Efectos de la COVID-19 en la calidad de la atención de los servicios de salud en Colombia: Revisión de literatura / Effects of COVID-19 on the quality of health care services in Colombia: a literature review / Efeitos da covid-19 na qualidade dos serviços de saúde na colômbia: revisão da literatura

Introducción: La pandemia por COVID-19 ha afectado significativamente la calidad de los servicios de cuidado de la salud. Objetivo: Analizar los efectos en los atributos de la calidad en salud de los servicios de atención de enfermedades diferentes a la COVID-19 en Colombia, durante el periodo 2020-2022. Materiales y métodos: Se analizaron 24 artículos de alcance nacional y otros específicos de departamentos como Antioquia, Córdoba, Santander y Cundinamarca. Resultados: La pandemia por COVID-19 impactó la calidad de los servicios en la atención de enfermedades como cáncer, accidentes cerebrovasculares y de eventos como la interrupción voluntaria del embarazo. Conclusión: La calidad de la salud se vio afectada en todas sus dimensiones durante las fases de la pandemia, especialmente en la población con enfermedades crónicas y relacionadas con la salud infantil y materna. Además, se destacaron respuestas como el uso de la telemedicina y de la atención domiciliaria para contribuir a la calidad de la salud en Colombia.

Introduction: The COVID-19 pandemic has significantly affected the quality of health care services. Objective: To analyze the effects of COVID-19 on the quality of health care services focused on treating diseases other than COVID-19 in Colombia during the 2020-2022 period. Materials and methods: 24 articles were analyzed, which included some studies focused on national issues and others specific to the departments of Antioquia, Cordoba, Santander, and Cundinamarca. Results: The COVID-19 pandemic affected the quality of health services caring for diseases such as cancer, strokes, and critical circumstances like voluntary termination of pregnancy. Conclusion: All dimensions of health care were affected during the pandemic, especially impacting populations with chronic diseases and diseases related to child and maternal health. It is important to highlight that telemedicine and home care contributed to improving the quality of health in Colombia.

Introdução: A pandemia de COVID-19 afetou significativamente a qualidade dos serviços de saúde. Objetivo: Analisar os efeitos da COVID-19 nos atributos de qualidade em saúde dos serviços de atenção a outras doenças além da COVID-19 na Colômbia, durante o período 2020-2022. Materiais e métodos: foram analisados 24 artigos de âmbito nacional e outros específicos de departamentos como Antioquia, Córdoba, Santander e Cundinamarca. Resultados: A pandemia da COVID-19 impactou a qualidade dos serviços no cuidado de doenças como câncer, acidente vascular cerebral e eventos como a interrupção voluntária da gravidez. Conclusão: A qualidade da saúde foi afetada em todas as suas dimensões durante as fases da pandemia, especialmente na população com doenças crônicas e doenças relacionadas à saúde infantil e materna. Além disso, foram destacadas respostas como o uso da telemedicina e do atendimento domiciliar para contribuir para a qualidade da saúde na Colômbia.

Incomplete small bowel capsule endoscopy: Risk factors and cost-effectiveness of real-time viewing.

Background and study aims International guidelines recommend real-time viewing (RTV) in capsule endoscopy for gastric emptying monitoring, yet it is often overlooked in clinical practice. We aimed to assess risk factors for incomplete small bowel capsule endoscopy (SBCE) and evaluate the clinical relevance and cost-effectiveness of RTV implementation. Methods We included consecutive SBCEs from 2013 to 2020. RTV was not applied per local protocol. We used multivariate logistic regression to identify risk factors for incomplete SBCE, including prolonged gastric transit time (GTT) and prolonged small bowel transit time (SBTT). Results Analyzing 858 SBCEs, we observed a completion rate of 94.6%. Prolonged GTT and SBTT were present in 4.9% and 18.2% of complete SBCEs, and in 13% ( P =0.03) and 10.8% ( P =0.24) of incomplete SBCEs, respectively. Only 0.7% (6 of 858) had incomplete SBCE with prolonged GTT. In both univariate and multivariate analysis, a modifiable (prolonged GTT odds ratio [OR] 2.9; 95% confidence interval [CI] 1.1-7.5) and two unmodifiable risk factors (inpatient status OR 2.3; 95% CI 1.1-4.5) and history of incomplete SBCE (OR 4.2; 95% CI 1.3-13.7) were independently linked to higher incomplete SBCE rates. The pretest completion probability was 90.5% and 95.8% in patients with and without unmodifiable risk factors, respectively ( P <0.01). The direct cost of systematic RTV adoption and prokinetics administration would be €5059, aiming to identify and treat each case of prolonged GTT associated with incomplete SBCE. Conclusions Modern devices make incomplete SBCE rare, usually not tied to prolonged GTT. In a low-incidence scenario, widespread RTV use brings high costs and uncertain effectiveness.

Assessment of colonoscopy skill using machine learning to measure quality: Proof-of-concept and initial validation.

Background and study aims Low-quality colonoscopy increases cancer risk but measuring quality remains challenging. We developed an automated, interactive assessment of colonoscopy quality (AI-CQ) using machine learning (ML). Methods Based on quality guidelines, metrics selected for AI development included insertion time (IT), withdrawal time (WT), polyp detection rate (PDR), and polyps per colonoscopy (PPC). Two novel metrics were also developed: HQ-WT (time during withdrawal with clear image) and WT-PT (withdrawal time subtracting polypectomy time). The model was pre-trained using a self-supervised vision transformer on unlabeled colonoscopy images and then finetuned for multi-label classification on another mutually exclusive colonoscopy image dataset. A timeline of video predictions and metric calculations were presented to clinicians in addition to the raw video using a web-based application. The model was externally validated using 50 colonoscopies at a second hospital. Results The AI-CQ accuracy to identify cecal intubation was 88%. IT ( P = 0.99) and WT ( P = 0.99) were highly correlated between manual and AI-CQ measurements with a median difference of 1.5 seconds and 4.5 seconds, respectively. AI-CQ PDR did not significantly differ from manual PDR (47.6% versus 45.5%, P = 0.66). Retroflexion was correctly identified in 95.2% and number of right colon evaluations in 100% of colonoscopies. HQ-WT was 45.9% of, and significantly correlated with ( P = 0.85) WT time. Conclusions An interactive AI assessment of colonoscopy skill can automatically assess quality. We propose that this tool can be utilized to rapidly identify and train providers in need of remediation.

An integrated approach through controlled experiment and LCIA to evaluate water quality and ecological impacts of irrigated paddy rice.

This study used an integrated approach to mainly assess the water quality of paddy field during cultivation and quantify its equivalent ecological damages. Accordingly, an isolated pilot area with 0.6 ha and subsurface drainage pipes was prepared for flow measurement and multiple pollutant examination (DO, EC, pH, COD, TKN, TN, TP, NO3, butachlor) under controlled condition during 94 days of rice cultivation. Based on life cycle impact assessment (LCIA) database, the indices of ReCiPe (2016) were used to convert the examined nutrient and herbicide pollution. Results showed that TKN and TP were significant pollutants and reached the maximum concentrations of 7.2 and 4.9 mg/L in pilot outflow, respectively. Here, their average discharged loads were 56.2 gN/day and 45.3 gP/day. These loads equal leaching 8.5% and 9.4% of applied urea and phosphate fertilizers, respectively. The nutrient export coefficients were 8.4 kgN/ha and 6.8 kgP/ha. Nevertheless, the majority of this pollution was transferred by inflow. The net export coefficients were 0.3 kgN/ha and 2.6 kgP/ha while net leaching rates were 0.3%TN and 3.3%TP. The trend of combined ecological damages also showed that the 11-17th day of cultivation imposed the highest ecological risks. The state-of-the-art index of ecological footprint per food production estimates the equivalent ratio of lost lives by impaired ecosystem against lives saved from starvation. This index showed that 7% of the potential of produced paddy rice in this area for saving lives would be spoiled by releasing pollution to the terrestrial ecosystem in the long term. Yet, it can be enhanced as a matter of direct discharge to the freshwater. Therefore, using suitable agricultural operations or improving farm management practices for pollution abatement or assimilation potential is highly recommended.

Internal Auditing Risk Analysis for Medical Laboratories Seeking Accreditation through the Hong Kong Laboratory Accreditation Scheme (HOKLAS).

Objectives: The primary aim of this study was to determine quantitatively the extent of coverage of the Hong Kong Laboratory Accreditation Scheme (HOKLAS 015) requirements by guidance checklists (HOKLAS 016-02 and HOKLAS 021). Methods: The level of conformance requirement coverage of HOKLAS 015 by HOKLAS 016-02 and HOKLAS 021 was calculated by an evaluation checklist based on conformance requirements in HOKLAS 015. A distribution analysis of conformance requirements relating to the International Standard ISO 15189:2012 process-based quality management system model was also performed to elicit further coverage information. Results: HOKLAS 016-02 was found to provide coverage of 76% while HOKLAS 021 was found to provide coverage of 11%. HOKLAS 015 was also found to have a distribution coverage of 78% relating to the International Standard ISO 15189:2012 process-based quality management system model. Conclusion: The results of this analysis should be of value to medical laboratories wishing to maintain the internal auditability required by HOKLAS 015 by gaining an awareness of the extent of coverage provided by HOKLAS 016-02 and HOKLAS 021.

Patients' Satisfaction Regarding Oral Healthcare Services in the North-East Region of Romania: A Preliminary Questionnaire Survey.

This research addresses a gap in the literature by conducting a comprehensive analysis of patients' level of satisfaction with dental care. METHODS: By combining quantitative and qualitative survey methods with a PSQ, this study aims to augment ongoing initiatives to enhance dental patients' experiences by painting a more comprehensive depiction of patients' level of satisfaction. RESULTS: When asked about their overall level of satisfaction 77.1% of the patients said that they received excellent services from office personnel and 72.2% said they trust their doctors. CONCLUSIONS: Assessing patient satisfaction in the realm of dental service quality is crucial for enhancing service quality and accuracy, which would benefit both patients and dentists and, ultimately, improve public health.

State of the Art and Science of Immunocytochemistry.

BACKGROUND: Immunocytochemistry (ICC) is a widely available and extensively used ancillary method in diagnostic cytopathology with great variability in all test phases and a low level of adequate quality management. The non-standardized ICC landscape is now challenged with the introduction of the new European (EU) In Vitro Diagnostic Medical Devices Regulation (IVDR). According to this regulation, ICC on cytological slides falls under the category of Laboratory-Developed Tests (LDT), which requires rigorous standardization, validation, and thorough quality management. SUMMARY: Complete standardization of pre-analytical and analytical steps in ICC is impossible due to the complexity of the method and the constantly evolving antibodies, detection systems, and platforms. However, similar to the approach in immunohistochemistry, improving and standardizing "best practices" in quality management will result in high-quality, correct, accurate, and reliable ICC results. In this review, the current challenges of ICC in diagnostic cytopathology will be discussed, along with practical insights into ICC standardization and validation. KEY MESSAGES: Control slides prepared in the same manner as the patient samples, optimized ICC protocols, and participation in external quality control for ICC are the pillars of good quality management and essential to ensure safe and reliable patient diagnostics.

A Broad-Scale Look at Nutrient Limitation and a Shift toward Co-limitation in United States Lakes.

There is a longstanding debate about the role of nitrogen (N) vs phosphorus (P) in limiting primary production in lakes and whether co-nutrient limitation should be considered for managing eutrophication. We evaluated nutrient limitation and eutrophication at a subcontinental scale. Using U.S. Environmental Protection Agency National Lakes Assessment data, we assessed broad-scale patterns in nutrient limitation and compared samples of all surveyed lakes and lakes resurveyed in multiple surveys. We found that N correlated more strongly with productivity in the western U.S., while P correlated more strongly in the eastern U.S. The aggregated subcontinental effect suggests the importance of factors like N-deposition, terrestrial vegetation, underlying geology, and land use for understanding drivers of nutrient dynamics in lakes. Our study showed how patterns can aggregate across subcontinental scales yet still demonstrate considerable variation when more deeply examined on an individual lake level. Overall, we found that nutrient limitation is dynamic over space and time, with most lakes being co-limited. The prevalence of co-limitation also increased from 2007 to 2017. Trophic states within each limitation category varied substantially. Our findings underscore the need for combined N and P reductions to mitigate accelerated eutrophication.

The Effects of Music Therapy on Patients Undergoing Colonoscopy in a Tertiary Care Hospital at Karachi, Pakistan: A Comparative Study.

A colonoscopy is a procedure commonly used for the diagnosis of colorectal diseases but may be associated with high levels of anxiety and discomfort, which can lead to complications during sedation and decreased patient comfort and cooperation. This study was conducted at a tertiary care hospital in Karachi to assess the effectiveness of music therapy on pre-procedural anxiety, sedation requirements, pain, and procedure duration among patients undergoing colonoscopies. This comparative study included 110 outpatients. The intervention arm received non-lyrical soft music through earphones before and during the colonoscopy procedure, while the control group did not receive any music. In the intervention arm, significant reductions were seen in pre-procedural anxiety scores (p < 0.001), physiological measures (p < 0.001), sedation doses (p < 0.001), and procedure durations (p < 0.05). Control arm showed an increase in heart rate and systolic blood pressure (p < 0.001). Pain scores were similar for both groups. Music therapy is an effective tool to reduce patient anxiety pre- procedure. It is a simple, safe, and noninvasive relaxing intervention that could be used as an adjunct to sedative medications before and during the colonoscopy procedure.

Single-center experience with intraprocedural cleansing system to improve inadequate bowel preparation during colonoscopy.

Inadequate bowel preparation is common despite various preprocedure interventions. There is a need for an intervention at the time of colonoscopy to combat poor preparation. In this retrospective, observational study of 46 patients, we evaluated the clinical efficacy and feasibility of implementing the third generation of the Pure-Vu EVS System, a US Food and Drug Administration-cleared over-the-scope-based intraprocedural cleansing device, into our practice at the Minneapolis VA Medical Center (Minneapolis, Minnesota, United States). To study clinical efficacy, we measured bowel preparation adequacy before and after using the device, as measured by the Boston Bowel Preparation Score, and reviewed colonoscopy surveillance interval recommendations. Technical success and feasibility of using the device were measured by procedure success rates and duration. We found that BBPS scores increased from 4.4 to 7.9 when using the device. Technical success was achieved 78.3% of the time (36/46 cases). Median colonoscopy duration was 46 minutes, although there was a trend toward shorter procedures over time. This is the first clinical evaluation of the third generation of an intraprocedural cleansing device. We found the device efficacious and easy to use with low procedure failure rates, but it does come with a learning curve. We suspect that adoption of this device mutually will benefit patients and health systems with the potential to improve resource utilization.

EFLM Working Group Accreditation and ISO/CEN standards on dealing with ISO 15189 demands for retention of documents and examination objects.

Many aspects of the activity of a medical laboratory have to be documented so as to facilitate the maintenance of the ongoing quality of service. As a consequence, many documents, forms and reports are generated. The retention time for each of these has to be specified. In addition to medical laboratory reports as part of the patient's medical record, the medical laboratory has to retain many documents and specimens according to national legislation or guidance from professional organizations, if these exist. If not, the laboratory management needs to define a retention schedule, which shall define the storage conditions and period of storage, according to ISO 15189:2022 requirements for retention of general quality management documents and records. The EFLM Working Group on Accreditation and ISO/CEN standards provides here a proposal on retention periods of documentation and specimens based on a failure-mode-effects-analysis (FMEA) risk-based approach, a concept of risk reduction that has become an integral part of modern standards.

Laboratory specimen rejection rate and associated factors among referred specimens at Debre Markos Referral Hospital, Ethiopia: prospective cross-sectional study.

Introduction: laboratory errors mostly emerge from the pre-analytical phase, mainly those related to collection, handling, transportation, and storage of diagnostic specimens. Specimen rejection due to improper sample collection, may lead to poor patient outcomes, such as incorrect diagnosis, inappropriate treatment, and death. This study aimed to assess the specimen rejection rate and associated factors among referred specimens at Debre Markos Referral Hospital. Methods: a prospective cross-sectional study design was applied from January 2020 to April 2020 to investigate specimen rejection rate and associated factors among referred specimens. The study population was all laboratory specimens referred for viral load, CD4 count, gene expert, and early infant diagnosis to the Debre Markos Referral Hospital laboratory. The statistical analysis was done with Statistical Package for Social Sciences version 20.0 software. Results: of the total of 2750 specimens submitted to the laboratory from January 2020 to April 2020, 37 (1.34%) specimens were rejected due to different reasons like insufficient volume, hemolysis, and an inappropriate specimen container. Specimen collector training status and experience had a significant association with the specimen rejection rate. Conclusion: the results of our study show that the specimen rejection rate among referred specimens was high, indicating that more interventions are required to decrease the specimen rejection rate.

Good Statistical Monitoring: A Flexible Open-Source Tool to Detect Risks in Clinical Trials.

BACKGROUND: Risk-based quality management is a regulatory-recommended approach to manage risk in a clinical trial. A key element of this strategy is to conduct risk-based monitoring to detect potential risks to critical data and processes earlier. However, there are limited publicly available tools to perform the analytics required for this purpose. Good Statistical Monitoring is a new open-source solution developed to help address this need. METHODS: A team of statisticians, data scientists, clinicians, data managers, clinical operations, regulatory, and quality compliance staff collaborated to design Good Statistical Monitoring, an R package, to flexibly and efficiently implement end-to-end analyses of key risks. The package currently supports the mapping of clinical trial data from a variety of formats, evaluation of 12 key risk indicators, interactive visualization of analysis results, and creation of standardized reports. RESULTS: The Good Statistical Monitoring package is freely available on GitHub and empowers clinical study teams to proactively monitor key risks. It employs a modular workflow to perform risk assessments that can be customized by replacing any workflow component with a study-specific alternative. Results can be exported to other clinical systems or can be viewed as an interactive report to facilitate follow-up risk mitigation. Rigorous testing and qualification are performed as part of each release to ensure package quality. CONCLUSIONS: Good Statistical Monitoring is an open-source solution designed to enable clinical study teams to implement statistical monitoring of critical risks, as part of a comprehensive risk-based quality management strategy.

State Regulation of Ensuring the Quality Medical Care During Martial Law in Ukraine: Lessons for the International Community.

Background: Nowadays, the quality of medical care and health care measures is considered the main target function of the health care system and at the same time the determining criterion for its activities. Objective: The article examines state regulation of medical care quality post- COVID and during martial law, identifying improvement areas. It emphasizes state roles in healthcare standardization, continuous feedback monitoring, and studying patient satisfaction. Interrelationships among Ukraine's state regulation mechanisms are determined, highlighting the need to enhance tools such as criteria and quality indicators for medical care assurance. Methods: The authors of this article utilize various scientific methods, including analysis, synthesis, induction, and deduction, as well as historical and legal, formal legal, and comparative legal methods to examine the state regulation of ensuring the quality of medical care during martial law in Ukraine. Results: The article considered the interrelationships of mechanisms and instruments of state regulation of quality assurance of medical care in Ukraine. Conclusions: The state should enhance medical care quality regulation, drawing on international experiences from the EU and the USA and adapting best practices to national circumstances. The resilience of the healthcare system depends on effective quality assurance, ensuring preparedness, stability, and ongoing improvement prospects.

Efficiency and safety of nasal positive airway pressure systems during endoscopic procedures in high-risk patients: Endo-Breath study.

Background and study aims Sedation of high-risk patients is a relevant issue in interventional endoscopy. This is especially because standard oximetric monitors display only hypoxia and not the preceding hypercapnia. Therefore, the question arises whether use of a nasal positive airway pressure (nPAP) system can decrease the rate of sedation-associated events. Patients and methods A randomized, prospective trial was conducted at University Hospital Ulm, including 98 consecutive patients, identified as high-risk (American Society of Anesthesiologists physical status ≥3) and scheduled for prolonged (>15 minutes) endoscopic procedures. Patients underwent 1:1 randomization to two groups: interventional (nPAP-Mask) and control (conventional oxygen supplementation). Levels of CO 2 were measured noninvasively by transcutaneous capnometry device. The primary outcome was incidence of hypoxia (SpO 2 <90% over 10 seconds) and incidence of severe hypoxia was incidence of SpO 2 <80% over 10 seconds. One of our secondary objectives was to determine if the nPAP-Mask could result in significant CO 2 retention among high-risk patients. Results Data analysis showed lower incidence of hypoxia in the interventional group (10/47 vs. 31/251) P <0.05. Episodes of severe hypoxia (SpO 2 <80% over 10 seconds) were more frequent in the control group (8/51) compared with the intervention group (2/47) P <0.05. There was no significant difference in ΔCO 2 levels in the interventional vs. control group (-6.01±7.66 vs. -7.35±8.59 mm Hg). Conclusions In high-risk patients use of a nasal positive airway pressure system could significantly lower risk of hypoxia, especially in prolonged procedures. The nPAP-Mask does not induce CO 2 retention when compared with conventional oxygen supplementation.

More than 20 procedures are necessary to learn small bowel capsule endoscopy: Learning curve pilot study of 535 trainee cases.

Background and study aims The number of procedures needed to acquire a sufficient level of skills to perform an unassisted evaluation of small bowel capsule endoscopy (SBCE) is unknown. We aimed to establish learning curves, diagnostic accuracy, and the number of procedures needed for reviewing small bowel capsule endoscopies unassisted. Methods An expert panel developed a 1-day course including lessons (examination, anatomy, and pathology) and hands-on training. After completing the course, participants received 50 cases in a randomized sequence. An interactive questionnaire about landmarks, findings, and diagnosis followed each case. After submitting the questionnaire, participants received feedback. Data are presented using CUSUM (cumulative sum control chart) learning curves and sensitivity/specificity analyses compared with expert opinions. Results We included 22 gastroenterologists from 11 different Danish hospitals. A total of 535 cases were reviewed (mean: 28; range: 11-50). CUSUM plots demonstrated learning progression for diagnosis and findings during the course, but none of the participants reached a learning plateau with sufficient competencies. The sensitivity for all findings was 65% (95% confidence interval [CI] 0.51-0.82) for the first 20 procedures and 67% (95% CI 0.58-0.73) from case 21 until completion or dropout. The specificity was 63% (95% CI 0.52-0.74) for the first 20 procedures and 57% (95% CI 0.37-0.77) for the rest. Conclusions Our data indicate that learning SBCE may be more difficult than previously recognized due to low discriminative abilities after 20 cases except for the identification of CD. This indicates that 20 SBCE cases may not be sufficient to achieve competency for reviewing SBCE without supervision.

Content analysis of succession planning in nursing management: a qualitative study.

AIM: The identification and development of managerial talents for nursing manager succession in the future should be a concern for organisations, as the concept of succession planning has not been seriously addressed in nursing. This study aimed to explore managers' perceptions of the concept of succession planning in nursing management. DESIGN: This qualitative study used a conventional content analysis approach. METHODS: Participants included 15 nursing managers, who were purposively selected based on predetermined inclusion and exclusion criteria. After obtaining ethical approval, data were collected through semistructured interviews. MAXQDA software was used for data management, and data analysis was performed using the seven-stage method by Graneheim and Lundman. The credibility and dependability of the data were assessed using Guba and Lincoln's criteria. RESULTS: The main categories identified in this study were barriers to succession planning, facilitators, succession planning requirements, contextualisation, succession planning cycle, the dynamism of the successor organisation and consequences of lack of succession planning. Based on the findings of this study, it is recommended that organisations plan and adopt policies to develop qualified personnel management in nursing organisations and appoint these individuals to critical managerial positions.

Creating and Validating a Questionnaire for Assessing Dentists' Self-Perception on Oral Healthcare Management-A Pilot Study.

BACKGROUND AND OBJECTIVES: Questionnaires designed to test knowledge and self-perception can be valuable tools for diagnosing a dentist's understanding of the management and administration of a practice. The objective of this study was to create and authenticate a questionnaire for assessing dentists' self-perception on oral healthcare management developed from discussions with experts in this field. MATERIAL AND METHODS: In order to create and verify a questionnaire survey, a cross-sectional, descriptive, and analytical study was carried out. Participants' personal information and 31 statements across four categories made up the final questionnaire form. The answers to the questionnaire were in the form of a Likert scale. After refining the initial version, a total of 36 interviews were conducted at dental offices to verify the validity. For the Exploratory Factor Analysis (EFA), we used the Kaiser-Meyer-Olkin (KMO) index, the Bartlett sphericity test, and also Cronbach alpha coefficient for the validity of the questionnaire. RESULTS: The accuracy of the instrument was measured by intrarater and interrater reliability. For the EFA, all the communalities exceeded the threshold of 0.05. With a Cronbach's alpha coefficient of 0.898, the questionnaire has sufficient internal consistency. CONCLUSIONS: The questionnaire demonstrates robust reliability and validity, thereby affirming its suitability for its intended purpose.

Plan-do-study-act (PDSA) interventions to improve real-world endoscopy unit productivity.

Background and study aims The Plan-Do-Study Act (PDSA) ramp is a framework that uses initial small changes to build consensus and momentum for subsequent, iterative process improvement. Our aim was to study its impact on endoscopy unit efficiency and throughput. Methods Following a granular time-and-motion analysis to evaluate baseline performance (phase 1) we instituted successive interventions and measured their impact on core efficiency metrics including procedure volume and turnover time (phases 2-3). Results We identified that inefficiency in turnover of anesthesia-supported endoscopy was the most crucial issue. Implementation of a pre-procedure anesthesia visit in phase 2 reduced turnover time by 15.5 minutes (95% confidence interval 3.9-27.1 minutes). Subsequent changes (phase 3) including front-loaded procedure scheduling and parallel in-room preparation resulted in an 18% increase in procedure volume. Conclusions The PDSA ramp model is an effective means of assessing operational processes, developing novel interventions, and building consensus to improve the real-world productivity in a resource-conscious manner.

Quality management system in forensic science: An African perspective.

Critical issues in forensic science quality management have emerged in recent decades. The debate on accrediting quality management systems of forensic laboratories is relevant to the African context. Neuteboom, Ross, Bugeja, Willis, Roux, and Lothridge (2022) have conducted a comprehensive survey exploring critical issues in their article "Quality Management in Forensic Science: A Closer Inspection." Their work is a crucial foundation for our discussion, urging the African forensic community to engage in more in-depth conversations. This letter briefly describes the survey, discussing embracing the Sydney Declaration (SD) for Forensic Sciences and issues of quality management systems comprising standards, accreditation, and potential regulation, and highlights the issue of cognitive competency from an African perspective. This underscores the urgent need for critical dialogue, emphasizing that the time for action is now, and urges practitioners, particularly in Africa, to enhance quality management systems to deliver superior forensic products.