The proper management of hospital/healthcare/biomedical waste has become topic of enormous concern having global implications and attention. Healthcare facilities such as hospitals, physician clinics, dental facilities, laboratories, medical research facilities, veterinary clinics, etc., produce 10 to 15 per cent infectious waste of total general waste according to World Health Organization (WHO). The waste generated in such facilities is termed as biomedical waste. The mushrooming of the healthcare industry within the milieu of the developing countries coinciding with the drift towards greater environmental consciousness, and greater accountability of both the occupier and the common bio medical waste treatment facility operator, bring the concept of reducing, recycling and reusing to the fore.

A study by Marinkovic et al. (2007) indicated that the hazardous medical waste including infectious waste, sharps, pathological waste, chemical waste, pharmacological waste and cytostatics corresponded to 14 per cent of the waste generated from healthcare services in Croatia. Similarly, the amount of infectious waste was determined as 15 to 20 per cent of healthcare waste, and in the U.S. this rate was around 15 per cent according to Lee and Hufman (1996). In a case study it was found that the major producers of hazardous waste are state hospitals with a generation rate of 57.9 per cent.

As of now the untreated infectious waste is directly sent to common bio medical waste treatment facility for incineration or final disposal. Thereby, the chance of infection during transportation, interim storage and handling is greater.

Therefore, due importance must be given to disinfection or sterilisation of infectious laboratory and bio-hazardous wastes at the point of generation, to find a better solution or appropriate technology for the proper management. However, various technologies are available in the market at a global level, in which the most commonly used technology for biomedical waste management are incineration, chemical disinfection, steam sterilisation, land disposal and inertisation. Recently, microwave technological leaps have opened new horizons for medical waste treatment and are promising an opportunity that has less burden on the environment, shorter time of treatment and are more cost effective. The aim of this study is to explore the efficacy and benefits of microwave technology in comparison to the existing available methods of bio-hazardous wastes treatment.Comparison of microwave to other waste treatment technologies

Among all the technologies, steam autoclave is a broadly used technology as an alternative to conventional incinerators. However, steam-based sterilisation has several limitations such as slow heating, penetration depth, pre-and post-treatment process, size and load limitations. Concerning operating costs, the compendium noted for autoclaves between US$0.14 and US$0.33 per kg, and for batch microwaves about US$0.13 per kg, respectively (UNEP, 2012). Other limitations of steam sterilisations like some plastic ware melts in the high heat, and sharp instruments often become dull. Moreover, many chemicals breakdown during the sterilisation process and oily substances cannot be treated because they do not mix with water. Previously it was reported that the anatomical and pathological wastes, low-level radioactive waste, organic solvents, laboratory chemicals, and chemotherapy waste should not be treated in an autoclave.

From the above mentioned four methods (i.e. thermal, chemical, irradiative and biological), the irradiation is very effective as well as rapid. The irradiation-based technologies involve ultraviolet, gamma, electron beam as well as the microwave. However, radiation sterilisation techniques do have a number of drawbacks. Capital costs are high and specialised facilities are often needed. Gamma radiation requires a nuclear reactor; E-beam/X-ray radiation is generated using electron beam accelerators. Common plastics such as polyvinyl chloride (PVC), acetyl and polytetrafluoroethylene (PTFE) are sensitive to gamma radiation, thereby limiting the use of Gamma. The high energies involved in e-beam radiation can also lead to main chain scission (breaking of the long chain backbone) and chemical cross linking of packaging polymers.

But in case of microwave irradiation such types of limitations are overruled. This technology is based on the low heat thermal process where disinfection occurs through action of dielectric heating. In this process, the changing electric field forces the molecular dipoles (such as water) to be aligned according to field, which creates rapid heat due to molecular friction. However, back and forth movement of ionic molecules in the oscillating electric field is another reason for instant heat generation and subsequent annihilation of virus, fungus, yeast, bacteria and spores. In a study, the efficacy of a batch microwave was evaluated by Dhole and his team at Sanjay Gandhi Postgraduate Institute of Medical Sciences against the NPEB/Polio-1 virus of NIBSC strain and for quantitative analysis and the viral load was determined via 50 per cent tissue culture infective dose (TCID-50), and it was found that the value of TCID-50 is zero, which means no contaminants were found after 360 seconds of microwave exposure at 100 degree C and there is no cytopathic effect (CPE), as was observed (Qualitative Analysis).

Comparison of microwave to autoclave

In conventional or surface-heating systems, such as those found in autoclaves, a composite part heats from the outside inwards: as heat energy is transferred through the part’s thickness. The process duration is determined by the rate of heat flow into the composite structure. The flow rate depends on the material’s specific heat, thermal conductivity, density and viscosity. As a result, the edges and corners of the part achieve the set point temperature before the centre does. The subject part also heats at an uneven rate, which can stress the finished product. Therefore, the temperature in an autoclave and a conventional oven must be ramped up and down slowly to minimise part stress, a factor that makes overall sterilisation difficult and awkward.

Conversely, microwave technology relies on volumetric heating. Heat energy is transferred electromagnetically and relatively evenly and quickly throughout the part and therefore, not as a thermal heat flux. This enables better process temperature control and less overall energy use and thereby resulting in shorter cure cycles. It also enables the processor to direct heat specifically toward the part to be cured, thus maximising the curing process efficiency. Surprisingly, all this sterilisation is archived more effectively with very high sterilisation quotient. In various studies conducted at the Centre for Innovation and Translational Research (CITAR), CSIR-Indian Institute of Toxicology Research, the disinfection efficacy of a portable batch microwave system was assessed against both gram-negative and gram-positive bacteria and yeast on different types of materials used in hospitals and laboratories such as linen cloth and fabrics, rice husk, corn cob (animal bedding material) and blood culture bottles and from these studies it was concluded that the log reduction efficacy of microwave is much greater than autoclave.

In case of contaminated linen, the efficacy of microwave is up to 8 log reduction, within 10-minute exposure of 2.45 GHz (Gigahertz) at 70 °C. Similarly, a 10-log reduction was achieved after the 30-minute exposure of microwave irradiation at 100 degree C for rice husk and corncob but in case of blood culture bottles the same temperature is sufficient for 10-minutes to inactivate any type of bacteria, fungi, yeast and spores. Inevitably, microwave-based sterilisation is much under 100 Celsius and thereby allowing heat sensitive materials an easy pathway with minimum application of resources.

The following table-1 summaries the comparison outcome between the autoclave and microwave from many different aspects, which any healthcare facility may take into consideration when planning for effective on-site bio-hazardous waste management.

The steam autoclave is the closest market competitor for Microwave (MATS) but the comparison of the technology platform, infrastructure requirement, environmental impact and operational cost would make Microwave of more favourable choice over steam autoclave. As shown in Figure 1, the power consumption, water consumption and cost per kilogram of waste treatment through microwave technology make it an eco-friendly and cost-effective system.

Microwave technologies are available at a global level, which negates all kinds of limitations and challenges usually for disinfection and/or sterilisation of infectious medical waste at the point of generation. Usually, in small and medium size hospitals, it is difficult to follow all the steps and guidelines for medical waste management. However, such hospitals manage the wastes through agencies or vendors to transport at incinerators. Therefore, an on-site solution for medical waste treatment with real-time monitoring is needed, to avoid any kind of security breach during interim storage in the facility and transportation of medical waste from the hospital to treatment site.

The WHO has also recommended “microwaving” as one of the alternative non-burn methods for biomedical waste management. Thus, proper segregation of hazardous and non-hazardous waste and treatment of non-hazardous waste through microwave-based disinfection/sterilisation system will help in the following ways:

1. Drastically reducing the amount of waste going for incineration and thus decreasing the institutions/user carbon footprint as pollution caused by incineration is reduced.

2. Concerning scarce natural resources with almost zero utilisation of water and electric energy.

3. Very high level of microwave sterilisation archived in 1/4th the time reduces infection load and safe disposal.

4. Low cost of installation and maintenance.

Exciting outcomes from various studies using microwave (MATS)

In further studies at CITAR, a microwave unit was shown to provide multiple logarithm reductions in both vegetative bacterial cell counts, and bacterial spore counts in laboratory-inoculated samples. From this study a 10-log disinfection efficacy of representative bacteria and fungi (in liquid cultures) was achieved via microwave (2.45 GHz) treatment at 70 degree C with a hold time of 20 min. A 6-log disinfection efficacy of representative heat resistant Bacillus subtilis spores was also achieved at 100 degree C with a hold time of 30 minutes.

On the other hand, the effective disintegration of gram-negative cell walls in municipal secondary sludge by microwave was confirmed by scanning electron microscopy and it was suggested that this technology could be an effective pre-treatment method for sludge that is dominated by gram-negative microorganisms. It was already said that due to exposure to the microwave, E. Coli and B. subtilis was entirely due to thermal energy.

For healthcare waste, scientists at the National Institute of Standards have devised a way to sterilise medical instruments and waste for hospitals in a device similar to a conventional microwave oven and termed this the “sterilisation wave of the future”. In 2007, an experiment was designed to simulate a poultry mass mortality event and generated a 7-log reduction in the microbial load of Salmonella enterica and a 5-log reduction in Bacillus atrophaeus spores. Therefore, the literature review and ongoing researches show clear evidence base that the use of microwave for the management of biomedical waste is a promising concept.

Conclusion

Ongoing research and applications of microwave technologies (MATS) have shown and proven that microwave devices are an effective tool for the inertia of biohazard waste to control the spreading of highly pathogenic microbes present in waste during the interim storage in healthcare facilities and transportation when the infectious waste is treated at the point of generation. When compared to other technologies especially autoclave, microwave MATS is likely to have similar sterilisation efficacy if not better in protecting the integrity of heat sensitive materials, has shorter processing time, and takes advantage of microwave-assisted processes requiring control of water content. In addition, it saves energy, cost and thus leads to a low carbon footprint.

In our opinion, for those healthcare facilities seeking operational excellence and sustainable resources in line with the untied nation (UN) goals and WHO initiatives in reducing infections worldwide, global warming and energy/water consumption, microwave technologies provide promising clean solutions and are becoming the leading cutting-edge solution for the biomedical waste management industry thanks to its supportive applications. References available on request.

Meeting the global demand for healthcare services presents clinicians and medical staff with a range of challenges, from securing patient data, supporting aging populations, short staffing, meeting strict targets and, unfortunately, dealing with problems when things go wrong. Patient safety is a serious global public concern. Estimates show that in high income countries, as many as one in 10 patients is harmed in some way while receiving hospital care, with nearly 50 per cent of accidents being preventable. Globally, the annual cost of medication errors has been estimated at €42 billion.

Medical errors are reported to be the third-leading cause of death after heart disease and cancer. A recent Johns Hopkins study claims that more than 250,000 deaths in the U.S. every year occur through medical errors. The World Health Organization (WHO) estimates that strategies to reduce the rate of adverse events in the European Union could help prevent more than 750,000 harm-inflicting medical errors every year, leading to over 3.2 million fewer days of hospitalisation, 260,000 fewer incidents of permanent disability, and 95,000 fewer deaths per year. As a result, it’s no surprise that calls for safer health systems and high-quality legislation on patient safety are growing.

Technology has a role to play. The right application of technology can enhance clinician communication, improve medication safety, reduce potential medical errors and improve the overall patient experience. At the heart of this digital transformation of healthcare is the use of printing technology and mobile computers to help reduce human errors and ensure data is used to its maximum benefit, and cost effectively – thanks partly to the barcode.

Reducing human errors

One of the major causes of errors in medical care is poor quality information capture. Today, European hospitals still record essential patient data in hand-written form, increasing the risk of the wrong medicine being administered to the patient. To improve this situation, scanning and printing technologies should be used to collect and print patient information accurately and swiftly, to identify and help protect the patient.

When a patient is first admitted into a hospital, details such as date of birth, case history and allergies must be captured accurately, or it can lead to problems. The ability to obtain patient information instantly is vital and any delay caused by lost documents, smudged lettering or misspelling could prove fatal. We know that around 10 per cent of blood bags are incorrectly administered due to human error. In the case of blood transfusions, using an auto ID solution with barcode tracking from printers and mobile computers could reduce the error rate to less than 1 per cent. If patient information is accurately recorded by scanners, printers and mobile computers, there is less chance of the wrong blood type being administered to the patient.

Fatigue is a very common reason for human error and technology could help eliminate this. When mobile computing is used, information on a printed drug label can be linked back to a system that will check clinical decisions against patient medical history, at the touch of a button. In this case, technology will help enhance the safety of patients and the reputation of a medical organisation.  

Using data

Better use of data capture and analysis means a better healthcare system for the future. One way to improve healthcare provision is to look at potential mistakes in patient care and to carve out a ‘lessons learned’ manual. ‘Near misses’ refer to errors in medical practice that almost happened (such as the incorrect administration of medicines) and learning from these incidents can help drive effective staff training, improving patient safety. Today, technology can drive efficiency, safety, productivity and visibility across global healthcare. There is clear evidence that technology can save money, reduce errors and help reduce litigation culture.

Today, technology can drive efficiency, safety, productivity and visibility across global healthcare.

Barcoding healthcare

Invented in 1952 and inspired by Morse code, the barcode is enhancing processes in hospitals and the pharmaceutical sector, where there is still a reliance on handwritten documents, leading to potential errors. Instead of manually documenting treatment, barcodes and scanners can be implemented along with a patient identity management solution to accurately and quickly match patients to their records, medication and treatments. This ensures mistakes are kept to a minimum, while patients receive the right care.

The benefits can also be seen across an entire healthcare facility, ensuring care teams can communicate and work together to assist multiple patients, by adopting healthcare mobility solutions. These solutions enable hospital staff to reliably communicate with each other and quickly and securely provide critical medical information. Patient data can also be collected and shared in real-time, providing access to patient vitals, diagnoses, imaging and much more. This all leads to workflow efficiency improvements and a reduction in false alarms, notifications and most importantly, fatalities.

The barcode is even being used to monitor the health of the institution itself. From physical assets like an MRI machine to the staff, it can help enhance real-time data sharing and analytics, making the facility even more efficient and effective – and safer.

References available on request.

April 2015, Beijing Airport. “Finally, my turn!” I think, as I reach the passport control desk. But my Mexican passport is met with a frown, then several gestures and some rapid Mandarin that sees me routed off to the medical office. The world has belatedly woken up to the threat of Zika virus, an outbreak that started in Brazil but rapidly spread throughout America, representing a world threat.

Every major airport deployed extensive security measures to try and prevent entry of the virus, a very visible reminder of the fact that pathogens do not respect borders. In a world where people travel all the time, coordinated efforts between countries are essential to tackle infectious diseases and simple, ‘point-of-care’ diagnostic tools are a key weapon in that fight. Within the Institute of Microbiology & Infection (IMI) at the University of Birmingham, UK, we are working with colleagues around the world to test new “hand-held” DNA sequencing instruments for the rapid identification of pathogens, allowing healthcare professionals to respond swiftly to emerging infections.

But how can an invisible organism such as a virus or bacteria cause global panic? First of all, although microscopic, these pathogenic agents are far from simple. Their genetic material is under incredibly dynamic control, integrating information from the environment in which the organism resides. Such mechanisms allow pathogens to develop new infectious strategies (e.g. colonising new hosts, or persisting within the environment), or acquire resistance to antimicrobial therapies.

In recent decades, this natural adaptability has been augmented by human irresponsibility, in particular in the prolific and often unnecessary use of antibiotics. The attraction of “trying” a safe wonder-drug antibiotic for an irritating cough frequently proves too alluring for many patients, but this comes at an often-unseen cost. Firstly, antibiotics do not kill viruses and the vast majority of coughs and colds are virally driven.

Secondly, antibiotic treatments must be taken for the entire time prescribed by the doctor. Without this, the pathogenic bacteria that are being treated may not have sufficient exposure to the antibiotic, which can lead them to survive, multiply and potentially become resistant to that antibiotic. Lastly, antibiotics typically have a broad effect, meaning that they kill all the bacteria of a given class. This class includes the pathogen but may also include other beneficial bacteria that humans carry in their gut. Many of these ‘inadvertent casualties’ carry out extremely important functions that help our health – aiding digestion, gut health or uptake of nutrients. Consequently, unnecessary antibiotic use may not be as ‘harmless’ as widely thought.

Tackling this threat needs multiple strategies. Within the IMI we have groups developing new drugs to combat resistant infections such as tuberculosis or salmonellosis. In addition, we are also exploring unique strategies to try and ‘re-use’ existing drugs for which resistance has already emerged, by blocking the mechanisms that bacteria use to become resistant in the first place.

Once evolved, antibiotic-resistant or virulent pathogens are not a major health concern if they don’t spread. However, as anyone who has travelled on rush hour public transport can attest, it is only too easy for such microbes to spread. Trains, buses and planes are full of people coughing (“Is it pneumonia…?”), sneezing (“…flu..?”) and wiping sticky hands on seats and handles (“…or something worse?”).

One of the most recent projects carried out in the IMI at the University of Birmingham has been aimed at characterising the microbial load in the carriage air from a train line that runs from London to Edinburgh in the UK. This is done by extracting the DNA of the microbes trapped in the filters of the train’s air conditioning system. The DNA is then processed to determine the presence and distribution of pathogens across the rail network, thus unveiling the implications such microbiome could have on the commuters. Using this information, the aim is to ultimately design improved infection prevention methods. As the saying goes, “prevention is better than cure”.

Mass gatherings

The challenges of pathogen spread are massively augmented when large numbers of people come together at mass gatherings such as religious celebrations, major festivals or even social gatherings such as football matches. Such events bring people from all over the world into close proximity, often sharing accommodation, food and sanitary facilities. Consequently, a novel virus from Sweden or an antibiotic-resistant bacterium from Chile can find themselves in Australia or Canada within days. The extraordinary growth of international travel means that new, faster and more accurate diagnostic tools – particularly those that harness the power of DNA analysis to identify pathogens precisely without relying on clinical symptoms – will be essential if we are to tackle these new risks before they threaten global populations.

Finally, a growing threat comes from so-called ‘nosocomial’ pathogens – infections that are acquired whilst in hospital or other healthcare settings. Hospitals represent a particular infectious challenge; antibiotics are being used all the time, staff go from room to room and across halls visiting their different patients and there are roomfuls of sick, undiagnosed people in waiting rooms. Hospitals, therefore, represent a particular environment that selects for pathogens that are resistant to antibiotics and that are more virulent compared to those pathogens out in the community. Thus, hospitals require special infectious risk management.

Klebsiella pneumoniae is one such example. This bacterium is a major cause of antibiotic resistant nosocomial infections, with mortality rates >50 per cent. In 2011, there was a K. pneumoniae outbreak in a hospital in the U.S., where one of the transmission events was from a ventilator that had been used for a single patient with K. penumoniae. This ventilator had been thoroughly cleaned after usage. However, the high degree of environmental stability of K. penumoniae allowed it to survive and infect a new host.

Without rapid and diverse new therapies, humanity faces the prospect of a bleak future without routine antibiotic treatments and where emerging pathogens can sweep around the world unimpeded within days. However, by working in close international collaboration and taking multiple, innovative approaches to treatment and prevention strategies, we may yet avoid a return to the “Dark Ages” of infectious disease.

As a former Professor and Director of the Infectious Disease Diagnostic Laboratory service for two multi-system hospitals in the U.S., I have experienced an evolutionary change in laboratory medicine, specifically Infectious Disease Diagnostic Laboratories. Over the course of several years, we have been faced with numerous threats including new or re-emerging illnesses, antimicrobial resistance, healthcare-acquired infections (HAIs), more administrative requirements, staffing shortages, and decreased reimbursement. In addition to these challenges, there has been greater emphasis on decreasing hospital length of stay, improving quality of care, patient safety and experience, and supporting antimicrobial stewardship programs (ASPs).

TeamSTEPPS programme

In 1999, the Institute of Medicine (renamed National Academy of Medicine) published To Err is Human, a real eye opener, not only for the medical community, but also for the public. The article stated most adverse events (AEs) are preventable and caused by poor communication, yet they cause thousands of lives lost and billions of dollars spent. They concluded that AEs are due to process problems. This publication really began the patient safety and team training movement that led to the development of the evidenced-based TeamSTEPPS programme in 2005 by the Department of Defense (DoD) and Agency for Healthcare, Research and Quality (AHRQ), initially used by the U.S. military and now used internationally.

TeamSTEPPS is based on the use of a 3-phase programme (i.e., Assessment, Action Plan/Training/ Implementation, and Sustainment), led by a multi-disciplinary change team (e.g., senior administrator who will have clout and resources to support and advocate for the programme, nurse/physician/lab leaders and other champions). They are responsible for mapping a process associated with AEs to identify when, where and who is involved, and then redesigning the process for a successful outcome.

A comprehensive tool-kit is provided that includes a multi-curricula of teaching materials based on the TeamSTEPPS framework, whereby change teams develop competencies in teachable-learnable skills (i.e., communication, leadership, situational awareness, and mutual support) and use communication tools to positively affect innate abilities of knowledge, attitudes, and performance. Some of the keys to a successful outcome include having an excellent team leader, team communication, and a shared mental model, i.e., all team members are on the same page. Although the TeamSTEPPS programme has commonly been used to correct problems related to direct patient care, it is amenable to being used successfully in other departments that affect patient care and quality, albeit indirectly.

Laboratory Utilization & Stewardship Team (LUST)

Laboratories are now playing an even greater role in addressing current challenges by using a value-based model and providing more timely results for improved patient care and treatment. Many laboratories have introduced automated equipment and molecular platforms for direct specimen plating and direct sample identification, respectively, MALDI-TOF for organism identification of an almost unlimited number of organisms, and next-generation sequencing of difficult to isolate or identify organisms.

Although an estimated 70 per cent of clinical decisions are based on laboratory results, close to 40 per cent of these tests are deemed unnecessary and are an over-utilisation of laboratory resources. Likewise, underutilisation of laboratory tests occurs leading to missed or delayed diagnosis, increased length of stay, and legal liability. To that point, some healthcare facilities are developing a LUST to ensure the right tests are offered, ordered and performed. This is where multi-disciplinary teams are essential. Various models for developing a LUST exist based on resources and commitments of stakeholders. For example, a stewardship team supported by the C-suite, may include a pathologist, laboratory administrator and technical staff, a cross-section of physicians and nurses, information technology representative, and ad hoc members as needed. Toolbox strategies for improved laboratory utilisation are available, e.g., discontinuing obsolete tests, improving physician order entry design by test harmonisation, and using an evidence-based approach to establish practice guidelines.

Diagnostic Management Team (DMT)

In May 2017, the World Health Organization (WHO), recognising the importance of diagnosis prior to treatment, released the first essential in vitro diagnostics list of > 100 tests to be expanded annually, to guide countries regarding appropriate test selection. Some hospitals have even developed multi-disciplinary DMTs comprised of experts covering each of the laboratory disciplines to provide guidance to physicians in selecting the appropriate tests, avoiding over- and underutilisation of tests, and interpreting complex test results.

Clinical role of multi-disciplinary teams in sepsis

Kumar et al. reported a 7.6 per cent increase in mortality with each hour of delay in providing an effective antibiotic for septic patients. One of the milestone publications on sepsis, 3rd International Consensus Definition for Sepsis and Septic Shock (Sepsis-3) – 2016 guidelines advocate for patients with hypotension and a lactate > 2 mmol/L to receive antibiotics and fluid resuscitation along with blood cultures (BCs) and rapid molecular testing within 3 hrs (the so-called 3 h bundle). In 2018, an update was published calling for a 1 h bundle. These recommendations are challenging to adhere to, especially a 1 h bundle in a busy emergency department (ED) with high patient acuity. That said, they may be achievable using a multi-disciplinary TeamSTEPP approach for immediate assessment of qSOFA criteria (altered mental status, elevated heart rate, low systolic blood pressure) and point-of-care lactate for patients presenting with signs and symptoms of sepsis.

Laboratory role of multi-disciplinary teams in sepsis

BCs are still considered the gold standard for sepsis, even with less than optimal sensitivity and turnaround to results. Many laboratories have turned to using a molecular platform for pathogen identification to speed up results once a BC turns positive, e.g., Biofire film array, Nanosphere, ePlex BCID, or Accelerate that includes susceptibilities. In contrast, the T2Biosystems has the capability of identifying the most common Candida spp. and sepsis-causing bacteria directly from whole blood in ~3-6 hrs. Circumventing the need for a positive BC provides even more timely decisions for optimal antibiotic therapy or discontinuation of therapy, supporting the goal of ASPs.

We developed a multi-disciplinary committee (D.C. Halstead, unpublished data), e.g., pharmacy, infectious disease (ID) physician, and microbiology, with the goal of decreasing time to effective or optimal therapy in septic patients using a rapid molecular platform and immediate 24/7 communication of results to a pharmD. We appreciated a statistically significant decrease in time to appropriate and optimal therapy between the pre- and post- intervention period and attributed our success to the use of a multi-disciplinary team and improved use of communication skills.

The TeamSTEPPS approach can also have a significant impact on decreasing BC contamination rates to <3 per cent per guidelines. False-positive results can have severe consequences, e.g., overuse of antibiotics, resistance and AEs and increased costs. Meta-analysis has shown team strategies to be effective, e.g., saturation training using a shared mental model, collecting blood from venipunctures, not catheters, and using sterile gloves. The next guideline from the American Society for Microbiology (ASM) in collaboration with the Centers for Disease Control and Prevention (CDC), i.e., The Laboratory Medicine Best Practice initiative, will focus on updating their 2012 BC contamination guideline.

BCs are still considered the gold standard for sepsis, even with less than optimal sensitivity and turnaround to results.

Summary

We will continue to see staff moving out of their safe silos into a multi-disciplinary workforce, greater reliance on developing basic skill competencies as advocated in the TeamSTEPPS programme for improved patient safety and quality of care, and implementation of Laboratory Stewardship and Diagnostic Management Teams for improved laboratory utilisation and test interpretations, respectively. Even though there have been many improvements in healthcare over the course of the last 10+ years, we need to be prepared for even more changes in ‘culture’ as we move into the third decade of the 21st century. Are you ready?

References available on request.

The principles of infection prevention are a systematic approach based on infectious agents, epidemiology, social science and health system strengthening. It ensures patient safety and also the safety of healthcare workers, whether in a hospital set up or in community. These are broadly divided into standard and transmission-based precautions.  

Standard precautions

It applies to all patients to minimise the transmission of infections in healthcare settings. It is essential that standard precautions are applied at all times when caring for any patient regardless of their infectious disease status.

The practices that form part of standard precautions include:

• hand hygiene
• appropriate use of personal protective equipment (PPE)
• use of aseptic technique where required
• appropriate reprocessing of reusable instruments and equipment
• safe handling and disposal of sharps and potentially infectious material
• safe handling of waste and linen
• environmental controls including cleaning and spills management

Transmission-based precautions

These are applied in addition to standard precautions for patients suspected or confirmed to be infected with specific organisms of concern and the route of transmission (airborne, droplet or contact), like isolation cubicles/ use of N95 mask respirators etc.

Public health is the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention, and detection and control of infectious diseases. Most of the infection prevention champions do the following:

• Lead and participate in clinics that aim to prevent or decrease infectious disease transmission. 
• Assess health trends and risk factors of groups to prioritise for targeted interventions.
• Provide input to programmes that monitor, anticipate, and respond to public health problems in population.
• Work with communities or specific population groups within the community.
• Participate in assessing and evaluating the healthcare needs of the public to ensure people are aware of programmes.
• Provide health education, care management, and primary care to individuals and families who are at high risk for certain infection.

All these above mentioned measures when put together as a bundle can lead to a healthier and infection free society

Steve Jobs said; “get closer than ever to your customer. So close that you tell them what they need well before they realise it themselves.” In fact, organisations build their strategic perspectives and associated metric dimensions from their consumers.

A popular perspective is the balanced scorecard (BSC) with four dimensions: financial, customer, internal processes, and learning and growth. A less common perspective is the process scorecard (PSC) with four dimensions: effectiveness, quality, efficiency, and productivity. Here, we propose a framework for organisational excellence that is based on an integrated scorecard that combines both the balanced and process perspectives.

The Meaning of Quality

Definition of quality has evolved over time, from focusing on the product and the provided service, to considering the process and the value. Currently, the most prevalent definition of quality is “customer delight”. Delighting the customer requires addressing four questions:

Who are your customers? The purpose is to profile and pareto your customer population. For hospitals, patients are the customer. They may be profiled on age, nationality, and/or payment method.

What delights your customers? The purpose is to identify those characteristics that are valued by the customer. These may include responsiveness, tangibles, reliability, empathy and cost.

How delighted are they currently? For the critical-to-customer characteristics, the organisation needs to determine how far its current performance from the target. This requires soliciting the opinion of the customers, usually through a survey method.

Why aren’t you delighting them more? The purpose is to initiate improvement projects. Depending on the answer to the previous question, a project mandate is developed with specific objective and timeline.Before we go further, we need to clarify some points associated with the customer concept. The customer is the recipient of the service. The partners assist in the delivery of the products and services. Some of the customers are internal; as is the case with the human resources or information technology departments, whose customers are internal. The customer who receives the service and the client who pays for it are not necessarily the same. For example, a patient is the customer of the hospital, and the insurance firm is the client. The needs and requirements of both must be considered separately when designing the service that may affect both. Customers are not one monolithic thing; they should be profiled and prioritised for effectiveness and value.

Metrics’ Perspectives

To delight customers, specific features and their associated metrics need to be defined. The features are typically identified from insightful reading, and in some cases anticipation, of customer requirements. This is a serious exercise that falls under the area of “Quality of Design.”

Some of the identified metrics are process-related that are reflected in the produced service or product, while others are related to the opinion of the customer that is usually captured through customer opinion surveys. Process metrics may be classified into two types; productivity that focuses on getting more outputs from the available resources, and efficiency that focuses on reducing the resources for a given output.

Productivity may be simply determined by dividing the output by the input. One example is the number of patients served per clinic, or at a micro perspective, the number of patients served for each type of sickness. On the other hand, efficiency is defined as the input divided by the output. For instance, utilization of resources, such as MRI or beds, may be measured by dividing the time used by the available time for the resource. Another important metric is the waiting time of the patient or timeliness, which is measured as the percentage of patients that are served on-time. Process compliance or Sigma level is another measure of interest. A four Sigma level process is better than a two or three Sigma level process.

Examples of customer metrics are those related to soliciting the opinion of patients in the services they’ve received. Various service dimensions such as tangibility, responsiveness, and empathy may be measured by a set of questions each, and then aggregated to compute a composite measure. Another more efficient measure is the net promoter score that measures patient loyalty.

The instance of ‘delight’ typically drives values to the organization, which are captured with financial and effectiveness metrics. Typical examples of financial metrics are net profit margin, operating expense ratio, and return on assets. Effectiveness is measured as actual output divided by planned output. Examples of effectiveness metrics may relate to growth targets such as sales and number of people served. Impact metrics also fall under the banner of effectiveness. Examples are Carbon Footprint and eradication of a certain disease.The three key factors that impact the process well-being are the technology, the management system, and the people. The latter is the one that has the highest impact and yet pauses the greatest challenge. The performance of people may be captured through learning and growth metrics. An example is the training intensity, which measures the amount of training the worker receive, and their contribution to work improvement activities and initiatives.

The balanced scorecard (BSC) consists of four perspectives; financial, customer, internal processes, and learning and growth. The process scorecard (PSC) also consists of four perspectives; effectiveness, quality, productivity, and efficiency.

An integrated scorecard (ISC) may be derived by combining the two perspectives, which will also consist of the following four perspectives:

Financial and Effectiveness.

Quality.

Productivity & Efficiency.

Learning and Growth.

It is not enough to balance metrics based on the ISC; equally important is to ensure that there is a balance between leading and lagging metrics. For example, at process sigma level, a leading indicator should resonate in the lagging indicator of higher level of patient satisfaction.

Performance Management System Framework

Using the integrated scorecard (ISC), we construct a performance measurement system framework. There are four types of strategic objectives associated with the ISC:

Grow and sustain.

Provide outstanding services and products, and delight customers.

Improve processes and resources utilization.

Develop the human capital.

Using the proposed framework, the organization may develop its set of metrics for each sector and department, and then cascade these metrics to the individual employee level. For a small size organization, the total number of metrics ranges from 150 to 200. Applying the Pareto Principle, few of these metrics, in the range of 10 to 15, are selected as Key Performance Indicators (KPIs) to be monitored at the corporate level.

Each metric must have a complete definition that includes: code, name, dimension/perspective, strategic objective, formula, unit, assumptions, frequency of measurement, accountable party, responsible party, data sources, target values, base value, standard, and levels of performance.

Conclusion

It is important that people in the organisation share a clear understanding of the meaning of quality and how it impacts the organisation performance. Here, we proposed an integrated scorecard to relate the performance in quality to other areas of performances. Then we developed a performance measurement system framework to relate the integrated scorecard to strategic objectives and set the stage for the development of metrics at the department and corporate levels.

References available on request.

With the ongoing emergence of new ground-breaking technologies including AI, telemedicine platforms and digital transformation within medicine, 2019 looks set to be another year which pushed the boundaries within healthcare.

However, while we’ve seen leaps and bounds within the healthcare offered to patients, the processes that exist for medical professionals to secure employment seem out of sync with the work that’s carried out by such individuals. The technological changes we have seen within the industry shows a workforce that is committed to advancement, however HR processes for healthcare employees still involve laborious, manual processes, which often halt the pace of professional progression.

The slow-moving pace of document verification for international healthcare and the impact that this can have on the professional migrant community has been readily documented by the World Health Organisation where it states:

“All people who plan to leave their country of origin in order to work as doctors or nurses in another country have to produce a certificate of good standing and proof of registration in their own country. This information is sometimes used to estimate the emigration potential (the number of people who plan to leave their country), but available evidence shows that there is a large gap between the intention to emigrate and actually doing so. This gap can be explained, for example, by difficulties in finding a job or in getting one’s qualification recognised in the destination country.”

Verification is of course in place to protect healthcare professionals and their patients, that we must all agree on. However, existing processes are actually hurting those that it seeks to help by being too slow, too manual and too repetitive - particularly when the availability of technology today means that they really don’t need to be.

Professional Migration Within Healthcare

The push and pull factors around skill shortages within the medical industry mean that a huge number of healthcare professionals migrate to pursue employment opportunities in other countries. As a result, healthcare employers face a huge influx of skilled medical professionals from overseas in order to cater for the demand within their regions. Add to this the fact that over 50 per cent of CVs contain misleading information and that around 4-6 per cent of applications are a result of employment fraud, and the need for fully verifying and checking each new hire becomes highly apparent.

To set the scene, consider the workforce here in the UAE. The majority of healthcare workers originate from overseas and within the population as a whole, 88.4 per cent belongs to the expat community. Of course, due to the nature of the healthcare industry, each and every employee here in the UAE must have their details and qualifications fully verified before employment can commence. This means that for every worker and every job application, medical licences, good standing certificates, accreditations and educational qualifications must be checked, confirmed and verified.

These checks are completely essential and their mandatory nature safeguards patient care and the working environment of other medical professionals. It’s without surprise that these background employment checks are a huge burden on applicants, former employees, issuing authorities such as universities and government regulators. Particularly as these checks are done with each new professional migrant, each job change, and also in the instance that verified documents expire or are misplaced.

The manual, analogue processes that are involved in document verification seem somewhat archaic in comparison to the leaps and bounds seen within the medical industry itself; that is, until now.

The New Standard within Document Verification

TrueProfile.io is a new creation within the document verification industry, which seeks to abolish repetitive background check by using cutting-edge technology. This new technology is powered by the DataFlow Group, a familiar name within the healthcare space, as document verification has been carried out by the DataFlow Group since 2006. Since its inception, the DataFlow Group has completed over 1 million employment background checks for applicants, the majority of which originated from the healthcare industry.

The DataFlow Group saw the friction caused by the current processes for document verification and so, TrueProfile.io was born. It is an applicant and employer-centric professional platform, which places the needs of these individuals at the heart of its offering. The platform is built upon Ethereum blockchain, which remedies the need for continual background checks, while employers and employees reap the benefits of a professional platform.

How can TrueProfile.io assist professional migrants within healthcare? The process is simple: an applicant signs up on the TrueProfile.io platform as a ‘Member’, enters their details and submits the necessary documents for verification. Once these are returned with a positive verification, the documents are stored on blockchain and are now known as ‘TrueProofs’. This simply means that they have the verified stamp of approval from TrueProfile.io and can now be used as part of a job application.

TrueProofs can be housed on a professional profile, which is all part of the TrueProfile.io member offering, known as myTrueProfile. A myTrueProfile page offers the perfect opportunity for members to showcase their credentials in a positive light, while knowing that the information offered is fully verified. The information can be downloaded or shared via a link with a potential employer, in order to build instant trust.

The use of blockchain means that once verified, a members’ documents are secure, cannot be tampered with and the information is owned by them. This provides a fully portable professional profile, which can be used time and time again throughout an individual’s career.

TrueProfile.io’s document verifications can be done at any time, either during the application process or in order to expedite the professional migration timespan; they can be carried out ahead of applying.

Assisting Healthcare Providers

The other side of the coin is of course HR professionals who collectively carry out countless background checks on a continual basis. By using TrueProfile.io as part of their hiring practices, an employer becomes a TrueProfile.io ‘Business Partner’, which offers a number of benefits, most namely, complete assurance that healthcare employees are qualified for the role they will be carrying out.

In addition, time-to-hire is significantly reduced which in turn improves the efficiency of HR teams, allowing them to get on with more human-centric tasks. TrueProfile.io is quick and easy to use, while displaying all of your applicants submitted verifications in a user-friendly dashboard. This allows you to see the right, qualified and verified hires for your business, meaning that hiring decisions become a lot easier to make, with added peace of mind.

Future Prospects

We are ready to welcome employers and applicants within the healthcare sector who are keen to be part of the new standard offered by TrueProfile.io. Getting started is easy, simply visit our website and sign up as either a Business Partner or a Member. There’s no compromise on the quality or depth of background checks with TrueProfile.io - they still remain as thorough as ever. Instead, its new technology means that the final hurdle in recruiting and placing essential healthcare staff across borders simply ceases to exist.