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Abstract Over the last years, pharmaceutical industries have adopted continuous improvement and operational excellence programs to optimize processes, improve quality and reduce operational costs. Worldwide, Lean Manufacturing (LM) and Six Sigma (SS), as well as the integration of the two methods: Lean Six Sigma (LSS) are the most used approaches in the continuous improvement of industries and services. This work aims to investigate the employment of the Lean Six Sigma methodology in the productive areas of pharmaceutical companies located in Brazil. Interviews were conducted with managers of pharmaceutical industries that apply the approach. The results indicated the greater use of Lean Manufacturing tools compared to Six Sigma and the influence of specific peculiarities of the pharmaceutical industry on the benefits that are achieved with the use of Lean Six Sigma. The approach is considered of great value as it provides substantial benefits to the pharmaceutical industry. It is concluded that the work corroborates to the theoretical and empirical knowledge about the methodology use in the context of Brazilian pharmaceutical industries, as well as contributes to the implementation, reformulation, and improvement of Lean Six Sigma programs in this industrial segment.

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ABSTRACT The aim of this study was to examine the influence of service quality perception on spectators' satisfaction and behavioral intentions in the Pernambuco Professional Football Championship of 2017 - Brazil. Data were collected on match days, using an adapted questionnaire, consisting of four variables. The sample was composed of spectators at the competition, divided into two moments (1st. n = 386 / 2nd. n = 620). The data were analyzed through two-step structural equation modeling in AMOS 24. After the refinement of the model, the results of the structural model [χ² (314) = 762.849 (p <.001) χ² / df = 2.42; GFI = .92; CFI = .95; RMSEA = .05] indicated that the players' performance positively influenced both satisfaction (β = .76, p <.001) and behavioral intentions (β = .33, p <.001). In turn, the crowd experience had a positive influence only on the spectators' behavioral intentions (β = .38, p <.001). It is concluded that provision of service quality, positively evaluated by the spectators, especially in relation to the aspects of the game/players, is a way for the club to satisfy them and generate positive behavioral intentions.

RESUMO O objetivo deste estudo foi examinar a influência da percepção da qualidade do serviço na satisfação e nas intenções comportamentais dos espectadores do Campeonato de Futebol Profissional de Pernambuco de 2017 - Brasil. Os dados foram coletados em dia de jogos, a partir de um questionário adaptado, composto por quatro variáveis. A amostra foi composta por espectadores da competição, dividida em dois momentos (1º. n=386 / 2º. n= 620). Os dados foram analisados através da análise de equações estruturais de duas etapas no AMOS 24. Após o refinamento do modelo, os resultados do modelo estrutural [χ² (314) = 762,849 (p < .001) χ²/df = 2,42; GFI = .92; CFI = .95; RMSEA = .05] indicaram que a performance dos jogadores influenciou positivamente tanto a satisfação (β = .76, p < .001) quanto as intenções comportamentais (β = .33, p < .001). Por sua vez, a experiência como torcedor influenciou de forma positiva unicamente as intenções comportamentais dos espectadores (β = .38, p < .001). Conclui-se que para o clube prestar um serviço de qualidade, bem avaliado por parte dos espectadores, principalmente em relação aos aspectos do jogo/jogadores é um caminho para satisfazê-los e gerar intenções comportamentais positivas.

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Background and objectives: Psoriasis (Pso) is a common skin condition characterized by a strong psychosocial impact, and is nowadays accepted as a systemic immune-mediated inflammatory disease. Diagnostic-Therapeutic Care Pathways (DTCPs) represent a predefined sequence of diagnostic, therapeutic, and assistance activities that integrate the participation of several specialists to obtain, for each patient, the correct diagnosis and thus the most appropriate therapy. A DTCP was validated in our dermatology clinic (AOU Maggiore della Carità, Novara, Italy). The validation process included the detailed elaboration of a protocol of diagnosis, staging of care, therapies, and follow-up of the patient with Pso. The formalization and adaptation of our DTCP resulted in ISO 9001: 2015 certification in May 2019. Materials and methods: This process involved several stages, including analysis of context and the identification of (i) targets, (ii) indicators, and (iii) service providers. The evaluation was based on a cohort of over 200 patients affected by moderate to severe Pso, who were treated and followed-up at our institution from September 2017 to April 2019. Results: The ISO 9001:2015 quality certification process allowed us to identify our weaknesses, i.e., the long waiting times for the first visit and the reduced physician-patient ratio, but also our strengths, such as the commitment to clinical research, effective collaboration with other specialists, the efficient use of technological and human resources, and attention to ensuring patient follow-up. Conclusions: In qualifying for and achieving the ISO Quality Management System (QMS) certification we were heartened to realize that our basic methodology and approach were fit for purpose. The implementation of the ISO QMS helped us to reorganize our priorities by placing the patient at the center of the process and raising awareness that Pso is not just a skin disease.

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AIM: This study explores the perceptions and experiences of nurse managers involved in implementing the Lean management system in a Western Canadian province. BACKGROUND: The provincial government of Saskatchewan, Canada, implemented a multimillion-dollar investment in the Lean management system to transform health care delivery by reducing waste and increasing efficiency of processes and outcomes. METHODS: This qualitative exploratory study employed semi-structured interviews with 14 nurse managers in urban and rural health regions in one Canadian province. RESULTS: Six themes outline the difficulties nurse managers experienced in juggling role responsibilities alongside a poorly implemented change system with scarce resources. CONCLUSION: The results showed tensions in the implementation of a Lean model adapted in the context of health care organisations. The expectations for nurse managers to be pivotal players in the implementation of transformative health care practices that promote and sustain strategies to reduce waste, improve coordination and increase patient safety require investment in leadership development. IMPLICATIONS FOR NURSING MANAGEMENT: Lean management systems significantly impact the roles of nurse managers who require adequate resources and training to successfully adapt. The results of this study may be used for more effective support mechanisms for nurse managers.

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This article discusses performance improvement (PI) and the various methods that PI teams can use to provide a framework for improvement. Teams that complete successful PI projects use a systematic methodology that guides them through the process in a step-by-step manner, with each step building upon the previous one using data collection methods and analytics. Personnel involved with PI projects may need to use various methodologies to achieve improvement. These tools range from Plan-Do-Study-Act cycles to more complex methods such as Six Sigma, which uses a define, measure, analyze, improve, and control process as its foundation. This article includes examples of how PI project team members can implement various methodologies and analysis tools to improve processes across the PI project continuum. After reviewing this article, the reader should have a better understanding of the systematic methodologies supporting the PI process. This is the third article of a six-part series about performance improvement.

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Introduction: In the current health care environment, the needs of the population provided the perfect opportunity for nurses to (re)define their practice and professional career. Within this framework, this study aimed thus at identifying the bases that are underlying the practice, as well as the factors that stimulate or jeopardise the quality of care and a practice that is consistent with the desired grounding. Method: Qualitative study with a phenomenological nature carried out in 19 public hospitals in mainland Portugal with the participation of 56 nurses. The tool used for collecting data was a semi-structured interview. Results: Regarding the factors that stimulate or jeopardise the quality of care a prac-tice that is consistent with the desired grounding, we could highlight features that were perfectly integrated in the triad structure, process and result. In relation to "structure", we could point out the following: organizational resources, human and material resources, service organization, nursing sustainment practices and organization of nursing care. Concerning "process", we could analyse: decision-making process, guiding principles for the professional practice, scientific methodology of health care service, health care documentation process, communication process, collaborative practice and management practice. In what concerns "result", the features were less evident in the participants' speech, and more stressed among clients and nurses. Conclusion: The explanatory approach to the grounding of the professional nursing practice, outlined in a three-dimensional perspective, makes clear the theoretical framework that grounds the practice, as well as the factors in hospital environment, that stimulate or jeopardise the quality of the nursing care

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BACKGROUND: We are witnessing an exponential increase in the number of randomized controlled trials (RCTs) reported from mainland China. The increase is particularly notable in the field of new generation antidepressants and antipsychotics. Several previous studies have raised doubts regarding their quality. However, the quality of most recent RCTs published in China may have improved. METHODS: We searched RCTs that examined new generation antidepressants and antipsychotics published between 2013 and 2016 in the China National Knowledge Infrastructure (CNKI), the largest database of scientific publications in China. We interviewed the authors of a random subset of the identified references. We assessed the methodological rigor of each study based on the published reports and telephone interviews with the authors using six methodological domains adapted from the Cochrane's risk of bias tool. RESULTS: The final sample consisted of 138 studies, for which we interviewed 58 authors; the authors of 51 studies declined the interview, and the authors of 29 studies could not be contacted. The 51 studies with refused interviews were significantly less likely to be reported from university-affiliated hospitals and were less likely to be published in Chinese core journals. Based on the published reports, most of the 58 studies were assessed to be at unclear risk of bias in most methodological domains. After the interview, only 10 studies were assessed to be at low risk of bias for sequence generation and allocation concealment. Assuming that the studies for which the authors declined interviews had an unclear risk, the proportion of RCTs at low risk of bias in both sequence generation and allocation concealment was 9.2% (10/109, 95% confidence interval [CI]: 5.0 to 16.2). The interviews indicated that the studies were at high risk of bias for most of the other domains. CONCLUSION: In general, RCTs that evaluate new generation antidepressants or antipsychotics and are indexed in the CNKI continue to be of low quality. When conducting systematic reviews and meta-analyses in this field, it would be wise to include a specialist from China as a coresearcher to help assess the risk of bias in the identified studies.

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Public reporting of healthcare metrics provides transparency that allows patients and emergency medical providers to make informed decisions about where patients should receive care. Most previous reports about public reporting of health metrics have demonstrated significant improvements in outcome metrics after implementation. However, no mechanism exists, voluntary or otherwise, for the public reporting of outcomes of stroke care. We review the components of public reporting of health outcomes data and its limited history in stroke outcomes. We summarize the literature on public reporting in cardiovascular interventions, particularly percutaneous coronary interventions, as a close corollary to mechanical neurothrombectomy. The benefits, limitations, and controversies associated with reporting of cardiovascular outcomes are reviewed with a focus on the development of risk-avoidant behaviors. This article serves as a primer for discussion of the potential benefits, limitations, and unintended consequences of public reporting of stroke data.

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BACKGROUND: Lean philosophy is used by companies to increase productivity and reduce costs. Although uncontested benefits are created, it is necessary to highlight the problems related to employees' health and welfare caused by implementing lean manufacturing projects. OBJECTIVE: The primary objective of this paper is to review the literature and identify the most relevant problems created by lean philosophy for employees. METHODS: Research about the theme was performed on many international databases over three months, and an initial sample of 77 papers was found. Twenty-seven sources were utilized. RESULTS: We identified 22 categories of problems related to health and welfare of employees. CONCLUSIONS: The most cited problem was work intensification, mentioned by thirteen papers. Increased stress and increased responsibilities, demands and, consequently, pressure on the workers are among the primary problems observed in the research.

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Informed by quality theory, this systematic literature review seeks to determine the relative importance of beef quality attributes from a consumer perspective, considering search, experience and credence quality attributes. While little change is anticipated in consumer ranking of search and experience attributes in the future, movement is expected in terms of ranking within the credence category and also in terms of the ranking of credence attributes overall. This highlights an opportunity for quality assurance schemes (QAS) to become more consumer focused through including a wider range of credence attributes. To capitalise on this opportunity, the meat industry should actively anticipate new relevant credence attributes and researchers need to develop new or better methods to measure them. This review attempts to identify the most relevant quality attributes in beef that may be considered in future iterations of QAS, to increase consumer satisfaction and, potentially, to increase returns to industry.

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Six Sigma and Lean methodologies are effective quality improvement tools in many health care settings. We applied the DMAIC methodology (define, measure, analyze, improve, control) to address deficiencies in our pediatric anesthesia supply chain. We defined supply chain problems by mapping existing processes and soliciting comments from those involved. We used daily distance walked by anesthesia technicians and number of callouts for missing supplies as measurements that we analyzed before and after implementing improvements (anesthesia cart redesign). We showed improvement in the metrics after those interventions were implemented, and those improvements were sustained and thus controlled 1 year after implementation.

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