Implementing performance improvement through the enterprise culture

The purpose of this article is to evaluate performance improvements made through a case study of a rural English hospital’s emergency department within the framework of the enterprise culture—the NHS adoption of the private sector’s performance improvement best practice. Additionally, the process of the research and the significant barriers encountered are documented to inform future researchers of potential drawbacks when considering this type of research. An intervention addressing local performance issues was defined by medical consultants. A pathway to care for emergency care patients requiring clinical observation for more than four hours—but not admission as a hospital inpatient—was created. The efficacy of the intervention was evaluated by measuring compliance to the pathway standards and conducting an ethnographic study and semi-structured interviews. Structural barriers to research caused by lack of staff availability were encountered. Additionally, although improvement from the intervention was encouraging, the ability of the people within the system to consistently enact the process caused performance issues against expected targets

Explicit feedback from users attenuates memory biases in human-system dialogue

In human–human dialogue, the way in which a piece of information is added to the partners’ common ground (i.e., presented and accepted) constitutes an important determinant of subsequent dialogue memory. The aim of this study was to determine whether this is also the case in human-system dialogue. An experiment was conducted in which naïve participants and a simulated dialogue system took turns to present references to various landmarks featured on a list. The kind of feedback used to accept these references (verbatim repetition vs. implicit acceptance) was manipulated. The participants then performed a recognition test during which they attempted to identify the references mentioned previously. Self-presented references were recognised better than references presented by the system; however, such presentation bias was attenuated when the initial presentation of these references was followed by verbatim repetition. Implications for the design of automated dialogue systems are discussed

Investigating medical handover practice: a process evaluation of a new initiative from an acute setting

Aims: To independently evaluate and assess the potential benefits and drawbacks of an innovative approach to the delivery of morning medical handover, in an acute medical emergency assessment unit (EAU). Methods: A survey was conducted with junior and middle-grade doctors attending the handover (N = 14). Three focus groups, with middle-grade doctors (n = 5), junior doctors (n = 11) and senior nurses (n = 3), were conducted to gain further insights into the views and experiences of attendees. Interviews with two medical consultants and two directors of postgraduate medical education were conducted to gain insight into the strategic training and management perspective. Focus groups and interviews were recorded, transcribed, and analysed using thematic analysis. The timeframe was May–August 2014. Results: Quantitative survey data were analysed using SPSS, generating descriptive frequencies. 79% of respondents preferred to discuss safety incidents verbally, 79% found it helpful to learn about clinical guidelines and 50% regarded the process as too long on most days. Qualitative findings revealed that the handover was regarded as a crucial process for prioritising and managing patients and communicating critical information across a multidisciplinary team. Including a nursing perspective was consistently viewed as particularly beneficial, owing to nurses’ detailed overview of patients within the unit. Discussing audit results, care bundles and clinical reminders was viewed as well placed, owing to their concise nature. However, the danger of detracting from the clinical handover by incorporating education and a lack of a consistent clear focus was highlighted. Detailed patient presentations and theoretical discussions were considered to be more suitable in an alternative setting, potentially during rounds and bedside teaching. Suggestions of utilising an electronic system, separating the night team handover from an EAU morning meeting, and changing shift times were also discussed. Conclusions: The foremost principle of a handover is to ensure that there is a robust clinical handover of continuous patient care from the outgoing to the incoming team. While there is the potential to augment this process with unique educational elements, it is essential that the delivery and content are carefully managed and structured in a manner that does not detract from the primary focus of a clinical handover and compromise clinical decision making. The handover model may benefit from having a more consistent time-bound structure, allowing the team to have a clear focus on managing and directing optimal patient care, whilst providing relevant educational aspects that improve patient safety and quality of care

Leaf and stem physiological responses to summer and winter extremes of woody species across temperate ecosystems

© 2014 The Authors. Winter cold limits temperate plant performance, as does summer water stress in drought-prone ecosystems. The relative impact of seasonal extremes on plant performance has received considerable attention for individual systems. An integrated study compiling the existing literature was needed to identify overall trends. First, we conducted a meta-analysis of the impacts of summer and winter on ecophysiology for three woody plant functional types (winter deciduous angiosperms, evergreen angiosperms and conifers), including data for 210 records from 75 studies of ecosystems with and without summer drought across the temperate zone. Second, we tested predictions by conducting a case study in a drought-prone Mediterranean ecosystem subject to winter freezing. As indicators of physiological response of leaves and xylem to seasonal stress, we focused on stomatal conductance (gs), percent loss of stem xylem hydraulic conductivity (PLC) and photochemical efficiency of photosystem II (Fv/Fm). Our meta-analysis showed that in ecosystems without summer drought, gs was higher during summer than winter. By contrast, in drought-prone ecosystems many species maintained open stomata during winter, with potential strong consequences for plant carbon gain over the year. Further, PLC tended to increase and Fv/Fm to decrease from summer to winter for most functional types and ecosystems due to low temperatures. Overall, deciduous angiosperms were most sensitive to climatic stress. Leaf gas exchange and stem xylem hydraulics showed a coordinated seasonal response at ecosystems without summer drought. In our Mediterranean site subjected to winter freezing the species showed similar responses to those typically found for ecosystems without summer drought. We conclude that winter stress is most extreme for systems without summer drought and systems with summer drought and winter freezing, and less extreme for drought-prone systems without freezing. In all cases the evergreen species show less pronounced seasonal responses in both leaves and stems than deciduous species.Th is research was supported by the Spanish Ministry of Economy and Competitiveness with the grants FPI (CGL2007-66066-C04-02), Consolider Montes (CSD2008 00040) and VULGLO (CGL2010 22180 C03 03), and by the Community of Madrid grant REMEDINAL 2 (CM S2009 AMB 1783) and National Science Foundation Grant no. 0546784.Peer Reviewe

Developing and Supporting Clinical Academic Research Careers for Nurses, Midwives and Allied Health Professionals: the UK Experience

Internationally the need for the development of clinical academic careers for nurses, midwives and allied health professionals is becoming ever more apparent. Clinical academics maintain their clinical practice whilst also carrying out research, placing them in a unique position to make connections between the two fields. Integrated academic training pathways have been introduced across the UK since 2006 to combine clinical training with research experience; however, aspiring clinical academics still face a range of challenges in balancing the clinical and research aspects of their careers and there is a lack of evidence to demonstrate impact of clinical academic career pathways, post initial training. AIMS This research aimed to follow up scholars from a Pre-Masters and Pre-PhD Clinical Academic Training Programme delivered since 2013, to investigate the extent to which their training has been implemented in clinical practice and to explore the extent to which the training enabled them to move on to develop and support subsequent research activity in the clinical setting. METHODS This qualitative study followed up participants (including those who did not successfully complete) from the Health Education England: East Midlands funded Clinical Academic Careers training programme, delivered at Lincoln from 2013-2017. All previous scholars were contacted and invited to take part in an individual interview. Data were collected from May to July 2017. Ethical approval was granted by the host Higher Education Institution. 18 in-depth interviews were conducted, transcribed verbatim and thematically analysed. RESULTS The results of the study will be presented at the conference. Key barriers and facilitators to accessing and sustaining, both initial research training and on-going implementation have been identified. DISCUSSION This research highlights the importance of clinical academic training programmes in developing and supporting an environment conducing to research in the clinical healthcare setting. CONCLUSION There is a need for on-going work to support both clinical academic scholars and also manages working in the healthcare setting, to overcome some of the practical and financial barriers to the development of clinical academics

Enterprise improvements in emergency care systems

Introduction English health policy is written with an aim to recreate in health care services the quality and efficiency improvements successfully used by enterprise organisations. The aim of this paper is to examine whether policy has resulted in a framework that will achieve such improvements in the Emergency Department of a rural English hospital. Methods A mixed method approach is applied through a single site case study. Results The research uncovered a lack of defined processes and competent actors, rigid departmental barriers and reactionary decisions leading to poor performance against a policy target designed for Emergency Departments. Also, in an improvement intervention to meet local needs, pressure from the policy target and the competence of people enacting the process failed to support its continued efficacy. Discussion and conclusion Policy has not provided a framework for improvement that replicates enterprise success. Capacity and demand planning should be considered within the emergency care system and lead to robust processes run by competent people

The Invisible Hand in Clinical Research: The Study Coordinator's Critical Role in Human Subjects Protection

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74962/1/j.1748-720X.2002.tb00410.x.pd

“Is there anything else you would like to tell us?” – A thematic analysis of free-text comments from a self-management questionnaire with people affected by cancer

Background: Researchers are frequently using open-ended questions at the end of questionnaires that invite respondents to add, in their own words, further information about issues covered in the questionnaire. The aim of this study was to present the qualitative findings from the further information section at the end of a questionnaire that was designed to collect data on aspects of self-management in people affected by cancer. Methods: Respondents were asked: ‘Thinking about how you manage your health and health care, if there is anything else you would like to tell us about your experience, please write in the box below.’ Free-text responses were analysed thematically. Results: 128 participants completed the free-text response at the end of the questionnaire. The main overarching theme was the concept of the participants “moving on” from cancer and developing a meaningful life for themselves following diagnosis and treatment. For most, this incorporated making adjustments to their physical, social, psychological, spiritual and emotional wellbeing. “Luck” was another overwhelming theme where many participants stated they were “glad to still be alive” and “consider myself very lucky.” Participants reported adjustments made to health behaviours such as leading an active lifestyle and making changes to their diet and nutrition. The final theme incorporates the participants identifying their main sources of support, both clinical and non-clinical, some of which they stated “could not have done it without them.” Conclusions: The findings highlight the valuable insight that free-text comments can add as a data source at the end of self-completion questionnaires with people affected by cancer

An Exploration of Rural–Urban Residence on Self-Reported Health Status with UK Cancer Survivors Following Treatment: A Brief Report

Objective: To explore the effect of rural–urban residence on the self-reported health status of UK cancer survivors following primary treatment. Design: A post-positivist approach utilizing a cross-sectional survey that collected data on demographics, postcode and self-reported health status. Methods: An independent samples t test was used to detect differences in health status between rural and urban respondents. Pearson’s χ2 was used to control for confounding variables and a multivariate analysis was conducted using Stepwise linear regression. Setting: East Midlands of England. Participants: Adult cancer survivors who had undergone primary treatment in the last five years. Participants were excluded if they had recurrence or metastatic spread, started active oncology treatment in the last twelve months, and/or were in receipt of palliative or end-of-life care. Main outcome: Residence was measured using the UK Office for National Statistics (ONS) RUC2011 Rural–Urban Classifications and Health Status via the UK ONS self-reported health status measure. Ethics: The study was reviewed and approved (Ref: 17/WS/0054) by an NHS Research Ethics Committee and the Health Research Authority (HRA) prior to recruitment and data collection taking place. Results: 227 respondents returned a questionnaire (response rate 27%). Forty-five percent (n = 103) were resident in a rural area and fifty-three percent (n = 120) in an urban area. Rural (4.11 ± 0.85) respondents had significantly (p < 0.001) higher self-reported health statuses compared to urban (3.65 ± 0.93) respondents (MD 0.47; 95% CI 0.23, 0.70). Conclusion: It is hoped that the results will stimulate further work in this area and that researchers will be encouraged to collect data on rural–urban residency where appropriate

La otra ribera

En Arequipa, ciudad ubicada al sur peruano, aproximadamente a finales de la segunda década del siglo XX, Manuel Jesús Glave y Victor Alcázar decidieron dejar el Estudio de Arte Vargas Hnos., donde aprendieron la práctica fotográfica y trabajaron durante años, para abrir su propio estudio