Dental Therapy: Evolving in Minnesota’s Safety Net

PubMed Central

Born, David; Nagy, Amanda

2014-01-01

Objectives. We identified Minnesota’s initial dental therapy employers and surveyed dental safety net providers’ perceptions of dental therapy. Methods. In July 2011, we surveyed 32 Minnesota dental safety net providers to assess their prospective views on dental therapy employment options. In October 2013, we used an employment scan to reveal characteristics of the early adopters of dental therapy. Results. Before the availability of licensed dental therapists, safety net dental clinic directors overwhelmingly (77%) supported dental therapy. As dental therapists have become licensed over the past 2 years, the early employers of dental therapists are safety net clinics. Conclusions. Although the concept of dental therapy remains controversial in Minnesota, it now has a firm foundation in the state’s safety net clinics. Dental therapists are being used in innovative and diverse ways, so, as dental therapy continues to evolve, further research to identify best practices for incorporating dental therapists into the oral health care team is needed. PMID:24825234

Closing the Health Care Gap in Communities: A Safety Net System Approach.

PubMed

Gabow, Patricia A

2016-10-01

The goal of U.S. health care should be good health for every American. This daunting goal will require closing the health care gap in communities with a particular focus on the most vulnerable populations and the safety net institutions that disproportionately serve these communities. This Commentary describes Denver Health's (DH's) two-pronged approach to achieving this goal: (1) creating an integrated system that focuses on the needs of vulnerable populations, and (2) creating an approach for financial viability, quality of care, and employee engagement. The implementation and outcomes of this approach at DH are described to provide a replicable model. An integrated delivery system serving vulnerable populations should go beyond the traditional components found in most integrated health systems and include components such as mental health services, school-based clinics, and correctional health care, which address the unique and important needs of, and points of access for, vulnerable populations. In addition, the demands that a safety net system experiences from an open-door policy on access and revenue require a disciplined approach to cost, quality of care, and employee engagement. For this, DH chose Lean, which focuses on reducing waste to respect the patients and employees within its health system, as well as all citizens. DH's Lean effort produced almost $195 million of financial benefit, impressive clinical outcomes, and high employee engagement. If this two-pronged approach were widely adopted, health systems across the United States would improve their chances of giving better care at costs they can afford for every person in society.

Emergency general surgery outcomes at safety net hospitals.

PubMed

Shahan, Charles Patrick; Bell, Teresa; Paulus, Elena; Zarzaur, Ben L

2015-06-01

The United States hospital safety net is defined by the Agency for Healthcare Research and Quality as the top decile of hospitals, which see the greatest proportion of uninsured patients. These hospitals provide important access to health care for uninsured patients but are commonly believed to have worse outcomes. The aim of this study was to compare the outcomes of emergency general surgery procedures performed at safety net and nonsafety net hospitals. The Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 2008-2010 was used to create a cohort of inpatients who underwent emergency appendectomy, cholecystectomy, or herniorrhaphy. Outcomes measured included length of stay, charge, cost, death in hospital, complications, and failure to rescue (FTR). Univariate and logistic regression analysis was performed to associate variables with outcomes. A total of 187,913 emergency general surgery cases were identified, 11.5% of which were performed at safety net hospitals. The safety net cohort had increased length of stay but lower mean charge and cost. Age, comorbidity score, black race, male gender, and Medicaid and Medicare insurance were associated with mortality, complication, and FTR. Lower socioeconomic status was associated with mortality and complication. Safety net status was positively associated with complication but not mortality or FTR. Safety net hospitals had higher complication rates but no difference in FTR or mortality. This may mean that the hospitals are able to effectively recognize and treat patient complications and do so without increased cost. Copyright © 2015 Elsevier Inc. All rights reserved.

Integrating evidence-based practices for increasing cancer screenings in safety net health systems: a multiple case study using the Consolidated Framework for Implementation Research.

PubMed

Liang, Shuting; Kegler, Michelle C; Cotter, Megan; Emily, Phillips; Beasley, Derrick; Hermstad, April; Morton, Rentonia; Martinez, Jeremy; Riehman, Kara

2016-08-02

Implementing evidence-based practices (EBPs) to increase cancer screenings in safety net primary care systems has great potential for reducing cancer disparities. Yet there is a gap in understanding the factors and mechanisms that influence EBP implementation within these high-priority systems. Guided by the Consolidated Framework for Implementation Research (CFIR), our study aims to fill this gap with a multiple case study of health care safety net systems that were funded by an American Cancer Society (ACS) grants program to increase breast and colorectal cancer screening rates. The initiative funded 68 safety net systems to increase cancer screening through implementation of evidence-based provider and client-oriented strategies. Data are from a mixed-methods evaluation with nine purposively selected safety net systems. Fifty-two interviews were conducted with project leaders, implementers, and ACS staff. Funded safety net systems were categorized into high-, medium-, and low-performing cases based on the level of EBP implementation. Within- and cross-case analyses were performed to identify CFIR constructs that influenced level of EBP implementation. Of 39 CFIR constructs examined, six distinguished levels of implementation. Two constructs were from the intervention characteristics domain: adaptability and trialability. Three were from the inner setting domain: leadership engagement, tension for change, and access to information and knowledge. Engaging formally appointed internal implementation leaders, from the process domain, also distinguished level of implementation. No constructs from the outer setting or individual characteristics domain differentiated systems by level of implementation. Our study identified a number of influential CFIR constructs and illustrated how they impacted EBP implementation across a variety of safety net systems. Findings may inform future dissemination efforts of EBPs for increasing cancer screening in similar settings. Moreover

CEDRIC: a computerized chronic disease management system for urban, safety net clinics.

PubMed

Ogunyemi, Omolola; Mukherjee, Sukrit; Ani, Chizobam; Hindman, David; George, Sheba; Ilapakurthi, Ramarao; Verma, Mary; Dayrit, Melvin

2010-01-01

To meet the challenge of improving health care quality in urban, medically underserved areas of the US that have a predominance of chronic diseases such as diabetes, we have developed a new information system called CEDRIC for managing chronic diseases. CEDRIC was developed in collaboration with clinicians at an urban safety net clinic, using a community-participatory partnered research approach, with a view to addressing the particular needs of urban clinics with a high physician turnover and large uninsured/underinsured patient population. The pilot implementation focuses on diabetes management. In this paper, we describe the system's architecture and features.

Under the radar: community safety nets for AIDS-affected households in sub-Saharan Africa.

PubMed

Foster, G

2007-01-01

Safety nets are mechanisms to mitigate the effects of poverty on vulnerable households during times of stress. In sub-Saharan Africa, extended families, together with communities, are the most effective responses enabling access to support for households facing crises. This paper reviews literature on informal social security systems in sub-Saharan Africa, analyses changes taking place in their functioning as a result of HIV/AIDS and describes community safety net components including economic associations, cooperatives, loan providers, philanthropic groups and HIV/AIDS initiatives. Community safety nets target households in greatest need, respond rapidly to crises, are cost efficient, based on local needs and available resources, involve the specialized knowledge of community members and provide financial and psycho-social support. Their main limitations are lack of material resources and reliance on unpaid labour of women. Changes have taken place in safety net mechanisms because of HIV/AIDS, suggesting the resilience of communities rather than their impending collapse. Studies are lacking that assess the value of informal community-level transfers, describe how safety nets assist the poor or analyse modifications in response to HIV/AIDS. The role of community safety nets remains largely invisible under the radar of governments, non-governmental organizations and international bodies. External support can strengthen this system of informal social security that provides poor HIV/AIDS-affected households with significant support.

29 CFR 1926.105 - Safety nets.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 8 2010-07-01 2010-07-01 false Safety nets. 1926.105 Section 1926.105 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR (CONTINUED) SAFETY AND HEALTH REGULATIONS FOR CONSTRUCTION Personal Protective and Life Saving Equipment § 1926.105...

Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California

PubMed Central

McHugh, Matthew D; Brooks Carthon, Margo; Sloane, Douglas M; Wu, Evan; Kelly, Lesly; Aiken, Linda H

2012-01-01

Context California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care—safety-net hospitals—remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals. Methods We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals. Findings The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (−0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant. Conclusions California's mandate improved staffing for all hospitals, including safety-net hospitals

Small town health care safety nets: report on a pilot study.

PubMed

Taylor, Pat; Blewett, Lynn; Brasure, Michelle; Call, Kathleen Thiede; Larson, Eric; Gale, John; Hagopian, Amy; Hart, L Gary; Hartley, David; House, Peter; James, Mary Katherine; Ricketts, Thomas

2003-01-01

Very little is known about the health care safety net in small towns, especially in towns where there is no publicly subsidized safety-net health care. This pilot study of the primary care safety net in 7 such communities was conducted to start building knowledge about the rural safety net. Interviews were conducted and secondary data collected to assess the community need for safety-net care, the health care safety-net role of public officials, and the availability of safety-net care at private primary care practices and its financial impact on these practices. An estimated 20% to 40% of the people in these communities were inadequately insured and needed access to affordable health care, and private primary care practices in most towns played an important role in making primary care available to them. Most of the physician practices were owned or subsidized by a hospital or regional network, though not explicitly to provide charity care. It is likely this ownership or support enabled the practices to sustain a higher level of charity care than would have been possible otherwise. In the majority of communities studied, the leading public officials played no role in ensuring access to safety-net care. State and national government policy makers should consider subsidy programs for private primary care practices that attempt to meet the needs of the inadequately insured in the many rural communities where no publicly subsidized primary safety-net care is available. Subsidies should be directed to physicians in primary care shortage areas who provide safety-net care; this will improve safety-net access and, at the same time, improve physician retention by bolstering physician incomes. Options include enhanced Medicare physician bonuses and grants or tax credits to support income-related sliding fee scales.

Safety-net providers in some US communities have increasingly embraced coordinated care models.

PubMed

Cunningham, Peter; Felland, Laurie; Stark, Lucy

2012-08-01

Safety-net organizations, which provide health services to uninsured and low-income people, increasingly are looking for ways to coordinate services among providers to improve access to and quality of care and to reduce costs. In this analysis, a part of the Community Tracking Study, we examined trends in safety-net coordination activities from 2000 to 2010 within twelve communities in the United States and found a notable increase in such activities. Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. We also identified key attributes of safety-net coordinated care systems, such as reliance on a medical home for meeting patients' primary care needs, and lingering challenges to safety-net integration, such as competition among hospitals and community health centers for Medicaid patients.

Association of emergency department length of stay with safety net status

PubMed Central

Fee, Christopher; Burstin, Helen; Maselli, Judith H.; Hsia, Renee Y.

2013-01-01

Context Performance measures, particularly pay-for-performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. Objective Describe emergency department (ED) compliance with proposed length of stay measures for admissions (8 hours) and discharges, transfers, and observations (4 hours) by safety-net status. Design, Setting, and Participants 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (CDC definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34,134 patient records. Visits were excluded for age <18, missing length of stay, or dispositions of: missing, “other”, left against medical advice, dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariate analyses determined associations with length of stay measure compliance. Results are presented as odds ratios with 95% confidence intervals. Main Outcome ED length of stay measure compliance by disposition and safety-net status. Results 27.87% of the 2008 ED visits from the weighted NHAMCS dataset were excluded leaving 72.13% for analysis. Of these, 42.3% were to safety-net and 57.7% to non-safety-net EDs. The median (interquartile range) ED lengths of stay for safety-net and non-safety-net ED visits respectively are as follows: 269 minutes (178, 397) and 281 (178, 401) for admissions, 156 (95, 239) and 148 (88, 238) for discharges, 355 (221, 675) and 298 (195, 440) for observations, and 235 (155, 378) and 239 (142, 368) for transfers. Safety-net status is not independently associated with compliance with ED length of stay measures for admissions (OR 0.83, [95%CI 0.52, 1.34]), discharges (1.03 [0

Caught in the competitive crossfire: safety-net providers balance margin and mission in a profit-driven health care market.

PubMed

Cunningham, Peter J; Bazzoli, Gloria J; Katz, Aaron

2008-01-01

This paper describes how intensifying competitive pressures in the health system are simultaneously driving increased demand for safety-net care and taxing safety-net providers' ability to maintain the mission of serving all, regardless of ability to pay. Although safety-net providers adapted to previous challenges arising from managed care, health system pressures have been more intense and more generalized across different sectors in recent years than in the past. Providers are adopting some of the same strategies being used in the private sector to attract higher-paying patients and changing their "image" as a safety-net provider.

How do general practitioners use 'safety netting' in acutely ill children?

PubMed

Bertheloot, Karen; Deraeve, Pieterjan; Vermandere, Mieke; Aertgeerts, Bert; Lemiengre, Marieke; De Sutter, An; Buntinx, Frank; Verbakel, Jan Y

2016-01-01

'Safety netting' advice allows general practitioners (GPs) to cope with diagnostic uncertainty in primary care. It informs patients on 'red flag' features and when and how to seek further help. There is, however, insufficient evidence to support useful choices regarding 'safety netting' procedures. To explore how GPs apply 'safety netting' in acutely ill children in Flanders. We designed a qualitative study consisting of semi-structured interviews with 37 GPs across Flanders. Two researchers performed qualitative analysis based on grounded theory components. Although unfamiliar with the term, GPs perform 'safety netting' in every acutely ill child, guided by their intuition without the use of specific guidelines. They communicate 'red flag' features, expected time course of illness and how and when to re-consult and try to tailor their advice to the context, patient and specific illness. Overall, GPs perceive 'safety netting' as an important element of the consultation, acknowledging personal and parental limitations, such as parents' interpretation of their advice. GPs do not feel a need for any form of support in the near future. GPs apply 'safety netting' intuitively and tailor the content. Further research should focus on the impact of 'safety netting' on morbidity and how the advice is conveyed to parents.

Addressing the High Costs of Pancreaticoduodenectomy at Safety-Net Hospitals.

PubMed

Go, Derek E; Abbott, Daniel E; Wima, Koffi; Hanseman, Dennis J; Ertel, Audrey E; Chang, Alex L; Shah, Shimul A; Hoehn, Richard S

2016-10-01

Safety-net hospitals care for vulnerable patients, providing complex surgery at increased costs. These hospitals are at risk due to changing health care reimbursement policies and demand for better value in surgical care. To model different techniques for reducing the cost of complex surgery performed at safety-net hospitals. Hospitals performing pancreaticoduodenectomy (PD) were queried from the University HealthSystem Consortium database (January 1, 2009, to December 31, 2013) and grouped according to safety-net burden. A decision analytic model was constructed and populated with clinical and cost data. Sensitivity analyses were then conducted to determine how changes in the management or redistribution of patients between hospital groups affected cost. Overall cost per patient after PD. During the 5 years of the study, 15 090 patients underwent PD. Among safety-net hospitals, low-burden hospitals (LBHs), medium-burden hospitals (MBHs), and high-burden hospitals (HBHs) treated 4220 (28.0%), 9505 (63.0%), and 1365 (9.0%) patients, respectively. High-burden hospitals had higher rates of complications or comorbidities and more patients with increased severity of illness. Perioperative mortality was twice as high at HBHs (3.7%) than at LBHs (1.6%) and MBHs (1.7%) (P < .001). In the base case, when all clinical and cost data were considered, PD at HBHs cost $35 303 per patient, 30.1% and 36.2% higher than at MBHs ($27 130) and LBHs ($25 916), respectively. Reducing perioperative complications or comorbidities by 50% resulted in a cost reduction of up to $4607 for HBH patients, while reducing mortality rates had a negligible effect. However, redistribution of HBH patients to LBHs and MBHs resulted in significantly more cost savings of $9155 per HBH patient, or $699 per patient overall. Safety-net hospitals performing PD have inferior outcomes and higher costs, and improving perioperative outcomes may have a nominal effect on reducing these costs

Testing Electronic Algorithms to Create Disease Registries in a Safety Net System

PubMed Central

Hanratty, Rebecca; Estacio, Raymond O.; Dickinson, L. Miriam; Chandramouli, Vijayalaxmi; Steiner, John F.; Havranek, Edward P.

2008-01-01

Electronic disease registries are a critical feature of the chronic disease management programs that are used to improve the care of individuals with chronic illnesses. These registries have been developed primarily in managed care settings; use in safety net institutions—organizations whose mission is to serve the uninsured and underserved—has not been described. We sought to assess the feasibility of developing disease registries from electronic data in a safety net institution, focusing on hypertension because of its importance in minority populations. We compared diagnoses obtained from algorithms utilizing electronic data, including laboratory and pharmacy records, against diagnoses derived from chart review. We found good concordance between diagnoses identified from electronic data and those identified by chart review, suggesting that registries of patients with chronic diseases can be developed outside the setting of closed panel managed care organizations. PMID:18469416

Innovation in the safety net: integrating community health centers through accountable care.

PubMed

Lewis, Valerie A; Colla, Carrie H; Schoenherr, Karen E; Shortell, Stephen M; Fisher, Elliott S

2014-11-01

Safety net primary care providers, including as community health centers, have long been isolated from mainstream health care providers. Current delivery system reforms such as Accountable Care Organizations (ACOs) may either reinforce the isolation of these providers or may spur new integration of safety net providers. This study examines the extent of community health center involvement in ACOs, as well as how and why ACOs are partnering with these safety net primary care providers. Mixed methods study pairing the cross-sectional National Survey of ACOs (conducted 2012 to 2013), followed by in-depth, qualitative interviews with a subset of ACOs that include community health centers (conducted 2013). One hundred and seventy-three ACOs completed the National Survey of ACOs. Executives from 18 ACOs that include health centers participated in in-depth interviews, along with leadership at eight community health centers participating in ACOs. Key survey measures include ACO organizational characteristics, care management and quality improvement capabilities. Qualitative interviews used a semi-structured interview guide. Interviews were recorded and transcribed, then coded for thematic content using NVivo software. Overall, 28% of ACOs include a community health center (CHC). ACOs with CHCs are similar to those without CHCs in organizational structure, care management and quality improvement capabilities. Qualitative results showed two major themes. First, ACOs with CHCs typically represent new relationships or formal partnerships between CHCs and other local health care providers. Second, CHCs are considered valued partners brought into ACOs to expand primary care capacity and expertise. A substantial number of ACOs include CHCs. These results suggest that rather than reinforcing segmentation of safety net providers from the broader delivery system, the ACO model may lead to the integration of safety net primary care providers.

Organizational Factors Affect Safety-Net Hospitals' Breast Cancer Treatment Rates.

PubMed

Bickell, Nina A; Moss, Alexandra DeNardis; Castaldi, Maria; Shah, Ajay; Sickles, Alan; Pappas, Peter; Lewis, Theophilus; Kemeny, Margaret; Arora, Shalini; Schleicher, Lori; Fei, Kezhen; Franco, Rebeca; McAlearney, Ann Scheck

2017-12-01

To identify key organizational approaches associated with underuse of breast cancer care. Nine New York City area safety-net hospitals. Mixed qualitative-quantitative, cross-sectional cohort. We used qualitative comparative analysis (QCA) of key stakeholder interviews, defined organizational "conditions," calibrated conditions, and identified solution pathways. We defined underuse as no radiation after lumpectomy in women <75 years or mastectomy in women with ≥4 positive nodes, or no systemic therapy in women with tumors ≥1 cm. We used hierarchical models to assess organizational and patient factors' impact on underuse. Underuse varied by hospital (8-29 percent). QCA found lower underuse sites designated individuals to track and follow-up no-shows; shared clinical information during handoffs; had fully integrated electronic medical records enabling transfer of responsibility across specialties; had strong system support; allocated resources to cancer clinics; had a patient-centered culture paying close organizational attention to clinic patients. High underuse sites lacked these characteristics. Multivariate modeling found that hospitals with strong approaches to follow-up had low underuse rates (RR = 0.28; 0.08-0.95); individual patient characteristics were not significant. At safety-net hospitals, underuse of needed cancer therapies is associated with organizational approaches to track and follow-up treatment. Findings provide varying approaches to safety nets to improve cancer care delivery. © Health Research and Educational Trust.

Implementation of an integrated computerized prescriber order-entry system for chemotherapy in a multisite safety-net health system.

PubMed

Chung, Clement; Patel, Shital; Lee, Rosetta; Fu, Lily; Reilly, Sean; Ho, Tuyet; Lionetti, Jason; George, Michael D; Taylor, Pam

2018-03-15

The development of a computerized prescriber order-entry (CPOE) system for chemotherapy in a multisite safety-net health system and the challenges to its successful implementation are described. Before CPOE for chemotherapy was first implemented and embedded in the electronic medical record system of Harris Health System (HHS), pharmacy personnel relied on regimen-specific preprinted order sets. However, due to differences in practice styles and workflow logistics, the paper orders across the 3 facilities were mostly site specific, with varying clinical content. Many of these order sets had not been approved by the oncology subcommittee. In addition, disparities in clinical knowledge and lack of communication contributed to inconsistencies in order set development. Led by medical directors from medical oncology departments at the 3 facilities, pharmacy administrators, and information technology representatives, HHS committed resources to supporting the adoption and use of a CPOE system for chemotherapy. Five practical lessons of broad applicability have been learned: engagement of interprofessional stakeholders, optimization of workflow before CPOE implementation, requirement of verification tool for CPOE, consolidation of protocols, and commitment to ongoing training and support. Evaluation of the CPOE system demonstrated a systemwide reduction in medication errors by 75% ( p < 0.05). Satisfaction with the CPOE system varied among sites and was unchanged institutionwide 6 months after the CPOE implementation. The development and implementation of CPOE for chemotherapy at a multisite safety-net health system created opportunities to optimize patient care and reduce variations through interprofessional collaborations. Initial evaluation suggested that CPOE reduced the medication-order error rate and improved user satisfaction in 1 of 3 facilities. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Social Security: Strengthening a Vital Safety Net for Latinos

ERIC Educational Resources Information Center

Cruz, Jeff

2012-01-01

Since 1935, Social Security has provided a vital safety net for millions of Americans who cannot work because of age or disability. This safety net has been especially critical for Americans of Latino decent, who number more than 50 million or nearly one out of every six Americans. Social Security is critical to Latinos because it is much more…

Opportunities for improved diabetes care among patients of safety net practices: a safety net providers' strategic alliance study.

PubMed

Reichsman, Ann; Werner, James; Cella, Peggi; Bobiak, Sarah; Stange, Kurt C

2009-01-01

To identify barriers and opportunities for quality diabetes care in safety net practices. In 3 federally qualified health centers and 1 free clinic, 19 primary care clinicians profiled patient and visit characteristics and quality of care measures for 181 consecutive visits by adult type 2 diabetic patients. Open-ended questions assessed patient and clinician perception of barriers to diabetes care and patient report of enabling factors. A multidisciplinary team identified themes from open-ended responses. Logistic regression analyses assessed the association of the identified barriers/enablers with 2 measures of quality care: glycosylated hemoglobin and prophylactic aspirin use. Ranked barriers noted by patients included adherence (40%), financial/insurance (23%), and psychosocial (13%) factors. Clinicians ranked systemic factors, including financial/ insurance (32%) and cultural/psychosocial (29%) factors, as important to adherence (29%) in determining quality diabetes care. Patients reported dietary and medical adherence (37%) and family/health care worker support (17%) as helpful factors. Among 175 patients with available data, glycosylated hemoglobin levels were associated with patient report of financial/insurance factors both as a barrier when visits and medications were unaffordable and as an opportunity when free or low-cost medications and services were provided. Patients' adherence with aspirin prophylaxis was strongly associated with African American race, prior prescription of aspirin and distribution of aspirin at the practice site (p<.001). Patients were less likely than clinicians to identify systemic and contextual factors contributing to poor diabetes care. From the front line's perspective, enabling patient self-management and systemic support is a target for improving diabetes care in safety net practices.

Performance Measurement and Target-Setting in California's Safety Net Health Systems.

PubMed

Hemmat, Shirin; Schillinger, Dean; Lyles, Courtney; Ackerman, Sara; Gourley, Gato; Vittinghoff, Eric; Handley, Margaret; Sarkar, Urmimala

Health policies encourage implementing quality measurement with performance targets. The 2010-2015 California Medicaid waiver mandated quality measurement and reporting. In 2013, California safety net hospitals participating in the waiver set a voluntary performance target (the 90th percentile for Medicare preferred provider organization plans) for mammography screening and cholesterol control in diabetes. They did not reach the target, and the difference-in-differences analysis suggested that there was no difference for mammography ( P = .39) and low-density lipoprotein control ( P = .11) performance compared to measures for which no statewide quality improvement initiative existed. California's Medicaid waiver was associated with improved performance on a number of metrics, but this performance was not attributable to target setting on specific health conditions. Performance may have improved because of secular trends or systems improvements related to waiver funding. Relying on condition-specific targets to measure performance may underestimate improvements and disadvantage certain health systems. Achieving ambitious targets likely requires sustained fiscal, management, and workforce investments.

Facing the Recession: How Did Safety-Net Hospitals Fare Financially Compared with Their Peers?

PubMed Central

Reiter, Kristin L; Jiang, H Joanna; Wang, Jia

2014-01-01

Objective To examine the effect of the recession on the financial performance of safety-net versus non-safety-net hospitals. Data Sources/Study Setting Agency for Healthcare Research and Quality Hospital Cost and Utilization Project State Inpatient Databases, Medicare Cost Reports, American Hospital Association Annual Survey, InterStudy, and Area Health Resource File. Study Design Retrospective, longitudinal panel of hospitals, 2007–2011. Safety-net hospitals were identified using percentage of patients who were Medicaid or uninsured. Generalized estimating equations were used to estimate average effects of the recession on hospital operating and total margins, revenues and expenses in each year, 2008–2011, comparing safety-net with non-safety-net hospitals. Data Collection/Extraction Methods 1,453 urban, nonfederal, general acute hospitals in 32 states with complete data. Principal Findings Safety-net hospitals, as identified in 2007, had lower operating and total margins. The gap in operating margin between safety-net and non-safety-net hospitals was sustained throughout the recession; however, total margin was more negatively affected for non-safety-net hospitals in 2008. Higher percentages of Medicaid and uninsured patients were associated with lower revenue in private hospitals in all years, and lower revenue and expenses in public hospitals in 2011. Conclusions Safety-net hospitals may not be disproportionately vulnerable to macro-economic fluctuations, but their significantly lower margins leave less financial cushion to weather sustained financial pressure. PMID:25220012

Comparing the financial condition of Texas hospitals using a novel definition for the safety net.

PubMed

Stauffer, Brett D; Amarasingham, Ruben; Pickens, Sue; Anderson, Ron J

2008-08-01

Lack of health insurance is more prevalent in the state of Texas than in the rest of the country. To get necessary medical care, uninsured Texans must rely on safety net hospitals. Economic turmoil and fluctuating public support routinely threaten the financial stability of these hospitals. Safety net hospitals must be identified to craft public policy solutions that ensure their viability. In this paper, we propose a new method to identify these hospitals by incorporating criteria established previously by economists with additional measures of community value. Our data indicate that safety net hospitals continue to face financial challenges. Texas will need to move forward along several policy fronts to preserve this vital system of care.

Assessment of Oropharyngeal and Laryngeal Cancer Treatment Delay in a Private and Safety Net Hospital System.

PubMed

Perlow, Haley K; Ramey, Stephen J; Silver, Ben; Kwon, Deukwoo; Chinea, Felix M; Samuels, Stuart E; Samuels, Michael A; Elsayyad, Nagy; Yechieli, Raphael

2018-04-01

Objective To examine the impact of treatment setting and demographic factors on oropharyngeal and laryngeal cancer time to treatment initiation (TTI). Study Design Retrospective case series. Setting Safety net hospital and adjacent private academic hospital. Subjects and Methods Demographic, staging, and treatment details were retrospectively collected for 239 patients treated from January 1, 2014, to June 30, 2016. TTI was defined as days between diagnostic biopsy and initiation of curative treatment (defined as first day of radiotherapy [RT], surgery, or chemotherapy). Results On multivariable analysis, safety net hospital treatment (vs private academic hospital treatment), initial diagnosis at outside hospital, and oropharyngeal cancer (vs laryngeal cancer) were all associated with increased TTI. Surgical treatment, severe comorbidity, and both N1 and N2 status were associated with decreased TTI. Conclusion Safety net hospital treatment was associated with increased TTI. No differences in TTI were found when language spoken and socioeconomic status were examined in the overall cohort.

Vaccine adverse events in a safety net healthcare system and a managed care organization.

PubMed

Narwaney, Komal J; Breslin, Kristin; Ross, Colleen A; Shoup, Jo Ann; Wain, Kris F; Weintraub, Eric S; McNeil, Michael M; Hambidge, Simon J

2017-03-01

The Institute of Medicine, in a 2013 report, recommended that the Vaccine Safety Datalink (VSD) expand collaborations to include more diversity in the study population. Kaiser Permanente Colorado (KPCO), an established VSD site, partnered with Denver Health (DH), an integrated safety net healthcare system, to demonstrate the feasibility of integrating DH data within the VSD. Prior to incorporating the data, we examined the identification of specific vaccine associated adverse events (VAEs) in these two distinct healthcare systems. We conducted retrospective cohort analyses within KPCO and DH to compare select VAEs between the two populations. We examined the following associations between January 1, 2004 and December 31, 2013: Measles, Mumps, and Rubella (MMR) vaccine and febrile seizures in children 2years and younger, intussusception after rotavirus vaccine in infants 4-34weeks, syncope after adolescent vaccines (Tetanus, Diphtheria, acellular Pertussis; Meningococcal and Human Papillomavirus) in adolescents 13-17years and medically attended local reactions after pneumococcal polysaccharide (PPSV23) vaccine in adults 65years and older. Both sites used similar data procurement methods and chart review processes. For seizures after MMR vaccine (KPCO - 3.15vs. DH - 2.97/10,000 doses) and syncope after all adolescent vaccines (KPCO - 3.0vs. DH - 2.37/10,000 doses), the chart confirmed rates were comparable at the two sites. However, for medically attended local reactions after PPSV23, there were differences in chart confirmed rates between the sites (KPCO - 31.65vs. DH - 14.90/10,000 doses). For intussusception after rotavirus vaccine, the number of cases was too low to make a valid comparison (KPCO - 0vs. DH - 0.13/10,000 doses). We demonstrated that data on important targeted VAEs can be captured at DH and rates appear similar to those at KPCO. Work is ongoing on the optimal approach to assimilate DH data as a potential safety net healthcare system in the VSD

California safety-net hospitals likely to be penalized by ACA value, readmission, and meaningful-use programs.

PubMed

Gilman, Matlin; Adams, E Kathleen; Hockenberry, Jason M; Wilson, Ira B; Milstein, Arnold S; Becker, Edmund R

2014-08-01

The Affordable Care Act includes provisions to increase the value obtained from health care spending. A growing concern among health policy experts is that new Medicare policies designed to improve the quality and efficiency of hospital care, such as value-based purchasing (VBP), the Hospital Readmissions Reduction Program (HRRP), and electronic health record (EHR) meaningful-use criteria, will disproportionately affect safety-net hospitals, which are already facing reduced disproportionate-share hospital (DSH) payments under both Medicare and Medicaid. We examined hospitals in California to determine whether safety-net institutions were more likely than others to incur penalties under these programs. To assess quality, we also examined whether mortality outcomes were different at these hospitals. Our study found that compared to non-safety-net hospitals, safety-net institutions had lower thirty-day risk-adjusted mortality rates in the period 2009-11 for acute myocardial infarction, heart failure, and pneumonia and marginally lower adjusted Medicare costs. Nonetheless, safety-net hospitals were more likely than others to be penalized under the VBP program and the HRRP and more likely not to meet EHR meaningful-use criteria. The combined effects of Medicare value-based payment policies on the financial viability of safety-net hospitals need to be considered along with DSH payment cuts as national policy makers further incorporate performance measures into the overall payment system. Project HOPE—The People-to-People Health Foundation, Inc.

Predictors of Payer Mix and Financial Performance Among Safety Net Hospitals Prior to the Affordable Care Act.

PubMed

Sommers, Benjamin D; Stone, Juliana; Kane, Nancy

2016-01-01

The objective of this study was to use audited hospital financial statements to identify predictors of payer mix and financial performance in safety net hospitals prior to the Affordable Care Act. We analyzed the 2010 financial statements of 98 large, urban safety net hospital systems in 34 states, supplemented with data on population demographics, hospital features, and state policies. We used multivariate regression to identify independent predictors of three outcomes: 1) Medicaid-reliant payer mix (hospitals for which at least 25% of hospital days are paid for by Medicaid); 2) safety net revenue-to-cost ratio (Medicaid and Medicare Disproportionate Share Hospital payments and local government transfers, divided by charity care costs and Medicaid payment shortfall); and 3) operating margin. Medicaid-reliant payer mix was positively associated with more inclusive state Medicaid eligibility criteria and more minority patients. More inclusive Medicaid eligibility and higher Medicaid reimbursement rates positively predicted safety net revenue-to-cost ratio. University governance was the strongest positive predictor of operating margin. Safety net hospital financial performance varied considerably. Academic hospitals had higher operating margins, while more generous Medicaid eligibility and reimbursement policies improved hospitals' ability to recoup costs. Institutional and state policies may outweigh patient demographics in the financial health of safety net hospitals. © The Author(s) 2015.

Understanding Medicare Hospital Readmission Rates And Differing Penalties Between Safety-Net And Other Hospitals.

PubMed

Sheingold, Steven H; Zuckerman, Rachael; Shartzer, Adele

2016-01-01

Since the implementation of Medicare's Hospital Readmissions Reduction Program in 2012, concerns have been raised about the effect its payment penalties for excess readmissions may have on safety-net hospitals. A number of policy solutions have been proposed to ensure that the program does not unfairly penalize safety-net institutions, which treat a disproportionate number of patients with low socioeconomic status. We examined the extent to which the program's current risk-adjustment factors, measures of patient socioeconomic status, and hospital-level factors explain the observed differences in readmission rates between safety-net and other hospitals. Our analyses suggest that patient socioeconomic status can explain some of the difference in readmission rates but that unmeasured factors such as hospitals' performance may also play a role. We also found that safety-net hospitals have experienced only slightly higher readmission penalties under the program than other hospitals have. Together, these findings suggest the need for a careful evaluation of policy alternatives that factor socioeconomic status into penalty calculations for excess readmissions to determine whether such alternatives could have a significant impact on penalties while remaining consistent with overall objectives for delivery system transformation. Project HOPE—The People-to-People Health Foundation, Inc.

GPs' understanding and practice of safety netting for potential cancer presentations: a qualitative study in primary care.

PubMed

Evans, Julie; Ziebland, Sue; MacArtney, John I; Bankhead, Clare R; Rose, Peter W; Nicholson, Brian D

2018-05-08

Safety netting is a diagnostic strategy used in UK primary care to ensure patients are monitored until their symptoms or signs are explained. Despite being recommended in cancer diagnosis guidelines, little evidence exists about which components are effective and feasible in modern-day primary care. To understand the reality of safety netting for cancer in contemporary primary care. A qualitative study of GPs in Oxfordshire primary care. In-depth interviews with a purposive sample of 25 qualified GPs were undertaken. Interviews were recorded and transcribed verbatim, and analysed thematically using constant comparison. GPs revealed uncertainty about which aspects of clinical practice are considered safety netting. They use bespoke personal strategies, often developed from past mistakes, without knowledge of their colleagues' practice. Safety netting varied according to the perceived risk of cancer, the perceived reliability of each patient to follow advice, GP working patterns, and time pressures. Increasing workload, short appointments, and a reluctance to overburden hospital systems or create unnecessary patient anxiety have together led to a strategy of selective active follow-up of patients perceived to be at higher risk of cancer or less able to act autonomously. This left patients with low-risk-but-not-no-risk symptoms of cancer with less robust or absent safety netting. GPs would benefit from clearer guidance on which aspects of clinical practice contribute to effective safety netting for cancer. Practice systems that enable active follow-up of patients with low-risk-but-not-no-risk symptoms, which could represent malignancy, could reduce delays in cancer diagnosis without increasing GP workload. © British Journal of General Practice 2018.

Implementation and Evaluation of the Safety Net Specialty Care Program in the Denver Metropolitan Area

PubMed Central

Fort, Meredith P; Namba, Lynnette M; Dutcher, Sarah; Copeland, Tracy; Bermingham, Neysa; Fellenz, Chris; Lantz, Deborah; Reusch, John J; Bayliss, Elizabeth A

2017-01-01

Objectives: In response to limited access to specialty care in safety-net settings, an integrated delivery system and three safety-net organizations in the Denver, CO, metropolitan area launched a unique program in 2013. The program offers safety-net providers the option to electronically consult with specialists. Uninsured patients may be seen by specialists in office visits for a defined set of services. This article describes the program, identifies aspects that have worked well and areas that need improvement, and offers lessons learned. Methods: We quantified electronic consultations (e-consults) between safety-net clinicians and specialists, and face-to-face specialist visits between May 2013 and December 2014. We reviewed and categorized all e-consults from November and December 2014. In 2015, we interviewed 21 safety-net clinicians and staff, 12 specialists, and 10 patients, and conducted a thematic analysis to determine factors facilitating and limiting optimal program use. Results: In the first 20 months of the program, safety-net clinicians at 23 clinics made 602 e-consults to specialists, and 81 patients received face-to-face specialist visits. Of 204 primary care clinicians, 103 made e-consults; 65 specialists participated in the program. Aspects facilitating program use were referral case managers’ involvement and the use of clear, concise questions in e-consults. Key recommendations for process improvement were to promote an understanding of the different health care contexts, support provider-to-provider communication, facilitate hand-offs between settings, and clarify program scope. Conclusion: Participants perceived the program as responsive to their needs, yet opportunities exist for continued uptake and expansion. Communitywide efforts to assess and address needs remain important. PMID:28241908

Patient portal readiness among postpartum patients in a safety net setting.

PubMed

Wieland, Daryl; Gibeau, Anne; Dewey, Caitlin; Roshto, Melanie; Frankel, Hilary

2017-07-05

Maternity patients interact with the healthcare system over an approximately ten-month interval, requiring multiple visits, acquiring pregnancy-specific education, and sharing health information among providers. Many features of a web-based patient portal could help pregnant women manage their interactions with the healthcare system; however, it is unclear whether pregnant women in safety-net settings have the resources, skills or interest required for portal adoption. In this study of postpartum patients in a safety net hospital, we aimed to: (1) determine if patients have the technical resources and skills to access a portal, (2) gain insight into their interest in health information, and (3) identify the perceived utility of portal features and potential barriers to adoption. We developed a structured questionnaire to collect demographics from postpartum patients and measure use of technology and the internet, self-reported literacy, interest in health information, awareness of portal functions, and perceived barriers to use. The questionnaire was administered in person to women in an inpatient setting. Of the 100 participants surveyed, 95% reported routine internet use and 56% used it to search for health information. Most participants had never heard of a patient portal, yet 92% believed that the portal functions were important. The two most appealing functions were to check results and manage appointments. Most participants in this study have the required resources such as a device and familiarity with the internet to access a patient portal including an interest in interacting with a healthcare institution via electronic means. Pregnancy is a critical episode of care where active engagement with the healthcare system can influence outcomes. Healthcare systems and portal developers should consider ways to tailor a portal to address the specific health needs of a maternity population including those in a safety net setting.

Low-Value Medical Services in the Safety-Net Population

PubMed Central

Linder, Jeffrey A.; Clark, Cheryl R.; Sommers, Benjamin D.

2017-01-01

Importance National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined. Objective To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non–safety-net physicians. Design, Setting, and Participants This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics. Exposures Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non–safety-net physicians (seeing 1%-10%). Main Outcomes and Measures Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit. Results Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high

Trends in readmission rates for safety net hospitals and non-safety net hospitals in the era of the US Hospital Readmission Reduction Program: a retrospective time series analysis using Medicare administrative claims data from 2008 to 2015.

PubMed

Salerno, Amy M; Horwitz, Leora I; Kwon, Ji Young; Herrin, Jeph; Grady, Jacqueline N; Lin, Zhenqiu; Ross, Joseph S; Bernheim, Susannah M

2017-07-13

To compare trends in readmission rates among safety net and non-safety net hospitals under the US Hospital Readmission Reduction Program (HRRP). A retrospective time series analysis using Medicare administrative claims data from January 2008 to June 2015. We examined 3254 US hospitals eligible for penalties under the HRRP, categorised as safety net or non-safety net hospitals based on the hospital's proportion of patients with low socioeconomic status. Admissions for Medicare fee-for-service patients, age ≥65 years, discharged alive, who had a valid five-digit zip code and did not have a principal discharge diagnosis of cancer or psychiatric illness were included, for a total of 52 516 213 index admissions. Mean hospital-level, all-condition, 30-day risk-adjusted standardised unplanned readmission rate, measured quarterly, along with quarterly rate of change, and an interrupted time series examining: April-June 2010, after HRRP was passed, and October-December 2012, after HRRP penalties were implemented. 58.0% (SD 15.3) of safety net hospitals and 17.1% (SD 10.4) of non-safety net hospitals' patients were in the lowest quartile of socioeconomic status. The mean safety net hospital standardised readmission rate declined from 17.0% (SD 3.7) to 13.6% (SD 3.6), whereas the mean non-safety net hospital declined from 15.4% (SD 3.0) to 12.7% (SD 2.5). The absolute difference in rates between safety net and non-safety net hospitals declined from 1.6% (95% CI 1.3 to 1.9) to 0.9% (0.7 to 1.2). The quarterly decline in standardised readmission rates was 0.03 percentage points (95% CI 0.03 to 0.02, p<0.001) greater among safety net hospitals over the entire study period, and no differential change among safety net and non-safety net hospitals was found after either HRRP was passed or penalties enacted. Since HRRP was passed and penalties implemented, readmission rates for safety net hospitals have decreased more rapidly than those for non-safety net hospitals. © Article

How five leading safety-net hospitals are preparing for the challenges and opportunities of health care reform.

PubMed

Coughlin, Teresa A; Long, Sharon K; Sheen, Edward; Tolbert, Jennifer

2012-08-01

Safety-net hospitals will continue to play a critical role in the US health care system, as they will need to care for the more than twenty-three million people who are estimated to remain uninsured after the Affordable Care Act is implemented. Yet such hospitals will probably have less federal and state support for uncompensated care. At the same time, safety-net hospitals will need to reposition themselves in the marketplace to compete effectively for newly insured people who will have a choice of providers. We examine how five leading safety-net hospitals have begun preparing for reform. Building upon strong organizational attributes such as health information technology and system integration, the study hospitals' preparations include improving the efficiency and quality of care delivery, retaining current and attracting new patients, and expanding the medical home model.

The evolving role and care management approaches of safety-net Medicaid managed care plans.

PubMed

Gusmano, Michael K; Sparer, Michael S; Brown, Lawrence D; Rowe, Catherine; Gray, Bradford

2002-12-01

This article provides new empirical data about the viability and the care management activities of Medicaid managed-care plans sponsored by provider organizations that serve Medicaid and other low-income populations. Using survey and case study methods, we studied these "safety-net" health plans in 1998 and 2000. Although the number of safety-net plans declined over this period, the surviving plans were larger and enjoying greater financial success than the plans we surveyed in 1998. We also found that, based on a partnership with providers, safety-net plans are moving toward more sophisticated efforts to manage the care of their enrollees. Our study suggests that, with supportive state policies, safety-net plans are capable of remaining viable. Contracting with safety-net plans may not be an efficient mechanism for enabling Medicaid recipients to "enter the mainstream of American health care," but it may provide states with an effective way to manage and coordinate the care of Medicaid recipients, while helping to maintain the health care safety-net for the uninsured.

Erosion in the Healthcare Safety Net: Impacts on Different Population Groups.

PubMed

Mobley, Lee; Kuo, Tzy-Mey; Bazzoli, Gloria J

2011-03-30

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990-2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4-5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs.

Erosion in the Healthcare Safety Net: Impacts on Different Population Groups

PubMed Central

Mobley, Lee; Kuo, Tzy-Mey; Bazzoli, Gloria J.

2011-01-01

Safety net hospitals (SNHs) have played a critical role in the U.S. health system providing access to health care for vulnerable populations, in particular the Medicaid and uninsured populations. However, little research has examined how access for these populations changes when contraction of the safety net occurs. Institutional policies, such as hospital closure or ownership conversion, could affect the supply of minority health care providers, thus exacerbating disparities in outcomes. We use multilevel logistic modeling of person-level hospital discharge data to examine the effects of contractions in the California safety net over the period of 1990–2000 on access to care as measured by changes in ambulatory care sensitive condition (ACSC) admissions, using geographic methods to characterize proximity to a contraction event. We found that presence of a contraction event was associated with a statistically significant increase in the predicted probability of impeded access, with an increase of about 1% for Medicaid-insured populations and about 4–5% for the uninsured. The Medicaid-insured group also maintained the highest rates of ACSC admissions over time, suggesting persistent access problems for this vulnerable group. This research is timely given continued budget problems in many states, where rising unemployment has increased the number of Medicaid enrollees by 6 million and uninsured individuals by 1.5 million, increasing pressure on remaining SNHs. PMID:21892377

From striving to thriving: systems thinking, strategy, and the performance of safety net hospitals.

PubMed

Clark, Jonathan; Singer, Sara; Kane, Nancy; Valentine, Melissa

2013-01-01

Safety net hospitals (SNH) have, on average, experienced declining financial margins and faced an elevated risk of closure over the past decade. Despite these challenges, not all SNHs are weakening and some are prospering. These higher-performing SNHs provide substantial care to safety net populations and produce sustainable financial returns. Drawing on the alternative structural positioning and resource-based views, we explore strategic management as a source of performance differences across SNHs. We employ a mixed-method design, blending quantitative and qualitative data and analysis. We measure financial performance using hospital operating margin and quantitatively evaluate its relationship with a limited set of well-defined structural positions. We further evaluate these structures and also explore the internal resources of SNHs based on nine in-depth case studies developed from site visits and extensive interviews. Quantitative results suggest that structural positions alone are not related to performance. Comparative case studies suggest that higher-performing SNH differ in four respects: (1) coordinating patient flow across the care continuum, (2) engaging in partnerships with other providers, (3) managing scope of services, and (4) investing in human capital. On the basis of these findings, we propose a model of strategic action related to systems thinking--the ability to see wholes and interrelationships rather than individual parts alone. Our exploratory findings suggest the need to move beyond generic strategies alone and acknowledge the importance of underlying managerial capabilities. Specifically, our findings suggest that effective strategy is a function of both the internal resources (e.g., managers' systems-thinking capability) and structural positions (e.g., partnerships) of organizations. From this perspective, framing resources and positioning as distinct alternatives misses the nuances of how strategic advantage is actually achieved.

Fostering a Commitment to Quality: Best Practices in Safety-net Hospitals.

PubMed

Hochman, Michael; Briggs-Malonson, Medell; Wilkes, Erin; Bergman, Jonathan; Daskivich, Lauren Patty; Moin, Tannaz; Brook, Ilanit; Ryan, Gery W; Brook, Robert H; Mangione, Carol M

2016-01-01

In 2007, the Martin Luther King, Jr.-Harbor Hospital (MLK-Harbor), which served a large safety-net population in South Los Angeles, closed due to quality challenges. Shortly thereafter, an agreement was made to establish a new hospital, Martin Luther King, Jr. Community Hospital (MLKCH), to serve the unmet needs of the community. To assist the newly appointed MLKCH Board of Directors in building a culture of quality, we conducted a series of interviews with five high-performing hospital systems. In this report, we describe our findings. The hospitals we interviewed achieved a culture of quality by: 1) developing guiding principles that foster quality; 2) hiring and retaining personnel who are stewards of quality; 3) promoting efficient resource utilization; 4) developing a well-organized quality improvement infrastructure; and 5) cultivating integrated, patient-centric care. The institutions highlighted in this report provide important lessons for MLKCH and other safety-net institutions.

Differences in emergency colorectal surgery in Medicaid and uninsured patients by hospital safety net status.

PubMed

Bradley, Cathy J; Dahman, Bassam; Sabik, Lindsay M

2015-02-01

We examined whether safety net hospitals reduce the likelihood of emergency colorectal cancer (CRC) surgery in uninsured and Medicaid-insured patients. If these patients have better access to care through safety net providers, they should be less likely to undergo emergency resection relative to similar patients at non- safety net hospitals. Using population-based data, we estimated the relationship between safety net hospitals, patient insurance status, and emergency CRC surgery. We extracted inpatient admission data from the Virginia Health Information discharge database and matched them to the Virginia Cancer Registry for patients aged 21 to 64 years who underwent a CRC resection between January 1, 1999, and December 31, 2005 (n = 5488). We differentiated between medically defined emergencies and those that originated in the emergency department (ED). For each definition of emergency surgery, we estimated the linear probability models of the effects of being treated at a safety net hospital on the probability of having an emergency resection. Safety net hospitals reduce emergency surgeries among uninsured and Medicaid CRC patients. When defining an emergency resection as those that involved an ED visit, these patients were 15 to 20 percentage points less likely to have an emergency resection when treated in a safety net hospital. Our results suggest that these hospitals provide a benefit, most likely through the access they afford to timely and appropriate care, to uninsured and Medicaid-insured patients relative to hospitals without a safety net mission.

NPOESS C3S Expandability: SafetyNetTM and McMurdo Improvements

NASA Astrophysics Data System (ADS)

Jamilkowski, M. L.; Paciaroni, J.; Pela, F.

2010-12-01

The National Oceanic & Atmospheric Administration (NOAA), Department of Defense (DoD), and National Aeronautics & Space Administration (NASA) are jointly acquiring the next-generation weather & environmental satellite system; the National Polar-orbiting Operational Environmental Satellite System (NPOESS). NPOESS replaces the current NOAA Polar-orbiting Operational Environmental Satellites (POES) and Dod's Defense Meteorological Satellite Program (DMSP). The NPOESS satellites carry a suite of sensors that collect meteorological, oceanographic, climatological, and solar-geophysical observations of the earth, atmosphere, and space. The command & telemetry portion of NPOESS is the Command, Control and Communications Segment (C3S), developed by Raytheon Intelligence & Information Systems. C3S is responsible for managing the overall NPOESS mission from control and status of the space and ground assets to ensuring delivery of timely, high quality data from the Space Segment (SS) to the Interface Data Processing Segment (IDPS) for processing. In addition, the C3S provides the globally distributed ground assets necessary to collect and transport mission, telemetry, and command data between the satellites and the processing locations. The C3S provides all functions required for day-to-day commanding & state-of-health monitoring of the NPP & NPOESS satellites, and delivery of Stored Mission Data (SMD) to each US Weather Central Interface Data Processor (IDP) for data products development and transfer to System subscribers. The C3S also monitors and reports system-wide health and status & data communications with external systems and between NPOESS segments. Two crucial elements of NPOESS C3S expandability are SafetyNetTM and communications improvements to McMurdo Station, Antarctica. SafetyNetTM is a key feature of NPOESS and a vital element of the C3S and Northrop Grumman Aerospace Systems patented data collection architecture. The centerpiece of SafetyNetTM is the system of

Possible consequences of regionally based bundled payments for diabetic amputations for safety net hospitals in Texas.

PubMed

Newhall, Karina; Stone, David; Svoboda, Ryan; Goodney, Philip

2016-12-01

Ongoing health reform in the United States encourages quality-based reimbursement methods such as bundled payments for surgery. The effect of such changes on high-risk procedures is unknown, especially at safety net hospitals. This study quantified the burden of diabetes-related amputation and the potential financial effect of bundled payments at safety net hospitals in Texas. We performed a cross-sectional analysis of diabetic amputation burden and charges using publically available data from Centers for Medicare and Medicaid and the Texas Department of Health from 2008 to 2012. Using hospital referral region (HRR)-level analysis, we categorized the proportion of safety net hospitals within each region as very low (0%-9%), low (10%-20%), average (20%-33%), and high (>33%) and compared amputation rates across regions using nonparametric tests of trend. We then used charge data to create reimbursement rates based on HRR to estimate financial losses. We identified 51 adult hospitals as safety nets in Texas. Regions varied in the proportion of safety net hospitals from 0% in Victoria to 65% in Harlingen. Among beneficiaries aged >65, amputation rates correlated to the proportion of safety net hospitals in each region; for example, patients in the lowest quartile of safety net had a yearly rate of 300 amputations per 100,000 beneficiaries, whereas those in the highest quartile had a yearly rate of 472 per 100,000 (P = .007). Charges for diabetic amputation-related admissions varied almost 200-fold, from $5000 to $1.4 million. Using reimbursement based on HRR to estimate a bundled payment, we noted net losses would be higher at safety net vs nonsafety net hospitals ($180 million vs $163 million), representing a per-hospital loss of $1.6 million at safety nets vs $700,000 at nonsafety nets (P < .001). Regions with a high proportion of safety net hospitals perform almost half of the diabetic amputations in Texas. Changes to traditional payment models should account for

Modelling safety of gantry crane operations using Petri nets.

PubMed

Singh, Karmveer; Raj, Navneet; Sahu, S K; Behera, R K; Sarkar, Sobhan; Maiti, J

2017-03-01

Being a powerful tool in modelling industrial and service operations, Petri net (PN) has been extremely used in different domains, but its application in safety study is limited. In this study, we model the gantry crane operations used for industrial activities using generalized stochastic PNs. The complete cycle of operations of the gantry crane is split into three parts namely inspection and loading, movement of load, and unloading of load. PN models are developed for all three parts and the whole system as well. The developed PN models have captured the safety issues through reachability tree. The hazardous states are identified and how they ultimately lead to some unwanted accidents is demonstrated. The possibility of falling of load and failure of hook, sling, attachment and hoist rope are identified. Possible suggestions based on the study are presented for redesign of the system. For example, mechanical stoppage of operations in case of loosely connected load, and warning system for use of wrong buttons is tested using modified models.

33 CFR 149.696 - What are the requirements for a helicopter landing deck safety net?

Code of Federal Regulations, 2013 CFR

2013-07-01

... 33 Navigation and Navigable Waters 2 2013-07-01 2013-07-01 false What are the requirements for a helicopter landing deck safety net? 149.696 Section 149.696 Navigation and Navigable Waters COAST GUARD... helicopter landing deck safety net? A helicopter landing deck safety net must comply with 46 CFR 108.235...

33 CFR 149.696 - What are the requirements for a helicopter landing deck safety net?

Code of Federal Regulations, 2012 CFR

2012-07-01

... 33 Navigation and Navigable Waters 2 2012-07-01 2012-07-01 false What are the requirements for a helicopter landing deck safety net? 149.696 Section 149.696 Navigation and Navigable Waters COAST GUARD... helicopter landing deck safety net? A helicopter landing deck safety net must comply with 46 CFR 108.235...

33 CFR 149.696 - What are the requirements for a helicopter landing deck safety net?

Code of Federal Regulations, 2010 CFR

2010-07-01

... 33 Navigation and Navigable Waters 2 2010-07-01 2010-07-01 false What are the requirements for a helicopter landing deck safety net? 149.696 Section 149.696 Navigation and Navigable Waters COAST GUARD... helicopter landing deck safety net? A helicopter landing deck safety net must comply with 46 CFR 108.235...

33 CFR 149.696 - What are the requirements for a helicopter landing deck safety net?

Code of Federal Regulations, 2011 CFR

2011-07-01

... 33 Navigation and Navigable Waters 2 2011-07-01 2011-07-01 false What are the requirements for a helicopter landing deck safety net? 149.696 Section 149.696 Navigation and Navigable Waters COAST GUARD... helicopter landing deck safety net? A helicopter landing deck safety net must comply with 46 CFR 108.235...

33 CFR 149.696 - What are the requirements for a helicopter landing deck safety net?

Code of Federal Regulations, 2014 CFR

2014-07-01

... 33 Navigation and Navigable Waters 2 2014-07-01 2014-07-01 false What are the requirements for a helicopter landing deck safety net? 149.696 Section 149.696 Navigation and Navigable Waters COAST GUARD... helicopter landing deck safety net? A helicopter landing deck safety net must comply with 46 CFR 108.235...

SAFEGUARD: An Assured Safety Net Technology for UAS

NASA Technical Reports Server (NTRS)

Dill, Evan T.; Young, Steven D.; Hayhurst, Kelly J.

2016-01-01

As demands increase to use unmanned aircraft systems (UAS) for a broad spectrum of commercial applications, regulatory authorities are examining how to safely integrate them without loss of safety or major disruption to existing airspace operations. This work addresses the development of the Safeguard system as an assured safety net technology for UAS. The Safeguard system monitors and enforces conformance to a set of rules defined prior to flight (e.g., geospatial stay-out or stay-in regions, speed limits, altitude limits). Safeguard operates independently of the UAS autopilot and is strategically designed in a way that can be realized by a small set of verifiable functions to simplify compliance with regulatory standards for commercial aircraft. A framework is described that decouples the system from any other devices on the UAS as well as introduces complementary positioning source(s) for applications that require integrity and availability beyond what the Global Positioning System (GPS) can provide. Additionally, the high level logic embedded within the software is presented, as well as the steps being taken toward verification and validation (V&V) of proper functionality. Next, an initial prototype implementation of the described system is disclosed. Lastly, future work including development, testing, and system V&V is summarized.

Shared decision making in the safety net: where do we go from here?

PubMed

Bouma, Angelique B; Tiedje, Kristina; Poplau, Sara; Boehm, Deborah H; Shah, Nilay D; Commers, Matthew J; Linzer, Mark; Montori, Victor M

2014-01-01

Shared decision making (SDM) is an interactive process between clinicians and patients in which both share information, deliberate together, and make clinical decisions. Clinics serving safety net patients face special challenges, including fewer resources and more challenging work environments. The use of SDM within safety net institutions has not been well studied. We recruited a convenience sample of 15 safety net primary care clinicians (13 physicians, 2 nurse practitioners). Each answered a 9-item SDM questionnaire and participated in a semistructured interview. From the transcribed interviews and questionnaire data, we identified themes and suggestions for introducing SDM into a safety net environment. Clinicians reported only partially fulfilling the central components of SDM (sharing information, deliberating, and decision making). Most clinicians expressed interest in SDM by stating that they "selected a treatment option together" with patients (8 of 15 in strong or complete agreement), but only a minority (3 of 15) "thoroughly weighed the different treatment options" together with patients. Clinicians attributed this gap to many barriers, including time pressure, overwhelming visit content, patient preferences, and lack of available resources. All clinicians believed that lack of time made it difficult to practice SDM. To increase use of SDM in the safety net, efficient SDM interventions designed for this environment, team care, and patient engagement in SDM will need further development. Future studies should focus on adapting SDM to safety net settings and determine whether SDM can reduce health care disparities.

Innovation and Transformation in California’s Safety-net Healthcare Settings: An Inside Perspective

PubMed Central

Lyles, Courtney R.; Aulakh, Veenu; Jameson, Wendy; Schillinger, Dean; Yee, Hal; Sarkar, Urmimala

2016-01-01

Background Health reform requires safety-net settings to transform care delivery, but how they will innovate in order to achieve this transformation is unknown. Methods We conducted two series of key informant interviews (N= 28) in 2012 with leadership from both California’s public hospital systems and community health centers. Interviews focused on how innovation was conceptualized and solicited examples of successful innovations. Results In contrast to disruptive innovation, interviewees often defined innovation as improving implementation, making incremental changes, and promoting integration. Many leaders gave examples of existing innovative practices such as patient-centered approaches to meeting their diverse patient needs. Participants expressed challenges to adapting quickly, but a desire to partner together. Conclusions Safety-net systems have already begun implementing innovative practices supporting their key priority areas. However, more support is needed, specifically to accelerate the change needed to succeed under health reform. PMID:24170938

Racial differences in colorectal cancer survival at a safety net hospital.

PubMed

Tapan, Umit; Lee, Shin Yin; Weinberg, Janice; Kolachalama, Vijaya B; Francis, Jean; Charlot, Marjory; Hartshorn, Kevan; Chitalia, Vipul

2017-08-01

While racial disparity in colorectal cancer survival have previously been studied, whether this disparity exists in patients with metastatic colorectal cancer receiving care at safety net hospitals (and therefore of similar socioeconomic status) is poorly understood. We examined racial differences in survival in a cohort of patients with stage IV colorectal cancer treated at the largest safety net hospital in the New England region, which serves a population with a majority (65%) of non-Caucasian patients. Data was extracted from the hospital's electronic medical record. Survival differences among different racial and ethnic groups were examined graphically using Kaplan-Meier analysis. A univariate cox proportional hazards model and a multivariable adjusted model were generated. Black patients had significantly lower overall survival compared to White patients, with median overall survival of 1.9 years and 2.5 years respectively. In a multivariate analysis, Black race posed a significant hazard (HR 1.70, CI 1.01-2.90, p=0.0467) for death. Though response to therapy emerged as a strong predictor of survival (HR=0.4, CI=0.2-0.7, p=0.0021), it was comparable between Blacks and Whites. Despite presumed equal access to healthcare and socioeconomic status within a safety-net hospital system, our results reinforce findings from previous studies showing lower colorectal cancer survival in Black patients, and also point to the importance of investigating other factors such as genetic and pathologic differences. Copyright © 2017 Elsevier Ltd. All rights reserved.

The relationship between safety net activities and hospital financial performance

PubMed Central

2010-01-01

Background During the 1990's hospitals in the U.S were faced with cost containment charges, which may have disproportionately impacted hospitals that serve poor patients. The purposes of this paper are to study the impact of safety net activities on total profit margins and operating expenditures, and to trace these relationships over the 1990s for all U.S urban hospitals, controlling for hospital and market characteristics. Methods The primary data source used for this analysis is the Annual Survey of Hospitals from the American Hospital Association and Medicare Hospital Cost Reports for years 1990-1999. Ordinary least square, hospital fixed effects, and two-stage least square analyses were performed for years 1990-1999. Logged total profit margin and operating expenditure were the dependent variables. The safety net activities are the socioeconomic status of the population in the hospital serving area, and Medicaid intensity. In some specifications, we also included uncompensated care burden. Results We found little evidence of negative effects of safety net activities on total margin. However, hospitals serving a low socioeconomic population had lower expenditure raising concerns for the quality of the services provided. Conclusions Despite potentially negative policy and market changes during the 1990s, safety net activities do not appear to have imperiled the survival of hospitals. There may, however, be concerns about the long-term quality of the services for hospitals serving low socioeconomic population. PMID:20074367

Shaking up the dental safety-net: elimination of optional adult dental Medicaid benefits in California.

PubMed

Wides, Cynthia; Alam, Sonia Rab; Mertz, Elizabeth

2014-02-01

In July 2009, California eliminated funding for most adult non-emergency Medicaid dental benefits (Denti-Cal). This paper presents the findings from a qualitative assessment of the impacts of the Denti-Cal cuts on California's oral health safety-net. Interviews were conducted with dental safety-net providers throughout the state, including public health departments, community health centers, dental schools, Native American health clinics, and private providers, and were coded thematically using Atlas.ti. Safety-net providers reported decreased utilization by Denti-Cal-eligible adults, who now primarily seek emergency dental services, and reported shifting to focus on pediatric and privately-insured patients. Significant changes were reported in safety-net clinic finances, operations, and ability to refer. The impact of the Denti-Cal cuts has been distributed unevenly across the safety-net, with private providers and County Health Departments bearing the highest burden.

Health reform holds both risks and rewards for safety-net providers and racially and ethnically diverse patients.

PubMed

Andrulis, Dennis P; Siddiqui, Nadia J

2011-10-01

The Affordable Care Act of 2010 creates both opportunities and risks for safety-net providers in caring for low-income, diverse patients. New funding for health centers; support for coordinated, patient-centered care; and expansion of the primary care workforce are some of the opportunities that potentially strengthen the safety net. However, declining payments to safety-net hospitals, existing financial hardships, and shifts in the health care marketplace may intensify competition, thwart the ability to innovate, and endanger the financial viability of safety-net providers. Support of state and local governments, as well as philanthropies, will be crucial to helping safety-net providers transition to the new health care environment and to preventing the unintended erosion of the safety net for racially and ethnically diverse populations.

The Relationship between Private Safety Nets and Economic Outcomes among Single Mothers

ERIC Educational Resources Information Center

Harknett, Kristen

2006-01-01

This article examines the relationship between private safety nets and economic outcomes among 2,818 low-income single mothers in three U.S. counties in the 1990s. I define private safety nets as the potential to draw upon family and friends for material or emotional support if needed. Using a combination of survey and administrative records data…

The influence of health policy and market factors on the hospital safety net.

PubMed

Bazzoli, Gloria J; Lindrooth, Richard C; Kang, Ray; Hasnain-Wynia, Romana

2006-08-01

To examine how the financial pressures resulting from the Balanced Budget Act (BBA) of 1997 interacted with private sector pressures to affect indigent care provision. American Hospital Association Annual Survey, Area Resource File, InterStudy Health Maintenance Organization files, Current Population Survey, and Bureau of Primary Health Care data. We distinguished core and voluntary safety net hospitals in our analysis. Core safety net hospitals provide a large share of uncompensated care in their markets and have large indigent care patient mix. Voluntary safety net hospitals provide substantial indigent care but less so than core hospitals. We examined the effect of financial pressure in the initial year of the 1997 BBA on uncompensated care for three hospital groups. Data for 1996-2000 were analyzed using approaches that control for hospital and market heterogeneity. All urban U.S. general acute care hospitals with complete data for at least 2 years between 1996 and 2000, which totaled 1,693 institutions. Core safety net hospitals reduced their uncompensated care in response to Medicaid financial pressure. Voluntary safety net hospitals also responded in this way but only when faced with the combined forces of Medicaid and private sector payment pressures. Nonsafety net hospitals did not exhibit similar responses. Our results are consistent with theories of hospital behavior when institutions face reductions in payment. They raise concern given continuing state budget crises plus the focus of recent federal deficit reduction legislation intended to cut Medicaid expenditures.

Development of a Mapped Diabetes Community Program Guide for a Safety Net Population

PubMed Central

Zallman, Leah; Ibekwe, Lynn; Thompson, Jennifer W.; Ross-Degnan, Dennis; Oken, Emily

2014-01-01

Purpose Enhancing linkages between patients and community programs is increasingly recognized as a method for improving physical activity, nutrition and weight management. Although interactive mapped community program guides may be beneficial, there remains a dearth of articles that describe the processes and practicalities of creating such guides. This article describes the development of an interactive, web-based mapped community program guide at a safety net institution and the lessons learned from that process. Conclusions This project demonstrated the feasibility of creating two maps – a program guide and a population health map. It also revealed some key challenges and lessons for future work in this area, particularly within safety-net institutions. Our work underscores the need for developing partnerships outside of the health care system and the importance of employing community-based participatory methods. In addition to facilitating improvements in individual wellness, mapping community programs also has the potential to improve population health management by healthcare delivery systems such as hospitals, health centers, or public health systems, including city and state departments of health. PMID:24752180

Organizing seniors to protect the health safety net: the way forward.

PubMed

Sharma, Leena; Regan, Carol; Villers, Katherine S

2018-04-12

Over the past century, the organized voice of seniors has been critical in building the U.S. health safety net. Since the 2016 election, that safety net, particularly the Medicaid program, is in jeopardy. As we have seen with the rise of the Tea Party, senior support for health care programs-even programs that they use in large numbers-cannot and should not be taken for granted. This article provides a brief history of senior advocacy and an overview of the current senior organizing landscape. It also identifies opportunities for building the transformational organizing of low-income seniors needed to defend against sustained attacks on critical programs. Several suggestions are made, drawn from years of work in philanthropy, advocacy, and campaigns, for strengthening the ability to organize seniors-particularly low-income seniors-into an effective political force advocating for Medicaid and other safety net programs.

The safety net medical home initiative: transforming care for vulnerable populations.

PubMed

Sugarman, Jonathan R; Phillips, Kathryn E; Wagner, Edward H; Coleman, Katie; Abrams, Melinda K

2014-11-01

Despite findings that medical homes may reduce or eliminate health care disparities among underserved and minority populations, most previous medical home pilot and demonstration projects have focused on health care delivery systems serving commercially insured patients and Medicare beneficiaries. To develop a replicable approach to support medical home transformation among diverse practices serving vulnerable and underserved populations. Facilitated by a national program team, convening organizations in 5 states provided coaching and learning community support to safety net practices over a 4-year period. To guide transformation, we developed a framework of change concepts aligned with supporting tools including implementation guides, activity checklists, and measurement instruments. Sixty-five health centers, homeless clinics, private practices, residency training centers, and other safety net practices in Colorado, Idaho, Massachusetts, Oregon, and Pennsylvania. We evaluated implementation of the change concepts using the Patient-Centered Medical Home-Assessment, and conducted a survey of participating practices to assess perceptions of the impact of the technical assistance. All practices implemented key features of the medical home model, and nearly half (47.6%) implemented the 33 identified key changes to a substantial degree as evidenced by level A Patient-Centered Medical Home-Assessment scores. Two thirds of practices that achieved substantial implementation did so only after participating in the initiative for >2 years. By the end of the initiative, 83.1% of sites achieved external recognition as medical homes. Despite resource constraints and high-need populations, safety net clinics made considerable progress toward medical home implementation when provided robust, multimodal support over a 4-year period.

The Influence of Health Policy and Market Factors on the Hospital Safety Net

PubMed Central

Bazzoli, Gloria J; Lindrooth, Richard C; Kang, R ay; Hasnain-Wynia, R omana

2006-01-01

Objective To examine how the financial pressures resulting from the Balanced Budget Act (BBA) of 1997 interacted with private sector pressures to affect indigent care provision. Data Sources/Study Setting American Hospital Association Annual Survey, Area Resource File, InterStudy Health Maintenance Organization files, Current Population Survey, and Bureau of Primary Health Care data. Study Design We distinguished core and voluntary safety net hospitals in our analysis. Core safety net hospitals provide a large share of uncompensated care in their markets and have large indigent care patient mix. Voluntary safety net hospitals provide substantial indigent care but less so than core hospitals. We examined the effect of financial pressure in the initial year of the 1997 BBA on uncompensated care for three hospital groups. Data for 1996–2000 were analyzed using approaches that control for hospital and market heterogeneity. Data Collection/Extraction Methods All urban U.S. general acute care hospitals with complete data for at least 2 years between 1996 and 2000, which totaled 1,693 institutions. Principal Findings Core safety net hospitals reduced their uncompensated care in response to Medicaid financial pressure. Voluntary safety net hospitals also responded in this way but only when faced with the combined forces of Medicaid and private sector payment pressures. Nonsafety net hospitals did not exhibit similar responses. Conclusions Our results are consistent with theories of hospital behavior when institutions face reductions in payment. They raise concern given continuing state budget crises plus the focus of recent federal deficit reduction legislation intended to cut Medicaid expenditures. PMID:16899001

Cervical cancer screening among HIV infected women in an urban, U.S. safety-net healthcare system.

PubMed

Barnes, Arti; Betts, Andrea C; Borton, Eric K; Sanders, Joanne M; Pruitt, Sandi L; Werner, Claudia; Bran, Andres; Estelle, Carolee D; Balasubramanian, Bijal A; Inrig, Stephen J; Halm, Ethan A; Skinner, Celette Sugg; Tiro, Jasmin A

2018-05-11

Little is known about cervical cancer screening and results patterns among HIV infected (HIV+) women in real-world healthcare settings. We characterized two periods of screening opportunity. Retrospective cohort. U.S. safety-net healthcare system in Dallas County, Texas. We analyzed data from electronic medical records (EMR) of 1,490 HIV+ women receiving care 2010-2014. At baseline, we categorized a woman's Pap status 15 months prior to index date as under-screened (vs. screened), and cytology result (normal vs. abnormal). Then, we examined screening completion and results, and colposcopy uptake and results after an abnormal screen, in the subsequent 15-month period. More than half of women (56%) had no evidence of a Pap test (i.e., under-screened) at baseline. Under-screened women were more likely to be older (50-64 years), have diabetes, and unknown viral load; they were less likely to be Black, Hispanic, have Medicaid, recently pregnant, have a HIV clinic visit, or a CD4 count ≥200 cells/mm. Nearly half of under-screened women (46%, n = 383) remained under-screened in the subsequent 15 months. Among women under-screened at baseline who later completed screening and follow-up during the study period, 21 high-grade dysplasia and 3 cancers were diagnosed. Overall, 40% of women did not receive colposcopy when needed, with most failures to follow-up occurring in women who were under-screened at baseline. Most HIV+ women receiving care in a safety-net system did not receive sufficient screening for cervical cancer and remained at exceptionally high risk of developing high-grade dysplasia.

Improving diabetic foot care in a nurse-managed safety-net clinic.

PubMed

Peterson, Joann M; Virden, Mary D

2013-05-01

This article is a description of the development and implementation of a Comprehensive Diabetic Foot Care Program and assessment tool in an academically affiliated nurse-managed, multidisciplinary, safety-net clinic. The assessment tool parallels parameters identified in the Task Force Foot Care Interest Group of the American Diabetes Association's report published in 2008, "Comprehensive Foot Examination and Risk Assessment." Review of literature, Silver City Health Center's (SCHC) 2009 Annual Report, retrospective chart review. Since the full implementation of SCHC's Comprehensive Diabetic Foot Care Program, there have been no hospitalizations of clinic patients for foot-related complications. The development of the Comprehensive Diabetic Foot Assessment tool and the implementation of the Comprehensive Diabetic Foot Care Program have resulted in positive outcomes for the patients in a nurse-managed safety-net clinic. This article demonstrates that quality healthcare services can successfully be developed and implemented in a safety-net clinic setting. ©2012 The Author(s) Journal compilation ©2012 American Association of Nurse Practitioners.

Safety-net hospitals more likely than other hospitals to fare poorly under Medicare's value-based purchasing.

PubMed

Gilman, Matlin; Adams, E Kathleen; Hockenberry, Jason M; Milstein, Arnold S; Wilson, Ira B; Becker, Edmund R

2015-03-01

Medicare's value-based purchasing (VBP) program potentially puts safety-net hospitals at a financial disadvantage compared to other hospitals. In 2014, the second year of the program, patient mortality measures were added to the VBP program's algorithm for assigning penalties and rewards. We examined whether the inclusion of mortality measures in the second year of the program had a disproportionate impact on safety-net hospitals nationally. We found that safety-net hospitals were more likely than other hospitals to be penalized under the VBP program as a result of their poorer performance on process and patient experience scores. In 2014, 63 percent of safety-net hospitals versus 51 percent of all other sample hospitals received payment rate reductions under the program. However, safety-net hospitals' performance on mortality measures was comparable to that of other hospitals, with an average VBP survival score of thirty-two versus thirty-one among other hospitals. Although safety-net hospitals are still more likely than other hospitals to fare poorly under the VBP program, increasing the weight given to mortality in the VBP payment algorithm would reduce this disadvantage. Project HOPE—The People-to-People Health Foundation, Inc.

Horizontal ichthyoplankton tow-net system with unobstructed net opening

USGS Publications Warehouse

Nester, Robert T.

1987-01-01

The larval fish sampler described here consists of a modified bridle, frame, and net system with an obstruction-free net opening and is small enough for use on boats 10 m or less in length. The tow net features a square net frame attached to a 0.5-m-diameter cylinder-on-cone plankton net with a bridle designed to eliminate all obstructions forward of the net opening, significantly reducing currents and vibrations in the water directly preceding the net. This system was effective in collecting larvae representing more than 25 species of fish at sampling depths ranging from surface to 10 m and could easily be used at greater depths.

A Mixed-Methods Study of Patient-Provider E-mail Content in a Safety-Net Setting

PubMed Central

Mirsky, Jacob B.; Tieu, Lina; Lyles, Courtney; Sarkar, Urmimala

2016-01-01

Objective To explore the content of patient-provider e-mails in a safety-net primary care clinic. Methods We conducted a content analysis using inductive and deductive coding of e-mail exchanges (n=31) collected from January through November of 2013. Participants were English-speaking adult patients with a chronic condition (or their caregivers) cared for at a single publicly-funded general internal medicine clinic and their primary care providers (attending general internist physicians, clinical fellows, internal medicine residents, and nurse practitioners). Results All e-mails were non-urgent. Patients included a medical update in 19% of all e-mails. Patients requested action in 77% of e-mails, and the most common requests overall were for action regarding medications or treatment (29%). Requests for information were less common (45% of e-mails). Patient requests (n=56) were resolved in 84% of e-mail exchanges, resulting in 63 actions. Conclusion Patients in safety-net clinics are capable of safely and effectively using electronic messaging for between-visit communication with providers. Practical Implications Safety-net systems should implement electronic communications tools as soon as possible to increase healthcare access and enhance patient involvement in their care. PMID:26332306

The effect of changes in hospital reimbursement on nurse staffing decisions at safety net and nonsafety net hospitals.

PubMed

Lindrooth, Richard C; Bazzoli, Gloria J; Needleman, Jack; Hasnain-Wynia, Romana

2006-06-01

The financial savings from the Balanced Budget Act (BBA) are attractive to policy makers, but such savings come at a cost. We measure changes in nurse staffing at hospitals related to potential declines in reimbursement through the BBA. Following Hadley, Zuckerman, and Feder (1989), we define a fiscal pressure index (FPI) to measure the differential effect of the BBA. We estimate the effect of the FPI on the number of full-time equivalent registered nurses (RN) and licensed practical nurses (LPN) per adjusted patient day using American Hospital Association (AHA) data of a panel of hospitals from 1996 to 2001. The AHA data are combined with the Area Resource Files and health maintenance organizations penetration data. We control for hospital heterogeneity using fixed effects. All urban short-term general hospitals that responded to the staffing and uncompensated care questions in the AHA survey between 1996 and 2001. We define safety net hospitals as those with a high ratio of uncompensated costs to total hospital expenses (see, e.g., Zuckerman et al. 2001). We find that the nonsafety net hospitals that were most susceptible to the provisions of the BBA experienced a decline in RN staffing ratios about twice the rate of the nonsafety net hospitals that were least susceptible to the BBA. We are unable to detect an effect of the BBA on staffing at safety net hospitals. RN and LPN staffing levels per adjusted patient day declined, on average, between 1996 and 2001. Within the context of the general decline, we find that RN staffing per adjusted patient day declined even more at nonsafety net hospitals that were most susceptible to lower reimbursement related to the BBA. Thus, there was a small but statistically significant incremental effect of potential BBA losses on RN staffing at hospitals that were expected to be affected most. This incremental decline represented about a 6 percent increase in nurse workload that in isolation might not affect quality. Nevertheless

Impact of a Primary Care CKD Registry in a US Public Safety-Net Health Care Delivery System: A Pragmatic Randomized Trial.

PubMed

Tuot, Delphine S; McCulloch, Charles E; Velasquez, Alexandra; Schillinger, Dean; Hsu, Chi-Yuan; Handley, Margaret; Powe, Neil R

2018-04-23

Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. Pragmatic trial of a CKD registry versus a usual-care registry for 1 year. Primary care providers (PCPs) and their patients with CKD in a safety-net primary care setting in San Francisco. The CKD registry identified at point of care all patients with CKD, those with blood pressure (BP)>140/90mmHg, those without angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB) prescription, and those without albuminuria quantification in the past year. It also provided quarterly feedback pertinent to these metrics to promote "outreach" to patients with CKD. The usual-care registry provided point-of-care cancer screening and immunization data. Changes in systolic BP at 12 months (primary outcome), proportion of patients with BP control, prescription of ACE inhibitors/ARBs, quantification of albuminuria, severity of albuminuria, and estimated glomerular filtration rate. The patient population (n=746) had a mean age of 56.7±12.1 (standard deviation) years, was 53% women, and was diverse (8% non-Hispanic white, 35.7% black, 24.5% Hispanic, and 24.4% Asian). Randomization to the CKD registry (30 PCPs, 285 patients) versus the usual-care registry (49 PCPs, 461 patients) was associated with 2-fold greater odds of ACE inhibitor/ARB prescription (adjusted OR, 2.25; 95% CI, 1.45-3.49) and albuminuria quantification (adjusted OR, 2.44; 95% CI, 1.38-4.29) during the 1-year study period. Randomization to the CKD registry was not associated with changes in systolic BP, proportion of patients with uncontrolled BP, or degree of albuminuria or estimated glomerular filtration rate. Potential misclassification of CKD; missing baseline medication data; limited to study of a public safety-net

Do HMO and its for-profit expansion jeopardize the survival of hospital safety net services?

PubMed

Shen, Yu-Chu

2009-03-01

This study examines the effect of health maintenance organizations (HMOs) and for-profit HMO share on the survival of safety net services in hospitals between 1990 and 2004. The primary data sources are the American Hospital Association Annual Surveys, the Medicare hospital cost reports, and the HMO enrollment and ownership data from Interstudy. I analyze the risks of shutting down each safety net service separately using the proportional hazard models. I find that the risks of shutting down hospital safety net services do not vary by different levels of overall HMO penetration. However, conditional on the overall HMO penetration level, increasing for-profit presence of HMO does increase the risks of shutting down several safety net services. Policies evaluating the for-profit expansion or ownership conversion of health plans should take this potential adverse effect into consideration.

Acceptability of text messages for safety netting patients with low-risk cancer symptoms: a qualitative study.

PubMed

Hirst, Yasemin; Lim, Anita Wey Wey

2018-05-01

Safety netting is an important diagnostic strategy for patients presenting to primary care with potential (low-risk) cancer symptoms. Typically, this involves asking patients to return if symptoms persist. However, this relies on patients re-appraising their symptoms and making follow-up appointments, which could contribute to delays in diagnosis. Text messaging is increasingly used in primary care to communicate with patients, and could be used to improve safety netting. To explore the acceptability and feasibility of using text messages to safety net patients presenting with low-risk cancer symptoms in GP primary care (txt-netting). Qualitative focus group and interview study with London-based GPs. Participants were identified using convenience sampling methods. Five focus groups and two interviews were conducted with 22 GPs between August and December 2016. Sessions were audiorecorded, transcribed verbatim, and analysed using thematic analysis. GPs were amenable to the concept of using text messages in cancer safety netting, identifying it as an additional tool that could help manage patients and promote symptom awareness. There was wide variation in GP preferences for text message content, and a number of important potential barriers to txt-netting were identified. Concerns were raised about the difficulties of conveying complex safety netting advice within the constraints of a text message, and about confidentiality, widening inequalities, and workload implications. Text messages were perceived to be an acceptable potential strategy for safety netting patients with low-risk cancer symptoms. Further work is needed to ensure it is cost-effective, user friendly, confidential, and acceptable to patients. © British Journal of General Practice 2018.

Burnout, Perceived Stress, and Job Satisfaction Among Trauma Nurses at a Level I Safety-Net Trauma Center.

PubMed

Munnangi, Swapna; Dupiton, Lynore; Boutin, Anthony; Angus, L D George

Nurses are at the forefront of our health care delivery system and have been reported to exhibit a high level of burnout. Burnout and stress in trauma nurses at a safety-net hospital can negatively impact patient care. Safety-net hospitals are confronted with unique social, financial, as well as resource problems that can potentially make the work environment frustrating. The purpose of this study was to explore the levels of burnout, stress, and job satisfaction in nurses providing care to trauma patients at a Level I safety-net trauma center. A cross-sectional survey design was used to investigate principal factors including personal and professional demographics, burnout, perceived stress, and job satisfaction. Trauma nurses working at a Level I safety-net trauma center are stressed and exhibited moderate degree of burnout. The extent of emotional exhaustion experienced by the nurses varied with work location and was highest in surgical intensive care unit nurses. The level of job satisfaction in terms of opportunities for promotion differed significantly by race and the health status of the nurses. Satisfaction with coworkers was lowest in those nurses between the ages of 60-69 years. Female nurses were more satisfied with their coworkers than male nurses. In addition, the study revealed that significant relationships exist among perceived stress, burnout, and job satisfaction. Work environment significantly impacts burnout, job satisfaction, and perceived stress experienced by trauma nurses in a safety-net hospital. Nursing administration can make an effort to understand the levels of burnout and strategically improve work environment for trauma nurses in order to minimize stressors leading to attrition and enhance job satisfaction.

Factors shaping effective utilization of health information technology in urban safety-net clinics.

PubMed

George, Sheba; Garth, Belinda; Fish, Allison; Baker, Richard

2013-09-01

Urban safety-net clinics are considered prime targets for the adoption of health information technology innovations; however, little is known about their utilization in such safety-net settings. Current scholarship provides limited guidance on the implementation of health information technology into safety-net settings as it typically assumes that adopting institutions have sufficient basic resources. This study addresses this gap by exploring the unique challenges urban resource-poor safety-net clinics must consider when adopting and utilizing health information technology. In-depth interviews (N = 15) were used with key stakeholders (clinic chief executive officers, medical directors, nursing directors, chief financial officers, and information technology directors) from staff at four clinics to explore (a) nonhealth information technology-related clinic needs, (b) how health information technology may provide solutions, and (c) perceptions of and experiences with health information technology. Participants identified several challenges, some of which appear amenable to health information technology solutions. Also identified were requirements for effective utilization of health information technology including physical infrastructural improvements, funding for equipment/training, creation of user groups to share health information technology knowledge/experiences, and specially tailored electronic billing guidelines. We found that despite the potential benefit that can be derived from health information technologies, the unplanned and uninformed introduction of these tools into these settings might actually create more problems than are solved. From these data, we were able to identify a set of factors that should be considered when integrating health information technology into the existing workflows of low-resourced urban safety-net clinics in order to maximize their utilization and enhance the quality of health care in such settings.

Assessing Patient Activation among High-Need, High-Cost Patients in Urban Safety Net Care Settings.

PubMed

Napoles, Tessa M; Burke, Nancy J; Shim, Janet K; Davis, Elizabeth; Moskowitz, David; Yen, Irene H

2017-12-01

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing

Transforming primary care in the New Orleans safety-net: the patient experience.

PubMed

Schmidt, Laura A; Rittenhouse, Diane R; Wu, Kevin J; Wiley, James A

2013-02-01

The patient-centered medical home (PCMH) is a key service delivery innovation in health reform. However, there are growing questions about whether the changes in clinics promoted by the PCMH model lead to improvements in the patient experience. To test the hypothesis that PCMH improvements in safety-net primary care clinics are associated with a more positive patient experience. Multilevel cross-sectional analysis of patients nested within the primary care clinics that serve them. Primary care clinic leaders and patients throughout the City of New Orleans health care safety-net. Dependent variables included patient ratings of accessibility, coordination, and confidence in the quality/safety of care. The key independent variable was a score measuring PCMH structural and process improvements at the clinic level. Approximately two thirds of patients in New Orleans gave positive ratings to their clinics on access and quality/safety, but only one third did for care coordination. In all but the largest clinics, patient experiences of care coordination were positively associated with the clinic's use of PCMH structural and process changes. Results for patient ratings of access and quality/safety were mixed. Among primary care clinics in the New Orleans safety-net, use of more PCMH improvements at the clinic level led to more positive patient rating of care coordination, but not of accessibility or confidence in quality/safety. Ongoing efforts to pilot, demonstrate, implement, and evaluate the PCMH should consider how the impact of medical practice transformation could vary across different aspects of the patient experience.

The research and implementation of PDM systems based on the .NET platform

NASA Astrophysics Data System (ADS)

Gao, Hong-li; Jia, Ying-lian; Yang, Ji-long; Jiang, Wei

2005-12-01

A new kind of PDM system scheme based on the .NET platform for solving application problems of the current PDM system applied in an enterprise is described. The key technologies of this system, such as .NET, Accessing Data, information processing, Web, ect., were discussed. The 3-tier architecture of a PDM system based on the C/S and B/S mixed mode was presented. In this system, all users share the same Database Server in order to ensure the coherence and safety of client data. ADO.NET leverages the power of XML to provide disconnected access to data, which frees the connection to be used by other clients. Using this approach, the system performance was improved. Moreover, the important function modules in a PDM system such as project management, product structure management and Document Management module were developed and realized.

Health safety nets can break cycles of poverty and disease: a stochastic ecological model.

PubMed

Plucinski, Mateusz M; Ngonghala, Calistus N; Bonds, Matthew H

2011-12-07

The persistence of extreme poverty is increasingly attributed to dynamic interactions between biophysical processes and economics, though there remains a dearth of integrated theoretical frameworks that can inform policy. Here, we present a stochastic model of disease-driven poverty traps. Whereas deterministic models can result in poverty traps that can only be broken by substantial external changes to the initial conditions, in the stochastic model there is always some probability that a population will leave or enter a poverty trap. We show that a 'safety net', defined as an externally enforced minimum level of health or economic conditions, can guarantee ultimate escape from a poverty trap, even if the safety net is set within the basin of attraction of the poverty trap, and even if the safety net is only in the form of a public health measure. Whereas the deterministic model implies that small improvements in initial conditions near the poverty-trap equilibrium are futile, the stochastic model suggests that the impact of changes in the location of the safety net on the rate of development may be strongest near the poverty-trap equilibrium.

Estimating the Size and Cost of the STD Prevention Services Safety Net.

PubMed

Gift, Thomas L; Haderxhanaj, Laura T; Torrone, Elizabeth A; Behl, Ajay S; Romaguera, Raul A; Leichliter, Jami S

2015-01-01

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years.

Estimating the Size and Cost of the STD Prevention Services Safety Net

PubMed Central

Haderxhanaj, Laura T.; Torrone, Elizabeth A.; Behl, Ajay S.; Romaguera, Raul A.; Leichliter, Jami S.

2015-01-01

The Patient Protection and Affordable Care Act is expected to reduce the number of uninsured people in the United States during the next eight years, but more than 10% are expected to remain uninsured. Uninsured people are one of the main populations using publicly funded safety net sexually transmitted disease (STD) prevention services. Estimating the proportion of the uninsured population expected to need STD services could help identify the potential demand for safety net STD services and improve program planning. In 2013, an estimated 8.27 million people met the criteria for being in need of STD services. In 2023, 4.70 million uninsured people are expected to meet the criteria for being in need of STD services. As an example, the cost in 2014 U.S. dollars of providing chlamydia screening to these people was an estimated $271.1 million in 2013 and is estimated to be $153.8 million in 2023. A substantial need will continue to exist for safety net STD prevention services in coming years. PMID:26556931

Organizing uninsured safety-net access to specialist physician services.

PubMed

Hall, Mark A

2013-05-01

Arranging referrals for specialist services is often the greatest difficulty that safety-net access programs face in attempting to provide fairly comprehensive services for the uninsured. When office-based community specialists are asked to care for uninsured patients, they cite the following barriers: difficulty determining which patients merit charity care, having to arrange for services patients need from other providers, and concerns about liability for providing inadequate care. Solutions to these barriers to specialist access can be found in the same institutional arrangements that support primary care and hospital services for the uninsured. These safety-net organization structures can be extended to include specialist physician care by funding community health centers to contract for specialist referrals, using free-standing referral programs to subsidize community specialists who accept uninsured patients at discounted rates, and encouraging hospitals through tax exemption or disproportionate share funding to require specialists on their medical staffs to accept an allocation of uninsured office-based referrals.

Meaningful use in the safety net: a rapid ethnography of patient portal implementation at five community health centers in California.

PubMed

Ackerman, Sara L; Sarkar, Urmimala; Tieu, Lina; Handley, Margaret A; Schillinger, Dean; Hahn, Kenneth; Hoskote, Mekhala; Gourley, Gato; Lyles, Courtney

2017-09-01

US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations. Our rapid ethnography involved visits at 4 California safety net health systems and in-depth interviews at a fifth. Visits included interviews with clinicians and executives ( n  = 12), informal focus groups with front-line staff ( n  = 35), observations of patient portal sign-up procedures and clinic work, review of marketing materials and portal use data, and a brief survey ( n  = 45). Our findings demonstrate that the health systems devoted considerable effort to enlisting staff support for portal adoption and integrating portal-related work into clinic routines. Although all health systems had achieved, or were close to achieving, MU benchmarks, patients faced numerous barriers to portal use and our participants were uncertain how to achieve and sustain "meaningful use" as defined by and for their patients. Health systems' efforts to achieve MU certification united clinic staff under a shared ethos of improved quality of care. However, MU's assumptions about patients' demand for electronic access to health information and ability to make use of it directed clinics' attention to enrollment and message routing rather than to the relevance and usability of a tool that is minimally adaptable to the safety net context. We found a mismatch between MU-based metrics of patient engagement and the priorities and needs of safety net patient populations. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Early experience of a safety net provider reorganizing into an accountable care organization.

PubMed

Hacker, Karen; Santos, Palmira; Thompson, Douglas; Stout, Somava S; Bearse, Adriana; Mechanic, Robert E

2014-08-01

Although safety net providers will benefit from health insurance expansions under the Affordable Care Act, they also face significant challenges in the postreform environment. Some have embraced the concept of the accountable care organization to help improve quality and efficiency while addressing financial shortfalls. The experience of Cambridge Health Alliance (CHA) in Massachusetts, where health care reform began six years ago, provides insight into the opportunities and challenges of this approach in the safety net. CHA's strategies include care redesign, financial realignment, workforce transformation, and development of external partnerships. Early results show some improvement in access, patient experience, quality, and utilization; however, the potential efficiencies will not eliminate CHA's current operating deficit. The patient population, payer mix, service mix, cost structure, and political requirements reduce the likelihood of financial sustainability without significant changes in these factors, increased public funding, or both. Thus the future of safety net institutions, regardless of payment and care redesign success, remains at risk. Copyright © 2014 by Duke University Press.

Child Poverty, the Great Recession, and the Social Safety Net in the United States.

PubMed

Bitler, Marianne; Hoynes, Hiliary; Kuku, Elira

In this paper, we comprehensively examine the effects of the Great Recession on child poverty, with particular attention to the role of the social safety net in mitigating the adverse effects of shocks to earnings and income. Using a state panel data model and data for 2000 to 2014, we estimate the relationship between the business cycle and child poverty, and we examine how and to what extent the safety net is providing protection to at-risk children. We find compelling evidence that the safety net provides protection; that is, the cyclicality of after-tax-and-transfer child poverty is significantly attenuated relative to the cyclicality of private income poverty. We also find that the protective effect of the safety net is not similar across demographic groups, and that children from more disadvantaged backgrounds, such as those living with Hispanic or single heads, or particularly those living with immigrant household heads—or immigrant spouses—experience larger poverty cyclicality than those living with non- Hispanic white or married heads, or those living with native household heads with native spouses. Our findings hold across a host of choices for how to define poverty. These include measures based on absolute thresholds or more relative thresholds. They also hold for measures of resources that include not only cash and near-cash transfers net of taxes but also several measures of the value of public medical benefits.

Improving timeliness and efficiency in the referral process for safety net providers: application of the Lean Six Sigma methodology.

PubMed

Deckard, Gloria J; Borkowski, Nancy; Diaz, Deisell; Sanchez, Carlos; Boisette, Serge A

2010-01-01

Designated primary care clinics largely serve low-income and uninsured patients who present a disproportionate number of chronic illnesses and face great difficulty in obtaining the medical care they need, particularly the access to specialty physicians. With limited capacity for providing specialty care, these primary care clinics generally refer patients to safety net hospitals' specialty ambulatory care clinics. A large public safety net health system successfully improved the effectiveness and efficiency of the specialty clinic referral process through application of Lean Six Sigma, an advanced process-improvement methodology and set of tools driven by statistics and engineering concepts.

Incentivizing primary care providers to innovate: building medical homes in the post-Katrina New Orleans safety net.

PubMed

Rittenhouse, Diane R; Schmidt, Laura A; Wu, Kevin J; Wiley, James

2014-02-01

To evaluate safety-net clinics' responses to a novel community-wide Patient-Centered Medical Home (PCMH) financial incentive program in post-Katrina New Orleans. Between June 2008 and June 2010, we studied 50 primary care clinics in New Orleans receiving federal funds to expand services and improve care delivery. Multiwave, longitudinal, observational study of a local safety-net primary care system. Clinic-level data from a semiannual survey of clinic leaders (89.3 percent response rate), augmented by administrative records. Overall, 62 percent of the clinics responded to financial incentives by achieving PCMH recognition from the National Committee on Quality Assurance (NCQA). Higher patient volume, higher baseline PCMH scores, and type of ownership were significant predictors of achieving NCQA recognition. The steepest increase in adoption of PCMH processes occurred among clinics achieving the highest, Level 3, NCQA recognition. Following NCQA recognition, 88.9 percent stabilized or increased their use of PCMH processes, although several specific PCMH processes had very low rates of adoption overall. Findings demonstrate that widespread PCMH implementation is possible in a safety-net environment when external financial incentives are aligned with the goal of practice innovation. © Health Research and Educational Trust.

URBAN-NET: A Network-based Infrastructure Monitoring and Analysis System for Emergency Management and Public Safety

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lee, Sangkeun; Chen, Liangzhe; Duan, Sisi

Abstract Critical Infrastructures (CIs) such as energy, water, and transportation are complex networks that are crucial for sustaining day-to-day commodity flows vital to national security, economic stability, and public safety. The nature of these CIs is such that failures caused by an extreme weather event or a man-made incident can trigger widespread cascading failures, sending ripple effects at regional or even national scales. To minimize such effects, it is critical for emergency responders to identify existing or potential vulnerabilities within CIs during such stressor events in a systematic and quantifiable manner and take appropriate mitigating actions. We present here amore » novel critical infrastructure monitoring and analysis system named URBAN-NET. The system includes a software stack and tools for monitoring CIs, pre-processing data, interconnecting multiple CI datasets as a heterogeneous network, identifying vulnerabilities through graph-based topological analysis, and predicting consequences based on what-if simulations along with visualization. As a proof-of-concept, we present several case studies to show the capabilities of our system. We also discuss remaining challenges and future work.« less

No Safety Net Required

ERIC Educational Resources Information Center

Benigni, Mark D.; Moylan, Maureen

2009-01-01

This article discusses the Berlin (Connecticut) High School's NET (Non-Traditional Educational Training) program. NET is a self-contained program that is composed of three components: academics, social and emotional support, and vocational training. Rather than treat students alike, the NET program tailors their high school experience to meet…

Neural Net Safety Monitor Design

NASA Technical Reports Server (NTRS)

Larson, Richard R.

2007-01-01

The National Aeronautics and Space Administration (NASA) at the Dryden Flight Research Center (DFRC) has been conducting flight-test research using an F-15 aircraft (figure 1). This aircraft has been specially modified to interface a neural net (NN) controller as part of a single-string Airborne Research Test System (ARTS) computer with the existing quad-redundant flight control system (FCC) shown in figure 2. The NN commands are passed to FCC channels 2 and 4 and are cross channel data linked (CCDL) to the other computers as shown. Numerous types of fault-detection monitors exist in the FCC when the NN mode is engaged; these monitors would cause an automatic disengagement of the NN in the event of a triggering fault. Unfortunately, these monitors still may not prevent a possible NN hard-over command from coming through to the control laws. Therefore, an additional and unique safety monitor was designed for a single-string source that allows authority at maximum actuator rates but protects the pilot and structural loads against excessive g-limits in the case of a NN hard-over command input. This additional monitor resides in the FCCs and is executed before the control laws are computed. This presentation describes a floating limiter (FL) concept1 that was developed and successfully test-flown for this program (figure 3). The FL computes the rate of change of the NN commands that are input to the FCC from the ARTS. A window is created with upper and lower boundaries, which is constantly floating and trying to stay centered as the NN command rates are changing. The limiter works by only allowing the window to move at a much slower rate than those of the NN commands. Anywhere within the window, however, full rates are allowed. If a rate persists in one direction, it will eventually hit the boundary and be rate-limited to the floating limiter rate. When this happens, a persistent counter begins and after a limit is reached, a NN disengage command is generated. The

NPOESS C3S Expandability: SafetyNet(TM) and McMurdo Improvements

NASA Astrophysics Data System (ADS)

Paciaroni, J.; Jamilkowski, M. L.

2009-12-01

The National Oceanic & Atmospheric Administration (NOAA), Department of Defense (DoD), and National Aeronautics and Space Administration (NASA) are jointly acquiring the next-generation weather and environmental satellite system; the National Polar-orbiting Operational Environmental Satellite System (NPOESS). NPOESS replaces the current Polar-orbiting Operational Environmental Satellites (POES) managed by NOAA and the Defense Meteorological Satellite Program (DMSP) managed by the DoD. The NPOESS satellites carry a suite of sensors that collect meteorological, oceanographic, climatological, and solar-geophysical observations of the earth, atmosphere, and space. The command and telemetry portion of NPOESS is the Command, Control and Communications Segment (C3S), developed by Raytheon Intelligence & Information Systems. C3S is responsible for managing the overall NPOESS mission from control and status of the space and ground assets to ensuring delivery of timely, high quality data from the Space Segment (SS) to the Interface Data Processing Segment (IDPS) for processing. In addition, the C3S provides the globally distributed ground assets necessary to collect and transport mission, telemetry, and command data between the satellites and the processing locations. The C3S provides all functions required for day-to-day commanding and state-of-health monitoring of the NPP and NPOESS satellites, and delivery of Stored Mission Data (SMD) to each U.S. Weather Central Interface Data Processor (IDP) for data products development and transfer to System subscribers. The C3S also monitors and reports system-wide health and status and data communications with external systems and between the NPOESS segments. Two crucial elements of NPOESS C3S expandability are SafetyNet(TM) and communications improvements to McMurdo Station, Antarctica. ‘SafetyNet(TM)’ is a key feature of the National Polar-orbiting Operational Environmental Satellite System (NPOESS), vital element of the C3S

Evaluating predictive modeling's potential to improve teleretinal screening participation in urban safety net clinics.

PubMed

Ogunyemi, Omolola; Teklehaimanot, Senait; Patty, Lauren; Moran, Erin; George, Sheba

2013-01-01

Screening guidelines for diabetic patients recommend yearly eye examinations to detect diabetic retinopathy and other forms of diabetic eye disease. However, annual screening rates for retinopathy in US urban safety net settings remain low. Using data gathered from a study of teleretinal screening in six urban safety net clinics, we assessed whether predictive modeling could be of value in identifying patients at risk of developing retinopathy. We developed and examined the accuracy of two predictive modeling approaches for diabetic retinopathy in a sample of 513 diabetic individuals, using routinely available clinical variables from retrospective medical record reviews. Bayesian networks and radial basis function (neural) networks were learned using ten-fold cross-validation. The predictive models were modestly predictive with the best model having an AUC of 0.71. Using routinely available clinical variables to predict patients at risk of developing retinopathy and to target them for annual eye screenings may be of some usefulness to safety net clinics.

Development and Validation of a Short-Form Safety Net Medical Home Scale.

PubMed

Nocon, Robert S; Gunter, Kathryn E; Gao, Yue; Lee, Sang Mee; Chin, Marshall H

2017-12-01

To develop a short-form Safety Net Medical Home Scale (SNMHS) for assessing patient-centered medical home (PCMH) capability in safety net clinics. National surveys of federally qualified health centers (FQHCs). Interviews with FQHC directors. We constructed three short-form SNMHS versions and examined correlations with full SNMHS and related primary care assessments. We tested usability with FQHC directors and reviewed scale development with an advisory group. Federally qualified health center surveys were administered in 2009 and 2013, by mail and online. Usability testing was conducted through telephone interviews with FQHC directors in 2013. Six-, 12-, and 18-question short-form SNMHS versions had Pearson correlations with full scale of 0.84, 0.92, and 0.96, respectively. All versions showed a level of convergent validity with other primary care assessment scales comparable to the full SNMHS. User testers found short forms to be low-burden, though missing some PCMH concepts. Advisory group members expressed caution over missing concepts and appropriate use of short-form self-assessments. Short-form versions of SNMHS showed strong correlations with full scale and may be useful for brief assessment of safety net PCMH capability. Each short-form SNMHS version may be appropriate for different research, quality improvement, and assessment purposes. © Health Research and Educational Trust.

Teleretinal screening for diabetic retinopathy in six Los Angeles urban safety-net clinics: initial findings.

PubMed

Ogunyemi, Omolola; Terrien, Elizabeth; Eccles, Alicia; Patty, Lauren; George, Sheba; Fish, Allison; Teklehaimanot, Senait; Ilapakurthi, Ramarao; Aimiuwu, Otaren; Baker, Richard

2011-01-01

Diabetic retinopathy is a leading cause of blindness in US adults. This paper presents initial results of a teleretinal screening project for diabetic retinopathy involving six Los Angeles safety net clinics. A total of 1,943 patients have been screened for diabetic retinopathy by three ophthalmologist readers, with 416 receiving a recommendation for referral to specialty care. Of the cases recommended for referral, 24 had proliferative diabetic retinopathy, 62 had severe non-proliferative diabetic retinopathy (NPDR), 60 had moderate NPDR, 19 had mild NPDR, 138 had a non-diabetic condition, such as glaucoma, 63 had clinically significant macular edema without retinopathy and 50 had non-gradable images. Between 3% and 12.2% of retinal images taken at the clinics were assessed by readers as inadequate for any interpretation. The study shows the feasibility and challenges of teleretinal screening for diabetic retinopathy in urban areas facing specialist shortages and an overburdened, under-resourced safety net care-delivery system.

Teleretinal Screening for Diabetic Retinopathy in Six Los Angeles Urban Safety-Net Clinics: Initial Findings

PubMed Central

Ogunyemi, Omolola; Terrien, Elizabeth; Eccles, Alicia; Patty, Lauren; George, Sheba; Fish, Allison; Teklehaimanot, Senait; Ilapakurthi, Ramarao; Aimiuwu, Otaren; Baker, Richard

2011-01-01

Diabetic retinopathy is a leading cause of blindness in US adults. This paper presents initial results of a teleretinal screening project for diabetic retinopathy involving six Los Angeles safety net clinics. A total of 1,943 patients have been screened for diabetic retinopathy by three ophthalmologist readers, with 416 receiving a recommendation for referral to specialty care. Of the cases recommended for referral, 24 had proliferative diabetic retinopathy, 62 had severe non-proliferative diabetic retinopathy (NPDR), 60 had moderate NPDR, 19 had mild NPDR, 138 had a non-diabetic condition, such as glaucoma, 63 had clinically significant macular edema without retinopathy and 50 had non-gradable images. Between 3% and 12.2% of retinal images taken at the clinics were assessed by readers as inadequate for any interpretation. The study shows the feasibility and challenges of teleretinal screening for diabetic retinopathy in urban areas facing specialist shortages and an overburdened, under-resourced safety net care-delivery system. PMID:22195163

Oil and water? Lessons from Maryland's effort to protect safety net providers in moving to Medicaid managed care.

PubMed

Gold, M; Mittler, J; Lyons, B

2000-12-01

Studies have highlighted the tensions that can arise between Medicaid managed care organizations and safety net providers. This article seeks to identify what other states can learn from Maryland's effort to include protections for safety net providers in its Medicaid managed care program--HealthChoice. Under HealthChoice, traditional provider systems can sponsor managed care organizations, historical providers are assured of having a role, patients can self-refer and have open access to certain public health providers, and capitation rates are risk adjusted through the use of adjusted clinical groups and claims data. The article is based on a week-long site visit to Maryland in fall 1998 that was one part of a seven-state study. Maryland's experience suggests that states have much to gain in the way of "good" public policy by considering the impact of their Medicaid managed care programs on the safety net, but states should not underestimate the challenges involved in balancing the need to protect the safety net with the need to contain costs and minimize the administrative burden on providers. No amount of protection can compensate for a poorly designed or implemented program. As the health care environment continues to change, so may the need for and the types of protections change. It also may be most difficult to guarantee adequate protections to those who need it most--among relatively financially insecure providers that have a limited management infrastructure and that depend heavily on Medicaid and the state for funds to care for the uninsured.

Medicare Payment Penalties and Safety Net Hospital Profitability: Minimal Impact on These Vulnerable Hospitals.

PubMed

Bazzoli, Gloria J; Thompson, Michael P; Waters, Teresa M

2018-02-08

To examine relationships between penalties assessed by Medicare's Hospital Readmission Reduction Program and Value-Based Purchasing Program and hospital financial condition. Centers for Medicare and Medicaid Services, American Hospital Association, and Area Health Resource File data for 4,824 hospital-year observations. Bivariate and multivariate analysis of pooled cross-sectional data. Safety net hospitals have significantly higher HRRP/VBP penalties, but, unlike nonsafety net hospitals, increases in their penalty rate did not significantly affect their total margins. Safety net hospitals appear to rely on nonpatient care revenues to offset higher penalties for the years studied. While reassuring, these funding streams are volatile and may not be able to compensate for cumulative losses over time. © Health Research and Educational Trust.

Health safety nets can break cycles of poverty and disease: a stochastic ecological model

PubMed Central

Pluciński, Mateusz M.; Ngonghala, Calistus N.; Bonds, Matthew H.

2011-01-01

The persistence of extreme poverty is increasingly attributed to dynamic interactions between biophysical processes and economics, though there remains a dearth of integrated theoretical frameworks that can inform policy. Here, we present a stochastic model of disease-driven poverty traps. Whereas deterministic models can result in poverty traps that can only be broken by substantial external changes to the initial conditions, in the stochastic model there is always some probability that a population will leave or enter a poverty trap. We show that a ‘safety net’, defined as an externally enforced minimum level of health or economic conditions, can guarantee ultimate escape from a poverty trap, even if the safety net is set within the basin of attraction of the poverty trap, and even if the safety net is only in the form of a public health measure. Whereas the deterministic model implies that small improvements in initial conditions near the poverty-trap equilibrium are futile, the stochastic model suggests that the impact of changes in the location of the safety net on the rate of development may be strongest near the poverty-trap equilibrium. PMID:21593026

Computer use, language, and literacy in safety net clinic communication

PubMed Central

Barton, Jennifer L; Lyles, Courtney R; Wu, Michael; Yelin, Edward H; Martinez, Diana; Schillinger, Dean

2017-01-01

Objective: Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients. We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. Materials and Methods: We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. Results: Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (−0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (−0.9, P < .01), fewer clinician psychosocial statements (−3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. Conclusion: Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. Discussion: Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era. PMID:27274017

Comparing the Affordable Care Act's Financial Impact on Safety-Net Hospitals in States That Expanded Medicaid and Those That Did Not.

PubMed

Dobson, Allen; DaVanzo, Joan E; Haught, Randy; Phap-Hoa, Luu

2017-11-01

Safety-net hospitals play a vital role in delivering health care to Medicaid enrollees, the uninsured, and other vulnerable patients. By reducing the number of uninsured Americans, the Affordable Care Act (ACA) was also expected to lower these hospitals’ significant uncompensated care costs and shore up their financial stability. To examine how the ACA’s Medicaid expansion affected the financial status of safety-net hospitals in states that expanded Medicaid and in states that did not. Using Medicare hospital cost reports for federal fiscal years 2012 and 2015, the authors compared changes in Medicaid inpatient days as a percentage of total inpatient days, Medicaid revenues as a percentage of total net patient revenues, uncompensated care costs as a percentage of total operating costs, and hospital operating margins. Medicaid expansion had a significant, favorable financial impact on safety-net hospitals. From 2012 to 2015, safety-net hospitals in expansion states, compared to those in nonexpansion states, experienced larger increases in Medicaid inpatient days and Medicaid revenues as well as reduced uncompensated care costs. These changes improved operating margins for safety-net hospitals in expansion states. Margins for safety-net hospitals in nonexpansion states, meanwhile, declined.

Patient preferences and access to text messaging for health care reminders in a safety-net setting.

PubMed

Zallman, Leah; Bearse, Adriana; West, Catherine; Bor, David; McCormick, Danny

2017-01-01

Text messaging may be an effective method for providing health care reminders to patients. We aimed to understand patient access to and preferences for receiving health-related reminders via text message among patients receiving care in safety-net hospitals. We conducted face-to-face surveys with 793 patients seeking care in three hospital emergency departments at a large safety-net institution and determined clinical and demographic predictors of preferences for text messaging for health care reminders. 95% of respondents reported having daily access to text messaging. Text messaging was preferred over e-mail, phone, and letters for communication. 78% of respondents wanted to receive appointment reminders, 56% wanted expiring insurance reminders, and 36% wanted reminders to take their medications. We found no clinical predictors but did find some demographic predictors-including age, ethnicity, insurance status, and income-of wanting text message reminders. In our convenience sample of safety-net patients, text messaging is an accessible, acceptable, and patient-preferred modality for receiving health care reminders. Text messaging may be a promising patient-centered approach for providing health care and insurance reminders to patients seeking care at safety-net institutions.

Diabetes and Hypertension Quality Measurement in Four Safety-Net Sites

PubMed Central

Benkert, R.; Dennehy, P.; White, J.; Hamilton, A.; Tanner, C.

2014-01-01

Summary Background In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. Objectives Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. Methods A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. Results While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. Conclusions Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care

Potential cost savings of medication therapy management in safety-net clinics.

PubMed

Truong, Hoai-An; Groves, C Nicole; Congdon, Heather B; Dang, Diem-Thanh Tanya; Botchway, Rosemary; Thomas, Jennifer

2015-01-01

To evaluate potential cost savings based on estimated cost avoidance from medication therapy management (MTM) services delivered in safety-net clinics over 4 years. High-risk patients taking multiple medications and with chronic conditions were referred for MTM services in primary care safety-net clinics in Maryland from October 1, 2009, to September 30, 2013. Medication-related problems (MRPs) were identified and pharmacists' costs determined to evaluate the estimated cost savings and return on investment (ROI). A range of potential economic outcomes for each MRP identified was assigned to a cost avoidance for outpatient visit, urgent care visit, emergency department visit, and/or hospitalization. Over 4 years, 246 patients received MTM, nearly 2,100 medications were reviewed, and 814 MRPs were identified. The most common MRPs identified were subtherapeutic doses, nonadherence, and untreated indications, with respective prevalences of 38%, 19%, and 16%. The corresponding costs of medical services were estimated at $115,220-$614,570 for all MRPs identified, yielding a mean of $141.55-$755.00 per identified MRP. Pharmacists' expenses for encounters were calculated at a total expenditure of $57,307.50 for 16,965 minutes. ROI based on the time spent during billable face-to-face encounters ranged from 1:5 to 1:25. Pharmacist-provided MTM in safety-net clinics yielded potential economic benefits to the organization. The Primary Care Coalition of Montgomery County plans to expand MTM services to additional clinics to improve patient care and increase cost savings through preventable medical services.

Evaluating predictive modeling’s potential to improve teleretinal screening participation in urban safety net clinics

PubMed Central

Ogunyemi, Omolola; Teklehaimanot, Senait; Patty, Lauren; Moran, Erin; George, Sheba

2013-01-01

Introduction Screening guidelines for diabetic patients recommend yearly eye examinations to detect diabetic retinopathy and other forms of diabetic eye disease. However, annual screening rates for retinopathy in US urban safety net settings remain low. Methods Using data gathered from a study of teleretinal screening in six urban safety net clinics, we assessed whether predictive modeling could be of value in identifying patients at risk of developing retinopathy. We developed and examined the accuracy of two predictive modeling approaches for diabetic retinopathy in a sample of 513 diabetic individuals, using routinely available clinical variables from retrospective medical record reviews. Bayesian networks and radial basis function (neural) networks were learned using ten-fold cross-validation. Results The predictive models were modestly predictive with the best model having an AUC of 0.71. Discussion Using routinely available clinical variables to predict patients at risk of developing retinopathy and to target them for annual eye screenings may be of some usefulness to safety net clinics. PMID:23920536

Medicaid managed care for mental health services: the survival of safety net institutions in rural settings.

PubMed

Willging, Cathleen E; Waitzkin, Howard; Nicdao, Ethel

2008-09-01

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.

Health policy making through operative actions: a case study of provider capacity reduction in a public safety-net system.

PubMed

Tataw, David B

2014-01-01

This article describes and assesses the implications of policy decisions affecting health provider capacity in the Los Angeles County municipal safety-net health system from 1980 to 2000. Although never articulated in law or a county ordinance, the county pursued a sustained and discernable policy of cost reductions that affected capacity at King/Drew Medical Center from 1980 to 2000 without the input of beneficiaries or their advocates. Year after year, the county reduced personnel, supplies, and available beds either by reducing formal budgets or through operative actions of facility administrators that prevented the implementation of formally approved expenditures. This policy appears to have undermined the hospital system's mission of providing health services to at-risk populations with nowhere else to go. Decision making during the two decades under study revealed a decision-making pattern that challenged traditional models of policy decision making.

Computer use, language, and literacy in safety net clinic communication.

PubMed

Ratanawongsa, Neda; Barton, Jennifer L; Lyles, Courtney R; Wu, Michael; Yelin, Edward H; Martinez, Diana; Schillinger, Dean

2017-01-01

Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL. We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status. Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (-0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (-0.9, P < .01), fewer clinician psychosocial statements (-3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication. Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy. Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association.

The Financial Effect of Value-Based Purchasing and the Hospital Readmissions Reduction Program on Safety-Net Hospitals in 2014: A Cohort Study.

PubMed

Gilman, Matlin; Hockenberry, Jason M; Adams, E Kathleen; Milstein, Arnold S; Wilson, Ira B; Becker, Edmund R

2015-09-15

Medicare's value-based purchasing (VBP) and the Hospital Readmissions Reduction Program (HRRP) could disproportionately affect safety-net hospitals. To determine whether safety-net hospitals incur larger financial penalties than other hospitals under VBP and HRRP. Cross-sectional analysis. United States in 2014. 3022 acute care hospitals participating in VBP and the HRRP. Safety-net hospitals were defined as being in the top quartile of the Medicare disproportionate share hospital (DSH) patient percentage and Medicare uncompensated care (UCC) payments per bed. The differences in penalties in both total dollars and dollars per bed between safety-net hospitals and other hospitals were estimated with the use of bivariate and graphical regression methods. Safety-net hospitals in the top quartile of each measure were more likely to be penalized under VBP than other hospitals (62.9% vs. 51.0% under the DSH definition and 60.3% vs. 51.5% under the UCC per-bed definition). This was also the case under the HRRP (80.8% vs. 69.0% and 81.9% vs. 68.7%, respectively). Safety-net hospitals also had larger payment penalties ($115 900 vs. $66 600 and $150 100 vs. $54 900, respectively). On a per-bed basis, this translated to $436 versus $332 and $491 versus $314, respectively. Sensitivity analysis setting the cutoff at the top decile rather than the top quartile decile led to similar conclusions with somewhat larger differences between safety-net and other hospitals. The quadratic fit of the data indicated that the larger effect of these penalties is in the middle of the distribution of the DSH and UCC measures. Only 2 measures of safety-net status were included in the analyses. Safety-net hospitals were disproportionately likely to be affected under VBP and the HRRP, but most incurred relatively small payment penalties in 2014. Patient-Centered Outcomes Research Institute.

Effects of hospital safety-net burden and hospital volume on failure to rescue after open abdominal aortic surgery.

PubMed

Rosero, Eric B; Joshi, Girish P; Minhajuddin, Abu; Timaran, Carlos H; Modrall, J Gregory

2017-08-01

Failure to rescue (FTR) is defined as the inability to rescue a patient from major perioperative complications, resulting in operative mortality. FTR is a known contributor to operative mortality after open abdominal aortic surgery. Understanding the causes of FTR is essential to designing interventions to improve perioperative outcomes. The objective of this study was to determine the relative contributions of hospital volume and safety-net burden (the proportion of uninsured and Medicaid-insured patients) to FTR. The Nationwide Inpatient Sample (2001-2011) was analyzed to investigate variables associated with FTR after elective open abdominal aortic operations in the United States. FTR was defined as in-hospital death following postoperative complications. Mixed multivariate regression models were used to assess independent predictors of FTR, taking into account the clustered structure of the data (patients nested into hospitals). A total of 47,233 elective open abdominal aortic operations were performed in 1777 hospitals during the study period. The overall incidences of postoperative complications, in-hospital mortality, and FTR in the whole cohort were 32.7%, 3.2%, and 8.6%, respectively. After adjusting for demographics, comorbidities, and hospital characteristics, safety-net burden was significantly associated with increased likelihood of FTR (highest vs lowest quartile of safety-net burden, odds ratio, 1.59; 95% confidence interval, 1.32-1.91; P < .0001). In contrast, after adjusting for safety-net burden, procedure-specific hospital volume was not significantly associated with FTR (P = .897). After adjusting for patient- and hospital-level variables, including hospital volume, safety-net burden was an independent predictor of FTR after open aortic surgery. Future investigations should be aimed at better understanding the relationship between safety-net hospital burden and FTR to design interventions to improve outcomes after open abdominal aortic surgery

Advances in measuring culturally competent care: a confirmatory factor analysis of CAHPS-CC in a safety-net population.

PubMed

Stern, Rachel J; Fernandez, Alicia; Jacobs, Elizabeth A; Neilands, Torsten B; Weech-Maldonado, Robert; Quan, Judy; Carle, Adam; Seligman, Hilary K

2012-09-01

Providing culturally competent care shows promise as a mechanism to reduce health care inequalities. Until the recent development of the Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration. We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings. A 7-factor model demonstrated satisfactory fit (χ²₂₃₁=484.34, P<0.0001) with significant factor loadings at P<0.05. Three domains showed excellent reliability-Doctor Communication-Positive Behaviors (α=0.82), Trust (α=0.77), and Doctor Communication-Health Promotion (α=0.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication-Negative Behaviors (α=0.54), Equitable Treatment (α=0.69), Doctor Communication-Alternative Medicine (α=0.52), and Shared Decision-Making (α=0.51). CAHPS-CC domains were positively and significantly correlated with global physician rating. Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings.

Buffering the Uneven Impact of the Affordable Care Act: Immigrant-serving Safety-net Providers in New Mexico.

PubMed

Getrich, Christina M; García, Jacqueline M; Solares, Angélica; Kano, Miria

2018-06-01

We conducted a study in early 2014 to document how the initial implementation of the Affordable Care Act (ACA) affected health care provision to different categories of immigrants from the perspective of health care providers in New Mexico. Though ACA navigators led enrollment, a range of providers nevertheless became involved by necessity, expressing concern about how immigrants were faring in the newly configured health care environment and taking on advocacy roles. Providers described interpreting shifting eligibility and coverage, attending to vulnerable under/uninsured patients, and negotiating new bureaucratic barriers for insured patients. Findings suggest that, like past efforts, this recent reform to the fragmented health care system has perpetuated a condition in which safety-net clinics and providers are left to buffer a widening gap for immigrant patients. With possible changes to the ACA ahead, safety-net providers' critical buffering roles will likely become more crucial, underscoring the necessity of examining their experiences with past reforms. © 2017 by the American Anthropological Association.

Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study.

PubMed

Tieu, Lina; Sarkar, Urmimala; Schillinger, Dean; Ralston, James D; Ratanawongsa, Neda; Pasick, Rena; Lyles, Courtney R

2015-12-03

Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online. To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital. We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers. We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient

Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study

PubMed Central

Sarkar, Urmimala; Schillinger, Dean; Ralston, James D; Ratanawongsa, Neda; Pasick, Rena; Lyles, Courtney R

2015-01-01

Background Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online. Objective To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital. Methods We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers. Results We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health

Petri net controllers for distributed robotic systems

NASA Technical Reports Server (NTRS)

Lefebvre, D. R.; Saridis, George N.

1992-01-01

Petri nets are a well established modelling technique for analyzing parallel systems. When coupled with an event-driven operating system, Petri nets can provide an effective means for integrating and controlling the functions of distributed robotic applications. Recent work has shown that Petri net graphs can also serve as remarkably intuitive operator interfaces. In this paper, the advantages of using Petri nets as high-level controllers to coordinate robotic functions are outlined, the considerations for designing Petri net controllers are discussed, and simple Petri net structures for implementing an interface for operator supervision are presented. A detailed example is presented which illustrates these concepts for a sensor-based assembly application.

Shuttle Net, Tuna Net

NASA Technical Reports Server (NTRS)

1983-01-01

Rockwell International, NASA's prime contractor for the Space Shuttle, asked West Coast Netting (WCN) to develop a safety net for personnel working on the Shuttle Orbiter. This could not be an ordinary net, it had to be relatively small, yet have extraordinary tensile strength. It also had to be fire resistant and resistant to ultraviolet (UV) light. After six months, WCN found the requisite fiber, a polyester-like material called NOMEX. The company was forced to invent a more sophisticated twisting process since conventional methods did not approach specified breaking strength. The resulting product, the Hyperester net, sinks faster and fishes deeper, making it attractive to fishing fleets. A patented treatment for UV protection and greater abrasion resistance make Hyperester nets last longer, and the no-shrink feature is an economic bonus.

Safety analysis of discrete event systems using a simplified Petri net controller.

PubMed

Zareiee, Meysam; Dideban, Abbas; Asghar Orouji, Ali

2014-01-01

This paper deals with the problem of forbidden states in discrete event systems based on Petri net models. So, a method is presented to prevent the system from entering these states by constructing a small number of generalized mutual exclusion constraints. This goal is achieved by solving three types of Integer Linear Programming problems. The problems are designed to verify the constraints that some of them are related to verifying authorized states and the others are related to avoiding forbidden states. The obtained constraints can be enforced on the system using a small number of control places. Moreover, the number of arcs related to these places is small, and the controller after connecting them is maximally permissive. © 2013 ISA. Published by Elsevier Ltd. All rights reserved.

Transformation of the Urban Health Care Safety Net: The Devolution of a Public Responsibility.

PubMed

Kulesher, Robert

2015-01-01

Reduced spending in both federal and state programs and the closure of public hospitals have serious consequences for the health of urban dwellers, especially the poor and uninsured. Through a combination of economic factors, many municipalities have formed public-private partnerships and launched community initiatives to preserve some of the elements of the health care safety net. What once was a responsibility of municipal governments, the provision of health care to poor and uninsured populations, is now posing challenges for private-sector providers. This article identifies several factors that have contributed to the incremental demise of the publicly funded urban health care safety net and how local entities and the federal government are responding to the care of the poor and uninsured.

Financial Stability of Level I Trauma Centers Within Safety-Net Hospitals.

PubMed

Knowlton, Lisa M; Morris, Arden M; Tennakoon, Lakshika; Spain, David A; Staudenmayer, Kristan L

2018-04-20

Level I trauma centers often exist within safety-net hospitals (SNHs), facilities servicing high proportions of low-income and uninsured patients. Given the current health care funding environment, trauma centers within SNHs may be at particular risk. Using California as a model, we hypothesized that SNHs with trauma centers vary in terms of financial stability. We performed a retrospective cohort study using data from publicly available financial disclosure reports from California's Office of Statewide Health Planning and Development. Safety-net hospitals were identified from the California Association of Public Hospitals and Health Systems. The primary outcomes metric for financial performance was operating margin. California hospitals with Level I trauma centers were analyzed (11 SNH sites, 2 non SNH). The SNHs did not behave uniformly, and were clustered into county-owned SNHs (36%, n = 4) and nonprofit-owned SNHs (64%, n = 7). Mean operating margins for county SNHs, nonprofit SNHs, and non SNHs were -16.5%, 8.4%, and 9.5%, respectively (p < 0.001). From 2010 to 2015, operating margins improved for all hospitals, partly due to increases in the percent of insured patients and changes in payer mix. Nonprofit SNHs had a payer mix similar to that of non SNHs; county SNHs had the highest proportions of MediCal (California Medicaid) (45% vs 36% vs 12%, respectively, p < 0.001) and uninsured patients (17% vs 5% vs 0%, respectively, p < 0.001) compared with nonprofit SNHs and non SNHs, respectively. The majority (85%) of Level I trauma centers are within SNHs, whose financial stability is highly variable. A group of SNHs rely on infusions of government funds and are therefore susceptible to changes in policy. These findings suggest deliberate funding efforts are critical to protect the health of the US academic trauma system. Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Physicians' Perceptions of Volunteer Service at Safety-Net Clinics.

PubMed

Mcgeehan, Laura; Takehara, Michael A; Daroszewski, Ellen

2017-01-01

Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal. To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care. The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them. Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective "escape hatch" from the pressures of the physicians' regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients' social, transportation, and financial challenges. The results suggest that appealing to physicians' values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics.

Physicians’ Perceptions of Volunteer Service at Safety-Net Clinics

PubMed Central

McGeehan, Laura; Takehara, Michael A; Daroszewski, Ellen

2017-01-01

Background: Volunteer physicians are crucial for the operation of safety-net clinics, which provide medical care for uninsured and underinsured populations. Thus, identifying ways to maximize the number of physicians volunteering at such clinics is an important goal. Objective: To investigate the perceptions, motivations, functions, and barriers associated with physician volunteering in four safety-net clinics in San Bernardino County, Southern California, a location of great medical need with many barriers to care. Methods: The study participants are physicians belonging to the Southern California Permanente Medical Group who use a combination of discretionary time (during regular work hours) and personal time in evening and weekend hours to volunteer their services. The experimental design incorporates a mixed methodology: an online survey of 31 physicians and follow-up interviews with 8 of them. Results: Physicians conveyed uniformly positive perceptions of their volunteer service, and most were motivated by humanitarian or prosocial desires. Volunteering also provided a protective “escape hatch” from the pressures of the physicians’ regular jobs. Physicians cited few challenges to volunteering. The most common personal barrier was a lack of time. The most common professional barriers were organizational and supply issues at the clinic, along with the patients’ social, transportation, and financial challenges. Conclusion: The results suggest that appealing to physicians’ values and faith, and highlighting the burnout-prevention qualities of volunteering, may be key to recruitment and retention of volunteer physicians who serve underserved and underinsured populations in community clinics. PMID:28241907

SafeNet: a methodology for integrating general-purpose unsafe devices in safe-robot rehabilitation systems.

PubMed

Vicentini, Federico; Pedrocchi, Nicola; Malosio, Matteo; Molinari Tosatti, Lorenzo

2014-09-01

Robot-assisted neurorehabilitation often involves networked systems of sensors ("sensory rooms") and powerful devices in physical interaction with weak users. Safety is unquestionably a primary concern. Some lightweight robot platforms and devices designed on purpose include safety properties using redundant sensors or intrinsic safety design (e.g. compliance and backdrivability, limited exchange of energy). Nonetheless, the entire "sensory room" shall be required to be fail-safe and safely monitored as a system at large. Yet, sensor capabilities and control algorithms used in functional therapies require, in general, frequent updates or re-configurations, making a safety-grade release of such devices hardly sustainable in cost-effectiveness and development time. As such, promising integrated platforms for human-in-the-loop therapies could not find clinical application and manufacturing support because of lacking in the maintenance of global fail-safe properties. Under the general context of cross-machinery safety standards, the paper presents a methodology called SafeNet for helping in extending the safety rate of Human Robot Interaction (HRI) systems using unsafe components, including sensors and controllers. SafeNet considers, in fact, the robotic system as a device at large and applies the principles of functional safety (as in ISO 13489-1) through a set of architectural procedures and implementation rules. The enabled capability of monitoring a network of unsafe devices through redundant computational nodes, allows the usage of any custom sensors and algorithms, usually planned and assembled at therapy planning-time rather than at platform design-time. A case study is presented with an actual implementation of the proposed methodology. A specific architectural solution is applied to an example of robot-assisted upper-limb rehabilitation with online motion tracking. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Comparative Studies of Collaborative Team Depression Care Adoption in Safety Net Clinics

ERIC Educational Resources Information Center

Ell, Kathleen; Wu, Shinyi; Guterman, Jeffrey; Schulman, Sandra-Gross; Sklaroff, Laura; Lee, Pey-Jiuan

2018-01-01

Purpose: To evaluate three approaches adopting collaborative depression care model in Los Angeles County safety net clinics with predominantly Latino type 2 diabetes patients. Methods: Pre-post differences in treatment rates and symptom reductions were compared between baseline, 6-month, and 12-month follow-ups for each approach: (a) Multifaceted…

Implementing a Commercial Rule Base as a Medication Order Safety Net

PubMed Central

Reichley, Richard M.; Seaton, Terry L.; Resetar, Ervina; Micek, Scott T.; Scott, Karen L.; Fraser, Victoria J.; Dunagan, W. Claiborne; Bailey, Thomas C.

2005-01-01

A commercial rule base (Cerner Multum) was used to identify medication orders exceeding recommended dosage limits at five hospitals within BJC HealthCare, an integrated health care system. During initial testing, clinical pharmacists determined that there was an excessive number of nuisance and clinically insignificant alerts, with an overall alert rate of 9.2%. A method for customizing the commercial rule base was implemented to increase rule specificity for problematic rules. The system was subsequently deployed at two facilities and achieved alert rates of less than 1%. Pharmacists screened these alerts and contacted ordering physicians in 21% of cases. Physicians made therapeutic changes in response to 38% of alerts presented to them. By applying simple techniques to customize rules, commercial rule bases can be used to rapidly deploy a safety net to screen drug orders for excessive dosages, while preserving the rule architecture for later implementations of more finely tuned clinical decision support. PMID:15802481

The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics.

PubMed

Li, Suhui; Dor, Avi; Pines, Jesse M; Zocchi, Mark S; Hsia, Renee Y

2016-10-01

In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics. © The Author(s) 2015.

Feasibility of a Video-Based Advance Care Planning Website to Facilitate Group Visits among Diverse Adults from a Safety-Net Health System.

PubMed

Zapata, Carly; Lum, Hillary D; Wistar, Emily; Horton, Claire; Sudore, Rebecca L

2018-02-20

Primary care providers in safety-net settings often do not have time to discuss advance care planning (ACP). Group visits (GV) may be an efficient means to provide ACP education. To assess the feasibility and impact of a video-based website to facilitate GVs to engage diverse adults in ACP. Feasibility pilot among patients who were ≥55 years of age from two primary care clinics in a Northern California safety-net setting. Participants attended two 90-minute GVs and viewed the five steps of the movie version of the PREPARE website ( www.prepareforyourcare.org ) concerning surrogates, values, and discussing wishes in video format. Two clinician facilitators were available to encourage participation. We assessed pre-to-post ACP knowledge, whether participants designated a surrogate or completed an advance directive (AD), and acceptability of GVs and PREPARE materials. We conducted two GVs with 22 participants. Mean age was 64 years (±7), 55% were women, 73% nonwhite, and 55% had limited literacy. Knowledge improved about surrogate designation (46% correct pre vs. 85% post, p = 0.01) and discussing decisions with others (59% vs. 90%, p = 0.01). Surrogate designation increased (48% vs. 85%, p = 0.01) and there was a trend toward AD completion (9% vs. 24%, p = 0.21). Participants rated the GVs and PREPARE materials a mean of 8 (±3.1) on a 10-point acceptability scale. Using the PREPARE movie to facilitate ACP GVs for diverse adults in safety net, primary care settings is feasible and shows potential for increasing ACP engagement.

Overcrowding and diversion in the emergency department: the health care safety net unravels.

PubMed

Velianoff, George D

2002-03-01

Emergency department overcrowding and diversion of patients are serious problems that are symptomatic of larger health care system issues. Downsizing, government regulations, managed care, increased numbers of uninsured, and reimbursement decreases are issues that have created the overcrowding and diversion issues. The Emergency Medical Treatment and Active Labor Act (EMTALA), poor operations and hospital processes, unavailable inpatient beds and closures, consolidations and workforce shortages are also contributors to the overcrowding and diversion issues. Options and solutions are proposed to alleviate the problem, however, greater collaboration, changed work environments, and reimbursement structures need to be developed and instituted. The safety net of the US health system is unraveling, and without intervention, the emergency department will not be able to provide services to the public at any level of quality and efficiency.

Between the flags: implementing a safety-net system at scale to recognise and manage deteriorating patients in the New South Wales Public Health System.

PubMed

Pain, Charles; Green, Malcolm; Duff, Colette; Hyland, Deborah; Pantle, Annette; Fitzpatrick, Kimberley; Hughes, Cliff

2017-02-01

In 2005, the Clinical Excellence Commission (CEC) found that unrecognised patient deterioration remained an important problem in New South Wales (NSW) public hospitals. The challenge was to design and implement an effective and sustainable safety-net system in all 225 NSW public hospitals. The CEC's system was designed in collaboration with a broad coalition of partners, including clinicians, managers, system administrators and collaborating agencies. A five-element system comprising governance, standard calling criteria in standard observation charts, two-level clinical emergency response systems (CERS) in each facility, an education programme and evaluation, was designed for state-wide implementation. This system was called 'Between the Flags' (BTF). Implementation was led by the CEC on behalf of a NSW coalition, and commenced in January 2010 with the implementation of the Standard Adult General Observation Chart, awareness training for all staff and a CERS in each facility. Since the introduction of BTF, the cardiac arrest rate has declined by 42% (P < 0.05) and the Rapid Response rate has increased by 135.9% (P < 0.05) in NSW. The strength of staff support for BTF has grown with the proportion of respondents strongly agreeing that BTF has benefitted patient safety more than doubling from 21% to 44%, and overall agreement rising from 68% to 82% between 2010 and 2012. Key success factors are a focus on governance, standardisation of observation charts and striking the right balance between a rule-based approach and individual clinical judgement. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Who Lacks Support and Why? An Examination of Mothers' Personal Safety Nets

ERIC Educational Resources Information Center

Harknett, Kristen S.; Hartnett, Caroline Sten

2011-01-01

We use data from the Fragile Families and Child Wellbeing Study (N = 12,140 person-waves) to identify characteristics associated with mothers' having or lacking "personal safety net" support from family and friends. We focus on characteristics that are likely to increase the importance of having support available but may also interfere with the…

Failure to rescue in safety-net hospitals: availability of hospital resources and differences in performance.

PubMed

Wakeam, Elliot; Hevelone, Nathanael D; Maine, Rebecca; Swain, Jabaris; Lipsitz, Stuart A; Finlayson, Samuel R G; Ashley, Stanley W; Weissman, Joel S

2014-03-01

Failure to rescue (FTR), the mortality rate among surgical patients with complications, is an emerging quality indicator. Hospitals with a high safety-net burden, defined as the proportion of patients covered by Medicaid or uninsured, provide a disproportionate share of medical care to vulnerable populations. Given the financial strains on hospitals with a high safety-net burden, availability of clinical resources may have a role in outcome disparities. To assess the association between safety-net burden and FTR and to evaluate the effect of clinical resources on this relationship. A retrospective cohort of 46,519 patients who underwent high-risk inpatient surgery between January 1, 2007, and December 31, 2010, was assembled using the Nationwide Inpatient Sample. Hospitals were divided into the following 3 safety-net categories: high-burden hospitals (HBHs), moderate-burden hospitals (MBHs), and low-burden hospitals (LBHs). Bivariate and multivariate analyses controlling for patient, procedural, and hospital characteristics, as well as clinical resources, were used to evaluate the relationship between safety-net burden and FTR. FTR. Patients in HBHs were younger (mean age, 65.2 vs 68.2 years; P = .001), more likely to be of black race (11.3% vs 4.2%, P < .001), and less likely to undergo an elective procedure (39.3% vs 48.6%, P = .002) compared with patients in LBHs. The HBHs were more likely to be large, major teaching facilities and to have high levels of technology (8.6% vs 4.0%, P = .02), sophisticated internal medicine (7.7% vs 4.3%, P = .10), and high ratios of respiratory therapists to beds (39.7% vs 21.1%, P < .001). However, HBHs had lower proportions of registered nurses (27.9% vs 38.8%, P = .02) and were less likely to have a positron emission tomographic scanner (15.4% vs 22.0%, P = .03) and a fully implemented electronic medical record (12.6% vs 17.8%, P = .03). Multivariate analyses showed that HBHs (adjusted odds ratio, 1.35; 95% CI

Childhood poverty and the social safety net.

PubMed

Oberg, Charles N; Aga, Andrea

2010-11-01

Childhood poverty in the USA remains an issue that concerns the child, the family, the community, each state, and the nation. It also is a topic that pediatricians must become cognizant of because of the impact it has on the children we care for daily. It goes beyond the specific income threshold that sets the federal poverty level; rather it impacts on the ability of families to acquire life's basic needs to allow their children the opportunity to reach their full potential. These basic needs include adequate nutrition to grow and develop in an optimal fashion and a secure and stable home in a safe neighborhood, which allows for play, exploration, and physical activity. It must also include access to health insurance coverage as well as a physician, health center, and health system to meet their medical needs. In addition, we must provide early education opportunities to nurture the social and emotional health of our children and prepare each child for school. The school environment must promote academic achievement and the broader community must foster opportunities to minimize violence and reduce the need for incarceration. The integration of such provisions represents a broadening and redefinition of the Social Safety Net that incorporates both public and private sector efforts to maximize the life potential of each child. Copyright © 2010 Mosby, Inc. All rights reserved.

Using a safety net and following the safety instructions could prevent half the paediatric trampoline injuries.

PubMed

Rättyä, J; Serlo, W

2008-08-01

The number of recreational trampolines in Finnish households has increased. There also appears to be a drastic increase in trampoline-related injuries among paediatric patients. The aim of this study was to quantify and describe trampoline-related injuries in North Finnish paediatric patients. A retrospective analysis of medical data was used in the study, covering children 16 years and younger treated for trampoline-related injuries at Oulu University Hospital over a five-month period of time from May 1 to September 30, 2005. Medical records were reviewed and additional details regarding the injuries were obtained by questionnaire. Altogether 76 patients were treated for trampoline-related injuries, which represented 13.4 % of all paediatric accidental trauma patients. In 57 accidents (86 %), there had been multiple jumpers on the trampoline. Twenty-five of the injuries (38 %) had occurred on the trampoline, in 25 cases (38 %) a child had fallen off, in 8 cases (12 %) there had been a collision with another jumper and the person had jumped onto a trampoline from a high platform in 5 incidents (8 %). Only 3 children (5 %) hurt themselves on the trampoline when jumping alone. Orthopaedic procedures requiring general anaesthesia were necessary in a total of 31 cases (41 %). The study shows that 50 % of traumas (falling off and collisions) could have been avoided by using a safety net and by jumping one at a time. The importance of following safety instructions and the need for a safety net should be emphasised to both the supervising adults and the children.

Public housing relocations in Atlanta, Georgia, and declines in spatial access to safety net primary care

PubMed Central

Cooper, Hannah LF; Wodarski, Stephanie; Cummings, Janet; Hunter-Jones, Josalin; Karnes, Conny; Ross, Zev; Druss, Ben; Bonney, Loida E

2012-01-01

This analysis investigates changes in spatial access to safety-net primary care in a sample of US public housing residents relocating via the HOPE VI initiative from public housing complexes to voucher-subsidized rental units; substance misusers were oversampled. We used gravity-based models to measure spatial access to care, and used mixed models to assess pre-/post-relocation changes in access. Half the sample experienced declines in spatial access of ≥79.83%; declines did not vary by substance misuse status. Results suggest that future public housing relocation initiatives should partner with relocaters, particularly those in poor health, to help them find housing near safety-net clinics. PMID:23060002

Initial surgical experience following implementation of lung cancer screening at an urban safety net hospital.

PubMed

Muñoz-Largacha, Juan A; Steiling, Katrina A; Kathuria, Hasmeena; Charlot, Marjory; Fitzgerald, Carmel; Suzuki, Kei; Litle, Virginia R

2018-06-01

Safety net hospitals provide care mostly to low-income, uninsured, and vulnerable populations, in whom delays in cancer screening are established barriers. Socioeconomic barriers might pose important challenges to the success of a lung cancer screening program at a safety net hospital. We aimed to determine screening follow-up compliance, rates of diagnostic and treatment procedures, and the rate of cancer diagnosis in patients classified as category 4 by the Lung CT Screening Reporting and Data System (Lung-RADS 4). We conducted a retrospective review of all patients enrolled in our multidisciplinary lung cancer screening program between March 2015 and July 2016. Demographics, smoking status, Lung-RADS score, and number of diagnostic and therapeutic interventions and cancer diagnoses were captured. A total of 554 patients were screened over a 16-month period. The mean patient age was 63 years (range, 47-85 years), and 60% were male. The majority (92%; 512 of 554) were classified as Lung-RADS 1 to 3, and 8% (42 of 554) were classified as Lung-RADS 4. Among the Lung-RADS 4 patients, 98% (41 of 42) completed their recommended follow-up; 29% (12 of 42) underwent a diagnostic procedure, for an overall diagnostic intervention rate of 2% (12 of 554). Eleven of these 12 patients had cancer, and 1 patient had sarcoidosis. The overall rate of surgical resection was 0.9% (5 of 554), and the rate of diagnostic intervention for noncancer diagnosis was 0.1% (1 of 554). Implementation of a multidisciplinary lung cancer screening program at a safety net hospital is feasible. Compliance with follow-up and interventional recommendations in Lung-RADS 4 patients was high despite anticipated social challenges. Overall diagnostic and surgical resection rates and interventions for noncancer diagnosis were low in our initial experience. Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Effectiveness of direct-acting antiviral therapy for hepatitis C in difficult-to-treat patients in a safety-net health system: a retrospective cohort study.

PubMed

Yek, Christina; de la Flor, Carolina; Marshall, John; Zoellner, Cindy; Thompson, Grace; Quirk, Lisa; Mayorga, Christian; Turner, Barbara J; Singal, Amit G; Jain, Mamta K

2017-11-20

Direct-acting antivirals (DAAs) have revolutionized chronic hepatitis C (HCV) treatment, but real-world effectiveness among vulnerable populations, including uninsured patients, is lacking. This study was conducted to characterize the effectiveness of DAAs in a socioeconomically disadvantaged and underinsured patient cohort. This retrospective observational study included all patients undergoing HCV treatment with DAA-based therapy between April 2014 and June 2016 at a large urban safety-net health system (Parkland Health and Hospital System, Dallas, TX, USA). The primary outcome was sustained virologic response (SVR), with secondary outcomes including treatment discontinuation, treatment relapse, and loss to follow-up. DAA-based therapy was initiated in 512 patients. The cohort was socioeconomically disadvantaged (56% uninsured and 13% Medicaid), with high historic rates of alcohol (41%) and substance (50%) use, and mental health disorders (38%). SVR was achieved in 90% of patients (n = 459); 26 patients (5%) were lost to follow-up. SVR was significantly lower in patients with decompensated cirrhosis (82% SVR; OR 0.37, 95% CI 0.16-0.85) but did not differ by insurance status (P = 0.98) or alcohol/substance use (P = 0.34). Reasons for treatment failure included loss to follow-up (n = 26, 5%), viral relapse (n = 16, 3%), non-treatment-related death (n = 7, 1%), and treatment discontinuation (n = 4, 1%). Of patients with viral relapse, 6 reported non-compliance and have not been retreated, 5 have been retreated and achieved SVR, 4 have undergone resistance testing but not yet initiated retreatment, and 1 was lost to follow-up. Effective outcomes with DAA-based therapy can be achieved in difficult-to-treat underinsured populations followed in resource-constrained safety-net health systems.

Understanding the Knowledge Gap Experienced by U.S. Safety Net Patients in Teleretinal Screening.

PubMed

George, Sheba M; Hayes, Erin Moran; Fish, Allison; Daskivich, Lauren Patty; Ogunyemi, Omolola I

2016-01-01

Safety-net patients' socioeconomic barriers interact with limited digital and health literacies to produce a "knowledge gap" that impacts the delivery of healthcare via telehealth technologies. Six focus groups (2 African- American and 4 Latino) were conducted with patients who received teleretinal screening in a U.S. urban safety-net setting. Focus groups were analyzed using a modified grounded theory methodology. Findings indicate that patients' knowledge gap is primarily produced at three points during the delivery of care: (1) exacerbation of patients' pre-existing personal barriers in the clinical setting; (2) encounters with technology during screening; and (3) lack of follow up after the visit. This knowledge gap produces confusion, potentially limiting patients' perceptions of care and their ability to manage their own care. It may be ameliorated through delivery of patient education focused on both disease pathology and specific role of telehealth technologies in disease management.

Modeling of Electrocardiograph Telediagnosing System Based on Petri Net

NASA Astrophysics Data System (ADS)

Hu, Wensong; Li, Ming; Li, Lan

This paper analyzed the characteristics of the electrocardiograph telediagnosing system. Firstly, we introduce the system and Petri nets. Secondly, we built a topological diagram of this system. Then we use Petri nets to show the physical process of this system. Finally, we verified the model of the electrocardiograph telediagnosing system. With the help of model based on Petri nets, we analyzed the system performance and feasibility.

How 3 rural safety net clinics integrate care for patients: a qualitative case study.

PubMed

Derrett, Sarah; Gunter, Kathryn E; Nocon, Robert S; Quinn, Michael T; Coleman, Katie; Daniel, Donna M; Wagner, Edward H; Chin, Marshall H

2014-11-01

Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients. To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Qualitative case study. Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.

FiberNet--a new embolic protection device for carotid artery stenting.

PubMed

Bauer, C; Franke, J; Bertog, S C; Woerner, V; Ghasemzadeh-Asl, S; Sievert, H

2014-05-01

Though distal filter protection during carotid stenting reduces the risk of cerebrovascular events, periprocedural stroke remains a risk despite their broad usage. This observation may be related to the pore size of common filters. The FiberNet distal filter system is unique by its very small pore size (40 µm) as well as its low profile and flexibility. Little data is available regarding the clinical performance and safety of this device. The aim was the evaluation of the safety of the FiberNet embolic protection system during carotid artery stenting. All consecutive patients treated with carotid stenting at our institution using the FiberNet device were systematically followed. Primary endpoint was the rate of all death and stroke within 30 days of the procedure. Carotid artery stenting using the FiberNet embolic protection system was performed in 54 patients. The procedure was technical successful in all patients. Three patients (5.5%) had a TIA. Amauosis fugax occurred in two patients (3.7%). One patient (1.9%) had a minor stroke with hemiparesis of the left arm and face which resolved completely within 48 hr after the procedure. No patient died or suffered a major stroke. The safety and feasibility of the FiberNet distal protection system appears to be at least equivalent to that reported in studies using conventional distal filter protection. Copyright © 2013 Wiley Periodicals, Inc.

Patient and provider perspectives on the potential value and use of a bilingual online patient portal in a Spanish-speaking safety-net population.

PubMed

Ochoa, Alejandro; Kitayama, Ken; Uijtdehaage, Sebastian; Vermillion, Michelle; Eaton, Michael; Carpio, Felix; Serota, Martin; Hochman, Michael E

2017-11-01

To assess patient and provider perspectives on the potential value and use of a bilingual patient portal in a large safety-net health system serving predominantly Spanish-speaking patients. We captured patient and provider perspectives through the administration of surveys to assess Internet access, barriers, and facilitators to patient portal adoption, along with portal preferences. We report on these survey results using descriptive and comparative statistics. Four hundred patients (82% response rate) and 59 providers (80% response rate) participated in the study. Although 73% of providers believed that the patient portal would increase patient satisfaction, just 39% planned to recommend portal use to patients, citing concerns related to time and reimbursement. In contrast, 72% of patients believed the patient portal would strengthen the patient-provider relationship and 77% believed it would improve the quality of care. Latino patients in particular believed the patient portal would strengthen the patient-provider relationship. Seventy-five percent of patients reported interest in a mobile version of the portal. Patients from a safety-net health system, most of whom were Spanish-speaking, reported a high level of interest in the patient portal. Providers at the same health system expressed reluctance about the portal due to concerns related to time and reimbursement. Bilingual patient portal implementation has considerable potential to promote health care engagement within Spanish-speaking safety-net populations; however, lack of provider engagement in the process could undermine the effort. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Translating self-persuasion into an adolescent HPV vaccine promotion intervention for parents attending safety-net clinics.

PubMed

Baldwin, Austin S; Denman, Deanna C; Sala, Margarita; Marks, Emily G; Shay, L Aubree; Fuller, Sobha; Persaud, Donna; Lee, Simon Craddock; Skinner, Celette Sugg; Wiebe, Deborah J; Tiro, Jasmin A

2017-04-01

Self-persuasion is an effective behavior change strategy, but has not been translated for low-income, less educated, uninsured populations attending safety-net clinics or to promote human papillomavirus (HPV) vaccination. We developed a tablet-based application (in English and Spanish) to elicit parental self-persuasion for adolescent HPV vaccination and evaluated its feasibility in a safety-net population. Parents (N=45) of age-eligible adolescents used the self-persuasion application. Then, during cognitive interviews, staff gathered quantitative and qualitative feedback on the self-persuasion tasks including parental decision stage. The self-persuasion tasks were rated as easy to complete and helpful. We identified six question prompts rated as uniformly helpful, not difficult to answer, and generated non-redundant responses from participants. Among the 33 parents with unvaccinated adolescents, 27 (81.8%) reported deciding to get their adolescent vaccinated after completing the self-persuasion tasks. The self-persuasion application was feasible and resulted in a change in parents' decision stage. Future studies can now test the efficacy of the tablet-based application on HPV vaccination. The self-persuasion application facilitates verbalization of reasons for HPV vaccination in low literacy, safety-net settings. This self-administered application has the potential to be more easily incorporated into clinical practice than other patient education approaches. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

The methodology for modeling queuing systems using Petri nets

NASA Astrophysics Data System (ADS)

Kotyrba, Martin; Gaj, Jakub; Tvarůžka, Matouš

2017-07-01

This papers deals with the use of Petri nets in modeling and simulation of queuing systems. The first part is focused on the explanation of basic concepts and properties of Petri nets and queuing systems. The proposed methodology for the modeling of queuing systems using Petri nets is described in the practical part. The proposed methodology will be tested on specific cases.

The unintended consequences of The Centers for Medicare and Medicaid Services pay-for-performance structures on safety-net hospitals and the low-income, medically vulnerable population.

PubMed

Fos, Elmer B

2017-02-01

Safety-net hospitals are hospitals with patient mix that is substantially composed of the uninsured, underinsured, and low-income, medically vulnerable patient populations. They are the hospitals of last resort for poor patients. This article examined the impact of The Centers for Medicare and Medicaid Services pay-for-performance reimbursement policies on the financial viability of safety-net hospitals. Studies showed that these policies, which are based on the principle of reward and punishment, might have unintentionally placed safety-net hospitals on financial disadvantage compared to other hospital organizations. Several studies implied that these payment structures might have resulted in a situation where safety-net hospitals that are serving poor patient populations become more susceptible to penalties than hospitals that are serving affluent patients.

Are Latino immigrants a burden to safety net services in nontraditional immigrant states? Lessons from Oregon.

PubMed

López-Cevallos, Daniel

2014-05-01

The significant growth of the Latino population in the midst of an economic recession has invigorated anti-Latino, anti-immigrant sentiments in many US states. One common misconception is that Latino immigrants are a burden to safety net services. This may be particularly true in nontraditional immigrant states that have not historically served Latino immigrants. Oregon data suggest that despite a higher prevalence of poverty, use of safety net services among Latino immigrants in Oregon is lower than that among non-Latino Whites. Immigration status, costs, lack of insurance coverage, and discrimination are among the reasons for this group's limited use of services. Nevertheless, policies designed to strengthen community and institutional support for Latino immigrant families should be considered in the context of current health care and immigration reform efforts.

Are Latino Immigrants a Burden to Safety Net Services in Nontraditional Immigrant States? Lessons From Oregon

PubMed Central

2014-01-01

The significant growth of the Latino population in the midst of an economic recession has invigorated anti-Latino, anti-immigrant sentiments in many US states. One common misconception is that Latino immigrants are a burden to safety net services. This may be particularly true in nontraditional immigrant states that have not historically served Latino immigrants. Oregon data suggest that despite a higher prevalence of poverty, use of safety net services among Latino immigrants in Oregon is lower than that among non-Latino Whites. Immigration status, costs, lack of insurance coverage, and discrimination are among the reasons for this group’s limited use of services. Nevertheless, policies designed to strengthen community and institutional support for Latino immigrant families should be considered in the context of current health care and immigration reform efforts. PMID:24625168

Modeling of Biometric Identification System Using the Colored Petri Nets

NASA Astrophysics Data System (ADS)

Petrosyan, G. R.; Ter-Vardanyan, L. A.; Gaboutchian, A. V.

2015-05-01

In this paper we present a model of biometric identification system transformed into Petri Nets. Petri Nets, as a graphical and mathematical tool, provide a uniform environment for modelling, formal analysis, and design of discrete event systems. The main objective of this paper is to introduce the fundamental concepts of Petri Nets to the researchers and practitioners, both from identification systems, who are involved in the work in the areas of modelling and analysis of biometric identification types of systems, as well as those who may potentially be involved in these areas. In addition, the paper introduces high-level Petri Nets, as Colored Petri Nets (CPN). In this paper the model of Colored Petri Net describes the identification process much simpler.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

PubMed Central

Matta, George Yaccoub; Khoong, Elaine C; Lyles, Courtney R; Schillinger, Dean

2018-01-01

Background Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication. Objective This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system. Methods This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as “multitasking EHR use,” “silent EHR use,” “non-EHR multitasking,” and “focused patient-clinician talk.” Finally, we analyzed communication patterns to develop a conceptual framework. Results We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1

EPA NetDMR CROMERR System Checklist

EPA Pesticide Factsheets

The Network Disharge Monitoring Report (NetDMR) electronic reporting system is used for the receipt of discharge monitoring reports (DMRs) under the National Pollutant Discharge Elimination System (NPDES) program,

Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Process Breakdowns.

PubMed

Ackerman, Sara L; Gourley, Gato; Le, Gem; Williams, Pamela; Yazdany, Jinoos; Sarkar, Urmimala

2018-03-14

The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized. Surveys and transcripts from the meetings were analyzed to understand the decision-making process. The Delphi process included eight panelists. Consensus was reached to adopt 9 of 13 proposed measures. All 9 measures were unanimously considered valid, but concern was expressed about the feasibility of implementing several of the measures. Although safety net health systems face high barriers to standardized measurement, our study demonstrates that consensus can be reached on acceptable and feasible methods for tracking patient safety gaps in safety net health systems. If accompanied by the active participation key stakeholder groups, including patients, clinicians, staff, data system professionals, and health system leaders, the consensus measures reported here represent one step toward improving ambulatory patient safety in safety net health systems.

Disproportionate-share hospital payment reductions may threaten the financial stability of safety-net hospitals.

PubMed

Neuhausen, Katherine; Davis, Anna C; Needleman, Jack; Brook, Robert H; Zingmond, David; Roby, Dylan H

2014-06-01

Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid (known as Medicaid shortfalls). The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability by estimating how total DSH costs (uncompensated care costs and Medicaid shortfalls) will change as a result of insurance expansion and the offsetting DSH reductions. Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. Taking these three factors into account, we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363-$2.503 billion in 2019, with unmet DSH costs of $1.381-$1.537 billion. Project HOPE—The People-to-People Health Foundation, Inc.

A Petri net controller for distributed hierarchical systems. Thesis

NASA Technical Reports Server (NTRS)

Peck, Joseph E.

1991-01-01

The solutions to a wide variety of problems are often best organized as a distributed hierarchical system. These systems can be graphically and mathematically modeled through the use of Petri nets, which can easily represent synchronous, asynchronous, and concurrent operations. This thesis presents a controller implementation based on Petri nets and a design methodology for the interconnection of distributed Petri nets. Two case studies are presented in which the controller operates a physical system, the Center for Intelligent Robotic Systems for Space Exploration Dual Arm Robotic Testbed.

Risk factors for reporting poor cultural competency among patients with diabetes in safety net clinics.

PubMed

Seligman, Hilary K; Fernandez, Alicia; Stern, Rachel J; Weech-Maldonado, Robert; Quan, Judy; Jacobs, Elizabeth A

2012-09-01

The Consumer Assessment of Healthcare Providers and Systems Cultural Competency Item Set assesses patient perceptions of aspects of the cultural competence of their health care. To determine characteristics of patients who identify the care they receive as less culturally competent. Cross-sectional survey consisting of face-to-face interviews. Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care. Participants completed the Consumer Assessment of Healthcare Providers and Systems Cultural Competency and answered questions about their race/ethnicity, sex, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and comorbidities. In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication--Positive Behaviors domain [odds ratio (OR) 1.73, 95% confidence interval, 1.11-2.69]. African Americans were less likely than whites to report poor cultural competence in the Doctor Communication--Positive Behaviors domain (OR 0.52, 95% CI, 0.28-0.97). Participants who reported a longer relationship (≥ 3 y) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication--Health Promotion (OR 0.35, 95% CI, 0.21-0.60) and Trust domains (OR 0.4, 95% CI, 0.24-0.67), whereas participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 95% CI, 0.30-0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.

Drug company-sponsored patient assistance programs: a viable safety net?

PubMed

Choudhry, Niteesh K; Lee, Joy L; Agnew-Blais, Jessica; Corcoran, Colleen; Shrank, William H

2009-01-01

Drug company-sponsored patient assistance programs (PAPs) provide access to brand-name medications at little or no cost and have been advocated as a safety net for inadequately insured patients. Yet little is known about these programs. We surveyed drug company-sponsored PAPs and found much variability in their structures and application processes. Most cover one or two drugs. Only 4 percent disclosed how many patients they had directly helped, and half would not disclose their income eligibility criteria. A better understanding of PAPs might clarify their role in improving access to medications, the adequacy of existing public programs, and their impact on cost-effective medication use.

Teleretinal screening for diabetic retinopathy in six Los Angeles urban safety-net clinics: final study results.

PubMed

Ogunyemi, Omolola; George, Sheba; Patty, Lauren; Teklehaimanot, Senait; Baker, Richard

2013-01-01

In a previous paper, we presented initial findings from a study on the feasibility and challenges of implementing teleretinal screening for diabetic retinopathy in an urban safety net setting facing eyecare specialist shortages. This paper presents some final results from that study, which involved six South Los Angeles safety net clinics. A total of 2,732 unique patients were screened for diabetic retinopathy by three ophthalmologist readers, with 1035 receiving a recommendation for referral to specialty care. Referrals included 48 for proliferative diabetic retinopathy, 115 for severe non-proliferative diabetic retinopathy (NPDR), 247 for moderate NPDR, 246 for mild NPDR, 97 for clinically significant macular edema, and 282 for a non-diabetic condition, such as glaucoma. Image quality was also assessed, with ophthalmologist readers grading 4% to 13% of retinal images taken at the different clinics as being inadequate for any diagnostic interpretation.

Supporting Medical Home Transformation Through Evaluation of Patient Experience in a Large Culturally Diverse Primary Care Safety Net.

PubMed

Cook, Nicole; Hollar, T Lucas; Zunker, Christie; Peterson, Michael; Phillips, Teina; De Lucca, Michael

2016-01-01

The prevalence of chronic disease in the United States is rapidly increasing, with a disproportionate number of underserved, vulnerable patients sharing the burden. The Patient-Centered Medical Home (PCMH) is a care delivery model that has shown promise to improve primary care and address the burden of chronic illness. The purpose of this study was to (1) understand patient characteristics that might influence perceived patient experience in a large primary care safety net undergoing PCMH transformation; (2) identify community-level quality improvement opportunities to support ongoing transformation activities; and (3) establish a baseline of patient experience across the primary care safety net that could be used in repeated evaluations over the course of transformation. A cross-sectional study design was used to conduct this research. A total of 351 racially and ethnically diverse patients of 4 primary care safety net organizations in Broward County, Florida, were surveyed regarding their experience with access to care and coordination of care. Reported access to care and coordination of care. Patients with chronic disease who reported having visited the clinic 3 or more times in the past 12 months reported a better coordination of care experience than patients who had fewer than 3 visits in the past 12 months (odds ratio = 3.57; 95% confidence interval, 1.76-7.24). Patients without chronic disease who had been receiving care at the clinic for 2 or more years of care reported worse experience with access to care than patients with less than 2 years of care (odds ratio = 0.26; 95% confidence interval, 0.11-0.60.) Race, ethnicity, language, and education were not significant predictors of patient experience. Findings support ongoing efforts to improve patient engagement among all patients and to enhance resources to manage chronic disease, including community-based self-management programs, in primary care safety nets undergoing PCMH transformation.

A Pilot Quality Improvement Collaborative to Improve Safety Net Dental Access for Pregnant Women and Young Children.

PubMed

Vander Schaaf, Emily B; Quinonez, Rocio B; Cornett, Amanda C; Randolph, Greg D; Boggess, Kim; Flower, Kori B

2018-02-01

Objectives To determine acceptability and feasibility of a quality improvement (QI) collaborative in safety net dental practices, and evaluate its effects on financial stability, access, efficiency, and care for pregnant women and young children. Methods Five safety net dental practices participated in a 15-month learning collaborative utilizing business assessments, QI training, early childhood oral health training, and prenatal oral health training. Practices collected monthly data on: net revenue, no-show rates, total encounters, and number of encounters for young children and pregnant women. We analyzed quantitative data using paired t-tests before and after the collaborative and collected supplemental qualitative feedback from clinic staff through focus groups and directed email. Results All mean measures improved, including: higher monthly revenue ($28,380-$33,102, p = 0.37), decreased no-show rate (17.7-14.3%, p = 0.11), higher monthly dental health encounters (283-328, p = 0.08), and higher monthly encounters for young children (8.8-10.5, p = 0.65), and pregnant women (2.8-9.7, p = 0.29). Results varied by practice, with some demonstrating largest increases in encounters for young children and others pregnant women. Focus group participants reported that the collaborative improved access for pregnant women and young children, and that QI methods were often new and difficult. Conclusion for practice Participation by safety net dental practices in a QI collaborative is feasible and acceptable. Individual sites saw greater improvements in different outcomes areas, based on their own structures and needs. Future efforts should focus on specific needs of each dental practice and should offer additional QI training.

Population characteristics of markets of safety-net and non-safety-net hospitals.

PubMed

Gaskin, D J; Hadley, J

1999-09-01

To compare and contrast the markets of urban safety-net (USN) hospitals with the markets of other urban hospitals. To develop profiles of the actual inpatient markets of hospitals, we linked 1994 patient-level information from hospital discharge abstracts from nine states with 1990 data at the ZIP code level from the US Census Bureau. Each hospital's market was characterized by its racial and ethnic composition, median household income, poverty rate, and educational attainment. Measures of hospital competition were also calculated for each hospital. The analysis compared the market profiles of USN hospitals to those of other urban hospitals. We also compared the level of hospital competition and financial status of USN and other urban hospitals. The markets of USN hospitals had higher proportions of racial and ethnic minorities and non-English-speaking residents. Adults residing in markets of USN hospitals were less educated. Families living in markets of USN hospitals had lower incomes and were more likely to be living at or below the federal poverty level. USN hospitals and other urban hospitals faced similar levels of competition and had similar margins. However, USN hospitals were more dependent on Medicare disproportionate share payments and on state and local government subsidies to remain solvent. USN hospitals disproportionately serve vulnerable minority and low-income communities that otherwise face financial and cultural barriers to health care. USN hospitals are dependent on the public subsidies they receive from federal, state, and local governments. Public policies and market pressures that affect the viability of USN hospitals place the access to care by vulnerable populations at risk. Public policy that jeopardizes public subsidies places in peril the financial health of these institutions. As Medicare and Medicaid managed care grow, USN hospitals may lose these patient revenues and public subsidies based on their Medicaid and Medicare patient

Designing an IMAC system using TeraNet

NASA Astrophysics Data System (ADS)

Mun, In K.; Hilal, S. K.; Andrews, M. C.; Gidron, Rafael

1992-07-01

Even though considerable progresses have been made with communication technology, one of the more difficult problems facing in installing a comprehensive clinically effective Image Management and Communication (IMAC) system for a hospital is the communication problem. Most existing systems are based on Ethernet or Token-ring net. Some of the newer systems are being installed using FDDL. All these systems have inherent problems like communication speed, control of bandwidth usage, or/and poor performance under heavy traffic. In order to overcome these difficulties, we are designing a complete IMAC system based on a novel network known as TeraNet, being developed at Center for Telecommunication Research, Columbia University.

Shifts in Medicaid and Uninsured Payer Mix at Safety-Net and Non-Safety-Net Hospitals During the Great Recession.

PubMed

Fingar, Kathryn R; Coffey, Rosanna M; Mulcahy, Andrew W; Andrews, Roxanne M; Stocks, Carol

2018-01-01

There has been ongoing concern regarding the viability of safety-net hospitals (SNHs), which care for vulnerable populations. The authors examined payer mix at SNHs and non-SNHs during a period covering the Great Recession using data from the 2006 to 2012 Healthcare Cost and Utilization Project State Inpatient Databases from 38 states. The number of privately insured stays decreased at both SNHs and non-SNHs. Non-SNHs increasingly served Medicaid-enrolled and uninsured patients; in SNHs, the number of Medicaid stays decreased and uninsured stays remained stable. These study findings suggest that SNHs were losing Medicaid-enrolled patients relative to non-SNHs before the Medicaid expansion under the Affordable Care Act (ACA). Postexpansion, Medicaid stays will likely increase for both SNHs and non-SNHs, but the increase at SNHs may not be as large as expected if competition increases. Because hospital stays with private insurance and Medicaid help SNHs offset uncompensated care, a lower-than-expected increase could affect SNHs' ability to care for the remaining uninsured population. Continued monitoring is needed once post-ACA data become available.

Study on launch scheme of space-net capturing system.

PubMed

Gao, Qingyu; Zhang, Qingbin; Feng, Zhiwei; Tang, Qiangang

2017-01-01

With the continuous progress in active debris-removal technology, scientists are increasingly concerned about the concept of space-net capturing system. The space-net capturing system is a long-range-launch flexible capture system, which has great potential to capture non-cooperative targets such as inactive satellites and upper stages. In this work, the launch scheme is studied by experiment and simulation, including two-step ejection and multi-point-traction analyses. The numerical model of the tether/net is based on finite element method and is verified by full-scale ground experiment. The results of the ground experiment and numerical simulation show that the two-step ejection and six-point traction scheme of the space-net system is superior to the traditional one-step ejection and four-point traction launch scheme.

Study on launch scheme of space-net capturing system

PubMed Central

Zhang, Qingbin; Feng, Zhiwei; Tang, Qiangang

2017-01-01

With the continuous progress in active debris-removal technology, scientists are increasingly concerned about the concept of space-net capturing system. The space-net capturing system is a long-range-launch flexible capture system, which has great potential to capture non-cooperative targets such as inactive satellites and upper stages. In this work, the launch scheme is studied by experiment and simulation, including two-step ejection and multi-point-traction analyses. The numerical model of the tether/net is based on finite element method and is verified by full-scale ground experiment. The results of the ground experiment and numerical simulation show that the two-step ejection and six-point traction scheme of the space-net system is superior to the traditional one-step ejection and four-point traction launch scheme. PMID:28877187

Advances in Measuring Culturally Competent Care: A Confirmatory Factor Analysis of CAHPS-CC in a Safety-net Population

PubMed Central

Stern, RJ; Fernandez, A; Jacobs, EA; Neilands, TB; Weech-Maldonado, R; Quan, J; Carle, A; Seligman, HK

2012-01-01

Background Providing culturally competent care shows promise as a mechanism to reduce healthcare inequalities. Until the recent development of the CAHPS Cultural Competency Item Set (CAHPS-CC), no measures capturing patient-level experiences with culturally competent care have been suitable for broad-scale administration. Methods We performed confirmatory factor analysis and internal consistency reliability analysis of CAHPS-CC among patients with type 2 diabetes (n=600) receiving primary care in safety-net clinics. CAHPS-CC domains were also correlated with global physician ratings. Results A 7-factor model demonstrated satisfactory fit (χ2(231)=484.34, p<.0001) with significant factor loadings at p<.05. Three domains showed excellent reliability – Doctor Communication- Positive Behaviors (α=.82), Trust (α=.77), and Doctor Communication- Health Promotion (α=.72). Four domains showed inadequate reliability either among Spanish speakers or overall (overall reliabilities listed): Doctor Communication- Negative Behaviors (α=.54), Equitable Treatment (α=.69), Doctor Communication- Alternative Medicine (α=.52), and Shared Decision-Making (α=.51). CAHPS-CC domains were positively and significantly correlated with global physician rating. Conclusions Select CAHPS-CC domains are suitable for broad-scale administration among safety-net patients. Those domains may be used to target quality-improvement efforts focused on providing culturally competent care in safety-net settings. PMID:22895231

Changing safety net of last resort: downsizing general assistance for employable adults.

PubMed

Anderson, Steven G; Halter, Anthony P; Gryzlak, Brian M

2002-07-01

General assistance (GA) has served as an income support program of last resort for people not eligible for other programs. Because each state has complete discretion to design its program, the GA services model parallels Temporary Assistance for Needy Families (TANF) in its reliance on decentralized government decision making. Thus, GA programs can provide lessons about services variability and common program features that have arisen in a decentralized income support system. This study examined the characteristics of state GA programs across several program dimensions--eligibility criteria, work requirements, time limits, administrative arrangements, and caseloads. The authors show that GA programs have changed from 1989 to 1998. Although most states retained GA programs in some form, caseloads declined as a result of tightening eligibility requirements for people considered employable. This casts doubt on the viability of GA as a safety net program for economically vulnerable people, including those who do not qualify for or exceed time limits under TANF.

Exploring Facilitators and Barriers to Initiation and Completion of the Human Papillomavirus (HPV) Vaccine Series among Parents of Girls in a Safety Net System

PubMed Central

O’Leary, Sean T.; Lockhart, Steven; Barnard, Juliana; Furniss, Anna; Dickinson, Miriam; Dempsey, Amanda F.; Stokley, Shannon; Federico, Steven; Bronsert, Michael; Kempe, Allison

2018-01-01

Objective: To assess, among parents of predominantly minority, low-income adolescent girls who had either not initiated (NI) or not completed (NC) the HPV vaccine series, attitudes and other factors important in promoting the series, and whether attitudes differed by language preference. Design/Methods: From August 2013–October 2013, we conducted a mail survey among parents of girls aged 12–15 years randomly selected from administrative data in a Denver safety net system; 400 parents from each group (NI and NC) were targeted. Surveys were in English or Spanish. Results: The response rate was 37% (244/660; 140 moved or gone elsewhere; 66% English-speaking, 34% Spanish-speaking). Safety attitudes of NIs and NCs differed, with 40% NIs vs. 14% NCs reporting they thought HPV vaccine was unsafe (p < 0.0001) and 43% NIs vs. 21% NCs that it may cause long-term health problems (p < 0.001). Among NCs, 42% reported they did not know their daughter needed more shots (English-speaking, 20%, Spanish-speaking 52%) and 39% reported that “I wasn’t worried about the safety of the HPV vaccine before, but now I am” (English-speaking, 23%, Spanish-speaking, 50%). Items rated as very important among NIs in the decision regarding vaccination included: more information about safety (74%), more information saying it prevents cancer (70%), and if they knew HPV was spread mainly by sexual contact (61%). Conclusions: Safety concerns, being unaware of the need for multiple doses, and low perceived risk of infection remain significant barriers to HPV vaccination for at-risk adolescents. Some parents’ safety concerns do not appear until initial vaccination. PMID:29360785

Effective Strategies for Affordable Care Act Enrollment in Immigrant-Serving Safety Net Clinics in New Mexico.

PubMed

Getrich, Christina M; García, Jacqueline M; Solares, Angélica; Kano, Miria

2017-01-01

In the new Affordable Care Act (ACA) health care environment, safety-net institutions continue to serve as important sources of culturally appropriate care for different groups of immigrant patients. This article reports on a qualitative study examining the early ACA enrollment experiences of a range of health care providers (n = 29) in six immigrant-serving safety-net clinics in New Mexico. The six clinics configured their ACA enrollment strategies differently with regard to operations, staffing, and outreach. Providers reported a generally chaotic rollout overall and expressed frustration with strategies that did not accommodate patients, provided little training for providers, and engaged in minimal outreach. Conversely, providers lauded strategies that flexibly met patient needs, leveraged trust through strategic use of staff, and prioritized outreach. Findings underscore the importance of using and funding concerted strategies for future enrollment of immigrant patients, such as featuring community health workers and leveraging trust for outreach.

Teleretinal Screening for Diabetic Retinopathy in Six Los Angeles Urban Safety-Net Clinics: Final Study Results

PubMed Central

Ogunyemi, Omolola; George, Sheba; Patty, Lauren; Teklehaimanot, Senait; Baker, Richard

2013-01-01

In a previous paper, we presented initial findings from a study on the feasibility and challenges of implementing teleretinal screening for diabetic retinopathy in an urban safety net setting facing eyecare specialist shortages. This paper presents some final results from that study, which involved six South Los Angeles safety net clinics. A total of 2,732 unique patients were screened for diabetic retinopathy by three ophthalmologist readers, with 1035 receiving a recommendation for referral to specialty care. Referrals included 48 for proliferative diabetic retinopathy, 115 for severe non-proliferative diabetic retinopathy (NPDR), 247 for moderate NPDR, 246 for mild NPDR, 97 for clinically significant macular edema, and 282 for a non-diabetic condition, such as glaucoma. Image quality was also assessed, with ophthalmologist readers grading 4% to 13% of retinal images taken at the different clinics as being inadequate for any diagnostic interpretation. PMID:24551394

The Great Recession and the Social Safety Net

PubMed Central

Moffitt, Robert A.

2016-01-01

The social safety net responded in significant and favorable ways during the Great Recession. Aggregate per capita expenditures grew significantly, with particularly strong growth in the SNAP, EITC, UI, and Medicaid programs. Distributionally, the increase in transfers was widely shared across demographic groups, including families with and without children, single-parent and two-parent families. Transfers grew as well among families with more employed members and with fewer employed members. However, the increase in transfer amounts was not strongly progressive across income classes within the low-income population, increasingly slightly more for those just below the poverty line and those just above it, compared to those at the bottom of the income distribution. This is mainly the result of the EITC program, which provides greater benefits to those with higher family earnings. The expansions of SNAP and UI benefitted those at the bottom of the income distribution to a greater extent. PMID:27065356

Applications of the Petri net to simulate, test, and validate the performance and safety of complex, heterogeneous, multi-modality patient monitoring alarm systems.

PubMed

Sloane, E B; Gelhot, V

2004-01-01

This research is motivated by the rapid pace of medical device and information system integration. Although the ability to interconnect many medical devices and information systems may help improve patient care, there is no way to detect if incompatibilities between one or more devices might cause critical events such as patient alarms to go unnoticed or cause one or more of the devices to become stuck in a disabled state. Petri net tools allow automated testing of all possible states and transitions between devices and/or systems to detect potential failure modes in advance. This paper describes an early research project to use Petri nets to simulate and validate a multi-modality central patient monitoring system. A free Petri net tool, HPSim, is used to simulate two wireless patient monitoring networks: one with 44 heart monitors and a central monitoring system and a second version that includes an additional 44 wireless pulse oximeters. In the latter Petri net simulation, a potentially dangerous heart arrhythmia and pulse oximetry alarms were detected.

Less-Educated Workers' Unstable Employment: Can the Safety Net Help? Fast Focus. No. 19-2014

ERIC Educational Resources Information Center

Hill, Heather D.; Ybarra, Marci A.

2014-01-01

Since the 1980s, U.S. workers with less than a college education have faced increasing job instability at the same time that the safety net has become increasingly contingent on employment. The sources of instability are many, including variable schedules, not enough hours, and temporary employment. A policy forum hosted by the Employment…

Survivorship Care Plan Information Needs: Perspectives of Safety-Net Breast Cancer Patients.

PubMed

Burke, Nancy J; Napoles, Tessa M; Banks, Priscilla J; Orenstein, Fern S; Luce, Judith A; Joseph, Galen

2016-01-01

Despite the Institute of Medicine's (IOM) 2005 recommendation, few care organizations have instituted standard survivorship care plans (SCPs). Low health literacy and low English proficiency are important factors to consider in SCP development. Our study aimed to identify information needs and survivorship care plan preferences of low literacy, multi-lingual patients to support the transition from oncology to primary care and ongoing learning in survivorship. We conducted focus groups in five languages with African American, Latina, Russian, Filipina, White, and Chinese medically underserved breast cancer patients. Topics explored included the transition to primary care, access to information, knowledge of treatment history, and perspectives on SCPs. Analysis of focus group data identified three themes: 1) the need for information and education on the transition between "active treatment" and "survivorship"; 2) information needed (and often not obtained) from providers; and 3) perspectives on SCP content and delivery. Our data point to the need to develop a process as well as written information for medically underserved breast cancer patients. An SCP document will not replace direct communication with providers about treatment, symptom management and transition, a communication that is missing in participating safety-net patients' experiences of cancer care. Women turned to peer support and community-based organizations in the absence of information from providers. "Clear and effective" communication of survivorship care for safety-net patients requires dedicated staff trained to address wide-ranging information needs and uncertainties.

Safety-Net Institutions Buffer the Impact of Medicaid Managed Care: A Multi-Method Assessment in a Rural State

PubMed Central

Waitzkin, Howard; Williams, Robert L.; Bock, John A.; McCloskey, Joanne; Willging, Cathleen; Wagner, William

2002-01-01

Objectives. This project used a long-term, multi-method approach to study the impact of Medicaid managed care. Methods. Survey techniques measured impacts on individuals, and ethnographic methods assessed effects on safety-net providers in New Mexico. Results. After the first year of Medicaid managed care, uninsured adults reported less access and use (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.34, 0.64) and worse barriers to care (OR = 6.60; 95% CI = 3.95, 11.54) than adults in other insurance categories. Medicaid children experienced greater access and use (OR = 2.11; 95% CI = 1.21, 3.72) and greater communication and satisfaction (OR = 3.64; 95% CI = 1.13, 12.54) than children in other insurance categories; uninsured children encountered greater barriers to care (OR = 6.29; 95% CI = 1.58, 42.21). There were no consistent changes in the major outcome variables over the period of transition to Medicaid managed care. Safety-net institutions experienced marked increases in workload and financial stress, especially in rural areas. Availability of mental health services declined sharply. Providers worked to buffer the impact of Medicaid managed care for patients. Conclusions. In its first year, Medicaid managed care exerted major effects on safety-net providers but relatively few measurable effects on individuals. This reform did not address the problems of the uninsured. PMID:11919059

A Petri net synthesis theory for modeling flexible manufacturing systems.

PubMed

Jeng, M D

1997-01-01

A theory that synthesizes Petri nets for modeling flexible manufacturing systems is presented. The theory adopts a bottom-up or modular-composition approach to construct net models. Each module is modeled as a resource control net (RCN), which represents a subsystem that controls a resource type in a flexible manufacturing system. Interactions among the modules are described as the common transition and transition subnets. The net obtained by merging the modules with two minimal restrictions is shown to be conservative and thus bounded. An algorithm is developed to detect two sufficient conditions for structural liveness of the net. The algorithm examines only the net's structure and the initial marking, and appears to be more efficient than state enumeration techniques such as the reachability tree method. In this paper, the sufficient conditions for liveness are shown to be related to some structural objects called siphons. To demonstrate the applicability of the theory, a flexible manufacturing system of a moderate size is modeled and analyzed using the proposed theory.

The Affordable Care Act Decreased the Proportion of Uninsured Patients in a Safety Net Orthopaedic Clinic.

PubMed

Gil, Joseph A; Goodman, Avi D; Kleiner, Justin; Kamal, Robin N; Baker, Laurence C; Akelman, Edward

2018-05-01

The Patient Protection and Affordable Care Act (ACA) was approved in 2010, substantially altering the economics of providing and receiving healthcare services in the United States. One of the primary goals of this legislation was to expand insurance coverage for under- and uninsured residents. Our objective was to examine the effect of the ACA on the insurance status of patients at a safety net clinic. Our institution houses a safety net clinic that provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, our study allows us to accurately examine the magnitude of the effect on insurance status in safety net orthopaedic clinics. (1) Did the ACA result in a decrease in the number of uninsured patients at a safety net orthopaedic clinic that provides the dominant majority of orthopaedic care for the uninsured in the state? (2) Did the proportion of patients insured after passage of the ACA differ across age or demographic groups in one state? We retrospectively examined our longitudinally maintained adult orthopaedic surgery clinic database from January 2009 to March 2015 and collected visit and demographic data, including zip code income quartile. Based on the data published by the Rhode Island Department of Health, our clinic provides the dominant majority of orthopaedic care for uninsured patients in our state. Therefore, examination of the changes in the proportion of insurance status in our clinic allows us to assess the effect of the ACA on the state level. Univariate and multivariable logistic regression analyses were used to determine the relationship between demographic variables and insurance status. Adjusted odds ratios and 95% CIs were calculated for the proportion of uninsured visits. The proportion of uninsured visits before and after implementation of the ACA was evaluated with an interrupted time-series analysis. The reduction in the proportion of patients without insurance between demographic groups (ie, race

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations

PubMed Central

Chan, Lenny L. S.; Fouts, Michelle M.; Murphy, Elizabeth J.

2017-01-01

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations. PMID:28197420

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations.

PubMed

Ratanawongsa, Neda; Chan, Lenny L S; Fouts, Michelle M; Murphy, Elizabeth J

2017-01-01

Widespread electronic health record (EHR) implementation creates new challenges in the diabetes care of complex and diverse populations, including safe medication prescribing for patients with limited health literacy and limited English proficiency. This review highlights how the EHR electronic prescribing transformation has affected diabetes care for vulnerable patients and offers recommendations for improving patient safety through EHR electronic prescribing design, implementation, policy, and research. Specifically, we present evidence for (1) the adoption of RxNorm; (2) standardized naming and picklist options for high alert medications such as insulin; (3) the widespread implementation of universal medication schedule and language-concordant labels, with the expansion of electronic prescription 140-character limit; (4) enhanced bidirectional communication with pharmacy partners; and (5) informatics and implementation research in safety net healthcare systems to examine how EHR tools and practices affect diverse vulnerable populations.

Impact of a Patient Navigator Program on Hospital-Based and Outpatient Utilization Over 180 Days in a Safety-Net Health System.

PubMed

Balaban, Richard B; Zhang, Fang; Vialle-Valentin, Catherine E; Galbraith, Alison A; Burns, Marguerite E; Larochelle, Marc R; Ross-Degnan, Dennis

2017-09-01

With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies. To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period. Randomized controlled trial conducted October 2011 through April 2013. Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls. Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care. Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods. The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes. A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over

Net current control device. Final report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fugate, D.; Cooper, J.H.

1998-11-01

Net currents generally result in elevated magnetic fields because the alternate paths are distant from the circuit conductors. Investigations have shown that one of the primary sources of power frequency magnetic fields in residential buildings is currents that return to their source via paths other than the neutral conductors. As part of EPRI`s Magnetic Field Shielding Project, ferromagnetic devices, called net current control (NCC) devices, were developed and tested for use in reducing net currents on electric power cables and the resulting magnetic fields. Applied to a residential service drop, an NCC device reduces net current by forcing current offmore » local non-utility ground paths, and back onto the neutral conductor. Circuit models and basic design equations for the NCC concept were developed, and proof-of-principles tests were carried out on an actual residence with cooperation from the local utility. After proving the basic concepts, three prototype NCC devices were built and tested on a simulated neighborhood power system. Additional prototypes were built for testing by interested EPRI utility members. Results have shown that the NCC prototypes installed on residential service drops reduce net currents to milliampere levels with compromising the safety of the ground system. Although the focus was on application to residential service cables, the NCC concept is applicable to single-phase and three-phase distribution systems as well.« less

Provider Experiences With the Identification, Management, and Treatment of Co-Occurring Chronic Non-cancer Pain and Substance Use in the Safety Net

PubMed Central

Chang, Jamie Suki; Kushel, Margot; Miaskowski, Christine; Ceasar, Rachel; Zamora, Kara; Hurstak, Emily; Knight, Kelly R.

2017-01-01

Background In the US and internationally, providers have adopted guidelines on the management of prescription opioids for chronic non-cancer pain (CNCP). For “high-risk” patients with co-occurring CNCP and a history of substance use, guidelines advise providers to monitor patients using urine toxicology screening tests, develop opioid management plans, and refer patients to substance use treatment. Objective We report primary care provider experiences in the safety net interpreting and implementing guideline recommendations for patients with CNCP and substance use. Methods We interviewed primary care providers who work in the safety net (N=23) on their experiences managing CNCP and substance use. We analyzed interviews using a content analysis method. Results Providers found management plans and urine toxicology screening tests useful for informing patients about clinic expectations of opioid therapy and substance use. However, they described that guideline-based clinic policies had unintended consequences, such as raising barriers to open, honest dialogue about substance use and treatment. While substance use treatment was recommended for “high-risk” patients, providers described lack of integration with and availability of substance use treatment programs. Conclusions Our findings indicate that clinicians in the safety net found guideline-based clinic policies helpful. However, effective implementation was challenged by barriers to open dialogue about substance use and limited linkages with treatment programs. Further research is needed to examine how the context of safety net settings shapes the management and treatment of co-occurring CNCP and substance use. PMID:27754719

Exploring inattention and distraction in the SafetyNet Accident Causation Database.

PubMed

Talbot, Rachel; Fagerlind, Helen; Morris, Andrew

2013-11-01

Distraction and inattention are considered to be very important and prevalent factors in the causation of road accidents. There have been many recent research studies which have attempted to understand the circumstances under which a driver becomes distracted or inattentive and how distraction/inattention can be prevented. Both factors are thought to have become more important in recent times partly due to the evolution of in-vehicle information and communication technology. This study describes a methodology that was developed to understand when factors such as distraction and inattention may have been contributors to crashes and also describes some of the consequences of distraction and inattention in terms of subsequent driver actions. The study uses data relating to distraction and inattention from the SafetyNet Accident Causation Database. This database was formulated as part of the SafetyNet project to address the lack of representative in-depth accident causation data within the European Union. Data were collected in 6 European countries using 'on-scene' and 'nearly on-scene' crash investigation methodologies. 32% of crashes recorded in the database, involved at least one driver, rider or pedestrian, who was determined to be 'Inattentive' or 'Distracted'. 212 of the drivers were assigned 'Distraction' and 140 drivers were given the code 'Inattention'. It was found that both distraction and inattention often lead to missed observations within the driving task and consequently 'Timing' or 'Direction' become critical events in the aetiology of crashes. In addition, the crash types and outcomes may differ according to the type and nature of the distraction and inattention as determined by the in-depth investigations. The development of accident coding methodology is described in this study as is its evolution into the Driver Reliability and Error Analysis Model (DREAM) version 3.0. Copyright © 2012 Elsevier Ltd. All rights reserved.

Modifying physician behavior to improve cost-efficiency in safety-net ambulatory settings.

PubMed

Borkowski, Nancy; Gumus, Gulcin; Deckard, Gloria J

2013-01-01

Change interventions in one form or another are viewed as important tools to reduce variation in medical services, reduce costs, and improve quality of care. With the current focus on efficient resource use, the successful design and implementation of change strategies are of utmost importance for health care managers. We present a case study in which macro and micro level change strategies were used to modify primary care physicians' practice patterns of prescribing diagnostic services in a safety-net's ambulatory clinics. The findings suggest that health care managers using evidence-based strategies can create a practice environment that reduces barriers and facilitates change.

Fault Diagnosis System of Wind Turbine Generator Based on Petri Net

NASA Astrophysics Data System (ADS)

Zhang, Han

Petri net is an important tool for discrete event dynamic systems modeling and analysis. And it has great ability to handle concurrent phenomena and non-deterministic phenomena. Currently Petri nets used in wind turbine fault diagnosis have not participated in the actual system. This article will combine the existing fuzzy Petri net algorithms; build wind turbine control system simulation based on Siemens S7-1200 PLC, while making matlab gui interface for migration of the system to different platforms.

Material Gradients in Oxygen System Components Improve Safety

NASA Technical Reports Server (NTRS)

Forsyth, Bradley S.

2011-01-01

Oxygen system components fabricated by Laser Engineered Net Shaping (TradeMark) (LENS(TradeMark)) could result in improved safety and performance. LENS(TradeMark) is a near-net shape manufacturing process fusing powdered materials injected into a laser beam. Parts can be fabricated with a variety of elemental metals, alloys, and nonmetallic materials without the use of a mold. The LENS(TradeMark) process allows the injected materials to be varied throughout a single workpiece. Hence, surfaces exposed to oxygen could be constructed of an oxygen-compatible material while the remainder of the part could be one chosen for strength or reduced weight. Unlike conventional coating applications, a compositional gradient would exist between the two materials, so no abrupt material boundary exists. Without an interface between dissimilar materials, there is less tendency for chipping or cracking associated with thermal-expansion mismatches.

Risk Factors for Reporting Poor Cultural Competency Among Patients with Diabetes in Safety-Net Clinics

PubMed Central

Seligman, Hilary K.; Fernandez, Alicia; Stern, Rachel J.; Weech-Maldonado, Robert; Quan, Judy; Jacobs, Elizabeth A.

2012-01-01

Background The Consumer Assessment of Healthcare Providers and Systems Cultural Competency (CAHPS-CC) Item Set assesses patient perceptions of aspects of the cultural competence of their health care. Objective To determine characteristics of patients who identify the care they receive as less culturally competent Research Design Cross-sectional survey consisting of face-to-face interviews Subjects Safety-net population of patients with type 2 diabetes (n=600) receiving ongoing primary care Measures Participants completed the CAHPS-CC and answered questions about their race/ethnicity, gender, age, education, health status, depressive symptoms, insurance coverage, English proficiency, duration of relationship with primary care provider, and co-morbidities. Results In adjusted models, depressive symptoms were significantly associated with poor cultural competency in the Doctor Communication – Positive Behaviors domain (OR 1.73, 95%CI 1.11, 2.69). African-Americans were less likely than Whites to report poor cultural competence in the Doctor Communication – Positive Behaviors domain (OR 0.52, 0.28–0.97). Participants who reported a longer relationship (≥3 years) with their primary care provider were less likely to report poor cultural competence in the Doctor Communication – Health Promotion (OR 0.35, 0.21–0.60) and Trust domains (OR 0.4, 0.24–0.67), while participants with lower educational attainment were less likely to report poor cultural competence in the Trust domain (OR 0.51, 0.30–0.86). Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence examined. Conclusions Cultural competence interventions in safety-net settings should be implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups. PMID:22895232

Securing a Suicide Hot Spot: Effects of a Safety Net at the Bern Muenster Terrace

ERIC Educational Resources Information Center

Reisch, Thomas; Michel, Konrad

2005-01-01

The city of Bern has a high percentage of suicides by jumping (28.6%). Related to other local hotspots, the highest number of deaths (mean 2.5 per year) is found at the Muenster Terrace in the old city. In 1998, after a series of suicides, a safety net was built to prevent people from leaping from the terrace and to avoid further traumatization of…

Causation mechanisms in car-to-vulnerable road user crashes: implications for active safety systems.

PubMed

Habibovic, Azra; Davidsson, Johan

2012-11-01

Vulnerable road users (VRUs), such as pedestrians and bicyclists, are often involved in crashes with passenger cars. One way to prevent these crashes is to deploy active safety systems that support the car drivers and/or VRUs. However, to develop such systems, a thorough understanding of crash causation mechanisms is required. The aim of this study is to identify crash causation mechanisms from the perspective of the VRUs, and to explore the implications of these mechanisms for the development of active safety systems. Data originate from the European project SafetyNet, where 995 crashes were in-depth investigated using the SafetyNet Accident Causation System (SNACS). To limit the scope, this study analyzed only intersection crashes involving VRUs. A total of 56 VRU crashes were aggregated. Results suggest that, while 30% of the VRUs did not see the conflict car due to visual obstructions in the traffic environment, 70% of the VRUs saw the car before the collision, but still misunderstood the traffic situation and/or made an inadequate plan of action. An important implication that follows from this is that, while detection of cars is clearly an issue that needs to be addressed, it is even more important to help the VRUs to correctly understand traffic situation (e.g., does the driver intend to slow down, and if s/he does, is it to let the VRU cross or for some other reason?). The former issue suggests a role for various cooperative active safety systems, as the obstacles are generally impenetrable with regular sensors. The latter issue is less straightforward. While various systems can be proposed, such as providing gap size estimation and reducing the car speed variability, the functional merits of each such a system need to be further investigated. Copyright © 2012 Elsevier Ltd. All rights reserved.

Fuzzy Petri nets to model vision system decisions within a flexible manufacturing system

NASA Astrophysics Data System (ADS)

Hanna, Moheb M.; Buck, A. A.; Smith, R.

1994-10-01

The paper presents a Petri net approach to modelling, monitoring and control of the behavior of an FMS cell. The FMS cell described comprises a pick and place robot, vision system, CNC-milling machine and 3 conveyors. The work illustrates how the block diagrams in a hierarchical structure can be used to describe events at different levels of abstraction. It focuses on Fuzzy Petri nets (Fuzzy logic with Petri nets) including an artificial neural network (Fuzzy Neural Petri nets) to model and control vision system decisions and robot sequences within an FMS cell. This methodology can be used as a graphical modelling tool to monitor and control the imprecise, vague and uncertain situations, and determine the quality of the output product of an FMS cell.

49 CFR Appendix C to Part 238 - Suspension System Safety Performance Standards

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 4 2011-10-01 2011-10-01 false Suspension System Safety Performance Standards C... industry standard acceptable to FRA is developed and approved under the procedures provided in § 238.21. (a... as follows: ER12MY99.005 where: δ=flange angle (deg). μ=coefficient of friction of 0.5. (2) The net...

49 CFR Appendix C to Part 238 - Suspension System Safety Performance Standards

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 4 2012-10-01 2012-10-01 false Suspension System Safety Performance Standards C... industry standard acceptable to FRA is developed and approved under the procedures provided in § 238.21. (a... as follows: ER12MY99.005 where: δ=flange angle (deg). μ=coefficient of friction of 0.5. (2) The net...

Famine Early Warning System Network (FEWS NET)

USGS Publications Warehouse

Verdin, James P.

2006-01-01

The FEWS NET mission is to identify potentially food-insecure conditions early through the provision of timely and analytical hazard and vulnerability information. U.S. Government decision-makers act on this information to authorize mitigation and response activities. The U.S. Geological Survey (USGS) FEWS NET provides tools and data for monitoring and forecasting the incidence of drought and flooding to identify shocks to the food supply system that could lead to famine. Historically focused on Africa, the scope of the network has expanded to be global coverage. FEWS NET implementing partners include the USGS, National Aeronautics and Space Administration (NASA), National Oceanic and Atmospheric Administration (NOAA), United States Agency for International Development (USAID), United States Department of Agriculture (USDA), and Chemonics International.

Technology-facilitated depression care management among predominantly Latino diabetes patients within a public safety net care system: comparative effectiveness trial design.

PubMed

Wu, Shinyi; Ell, Kathleen; Gross-Schulman, Sandra G; Sklaroff, Laura Myerchin; Katon, Wayne J; Nezu, Art M; Lee, Pey-Jiuan; Vidyanti, Irene; Chou, Chih-Ping; Guterman, Jeffrey J

2014-03-01

Health disparities in minority populations are well recognized. Hispanics and Latinos constitute the largest ethnic minority group in the United States; a significant proportion receives their care via a safety net. The prevalence of diabetes mellitus and comorbid depression is high among this group, but the uptake of evidence-based collaborative depression care management has been suboptimal. The study design and baseline characteristics of the enrolled sample in the Diabetes-Depression Care-management Adoption Trial (DCAT) establishes a quasi-experimental comparative effectiveness research clinical trial aimed at accelerating the adoption of collaborative depression care in safety net clinics. The study was conducted in collaboration with the Los Angeles County Department of Health Services at eight county-operated clinics. DCAT has enrolled 1406 low-income, predominantly Hispanic/Latino patients with diabetes to test a translational model of depression care management. This three-group study compares usual care with a collaborative care team support model and a technology-facilitated depression care model that provides automated telephonic depression screening and monitoring tailored to patient conditions and preferences. Call results are integrated into a diabetes disease management registry that delivers provider notifications, generates tasks, and issues critical alerts. All subjects receive comprehensive assessments at baseline, 6, 12, and 18 months by independent English-Spanish bilingual interviewers. Study outcomes include depression outcomes, treatment adherence, satisfaction, acceptance of assessment and monitoring technology, social and economic stress reduction, diabetes self-care management, health care utilization, and care management model cost and cost-effectiveness comparisons. DCAT's goal is to optimize depression screening, treatment, follow-up, outcomes, and cost savings to reduce health disparities. Copyright © 2013 Elsevier Inc. All rights

Holding up the oral health safety net: the role of National Health Service Corps alumni dentists in North Carolina.

PubMed

Bhatavadekar, Neel B; Rozier, R Gary; Konrad, Thomas R

2011-06-01

  Access to oral health care among low income populations is a growing problem. The National Health Service Corps (NHSC) might increase the supply of dentists motivated to provide services for this population.   To determine if North Carolina dentists who began a service obligation with the NHSC in 1990-1999 continued to provide care for underserved populations and if they differ from non-NHSC alumni primary care dentists who started practice in the state during that same period.   All 19 NHSC alumni and 50 comparison dentists were surveyed by mail. NHSC alumni also responded to selected items in a telephone follow-up interview. The two groups were compared using difference of means tests and multivariate contingency tables.   National Health Service Corps alumni were more likely to be African-American (38%vs. 10%), work in safety net practices (84%vs. 23%), and see more publicly insured patients (60%vs. 19%) than comparison dentists. Yet their job satisfaction was comparable to non-NHSC alumni dentists. Analyses suggested that current practice in safety net settings is affected by dentists' race, altruistic motivations and previous NHSC participation. CONCLUSION AND POLICY IMPLICATION:  Targeted recruitment of African-American dentists and others wanting to work in underserved communities could amplify the effectiveness of the financial incentive of NHSC loan repayment and induce dentists to remain in 'safety net' settings. © 2011 FDI World Dental Federation.

Access, interest, and attitudes toward electronic communication for health care among patients in the medical safety net.

PubMed

Schickedanz, Adam; Huang, David; Lopez, Andrea; Cheung, Edna; Lyles, C R; Bodenheimer, Tom; Sarkar, Urmimala

2013-07-01

Electronic and internet-based tools for patient-provider communication are becoming the standard of care, but disparities exist in their adoption among patients. The reasons for these disparities are unclear, and few studies have looked at the potential communication technologies have to benefit vulnerable patient populations. To characterize access to, interest in, and attitudes toward internet-based communication in an ethnically, economically, and linguistically diverse group of patients from a large urban safety net clinic network. Observational, cross-sectional study Adult patients (≥ 18 years) in six resource-limited community clinics in the San Francisco Department of Public Health (SFDPH) MAIN MEASURES: Current email use, interest in communicating electronically with health care professionals, barriers to and facilitators of electronic health-related communication, and demographic data-all self-reported via survey. Sixty percent of patients used email, 71 % were interested in using electronic communication with health care providers, and 19 % reported currently using email informally with these providers for health care. Those already using any email were more likely to express interest in using it for health matters. Most patients agreed electronic communication would improve clinic efficiency and overall communication with clinicians. A significant majority of safety net patients currently use email, text messaging, and the internet, and they expressed an interest in using these tools for electronic communication with their medical providers. This interest is currently unmet within safety net clinics that do not offer a patient portal or secure messaging. Tools such as email encounters and electronic patient portals should be implemented and supported to a greater extent in resource-poor settings, but this will require tailoring these tools to patients' language, literacy level, and experience with communication technology.

Evaluation of three elevated mist-net systems for sampling birds

USGS Publications Warehouse

Meyers, J.M.; Pardieck, K.L.

1993-01-01

Three light-weight, low-canopy mist-net systems were developed and tested in dry tropical scrub, mangrove and forest habitats. One plastic (polyvinyl chloride) and two aluminum pole systems (with and without pulleys) were used to support mist nets to heights of up to 7.3 m. Although the aluminum telescoping-pole system (without pulleys) was expensive initially ( 79-141/unit (US)), its use reduced capture of nontarget species and may have increased capture of target species when compared with ground-level netting. In one year, its use also reduced labor costs by 756, which completely offset the higher cost of the aluminum telescoping-pole system when compared to the plastic-pole system ( 19/unit). Unlike the plastic-pole system, the aluminum telescoping-pole system was adjustable to any height within its range of 1.8 to 7.3 m, was 1.5 m higher, was more efficient to operate in the field, and was easily moved to new locations. For capture of psittacines, the pulleys of the aluminum telescoping-pole system were not necessary, but their use may assist in efficiently retrieving large numbers of birds from the nets. The aluminum telescoping-pole system was efficient in capturing psittacines, columbids, passerines and possibly chiropterans in habitats with canopies lt 10 m or in the forest subcanopy.

Challenges of standardized continuous quality improvement programs in community pharmacies: the case of SafetyNET-Rx.

PubMed

Boyle, Todd A; MacKinnon, Neil J; Mahaffey, Thomas; Duggan, Kellie; Dow, Natalie

2012-01-01

Research on continuous quality improvement (CQI) in community pharmacies lags in comparison to service, manufacturing, and various health care sectors. As a result, very little is known about the challenges community pharmacies face when implementing CQI programs in general, let alone the challenges of implementing a standardized and technologically sophisticated one. This research identifies the initial challenges of implementing a standardized CQI program in community pharmacies and how such challenges were addressed by pharmacy staff. Through qualitative interviews, a multisite study of the SafetyNET-Rx CQI program involving community pharmacies in Nova Scotia, Canada, was performed to identify such challenges. Interviews were conducted with the CQI facilitator (ie, staff pharmacist or technician) in 55 community pharmacies that adopted the SafetyNET-Rx program. Of these 55 pharmacies, 25 were part of large national corporate chains, 22 were part of banner chains, and 8 were independent pharmacies. A total of 10 different corporate chains and banners were represented among the 55 pharmacies. Thematic content analysis using well-established coding procedures was used to explore the interview data and elicit the key challenges faced. Six major challenges were identified, specifically finding time to report, having all pharmacy staff involved in quality-related event (QRE) reporting, reporting apprehensiveness, changing staff relationships, meeting to discuss QREs, and accepting the online technology. Challenges were addressed in a number of ways including developing a manual-online hybrid reporting system, managers paying staff to meet after hours, and pharmacy managers showing visible commitment to QRE reporting and learning. This research identifies key challenges to implementing CQI programs in community pharmacies and also provides a starting point for future research relating to how the challenges of QRE reporting and learning in community pharmacies change

The Design and Realization of Net Testing System on Campus Network

ERIC Educational Resources Information Center

Ren, Zhanying; Liu, Shijie

2005-01-01

According to the requirement of modern teaching theory and technology, based on software engineering, database theory, the technique of net information security and system integration, a net testing system on local network was designed and realized. The system benefits for dividing of testing & teaching and settles the problems of random…

Optimizing efficiency and operations at a California safety-net endoscopy center: a modeling and simulation approach.

PubMed

Day, Lukejohn W; Belson, David; Dessouky, Maged; Hawkins, Caitlin; Hogan, Michael

2014-11-01

Improvements in endoscopy center efficiency are needed, but scant data are available. To identify opportunities to improve patient throughput while balancing resource use and patient wait times in a safety-net endoscopy center. Safety-net endoscopy center. Outpatients undergoing endoscopy. A time and motion study was performed and a discrete event simulation model constructed to evaluate multiple scenarios aimed at improving endoscopy center efficiency. Procedure volume and patient wait time. Data were collected on 278 patients. Time and motion study revealed that 53.8 procedures were performed per week, with patients spending 2.3 hours at the endoscopy center. By using discrete event simulation modeling, a number of proposed changes to the endoscopy center were assessed. Decreasing scheduled endoscopy appointment times from 60 to 45 minutes led to a 26.4% increase in the number of procedures performed per week, but also increased patient wait time. Increasing the number of endoscopists by 1 each half day resulted in increased procedure volume, but there was a concomitant increase in patient wait time and nurse utilization exceeding capacity. By combining several proposed scenarios together in the simulation model, the greatest improvement in performance metrics was created by moving patient endoscopy appointments from the afternoon to the morning. In this simulation at 45- and 40-minute appointment times, procedure volume increased by 30.5% and 52.0% and patient time spent in the endoscopy center decreased by 17.4% and 13.0%, respectively. The predictions of the simulation model were found to be accurate when compared with actual changes implemented in the endoscopy center. Findings may not be generalizable to non-safety-net endoscopy centers. The combination of minor, cost-effective changes such as reducing appointment times, minimizing and standardizing recovery time, and making small increases in preprocedure ancillary staff maximized endoscopy center

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve

PubMed Central

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

Objectives: The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Methods: Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Results: Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Conclusion: Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening. PMID:28241912

End-Stage Renal Disease Outcomes among the Kaiser Permanente Southern California Creatinine Safety Program (Creatinine SureNet): Opportunities to Reflect and Improve.

PubMed

Sim, John J; Batech, Michael; Danforth, Kim N; Rutkowski, Mark P; Jacobsen, Steven J; Kanter, Michael H

2017-01-01

The Kaiser Permanente Southern California (KPSC) creatinine safety program (Creatinine SureNet) identifies and outreaches to thousands of people annually who may have had a missed diagnosis for chronic kidney disease (CKD). We sought to determine the value of this outpatient program and evaluate opportunities for improvement. Longitudinal cohort study (February 2010 through December 2015) of KPSC members captured into the creatinine safety program who were characterized using demographics, laboratory results, and different estimations of glomerular filtration rate. Age- and sex-adjusted rates of end-stage renal disease (ESRD) were compared with those in the overall KPSC population. Among 12,394 individuals, 83 (0.7%) reached ESRD. The age- and sex-adjusted relative risk of ESRD was 2.7 times higher compared with the KPSC general population during the same period (94.7 vs 35.4 per 100,000 person-years; p < 0.001). Screening with the Chronic Kidney Disease Epidemiology Collaboration (vs Modification Diet in Renal Diseases) equation would capture 44% fewer individuals and have a higher predictive value for CKD. Of those who had repeated creatinine measurements, only 13% had a urine study performed (32% among patients with confirmed CKD). Our study found a higher incidence of ESRD among individuals captured into the KPSC creatinine safety program. If the Chronic Kidney Disease Epidemiology Collaboration equation were used, fewer people would have been captured while improving the accuracy for diagnosing CKD. Urine testing was low even among patients with confirmed CKD. Our findings demonstrate the importance of a creatinine safety net program in an integrated health system but also suggest opportunities to improve CKD care and screening.

NetCDF-CF: Supporting Earth System Science with Data Access, Analysis, and Visualization

NASA Astrophysics Data System (ADS)

Davis, E.; Zender, C. S.; Arctur, D. K.; O'Brien, K.; Jelenak, A.; Santek, D.; Dixon, M. J.; Whiteaker, T. L.; Yang, K.

2017-12-01

NetCDF-CF is a community-developed convention for storing and describing earth system science data in the netCDF binary data format. It is an OGC recognized standard with numerous existing FOSS (Free and Open Source Software) and commercial software tools can explore, analyze, and visualize data that is stored and described as netCDF-CF data. To better support a larger segment of the earth system science community, a number of efforts are underway to extend the netCDF-CF convention with the goal of increasing the types of data that can be represented as netCDF-CF data. This presentation will provide an overview and update of work to extend the existing netCDF-CF convention. It will detail the types of earth system science data currently supported by netCDF-CF and the types of data targeted for support by current netCDF-CF convention development efforts. It will also describe some of the tools that support the use of netCDF-CF compliant datasets, the types of data they support, and efforts to extend them to handle the new data types that netCDF-CF will support.

Who is Using Telehealth in Primary Care? Safety Net Clinics and Health Maintenance Organizations (HMOs).

PubMed

Coffman, Megan; Moore, Miranda; Jetty, Anuradha; Klink, Kathleen; Bazemore, Andrew

2016-01-01

Despite rapid advancements in telehealth services, only 15% of family physicians in a 2014 survey reported using telehealth; use varied widely according to the physician's practice setting or designation. Users were significantly more likely than nonusers to work in federally designated "safety net" clinics and health maintenance organizations (HMOs) but not more likely than nonusers to report working in a patient-centered medical home (PCMH) or accountable care organization. © Copyright 2016 by the American Board of Family Medicine.

Are HPV vaccination services accessible to high-risk communities? A spatial analysis of HPV-associated cancer and Chlamydia rates and safety-net clinics.

PubMed

Tsui, Jennifer; Rodriguez, Hector P; Gee, Gilbert C; Escobedo, Loraine A; Kominski, Gerald F; Bastani, Roshan

2013-12-01

While HPV vaccines can greatly benefit adolescents and young women from high-risk areas, little is known about whether safety-net immunization services are geographically accessible to communities at greatest risk for HPV-associated diseases. We explore the spatial relationship between areas with high HPV risk and proximity to safety-net clinics from an ecologic perspective. We used cancer registry data and Chlamydia surveillance data to identify neighborhoods within Los Angeles County with high risk for HPV-associated cancers. We examined proximity to safety-net clinics among neighborhoods with the highest risk. Proximity was measured as the shortest distance between each neighborhood center and the nearest clinic and having a clinic within 3 miles of each neighborhood center. The average 5-year non-age-adjusted rates were 1,940 cases per 100,000 for Chlamydia and 60 per 100,000 for HPV-associated cancers. A large majority, 349 of 386 neighborhoods with high HPV-associated cancer rates and 532 of 537 neighborhoods with high Chlamydia rates, had a clinic within 3 miles of the neighborhood center. Clinics were more likely to be located within close proximity to high-risk neighborhoods in the inner city. High-risk neighborhoods outside of this urban core area were less likely to be near accessible clinics. The majority of high-risk neighborhoods were geographically near safety-net clinics with HPV vaccination services. Due to low rates of vaccination, these findings suggest that while services are geographically accessible, additional efforts are needed to improve uptake. Programs aimed to increase awareness about the vaccine and to link underserved groups to vaccination services are warranted.

Are HPV vaccination services accessible to high-risk communities?: A spatial analysis of HPV-associated cancer and Chlamydia rates and safety-net clinics

PubMed Central

Tsui, Jennifer; Rodriguez, Hector P.; Gee, Gilbert C.; Escobedo, Loraine A.; Kominski, Gerald F.; Bastani, Roshan

2013-01-01

Purpose While HPV vaccines can greatly benefit adolescents and young women from high-risk areas, little is known about whether safety-net immunization services are geographically accessible to communities at greatest risk for HPV-associated diseases. We explore the spatial relationship between areas with high HPV risk and proximity to safety-net clinics from an ecologic perspective. Methods We used cancer registry data and Chlamydia surveillance data to identify neighborhoods within Los Angeles County with high risk for HPV-associated cancers. We examined proximity to safety-net clinics among neighborhoods with the highest risk. Proximity was measured as the shortest distance between each neighborhood center and the nearest clinic and having a clinic within 3 miles of each neighborhood center. Results The average 5-year non-age-adjusted rates were 1,940 cases per 100,000 for Chlamydia and 60 per 100,000 for HPV-associated cancers. A large majority, 349 of 386 neighborhoods with high HPV-associated cancer rates and 532 of 537 neighborhoods with high Chlamydia rates had a clinic within 3 miles of the neighborhood center. Clinics were more likely to be located within close proximity to high-risk neighborhoods in the inner city. High-risk neighborhoods outside of this urban core area were less likely to be near accessible clinics. Conclusions The majority of high-risk neighborhoods were geographically near safety-net clinics with HPV vaccination services. Due to low rates of vaccination, these findings suggest that while services are geographically accessible, additional efforts are needed to improve uptake. Programs aimed to increase awareness about the vaccine and to link underserved groups to vaccination services are warranted. PMID:24043448

Differential ubiquitination in NETs regulates macrophage responses in systemic lupus erythematosus.

PubMed

Barrera-Vargas, Ana; Gómez-Martín, Diana; Carmona-Rivera, Carmelo; Merayo-Chalico, Javier; Torres-Ruiz, Jiram; Manna, Zerai; Hasni, Sarfaraz; Alcocer-Varela, Jorge; Kaplan, Mariana J

2018-06-01

To assess if ubiquitinated proteins potentially present in neutrophil extracellular traps (NETs) can modify cellular responses and induce inflammatory mechanisms in patients with systemic lupus erythematosus (SLE) and healthy subjects. We studied 74 subjects with SLE and 77 healthy controls. Neutrophils and low-density granulocytes were isolated, and NETs were induced. Ubiquitin content was quantified in NETs by western blot analysis, ELISA and immunofluorescence microscopy, while ubiquitination of NET proteins was assessed by immunoprecipitation. Monocyte-derived macrophages from SLE and controls were isolated and stimulated with NETs or ubiquitin. Calcium flux and cytokine synthesis were measured following these stimuli. NETs contain ubiquitinated proteins, with a lower expression of polyubiquitinated proteins in subjects with SLE than in controls. Myeloperoxidase (MPO) is present in ubiquitinated form in NETs. Patients with SLE develop antiubiquitinated MPO antibodies, and titres positively correlate with Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score (P<0.01), and negatively correlate with complement components (P<0.01). Stimulation of monocyte-derived macrophages with NETs or with ubiquitin led to enhanced calcium flux. In addition, stimulation with NETs led to enhanced cytokine (tumour necrosis factor-α and interleukin-10) production in macrophages from patients with SLE when compared with controls, which was hampered by inhibition of NET internalisation by macrophages. This is the first study to find ubiquitinated proteins in NETs, and evidence for adaptive immune responses directed towards ubiquitinated NET proteins in SLE. The distinct differences in ubiquitin species profile in NETs compared with healthy controls may contribute to dampened anti-inflammatory responses observed in SLE. These results also support a role for extracellular ubiquitin in inflammation in SLE. © Article author(s) (or their employer(s) unless otherwise stated

Neural system modeling and simulation using Hybrid Functional Petri Net.

PubMed

Tang, Yin; Wang, Fei

2012-02-01

The Petri net formalism has been proved to be powerful in biological modeling. It not only boasts of a most intuitive graphical presentation but also combines the methods of classical systems biology with the discrete modeling technique. Hybrid Functional Petri Net (HFPN) was proposed specially for biological system modeling. An array of well-constructed biological models using HFPN yielded very interesting results. In this paper, we propose a method to represent neural system behavior, where biochemistry and electrical chemistry are both included using the Petri net formalism. We built a model for the adrenergic system using HFPN and employed quantitative analysis. Our simulation results match the biological data well, showing that the model is very effective. Predictions made on our model further manifest the modeling power of HFPN and improve the understanding of the adrenergic system. The file of our model and more results with their analysis are available in our supplementary material.

A Petri Net Approach Based Elementary Siphons Supervisor for Flexible Manufacturing Systems

NASA Astrophysics Data System (ADS)

Abdul-Hussin, Mowafak Hassan

2015-05-01

This paper presents an approach to constructing a class of an S3PR net for modeling, simulation and control of processes occurring in the flexible manufacturing system (FMS) used based elementary siphons of a Petri net. Siphons are very important to the analysis and control of deadlocks of FMS that is significant objectives of siphons. Petri net models in the efficiency structure analysis, and utilization of the FMSs when different policy can be implemented lead to the deadlock prevention. We are representing an effective deadlock-free policy of a special class of Petri nets called S3PR. Simulation of Petri net structural analysis and reachability graph analysis is used for analysis and control of Petri nets. Petri nets contain been successfully as one of the most powerful tools for modelling of FMS, where Using structural analysis, we show that liveness of such systems can be attributed to the absence of under marked siphons.

The risks of opioid treatment: Perspectives of primary care practitioners and patients from safety-net clinics

PubMed Central

Hurstak, Emily E.; Kushel, Margot; Chang, Jamie; Ceasar, Rachel; Zamora, Kara; Miaskowski, Christine; Knight, Kelly

2017-01-01

Background Patients with a history of substance use are more likely than those without substance use to experience chronic noncancer pain (CNCP), to be prescribed opioids, and to experience opioid misuse or overdose. Primary care practitioners (PCPs) in safety-net settings care for low-income patients with CNCP and substance use, usually without specialist consultation. To inform communication related to opioid risk, we explored PCPs’ and patients’ perceptions of the risks of chronic opioid therapy. Methods We conducted semistructured interviews with 23 PCPs and 46 of their patients, who had a history of CNCP and substance use. We recruited from 6 safety-net health care settings in the San Francisco Bay Area. We transcribed interviews verbatim and analyzed transcripts using grounded theory methodology. Results (1) PCPs feared harming patients and the community by opioid prescribing. PCPs emphasized fear of opioid overdose. (2) Patients did not highlight concerns about the adverse health consequences of opioids, except for addiction. (3) Both patients and PCPs were concerned about PCPs’ medicolegal risks related to opioid prescribing. (4) Patients reported feeling stigmatized by policies aimed at reducing opioid misuse. Conclusion We identified differences in how clinicians and patients perceive opioid risk. To improve the informed consent process for opioid therapy, patients and PCPs need to have a shared understanding of the risks of opioids and engage in discussions that promote patient autonomy and safety. As clinics implement opioid prescribing policies, clinicians must develop effective communication strategies in order to educate patients about opioid risks and decrease patients’ experiences of stigma and discrimination. PMID:28394752

Rethinking the therapeutic misconception: social justice, patient advocacy, and cancer clinical trial recruitment in the US safety net.

PubMed

Burke, Nancy J

2014-09-20

Approximately 20% of adult cancer patients are eligible to participate in a clinical trial, but only 2.5-9% do so. Accrual is even less for minority and medically underserved populations. As a result, critical life-saving treatments and quality of life services developed from research studies may not address their needs. This study questions the utility of the bioethical concern with therapeutic misconception (TM), a misconception that occurs when research subjects fail to distinguish between clinical research and ordinary treatment, and therefore attribute therapeutic intent to research procedures in the safety net setting. This paper provides ethnographic insight into the ways in which research is discussed and related to standard treatment. In the course of two years of ethnographic fieldwork in a safety net hospital, I conducted clinic observations (n=150 clinic days) and in-depth in-person qualitative interviews with patients (n=37) and providers (n=15). I used standard qualitative methods to organize and code resulting fieldnote and interview data. Findings suggest that TM is limited in relevance for the interdisciplinary context of cancer clinical trial recruitment in the safety net setting. Ethnographic data show the value of the discussions that happen prior to the informed consent, those that introduce the idea of participation in research. These preliminary discussions are elemental especially when recruiting underserved and vulnerable patients for clinical trial participation who are often unfamiliar with medical research and how it relates to medical care. Data also highlight the multiple actors involved in research discussions and the ethics of social justice and patient advocacy they mobilize, suggesting that class, inequality, and dependency influence the forms of ethical engagements in public hospital settings. On the ground ethics of social justice and patient advocacy are more relevant than TM as guiding ethical principles in the context of

Diabetes Health Information Technology Innovation to Improve Quality of Life for Health Plan Members in Urban Safety Net

PubMed Central

Ratanawongsa, Neda; Handley, Margaret A.; Sarkar, Urmimala; Quan, Judy; Pfeifer, Kelly; Soria, Catalina; Schillinger, Dean

2014-01-01

Safety net systems need innovative diabetes self-management programs for linguistically diverse patients. A low-income government-sponsored managed care plan implemented a 27-week automated telephone self-management support (ATSM) / health coaching intervention for English, Spanish-, and Cantonese-speaking members from four publicly-funded clinics in a practice-based research network. Compared to waitlist, immediate intervention participants had greater 6-month improvements in overall diabetes self-care behaviors (standardized effect size [ES] 0.29, p<0.01) and SF-12 physical scores (ES 0.25, p=0.03); changes in patient-centered processes of care and cardiometabolic outcomes did not differ. ATSM is a strategy for improving patient-reported self-management and may also improve some outcomes. PMID:24594561

Rainbow net analysis of VAXcluster system availability

NASA Technical Reports Server (NTRS)

Johnson, Allen M., Jr.; Schoenfelder, Michael A.

1991-01-01

A system modeling technique, Rainbow Nets, is used to evaluate the availability and mean-time-to-interrupt of the VAXcluster. These results are compared to the exact analytic results showing that reasonable accuracy is achieved through simulation. The complexity of the Rainbow Net does not increase as the number of processors increases, but remains constant, unlike a Markov model which expands exponentially. The constancy is achieved by using tokens with identity attributes (items) that can have additional attributes associated with them (features) which can exist in multiple states. The time to perform the simulation increases, but this is a polynomial increase rather than exponential. There is no restriction on distributions used for transition firing times, allowing real situations to be modeled more accurately by choosing the distribution which best fits the system performance and eliminating the need for simplifying assumptions.

Net carbon flux in organic and conventional olive production systems

NASA Astrophysics Data System (ADS)

Saeid Mohamad, Ramez; Verrastro, Vincenzo; Bitar, Lina Al; Roma, Rocco; Moretti, Michele; Chami, Ziad Al

2014-05-01

Agricultural systems are considered as one of the most relevant sources of atmospheric carbon. However, agriculture has the potentiality to mitigate carbon dioxide mainly through soil carbon sequestration. Some agricultural practices, particularly fertilization and soil management, can play a dual role in the agricultural systems regarding the carbon cycle contributing to the emissions and to the sequestration process in the soil. Good soil and input managements affect positively Soil Organic Carbon (SOC) changes and consequently the carbon cycle. The present study aimed at comparing the carbon footprint of organic and conventional olive systems and to link it to the efficiency of both systems on carbon sequestration by calculating the net carbon flux. Data were collected at farm level through a specific and detailed questionnaire based on one hectare as a functional unit and a system boundary limited to olive production. Using LCA databases particularly ecoinvent one, IPCC GWP 100a impact assessment method was used to calculate carbon emissions from agricultural practices of both systems. Soil organic carbon has been measured, at 0-30 cm depth, based on soil analyses done at the IAMB laboratory and based on reference value of SOC, the annual change of SOC has been calculated. Substracting sequestrated carbon in the soil from the emitted on resulted in net carbon flux calculation. Results showed higher environmental impact of the organic system on Global Warming Potential (1.07 t CO2 eq. yr-1) comparing to 0.76 t CO2 eq. yr-1 in the conventional system due to the higher GHG emissions caused by manure fertilizers compared to the use of synthetic foliar fertilizers in the conventional system. However, manure was the main reason behind the higher SOC content and sequestration in the organic system. As a resultant, the organic system showed higher net carbon flux (-1.7 t C ha-1 yr-1 than -0.52 t C ha-1 yr-1 in the conventional system reflecting higher efficiency as a

System safety education focused on flight safety

NASA Technical Reports Server (NTRS)

Holt, E.

1971-01-01

The measures necessary for achieving higher levels of system safety are analyzed with an eye toward maintaining the combat capability of the Air Force. Several education courses were provided for personnel involved in safety management. Data include: (1) Flight Safety Officer Course, (2) Advanced Safety Program Management, (3) Fundamentals of System Safety, and (4) Quantitative Methods of Safety Analysis.

The Expected Net Present Value of Developing Weight Management Drugs in the Context of Drug Safety Litigation.

PubMed

Chawla, Anita; Carls, Ginger; Deng, Edmund; Tuttle, Edward

2015-07-01

Following withdrawals, failures, and significant litigation settlements, drug product launches in the anti-obesity category slowed despite a large and growing unmet need. Litigation concerns, a more risk-averse regulatory policy, and the difficulty of developing a product with a compelling risk-benefit profile in this category may have limited innovators' expected return on investment and restricted investment in this therapeutic area. The objective of the study was to estimate perceived manufacturer risk associated with product safety litigation and increased development costs vs. revenue expectations on anticipated return on investment and to determine which scenarios might change a manufacturer's investment decision. Expected net present value of a weight-management drug entering pre-clinical trials was calculated for a range of scenarios representing evolving expectations of development costs, revenue, and litigation risk over the past 25 years. These three factors were based on published estimates, historical data, and analogs from other therapeutic areas. The main driver in expected net present value calculations is expected revenue, particularly if one assumes that litigation risk and demand are positively correlated. Changes in development costs associated with increased regulatory concern with potential safety issues for the past 25 years likely did not impact investment decisions. Regulatory policy and litigation risk both played a role in anti-obesity drug development; however, product revenue-reflecting efficacy at acceptable levels of safety-was by far the most important factor. To date, relatively modest sales associated with recent product introductions suggest that developing a product that is sufficiently efficacious with an acceptable level of safety continues to be the primary challenge in this market.

A survey of North Carolina safety-net dental clinics' methods for communicating with patients of limited english proficiency (LEP).

PubMed

Hammersmith, Kimberly J; Lee, Jessica Y

2009-01-01

Dental providers are increasingly challenged in communicating with patients with limited English proficiency (LEP). Accordingly, the purpose of the study was to examine methods of communicating with patients with LEP in North Carolina (NC) safety-net dental clinics as perceived by dental staff. An anonymous, 36-item, cross-sectional survey was distributed to representatives of 68 NC safety-net dental clinics. Question domains included: a) a perceived need for language services; b) methods of language services provided; c) perceptions of dental staff about dental care experiences for patients with LEP; and d) perceived legal and financial roles in providing language services. Of the 68 clinics, 55 responded (81 percent). All clinics reported treating patients with LEP, and 93 percent of clinics reported a need for providing language services. Many clinics used multiple methods to provide language services. Some clinics reported differences in treatment recommendations (13 percent), treatment provided (19 percent), and visit length (61 percent) for patients with LEP. All responded that additional costs are incurred to treat patients with LEP, and only 69 percent of responding clinics recognized legal obligations of treating patients with LEP. There is a reported need for language services in NC safety-net dental clinics. These services often resulted in additional costs to the dental clinic. To maintain the quality of care and to comply with legal requirements related to dental patients with LEP, additional funding sources might be required to recruit multilingual staff, support language services in dental clinics, and provide language skills training for practicing dentists. Additionally, studies are suggested to measure the perception of the effectiveness of communication methods of patients with LEP.

Tissue-specific NETs alter genome organization and regulation even in a heterologous system.

PubMed

de Las Heras, Jose I; Zuleger, Nikolaj; Batrakou, Dzmitry G; Czapiewski, Rafal; Kerr, Alastair R W; Schirmer, Eric C

2017-01-02

Different cell types exhibit distinct patterns of 3D genome organization that correlate with changes in gene expression in tissue and differentiation systems. Several tissue-specific nuclear envelope transmembrane proteins (NETs) have been found to influence the spatial positioning of genes and chromosomes that normally occurs during tissue differentiation. Here we study 3 such NETs: NET29, NET39, and NET47, which are expressed preferentially in fat, muscle and liver, respectively. We found that even when exogenously expressed in a heterologous system they can specify particular genome organization patterns and alter gene expression. Each NET affected largely different subsets of genes. Notably, the liver-specific NET47 upregulated many genes in HT1080 fibroblast cells that are normally upregulated in hepatogenesis, showing that tissue-specific NETs can favor expression patterns associated with the tissue where the NET is normally expressed. Similarly, global profiling of peripheral chromatin after exogenous expression of these NETs using lamin B1 DamID revealed that each NET affected the nuclear positioning of distinct sets of genomic regions with a significant tissue-specific component. Thus NET influences on genome organization can contribute to gene expression changes associated with differentiation even in the absence of other factors and overt cellular differentiation changes.

Shared decision-making during surgical consultation for gallstones at a safety-net hospital.

PubMed

Mueck, Krislynn M; Leal, Isabel M; Wan, Charlie C; Goldberg, Braden F; Saunders, Tamara E; Millas, Stefanos G; Liang, Mike K; Ko, Tien C; Kao, Lillian S

2018-04-01

Understanding patient perspectives regarding shared decision-making is crucial to providing informed, patient-centered care. Little is known about perceptions of vulnerable patients regarding shared decision-making during surgical consultation. The purpose of this study was to evaluate whether a validated tool reflects perceptions of shared decision-making accurately among patients seeking surgical consultation for gallstones at a safety-net hospital. A mixed methods study was conducted in a sample of adult patients with gallstones evaluated at a safety-net surgery clinic between May to July 2016. Semi-structured interviews were conducted after their initial surgical consultation and analyzed for emerging themes. Patients were administered the Shared Decision-Making Questionnaire and Autonomy Preference Scale. Univariate analyses were performed to identify factors associated with shared decision-making and to compare the results of the surveys to those of the interviews. The majority of patients (N = 30) were female (90%), Hispanic (80%), Spanish-speaking (70%), and middle-aged (45.7 ± 16 years). The proportion of patients who perceived shared decision-making was greater in the Shared Decision-Making Questionnaire versus the interviews (83% vs 27%, P < .01). Age, sex, race/ethnicity, primary language, diagnosis, Autonomy Preference Scale score, and decision for operation was not associated with shared decision-making. Contributory factors to this discordance include patient unfamiliarity with shared decision-making, deference to surgeon authority, lack of discussion about different treatments, and confusion between aligned versus shared decisions. Available questionnaires may overestimate shared decision-making in vulnerable patients suggesting the need for alternative or modifications to existing methods. Furthermore, such metrics should be assessed for correlation with patient-reported outcomes, such as satisfaction with decisions and health status

Implementation intentions and colorectal screening: a randomized trial in safety-net clinics.

PubMed

Greiner, K Allen; Daley, Christine M; Epp, Aaron; James, Aimee; Yeh, Hung-Wen; Geana, Mugur; Born, Wendi; Engelman, Kimberly K; Shellhorn, Jeremy; Hester, Christina M; LeMaster, Joseph; Buckles, Daniel C; Ellerbeck, Edward F

2014-12-01

Low-income and racial/ethnic minority populations experience disproportionate colorectal cancer (CRC) burden and poorer survival. Novel behavioral strategies are needed to improve screening rates in these groups. The study aimed to test a theoretically based "implementation intentions" intervention for improving CRC screening among unscreened adults in urban safety-net clinics. Randomized controlled trial. Adults (N=470) aged ≥50 years, due for CRC screening, from urban safety-net clinics were recruited. The intervention (conducted in 2009-2011) was delivered via touchscreen computers that tailored informational messages to decisional stage and screening barriers. The computer then randomized participants to generic health information on diet and exercise (Comparison group) or "implementation intentions" questions and planning (Experimental group) specific to the CRC screening test chosen (fecal immunochemical test or colonoscopy). The primary study outcome was completion of CRC screening at 26 weeks based on test reports (analysis conducted in 2012-2013). The study population had a mean age of 57 years and was 42% non-Hispanic African American, 28% non-Hispanic white, and 27% Hispanic. Those receiving the implementation intentions-based intervention had higher odds (AOR=1.83, 95% CI=1.23, 2.73) of completing CRC screening than the Comparison group. Those with higher self-efficacy for screening (AOR=1.57, 95% CI=1.03, 2.39), history of asthma (AOR=2.20, 95% CI=1.26, 3.84), no history of diabetes (AOR=1.86, 95% CI=1.21, 2.86), and reporting they had never heard that "cutting on cancer" makes it spread (AOR=1.78, 95% CI=1.16, 2.72) were more likely to complete CRC screening. The results of this study suggest that programs incorporating an implementation intentions approach can contribute to successful completion of CRC screening even among very low-income and diverse primary care populations. Future initiatives to reduce CRC incidence and mortality disparities may

Petri net modelling of buffers in automated manufacturing systems.

PubMed

Zhou, M; Dicesare, F

1996-01-01

This paper presents Petri net models of buffers and a methodology by which buffers can be included in a system without introducing deadlocks or overflows. The context is automated manufacturing. The buffers and models are classified as random order or order preserved (first-in-first-out or last-in-first-out), single-input-single-output or multiple-input-multiple-output, part type and/or space distinguishable or indistinguishable, and bounded or safe. Theoretical results for the development of Petri net models which include buffer modules are developed. This theory provides the conditions under which the system properties of boundedness, liveness, and reversibility are preserved. The results are illustrated through two manufacturing system examples: a multiple machine and multiple buffer production line and an automatic storage and retrieval system in the context of flexible manufacturing.

Modelling of Biometric Identification System with Given Parameters Using Colored Petri Nets

NASA Astrophysics Data System (ADS)

Petrosyan, G.; Ter-Vardanyan, L.; Gaboutchian, A.

2017-05-01

Biometric identification systems use given parameters and function on the basis of Colored Petri Nets as a modelling language developed for systems in which communication, synchronization and distributed resources play an important role. Colored Petri Nets combine the strengths of Classical Petri Nets with the power of a high-level programming language. Coloured Petri Nets have both, formal intuitive and graphical presentations. Graphical CPN model consists of a set of interacting modules which include a network of places, transitions and arcs. Mathematical representation has a well-defined syntax and semantics, as well as defines system behavioural properties. One of the best known features used in biometric is the human finger print pattern. During the last decade other human features have become of interest, such as iris-based or face recognition. The objective of this paper is to introduce the fundamental concepts of Petri Nets in relation to tooth shape analysis. Biometric identification systems functioning has two phases: data enrollment phase and identification phase. During the data enrollment phase images of teeth are added to database. This record contains enrollment data as a noisy version of the biometrical data corresponding to the individual. During the identification phase an unknown individual is observed again and is compared to the enrollment data in the database and then system estimates the individual. The purpose of modeling biometric identification system by means of Petri Nets is to reveal the following aspects of the functioning model: the efficiency of the model, behavior of the model, mistakes and accidents in the model, feasibility of the model simplification or substitution of its separate components for more effective components without interfering system functioning. The results of biometric identification system modeling and evaluating are presented and discussed.

Application of growing nested Petri nets for modeling robotic systems operating under risk

NASA Astrophysics Data System (ADS)

Sorokin, E. V.; Senkov, A. V.

2017-10-01

The paper studies the peculiarities of modeling robotic systems engaged in mining. Existing modeling mechanisms are considered, which are based on nested Petri nets, and a new formalism of growing Petri nets is presented that allows modeling robotic systems operating under risk. Modeling is provided both for the regular operation mode and for non-standard modes in which individual elements of the system can perform uncharacteristic functions. The example shows growing Petri nets that are used for modeling extraction of flat coal seams by a robotic system consisting of several different-type autonomous robots.

From ontology selection and semantic web to an integrated information system for food-borne diseases and food safety.

PubMed

Yan, Xianghe; Peng, Yun; Meng, Jianghong; Ruzante, Juliana; Fratamico, Pina M; Huang, Lihan; Juneja, Vijay; Needleman, David S

2011-01-01

Several factors have hindered effective use of information and resources related to food safety due to inconsistency among semantically heterogeneous data resources, lack of knowledge on profiling of food-borne pathogens, and knowledge gaps among research communities, government risk assessors/managers, and end-users of the information. This paper discusses technical aspects in the establishment of a comprehensive food safety information system consisting of the following steps: (a) computational collection and compiling publicly available information, including published pathogen genomic, proteomic, and metabolomic data; (b) development of ontology libraries on food-borne pathogens and design automatic algorithms with formal inference and fuzzy and probabilistic reasoning to address the consistency and accuracy of distributed information resources (e.g., PulseNet, FoodNet, OutbreakNet, PubMed, NCBI, EMBL, and other online genetic databases and information); (c) integration of collected pathogen profiling data, Foodrisk.org ( http://www.foodrisk.org ), PMP, Combase, and other relevant information into a user-friendly, searchable, "homogeneous" information system available to scientists in academia, the food industry, and government agencies; and (d) development of a computational model in semantic web for greater adaptability and robustness.

Software Safety Risk in Legacy Safety-Critical Computer Systems

NASA Technical Reports Server (NTRS)

Hill, Janice L.; Baggs, Rhoda

2007-01-01

Safety Standards contain technical and process-oriented safety requirements. Technical requirements are those such as "must work" and "must not work" functions in the system. Process-Oriented requirements are software engineering and safety management process requirements. Address the system perspective and some cover just software in the system > NASA-STD-8719.13B Software Safety Standard is the current standard of interest. NASA programs/projects will have their own set of safety requirements derived from the standard. Safety Cases: a) Documented demonstration that a system complies with the specified safety requirements. b) Evidence is gathered on the integrity of the system and put forward as an argued case. [Gardener (ed.)] c) Problems occur when trying to meet safety standards, and thus make retrospective safety cases, in legacy safety-critical computer systems.

DMFS: A Data Migration File System for NetBSD

NASA Technical Reports Server (NTRS)

Studenmund, William

2000-01-01

I have recently developed DMFS, a Data Migration File System, for NetBSD. This file system provides kernel support for the data migration system being developed by my research group at NASA/Ames. The file system utilizes an underlying file store to provide the file backing, and coordinates user and system access to the files. It stores its internal metadata in a flat file, which resides on a separate file system. This paper will first describe our data migration system to provide a context for DMFS, then it will describe DMFS. It also will describe the changes to NetBSD needed to make DMFS work. Then it will give an overview of the file archival and restoration procedures, and describe how some typical user actions are modified by DMFS. Lastly, the paper will present simple performance measurements which indicate that there is little performance loss due to the use of the DMFS layer.

Software Safety Risk in Legacy Safety-Critical Computer Systems

NASA Technical Reports Server (NTRS)

Hill, Janice; Baggs, Rhoda

2007-01-01

Safety-critical computer systems must be engineered to meet system and software safety requirements. For legacy safety-critical computer systems, software safety requirements may not have been formally specified during development. When process-oriented software safety requirements are levied on a legacy system after the fact, where software development artifacts don't exist or are incomplete, the question becomes 'how can this be done?' The risks associated with only meeting certain software safety requirements in a legacy safety-critical computer system must be addressed should such systems be selected as candidates for reuse. This paper proposes a method for ascertaining formally, a software safety risk assessment, that provides measurements for software safety for legacy systems which may or may not have a suite of software engineering documentation that is now normally required. It relies upon the NASA Software Safety Standard, risk assessment methods based upon the Taxonomy-Based Questionnaire, and the application of reverse engineering CASE tools to produce original design documents for legacy systems.

Changes in the Healthcare Safety Net 1992–2003: Disparities in Access for Uninsured Persons in Florida

PubMed Central

Kuo, Tzy-Mey; Mobley, Lee R.; Bazzoli, Gloria J.

2011-01-01

A patchwork of services is available to the US uninsured through the healthcare safety net (SN). During 1996–2003, some SN hospitals (SNHs) closed or converted ownership from public or non-profit to for-profit status. However, around this time the number of community health centers (CHCs) grew due to new federal funding. This paper examines the impact of these two countervailing SN events on access to care for the uninsured. Hospital admissions for ambulatory care sensitive conditions (ACSCs) relative to marker conditions were used as our access measure. We examined 35,730 discharges for uninsured adults treated in Florida hospitals in the years 1992 or 2003. A generalized estimating equation model was used to assess differential access effects for racial and ethnic groups. We found that in communities with CHC openings but no SNH contractions, uninsured black and white individuals experienced deteriorations in access over time but the Hispanic uninsured did not. However, in communities where SNHs closed or converted, access deteriorations occurred for all three racial and ethnic groups. Thus, the potentially beneficial effects of CHC expansions on access to primary care for the uninsured Hispanic population in Florida appeared to be offset if contractions in the hospital safety net were present. PMID:24066421

Internet Access and Online Cancer Information Seeking Among Latino Immigrants From Safety Net Clinics

PubMed Central

SELSKY, CLAIRE; LUTA, GEORGE; NOONE, ANNE-MICHELLE; HUERTA, ELMER E.; MANDELBLATT, JEANNE S.

2013-01-01

Internet use is widespread, but little is known about Internet use for cancer information among Latinos, especially those who rely on safety net clinics. The authors investigated access to and intended use of the Internet for cancer information among low income, immigrant Latinos predominately from Central and South America. A cross-sectional study of 1,273 Latinos 21 years and older attending safety net clinics or health fairs was conducted from June 2007 to November 2008. The authors used logistic regression models to evaluate associations of age, acculturation, psychosocial factors and other covariates with Internet access and intended use of the Internet for cancer information among those with access. Of the sample, 44% reported Internet access. Higher information self-efficacy and greater trust in the Internet were independently associated with Internet access (p= .05 and p < .001, respectively). Among those with access, 53.8% reported they intended to seek cancer help online if they needed information. Those with younger age and higher acculturation, education and self-efficacy had higher odds of intended Internet use for cancer information, considering covariates. In addition, those with high (vs. low) perceived risk of cancer (OR = 1.76; 95% CI [1.14, 2.73]; p = .01) and higher levels of trust in online health information (OR = 1.47 per one-point increase; 95% [CI 1.19, 1.82]; p = .0004) were more likely to intend to seek cancer information online. These findings that Internet access is fairly high in the immigrant Latino population and that the Internet is a trusted source of cancer information suggest that the Internet may be a channel for cancer control interventions. PMID:23066874

Robustness analysis of non-ordinary Petri nets for flexible assembly systems

NASA Astrophysics Data System (ADS)

Hsieh, Fu-Shiung

2010-05-01

Non-ordinary controlled Petri nets (NCPNs) have the advantages to model flexible assembly systems in which multiple identical resources may be required to perform an operation. However, existing studies on NCPNs are still limited. For example, the robustness properties of NCPNs have not been studied. This motivates us to develop an analysis method for NCPNs. Robustness analysis concerns the ability for a system to maintain operation in the presence of uncertainties. It provides an alternative way to analyse a perturbed system without reanalysis. In our previous research, we have analysed the robustness properties of several subclasses of ordinary controlled Petri nets. To study the robustness properties of NCPNs, we augment NCPNs with an uncertainty model, which specifies an upper bound on the uncertainties for each reachable marking. The resulting PN models are called non-ordinary controlled Petri nets with uncertainties (NCPNU). Based on NCPNU, the problem is to characterise the maximal tolerable uncertainties for each reachable marking. The computational complexities to characterise maximal tolerable uncertainties for each reachable marking grow exponentially with the size of the nets. Instead of considering general NCPNU, we limit our scope to a subclass of PN models called non-ordinary controlled flexible assembly Petri net with uncertainties (NCFAPNU) for assembly systems and study its robustness. We will extend the robustness analysis to NCFAPNU. We identify two types of uncertainties under which the liveness of NCFAPNU can be maintained.

Reach and Validity of an Objective Medication Adherence Measure Among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study.

PubMed

Ratanawongsa, Neda; Karter, Andrew J; Quan, Judy; Parker, Melissa M; Handley, Margaret; Sarkar, Urmimala; Schmittdiel, Julie A; Schillinger, Dean

2015-08-01

With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a nonprofit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English- , Cantonese- , or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). For validity, we examined unadjusted associations of suboptimal adherence (CMG >  20%) with suboptimal cardiometabolic control. 429 members (63%) had calculable CMG. Compared with members without CMG, members with CMG were younger, more likely employed, and had poorer glycemic control but had better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, P = 0.02). CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable with its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG.

Reach and Validity of An Objective Medication Adherence Measure among Safety Net Health Plan Members with Diabetes: A Cross-Sectional Study

PubMed Central

Ratanawongsa, Neda; Karter, Andrew J.; Quan, Judy; Parker, Melissa M.; Handley, Margaret; Sarkar, Urmimala; Schmittdiel, Julie A.; Schillinger, Dean

2015-01-01

Background With the expansion of Medicaid and low-cost health insurance plans among diverse patient populations, objective measures of medication adherence using pharmacy claims could advance clinical care and translational research for safety net care. However, safety net patients may experience fluctuating prescription drug coverage, affecting the performance of adherence measures. Objective To evaluate the performance of continuous medication gap (CMG) for diverse, low-income managed care members with diabetes. Methods We conducted this cross-sectional analysis using administrative and clinical data for 680 members eligible for a self-management support trial at a non-profit, government-sponsored managed care plan. We applied CMG methodology to cardiometabolic medication claims for English-, Cantonese-, or Spanish-speaking members with diabetes. We examined inclusiveness (the proportion with calculable CMG) and selectivity (sociodemographic and medical differences from members without CMG). To examine validity, we examined unadjusted associations of suboptimal adherence (CMG>20%) with suboptimal cardiometabolic control. Results 429 members (63%) had calculable CMG. Compared to members without CMG, members with CMG were younger; more likely employed; and had poorer glycemic control, but better blood pressure and lipid control. Suboptimal adherence occurred more frequently among members with poor cardiometabolic control than among members with optimal control (28% vs. 12%, p=0.02). Conclusions CMG demonstrated acceptable inclusiveness and validity in a diverse, low-income safety net population, comparable to its performance in studies among other insured populations. CMG may provide a useful tool to measure adherence among increasingly diverse Medicaid populations, complemented by other strategies to reach those not captured by CMG. Trial Registration NCT00683020 PMID:26233541

NASA System Safety Handbook. Volume 2: System Safety Concepts, Guidelines, and Implementation Examples

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon; Benjamin, Allan; Everett, Christopher; Feather, Martin; Rutledge, Peter; Sen, Dev; Youngblood, Robert

2015-01-01

This is the second of two volumes that collectively comprise the NASA System Safety Handbook. Volume 1 (NASASP-210-580) was prepared for the purpose of presenting the overall framework for System Safety and for providing the general concepts needed to implement the framework. Volume 2 provides guidance for implementing these concepts as an integral part of systems engineering and risk management. This guidance addresses the following functional areas: 1.The development of objectives that collectively define adequate safety for a system, and the safety requirements derived from these objectives that are levied on the system. 2.The conduct of system safety activities, performed to meet the safety requirements, with specific emphasis on the conduct of integrated safety analysis (ISA) as a fundamental means by which systems engineering and risk management decisions are risk-informed. 3.The development of a risk-informed safety case (RISC) at major milestone reviews to argue that the systems safety objectives are satisfied (and therefore that the system is adequately safe). 4.The evaluation of the RISC (including supporting evidence) using a defined set of evaluation criteria, to assess the veracity of the claims made therein in order to support risk acceptance decisions.

Participation of low-income women in genetic cancer risk assessment and BRCA 1/2 testing: the experience of a safety-net institution.

PubMed

Komenaka, Ian K; Nodora, Jesse N; Madlensky, Lisa; Winton, Lisa M; Heberer, Meredith A; Schwab, Richard B; Weitzel, Jeffrey N; Martinez, Maria Elena

2016-07-01

Some communities and populations lack access to genetic cancer risk assessment (GCRA) and testing. This is particularly evident in safety-net institutions, which serve a large segment of low-income, uninsured individuals. We describe the experience of a safety-net clinic with limited resources in providing GCRA and BRCA1/2 testing. We compared the proportion and characteristics of high-risk women who were offered and underwent GCRA and genetic testing. We also provide a description of the mutation profile for affected women. All 125 patients who were offered GCRA accepted to undergo GCRA. Of these, 72 % had a breast cancer diagnosis, 70 % were Hispanic, 52.8 % were non-English speakers, and 66 % did not have health insurance. Eighty four (67 %) were offered genetic testing and 81 (96 %) agreed. Hispanic women, those with no medical insurance, and those with a family history of breast cancer were significantly more likely to undergo testing (p > 0.01). Twelve of 81 (15 %) patients were found to have deleterious mutations, seven BRCA1, and five BRCA2. Our experience shows that it is possible to offer GCRA and genetic testing even in the setting of limited resources for these services. This is important given that a large majority of the low-income women in our study agreed to undergo counseling and testing. Our experience could serve as a model for similar low-resource safety-net health settings.

The use of open source electronic health records within the federal safety net.

PubMed

Goldwater, Jason C; Kwon, Nancy J; Nathanson, Ashley; Muckle, Alison E; Brown, Alexa; Cornejo, Kerri

2014-01-01

To conduct a federally funded study that examines the acquisition, implementation and operation of open source electronic health records (EHR) within safety net medical settings, such as federally qualified health centers (FQHC). The study was conducted by the National Opinion Research Center (NORC) at the University of Chicago from April to September 2010. The NORC team undertook a comprehensive environmental scan, including a literature review, a dozen key informant interviews using a semistructured protocol, and a series of site visits to West Virginia, California and Arizona FQHC that were currently using an open source EHR. Five of the six sites that were chosen as part of the study found a number of advantages in the use of their open source EHR system, such as utilizing a large community of users and developers to modify their EHR to fit the needs of their provider and patient communities, and lower acquisition and implementation costs as compared to a commercial system. Despite these advantages, many of the informants and site visit participants felt that widespread dissemination and use of open source was restrained due to a negative connotation regarding this type of software. In addition, a number of participants stated that there is a necessary level of technical acumen needed within the FQHC to make an open source EHR effective. An open source EHR provides advantages for FQHC that have limited resources to acquire and implement an EHR, but additional study is needed to evaluate its overall effectiveness.

Space engine safety system

NASA Technical Reports Server (NTRS)

Maul, William A.; Meyer, Claudia M.

1991-01-01

A rocket engine safety system was designed to initiate control procedures to minimize damage to the engine or vehicle or test stand in the event of an engine failure. The features and the implementation issues associated with rocket engine safety systems are discussed, as well as the specific concerns of safety systems applied to a space-based engine and long duration space missions. Examples of safety system features and architectures are given, based on recent safety monitoring investigations conducted for the Space Shuttle Main Engine and for future liquid rocket engines. Also, the general design and implementation process for rocket engine safety systems is presented.

Development of Network Interface Cards for TRIDAQ systems with the NaNet framework

NASA Astrophysics Data System (ADS)

Ammendola, R.; Biagioni, A.; Cretaro, P.; Di Lorenzo, S.; Fiorini, M.; Frezza, O.; Lamanna, G.; Lo Cicero, F.; Lonardo, A.; Martinelli, M.; Neri, I.; Paolucci, P. S.; Pastorelli, E.; Piandani, R.; Pontisso, L.; Rossetti, D.; Simula, F.; Sozzi, M.; Valente, P.; Vicini, P.

2017-03-01

NaNet is a framework for the development of FPGA-based PCI Express (PCIe) Network Interface Cards (NICs) with real-time data transport architecture that can be effectively employed in TRIDAQ systems. Key features of the architecture are the flexibility in the configuration of the number and kind of the I/O channels, the hardware offloading of the network protocol stack, the stream processing capability, and the zero-copy CPU and GPU Remote Direct Memory Access (RDMA). Three NIC designs have been developed with the NaNet framework: NaNet-1 and NaNet-10 for the CERN NA62 low level trigger and NaNet3 for the KM3NeT-IT underwater neutrino telescope DAQ system. We will focus our description on the NaNet-10 design, as it is the most complete of the three in terms of capabilities and integrated IPs of the framework.

The Northern Virginia Supported Employment "Safety Nets" Demonstration Project. Final Evaluation Report (for October 1, 1991, through September 30, 1992).

ERIC Educational Resources Information Center

Wurbacher and Associates, Takoma Park, MD.

This report describes results and conclusions of a third-party evaluation of a 1-year demonstration project in Alexandria (Virginia) to develop "safety nets" for 12 people with disabilities who were either unemployed or with a history of unemployment. An Employment Security Specialist worked with these individuals and their families to:…

Understanding the digital divide in the clinical setting: the technology knowledge gap experienced by US safety net patients during teleretinal screening.

PubMed

George, Sheba; Moran, Erin; Fish, Allison; Ogunyemi, Lola

2013-01-01

Differential access to everyday technology and healthcare amongst safety net patients is associated with low technological and health literacies, respectively. These low rates of literacy produce a complex patient "knowledge gap" that influences the effectiveness of telehealth technologies. To understand this "knowledge gap", six focus groups (2 African-American and 4 Latino) were conducted with patients who received teleretinal screenings in U.S. urban safety-net settings. Findings indicate that patients' "knowledge gap" is primarily produced at three points: (1) when patients' preexisting personal barriers to care became exacerbated in the clinical setting; (2) through encounters with technology during screening; and (3) in doctor-patient follow-up. This "knowledge gap" can produce confusion and fear, potentially affecting patients' confidence in quality of care and limiting their disease management ability. In rethinking the digital divide to include the consequences of this knowledge gap faced by patients in the clinical setting, we suggest that patient education focus on both their disease and specific telehealth technologies deployed in care delivery.

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

PubMed

Alawadi, Zeinab M; Leal, Isabel; Phatak, Uma R; Flores-Gonzalez, Juan R; Holihan, Julie L; Karanjawala, Burzeen E; Millas, Stefanos G; Kao, Lillian S

2016-03-01

Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and

Systemic safety project selection tool.

DOT National Transportation Integrated Search

2013-07-01

"The Systemic Safety Project Selection Tool presents a process for incorporating systemic safety planning into traditional safety management processes. The Systemic Tool provides a step-by-step process for conducting systemic safety analysis; conside...

Home closure as a weapon in the Dutch war on drugs: Does judicial review function as a safety net?

PubMed

Bruijn, L Michelle; Vols, Michel; Brouwer, Jan G

2018-01-01

A widespread sense of a failing criminal justice system and increased feelings of insecurity changed the response to crime into a culture of control, which is characterized by policies that punish and exclude. In the Netherlands, these influences can be witnessed in the war on drugs where local authorities use their administrative power to close homes involved in drug-related crime. Citizens can invoke judicial review over these administrative interferences by claiming that such closure results in an unfair balance between purposes, means and consequences. This paper assesses whether judicial review functions as a safety net against losing one's home due to drug-related crime. We used doctrinal legal research methods to examine the "law in the books" and empirical legal research methods to analyse the "law in action". We used a survey to investigate how often the drug-related closure power was used in 2015, and we statistically analysed all published case law of Dutch lower courts between 2007 and 2016. The scope of the closure power broadened over the years and our data show that local authorities fiercely make use of this instrument. In 41.4% of the cases, citizens are successful in fighting the closure. While scholarly literature indicates that judicial courts function as safeguards by questioning the proportionality of administrative action, raising a proportionality defence does not necessarily result in a more favourable outcome for citizens. In fact, raising a proportionality defence makes it more likely to result in dismissal of the appeal. The stretched scope of the drug-related closure power together with the relatively low success rate of citizens who fight the loss of their home and a seemingly meaningless proportionality check show no sign of a safety net against the loss of one's home at the suit of a local authority. Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.

Can We Do That Here? Establishing the Scope of Surgical Practice at a New Safety-Net Community Hospital Through a Transparent, Collaborative Review of Physician Privileges.

PubMed

O'Neill, Sean M; Seresinghe, Sarah; Sharma, Arun; Russell, Tara A; Crawford, L'Orangerie; Frencher, Stanley K

2018-01-01

Stewarding of physician privileges wisely is imperative, but no guidelines exist for how to incorporate system-level factors in privileging decisions. A newly opened, safety-net community hospital tailored the scope of surgical practice through review of physician privileges. Martin Luther King, Jr. Community Hospital is a public-private partnership, safety-net institution in South Los Angeles that opened in July 2015. It has 131 beds, including a 28-bed emergency department, a 20-bed ICU, and 5 operating rooms. Staff privileging decisions were initially based only on physicians' training and experience, but this resulted in several cases that tested the boundaries of what a small community hospital was prepared to handle. A collaborative, transparent process to review physician privileges was developed. This began with physician-only review of procedure lists, followed by a larger, multidisciplinary group to assess system-level factors. Specific questions were used to guide discussion, and unanimous approval from all stakeholders was required to include a procedure. An initial list of 558 procedures across 11 specialties was reduced to 321 (57.5%). No new cases that fall outside these new boundaries have arisen. An inclusive process was crucial for obtaining buy-in and establishing cultural norms. Arranging transfer agreements remains a significant challenge. Accumulation of institutional experience continues through regular performance reviews. As this hospital's capabilities mature, a blueprint has been established for expanding surgical scope of practice based explicitly on system-level factors. Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.

Patient navigation for lung cancer screening in an urban safety-net system: Protocol for a pragmatic randomized clinical trial.

PubMed

Gerber, David E; Hamann, Heidi A; Santini, Noel O; Abbara, Suhny; Chiu, Hsienchang; McGuire, Molly; Quirk, Lisa; Zhu, Hong; Lee, Simon J Craddock

2017-09-01

The National Lung Screening Trial demonstrated improved lung cancer mortality with annual low-dose computed tomography (CT) screening, leading to lung cancer screening endorsement by the United States Preventive Services Task Force and coverage by the Centers for Medicare and Medicaid. Adherence to annual CT screens in that trial was 95%, which may not be representative of real-world, particularly medically underserved populations. This pragmatic trial will determine the effect of patient-focused, telephone-based patient navigation on adherence to CT-based lung cancer screening in an urban safety-net population. 340 adults who meet standard eligibility for lung cancer screening (age 55-77years, smoking history≥30 pack-years, quit within 15years if former smoker) are referred through an electronic medical record-based order by physicians in community- and hospital-based primary care settings within the Parkland Health and Hospital System in Dallas County, Texas. Eligible patients are randomized to usual care or patient navigation, which addresses adherence, patient-reported barriers, smoking cessation, and psycho-social concerns related to screening completion. Patients complete surveys and semi-structured interviews at baseline, 6-month, and 18-month follow-ups to assess attitudes toward screening. The primary endpoint of this pragmatic trial is adherence to three sequential, prospectively defined steps in the screening protocol. Secondary endpoints include self-reported tobacco use and other patient-reported outcomes. Results will provide real-world insight into the impact of patient navigation on adherence to CT-based lung cancer screening in a medically underserved population. This study was registered with the NIH ClinicalTrials.gov database (NCT02758054) on April 26, 2016. Copyright © 2017 Elsevier Inc. All rights reserved.

Petri net modeling of high-order genetic systems using grammatical evolution.

PubMed

Moore, Jason H; Hahn, Lance W

2003-11-01

Understanding how DNA sequence variations impact human health through a hierarchy of biochemical and physiological systems is expected to improve the diagnosis, prevention, and treatment of common, complex human diseases. We have previously developed a hierarchical dynamic systems approach based on Petri nets for generating biochemical network models that are consistent with genetic models of disease susceptibility. This modeling approach uses an evolutionary computation approach called grammatical evolution as a search strategy for optimal Petri net models. We have previously demonstrated that this approach routinely identifies biochemical network models that are consistent with a variety of genetic models in which disease susceptibility is determined by nonlinear interactions between two DNA sequence variations. In the present study, we evaluate whether the Petri net approach is capable of identifying biochemical networks that are consistent with disease susceptibility due to higher order nonlinear interactions between three DNA sequence variations. The results indicate that our model-building approach is capable of routinely identifying good, but not perfect, Petri net models. Ideas for improving the algorithm for this high-dimensional problem are presented.

MED31/437: A Web-based Diabetes Management System: DiabNet

PubMed Central

Zhao, N; Roudsari, A; Carson, E

1999-01-01

Introduction A web-based system (DiabNet) was developed to provide instant access to the Electronic Diabetes Records (EDR) for end-users, and real-time information for healthcare professionals to facilitate their decision-making. It integrates portable glucometer, handheld computer, mobile phone and Internet access as a combined telecommunication and mobile computing solution for diabetes management. Methods: Active Server Pages (ASP) embedded with advanced ActiveX controls and VBScript were developed to allow remote data upload, retrieval and interpretation. Some advisory and Internet-based learning features, together with a video teleconferencing component make DiabNet web site an informative platform for Web-consultation. Results The evaluation of the system is being implemented among several UK Internet diabetes discussion groups and the Diabetes Day Centre at the Guy's & St. Thomas' Hospital. Many positive feedback are received from the web site demonstrating DiabNet is an advanced web-based diabetes management system which can help patients to keep closer control of self-monitoring blood glucose remotely, and is an integrated diabetes information resource that offers telemedicine knowledge in diabetes management. Discussion In summary, DiabNet introduces an innovative online diabetes management concept, such as online appointment and consultation, to enable users to access diabetes management information without time and location limitation and security concerns.

The use of open source electronic health records within the federal safety net

PubMed Central

Goldwater, Jason C; Kwon, Nancy J; Nathanson, Ashley; Muckle, Alison E; Brown, Alexa; Cornejo, Kerri

2014-01-01

Objective To conduct a federally funded study that examines the acquisition, implementation and operation of open source electronic health records (EHR) within safety net medical settings, such as federally qualified health centers (FQHC). Methods and materials The study was conducted by the National Opinion Research Center (NORC) at the University of Chicago from April to September 2010. The NORC team undertook a comprehensive environmental scan, including a literature review, a dozen key informant interviews using a semistructured protocol, and a series of site visits to West Virginia, California and Arizona FQHC that were currently using an open source EHR. Results Five of the six sites that were chosen as part of the study found a number of advantages in the use of their open source EHR system, such as utilizing a large community of users and developers to modify their EHR to fit the needs of their provider and patient communities, and lower acquisition and implementation costs as compared to a commercial system. Discussion Despite these advantages, many of the informants and site visit participants felt that widespread dissemination and use of open source was restrained due to a negative connotation regarding this type of software. In addition, a number of participants stated that there is a necessary level of technical acumen needed within the FQHC to make an open source EHR effective. Conclusions An open source EHR provides advantages for FQHC that have limited resources to acquire and implement an EHR, but additional study is needed to evaluate its overall effectiveness. PMID:23744787

Information needs of parents for acute childhood illness: determining ‘what, how, where and when’ of safety netting using a qualitative exploration with parents and clinicians

PubMed Central

Jones, Caroline H D; Neill, Sarah; Lakhanpaul, Monica; Roland, Damian; Singlehurst-Mooney, Hayley; Thompson, Matthew

2014-01-01

Objective To explore the views of parents and clinicians regarding the optimal content, format and delivery of safety netting information for acute childhood illness. Design Qualitative study including semistructured focus groups and interviews. Setting First contact care settings, community centres, children's centres and nurseries in the Midlands, UK. Participants 27 parents from a travelling community, Asian British community and white British community. Sixteen clinicians including 10 doctors and 6 nurses from a general practice surgery, an out-of-hours service and two emergency departments (paediatric and combined adult and paediatric). Results Participants described a need for safety netting to contain information on signs and symptoms of serious and common illnesses, illness management and where and when to seek help. Resources should be basic, simple to use and contain simple symbols. A key criterion was professional endorsement of resources. Internet-based information was desired which is reliable, consistent and up-to-date. Participants described a need for different types of information: that which could be delivered during consultations, as well as more general information for parents to access before consulting a healthcare professional. Face-to-face education, written materials and digital media were suggested delivery mechanisms. Audiovisual material was preferred by families with low literacy. Participants commonly suggested internet-based and phone-based resources, but the travelling community was less comfortable with these approaches. Conclusions A multifaceted and tailored approach to safety netting is needed so that effective resources are available for parents with varying information needs, literacy levels and ability to use information technology. We have identified key aspects of content, quality criteria, format and delivery mechanisms for safety netting information from the perspectives of clinicians and parents. Resources should be

Reachability analysis of real-time systems using time Petri nets.

PubMed

Wang, J; Deng, Y; Xu, G

2000-01-01

Time Petri nets (TPNs) are a popular Petri net model for specification and verification of real-time systems. A fundamental and most widely applied method for analyzing Petri nets is reachability analysis. The existing technique for reachability analysis of TPNs, however, is not suitable for timing property verification because one cannot derive end-to-end delay in task execution, an important issue for time-critical systems, from the reachability tree constructed using the technique. In this paper, we present a new reachability based analysis technique for TPNs for timing property analysis and verification that effectively addresses the problem. Our technique is based on a concept called clock-stamped state class (CS-class). With the reachability tree generated based on CS-classes, we can directly compute the end-to-end time delay in task execution. Moreover, a CS-class can be uniquely mapped to a traditional state class based on which the conventional reachability tree is constructed. Therefore, our CS-class-based analysis technique is more general than the existing technique. We show how to apply this technique to timing property verification of the TPN model of a command and control (C2) system.

[Design and implementation of medical instrument standard information retrieval system based on APS.NET].

PubMed

Yu, Kaijun

2010-07-01

This paper Analys the design goals of Medical Instrumentation standard information retrieval system. Based on the B /S structure,we established a medical instrumentation standard retrieval system with ASP.NET C # programming language, IIS f Web server, SQL Server 2000 database, in the. NET environment. The paper also Introduces the system structure, retrieval system modules, system development environment and detailed design of the system.

Bi-directional transition nets

NASA Astrophysics Data System (ADS)

Staines, Anthony Spiteri

2017-06-01

Ordinary Petri nets are forward directed transition systems. Modern transition systems events and event flows are reversible. Hence modeling structures that reflect this are important. The creation of a bi-directional Petri net extends the modeling power of Petri nets. This work presents the successful implementation of a bi-directional transition net. Some toy examples in comparison to Petri nets are given showing the increased modeling power in a compacted form. The results show some interesting findings on how the expressive power of these structures has been increased.

Comorbid depression and substance abuse among safety-net clients in Los Angeles: a community participatory study.

PubMed

Chang, Evelyn T; Wells, Kenneth B; Gilmore, James; Tang, Lingqi; Morgan, Anna U; Sanders, Starr; Chung, Bowen

2015-03-01

Depression and substance abuse are common among low-income adults from racial-ethnic minority groups who receive services in safety-net settings, although little is known about how clients differ by service setting. This study examined characteristics and service use among depressed, low-income persons from minority groups in underresourced communities who did and did not have a substance abuse history. The study used cross-sectional baseline client data (N=957) from Community Partners in Care, an initiative to improve depression services in Los Angeles County. Clients with probable depression (eight-item Patient Health Questionnaire) from substance abuse programs were compared with depressed clients with and without a history of substance abuse from primary care, mental health, and social and community programs. Sociodemographic, health status, and services utilization variables were examined. Of the 957 depressed clients, 217 (23%) were from substance abuse programs; 269 (28%) clients from other sectors had a substance abuse history, and 471 (49%) did not. Most clients from substance abuse programs or with a substance abuse history were unemployed and impoverished, lacked health insurance, and had high rates of arrests and homelessness. They were also more likely than clients without a substance abuse history to have depression or anxiety disorders, psychosis, and mania and to use emergency rooms. Clients with depression and a substance abuse history had significant psychosocial stressors and high rates of service use, which suggests that communitywide approaches may be needed to address both depression and substance abuse in this safety-net population.

Traceability of Software Safety Requirements in Legacy Safety Critical Systems

NASA Technical Reports Server (NTRS)

Hill, Janice L.

2007-01-01

How can traceability of software safety requirements be created for legacy safety critical systems? Requirements in safety standards are imposed most times during contract negotiations. On the other hand, there are instances where safety standards are levied on legacy safety critical systems, some of which may be considered for reuse for new applications. Safety standards often specify that software development documentation include process-oriented and technical safety requirements, and also require that system and software safety analyses are performed supporting technical safety requirements implementation. So what can be done if the requisite documents for establishing and maintaining safety requirements traceability are not available?

Net ecosystem calcification and net primary production in two Hawaii back-reef systems

NASA Astrophysics Data System (ADS)

Kiili, S.; Colbert, S.; Hart, K.

2016-02-01

Back-reef systems have complex carbon cycling, driven by dominant benthic communities that change with environmental conditions and display characteristic patterns of net primary production (NP) and net ecosystem calcification (G). The G/NP ratio provides a fundamental community-level assessment to compare systems spatially and to evaluate temporal changes in carbon cycling. Carbon dynamics were examined at leeward Hōnaunau and windward Waíōpae, Hawaíi Island. Both locations discharge brackish groundwater, including geothermal water at Waíōpae. The change in total CO2 (TCO2) and total alkalinity (TA) between morning and afternoon was measured to calculate the G/NP ratio along a salinity gradient. At both sites, aragonite saturation (ΩAr) was lower than open ocean conditions, and increased with salinity. Between the morning and afternoon, ΩAr increased by at least 1 as photosynthesis consumed CO2. At Waíōpae, water was corrosive to aragonite due to the input of acidic groundwater, but not at Honaunau, demonstrating the importance of local watershed characteristics on ΩAr. Across the salinity gradient, TA and TCO2 decreased between morning and afternoon. At Hōnaunau, G/NP increased from 0.11 to 0.31 with salinity, consistent with an offshore increase in coral cover. But at Waíōpae, G/NP decreased from 0.49 to 0.0 with salinity, despite an increase in coral cover with salinity. Low G may be caused by benthic processes, including coral bleaching or high rates of carbonate dissolution in interstitial waters between tide pools. Broader environmental conditions than just salinity, including pH of fresh groundwater inputs, shape the carbon cycling in the back-reef system. Examining the G/NP ratio of a back-reef system allows for a simple method to establish community level activity, and possibly indicate changes in a dynamic system.

A Petri Net-Based Software Process Model for Developing Process-Oriented Information Systems

NASA Astrophysics Data System (ADS)

Li, Yu; Oberweis, Andreas

Aiming at increasing flexibility, efficiency, effectiveness, and transparency of information processing and resource deployment in organizations to ensure customer satisfaction and high quality of products and services, process-oriented information systems (POIS) represent a promising realization form of computerized business information systems. Due to the complexity of POIS, explicit and specialized software process models are required to guide POIS development. In this chapter we characterize POIS with an architecture framework and present a Petri net-based software process model tailored for POIS development with consideration of organizational roles. As integrated parts of the software process model, we also introduce XML nets, a variant of high-level Petri nets as basic methodology for business processes modeling, and an XML net-based software toolset providing comprehensive functionalities for POIS development.

Factors associated with surgical management in an underinsured, safety net population.

PubMed

Winton, Lisa M; Nodora, Jesse N; Martinez, Maria Elena; Hsu, Chiu-Hsieh; Djenic, Brano; Bouton, Marcia E; Aristizabal, Paula; Ferguson, Elizabeth M; Weiss, Barry D; Komenaka, Ian K

2016-02-01

Few studies include significant numbers of racial and ethnic minority patients. The current study was performed to examine factors that affect breast cancer operations in an underinsured population. We performed a retrospective review of all breast cancer patients from January 2010 to May 2012. Patients with American Joint Committee on Cancer clinical stage 0-IIIA breast cancer underwent evaluation for type of operation: breast conservation, mastectomy alone, and reconstruction after mastectomy. The population included 403 patients with mean age 53 years. Twelve of the 50 patients (24%) diagnosed at stage IIIB presented with synchronous metastatic disease. Of the remaining patients, only 2 presented with metastatic disease (0.6%). The initial operation was 65% breast conservation, 26% mastectomy alone, and 10% reconstruction after mastectomy. Multivariate analysis revealed that Hispanic ethnicity (odds ratio [OR], 0.38; 95% CI, 0.19-0.73; P = .004), presentation with palpable mass (OR, 0.34; 95% CI, 0.13-0.90; P = .03), preoperative chemotherapy (OR, 0.25; 95% CI, 0.10-0.62; P = .003) were associated with a lesser likelihood of mastectomy. Multivariate analysis of factors associated with reconstruction after mastectomy showed that operation with Breast surgical oncologist (OR, 18.4; 95% CI, 2.18-155.14; P < .001) and adequate health literacy (OR, 3.13; 95% CI, 0.95-10.30; P = .06) were associated with reconstruction. The majority of safety net patients can undergo breast conservation despite delayed presentation and poor use of screening mammography. Preoperative chemotherapy increased the likelihood of breast conservation. Routine systemic workup in patients with operable breast cancer is not indicated. Copyright © 2016 Elsevier Inc. All rights reserved.

The equivalency between logic Petri workflow nets and workflow nets.

PubMed

Wang, Jing; Yu, ShuXia; Du, YuYue

2015-01-01

Logic Petri nets (LPNs) can describe and analyze batch processing functions and passing value indeterminacy in cooperative systems. Logic Petri workflow nets (LPWNs) are proposed based on LPNs in this paper. Process mining is regarded as an important bridge between modeling and analysis of data mining and business process. Workflow nets (WF-nets) are the extension to Petri nets (PNs), and have successfully been used to process mining. Some shortcomings cannot be avoided in process mining, such as duplicate tasks, invisible tasks, and the noise of logs. The online shop in electronic commerce in this paper is modeled to prove the equivalence between LPWNs and WF-nets, and advantages of LPWNs are presented.

The Equivalency between Logic Petri Workflow Nets and Workflow Nets

PubMed Central

Wang, Jing; Yu, ShuXia; Du, YuYue

2015-01-01

Logic Petri nets (LPNs) can describe and analyze batch processing functions and passing value indeterminacy in cooperative systems. Logic Petri workflow nets (LPWNs) are proposed based on LPNs in this paper. Process mining is regarded as an important bridge between modeling and analysis of data mining and business process. Workflow nets (WF-nets) are the extension to Petri nets (PNs), and have successfully been used to process mining. Some shortcomings cannot be avoided in process mining, such as duplicate tasks, invisible tasks, and the noise of logs. The online shop in electronic commerce in this paper is modeled to prove the equivalence between LPWNs and WF-nets, and advantages of LPWNs are presented. PMID:25821845

Experiments and simulation of a net closing mechanism for tether-net capture of space debris

NASA Astrophysics Data System (ADS)

Sharf, Inna; Thomsen, Benjamin; Botta, Eleonora M.; Misra, Arun K.

2017-10-01

This research addresses the design and testing of a debris containment system for use in a tether-net approach to space debris removal. The tether-net active debris removal involves the ejection of a net from a spacecraft by applying impulses to masses on the net, subsequent expansion of the net, the envelopment and capture of the debris target, and the de-orbiting of the debris via a tether to the chaser spacecraft. To ensure a debris removal mission's success, it is important that the debris be successfully captured and then, secured within the net. To this end, we present a concept for a net closing mechanism, which we believe will permit consistently successful debris capture via a simple and unobtrusive design. This net closing system functions by extending the main tether connecting the chaser spacecraft and the net vertex to the perimeter and around the perimeter of the net, allowing the tether to actuate closure of the net in a manner similar to a cinch cord. A particular embodiment of the design in a laboratory test-bed is described: the test-bed itself is comprised of a scaled-down tether-net, a supporting frame and a mock-up debris. Experiments conducted with the facility demonstrate the practicality of the net closing system. A model of the net closure concept has been integrated into the previously developed dynamics simulator of the chaser/tether-net/debris system. Simulations under tether tensioning conditions demonstrate the effectiveness of the closure concept for debris containment, in the gravity-free environment of space, for a realistic debris target. The on-ground experimental test-bed is also used to showcase its utility for validating the dynamics simulation of the net deployment, and a full-scale automated setup would make possible a range of validation studies of other aspects of a tether-net debris capture mission.

Threat driven modeling framework using petri nets for e-learning system.

PubMed

Khamparia, Aditya; Pandey, Babita

2016-01-01

Vulnerabilities at various levels are main cause of security risks in e-learning system. This paper presents a modified threat driven modeling framework, to identify the threats after risk assessment which requires mitigation and how to mitigate those threats. To model those threat mitigations aspects oriented stochastic petri nets are used. This paper included security metrics based on vulnerabilities present in e-learning system. The Common Vulnerability Scoring System designed to provide a normalized method for rating vulnerabilities which will be used as basis in metric definitions and calculations. A case study has been also proposed which shows the need and feasibility of using aspect oriented stochastic petri net models for threat modeling which improves reliability, consistency and robustness of the e-learning system.

Autonomous Flight Safety System

NASA Technical Reports Server (NTRS)

Ferrell, Bob; Santuro, Steve; Simpson, James; Zoerner, Roger; Bull, Barton; Lanzi, Jim

2004-01-01

Autonomous Flight Safety System (AFSS) is an independent flight safety system designed for small to medium sized expendable launch vehicles launching from or needing range safety protection while overlying relatively remote locations. AFSS replaces the need for a man-in-the-loop to make decisions for flight termination. AFSS could also serve as the prototype for an autonomous manned flight crew escape advisory system. AFSS utilizes onboard sensors and processors to emulate the human decision-making process using rule-based software logic and can dramatically reduce safety response time during critical launch phases. The Range Safety flight path nominal trajectory, its deviation allowances, limit zones and other flight safety rules are stored in the onboard computers. Position, velocity and attitude data obtained from onboard global positioning system (GPS) and inertial navigation system (INS) sensors are compared with these rules to determine the appropriate action to ensure that people and property are not jeopardized. The final system will be fully redundant and independent with multiple processors, sensors, and dead man switches to prevent inadvertent flight termination. AFSS is currently in Phase III which includes updated algorithms, integrated GPS/INS sensors, large scale simulation testing and initial aircraft flight testing.

NetWeaver for EMDS user guide (version 1.1): a knowledge base development system.

Treesearch

Keith M. Reynolds

1999-01-01

The guide describes use of the NetWeaver knowledge base development system. Knowledge representation in NetWeaver is based on object-oriented fuzzy-logic networks that offer several significant advantages over the more traditional rulebased representation. Compared to rule-based knowledge bases, NetWeaver knowledge bases are easier to build, test, and maintain because...

Modelling and simulating reaction-diffusion systems using coloured Petri nets.

PubMed

Liu, Fei; Blätke, Mary-Ann; Heiner, Monika; Yang, Ming

2014-10-01

Reaction-diffusion systems often play an important role in systems biology when developmental processes are involved. Traditional methods of modelling and simulating such systems require substantial prior knowledge of mathematics and/or simulation algorithms. Such skills may impose a challenge for biologists, when they are not equally well-trained in mathematics and computer science. Coloured Petri nets as a high-level and graphical language offer an attractive alternative, which is easily approachable. In this paper, we investigate a coloured Petri net framework integrating deterministic, stochastic and hybrid modelling formalisms and corresponding simulation algorithms for the modelling and simulation of reaction-diffusion processes that may be closely coupled with signalling pathways, metabolic reactions and/or gene expression. Such systems often manifest multiscaleness in time, space and/or concentration. We introduce our approach by means of some basic diffusion scenarios, and test it against an established case study, the Brusselator model. Copyright © 2014 Elsevier Ltd. All rights reserved.

Dynamics of System of Systems and Applications to Net Zero Energy Facilities

DTIC Science & Technology

2017-10-05

collections and applied it in a variety of ways to energy - related problems. 1. REPORT DATE (DD-MM-YYYY) 4. TITLE AND SUBTITLE 13. SUPPLEMENTARY...UU UU 05-10-2017 1-Oct-2011 30-Sep-2016 Dynamics of System of Systems and Applications to Net Zero Energy Facilities The views, opinions and/or...Research Triangle Park, NC 27709-2211 Koopman operator analysis, Energy systems REPORT DOCUMENTATION PAGE 11. SPONSOR/MONITOR’S REPORT NUMBER(S) 10

Geographic information systems - transportation ISTEA management systems server net prototype pooled fund study : phase B - summary

DOT National Transportation Integrated Search

1997-06-01

The Geographic Information System-Transportation (GIS-T) ISTEA Management Systems Server Net Prototype Pooled Fund Study represents the first national cooperative effort in the transportation industry to address the management and monitoring systems ...

Health Services Utilization Among Fee-for-Service Medicare and Medicaid Patients Under Age 65 with Behavioral Health Illness at an Urban Safety Net Hospital.

PubMed

Cancino, Ramon S; Jack, Brian W; Jarvis, John; Cummings, Alice Kate; Cooper, Ellie; Cremieux, Pierre-Yves; Burgess, James F

2017-07-01

illness in the Medicaid fee-for-service plan had significantly higher rates of hospital admission and ED use compared with dual eligible patients without behavioral health illness at the largest urban safety net medical center in New England. Safety net hospitals care for a large proportion of dual eligible patients with behavioral health illness. Further research is needed to elucidate the systems-related and patient-centered factors contributing to the utilization behaviors of this patient population. This research was funded in part by a National Research Service Award (T3HP10028-14-01). The authors have no conflicts of interests to disclose. Cancino had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design were contributed by Cancino, Jack, and Burgess, with assistance from Cremieux. Cancino and Cremieux took the lead in data collection, along with Jack and Burgess, and data interpretation was performed by Jarvis, Cummings, and Cooper, along with the other authors. The manuscript was written primarily by Cancino, along with Jack and Burgess, and revised primarily by Cancino, along with the other authors.

Applying a semantic information Petri Net modeling method to AUV systems design

NASA Astrophysics Data System (ADS)

Feng, Xiao-Ning; Wang, Shuo; Wang, Zhuo; Liu, Qun

2008-12-01

This paper informally introduces colored object-oriented Petri Nets(COOPN) with the application of the AUV system. According to the characteristic of the AUV system’s running environment, the object-oriented method is used in this paper not only to dispart system modules but also construct the refined running model of AUV system, then the colored Petri Net method is used to establish hierarchically detailed model in order to get the performance analyzing information of the system. After analyzing the model implementation, the errors of architecture designing and function realization can be found. If the errors can be modified on time, the experiment time in the pool can be reduced and the cost can be saved.

Research and realization of info-net security controlling system

NASA Astrophysics Data System (ADS)

Xu, Tao; Zhang, Wei; Li, Xuhong; Wang, Xia; Pan, Wenwen

2017-03-01

The thesis introduces some relative concepts about Network Cybernetics, and we design and realize a new info-net security controlling system based on Network Cybernetics. The system can control the endpoints, safely save files, encrypt communication, supervise actions of users and show security conditions, in order to realize full-scale security management. At last, we simulate the functions of the system. The results show, the system can ensure the controllability of users and devices, and supervise them real-time. The system can maximize the security of the network and users.

The procedure safety system

NASA Technical Reports Server (NTRS)

Obrien, Maureen E.

1990-01-01

Telerobotic operations, whether under autonomous or teleoperated control, require a much more sophisticated safety system than that needed for most industrial applications. Industrial robots generally perform very repetitive tasks in a controlled, static environment. The safety system in that case can be as simple as shutting down the robot if a human enters the work area, or even simply building a cage around the work space. Telerobotic operations, however, will take place in a dynamic, sometimes unpredictable environment, and will involve complicated and perhaps unrehearsed manipulations. This creates a much greater potential for damage to the robot or objects in its vicinity. The Procedural Safety System (PSS) collects data from external sensors and the robot, then processes it through an expert system shell to determine whether an unsafe condition or potential unsafe condition exists. Unsafe conditions could include exceeding velocity, acceleration, torque, or joint limits, imminent collision, exceeding temperature limits, and robot or sensor component failure. If a threat to safety exists, the operator is warned. If the threat is serious enough, the robot is halted. The PSS, therefore, uses expert system technology to enhance safety thus reducing operator work load, allowing him/her to focus on performing the task at hand without the distraction of worrying about violating safety criteria.

Preferences for Self-Management Support: Findings from a Survey of Diabetes Patients in Safety-Net Health Systems

PubMed Central

Sarkar, Urmimala; Piette, John D.; Gonzales, Ralph; Lessler, Daniel; Chew, Lisa D.; Reilly, Brendan; Johnson, Jolene; Brunt, Melanie; Huang, Jennifer; Regenstein, Marsha; Schillinger, Dean

2009-01-01

in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences. Conclusion Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy. Practice Implications Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings. PMID:17997264

Discontinuation of Tocolytics for Preterm Labor in an Academic Safety Net Hospital: Impact on the Duration of Betamethasone Exposure.

PubMed

Alston, Meredith J; Alexandrovic, Kara; Stiglich, Norma; Metz, Torri D

2016-01-01

To evaluate the impact of discontinuation of tocolytics on the completion of the corticosteroid course among preterm neonates in an academic safety net hospital. Retrospective cohort study of all singleton pregnancies with preterm labor resulting in delivery between 24 and 34 weeks' gestation at Denver Health Medical Center (DHMC) between 1/1/2004 and 5/31/2009. In January 2007 DHMC discontinued the use of tocolytic therapy for preterm labor. Study subjects were grouped based on whether their delivery occurred before or after the change in policy. Multivariable logistic regression was used to determine whether the use of tocolysis increased the odds of completion of the betamethasone while adjusting for cervical examination at admission. Of 169 infant/mother pairs who met inclusion criteria, 102 delivered prior to the discontinuation of tocolytics and 67 delivered after the discontinuation of tocolytics. Treatment with tocolysis increased the odds of completing the 48-hour betamethasone window (OR 2.59, 95% CI 1.16-5.79). Each centimeter increase in cervical dilation at the time of admission decreased the odds of completing the betamethasone window (OR 0.50, 95% CI 0.39-0.62). The use of tocolytics increased the odds of completion of the betamethasone window in an academic safety net hospital among neonates born between 24 and 34 weeks' gestation.

Utilization Elementary Siphons of Petri Net to Solved Deadlocks in Flexible Manufacturing Systems

NASA Astrophysics Data System (ADS)

Abdul-Hussin, Mowafak Hassan

2015-07-01

This article presents an approach to the constructing a class structural analysis of Petri nets, where elementary siphons are mainly used in the development of a deadlock control policy of flexible manufacturing systems (FMSs), that has been exploited successfully for the design of supervisors of some supervisory control problems. Deadlock-free operation of FMSs is significant objectives of siphons in the Petri net. The structure analysis of Petri net models has efficiency in control of FMSs, however different policy can be implemented for the deadlock prevention. Petri nets models based deadlock prevention for FMS's has gained considerable interest in the development of control theory and methods for design, controlling, operation, and performance evaluation depending of the special class of Petri nets called S3PR. Both structural analysis and reachability tree analysis is used for the purposes analysis, simulation and control of Petri nets. In our ex-perimental approach based to siphon is able to resolve the problem of deadlock occurred to Petri nets that are illustrated with an FMS.

Realization of planning design of mechanical manufacturing system by Petri net simulation model

NASA Astrophysics Data System (ADS)

Wu, Yanfang; Wan, Xin; Shi, Weixiang

1991-09-01

Planning design is to work out a more overall long-term plan. In order to guarantee a mechanical manufacturing system (MMS) designed to obtain maximum economical benefit, it is necessary to carry out a reasonable planning design for the system. First, some principles on planning design for MMS are introduced. Problems of production scheduling and their decision rules for computer simulation are presented. Realizable method of each production scheduling decision rule in Petri net model is discussed. Second, the solution of conflict rules for conflict problems during running Petri net is given. Third, based on the Petri net model of MMS which includes part flow and tool flow, according to the principle of minimum event time advance, a computer dynamic simulation of the Petri net model, that is, a computer dynamic simulation of MMS, is realized. Finally, the simulation program is applied to a simulation exmple, so the scheme of a planning design for MMS can be evaluated effectively.

Optimal management of reconfigurable manufacturing system modeling with Petri nets developed three-dimensional - RPD3D

NASA Astrophysics Data System (ADS)

Teodor, F.; Marinescu, V.; Epureanu, A.

2016-11-01

Modeling of reconfigurable manufacturing systems would have done using existing Petri net types, but the complexity and dynamics of the new manufacturing system, mainly data reconfiguration feature, required looking for a more compact representation with many variables that to model as accurately not only the normal operation of the production system but can capture and model and reconfiguration process. Thus, it was necessary to create a new class of Petri nets, called RPD3D (Developed Petri nets with three dimensional) showing the name of both lineage (new class derived from Petri nets developed, created in 2000 by Prof. Dr. Ing Vasile Marinescu in his doctoral thesis) [1], but the most important of the new features defining (transformation from one 2D model into a 3D model).The idea was to introduce the classical model of a Petri third dimension to be able to overlay multiple levels (layers) formed in 2D or 3D Petri nets that interact with each other (receiving or giving commands to enable or disable the various modules together simulating the operation of reconfigurable manufacturing systems). The aim is to present a new type of Petri nets called RPD3D - Developed Petri three-dimensional model used for optimal control and simulation of reconfigurable manufacturing systems manufacture of products such systems.

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial

PubMed Central

Ell, Kathleen; Jin, Haomiao; Vidyanti, Irene; Chou, Chih-Ping; Lee, Pey-Jiuan; Gross-Schulman, Sandra; Sklaroff, Laura Myerchin; Belson, David; Nezu, Arthur M; Hay, Joel; Wang, Chien-Ju; Scheib, Geoffrey; Di Capua, Paul; Hawkins, Caitlin; Liu, Pai; Ramirez, Magaly; Wu, Brian W; Richman, Mark; Myers, Caitlin; Agustines, Davin; Dasher, Robert; Kopelowicz, Alex; Allevato, Joseph; Roybal, Mike; Ipp, Eli; Haider, Uzma; Graham, Sharon; Mahabadi, Vahid; Guterman, Jeffrey

2018-01-01

Background Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. Objective The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. Methods DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. Results DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported

Manned space flight nuclear system safety. Volume 6: Space base nuclear system safety plan

NASA Technical Reports Server (NTRS)

1972-01-01

A qualitative identification of the steps required to assure the incorporation of radiological system safety principles and objectives into all phases of a manned space base program are presented. Specific areas of emphasis include: (1) radiological program management, (2) nuclear system safety plan implementation, (3) impact on program, and (4) summary of the key operation and design guidelines and requirements. The plan clearly indicates the necessity of considering and implementing radiological system safety recommendations as early as possible in the development cycle to assure maximum safety and minimize the impact on design and mission plans.

Bounded Parametric Model Checking for Elementary Net Systems

NASA Astrophysics Data System (ADS)

Knapik, Michał; Szreter, Maciej; Penczek, Wojciech

Bounded Model Checking (BMC) is an efficient verification method for reactive systems. BMC has been applied so far to verification of properties expressed in (timed) modal logics, but never to their parametric extensions. In this paper we show, for the first time that BMC can be extended to PRTECTL - a parametric extension of the existential version of CTL. To this aim we define a bounded semantics and a translation from PRTECTL to SAT. The implementation of the algorithm for Elementary Net Systems is presented, together with some experimental results.

An Analysis of the Role of Social Safety Net Scholarships in Reducing School Drop-Out during the Indonesian Economic Crisis. Innocenti Working Papers.

ERIC Educational Resources Information Center

Cameron, Lisa A.

This paper uses regression and matching techniques to evaluate Indonesia's Social Safety Net Scholarships Programme. The scholarships program was developed to try to prevent large numbers of children from dropping out of school as a result of the Asian financial crisis. The expectation was that many families would find it difficult to keep their…

NASA System Safety Handbook. Volume 1; System Safety Framework and Concepts for Implementation

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon; Benjamin, Allan; Everett, Christopher; Smith, Curtis; Stamatelatos, Michael; Youngblood, Robert

2011-01-01

System safety assessment is defined in NPR 8715.3C, NASA General Safety Program Requirements as a disciplined, systematic approach to the analysis of risks resulting from hazards that can affect humans, the environment, and mission assets. Achievement of the highest practicable degree of system safety is one of NASA's highest priorities. Traditionally, system safety assessment at NASA and elsewhere has focused on the application of a set of safety analysis tools to identify safety risks and formulate effective controls.1 Familiar tools used for this purpose include various forms of hazard analyses, failure modes and effects analyses, and probabilistic safety assessment (commonly also referred to as probabilistic risk assessment (PRA)). In the past, it has been assumed that to show that a system is safe, it is sufficient to provide assurance that the process for identifying the hazards has been as comprehensive as possible and that each identified hazard has one or more associated controls. The NASA Aerospace Safety Advisory Panel (ASAP) has made several statements in its annual reports supporting a more holistic approach. In 2006, it recommended that "... a comprehensive risk assessment, communication and acceptance process be implemented to ensure that overall launch risk is considered in an integrated and consistent manner." In 2009, it advocated for "... a process for using a risk-informed design approach to produce a design that is optimally and sufficiently safe." As a rationale for the latter advocacy, it stated that "... the ASAP applauds switching to a performance-based approach because it emphasizes early risk identification to guide designs, thus enabling creative design approaches that might be more efficient, safer, or both." For purposes of this preface, it is worth mentioning three areas where the handbook emphasizes a more holistic type of thinking. First, the handbook takes the position that it is important to not just focus on risk on an individual

Algebraic properties of automata associated to Petri nets and applications to computation in biological systems.

PubMed

Egri-Nagy, Attila; Nehaniv, Chrystopher L

2008-01-01

Biochemical and genetic regulatory networks are often modeled by Petri nets. We study the algebraic structure of the computations carried out by Petri nets from the viewpoint of algebraic automata theory. Petri nets comprise a formalized graphical modeling language, often used to describe computation occurring within biochemical and genetic regulatory networks, but the semantics may be interpreted in different ways in the realm of automata. Therefore, there are several different ways to turn a Petri net into a state-transition automaton. Here, we systematically investigate different conversion methods and describe cases where they may yield radically different algebraic structures. We focus on the existence of group components of the corresponding transformation semigroups, as these reflect symmetries of the computation occurring within the biological system under study. Results are illustrated by applications to the Petri net modelling of intermediary metabolism. Petri nets with inhibition are shown to be computationally rich, regardless of the particular interpretation method. Along these lines we provide a mathematical argument suggesting a reason for the apparent all-pervasiveness of inhibitory connections in living systems.

Fuzzy Stochastic Petri Nets for Modeling Biological Systems with Uncertain Kinetic Parameters

PubMed Central

Liu, Fei; Heiner, Monika; Yang, Ming

2016-01-01

Stochastic Petri nets (SPNs) have been widely used to model randomness which is an inherent feature of biological systems. However, for many biological systems, some kinetic parameters may be uncertain due to incomplete, vague or missing kinetic data (often called fuzzy uncertainty), or naturally vary, e.g., between different individuals, experimental conditions, etc. (often called variability), which has prevented a wider application of SPNs that require accurate parameters. Considering the strength of fuzzy sets to deal with uncertain information, we apply a specific type of stochastic Petri nets, fuzzy stochastic Petri nets (FSPNs), to model and analyze biological systems with uncertain kinetic parameters. FSPNs combine SPNs and fuzzy sets, thereby taking into account both randomness and fuzziness of biological systems. For a biological system, SPNs model the randomness, while fuzzy sets model kinetic parameters with fuzzy uncertainty or variability by associating each parameter with a fuzzy number instead of a crisp real value. We introduce a simulation-based analysis method for FSPNs to explore the uncertainties of outputs resulting from the uncertainties associated with input parameters, which works equally well for bounded and unbounded models. We illustrate our approach using a yeast polarization model having an infinite state space, which shows the appropriateness of FSPNs in combination with simulation-based analysis for modeling and analyzing biological systems with uncertain information. PMID:26910830

Software reuse issues affecting AdaNET

NASA Technical Reports Server (NTRS)

Mcbride, John G.

1989-01-01

The AdaNet program is reviewing its long-term goals and strategies. A significant concern is whether current AdaNet plans adequately address the major strategic issues of software reuse technology. The major reuse issues of providing AdaNet services that should be addressed as part of future AdaNet development are identified and reviewed. Before significant development proceeds, a plan should be developed to resolve the aforementioned issues. This plan should also specify a detailed approach to develop AdaNet. A three phased strategy is recommended. The first phase would consist of requirements analysis and produce an AdaNet system requirements specification. It would consider the requirements of AdaNet in terms of mission needs, commercial realities, and administrative policies affecting development, and the experience of AdaNet and other projects promoting the transfer software engineering technology. Specifically, requirements analysis would be performed to better understand the requirements for AdaNet functions. The second phase would provide a detailed design of the system. The AdaNet should be designed with emphasis on the use of existing technology readily available to the AdaNet program. A number of reuse products are available upon which AdaNet could be based. This would significantly reduce the risk and cost of providing an AdaNet system. Once a design was developed, implementation would proceed in the third phase.

A business planning model to identify new safety net clinic locations.

PubMed

Langabeer, James; Helton, Jeffrey; DelliFraine, Jami; Dotson, Ebbin; Watts, Carolyn; Love, Karen

2014-01-01

Community health clinics serving the poor and underserved are geographically expanding due to changes in U.S. health care policy. This paper describes the experience of a collaborative alliance of health care providers in a large metropolitan area who develop a conceptual and mathematical decision model to guide decisions on expanding its network of community health clinics. Community stakeholders participated in a collaborative process that defined constructs they deemed important in guiding decisions on the location of community health clinics. This collaboration also defined key variables within each construct. Scores for variables within each construct were then totaled and weighted into a community-specific optimal space planning equation. This analysis relied entirely on secondary data available from published sources. The model built from this collaboration revolved around the constructs of demand, sustainability, and competition. It used publicly available data defining variables within each construct to arrive at an optimal location that maximized demand and sustainability and minimized competition. This is a model that safety net clinic planners and community stakeholders can use to analyze demographic and utilization data to optimize capacity expansion to serve uninsured and Medicaid populations. Communities can use this innovative model to develop a locally relevant clinic location-planning framework.

29 CFR 1926.105 - Safety nets.

Code of Federal Regulations, 2014 CFR

2014-07-01

... be hung with sufficient clearance to prevent user's contact with the surfaces or structures below... shall provide a minimum breaking strength of 5,000 pounds. (e) Forged steel safety hooks or shackles...

29 CFR 1926.105 - Safety nets.

Code of Federal Regulations, 2013 CFR

2013-07-01

... be hung with sufficient clearance to prevent user's contact with the surfaces or structures below... shall provide a minimum breaking strength of 5,000 pounds. (e) Forged steel safety hooks or shackles...

29 CFR 1926.105 - Safety nets.

Code of Federal Regulations, 2011 CFR

2011-07-01

... be hung with sufficient clearance to prevent user's contact with the surfaces or structures below... shall provide a minimum breaking strength of 5,000 pounds. (e) Forged steel safety hooks or shackles...

29 CFR 1926.105 - Safety nets.

Code of Federal Regulations, 2012 CFR

2012-07-01

... be hung with sufficient clearance to prevent user's contact with the surfaces or structures below... shall provide a minimum breaking strength of 5,000 pounds. (e) Forged steel safety hooks or shackles...

A new approach for modular robot system behavioral modeling: Base on Petri net and category theory

NASA Astrophysics Data System (ADS)

Zhang, Yun; Wei, Hongxing; Yang, Bo

2018-04-01

To design modular robot system, Petri nets and category theory are combined and the ability of simulation of Petri net is discussed. According to category theory, the method of describing the category of components in the dynamic characteristics of the system is deduced. Moreover, a modular robot system is analyzed, which provides a verifiable description of the dynamic characteristics of the system.

NASA Safety Manual. Volume 3: System Safety

NASA Technical Reports Server (NTRS)

1970-01-01

This Volume 3 of the NASA Safety Manual sets forth the basic elements and techniques for managing a system safety program and the technical methods recommended for use in developing a risk evaluation program that is oriented to the identification of hazards in aerospace hardware systems and the development of residual risk management information for the program manager that is based on the hazards identified. The methods and techniques described in this volume are in consonance with the requirements set forth in NHB 1700.1 (VI), Chapter 3. This volume and future volumes of the NASA Safety Manual shall not be rewritten, reprinted, or reproduced in any manner. Installation implementing procedures, if necessary, shall be inserted as page supplements in accordance with the provisions of Appendix A. No portion of this volume or future volumes of the NASA Safety Manual shall be invoked in contracts.

Vaccines and Internet: characteristics of the vaccine safety net web sites and suggested improvements.

PubMed

Martínez-Mora, Marta; Alvarez-Pasquín, María José; Rodríguez-Salvanés, Francisco

2008-12-09

The Internet contains a large amount of useful information on many subjects, but also information of doubtful quality. To help identify Web sites on vaccine safety that fulfil good practice, the Global Advisory Committee on Vaccine Safety of the World Health Organization (WHO) has published criteria to which sites should adhere and a listing of Web sites that fulfil them. There are no studies describing the common attributes of these sites. To examine the attributes, design characteristics and resources of Web sites belonging to the Vaccine Safety Net (VSN) of the WHO. A cross-sectional, descriptive observational study using an evaluation questionnaire was carried out applied to the VSN web sites listed in March-April 2007. Twenty-six Web sites accredited by the VSN by April 2007 were analysed. With respect to design and quality, all sites contained information about the site manager. Postal and Email addresses were available for 84.6% of the sites. About privacy and personal data processing, 73.1% of sites specified the data protection procedure used and stated that data were not sold or passed third parties. The most-used language was English (76.9%). 96.3% of sites had links to other pro-vaccination sites and 19.2% provided the addresses of vaccination centres. 63.6% of webs were aimed at general public and health care workers but there was no clear separation of documents or different entry routes. With respect to information on vaccine safety, 84.6% of sites had information on adverse effects. In the general information section, 92.3% of sites had a new developments section. Some sites had multiple sources of financing and in 57% of sites, the financing was public. The most-important plus factors found were the transparency of financing, the lack of links to the pharmaceutical industry, the transparency of site management and responsibility and the proven scientific quality and constant updating of contents.

Caught in a tightening fire safety net.

PubMed

Baillie, Jonathan

2008-06-01

How the Regulatory Reform (Fire Safety) Order 2005 has shifted responsibility for hospital fire safety from local fire authorities to so-called "responsible persons", and the implications for senior management/board-level personnel, as well as for hospital fire officers, fire wardens and department managers charged with implementation, was expertly examined by a leading expert in fire law at May's National Association of Healthcare Fire Officers (NAHFO) 2008 conference in Nottingham. Jonathan Baillie reports.

Comprehensive Lifecycle for Assuring System Safety

NASA Technical Reports Server (NTRS)

Knight, John C.; Rowanhill, Jonathan C.

2017-01-01

CLASS is a novel approach to the enhancement of system safety in which the system safety case becomes the focus of safety engineering throughout the system lifecycle. CLASS also expands the role of the safety case across all phases of the system's lifetime, from concept formation to decommissioning. As CLASS has been developed, the concept has been generalized to a more comprehensive notion of assurance becoming the driving goal, where safety is an important special case. This report summarizes major aspects of CLASS and contains a bibliography of papers that provide additional details.

The Effects of Safety Net Hospital Closures and Conversions on Patient Travel Distance to Hospital Services

PubMed Central

Bazzoli, Gloria J; Lee, Woolton; Hsieh, Hui-Min; Mobley, Lee Rivers

2012-01-01

Objective To examine the effects of safety net hospital (SNH) closure and for-profit conversion on uninsured, Medicaid, and racial/ethnic minorities. Data Sources/Extraction Methods Hospital discharge data for selected states merged with other sources. Study Design We examined travel distance for patients treated in urban hospitals for five diagnosis categories: ambulatory care sensitive conditions, referral sensitive conditions, marker conditions, births, and mental health and substance abuse. We assess how travel was affected for patients after SNH events. Our multivariate models controlled for patient, hospital, health system, and neighborhood characteristics. Principal Findings Our results suggested that certain groups of uninsured and Medicaid patients experienced greater disruption in patterns of care, especially Hispanic uninsured and Medicaid women hospitalized for births. In addition, relative to privately insured individuals in SNH event communities, greater travel for mental health and substance abuse care was present for the uninsured. Conclusions Closure or for-profit conversions of SNHs appear to have detrimental access effects on particular subgroups of disadvantaged populations, although our results are somewhat inconclusive due to potential power issues. Policy makers may need to pay special attention to these patient subgroups and also to easing transportation barriers when dealing with disruptions resulting from reductions in SNH resources. PMID:22091871

Catch of channel catfish with tandem-set hoop nets and gill nets in lentic systems of Nebraska

USGS Publications Warehouse

Richters, Lindsey K.; Pope, Kevin L.

2011-01-01

Twenty-six Nebraska water bodies representing two ecosystem types (small standing waters and large standing waters) were surveyed during 2008 and 2009 with tandem-set hoop nets and experimental gill nets to determine if similar trends existed in catch rates and size structures of channel catfish Ictalurus punctatus captured with these gears. Gear efficiency was assessed as the number of sets (nets) that would be required to capture 100 channel catfish given observed catch per unit effort (CPUE). Efficiency of gill nets was not correlated with efficiency of hoop nets for capturing channel catfish. Small sample sizes prohibited estimation of proportional size distributions in most surveys; in the four surveys for which sample size was sufficient to quantify length-frequency distributions of captured channel catfish, distributions differed between gears. The CPUE of channel catfish did not differ between small and large water bodies for either gear. While catch rates of hoop nets were lower than rates recorded in previous studies, this gear was more efficient than gill nets at capturing channel catfish. However, comparisons of size structure between gears may be problematic.

Airborne net-centric multi-INT sensor control, display, fusion, and exploitation systems

NASA Astrophysics Data System (ADS)

Linne von Berg, Dale C.; Lee, John N.; Kruer, Melvin R.; Duncan, Michael D.; Olchowski, Fred M.; Allman, Eric; Howard, Grant

2004-08-01

The NRL Optical Sciences Division has initiated a multi-year effort to develop and demonstrate an airborne net-centric suite of multi-intelligence (multi-INT) sensors and exploitation systems for real-time target detection and targeting product dissemination. The goal of this Net-centric Multi-Intelligence Fusion Targeting Initiative (NCMIFTI) is to develop an airborne real-time intelligence gathering and targeting system that can be used to detect concealed, camouflaged, and mobile targets. The multi-INT sensor suite will include high-resolution visible/infrared (EO/IR) dual-band cameras, hyperspectral imaging (HSI) sensors in the visible-to-near infrared, short-wave and long-wave infrared (VNIR/SWIR/LWIR) bands, Synthetic Aperture Radar (SAR), electronics intelligence sensors (ELINT), and off-board networked sensors. Other sensors are also being considered for inclusion in the suite to address unique target detection needs. Integrating a suite of multi-INT sensors on a single platform should optimize real-time fusion of the on-board sensor streams, thereby improving the detection probability and reducing the false alarms that occur in reconnaissance systems that use single-sensor types on separate platforms, or that use independent target detection algorithms on multiple sensors. In addition to the integration and fusion of the multi-INT sensors, the effort is establishing an open-systems net-centric architecture that will provide a modular "plug and play" capability for additional sensors and system components and provide distributed connectivity to multiple sites for remote system control and exploitation.

77 FR 70409 - System Safety Program

Federal Register 2010, 2011, 2012, 2013, 2014

2012-11-26

...-0060, Notice No. 2] 2130-AC31 System Safety Program AGENCY: Federal Railroad Administration (FRA... passenger railroads to develop and implement a system safety program (SSP) to improve the safety of their... Division, U.S. Department of Transportation, Federal Railroad Administration, Office of Railroad Safety...

Distributional impacts of water markets on small farmers: Is there a safety net?

NASA Astrophysics Data System (ADS)

Hadjigeorgalis, Ereney

2008-10-01

The United Nations 2006 human development report states that water markets have not been shown to protect the interests of the poor, while other research has found that water markets have benefited smaller, resource-constrained farmers. This article provides insight into this international development debate by analyzing the impact of water markets on small farmers in the Limarí River Basin of Chile. The analysis is based on data collected from an extensive in-person survey of 316 farmers in the basin. Results show that water markets in the basin have been successful in moving water and water rights from low- to high-valued uses and that resource-constrained farmers use temporary water sales as a safety net. The long-term beneficial effects of water market trades for the most resource-constrained farmers, however, remain unclear. These results are relevant to both Chile and a host of developing countries where agriculture is a predominant activity and water resources are scarce. They are also applicable to the western United States, where water market trades often originate in the agricultural sector.

Innovative Strategies Designed to Improve Adult Pneumococcal Immunizations in Safety Net Patient-Centered Medical Homes.

PubMed

Park, Nina J; Sklaroff, Laura Myerchin; Gross-Schulman, Sandra; Hoang, Khathy; Tran, Helen; Campa, David; Scheib, Geoffrey; Guterman, Jeffrey J

2016-08-01

Streptococcus pneumoniae is a principal cause of serious illness, including bacteremia, meningitis, and pneumonia, worldwide. Pneumococcal immunization is proven to reduce morbidity and mortality in high-risk adult and elderly populations. Current pneumococcal vaccination practices are suboptimal in part because of recommendation complexity, the high cost of provider-driven immunization interventions, and outreach methods that are not patient-centric. These barriers are amplified within the safety net. This paper identifies efforts by the Los Angeles County Department of Health Services to increase pneumococcal immunization rates for adult indigent patient populations. A 4-part approach will be used to increase vaccination rates: (1) protocol driven care, (2) staff education, (3) electronic identification of eligible patients, and (4) automated patient outreach and scheduling. The proposed analytics plan and potential for scalability are described. (Population Health Management 2016;19:240-247).

Assessment of the Electrification of the Road Transport Sector on Net System Emissions

NASA Astrophysics Data System (ADS)

Miller, James

As worldwide environmental consciousness grows, electric vehicles (EVs) are becoming more common and despite the incredible potential for emissions reduction, the net emissions of the power system supply side plus the transportation system are dependent on the generation matrix. Current EV charging patterns tend to correspond directly with the peak consumption hours and have the potential to increase demand sharply allowing for only a small penetration of Electric Vehicles. Using the National Household Travel Survey (NHTS) data a model is created for vehicle travel patterns using trip chaining. Charging schemes are modeled to include uncontrolled residential, uncontrolled residential/industrial charging, optimized charging and optimized charging with vehicle to grid discharging. A charging profile is then determined based upon the assumption that electric vehicles would directly replace a percentage of standard petroleum-fueled vehicles in a known system. Using the generation profile for the specified region, a unit commitment model is created to establish not only the generation dispatch, but also the net CO2 profile for variable EV penetrations and charging profiles. This model is then used to assess the impact of the electrification of the road transport sector on the system net emissions.

Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: A randomized controlled trial in a safety-net health system.

PubMed

Singal, Amit G; Gupta, Samir; Tiro, Jasmin A; Skinner, Celette Sugg; McCallister, Katharine; Sanders, Joanne M; Bishop, Wendy Pechero; Agrawal, Deepak; Mayorga, Christian A; Ahn, Chul; Loewen, Adam C; Santini, Noel O; Halm, Ethan A

2016-02-01

The effectiveness of colorectal cancer (CRC) screening is limited by underuse, particularly among underserved populations. Among a racially diverse and socioeconomically disadvantaged cohort of patients, the authors compared the effectiveness of fecal immunochemical test (FIT) outreach and colonoscopy outreach to increase screening participation rates, compared with usual visit-based care. Patients aged 50 to 64 years who were not up-to-date with CRC screening but used primary care services in a large safety-net health system were randomly assigned to mailed FIT outreach (2400 patients), mailed colonoscopy outreach (2400 patients), or usual care with opportunistic visit-based screening (1199 patients). Patients who did not respond to outreach invitations within 2 weeks received follow-up telephone reminders. The primary outcome was CRC screening completion within 12 months after randomization. Baseline patient characteristics across the 3 groups were similar. Using intention-to-screen analysis, screening participation rates were higher for FIT outreach (58.8%) and colonoscopy outreach (42.4%) than usual care (29.6%) (P <.001 for both). Screening participation with FIT outreach was higher than that for colonoscopy outreach (P <.001). Among responders, FIT outreach had a higher percentage of patients who responded before reminders (59.0% vs 29.7%; P <.001). Nearly one-half of patients in the colonoscopy outreach group crossed over to complete FIT via usual care, whereas <5% of patients in the FIT outreach group underwent usual-care colonoscopy. Mailed outreach invitations appear to significantly increase CRC screening rates among underserved populations. In the current study, FIT-based outreach was found to be more effective than colonoscopy-based outreach to increase 1-time screening participation. Studies with longer follow-up are needed to compare the effectiveness of outreach strategies for promoting completion of the entire screening process. © 2015 American

Public reporting and pay-for-performance: safety-net hospital executives' concerns and policy suggestions.

PubMed

Goldman, L Elizabeth; Henderson, Stuart; Dohan, Daniel P; Talavera, Jason A; Dudley, R Adams

2007-01-01

Safety-net hospitals (SNHs) may gain little financial benefit from the rapidly spreading adoption of public reporting and pay-for-performance, but may feel compelled to participate (and bear the costs of data collection) to meet public expectations of transparency and accountability. To better understand the concerns that SNH administrators have regarding public reporting and pay-for-performance, we interviewed 37 executives at randomly selected California SNHs. The main concerns noted by SNH executives were that human and financial resource constraints made it difficult for SNHs to accurately measure their performance. Additionally, some executives felt that market-driven public reporting and pay-for-performance may focus on clinical areas and incentive structures that may not be high-priority clinical areas for SNHs. Executives at SNHs suggested several policy responses to these concerns-such as offering training programs for SNH data collectors-that could be relatively inexpensive and might improve the cost-benefit ratio of public reporting and pay-for-performance programs.

Manned space flight nuclear system safety. Volume 5: Nuclear System safety guidelines. Part 1: Space base nuclear safety

NASA Technical Reports Server (NTRS)

1972-01-01

The design and operations guidelines and requirements developed in the study of space base nuclear system safety are presented. Guidelines and requirements are presented for the space base subsystems, nuclear hardware (reactor, isotope sources, dynamic generator equipment), experiments, interfacing vehicles, ground support systems, range safety and facilities. Cross indices and references are provided which relate guidelines to each other, and to substantiating data in other volumes. The guidelines are intended for the implementation of nuclear safety related design and operational considerations in future space programs.

WE-G-BRA-02: SafetyNet: Automating Radiotherapy QA with An Event Driven Framework

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hadley, S; Kessler, M; Litzenberg, D

2015-06-15

Purpose: Quality assurance is an essential task in radiotherapy that often requires many manual tasks. We investigate the use of an event driven framework in conjunction with software agents to automate QA and eliminate wait times. Methods: An in house developed subscription-publication service, EventNet, was added to the Aria OIS to be a message broker for critical events occurring in the OIS and software agents. Software agents operate without user intervention and perform critical QA steps. The results of the QA are documented and the resulting event is generated and passed back to EventNet. Users can subscribe to those eventsmore » and receive messages based on custom filters designed to send passing or failing results to physicists or dosimetrists. Agents were developed to expedite the following QA tasks: Plan Revision, Plan 2nd Check, SRS Winston-Lutz isocenter, Treatment History Audit, Treatment Machine Configuration. Results: Plan approval in the Aria OIS was used as the event trigger for plan revision QA and Plan 2nd check agents. The agents pulled the plan data, executed the prescribed QA, stored the results and updated EventNet for publication. The Winston Lutz agent reduced QA time from 20 minutes to 4 minutes and provided a more accurate quantitative estimate of radiation isocenter. The Treatment Machine Configuration agent automatically reports any changes to the Treatment machine or HDR unit configuration. The agents are reliable, act immediately, and execute each task identically every time. Conclusion: An event driven framework has inverted the data chase in our radiotherapy QA process. Rather than have dosimetrists and physicists push data to QA software and pull results back into the OIS, the software agents perform these steps immediately upon receiving the sentinel events from EventNet. Mr Keranen is an employee of Varian Medical Systems. Dr. Moran’s institution receives research support for her effort for a linear accelerator QA project

Aspects regarding at 13C isotope separation column control using Petri nets system

NASA Astrophysics Data System (ADS)

Boca, M. L.; Ciortea, M. E.

2015-11-01

This paper is intended to show that Petri nets can be also applicable in the chemical industry. It used linear programming, modeling underlying Petri nets, especially discrete event systems for isotopic separation, the purpose of considering and control events in real-time through graphical representations. In this paper it is simulate the control of 13C Isotope Separation column using Petri nets. The major problem with 13C comes from the difficulty of obtaining it and raising its natural fraction. Carbon isotopes can be obtained using many methods, one of them being the cryogenic distillation of carbon monoxide. Some few aspects regarding operating conditions and the construction of such cryogenic plants are known today, and even less information are available as far as the separation process modeling and control are concerned. In fact, the efficient control of the carbon monoxide distillation process represents a necessity for large-scale 13C production. Referring to a classic distillation process, some models for carbon isotope separation have been proposed, some based on mass, component and energy balance equations, some on the nonlinear wave theory or the Cohen equations. For modeling the system it was used Petri nets because in this case it is deal with discrete event systems. In use of the non-timed and with auxiliary times Petri model, the transport stream was divided into sections and these sections will be analyzed successively. Because of the complexity of the system and the large amount of calculations required it was not possible to analyze the system as a unitary whole. A first attempt to model the system as a unitary whole led to the blocking of the model during simulation, because of the large processing times.

The VirSR Two-Component Signal Transduction System Regulates NetB Toxin Production in Clostridium perfringens▿

PubMed Central

Cheung, Jackie K.; Keyburn, Anthony L.; Carter, Glen P.; Lanckriet, Anouk L.; Van Immerseel, Filip; Moore, Robert J.; Rood, Julian I.

2010-01-01

Clostridium perfringens causes several diseases in domestic livestock, including necrotic enteritis in chickens, which is of concern to the poultry industry due to its health implications and associated economic cost. The novel pore-forming toxin NetB is a critical virulence factor in the pathogenesis of this disease. In this study, we have examined the regulation of NetB toxin production. In C. perfringens, the quorum sensing-dependent VirSR two-component signal transduction system regulates genes encoding several toxins and extracellular enzymes. Analysis of the sequence upstream of the netB gene revealed the presence of potential DNA binding sites, or VirR boxes, that are recognized by the VirR response regulator. In vitro binding experiments showed that purified VirR was able to recognize and bind to these netB-associated VirR boxes. Furthermore, using a reporter gene assay, the netB VirR boxes were shown to be functional. Mutation of the virR gene in two avian C. perfringens strains was shown to significantly reduce the production of the NetB toxin; culture supernatants derived from these strains were no longer cytotoxic to Leghorn male hepatoma cells. Complementation with the virRS operon restored the toxin phenotypes to wild type. The results also showed that the VirSR two-component system regulates the expression of netB at the level of transcription. We postulate that in the gastrointestinal tract of infected birds, NetB production is upregulated when the population of C. perfringens cells reaches a threshold level that leads to activation of the VirSR system. PMID:20457789

Electro shield system applications on set gill net as efforts to preserve shark resources

NASA Astrophysics Data System (ADS)

Fitri Aristi, DP; Boesono, H.; Prihantoko, K. E.; Gautama, D. Y.

2018-05-01

Sharks are kind of ETP biota (Endangered, Threatened, and Protected), and are generally caught as by catch during fishing operations. In addition, sharks are one of the biota that plays a role in the life cycle in coastal waters. The Electro Shield System (ESS) was a device with an electromagnetic wave source that the shark can detect and make it afraid. ESS can be applied to set gill net operation to prevent the shark from getting caught. The objective of the study was to analyze the ESS on shark catches during set gill net operations. The research method was experimental fishing, conducted in March-May 2017 in Bangka Belitung Islands, Indonesia. Design the study by comparing shark catches during set gill net operation between those without using ESS (control) and using ESS with frequency 55 Hz. The shark catch by using Electro Shield System was 5.26% lower than control (7.80%). T-student analysis (sign 0.05) indicates that there was a significant difference between the set gill net without ESS and using the ESS against shark biota as bycatch. This indicates that the application of ESS in set gill net can reduce the capture of shark as by catch.

Why system safety programs can fail

NASA Technical Reports Server (NTRS)

Hammer, W.

1971-01-01

Factors that cause system safety programs to fail are discussed from the viewpoint that in general these programs have not achieved their intended aims. The one item which is considered to contribute most to failure of a system safety program is a poor statement of work which consists of ambiguity, lack of clear definition, use of obsolete requirements, and pure typographical errors. It is pointed out that unless safety requirements are stated clearly, and where they are readily apparent as firm requirements, some of them will be overlooked by designers and contractors. The lack of clarity is stated as being a major contributing factor in system safety program failure and usually evidenced in: (1) lack of clear requirements by the procuring activity, (2) lack of clear understanding of system safety by other managers, and (3) lack of clear methodology to be employed by system safety engineers.

Multibody dynamics driving GNC and system design in tethered nets for active debris removal

NASA Astrophysics Data System (ADS)

Benvenuto, Riccardo; Lavagna, Michèle; Salvi, Samuele

2016-07-01

Debris removal in Earth orbits is an urgent issue to be faced for space exploitation durability. Among different techniques, tethered-nets present appealing benefits and some open points to fix. Former and latter are discussed in the paper, supported by the exploitation of a multibody dynamics tool. With respect to other proposed capture mechanisms, tethered-net solutions are characterised by a safer capturing distance, a passive angular momentum damping effect and the highest flexibility to unknown shape, material and attitude of the target to interface with. They also allow not considering the centre of gravity alignment with thrust axis as a constraint, as it is for any rigid link solution. Furthermore, the introduction of a closing thread around the net perimeter ensures safer and more reliable grasping and holding. In the paper, a six degrees of freedom multibody dynamics simulator is presented: it was developed at Politecnico di Milano - Department of Aerospace Science and Technologies - and it is able to describe the orbital and attitude dynamics of tethered-nets systems and end-bodies during different phases, with great flexibility in dealing with different topologies and configurations. Critical phases as impact and wrapping are analysed by simulation to address the tethered-stack controllability. It is shown how the role of contact modelling is fundamental to describe the coupled dynamics: it is demonstrated, as a major novel contribution, how friction between the net and a tumbling target allows reducing its angular motion, stabilizing the system and allowing safer towing operations. Moreover, the so-called tethered space tug is analysed: after capture, the two objects, one passive and one active, are connected by the tethered-net flexible link, the motion of the system being excited by the active spacecraft thrusters. The critical modes prevention during this phase, by means of a closed-loop control synthesis is shown. Finally, the connection between

Does the concept of safety culture help or hinder systems thinking in safety?

PubMed

Reiman, Teemu; Rollenhagen, Carl

2014-07-01

The concept of safety culture has become established in safety management applications in all major safety-critical domains. The idea that safety culture somehow represents a "systemic view" on safety is seldom explicitly spoken out, but nevertheless seem to linger behind many safety culture discourses. However, in this paper we argue that the "new" contribution to safety management from safety culture never really became integrated with classical engineering principles and concepts. This integration would have been necessary for the development of a more genuine systems-oriented view on safety; e.g. a conception of safety in which human, technological, organisational and cultural factors are understood as mutually interacting elements. Without of this integration, researchers and the users of the various tools and methods associated with safety culture have sometimes fostered a belief that "safety culture" in fact represents such a systemic view about safety. This belief is, however, not backed up by theoretical or empirical evidence. It is true that safety culture, at least in some sense, represents a holistic term-a totality of factors that include human, organisational and technological aspects. However, the departure for such safety culture models is still human and organisational factors rather than technology (or safety) itself. The aim of this paper is to critically review the various uses of the concept of safety culture as representing a systemic view on safety. The article will take a look at the concepts of culture and safety culture based on previous studies, and outlines in more detail the theoretical challenges in safety culture as a systems concept. The paper also presents recommendations on how to make safety culture more systemic. Copyright © 2013 Elsevier Ltd. All rights reserved.

The aviation safety reporting system

NASA Technical Reports Server (NTRS)

Reynard, W. D.

1984-01-01

The aviation safety reporting system, an accident reporting system, is presented. The system identifies deficiencies and discrepancies and the data it provides are used for long term identification of problems. Data for planning and policy making are provided. The system offers training in safety education to pilots. Data and information are drawn from the available data bases.

A new technology perspective and engineering tools approach for large, complex and distributed mission and safety critical systems components

NASA Technical Reports Server (NTRS)

Carrio, Miguel A., Jr.

1988-01-01

Rapidly emerging technology and methodologies have out-paced the systems development processes' ability to use them effectively, if at all. At the same time, the tools used to build systems are becoming obsolescent themselves as a consequence of the same technology lag that plagues systems development. The net result is that systems development activities have not been able to take advantage of available technology and have become equally dependent on aging and ineffective computer-aided engineering tools. New methods and tools approaches are essential if the demands of non-stop and Mission and Safety Critical (MASC) components are to be met.

NASA Aviation Safety Reporting System (ASRS)

NASA Technical Reports Server (NTRS)

Connell, Linda

2011-01-01

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 900,000 reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 5,500 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides de-identified report information through the online ASRS Database at http://asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation \\vill discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

NASA Aviation Safety Reporting System (ASRS)

NASA Technical Reports Server (NTRS)

Connell, Linda J.

2017-01-01

The NASA Aviation Safety Reporting System (ASRS) collects, analyzes, and distributes de-identified safety information provided through confidentially submitted reports from frontline aviation personnel. Since its inception in 1976, the ASRS has collected over 1.4 million reports and has never breached the identity of the people sharing their information about events or safety issues. From this volume of data, the ASRS has released over 6,000 aviation safety alerts concerning potential hazards and safety concerns. The ASRS processes these reports, evaluates the information, and provides selected de-identified report information through the online ASRS Database at http:asrs.arc.nasa.gov. The NASA ASRS is also a founding member of the International Confidential Aviation Safety Systems (ICASS) group which is a collection of other national aviation reporting systems throughout the world. The ASRS model has also been replicated for application to improving safety in railroad, medical, fire fighting, and other domains. This presentation will discuss confidential, voluntary, and non-punitive reporting systems and their advantages in providing information for safety improvements.

Performance evaluation of automated manufacturing systems using generalized stochastic Petri Nets. Ph.D. Thesis

NASA Technical Reports Server (NTRS)

Al-Jaar, Robert Y.; Desrochers, Alan A.

1989-01-01

The main objective of this research is to develop a generic modeling methodology with a flexible and modular framework to aid in the design and performance evaluation of integrated manufacturing systems using a unified model. After a thorough examination of the available modeling methods, the Petri Net approach was adopted. The concurrent and asynchronous nature of manufacturing systems are easily captured by Petri Net models. Three basic modules were developed: machine, buffer, and Decision Making Unit. The machine and buffer modules are used for modeling transfer lines and production networks. The Decision Making Unit models the functions of a computer node in a complex Decision Making Unit Architecture. The underlying model is a Generalized Stochastic Petri Net (GSPN) that can be used for performance evaluation and structural analysis. GSPN's were chosen because they help manage the complexity of modeling large manufacturing systems. There is no need to enumerate all the possible states of the Markov Chain since they are automatically generated from the GSPN model.

Integrating system safety into the basic systems engineering process

NASA Technical Reports Server (NTRS)

Griswold, J. W.

1971-01-01

The basic elements of a systems engineering process are given along with a detailed description of what the safety system requires from the systems engineering process. Also discussed is the safety that the system provides to other subfunctions of systems engineering.

49 CFR 385.103 - Safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Safety monitoring system. 385.103 Section 385.103... Safety Monitoring System for Mexico-Domiciled Carriers § 385.103 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

49 CFR 385.103 - Safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Safety monitoring system. 385.103 Section 385.103... Safety Monitoring System for Mexico-Domiciled Carriers § 385.103 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

49 CFR 385.703 - Safety monitoring system.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 5 2010-10-01 2010-10-01 false Safety monitoring system. 385.703 Section 385.703... Safety Monitoring System for Non-North American Carriers § 385.703 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

49 CFR 385.703 - Safety monitoring system.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 5 2011-10-01 2011-10-01 false Safety monitoring system. 385.703 Section 385.703... Safety Monitoring System for Non-North American Carriers § 385.703 Safety monitoring system. (a) General... Vehicle Safety Standards (FMVSSs), and Hazardous Materials Regulations (HMRs). (b) Roadside monitoring...

NetView technical research

NASA Technical Reports Server (NTRS)

1993-01-01

This is the Final Technical Report for the NetView Technical Research task. This report is prepared in accordance with Contract Data Requirements List (CDRL) item A002. NetView assistance was provided and details are presented under the following headings: NetView Management Systems (NMS) project tasks; WBAFB IBM 3090; WPAFB AMDAHL; WPAFB IBM 3084; Hill AFB; McClellan AFB AMDAHL; McClellan AFB IBM 3090; and Warner-Robins AFB.

Community pharmacist participation in a practice-based research network: a report from the Medication Safety Research Network of Indiana (Rx-SafeNet).

PubMed

Patel, Puja; Hemmeger, Heather; Kozak, Mary Ann; Gernant, Stephanie A; Snyder, Margie E

2015-01-01

To describe the experiences and opinions of pharmacists serving as site coordinators for the Medication Safety Research Network of Indiana (Rx-SafeNet). Retail chain, independent, and hospital/health system outpatient community pharmacies throughout Indiana, with a total of 127 pharmacy members represented by 26 site coordinators. Rx-SafeNet, a statewide practice-based research network (PBRN) formed in 2010 and administered by the Purdue University College of Pharmacy. Barriers and facilitators to participation in available research studies, confidence participating in research, and satisfaction with overall network communication. 22 of 26 site coordinators participated, resulting in an 85% response rate. Most (72.2%) of the respondents had received a doctor of pharmacy degree, and 13.6% had postgraduate year (PGY)1 residency training. The highest reported benefits of PBRN membership were an enhanced relationship with the Purdue University College of Pharmacy (81% agreed or strongly agreed) and enhanced professional development (80% agreed or strongly agreed). Time constraints were identified as the greatest potential barrier to network participation, reported by 62% of respondents. In addition, the majority (59%) of survey respondents identified no prior research experience. Last, respondents' confidence in performing research appeared to increase substantially after becoming network members, with 43% reporting a lack of confidence in engaging in research before joining the network compared with 90% reporting confidence after joining the network. In general, Rx-SafeNet site coordinators appeared to experience increased confidence in research engagement after joining the network. While respondents identified a number of benefits associated with network participation, concerns about potential time constraints remained a key barrier to participation. These findings will assist network leadership in identifying opportunities to positively increase member participation

A Better Safety Net: It's Time to Get Smart about Online Safety

ERIC Educational Resources Information Center

Collier, Anne

2009-01-01

Online safety is obsolete. A concept little changed since the 1990s, it's one size fits all, emphasizing fear instead of facts, with young people stereotyped as potential victims in a hostile media environment. It's past time for Online Safety 3.0. Why 3.0? Previous versions--1.0 and 2.0--focused on inappropriate content, adult-to-child crime, and…

System safety engineering analysis handbook

NASA Technical Reports Server (NTRS)

Ijams, T. E.

1972-01-01

The basic requirements and guidelines for the preparation of System Safety Engineering Analysis are presented. The philosophy of System Safety and the various analytic methods available to the engineering profession are discussed. A text-book description of each of the methods is included.

Catch me if I fall! Enacted uncertainty avoidance and the social safety net as country-level moderators in the job insecurity-job attitudes link.

PubMed

Debus, Maike E; Probst, Tahira M; König, Cornelius J; Kleinmann, Martin

2012-05-01

Job insecurity is related to many detrimental outcomes, with reduced job satisfaction and affective organizational commitment being the 2 most prominent reactions. Yet, effect sizes vary greatly, suggesting the presence of moderator variables. On the basis of Lazarus's cognitive appraisal theory, we assumed that country-level enacted uncertainty avoidance and a country's social safety net would affect an individual's appraisal of job insecurity. More specifically, we hypothesized that these 2 country-level variables would buffer the negative relationships between job insecurity and the 2 aforementioned job attitudes. Combining 3 different data sources, we tested the hypotheses in a sample of 15,200 employees from 24 countries by applying multilevel modeling. The results confirmed the hypotheses that both enacted uncertainty avoidance and the social safety net act as cross-level buffer variables. Furthermore, our data revealed that the 2 cross-level interactions share variance in explaining the 2 job attitudes. Our study responds to calls to look at stress processes from a multilevel perspective and highlights the potential importance of governmental regulation when it comes to individual stress processes. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

The Evolution of System Safety at NASA

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon; Everett, Chris; Groen, Frank

2014-01-01

The NASA system safety framework is in the process of change, motivated by the desire to promote an objectives-driven approach to system safety that explicitly focuses system safety efforts on system-level safety performance, and serves to unify, in a purposeful manner, safety-related activities that otherwise might be done in a way that results in gaps, redundancies, or unnecessary work. An objectives-driven approach to system safety affords more flexibility to determine, on a system-specific basis, the means by which adequate safety is achieved and verified. Such flexibility and efficiency is becoming increasingly important in the face of evolving engineering modalities and acquisition models, where, for example, NASA will increasingly rely on commercial providers for transportation services to low-earth orbit. A key element of this objectives-driven approach is the use of the risk-informed safety case (RISC): a structured argument, supported by a body of evidence, that provides a compelling, comprehensible and valid case that a system is or will be adequately safe for a given application in a given environment. The RISC addresses each of the objectives defined for the system, providing a rational basis for making informed risk acceptance decisions at relevant decision points in the system life cycle.

Modelling safety of multistate systems with ageing components

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kołowrocki, Krzysztof; Soszyńska-Budny, Joanna

An innovative approach to safety analysis of multistate ageing systems is presented. Basic notions of the ageing multistate systems safety analysis are introduced. The system components and the system multistate safety functions are defined. The mean values and variances of the multistate systems lifetimes in the safety state subsets and the mean values of their lifetimes in the particular safety states are defined. The multi-state system risk function and the moment of exceeding by the system the critical safety state are introduced. Applications of the proposed multistate system safety models to the evaluation and prediction of the safty characteristics ofmore » the consecutive “m out of n: F” is presented as well.« less

A Patient Navigator Intervention to Reduce Hospital Readmissions among High-Risk Safety-Net Patients: A Randomized Controlled Trial.

PubMed

Balaban, Richard B; Galbraith, Alison A; Burns, Marguerite E; Vialle-Valentin, Catherine E; Larochelle, Marc R; Ross-Degnan, Dennis

2015-07-01

Evidence-based interventions to reduce hospital readmissions may not generalize to resource-constrained safety-net hospitals. To determine if an intervention by patient navigators (PNs), hospital-based Community Health Workers, reduces readmissions among high risk, low socioeconomic status patients. Randomized controlled trial. General medicine inpatients having at least one of the following readmission risk factors: (1) age ≥60 years, (2) any in-network inpatient admission within the past 6 months, (3) length of stay ≥3 days, (4) admission diagnosis of heart failure, or (5) chronic obstructive pulmonary disease. The analytic sample included 585 intervention patients and 925 controls. PNs provided coaching and assistance in navigating the transition from hospital to home through hospital visits and weekly telephone outreach, supporting patients for 30 days post-discharge with discharge preparation, medication management, scheduling of follow-up appointments, communication with primary care, and symptom management. The primary outcome was in-network 30-day hospital readmissions. Secondary outcomes included rates of outpatient follow-up. We evaluated outcomes for the entire cohort and stratified by patient age >60 years (425 intervention/584 controls) and ≤60 years (160 intervention/341 controls). Overall, 30-day readmission rates did not differ between intervention and control patients. However, the two age groups demonstrated marked differences. Intervention patients >60 years showed a statistically significant adjusted absolute 4.1% decrease [95% CI: -8.0%, -0.2%] in readmission with an increase in 30-day outpatient follow-up. Intervention patients ≤60 years showed a statistically significant adjusted absolute 11.8% increase [95% CI: 4.4%, 19.0%] in readmission with no change in 30-day outpatient follow-up. A patient navigator intervention among high risk, safety-net patients decreased readmission among older patients while increasing readmissions

A Cross-Sectional Study of Barriers to Personal Health Record Use among Patients Attending a Safety-Net Clinic

PubMed Central

Hilton, Joan F.; Barkoff, Lynsey; Chang, Olivia; Halperin, Lindsay; Ratanawongsa, Neda; Sarkar, Urmimala; Leykin, Yan; Muñoz, Ricardo F.; Thom, David H.; Kahn, James S.

2012-01-01

Background Personal health records (PHR) may improve patients' health by providing access to and context for health information. Among patients receiving care at a safety-net HIV/AIDS clinic, we examined the hypothesis that a mental health (MH) or substance use (SU) condition represents a barrier to engagement with web-based health information, as measured by consent to participate in a trial that provided access to personal (PHR) or general (non-PHR) health information portals and by completion of baseline study surveys posted there. Methods Participants were individually trained to access and navigate individualized online accounts and to complete study surveys. In response to need, during accrual months 4 to 12 we enhanced participant training to encourage survey completion with the help of staff. Using logistic regression models, we estimated odds ratios for study participation and for survey completion by combined MH/SU status, adjusted for levels of computer competency, on-study training, and demographics. Results Among 2,871 clinic patients, 70% had MH/SU conditions, with depression (38%) and methamphetamine use (17%) most commonly documented. Middle-aged patients and those with a MH/SU condition were over-represented among study participants (N = 338). Survey completion was statistically independent of MH/SU status (OR, 1.85 [95% CI, 0.93–3.66]) but tended to be higher among those with MH/SU conditions. Completion rates were low among beginner computer users, regardless of training level (<50%), but adequate among advanced users (>70%). Conclusions Among patients attending a safety-net clinic, MH/SU conditions were not barriers to engagement with web-based health information. Instead, level of computer competency was useful for identifying individuals requiring substantial computer training in order to fully participate in the study. Intensive on-study training was insufficient to enable beginner computer users to complete study surveys. PMID:22363761

The Mediterranean Decision Support System for Marine Safety dedicated to oil slicks predictions

NASA Astrophysics Data System (ADS)

Zodiatis, G.; De Dominicis, M.; Perivoliotis, L.; Radhakrishnan, H.; Georgoudis, E.; Sotillo, M.; Lardner, R. W.; Krokos, G.; Bruciaferri, D.; Clementi, E.; Guarnieri, A.; Ribotti, A.; Drago, A.; Bourma, E.; Padorno, E.; Daniel, P.; Gonzalez, G.; Chazot, C.; Gouriou, V.; Kremer, X.; Sofianos, S.; Tintore, J.; Garreau, P.; Pinardi, N.; Coppini, G.; Lecci, R.; Pisano, A.; Sorgente, R.; Fazioli, L.; Soloviev, D.; Stylianou, S.; Nikolaidis, A.; Panayidou, X.; Karaolia, A.; Gauci, A.; Marcati, A.; Caiazzo, L.; Mancini, M.

2016-11-01

In the Mediterranean sea the risk from oil spill pollution is high due to the heavy traffic of merchant vessels for transporting oil and gas, especially after the recent enlargement of the Suez canal and to the increasing coastal and offshore installations related to the oil industry in general. The basic response to major oil spills includes different measures and equipment. However, in order to strengthen the maritime safety related to oil spill pollution in the Mediterranean and to assist the response agencies, a multi-model oil spill prediction service has been set up, known as MEDESS-4MS (Mediterranean Decision Support System for Marine Safety). The concept behind the MEDESS-4MS service is the integration of the existing national ocean forecasting systems in the region with the Copernicus Marine Environmental Monitoring Service (CMEMS) and their interconnection, through a dedicated network data repository, facilitating access to all these data and to the data from the oil spill monitoring platforms, including the satellite data ones, with the well established oil spill models in the region. The MEDESS-4MS offer a range of service scenarios, multi-model data access and interactive capabilities to suite the needs of REMPEC (Regional Marine Pollution Emergency Response Centre for the Mediterranean Sea) and EMSA-CSN (European Maritime Safety Agency-CleanseaNet).

Helminth.net: expansions to Nematode.net and an introduction to Trematode.net

PubMed Central

Martin, John; Rosa, Bruce A.; Ozersky, Philip; Hallsworth-Pepin, Kymberlie; Zhang, Xu; Bhonagiri-Palsikar, Veena; Tyagi, Rahul; Wang, Qi; Choi, Young-Jun; Gao, Xin; McNulty, Samantha N.; Brindley, Paul J.; Mitreva, Makedonka

2015-01-01

Helminth.net (http://www.helminth.net) is the new moniker for a collection of databases: Nematode.net and Trematode.net. Within this collection we provide services and resources for parasitic roundworms (nematodes) and flatworms (trematodes), collectively known as helminths. For over a decade we have provided resources for studying nematodes via our veteran site Nematode.net (http://nematode.net). In this article, (i) we provide an update on the expansions of Nematode.net that hosts omics data from 84 species and provides advanced search tools to the broad scientific community so that data can be mined in a useful and user-friendly manner and (ii) we introduce Trematode.net, a site dedicated to the dissemination of data from flukes, flatworm parasites of the class Trematoda, phylum Platyhelminthes. Trematode.net is an independent component of Helminth.net and currently hosts data from 16 species, with information ranging from genomic, functional genomic data, enzymatic pathway utilization to microbiome changes associated with helminth infections. The databases’ interface, with a sophisticated query engine as a backbone, is intended to allow users to search for multi-factorial combinations of species’ omics properties. This report describes updates to Nematode.net since its last description in NAR, 2012, and also introduces and presents its new sibling site, Trematode.net. PMID:25392426

System safety education focused on industrial engineering

NASA Technical Reports Server (NTRS)

Johnston, W. L.; Morris, R. S.

1971-01-01

An educational program, designed to train students with the specific skills needed to become safety specialists, is described. The discussion concentrates on application, selection, and utilization of various system safety analytical approaches. Emphasis is also placed on the management of a system safety program, its relationship with other disciplines, and new developments and applications of system safety techniques.

Systems Thinking and Patient Safety

DTIC Science & Technology

2005-01-01

1 Prologue Systems Thinking and Patient Safety Paul M. Schyve Patient safety is a prominent theme in health care delivery today. This should... patient safety and a willingness to invest in patient safety research. This volume—published by the Agency for Healthcare Research and Quality (AHRQ...The recent advent of the health care field’s emphasis on patient safety came at a favorable time. One or two decades earlier, our response would have

Hennepin Health: a safety-net accountable care organization for the expanded Medicaid population.

PubMed

Sandberg, Shana F; Erikson, Clese; Owen, Ross; Vickery, Katherine D; Shimotsu, Scott T; Linzer, Mark; Garrett, Nancy A; Johnsrud, Kimry A; Soderlund, Dana M; DeCubellis, Jennifer

2014-11-01

Health care payment and delivery models that challenge providers to be accountable for outcomes have fueled interest in community-level partnerships that address the behavioral, social, and economic determinants of health. We describe how Hennepin Health--a county-based safety-net accountable care organization in Minnesota--has forged such a partnership to redesign the health care workforce and improve the coordination of the physical, behavioral, social, and economic dimensions of care for an expanded community of Medicaid beneficiaries. Early outcomes suggest that the program has had an impact in shifting care from hospitals to outpatient settings. For example, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. An increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. Hennepin Health offers lessons for counties, states, and public hospitals grappling with the problem of how to make the best use of public funds in serving expanded Medicaid populations and other communities with high needs. Project HOPE—The People-to-People Health Foundation, Inc.

The WORM site: worm.csirc.net

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jones, T.

2000-07-01

The Write One, Run Many (WORM) site (worm.csirc.net) is the on-line home of the WORM language and is hosted by the Criticality Safety Information Resource Center (CSIRC) (www.csirc.net). The purpose of this web site is to create an on-line community for WORM users to gather, share, and archive WORM-related information. WORM is an embedded, functional, programming language designed to facilitate the creation of input decks for computer codes that take standard ASCII text files as input. A functional programming language is one that emphasizes the evaluation of expressions, rather than execution of commands. The simplest and perhaps most common examplemore » of a functional language is a spreadsheet such as Microsoft Excel. The spreadsheet user specifies expressions to be evaluated, while the spreadsheet itself determines the commands to execute, as well as the order of execution/evaluation. WORM functions in a similar fashion and, as a result, is very simple to use and easy to learn. WORM improves the efficiency of today's criticality safety analyst by allowing: (1) input decks for parameter studies to be created quickly and easily; (2) calculations and variables to be embedded into any input deck, thus allowing for meaningful parameter specifications; (3) problems to be specified using any combination of units; and (4) complex mathematically defined models to be created. WORM is completely written in Perl. Running on all variants of UNIX, Windows, MS-DOS, MacOS, and many other operating systems, Perl is one of the most portable programming languages available. As such, WORM works on practically any computer platform.« less

TokenPasser: A petri net specification tool. Thesis

NASA Technical Reports Server (NTRS)

Mittmann, Michael

1991-01-01

In computer program design it is essential to know the effectiveness of different design options in improving performance, and dependability. This paper provides a description of a CAD tool for distributed hierarchical Petri nets. After a brief review of Petri nets, Petri net languages, and Petri net transducers, and descriptions of several current Petri net tools, the specifications and design of the TokenPasser tool are presented. TokenPasser is a tool to allow design of distributed hierarchical systems based on Petri nets. A case study for an intelligent robotic system is conducted, a coordination structure with one dispatcher controlling three coordinators is built to model a proposed robotic assembly system. The system is implemented using TokenPasser, and the results are analyzed to allow judgment of the tool.

Increased light-use efficiency sustains net primary productivity of shaded coffee plants in agroforestry system.

PubMed

Charbonnier, Fabien; Roupsard, Olivier; le Maire, Guerric; Guillemot, Joannès; Casanoves, Fernando; Lacointe, André; Vaast, Philippe; Allinne, Clémentine; Audebert, Louise; Cambou, Aurélie; Clément-Vidal, Anne; Defrenet, Elsa; Duursma, Remko A; Jarri, Laura; Jourdan, Christophe; Khac, Emmanuelle; Leandro, Patricia; Medlyn, Belinda E; Saint-André, Laurent; Thaler, Philippe; Van Den Meersche, Karel; Barquero Aguilar, Alejandra; Lehner, Peter; Dreyer, Erwin

2017-08-01

In agroforestry systems, shade trees strongly affect the physiology of the undergrown crop. However, a major paradigm is that the reduction in absorbed photosynthetically active radiation is, to a certain extent, compensated by an increase in light-use efficiency, thereby reducing the difference in net primary productivity between shaded and non-shaded plants. Due to the large spatial heterogeneity in agroforestry systems and the lack of appropriate tools, the combined effects of such variables have seldom been analysed, even though they may help understand physiological processes underlying yield dynamics. In this study, we monitored net primary productivity, during two years, on scales ranging from individual coffee plants to the entire plot. Absorbed radiation was mapped with a 3D model (MAESPA). Light-use efficiency and net assimilation rate were derived for each coffee plant individually. We found that although irradiance was reduced by 60% below crowns of shade trees, coffee light-use efficiency increased by 50%, leaving net primary productivity fairly stable across all shade levels. Variability of aboveground net primary productivity of coffee plants was caused primarily by the age of the plants and by intraspecific competition among them (drivers usually overlooked in the agroforestry literature) rather than by the presence of shade trees. © 2017 John Wiley & Sons Ltd.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield.

PubMed

Ulloa, Jesus G; Russell, Marika D; Chen, Alice Hm; Tuot, Delphine S

2017-06-23

Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case). Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014. Electronic consultation requests were reviewed for the presence/absence of consult domains: symptom acuity/severity, diagnostic evaluation, concurrent medical conditions, and attempted diagnosis. Logic regression was used to examine the association between completeness of consult requests and scheduling an ambulatory clinic visit. Surgical yield was also calculated, as was the percentage of patients requiring unanticipated healthcare visits. In 2014, 1743 electronic consultations were submitted to general surgery. Among the 150 abstracted, the presence of consult domains ranged from 49% to 99%. Consult completeness was not associated with greater likelihood of scheduling an ambulatory visit. Seventy-six percent of consult requests (114/150) were scheduled for a clinic appointment and surgical yield was 46%; without an eConsult system, surgical yield would have been 35% (p=0.07). Among patients not scheduled for a clinic visit (n=36), 4 had related unanticipated emergency department visits. Econsult systems can be used to safely optimize the surgical yield of a safety-net general surgery service.

NetCDF-U - Uncertainty conventions for netCDF datasets

NASA Astrophysics Data System (ADS)

Bigagli, Lorenzo; Nativi, Stefano; Domenico, Ben

2013-04-01

To facilitate the automated processing of uncertain data (e.g. uncertainty propagation in modeling applications), we have proposed a set of conventions for expressing uncertainty information within the netCDF data model and format: the NetCDF Uncertainty Conventions (NetCDF-U). From a theoretical perspective, it can be said that no dataset is a perfect representation of the reality it purports to represent. Inevitably, errors arise from the observation process, including the sensor system and subsequent processing, differences in scales of phenomena and the spatial support of the observation mechanism, lack of knowledge about the detailed conversion between the measured quantity and the target variable. This means that, in principle, all data should be treated as uncertain. The most natural representation of an uncertain quantity is in terms of random variables, with a probabilistic approach. However, it must be acknowledged that almost all existing data resources are not treated in this way. Most datasets come simply as a series of values, often without any uncertainty information. If uncertainty information is present, then it is typically within the metadata, as a data quality element. This is typically a global (dataset wide) representation of uncertainty, often derived through some form of validation process. Typically, it is a statistical measure of spread, for example the standard deviation of the residuals. The introduction of a mechanism by which such descriptions of uncertainty can be integrated into existing geospatial applications is considered a practical step towards a more accurate modeling of our uncertain understanding of any natural process. Given the generality and flexibility of the netCDF data model, conventions on naming, syntax, and semantics have been adopted by several communities of practice, as a means of improving data interoperability. Some of the existing conventions include provisions on uncertain elements and concepts, but, to our

Product Engineering Class in the Software Safety Risk Taxonomy for Building Safety-Critical Systems

NASA Technical Reports Server (NTRS)

Hill, Janice; Victor, Daniel

2008-01-01

When software safety requirements are imposed on legacy safety-critical systems, retrospective safety cases need to be formulated as part of recertifying the systems for further use and risks must be documented and managed to give confidence for reusing the systems. The SEJ Software Development Risk Taxonomy [4] focuses on general software development issues. It does not, however, cover all the safety risks. The Software Safety Risk Taxonomy [8] was developed which provides a construct for eliciting and categorizing software safety risks in a straightforward manner. In this paper, we present extended work on the taxonomy for safety that incorporates the additional issues inherent in the development and maintenance of safety-critical systems with software. An instrument called a Software Safety Risk Taxonomy Based Questionnaire (TBQ) is generated containing questions addressing each safety attribute in the Software Safety Risk Taxonomy. Software safety risks are surfaced using the new TBQ and then analyzed. In this paper we give the definitions for the specialized Product Engineering Class within the Software Safety Risk Taxonomy. At the end of the paper, we present the tool known as the 'Legacy Systems Risk Database Tool' that is used to collect and analyze the data required to show traceability to a particular safety standard

In-space propellant systems safety. Volume 3: System safety analysis

NASA Technical Reports Server (NTRS)

1972-01-01

The primary objective was to examine from a system safety viewpoint in-space propellant logistic elements and operations to define the potential hazards and to recommend means to reduce, eliminate or control them. A secondary objective was to conduct trade studies of specific systems or operations to determine the safest of alternate approaches.

A Petri Net model for distributed energy system

NASA Astrophysics Data System (ADS)

Konopko, Joanna

2015-12-01

Electrical networks need to evolve to become more intelligent, more flexible and less costly. The smart grid is the next generation power energy, uses two-way flows of electricity and information to create a distributed automated energy delivery network. Building a comprehensive smart grid is a challenge for system protection, optimization and energy efficient. Proper modeling and analysis is needed to build an extensive distributed energy system and intelligent electricity infrastructure. In this paper, the whole model of smart grid have been proposed using Generalized Stochastic Petri Nets (GSPN). The simulation of created model is also explored. The simulation of the model has allowed the analysis of how close the behavior of the model is to the usage of the real smart grid.

Software system safety

NASA Technical Reports Server (NTRS)

Uber, James G.

1988-01-01

Software itself is not hazardous, but since software and hardware share common interfaces there is an opportunity for software to create hazards. Further, these software systems are complex, and proven methods for the design, analysis, and measurement of software safety are not yet available. Some past software failures, future NASA software trends, software engineering methods, and tools and techniques for various software safety analyses are reviewed. Recommendations to NASA are made based on this review.

Child access to the nutritional safety net during and after the Great Recession: The case of WIC.

PubMed

Jackson, Margot I; Mayne, Patrick

2016-12-01

Because children disproportionately live in poverty, they are especially vulnerable during economic crises, making the social safety net a key buffer against the effects of economic disadvantage on their development. The Great Recession of 2007-2009 had strong and lasting effects on American children and families, including striking negative effects on their health environments. Understanding access to the health safety net during this time of increased economic need, as well as the extent to which all children-regardless of age, income or race/ethnicity-share in the increased use of transfer programs, is therefore important in identifying the availability and accessibility of government assistance for those in need. Focusing on the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) program because of its strong effects on child development, we use longitudinal data from the Survey of Income and Program Participation (SIPP) to examine change and stability in children's WIC enrollment before, during and after the recession. Specifically, we examine: 1) whether children's WIC enrollment increased alongside changing family income, and 2) the extent to which changes in participation were shared by all subpopulations, regardless of age, income, and race/ethnicity. Analyses reveal that WIC participation among eligible children increased leading up to, during, and after the Great Recession, suggesting that the program was responsive to increasing economic need. Examining the distribution of WIC enrollment across demographic groups largely reveals a pattern of stable inequality in access and "take up." Children born to poorer and less-educated mothers were more likely to be enrolled prior to the recession, and these differences remain mostly constant during and after the recession. Eligible Hispanic children had consistently higher enrollment, particularly among those in families with foreign-born mothers. The findings suggest that not all

Evaluation Of The Vehicle Radar Safety Systems Rashid Radar Safety Brake Collision Warning System, Final Report

DOT National Transportation Integrated Search

1988-02-01

THIS EVALUATION OF THE VEHICLE RADAR SAFETY SYSTEMS? ANTI-COLLISION DEVICE (HEREAFTER VRSS) WAS UNDERTAKEN BY THE OPERATOR PERFORMANCE AND SAFETY ANALYSIS DIVISION OF THE TRANSPORTATION SYSTEMS CENTER AT THE REQUEST OF THE NATIONAL HIGHWAY TRAFFIC SA...

Hybrid modeling in biochemical systems theory by means of functional petri nets.

PubMed

Wu, Jialiang; Voit, Eberhard

2009-02-01

Many biological systems are genuinely hybrids consisting of interacting discrete and continuous components and processes that often operate at different time scales. It is therefore desirable to create modeling frameworks capable of combining differently structured processes and permitting their analysis over multiple time horizons. During the past 40 years, Biochemical Systems Theory (BST) has been a very successful approach to elucidating metabolic, gene regulatory, and signaling systems. However, its foundation in ordinary differential equations has precluded BST from directly addressing problems containing switches, delays, and stochastic effects. In this study, we extend BST to hybrid modeling within the framework of Hybrid Functional Petri Nets (HFPN). First, we show how the canonical GMA and S-system models in BST can be directly implemented in a standard Petri Net framework. In a second step we demonstrate how to account for different types of time delays as well as for discrete, stochastic, and switching effects. Using representative test cases, we validate the hybrid modeling approach through comparative analyses and simulations with other approaches and highlight the feasibility, quality, and efficiency of the hybrid method.

WhaleNet/environet

DOE Office of Scientific and Technical Information (OSTI.GOV)

Williamson, J.M.

1994-12-31

WhaleNet has established a network where students, educators, and scientists can interact and share data for use in interdisciplinary curricular and student research activities in classrooms around the world by utilizing telecommunication. This program enables students to participate in marine/whale research programs in real-time with WhaleNet data and supplementary curriculum materials regardless of their geographic location. Systems have been established with research organizations and whale watch companies whereby research data is posted by scientists and students participating in whale watches on the WhaleNet bulletin board and shared with participating classrooms. WhaleNet presently has contacts with classrooms across the nation, andmore » with research groups, whale watch organizations, science museums, and universities from Alaska to North Carolina, Hawaii to Maine, and Belize to Norway. WhaleNet has plans to make existing whale and fisheries research databases available for classroom use and to have research data from satellite tagging programs on various species of whales available for classroom access in real-time.« less

Development of space simulation / net-laboratory system

NASA Astrophysics Data System (ADS)

Usui, H.; Matsumoto, H.; Ogino, T.; Fujimoto, M.; Omura, Y.; Okada, M.; Ueda, H. O.; Murata, T.; Kamide, Y.; Shinagawa, H.; Watanabe, S.; Machida, S.; Hada, T.

A research project for the development of space simulation / net-laboratory system was approved by Japan Science and Technology Corporation (JST) in the category of Research and Development for Applying Advanced Computational Science and Technology(ACT-JST) in 2000. This research project, which continues for three years, is a collaboration with an astrophysical simulation group as well as other space simulation groups which use MHD and hybrid models. In this project, we develop a proto type of unique simulation system which enables us to perform simulation runs by providing or selecting plasma parameters through Web-based interface on the internet. We are also developing an on-line database system for space simulation from which we will be able to search and extract various information such as simulation method and program, manuals, and typical simulation results in graphic or ascii format. This unique system will help the simulation beginners to start simulation study without much difficulty or effort, and contribute to the promotion of simulation studies in the STP field. In this presentation, we will report the overview and the current status of the project.

A Taxonomy of Fallacies in System Safety Arguments

NASA Technical Reports Server (NTRS)

Greenwell, William S.; Knight, John C.; Holloway, C. Michael; Pease, Jacob J.

2006-01-01

Safety cases are gaining acceptance as assurance vehicles for safety-related systems. A safety case documents the evidence and argument that a system is safe to operate; however, logical fallacies in the underlying argument may undermine a system s safety claims. Removing these fallacies is essential to reduce the risk of safety-related system failure. We present a taxonomy of common fallacies in safety arguments that is intended to assist safety professionals in avoiding and detecting fallacious reasoning in the arguments they develop and review. The taxonomy derives from a survey of general argument fallacies and a separate survey of fallacies in real-world safety arguments. Our taxonomy is specific to safety argumentation, and it is targeted at professionals who work with safety arguments but may lack formal training in logic or argumentation. We discuss the rationale for the selection and categorization of fallacies in the taxonomy. In addition to its applications to the development and review of safety cases, our taxonomy could also support the analysis of system failures and promote the development of more robust safety case patterns.

Study protocol for "Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET)": a pragmatic trial comparing implementation strategies.

PubMed

Gold, Rachel; Hollombe, Celine; Bunce, Arwen; Nelson, Christine; Davis, James V; Cowburn, Stuart; Perrin, Nancy; DeVoe, Jennifer; Mossman, Ned; Boles, Bruce; Horberg, Michael; Dearing, James W; Jaworski, Victoria; Cohen, Deborah; Smith, David

2015-10-16

Little research has directly compared the effectiveness of implementation strategies in any setting, and we know of no prior trials directly comparing how effectively different combinations of strategies support implementation in community health centers. This paper outlines the protocol of the Study of Practices Enabling Implementation and Adaptation in the Safety Net (SPREAD-NET), a trial designed to compare the effectiveness of several common strategies for supporting implementation of an intervention and explore contextual factors that impact the strategies' effectiveness in the community health center setting. This cluster-randomized trial compares how three increasingly hands-on implementation strategies support adoption of an evidence-based diabetes quality improvement intervention in 29 community health centers, managed by 12 healthcare organizations. The strategies are as follows: (arm 1) a toolkit, presented in paper and electronic form, which includes a training webinar; (arm 2) toolkit plus in-person training with a focus on practice change and change management strategies; and (arm 3) toolkit, in-person training, plus practice facilitation with on-site visits. We use a mixed methods approach to data collection and analysis: (i) baseline surveys on study clinic characteristics, to explore how these characteristics impact the clinics' ability to implement the tools and the effectiveness of each implementation strategy; (ii) quantitative data on change in rates of guideline-concordant prescribing; and (iii) qualitative data on the "how" and "why" underlying the quantitative results. The outcomes of interest are clinic-level results, categorized using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework, within an interrupted time-series design with segmented regression models. This pragmatic trial will compare how well each implementation strategy works in "real-world" practices. Having a better understanding of how different

System safety management: A new discipline

NASA Technical Reports Server (NTRS)

Pope, W. C.

1971-01-01

The systems theory is discussed in relation to safety management. It is suggested that systems safety management, as a new discipline, holds great promise for reducing operating errors, conserving labor resources, avoiding operating costs due to mistakes, and for improving managerial techniques. It is pointed out that managerial failures or system breakdowns are the basic reasons for human errors and condition defects. In this respect, a recommendation is made that safety engineers stop visualizing the problem only with the individual (supervisor or employee) and see the problem from the systems point of view.

NASA's Software Bank (NETS)

NASA Technical Reports Server (NTRS)

1992-01-01

NETS (A Neural Network Development Tool) is a software system for mimicking the human brain. It is used in a University of Arkansas project in pattern matching of chemical systems. If successful, chemists would be able to identify mixtures of compounds without long and costly separation procedures. Using NETS, the group has trained the computer to recognize pattern relationships in a known compound and associate the results to an unknown compound. The research appears to be promising.

Ensuring Patient Safety by using Colored Petri Net Simulation in the Design of Heterogeneous, Multi-Vendor, Integrated, Life-Critical Wireless (802.x) Patient Care Device Networks.

PubMed

Sloane, Elliot; Gehlot, Vijay

2005-01-01

Hospitals and manufacturers are designing and deploying the IEEE 802.x wireless technologies in medical devices to promote patient mobility and flexible facility use. There is little information, however, on the reliability or ultimate safety of connecting multiple wireless life-critical medical devices from multiple vendors using commercial 802.11a, 802.11b, 802.11g or pre-802.11n devices. It is believed that 802.11-type devices can introduce unintended life-threatening risks unless delivery of critical patient alarms to central monitoring systems and/or clinical personnel is assured by proper use of 802.11e Quality of Service (QoS) methods. Petri net tools can be used to simulate all possible states and transitions between devices and/or systems in a wireless device network, and can identify failure modes in advance. Colored Petri Net (CPN) tools are ideal, in fact, as they allow tracking and controlling each message in a network based on pre-selected criteria. This paper describes a research project using CPN to simulate and validate alarm integrity in a small multi-modality wireless patient monitoring system. A 20-monitor wireless patient monitoring network is created in two versions: one with non-prioritized 802.x CSM protocols and the second with simulated Quality of Service (QoS) capabilities similar to 802.11e (i.e., the second network allows message priority management.) In the standard 802.x network, dangerous heart arrhythmia and pulse oximetry alarms could not be reliably and rapidly communicated, but the second network's QoS priority management reduced that risk significantly.

The NetLogger Toolkit V2.0

DOE Office of Scientific and Technical Information (OSTI.GOV)

Gunter, Dan; Lee, Jason; Stoufer, Martin

2003-03-28

The NetLogger Toolkit is designed to monitor, under actual operating conditions, the behavior of all the elements of the application-to-application communication path in order to determine exactly where time is spent within a complex system Using NetLogger, distnbuted application components are modified to produce timestamped logs of "interesting" events at all the critical points of the distributed system Events from each component are correlated, which allov^ one to characterize the performance of all aspects of the system and network in detail. The NetLogger Toolkit itself consists of four components an API and library of functions to simplify the generation ofmore » application-level event logs, a set of tools for collecting and sorting log files, an event archive system, and a tool for visualization and analysis of the log files In order to instrument an application to produce event logs, the application developer inserts calls to the NetLogger API at all the critical points in the code, then links the application with the NetLogger library All the tools in the NetLogger Toolkit share a common log format, and assume the existence of accurate and synchronized system clocks NetLogger messages can be logged using an easy-to-read text based format based on the lETF-proposed ULM format, or a binary format that can still be used through the same API but that is several times faster and smaller, with performance comparable or better than binary message formats such as MPI, XDR, SDDF-Binary, and PBIO. The NetLogger binary format is both highly efficient and self-describing, thus optimized for the dynamic message construction and parsing of application instrumentation. NetLogger includes an "activation" API that allows NetLogger logging to be turned on, off, or modified by changing an external file This IS useful for activating logging in daemons/services (e g GndFTP server). The NetLogger reliability API provides the ability to specify backup logging locations and

Patient Safety and the Malpractice System.

PubMed

Swift, James Q

2017-05-01

The cost of health care in the United States and malpractice insurance has escalated greatly over the past 30 years. In an ideal world, the goals of the tort system would be aligned with efforts at improving safety. In fact, there is little evidence that the tort system and the processes of risk management and informed consent have improved patient safety. This article explores the disunion between patient safety and the malpractice system. Copyright © 2016 Elsevier Inc. All rights reserved.

Primary Care Providers’ Experiences with Urine Toxicology Tests to Manage Prescription Opioid Misuse and Substance Use Among Chronic Non-Cancer Pain Patients in Safety Net Healthcare Settings

PubMed Central

Ceasar, Rachel; Chang, Jamie; Zamora, Kara; Hurstak, Emily; Kushel, Margot; Miaskowski, Christine; Knight, Kelly

2016-01-01

Background Guideline recommendations to reduce prescription opioid misuse among patients with chronic non-cancer pain include the routine use of urine toxicology tests for high-risk patients. Yet little is known about how the implementation of urine toxicology tests among patients with co-occurring chronic non-cancer pain and substance use impacts primary care providers’ management of misuse. In this paper, we present clinicians’ perspectives on the benefits and challenges of implementing urine toxicology tests in the monitoring of opioid misuse and substance use in safety net healthcare settings. Methods We interviewed 23 primary care providers from six safety net healthcare settings whose patients had a diagnosis of co-occurring chronic non-cancer pain and substance use. We transcribed, coded, and analyzed interviews using grounded theory methodology. Results The benefits of implementing urine toxicology tests for primary care providers included less reliance on intuition to assess for misuse and the ability to identify unknown opioid misuse and/or substance use. The challenges of implementing urine toxicology tests included insufficient education and training about how to interpret and implement tests, and a lack of clarity on how and when to act on tests that indicated misuse and/or substance use. Conclusions These data suggest that primary care clinicians’ lack of education and training to interpret and implement urine toxicology tests may impact their management of patient opioid misuse and/or substance use. Clinicians may benefit from additional education and training about the clinical implementation and use of urine toxicology tests. Additional research is needed on how primary care providers implementation and use of urine toxicology tests impacts chronic non-cancer pain management in primary care and safety net healthcare settings among patients with co-occurring chronic non-cancer pain and substance use. PMID:26682471

Comparative Effectiveness of a Technology-Facilitated Depression Care Management Model in Safety-Net Primary Care Patients With Type 2 Diabetes: 6-Month Outcomes of a Large Clinical Trial.

PubMed

Wu, Shinyi; Ell, Kathleen; Jin, Haomiao; Vidyanti, Irene; Chou, Chih-Ping; Lee, Pey-Jiuan; Gross-Schulman, Sandra; Sklaroff, Laura Myerchin; Belson, David; Nezu, Arthur M; Hay, Joel; Wang, Chien-Ju; Scheib, Geoffrey; Di Capua, Paul; Hawkins, Caitlin; Liu, Pai; Ramirez, Magaly; Wu, Brian W; Richman, Mark; Myers, Caitlin; Agustines, Davin; Dasher, Robert; Kopelowicz, Alex; Allevato, Joseph; Roybal, Mike; Ipp, Eli; Haider, Uzma; Graham, Sharon; Mahabadi, Vahid; Guterman, Jeffrey

2018-04-23

Comorbid depression is a significant challenge for safety-net primary care systems. Team-based collaborative depression care is effective, but complex system factors in safety-net organizations impede adoption and result in persistent disparities in outcomes. Diabetes-Depression Care-management Adoption Trial (DCAT) evaluated whether depression care could be significantly improved by harnessing information and communication technologies to automate routine screening and monitoring of patient symptoms and treatment adherence and allow timely communication with providers. The aim of this study was to compare 6-month outcomes of a technology-facilitated care model with a usual care model and a supported care model that involved team-based collaborative depression care for safety-net primary care adult patients with type 2 diabetes. DCAT is a translational study in collaboration with Los Angeles County Department of Health Services, the second largest safety-net care system in the United States. A comparative effectiveness study with quasi-experimental design was conducted in three groups of adult patients with type 2 diabetes to compare three delivery models: usual care, supported care, and technology-facilitated care. Six-month outcomes included depression and diabetes care measures and patient-reported outcomes. Comparative treatment effects were estimated by linear or logistic regression models that used generalized propensity scores to adjust for sampling bias inherent in the nonrandomized design. DCAT enrolled 1406 patients (484 in usual care, 480 in supported care, and 442 in technology-facilitated care), most of whom were Hispanic or Latino and female. Compared with usual care, both the supported care and technology-facilitated care groups were associated with significant reduction in depressive symptoms measured by scores on the 9-item Patient Health Questionnaire (least squares estimate, LSE: usual care=6.35, supported care=5.05, technology-facilitated care=5

Safer Systems: A NextGen Aviation Safety Strategic Goal

NASA Technical Reports Server (NTRS)

Darr, Stephen T.; Ricks, Wendell R.; Lemos, Katherine A.

2008-01-01

The Joint Planning and Development Office (JPDO), is charged by Congress with developing the concepts and plans for the Next Generation Air Transportation System (NextGen). The National Aviation Safety Strategic Plan (NASSP), developed by the Safety Working Group of the JPDO, focuses on establishing the goals, objectives, and strategies needed to realize the safety objectives of the NextGen Integrated Plan. The three goal areas of the NASSP are Safer Practices, Safer Systems, and Safer Worldwide. Safer Practices emphasizes an integrated, systematic approach to safety risk management through implementation of formalized Safety Management Systems (SMS) that incorporate safety data analysis processes, and the enhancement of methods for ensuring safety is an inherent characteristic of NextGen. Safer Systems emphasizes implementation of safety-enhancing technologies, which will improve safety for human-centered interfaces and enhance the safety of airborne and ground-based systems. Safer Worldwide encourages coordinating the adoption of the safer practices and safer systems technologies, policies and procedures worldwide, such that the maximum level of safety is achieved across air transportation system boundaries. This paper introduces the NASSP and its development, and focuses on the Safer Systems elements of the NASSP, which incorporates three objectives for NextGen systems: 1) provide risk reducing system interfaces, 2) provide safety enhancements for airborne systems, and 3) provide safety enhancements for ground-based systems. The goal of this paper is to expose avionics and air traffic management system developers to NASSP objectives and Safer Systems strategies.

A Petri Net model for distributed energy system

DOE Office of Scientific and Technical Information (OSTI.GOV)

Konopko, Joanna

2015-12-31

Electrical networks need to evolve to become more intelligent, more flexible and less costly. The smart grid is the next generation power energy, uses two-way flows of electricity and information to create a distributed automated energy delivery network. Building a comprehensive smart grid is a challenge for system protection, optimization and energy efficient. Proper modeling and analysis is needed to build an extensive distributed energy system and intelligent electricity infrastructure. In this paper, the whole model of smart grid have been proposed using Generalized Stochastic Petri Nets (GSPN). The simulation of created model is also explored. The simulation of themore » model has allowed the analysis of how close the behavior of the model is to the usage of the real smart grid.« less

Transportation systems safety hazard analysis tool (SafetyHAT) user guide (version 1.0)

DOT National Transportation Integrated Search

2014-03-24

This is a user guide for the transportation system Safety Hazard Analysis Tool (SafetyHAT) Version 1.0. SafetyHAT is a software tool that facilitates System Theoretic Process Analysis (STPA.) This user guide provides instructions on how to download, ...

Hospice Knowledge and Intentions among Latinos Using Safety-Net Clinics

PubMed Central

Selsky, Claire; Kreling, Barbara; Luta, Gheorghe; Makgoeng, Solomon B.; Gomez-Duarte, Jessika; Barbo, Andrea Gabriela A.

2012-01-01

Abstract Background Hospice use is low in Latinos but we know little about explanations for this pattern. Objective To describe factors associated with knowledge of and intention to use hospice for cancer care. Methods We conducted a Spanish-language, interviewer-administered cross-sectional survey of 331 Latino immigrants from Central and South America in safety-net clinics. Hospice intentions were measured using a hypothetical scenario. We used logistic regression and multiple imputations to test associations between cultural values, social acculturation, and other variables and knowledge and intentions. Results Only 29% knew about hospice and 35% would choose hospice care (once it was defined). Collectivist (group-focused) views (odds ratio [OR] 1.06 per 1-point increase, 95% confidence interval [CI] 1.01-1.12, p=.05), endorsing family-centric values (OR 1.03 per 1-point increase, 95% CI 1.01-1.04, p=.004), and higher education were associated with greater hospice knowledge after considering covariates. Greater social ties were also independently associated with greater knowledge, but knowledge was not related to hospice intentions. Individuals who believed in maintaining secrecy about prognosis were 19% less likely to choose hospice than those who did not endorse secrecy (OR 0.81, 95% CI 0.67-0.99, p=.038). The most socially acculturated individuals were significantly more likely to choose hospice than those with less acculturation (OR 1.19 for each 1-unit increase, 95% CI 10.6-1.34, p=.004). Conclusions Hospice knowledge may be necessary but is not sufficient to increase hospice use among immigrant Latinos. Latino social networks and organizations may provide a natural leverage point for interventions. Interventions to increase hospice use may need to consider culturally related values. PMID:22731515

Collaborative Interventions Reduce Time-to-Thrombolysis for Acute Ischemic Stroke in a Public Safety Net Hospital.

PubMed

Threlkeld, Zachary D; Kozak, Benjamin; McCoy, David; Cole, Sara; Martin, Christine; Singh, Vineeta

2017-07-01

Shorter time-to-thrombolysis in acute ischemic stroke (AIS) is associated with improved functional outcome and reduced morbidity. We evaluate the effect of several interventions to reduce time-to-thrombolysis at an urban, public safety net hospital. All patients treated with tissue plasminogen activator for AIS at our institution between 2008 and 2015 were included in a retrospective analysis of door-to-needle (DTN) time and associated factors. Between 2011 and 2014, we implemented 11 distinct interventions to reduce DTN time. Here, we assess the relative impact of each intervention on DTN time. The median DTN time pre- and postintervention decreased from 87 (interquartile range: 68-109) minutes to 49 (interquartile range: 39-63) minutes. The reduction was comprised primarily of a decrease in median time from computed tomography scan order to interpretation. The goal DTN time of 60 minutes or less was achieved in 9% (95% confidence interval: 5%-22%) of cases preintervention, compared with 70% (58%-81%) postintervention. Interventions with the greatest impact on DTN time included the implementation of a stroke group paging system, dedicated emergency department stroke pharmacists, and the development of a stroke code supply box. Multidisciplinary, collaborative interventions are associated with a significant and substantial reduction in time-to-thrombolysis. Such targeted interventions are efficient and achievable in resource-limited settings, where they are most needed. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Keys to Successful Diabetes Self-Management for Uninsured Patients: Social Support, Observational Learning, and Turning Points A Safety Net Providers’ Strategic Alliance Study

PubMed Central

Hanahan, Melissa A.; Werner, James J.; Tomsik, Phillip; Weirich, Stephen A.; Reichsman, Ann; Navracruz, Lisa; Clemons-Clark, Terri; Cella, Peggi; Terchek, Joshua; Munson, Michelle R.

2015-01-01

Objective To determine how medically uninsured patients with limited material resources successfully manage diabetes. Methods Clinicians at 5 safety net practices enrolled uninsured adult patients (N=26) with prior diagnosis of diabetes for 6 months or longer. Patients were interviewed about enabling factors, motivations, resources, and barriers. Chart reviews and clinician surveys supplemented interview data. Interview, survey, and chart review data were analyzed and findings were summarized. Results Two distinct groups of patients were investigated: 1) “successful,” defined as those with an HbA1c of ≤7% or a recent improvement of at least 2% (n=17); and 2) “unsuccessful,” defined as patients with HbA1c of ≥9% (n=9) without recent improvement. In comparison to unsuccessful patients, successful patients more often reported having friends or family with diabetes, sought information about the disease, used evidence-based self-management strategies, held an accurate perception of their own disease control, and experienced “turning point” events that motivated increased efforts in disease management. Conclusions Uninsured safety net patients who successfully managed diabetes learned from friends and family with diabetes and leveraged disease-related events into motivational turning points. It may be beneficial for clinicians to incorporate social learning and motivational enhancement into diabetes interventions to increase patients’ motivation for improved levels of self-management. PMID:21671529

Safety features of subcritical fluid fueled systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bell, C.R.

1995-10-01

Accelerator-driven transmutation technology has been under study at Los Alamos for several years for application to nuclear waste treatment, tritium production, energy generation, and recently, to the disposition of excess weapons plutonium. Studies and evaluations performed to date at Los Alamos have led to a current focus on a fluid-fuel, fission system operating in a neutron source-supported subcritical mode, using molten salt reactor technology and accelerator-driven proton-neutron spallation. In this paper, the safety features and characteristics of such systems are explored from the perspective of the fundamental nuclear safety objectives that any reactor-type system should address. This exploration is qualitativemore » in nature and uses current vintage solid-fueled reactors as a baseline for comparison. Based on the safety perspectives presented, such systems should be capable of meeting the fundamental nuclear safety objectives. In addition, they should be able to provide the safety robustness desired for advanced reactors. However, the manner in which safety objectives and robustness are achieved is very different from that associated with conventional reactors. Also, there are a number of safety design and operational challenges that will have to be addressed for the safety potential of such systems to be credible.« less

46 CFR 62.25-15 - Safety control systems.

Code of Federal Regulations, 2011 CFR

2011-10-01

....35-50. Note: Safety control systems include automatic and manual safety trip controls and automatic... engines. (e) Automatic safety trip control systems must— (1) Be provided where there is an immediate... 46 Shipping 2 2011-10-01 2011-10-01 false Safety control systems. 62.25-15 Section 62.25-15...

Approximation methods for stochastic petri nets

NASA Technical Reports Server (NTRS)

Jungnitz, Hauke Joerg

1992-01-01

Stochastic Marked Graphs are a concurrent decision free formalism provided with a powerful synchronization mechanism generalizing conventional Fork Join Queueing Networks. In some particular cases the analysis of the throughput can be done analytically. Otherwise the analysis suffers from the classical state explosion problem. Embedded in the divide and conquer paradigm, approximation techniques are introduced for the analysis of stochastic marked graphs and Macroplace/Macrotransition-nets (MPMT-nets), a new subclass introduced herein. MPMT-nets are a subclass of Petri nets that allow limited choice, concurrency and sharing of resources. The modeling power of MPMT is much larger than that of marked graphs, e.g., MPMT-nets can model manufacturing flow lines with unreliable machines and dataflow graphs where choice and synchronization occur. The basic idea leads to the notion of a cut to split the original net system into two subnets. The cuts lead to two aggregated net systems where one of the subnets is reduced to a single transition. A further reduction leads to a basic skeleton. The generalization of the idea leads to multiple cuts, where single cuts can be applied recursively leading to a hierarchical decomposition. Based on the decomposition, a response time approximation technique for the performance analysis is introduced. Also, delay equivalence, which has previously been introduced in the context of marked graphs by Woodside et al., Marie's method and flow equivalent aggregation are applied to the aggregated net systems. The experimental results show that response time approximation converges quickly and shows reasonable accuracy in most cases. The convergence of Marie's method and flow equivalent aggregation are applied to the aggregated net systems. The experimental results show that response time approximation converges quickly and shows reasonable accuracy in most cases. The convergence of Marie's is slower, but the accuracy is generally better. Delay

BioNet Digital Communications Framework

NASA Technical Reports Server (NTRS)

Gifford, Kevin; Kuzminsky, Sebastian; Williams, Shea

2010-01-01

BioNet v2 is a peer-to-peer middleware that enables digital communication devices to talk to each other. It provides a software development framework, standardized application, network-transparent device integration services, a flexible messaging model, and network communications for distributed applications. BioNet is an implementation of the Constellation Program Command, Control, Communications and Information (C3I) Interoperability specification, given in CxP 70022-01. The system architecture provides the necessary infrastructure for the integration of heterogeneous wired and wireless sensing and control devices into a unified data system with a standardized application interface, providing plug-and-play operation for hardware and software systems. BioNet v2 features a naming schema for mobility and coarse-grained localization information, data normalization within a network-transparent device driver framework, enabling of network communications to non-IP devices, and fine-grained application control of data subscription band width usage. BioNet directly integrates Disruption Tolerant Networking (DTN) as a communications technology, enabling networked communications with assets that are only intermittently connected including orbiting relay satellites and planetary rover vehicles.

Characterizing Safety-net Providers’ HPV Vaccine Recommendations to Undecided Parents: A Pilot Study

PubMed Central

Shay, L. Aubree; Street, Richard L.; Baldwin, Austin S.; Marks, Emily G.; Lee, Simon Craddock; Higashi, Robin T.; Skinner, Celette Sugg; Fuller, Sobha; Persaud, Donna; Tiro, Jasmin A.

2016-01-01

Objective Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations. Methods We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination. Results We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale. Conclusion Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction. Practice Implications Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale. PMID:27401828

System theory and safety models in Swedish, UK, Dutch and Australian road safety strategies.

PubMed

Hughes, B P; Anund, A; Falkmer, T

2015-01-01

Road safety strategies represent interventions on a complex social technical system level. An understanding of a theoretical basis and description is required for strategies to be structured and developed. Road safety strategies are described as systems, but have not been related to the theory, principles and basis by which systems have been developed and analysed. Recently, road safety strategies, which have been employed for many years in different countries, have moved to a 'vision zero', or 'safe system' style. The aim of this study was to analyse the successful Swedish, United Kingdom and Dutch road safety strategies against the older, and newer, Australian road safety strategies, with respect to their foundations in system theory and safety models. Analysis of the strategies against these foundations could indicate potential improvements. The content of four modern cases of road safety strategy was compared against each other, reviewed against scientific systems theory and reviewed against types of safety model. The strategies contained substantial similarities, but were different in terms of fundamental constructs and principles, with limited theoretical basis. The results indicate that the modern strategies do not include essential aspects of systems theory that describe relationships and interdependencies between key components. The description of these strategies as systems is therefore not well founded and deserves further development. Copyright © 2014 Elsevier Ltd. All rights reserved.

Design an optimum safety policy for personnel safety management - A system dynamic approach

NASA Astrophysics Data System (ADS)

Balaji, P.

2014-10-01

Personnel safety management (PSM) ensures that employee's work conditions are healthy and safe by various proactive and reactive approaches. Nowadays it is a complex phenomenon because of increasing dynamic nature of organisations which results in an increase of accidents. An important part of accident prevention is to understand the existing system properly and make safety strategies for that system. System dynamics modelling appears to be an appropriate methodology to explore and make strategy for PSM. Many system dynamics models of industrial systems have been built entirely for specific host firms. This thesis illustrates an alternative approach. The generic system dynamics model of Personnel safety management was developed and tested in a host firm. The model was undergone various structural, behavioural and policy tests. The utility and effectiveness of model was further explored through modelling a safety scenario. In order to create effective safety policy under resource constraint, DOE (Design of experiment) was used. DOE uses classic designs, namely, fractional factorials and central composite designs. It used to make second order regression equation which serve as an objective function. That function was optimized under budget constraint and optimum value used for safety policy which shown greatest improvement in overall PSM. The outcome of this research indicates that personnel safety management model has the capability for acting as instruction tool to improve understanding of safety management and also as an aid to policy making.

Design an optimum safety policy for personnel safety management - A system dynamic approach

DOE Office of Scientific and Technical Information (OSTI.GOV)

Balaji, P.

2014-10-06

Personnel safety management (PSM) ensures that employee's work conditions are healthy and safe by various proactive and reactive approaches. Nowadays it is a complex phenomenon because of increasing dynamic nature of organisations which results in an increase of accidents. An important part of accident prevention is to understand the existing system properly and make safety strategies for that system. System dynamics modelling appears to be an appropriate methodology to explore and make strategy for PSM. Many system dynamics models of industrial systems have been built entirely for specific host firms. This thesis illustrates an alternative approach. The generic system dynamicsmore » model of Personnel safety management was developed and tested in a host firm. The model was undergone various structural, behavioural and policy tests. The utility and effectiveness of model was further explored through modelling a safety scenario. In order to create effective safety policy under resource constraint, DOE (Design of experiment) was used. DOE uses classic designs, namely, fractional factorials and central composite designs. It used to make second order regression equation which serve as an objective function. That function was optimized under budget constraint and optimum value used for safety policy which shown greatest improvement in overall PSM. The outcome of this research indicates that personnel safety management model has the capability for acting as instruction tool to improve understanding of safety management and also as an aid to policy making.« less

Autonomous Flight Safety System

NASA Technical Reports Server (NTRS)

Simpson, James

2010-01-01

The Autonomous Flight Safety System (AFSS) is an independent self-contained subsystem mounted onboard a launch vehicle. AFSS has been developed by and is owned by the US Government. Autonomously makes flight termination/destruct decisions using configurable software-based rules implemented on redundant flight processors using data from redundant GPS/IMU navigation sensors. AFSS implements rules determined by the appropriate Range Safety officials.

System Safety in Aircraft Acquisition

DTIC Science & Technology

1984-01-01

Relationship Between JSSC and SOHP ..... .......... 6- 1 Some Similarities in the Departments’ Approaches to System Safety... RELATIONSHIP BETWEEN JSSC AND SOHP The annual JSSC sponsored by the safety centers coordinates safety activities. It was described recently as "an unchartered...developed an excellent working relationship . Re- presentatives from SOHP can and do influence tasks undertaken by JSSC. Con- versely, SOUP is the one

The relative effectiveness of managed care penetration and the healthcare safety net in reducing avoidable hospitalizations.

PubMed

Pracht, Etienne E; Orban, Barbara L; Comins, Meg M; Large, John T; Asin-Oostburg, Virginia

2011-01-01

Avoidable hospitalizations represent a key indicator for access to, and the quality of, primary care. Therefore, understanding their behavior is essential in terms of management of healthcare resources and costs. This analysis examines the affect of 2 healthcare strategies on the rate of avoidable hospitalization, managed care and the healthcare safety net. The avoidable hospitalizations definition developed by Weissman et al. (1992) was used to identify relevant inpatient episodes. A 2-stage simultaneous equations multivariate regression model with instrumental variables was used to estimate the relative influence of HMO penetration and the composition of local hospital markets on the rate of avoidable hospitalizations. Control variables in the model include healthcare supply and demand, demographic, socioeconomic, and health status characteristics. Increased market presence of public hospitals significantly reduced avoidable hospitalizations. HMO penetration did not influence the rate of avoidable hospitalizations. The results suggest that public investments in healthcare facilities and infrastructure are more effective in reducing avoidable hospitalizations. © 2011 National Association for Healthcare Quality.

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch" awards.

PubMed

Herzer, Kurt R; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A; Mark, Lynette J

2012-08-01

Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.

System safety education focused on system management

NASA Technical Reports Server (NTRS)

Grose, V. L.

1971-01-01

System safety is defined and characteristics of the system are outlined. Some of the principle characteristics include role of humans in hazard analysis, clear language for input and output, system interdependence, self containment, and parallel analysis of elements.

76 FR 14592 - Safety Management System; Withdrawal

Federal Register 2010, 2011, 2012, 2013, 2014

2011-03-17

...-06A] RIN 2120-AJ15 Safety Management System; Withdrawal AGENCY: Federal Aviation Administration (FAA... (``product/ service providers'') to develop a Safety Management System (SMS). The FAA is withdrawing the... management with a set of robust decision-making tools to use to improve safety. The FAA received 89 comments...

Database management systems for process safety.

PubMed

Early, William F

2006-03-17

Several elements of the process safety management regulation (PSM) require tracking and documentation of actions; process hazard analyses, management of change, process safety information, operating procedures, training, contractor safety programs, pre-startup safety reviews, incident investigations, emergency planning, and compliance audits. These elements can result in hundreds of actions annually that require actions. This tracking and documentation commonly is a failing identified in compliance audits, and is difficult to manage through action lists, spreadsheets, or other tools that are comfortably manipulated by plant personnel. This paper discusses the recent implementation of a database management system at a chemical plant and chronicles the improvements accomplished through the introduction of a customized system. The system as implemented modeled the normal plant workflows, and provided simple, recognizable user interfaces for ease of use.

Nuclear Safety for Space Systems

NASA Astrophysics Data System (ADS)

Offiong, Etim

2010-09-01

It is trite, albeit a truism, to say that nuclear power can provide propulsion thrust needed to launch space vehicles and also, to provide electricity for powering on-board systems, especially for missions to the Moon, Mars and other deep space missions. Nuclear Power Sources(NPSs) are known to provide more capabilities than solar power, fuel cells and conventional chemical means. The worry has always been that of safety. The earliest superpowers(US and former Soviet Union) have designed and launched several nuclear-powered systems, with some failures. Nuclear failures and accidents, however little the number, could be far-reaching geographically, and are catastrophic to humans and the environment. Building on the numerous research works on nuclear power on Earth and in space, this paper seeks to bring to bear, issues relating to safety of space systems - spacecrafts, astronauts, Earth environment and extra terrestrial habitats - in the use and application of nuclear power sources. It also introduces a new formal training course in Space Systems Safety.

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 7 2012-10-01 2012-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 7 2011-10-01 2011-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 7 2013-10-01 2013-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 7 2014-10-01 2014-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

49 CFR 659.19 - System safety program plan: contents.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false System safety program plan: contents. 659.19... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.19 System safety program plan: contents. The system safety plan shall...

Safety climate and culture: Integrating psychological and systems perspectives.

PubMed

Casey, Tristan; Griffin, Mark A; Flatau Harrison, Huw; Neal, Andrew

2017-07-01

Safety climate research has reached a mature stage of development, with a number of meta-analyses demonstrating the link between safety climate and safety outcomes. More recently, there has been interest from systems theorists in integrating the concept of safety culture and to a lesser extent, safety climate into systems-based models of organizational safety. Such models represent a theoretical and practical development of the safety climate concept by positioning climate as part of a dynamic work system in which perceptions of safety act to constrain and shape employee behavior. We propose safety climate and safety culture constitute part of the enabling capitals through which organizations build safety capability. We discuss how organizations can deploy different configurations of enabling capital to exert control over work systems and maintain safe and productive performance. We outline 4 key strategies through which organizations to reconcile the system control problems of promotion versus prevention, and stability versus flexibility. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

NASA aviation safety reporting system

NASA Technical Reports Server (NTRS)

Billings, C. E.; Lauber, J. K.; Funkhouser, H.; Lyman, E. G.; Huff, E. M.

1976-01-01

The origins and development of the NASA Aviation Safety Reporting System (ASRS) are briefly reviewed. The results of the first quarter's activity are summarized and discussed. Examples are given of bulletins describing potential air safety hazards, and the disposition of these bulletins. During the first quarter of operation, the ASRS received 1464 reports; 1407 provided data relevant to air safety. All reports are being processed for entry into the ASRS data base. During the reporting period, 130 alert bulletins describing possible problems in the aviation system were generated and disseminated. Responses were received from FAA and others regarding 108 of the alert bulletins. Action was being taken with respect to 70 of the 108 responses received. Further studies are planned of a number of areas, including human factors problems related to automation of the ground and airborne portions of the national aviation system.

Health and safety management systems: liability or asset?

PubMed

Bennett, David

2002-01-01

Health and safety management systems have a background in theory and in various interests among employers and workplace health and safety professionals. These have resulted in a number of national systems emanating from national standard-writing centres and from employers' organizations. In some cases these systems have been recognized as national standards. The contenders for an international standard have been the International Organization of Standardization (ISO) and the International Labour Organization (ILO). The quality and environmental management systems of ISO indicate what an ISO health and safety management standard would look like. The ILO Guidelines on Safety and Health Management Systems, by contrast, are stringent, specific and potentially effective in improving health and safety performance in the workplace.

Quantitative safety assessment of air traffic control systems through system control capacity

NASA Astrophysics Data System (ADS)

Guo, Jingjing

Quantitative Safety Assessments (QSA) are essential to safety benefit verification and regulations of developmental changes in safety critical systems like the Air Traffic Control (ATC) systems. Effectiveness of the assessments is particularly desirable today in the safe implementations of revolutionary ATC overhauls like NextGen and SESAR. QSA of ATC systems are however challenged by system complexity and lack of accident data. Extending from the idea "safety is a control problem" in the literature, this research proposes to assess system safety from the control perspective, through quantifying a system's "control capacity". A system's safety performance correlates to this "control capacity" in the control of "safety critical processes". To examine this idea in QSA of the ATC systems, a Control-capacity Based Safety Assessment Framework (CBSAF) is developed which includes two control capacity metrics and a procedural method. The two metrics are Probabilistic System Control-capacity (PSC) and Temporal System Control-capacity (TSC); each addresses an aspect of a system's control capacity. And the procedural method consists three general stages: I) identification of safety critical processes, II) development of system control models and III) evaluation of system control capacity. The CBSAF was tested in two case studies. The first one assesses an en-route collision avoidance scenario and compares three hypothetical configurations. The CBSAF was able to capture the uncoordinated behavior between two means of control, as was observed in a historic midair collision accident. The second case study compares CBSAF with an existing risk based QSA method in assessing the safety benefits of introducing a runway incursion alert system. Similar conclusions are reached between the two methods, while the CBSAF has the advantage of simplicity and provides a new control-based perspective and interpretation to the assessments. The case studies are intended to investigate the

49 CFR 659.15 - System safety program standard.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false System safety program standard. 659.15 Section 659... ADMINISTRATION, DEPARTMENT OF TRANSPORTATION RAIL FIXED GUIDEWAY SYSTEMS; STATE SAFETY OVERSIGHT Role of the State Oversight Agency § 659.15 System safety program standard. (a) General requirement. Each state...