Controle Local na era de responsabilidades: Um caso de estudo de pré-escola infantil (preK) em Wisconsin

The opposing principles of local control and increased standardization are a prominent tension in the United States’ education system. Since at least the early 1990s, this tension has taken shape around the accountability movement, defined by educational reforms that hold schools, teachers, and students accountable for performance on new standards, assessments, and curricula. While many scholars have examined the manifestations of the current accountability movement, few have looked at this phenomenon within the growing public preK movement. Drawing from interviews with state policymakers and district-level actors, this paper describes how the seemingly contradictory principles of local control and increased state and national standards (what we refer to simply as standardization) are shaping the policy and practice of Wisconsin’s preK system, known as 4K. We argue that rational models of policy making fail to explain the coexistence and blending of the strands of local control and standardization we found in our data, and suggest that Deborah Stone’s (2001) policy paradox provides a better theoretical framework for our findings.Los principios opuestos al control local y el aumentado de exámenes estandarizados han causado bastante tensión en el sistema de educación en los Estados Unidos. Desde el inicio del 1990, esta tensión ha tomado forma alrededor del movimiento de responsabilidad, que se distingue por las reformas educativas que tratan de asumir la responsabilidad a las escuelas, los profesores y estudiantes sobre las nuevas normas, evaluaciones y planes de estudio. Mientras muchos han examinado las manifestaciones del movimiento de la responsabilidad actual, pocos han observado este fenómeno que va creciendo dentro del movimiento preescolar (preK). Usando entrevistas con diseñadores de políticas de estado y autores a nivel del distrito, en este artículo se describe cómo aparentemente se contradicen los principios de control local y se aumentan las pólices estándares, nacionales y estatales (las que nos referimos simplemente como la estandarización) son mol-da la política y la práctica del sistema de pre-escolar (preK) de Wisconsin, conocido como "4K". Nuestro argumento es que los modelos racionales de la formulación de políticas fallan al explicar la convivencia y la mezcla de aspectos de control local y la paradoja política que encontramos en nuestros datos, sugieren que la política de Deborah Stone (2011) proporciona una mejor estructura teórico para nuestras recomendaciones.Os princípios opostos de controle local e o aumento na padronização são uma tensão proeminente no sistema de ensino dos Estados Unidos. Pelo menos desde o início dos anos 1990, essa tensão tem tomado forma em torno do movimento de responsabilidade, definido por reformas educacionais que sustentam escolas, professores, e estudantes responsáveis pelo desempenho de novos padrões, avaliações e currículos. Enquanto muitos estudiosos têm examinado as manifestações do atual movimento de responsabilização, poucos têm olhado para esse fenômeno dentro do crescimento público do movimento pré-escolar infantil (preK). Tomando de entrevistas com formuladores de políticas estatais e autores de nível distrital, este artigo descreve como princípios aparentemente contraditórios de controle local e o aumento de padrões nacionais e estatais (o que nos referimos simplesmente como padronização) estão moldando a política e a prática do sistema de pré-escola infantil (preK) de Wisconsin, conhecido como “4K”. Defendemos que os modelos racionais de formulação de políticas falham em explicar a coexistência e mistura dos fios de controle local e padronização que encontramos em nossos dados, e sugerem que o paradoxo da política de Deborah Stone (2011) proporciona uma melhor estrutura teórica para as nossas descobertas

Prediction and optimization techniques to streamline surgical scheduling

Thesis (M.B.A.)--Massachusetts Institute of Technology, Sloan School of Management; and, (S.M.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics; in conjunction with the Leaders for Global Operations Program at MIT, 2013.This electronic version was submitted and approved by the author's academic department as part of an electronic thesis pilot project. The certified thesis is available in the Institute Archives and Special Collections.Cataloged from department-submitted PDF version of thesisIncludes bibliographical references (p. 72-76).Abstract We have created a set of decision support tools to streamline the surgical case scheduling process by allowing surgical wait list cases (elective cases that cannot be assigned a slot on the operating room schedule at the time of booking) to be confirmed onto the operating room schedule up to three weeks in advance of the day of surgery. Prior to our research, wait list cases could not be confirmed more than a few days prior to the desired day of surgery due to uncertainty about available time prior to the release of dedicated OR capacity. Earlier confirmation of wait list cases serves three purposes: (1) to improve patients' ability to plan logistics to prepare for their visits, (2) to reduce wait list case backlogs for surgeons' offices, and (3) to reduce variability in the total daily caseload through proactive decision making. Our contributions assist scheduling personnel in confirming wait list case dates sooner to help medical institutions achieve these benefits. We have developed two Excel-based pieces of software: a prediction tool and a schedule optimization tool. The prediction tool predicts time that is available each day between one and three weeks in advance to accommodate wait list cases, and the schedule optimization tool automates the consolidation process for all cases that are currently booked on a future date so that rooms and equipment are used as efficiently as possible. Our platform lets users interact with simple GUIs in which they make selections to generate prediction results and optimized daily case schedules. Specifically, our prediction algorithm employs a multiple linear regression model over historical data to forecast unused time, and the optimization tool uses a mixed integer linear program to optimize the daily schedule by consolidating cases into a minimum number of rooms and closing any gaps between cases, subject to constraints that are specific to the facility and the date in question. We have achieved our desired outcome of maximizing operating room resource utilization by giving human schedulers a set of tools to use on a daily basis that simplifies the scheduling process and confirms wait list cases with more advance notice. This system is generalizable to other areas within healthcare delivery environments and any other industry where tasks are scheduled in advance into a fixed set of resources with a record of historical demand over time.by Ryan M. Graue.S.M.M.B.A

Telemedicine in diabetes foot care delivery: health care professionals’ experience

Background: Introducing new technology in health care is inevitably a challenge. More knowledge is needed to better plan future telemedicine interventions. Our aim was therefore to explore health care professionals’ experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. Methods: Our methodological strategy was Interpretive Description. Data were collected between 2014 and 2015 using focus groups (n = 10). Participants from home-based care, primary care and outpatient hospital clinics were recruited from the intervention arm of an ongoing cluster randomized controlled trial (RCT) (Clinicaltrials.gov: NCT01710774). Most were nurses (n = 29), but the sample also included one nurse assistant, podiatrists (n = 2) and physicians (n = 2). Results: The participants reported experiencing meaningful changes to their practice arising from telemedicine, especially associated with increased wound assessment knowledge and skills and improved documentation quality. They also experienced more streamlined communication between primary health care and specialist health care. Despite obstacles associated with finding the documentation process time consuming, the participants’ attitudes to telemedicine were overwhelmingly positive and their general enthusiasm for the innovation was high. Conclusions: Our findings indicate that using a telemedicine intervention enabled the participating health care professionals to approach their patients with diabetic foot ulcer with more knowledge, better wound assessment skills and heightened confidence. Furthermore, it streamlined the communication between health care levels and helped seeing the patients in a more holistic way. Keywords: telemedicine, diabetic foot ulcer, focus groups, interpretive description, health care professional

Use of patient-reported outcome measures (PROMs) in clinical diabetes consultations: Study protocol for the DiaPROM randomised controlled trial pilot study

This is the final version. Available from BMJ Publishing Group via the DOI in this record.Introduction Although diabetes distress is found to be associated with decreased glycaemic control among adults with type 1 diabetes, the psychological and emotional impact of living with the condition is often not recognised and often under-reported in diabetes care. Therefore, regular assessment of diabetes distress is recommended. Assessment of diabetes distress using patient-reported outcome measures (PROMs) in clinical practice has the potential to enhance care for people with diabetes by identifying problems and improving patient-clinician communication. In this study protocol, we describe a pilot randomised controlled trial (RCT) aiming to test the feasibility of all components of an empowerment-based intervention using PROMs as dialogue support in clinical diabetes consultations, and to address the uncertainties associated with running a fully powered evaluation study. Methods and analysis We will undertake a two-Arm pilot RCT of an intervention using the Problem Areas In Diabetes (PAID) scale in clinical diabetes consultations in order to conclude whether a fully powered trial is appropriate and/or feasible. The study will also include qualitative indepth interviews with participants and healthcare providers. Our objectives are to (1) evaluate the recruitment procedures and attrition rates; (2) evaluate the performance of the randomisation procedure; (3) evaluate the participants' mean scores on the outcome measures before and after the intervention; (4) evaluate if the intervention consultations are acceptable and feasible; and (5) explore patients' and healthcare providers' experiences with the use of PAID as dialogue support and empowerment-based communication skills in clinical diabetes consultations. The quantitative data analysis includes descriptive statistics (frequencies, percentages, means, SD and CI). For the qualitative data, we will perform thematic analysis. Ethics and dissemination Ethical approval has been obtained from the Western Norway Regional Committee for Medical and Health Research Ethics (2017/1506/REC west). We will present the findings from the study phases at national and international conferences and submit manuscripts to peer-reviewed journals and popular science journals. Trial registration number NCT03471104; Pre-results.Norwegian Nurses AssociationNorwegian Diabetes AssociationWestern Norway University of Applied Science

Electronic capturing of patient-reported outcome measures on a touchscreen computer in clinical diabetes practice (the DiaPROM trial): A feasibility study

This is the final version. Available from the publisher via the DOI in this record.The datasets generated during the current study are available from the corresponding author on reasonable request.. Background: Living with type 1 diabetes (T1D) is demanding, and emotional problems may impair ability for diabetes self-management. Thus, diabetes guidelines recommend regular assessment of such problems. Using patient-reported outcome measures (PROMs) to assess diabetes-related distress and psychological well-being is considered useful. It has been proposed that future work should examine the use of PROMs to support the care of individual patients and improve the quality of health services. To our knowledge, the use of PROMs has not been systematically evaluated in diabetes care services in Norway. Electronically captured PROMs can be directly incorporated into electronic patient records. Thus, the study fs overall aim was to examine the feasibility and acceptability of capturing PROMs electronically on a touchscreen computer in clinical diabetes practice. Methods: Adults with T1D age ≥ 40 years completed PROMs on a touchscreen computer at Haukeland University Hospital fs diabetes outpatient clinic. We included 46 items related to diabetes-related distress, self-perceived diabetes competence, awareness of hypoglycaemia, occurrence of hyperglycaemia, hypoglycaemia and fluctuating glucose levels, routines for glucose monitoring, general well-being and health-related quality of life. Participants subsequently completed a paper-based questionnaire regarding comprehension and relevance of the PROMs, acceptance of the number of items and willingness to complete electronic PROMs annually. We wrote field notes in the outpatient clinic based on observations and comments from the invited participants. Results: During spring 2017, 69 participants (50.7% men), age 40 to 74 years, were recruited. Generally, the touchscreen computer functioned well technically. Median time spent completing the PROMs was 8 min 19 s. Twenty-nine (42.0%) participants completed the PROMs without missing items, with an 81.4% average instrument completion rate. Participants reported that the PROMs were comprehensible (n = 62) and relevant (n = 46) to a large or very large degree, with an acceptable number of items (n = 51). Moreover, 54 were willing to complete PROMs annually. Participants commented that the focus on living with diabetes was valued. Conclusions: Capturing PROMs on a touchscreen computer in an outpatient clinic was technically and practically feasible. The participants found the PROMs to be relevant and acceptable with a manageable number of items, and reported willingness to complete PROMs annually

Explaining the Adjustment of Adolescents With Type 1 Diabetes: Role of diabetes-specific and psychosocial factors

OBJECTIVE - The aim of this study was to explain adjustment (diabetes-related quality of life, general well-being, and psychopathology) in adolescents with type 1 diabetes by testing the direct, mediating, and moderating effects of diabetes-specific and psychosocial factors, using an adapted version of the Disability-Stress-Coping model of Wallander and Varni. RESEARCH DESIGN AND METHODS - A total of 437 adolescents (54.5% girls; age range 11-19 years) with type 1 diabetes (mean ± SD diabetes duration 6.13 ± 3.78 years) were recruited from 25 hospitals in the Netherlands. Questionnaires were completed by the adolescents and their family members. Metabolic control was assessed by measuring A1C in all participants in one laboratory. RESULTS - Diabetes stress mediated between A1C and adjustment, after controlling for protective factors, and explained an additional 16% variance in quality of life and a 15% variance in general well-being, whereas a 19% additional variance in psychopathology was explained by both diabetes-related and general stress. No moderating effects were identified after controlling for the main effects of all risk and protective factors in the model. CONCLUSIONS - Both diabetes-related and general stress are critical predictors of the adjustment of adolescents with type 1 diabetes. Protective factors such as self-worth and social support may mediate the effects of generic stress and thus should be encouraged. Diabetes-related stress has the potential to displace the effects of protective factors and thus may play a critical role in the development of maladjustment in adolescents with type 1 diabetes. © 2009 by the American Diabetes Association

Endophthalmitis after pars plana vitrectomy: Results of the pan American collaborative retina study group

Purpose: To determine the incidence of endophthalmitis after 20-, 23-, and 25-gauge pars plana vitrectomies (PPVs). Methods: Retrospective comparative case series of consecutive patients who underwent 20-, 23-, or 25-gauge PPV at 11 centers from Latin America between 2005 to 2009. Pars plana vitrectomy cases were identified through a search of the billing records of each institution. Cases of PPV performed in the management of trauma, endophthalmitis, and combined PPV phacoemulsification cases were excluded. Endophthalmitis was diagnosed by clinical criteria regardless of the microbiologic results. The incidence of post-PPV endophthalmitis was compared between 20-, 23-, and 25-gauge PPVs. Results: A total of 35,427 cases of PPV were identified during the study period (n = 19,865 for 20 gauge, n = 10,845 for 23 gauge, and n = 4,717 for 25 gauge). The 5-year post-PPV endophthalmitis incidence rates were 0.020% (4 of 19,865), 0.028% (3 of 10,845), and 0.021% (1 of 4,717) for 20 gauge, 23 gauge, and 25 gauge, respectively (P = 0.9685). Conclusion: Small-gauge transconjunctival PPV does not appear to increase the rates of post-PPV endophthalmitis. © The Ophthalmic Communications Society, Inc

Structure of isobaric analog states in 91Nb populated by the 90Zr(a,t) reaction

Decay via proton emission of isobaric analog states (IAS's) in $^{91}{Nb}$ was studied using the $^{90}{Zr}(\alpha,t)$ reaction at $E_\alpha$=180 MeV. This study provides information about the damping mechanism of these states. Decay to the ground state and low-lying phonon states in $^{90}{Zr}$ was observed. The experimental data are compared with theoretical predictions wherein the IAS `single-particle' proton escape widths are calculated in a continuum RPA approach. The branching ratios for decay to the phonon states are explained using a simple model.Comment: 3 figures. submitted to Phys. Lett.

History of Foot Ulcer Increases Mortality Among Individuals With Diabetes: Ten-year follow-up of the Nord-Trøndelag Health Study, Norway

OBJECTIVE To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population. RESEARCH DESIGN AND METHODS This population-based study included 155 diabetic individuals with an HFU, 1,339 diabetic individuals without an HFU, and 63,632 nondiabetic individuals who were all followed for 10 years with mortality as the end point. RESULTS During the follow-up period, a total of 49.0% of diabetic individuals with an HFU died, compared with 35.2% of diabetic individuals without an HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having an HFU was associated with more than a twofold (2.29 [95% CI 1.82–2.88]) hazard risk for mortality compared with that of the nondiabetic group. In corresponding analyses comparing diabetic individuals with and without an HFU, an HFU was associated with 47% increased mortality (1.47 [1.14–1.89]). Significant covariates were older age, male sex, and current smoking. After inclusion of A1C, insulin use, microalbuminuria, cardiovascular disease, and depression scores in the model, each was significantly related to life expectancy. CONCLUSIONS AN HFU increased mortality risk among community-dwelling adults and elderly individuals with diabetes. The excess risk persisted after adjustment for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among individuals with an HFU, who may be particularly vulnerable to adverse outcomes. Hospital-based studies have shown that mortality rates in individuals with diabetic foot ulcers are about twice those observed in individuals with diabetes without foot ulcers (1,2). A diabetic foot ulcer reflects the presence of underlying pathological conditions, and the risk of recurrent ulcers is high (3,4). It has been suggested that the elevated mortality rate among individuals with diabetic foot ulcers is related to comorbid disease such as cardiovascular disease and nephropathy (5) or to psychological factors including depression (6). Although the mortality rate in individuals with diabetes is high, no large population-based studies have examined the impact on mortality of a history of foot ulcers (HFU) among individuals with diabetes. The purpose of this study was to compare mortality rates for individuals with diabetes reporting an HFU with those for individuals without an HFU and the nondiabetic population. These issues were investigated in the Nord-Trøndelag Health Study (HUNT 2), which includes a very large population-based sample of men and women from a well-defined geographic area. Participants with self-reported diabetes were well characterized with regard to their diabetes, and information on demographics, lifestyle, and prevalent disease including depression was available