A strategic approach to safeguard global supply chains against COVID‐19 disruptions

The global system of supply chains has been dramatically disrupted over the last years due to the outbreak of the COVID‐19 pandemic. In these current challenging times, this paper proposes a methodological approach for managing dependence and uncertainty in dynamic industrial scenarios. A detailed study of epidemic effects is carried out according to an operational management‐based perspective. We proceed by analyzing connections among effects and risks potentially leading to significant supply chain disturbances through a multicriteria approach. Risks and effects are weighted by applying the Analytic Network Process (ANP). Weighted risks are then assumed as criteria for selecting the most suitable contingency strategy. To this aim, the Fuzzy Technique for Order of Preference by Similarity to Ideal Solution (FTOPSIS) is able to rank a set of strategies by addressing and quantifying uncertainty. A case study on the sector of the automotive industry is implemented to validate the proposed methodological approach. [ FROM AUTHOR] Copyright of Mathematical Methods in the Applied Sciences is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Analysis of the Application Effect of Career Planning Management-A Case of the Tax Consulting Industry

The epidemic situation in COVID-19 aggravated the pressure and challenges of enterprises management, which directly affected employees' working attitudes. This paper takes organizational career planning management as the independent variable and takes job satisfaction, turnover intention, and organizational commitment as the proxy variables of dependent variables. H Company is taken as the research object, with 17 qualitative interviews and 645 cluster sampling surveys. Through correlation and regression analysis, the conclusions can be drawn: 1. The implementation of career planning management has a significant impact on employees' work attitude, a positive impact on job satisfaction and organizational commitment, and a negative impact on turnover intention. 2. Each dimension of career planning management has a different action mechanism on each proxy variable of employees' work attitudes. Fair promotion, providing information, and paying attention to training and career development in career planning management can significantly promote job satisfaction and job commitment. However, paying attention to training and career development significantly inhibits turnover intention, while the other two dimensions have no significant influence. Based on these conclusions, the enterprises can promote employees' job satisfaction and organizational commitment by enhancing their career planning management awareness, establishing a perfect career planning management system, and carrying out diversified career planning management practices. © 2023 The authors and IOS Press.

Teaching effect Analysis and Behavior detection of an online dance Learning Platform in the Context of CoVId-19

Online classrooms have been widely used during the COVID-19 epidemic. However, due to the intuitive, practical, and emotional characteristics of dance majors, online classroom teaching still has certain limitations. Through the advantages of online classroom teaching during the epidemic prevention and control stage, the problems faced and their solutions are summarized and reflected. The article analyzes the advantages, existing problems, and solutions of online dance teaching, and designs an online dance learning platform quality assessment. After using the online learning platform, students' enthusiasm for dance learning has improved a lot, and students are more interested in dance teaching. The satisfaction of the effect has increased from 76% to 85%, and the detection efficiency of the platform is very high. The experimental results also show that in the context of the new crown epidemic, the use of online learning platforms can not only stimulate students' interest in learning, but also improve the quality of teaching. Copyright © 2022, IGI Global.

Logistics System Risk Analysis Using FMEA-AHP Methodology: During and after the COVID-19 pandemic

The COVID-19 pandemic broke out, and the global logistics industry suffered severe losses, therefore, the FMEA-AHP (Failure Mode and Effects Analysis-Analytic Hierarchy Process) method is proposed to analyze the failure reasons of the logistics system in the COVID-19 pandemic. In this article, we have made an improvement on the basis of the traditional FMEA method: The AHP is integrated into the FMEA algorithm (referred to as RPWN (risk priority weighted number) in this article). In this algorithm, the AHP is to determine the weights of risk indicators. Meanwhile, in this article, we also consider about the new logistics failures, such as the failure modes and failure reasons of the logistics system under the COVID-19 pandemic. 12 failures have been identified, and corresponding preventive and corrective measures have been suggested to cut off the path of failure propagation and reduce the impact of failures. © 2022 ACM.

Implementation of a health screening process for cystic fibrosis care during the COVID-19 pandemic

Background: Cystic fibrosis (CF) is associated with complications such as CF-related diabetes (CFRD) and bone disease. The Cystic Fibrosis Foundation advises routine screenings as the standard of care for early identification and treatment of these complications. Specifically, the foundation recommends annual completion of an oral glucose tolerance test (OGTT) and a dual-energy X-ray absorptiometry (DEXA) bone density scan at least every 5 years. In 2019, 55% of eligible patients completed an OGTT, and 68% completed a DEXA scan at UVA Health System (UVAHS). Transition of in-person clinic visits to telemedicine during 2020 and 2021 decreased completion of health screenings. The UVAHS team used quality improvement tools to design a process to maintain and increase OGTT and DEXA completion rates with the newhybrid nature of clinical care. The aim of this project is to define a replicable, reliable process for obtaining health screenings in the setting of hybrid patient care. Method(s): Quality improvement tools highilghted in the Model for Improvement methodology guided production of a simplified failure mode effects analysis (sFMEA) to identify areas for intervention. A process was developed to track patient eligibility and completion of screenings and adapted through iterative plan-do-study-act (PDSA) cycles. CF registered dietitians (RDs) documented completion of OGTTs and DEXAs in a secure Excel spreadsheet coded to flag patients due for each health screening. Two weeks before clinic, both RDs referenced the spreadsheet to determine patients due for health screenings. All identified patientswere contacted to inform them of the health screenings due. Patients and RDs then coproduced a plan for completion of the health screenings at an in-person visit, at a local lab, or in conjunction with a non-CF health care appointment. Regardless of the plan, patients were provided outpatient lab order requisitions. To ensure communication with other care team members, patients contacted about and scheduled for their screenings were denoted in the shared Health Insurance Portability and Accountability Act-compliant clinic tracking platform. Clinic nurses received outside lab results via fax and all in-house results through the electronic medical record system. Once lab results were reviewed and communicated to the patient, the health screening spreadsheet was updated. Result(s): In 2020 and 2021, 39% of eligible patients completed an OGTT, and 76% of eligible patients completed a DEXA scan. Of thosewho completed an OGTT in 2020 and 2021, 68% and 74%, respectively, indicated abnormal results consistent with impaired fasting glucose tolerance or CF-related diabetes. Most patients with up-to-date DEXA scans by the end of 2021 were positive for osteopenia or osteoporosis (53%). Conclusion(s): Through the creation of a standardized protocol using iterative PDSA cycles, patients continued to sustain routine health screenings despite reduced in-person clinic visits, allowing for identification and intervention for many patients regarding diabetes and bone health. Continuation of this protocol will enhance our ability to collect patient health screenings while providing the same high-quality care via telemedicine that we provide with in-person visits. Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

A New Emergency-Risk-Evaluation Approach under Spherical Fuzzy-Information Environments

When major emergencies or accidents occur, risk evaluation and prediction are the most important means to reduce their impact. Typical risk evaluation uses the failure mode and effects analysis (FMEA) method for failure-risk ranking and control. However, when faced with severe special infectious diseases such as COVID-19, there are many cognitive and information uncertainties that the FMEA method is unable to effectively handle. To effectively deal with the issue of risk evaluation when major emergencies or accidents occur, this paper integrated the risk-priority number and spherical fuzzy-sets methods to propose a novel emergency-risk-evaluation method. In the numerical verification, this paper applied the example of preventing secondary COVID-19 transmissions in hospitals to explain the calculation procedure and validity of the proposed new emergency-risk-evaluation approach. The calculation results were also compared with the typical RPN, fuzzy-set, and intuitionistic fuzzy-set methods. The calculation results showed that the proposed new emergency-risk-evaluation approach could effectively handle the cognitive and informational uncertainties of emergency-risk-evaluation issues during the COVID-19 pandemic. [ FROM AUTHOR] Copyright of Axioms (2075-1680) is the property of MDPI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Balancing Infectious Disease Control and Radiotherapy Risk Management Using a Novel Analytic Approach

To develop an analytic risk management method that uses mathematical models in Failure Modes and Effects Analysis (FMEA) to design mitigation efforts to control pandemic infection, while ensuring safe delivery of radiotherapy. A two-stage FMEA approach is proposed to modify radiotherapy workflow during a pandemic. In stage 1, an Infection Control FMEA (IC-FMEA) is conducted, where risks are evaluated based on environmental parameters, clinical interactions, and modeling of the pandemic infection risk. Occupancy' Risk Index (ORI) is defined as a metric of infection risk probability in each room, based on the degree of occupancy during clinical operations. ORI, in combination with ventilation rate per person (R p), is used to provide a broad infection risk assessment of workspaces. For detailed IC-FMEA of clinical processes, Infection containment failure mode (ICFM) is defined to be any instance of disease transmission within the clinic. Infection risk priority number (IRPN) has been formulated as a function of time, distance, and degree of protective measures. Infection control measures are then systematically integrated into the workflow. In stage 2, a conventional radiotherapy FMEA (RT-FMEA) can be performed on the adjusted workflow. A number of different clinical processes within radiotherapy workflow have been evaluated with this approach. The COVID-19 pandemic was used to illustrate stage 1 IC-FMEA. ORI and R p values were calculated for various workspaces within a radiotherapy clinic. A deep inspiration breath hold (DIBH) CT simulation was used as an example to demonstrate detailed IC-FMEA with ICFM identification and IRPN evaluation. A total of 90 ICFMs were identified in the DIBH process. For minimal protective measures the IRPN values ranged from 2 – 1200, while for increasing degrees of infection control the values decreased to 2-530 and 1-189 corresponding to moderate and enhanced measures respectively. The framework developed in this work provides tools for radiotherapy clinics to analytically assess risks and adjust workflows during a pandemic. [ FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Medication Safety Training: An Opportunity for Virtual Interactive Case System Innovation

Background: Current literature on virtual cases illustrates increased student self-directed learning and satisfaction. Yet, the use of virtual cases has not been explored in the context of patient or medication safety. Description: The Virtual Interactive Case (VIC) System allows educators to create online clinical reasoning scenarios with a bridge between theory and practice. We aimed to share our experience in the development and evaluation of 3 VIC teaching modules on patient or medication safety. Action: We created VIC training modules on medication incident disclosure, root cause analysis (RCA), and failure mode and effects analysis (FMEA). We piloted tested them during the COVID-19 pandemic. Evaluation: We administered a 16-item online questionnaire from May 22, 2020, to June 8, 2020 and obtained feedback from pharmacy students and practitioners in Ontario, Canada. Most of our 18 respondents had 1-5 years of practice experience. Their practice settings ranged from associations, academia, to community pharmacies and hospitals. Respondents found the VIC platform easy to navigate. They perceived the content to be relevant and easy to implement in patient care settings. Majority of them indicated that they were confident in carrying out incident disclosure, RCA, and FMEA at their practice settings. Implications: The VIC System can be used to educate students and practitioners on patient or medication safety. It is a safe and user-friendly platform to support patient safety in virtual pharmacy care.

Telehealth and Medical Education - Training the Next Generation of Virtual Care Providers

Background: The COVID-19 pandemic transformed care delivery and impacted how academic healthcare systems teach and train. Teaching hospitals launched telehealth programs in multiple specialties with high adoption rates. The AAMC developed crosscontinuum competencies in TeleHealth & the ACGME revised its common program requirements' levels of supervision with guidance on telehealth supervision by faculty. As adoption increased, telehealth issues unique to teaching settings arose such as rounding, faculty & trainees' competence, supervision skills, among others. The main goal of this is to effectively embed TeleHealth across a free-standing teaching hospital and evaluate its impact. Methods: To reach our goals, we aligned telehealth training and competence-building with institutional inter-disciplinary areas including Medical Education. This focused on two areas: 1- Competence-building throughout GME training: TeleHealth-specific educational goals, training models, and aligning telehealth training and implementation with trainees' daily activities e.g. orientation, integration in resident subspecialty experiences, virtual care, virtual rounding and shadowing, to enhance residents' experiences. TeleHealth was also adopted as one of the quality improvement (QI) focus areas in trainees' projects addressing care coordination, discharge planning, patient satisfaction, among others. 2- Faculty professional development to prepare supervisors for their roles in feedback and supervision and the provision of safe care. Data sources for program evaluation metrics and key performance indicators and QI projects included clinical databases e.g. electronic health record;Business Intelligence Telehealth Dashboard;surveys;telehealth App reports and other tools. Data was collected monthly and reported quarterly. Process improvement, Lean methodologies were used for program evaluation (e.g., A3, process mapping flowchart, failure modes and effects analysis). Metrics included number of providers and trainees who completed TeleHealth training;unique children receiving virtual care in over 24 pediatric specialties;access to virtual care (wait time) compared to in-person;patient/parent and guardian satisfaction;among other metrics. Results: Through phased implementation and stakeholders' collaboration in various settings, a pediatric teaching hospital incorporated telehealth training across the GME continuum, and aligned GME trainees' competencies with the AAMC telehealth competencies. Details on few residents' QI projects will be shared in discharge planning, care transition, and patient experience. Program evaluation results and lean tools supported identification of best practices in telehealth care, lessons learned in training, and implementation which are used to inform future planning, implementation, and continuous program evaluation. Process improvement and lean projects contributed to enhancements in telehealth training and competence-building. Conclusion: Our results along with the lessons learned will help inform medical education and telehealth training implementation for students, and trainees to deliver high quality virtual care, improve access, control costs and optimize the patient experience. Best practices will be highlighted aimed at preparing the next generation of physicians and support healthcare innovation to meet the needs of patients and families during the pandemic and beyond. (Figure Presented).

Extra-analytical Point of Care Testing errors in the pandemic era

Introduction: during the current SARS-CoV-2 pandemic phase, the use of rapid diagnostic devices outside the laboratory has expanded enormously, creating great opportunities but also new risks. Methods: the present observational study evaluated the type and frequency of errors of the extra-analytical phases through an active search on all unclear or ambiguous cases. 252 241 rapid antigenic tests performed outside the laboratory in different health facilities over a 132-day period were considered. The requests, the patient demographics and the results were later entered manually onto the Laboratory Information System (LIS). Results: through a number of data checks and internal reports, 2 556 cases of errors in the pre-examination phase were recorded, with a relative frequency of 12,274 parts per million (ppm). The vast majority of errors were observed in this phase;these were due mainly to computer communication problems induced by human errors that made the loading of results or the issuing of the reports difficult. The remaining cases involving erroneous personal data or patient identification amounted to 16 (64 ppm), confirming the relative safety of this phase in decentralized analysis. The errors identified in the post-examination phase were 540, with a relative frequency of 2140 ppm. The assessment of the severity of the errors with Failure Mode and Effect Analysis (FMEA) allowed us to identify in particular, the attribution of the report to the wrong person (20 ppm) and the manual transcription of an incorrect result (20 ppm). Discussion: this study contributes to the comprehension of the critical issues connected to the Point of Care Testing and made it possible to establish corrective actions: improving staff training, choice of instruments with reading devices and establishing direct computer connection for the entering of the requests and results to the LIS.

A fuzzy multicriteria group decision approach for classification of failure modes in a hospital’s operating room

The operating room (OR) is one of the most important departments of any hospital. Mismanagement can lead to severe problems with patient’s safety and satisfaction, costs, and profitability. The Failure Mode and Effects Analysis (FMEA) is a risk assessment tool used to identify potential failure modes (FM) which should be prioritized to be mitigated. To assess the risks of an OR, some important aspects cannot be neglected: it should be conducted by a team of experts from different functional areas;address the non-compensation between criteria;classify FM, instead of ranking it, since it is easier to understand and support decision making;address the subjectivity present on experts’ opinion;and consider the mitigation complexity, since hospital’s resources are limited. However, were not found studies in the literature which simultaneously covered all these aspects. Therefore, this paper proposes a new group decision model, which combines a consensus reaching process with ELECTRE TRI and double hierarchy hesitant fuzzy linguistic term sets (DHHFLTS). A pilot application of the model was conducted in an OR of a Brazilian hospital. The results have shown that the consensus technique, the mitigation complexity, and the non-compensation can modify the failure modes classification. Also, the DHHFLTS allowed the experts to use more complex linguistic terms to express their opinion. In addition, the pilot application was carried out during the covid-19 pandemic and the results have shown that due to the high number of elective surgeries being rescheduled to give space to urgent surgeries, the patients' health problems become even worst and they turn to urgent surgeries.

Cystic fibrosis learning network telehealth innovation lab during the COVID-19 pandemic: a success QI story for interdisciplinary care and agenda setting.

INTRODUCTION: The Cystic Fibrosis Foundation chronic care guidelines recommend monitoring clinical status of a patient with cystic fibrosis (CF) through quarterly interdisciplinary visits. At the beginning of the COVID-19 pandemic, the Cystic Fibrosis Learning Network (CFLN) designed and initiated a telehealth (TH) innovation lab (TH ILab) to support transition from the classic CF care model of quarterly in-person office visits to a care model that included TH. AIM: The specific aims of the TH ILab were to increase the percentage of virtual visits with interdisciplinary care (IDC) from 60% to 85% and increase the percentage of virtual visits in which patients and families participated in shared agenda setting (AS) from 52% to 85% by 31 December 2020. METHODS: The model for improvement methodology was used to determine the ILab aims, theory, interventions and measures. In the testing phase of the ILab, data related to process and outcome measures as well as learnings from plan-do-study-act cycles were collected, analysed and shared weekly with the TH ILab teams. Participating centres created processes for IDC and AS for TH visits and developed and shared quality improvement tools specific to their local context with other centres during the ILab weekly meetings and via a secure CFLN-maintained platform. RESULTS: Both specific aims were achieved ahead of the expected target date. By August 2020, 85% of the TH ILab visits provided IDC and 92% of patients were seen for CF care by teams from the TH ILab that participated in AS. CONCLUSION: Shared learning through a collaborative, data-driven process in the CFLN TH ILab rapidly led to standardised TH IDC and AS, which achieved reliable and sustainable processes which could be reproduced by other networks.

Modification in the Motor Skills of Seniors in Care Homes Using Serious Games and the Impact of COVID-19: Field Study.

BACKGROUND: The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. At the beginning of 2020, the COVID-19 pandemic led to many restrictions, which affected seniors in care facilities in the form of severe isolation. The isolation led, among other things, to a lack of exercise, which has led to a multitude of negative effects for this target group. Serious games can potentially help by being used anywhere at any time to strengthen skills with few resources. OBJECTIVE: The aim of this study is to evaluate the effectiveness of a serious game to strengthen motor skills (study 1) and the influence of pandemic restrictions (study 2) on seniors in care facilities. METHODS: The data on motor skills (measured by the Tinetti test) originated from an intervention study with repeated measurements that was interrupted by the pandemic conditions. Data were collected 4 times every 3 months with an intervention group (IG, training 3 times for 1 hour per week) and a control group (CG, no intervention). There were 2 substudies. The first considered the first 6 months until the pandemic restrictions, while the second considered the influence of the restrictions on motor skills. RESULTS: The sample size was 70. The IG comprised 31 (44%) participants, with 22 (71%) female and 9 (29%) male seniors with an average age of 85 years. The CG comprised 39 (56%) participants, with 31 (79%) female and 8 (21%) male seniors with an average age of 87 years. In study 1, mixed-design ANOVA showed no significant interaction between measurement times and group membership for the first measurements (F2.136=1.414, P<.25, partial η2=.044), but there was a significant difference between the CG (mean 16.23, SD 1.1) and the IG (mean 19.81, SD 1.2) at the third time of measurement (P=.02). In study 2 the mixed-design ANOVA (used to investigate motor skills before and after the pandemic conditions between the 2 groups) couldn't reveal any significant interaction between measurement times and group membership: F1.67=2.997, P<.09, partial η2=.043. However, there was a significant main effect of the time of measurement: F1.67=5.44, P<.02, partial η²=.075. CONCLUSIONS: During the first 6 months, the IG showed increased motor skills, whereas the motor skills of the CG slightly deteriorated and showed a statistically significant difference after 6 months. The pandemic restrictions leveled the difference and showed a significant negative effect on motor skills over 3 months. As our results show, digital games have the potential to break down access barriers and promote necessary maintenance for important skills. The pandemic has highlighted the importance of low-threshold opportunities for exercise and physical activity. This potentially great benefit for the challenges of tomorrow shows the relevance of the topic and demonstrates the urgent need for action and research. TRIAL REGISTRATION: Deutsches Register klinischer Studien DRKS00016633; https://tinyurl.com/yckmj4px.

Upstream cell culture process characterization and in-process control strategy development at pandemic speed.

As of early 2022, the coronavirus disease 2019 (COVID-19) pandemic remains a substantial global health concern. Different treatments for COVID-19, such as anti-COVID-19 neutralizing monoclonal antibodies (mAbs), have been developed under tight timelines. Not only mAb product and clinical development but also chemistry, manufacturing, and controls (CMC) process development at pandemic speed are required to address this highly unmet patient need. CMC development consists of early- and late-stage process development to ensure sufficient mAb manufacturing yield and consistent product quality for patient safety and efficacy. Here, we report a case study of late-stage cell culture process development at pandemic speed for mAb1 and mAb2 production as a combination therapy for a highly unmet patient treatment. We completed late-stage cell culture process characterization (PC) within approximately 4 months from the cell culture process definition to the initiation of the manufacturing process performance qualification (PPQ) campaign for mAb1 and mAb2, in comparison to a standard one-year PC timeline. Different strategies were presented in detail at different PC steps, i.e., pre-PC risk assessment, scale-down model development and qualification, formal PC experiments, and in-process control strategy development for a successful PPQ campaign that did not sacrifice quality. The strategies we present may be applied to accelerate late-stage process development for other biologics to reduce timelines.

Construction and Effect Analysis of MOOC-Based Self-organized Teaching and Research Model for Primary and Secondary School Teachers

The outbreak of the COVID-19 epidemic has promoted the development of online teaching and research for primary and secondary school teachers, and has forced them to improve their informatized teaching abilities rapidly. This research is guided by the basic principles of online teaching and learning, integrated into the 'Internet +' thinking, and adopts literature research and theoretical deduction to determine self-organized teaching and research steps, which includes 'Clear needs and starting evolution-Spontaneous learning, triggering ups and downs- Interactive communication and cause mutations- Generating results and triggering transitions-Migration practices, gathering and bifurcating'. This research gives full play to the supporting role of MOOC (Massive Open Online Course) platforms, resources and tools. Finally, the MOOC-based self-organized teaching and research model for primary and secondary school teachers is constructed. On this basis, this research relies on the 'Smart Classroom Teaching' on the Chinese University MOOCs Platform, and the quasiexperimental research method is used to carry out the practical application of the self-organized teaching and research model. Effect analysis shows that this model can improve the teaching and research performance of primary and secondary school teachers in a short period, prompting teachers to achieve a deep understanding of smart classroom teaching, and effectively solve real-world education and teaching problems. © 2021 IEEE.

Holistic risk assessment of container shipping service based on Bayesian Network Modelling

Container shipping makes significant contribution to the global economy and is confronted with various hazards and risks especially during the COVID-19 pandemic. These risks can disrupt resilient container shipping service, leading to further deterioration of the global economy. Hence, it is vital to develop resilient container shipping service, which is associated with being on-time, safe, and hassle-free. Theoretically, this research identifies 28 root risks using the PESTLE framework, conducts risk assessment using a hybrid method comprising failure modes and effects analysis, evidential reasoning, and rule-based Bayesian network. A three-hierarchy Bayesian network model is established. The results reveal that economic, political, and technical risks are the most threatening risks affecting resilient container shipping service. Moreover, the holistic container shipping risk is most sensitive to environmental risks. Managerially, this research provides container shipping companies with guidance of drafting risk mitigation plans with economic risks and political risks as priorities.

Systems engineering analysis of diagnostic referral closed-loop processes.

BACKGROUND: Closing loops to complete diagnostic referrals remains a significant patient safety problem in most health systems, with 65%-73% failure rates and significant delays common despite years of improvement efforts, suggesting new approaches may be useful. Systems engineering (SE) methods increasingly are advocated in healthcare for their value in studying and redesigning complex processes. OBJECTIVE: Conduct a formative SE analysis of process logic, variation, reliability and failures for completing diagnostic referrals originating in two primary care practices serving different demographics, using dermatology as an illustrating use case. METHODS: An interdisciplinary team of clinicians, systems engineers, quality improvement specialists, and patient representatives collaborated to understand processes of initiating and completing diagnostic referrals. Cross-functional process maps were developed through iterative group interviews with an urban community-based health centre and a teaching practice within a large academic medical centre. Results were used to conduct an engineering process analysis, assess variation within and between practices, and identify common failure modes and potential solutions. RESULTS: Processes to complete diagnostic referrals involve many sub-standard design constructs, with significant workflow variation between and within practices, statistical instability and special cause variation in completion rates and timeliness, and only 21% of all process activities estimated as value-add. Failure modes were similar between the two practices, with most process activities relying on low-reliability concepts (eg, reminders, workarounds, education and verification/inspection). Several opportunities were identified to incorporate higher reliability process constructs (eg, simplification, consolidation, standardisation, forcing functions, automation and opt-outs). CONCLUSION: From a systems science perspective, diagnostic referral processes perform poorly in part because their fundamental designs are fraught with low-reliability characteristics and mental models, including formalised workaround and rework activities, suggesting a need for different approaches versus incremental improvement of existing processes. SE perspectives and methods offer new ways of thinking about patient safety problems, failures and potential solutions.

Home spirometry utilisation in telemedicine clinic for cystic fibrosis care during COVID-19 pandemic: a quality improvement process.

IntroductionThe Cystic Fibrosis (CF) Foundation chronic care guidelines recommend monitoring spirometry during quarterly multidisciplinary visits to identify early lung function decline. During the COVID-19 pandemic, the CF adult clinic at University of Virginia (UVA) transitioned from the classic CF care model to a model that included quarterly multidisciplinary telemedicine visits. While using telemedicine, CF care needed to include spirometry monitoring. Only a fraction of adult CF patients at UVA owned and used home spirometers (HS) in March 2020. AIM: The specific aims of this quality improvement (QI) project were to increase the percentage of eligible adult CF patients who owned an HSs from 37% to 85% and to increase the percentage of adult CF patients seen at UVA with available spirometry in telemedicine from 50% to 95% by 31 December 2020. METHODS: Following the Model for Improvement QI methodology, a standardised process was developed for monitoring forced expiratory volume in 1 s with HS during multidisciplinary telemedicine visits during the COVID-19 pandemic. INTERVENTION: (1) HSs were distributed to eligible patients and (2) Home spirometry was monitored in eligible patients with each telemedicine visit and results were used for clinical care decisions. RESULTS: Both specific aims were achieved ahead of expected date. In March 2020, the beginning of the pandemic, 37% (49/131) of patients owned an HS and 50% (9/18) of patients seen via telemedicine performed spirometry at home. By September 2020, 97% (127/131) of adult patients at UVA owned an HS and by October 2020, 96% (24/25) of patients provided spirometry results during their telemedicine encounters. CONCLUSION: Employing QI tools to standardise the process of monitoring spirometry data with home devices via telemedicine is reliable and sustainable and can be replicated across centres that provide care for patients with CF.

Use of failure modes and effects analysis to mitigate potential risks prior to implementation of an intravenous compounding technology.

PURPOSE: The purpose of this study was to identify potential failure points in a new chemotherapy preparation technology and to implement changes that prevent or minimize the consequences of those failures before they occur using the failure modes and effects analysis (FMEA) approach. METHODS: An FMEA was conducted by a team of medication safety pharmacists, oncology pharmacists and technicians, leadership from informatics, investigational drug, and medication safety services, and representatives from the technology vendor. Failure modes were scored using both Risk Priority Number (RPN) and Risk Hazard Index (RHI) scores. RESULTS: The chemotherapy preparation workflow was defined in a 41-step process with 16 failure modes. The RPN and RHI scores were identical for each failure mode because all failure modes were considered detectable. Five failure modes, all attributable to user error, were deemed to pose the highest risk. Mitigation strategies and system changes were identified for 2 failure modes, with subsequent system modifications resulting in reduced risk. CONCLUSION: The FMEA was a useful tool for risk mitigation and workflow optimization prior to implementation of an intravenous compounding technology. The process of conducting this study served as a collaborative and proactive approach to reducing the potential for medication errors upon adoption of new technology into the chemotherapy preparation process.

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly.

BACKGROUND: To analyse a medical accident, much time and experience are needed. However, people without experience in analysis have difficulty understanding its conditions and methods, and as a result it takes longer to establish countermeasures. It must be noted that understanding conditions by simply aligning occurrences in the accident in a chronological order is difficult. PURPOSE: A workflow chart that considers time was proposed so that individuals without adequate experience in analysis could easily carry out root cause analysis. METHODS: In the 'workflow chart (WFC)', the time sequence was described horizontally. On the vertical axis, the business manual, the occurrence of the accident, and the time of the occurrence are displayed. In the bottom column of patient event, information regarding damage to patients was written in accordance with time axis. Regarding the degree of damage, the time of error until the accident was identified was connected using a straight line (when the patient was not affected, a dotted line was used) in order to show the overall picture of the accident. RESULTS: According to the time flow chart, hints to identify potential risks were proposed. Focus was placed not only on the error event, but also on keywords such as manual inadequacy, time gap, degree of error and so on to easily lead to the question 'why?' To visualise this, I proposed an operation flow chart. By using time-WFC, even beginners can easily develop accident countermeasure strategies. CONCLUSION: Using a WFC that considers time, time of error and the occurrence of accident could be visualised. As a result, even individuals without experience in analysis could easily perform an analysis.