Lean thinking: using 6S and visual management for efficient adverse event closure

BackgroundWe focused on a busy Adult Oncology Department having over 130 staff members, with around 70 of them being physicians with different levels of specialties. A multidisciplinary committee was formed in the department, consisting of physicians, nurses, pharmacists, a medication safety representative and a quality specialist to look after all reported incidents.Local problemThe department staff at the institution in question in this study expressed their concern about the surging number of reported incidents, delays in closing reports within the set timeframe, ambiguity of individuals’ roles at the committee level and errors in using the safety reporting system (SRS). Accordingly, this study focused on the development of a visual aid through the creation of a functional process map to help clarify team roles and stipulate the steps for adverse event closure.MethodsThe Sort, Set-in order, Shine, Standardise, Sustain and Safety and visual management lean principles, as well as the eight lean wastes—Transportation, Inventory, Motion, Waiting, Overprocessing, Overproduction, Defect and Staff underutilisation—were introduced in early May 2016 and used during SRS committee meetings over 3 years.InterventionThe indicators used were the average number of days for both medication and non-medication incidents from the day of reporting until the closure. The extent that the limit was exceeded was compared.ResultsThe average number of days until closure showed a reduction from 67 to 37 and 134 to 61 between Periods I (2016) and III (2018) for medication and non-medication incidents, respectively.ConclusionsThe developed process map was a useful communication tool. It helped to sort process activities, team roles and streamline the process. It brought the average number of days until closure within the acceptable 45-day limit for medication incidents. Thus, using visual aids in the working environment is helpful in improving communication among the workers.

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The need and availability of support systems for physicians involved in a serious adverse event

Journal of Hospital Administration ◽

10.5430/jha.v7n2p23 ◽

2018 ◽

Vol 7 (2) ◽

pp. 23 ◽

Cited By ~ 1

Author(s):

Esther H.M. Leferink ◽

Aline Bos ◽

Martijn P. Heringa ◽

Elizabeth L.J. van Rensen ◽

Dorien L.M. Zwart

Keyword(s):

Adverse Event ◽

Adverse Events ◽

Healthcare Professionals ◽

Well Being ◽

Working Environment ◽

Support Needs ◽

Quality And Safety ◽

Serious Adverse Events ◽

Serious Adverse Event ◽

Staff Members

Objective: Serious adverse events occur in healthcare, and do not solely have consequences for patients (first victims), but also affect physicians involved (second victims). These second victims experience diminished emotional well-being and less professional performance. An increasing number of hospitals organize support for second victims, although scientific evidence on the kind of support that is expected and needed is poor. This study therefore investigates support needs after serious adverse events from both personal (physicians) and organizational (quality and safety staff members) perspectives.Methods: We conducted semi-structured interviews in a Dutch university medical center. Physicians (N = 19) who had been directly involved in a serious adverse event participated. In addition, quality and safety staff members (N = 3) reflected on the support needs as expressed by physicians. Verbatim transcripts were three-fold coded, which led to several themes for our inductive thematic analysis.Results: Contrary to recent developments in healthcare organizations, participants did not plea for a hospital-wide support team. Acceptance of the emotional and professional impact of an adverse event by direct colleagues and supervisors is more important. Where such a cultural context is provided, physicians prefer support of a close and reliable colleague to cope with emotions and doubts, a supervisor who monitors recovery, and a healthcare organization that provides information about required procedures to learn from the events. However, this ideal was seldom found in the competitive working environment. This underlines the need for a shift from a competitive professional culture into a more supportive one.Conclusions: Ideally, direct colleagues support each other after an adverse event. This form of collegial support can only be successful if there is general acceptance of healthcare professionals’ vulnerability and their support needs within the direct working environment. To create the right circumstances to meet these support needs, both healthcare professionals and hospital organizations have to recognize and take their responsibilities.

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Disentangling the clinical data chaos: User-centered interface system design for trauma centers

PLoS ONE ◽

10.1371/journal.pone.0251140 ◽

2021 ◽

Vol 16 (5) ◽

pp. e0251140

Author(s):

JaeYeon Park ◽

Soyoung Rhim ◽

Kyungsik Han ◽

JeongGil Ko

Keyword(s):

Clinical Data ◽

Trauma Center ◽

User Study ◽

Working Environment ◽

Center Staff ◽

Staff Members ◽

Clinical Nurses ◽

Interface System ◽

Target Environment ◽

User Centered

This paper presents a year-long study of our project, aiming at (1) understanding the work practices of clinical staff in trauma intensive care units (TICUs) at a trauma center, with respect to their usage of clinical data interface systems, and (2) developing and evaluating an intuitive and user-centered clinical data interface system for their TICU environments. Based on a long-term field study in an urban trauma center that involved observation-, interview-, and survey-based studies to understand our target users and their working environment, we designed and implemented MediSenseView as a working prototype. MediSenseView is a clinical-data interface system, which was developed through the identification of three core challenges of existing interface system use in a trauma care unit—device separation, usage inefficiency, and system immobility—from the perspectives of three staff groups in our target environment (i.e., doctors, clinical nurses and research nurses), and through an iterative design study. The results from our pilot deployment of MediSenseView and a user study performed with 28 trauma center staff members highlight their work efficiency and satisfaction with MediSenseView compared to existing clinical data interface systems in the hospital.

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The potential of the pinhole as a visual aid in the developing world

African Vision and Eye Health ◽

10.4102/aveh.v75i1.318 ◽

2016 ◽

Vol 75 (1) ◽

Author(s):

Antony S. Carlson ◽

Warren A. Carlson ◽

William F. Harris

Keyword(s):

Visual Impairment ◽

Developing World ◽

Relative Performance ◽

Visual Aids ◽

Healthcare Facilities ◽

Lighting Conditions ◽

Vision Correction ◽

Visual Aid ◽

Comparative Measure

Purpose: Providing vision correction in communities where healthcare facilities are unavailable is problematic. Here, we explore the possibility of using pinholes as near visual aids in the developing world.Method: Uncompensated (without the pinhole) proximal visual acuities (VAs) were measured and recorded for one eye of 45 presbyopic subjects over the age of 50 years in photopic (250 lux) and scotopic (20 lux) conditions. The proximal VAs were then repeated while the subjects looked through nine different pinholes.Results: The VAs varied with the diameter of each pinhole. A comparative measure was devised to determine the relative performance of different diameter pinholes as a near visual aid. The results suggest an improvement of more than 40% in VA in about 67% of subjects in good lighting conditions and about 60% in poorer lighting conditions.Conclusion: By creating more awareness that there are other ways of improving vision that cost almost nothing, visual impairment can be reduced until spectacles become available.

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Graph paper: a versatile visual aid

The Arithmetic Teacher ◽

10.5951/at.16.2.0144 ◽

1969 ◽

Vol 16 (2) ◽

pp. 144-148

Author(s):

Robert Parker

Keyword(s):

Ease Of Use ◽

Upper Elementary ◽

Elementary Grades ◽

Visual Aids ◽

Sequential Development ◽

Graph Paper ◽

Visual Aid ◽

Mathematics Program ◽

Points Of View ◽

The Many

In considering the mathematics program for elementary children, it is important for teachers to examine not only mathematical ideas but also the contexts within which such ideas are used. This usually means an examination of visual aids or tools of learning, since instruction in elementary grades depends upon the concrete to explain the abstract. With this in mind, one such tool that deserves special attention is graph, or squared, paper. Until one looks at the many possible uses of this visual aid, it may be taken for granted, and its applications remain sporadic and disconnected. This article is presented for the purpose of showing that graph paper is an educational device having few peers, especially from the points of view of economy, availability, and ease of use. An ordinary compilation of graph paper uses would be helpful to some degree, but what follows is a sequential development from the primary level through the upper elementary grades.

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Audio-Visual Aid: An Effective Means to improve Parental Awareness toward Habits and Malocclusion Prevention in Children

World Journal of Dentistry ◽

10.5005/jp-journals-10015-1267 ◽

2014 ◽

Vol 5 (2) ◽

pp. 98-101 ◽

Cited By ~ 1

Author(s):

K Kiran ◽

Swati Dwivedi ◽

Satyaki Arora ◽

Deepa Singal ◽

Varun Nikhra ◽

...

Keyword(s):

Sample Size ◽

Effective Means ◽

Preventive Dentistry ◽

Visual Aids ◽

Oral Habits ◽

Parental Awareness ◽

Normal Individuals ◽

Before And After ◽

Visual Aid ◽

Knowledge And Attitude

ABSTRACT Introduction Malocclusion is a very prevalent disorder of children. These disorders are frequently the result of deleterious oral habits. These disorders and their etiology are very difficult to explain to the parent, but the advent of audio-visual aids has solved this dilemma for the clinician. They allow the clinician to make the parents understand problems and also to compare with normal individuals. Aim The aim of the present study was to evaluate the awareness of parent toward malocclusion and the efficiency of audio-visual aid in improving parent awareness and compliance toward treatment. Materials and methods A sample size of 100 was estimated which were selected randomly from patients coming to the Department of Pedodontics and Preventive Dentistry, IDS Bareilly. An audio-visual aid was prepared describing the oral habits and their associated malocclusions. A self-prepared questionnaire was presented to the parent before and after the audio-visual aid was shown to them. Their awareness and change in attitude was recorded. Results There was statistically significant (p ≤ 0.001) improvement in the knowledge and attitude toward treatment after audio-visual aids were used. Conclusion Audio-visual aid is effective in improving awareness toward malocclusion caused due to oral habits. How to cite this article Chandra S, Singal D, Arora S, Dwivedi S, Kiran K, Nikhra V, Chandra N. Audio-Visual Aid: An Effective Means to Improve Parental Awareness toward Habits and Malocclusion Prevention in Children. World J Dent 2014;5(2):98-101.

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EFFICACY OF AN AUDIO-VISUAL AID IN IMPROVING KNOWLEDGE AND AWARENESS TOWARDS INFANT ORAL HEALTH CARE FOR EXPECTANT MOTHERS

Journal of Indian Dental Association ◽

10.33882/jida.13.25520 ◽

2020 ◽

Author(s):

Chahita Mahesh Lalchandani ◽

Sandeep Tandon ◽

Tripti Sharma Rai ◽

Anupama Kajal

Keyword(s):

Health Care ◽

Oral Health ◽

Oral Health Care ◽

Visual Aids ◽

Maternity Hospitals ◽

Before And After ◽

Visual Aid ◽

Expectant Mothers ◽

The Mean ◽

Infant Oral Health

Aim: The objective of this study was to evaluate the efficacy of a PowerPoint Presentation in Up-grading the knowledge and awareness towards infant oral health care among expectant mothers. Methods: This was a cross sectional survey conducted in various maternity hospitals throughout Jaipur city, India. A 15 minute PowerPoint Presentation based on infant oral health care was presented to a total of 120 expectant mothers. The participants were made to fill a 15-point questionnaire on the same subject before and after the presentation. Based on a formulated scoring criterion, the knowledge and awareness level of each participant was quantified pre-intervention and post-intervention. The data thus obtained was analysed using descriptive statistics and chi square test, with the level of significance set at P<0.05. Results: There was a very high statistical difference (p=0.000) between the mean scores of the participants before and after the presentation, from 5.55 to 13.96 out of a maximum possible score of 15. The range of scores improved from 0-14 pre-presentation to 9-15 post- presentation. A significant improvement was seen in the mean scores of every socio- demographic group (p=0.000). A relatively high number of participants (85.8%) agreed that the presentation would change how they care for their child in the future. Conclusion: Based on the results of the study, it can be concluded that the use of audio-visual aids is beneficial in improving the knowledge and awareness towards infant oral health care among expectant mothers. Further research can be conducted to evaluate different designs of various audio-visual aids and their long-term efficacy catering to different socio- demographic groups. KEYWORDS Expectant mothers, infant oral health care, awareness, audio-visual aid, pregnant women, maternal awareness

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Visual Aids for Relating Direct and Inverse Circular Functions

Mathematics Teacher ◽

10.5951/mt.65.5.0431 ◽

1972 ◽

Vol 65 (5) ◽

pp. 431

Author(s):

William K. Viertel

Keyword(s):

Inverse Function ◽

Trigonometric Function ◽

Visual Aids ◽

Transparent Material ◽

Visual Aid ◽

One To One ◽

Circular Functions ◽

Relationship Of ◽

The Relationship

A visual aid for vividly demonstrating the relationship of the direct and inverse circular functions can be made quite easily and cheaply out of transparent sheets. The principle is simple, and the aid is similar to the graphs that are shown in all trigonometry texts. A graph of a trigonometric function is drawn on transparent material for an interval that makes it a one-to-one function. This graph is then turned over and rotated 90°, so that the x- and y-axes are interchanged and properly directed. The viewer now sees the graph of the inverse function with the proper domain and range.

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Can visual aides influence rehabilitation and length of stay following knee replacement? A randomized controlled study

Orthopedic Reviews ◽

10.4081/or.2015.5758 ◽

2015 ◽

Vol 7 (1) ◽

Author(s):

Simon Abson ◽

Benjamin Kenny ◽

Reza Rahim ◽

Daniel Benz ◽

Jorgen Hellman

Keyword(s):

Length Of Stay ◽

Range Of Motion ◽

Goal Attainment ◽

Controlled Study ◽

Visual Aids ◽

Visual Aid ◽

Patient Stay ◽

American Society ◽

Cohort Groups ◽

American Society Of Anesthesiologists

Arthroplasty is increasingly performed within Australia, with a 2.7% rate increase of total knee arthroplasty (TKR) over the last year. With an increasing burden on the public health system and increasing waiting lists, all efforts are being made to decrease length of stay and improve the post operative rehabilitation process. There is currently insufficient evidence to make a conclusive statement about visual aids and improved goal attainment post TKR. The purpose of this study is to evaluate one such visual aid clinical photographs of patients knee range of motion (ROM) pre- and post-operatively and their effect on length of stay. Photographs of knee range of motion were obtained pre and post-operatively while the patient was anesthetized. In this study, a randomized, single blinded design allocated patients to either be shown or not shown their photographs on day 1 post operatively. Primary outcome measures were the number of days the patient remained in hospital. Secondary measures were Western Ontario and McMaster Universities Arthritis Index scores, Oxford Knee Scores, American Society of Anesthesiologists Score and knee ROM. Thirty-two patients (3 exclusions) were randomized to the photo group and 27 patients (4 exclusions) were randomized to the no photo group. The median length of stay between groups was not significantly different. Currently there is not enough evidence to conclude that visual aids effect length of stay or rehabilitation pathways. Further assessment with larger cohort groups is needed. Preoperative targeting and rehabilitation for patients with lower functional status may shorten post operative length of patient stay in our institution.

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A retrospective study: root cause analysis of reported serious adverse event and development of corrective action and preventive action for deviated serious adverse event reports at a clinical trial site management office

International Journal of Clinical Trials ◽

10.18203/2349-3259.ijct20203106 ◽

2020 ◽

Vol 7 (3) ◽

pp. 194

Author(s):

Dayanand Raddi ◽

Revena S. Deveriniti ◽

M. S. Ganachari ◽

Geetanjali Salimath

Keyword(s):

Clinical Trials ◽

Adverse Event ◽

Retrospective Study ◽

Case Reports ◽

Corrective Action ◽

Preventive Action ◽

Initial Report ◽

Serious Adverse Event ◽

Root Cause ◽

Safety Reporting

Background: Serious adverse events (SAEs) are preventable if reported on time. Assessment of harm caused by clinical trials is difficult than assessing the benefits as it relied on the information as recorded by the study team. Hence it is important to have knowledge about quality safety reporting. The objectives of the study were to assess root cause for the timeline deviation found in SAE report and to develop the corrective action and preventive action to minimize deviation rate.Methods: A retrospective study was conducted in KLE’s Hospital and MRC, Belagavi. Data was collected from SAE documented trial study files. Between August 2016 to August 2019, 25 SAE occurred during clinical trials which were included in the study through complete enumeration and purposive sampling.Results: Data was analyzed for SAE reporting timeline where in no deviation was found in initial report. It was seen that all SAEs were not related to investigational product. The narrations of SAE were according to standardized format as per Ethics Committee review report. A gap was observed between onset of SAE and initial report in 16 case reports.Conclusions: The study concluded that there was a lag in reporting from onset of SAE to initial report even though there was no deviation observed in the initial report timeline. The main contributing factors were admitting in different hospital without information and lack of knowledge by subjects or their relatives which shows the need of awareness about quality safety reporting.

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Experimental prototype for visual support in the calibration of the precision indicator lights of approach slope, for a landing track using a drone

Respuestas ◽

10.22463/0122820x.1795 ◽

2019 ◽

Vol 24 (1) ◽

pp. 42-49

Author(s):

Jorge Enrique Herrera Rubio ◽

Sergio Andrés Parra Prada

Keyword(s):

Mobile Application ◽

Experimental System ◽

Experimental Tests ◽

Lighting System ◽

Visual Aids ◽

Wireless Devices ◽

Experimental Prototype ◽

Flight Plan ◽

Calibration Methods ◽

Visual Aid

The use of calibration methods for visual aids systems in airports guarantees aviation safety with new alternatives and precision methods. The article shows the implementation of an experimental prototype for the support of visual aid in the calibration of precision indicator lights by means of a drone to improve the approach slopes of aircraft. In each of the experimental tests the following activities were developed: a) execute the program that contains the code to perform the process of emulation / calibration of the lights, b) connect the model of the lights to the Arduino and be connected to the portable equipment, c) perform the drone calibration process each time a flight plan is made, d) connect the mobile device to the drone’s remote control to integrate them into the wireless network (Wi-Fi), e) on the device mobile the application is executed to configure the flight plan and f) the emulation / calibration is performed with the model of the lights. Obtain the best visibility angles according to the effective percentages of experimentation that indicate the accuracy of the experimental system proposed through a mobile application. In addition, this article proposes a methodology for the calibration of the Precision Approach Path Indicator (PAPI) lights through wireless devices. The proposed methodology establishes the basic conditions for the development of the process of supervision, monitoring and calibration of the PAPI lighting system of any track in Colombia according to the regulations on luminous visual aids.

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