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In order to meet the requirements of 6σ management and to overcome the deficiencies of the theory for using the pre-control chart to evaluate and monitor quality stability, the purpose of this paper is to probe into the quality stability evaluation and monitoring guidelines of small batch production process based on the pre-control chart under the conditions of the distribution center and specifications center non-coincidence (0<ɛ≤1.5σ), the process capability index C _p ≥2 and the virtual alarm probability α=0.27 percent.

First, the range of the quality stability evaluation sampling number in initial production process is determined by using probability and statistics methods, the sample size for the quality stability evaluation is adjusted and determined in initial production process according to the error judgment probability theory, and the guideline for quality stability evaluation has been proposed in initial production process based on the theory of small probability events. Second, the alternative guidelines for quality stability monitoring and control in formal production process are proposed by using combination theory, the alternative guidelines are initially selected based on the theory of small probability events, a comparative analysis of the guidelines is made according to the average run lengths values, and the monitoring and control guidelines for quality stability are determined in formal production process.

The results obtained from research indicate that when the virtual alarm probability α=0.27 percent, the shifts ɛ in the range 0<ɛ≤1.5σ and the process capability index C _p ≥2, the quality stability evaluation sample size of the initial production process is 11, whose scondition is that the number of the samples falling into the yellow zone is 1 at maximum. The quality stability evaluation sample size of the formal production process is 5, and when the number of the samples falling into the yellow zone is ≤1, the process is stable, while when two of the five samples falling into the yellow, then one more sample needs to be added, and only if this sample falls into the green zone, the process is stable.

Research results can overcome the unsatisfactory 6σ management assumptions and requirements and the oversize virtual alarm probability α of the past pre-control charts, as well as the shortage only adaptable to the pre-control chart when the shifts ɛ=0. And at the same time, the difficult problem hard to adopt the conventional control charts to carry out process control because of a fewer sample sizes is solved.

Inappropriate cardiac monitoring leads to increased hospital resource utilization and alarm fatigue, which is ultimately detrimental to patient safety. Our institution implemented a continuous cardiac monitoring (CCM) policy that focused on selective monitoring for patients based on the American Heart Association (AHA) guidelines. The primary goal of this study was to perform a three-year median follow-up review on the longitudinal impact of a selective CCM policy on usage rates, length of stay (LOS), and mortality rates across the medical center. A secondary goal was to determine the effect of smaller-scale interventions focused on reeducating the nursing population on the importance of cardiac alarms.

A system-wide policy was developed at The Ohio State University in December 2013 based on guidelines for selective CCM in all patient populations. Patients were stratified into Critical Class I, II, and III with 72 hours, 48 hours, or 36 hours of CCM, respectively. Pre- and post-implementation measures included average cardiac monitoring days (CMD), emergency department (ED) boarding rate, mortality rates, and LOS. A 12-week evaluation period was analyzed prior to, directly after, and three years after implementation.

There was an overall decrease of 53.5% CMDs directly after implementation of selective CCM. This had remained stable at the three-year follow-up with slight increase of 0.5% (p = 0.2764). Subsequent analysis by hospital type revealed that the largest and most stable reductions in CMD were in noncardiac hospitals. The cardiac hospital CMD reduction was stable for roughly one year, then dipped into a lower stable level for nine months, then returned to the previous post-implementation levels. This change coincided with a smaller intervention to further reduce CMD in the cardiac hospital. There was no significant change in mortality rates with a slight decrease of 3.1% at follow-up (p = 0.781). Furthermore, there was no significant difference in LOS with a slight increase of 1.1% on follow-up (p = 0.649). However, there was a significant increase in ED boarding rate of 7.7% (p < 0.001) likely due to other hospital factors altering boarding times.

Implementing selective CCM decreases average cardiac monitoring rate without affecting LOS or overall mortality rate. Selective cardiac monitoring is also a sustainable way to decrease overall hospital resource utilization and more appropriately focus on patient care.

The routine use of intrapartum electronic fetal monitoring (EFM) has resulted in an increased burden of operative and vaginal instrumental deliveries for women at low obstetric risk. Such modes of delivery increase maternal mortality and morbidity risks. This study aims to explore midwives' values, attitudes and beliefs when using intrapartum fetal monitoring techniques in clinical practice.

A total of 58 registered midwives across two NHS Trusts in one region in the north of England were interviewed using a qualitative approach.

Midwives attempted to manage the psychological burden of the threat from clinical negligence by using EFM. This meant that some midwives used electronic monitoring regardless of clinical need. Midwives lack confidence in the ability of EFM to accurately detect fetal compromise but are aware that the visual monitoring record is recognised as a valuable piece of legal evidence. The midwives' perceptions of professional self‐efficacy in seeking to avoid a claim in clinical negligence contributed to defensive practice. Research limitations/implications – The study was conducted in only two hospitals in one region of England; however the Trust demographics were similar and midwifery practice within the unit reflects national maternity standards of care.

Multidisciplinary strategies may be required to overcome barriers to the effective implementation of clinical guidelines where intrapartum fetal monitoring is concerned and Trust audit departments must undertake regular audit cycles in order to ascertain practice compliance with best evidence.

The paper provides information so that midwives' knowledge regarding the limitations of EFM can be improved.

The purpose of this study is to better understand the nexus between environmental taxes and other environmental management systems (EMSs) and to propose an alternative framework for implementing environmental protection tax (EPT) in China.

The study uses a multimethod approach encompassing document analysis and comparative analysis. The archival data covers laws, reports, regulations, guidelines and standards related to the EPT and EMS sub-systems in China.

The study identifies several institutional features of environmental taxes that have not been fully explored in past tax research. In addition, the study reveals that information-sharing mechanisms are key to addressing the risks and uncertainties associated with the implementation of an environmental tax and that the mechanisms are grounded in the nexus among EPT and two EMS sub-systems.

The findings of this study have implications for the understanding of China’s environmental tax system, the Environmental Impact Assessment system and the pollutants discharge permit (PDP) system. The construction of an alternative framework provides insights for approaches to environmental taxation. A limitation of this study is that the application of the framework might be undermined by the inaccurate manual sampling, as some pollutants may be non-replicable.

The findings of this study are relevant to policymakers who are designing, improving or abandoning environmental taxes for alternate solutions to environmental issues.

The insights gained from this study may be of assistance to lower the risks and uncertainties associated with the implementation of an environmental tax.

The study contributes to approaches to environmental taxes by constructing an alternative framework that connects an environmental tax system with two EMSs. The framework lays the groundwork for some promising research opportunities. Additionally, the study extends the tax accounting literature (Hanlon and Heitzman, 2010) by connecting accounting and environmental knowledge and developing a transdisciplinary approach. The study also contributes to the emerging body of literature that addresses the challenges in implementing environmental taxes in China.

Clinical guidelines aim to disseminate evidence and thus to change behaviour. This process is complex and needs a coherent approach. Aims to develop a model for implementing clinical guidelines in primary care and thus influencing prescribing by general practitioners (GPs). A total of 25 semi‐structured interviews were conducted with GPs and primary care academics. To enrich the model an ongoing literature review of guideline implementation and changing prescribing behaviour was used. A simple model was derived to guide primary care organisations and GPs in implementing guidelines for prescribing, which comprises six steps: choose the condition; choose the guideline; identify influential people; identify organisational factors; plan and adopt an implementation strategy; and monitor the resulting adherence. The model provides a framework for planning the implementation of guidelines, and recognising barriers that hinder adherence to guidelines. It may help to explain why clinical guidelines vary in their uptake.

The Path.Finder NHS consortium consists of ten acute hospitals sharing a common approach to the production and dissemination of local information for primary care, including clinical practice guidelines. Ten local guidelines were studied across four clinical areas: dyspepsia, lipids, eczema, and menorrhagia. Local guideline developers largely appear to be unconvinced that investment of time and resources in “proper” guideline development is cost‐effective. At the same time, primary care professionals’ views about future NICE guidelines may have been coloured by their current much more variable experience. Successful implementation of local guidelines is unlikely to be straightforward.

The purpose of this paper is to examine the question of how official bodies, health care organisations, and professional associations deal with the absence of a methodological gold standard for the simultaneous development of clinical practice guidelines and quality indicators, what procedures they use and what they feel are major strengths and limitations of their methods.

The authors conducted a web‐based survey among 90 organisational members of the Guidelines International Network (G‐I‐N) representing 34 countries from Africa, America, Asia, Europe and Oceania. All organisational G‐I‐N members were invited to participate in the survey by following a link provided in the invitation e‐mail.

The responses of 24 organisations were included in the final analysis. The results indicate a broad variability in the approaches and methods used to develop quality indicators and guidelines simultaneously. The answers of the participants indicated a lack of formal procedures for the simultaneous development. Formal procedures exist in only about half of the participating organisations. In addition, piloting or evaluation of the procedures is almost completely missing. Significantly, respondents mainly reported that the procedure used in their organisation “could certainly be more rigorous”. Besides various strengths, participants reported a considerable number of limitations of the development processes they use.

This survey among G‐I‐N members – despite limitations – gives helpful insights in the state of the simultaneous development of quality indicators and clinical practice guidelines and underlines the need for future activities in methodological standard development and quality improvement of these processes.

Integrated health care occurs when specialty and general care providers work together to address both the physical and mental health needs of their patients. The Substance Abuse and Mental Health Services Administration model of integration is broken into six levels of coordinated, co-located and integrated care. Our institution offers both co-located and integrated care among eight clinic sites. The care team is typically composed of the primary care provider, nurse and medical assistant, but other professionals may be introduced based on the patient’s medical and psychiatric conditions. The purpose of this prospective, quality improvement study was to compare the rates of adherence to long-acting injectable antipsychotics (LAIAs) between both types of integrated primary care settings at our institution. The comparison of the two settings sought to determine which environment provides improved outcomes for patients with serious psychiatric illnesses. Additionally, we aimed to assess the quality of medication-related monitoring and care team composition between care settings, and the ability of pharmacists to deliver interprofessional care team training and education on LAI use in clinical practice.

Subjects were identified and included in the study if they had received primary care services from our institution within the previous 12 months. Patient demographic and laboratory variables were collected at baseline and when clinically indicated. The rates of adherence between care settings were assessed at intervals that align with the medication’s administration schedule (e.g. every four weeks). Medication-related monitoring parameters were collected at baseline and when clinically indicated. The interprofessional care team completed Likert scale surveys to evaluate the pharmacist’s LAIA education and training.

There was not a statistically significant difference detected between integrated primary care settings on the rates of adherence to LAIAs. Additionally, there was not a statistically significant difference between rates of adherence to medication-related monitoring parameters or the effect of the patient treatment team composition. There was a statistically significant difference between pre- and post-session survey scores following interprofessional education and training provided by a pharmacist.

Because overall rates of adherence were low, both primary care settings were found to be equivalent. Our study may have been underpowered to detect a difference in the primary endpoint because of the small sample size. However, our study demonstrates that interprofessional education and training may lend itself to changes in practice, which is evident by the clinically significant relative increase in adherence. The Henry J. Austin Health Center network will be implementing a standard operating procedure regarding LAIA management within the primary care setting. Further studies are needed to assess a larger number of patients between both types of primary care settings, as well as the impact of the clinical psychiatric pharmacist as a member of the treatment team.

All countries need to track the implementation of their educational policies and legislation. The justifications and pressures for mapping such developments are very clear at the international level, as can be seen in the 2006 United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) call for data collection and monitoring at State level. They are also apparent at the European level, as outlined in the European Council priorities and targets outlined in the education and training ET 2020 strategy. This chapter will focus on the current situation in European Union member countries. It will attempt to identify the issues that must be addressed by systems of data collection at international and national levels in order to monitor learners’ rights to inclusive education.

Deferred prosecution agreements (DPAs) are the tool of choice for federal prosecutors when adjudicating corporate misconduct. A DPA is a negotiation that permits the allegedly guilty party from undergoing a criminal trial if they avoid committing further wrongdoing for a specified period. This paper aims to examine whether DPAs are a beneficial mechanism for the criminal justice system to use while adjudicating corporate misconduct. By conducting in-depth semi-structured qualitative interviews with 24 practitioners in the legal field and white-collar crime experts, this study identifies the shortcomings and advantages of DPAs and highlights what policy enactments might enhance their application. The study contributes to the existing literature by expanding the narratives used by judicial officials, legal practitioners and white-collar crime scholars on the role of DPAs.

The current study is an in-depth qualitative analysis that explores judicial actors’ and white-collar crime scholars’ opinions on the adoption of DPAs to adjudicate corporate misconduct. The literature on DPAs is currently derived primarily from law and literature reviews published by legal scholars. Clandestine negotiations are not accessible to the public and are frequently kept in sealed files unless a breach of contract occurs, resulting in the case proceeding to trial. Hence, a qualitative analysis is the best approach to evaluate the effectiveness of DPAs. Further, little evidence is available that focuses on the opinions of professionals who have participated in these agreements. The interviews were conducted over Zoom and lasted an average of 43 min, with the longest interview spanning 1 h and 45 min and the shortest interview being 14 minutes. A non-probability sampling method – specifically, snowball sampling – was used to generate a total sample of 24 legal professionals and white-collar crime scholars. Initial participants were found by contacting law offices specializing in white-collar crime litigation and using current networks to attain access to a broader range of participants. Then, 19 participants provided referrals throughout the study. The final sample consisted of nine government officials, eight legal practitioners and seven white-collar crime academics experts. One of the government official interviews was excluded from the final research project due to a lack of expertise in the field of white-collar crime. The interview questions were designed to promote in-depth conversation and insight into personal opinions on the adoption of DPAs. Several inquiries highlighted whether DPAs are an appropriate response to corporate misconduct and whether they reduced recidivism through their intended deterrent effect. Furthermore, several descriptive questions sought to understand which criminal justice actors support the adoption of DPAs in white-collar crime cases and why. Coding of the data was first conducted individually by each author. The researchers then compared thematic findings that reflected consensus.

An immediate theme identifiable in the research is the intrinsic value that DPAs offer in adjudicating corporate wrongdoing. As indicated by a participant, corporate misconduct is not “black or white,” stressing the importance of prosecutors having a middle ground between criminal prosecution and the dismissal of charges. A judicial official indicated that “DPAs are another essential arrow in a prosecutor’s quiver – and something a defense attorney can bargain for” (Respondent 5). Seven government officials and legal practitioners noted that you are unable to send a corporation to jail, and you do not simply want to put them out of business; thus, a DPA is the only tool in which the government can mandate structural change in a company without dismantling the entire entity. Only three academics concurred with the government officials and legal practitioners that DPAs are beneficial and offer prosecutors a vital middle ground. One academic, for example, stated that “DPAs have given U.S Attorney offices that ability to be involved for a considerable amount of time in a company's business, while simultaneously promoting change within the entity” (Respondent 14). Additionally, DPAs ensure that corporations are held criminally liable without triggering an endless cycle of collateral consequences for innocent third parties. One legal practitioner, for example, stated: “Just look at the Enron case; they charged Arthur Andersen with obstruction of justice and dismantled the entire entity they made it where the business was never going to come back. A small subset of individuals, in this case, should have been held responsible but instead, hundreds and if not thousands of people were harmed. With this in mind, DPAs are extremely important, in that it limits collateral consequences because DPAs take a more holistic view that criminal prosecution does not consider” (Respondent 21). Another respondent highlighted that “DPAs are the only tool available that can be employed to change an entire organization structurally” (Respondent 20). Ultimately, the findings suggest that there is a consensus among respondents that DPAs are an appropriate response to corporate misconduct, particularly when the agreement stipulates that a company must hire an external compliance monitor and update their current compliance system. Overall, participants emphasized that these stipulations promote a sense of corporate accountability, provide for the dismissal of guilty employees and mandate structural change. The majority of the respondents (n = 20) insisted that DPAs are advantageous, yet a subset of participants were skeptical of their use in white-collar crime prosecutions. One legal practitioner, for example, noted that “DPAs are political creatures that are awarded as political favors to the largest of corporations that our economy relies upon” (Respondent 17). Another government official confirmed this statement, indicating that “DPAs are a mere slap on the wrist for large corporations – they simply see it as doing business” (Respondent 6). Four academic participants emphasized that DPAs are typically negotiated with multi-level corporations and are not extended to the small businesses that suffer the dire consequences of criminal prosecution. One academic, for instance, stressed that “the question becomes is it fairly applied and being implemented properly. Larger companies are more likely to receive and benefit from a DPA, thus, raising the question of fairness” (Respondent 12). Another academic who was previously a government official stated: “DPAs risk abuse – there have been several instances where prosecutors have forced companies to donate money to favored charities and overstepped their powers. Sometimes DPAs also come with monitors. For example, banks typically have to pay for the auditor, and it becomes extremely intrusive, and it it not clear that they are efficient.”

Several limitations exist in this research. First, it is not a comprehensive study that is representative of the larger population, which limits generalizability. Given the contention of research on DPAs, this qualitative research contributes to the literature, and its findings are likely transferable to multiple settings in which DPAs are used. Second, DPAs are processed and drafted differently across jurisdictions; thus, comparing DPAs across state levels and among departments in the federal government would be equivalent to comparing apples to oranges. This comparison is yet another limitation to the study because criminal justice practitioners operate in both the state and federal jurisdictions. Another challenge in the current study and something that likely will be a problem for future researchers is the difficulty of gaining access to experts in an exclusive field of criminal justice, such as federal prosecutors, Department of Justice officials, federal judges and elite corporate defense attorneys. Ultimately, several obstacles arose during the study, particularly when recruiting participants to gain a large enough sample size to conduct meaningful analysis. This resulted in smaller sample size but rich, in-depth data that achieved saturation among participants.

Several policy implications are identifiable. First, it appears that DPAs are a mainstay of white-collar crime prosecution. No participants advocate for their complete removal from the prosecution process. Participants highlight that DPAs occupy an essential middle-ground between dismissal and criminal charges. Without this mechanism, prosecution would be impeded, and holding corporate criminal actors liable would increasingly become formidable. Although it appears that the system cannot function without DPAs, several respondents emphasize that we must begin to hold individuals accountable alongside corporations. Another policy implication that a minority of participants mentioned within the study involves ensuring that our compliance monitoring system operates appropriately. A majority of participants note that the overarching stipulation that promotes structural change within an organization is adopting a functioning compliance monitoring system, thus, emphasizing the importance of this process operating smoothly and ethically. The selection of an independent compliance monitor may be problematic. For example, a former government compliance monitor notes that not all monitors are experts in the field they are overseeing. A pharmaceutical expert, for example, may be attempting to regulate an automotive organization, which may present unique challenges. An agency of federal professionals dedicated to supervising specific industries such as automotive, pharmaceutical and financial would ensure that organizations are actually implementing the terms of the DPA.

Ultimately, the current research highlights the necessity of empirically studying the benefits and drawbacks of such agreements. Future research on the topic remains onerous due to the scarcity of a centralized database that contains extensive details of DPAs. The present study suggests that the verdict on DPAs is undecided, with more than half of the study's criminal justice professionals advocating for their continued and even increased use. However, about half of the participants, particularly academics, called attention to the agreements’ potential bias. The disagreement among participants is most contentious in the consideration of a DPA centralized database which would immensely aid future research and policy advancements.