Discrete-event Simulation and Optimization to Improve the Performance of a Healthcare System

Thesis (Ph.D.)--University of Washington, 2016-08

Effect of organic amendments on the afforestation performance of plant species on degraded semiarid conditions

Vegetation plays a fundamental role in soil conservation, so it is common to consider an increase in vegetation cover as one of the techniques to mitigate the effects of desertification in Mediterranean forest environments. There are two factors limiting the establishment and growth of seedlings in dry environments: (i) an excessive radiation and, (ii) the limited availability of water during the summer drought. During an afforestation plan, soil preparation is always necessary to reduce sapling mortality. The goal of this study was to analyze the effect of various organic amendments on soil according to chemical and hydrological properties, and to assess the effects of these parameters on an afforestal proposal under Mediterranean climate conditions. Five amendments were applied in an experimental set of plots: straw mulching (SM); mulch with chipped branches of Aleppo Pine (PM); TerraCotten hydroabsobent polymers (HP); sewage sludge (RU); sheep manure (SH) and control (C). Plots were afforested following the same spatial pattern, and amendments were mixed with the soil at the rate 10 Mg ha -1 . Under bare soil conditions (C), most of mortalities occurred during the summer period of the first year. A substantial positive effect of SM, PM and HP on the survival rates have been clearly observed. Conversely, when the soil was amended with SH, the survival rate quickly decreased or remained more or less constant regarding to C. In this study, the lack of differences on chemical properties indicates that there may exist other reasons to justify the differences that were found in the pattern of vegetation. However, regarding to the hydrological properties some differences have been found. In C, soils were registered below the wilting point during 4 months a year, and therefore, in the area of water unusable by plants. These months were coinciding with the summer Mediterranean drought and can justify the high mortality found on plants. Conversely, in SM, PM and HP, soil moisture remained below the wilting point less period than C and, the plant available water was also higher. In these treatments, the survival sapling rates measured were the highest. SH showed water holding capacity slightly more limited than C. For this treatment, the survival sapling rates measured were the lowest. In conclusion, from a land management standpoint, the PM, SM and HP have been proved as a significant method to reduce sapling mortality rates during the Mediterranean summer drought.

Health services performance for TB treatment in Brazil: a cross-sectional study

Background: Researches to evaluate Primary Health Care performance in TB control in Brazil show that different cities aggregate local specificities in the dynamics of coping with the disease. This study aims to evaluate health services' performance in TB treatment in cities across different Brazilian regions. Methods: This cross-sectional study was conducted in five cities that are considered priorities for TB control in Brazil: Itaborai (ITA), Ribeirao Preto (RP) and Sao Jose do Rio Preto (SJRP) in the Southeast; Campina Grande (CG) and Feira de Santana (FS) in the Northeast. Data were collected through interviews with 514 TB patients under treatment in 2007, using the Primary Care Assessment Tool adapted for TB care in Brazil. Indicators were constructed based on the mean response scores (Likert scale) and compared among the study sites. Results: ""Access to treatment"" was evaluated as satisfactory in the Southeast and regular in the Northeast, which displayed poor results on 'home visits' and 'distance between treatment site and patient's house'. ""Bond"" was assessed as satisfactory in all cities, with a slightly better performance in RP and SJRP. ""Range of services"" was rated as regular, with better performance of southeastern cities. 'Health education', 'DOT' and 'food vouchers' were less offered in the Northeast. ""Coordination"" was evaluated as satisfactory in all cities. ""Family focus"" was evaluated as satisfactory in RP and SJRP, and regular in the others. 'Professional asking patient's family about other health problems' was evaluated as unsatisfactory, except in RP. Conclusions: Two types of obstacles are faced for health service performance in TB treatment in the cities under analysis, mainly in the Northeast. The first is structural and derives from difficulties to access health services and actions. The second is organizational and derives from the way health technologies and services are distributed and integrated. Incentives to improve care organization and management practices, aimed at the integration of primary, secondary and tertiary services, can contribute towards a better performance of health services in TB treatment.

Impact of cancer-related symptom synergisms on health-related quality of life and performance status

To identify the impact of multiple symptoms and their co-occurrence on health-related quality of life (HRQOL) dimensions and performance status (PS), 115 outpatients with cancer, who were not receiving active cancer treatment and were recruited from, a university hospital in Sao Paulo, Brazil completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30, the Beck Depression Inventory, and the Brief Pain Inventory. Karnofsky Performance Status scores also were completed. Application of TwoStep Cluster analysis resulted in two distinct patient subgroups based on 113 patient experiences with pain, depression, fatigue, insomnia, constipation, lack of appetite, dyspnea, nausea, vomiting, and diarrhea. One group had multiple and severe symptom subgroup and another had Less symptoms and with lower severity. Multiple and severe symptoms had worse PS, role functioning, and physical, emotional, cognitive, social, and overall HRQOL. Multiple and severe symptom subgroup was also six times as likely as lower severity to have poor role functioning;five times more likely to have poor emotional;four times more likely to have poor PS, physical, and overall HRQOL, and three times as likely to have poor cognitive and social HRQOL, independent of gender, age, level of education, and economic condition. Classification and Regression Tree analyses were undertaken to identify which co-occurring symptoms would best determine reduction in HRQOL and PS. Pain and fatigue were identified as indicators of reduction on physical HRQOL and PS. Fatigue and insomnia were associated with reduction in cognitive; depression and pain in social; and fatigue and constipation in role functioning. Only depression was associated with reduction in overall HRQOL. These data demonstrate that there is a synergic effect among distinct cancer symptoms that result in reduction in HRQOL dimensions and PS.

Performance of the Equivalent Reservoir Modelling Technique for Multi-Reservoir Hydropower Systems

This paper investigates the validity of a simplified equivalent reservoir representation of a multi-reservoir hydroelectric system for modelling its optimal operation for power maximization. This simplification, proposed by Arvanitidis and Rosing (IEEE Trans Power Appar Syst 89(2):319-325, 1970), imputes a potential energy equivalent reservoir with energy inflows and outflows. The hydroelectric system is also modelled for power maximization considering individual reservoir characteristics without simplifications. Both optimization models employed MINOS package for solution of the non-linear programming problems. A comparison between total optimized power generation over the planning horizon by the two methods shows that the equivalent reservoir is capable of producing satisfactory power estimates with less than 6% underestimation. The generation and total reservoir storage trajectories along the planning horizon obtained by equivalent reservoir method, however, presented significant discrepancies as compared to those found in the detailed modelling. This study is motivated by the fact that Brazilian generation system operations are based on the equivalent reservoir method as part of the power dispatch procedures. The potential energy equivalent reservoir is an alternative which eliminates problems with the dimensionality of state variables in a dynamic programming model.

Permeability optimization and performance evaluation of hot aerosol filters made using foam incorporated alumina suspension

Porous ceramic samples were prepared from aqueous foam incorporated alumina suspension for application as hot aerosol filtering membrane. The procedure for establishment of membrane features required to maintain a desired flow condition was theoretically described and experimental work was designed to prepare ceramic membranes to meet the predicted criteria. Two best membranes, thus prepared, were selected for permeability tests up to 700 degrees C and their total and fractional collection efficiencies were experimentally evaluated. Reasonably good performance was achieved at room temperature, while at 700 degrees C, increased permeability was obtained with significant reduction in collection efficiency, which was explained by a combination of thermal expansion of the structure and changes in the gas properties. (C) 2008 Elsevier B.V. All rights reserved.

A decision support system to facilitate management of patients with acute gastrointestinal bleeding

Objective: To develop a model to predict the bleeding source and identify the cohort amongst patients with acute gastrointestinal bleeding (GIB) who require urgent intervention, including endoscopy. Patients with acute GIB, an unpredictable event, are most commonly evaluated and managed by non-gastroenterologists. Rapid and consistently reliable risk stratification of patients with acute GIB for urgent endoscopy may potentially improve outcomes amongst such patients by targeting scarce health-care resources to those who need it the most. Design and methods: Using ICD-9 codes for acute GIB, 189 patients with acute GIB and all. available data variables required to develop and test models were identified from a hospital medical records database. Data on 122 patients was utilized for development of the model and on 67 patients utilized to perform comparative analysis of the models. Clinical data such as presenting signs and symptoms, demographic data, presence of co-morbidities, laboratory data and corresponding endoscopic diagnosis and outcomes were collected. Clinical data and endoscopic diagnosis collected for each patient was utilized to retrospectively ascertain optimal management for each patient. Clinical presentations and corresponding treatment was utilized as training examples. Eight mathematical models including artificial neural network (ANN), support vector machine (SVM), k-nearest neighbor, linear discriminant analysis (LDA), shrunken centroid (SC), random forest (RF), logistic regression, and boosting were trained and tested. The performance of these models was compared using standard statistical analysis and ROC curves. Results: Overall the random forest model best predicted the source, need for resuscitation, and disposition with accuracies of approximately 80% or higher (accuracy for endoscopy was greater than 75%). The area under ROC curve for RF was greater than 0.85, indicating excellent performance by the random forest model Conclusion: While most mathematical models are effective as a decision support system for evaluation and management of patients with acute GIB, in our testing, the RF model consistently demonstrated the best performance. Amongst patients presenting with acute GIB, mathematical models may facilitate the identification of the source of GIB, need for intervention and allow optimization of care and healthcare resource allocation; these however require further validation. (c) 2007 Elsevier B.V. All rights reserved.

A risk-based system to penalize and reward line management for occupational safety and health performance

Penalizing line management for the occurrence of lost time injuries has in some cases had unintended negative consequences. These are discussed. An alternative system is suggested that penalizes line management for accidents where the combination of the probability of recurrence and the maximum reasonable consequences such a recurrence may have exceeds an agreed limit. A reward is given for prompt effective control of the risk to below the agreed risk limit. The reward is smaller than the penalty. High-risk accidents require independent investigation by a safety officer using analytical techniques. Two case examples are given to illustrate the system. Continuous safety improvement is driven by a planned reduction in the agreed risk limit over time and reward for proactive risk assessment and control.

Performance measurement and management in Portuguese law enforcement

Performance measurement of police services is complicated by ambiguous and complex goal- and objectives-setting, and by the difficulties of measuring outputs. This article looks at the organizational and management changes being made in Portuguese police forces. The authors fill a gap in the literature on performance measurement in Portugal by taking a national approach to the study of how law enforcement agencies are introducing new management accounting changes. The article therefore widens the debate on performance measurement and performance improvements in law enforcement.

Performance management framework: the fit between PM framework adopted in Portuguese local government and the Otley’s framework

Purpose/objectives: This paper seeks to investigate whether performance management (PM) framework adopted in Portuguese local government (PLG) fit the Otley’s PM framework (1999). In particularly, the research questions are (1) whether PM framework adopted in PLG (SIADAP) fit the Otley´s framework, and (2) how local politicians (aldermen) see the operation of performance management systems (PMS) in PLG (focusing on the goal-setting process and incentive and reward structures). Theoretical positioning/contributions: With this paper we intend to contribute to literature on how the Otley’s PM framework can guide empirical research about the operation of PMS. In particular, the paper contributes to understand the fit between PMS implemented in PLG and the Otley´s PM framework. The analysis of this fit can be a good contribution to understand if PMS are used in PLG as a management tool or as a strategic response to external pressures (based on interviews conducted to aldermen). We believe that the Otley’s PM framework, as well as the extended PM framework presented by Ferreira and Otley (2009), can provide a useful research tool to understand the operation of PMS in PLG. Research method: The first research question is the central issue in this paper and is analyzed based on the main reforms introduced by Portuguese government on PM of public organizations (like municipalities). On the other hand, interviews conducted on three larger Portuguese municipalities (Oporto, Braga, and Matosinhos) show how aldermen see the operation of PMS in PLG, highlighting the goals setting process with targets associated and the existing of incentive and reward structures linked with performance. Findings: Generally we find that formal and regulated PM frameworks in PLG fit the main issues of the Otley’s PM framework. However, regarding the aldermen perceptions about PMS in practice we find a gap between theory and practice, especially regarding difficulties associated with the lack of a culture of goals and targets setting and the lack of incentive and reward structures linked with performance.

An optimal level of technology reliance on foreign partners in a global sourcing partnership: components procurement, technology management and market performance

Existing studies on global sourcing strategy have implicitly adopted a cJosed-systems perspective in which sourcing activities are managed within a multinational company across national boundaries. Produd and process innovations and components procurement that are jointly managed by a consortium of cooperating firms have not been examined. In this paper, we empiricallyexamine the issues concerning sourcing partnerships in an open-systems perspective. Findings suggest that even in a sourcing partnership arrangement with a foreign supplier, the principal firm's ability to procure and control the supply of major components has a positive bearing on its market performance.

Performance management in health centres: evidence from a field study

There has been a growing interest in research on performance measurement and management practices, which seems to reflect researchers’ response to calls for the need to increase the relevance of management accounting research. However, despite the development of the new public management literature, studies involving public sector organizations are relatively small compared to those involving business organizations and extremely limited when it comes to public primary health care organizations. Yet, the economic significance of public health care organizations in the economy of developed countries and the criticisms these organizations regularly face from the public suggests there is a need for research. This is particularly true in the case of research that may lead to improvement in performance measurement and management practices and ultimately to improvements in the way health care organizations use their limited resources in the provision of services to the communities. This study reports on a field study involving three public primary health care organisations. The evidence obtained from interviews and archival data suggests a performance management practices in these institutions lacked consistency and coherence, potentially leading to decreased performance. Hierarchical controls seemed to be very weak and accountability limited, leading to a lack of direction, low motivation and, in some circumstances to insufficient managerial abilities and skills. Also, the performance management systems revealed a number of weaknesses, which suggests that there are various opportunities for improvement in performance in the studied organisations.

Distributed energy resource short-term scheduling using signaled particle swarm optimization

Distributed Energy Resources (DER) scheduling in smart grids presents a new challenge to system operators. The increase of new resources, such as storage systems and demand response programs, results in additional computational efforts for optimization problems. On the other hand, since natural resources, such as wind and sun, can only be precisely forecasted with small anticipation, short-term scheduling is especially relevant requiring a very good performance on large dimension problems. Traditional techniques such as Mixed-Integer Non-Linear Programming (MINLP) do not cope well with large scale problems. This type of problems can be appropriately addressed by metaheuristics approaches. This paper proposes a new methodology called Signaled Particle Swarm Optimization (SiPSO) to address the energy resources management problem in the scope of smart grids, with intensive use of DER. The proposed methodology’s performance is illustrated by a case study with 99 distributed generators, 208 loads, and 27 storage units. The results are compared with those obtained in other methodologies, namely MINLP, Genetic Algorithm, original Particle Swarm Optimization (PSO), Evolutionary PSO, and New PSO. SiPSO performance is superior to the other tested PSO variants, demonstrating its adequacy to solve large dimension problems which require a decision in a short period of time.