Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

Optimal design for correlated processes with input-dependent noise

Optimal design for parameter estimation in Gaussian process regression models with input-dependent noise is examined. The motivation stems from the area of computer experiments, where computationally demanding simulators are approximated using Gaussian process emulators to act as statistical surrogates. In the case of stochastic simulators, which produce a random output for a given set of model inputs, repeated evaluations are useful, supporting the use of replicate observations in the experimental design. The findings are also applicable to the wider context of experimental design for Gaussian process regression and kriging. Designs are proposed with the aim of minimising the variance of the Gaussian process parameter estimates. A heteroscedastic Gaussian process model is presented which allows for an experimental design technique based on an extension of Fisher information to heteroscedastic models. It is empirically shown that the error of the approximation of the parameter variance by the inverse of the Fisher information is reduced as the number of replicated points is increased. Through a series of simulation experiments on both synthetic data and a systems biology stochastic simulator, optimal designs with replicate observations are shown to outperform space-filling designs both with and without replicate observations. Guidance is provided on best practice for optimal experimental design for stochastic response models. © 2013 Elsevier Inc. All rights reserved.

Robust automatic mapping algorithms in a network monitoring scenario

Automatically generating maps of a measured variable of interest can be problematic. In this work we focus on the monitoring network context where observations are collected and reported by a network of sensors, and are then transformed into interpolated maps for use in decision making. Using traditional geostatistical methods, estimating the covariance structure of data collected in an emergency situation can be difficult. Variogram determination, whether by method-of-moment estimators or by maximum likelihood, is very sensitive to extreme values. Even when a monitoring network is in a routine mode of operation, sensors can sporadically malfunction and report extreme values. If this extreme data destabilises the model, causing the covariance structure of the observed data to be incorrectly estimated, the generated maps will be of little value, and the uncertainty estimates in particular will be misleading. Marchant and Lark [2007] propose a REML estimator for the covariance, which is shown to work on small data sets with a manual selection of the damping parameter in the robust likelihood. We show how this can be extended to allow treatment of large data sets together with an automated approach to all parameter estimation. The projected process kriging framework of Ingram et al. [2007] is extended to allow the use of robust likelihood functions, including the two component Gaussian and the Huber function. We show how our algorithm is further refined to reduce the computational complexity while at the same time minimising any loss of information. To show the benefits of this method, we use data collected from radiation monitoring networks across Europe. We compare our results to those obtained from traditional kriging methodologies and include comparisons with Box-Cox transformations of the data. We discuss the issue of whether to treat or ignore extreme values, making the distinction between the robust methods which ignore outliers and transformation methods which treat them as part of the (transformed) process. Using a case study, based on an extreme radiological events over a large area, we show how radiation data collected from monitoring networks can be analysed automatically and then used to generate reliable maps to inform decision making. We show the limitations of the methods and discuss potential extensions to remedy these.

Deep hole drilling with twist drills: aspects of the CNC process and its real time monitoring and adaptive control

Deep hole drilling is one of the most complicated metal cutting processes and one of the most difficult to perform on CNC machine-tools or machining centres under conditions of limited manpower or unmanned operation. This research work investigates aspects of the deep hole drilling process with small diameter twist drills and presents a prototype system for real time process monitoring and adaptive control; two main research objectives are fulfilled in particular : First objective is the experimental investigation of the mechanics of the deep hole drilling process, using twist drills without internal coolant supply, in the range of diarneters Ø 2.4 to Ø4.5 mm and working length up to 40 diameters. The definition of the problems associated with the low strength of these tools and the study of mechanisms of catastrophic failure which manifest themselves well before and along with the classic mechanism of tool wear. The relationships between drilling thrust and torque with the depth of penetration and the various machining conditions are also investigated and the experimental evidence suggests that the process is inherently unstable at depths beyond a few diameters. Second objective is the design and implementation of a system for intelligent CNC deep hole drilling, the main task of which is to ensure integrity of the process and the safety of the tool and the workpiece. This task is achieved by means of interfacing the CNC system of the machine tool to an external computer which performs the following functions: On-line monitoring of the drilling thrust and torque, adaptive control of feed rate, spindle speed and tool penetration (Z-axis), indirect monitoring of tool wear by pattern recognition of variations of the drilling thrust with cumulative cutting time and drilled depth, operation as a data base for tools and workpieces and finally issuing of alarms and diagnostic messages.

Monitoring of deployment process of shape memory polymers for morphing structures with embedded fibre Bragg grating sensors

This article demonstrates the use of embedded fibre Bragg gratings as vector bending sensor to monitor two-dimensional shape deformation of a shape memory polymer plate. The shape memory polymer plate was made by using thermal-responsive epoxy-based shape memory polymer materials, and the two fibre Bragg grating sensors were orthogonally embedded, one on the top and the other on the bottom layer of the plate, in order to measure the strain distribution in both longitudinal and transverse directions separately and also with temperature reference. When the shape memory polymer plate was bent at different angles, the Bragg wavelengths of the embedded fibre Bragg gratings showed a red-shift of 50 pm/°caused by the bent-induced tensile strain on the plate surface. The finite element method was used to analyse the stress distribution for the whole shape recovery process. The strain transfer rate between the shape memory polymer and optical fibre was also calculated from the finite element method and determined by experimental results, which was around 0.25. During the experiment, the embedded fibre Bragg gratings showed very high temperature sensitivity due to the high thermal expansion coefficient of the shape memory polymer, which was around 108.24 pm/°C below the glass transition temperature (Tg) and 47.29 pm/°C above Tg. Therefore, the orthogonal arrangement of the two fibre Bragg grating sensors could provide a temperature compensation function, as one of the fibre Bragg gratings only measures the temperature while the other is subjected to the directional deformation. © The Author(s) 2013.

Inventory parameter management and focused continuous improvement for repetitive batch manufacturers

What this thesis proposes is a methodology to assist repetitive batch manufacturers in the adoption of certain aspects of the Lean Production principles. The methodology concentrates on the reduction of inventory through the setting of appropriate batch sizes, taking account of the effect of sequence dependent set-ups and the identification and elimination of bottlenecks. It uses a simple Pareto and modified EBQ based analysis technique to allocate items to period order day classes based on a combination of each item's annual usage value and set-up cost. The period order day classes the items are allocated to are determined by the constraints limits in the three measured dimensions, capacity, administration and finance. The methodology overcomes the limitations associated with MRP in the area of sequence dependent set-ups, and provides a simple way of setting planning parameters taking this effect into account by concentrating on the reduction of inventory through the systematic identification and elimination of bottlenecks through set-up reduction processes, so allowing batch sizes to reduce. It aims to help traditional repetitive batch manufacturers in a route to continual improvement by: Highlighting those areas where change would bring the greatest benefits. Modelling the effect of proposed changes. Quantifying the benefits that could be gained through implementing the proposed changes. Simplifying the effort required to perform the modelling process. It concentrates on increasing flexibility through managed inventory reduction through rationally decreasing batch sizes, taking account of sequence dependent set-ups and the identification and elimination of bottlenecks. This was achieved through the development of a software modelling tool, and validated through a case study approach.

The challenge of real-time automatic mapping for environmental monitoring network management

The automatic interpolation of environmental monitoring network data such as air quality or radiation levels in real-time setting poses a number of practical and theoretical questions. Among the problems found are (i) dealing and communicating uncertainty of predictions, (ii) automatic (hyper)parameter estimation, (iii) monitoring network heterogeneity, (iv) dealing with outlying extremes, and (v) quality control. In this paper we discuss these issues, in light of the spatial interpolation comparison exercise held in 2004.

Approximately optimal experimental design for heteroscedastic Gaussian process models

This paper presents a greedy Bayesian experimental design criterion for heteroscedastic Gaussian process models. The criterion is based on the Fisher information and is optimal in the sense of minimizing parameter uncertainty for likelihood based estimators. We demonstrate the validity of the criterion under different noise regimes and present experimental results from a rabies simulator to demonstrate the effectiveness of the resulting approximately optimal designs.

A novel plasma etching and emission monitoring system (PEEMS) to assess protein and lipid spoilation for hydrogel contact lenses

The work presents a new method that combines plasma etching with extrinsic techniques to simultaneously measure matrix and surface protein and lipid deposits. The acronym for this technique is PEEMS - Plasma Etching and Emission Monitoring System. Previous work has identified the presence of proteinaceous and lipoidal deposition on the surface of contact lenses and highlighted the probability that penetration of these spoilants will occur. This technique developed here allows unambiguous identification of the depth of penetration of spoilants to be made for various material types. It is for this reason that the technique has been employed in this thesis. The technique is applied as a 'molecular' scalpel, removing known amounts of material from the target. In this case from both the anterior .and posterior surfaces of a 'soft' contact lens. The residual material is then characterised by other analytical techniques such as UV/visible .and fluorescence spectroscopy. Several studies have be.en carried out for both in vivo and in vitro spoilt materials. The analysis and identification of absorbed protein and lipid of the substrate revealed the importance of many factors in the absorption and adsorption process. The effect of the material structure, protein nature (in terms of size, shape and charge) and environment conditions were examined in order to determine the relative uptake of tear proteins. The studies were extended to real cases in order to study the. patient dependent factors and lipoidal penetration.

A projected process kriging algorithm for sensor networks with heterogeneous error characteristics

Large monitoring networks are becoming increasingly common and can generate large datasets from thousands to millions of observations in size, often with high temporal resolution. Processing large datasets using traditional geostatistical methods is prohibitively slow and in real world applications different types of sensor can be found across a monitoring network. Heterogeneities in the error characteristics of different sensors, both in terms of distribution and magnitude, presents problems for generating coherent maps. An assumption in traditional geostatistics is that observations are made directly of the underlying process being studied and that the observations are contaminated with Gaussian errors. Under this assumption, sub–optimal predictions will be obtained if the error characteristics of the sensor are effectively non–Gaussian. One method, model based geostatistics, assumes that a Gaussian process prior is imposed over the (latent) process being studied and that the sensor model forms part of the likelihood term. One problem with this type of approach is that the corresponding posterior distribution will be non–Gaussian and computationally demanding as Monte Carlo methods have to be used. An extension of a sequential, approximate Bayesian inference method enables observations with arbitrary likelihoods to be treated, in a projected process kriging framework which is less computationally intensive. The approach is illustrated using a simulated dataset with a range of sensor models and error characteristics.

Intelligent execution monitoring and error analysis in planning involving processes

An intelligent agent, operating in an external world which cannot be fully described in its internal world model, must be able to monitor the success of a previously generated plan and to respond to any errors which may have occurred. The process of error analysis requires the ability to reason in an expert fashion about time and about processes occurring in the world. Reasoning about time is needed to deal with causality. Reasoning about processes is needed since the direct effects of a plan action can be completely specified when the plan is generated, but the indirect effects cannot. For example, the action `open tap' leads with certainty to `tap open', whereas whether there will be a fluid flow and how long it might last is more difficult to predict. The majority of existing planning systems cannot handle these kinds of reasoning, thus limiting their usefulness. This thesis argues that both kinds of reasoning require a complex internal representation of the world. The use of Qualitative Process Theory and an interval-based representation of time are proposed as a representation scheme for such a world model. The planning system which was constructed has been tested on a set of realistic planning scenarios. It is shown that even simple planning problems, such as making a cup of coffee, require extensive reasoning if they are to be carried out successfully. The final Chapter concludes that the planning system described does allow the correct solution of planning problems involving complex side effects, which planners up to now have been unable to solve.

Computer integrated monitoring

Computer integrated monitoring is a very large area in engineering where on-line, real time data acquisition with the aid of sensors is the solution to many problems in the manufacturing industry as opposed to the old data logging method by graphics analysis. The raw data which is collected this way however is useless in the absence of a proper computerized management system. The transfer of data between the management and the shop floor processes has been impossible in the past unless all the computers in the system were totally compatible with each other. This limits the efficiency of the systems because they get governed by the limitations of the computers. General Motors of U.S.A. have recently started research on a new standard called the Manufacturing Automation Protocol (MAP) which is expected to allow data transfer between different types of computers. This is still in early development stages and also is currently very expensive. This research programme shows how such a shop floor data acquisition system and a complete management system on entirely different computers can be integrated together to form a single system by achieving data transfer communications using a cheaper but a superior alternative to MAP. Standard communication character sets and hardware such as ASCII and UARTs have been used in this method but the technique is so powerful that totally incompatible computers are shown to run different programs (in different languages) simultaneously and yet receive data from each other and process in their own CPUs with no human intervention.

The accuracy of parameter estimation from noisy data, with application to resonance peak estimation in distributed Brillouin sensing

Distributed Brillouin sensing of strain and temperature works by making spatially resolved measurements of the position of the measurand-dependent extremum of the resonance curve associated with the scattering process in the weakly nonlinear regime. Typically, measurements of backscattered Stokes intensity (the dependent variable) are made at a number of predetermined fixed frequencies covering the design measurand range of the apparatus and combined to yield an estimate of the position of the extremum. The measurand can then be found because its relationship to the position of the extremum is assumed known. We present analytical expressions relating the relative error in the extremum position to experimental errors in the dependent variable. This is done for two cases: (i) a simple non-parametric estimate of the mean based on moments and (ii) the case in which a least squares technique is used to fit a Lorentzian to the data. The question of statistical bias in the estimates is discussed and in the second case we go further and present for the first time a general method by which the probability density function (PDF) of errors in the fitted parameters can be obtained in closed form in terms of the PDFs of the errors in the noisy data.