Nurses and physicians in General Internal Medicine (GIM) work in a complex environment where patients present with complex (co)morbidities; management of such patients requires input from a full range of medical disciplines. In addition, there is regular resident physician changeover every 8-9 weeks in this teaching environment, and patient “flow” problems caused by overcrowding and placement issues. This complexity causes difficulties in the information exchange between nurses and physicians necessary to manage patient care. Multidisciplinary team meetings have been suggested as helpful to interprofessional communication, and in General Internal Medicine these take place in the form of daily “Bullet Rounds”. More recently the use of process engineering approaches has been suggested as a way to increase efficiency in healthcare; this dissertation evaluates its impact on communication between nurses and physicians. The initial observational field study showed that information exchange was the main focus of dialogue in Bullet Rounds, and identified information gaps between nurses and physicians. Script Theory (Schank and Abelson 1977) was used to propose that information gaps in Bullet Rounds are caused by different knowledge and goals, which result in inconsistent scripts. A process engineering intervention took place in General Internal Medicine. Process engineering methods have been proposed as being helpful in process design and improvement in healthcare but have not been systematically evaluated. The researcher conducted a pre and post intervention study of Bullet Rounds in order to identify and analyse the impacts of a process engineering intervention on information exchange between nurses and physicians. The results showed that information loss decreased after the intervention but that resident physicians were not satisfied with the nurses-physician information exchange. The staff and resident physicians appeared to have distinct and different information needs and perspectives, while the nurses felt that the Bullet Rounds process had improved, but that it needed revisiting, and were not aligned with staff physicians on respective roles and responsibilities. The overall results suggest that even after the process engineering intervention, there was still misalignment of goals and scripts between the two groups of physicians and between the physicians and nurses, and strategies for addressing these gaps are proposed.

No description available.

Supply chain management is the set of tasks through which businesses acquire, process, and move raw materials and final products from suppliers through factories and distribution points to customers. The mathematical problems encountered in supply chain optimization models are difficult to solve. Free Trade Agreements can simplify the models of inter-company trade between countries. Another way to make these models more tractable is to decompose the complete supply chain into a set of small, manageable units representing businesses or business processes and optimize the system by controlling the interactions between these units. We illustrate such a model and optimize it with genetic-algorithm-controlled Multidisciplinary Design Optimization

Abstract PURPOSE: The aim of this study was to describe and compare possible differences regarding selected prognostic factors for disability between patients with non-specific chronic pain who were about to start a multidisciplinary treatment program (MMR), either within primary care (MMR1) or hospital care (MMR2). METHODS: The study had a descriptive and comparative cross sectional design. Eighty-nine patients were recruited consecutively when they were about to start their team treatment (50 in MMR1,39 in MMR2). The measurements were; Evaluation of self-reported self-efficacy for eight daily activities (STIVA-8), The Pain Belief Screening Instrument (PBSI) and Hospital Anxiety and Depression Scale (HADS). RESULTS: The study found some significant differences between the answers from patients in MMR1 and those from patients in MMR2. For instance, patients in MMR2 estimated lower self-efficacy according to STIVA-8 than patients in MMR1. Also, there were fewer low risk patients and more high risk patients in MMR2 than in MMR1 regarding pain intensity according to PBSI. In addition to this, there were fewer patients without depression and more with moderate depression in MMR2 than in MMR1 according to HADS. No significant differences could be shown for either anxiety according to HADS or for low- and high risk regarding activity disability according to PBSI. No significant differences could be found when pain intensity was measured with mean values on a scale from 0-10. CONCLUSIONS: Patients in MMR2 experienced more negative consequences from their pain disease than patients in MMR1. Systematic use of standardized self-reported instruments for selected prognostic factors could be helpful when screening for complexity and make it easier to decide whether the rehabilitation should be within MMR1 or MMR2 for patients in need of MMR. / Sammanfattning SYFTE: Syftet med denna studie var att beskriva och jämföra om patienter med långvarig smärtproblematik inom primärvård (MMR1) respektive specialiserad sjukhusvård (MMR2), som stod i begrepp att påbörja multimodal smärtrehabilitering (MMR), skattade olika avseende ett antal prognostiska faktorer för funktionsförmåga. METOD: Studien hade en deskriptiv och komparativ tvärsnittsdesign. Åttionio konsekutivt tillfrågade patienter deltog (50 i MMR1, 39 i MMR2). Datainsamlingen gjordes vid start av MMR med tre självskattningsformulär; Skattning av tilltro till sin förmåga att utföra åtta specificerade vardagsaktiviteter (STIVA-8), The Pain Belief Screening Instrument (PBSI) och Hospital Anxiety and Depression Scale (HADS). RESULTAT: Studien visade statistiskt signifikanta skillnader avseende att patienterna i MMR2 skattade lägre tilltro till sin förmåga enligt STIVA-8, det var färre andel lågriskpatienter och större andel högriskpatienter i MMR2 avseende smärtintensitet enligt PBSI samt färre andel patienter utan depression i MMR2 och fler med måttliga depressionsbesvär i MMR2 enligt HADS. Inga signifikanta skillnader kunde visas avseende låg- och högrisk för aktivitetsbegränsning enligt PBSI och inte heller för ångest enligt HADS. När smärtintensitet beräknades med medelvärde på skalan 0-10 fanns inga signifikanta skillnader. KONKLUSION: Patienterna i MMR2 skattade mer negativa konsekvenser av sin smärtsjukdom än i MMR1. Systematisk användning av skattningsformulär som ringar in olika prognostiska faktorer bör kunna underlätta selektion och sortering vid val av vårdnivå för patienter i behov av MMR.

Supply chain management is the set of tasks through which businesses acquire, process, and move raw materials and final products from suppliers through factories and distribution points to customers. The mathematical problems encountered in supply chain optimization models are difficult to solve. Free Trade Agreements can simplify the models of inter-company trade between countries. Another way to make these models more tractable is to decompose the complete supply chain into a set of small, manageable units representing businesses or business processes and optimize the system by controlling the interactions between these units. We illustrate such a model and optimize it with genetic-algorithm-controlled Multidisciplinary Design Optimization

The research examines how the Bi-Level Integrated System Synthesis decomposition technique can be adapted to perform as the conceptual aeroelastic design tool. The study describes a comprehensive solution of the aeroelastic coupled problem cast in this decomposition format and implementation in an integrated framework. The method is supported by application details of a proof-of-concept high speed vehicle. Physics-based codes such as finite element and an aerodynamic panel method are used to model the high-definition geometric characteristics of the vehicle. A synthesis and sizing code was added to referee the conflicts that arise between the two disciplines. This research's novelty lies in four points. First is the use of physics-based tools at the conceptual design phase to calculate the aeroelastic properties. Second is the projection of flutter and divergence velocity constraint lines in a power loading versus wing loading graph. The mapping of such constraints in a designer's familiar format is a valuable tool for fast examination of the design space. Third is the improvement of the aeroelastic assessment given the time allotted. Until recently, because of extensive computational and time requirements, aeroelasticity was only assessed at the preliminary design phase. This research illustrates a scheme whereby, for the first time, aeroelasticity can be assessed at the early design formulation stages. Forth, this assessment allowed to verify the impact of changing velocity, altitude, and angle of attack and identify robust design space with these three mission properties. The method's application to the quiet supersonic business jet gave a delta shaped wing for the supersonic speed regime. A subsonic case resulted in a high aspect ratio wing. The scaling approach allowed iso-flutter and iso-divergence lines to be plotted. The main effects of velocity, altitude, and angle of attack on these iso-lines were also discussed, as was the identification of robust design space. The response surface surrogate models allowed convergence of the system optimization but questions were posed as to the accuracy of these quadratic models. Other future improvements include the addition of more disciplines and more detailed models.

Throughout the evolution of rotorcraft design, great advancements have been made in developing performance analysis and sizing tools to assist designers during the preliminary and detailed design phases. However, very few tools exist to assist designers during the conceptual design phase. Most performance analysis tools are very discipline or concept specific, and many are far too cumbersome to use for comparing vastly different concepts in a timely manner. Consequently, many conceptual decisions must be made qualitatively. A need exists to develop a single software tool which is capable of modeling any type of feasible rotorcraft concept using different levels of detail and accuracy in order to assist in the decision making throughout the conceptual and preliminary design phases. This software should have a very intuitive and configurable user interface which allows users of different backgrounds and experience levels to use it, while providing a broad capability of modeling traditional, innovative, and highly complex design concepts. As an illustration, a newly developed Concept Independent Rotorcraft Analysis and Design Software (CIRADS) will be presented to prove the applicability of such software tools. CIRADS is an object oriented application with a Graphical User Interface (GUI) for specifying mission requirements, aircraft configurations, weight component breakdowns, engine performance, and airfoil characteristics. Input files from the GUI are assembled to form analysis and design project files which are processed using algorithms developed in MATLAB but compiled as a stand alone executable and imbedded in the GUI. The performance calculations are based primarily upon a modified momentum theory with empirical correction factors and simplified blade stall models. The ratio of fuel (RF) sizing methodology is used to size the aircraft based on the mission requirements specified by the user. The results of the analysis/design simulations are then displayed in tables and Text Fields in the GUI. The intent for CIRADS is to become a primary conceptual sizing and performance estimation tool for the Georgia Institute of Technology rotorcraft design teams for use in the annual American Helicopter Society Rotorcraft Design Competition.

The Multidisciplinary Design Optimization (MDO) system is needed to reduce the developing time and production cost in most industries. The MDO is the new technology for optimization design, and considers solid mechanics, dynamics, kinematics, vibration/noise control, and fluid mechanics, simultaneously. Higher product quality, less developing time and lower manufacturing cost will be achieved through a balanced and organic MDO method. In this paper, numerical stress analysis, optimization method, and experimental stress analysis will be conducted to accomplish: 1) production cost; 2) developing time; 3) quality improvement; and 4) service-rate drop. First, the coupled analysis using the finite element method will be performed to obtain the accurate data. Second, OPTISTRUCT, which is commercial optimization software, will be used for shape and size optimization analysis. Third, an experimental stress analysis system will be established to assist the optimization design and numerical analysis.

No description available.

Background: Low performance rate of comprehensive diabetic foot examinations (CDFEs) causing health care disparity. Objective: Increasing performance of CDFEs at Phoenix Indian Medical Center, an Indian Health Service (IHS) facility. Design: Before-after design, convenience sample. Setting: An IHS adult ambulatory care clinic in urban Phoenix, Arizona. Target: Four primary care providers (PCPs).Interventions: Utilizing the PDSA framework, a multidisciplinary group of clinical staff developed a process to increase the performance rate of CDFEs. Brainstorming, use of the Ishikawa diagram, and root cause analysis led to identification of factors contributing to low rates of CDFEs in the clinic. The QI intervention addressed multiple aspects of activities related to the CDFE performance, including pre-visit planning, enhanced communication, making equipment for CDFEs accessible to healthcare providers, and requesting patients to remove shoes and socks. Measurement: Weekly performance rate of CDFEs. Results: The results, analyzed with a run chart, showed an upward trend in performance for some providers. The median aggregate performance rates for pre and post intervention were 82.6% and 80.2%, respectively. Limitations: This study should be replicated over a longer time frame with more participants. Two significant weaknesses were identified in this study. The required provider de-identification prevented provider feedback. The data collection method provided CDFE performance data based on provider empanelment. This method of data collection reflects composite team care rather than specific provider behaviors. Conclusions: This multidisciplinary approach to improving the performance rates of CDFEs showed an upward trend for some providers but was not statistically significant. Post intervention CDFE performance rates were not improved. Significance: This study highlights the role of the doctorally prepared advanced practice nurse (DNP) in designing, facilitating and evaluating a practice change project to address the rate of provider performance of CDFE for their AI/NA patients. An exemplar, this QI intervention can be replicated for quality improvement initiatives targeting improved healthcare outcomes, crucial to the national effort of addressing healthcare disparities.