Five-dimensional simulation for advanced decision making

Background: Regional variation in the utilization of health services is a well-documented phenomenon in health care with numerous studies reporting substantial and unexplained variations in coronary revascularization. In the Canadian province of British Columbia (BC), five cardiac centers provide coronary revascularization services. In 2011 Cardiac Services BC (CSBC) undertook a study that identified substantial regional variation in coronary revascularization that could not be explained by patient characteristics or risk factors. Following this initial project, CSBC launched an initiative to help better understand the regional variations and possibly devise and implement strategies to reduce them. Methods: Using Lean methodology, we are mapping the key processes of care for ACS patients across BC (initially excluding emergent STEMI and cardiogenic shock) at each cardiac centre. The ACS patient journey will be mapped from admission to discharge through several key decision points that determine whether they will continue through to diagnostic catheterization and revascularization or to be medically managed alone. The key decision points are: 1. Decision to refer to diagnostic catheterization and subsequent transfer if necessary. 2. Decision to continue to a revascularization procedure (PCI or CABG) after diagnostic catheterization. The map will summarized these key decision points using multiple sources of data: 1. Flow and patient volumes into and out of each of these decision 2. Times between decision points and key care processes 3. Clinical influencers (ex: standard orders, best practice, established patterns of referral, and consultations) and non-clinical influencers (ex: resource capacity, transportation) that are considered at each decision point (process mapping and interview data). Discussion: BC is attempting to reduce unexplained variation in coronary revascularization using the Lean methodology to take a systematic approach to the analysis of the process of ACS care across the province. Involving physicians and point of care staff in the detailed mapping process has proven to be a significant step in engaging key stakeholders in the project by allowing input into the process of describing the factors affecting variation of practice at each site. The next step is to convene provincially to determine where to improve standardized practice in order to improve patient outcomes at key points along the value stream.

Run time variability of parallel applications continues to be a significant challenge in high performance computing (HPC) systems. We are currently studying run time variability in the context of both systemic performance and energy management. Our perspective is from that of the application, focusing on the interactions of the inter-process communication system on the set of concurrently executing parallel applications. In such a scenario, application run time can be extended and become highly variable. While some applications may be more sensitive to these interactions, others may in fact be generating the interactions that cause inconsistent run time, thus forming the notion of application-level behavioral attributes. To gain insight into this problem, our earlier work developed a framework that emulates parallel applications, called PACE. We also introduced a Parallel Application Run time Sensitivity Evaluation (PARSE) function that uses the PACE framework to study the run time effects of controlled network performance degradation on applications. Inter-process communication has evolved over the last decade from network communication between single-processor, single-core nodes to hybrid systems whose compute nodes contain several multi-core processor units. Motivated by the evolution of compute hardware and systems software, this work introduces PARSE 2.0, which is a nearly complete re-write that extends PARSE capabilities to include fully automating the processes of evaluating and quantifying run time critical parallel application-level behavioral attributes. We present an overview of the tool and the attributes being evaluated, and present experimental results from tests conducted on several widely used parallel benchmarks and application code fragments. The results re-enforce our earlier work, demonstrating that parallel applications can be classified according to their behavioral attributes, in the context of communication system resources.

Post–residential treatment outpatient care preferences: Perspectives of youth with opioid use disorder

Rationale and aims: Contextual factors are increasingly recognized as having a significant influence on clinical-decision-making. Contextual influences however, are considered ‘less scientific’ or ‘non-clinical’ in the eyes of practicing clinicians, making it a sensitive issue for discussion. Therefore, exploring these contextual influences can be challenging. Methods which can circumvent this challenge are required to evaluate clinical decision making at natural settings. This paper reports on the development of an innovative research method to address this challenge of exploring contextual influences and similar sensitive and complex clinical practice issues. Method: The researchers conducted a field research to test an interview based method which was termed as ‘Clinician Recalled Vignette (CRV) Method’. Based on reflections on the field research experience this preliminary method was refined to develop an innovative method which is potentially capable of eliciting sensitive and complex clinical practice issues. Results: Reflections on field test data provided preliminary evidence on the usefulness of the CRV method and limitations. The method that was refined, in response to limitations, focused on key decision points relevant to the clinical vignettes recalled by clinicians, and included a mechanism to identify how contextual factors influence these key decision points. This innovative method was termed ‘Vignette-based Decision Point Analysis’. Conclusions: The innovative method discussed in this paper will assist other researchers in conceptualising and conducting research projects to explore sensitive and complex clinical practice issues in natural settings.

Distilling the Key Elements of Pediatric Appendicitis Clinical Practice Guidelines

Cost estimates are necessary for government acquisition program to support decisions about funding, to develop annual budget requests and to validate resource requirements at key decision points. Many researches have been done about cost estimating technique recently. Parametric cost estimating models based on CERs(Cost Estimating Relationships) have been mainly used using regression method with historical data. However, there are many restrictions in developing Korean version CERs because the number of data points are too small. Specially, data collection and data management system are unstable in Korean defense environment, when developing CERs. In this research, we analyzed the historical data, and found some cost drivers in guided weapon system area. We developed the Acquisition Unit Cost CER using the regression to remove multicollinearity in the historical data. So we could overcome the restriction of the insufficient sample number. This research as a first attempt is meaningful in terms of obtaining our own Acquisition Unit Cost CER using historical cost and physical characteristic in Korean development environment.

The ability to find one's way in the world, known as wayfinding, is impaired in individuals with Alzheimer's disease (AD). Older adult residential environments (e.g., independent living, assisted living, nursing home residences) are often especially difficult for wayfinding, with long, non-distinctive hallways and poorly differentiated routes. Wayfinding problems can cause anxiety, distress, and decreased interaction in individuals with dementia. Visual cues are one promising intervention to help this population find their way more easily. The current article reviews research studies that examine the influence of visual cues on wayfinding. The literature shows evidence that individuals with AD have difficulty wayfinding, yet can still learn their way if the environment is supportive of wayfinding. There is beginning evidence that colorful, familiar (easily identified), and personally meaningful cues placed at key decision points and residents' rooms can help individuals with AD find their way.

One of the great management challenges is cultivating long-term organizational culture change. There are many key decision points in the success of such a complex effort, and hence many “veto” opportunities to impede change progress. In this chapter, we present a diagnostic change resistance typology that identifies the various motivational attributes that contribute to opposing change. This chapter concludes with an outline of a change management process to overcome resistance and obstacles. It is important to embrace the belief that the power to change organizational culture begins with committed servant leaders who love their employees and other key stakeholders.

How does the brain learn the relevance of landmarks at key decision points? An imaging study now shows that the parahippocampal gyrus responds to the navigational relevance of landmarks, even those that were not remembered.

Studies in international relations point to the utility and importance of the concept of reciprocity allowing actors to mitigate and overcome some of the inherent difficulties in international interactions, including mistrust and uncertainty. Through the process of tit-for-tat (TFT) actors learn to trust and engage in a positive reciprocal cycle. Yet reciprocity could as easily evolve into a negative cycle. The concept of reciprocity and the two options of positive and negative cycles are examined here. Critical junctures, or key decision points, and the processes occurring during these times become crucial for understanding the direction of the reciprocal cycle. The questions of why such critical junctures are important and how to identify and define these are addressed and discussed

Professionals who collect and use traditional knowledge to support resource management decisions often are preoccupied with concerns over how and if traditional knowledge should be integrated with science. To move beyond the integration dilemma, we treat traditional knowledge and science as distinct and complementary knowledge systems. We focus on applying traditional knowledge within the decision-making process. We present succinct examples of how the Bureau of Ocean Energy Management has used traditional knowledge in decision making in the North Slope Borough, Alaska: 1) using traditional knowledge in designing, planning, and conducting scientific research; 2) applying information from both knowledge systems at the earliest opportunity in the process; 3) using traditional knowledge in environmental impacts assessment; 4) consulting with indigenous leaders at key decision points; and 5) applying traditional knowledge at a programmatic decision level. Clearly articulating, early in the process, how best to use traditional knowledge and science can allow for more complete and inclusive use of available and pertinent information.

Decision-making in operative vaginal delivery: when to intervene, where to deliver and which instrument to use? Qualitative analysis of expert clinical practice

Abstract. In low-rainfall cropping systems, understanding the water balance, and in particular the storage of soil water in the rooting zone for use by crops, is considered critical for devising risk management strategies for grain-based farming. Crop-soil modeling remains a cost-effective option for understanding the interactions between rainfall, soil, and crop growth, from which management options can be derived. The objective of this study was to assess the error in the prediction of soil water content at key decision points in the season against continuous, multi-layer soil water measurements made with frequency domain reflectometry (FDR) probes in long-term experiments in the Mallee region of South Australia and New South Wales. Field estimates of the crop lower limit or drained upper limit were found to be more reliable than laboratory-based estimates, despite the fact that plant-available water capacity (PAWC) did not substantially differ between the methods. Using the Agricultural Production Systems sIMulator (APSIM) to simulate plant-available water over three-year rotations, predicted soil water was within 7 mm (PAWC 64 to 99 mm) of the measured data across all sowing events and rotations. Simulated (n = 46) wheat grain production resulted in a root mean square error (RMSE) of 492 kg ha-1, which is only marginally smaller than that of other field studies that derived soil water limits with less detailed methods. This study shows that using field-derived data of soil water limits and soil-specific settings for parameterization of other properties that determine soil evaporation and water redistribution enables APSIM to be widely applied for managing climate risk in low-rainfall environments. Keywords: APSIM, Climate risk management, Crop models, Decision support, Soil moisture.

1 - Introduction: Key decision points and information requirements in fast fashion supply chains

Objectives Demonstrate how to improve well delivery performance by strengthening discipline integration at key decision points. This draws on insight from implementing a well delivery process at Maersk Oil. Methods This paper analyses well delivery team performance, identifying issues and success factors through 30+ interviews and feedback from 100+ practitioners. It identifies five decision points with the greatest performance improvement potential. The study consistently found Subsurface/Wells integration challenges at the heart of issues, decisions and success stories. It presents methods to systematically strengthen integration at each decision to improve performance. It defines enablers for effective integration, including learnings from prior projects and subject matter experts. The approach was implemented globally in all 2015/16 projects. Results and Conclusions Integration was strengthened through activities leading up to each decision. This covers deliverables, peer reviews, freezes and gates. For deliverables, this required clearer expectations and divisions of responsibilities. Peer reviews were adjusted to force trade-off debates and fulfil sharper requirements. Freeze points were created representing leadership commitment to minimise re-work. The gates were reinforced to drive cross-discipline integration and finalise decisions. These integration activities aren't effective in isolation. They depend on enablers: building a robust case for integration, up-front collaboration, communicating the intent and cross-discipline leadership commitment. The paper describes best practices for each and how they fit together. By strengthening integration and implementing enablers, project teams have improved efficiency, risk management and decision quality. The results are quantified with metrics and supported by examples and interviews. Novel Information Novelty lies in the systematic approach to strengthening cross-discipline integration at decision points. This goes beyond existing literature in scope and specificity. Operators can apply this to improve performance. The approach can be applied to other decision points, disciplines and capital project processes.