UK community health visiting: challenges faced during lean implementation

This paper presents an overview of the challenges and potential of lean implementation for the health visiting service in England and examines the rhetoric and the reality of the situation. It is coauthored by academic researchers and senior service providers so as to embrace the multidimensional issues impacting on this subject. If lean thinking is to be implemented in relation to health visiting, it is important to understand how it is likely to be viewed by practitioners and line managers in settings where it is used. In order to contextualize the discussion, an introduction to the roles, systems, and structures of health visiting are provided. The literature on what lean implementation is, what it means, and in particular the application and potential of the approach to primary care and public health services is reviewed. The process and findings from a focus group convened within a large primary care organization in the National Health Service during their lean implementation is reported. The paper concludes that it is important for staff at all levels to see a clear link between strategic aims and objectives and the planning processes operated by providers and commissioners. It appears that the successful introduction of lean thinking should focus more on productive working and thereby reducing waste. This has the potential to refresh workforce models to ensure that health visiting and other practitioners liberate the use of their specialist knowledge and skills. In a context of enhanced partnership working, the stage is then set for providers to add value to the whole system and together improve service user outcomes

Measurement of left ventricular function in anaesthetised horses using transoesophageal doppler echocardiography

Studies were undertaken using transesophageal Doppler echocardiography to monitor left ventricular systolic function in anaesthetised horses. A 3.5 MHz transoesophageal probe was specifically developed in collaboration with Vingmed Sound for equine use. The indices of systolic function investigated were maximum acceleration of aortic blood flow (dv/dt^J, maximum blood flow velocity, (V^J, cardiac output (CO), left ventricular pre-ejection period (PEP) and left ventricular ejection time (ET).The feasibility of the technique was demonstrated in a group of 8 healthy Thoroughbred horses anaesthetised using a standard protocol. It was established that two dimensional transoesophageal echocardiography provided a reference view of the left ventricular outflow tract and aorta that consistently allowed high quality Doppler echocardiographic measurement of aortic blood flow velocity. The flow envelopes obtained were suitable for measurement of indices of left ventricular systolic function. The repeatability of the measured indices was similar to that of the maximum rate of rise of left ventricular pressure (LVdp/dtmax), obtained simultaneously by cardiac catheterisation.Cardiac output estimations made using transoesophageal Doppler echocardiography were compared with those obtained by thermodilution in the same group of horses under general anaesthesia. Cardiac output was altered by infusions of the sympathomimetic amine, dobutamine. Aortic velocity spectra obtained both by high pulse repetition frequency and continuous wave insonation modes were used to obtain the velocity time integral for calculation of cardiac output. The measurements derived from transoesophageal echocardiography agreed well with those obtained by thermodilution. Both correlation coefficients and limits of agreement between the two techniques were better than those obtained from similar studies in standing horses using transthoracic echocardiography.The sensitivity of the Doppler derived indices of left ventricular function to inotropic intervention was assessed in the final sequence of studies. As these indices are derived during the ejection period they are load dependent, so their response to changes in ventricular loading was also assessed and compared with the most commonly used index of myocardial contractility in horses, LVdp/dtmax. Three drugs were administered to the anaesthetised horses in a randomised sequence during three separate anaesthetic episodes. The drugs, dobutamine, dopamine and dopexamine were selected because of their relatively different effects on afterload, preload and contractility. Maximum acceleration of aortic blood flow was as sensitive to the changes in ventricular performance as LVdp/dtmax. Maximum aortic blood velocity showed the same qualitative response to infusion of the drugs but the changes were quantitatively less than in dv/dtmax and LVdp/dtmax. The systolic time intervals, PEP and ET, were also responsive to drug infusion; pre-ejection period shortened with each drug, whilst ET increased after dopamine and dopexamine, but was reduced by dobutamine.These studies have shown that dv/dtmax is as sensitive as the invasive index LVdp/dtmax for detecting changes in left ventricular performance. In addition dv/dtmax and Vmax appear to be no more affected by changes in ventricular loading conditions than the isovolumic index LVdp/dtmax. It is concluded that transoesophageal Doppler echocardiography provides a minimally invasive technique for assessment of left ventricular systolic function in anaesthetised horses

RE-ASSESSING THE IMPORTANCE OF NECESSARY OR SUFFICIENT CONDITIONS OF CRITICAL SUCCESS FACTORS IN IT PROJECT SUCCESS: A FUZZY SETTHEORETIC APPROACH

Despite more than fifty years of intensive effort, the issue of IT project failure remains unresolved. It has been suggested that conventional approaches may be misdirecting project management effort and moreover research shows top management support to be of critical importance (e.g. Young and Jordan 2008; Tichy and Bascom 2008). However, existing empirical evidence may have a strong reliance on selective exemplary cases of top management support and they do not account for counterexamples and counterfactuals. This paper lays the foundation for further research to resolve this issue by reassessing the original research using a more systematic approach: fuzzy-set analysis. The main contribution of the paper is methodological. In overcoming the numerical limitation of multiple case study research it provides a standard approach to compare large numbers of case studies. Researchers and practitioners are provided with an approach to compare and reconcile diverse project experiences and unambiguously determine the critical success factors that are the most important for project success

What are the ‘active ingredients’ of interventions targeting the public's engagement with antimicrobial resistance and how might they work?

Objectives. Changing public awareness of antimicrobial resistance (AMR) represents a global public health priority. A systematic review of interventions that targeted public AMR awareness and associated behaviour was previously conducted. Here, we focus on identifying the active content of these interventions and explore potential mechanisms of action. Methods. The project took a novel approach to intervention mapping utilizing the following steps: (1) an exploration of explicit and tacit theory and theoretical constructs within the interventions using the Theoretical Domains Framework (TDFv2), (2) retrospective coding of behaviour change techniques (BCTs) using the BCT Taxonomy v1, and (3) an investigation of coherent links between the TDF domains and BCTs across the interventions. Results. Of 20 studies included, only four reported an explicit theoretical basis to their intervention. However, TDF analysis revealed that nine of the 14 TDF domains were utilized, most commonly ‘Knowledge’ and ‘Environmental context and resources’. The BCT analysis showed that all interventions contained at least one BCT, and 14 of 93 (15%) BCTs were coded, most commonly ‘Information about health consequences’, ‘Credible source’, and ‘Instruction on how to perform the behaviour’. Conclusions. We identified nine relevant TDF domains and 14 BCTs used in these interventions. Only 15% of BCTs have been applied in AMR interventions thus providing a clear opportunity for the development of novel interventions in this context. This methodological approach provides a useful way of retrospectively mapping theoretical constructs and BCTs when reviewing studies that provide limited information on theory and intervention content

From Soldier to Student II: Assessing Campus Programs for Veterans and Service Members

The United States is in the process of bringing more than 2 million service members home from Iraq and Afghanistan and reducing the size of America's military. Today's veterans are the beneficiaries of the Post-9/11 GI Bill, which has provided unprecedented financial support for attending college. More than 500,000 veterans and their families have utilized Post-9/11 GI Bill benefits since the law's enactment in 2008. Many returning veterans -- as well as service members in the active and reserve components of the armed forces -- will enroll in higher education to enhance their job prospects, achieve career goals, expand their knowledge and skill sets for both personal and career enrichment, and facilitate their transition to civilian life.How well prepared is higher education to serve these new students, and what changes has it made in response to the first wave of Post-9/11 GI Bill recipients on campus? Despite the long history of veterans' education benefits and presence of veteran students on campus, current research is still catching up to the veteran and military student population. This report represents the second assessment of the current state of programs and services for veterans and service members on campuses across the nation, based on survey results from 690 institutions