Effect of a quality improvement programme on leadership, innovation and use of quality improvement methods in general practice

Introduction Market mechanisms and pay-for-performance have failed to deliver continuing improvements in UK clinical care. Leadership and innovation are currently seen as essential to maintain and improve clinical quality but little is known about the relationship between these and the extent to which quality improvement (QI) methods are used in general practice. This study aimed to investigate the effect of quality improvement training on leadership behaviour, culture of innovation and adoption of QI methods in general practice. Method Self-administered postal questionnaires were sent to general practitioner quality leads in one UK county at the beginning (2007) and the end (2010) of a QI programme. The questionnaire consisted of background demographic information, a 12-item scale to assess leadership behaviour, a seven-dimension self-rating scale for innovation culture and questions on current use of quality improvement techniques and the effect of this on practice. We analysed change between the two surveys and the effect of participation in QI training. Results Sixty-three completed questionnaires (62%) were returned in 2007 and 47 (46%) in 2010; 32 practices completed both surveys. Although leadership behaviours were not commonly expressed, many practices reported a positive culture of innovation with significant positive correlation between leadership and innovation (r = 0.57; P < 0.001); apart from clinical audit and significant event analysis, QI methods were not reported as having been adopted by most participating practices. Percentage leadership score changed little over three years (increase 4.0 points, 95%CI -8.9 to 16.9) with little difference between participating and non-participating practices (7.6, -6.4 to 21.6) and no evidence of differential change (-1.5, -17.0 to 14.0). Percentage innovation culture scores showed a similar pattern (time -4.1 points, -15.1 to 6.9, group -1.6, -12.7 to 9.4, differential change 5.3, -7.8 to 18.5). Conclusions Leadership behaviours were infrequently reported, and despite describing a culture of innovation there was low uptake of QI methods beyond clinical and significant event audit even after practices participated in a QI programme. There is evidence that practices may need greater support to enhance leadership competences and develop quality improvement skills to stimulate innovation if improvements in health care are to accelerate

Putting Our Best Boots Forward: US Military Deployments and Host-Country Crime

The deployment of military forces abroad has been a major component of the US’s grand strategy since the beginning of the Cold War. However, some scholars have argued that the presence of US military personnel abroad creates a series of negative externalities afflicting local communities. We put some of these claims to the test by looking at the effect of US military deployments on crime rates in the host-state. Using cross-national crime statistics from the United Nations and data on US troop deployments, we examine whether US military deployments are associated with higher levels of criminal activity across a large subset of crimes. In aggregate, the mere presence of troops does not increase the criminal activity in a state; however, there is a conditional effect when we account for a difference in culture between the host-state and the US; the presence of foreign deployed troops is associated with higher levels of property-related crimes in a country. Consequently, this paper contributes to a better understanding of the impact that US military deployments, and US foreign policy more broadly, have had on other countries, and also enhances our understanding of the micro-level factors that might affect relationships between alliance partners

Why Does the US Pay So Much for the Defense of Its Allies?: 5 Questions Answered

Since the start of Donald Trump’s run for the U.S. presidency in 2015, he has been critical of the amount of money U.S. allies contribute to their own defense. Now, the Trump administration is demanding that Japan and South Korea pay more for hosting U.S. troops stationed in those countries. The media also reported that U.S. military leadership in South Korea discussed the possibility of withdrawing up to 4,000 troops from South Korea if it does not increase its contributions. The Pentagon has since denied having such plans. We have each studied overseas deployments of U.S. military personnel for nearly a decade and have recently come together to research the costs and benefits of such deployments

Regions of Hierarchy and Security: US Troop Deployments, Spatial Relations, and Defense Burdens

Recent work has begun exploring the effects of foreign military deployments on hoststate foreign policies. However, research mostly focuses on dyadic relationships between major powers and host-states, ignoring the broader regional security environment of host-states. We develop a theory of spatial hierarchies to understand how security relationships throughout the region surrounding the host-state affect hoststate foreign policy. Using data on US military deployments from 1950–2005, we show that regional security considerations condition how host-states respond to the deployment of military forces to their territory. Consequently, regional analyses are fundamental in understanding monadic and dyadic decisions about security, alliance behavior, and conflict

Highly Ionized High-Velocity Clouds toward PKS 2155-304 and Markarian 509

To gain insight into four highly ionized high-velocity clouds (HVCs) discovered by Sembach et al. (1999), we have analyzed data from the Hubble Space Telescope (HST) and Far Ultraviolet Spectroscopic Explorer (FUSE) for the PKS 2155-304 and Mrk 509 sight lines. We measure strong absorption in OVI and column densities of multiple ionization stages of silicon (SiII/III/IV) and carbon (CII/III/IV). We interpret this ionization pattern as a multiphase medium that contains both collisionally ionized and photoionized gas. Toward PKS 2155-304, for HVCs at -140 and -270 km/s, respectively, we measure logN(OVI)=13.80+/-0.03 and log N(OVI)=13.56+/-0.06; from Lyman series absorption, we find log N(HI)=16.37^(+0.22)_(-0.14) and 15.23^(+0.38)_(-0.22). The presence of high-velocity OVI spread over a broad (100 km/s) profile, together with large amounts of low-ionization species, is difficult to reconcile with the low densities, n=5x10^(-6) cm^(-3), in the collisional/photoionization models of Nicastro et al. (2002), although the HVCs show a similar relation in N(SiIV)/N(CIV) versus N(CII)/N(CIV) as high-z intergalactic clouds. Our results suggest that the high-velocity OVI in these absorbers do not necessarily trace the WHIM, but instead may trace HVCs with low total hydrogen column density. We propose that the broad high-velocity OVI absorption arises from shock ionization, at bowshock interfaces produced from infalling clumps of gas with velocity shear. The similar ratios of high ions for HVC Complex C and these highly ionized HVCs suggest a common production mechanism in the Galactic halo.Comment: 38 pages, including 10 figures. ApJ, 10 April, 2004. Replaced with accepted versio

Hemagglutinin sequence conservation guided stem immunogen design from influenza A H3 subtype

Seasonal epidemics caused by influenza A (H1 and H3 subtypes) and B viruses are a major global health threat. The traditional, trivalent influenza vaccines have limited efficacy because of rapid antigenic evolution of the circulating viruses. This antigenic variability mediates viral escape from the host immune responses, necessitating annual vaccine updates. Influenza vaccines elicit a protective antibody response, primarily targeting the viral surface glycoprotein hemagglutinin (HA). However, the predominant humoral response is against the hypervariable head domain of HA, thereby restricting the breadth of protection. In contrast, the conserved, subdominant stem domain of HA is a potential ‘universal’ vaccine candidate. We designed an HA stem-fragment immunogen from the 1968 pandemic H3N2 strain (A/Hong Kong/1/68) guided by a comprehensive H3 HA sequence conservation analysis. The biophysical properties of the designed immunogen were further improved by C-terminal fusion of a trimerization motif, ‘isoleucine-zipper’ or ‘foldon’. These immunogens elicited cross-reactive, antiviral antibodies and conferred partial protection against a lethal, homologous HK68 virus challenge in vivo. Furthermore, bacterial expression of these immunogens is economical and facilitates rapid scale-up

Design and Calibration of a Flowfield Survey Rake for Inlet Flight Research

The Propulsion Flight Test Fixture at the NASA Dryden Flight Research Center is a unique test platform available for use on NASA's F-15B aircraft, tail number 836, as a modular host for a variety of aerodynamics and propulsion research. For future flight data from this platform to be valid, more information must be gathered concerning the quality of the airflow underneath the body of the F-15B at various flight conditions, especially supersonic conditions. The flow angularity and Mach number must be known at multiple locations on any test article interface plane for measurement data at these locations to be valid. To determine this prerequisite information, flight data will be gathered in the Rake Airflow Gauge Experiment using a custom-designed flowfield rake to probe the airflow underneath the F-15B at the desired flight conditions. This paper addresses the design considerations of the rake and probe assembly, including the loads and stress analysis using analytical methods, computational fluid dynamics, and finite element analysis. It also details the flow calibration procedure, including the completed wind-tunnel test and posttest data reduction, calibration verification, and preparation for flight-testing

Outside the Wire: U.S. Military Deployments and Public Opinion in Host States

How do citizens within countries hosting U.S. military personnel view that presence? Using new cross-national survey data from 14 countries, we examine how different forms of exposure to a U.S. military presence in a country affect attitudes towards the U.S. military, government, and people. We find that contact with U.S. military personnel or the receipt of economic benefits from the U.S. presence correlates with stronger support for the U.S. presence, people, and government. This study has profound implications for the role that U.S. installations play in affecting the social fabric of host nations, and policy implications for the conduct of U.S. military activities outside the United States

Results and Interpretation of the WFRD ELS Distillation Down-Select Test Data

Testing of the Wiped-film Rotating-disk (WFRD) evaporator was conducted in support of the Exploration Life Support Distillation Down-Select Test. The WFRD was constructed at NASA Ames Research Center (ARC) and tested at NASA Marshall Space Flight Center (MSFC). The WFRD was delivered to MSFC in September 2009, and testing of solution #1 and solution #2 immediately following. Solution #1 was composed of humidity condensate and urine, including flush water and pretreatment chemicals. Solution #2 was composed of hygiene water, humidity condensate, and urine, including flush water and pretreatment chemicals. During the testing, the operational parameters of the WFRD were recorded and samples of the feed, brine, and product were collected and analyzed. The steady-state results of processing 414L of feed solution #1 and 1283L of feed solution #2 demonstrated that running the WFRD at a brine temperature of 50 C gave an average production rate of 16.7 L/hr. The specific energy consumption was 80.5W-hr/L. Data Analysis shows that the water recovery rates were 94% and 91%, respectively. The total mass of the WFRD as delivered to MSFC was 300 Kg. The volume of the tests stand rack was 1m width x 0.7m depth x 1.9m height or 1.5 cu m of which about half of the total volume is occupied by equipment. Chemical analysis of the distillate showed an average TOC of 20ppm, a pH of 3.5, and a conductivity of 98 mho/cm. The conductivity of the distillate, compared to the feed, decreased by 98.9%., the total ion concentration decreased by 99.6%, the total organics decreased 98.6%, and the metals were at or below detection limit

NASA Advanced Explorations Systems: Concepts for Logistics to Living

The NASA Advanced Exploration Systems (AES) Logistics Reduction and Repurposing (LRR) project strives to enable a largely mission-independent cradle-to-grave-to-cradle approach to minimize logistics contributions to total mission architecture mass. The goals are to engineer logistics materials, common crew consumables, and container configurations to meet the following five basic goals: 1. Minimize intrinsic logistics mass and improve ground logistics flexibility. 2. Allow logistics components to be directly repurposed for on-orbit non-logistics functions (e.g., crew cabin outfitting) thereby indirectly reducing mass/volume. 3. Compact and process logistics that have not been directly repurposed to generate useful on-orbit components and/or compounds (e.g., radiation shielding, propellant, other usable chemical constituents). 4. Enable long-term stable storage and disposal of logistics end products that cannot be reused or repurposed (e.g., compaction for volume reduction, odor control, and maintenance of crew cabin hygienic conditions). 5. Allow vehicles in different mission phases to share logistics resources. This paper addresses the work being done to meet the second goal, the direct repurposing of logistics components to meet other on-orbit needs, through a strategy termed Logistics to Living (L2L). L2L has several areas but can be defined as repurposing or converting logistical items (bags, containers, foam, components, etc.) into useful crew items or life support augmentation on-orbit after they have provided their primary logistics function. The intent is that by repurposing items, dedicated crew items do not have to be launched and overall launch mass is decreased. For non-LEO missions, the vehicle interior volume will be relatively fixed so L2L will enable this volume to be used more effectively through reuse and rearrangement of logistical components. Past work in the area of L2L has already conceptually developed several potential technologies [Howe, Howard 2010]. Several of the L2L concepts that have shown the most potential in the past are based on NASA cargo transfer bags (CTBs) or their equivalents which are currently used to transfer cargo to and from the ISS. A high percentage of all logistics supplies are packaging mass and for a 6-month mission a crew of four might need over 100 CTBs. These CTBs are used for on-orbit transfer and storage but eventually becomes waste after use since down mass is very limited. The work being done in L2L also considering innovative interior habitat construction that integrate the CTBs into the walls of future habitats. The direct integration could provide multiple functions: launch packaging, stowage, radiation protection, water processing, life support augmentation, as well as structure. Reuse of these CTBs would reduce the amount of waste generated and also significantly reduce future up mass requirements for exploration missions. Also discussed here is the L2L water wall , an innovative reuse of an unfolded CTB as a passive water treatment system utilizing forward osmosis. The bags have been modified to have an inner membrane liner that allows them to purify wastewater. They may also provide a structural water-wall element that can be used to provide radiation protection and as a structural divider. Integration of the components into vehicle/habitat architecture and consideration of operations concepts and human factors will be discussed. In the future these bags could be designed to treat wastewater, concentrated brines, and solid wastes, and to dewater solid wastes and produce a bio-stabilized construction element. This paper will describe the follow-on work done in design, fabrication and demonstrations of various L2L concepts, including advanced CTBs for reuse/repurposing, internal outfitting studies and the CTB-based forward osmosis water wall