Quality Improvement through Experiments with Mixtures

Mixture experiments are typical for chemical, food, metallurgical and other industries. The aim of these experiments is to find optimal component proportions that provide desired values of some product performance characteristics.

Combined quality function deployment and logical framework analysis to improve quality of emergency care in Malta

Purpose – The purpose of this paper is to develop an integrated patient-focused analytical framework to improve quality of care in accident and emergency (A&E) unit of a Maltese hospital. Design/methodology/approach – The study adopts a case study approach. First, a thorough literature review has been undertaken to study the various methods of healthcare quality management. Second, a healthcare quality management framework is developed using combined quality function deployment (QFD) and logical framework approach (LFA). Third, the proposed framework is applied to a Maltese hospital to demonstrate its effectiveness. The proposed framework has six steps, commencing with identifying patients’ requirements and concluding with implementing improvement projects. All the steps have been undertaken with the involvement of the concerned stakeholders in the A&E unit of the hospital. Findings – The major and related problems being faced by the hospital under study were overcrowding at A&E and shortage of beds, respectively. The combined framework ensures better A&E services and patient flow. QFD identifies and analyses the issues and challenges of A&E and LFA helps develop project plans for healthcare quality improvement. The important outcomes of implementing the proposed quality improvement programme are fewer hospital admissions, faster patient flow, expert triage and shorter waiting times at the A&E unit. Increased emergency consultant cover and faster first significant medical encounter were required to start addressing the problems effectively. Overall, the combined QFD and LFA method is effective to address quality of care in A&E unit. Practical/implications – The proposed framework can be easily integrated within any healthcare unit, as well as within entire healthcare systems, due to its flexible and user-friendly approach. It could be part of Six Sigma and other quality initiatives. Originality/value – Although QFD has been extensively deployed in healthcare setup to improve quality of care, very little has been researched on combining QFD and LFA in order to identify issues, prioritise them, derive improvement measures and implement improvement projects. Additionally, there is no research on QFD application in A&E. This paper bridges these gaps. Moreover, very little has been written on the Maltese health care system. Therefore, this study contributes demonstration of quality of emergency care in Malta.

Effects of light quantity and quality on early seedling development in the red mangrove Rhizophora mangle L

Seedlings of the red mangrove, Rhizophora mangle L., were grown under light conditions differing in both photosynthetic photon flux density (PPFD) and spectral quality (red:far-red ratio, R:FR). During the first 8 mo of development, parameters of stem, leaf, and root growth were affected by PPFD. Significant responses to lowered R:FR, however, were limited to internode extension. The results are moderately indicative of a strategy to persist in shade, but illustrate the complexity of light responses and suggest that precise categorization as shade-tolerant or -intolerant may be unbefitting for this species at this particular stage of development.

The effect of a breakfast program on nutritional status, quality of life, and health care use among frail homebound older adults

The population of older adults is rapidly increasing, creating a need for community services that assist vulnerable older adults in maintaining independence and quality of life. Recent evidence confirms the importance of food and nutrition in reaching this objective. The Elderly Nutrition Program (ENP) is part of a system of federally funded community based programs, authorized through the Older Americans Act. ENP services include the home-delivered meals program, which targets frail homebound older adults at nutritional risk. Traditionally, ENP services provide a noon meal 5 days/week. This study evaluated the impact of expanding the home-delivered meals service to include breakfast + lunch, on the nutritional status, quality of life and health care utilization of program participants. ^ This cross-sectional study compared 2 groups. The Breakfast group (n = 167) received a home-delivered breakfast + lunch, 5 days/week. The Comparison group (n = 214) received lunch 5 days/week. Participants, recruited from 5 ENP programs, formed a geographically, racially/ethnically diverse sample. Participants ranged in age from 60–100 years, they were functionally limited, at high nutritional risk, low income, and they lived alone and had difficulty shopping or preparing food. Participant data were collected through in-home interviews and program records. A 24-hour food recall and information on participant demographics, malnutrition risk, functional status, health care use, and applicable quality of life factors were obtained. Service and cost data were collected from program administrators. ^ Breakfast group participants had greater energy/nutrient intakes (p < .05), fewer health care contacts (p < .05), and greater quality of life measured as food security (p < .05) and fewer depressive symptoms (p < .05), than comparison group participants. These benefits were achieved for $1.30/person/day. ^ The study identified links from improvements in nutritional status to enhanced quality of life to diminished health care utilization and expenditures. A model of health, loneliness, food enjoyment, food insecurity, and depression as factors contributing to quality of life for this population, was proposed and tested (p < .01). ^ The breakfast service is an inexpensive addition to traditional home-delivered meals services and can improve the lives of frail homebound older adults. Agencies should be encouraged to expand meals programs to include a breakfast service. ^

Tropical seagrass-associated macroalgae distributions and trends relative to water quality

Tropical coastal marine ecosystems including mangroves, seagrass beds and coral reef communities are undergoing intense degradation in response to natural and human disturbances, therefore, understanding the causes and mechanisms present challenges for scientist and managers. In order to protect our marine resources, determining the effects of nutrient loads on these coastal systems has become a key management goal. Data from monitoring programs were used to detect trends of macroalgae abundances and develop correlations with nutrient availability, as well as forecast potential responses of the communities monitored. Using eight years of data (1996–2003) from complementary but independent monitoring programs in seagrass beds and water quality of the Florida Keys National Marine Sanctuary (FKNMS), we: (1) described the distribution and abundance of macroalgae groups; (2) analyzed the status and spatiotemporal trends of macroalgae groups; and (3) explored the connection between water quality and the macroalgae distribution in the FKNMS. In the seagrass beds of the FKNMS calcareous green algae were the dominant macroalgae group followed by the red group; brown and calcareous red algae were present but in lower abundance. Spatiotemporal patterns of the macroalgae groups were analyzed with a non-linear regression model of the abundance data. For the period of record, all macroalgae groups increased in abundance (Abi) at most sites, with calcareous green algae increasing the most. Calcareous green algae and red algae exhibited seasonal pattern with peak abundances (Φi) mainly in summer for calcareous green and mainly in winter for red. Macroalgae Abi and long-term trend (mi) were correlated in a distinctive way with water quality parameters. Both the Abi and mi of calcareous green algae had positive correlations with NO3−, NO2−, total nitrogen (TN) and total organic carbon (TOC). Red algae Abi had a positive correlation with NO2−, TN, total phosphorus and TOC, and the mi in red algae was positively correlated with N:P. In contrast brown and calcareous red algae Abi had negative correlations with N:P. These results suggest that calcareous green algae and red algae are responding mainly to increases in N availability, a process that is happening in inshore sites. A combination of spatially variable factors such as local current patterns, nutrient sources, and habitat characteristics result in a complex array of the macroalgae community in the seagrass beds of the FKNMS.

Spatial and temporal distributions of epiphytic diatoms growing on Thalassia testudinum Banks ex König: relationships to water quality

The spatial and temporal distributions of the epiphytic diatom flora on Thalassia testudinum was described within the Florida Bay estuary and at one Atlantic site east of the Florida Keys over a 1-year period. Species of the genus Mastogloia dominated the epiphytic diatom flora (82 out of 332 total species). Nonmetric Multidimensional Scaling (NMDS) and Analysis of Similarity (ANOSIM) revealed four distinct spatial assemblages and two temporal assemblages. Eastern and western Florida Bay assemblages were identified within the estuary. The eastern diatom assemblage was characterized by high relative abundances of Brachysira aponina and Nitzschia liebetruthii, while the western assemblage was characterized by the abundance of Reimerothrix floridensis, particularly during summer. Two diverse and distinct marine assemblages, one located in the Gulf of Mexico along the western edge of Florida Bay and the other behind the Florida reef tract in the Atlantic Ocean, were also identified. Analysis of the spatial distribution of diatoms and water quality characteristics within Florida Bay suggest that these assemblages may be structured by salinity and nutrient availability, particularly P. The Gulf of Mexico and the western Florida Bay assemblages were associated with higher water column salinities and TP concentrations and lower DIN concentrations and TN:TP ratios relative to the eastern Florida Bay assemblage. The temporal variation in diatom assemblages was associated with water temperature, though temporal indicator species were few relative to the number of spatial indicators.

Personality and job performance: The mediating roles of leader -member exchange quality and action control

The present investigation examined the relationships among personality (as conceptualized by the Big Five Factors), leader-member exchange (LMX) quality, action control, organizational citizenship behaviors (OCB), and overall job performance (OJP). Two mediator variables were proposed and tested in this study: LMX and Action Control. Two-hundred and seven currently employed regular elementary school classroom teachers provided data during the 2000–2001 academic school year. Teachers provided personality, LMX quality (member or subordinate perspective), action control, job tenure, and demographic data. Nine school administrators (i.e., Principals, Assistant Principals) were the source for supervisor ratings of OCB, OJP, and LMX quality (leader or supervisor perspective). In eight of the nine total schools, teachers completed questionnaires during an after-school teacher gathering; in the remaining school location questionnaires were dropped off, distributed to teachers, and re-collected two weeks later. Results indicated a significant relationship between the OCB scale and overall supervisory ratings of OJP. The relationship among the big five factors of personality and OJP did not reach statistical significance, nor did the relationships among personality and OCB. The data indicated that none of the teacher tenure variables (i.e., teacher, school, or time worked with principal tenure) moderated the personality-OCB relationship nor the personality-OJP relationship. Finally, a review of the correlations among the variables of interest precluded conducting a mediation between personality-performance by OCB, mediation of personality-OCB by action control, and mediation of personality-OCB by LMX. In conclusion, the data reveal that personality was not significantly correlated with supervisory ratings of OJP or significantly related to supervisory ratings of overall OCB. Moreover, LMX quality and action control did not mediate the relationships between Personality-OJP nor the Personality-OCB relationship. Significant relationships were found between disengagement and overall LMX quality and between Initiative and overall LMX quality (both LMX-Teacher perspectives) as well as between personality variables and both Disengagement and Initiative action control variables. Despite the limitations inherent in this study, these latter findings suggest “lessons” for teachers and school administrators alike. ^

Structural Basis of RNA Recognition by Mycobacterium tuberculosis MazF Homologues

The MazEF toxin-antitoxin (TA) system consists of the antitoxin MazE and the toxin MazF. MazF is a sequence-specific endoribonuclease that upon activation causes cellular growth arrest and increass the level of persisters. Moreover, MazF-induced cells are in a quasi-dormant state that cells remain metabolically active while stop dividing. The quasi-dormancy is similar to the nonreplicating state of M. tuberculosis during latent tuberculosis, thus suggesting the role of mazEF in M. tuberculosis dormancy and persistence. M. tuberculosis has nine mazEF TA modules, each with different RNA cleavage specificities and implicated in selective gene expression during stress conditions. To date only the Bacillus subtilis MazF-RNA complex structure has been determined. As M. tuberculosis MazF homologues recognize distinct RNA sequences, their molecular mechanisms of substrate specificity remain unclear. By taking advantage of X-ray crystallography, we have determined structures of two M. tuberculosis MazF-RNA complexes, MazF-mt1 (Rv2801c) and MazF-mt3 (Rv1991c) in complex with an uncleavable RNA substrate. These structures have provided the molecular basis of sequence-specific RNA recognition and cleavage by MazF toxins.

Both MazF-mt1-RNA and MazF-mt3-RNA complexes showed similar structural organization with one molecule of RNA bound to a MazF-mt1 or MazF-mt3 dimer and occupying the same pocket within the MazF dimer interface. Similar to B. subtilis MazF-RNA complex, MazF-mt1 and MazF-mt3 displayed a conserved active site architecture, where two highly conserved residues, Arg and Thr, form hydrogen bonds with the scissile phosphate group in the cleavage site of the bound RNA. The MazF-mt1-RNA complex also showed specific interactions with its three-base RNA recognition element. Compared with the B. subtilis MazF-RNA complex, our structures showed that residues involved in sequence-specific recognition of target RNA vary between the MazF homologues, therefore explaining the molecular basis for their different RNA recognition sequences. In addition, local conformational changes of the loops in the RNA binding site of MazF-mt1 appear to play a role in MazF targeting different RNA lengths and sequences. In contrast, the MazF-mt3-RNA complex is in a non-optimal RNA binding state with a symmetry-related MazF-mt3 molecule found to make interactions with the bound RNA in the crystal. The crystal-packing interactions were further examined by isothermal titration calorimetry (ITC) studies on selected MazF-mt3 mutants. Our attempts to utilize a MazF-mt3 mutant bearing mutations involved in crystal contacts all crystallized with few nucleotides, which are still found to interact with a symmetry mate. However, these different crystal forms revealed the conformational flexibility of loops in the RNA binding interface of MazF-mt3, suggesting their role in RNA binding and recognition, which will require further studies on additional MazF-mt3-RNA complex interactions.

In conclusion, the structures of the MazF-mt1-RNA and MazF-mt3-RNA complexes provide the first structural information on any M. tuberculosis MazF homologues. Supplemented with structure-guided mutational studies on MazF toxicity in vivo, this study has addressed the structural basis of different RNA cleavage specificities among MazF homologues. Our work will guide future studies on the function of other M. tuberculosis MazF and MazE-MazF homologues, and will help delineate their physiological roles in M. tuberculosis stress responses and pathogenesis.

Election Quality and International Observation 1975-2004: Two New Datasets

This paper introduces two new datasets on national level elections from 1975 to 2004. The data are grouped into two separate datasets, the Quality of Elections Data and the Data on International Election Monitoring. Together these data sets provide original information on elections, election observation and election quality, and will enable researchers to study a variety of research questions. The datasets will be publicly available and are maintained at a project website.

Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS)

© 2014, Canadian Anesthesiologists' Society.Optimal perioperative fluid management is an important component of Enhanced Recovery After Surgery (ERAS) pathways. Fluid management within ERAS should be viewed as a continuum through the preoperative, intraoperative, and postoperative phases. Each phase is important for improving patient outcomes, and suboptimal care in one phase can undermine best practice within the rest of the ERAS pathway. The goal of preoperative fluid management is for the patient to arrive in the operating room in a hydrated and euvolemic state. To achieve this, prolonged fasting is not recommended, and routine mechanical bowel preparation should be avoided. Patients should be encouraged to ingest a clear carbohydrate drink two to three hours before surgery. The goals of intraoperative fluid management are to maintain central euvolemia and to avoid excess salt and water. To achieve this, patients undergoing surgery within an enhanced recovery protocol should have an individualized fluid management plan. As part of this plan, excess crystalloid should be avoided in all patients. For low-risk patients undergoing low-risk surgery, a “zero-balance” approach might be sufficient. In addition, for most patients undergoing major surgery, individualized goal-directed fluid therapy (GDFT) is recommended. Ultimately, however, the additional benefit of GDFT should be determined based on surgical and patient risk factors. Postoperatively, once fluid intake is established, intravenous fluid administration can be discontinued and restarted only if clinically indicated. In the absence of other concerns, detrimental postoperative fluid overload is not justified and “permissive oliguria” could be tolerated.

Characterization of a Full-Length TTP Family Member Association with RNA Sequence Elements

Post-transcriptional regulation of cytoplasmic mRNAs is an efficient mechanism of regulating the amounts of active protein within a eukaryotic cell. RNA sequence elements located in the untranslated regions of mRNAs can influence transcript degradation or translation through associations with RNA-binding proteins. Tristetraprolin (TTP) is the best known member of a family of CCCH zinc finger proteins that targets adenosine-uridine rich element (ARE) binding sites in the 3’ untranslated regions (UTRs) of mRNAs, promoting transcript deadenylation through the recruitment of deadenylases. More specifically, TTP has been shown to bind AREs located in the 3’-UTRs of transcripts with known roles in the inflammatory response. The mRNA-binding region of the protein is the highly conserved CCCH tandem zinc finger (TZF) domain. The synthetic TTP TZF domain has been shown to bind with high affinity to the 13-mer sequence of UUUUAUUUAUUUU. However, the binding affinities of full-length TTP family members to the same sequence and its variants are unknown. Furthermore, the distance needed between two overlapping or neighboring UUAUUUAUU 9-mers for tandem binding events of a full-length TTP family member to a target transcript has not been explored. To address these questions, we recombinantly expressed and purified the full-length C. albicans TTP family member Zfs1. Using full-length Zfs1, tagged at the N-terminus with maltose binding protein (MBP), we determined the binding affinities of the protein to the optimal TTP binding sequence, UUAUUUAUU. Fluorescence anisotropy experiments determined that the binding affinities of MBP-Zfs1 to non-canonical AREs were influenced by ionic buffer strength, suggesting that transcript selectivity may be affected by intracellular conditions. Furthermore, electrophoretic mobility shift assays (EMSAs) revealed that separation of two core AUUUA sequences by two uridines is sufficient for tandem binding of MBP-Zfs1. Finally, we found evidence for tandem binding of MBP-Zfs1 to a 27-base RNA oligonucleotide containing only a single ARE-binding site, and showed that this was concentration and RNA length dependent; this phenomenon had not been seen previously. These data suggest that the association of the TTP TZF domain and the TZF domains of other species, to ARE-binding sites is highly conserved. Domains outside of the TZF domain may mediate transcript selectivity in changing cellular conditions, and promote protein-RNA interactions not associated with the ARE-binding TZF domain.

In summary, the evidence presented here suggests that Zfs1-mediated decay of mRNA targets may require additional interactions, in addition to ARE-TZF domain associations, to promote transcript destabilization and degradation. These studies further our understanding of post-transcriptional steps in gene regulation.

Some Remarks on Quality in Interpreting, Interpreting Modes and the Interpreter’s Role

Quality in interpreting is a hotly debated issue whose complexity is determined by a mix of factors. In this article I analyze it in the light of the role played by interpreters, stressing how the constraints imposed by the different interpreting modes, the different roles actually played by professionals (who become more or less visible, even within the same assignment) and the expectations they generate require the adoption of a flexible perspective when it comes to identifying and assessing quality criteria and drafting professional codes that are open enough to adjust to diverse communicative settings and to the dynamic character of quality.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care

Background: Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care.

Methods: A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models’ characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria.

Results: From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0–32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported.

Conclusions: The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Validation of stress indicators for the assessment of animal welfare and prediction of pork meat quality variation at commercial level

Les procédures appliquées avant l’abattage des animaux influencent directement la qualité de la viande en modulant l’état physiologique des porcs; ainsi, l’augmentation de la température corporelle, les taux élevés de lactate sanguin et l’épuisement des réserves de glycogène entre autres, occasionnent la majorité des baisses de qualité. L’objectif de cette thèse était de valider des outils indicateurs de stress porcin pour les fermes et les abattoirs. Ceux-ci seraient appliqués à la surveillance du bien-être animal et à la prédiction de variation de qualité de la viande porcine au niveau commercial. Premierement, les résultats de la thèse ont permis de conclure qu’un des outils développés (analyseur portatif de lactate) mesure la variation du niveau de lactate sanguin associé à l’état physiologique des porcs dans la phase péri-mortem et aide à expliquer la variation de la qualité de la viande chez le porc à l’abattoir, en particulier dans les muscles du jambon. Deuxièmement, les résultats des audits du bien-être animal appliqués de la ferme à l’abattoir ont démontré que la qualité du système d’élevage à la ferme d’origine et les compétences du chauffeur de camion sont d’importants critères affectant la réponse comportementale des porcs à la manipulation avant l’abattage. Ces résultats ont également démontré que les conditions de logement à la ferme (la faible densité et l’enrichissement dans les enclos), le comportement des porcs en période pré-abattage (glissade), ainsi que les interventions du manipulateur (utilisation du bâton électrique) dans la zone d’étourdissement de l’abattoir affectent négativement la variation de la qualité de la viande. L’application des protocoles d’audits dans la filière porcine a également démontré que le respect des critères de bien-être animal fixés par un outil de vérification est primordiale et permet de contrôler les conditions de bien-être des porcs à chaque étape de la période pré-abattage, de produire une viande de qualité supérieure et de réduire les pertes. Les audits de bien-être animal sont donc un outil qui apporte des resultats très pertinents pour aider a éviter les variations de la qualité de la viande chez le porc. Troisièmement, la thermographie infrarouge s’est avéré être une technique prometteuse permettant d’évaluer la variation de température corporelle de l’animal pendant et après un stress physique, en particulier lorsque cette mesure est prise derrière les oreilles. En conclusion, les outils validés à travers cette thèse représentent des méthodologies non invasives et potentiellement complémentaires à d’autres approches d’évaluation de l’état physiologique et du bien-être animal par rapport au stress, permettant de réduire les pertes de qualité de viande (par exemple en utilisation conjointe avec le niveau de lactate sanguin et les indicateurs de stress comportemental, entre autres).

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

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