Studies indicate that voluntary reporting detects relatively few adverse events (AEs) (Ehland et al., 1999, Cooper et al., 1984). At Boston Children’s Hospital (BCH), several systems exist to document AEs. First, anesthesiologists document clinical care and AEs in the patient medical record (the Anesthesia Information Management System (AIMS)). Second, in an effort to capture AEs, the Department of Anesthesiology, Critical Care and Pain Medicine developed an internal tool, the Anesthesia System for Clinical Event Tracking (ASCENT), which is integrated into clinicians’ electronic documentation. Finally, a BCH hospital-wide reporting system, the Safety Event Reporting System (SERS), allows all employees and patients to report an AE.  The goals of this study are 1) to compare the effectiveness of documentation in AIMS, ASCENT, and SERS, 2) to determine the incidence of AEs in January 2018 and June 2019, independently, and 3) compare the effectiveness of documentation AEs in ASCENT after implementation of an improved, integrated reporting system. After IRB approval, a manual chart review of 3,3204 cases requiring anesthesia in January 2018 and 3,387 cases requiring anesthesia in June 2019 was conducted. Anesthesia notes, vital signs, and administered medications documented in AIMS were reviewed to determine if an AE had occurred. Descriptions of each case were recorded, and cases with indications for AEs were verified by clinicians. Next, each AE was categorized by event type. Both ASCENT and SERS were then queried for the reported adverse events during the same time period. The total number of AEs was described using counts with the distribution of types of AEs presented using percentages.     Among the 3,204 cases reviewed in January 2018, there were 569 events documented in AIMS, out of which, 39 (6.9%) were documented in ASCENT, and 2 (0.4%) in SERS. The overall rate of AEs was determined to be 1.8 events/10 cases. For June 2019, a total of 3,387 cases were reviewed for the occurrence of AEs. Among the reviewed cases, there were 396 events documented in AIMS, out of which, 106 (26.8%) were documented in the ASCENT database, and 3 (0.8%) in SERS. The overall rate of AEs was determined to be 1.2 events/10 cases. This study demonstrates that voluntary reporting of AEs may be improved if the reporting systems are better-integrated with patient medical records. In agreement with existing literature, this study also illustrates that hospital-wide reporting systems, such as SERS, fail to collect most adverse events (Levinson, 2012). To achieve comprehensive reporting of AEs, systems must be integrated into clinicians’ workflow. Education regarding the reporting systems along with technology improvements may further enhance the capture of AEs. Further investigation will be conducted to determine severity, preventability and association with anesthesia.

Denna rapport går in på vad Lean är och hur det kan användas. Fokusligger på att försöka identifiera hur Lean används inom två olika företagoch hur arbetet med Lean skiljer sig åt mellan dessa. Är Lean merapplicerbart inom vissa processer än andra och vad ser man för resultatav användandet? Om man kommer till en arbetsplats där Lean användsär det viktigt att förstå att det är ett väldigt omfattande arbete för attupprätthålla de rutiner som behövs. Detta synliggörs tydligare av dennajämförelse mellan två företags arbete med Lean än av den litteratur somanvänts under kurserna för högskoleprogrammet till Processoperatör.För att göra jämförelsen har ena företaget intervjuats medan det andraförtaget har besvarat skriftliga frågor. Resultatet av detta visar att de tvåföretagen använder Lean och dess verktyg på olika sätt och företagensprocesser ser även olika ut. Detta styrker resonemanget om att Leanlämpar sig bättre i vissa processer än andra. Arbete med Lean medförstora fördelar för arbetsmiljön för operatörerna men kan även leda tillförsämrad arbetsmiljö om man inte är aktsam. Båda företagen har funnitfördelar med vissa verktyg som underlättar vardagen för de befintligaoperatörerna och även underlättar vid upplärning av ny personal. / This report discusses what Lean is and how it can be used. The focus ison trying to identify how Lean is used in two different companies andhow the work with Lean differs between these companies. Is Lean moreapplicable in some processes than others and what results of using Leancan you see in the company? If you come to a workplace where Lean isused, it is important to understand that it is a very extensive job tomaintain the routines that are needed. This is made clearer bycomparing two companies work with Lean than the literature usedduring the courses for the university program for Process Operator. Tobe able to make the comparison, one of the companies has beeninterviewed while the other company has answered written questions.The result of this shows that the two companies use Lean and its tools indifferent ways and the companies' processes also looks different. Thissupports the reasoning that Lean is better suited to certain processesthan others. Working with Lean entails great benefits for the operatorsworking environment but can also lead to a deteriorating workingenvironment if you are not careful. Both companies have foundadvantages with certain tools that facilitate the everyday life of theexisting operators and facilitate the training of new staff.

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This diploma thesis analyses present state of quality management in small business and include proposal for quality improvement, which lead to effective cooperation, enterprise culture, understanding consumers requests and cost reduction.

Background: Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among patients with atrial fibrillation (AF) and adversely impact patient’s long-term outcomes. Little is known, however, about the association between OSA and frailty, cognitive performance, and AF-related quality of life in older men and women with AF. Objective: To examine the association of OSA with frailty, cognitive performance, and AF- related quality of life among older adults with AF. Methods: Data from the Systemic Assessment of Geriatrics Elements-AF study were used which includes participants ≥ 65 years with AF and a CHA2DS2-VASc ≥ 2. Multivariable adjusted logistic regression models were used to examine the association between OSA, as measured by the STOP-BANG questionnaire, and geriatric impairments including frailty, cognitive performance, and AF-related quality of life. Results: A total of 970 participants with AF (mean age 75 years, 51% male) were included in the analysis. Among the 680 participants without a medical history of OSA, 179 (26%) participants had low risk of OSA, 360 (53%) had an intermediate risk, and 141 participants (21%) had a high risk for OSA. Compared to those with low risk of OSA, those at intermediate or high risk for OSA were significantly more likely to be frail (aOR= 1.66, 95% CI: 1.08–2.56; aOR= 3.00, 95% CI: 1.69-5.32, respectively) after adjusting for sociodemographic, clinical, and health behavioral variables. Risk of OSA was not associated with cognitive performance and AF- related quality of life after adjusting for several potentially confounding factors. Conclusions: Older adults with AF who are at intermediate or high risk for OSA have a greater likelihood of being frail. Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and QoL among patients with AF.

BACKGROUND: Medical professional organizations in the U.S. recommend shared decision-making for routine labor induction in healthy term pregnancies. Shared decision-making is part of high quality, person-centered care and has substantial positive impacts. Despite these recommendations for, and impacts of, shared decision-making many people, especially people of color and those who are Medicaid-insured, do not experience shared decision-making concerning induction and according to a 2020 scoping review there are no patient decision aids on this topic. METHODS: We used quality improvement and qualitative methods to develop, test, and refine a patient decision aid on labor induction in healthy pregnancies at or beyond 39 weeks to support shared decision-making. We assessed shared decision-making primarily with these outcomes: patients’ understanding of choices, pros and cons of choices, and their role as primary decision-maker. A quality improvement team developed an initial prototype and used Plan-Do-Study-Act cycles to get patient and provider feedback. The decision aid was tested in three languages by providers across obstetrics, family medicine, and midwifery at a tertiary hospital and two community health centers in Boston, MA between September 2020 and December 2021. RESULTS: Shared decision-making on labor induction in healthy pregnancies was achieved. Across three Plan-Do-Study-Act cycles 24 pregnant people were interviewed. Most were people of color and Medicaid-insured. Many were recent immigrants and/or non-Native English speakers. Nearly all interviewees experienced shared decision making: 23/24 understood their role as the decision-maker. The majority could name two or three choices they had and pros and cons of different choices. Many described the process as empowering and positive. Nine medical providers tested the decision aid and gave feedback. Providers said using the tool helped improve the consistency and content of their counseling and reduce the role of bias. CONCLUSION: A balanced, evidence-based decision aid can support patients and providers in achieving shared decision-making on induction. Quality improvement and qualitative methods were shown effective for decision aid development and can be applied to other topics within and beyond maternity care. Decision aids may be a meaningful part of efforts to improve equity when development, testing, and evaluation centers people with marginalized identities.

Delivery of primary care preventative services can be significantly increased utilizing Six Sigma methods. Missed preventative service opportunities were compared in the study clinic with the community clinic in the same practice. The study clinic had 100% preventative services, compared with only 16.3% in the community clinic. Preventative services can be enhanced to Six Sigma quality when the nurse executive and medical staff agree on a single standard of nursing care executed via standing orders.

This study examines the strategic and operational outcomes of effective implementation of quality improvement initiatives in different service operational environments. Using a sample of 354 service organisations, this study utilises a structural equation modelling (SEM) approach to investigate the effectiveness of quality improvement initiatives. The results show clear strategic and operational benefits of effective implementation of quality improvement initiatives. The study concludes that the quality improvement efforts of service organisations should be viewed from a system-wide perspective. This systematic orientation leads to benefits which are not always achievable based on a piece-meal implementation orientation.

Purpose – The objective of this study is to shed some light on quality improvement practices of for-profit and not-for-profit hospitals Design/methodology/approach – The scope and effectiveness of several quality improvement efforts are studied for a sample of 110 hospitals. Factor analysis was utilized to analyze the data collected. Findings – The results of this study tended to suggest that for-profit and not-for-profit hospitals were more similar than different with the regard to the effective utilization of quality improvement initiatives, thus underscoring the utility of quality improvement efforts despite differences in operating characteristics, strategies and operating constraints. Research limitations/implications – The sample used in this study is limited. Thus, the results should be interpreted accordingly. Practical implications – This study offers decision-makers in healthcare operational settings empirical evidence of the operational and strategic effectiveness of different quality improvement efforts, thus justifying investments related to the initiation and implementation of such quality improvement efforts. Originality/value – This study represents an important step toward understanding the effective implementation of quality improvement initiatives in different operational settings.

While many researchers tend to agree that quality improvement efforts lead to operational and customer-related organizational gains, the financial bottom-line impact of quality efforts is still debatable. Utilizes a sample of 68 certified Portuguese firms to shed some light on the nature of the relationships between quality improvement efforts and financial performance measures. Uses factor analysis, cluster analysis, and analysis of variance to analyze the data gathered using a survey-based research instrument. Concludes that quality efforts directed toward the customer tend to be associated with higher financial performance in terms of net profit after tax.