Community-engaged Systems for Population Health Improvement: A Novel Approach to Improve Diabetes Outcomes in Rural Communities.

BACKGROUND: Approaches to prevent and manage diabetes at a community population level are hindered because current strategies are not aligned with the structure and function of a community system. We describe a community-driven process based on local data and rapid prototyping as an alternative approach to create diabetes prevention and care management solutions appropriate for each community. We report on the process and provide baseline data for a 3-year case study initiative to improve diabetes outcomes in two rural Nebraska communities. METHODS: We developed an iterative design process based on the assumption that decentralized decision-making using local data feedback and monitoring will lead to the innovation of local sustainable solutions. Coalitions act as community innovation hubs and meet monthly to work through a facilitated design process. Six core diabetes measures will be tracked over the course of the project using the electronic health record from community clinics as a proxy for the entire community. RESULTS: Baseline data indicate two-thirds of the population in both communities are at risk for prediabetes based on age and body mass index. However, only a fraction (35% and 12%) of those at risk have been screened. This information led both coalitions to focus on improving screening rates in their communities. DISCUSSION: In order to move a complex system towards an optimal state (e.g., improved diabetes outcomes), stakeholders must have access to continuous feedback of accurate, pertinent information in order to make informed decisions. Conventional approaches of implementing evidence-based interventions do not facilitate this process.

Barriers and Facilitators to Breast and Cervical Cancer Screenings for Hispanic Women in a Rural State.

INTRODUCTION: The Centers for Disease Control and Prevention (CDC) and the Division of Cancer Prevention of Control administer the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), designed to increase early detection of cancers among low-income uninsured and underinsured women. However, rates of cancer diagnosis and survivorship differ among women of different ethnicities. We investigated two questions: 1) what are the potential barriers and facilitators for women to complete recommended breast and cervical cancer screenings, and 2) are the barriers and facilitators different for Hispanic women when compared to non-Hispanic White women? METHODS: We used a community-based participatory research approach and mixed methods: qualitative interviews with women enrolled in the program and a systematic process improvement approach to identify root causes of completing or not completing screenings. We conducted semi-structured interviews in English (n = 11) and Spanish (n = 9) and analyzed responses using fishbone diagrams. RESULTS: We recruited 20 participants in four categories: (a) non-Hispanic White women who completed screenings (n = 9), (b) non-Hispanic White women who did not complete screenings (n = 2), (c) Hispanic women who completed screenings (n = 7), and (d) Hispanic women who did not complete screenings (n = 2). Among all women, facilitators included assistance from program staff with appointments and reminders. Hispanic women reported barriers including language difficulties and confusion about the program. Non-Hispanic White women identified barriers as confusion about the role of insurance. CONCLUSIONS: We found that there are differences in barriers and facilitators for non-Hispanic White women and Hispanic women due to language, the role of insurance, and the level of trust in the program. Reasons for not completing screenings for Hispanic women were structural and systemic in nature; reasons for non-Hispanic White women were based on personal choices.

Diagnosing patient flow issues in the emergency department: an Australasian hospital case study.

PURPOSE: This study investigates how a hospital can increase the flow of patients through its emergency department by using benchmarking and process improvement techniques borrowed from the manufacturing sector. DESIGN/METHODOLOGY/APPROACH: An in-depth case study of an Australasian public hospital utilises rigorous, multi-method data collection procedures with systems thinking to benchmark an emergency department (ED) value stream and identify the performance inhibitors. FINDINGS: High levels of value stream uncertainty result from inefficient processes and weak controls. Reduced patient flow arises from senior management's commitment to simplistic government targets, clinical staff that lack basic operations management skills, and fragmented information systems. High junior/senior staff ratios aggravate the lack of inter-functional integration and poor use of time and material resources, increasing the risk of a critical patient incident. RESEARCH LIMITATIONS/IMPLICATIONS: This research is limited to a single case; hence, further research should assess value stream maturity and associated performance enablers and inhibitors in other emergency departments experiencing patient flow delays. PRACTICAL IMPLICATIONS: This study illustrates how hospital managers can use systems thinking and a context-free performance benchmarking measure to identify needed interventions and transferable best practices for achieving seamless patient flow. ORIGINALITY/VALUE: This study is the first to operationalise the theoretical concept of the seamless healthcare system to acute care as defined by Parnaby and Towill (2008). It is also the first to use the uncertainty circle model in an Australasian public healthcare setting to objectively benchmark an emergency department's value stream maturity.

Patient-perceived barriers to early initiation of prenatal care at a large, urban federally qualified health center: a mixed-methods study.

BACKGROUND: Early initiation of prenatal care is widely accepted to improve the health outcomes of pregnancy for both mothers and their infants. Identification of the various barriers to entry into care that patients experience may inform and improve health care provision and, in turn, improve the patient's ability to receive necessary care. AIM: This study implements a mixed-methods approach to establish methods and procedures for identifying barriers to early entry to prenatal care in a medically-vulnerable patient population and areas for future quality improvement initiatives. METHODS: An initial chart review was conducted on obstetrics patients that initiated prenatal care after their first trimester at a large federally qualified health center in Brooklyn, NY, to determine patient-specified reasons for delay. A thematic analysis of these data was implemented in combination with both parametric and non-parametric analyses to characterize the population of interest, and to identify the primary determinants of delayed entry. RESULTS: The age of patients in the population of interest (n = 169) was bimodal, with a range of 15 - 43 years and a mean of 28 years. The mean gestational age of entry into prenatal care was 19 weeks. The chart review revealed that 8% recently moved to Brooklyn from outside of NYC or the USA. Nine percent had difficulty scheduling an initial prenatal visit within their first trimester. Teenage pregnancy accounted for 7%. Provider challenges with documentation (21%) were noted. The most common themes identified (n = 155) were the patient being in transition (21%), the pregnancy being unplanned (17%), and issues with linkage to care (15%), including no shows or patient cancellations. Patients who were late to prenatal care also differed from their peers dramatically, as they were more likely to be Spanish-speaking, to be young, and to experience a relatively long delay between pregnancy confirmation and entry into care. Moreover, the greatest determinant of delayed entry into care was patient age. CONCLUSION: Our study provides a process for other like clinics to identify patients who are at risk for delayed entry to prenatal care and highlight common barriers to entry. Future initiatives include the introduction of a smart data element to document reasons for delay and use of community health workers for dedicated outreach after no show appointments or patient cancellations.

Conversion of an outpatient pharmacy to a mail-order pharmacy within a health system.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: The establishment of a new outpatient pharmacy provided a strategic opportunity to repurpose and convert an existing outpatient pharmacy into a closed-door mail-order pharmacy within a health system. This article describes the steps taken to successfully make this change and evaluates the impact. SUMMARY: The mail-order pharmacy conversion project was divided into 3 phases: phase 1 (before conversion) from July through August 2022, phase 2 (conversion) from October through November 2022, and phase 3 (after conversion) from December 2022 through February 2023. Phase 1 included standardizing workflows with standard operating procedure (SOP) development, improving automation, determining staffing ratios, gathering baseline staff engagement data, and identifying primary and secondary outcomes of interest. Phase 2 encompassed SOP implementation and training of mail-order team members. Phase 3 involved evaluating available pharmacy floorspace, marketing mail-order services, and the second distribution of the staff engagement survey. The measured outcomes of this project were total prescription volumes, increase in total revenue, and staff engagement. Data collection was completed in phase 3. CONCLUSION: The existing outpatient pharmacy was successfully converted to a closed-door pharmacy, and the associated prescription volume increased. Developing a strategic action plan to establish SOPs, calculate staffing performance metrics, and identify opportunities for growth and engaging frontline team members were essential to the success of this project.

Picking Apart a Program Evaluation Committee: A Multiple Case Study Characterizing Primary Care Residency Program Evaluation Committee Structure, Program Improvement, and Outcomes.

BACKGROUND: As of 2014, the Accreditation Council for Graduate Medical Education (ACGME) mandates initiating a Program Evaluation Committee (PEC) to guide ongoing program improvement. However, little guidance nor published reports exist about how individual PECs have undertaken this mandate. OBJECTIVE: To explore how four primary care residency PECs configure their committees, review program goals and undertake program evaluation and improvement. METHODS: We conducted a multiple case study between December 2022 and April 2023 of four purposively selected primary care residencies (e.g., family medicine, pediatrics, internal medicine). Data sources included semi-structured interviews with four PEC members per program and diverse program artifacts. Using a constructivist approach, we utilized qualitative coding to analyze participant interviews and content analysis for program artifacts. We then used coded transcripts and artifacts to construct logic models for each program guided by a systems theory lens.  Results: Programs adapt their PEC structure, execution, and outcomes to meet short- and long-term needs based on organizational and program-unique factors such as size and local practices. They relied on multiple data sources and sought diverse stakeholder participation to complete program evaluation and improvement. Identified deficiencies were often categorized as internal versus external to delineate PEC responsibility, boundaries, and feasibility of interventions. CONCLUSION: The broad guidance provided by the ACGME for PEC configuration allows programs to adapt the committee based on individual needs. However, further instruction on program evaluation and organizational change principles would augment existing PEC efforts.

Improvement of a pharmaceutical powder mixing process in a tote blender via DEM simulations.

An industrial-scale pharmaceutical powder blending process was studied via discrete element method (DEM) simulations. A DEM model of two active pharmaceutical ingredient (API) components and a combined excipient component was calibrated by matching the simulated response in a dynamic angle of repose tester to the experimentally observed response. A simulation of the 25-minute bin blending process predicted inhomogeneous API distributions along the rotation axis of the blending container. These concentration differences were confirmed experimentally in a production-scale mixing trial using high-performance liquid chromatography analysis of samples from various locations in the bin. Several strategies to improve the blend homogeneity were then studied using DEM simulations. Reversing the direction of rotation of the blender every minute was found to negligibly improve the blending performance. Introducing a baffle into the lid at a 45° angle to the rotation axis sped up the axial mixing and resulted in a better final blend uniformity. Alternatively, rotating the blending container 90° around the vertical axis five minutes prior to the process end was predicted to reduce axial segregation tendencies.

Decoding the persistence of delayed hospital discharge: An in-depth scoping review and insights from two decades.

OBJECTIVE: This article addresses the persistent challenge of Delayed Hospital Discharge (DHD) and aims to provide a comprehensive overview, synthesis, and actionable, sustainable plan based on the synthesis of the systematic review articles spanning the past 24 years. Our research aims to comprehensively examine DHD, identifying its primary causes and emphasizing the significance of effective communication and management in healthcare settings. METHODS: We conducted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) method for synthesizing findings from 23 review papers published over the last two decades, encompassing over 700 studies. In addition, we employed a practical and comprehensive framework to tackle DHD. Rooted in Linderman's model, our approach focused on continuous process improvement (CPI), which highlights senior management commitment, technical/administrative support, and social/transitional care. Our proposed CPI method comprised several stages: planning, implementation, data analysis, and adaptation, all contributing to continuous improvement in healthcare delivery. This method provided valuable insights and recommendations for addressing DHD challenges. FINDINGS: Our DHD analysis revealed crucial insights across multiple dimensions. Firstly, examining causes and interventions uncovered issues such as limited discharge destinations, signaling unsustainable solutions, and inefficient care coordination. The second aspect explored the patient and caregiver experience, emphasizing challenges linked to staff uncertainty and negative physical environments, with notable attention to the underexplored area of caregiver experience. The third theme explored organizational and individual factors, including cognitive impairment and socioeconomic influences. The findings emphasized the importance of incorporating patients' data, recognizing its complexity and current avoidance. Finally, the role of transitional and social care and financial strategies was scrutinized, emphasizing the need for multicomponent, context-specific interventions to address DHD effectively. CONCLUSION: This study addresses gaps in the literature, challenges prevailing solutions, and offers practical pathways for reducing DHD, contributing significantly to healthcare quality and patient outcomes. The synthesis introduces the vital CPI stage, enhancing Linderman's work and providing a pragmatic framework to eradicate delayed discharge. Future efforts will address practitioner consultations to enhance perspectives and further enrich the study. PATIENT OR PUBLIC CONTRIBUTION: Our scoping review synthesizes and analyzes existing systematic review articles and emphasizes offering practical, actionable solutions. While our approach does not directly engage patients, it strategically focuses on extracting insights from the literature to create a CPI framework. This unique aspect is intentionally designed to yield tangible benefits for patients, service users, caregivers, and the public. Our actionable recommendations aim to improve hospital discharge processes for better healthcare outcomes and experiences. This detailed analysis goes beyond theoretical considerations and provides a practical guide to improve healthcare practices and policies.

Increasing and sustaining discharges by noon - a multi-year process improvement project.

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

A Daily Checklist Method Increases Documentation of Code Status in Trauma Patients.

OBJECTIVES: While insufficient code status documentation (CSD) is a longstanding challenge, all patients deserve the opportunity to participate in decision-making regarding code status, especially trauma patients with an unpredictable course. Prior interventions to increase CSD relied on reminder systems. We hypothesize that introducing a daily checklist will increase CSD for patients in the trauma ICU. METHODS: This quality improvement study examined the efficacy of a twice-daily checklist for improving CSD in trauma patients at a level I trauma center. A pre-intervention (PRE) and post-intervention (POST) daily census characterized the percentage of patients with CSD (primary outcome), time-to-code status (TTCS, secondary outcome) documentation, and information about patients who were discharged with no code status (DNCS, secondary outcome). RESULTS: Of 213 PRE and 207 POST, daily census CSD for all patients increased from a median of 50.0% PRE to 64.4% POST (P < .05). Time-to-code status was halved (PRE: 25.30 h, POST: 12.71 h, P < .05). Code status documentation within 12 h increased from 41.8% PRE to 60.9% POST (P < .05). Overall, the percentage of patients with CSD during their hospitalization increased 20% (PRE: 63.8%, POST: 83.6%, P < .05). Discharged with no code status patients decreased 20% (PRE: 35.2%, POST: 15.5%, P < .05). CONCLUSION: Including code status in a daily checklist involving key aspects of care for trauma patients is an effective method for improving code status documentation. Capturing code status for more patients in trauma allows us to provide patient-centered, goal-concordant care.

Modeling-based Approach Towards Quality by Design for a Telescoped Process.

A telescoped, two-step synthesis was investigated by applying Quality by Design principles. A kinetic model consisting of 12 individual reactions was successfully established to describe the synthesis and side reactions. The resulting model predicts the effects of changes in process parameters on total yield and quality. Contour plots were created by varying process parameters and displaying the model predicted process response. The areas in which the process response fulfils predetermined quality requirements are called design spaces. New ranges for process parameters were explored within these design spaces. New conditions were found that increased the robustness of the process and allowed for a considerable reduction of the used amounts of a reagent. Further optimizations, based on the newly generated knowledge, are expected. Improvements can either be direct process improvements or enhancements to control strategies. The developed strategies can also be applied to other processes, enhancing upcoming and preexisting research and development efforts.

Improving Anesthesia Start Time Documentation Through a Departmental Education Initiative at Yale New Haven Hospital, New Haven, United States.

Background Reimbursement for anesthetic services in the United States utilizes a formula that incorporates procedural and patient factors with total anesthesia time. According to the Centers for Medicare & Medicaid Services and the American Society of Anesthesiologists, the period of billable time starts when the anesthesia practitioner assumes care of the patient and may include transport to the operating room from the preoperative holding area. In this report on a quality improvement effort, we implemented a departmental education initiative aimed at improving the accuracy of anesthesia start-time documentation. Methods Utilizing de-identified, internal data on surgical procedures at Yale New Haven Hospital (YNHH), New Haven, United States, the difference between documented anesthesia start and patient in-room time was determined for all cases. Those with a difference between 0-1 minute were assumed "likely underbilled," and the total revenue lost for these cases was estimated using a weighted average of institutional reimbursement per unit of time. A monthly, department-wide educational email was then introduced to inform practitioners about the guidelines around start-time documentation, and the percentage of "likely underbilled" cases and lost revenue estimates trended over a one-year period. Results Baseline data in December 2020 showed that of the 6,877 total surgical cases requiring anesthesia at YNHH, 55.1% (N=3,790) had an anesthesia start to in-room time of 0-1 minute, which were considered "likely underbilled." The average start-to-in-room time for properly recorded cases (44.9%, N=3,087) was 4.42 minutes. The baseline revenue lost in December 2020 for underbilled cases was estimated at $52,302. Over the one-year quality improvement initiative, the proportion of underbilled cases showed a downward trend, decreasing to 29.2% of total cases by November 2021. The estimate of revenue lost due to underbilling also showed a downward trend, decreasing to $29,300 in November 2021. Conclusion This quality improvement study demonstrated that a relatively simple, department-wide educational email sent monthly correlated with an improvement in anesthesia start-time documentation accuracy and a reduction in estimated revenue lost to underbilling over a one-year period.

Need for a Cardiogenic Shock Team Collaborative-Promoting a Team-Based Model of Care to Improve Outcomes and Identify Best Practices.

Cardiogenic shock continues to carry a high mortality rate despite contemporary care, with no breakthrough therapies shown to improve survival over the past few decades. It is a time-sensitive condition that commonly results in cardiovascular complications and multisystem organ failure, necessitating multidisciplinary expertise. Managing patients with cardiogenic shock remains challenging even in well-resourced settings, and an important subgroup of patients may require cardiac replacement therapy. As a result, the idea of leveraging the collective cognitive and procedural proficiencies of multiple providers in a collaborative, team-based approach to care (the "shock team") has been advocated by professional societies and implemented at select high-volume clinical centers. A slowly maturing evidence base has suggested that cardiogenic shock teams may improve patient outcomes. Although several registries exist that are beginning to inform care, particularly around therapeutic strategies of pharmacologic and mechanical circulatory support, none of these are currently focused on the shock team approach, multispecialty partnership, education, or process improvement. We propose the creation of a Cardiogenic Shock Team Collaborative-akin to the successful Pulmonary Embolism Response Team Consortium-with a goal to promote sharing of care protocols, education of stakeholders, and discovery of how process and performance may influence patient outcomes, quality, resource consumption, and costs of care.

Improving Human-Service Organizations through Process Mapping: A Tutorial for Practitioners.

Developing and improving organizational processes is an important element for staff satisfaction, effective communication, and ultimately the success of an organization (Rummler & Brache, 2013). Human-service organizations are no exception and, in fact, could greatly benefit from process improvement. This article provides guided steps for using process maps as a means for improving processes in human-service organizations.

Promoting Learning Health System Cycles by Optimizing EHR Data Clinical Concept Encoding Processes.

Electronic health records (EHRs) and other real-world data (RWD) are critical to accelerating and scaling care improvement and transformation. To efficiently leverage it for secondary uses, EHR/RWD should be optimally managed and mapped to industry standard concepts (ISCs). Inherent challenges in concept encoding usually result in inefficient and costly workflows and resultant metadata representation structures outside the EHR. Using three related projects to map data to ISCs, we describe the development of standard, repeatable processes for precisely and unambiguously representing EHR data using appropriate ISCs within the EHR platform lifecycle and mappings specific to SNOMED-CT for Demographics, Specialty and Services. Mappings in these 3 areas resulted in ISC mappings of 779 data elements requiring 90 new concept requests to SNOMED-CT and 738 new ISCs mapped into the workflow within an accessible, enterprise-wide EHR resource with supporting processes.

Process improvement of a paediatric feeding clinic.

Purpose: The purpose of this study is to identify opportunities to improve processes within a paediatric feeding clinic to enhance timely patient access to healthcare through effective and efficient resource use. Design/methodology/approach: The study involved three interrelated methods. First, de-identified feeding clinic data, collected over seven years, were analysed to understand patient appointments. Second, clinician workshops and the swim lane method were used to map feeding clinic processes. Third, root cause analysis was conducted to identify bottlenecks and identify improvement opportunities. Findings: The results revealed three, poorly connected sub-processes within the feeding clinic - namely: the patient triaging and appointment scheduling or allocation process; the clinic reporting process; and the cancellation and rescheduling process. These sub-processes were poorly connected because of inadequate resources, few standardised processes, and limited coordination between the different processes. Consequently, patient appointments were typically delayed, and patient reports were not always completed in a timely manner. Processes within the paediatric feeding clinic could therefore be improved by using digital tools, patient portals and telehealth, online interventions, an automated appointment confirmation system, and/or an automated transcription of each appointment. Originality/value: This is the first published study to apply business process management to a paediatric feeding clinic. By using three methods to clarify opportunities to improve clinic processes, it highlights the potential value of health information technology in this context. This evidence will enable health service managers to ensure that children with feeding difficulties have timely access to appropriate care.

The measure of impact: Proposal of quality metrics for solid organ transplant pharmacy practice.

As healthcare continues its transition toward value-based care, it is increasingly important for transplant pharmacists to demonstrate their impact on patient care, health-related outcomes, and healthcare costs. Evidence-based quality and performance metrics are recognized as crucial tools for measuring the value of service. Yet, there is a lack of well-developed and agreed-upon specific metrics for many clinical pharmacy specialties, including solid organ transplantation. To address this need, a panel of transplant pharmacy specialists conducted a detailed literature review and engaged in several panel discussions to identify quality metrics to be considered for assessing the value of clinical pharmacy services provided to solid organ transplant recipients and living donors. The proposed metrics are based on the Donabedian model and are categorized to coincide with the typical phases of transplant care. The measures focus on key issues that arise in transplant recipients related to medication therapy, including adverse drug events, nonadherence, and clinical outcomes attributable to medication therapy management. This article proposes a comprehensive set of measures, any number of which transplant pharmacists can adopt and measure over time to objectively gauge the value of services they are providing to transplant recipients, the transplant center, and the overall healthcare system.

Pregnancy outcomes after implementation of an induction of labor care pathway.

BACKGROUND: Induction of labor is common; however, the optimum clinical strategy for induction of labor is less clear. Variations in clinical practices related to induction of labor may lead to increased complications and longer induction of labor times. OBJECTIVE: This study aimed to analyze whether the implementation of an evidence-based standardized care pathway improves the clinical outcomes associated with induction of labor. STUDY DESIGN: This was an approved quality improvement project implementing a clinical care pathway for induction of labor. Moreover, this was a retrospective cohort study of inductions of labor for 5 months before (January 2018 to May 2018) and 14 months after (August 2018 to September 2019) the implementation of the care pathway. The primary outcome was time from admission to delivery. Time from admission to delivery was stratified by mode of delivery. The secondary outcomes included chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, postpartum hemorrhage, and a composite of unanticipated outcomes (chorioamnionitis, endometritis, neonatal intensive care unit admissions, cesarean delivery, and postpartum hemorrhage). In addition, pathway adherence was analyzed. The outcomes were analyzed using 2-tailed t tests for continuous data and the Fisher exact test and chi-square tests for categorical data. Propensity score matching was used to assess for confounding by potential covariates. RESULTS: A total of 1471 inductions of labor were reviewed, with 392 inductions of labor before the implementation of the care pathway and 1079 inductions of labor after the implementation of the care pathway. The pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours (from 23.4 to 22.2 hours; P=.08). There was a nonsignificant increase in the time to cesarean delivery before (28.2 hours) and after (28.8 hours) protocol implementation (P=.71). There was a significant decrease in the time to delivery by 1.7 hours for vaginal deliveries (from 22.2 to 20.5 hours) after protocol implementation (P=.02). There was a significant decrease in chorioamnionitis (from 12.5% to 6.0%; odds ratio, 0.44; 95% confidence interval, 0.29-0.67), a significant decrease in endometritis (from 6.9% to 2.6%; odds ratio, 0.36; 95% confidence interval, 0.20-0.65), and a significant decrease in composite unanticipated outcomes (from 56.9% to 36.6%; odds ratio, 0.46; 95% confidence interval, 0.34-0.56) after the implementation of the care pathway. There was no significant difference in postpartum hemorrhage (from 7.9% to 6.1%; odds ratio, 0.76; 95% confidence interval, 0.48-1.22), neonatal intensive care unit admissions (from 18.1% to 14.0%; odds ratio, 0.74; 95% confidence interval, 0.54-1.02), or cesarean deliveries (from 19.6% to 20.1%; odds ratio, 1.03; 95% confidence interval, 0.76-1.40) after the implementation of the care pathway. Pathway adherence varied, ranging from 50% to 89%. CONCLUSION: The introduction of a standardized induction of labor pathway was associated with a nonsignificant reduction in the time from admission to delivery by 1.2 hours and improved pregnancy outcomes, including decreased infections and unanticipated outcomes. Further opportunities for improvements in clinical outcomes may be realized with increased compliance with the care pathway.

Comparative study of SPI success factors in global and in-house environment for large-scale software companies.

Background: Software process improvement (SPI) is an indispensable phenomenon in the evolution of a software development company that adopts global software development (GSD) or in-house development. Several software development companies do not only adhere to in-house development but also go for the GSD paradigm. Both development approaches are of paramount significance because of their respective advantages. Many studies have been conducted to find the SPI success factors in the case of companies that opt for in-house development. Still, less attention has been paid to the SPI success factors in the case of the GSD environment for large-scale software companies. Factors that contribute to the SPI success of small as well as medium-sized companies have been identified, but large-scale companies have still been overlooked. The research aims to identify the success factors of SPI for both development approaches (GSD and in-house) in the case of large-scale software companies. Methods: Two systematic literature reviews have been performed. An industrial survey has been conducted to detect additional SPI success factors for both development environments. In the subsequent step, a comparison has been made to find similar SPI success factors in both development environments. Lastly, another industrial survey is conducted to compare the common SPI success factors of GSD and in-house software development, in the case of large-scale companies, to divulge which SPI success factor carries more value in which development environment. For this reason, parametric (Pearson correlation) and non-parametric (Kendall's Tau correlation and the Spearman correlation) tests have been performed. Results: The 17 common SPI factors have been identified. The pinpointed common success factors expedite and contribute to SPI in both environments in the case of large-scale companies.