Integrated Lean Six Sigma approach for patient flow improvement in hospital emergency department

Because of increased competition between healthcare providers, higher customer expectations, stringent checks on insurance payments and new government regulations, it has become vital for healthcare organisations to enhance the quality of the care they provide, to increase efficiency, and to improve the cost effectiveness of their services. Consequently, a number of quality management concepts and tools are employed in the healthcare domain to achieve the most efficient ways of using time, manpower, space and other resources. Emergency departments are designed to provide a high-quality medical service with immediate availability of resources to those in need of emergency care. The challenge of maintaining a smooth flow of patients in emergency departments is a global problem. This study attempts to improve the patient flow in emergency departments by considering Lean techniques and Six Sigma methodology in a comprehensive conceptual framework. The proposed research will develop a systematic approach through integration of Lean techniques with Six Sigma methodology to improve patient flow in emergency departments. The results reported in this paper are based on a standard questionnaire survey of 350 patients in the Emergency Department of Aseer Central Hospital in Saudi Arabia. The results of the study led us to determine the most significant variables affecting patient satisfaction with patient flow, including waiting time during patient treatment in the emergency department; effectiveness of the system when dealing with the patient’s complaints; and the layout of the emergency department. The proposed model will be developed within a performance evaluation metric based on these critical variables, to be evaluated in future work within fuzzy logic for continuous quality improvement.

Beyond compliance : project on an integrated systems approach for pest risk management in South East Asia

The Beyond Compliance project, which began in July 2011 with funding from the Standards and Trade Development Facility for 2 years, aims to enhance competency and confidence in the South East Asian sub-region by applying a Systems Approach for pest risk management. The Systems Approach involves the use of integrated measures, at least two of which are independent, that cumulatively reduce the risk of introducing exotic pests through trade. Although useful in circumstances where single measures are inappropriate or unavailable, the Systems Approach is inherently more complicated than single-measure approaches, which may inhibit its uptake. The project methodology is to take prototype decision-support tools, such as Control Point-Bayesian Networks (CP-BN), developed in recent plant health initiatives in other regions, including the European PRATIQUE project, and to refine them within this sub-regional context. Case studies of high-priority potential agricultural trade will be conducted by National Plant Protection Organizations of participating South East Asian countries in trials of the tools, before further modifications. Longer term outcomes may include: more robust pest risk management in the region (for exports and imports); greater inclusion of stakeholders in development of pest risk management plans; increased confidence in trade negotiations; and new opportunities for trade.

Stakeholder engagement and asset management : a case study of the Gold Coast airport, Queensland

One of the fastest growing industries – aviation – faces serious and compounding challenges in maintaining healthy relationships with community stakeholders. One area in aviation creating community conflict is noise pollution. However, current understandings of the factors that affect noise annoyance of the community are poorly conceptualized. More importantly, the way community needs and expectations could be incorporated in airport governance has been inadequately framed to address the issue of aircraft noise. This paper proposes the util-ity of adopting an integrated strategic asset management (ISAM) framework [1] to explore the dynamic nature of relationships between and airport and its surrounding area. The case of the Gold Coast Airport (OOL) operator and community stakeholders is used. This paper begins with an overview of the ISAM framework in the context of airport governance and sustainable development – as a way to find a balance between economic opportunities and societal concerns through stakeholder engagement. Next, an exploratory case study is adopted as a method to explore the noise-related complaints, complainants, and possible causes. Fol-lowing this, the paper reviews three approaches to community stakeholder engagement in Australia, Japan, and UK and discusses their implications in the con-text of OOL. The paper concludes with a contention that airport governance is likely to be much more effective with the adoption of ISAM framework than without it.

Towards an integrated maturity model of asset management capabilities

Asset service organisations often recognize asset management as a core competence to deliver benefits to their business. But how do organizations know whether their asset management processes are adequate? Asset management maturity models, which combine best practices and competencies, provide a useful approach to test the capacity of organisations to manage their assets. Asset management frameworks are required to meet the dynamic challenges of managing assets in contemporary society. Although existing models are subject to wide variations in their implementation and sophistication, they also display a distinct weakness in that they tend to focus primarily on the operational and technical level and neglect the levels of strategy, policy and governance as well as the social and human resources – the people elements. Moreover, asset management maturity models have to respond to the external environmental factors, including such as climate change and sustainability, stakeholders and community demand management. Drawing on five dimensions of effective asset management – spatial, temporal, organisational, statistical, and evaluation – as identified by Amadi Echendu et al. [1], this paper carries out a comprehensive comparative analysis of six existing maturity models to identify the gaps in key process areas. Results suggest incorporating these into an integrated approach to assess the maturity of asset-intensive organizations. It is contended that the adoption of an integrated asset management maturity model will enhance effective and efficient delivery of services.

Research trends of post disaster reconstruction : the past and the future

Natural disasters can have adverse effect on human lives. To raise the awareness of research and better combat future events, it is important to identify recent research trends in the area of post disaster reconstruction (PDR). The authors used a three-round literature review strategy to study journal papers published in the last decade that are related to PDR with specific conditions using the Scopus search engine. A wide range of PDR related papers from a general perspective was examined in the first two rounds while the final round established 88 papers as target publications through visual examination of the abstracts, keywords and as necessary, main texts. These papers were analysed in terms of research origins, active researchers, research organisations, most cited papers, regional concerns, major themes and deliverables, for clues of the past trends and future directions. The need for appropriate PDR research is increasingly recognised. The publication number multiplied 5 times from 2002 to 2012. For PDR research with a construction perspective, the increase is sixfold. Developing countries such as those in Asia attract almost 50% researchers' attention for regional concerns while the US is the single most concentrated (24%) country. Africa is hardly represented. Researchers in developed countries lead in worldwide PDR research. This contrasts to the need for expertise in developing countries. Past works focused on waste management, stakeholder analysis, resourcing, infrastructure issue, resilience and vulnerability, reconstruction approach, sustainable reconstruction and governance issues. Future research should respond to resourcing, integrated development, sustainability and resilience building to cover the gaps. By means of a holistic summary and structured analysis of key patterns, the authors hope to provide a streamlined access to existing research findings and make predictions of future trends. They also hope to encourage a more holistic approach to PDR research and international collaborations.

Estimating the burden of malignant neoplasm on village residents in a mountainous area [山区农村居民恶性肿瘤疾病负担的估计]

Objective To make a comprehensive estimation of the burden of malignant neoplasm on village residents in Linqu County by the means of DALY (Disability-adjusted life year). Methods DALYs, YLLs and YLDs were calculated following the procedures developed for the Global Burden of Disease (GBD) study to ensure comparability, based on the cancer registration data of Linqu villages during 1998-2004, in order to measure the burden of various caners. Results All cancers were responsible for 20.00 DALYs for every thousand population in Linqu County (24.82 for men and 14.96 for women). 92.5% of the losses were due to premature death and 7.5% to disability. 31.5% of the DALYs happened among 45-59 age group. The top 10 cancers for DALYs were stomach cancer, lung cancer, liver cancer, oesophagus cancer, leukemia,colon/rectum cancer, brain cancer, pancreas cancer, breast cancer and bone cancer in turn. Only stomach cancer, lung cancer and liver cancer together account for 69.3% of total DALYs due to malignant neoplasm. The burden of malignant neoplasm was on rising recent years. Conclusions The burden of disease of malignant neoplasm is mainly because of premature death. Stomach cancer, lung cancer and liver cancer lead to heavier burden than the global and national levels. Abstract in Chinese 目的 应用伤残调整寿命年(DALY)对临朐县农村恶性肿瘤疾病负担进行评价. 方法 以1998～2004年临朐县农村肿瘤登记资料为基础,利用全球疾病负担研究中使用的专门公式计算恶性肿瘤的YLLs、YLDs和DALYs,以此评价各类恶性肿瘤的疾病负担. 结果 临朐农村每千人每年因恶性肿瘤造成20.0个DALYs损失(男性24.82,女性14.96),其中92.5%为早死所致,7.5%因残疾所致;恶性肿瘤主要导致45～59岁人群的DALYs损失,占31.5%;恶性肿瘤疾病负担前10位依次为胃癌、肺癌、肝癌、食道癌、白血病、肠癌、脑癌、胰腺癌、乳腺癌和骨癌,其中仅胃癌、肺癌和肝癌三大肿瘤DALYs就占全部肿瘤的69.3%;临朐县农村恶性肿瘤疾病负担有进一步上升的趋势. 结论 恶性肿瘤疾病负担主要由早死所致,胃癌、肺癌、肝癌等主要癌症疾病负担高于全球和中国区水平.

Building Healthy Communities : GP Network, Medicare Local and Primary Health Care in the Wheatbelt Region of Western Australia

• Government reports consistently recognise the importance of Primary Health Care to an efficient health system. Barriers identified in Australia’s Primary Health Care include workforce pressures, increase rate of chronic disease, and equitable access to Primary Health Care services. • General Practitioners (GPs) are the key to the successful delivery of Primary Health Care especially in rural and remote regions such as the Wheatbelt region in Western Australia (WA). • The Wheatbelt region of WA is vast: some 72,500 residents spread across 150,000km2 in 43 Local Government Authorities catchments. Majority of the Wheatbelt residents live in small towns. There is a higher reported rates of chronic disease, more at risk of chronic diseases and less utilisation of Primary Health Care services in this region. • General practice patients in the Wheatbelt are among those most in need of Primary Health Care services. • Wheatbelt GP Network (the “Network”) was established in 1998. It is a key health service delivery stakeholder in the Wheatbelt. • The Network has responded to the health needs of the community by creating a mobile Allied Health Team that works closely with GPs and is adaptive to ensure priority needs are met. • The Medicare Local model introduced by the Australian Government in 2011 aimed to improve the delivery of Primary Health Care services by improved health planning and coordinating service delivery. • Little if any recognition has been given to the outstanding work that many Divisions of General Practice have done in improving the delivery of Primary Health Care services such as the Network. • The Network has continued to support GPs and general practices and created a complementary system that integrated general practice with the work of an Allied Health Team. Its program mix is extensive. • The Network has consistently delivered on-required contract outputs and has a fifteen (15) years history of operating successfully in a large geographical area comprising in the main smaller communities that cannot support the traditional health services model. • The complexity of supporting International Medical Graduates in the region requires special attention. • The introduction of the Medicare Local in the South West of WA and their intention to take over the delivery of health services, thus effectively shutting the Network will have catastrophic consequences and cannot be supported economically. • The Network proposes to create a new model, built on its past work that increases the delivery of Primary Health Care services through its current Allied Health Team. • The proposal uses the Wheatbelt GP Super Clinic currently under construction in Northam, part of the Network and funded by the Australian Government is a key to the proposed new model. • Wheatbelt GP Super Clinic is different from existing models of GP Super Clinics around Australia which focus predominately on co-location of services. Wheatbelt GP Super Clinic utilises a hub and spoke model of service outreach to small rural towns to ensure equitable Primary Health Care coverage and continuum of care in a financially responsible and viable manner. In particular, the Wheatbelt GP Super Clinic recognises the importance of Allied Health Professionals and will involve them in a collaborative model with rural general practice. • The proposed model advocated by the Network aims to substitute the South West WA Medicare Local direct service delivery proposed for the Wheatbelt. The Network’s proposed model is to expand on the current hub and spoke model of Primary Health Care delivery to otherwise small unviable Wheatbelt towns. A flexible and adaptive skill mix of Allied Health Professionals, Nurse Practitioners and GPs ensure equitable access to service. Expanded scope of practices are utilised to reduce duplication of service and concentration of services in major towns. This involves a partnership approach. • If the proposed model not funded, the Network and the Wheatbelt region will stand to lose 16 Allied Health Professionals and defeats the purpose of Australian Government current funding for the construction of the Wheatbelt GP Super Clinic. • The Network has considered how its model can best be funded. It proposes a re-allocation of funds made available to the South West WA Medicare Local. • This submission argues that the proposal for the South West WA Medicare Local to take over the service delivery of Primary Health Care services in the Wheatbelt makes no economic sense when an existing agency (the Network) has the infrastructure in place, is experienced in working in this geographical area that has special needs and is capable to expand its programs to meet demand.

Bioequivalence of two tablet formulations of capecitabine and exploration of age, gender, body surface area, and creatinine clearance as factors influencing systemic exposure in cancer patients

Purpose: The objective of the study was to assess the bioequivalence of two tablet formulations of capecitabine and to explore the effect of age, gender, body surface area and creatinine clearance on the systemic exposure to capecitabine and its metabolites. Methods: The study was designed as an open, randomized two-way crossover trial. A single oral dose of 2000 mg capecitabine was administered on two separate days to 25 patients with solid tumors. On one day, the patients received four 500-mg tablets of formulation B (test formulation) and on the other day, four 500-mg tablets of formulation A (reference formulation). The washout period between the two administrations was between 2 and 8 days. After each administration, serial blood and urine samples were collected for up to 12 and 24 h, respectively. Unchanged capecitabine and its metabolites were determined in plasma using LC/MS-MS and in urine by NMRS. Results: Based on the primary pharmacokinetic parameter, AUC(0-∞) of 5'-DFUR, equivalence was concluded for the two formulations, since the 90% confidence interval of the estimate of formulation B relative to formulation A of 97% to 107% was within the acceptance region 80% to 125%. There was no clinically significant difference between the t(max) for the two formulations (median 2.1 versus 2.0 h). The estimate for C(max) was 111% for formulation B compared to formulation A and the 90% confidence interval of 95% to 136% was within the reference region 70% to 143%. Overall, these results suggest no relevant difference between the two formulations regarding the extent to which 5'-DFUR reached the systemic circulation and the rate at which 5'-DFUR appeared in the systemic circulation. The overall urinary excretions were 86.0% and 86.5% of the dose, respectively, and the proportion recovered as each metabolite was similar for the two formulations. The majority of the dose was excreted as FBAL (61.5% and 60.3%), all other chemical species making a minor contribution. Univariate and multivariate regression analysis to explore the influence of age, gender, body surface area and creatinine clearance on the log-transformed pharmacokinetic parameters AUC(0-∞) and C(max) of capecitabine and its metabolites revealed no clinically significant effects. The only statistically significant results were obtained for AUC(0-∞) and C(max) of intact drug and for C(max) of FBAL, which were higher in females than in males. Conclusion: The bioavailability of 5'-DFUR in the systemic circulation was practically identical after administration of the two tablet formulations. Therefore, the two formulations can be regarded as bioequivalent. The variables investigated (age, gender, body surface area, and creatinine clearance) had no clinically significant effect on the pharmacokinetics of capecitabine or its metabolites.

Ergonomic DHM systems - limitations and trends – a systematic literature review focused on the ‘future of ergonomics’

Digital Human Models (DHM) have been used for over 25 years. They have evolved from simple drawing templates, which are nowadays still used in architecture, to complex and Computer Aided Engineering (CAE) integrated design and analysis tools for various ergonomic tasks. DHM are most frequently used for applications in product design and production planning, with many successful implementations documented. DHM from other domains, as for example computer user interfaces, artificial intelligence, training and education, or the entertainment industry show that there is also an ongoing development towards a comprehensive understanding and holistic modeling of human behavior. While the development of DHM for the game sector has seen significant progress in recent years, advances of DHM in the area of ergonomics have been comparatively modest. As a consequence, we need to question if current DHM systems are fit for the design of future mobile work systems. So far it appears that DHM in Ergonomics are rather limited to some traditional applications. According to Dul et al. (2012), future characteristics of Human Factors and Ergonomics (HFE) can be assigned to six main trends: (1) global change of work systems, (2) cultural diversity, (3) ageing, (4) information and communication technology (ICT), (5) enhanced competiveness and the need for innovation, and; (6) sustainability and corporate social responsibility. Based on a literature review, we systematically investigate the capabilities of current ergonomic DHM systems versus the ‘Future of Ergonomics’ requirements. It is found that DHMs already provide broad functionality in support of trends (1) and (2), and more limited options in regards to trend (3). Today’s DHM provide access to a broad range of national and international databases for correct differentiation and characterization of anthropometry for global populations. Some DHM explicitly address social and cultural modeling of groups of people. In comparison, the trends of growing importance of ICT (4), the need for innovation (5) and sustainability (6) are addressed primarily from a hardware-oriented and engineering perspective and not reflected in DHM. This reflects a persistent separation between hardware design (engineering) and software design (information technology) in the view of DHM – a disconnection which needs to be urgently overcome in the era of software defined user interfaces and mobile devices. The design of a mobile ICT-device is discussed to exemplify the need for a comprehensive future DHM solution. Designing such mobile devices requires an approach that includes organizational aspects as well as technical and cognitive ergonomics. Multiple interrelationships between the different aspects result in a challenging setting for future DHM. In conclusion, the ‘Future of Ergonomics’ pose particular challenges for DHM in regards to the design of mobile work systems, and moreover mobile information access.

Street computing : towards an integrated open data Application Programming Interface (API) for cities

This special issue of the Journal of Urban Technology brings together five articles that are based on presentations given at the Street Computing Workshop held on 24 November 2009 in Melbourne in conjunction with the Australian Computer- Human Interaction conference (OZCHI 2009). Our own article introduces the Street Computing vision and explores the potential, challenges, and foundations of this research trajectory. In order to do so, we first look at the currently available sources of information and discuss their link to existing research efforts. Section 2 then introduces the notion of Street Computing and our research approach in more detail. Section 3 looks beyond the core concept itself and summarizes related work in this field of interest. We conclude by introducing the papers that have been contributed to this special issue.

Phase III trial comparing paclitaxel poliglumex (CT-2103, PPX) in combination with carboplatin versus standard paclitaxel and carboplatin in the treatment of PS 2 patients with chemotherapy-naïve advanced non-small cell lung cancer

INTRODUCTION: Performance status (PS) 2 patients with non-small cell lung cancer (NSCLC) experience more toxicity, lower response rates, and shorter survival times than healthier patients treated with standard chemotherapy. Paclitaxel poliglumex (PPX), a macromolecule drug conjugate of paclitaxel and polyglutamic acid, reduces systemic exposure to peak concentrations of free paclitaxel and may lead to increased concentrations in tumors due to enhanced vascular permeability. METHODS: Chemotherapy-naive PS 2 patients with advanced NSCLC were randomized to receive carboplatin (area under the curve = 6) and either PPX (210 mg/m/10 min without routine steroid premedication) or paclitaxel (225 mg/m/3 h with standard premedication) every 3 weeks. The primary end point was overall survival. RESULTS: A total of 400 patients were enrolled. Alopecia, arthralgias/myalgias, and cardiac events were significantly less frequent with PPX/carboplatin, whereas grade ≥3 neutropenia and grade 3 neuropathy showed a trend of worsening. There was no significant difference in the incidence of hypersensitivity reactions despite the absence of routine premedication in the PPX arm. Overall survival was similar between treatment arms (hazard ratio, 0.97; log rank p = 0.769). Median and 1-year survival rates were 7.9 months and 31%, for PPX versus 8 months and 31% for paclitaxel. Disease control rates were 64% and 69% for PPX and paclitaxel, respectively. Time to progression was similar: 3.9 months for PPX/carboplatin versus 4.6 months for paclitaxel/carboplatin (p = 0.210). CONCLUSION: PPX/carboplatin failed to provide superior survival compared with paclitaxel/carboplatin in the first-line treatment of PS 2 patients with NSCLC, but the results with respect to progression-free survival and overall survival were comparable and the PPX regimen was more convenient. © 2008International Association for the Study of Lung Cancer.

Spreading peak demand for urban rail transit through differential fare policy : a review of empirical evidence

More evenly spread demand for public transport throughout a day can reduce transit service provider‟s total asset and labour costs. A plausible peak spreading strategy is to increase peak fare and/or to reduce off-peak fare. This paper reviews relevant empirical studies for urban rail systems, as rail transit plays a key role in Australian urban passenger transport and experiences severe peak loading variability. The literature is categorised into four groups: a) passenger opinions on willingness to change time for travel, b) valuations of displacement time using stated preference technique, c) simulations of peak spreading based on trip scheduling models, and: d) real-world cases of peak spreading using differential fare. Policy prescription is advised to take into account impacts of traveller‟s time flexibility and joint effects of mode shifting and peak spreading. Although focusing on urban rail, arguments in this paper are relevant to public transport in general with values to researchers and practitioners.

Reliability of spatiotemporal and kinetic gait parameters determined by a new instrumented treadmill system

Background Despite the emerging use of treadmills integrated with pressure platforms as outcome tools in both clinical and research settings, published evidence regarding the measurement properties of these new systems is limited. This study evaluated the within– and between–day repeatability of spatial, temporal and vertical ground reaction forces measured by a treadmill system instrumented with a capacitance–based pressure platform. Methods Thirty three healthy adults (mean age, 21.5 ± 2.8 years; height, 168.4 ± 9.9 cm; and mass, 67.8 ± 18.6 kg), walked barefoot on a treadmill system (FDM–THM–S, Zebris Medical GmbH) on three separate occasions. For each testing session, participants set their preferred pace but were blinded to treadmill speed. Spatial (foot rotation, step width, stride and step length), temporal (stride and step times, duration of stance, swing and single and double support) and peak vertical ground reaction force variables were collected over a 30–second capture period, equating to an average of 52 ± 5 steps of steady–state walking. Testing was repeated one week following the initial trial and again, for a third time, 20 minutes later. Repeated measures ANOVAs within a generalized linear modelling framework were used to assess between–session differences in gait parameters. Agreement between gait parameters measured within the same day (session 2 and 3) and between days (session 1 and 2; 1 and 3) were evaluated using the 95% repeatability coefficient. Results There were statistically significant differences in the majority (14/16) of temporal, spatial and kinetic gait parameters over the three test sessions (P < .01). The minimum change that could be detected with 95% confidence ranged between 3% and 17% for temporal parameters, 14% and 33% for spatial parameters, and 4% and 20% for kinetic parameters between days. Within–day repeatability was similar to that observed between days. Temporal and kinetic gait parameters were typically more consistent than spatial parameters. The 95% repeatability coefficient for vertical force peaks ranged between ± 53 and ± 63 N. Conclusions The limits of agreement in spatial parameters and ground reaction forces for the treadmill system encompass previously reported changes with neuromuscular pathology and footwear interventions. These findings provide clinicians and researchers with an indication of the repeatability and sensitivity of the Zebris treadmill system to detect changes in common spatiotemporal gait parameters and vertical ground reaction forces.

Design and flight testing of an integrated solar powered UAV and WSN for remote gas sensing

This paper describes a generic and integrated solar powered remote Unmanned Air Vehicles (UAV) and Wireless Sensor Network (WSN) gas sensing system. The system uses a generic gas sensing system for CH4 and CO2 concentrations using metal oxide (MoX) and non-dispersive infrared sensors, and a new solar cell encapsulation method to power the UASs as well as a data management platform to store, analyse and share the information with operators and external users. The system was successfully field tested at ground and low altitudes, collecting, storing and transmitting data in real time to a central node for analysis and 3D mapping. The system can be used in a wide range of outdoor applications, especially in agriculture, bushfires, mining studies, opening the way to a ubiquitous low cost environmental monitoring. A video of the bench and flight test performed can be seen in the following link https://www.youtube.com/watch?v=Bwas7stYIxQ.