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Background: Both learning and problem solving are major goals of complex problem solving in engineering education. The order of knowledge construction and problem solving in learning through problem solving, however, has not been explained in current literature. Objectives: To understand their relationships, this study compared the effects of different goal type orders on collaborative simulation‐based inquiry in engineering problem solving. Methods: In the study, 24 engineering undergraduate students worked in pairs to solve a wind tunnel problem using a computer simulation application. Process mining and epistemic network analysis were used to model the inquiry process and identify inquiry patterns based on the log data and discussion discourse. Results and Conclusions: The results showed the goal type of first assigned subtask influenced the inquiry strategies of medium‐performance learners most. In addition, the goal type of first assigned subtask had influence on learners' inquiry process. The learners assigned with a problem‐solving goal subtask first (Problem solving goal‐Learning goal condition) had more simulation trials and centered their inquiry discourse around clarification while the learners assigned with a learning goal subtask first (Learning goal‐Problem solving goal condition) connected reflection with other inquiry phases more often. The findings of this study suggested assigning a learning goal subtask first in simulated‐based complex engineering problem solving could be used as an idea‐centered scaffolding, especially for medium‐performance learners. However, low‐performance learners would experience a "situate knowledge paradox" and needs extra guidance. It is important to monitor the knowledge construction process in complex problem solving, even when seeking a solution is the major task. Lay Description: What is currently known about this topic?: Eye movements have been used in learning research for analysing learning processes.It is assumed that eye tracking metrics correspond with specific (meta)cognitive processes during learning.However, the specificity of which metric corresponds which (meta)cognitive process is not evidence‐based.The seductive details effect is known to alter (meta)cognitive processes during learning, so it can be exploited to create validity hints for process measures. What does this paper add?: A multimethod approach is introduced combining eye tracking and think‐aloud protocols.Correlations and serial mediation analyses provide insights on relations and interrelation of different process measures.The sensitivity of applied process measures is confirmed by exploiting the seductive details effect.Despite some inconsistent findings, conclusions for necessary future validation research and multimethod process analyses are provided. Implications for practice/or policy: The study provides mainly implications for research practice as more systematic research is needed for validating process measures.The study points at necessary innovative ways for validating eye tracking metrics.Focusing on (meta)cognitive processes in multimedia learning provides fruitful insights on how learners deal with learning instruction.For practitioners, the study underlined how seductive details (i.e., appealing but irrelevant information) can impair learning processes. [ABSTRACT FROM AUTHOR]

Background: At a London-based hospital, a validated ward-based clinical pharmacy activity collection tool has been used to monitor activities of clinical pharmacy teams across all settings, including ambulatory care services. No data confirm its representativeness for the full range of ambulatory clinical pharmacy services, and pharmacists share this concern. Aim: This study aimed to identify the range of clinical pharmacy activities in ambulatory care, assess the suitability of the existing ward-based tool for capturing these activities, and recommend modifications. Method: Non-participant direct observations were conducted to record pharmacists' clinical activities in ambulatory clinics and multidisciplinary meetings. These observations were compared to the existing ward-based tool to identify discrepancies. Semi-structured interviews with eight ambulatory pharmacists were transcribed verbatim and thematically analysed inductively to explore the tool's representativeness of their routine clinical activities. Results: Twenty-nine clinical pharmacy activities were observed in ambulatory services. Only fifteen were captured by the existing tool, with therapy monitoring and recommending therapeutic changes not accurately captured. Pharmacists agreed that the tool was not fully representative and included irrelevant activities. Four common uncaptured activities were multidisciplinary meeting-specific activities, arranging laboratory tests, monitoring patient outcomes, and liaising with community healthcare professionals. This study identified 33 candidate ambulatory clinical pharmacy activities. Conclusion: The existing ward-based tool does not fully capture the full range of ambulatory care clinical pharmacy activities, highlighting the need for an improved tool. Pharmacists recommended including the uncaptured activities. The candidate activities provide a foundation for standardised measurement of relevant ambulatory care activities to enable effective workforce deployment and improve patient outcomes. [ABSTRACT FROM AUTHOR]

In order to solve the problems of high production cost, low user experience satisfaction, and difficulty in meeting consumers' individual needs in traditional down garment sewing due to the time- consuming and time-consuming process and the difficulty in quickly and intuitively feeling the dressing effect, a down jacket was taken as the research object and 3D virtual sewing was completed with Style3D modeling software, the sewing technology was improved and optimized, and the effective and feasible virtual sewing technology measures for down garments were discussed. The results show that the method of directly generating the lining layer can effectively reduce the virtual sewing time; choosing the appropriate type sewing will result in a cleaner sewing effect for clothing; the convenient filling effect can be achieved by cutting the bottom hem of down jacket separately; the double-layer folding effect of the cuffs can reduce collision detection time and improve simulation fidelity by cutting into a single layer, and increasing the additional rendering thickness of the fabric. The research results aim to provide reference for virtual setting, efficient simulation, and realistic display of similar types of clothing. [ABSTRACT FROM AUTHOR]

Purpose: Frailty is common in critically ill patients but the timing and optimal method of frailty ascertainment, trajectory and relationship with care processes remain uncertain. We sought to elucidate the trajectory and care processes of frailty in critically ill patients as measured by the Clinical Frailty Scale (CFS) and Frailty Index (FI). Methods: This is a multi-centre prospective cohort study enrolling patients ≥ 50 years old receiving life support > 24 h. Frailty severity was assessed with a CFS, and a FI based on the elements of a comprehensive geriatric assessment (CGA) at intensive care unit (ICU) admission, hospital discharge and 6 months. For the primary outcome of frailty prevalence, it was a priori dichotomously defined as a CFS ≥ 5 or FI ≥ 0.2. Processes of care, adverse events were collected during ICU and ward stays while outcomes were determined for ICU, hospital, and 6 months. Results: In 687 patients, whose age (mean ± standard deviation) was 68.8 ± 9.2 years, frailty prevalence was higher when measured with the FI (CFS, FI %): ICU admission (29.8, 44.8), hospital discharge (54.6, 67.9), 6 months (34.1, 42.6). Compared to ICU admission, aggregate frailty severity increased to hospital discharge but improved by 6 months; individually, CFS and FI were higher in 45.3% and 50.6% patients, respectively at 6 months. Compared to hospital discharge, 18.7% (CFS) and 20% (FI) were higher at 6 months. Mortality was higher in frail patients. Processes of care and adverse events were similar except for worse ICU/ward mobility and more frequent delirium in frail patients. Conclusions: Frailty severity was dynamic, can be measured during recovery from critical illness using the CFS and FI which were both associated with worse outcomes. Although the CFS is a global measure, a CGA FI based may have advantages of being able to measure frailty levels, identify deficits, and potential targets for intervention. [ABSTRACT FROM AUTHOR]

Objectives National societies recommend against performing routine daily laboratory testing without a specific indication. Unnecessary testing can lead to patient harm, such as hospital-acquired anemia. The objective of this study was to reduce repeat complete blood counts (CBCs) after initial testing. Methods This was a quality improvement initiative implemented across 11 safety net hospitals in New York City. A best practice advisory (BPA) was implemented that asked the user to remove a CBC if the last 2 CBCs within 72 hours had normal white blood cell and platelet counts and unchanged hemoglobin levels. The outcome measure was the rate of CBCs per 1000 patient days preintervention (January 8, 2020, to December 22, 2020) to postintervention (December 23, 2020, to December 7, 2021). The process measure was the acceptance rate of the BPA, defined as the number of times the repeat CBC order was removed through the BPA divided by the total number of times the BPA triggered. Results Across 11 hospitals, repeat CBC testing decreased by 12.3% (73.05 to 64.04 per 1000 patient days, P <.001). Six of the 11 hospitals exhibited statistically significant decreases, ranging from a 10% to 48.9% decrease of repeat CBCs. The overall BPA action rate was 20.0% (24,029 of 119,944 repeat CBCs). Conclusions This low-effort, electronic health record–based intervention can effectively reduce unnecessary laboratory testing. [ABSTRACT FROM AUTHOR]

Objectives: Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients. Design and setting: A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review. Outcome measures: The performance measures used across the studies were analysed and other qualitative findings were also obtained. Results: We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care. Conclusion: The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care. [ABSTRACT FROM AUTHOR]

In ambulatory care, monitoring process performance measures (PPMs) is essential to meet regulatory requirements, establish targets for care, seek reimbursement, and evaluate patient care responsibilities. We implemented a comprehensive program, "Engage to Sustain," for licensed practical nurses (LPNs) and certified medical assistants (CMAs) to practice at the top of their licensure/certification. Screening rates for 4 key PPMs (depression screening, fall risk screening, and tobacco use screening and counseling) markedly increased following this intervention across 18 ambulatory departments with more than 2 million patient visits. These results suggest that shifting responsibilities for patient screening from physicians and advanced practitioners to LPNs and CMAs may improve screening rates. [ABSTRACT FROM AUTHOR]

Aim: To examine whether patients' body mass index is associated with missed hip fracture care consistent with national guideline‐recommended care. Design: A nationwide, population‐based cohort study using prospectively collected data from the Danish Multidisciplinary Hip Fracture Registry. Methods: The study population consisted of 39,835 patients ≥65 years admitted with a hip fracture and discharged between 1st of January 2012 and 29th of November 2017. National guideline‐recommended care consists of preoperative optimization, early surgery, mobilization within 24 h, basic mobility assessment, nutrition screening, post‐discharge rehabilitation program, and osteoporotic and fall prophylaxis. We used binomial regression to estimate the relative risk for the fulfilment of the individual measures with 95% confidence interval. Multiple imputation method was applied to handle missing values of body mass index. Results: The overall fulfilment of the individual measures ranged from 43% for pre‐operative optimization to 95% for receiving a post‐discharge rehabilitation program. The obese patients had a lower fulfilment of surgery within 36 h compared to patients with normal weight. No differences in fulfilment of the other measures were found. However, patients with missing data on body mass index had the highest risk of missed care. In conclusion, patients with missing BMI values had the highest risk of missed care. The obese patients had a slightly higher risk of long waiting times for surgery than normal‐weighted patients. No Patient or Public Contribution: This study was done based on population‐based data from medical registries and data was analysed by the authors only. [ABSTRACT FROM AUTHOR]

Abstract Background Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value‐based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer‐specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes. Methods Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient‐level risk adjustment. Hospital‐level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression. Results Seven hundred sixty‐eight thousand nine hundred sixty‐nine unique cancer cases were included from 1323 facilities. Increasing hospital‐level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58–0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77–0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08–1.20). For the remaining measures, hospital‐level compliance demonstrated no consistent association with patient survival. Conclusion Hospital‐level compliance with the CoC’s Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value‐based healthcare delivery.

• When compared to English preferring patients, aggregate data on non-English preferring patients with acute stroke fail to show a difference in stroke severity at presentation, clinical care or stroke outcomes. • Among non-English preferring patients, those who prefer a language other than English or Spanish present with significantly more severe strokes than patients who are Spanish preferring and less likely to have independent ambulation at discharge. In the United States, limited English proficiency may reduce the quality of care and worsen outcomes after stroke. The aim was to compare stroke process measures and clinical outcomes between English preferring and non-English preferring stroke patients. This single-center retrospective cohort study evaluated patients from one United States hospital with acute ischemic stroke between July 2013 and June 2022. The primary outcomes were defect-free care, a composite of 7 stroke process measures, and independent ambulation at hospital discharge. Multivariate logistic regression models quantified the association between language preference and outcomes. Secondary outcomes included individual components of defect-free care, discharge modified Rankin scale, and discharge disposition. There were 4,030 patients with acute ischemic stroke identified, of which 2,965 were matched with language data from the electronic medical record. There were 373 non-English preferring patients, among which 76.9% preferred Spanish and 23.1% were non-English, non-Spanish preferring. In the multivariable model, there was no significant association between non-English preference and defect-free care (OR=0.64, 95% CI=0.26-1.59) or independent ambulation at discharge (OR=0.89, 95% CI=0.67-1.17). When compared to Spanish preferring patients, non-English, non-Spanish preferring patients had more severe strokes (P<0.001) but there was no difference in defect-free care or independent ambulation after adjustment. Our results suggest that process and clinical outcomes are similar regardless of language preference; although, our data are limited by small numbers of non-English, non-Spanish preferring patients. Additional research is needed among this population. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Healthcare quality can be measured by studying structure, processes, and outcomes. This study examines how trialists capture process outcomes in implementation trials to provide guidance for researchers and health professionals. Electronic databases were searched, and two researchers performed the title, abstract, and full-text selection. Only implementation studies involving nonpharmacological approaches were included. Data were extracted by one reviewer and checked for accuracy and completeness by a second reviewer. Study quality was independently assessed by two reviewers. Of the 3,186 articles screened, 24 studies matched our inclusion criteria. Most studies were cluster randomized control trials, followed by interrupted time series studies and stepped wedge studies. The population in the studies was diverse and settings included hospitals, community centers, residential aged care facilities, and primary care. The reporting of process measures across the included studies varied, and there was limited information about the mechanisms of data collection procedures. Nineteen studies extracted information about processes from electronic medical records, patient records, or chart reviews. The remaining five studies used staff surveys. Challenges remain in the practical aspect of data collection for measuring process outcomes, particularly outside of hospital settings or where processes are hard to capture in patient records. [ABSTRACT FROM AUTHOR]

Employment agencies and funding systems commonly use distal outcome measures such as employed or not employed, full-time or part-time, and continuous measures such as wage, hours worked, and type of job to document the employment status of individuals with disabilities. These measures continue to demonstrate that individuals with disabilities fall behind individuals without disabilities in all employment outcomes. While there is utility in distal outcome measures, it is difficult to determine what intervention or program variables were responsible for a specific outcome. Moreover, outcome measures do not provide sufficient information about the quality of employment supports and services an individual with disabilities receives. One way to improve accountability in employment support programs is to link outcomes to specific processes for obtaining and maintaining employment. The purpose of this manuscript is to describe how employment programs can link short-term (proximal) and long term (distal) outcomes measures to specific processes for employment. A customized employment framework is used to illustrate how systematically linking outcomes and processes improves accountability in programs that support job seekers with most significant disabilities.

Objective: To provide a rapid clinical update on casemix, average length of stay, and the effectiveness of Australian private psychiatric hospitals.Methods: We conducted a descriptive analysis of the publicly available patient data from the Australian Private Hospitals Association Private Psychiatric Hospitals Data Reporting and Analysis Service website, from 2015-2016 to 2019-2020. This was compared with corresponding reporting on public and private hospitals from the Australian Institute of Health and Welfare, and Australian Mental Health Outcomes and Classification Network.Results: In 2019-2020, there were 72 private psychiatric hospitals in Australia with 3582 acute beds. There were 42,942 inpatients with 1,286,470 days of care, and a mean length of stay 19.6 days (SD 13.9) for the financial year 2019-2020. The main diagnoses were major affective and other mood disorders (49%), and alcohol and other substance abuse disorders (21%). Clinician-rated outcome measures, that is, the HoNOS, showed an improvement effect size of 1.64, while the patient-rated MHQ-14 showed an improvement effect size of 1.18. Results are similar for previous years.Conclusions: Private psychiatric hospitals provide substantial, effective psychiatric care. [ABSTRACT FROM AUTHOR]

Abstract Background The accreditation of medical educational programs is thought to be important in supporting program improvement, ensuring the quality of the education, and promoting diversity, equity, and population health. It has long been recognized that accreditation systems will need to shift their focus from processes to outcomes, particularly those related to the end goals of medical education: the creation of broadly competent, confident professionals and the improvement of health for individuals and populations. An international group of experts in accreditation convened in 2013 to discuss this shift. Main text Participants unequivocally supported the inclusion of more outcomes-based criteria in medical education accreditation, specifically those related to the societal accountability of the institutions in which the education occurs. Meaningful and feasible outcome metrics, however, are hard to identify. They are regionally variable, often temporally remote from the educational program, difficult to measure, and susceptible to confounding factors. The group identified the importance of health outcomes of the clinical milieu in which education takes place in influencing outcomes of its graduates. The ability to link clinical data with individual practice over time is becoming feasible with large repositories of assessment data linked to patient outcomes. This was seen as a key opportunity to provide more continuous oversight and monitoring of program impact. The discussants identified several risks that might arise should outcomes measures completely replace process issues. Some outcomes can be measured only by proxy process elements, and some learner experience issues may best be measured by such process elements: in brief, the “how” still matters. Conclusions Accrediting bodies are beginning to view the use of practice outcome measures as an important step toward better continuous educational quality improvement. The use of outcomes will present challenges in data collection, aggregation, and interpretation. Large datasets that capture clinical outcomes, experience of care, and health system performance may enable the assessment of multiple dimensions of program quality, assure the public that the social contract is being upheld, and allow identification of exemplary programs such that all may improve. There remains a need to retain some focus on process, particularly those related to the learner experience.

Heart failure (HF) is a growing healthcare burden and one of the leading causes of hospitalizations and readmission. Preventing readmissions for HF patients is an increasing priority for clinicians, researchers, and various stakeholders. The following review will discuss the interventions found to reduce readmissions for patients and improve hospital performance on the 30-day readmission process measure. While evidence-based therapies for HF management have proliferated, the consistent implementation of these therapies and development of new strategies to more effectively prevent readmissions remain areas for continued improvement.

Abstract Aims: This study aimed to compare the sedentary time measured using the ActiGraph GT3X accelerometer with the measurement of sitting and standing time obtained by ActivPAL inclinometers. Methods: This was a cross-sectional study conducted with a sample of 60 schoolchildren (34 males) of one elementary public school in Brazil. The students used both an ActiGraph GT3X accelerometer and an ActivPAL inclinometer, concurrently, positioned at the beginning and removed at the end of the school shift, for four days. For analysis, paired Student's t-tests, Pearson's correlation coefficients, intraclass correlation coefficients, and Bland-Altman plots were used. Results: When comparing sedentary time with sitting time, although correlated (r = 0.53; p < 0.001), the mean minutes were different (134.2 min/day in ActiGraph GT3X vs 120.3 min/day in ActivPAL; p < 0.001), with a bias of 13.9 min/day. When comparing the measurement of sedentary time with the sum of the sitting time plus standing time, different mean minutes were also observed (134.2 min/day in ActiGraph GT3X vs 177.0 min/day in ActivPAL; p < 0.001), and although the correlation was stronger (r = 0.75; p < 0.001), the bias was higher (−42.8 min/day). Conclusion: Sedentary time derived from the ActiGraph GT3X device should be used with caution to evaluate sedentary behavior in a school setting and may be interpreted only as non-moving activities (stationary behavior).

Background: Gastrointestinal leaks after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) occur infrequently but lead to clinical and socioeconomic burden on patients. Surgeons perform intraoperative leak test (IOLT) via gastric tube or endoscopy to help prevent postoperative leaks. However, there is knowledge gap in the literature on effectiveness of IOLT during bariatric surgery. Methods: In this observational cohort study using the 2015–2017 MBSAQIP database, we compared the outcomes in patients who received IOLT with those who did not during primary or revision RYGB and SG. The primary outcome was 30-day postoperative leak. Secondary outcomes were procedure duration and the rates of 30-day postoperative bleed, readmission, reoperation and intervention. Propensity score matching was used to assemble cohorts of patients with similar baseline characteristics. Results: Among 363,042 patients, 82% underwent IOLT. Four subgroups of patients who underwent operations with or without IOLT during primary RYGB (n = 13,756), primary SG (n = 110,810), revision RYGB (n = 1140), and revision SG (n = 5576) had similar propensity scores and were matched 1:1. Patients who underwent IOLT had similar postoperative leak rates compared to those who did not (Primary RYGB with IOLT 0.7% v. without IOLT 0.6%; Primary SG 0.4% v. 0.3%; Revision RYGB 2.3% v. 1.0%; Revision SG 1.1% v. 0.7%). In primary SG subgroup, patients who underwent IOLT had lower postoperative bleed rates (0.6% v. 0.8%, p = 0.002). In primary RYGB and SG subgroups, operations with IOLT were slightly longer. Conclusion: Postoperative leak rates after primary and revision bariatric surgery were low and similar irrespective of IOLT. Patients who had IOLT during primary SG had lower postoperative bleed rates. Current judgment as to whether to perform an IOLT leads to excellent outcomes, and thus, current practices should continue. However, one should consider an IOLT during primary SG, not necessarily to reduce leak rates but to help reduce postoperative bleeding occurrences. [ABSTRACT FROM AUTHOR]

The use of clinical dashboards has expanded significantly in healthcare in recent years in a variety of settings. The ability to analyze data related to quality metrics in one screen is highly desirable for cardiac anesthesiologists, as they have considerable influence on important clinical outcomes. Building a robust quality program within cardiac anesthesia relies on consistent access and review of quality outcome measures, process measures, and operational measures through a clinical dashboard. Signals and trends in these measures may be compared to other cardiac surgical programs to analyze gaps and areas for quality improvement efforts. In this article, the authors describe how they designed a clinical cardiac anesthesia dashboard for quality efforts at their institution. [ABSTRACT FROM AUTHOR]

Importance: Quality measures of palliative and end-of-life care relevant to patients with advanced cancer have been developed, but few are in routine use. It is unclear which of these measures are most important for providing patient- and family-centered care and have high potential for improving quality of care. Objective: To prioritize process quality measures for assessing delivery of patient- and family-centered palliative and end-of-life cancer care in US Veterans Affairs (VA) health care facilities. Design, Setting, Participants: A panel of 10 palliative and cancer care expert stakeholders (7 physicians, 2 nurses, 1 social worker) rated process quality measure concepts before and after a 1-day meeting. Measures: Panelists rated 64 measure concepts on a nine-point scale on: (1) importance to providing patient- and family-centered care, and (2) potential for quality improvement (QI). Panelists also nominated five highest priority measure concepts ("top 5") on each attribute. Results: Panelists rated most measure concepts (54 premeeting, 56 post-meeting) as highly important to patient- and family-centered care (median rating ≥7). Considerably fewer (17 premeeting, 22 post-meeting) were rated as having high potential for QI. Measure concepts having postpanel median ratings ≥7 and nominated by one or more panelists as "top 5" on either attribute comprised a shortlist of 20 measure concepts. Conclusions: A panel of expert stakeholders helped prioritize 64 measure concepts into a shortlist of 20. Half of the shortlisted measures were related to communication about patient preferences and decision making, and half were related to symptom assessment and treatment. [ABSTRACT FROM AUTHOR]

Research on genetic counseling outcomes has examined a range of metrics many that differ in quality and extent of psychometric assessment and in some cases fail to encompass potential benefits of genetic counseling for patients. Although a variety of possible outcomes have been explored, selecting the most important or relevant outcomes and identifying well‐validated measures remain challenging. An online, modified Delphi method was used to prioritize genetic counseling outcomes from the viewpoint of individuals from four stakeholder groups – clinical genetic counselors, outcome researchers, genetic counseling training directors, and genetic counseling consumers/advocates. A survey of 181 genetic counseling outcomes were rated based on perceived importance and then sorted and categorized using the Framework for Outcomes of Clinical Communication Services in Genetic Counseling (FOCUS‐GC) framework. Three of the FOCUS‐GC domains (Process, Patient Care Experience, and Patient Changes) were assessed as most important, while none of the most highly rated outcomes fell into the domains of Patient Health or Family Changes. The majority of outcomes deemed most important by stakeholder groups were within the process domain. When looking at the proportion of outcomes that overlapped with the consumer group, clinical genetic counselors had the highest degree of similarity with consumers when looking at the high relative importance band outcomes (61.1% overlap), followed by training directors (58.3%), and outcome researchers (41.7%). Variability in importance according to stakeholder groups was an important consideration and prioritizing outcomes was challenging given that the majority of outcomes were rated as important. Working to bridge the realities of clinical care and fundamental differences in the viewpoints and priorities of genetic counseling research directions is an area for future exploration. [ABSTRACT FROM AUTHOR]

Background: Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value‐based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer‐specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes. Methods: Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient‐level risk adjustment. Hospital‐level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression. Results: Seven hundred sixty‐eight thousand nine hundred sixty‐nine unique cancer cases were included from 1323 facilities. Increasing hospital‐level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58–0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77–0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08–1.20). For the remaining measures, hospital‐level compliance demonstrated no consistent association with patient survival. Conclusion: Hospital‐level compliance with the CoC's Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value‐based healthcare delivery. [ABSTRACT FROM AUTHOR]

ObjectiveTo identify an approach to summarizing publicly reported hospital performance data for acute myocardial infarction (AMI) or heart failure (HF) that best predicts current year hospital mortality rates.SettingA total of 1,868 U.S. hospitals reporting process and outcome measures for AMI and HF to the Centers for Medicare and Medicaid Services (CMS) from July 2005 to June 2006 (Year 0) and July 2006 to June 2007 (Year 1).DesignObservational cohort study measuring the percentage variation in Year 1 hospital 30-day risk-adjusted mortality rate explained by denominator-based weighted composite scores summarizing hospital Year 0 performance.Data collectionData were prospectively collected from hospitalcompare.gov.ResultsPercentage variation in Year 1 mortality was best explained by mortality rate alone in Year 0 over other composites including process performance. If only Year 0 mortality rates were reported, and consumers using hospitals in the highest decile of mortality instead chose hospitals in the lowest decile of mortality rate, the number of deaths at 30 days that potentially could have been avoided was 1.31 per 100 patients for AMI and 2.12 for HF (p < .001).ConclusionPublic reports focused on 30-day risk-adjusted mortality rate may more directly address policymakers' goals of facilitating consumer identification of hospitals with better outcomes.

The aim of this study was to predict self-report data for self-regulated learning with sensor data. In a longitudinal study multichannel data were collected: self-report data with questionnaires and embedded experience samples as well as sensor data like electrodermal activity (EDA) and electroencephalography (EEG). 100 students from a private university in Germany performed a learning experiment followed by final measures of intrinsic motivation, self-efficacy and gained knowledge. During the learning experiment psychophysiological data like EEG were combined with embedded experience sampling measuring motivational states like affect and interest every 270 s. Results of machine learning models show that consumer grade wearables for EEG and EDA failed to predict embedded experience sampling. EDA failed to predict outcome measures as well. This gap can be explained by some major technical difficulties, especially by lower quality of the electrodes. Nevertheless, an average activation of all EEG bands at T7 (left-hemispheric, lateral) can predict lower intrinsic motivation as outcome measure. This is in line with the personality system interactions (PSI) theory of Julius Kuhl. With more advanced sensor measures it might be possible to track affective learning in an unobtrusive way and support micro-adaptation in a digital learning environment.

The Primary Innovation programme investigated co-innovation to solve complex agricultural problems in five New Zealand primary sector projects. The projects engaged diverse stakeholders using a collaborative, integrative process to co-define problems, and co-create and implement solutions. Each project included a Reflexive Monitor, who facilitated group relationships, encouraged a systems perspective, and integration of multiple disciplinary and stakeholder knowledges. Reflexive Monitors also encouraged reflexive practice and adaptive project management, while helping the team pursue the project ambition for change. This paper, with respect to the five projects, seeks to address the following research question: Is co-innovation an effective research approach for achieving societal impact from innovations? To address this question, we describe attempts to operationalise and measure co-innovation through 1) five behavioural principles of co-innovation, 2) Reflexive Monitors' focus on each principle, and 3) the presence or absence of elements of the Integration and Implementation Sciences Framework (i2S) for enhancing research impact. We evaluate the relationship between these three process measures and project success, measured by outputs and two proxy impact measures: participants' subjective comparisons with the counterfactual and anticipated achievement of desired long-term impacts. Results indicated that the five principles of co-innovation and the presence or absence of elements defined in the i2S framework were positively related to the three success measures. This suggests validity of these measurement tools, and of using a co-innovation approach and/or systematic attention to the elements of the i2S framework to enhance the processes, outcomes and impacts of projects tackling complex real-world problems. [ABSTRACT FROM AUTHOR]

Little is known about which hospitals participate in voluntary public reporting of quality processes and what influences their performance, particularly in cancer care. We hypothesize that patient volume is positively associated with both reporting and performance. In 2014, when Pennsylvania became the first and only state to have public reporting for cancer care, it became possible to test these hypotheses, which we did in cross-sectional study of the 72 Pennsylvania hospitals accredited by the Commission on Cancer. Hospitals that publicly reported their performance (57 of 72) had higher patient volumes than hospitals that did not release performance. Among reporting hospitals, no association was found between patient volume and performance on process of care metrics. These findings suggest the importance of attending to volume effects in public reporting of cancer care and recognizing that volume is not a predictor of performance for reporting hospitals, which indicates the need for research to identify other factors that differentiate performance within and across reporting and nonreporting hospitals. [ABSTRACT FROM AUTHOR]

Background: The accreditation of medical educational programs is thought to be important in supporting program improvement, ensuring the quality of the education, and promoting diversity, equity, and population health. It has long been recognized that accreditation systems will need to shift their focus from processes to outcomes, particularly those related to the end goals of medical education: the creation of broadly competent, confident professionals and the improvement of health for individuals and populations. An international group of experts in accreditation convened in 2013 to discuss this shift. Main text: Participants unequivocally supported the inclusion of more outcomes-based criteria in medical education accreditation, specifically those related to the societal accountability of the institutions in which the education occurs. Meaningful and feasible outcome metrics, however, are hard to identify. They are regionally variable, often temporally remote from the educational program, difficult to measure, and susceptible to confounding factors. The group identified the importance of health outcomes of the clinical milieu in which education takes place in influencing outcomes of its graduates. The ability to link clinical data with individual practice over time is becoming feasible with large repositories of assessment data linked to patient outcomes. This was seen as a key opportunity to provide more continuous oversight and monitoring of program impact. The discussants identified several risks that might arise should outcomes measures completely replace process issues. Some outcomes can be measured only by proxy process elements, and some learner experience issues may best be measured by such process elements: in brief, the "how" still matters. Conclusions: Accrediting bodies are beginning to view the use of practice outcome measures as an important step toward better continuous educational quality improvement. The use of outcomes will present challenges in data collection, aggregation, and interpretation. Large datasets that capture clinical outcomes, experience of care, and health system performance may enable the assessment of multiple dimensions of program quality, assure the public that the social contract is being upheld, and allow identification of exemplary programs such that all may improve. There remains a need to retain some focus on process, particularly those related to the learner experience. [ABSTRACT FROM AUTHOR]

The aim of this study was to predict self-report data for self-regulated learning with sensor data. In a longitudinal study multichannel data were collected: self-report data with questionnaires and embedded experience samples as well as sensor data like electrodermal activity (EDA) and electroencephalography (EEG). 100 students from a private university in Germany performed a learning experiment followed by final measures of intrinsic motivation, self-efficacy and gained knowledge. During the learning experiment psychophysiological data like EEG were combined with embedded experience sampling measuring motivational states like affect and interest every 270 s. Results of machine learning models show that consumer grade wearables for EEG and EDA failed to predict embedded experience sampling. EDA failed to predict outcome measures as well. This gap can be explained by some major technical difficulties, especially by lower quality of the electrodes. Nevertheless, an average activation of all EEG bands at T7 (left-hemispheric, lateral) can predict lower intrinsic motivation as outcome measure. This is in line with the personality system interactions (PSI) theory of Julius Kuhl. With more advanced sensor measures it might be possible to track affective learning in an unobtrusive way and support micro-adaptation in a digital learning environment. [ABSTRACT FROM AUTHOR]

Carpal tunnel syndrome (CTS) is a common neuromuscular condition and a major cause of work-related disability. As healthcare in the United States transitions toward a value-based system from fee-for-service, quality measures assume importance in the evaluation of care provided. This report from the American Association of Neuromuscular & Electrodiagnostic Medicine Quality Improvement Committee provides an introduction to quality measures and outlines a quality measurement set for the electrodiagnosis of CTS. The measures attempt to standardize technical requirements for electrodiagnostic (EDX) studies of CTS, the criteria for diagnosing median neuropathy at the wrist and assessing its severity, and the role of operative EDX testing. The assumption is that implementation of these measures will improve the accuracy of CTS diagnosis when EDX is performed, help exclude mimics, and, therefore, improve care of patients with CTS with the ultimate goal of improving outcomes. Postimplementation assessment of outcomes will refine these measures. [ABSTRACT FROM AUTHOR]

Abstract Background The admission process of patients to a hospital is the starting point for inpatient services. In order to optimize the quality of the health services provision, one needs a good understanding of the patient admission workflow in a clinic. The aim of this study was to identify challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic from the perspective of an interdisciplinary team of health professionals. Methods Semi-structured interviews with eight health professionals (medical doctors, physical therapists, occupational therapists, nurses) at the Swiss Paraplegic Centre (acute and rehabilitation clinic) were conducted based on a maximum variety purposive sampling strategy. The interviews were analyzed using a thematic analysis approach. Results The interviewees described the challenges and potential improvements in this admission process, focusing on five themes. First, the characteristics of the patient with his/her health condition and personality and his/her family influence different areas in the admission process. Improvements in the exchange of information between the hospital and the patient could speed up and simplify the admission process. In addition, challenges and potential improvements were found concerning the rehabilitation planning, the organization of the admission process and the interdisciplinary work. Conclusion This study identified five themes of challenges and potential improvements in the admission process of spinal cord injury patients at a specialized rehabilitation clinic. When planning adaptations of process steps in one of the areas, awareness of effects in other fields is necessary. Improved pre-admission information would be a first important step to optimize the admission process. A common IT-system providing an interdisciplinary overview and possibilities for interdisciplinary exchange would support the management of the admission process. Managers of other hospitals can supplement the results of this study with their own process analyses, to improve their own patient admission processes.

Improving patient safety is an ongoing journey that benefits from periodic assessment to recognize, reward, and redirect efforts. As an independent, nonregulatory state agency, the Patient Safety Authority (PSA) is uniquely positioned to both conduct comprehensive safety assessments and support improvement efforts. A process measures survey of acute care facilities was conducted in November and December 2018. The purpose was to inform the PSA’s strategic direction, provide benchmarking data to facilities, and understand the current patient safety landscape. The survey consisted of 48 questions divided into 10 domains: Behavioral Health, Falls, Health Information Technology, Improving Diagnosis, Infection Prevention and Control, Leadership, Medication Safety, Obstetrics, Safe Surgery, and Transition of Care. Each question asked respondents to report the degree to which a specific safety practice has been implemented at their facility. In all, 153 unique facility responses with at least 30% of the survey questions completed were received and analyzed. According to respondents, the domains Safe Surgery, Infection Prevention and Control, and Obstetrics had the highest percentages of full implementation, while Behavioral Health, Medication Safety, and Improving Diagnosis had the lowest. Looking across domains, two new themes emerged: first, a high percentage of full implementation of safety practices to support communication about patient safety with frontline staff and second, a low percentage of full implementation of safety practices that promote patient engagement in organizational efforts to support safe patient care. These results will inform the PSA’s focus over the next several years. In a couple of places the phrase is used “Improving patient safety is an endless journey….”. I worry that the use of “endless journey” may imply progress can never be made in patient safety and be self-defeating. I suggest changing it to something like, “In the ongoing journey to improve patient safety….”

Objective: The aim of this pilot study was to explore what students of psychotherapy learn from intensively reviewing the work of experienced therapists whilst being focused on process measures developed to capture clients' emotional expressions. Methods: We interviewed 12 students who participated in the training and coding of emotional processes in psychotherapy to explore their learning experiences. The interviews were analysed using a thematic analysis methodology. In addition, we explored the change in clinical self‐efficacy among 26 students who participated in the training, and coding compared to scores from a sample of 26 fellow students who did not participate. Results: Three main themes in the participating students' descriptions of what they learned were identified: (1) You notice emotions better. An increase in emotional awareness and ability to identify emotional patterns both in the role as therapist and in one's own life (2) It feels a bit like model learning. Recognising the importance of interpersonal skills such as listening, being empathic and present as a therapist. (3) Even experienced therapists fumble. Developing more realistic and moderate expectations of the role as therapist, and feeling less anxious of entering the therapist role. Conclusions: Teaching students to code emotional processes and then giving them the opportunity to observe and code psychotherapy as it naturally unfolds over time may represent a promising approach to foster relevant therapeutic skills, reducing performance anxiety and thus preparing students for the role as a therapist. Implications for training are discussed. [ABSTRACT FROM AUTHOR]

The Acceptance and Commitment Therapy (ACT) literature now offers a range of process measures, including: the Acceptance and Action Questionnaire-II (AAQ-II), the Open and Engaged State Questionnaire (OESQ), the Comprehensive Assessment of ACT Processes (CompACT), and the Multidimensional Psychological Flexibility Inventory (MPFI). The current study sought to directly compare and contrast the information provided by those scales: (1) in a sample of 2,385 online respondents (67% female, 85% Caucasian, M = 33yo) and (2) in a case study of a client receiving ACT for a depressive disorder. Quantitative results revealed that all of the flexibility scales were strongly linked to wellbeing whereas the inflexibility scales were strongly linked to psychological distress. The results further highlighted that newer multidimensional scales (the 3-dimension CompACT, the 12-dimension MPFI) offered greater insights into current functioning, often doubling the amount of variance explained by the AAQ-II alone. Both the quantitative analyses and the clinical case study demonstrate the more nuanced and clinically meaningful patterns that emerge when multiple dimensions of flexibility and inflexibility are tracked. In particular, the results suggested the MPFI (and the online MindFlex Assessment System that makes the MPFI easy to administer and interpret) offers researchers and clinicians the most conceptually comprehensive scale to assess the dimensions of the Hexaflex model. Implications for clinical research and practice are discussed. • ACT process scales had strong convergent validity as measures of global inflexibility. • The MPFI was the only scale to comprehensively assess forms of flexibility as well. • The newer scales offered unique predictive insights above and beyond the AAQ-II. • The CompACT and MPFI offered more nuanced patterns of findings/clinical profiles. • Forms of inflexibility were strongly linked to distress, flexibility to wellbeing. [ABSTRACT FROM AUTHOR]

Objective: Electronic health records (EHRs) were expected to yield numerous benefits. However, early studies found mixed evidence of this. We sought to determine whether widespread adoption of modern EHRs in the US has improved clinical care.Methods: We studied hospitals reporting performance measures from 2008-2015 in the Centers for Medicare and Medicaid Services Hospital Compare database that also reported having an EHR in the American Hospital Association 2015 IT supplement. Using interrupted time-series analysis, we examined the association of EHR implementation, EHR vendor, and Meaningful Use status with 11 process measures and 30-day hospital readmission and mortality rates for heart failure, pneumonia, and acute myocardial infarction.Results: A total of 1246 hospitals contributed 8222 hospital-years. Compared to hospitals without EHRs, hospitals with EHRs had significant improvements over time on 5 of 11 process measures. There were no substantial differences in readmission or mortality rates. Hospitals with CPSI EHR systems performed worse on several process and outcome measures. Otherwise, we found no substantial improvements in process measures or condition-specific outcomes by duration of EHR use, EHR vendor, or a hospital's Meaningful Use Stage 1 or Stage 2 status.Conclusion: In this national study of hospitals with modern EHRs, EHR use was associated with better process of care measure performance but did not improve condition-specific readmission or mortality rates regardless of duration of EHR use, vendor choice, or Meaningful Use status. Further research is required to understand why EHRs have yet to improve standard outcome measures and how to better realize the potential benefits of EHR systems. [ABSTRACT FROM AUTHOR]

Abstract Background One way to facilitate the translation of research into the occupational health service practice is through clinical practice guidelines. To increase the implementability of guidelines it is important to include the end-users in the development, for example by a community of practice approach. This paper describes the development of an occupational health practice guideline aimed at the management of non-specific low back pain (LBP) by using a community of practice approach. The paper also includes a process evaluation of the development providing insight into the feasibility of the process. Methods A multidisciplinary community of practice group (n = 16) consisting of occupational nurses, occupational physicians, ergonomists/physical therapists, health and safety engineers, health educators, psychologists and researchers from different types of occupational health services and geographical regions within Sweden met eleven times (June 2012–December 2013) to develop the practice guideline following recommendations of guideline development handbooks. Process-outcomes recruitment, reach, context, satisfaction, feasibility and fidelity were assessed by questionnaire, observations and administrative data. Results Group members attended on average 7.5 out of 11 meetings. Half experienced support from their workplace for their involvement. Feasibility was rated as good, except for time-scheduling. Most group members were satisfied with the structure of the process (e.g. presentations, multidisciplinary group). Fidelity was rated as fairly high. Conclusions The described development process is a feasible process for guideline development. For future guideline development expectations of the work involved should be more clearly communicated, as well as the purpose and tasks of the CoP-group. Moreover, possibilities to improve support from managers and colleagues should be explored. This paper has important implications for future guideline development; it provides valuable information on how practitioners can be included in the development process, with the aim of increasing the implementability of the developed guidelines.