An audit of the editorial process at the Indian Journal of Cancer: Lessons learned, and how to improve chances of acceptance of your paper.

BACKGROUND: The editors of the Indian Journal of Cancer (IJC) have not, so far, objectively analyzed the editorial processes involving author, referee, and editor data of the journal. Hence, we aimed at doing so in this audit. METHODS: We retrospectively analyzed manuscripts submitted to the IJC from April 1, 2020, to May 31, 2020, for data related to the peer-review process. Microsoft Excel was used to enter the retrieved information and to carry out the statistical analysis. RESULTS: Three hundred and nineteen manuscripts were submitted during the study period. Of these, three were excluded from the study. Of the 316, 79 (25%) were articles on laboratory medicine; 182 (57.6%) were original articles. About half of the submitted manuscripts (166, 52.5%) were desk-rejected. Of the remaining 149 manuscripts, 105 did not follow the instructions to contributors (ITC) and required a median number of two revisions (range = 1-5) to satisfy the ITC. To review 107 manuscripts, 536 external referees were invited; of them 306 did not respond, 79 declined the invitation, and 151 accepted the invitation. Of these 151, 132 reverted with comments. Of the 200 Indians who were invited as referees, 118 (59%) accepted the invitation, whereas of the 336 non-Indian referees, only 33 (9.8%) did. Of the 107 Indian and 25 non-Indian referees who sent their comments, 86 (80.4%) and 19 (88%), respectively, offered useful comments. The median number of days to decision: for desk-rejection was 1 day (range = 0 - 42) days, for rejection after peer-review was 67 (range = 4 - 309) days, and for acceptance was 133.5 (range = 42 - 305) days. Decision has not yet been taken for 14 manuscripts. CONCLUSION: The study provides evidence that it is difficult to get referees. Also, a significant number of authors do not read or follow the ITC. We suggest that the time taken for a decision can be appreciably improved if these issues are addressed.

An institutional audit of the use of novel drugs in pediatric oncology.

BACKGROUND: Significant challenges persist in treating children with rare, relapsed, or refractory malignancies. Novel molecularly targeted drugs promise improved outcomes for these children with reduced toxicity. However, there is often limited evidence to substantiate their clinical efficacy and guide their use. This raises issues for clinical decision-making, ethical concerns surrounding equity of access to these often-expensive agents, and the management of families' expectations for cure. This audit evaluated the off-label use of novel drugs and associated clinical outcomes in order to guide the development of future clinical and ethical guidelines. AIM: To evaluate the patterns in the off-label use of novel drugs for treating childhood cancer and the associated clinical outcomes to guide prospective studies and inform ethical and clinical governance protocols for the use of these agents. METHODS: A retrospective audit was performed for all patients who received novel drugs off-label as treatment for their malignancy at an Australian pediatric oncology center between 2010 and 2019. RESULTS: One hundred patients with 32 unique diagnoses received 133 novel drugs across 124 regimens. Eighty-four patients received these drugs at the second line of treatment or greater. Novel drug median cost was $15 521 AUD (Range: $6.53 AUD to $258 339 AUD) and was primarily funded by the hospital (N = 60/133, 45.1%) or compassionate access from pharmaceutical companies (N = 52/133, 39.1%). Decision-making related to novel drugs was inconsistently documented. Ninety-one of 124 treatment regimens commenced between 2010 and 2019 resulted in objective responses (73.4%), but only 35 were still ongoing upon review in June 2020 (38.5%). Median response duration was 12.6 months (Range: 0-93.2 months). CONCLUSIONS: While novel drugs were largely unable to definitively cure patients, most achieved objective responses. Prospective trials and more rigorous documentation are needed to fully inform the future use of these agents given the heterogeneity of their applications.

Evaluating Disaster Damages and Operational Status of Health-Care Facilities During the Emergency Response Phase of Hurricane Maria in Puerto Rico.

On September 20, 2017, Hurricane Maria made landfall on Puerto Rico as a category 4 storm, resulting in serious widespread impact across the island, including communication and power outages, water systems impairment, and damage to life-saving infrastructure. In collaboration with the Puerto Rico Department of Health, the Public Health Branch (PHB), operating under the Department of Health and Human Services Incident Response Coordination Team, was tasked with completing assessments of health-care facilities in Puerto Rico to determine infrastructure capabilities and post-hurricane capacity. Additionally, in response to significant data entry and presentation needs, the PHB leadership worked with the Puerto Rico Planning Board to develop and test a new app-based infrastructure capacity assessment tool. Assessments of hospitals were initiated September 28, 2017, and completed November 10, 2017 (n = 64 hospitals, 97%). Assessments of health-care centers were initiated on October 7, 2017, with 186 health-care centers (87%) assessed through November 18, 2017. All hospitals had working communications; however, 9% (n = 17) of health-care centers reported no communication capabilities. For the health-care centers, 114 (61%) reported they were operational but had sustainment needs. In conclusion, health-care facility assessments indicated structural damage issues and operational capacity decreases, while health-care centers reported loss of communication capabilities post-Hurricane Maria.

Using electronic health record audit logs to study clinical activity: a systematic review of aims, measures, and methods.

OBJECTIVE: To systematically review published literature and identify consistency and variation in the aims, measures, and methods of studies using electronic health record (EHR) audit logs to observe clinical activities. MATERIALS AND METHODS: In July 2019, we searched PubMed for articles using EHR audit logs to study clinical activities. We coded and clustered the aims, measures, and methods of each article into recurring categories. We likewise extracted and summarized the methods used to validate measures derived from audit logs and limitations discussed of using audit logs for research. RESULTS: Eighty-five articles met inclusion criteria. Study aims included examining EHR use, care team dynamics, and clinical workflows. Studies employed 6 key audit log measures: counts of actions captured by audit logs (eg, problem list viewed), counts of higher-level activities imputed by researchers (eg, chart review), activity durations, activity sequences, activity clusters, and EHR user networks. Methods used to preprocess audit logs varied, including how authors filtered extraneous actions, mapped actions to higher-level activities, and interpreted repeated actions or gaps in activity. Nineteen studies validated results (22%), but only 9 (11%) through direct observation, demonstrating varying levels of measure accuracy. DISCUSSION: While originally designed to aid access control, EHR audit logs have been used to observe diverse clinical activities. However, most studies lack sufficient discussion of measure definition, calculation, and validation to support replication, comparison, and cross-study synthesis. CONCLUSION: EHR audit logs have potential to scale observational research but the complexity of audit log measures necessitates greater methodological transparency and validated standards.

Auditoría del conocimiento orientada a los procesos y al desarrollo profesional en la Editorial Ciencias Médicas / Knowledge audit of processes and professional development at the Medical Sciences Publishing House

Esta auditoría pretendió identificar el conocimiento presente en los procesos principales de la Editorial Ciencias Médicas y el comportamiento de un conjunto de indicadores acerca del desarrollo profesional, que permiten valorar la proyección actual y futura del conocimiento, así como conocer algunos aspectos en que se deben potenciar para contribuir a asegurar la actuación futura de la institución. Se empleó una metodología desarrollada por Ponjuán para valorar el conocimiento presente en los procesos actuales e identificar el comportamiento de sus trabajadores en relación con el desarrollo profesional. Se identificó el conocimiento que se aplica en todos los procesos principales de la organización, así como el comportamiento de la composición profesional del personal, su experiencia laboral y en la institución, el tiempo que dedican a su actualización, su visibilidad en eventos y redes sociales, entre otros. Los puntos fuertes y débiles de la institución, así como la identificación del conocimiento que se necesita en cada proceso, permitieron sugerir a la institución determinados aspectos relativos al conocimiento, su retención, los procesos organizacionales y los componentes humanos y tecnológicos necesarios. Estos resultados permiten conocer mejor a la organización y facilitan la introducción de un programa de gestión del conocimiento al conocer, con mayor profundidad y desde diferentes miradas, las debilidades y las fortalezas existentes relacionadas con el conocimiento necesario y su aplicación en los procesos internos, así como algunas características del desarrollo profesional(AU)

The audit intended to identify the knowledge underlying the main processes performed at the Medical Sciences Publishing House and the behavior of a number of indicators related to professional development which make it possible to assess the current status and future projection of knowledge, as well as become acquainted with areas to be strengthened to contribute to ensure the future performance of the institution. The study was based on a methodology developed by Ponjuán, to assess the knowledge base supporting current processes and identify the behavior of workers in relation to professional development. Identification was made of the knowledge applied in all the main processes of the organization, as well as the behavior of the professional composition of the personnel, their work experience in general and at the institution, the time they devote to their updating, and their visibility in conferences and the social networks, among other factors. The strengths and weaknesses of the institution, as well as identification of the knowledge needed in each process, allowed to suggest a number of aspects related to knowledge, its retention, the organizational processes, and the human and technological components required. These results make it possible to know the organization better and facilitate the introduction of a Knowledge Management program based on a more profound understanding from various perspectives of the current weaknesses and strengths in terms of the knowledge required and its application in internal processes, as well as some characteristics of professional development(AU)

Misappropriation of medications and equipment in the emergency department.

OBJECTIVE: To determine the nature and extent of misappropriation of medications and equipment from the ED. METHODS: We undertook a retrospective audit of medications procured and administered, and equipment replaced, in 2016, within a tertiary referral ED. Medication procurement and administration data were obtained from our MERLIN® pharmacy system and CERNER® electronic prescribing system, respectively. A medication 'discrepancy rate' was defined as the percentage of a medication procured that could not be accounted for by electronic administrations. The study also comprised a nested intervention sub-study where, from July 1, 2016, all Panadeine Forte tablets were stored in a locked facility. Victorian Hospital Healthcare Equipment invoices were audited to determine which major non-disposable equipment items most commonly needed resupply. RESULTS: Discrepancy rates for paracetamol 500mg and 665mg tablets were 23.3% and 54.9%, respectively. Following the Panadeine Forte intervention, the discrepancy rate for this medication fell from 70.5% to 8.8%. Orally administered medications with the potential for misappropriation had high discrepancy rates: caffeine (90.6%), cephalexin (62.9%), ondansetron (50.1%), pantoprazole (42.9%), amoxicillin (41.1%), metoclopramide (41.0%) and the 'morning after pill' (levonorgestrel) (36.4%). Parenterally administered medications had lower discrepancy rates: ceftriaxone (7.9%) and ampicillin (3.4%). The largest equipment replacement rates were for tourniquets and crutches. CONCLUSION: Discrepancy rates for many medications, especially those administered orally, are high. Further research is required to determine how these medications 'go missing'. Placing a medication with a high discrepancy rate in a locked facility with a 'logbook' substantially reduces this rate. Misappropriation of non-disposable equipment items is uncommon.

Hand hygiene compliance rates: Fact or fiction?

BACKGROUND: The mandatory national hand hygiene program requires Australian public hospitals to use direct human auditing to establish compliance rates. To establish the magnitude of the Hawthorne effect, we compared direct human audit rates with concurrent automated surveillance rates. METHODS: A large tertiary Australian teaching hospital previously trialed automated surveillance while simultaneously performing mandatory human audits for 20 minutes daily on a medical and a surgical ward. Subtracting automated surveillance rates from human audit rates provided differences in percentage points (PPs) for each of the 3 quarterly reporting periods for 2014 and 2015. RESULTS: Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter. The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates. CONCLUSIONS: Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians' ability to hyperrespond to produce habitual compliance.

Service evaluation project - Are local recommendations for onward referral to a specialist menopause clinic required to translate guidelines into practice?

Objective Referral audit - are local recommendations required to translate guideline to practice? Study design In total, 50 consecutive, anonymised referral letters reviewed during the initial consultation in a specialist menopause clinic; the reasons for referral along with the patient's age and the source of referral were analysed. Results Several common reasons for referral were identified. Sexual dysfunction, including loss of libido and dyspareunia, resulted in 11 (22%) referrals. Ten (20%) women were troubled by persistent symptoms or side effects from HRT; 9 (18%) women were referred before hormone replacement therapy was discussed or commenced; 7 (14%) women seeking advice for their menopausal symptoms had a family or personal history of cancer; 5(10%) were migraineurs; 2(4%) women had premature ovarian insufficiency; 2(4%) were denied hormone replacement therapy because of concern about venous thromboembolism risk; and 4 (8%) had miscellaneous medical disorders. Over 25% of referrals were older than 60. Conclusion Menopausal symptoms are predominately dealt with in primary care where advice and support is needed. National Institute for Health Care and Excellence published guidance regarding onward referral to a specialist menopause clinic, which is vague and referral patterns are haphazard. Our audit highlighted areas of clinical uncertainty and formed the basis for providing local pre-referral information and advice. Some of the information provided is quite detailed and aimed at healthcare professionals with a special interest in menopause. Further training is now required to improve the quality of referrals. The diversity and complexity of some referrals illustrates the need both for a menopause specialist and clear pathways for further advice or referral within each region.

Resource Planning in Glaucoma: A Tool to Evaluate Glaucoma Service Capacity.

BACKGROUND: The National Patient Safety Agency (2009) publication advising timely follow-up of patients with established glaucoma followed several reported instances of visual loss due to postponed appointments and patients lost to follow-up. The Royal College of Ophthalmologists Quality Standards Development Group stated that all hospital appointments should occur within 15% of the intended follow-up period. AIM: To determine whether: 1. Glaucoma follow-up appointments at a teaching hospital occur within the requested time 2. Appointments are requested at appropriate intervals based on the NICE Guidelines 3. The capacity of the glaucoma service is adequate Methods: A two-part audit was undertaken of 98 and 99 consecutive patients respectively attending specialist glaucoma clinics. In the first part, the reasons for delayed appointments were recorded. In the second part the requested follow-up was compared with NICE guidelines where applicable. Based on the findings, changes were implemented and a re-audit of 100 patients was carried out. RESULTS: The initial audit found that although clinical decisions regarding follow-up intervals were 100% compliant with NICE guidelines where applicable, 24% of appointments were delayed beyond 15% of the requested period, due to administrative errors and inadequate capacity, leading to significant clinical deterioration in two patients. Following the introduction of an electronic appointment tracker and increased clinical capacity created by extra clinics and clinicians, the re-audit found a marked decrease in the percentage of appointments being delayed (9%). CONCLUSIONS: This audit is a useful tool to evaluate glaucoma service provision, assist in resource planning for the service and bring about change in a non-confrontational way. It can be widely applied and adapted for use in other medical specialities.

Using Technology to Support Data Analytics: A Chief Nursing Officer Accountability Scorecard.

Accountability for health system improvement is a requirement for nursing leadership in practice. However, to be accountable for organizational goals, nurse leaders need the tools to identify gaps in their microsystems of care. The purpose of this article was to provide a case study example of chief nursing officer (CNO) leadership in using a technology solution to develop a CNO accountability scorecard. This project highlights the HQ Essential for data analytics using an innovative technological approach to drive improvement at the front line of clinical care.

St. Michael's Improvement Program - A Collaborative Approach to Sustainable Cost Savings.

In response to a challenging financial environment and increasing patient demand, St. Michael's Hospital needed to find long-term sustainable solutions to continue to provide high-quality patient care and invest in key priorities. By conducting Operational Reviews in focused areas, the hospital achieved $7.4 million of in-year savings in the first year, found standardizations, process efficiencies and direct cost savings that positioned itself for success in future funding models. Initiatives were grounded in evidence and relied heavily on the effective execution by the leadership, front-line staff and physicians. As organizations face similar challenges, this journey can provide key learnings.

Self-audit of lockout/tagout in manufacturing workplaces: A pilot study.

BACKGROUND: Occupational health and safety (OHS) self-auditing is a common practice in industrial workplaces. However, few audit instruments have been tested for inter-rater reliability and accuracy. METHODS: A lockout/tagout (LOTO) self-audit checklist was developed for use in manufacturing enterprises. It was tested for inter-rater reliability and accuracy using responses of business self-auditors and external auditors. RESULTS: Inter-rater reliability at ten businesses was excellent (κ = 0.84). Business self-auditors had high (100%) accuracy in identifying elements of LOTO practice that were present as well those that were absent (81% accuracy). Reliability and accuracy increased further when problematic checklist questions were removed from the analysis. CONCLUSIONS: Results indicate that the LOTO self-audit checklist would be useful in manufacturing firms' efforts to assess and improve their LOTO programs. In addition, a reliable self-audit instrument removes the need for external auditors to visit worksites, thereby expanding capacity for outreach and intervention while minimizing costs.

Afghan migrants face more suboptimal care than natives: a maternal near-miss audit study at university hospitals in Tehran, Iran.

BACKGROUND: Women from low-income settings have higher risk of maternal near miss (MNM) and suboptimal care than natives in high-income countries. Iran is the second largest host country for Afghan refugees in the world. Our aim was to investigate whether care quality for MNM differed between Iranians and Afghans and identify potential preventable attributes of MNM. METHODS: An MNM audit study was conducted from 2012 to 2014 at three university hospitals in Tehran. Auditors evaluated the quality of care by reviewing the hospital records of 76 MNM cases (54 Iranians, 22 Afghans) and considering additional input from interviews with patients and professionals. Main outcomes were frequency of suboptimal care and the preventable attributes of MNM. Crude and adjusted odds ratios with confidence intervals for the independent predictors were examined. RESULTS: Afghan MNM faced suboptimal care more frequently than Iranians after adjusting for educational level, family income, and insurance status. Above two-thirds (71%, 54/76) of MNM cases were potentially avoidable. Preventable factors were mostly provider-related (85%, 46/54), but patient- (31%, 17/54) and health system-related factors (26%, 14/54) were also important. Delayed recognition, misdiagnosis, inappropriate care plan, delays in care-seeking, and costly care services were the main potentially preventable attributes of MNM. CONCLUSIONS: Afghan mothers faced inequality in obstetric care. Suboptimal care was provided in a majority of preventable near-miss events. Improving obstetric practice and targeting migrants' specific needs during pregnancy may avert near-miss outcomes.

Impact of observing hand hygiene in practice and research: a methodological reconsideration.

The purpose of hand hygiene is to break the chain of healthcare-associated infection. In many countries hand hygiene is regularly audited as part of quality assurance based on recommendations from the World Health Organization. Direct observation is the recommended audit method but is associated with disadvantages, including potential for being observed to alter usual behaviour. The Hawthorne effect in relation to hand hygiene is analogous with productivity improvement by increasing the frequency with which hand hygiene is undertaken. Unobtrusive and/or frequent observation to accustom staff to the presence of observers is considered an acceptable way of reducing the Hawthorne effect, but few publications have discussed how to implement these techniques or examine their effectiveness. There is evidence that awareness of being watched can disrupt the usual behaviour of individuals in complex and unpredictable ways other than simple productivity effect. In the presence of auditors, health workers might defer or avoid activities that require hand hygiene, but these issues are not addressed in guidelines for practice or research studies. This oversight has implications for the validity of hand hygiene audit findings. Measuring hand hygiene product use overcomes avoidance tactics. It is cheaper and generates data continuously to assess the compliance of all clinicians without disrupting patient care. Disadvantages are the risk of overestimating uptake through spillage, wastage, or use by visitors and non-clinical staff entering patient care areas. Electronic devices may overcome the Hawthorne and avoidance effects but are costly and are not widely used outside research studies.

Should hospital managers read the orthopedic literature before surgeons? The example of femur fracture management.

BACKGROUND: Early surgical intervention in the treatment of proximal femur fractures has been shown to significantly reduce mortality and complications. Our study intends to evaluate early surgery rates in a single-center analysis before the clinical advantages of early surgical intervention were demonstrated in the literature (G1), after the orthopedic team aimed to treat those fractures within 48 h (G2), and after early intervention became a primary objective for hospital management (G3). MATERIALS AND METHODS: The hospital charts of 894 proximal femur fractures in patients aged >65 years between 2008 and 2015 were analyzed in a single teaching hospital. The patients were allocated to three groups according to admission date, relative to the introduction of the different targets for early intervention. Our primary aim was to evaluate the differences in the rate of surgical treatment within 48 h in the three groups, and our secondary aim was to see if those differences influenced clinical outcomes. RESULTS: The rate of treatment before 48 h was 23, 49 and 72 % in groups 1, 2 and 3, respectively (p < 0.001). There were no statistically significant differences between the three groups regarding time from surgery to discharge and perioperative mortality. The length of hospitalization was different only between groups 1 and 2. CONCLUSIONS: The adoption of an early treatment goal for proximal femur fractures by the orthopedic team significantly improved the results. However, it was only by introducing this goal into primary hospital management objectives that significantly increased the performance. Level of evidence Level IV (retrospective case-control study).

Optimising measurement of health-related characteristics of the built environment: Comparing data collected by foot-based street audits, virtual street audits and routine secondary data sources.

The role of the neighbourhood environment in influencing health behaviours continues to be an important topic in public health research and policy. Foot-based street audits, virtual street audits and secondary data sources are widespread data collection methods used to objectively measure the built environment in environment-health association studies. We compared these three methods using data collected in a nationally representative epidemiological study in 17 British towns to inform future development of research tools. There was good agreement between foot-based and virtual audit tools. Foot based audits were superior for fine detail features. Secondary data sources measured very different aspects of the local environment that could be used to derive a range of environmental measures if validated properly. Future built environment research should design studies a priori using multiple approaches and varied data sources in order to best capture features that operate on different health behaviours at varying spatial scales.

Psychometric properties of the Irish Management Standards Indicator Tool.

BACKGROUND: Work Positive is Ireland's national policy initiative to control work-related stress. Since the introduction of the UK Health and Safety Executive's Management Standards (MS) in 2004, a number of studies have been undertaken to assess the potential adaptation of the MS framework within Ireland. AIMS: To investigate the dimensionality, reliability and validity of the Irish version of the MS Indicator Tool (ROI-MSIT). METHODS: Between February 2011 and June 2014, we collected data from a wide range of public and private sector organizations that used the ROI-MSIT. In addition to the ROI-MSIT, respondents completed the WHO-Five Well-being Index (WHO-5). Exploratory factor analysis (EFA) was used to determine whether the ROI-MSIT maintained the structure of the UK instrument. The internal consistency of the ROI-MSIT was also assessed to determine its reliability, while its criterion-related validity was explored through correlation analysis with the WHO-5. RESULTS: Data were collected from 7377 participants. The factor structure of the ROI-MSIT consisted of six factors; the Demands, Control, Peer Support, Relationships and Role factors were equivalent to the original UK factors. Like the Italian version, a principal factor emerged that combined the Manager Support and Change domains. Cronbach's alpha scores ranged from 0.75 to 0.91. Finally, the ROI-MSIT's subscales and WHO-5 were positively correlated (r = 0.42-0.59, P < 0.001). CONCLUSIONS: The ROI-MSIT is reliable and valid, with a factor structure similar to the original UK instrument and the Italian MSIT. Further psychometric evaluation of the ROI-MSIT is recommended.