The Well Organised Working Environment: A mixed methods study

Background: The English National Health Service Institute for Innovation and Improvement designed a series of programmes called The Productive Series. These are innovations designed to help healthcare staff reduce inefficiency and improve quality, and have been implemented in healthcare organisations in at least 14 different countries. This paper examines an implementation of the first module of the Productive Community Services programme called 'The Well Organised Working Environment'. Objective: The quantitative component aims to identify the quantitative outcomes and impact of the implementation of the Well Organised Working Environment module. The qualitative component aims to describe the contexts, mechanisms and outcomes evident during the implementation, and to consider the implication of these findings for healthcare staff, commissioners and implementation teams. Design: Mixed methods explanatory sequential design. Settings: Community Healthcare Organisation in East Anglia, England. Participants: For the quantitative data, participants were 73 staff members that completed End of Module Assessments. Data from 25 services that carried out an inventory of stock items stored were also analysed. For the qualitative element, participants were 45 staff members working in the organisation during the implementation, and four members of the Productive Community Services Implementation Team. Methods: Staff completed assessments at the end of the module implementation, and the value of items stored by clinical services was recorded. After the programme concluded, semi-structured interviews with staff and a focus group with members of the Productive Community Services implementation team were analysed using Framework Analysis employing the principles of Realist Evaluation. Results: 62.5% respondents (n = 45) to the module assessment reported an improvement in their working environment, 37.5% (n = 27) reported that their working environment stayed the same or deteriorated. The reduction of the value of items stored by services ranged from £4 to £5039 across different services. Results of the qualitative analysis suggests explanations for why the programme worked in some contexts and not others, for instance due to varying levels of management support, and varying levels of resources allocated to carrying out or sustaining the improvement work. Conclusions: Quantitative analysis of data generated during healthcare improvement initiatives can give an impression of the benefits realised, but additional qualitative analysis also provides opportunity for learning to improve future implementations. Targets set by commissioners for innovation should focus on sustaining improvement rather demonstrating one-off benefits, and implementation teams should not let their preconceptions of what will and what will not work prevent them from trying interventions that may benefit staff

The ‘Productive Community Services’ Programme: Implementing Change in a Community Healthcare Organisation

The Productive Community Services (PCS) is a change programme which aims to engage frontline healthcare staff in improving quality and productivity. PCS draws on tested improvement methodologies such as Lean, however there has been little research specifically carried out on PCS in practice. The aims of this study were to explore the perceptions of the healthcare staff that implemented the programme, to identify the enabling and constraining contexts of the programme’s mechanisms of change, and to examine the meaningfulness and reliability of quantitative data generated during a PCS implementation. It also sought to explore the implications of these findings for managers, implementation teams, and commissioners in healthcare. To achieve this, an implementation of PCS was investigated using methods of participant observation, analysis of qualitative and quantitative data, semi-structured interviews and a focus group. A mixed methods approach was taken using the principles of Realist Evaluation. The results indicate that perspectives of the implementation varied widely, and that pay-for-performance targets contributed towards staff perceiving that the programme was irrelevant. Stock value was reduced by over £42,500, the time taken to find patient information was reduced by 62%, and services spent on average 36% of their time with patients. However, these figures lacked reliability and meaningfulness as the data were not validated or were produced using apparently flawed experimental designs. Contexts that constrained or enabled the mechanisms of change included staff attitudes, available resources, the effectiveness of communication, and whether technology could be used to resolve problems identified. The findings indicate that managers in healthcare should challenge implementation teams if the purpose of an innovation is unclear, that implementation teams need to be equipped with knowledge about technological solutions to efficiency in healthcare, and Commissioners need to ensure that pay-for-performance targets promote continuous quality improvement rather than temporary solutions

Trade integration, environmental degradation, and public health in Chile: assessing the linkages

We use an empirical simulation model to examine links between trade integration, pollution, and public health in Chile. We synthesize economic, engineering, and health data to elucidate this complex relationship and support more coherent policy. Trade integration scenarios examined include Chile\u27s accession to the NAFTA, MERCOSUR, and unilateral opening to world markets. The latter scenario induces substantial worsening of pollution, partly because it facilitates access to cheaper and dirty energy, and has a significant negative effect on urban morbidity and mortality. Damages caused by rising morbidity and mortality are of similar magnitude and substantial. Emissions of small particulates, SO2, and NO2, have the strongest impact on local mortality and morbidity. These three pollutants appear to be complementary in economic activity. Unilateral trade integration combined with a tax on small particulates brings welfare gains, which are 16 per cent higher than those obtained under unilateral trade reform alone

Edema Toxin Impairs Anthracidal Phospholipase A2 Expression by Alveolar Macrophages

Bacillus anthracis, the etiological agent of anthrax, is a spore-forming Gram-positive bacterium. Infection with this pathogen results in multisystem dysfunction and death. The pathogenicity of B. anthracis is due to the production of virulence factors, including edema toxin (ET). Recently, we established the protective role of type-IIA secreted phospholipase A2 (sPLA2-IIA) against B. anthracis. A component of innate immunity produced by alveolar macrophages (AMs), sPLA2-IIA is found in human and animal bronchoalveolar lavages at sufficient levels to kill B. anthracis. However, pulmonary anthrax is almost always fatal, suggesting the potential impairment of sPLA2-IIA synthesis and/or action by B. anthracis factors. We investigated the effect of purified ET and ET-deficient B. anthracis strains on sPLA2-IIA expression in primary guinea pig AMs. We report that ET inhibits sPLA2-IIA expression in AMs at the transcriptional level via a cAMP/protein kinase A–dependent process. Moreover, we show that live B. anthracis strains expressing functional ET inhibit sPLA2-IIA expression, whereas ET-deficient strains induced this expression. This stimulatory effect, mediated partly by the cell wall peptidoglycan, can be counterbalanced by ET. We conclude that B. anthracis down-regulates sPLA2-IIA expression in AMs through a process involving ET. Our study, therefore, describes a new molecular mechanism implemented by B. anthracis to escape innate host defense. These pioneering data will provide new molecular targets for future intervention against this deathly pathogen

Effect of Childhood Trauma on Adult Depression and Neuroendocrine Function: Sex-Specific Moderation by CRH Receptor 1 Gene

Variations of the corticotropin-releasing hormone receptor 1 (CRHR1) gene appear to moderate the development of depression after childhood trauma. Depression more frequently affects women than men. We examined sex differences in the effects of the CRHR1 gene on the relationship between childhood trauma and adult depression. We recruited 1,063 subjects from the waiting rooms of a public urban hospital. Childhood trauma exposure and symptoms of depression were assessed using dimensional rating scales. Subjects were genotyped for rs110402 within the CRHR1 gene. An independent sample of 78 subjects underwent clinical assessment, genotyping, and a dexamethasone/CRH test. The age range at recruitment was 18–77 years and 18–45, for the two studies respectively. In the hospital sample, the protective effect of the rs110402 A-allele against developing depression after childhood trauma was observed in men (N = 424), but not in women (N = 635). In the second sample, the rs110402 A-allele was associated with decreased cortisol response in the dexamethasone/CRH test only in men. In A-allele carriers with childhood trauma exposure women exhibited increased cortisol response compared men; there were no sex differences in A-allele carriers without trauma exposure. This effect may, however, not be related to gender differences per se, but to differences in the type of experienced abuse between men and women. CRHR × environment interactions in the hospital sample were observed with exposure to physical, but not sexual or emotional abuse. Physical abuse was the most common type of abuse in men in this cohort, while sexual abuse was most commonly suffered by women. Our results suggest that the CRHR1 gene may only moderate the effects of specific types of childhood trauma on depression. Gender differences in environmental exposures could thus be reflected in sex-specific CRHR1 × child abuse interactions

Features of the cervicovaginal microenvironment drive cancer biomarker signatures in patients across cervical carcinogenesis

Persistent human papillomavirus (HPV) infection is the vital factor driving cervical carcinogenesis; however, other features of the local cervicovaginal microenvironment (CVM) may play a critical role in development of precancerous cervical dysplasia and progression to invasive cervical carcinoma (ICC). Here we investigated relationships between locally secreted cancer biomarkers and features of the local CVM to better understand the complex interplay between host, virus and vaginal microbiota (VMB). We enrolled women with ICC, high- and low-grade squamous intraepithelial lesions, as well as, HPV-positive and healthy HPV-negative controls. A broad range of cancer biomarkers was present in the local CVM and specifically elevated in ICC patients. The majority of cancer biomarkers were positively correlated to other biomarkers and linked to genital inflammation. Several cancer biomarkers were also negatively correlated to Lactobacillus abundance and positively correlated with abnormal vaginal pH. Finally, a hierarchical clustering analysis of cancer biomarkers and immune mediators revealed three patient clusters, which varied in levels of cancer biomarkers, genital inflammation, vaginal pH and VMB composition. Specific cancer biomarkers discriminated patients with features of the CVM, such as high genital inflammation, elevated vaginal pH and dysbiotic non-Lactobacillus-dominant VMB, that have been associated with HPV persistence, dysplasia and progression to ICC.Flinn Foundation [1974]; National Institutes of Health NIAID [1R15AI113457-01A1]; National Institutes of Health NCI [P30 CA023074]Open access journalThis item from the UA Faculty Publications collection is made available by the University of Arizona with support from the University of Arizona Libraries. If you have questions, please contact us at [email protected]

Typical support and Sanov large deviations of correlated states

Discrete stationary classical processes as well as quantum lattice states are asymptotically confined to their respective typical support, the exponential growth rate of which is given by the (maximal ergodic) entropy. In the iid case the distinguishability of typical supports can be asymptotically specified by means of the relative entropy, according to Sanov's theorem. We give an extension to the correlated case, referring to the newly introduced class of HP-states.Comment: 29 pages, no figures, references adde

West Nile Virus Surveillance, Guadeloupe, 2003–2004

We conducted extensive surveillance for West Nile virus infection in equines and chickens in Guadeloupe in 2003–2004. We showed a high seroprevalence in equines in 2003 related to biome, followed by a major decrease in virus circulation in 2004. No human or equine cases were reported during the study