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3 A Pilot Study Using the KPIs for ``Management of Oral Function´´

3 A Pilot Study Using the KPIs for ``Management of Oral Function´´

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A System Promoting Cooperation Between Medicine and Dentistry Using Key. . .



185



Fig. 3 Importanceperformance analysis for

the certified nurses (n ¼ 21)



Table 2 Oral function management items

Code

A1

IT

O1

O2

O3

O4

O5

A2

A3

A4

O6

A5



Job items of oral management for nursing

I asses the patient’s oral cavity

As indirect training, I train patient on oral function

I help patients and their families understand the need for oral care

For oral care, I massage the oral mucosa with a sponge brush

I confirm the independence of oral care

For oral care, I assist the patient with denture cleaning

For oral care, I assist the patient with tooth brushing

I conduct physical assessments of the cranial nerve system

I confirm the functioning of patients’ dentures during mealtimes

I understand the problems related to feeding, such as in cases of higher

brain function disability

I confirm oral care according to the ADL

While assessing inflammation, malnutrition, and dehydration, I write the

individual plan for the patient



I

5.00

5.00

5.00

4.95

4.95

4.90

4.90

4.90

4.86

4.86



P

4.62

4.48

4.00

4.67

4.48

4.71

4.52

3.90

4.52

4.00



4.81

4.81



4.33

4.00



(a) I importance, P performance

(b) O oral care, IT indirect training, A assessment

(c) Means above 4.79 on the Importance scale and above 3.89 on the Performance scale in 77 items

are shown in the table

(d) A 5-point Likert-type scale was used



attention (Table 3). In Fig. 5, the dentists include two attributes in this quadrant: “I

conduct physical assessments of the cranial nerve system (A2),” and “As indirect

training, I train patient on oral function (IT).” Nurses identified four attributes in the

Keep up the Good Work quadrant, which could be considered primary oral care.

From the dentists’ point of view, 5 attributes are included in this quadrant.



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S. Nagaosa et al.



Fig. 4 Importanceperformance analysis for

managerial nurses (n ¼ 5)



Fig. 5 Importanceperformance analysis for

hospital dentists (n ¼ 5)



Table 3 lists the aggregate importance and performance values of each attribute

with the difference between the two for nurses and dentists. All the importance

scores are higher than the performance scores. It is necessary to analyze the

discrepancies between the performance and importance scores so that attributes

with greater differences will be given higher priority.

Table 4 presents the results for the difference between the nurses’ and the

dentists’ perceptions in service quality. The primary gap between the nurses’ and

the dentists’ perceptions is found for the job item “I help patients and their families

understand the need for oral care (O1).”



A System Promoting Cooperation Between Medicine and Dentistry Using Key. . .



187



Table 3 Aggregate importance and performance scores of each attribute (nurses and dentists)

Code

O1

O2

O3

O4

O5

O6

A1

A2

A3

A4

A5

IT



Nurses

Importance

5.4

6.0

5.8

6.4

6.4

6.2

6.2

5.6

5.4

5.8

5.6

5.8



Performance

4.8

4.8

5.4

6.2

6.0

5.6

5.2

4.2

4.6

4.2

4.4

4.2



Table 4 Oral management

service quality (Nurses

vs. Dentists)



3.4



Code

O1

A5

A4

IT

A2

A1

O3

O6

O2

A3

O4

O5



Difference

0.6

1.2

0.4

0.2

0.4

0.6

1.0

1.4

0.8

1.6

1.2

1.6



Nurses

4.8

4.4

4.2

4.2

4.2

5.2

5.4

5.6

4.8

4.6

6.2

6.0



Dentists

Importance

6.8

5.2

6.6

5.2

5.2

6.0

6.8

6.0

5.0

6.2

6.4

6.0



Dentists

6.0

5.4

4.8

4.4

4.4

5.4

5.6

5.2

4.0

3.6

4.6

4.2



Performance

6.0

4.0

5.6

4.6

4.2

5.2

5.4

4.4

3.6

4.8

5.4

4.4



Difference

0.8

1.2

1.0

0.6

1.0

0.8

1.4

1.6

2.4

1.4

1.2

1.6



Gap

À1.2

À1.0

À0.6

À0.2

À0.2

À0.2

À0.2

0.2

0.8

1.0

1.6

1.8



Ranking

1

2

3

4

4

4

4

8

9

10

11

12



Empirical Research Conducted Using KPIs on Nurses

in an Acute Care Hospital



Completed questionnaires were collected from 12 of the 14 regular nurses; thus, the

return rate was 86 %. IPA was used to assess the acute care hospital nurses’

perceptions of attributes in the KPIs for “management of oral function.” For nurses

(Fig. 6), the averages for the pooled data were importance, 6.42, and performance,

4.15. In Fig. 6, the Concentrate Here quadrant captured two attributes: “I asses the

patient’s oral cavity (O1),” and “While assessing inflammation, malnutrition, and

dehydration, I write the individual plan for the patient (A5).” These attributes also

present a major discrepancy between importance and performance (Table 5), which

also requires special attention. Nurses identified five attributes in the Keep up the

Good Work quadrant, which could be considered primary oral care.



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Fig. 6 IPA for nurses in

acute care hospital (n ¼ 12)



Table 5 Aggregate importance and performance scores and dental intervention scores (Nurses,

n ¼ 12, Hospital dentist, n ¼ 1)

Code

O1

O2

O3

O4

O5

O6

A1

A2

A3

A4

A5

IT



Nurses

Importance

6.50

6.25

6.92

6.58

6.50

6.75

6.92

6.33

6.08

6.25

6.50

5.50



Performance

3.83

4.42

5.75

4.92

4.92

5.58

5.17

2.75

3.58

3.75

3.33

1.83



Difference

2.67

1.83

1.17

1.66

1.58

1.17

1.75

3.58

2.50

2.50

3.17

3.67



Dentist

Intervention

7

7

7

6

6

7

6

5

6

5

7

7



Table 5 lists the aggregate importance and performance values of each attribute

for nurses and dental intervention scores for hospital dentists. All the importance

scores are higher than the performance scores.

Figure 7 shows the difference between importance and performance in the IPA

matrix; the size of the grid also shows a difference.

Figure 8 shows an IPA matrix applied to dental interventions; the size of the grid

shows the intervention value.

Service quality measure factors for oral management services in nursing are

shown in Table 6.



A System Promoting Cooperation Between Medicine and Dentistry Using Key. . .



189



Fig. 7 IPA Â difference for

nurses in acute care hospital

(n ¼ 12)



Fig. 8 IPA Â dental

intervention for nurses in

acute care hospital (n ¼ 12)



Table 6 Results of IF



Code

IT

A2

A5

A3

O1

A4

O2

O4

A1

O5

O6

O3



Improving factor (IF)

À0.667

À0.566

À0.487

À0.411

À0.410

À0.400

À0.293

À0.253

À0.253

À0.244

À0.173

À0.169



(a) IF ¼ (Performance-Importance)/Importance



Ranking

1

2

3

4

5

6

7

8

8

10

11

12



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S. Nagaosa et al.



4 Discussion

The methodology used here appears to be valid and may be applied to identify

professional roles for other rehabilitation fields [1]. The implementation of the

Delphi method was a straightforward and effective tool used to create a questionnaire. IPA is a strategic tool that can quickly enable a manager to understand

“identified customer needs” and “satisfied customer needs,” and to assess performance rather than rely solely on importance indicators. Moreover, IPA allows for

the visualization of the results of a strategic analysis (see Fig. 3), which facilitates

understanding and interpretation of the results.

This study also demonstrated the validity of IPA. A new job analysis using the

Delphi method and IPA showed one way of exploring human resource management

in swallowing rehabilitation. In addition, as an evaluation tool, KPIs for swallowing

rehabilitation (35 job items) were developed.

In this study, the authors devised a system that facilitated cooperation between

medicine and dentistry (multi-occupational cooperation) by identifying and using

KPIs. As such, one of the purposes of this study was to evaluate the effectiveness of

the system. In order to facilitate multi-occupational cooperation, the KPIs for

“management of oral function” (12 job items) were created by selecting items

such as “oral care,” “assessment,” and “indirect training” from the KPIs for

swallowing rehabilitation (35 job items). A pilot study using the KPIs for “management of oral function” was conducted on managerial nurses and dentists in five

hospitals. In each of the items, both the degrees of expected importance and

performance, which had an impact on increasing satisfaction, were measured and

evaluated. Accordingly the research was empirically conducted by using these KPIs

on nurses in an acute care hospital. This study then further identified key improvement areas concerning multi-occupational cooperation by using the KPIs. Note that

the KPIs for management of oral function were based on an activity evaluation of

the service provider and the structure, process, and outcomes (SBO) classification

in the Donabedian Model (1966) [6].

The initial portion of this research was the pilot study. There are importance and

performance values of each attribute together with the difference between the two

for nurses and dentists in five hospitals. There are the differences between the

nurses’ and the dentists’ perceptions in service quality, and the primary gap between

the nurses’ and the dentists’ perceptions is found for the job item “I help patients

and their families understand the need for oral care (O1).” This means that the

expected value of the dentist side was high. The results indicated a difference of

perspective, in that dentists could not predict the behavior of nurses. Therefore IPA

for KPIs is necessary.

The subsequent research was the implementation phase of this study, conducted

in an acute care hospital. We can conclude with certainty that three methods (IPA,

Difference, and IF) are able to explain service marketing and management. This is

more visible by representing the difference by the size of the grid in the IPA. The

Concentrate Here quadrant captured two attributes; these attributes also present a



A System Promoting Cooperation Between Medicine and Dentistry Using Key. . .



191



major discrepancy between importance and performance. However, it was possible

to receive dental interventions in these attributes. Thus, this can be solved by

coordination. Similarly, it is important to receive the help of doctors and dentists

in attributes with high IF.

Acknowledgments We would like to show our greatest appreciation to Ns. Koyama who

provided carefully considered feedback and valuable comments. Special thanks also go to nurses

who were the first graduates of swallowing rehabilitation nursing certified nurse education

program whose comments made enormous contribution to our work.

This study was supported by the Research Funding for Longevity Science (25–7) from

National Center for Geriatrics and Gerontology (2014).



References

1. Nagaosa S, Yaeda J, Matsushita H, Abdul MS, Sumi Y (2013) Visualization of the role

expectation for strategy management using the Delphi method and importance-performance

analysis in dysphagia rehabilitation nursing services. In: The 1st international conference of

serviceology, Tokyo, Japan, 16–18 October, pp 217–220

2. Sumi Y, Ozawa N, Miura H, Miura H, Toba K (2011) Community coordination of dental care

needs in a home medical care support ward and at home. Jpn J Geriatr 48(4):391–396

3. Martilla J, James J (1977) Importance-performance analysis. J Mark 41(1):77–79

4. Tzeng G, Chang H (2011) Applying importance-performance analysis as a service quality

measure in food service industry. J Technol Manag Innov 6(3):106–115

5. Dalkey N, Helmer O (1963) An experimental application of the Delphi method to the use of

experts. Manag Sci 9:458–467

6. Donabedian A (1966) Evaluating the quality of medical care. Milbank Q 83(4):691–729



Designing the Amount of Image Delay

in Tele-surgery

Iwane Maida, Hisashi Sato, Tetsuya Toma, and Takashi Maeno



Abstract It has become possible enough to take telemedicine by progression of the

ICT. However, telesurgery is limited to experimental trials. This reason is that

surgeon had been disturbed perceptual motor coordination by visual delay. This

study was analyzed to understand about range of work efficiency in telesurgery with

the delay. As a result of analysis, it was suggested that pointing task has threshold of

the difficulty between 2 mm and 4 mm in diameter. The similar range in the work

efficiency was up to approximately 300 ms independent on pointing size.

Keywords Medical service • Tele-surgery • Image delay • Pointing • Perceptual

motor coordination • Cognition



1 Introduction

The medical field plays an important role in society of realizing social security.

However, many countries and regions around the world lack sufficient healthcare

services; one factor for this shortage in medical services is the regional gap, which

depends on several parameters such as the size of a country, whether the country is

made up of islands, and the number of doctors.

Tele-surgery has attracted attention as a potential solution to this problem, but it

has not been established as a common form of medical care from a global standpoint. One reason is that the image delay during tele-surgery has a strong influence

on maneuvers. Past studies have not necessarily confirmed its suitability as a

medical service. In this study, a psychophysics experiment was carried out using

a simplified model for maneuvers. The purpose of this study was to specify that the

cognition of the subject changes according to the visual delay.



I. Maida (*) • T. Toma • T. Maeno

Graduate School of System Design and Management, Keio University, Yokohama 223-0061,

Japan

e-mail: i-maida@z6.keio.jp

H. Sato

Visualware Division, Keisoku Giken Co., Ltd, Yokohama 224-0037, Japan

© Springer Japan 2016

T. Maeno et al. (eds.), Serviceology for Designing the Future,

DOI 10.1007/978-4-431-55861-3_13



193



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I. Maida et al.



2 Experimental Tele-surgery and Visual-Delay

In order to provide a fair geographical distribution of healthcare services, the

medical system must add not only remote care but also tele-surgery. Surgical robots

have seen improved operability relative to actual surgical environments. A major

factor is that surgical robots have many degrees of freedom [1]. In other words,

while a forceps used for common endoscopic surgical operation has two degrees of

freedom, surgical robots such as the da Vinci have seven degrees of freedom.

Therefore, surgical robots can faithfully reproduce the movement of the hand

during an operation [2]. Surgical robots can also perform the same movements in

abdominal operations.

The tele-surgery system has come closer to realization by the development of

surgical robots with many degrees of freedom and steady progress in information

and communication technology. In one experimental case, Marescaux

et al. successfully performed gallbladder extraction remotely with a surgical robot

in the United States from France using ZEUS [3]. This surgery had an intermediate

degree of difficulty; thus, this group showed that tele-surgery of intermediate

difficulty is possible. However, tele-surgery has not been established as a common

form of medical care from a global standpoint.

There are two factors. First, the robot and transmission device for tele-surgery

requires a transaction, and the transmission data produces an image delay on the

screen like a Fig. 1.

Therefore, the visual delay affects perceptual motor coordination. In an example

of tele-surgery between Japan and Thailand, the surgical arms controlled by the

doctor operated with a delay of 582.4 ms [4]. The transmission speed over the

communication line was 10.4 Mb/s, and the total transmission distance was

3700 km. In another example of tele-surgery between the UNIITED STATES and

France, the doctor operated remotely on a patient with a delay of 200 ms. The

surgical robots were connected by a communication line with a transmission speed

of 20 Mb/s at a distance of 6230 km. This delay can have the effect of increasing

mistakes by the operator during surgery [3].

Second, surgical operations are very different from other forms of medical

treatment. Maneuvers for external invasion have the risk of death for the patient

when an operator commits a mistake during surgery. Thus, researchers must

increase safety by quantifying the risk factors of tele-surgery.



3 Relationship Between Visual Delay and Perceptual

Motor Coordination

The arms of a surgical robot enable complicated and detailed movement with high

operational flexibility. Therefore, tele-surgery is in constant demand for minimally

invasive surgery requiring accuracy. However, a major structural problem of the



Designing the Amount of Image Delay in Tele-surgery

Fig. 1 Difference delay

generating structure

between tele- surgery and

real site surgery



195



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I. Maida et al.



tele-surgery system is the image delay due to various instrumental transactions.

This delay comprises delays in transmission and digital signal processing in cameras and monitors.

In general, communication delay is about 200 ms for a person in Japan communicating with someone in the UNIITED STATES using an international communication line. However, a tele-surgery system has a greater delay because of the data

size, compression, and prevention of freezing in the camera and monitor. In general,

a delay of 0.5 s is very short. However, the time lag caused by the delay is a major

problem when the human senses are combined.

During surgery, the operator manipulates the arms based on visual information

obtained from the eyes. In other words, the operator moves the arms based on the

time order of information from the eyes. Therefore, visual information is always

located earlier in the time order of information from each sense. By this principle,

perceptual motor coordination works based on visual information. However, during

surgery the monitor displays an operating field with a delay because of the nature of

tele-surgery. Therefore, the movement of the arm by the operator is displayed on

the monitor with a delay. This makes maneuvers very difficult and is representative

of the challenges faced in perceptual motor coordination. The difficulty caused to

humans by a visual image delay needs to be evaluated. The next section reviews the

nuisance value of the image delay for conventional perceptual motor coordination.



4 Work Efficiency of Perceptual Motor Coordination

with Delay in Previous Research

Previous studies have shown that exercises with an image delay cause a discordance

of the senses, which decreases work efficiency. Past studies have shown that the

work efficiency of subjects decreases rapidly when the delay between vision and

somatic sensations is 0–500 ms [5]. Maneuvers consist of integrating the somatic

sensations of the hand with visual information from the eyes. This delay affects the

safety of surgical maneuvers and work efficiency because it suppresses the perceptual motor coordination of the operator. In addition, the transmission delay is not

constant and has some fluctuation, and study about delay on transmission has been

progressing but the studies cannot suppress a delay enough [6, 7]. Doctors are also

restricted in terms of working hours because a wound should be closed as soon as

possible to prevent infection and increase the QOL for a patient.

In surgical procedures, the time required to perform each step can be added up to

determine the total time necessary for the entire procedure. When the surgeon is

operating remotely, a delay occurs with each step. Therefore, surgeons have been

demanding the dangerous elements of tele-surgery to be quantified experimentally.

A maneuver basically consists of incision, detachment, suturing, and ligation. In

other words, a fundamental element of a maneuver is precisely pointing the fingers

based on the sight of the surgeon. The gap between the visual information and



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