieving integration. METHODS: The study is based on case study research carried out in a hospital in the Netherlands. All logistical tasks that are executed for surgery patients were studied. Using a mixed method, data were collected from the Hospital Information System (HIS), documentation, observations and interviews. These data were used to perform a social network analysis and calculate the network metrics of the hospital network. RESULTS: This paper shows that 23 tasks are executed by 635 different agents who interact through 31,499 interaction links. The social network of the hospital demonstrates both integration and differentiation. The network appears to function differently from what is assumed in literature, as the network does not reflect the formal organizational structure of the hospital, and tasks are mainly executed across functional silos. Nurses and physicians perform integrative tasks and two agents who mainly coordinate the tasks in the network, have no hierarchical position towards other agents. The HIS does not seem to fulfill the interactional needs of agents. CONCLUSIONS: This exploratory study reveals the network structure of a hospital. The cross-functional collaboration, the integration found, and position of managers, coordinators, nurses and doctors suggests a possible gap between organizational perspectives on hospitals and reality. This research sets a basis for further research that should focus on the relation between network structure and performance, on how integration is achieved and in what way organization theory concepts and social network analysis could be used in conjunction with one another.

Incorporating Comprehensive Assessment Parameters to Better Characterize and Plan Rehabilitation for Persons with Chronic Obstructive Pulmonary Disease.

OBJECTIVES: The current management of chronic obstructive pulmonary disease (COPD) largely ignores its heterogeneous pulmonary and extrapulmonary manifestations in the individual patient. This study aimed to identify clusters of patients with COPD based on a thorough traits assessment. DESIGN: An observational, prospective, single-center study. SETTING AND PARTICIPANTS: Patients with COPD referred by chest physicians for a comprehensive pulmonary rehabilitation program to CIRO (Horn, the Netherlands) were eligible to participate. CIRO is a specialized pulmonary rehabilitation center in the southern part of the Netherlands for patients with complex underlying respiratory diseases. METHODS: Clinically stable patients with COPD underwent a comprehensive assessment, including pulmonary traits (airflow limitation, static hyperinflation, gas transfer, respiratory pressures, and arterial blood gases), extrapulmonary functional traits, and health status (quadriceps muscle strength, physical functioning, body composition, comorbidities, symptoms perception, and social and emotional functioning). Clusters were generated using the SOM-Ward Cluster algorithm, a hybrid algorithm that applies the classical hierarchical method of Ward on top of the self-organizing map topology. RESULTS: Based on the abovementioned attributes of 518 patients with mild to very severe COPD (44% women, age 64.1 ± 9.1 years, forced expiratory volume in the first second 48.6% ± 20.0% of predicted), 7 clusters were identified. Clusters had unique patterns differing in demographics, pulmonary, extrapulmonary functional, and behavioral traits and/or health status. CONCLUSION AND IMPLICATIONS: The tremendous heterogeneity in pulmonary, extrapulmonary functional and behavioral traits, and health status in patients with COPD supports the need for an individual comprehensive assessment and a goal-directed personalized management strategy.

Electronic Health Record implementation in a large academic radiotherapy department: Temporarily disruptions but long-term benefits.

PURPOSE: To study the number of disruptions in patient processes in a radiotherapy centre after the replacement of an Electronic Health Record (EHR), integrating information tools for patient care and billing. METHODS: Our self-made Electronic Medical Record was replaced by a new EHR, including clinical path and workflow-management. A social-technological approach was used to reduce complexity. We measured disruptions in patient processes by the number and type of EHR related root causes and EHR-related incidents that reached patients, in our patient safety system 12 months before implementing the new EHR, 6 months after implementation (transition period) and 24 months after the transition period. We used Mann-Whitney U and X² tests to compare data before and after implementation. RESULTS: An increase of disruptions occurred only temporarily during 6 months. After this period, the number stabilized to the level before implementation while having more functionalities and benefits. Neither the number nor the severity of incidents reaching patients increased. CONCLUSIONS: Disruptions in patient processes are considered as a main barrier for implementing an EHR. Using a social/technical approach, the increase in disruptions did only temporarily occur and did not reach patients. We think it is important to share this insight with physicians because literature shows that their long-term opinion regarding the usefulness of the EHR is often based on the experience in the first months after implementation. Management of expectations is recommended. ADVANCES IN KNOWLEDGE: This study is the first of its kind measuring long-term effects of EHR on patient processes in radiotherapy.