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From the point of view of the development of libraries, technology has made possible the emergence and development of library automation; digital libraries; mobile libraries; and smart libraries. This article briefly describes the impact of technological developments and application in Health Science Libraries in China in relation to collections development, service provision and the role of library associations., (© 2023 Health Libraries Group.)

Background: Studies using Data Envelopment Analysis to benchmark Intensive Care Units (ICUs) are scarce. Previous studies have focused on comparing efficiency using only performance metrics, without accounting for resources. Hence, we aimed to perform a benchmarking analysis of ICUs using data envelopment analysis., Methods: We performed a retrospective analysis on observational data of patients admitted to ICUs in Brazil (ORCHESTRA Study). The outputs in our data envelopment analysis model were the performance metrics: Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU); whereas the inputs consisted of three groups of variables that represented staffing patterns, structure, and strain, thus resulting in three models. We compared efficient and non-efficient units for each model. In addition, we compared our results to the efficiency matrix method and presented targets to each non-efficient unit., Results: We performed benchmarking in 93 ICUs and 129,680 patients. The median age was 64 years old, and mortality was 12%. Median SMR was 1.00 [interquartile range (IQR): 0.79-1.21] and SRU was 1.15 [IQR: 0.95-1.56]. Efficient units presented lower median physicians per bed ratio (1.44 [IQR: 1.18-1.88] vs. 1.7 [IQR: 1.36-2.00]) and nursing workload (168 hours [IQR: 168-291] vs 396 hours [IQR: 336-672]) but higher nurses per bed ratio (2.02 [1.16-2.48] vs. 1.71 [1.43-2.36]) compared to non-efficient units. Units from for-profit hospitals and specialized ICUs presented the best efficiency scores. Our results were mostly in line with the efficiency matrix method: the efficiency units in our models were mostly in the "most efficient" quadrant., Conclusion: Data envelopment analysis provides managers the information needed to identify not only the outcomes to be achieved but what are the levels of resources needed to provide efficient care. Different perspectives can be achieved depending on the chosen variables. Its use jointly with the efficiency matrix can provide deeper understanding of ICU performance and efficiency., Competing Interests: The authors have declared that no competing interests exist.

Competing Interests: Dr. Shankar-Hari received funding from the National Institute for Health Research (NIHR) Clinician Scientist Award (NIHR-CS-2016-16-011). Dr. Wunsch received funding from a Canada Research Chair in Critical Care Organization and Outcomes, an Excellence in Research Award from the Department of Anesthesia at the University of Toronto, the Canadian Institutes of Health Research, and the National Institutes of Health (NIH) (R01 DA042299; HL137816). Dr. Singer’s institution received funding from Deltex, Biotest, Fresenius, Roche Diagnostics, and New B; he received funding from a NIHR Emeritus Senior Investigator Award. Dr. Angus received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Objective: The purpose of this study was to examine trends in application submission, rank lists, and applicant quality for vascular surgery integrated residency., Methods: The National Resident Matching Program Results and Data reports and the Electronic Residency Application Service Statistics from 2007 to 2017 were compiled and mined for trends in terms of application submission and the number of applicants a program needed to rank to fill all residency positions. Applicant pool depth and percentage of programs applied to were calculated. Outcome data from the National Resident Matching Program were reviewed for 2014 and 2016 for United States Medical Licensing Examination Step scores and experiences., Results: During the last 10 years, the number of vascular surgery integrated residency spots rose from 9 to 60 per year. Most programs offer one spot per year; none offer more than two. The average number of applications received by programs rose from 17 applications in 2008 to 63.8 in 2017. The average rank list depth needed by programs to fill the spots has not increased (range, 2.5-5.1; standard deviation, 0.73). The proportional depth of the applicant pool decreased from 4.6 U.S. and Canadian applicants for every one residency spot in 2008 to 1.7 applicants for every one residency spot in 2017. Applicant quality metrics were available for 2 years (2014 and 2016). Step 1 scores (237/239), Step 2 scores (250/250), research experiences (3.7/4.2), and volunteer experiences (5.9/5.5) remained nearly unchanged. The number of contiguous ranks for matched applicants remained stable (12.3/12.8)., Conclusions: The current system promotes multiple inefficiencies, resulting in application glut. Fewer applicants are flooding programs with an increasing number of applications. More money is being spent on Electronic Residency Application Service applications without changes in the number needed to rank by applicants or programs to achieve a match. There is no improvement in the quality of the applicant. Should these trends continue, they represent an unsustainable model for resident selection., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Poorly defined measurement impairs interinstitutional comparison, interpretation of results, and process improvement in health care operations. We sought to develop a unifying framework that could be used by administrators, practitioners, and investigators to help define and document operational performance measures that are comparable and reproducible., Study Design: Retrospective analysis., Methods: Health care operations and clinical investigators used an iterative process consisting of (1) literature review, (2) expert assessment and collaborative design, and (3) end-user feedback. We sampled the literature from the medical, health systems research, and health care operations (business and engineering) disciplines to assemble a representative sample of studies in which outpatient health care performance metrics were used to describe the primary or secondary outcome of the research., Results: We identified 2 primary deficiencies in outpatient performance metric definitions: incompletion and inconsistency. From our review of performance metrics, we propose the FASStR framework for the Focus, Activity, Statistic, Scale type, and Reference dimensions of a performance metric. The FASStR framework is a method by which performance metrics can be developed and examined from a multidimensional perspective to evaluate their comprehensiveness and clarity. The framework was tested and revised in an iterative process with both practitioners and investigators., Conclusions: The FASStR framework can guide the design, development, and implementation of operational metrics in outpatient health care settings. Further, this framework can assist investigators in the evaluation of the metrics that they are using. Overall, the FASStR framework can result in clearer, more consistent use and evaluation of outpatient performance metrics.

In this paper, we examine efficiency and total factor productivity for hospitals operating in China between the years of 2009-2016. Given reforms in China focusing on the hospital sector, it has been demonstrated that efficiency and productivity are important in meeting the overall objective of meeting more accessibility to hospital care for the population. Measuring an aggregate directional distance function is in itself a non-parametric approach, we report on the decomposition of hospital performance and found that between 2009 and 2010, technical inefficiency (using resources inefficiently) dominated overall inefficiency but beyond 2011-2016, mix inefficiency (misallocation of resources) was higher. Furthermore, an additive total factor productivity (TFP) indicator is proposed to capture contributions of individual provincial (or group) hospital performance to the total productivity gain. We also report that mix inefficiency had growth throughout this time period indicating a catching up in the correct mix of inputs. This finding is worth following as hospital reform in China also focuses on utilizing the right labor and capital mix in producing efficient care.

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. Since writing my 1st article for Managing Organizational Complexity in 2004, much has happened to further our understanding of complexity in healthcare systems. The growth of new computational methods in the fields of data science and data analytics has allowed scientists to identify signals or patterns in large complex data sets (big data) that in the past were seemingly hidden. Rather than relying on historical statistical methods to infer outcomes, these advanced methods combined with increased computer processing power allow machines to learn the structure of data and create artificial intelligence (AI). In our ongoing efforts to find solutions for complex healthcare problems, AI is becoming more and more an accepted method. The purpose of this edition of Managing Organizational Complexity is to define AI and machine learning, discuss the recent resurgence of AI, and then provide examples of how AI can provide value to healthcare with an emphasis on nursing.

Competing Interests: Competing interests: Seija Kromm and Deborah McNeil are employees of Alberta Health Services (AHS). David Johnson is remunerated through a contract with AHS. The Merck for Mothers global funding grant is a Merck initiative to reduce maternal mortality; Merck had no role in deciding how the MNCY SCN allocated the funds from that grant support. No other competing interests were declared.

Objective: To design, implement, and evaluate the effectiveness of an enhanced peer mentoring program (EPMP) for faculty in emergency medicine aimed at overcoming traditional mentoring challenges., Methods: Full time faculty (Clinical Instructor, Assistant, and Associate levels) were placed into peer groups (based upon their primary academic roles) led by senior faculty advisors at the Professor level. Peer groups met at least quarterly from 2012 to 2017. In lieu of a structured curriculum, session topics were informed by individual faculty surveys and peer group consensus. Areas of focus included work-life balance, prioritizing academic commitments, identification of mentors (both within and external to the department and university), networking opportunities, promotions goals, and career satisfaction., Results: Effectiveness of the EPMP was evaluated by academic productivity and advancement over a 5- year period. A total of 22 faculty members participated in the program. There was an increase in promotions to the next academic level, from 3 promotions in the five years before the program to 7 promotions in the five years of the program. Total grant funding increased 3-fold from $500,000 to $1,706,479 from the first year to the last year of the evaluation period., Conclusions: This enhanced peer mentoring program was effective in mitigating many of the traditional mentoring challenges faced by faculty in academia and was successful in improving both academic productivity and advancement., (Copyright © 2019. Published by Elsevier Inc.)

Non-operating room anesthesia (NORA) has grown and continues to expand as a proportion of all anesthesia practice in the United States [1, 2]. While many management processes have been adapted for NORA from the traditional operating room, it is still unclear what scheduling paradigm will maximize efficiency of resource utilization in this arena. In this study, we investigate the impact of tactical a shift from a shared group to individual, provider-specific block allocations for available anesthesia time in an endoscopy suite for adult patients undergoing elective endoscopy procedures at an academic hospital. Using a retrospective and prospective analysis, we measured elective time-in-block; elective time out-of-block; under-utilized (opportunity and non-opportunity unused) time; over-utilized time; and case tardiness to determine operational efficiency and clinical productivity. Over the study period, the monthly caseload remained constant. Elective time in block increased by 156% (p < 0.0001) and elective time out of block decreased by 38% (p < 0.0001). Opportunity unused time decreased by 28% (p < 0.0001) and productivity increased by 51% (p < 0.0001). Neither over-utilized time nor case tardiness showed a significant change after the intervention. Despite the evidence base supporting traditional approaches to anesthesia block allocation involving group block allocation and non-sequential case scheduling, we have demonstrated an advantage to individual block allocation in a GI endoscopy setting. This sequential case scheduling highlights how tactical decisions in NORA environments may require a rethinking of many practices that anesthesiologists have brought with them from the traditional OR. Using these efficiency and productivity metrics, further adjustments to scheduling practices should be investigated, and connecting these metrics to other systems outcomes, such as financial productivity, is an important next step as NORA services expand into the future.

Objective: The increasing demand for total hip arthroplasty (THA) combined with limited resources in healthcare puts pressure on decision-makers in orthopaedics to provide the procedure at minimum costs and with good outcomes while maintaining or increasing access. The objective of this study was to analyse the development in productivity between 2005 and 2012 in the provision of THA., Design: The study was a multiple registry-based longitudinal study., Setting and Participants: The study was conducted among 65 orthopaedic departments providing THA in Sweden from 2005 to 2012., Outcome Measures: The development in productivity was measured by Malmquist Productivity Index by relating department level total costs of THA to the number of non-cemented, hybrid and cemented THAs. We also break down the productivity change into changes in efficiency and technology., Results: Productivity increased significantly in three periods (between 1.6% and 27.0%) and declined significantly in four periods (between 0.8% and 12.1%). Technology improved significantly in three periods (between 3.2% and 16.9%) and deteriorated significantly in two periods (between 10.2% and 12.6%). Significant progress in efficiency was achieved in two periods (ranging from 2.6% to 8.7%), whereas a significant regress was attained in one period (3.9%). For the time span as a whole, an average increase in productivity of 1.4% per year was found, where changes in efficiency contributed more to the improvement (1.1%) than did technical change (0.2%)., Conclusions: We found a slight improvement of productivity over time in the provision of THA, which was mainly driven by changes in efficiency. Further research is, however, needed where differences in quality of care and patient case mix between departments are taken into account., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Inefficient rural medical service systems are one of major obstacles to the Deepening Healthcare Reform. The objectives of this work are to analyze the efficiency of China's rural medical service systems and explore the key related factors., Study Design: Two-stage study including measuring efficiency and identifying factors., Methods: An output-oriented slacks-based data envelopment analysis model was used to measure the efficiency, and a Spearman rank correlation analysis and a multiple linear regression model were used to explore the factors., Results: For the village-level medical service system, 20 out of 27 provinces were inefficient in 2013-2017, 12 out of 27 provinces had the efficiency lower than the average scores in 2013-2017 (0.633, 0.659, 0.638, 0.603, and 0.589), Guangdong had the highest scores of 1 in 2014-2017, whereas Tibet had the lowest scores (0.064-0.083) in 2013-2017, and the west region performed worst. For the township-level medical service system, 11 out of 27 provinces were inefficient in 2013-2017, 10 out of 27 provinces had the efficiency lower than the average scores in 2013-2017 (0.819, 0.791, 0.757, 0.787, and 0.811), Ningxia had the highest efficiency of 1 in 2013-2017, whereas Jilin had the lowest efficiency (0.313-0.370), and the central region performed worst. Additionally, rural residents' income was positively associated with the efficiency of village-level medical services, while the proportion of the vulnerable population was positively associated with the efficiency of township-level medical services., Conclusions: Most provinces had inefficient rural medical service systems in 2013-2017. The efficiency scores varied greatly across provinces, and most scores changed a little over time. Imbalances in the development of rural medical service systems existed across regions, and the efficiency of village-level medical services and township-level medical services was associated with different factors., (Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: To analyze the diffusion of e-SUS Primary Care innovation in Family Health Teams., Method: A qualitative approach case study, based on Innovation Diffusion Theory and Technology Acceptance Model. We conducted 62 interviews and observation of professionals from Family Health Teams in six municipalities of Minas Gerais State, between March 2016 and January 2017. The data were treated through Categorical Thematic Content Analysis and, systematized, with Atlas.ti software ., Results: It was verified that although the e-SUS Primary Care strategy is recognized as a technological innovation, situations predominate that weaken its acceptance as: incompatibilities with the work process; sudden deployment, poor training; work overload; resistance; and negative impacts on health care., Conclusion: The diffusion of the e-SUS Primary Care strategy as a technological innovation has presented potential situations of its rejection, conforming as challenges to be overcome.

Background: Scientometrics is a discipline that analyzes scientific publications to explore the structure and growth of science. In this work, the quantitative evaluation of the productivity of the Iranian Biomedical Journal (IBJ) is reviewed., Methods: The analysis was done based on a cross-sectional descriptive and an analytical scientometric study. Data were collected from PubMed, Scopus, and Scimago Databases (2000-2017). Scopus and Scimago were used for data search and feature analysis. Analyzed scientometric indicators included the number of citations, publications, CiteScore, SJR (Scimago Journal Rank), SNIP (source normalized impact per paper), self-citation, and Q (quartile) trend., Results: The evaluation of 586 documents, published in IBJ from 2000 to 2017, revealed that most of these documents (99.7%) have been published in the areas of biochemistry, genetics, and molecular biology, which yielded to an upgrade in Journal Q ranking from Q4 (in 2000) to Q2 (in 2016)., Conclusion: Nearly all of the scientometric indicators, evaluated in this study, were found on the rise. Therefore, a growing trend from Q2 to Q1 is predicted for the near future. It is recommended that the journal focuses on a specific subject area to improve the indicators and quality of the journal, in a timely manner.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

We assess technical efficiency (TE) level for Mexican Ministry of Health (MoH) primary care units. Assessment was focused on the production of adequate maternal health services defined as the coverage level of women who received timely and frequent antenatal care, and institutional and medical care during childbirth. We conducted a longitudinal analysis of administrative and socio-demographic information concerning 233 health jurisdictions for the period 2008-15. Crude TE was calculated using window data envelopment analysis (Windows-DEA). Empirical analysis included the description of several factors affecting the production of maternal health services, including the heterogeneity and trends assessment of TE among health jurisdictions. We estimated a pooled regression model with robust standard errors to identify correlates of TE and estimated adjusted performance scores. Results indicate that while the production of adequate maternal-health services and TE in health jurisdictions proved insufficient, they rose by 22% (from 40.9% to 49.8%) and 14% (from 54.3% to 62%), respectively, over time. Furthermore, variance in efficiency among production units diminished and persistent regularities were observed. Performance was highest in the Northern as opposed to the Southern and Southeastern health jurisdictions, but lowest in the most marginalized zones of the country marked by economic inequality and the presence of indigenous populations. The Mexican Health System has reached a paradoxical situation: the steady escalation of financial resources in the public health subsystem over the past 15 years has yielded sub-optimal results as regards coverage for essential maternal health interventions among the poorest. Mexican government must put in place a set of measures to guarantee efficiency in the system's performance without affecting equity gains. This necessarily involves reconsidering, and where necessary replacing, the criteria behind the allocation and distribution of resources, as well as the mechanisms for controlling how resources are used and accountability is fulfilled.

Objectives: Lean management (LM) principles were first developed by a Japanese manufacturing company to maximise value and minimise waste in the automotive industry. However, these principles can also be applied in the healthcare sector. This study aimed to illustrate the process of implementing LM principles in a radiation oncology department to streamline workflow and identify and reduce waste., Methods: This study took place in the Department of Radiation Oncology, Royal Hospital, Muscat, Oman, in December 2016. A value stream map (VSM) was created for the chain of processes followed in the department. A waste analysis was conducted to determine which processes did not add value for the patient or healthcare provider., Results: Based on the VSM analysis, only six out of 13 steps were found to be of value. Necessary and unnecessary non-value-adding activities were identified. Sources of waste included parking and registration. In addition, variabilities in workload were noted., Conclusion: Overall, LM principles improve workflow, reduce waste and enhance patient and staff satisfaction. In the current study, the application of LM principles helped to improve value in a radiation oncology department., Competing Interests: CONFLICT OF INTEREST The authors declare no conflicts of interest.

Challenges of Digital Medicine Abstract. Digitization is increasingly covering more and more sectors, including medicine. To ensure medical operation 365 × 24 hours, progressively more human and financial resources are necessary. The transformation of patient histories from paper into electronic patient records focused initially on documentation. Today, hospital information systems are increasingly used as a platform for the communication of all professionals involved in the patient process - in Switzerland, however, so far without providing patients direct access to their data. Digititizing processes intend to increase efficiency, but also to enhance clinical and administrative decision support and quality assurance. The introduction of the electronic patient record in Switzerland in 2020 is expected to provide cross-company, more complete documentation of patient care. Multimorbid patients, often treated in different institutions and by different specialists, should benefit from this in particular. Advances in artificial intelligence offer new opportunities in medicine. Challenges include ensuring reliable data protection, and better interoperability of the systems involved. Semantically structured, machine-readable data exchange is a necessity for both networked services and internationally competitive research.

We explore how reliance on part-time medical staff affects operational and medical outcome performance in two general surgery departments Whereas prior research has indicated that operational performance is positively associated with medical performance, we find that heavier reliance on part-time practice may deteriorate operational performance but not necessarily medical-outcome performance. For so-called "complex" patients, reliance on part-time practice may even override the effect of patients' characteristics on medical-outcome performance. This result calls into question common perceptions in behavior marketing literature regarding part-time employees' working patterns and efficiency, and thereby provides a new perspective regarding current labor-market trends.

This paper analyzes a set of selected German and French cities' performance in terms of the relative behavior of their eco-efficiencies, computed as the ratio of their gross domestic product (GDP) over their CO 2 emissions. For this analysis, eco-efficiency scores of the selected cities are computed using the data envelopment analysis (DEA) technique, taking the eco-efficiencies as outputs, and the inputs being the energy consumption, the population density, the labor productivity, the resource productivity, and the patents per inhabitant. Once DEA results are analyzed, the Malmquist productivity indexes (MPI) are used to assess the time evolution of the technical efficiency, technological efficiency, and productivity of the cities over the window periods 2000 to 2005 and 2005 to 2008. Some of the main conclusions are that (1) most of the analyzed cities seem to have suboptimal scales, being one of the causes of their inefficiency; (2) there is evidence that high GDP over CO 2 emissions does not imply high eco-efficiency scores, meaning that DEA like approaches are useful to complement more simplistic ranking procedures, pointing out potential inefficiencies at the input levels; (3) efficiencies performed worse during the period 2000-2005 than during the period 2005-2008, suggesting the possibility of corrective actions taken during or at the end of the first period but impacting only on the second period, probably due to an increasing environmental awareness of policymakers and governors; and (4) MPI analysis shows a positive technological evolution of all cities, according to the general technological evolution of the reference cities, reflecting a generalized convergence of most cities to their technological frontier and therefore an evolution in the right direction.

Total factor productivity (TFP) growth allows for additional healthcare services under restricted resources. We examine whether hospital policy can stimulate hospital TFP growth. We exploit variation across German federal states in the period 1993-2013. State governments decide on hospital capacity planning (number of hospitals, departments, and beds), ownership, medical students, and hospital investment funding. We show that TFP growth in German hospital care reflects quality improvements rather than increases in output volumes. Second-stage regression results indicate that reducing the length of stay is generally a proper way to foster TFP growth. The effects of other hospital policies depend on the reimbursement scheme: Under activity-based (German Diagnosis-related Group) hospital funding, scope-related policies (privatization and specialization) come with TFP growth. Under fixed daily rate funding, scale matters to TFP (hospital size and occupancy rates). Differences in capitalization in East and West Germany allow to show that deepening capital may enhance TFP growth if capital is scarce. We also show that there is less scope for hospital policies after large-scale restructurings of the hospital sector. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

MINI: The time trend for the number of minimally invasive spine surgery articles showed a significant increase over time with an average of 93.23 articles per year. Among all related journals, Spine published the largest number of articles in minimally invasive spine surgery research and was the most popular one in the top five countries., Study Design: Bibliometric analysis., Objective: This study aimed to reveal the characteristics of world productivity in the field of minimally invasive spine surgery (MISS) research and to provide a general picture for surgeons and researchers., Summary of Background Data: Significant growth has been observed in the field of MISS research in recent years. However, bibliometric studies concerning the quantity and quality of articles published in MISS journals are scarce., Methods: All the data concerning MISS in this study originate from the Web of Science (Thomson Reuters, New York, NY) without restrictions. All selected literates were evaluated in the following aspects: publication year, publication journals, author, times cited, Web of Science category, countries/territories., Results: A total number of 2051 articles were published worldwide. The articles published during 2000 to 2015 are more than 11.28 times when compared to those published before 2000. The United States published the largest number of articles (855/2051, 41.7%), followed by Germany (245/2051, 11.9%), South Korea (160/2051, 7.8%), China (147/2051, 7.2%), and Japan (108/2051, 5.2%) and had the highest total citations (16,626). Additionally, the United States had the highest average citations per article (12.14), followed by Japan (11.98), Germany (11.19), South Korea (11.04), and China (10.95). High-income countries published 98.73% of articles, upper-middle-income countries published 0.24% of articles, and middle-income countries published 1.03% of articles., Conclusion: The time trend for the number of MISS articles showed a significant increase over time with an average of 93.23 articles per year. The United States was the most productive country and had the highest average citations per article. Among related journals, Spine published the largest number of articles in MISS research and was the most popular one in the top five countries., Level of Evidence: 5.

Background: Evidence suggests emergency department (ED) overcrowding is associated with poor health outcomes. Children comprise 20-25% of general ED visits, yet few studies have examined the differential impact of ED overcrowding on pediatric and adult populations., Objective: The primary objective of this study was to compare flow measures, such as wait time to see a physician, length of stay (LOS), and rate of patients leaving without being seen by a physician (LWBS) between adults and children in British Columbia and Ontario, clustered by province, and then stratified by acuity level during the study period., Methods: We conducted a retrospective, repeated cross-sectional study using administrative data from all community EDs in Ontario and 10 EDs in the Vancouver Lower Mainland, British Columbia. Visits from January 1, 2008 and December 31, 2012 were included., Results: Visit volumes increased 13.9% per year in British Columbia and 2.2% per year in Ontario, with a more pronounced rise in adult visits. Both groups displayed a shift toward higher-acuity presentations. Adults spent more time in the ED compared to children (36 to 53 min longer), and were more likely to be admitted. Children consistently spent a greater portion of their visit awaiting assessment compared to adults., Conclusions: In the context of system incentives to reduce overcrowding, ED LOS and the LWBS rate did not significantly change for either children or adults, despite increased visit volume and acuity. Our findings suggest that measures to improve patient flow might have provided EDs with the means to meet increased demands on departmental resources., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The decarbonization of the global economy is an urgent concern. As a potential solution, it can be important to understand the efficiency of nuclear energy policies. For this purpose, the paper analyzes whether there is a unit root in nuclear energy consumption in 26 countries and it uses the unit root tests with two endogenous (unknown) structural breaks. The paper finds that nuclear energy consumption is stationary around a level and the time trend in 25 of 26 countries and nuclear energy consumption contains a unit root only in France. The paper also discusses the potential implications of the findings.

Objectives: Public hospitals in Nepal account for a major share of the total health budget. Therefore, questions are often asked about the performance of these hospitals. Existing measures of performance are limited to historical ratio analyses without any benchmarks. The objective of this study is to explore the trends in inputs, outputs and productivity changes in Nepalese public hospitals from 2011-2012 to 2013-2014., Setting and Participants: The study was conducted among 32 Nepalese public hospitals (23 district level and 9 higher level) for the three fiscal years from 2011-2012 to 2013-2014., Outcome Measures: First, basic ratio analyses were conducted for the input and output measures over the study years. Then, Malmquist productivity change scores were obtained using data envelopment analysis. Aggregated as well as separate analyses were conducted for district level and higher level hospitals., Results: Real expenditures of the sampled hospitals declined over the 3-year period from an average of US$ 371 000 in year 1 to US$ 368 730 in year 2 and US$ 328680 in year 3. The average aggregated hospital outputs increased marginally from 8276 in 2011-2012 to 8613 in 2013-2014. The total factor productivity of the study hospitals declined by 6.9% annually from 2011-2012 to 2013-2014. Of the total 32 hospitals, productivity increased in only 12 (37.5%) hospitals and declined in the remaining 20 hospitals. The total factor productivity loss was influenced by a decline in technology change, despite an increase in efficiency., Conclusions: In general, productivity of the study hospitals declined over the study period. Availability and accessibility of accurate, detailed and consistent measures of hospital inputs and outputs is a major challenge for this type of analysis., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

As systems evolve over time, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on the application of management strategies in health systems. This article is the 2nd in a series of articles that focuses on why technological complexity is increasing and strategies nurse administrators can use to successfully implement change in the face of it.

The call for care model innovation is clear, spearheaded by rising healthcare costs, changing payer expectations, overall fiscal and workforce shortages, and an increasingly comorbid patient population requiring significant, long-term support. As part of care model innovation, the leveraging of technology is key.

Objective: The purpose of this article is to describe the use of abbreviated breast MRI protocols for improving access to screening for women at intermediate risk., Conclusion: Breast MRI is not a cost-effective modality for screening women at intermediate risk, including those with dense breast tissue as the only risk. Abbreviated breast MRI protocols have been proposed as a way of achieving efficiency and rapid throughput. Use of these abbreviated protocols may increase availability and provide women with greater access to breast MRI.

Improving the efficiency of health care is a national priority. The purpose of this study was to estimate trends in the efficiency of nursing care. Specifically, the baseline and rate of change in efficiency in the association between select hospital and nursing unit characteristics (e.g., nurse staffing levels) and indicators of patient safety (e.g., fall rates and hospital-acquired pressure ulcer rates) was investigated. A small but significant improvement in efficiency for non-Magnet® hospitals and units with increased RN hours per patient day was found. Trends in efficiency varied by unit type, with medical units showing the greatest improvement. In general, efficiency improved most in health care settings having the greatest opportunity for improvement.

Aim: To examine how personality and leadership influence efficiency in the nursing service environment., Background: Leadership and personality contribute to the success and failure of a unit. However, how they interact to influence performance is still understudied., Methods: We used matched pairs sample design to survey 135 head nurses and 1353 registered nurses on validated instruments of demographic characteristics, leadership styles and personality during June and July of 2014. Efficiency was calculated using Data Envelopment Analysis. Tobit regression was used for analysis., Results: High conscientiousness and low neuroticism were significantly associated with higher efficiency. Particularly, under the initiating structure leadership style, high conscientiousness, high extraversion, high agreeableness, high openness and low neuroticism were related to higher efficiency. Openness would improve efficiency under a low consideration leadership style., Conclusions: Most personality traits were related to higher efficiency under the initiating leadership style. Only openness would improve leaders' efficiency under a high initiating structure and a low consideration leadership style., Implications for Nursing Management: Considering personality as one factor of selecting head nurses, selecting the right person can improve the fit between individuals and organisations, which in turn, improves job performance. Training head nurses to develop better leadership styles in nurses is another way to enhance efficiency., (© 2016 John Wiley & Sons Ltd.)

Objectives: Kaizen, or continuous improvement, lies at the core of lean. Kaizen is implemented through practices that enable employees to propose ideas for improvement and solve problems. The aim of this study is to describe the types of issues and improvement suggestions that hospital employees feel empowered to address through kaizen practices in order to understand when and how kaizen is used in healthcare., Methods: We analysed 186 structured kaizen documents containing improvement suggestions that were produced by 165 employees at a Swedish hospital. Directed content analysis was used to categorise the suggestions into following categories: type of situation (proactive or reactive) triggering an action; type of process addressed (technical/administrative, support and clinical); complexity level (simple or complex); and type of outcomes aimed for (operational or sociotechnical). Compliance to the kaizen template was calculated., Results: 72% of the improvement suggestions were reactions to a perceived problem. Support, technical and administrative, and primary clinical processes were involved in 47%, 38% and 16% of the suggestions, respectively. The majority of the kaizen documents addressed simple situations and focused on operational outcomes. The degree of compliance to the kaizen template was high for several items concerning the identification of problems and the proposed solutions, and low for items related to the test and implementation of solutions., Conclusions: There is a need to combine kaizen practices with improvement and innovation practices that help staff and managers to address complex issues, such as the improvement of clinical care processes. The limited focus on sociotechnical aspects and the partial compliance to kaizen templates may indicate a limited understanding of the entire kaizen process and of how it relates to the overall organisational goals. This in turn can hamper the sustainability of kaizen practices and results., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: The hand surgery service in our major trauma centre comprised predominantly emergency surgery with poor theatre access, resulting in many cases being postponed and performed after hours and with low rates of supervision., Method: We report the results of a before-and-after study describing the change in processes and outcomes associated with a change in the model of care to a sequestered, area-wide hand surgery service. The study uses data from 12 months prior to and 12 months after the change in practice., Results: The hand service experienced a 24.7% increase in demand for surgery in the first 12 months after the relocation. However, demand for overnight beds fell by 303%, the rate of specialist supervision increased from 23.5% to 81.3% (P < 0.0001), the time between admission and surgery fell from 5.1 to 2.7 h (P < 0.0001), the rate of cancellations fell from 21.8% to 7.7% (P < 0.0001), the proportion of emergency surgery conducted in normal hours increased from 65.8% to 93.6% (P < 0.0001), the 28-day unplanned reoperation rate fell from 1.2% to 0.5% (P = 0.02) and surgical time decreased to an equivalent of 41 half day operating sessions per year., Conclusion: These outcomes are in line with international experiences of service centralization. The project may be used as a template for practice change in other surgical fields., (© 2015 Royal Australasian College of Surgeons.)