Organisational culture and quality of health care

concerned with assessing and improving the quality of health care. The USA, in particular, has identified specific concerns over quality issues1 2 and a recent report from the Institute of Medicine pointed to the considerable toll of medical errors.3 In the UK a series of scandals has propelled quality issues to centre stage4 5 and made quality improvement a key policy area.6 But how are quality improvements to be wrought in such a complex system as health care? A recent issue of Quality in Health Care was devoted to considerations of organisational change in health care, calling it “the key to quality improvement”.7 In discussing how such change can be managed, the authors of one of the articles asserted that cultural change needs to be wrought alongside structural reorganisation and systems reform to bring about “a culture in which excellence can flourish”.8 A review of policy changes in the UK over the past two decades shows that these appeals for cultural change are not new but have appeared in various guises (box 1). However, talk of “culture” and “culture change” beg some diffi- cult questions about the nature of the underlying substrate to which change programmes are applied. What is “organisational culture” anyway? It is to this issue that this paper is addressed

Estimate of the hadronic vacuum polarization disconnected contribution to the anomalous magnetic moment of the muon from lattice QCD

The quark-line disconnected diagram is a potentially important ingredient in lattice QCD calculations of the hadronic vacuum polarization contribution to the anomalous magnetic moment of the muon. It is also a notoriously difficult one to evaluate. Here, for the first time, we give an estimate of this contribution based on lattice QCD results that have a statistically significant signal, albeit at one value of the lattice spacing and an unphysically heavy value of the u/d quark mass. We use HPQCD’s method of determining the anomalous magnetic moment by reconstructing the Adler function from time moments of the current-current correlator at zero spatial momentum. Our results lead to a total (including u, d and s quarks) quark-line disconnected contribution to aμ of −0.15% of the u/d hadronic vacuum polarization contribution with an uncertainty which is 1% of that contribution

Radial Excited States for Heavy Quark Systems in NRQCD

Following the Non-Relativistic QCD approach we use a gauge invariant smearing method with factorization to measure the excitation energies for a heavy $Q\bar{Q}$ system on a $24^3\times 48$ lattice at $\beta=6.2$. The results come from averaging over an ensemble of 60 QCD configurations. In order to enhance the signal from each configuration we use wall sources for quark propagators. The quark Hamiltonian contains only the simplest non-relativistic kinetic energy term. The results are listed for a range of bare quark masses. The mass splittings are insensitive to this variable though there are a slight trends with increasing quark mass. For an appropriate choice of UV cut-off ($a^{-1}=3.2$Gev) the mass spectrum compares reasonably well with the experimental values for the spin-averaged energy gaps of the $\Upsilon$ system. We also present results for the $DE$ and $DT$ waves for the lowest bare quark mass. The results are consistent with degeneracy between the two types of $D$ wave. This encourages the idea that even with our simple quark Hamiltonian the departure from rotational invariance is not great.Comment: 12 page

Non-Relativistic QCD for Heavy Quark Systems

We employ a nonrelativistic version of QCD (NRQCD) to study heavy quark-antiquark bound states in the lowest approximation without fine structure. We use gluon configurations on a 16^3 by 48 lattice at beta=6.2 from the UKQCD collaboration. For quark masses in the vicinity of the b we obtain bound state masses for S, P and both types of D wave. We also detect signals for two types of hybrids (quark,antiquark,gluon states). The results are sufficiently accurate to confirm that the values of the D wave mass from both lattice D waves coincide indicating that the cubical invariance of the lattice is restored to full rotational invariance at large distance. Our results also show that the S-P splitting is indeed insensitive to variations in the bare quark mass from Ma=1.0 to Ma=1.9.Comment: 13 pages, DAMTP-92-7

Accuracy of diagnosing atrial fibrillation on electrocardiogram by primary care practitioners and interpretative diagnostic software: analysis of data from screening for atrial fibrillation in the elderly (SAFE) trial

Objective To assess the accuracy of general practitioners, practice nurses, and interpretative software in the use of different types of electrocardiogram to diagnose atrial fibrillation. Design Prospective comparison with reference standard of assessment of electrocardiograms by two independent specialists. Setting 49 general practices in central England. Participants 2595 patients aged 65 or over screened for atrial fibrillation as part of the screening for atrial fibrillation in the elderly (SAFE) study; 49 general practitioners and 49 practice nurses. Interventions All electrocardiograms were read with the Biolog interpretative software, and a random sample of 12 lead, limb lead, and single lead thoracic placement electrocardiograms were assessed by general practitioners and practice nurses independently of each other and of the Biolog assessment. Main outcome measures Sensitivity, specificity, and positive and negative predictive values. Results General practitioners detected 79 out of 99 cases of atrial fibrillation on a 12 lead electrocardiogram (sensitivity 80%, 95% confidence interval 71% to 87%) and misinterpreted 114 out of 1355 cases of sinus rhythm as atrial fibrillation (specificity 92%, 90% to 93%). Practice nurses detected a similar proportion of cases of atrial fibrillation (sensitivity 77%, 67% to 85%), but had a lower specificity (85%, 83% to 87%). The interpretative software was significantly more accurate, with a specificity of 99%, but missed 36 of 215 cases of atrial fibrillation (sensitivity 83%). Combining general practitioners' interpretation with the interpretative software led to a sensitivity of 92% and a specificity of 91%. Use of limb lead or single lead thoracic placement electrocardiograms resulted in some loss of specificity. Conclusions Many primary care professionals cannot accurately detect atrial fibrillation on an electrocardiogram, and interpretative software is not sufficiently accurate to circumvent this problem, even when combined with interpretation by a general practitioner. Diagnosis of atrial fibrillation in the community needs to factor in the reading of electrocardiograms by appropriately trained peopl

Measurement does not always aid state discrimination

We have investigated the problem of discriminating between nonorthogonal quantum states with least probability of error. We have determined that the best strategy for some sets of states is to make no measurement at all, and simply to always assign the most commonly occurring state. Conditions which describe such sets of states have been derived.Comment: 3 page

Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: Screening versus routine practice in detection cluster randomised controlled trial

Objectives : To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening. Design : Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm. Setting : 50 primary care centres in England, with further individual randomisation of patients in the intervention practices. Participants : 14,802 patients aged 65 or over in 25 intervention and 25 control practices. Interventions : Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices. Main outcome measure : Newly identified atrial fibrillation. Results : The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, −0.5% to 0.5%). Conclusion : Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography. Trial registration Current Controlled Trials ISRCTN19633732

Minimum-error discrimination between symmetric mixed quantum states

We provide a solution of finding optimal measurement strategy for distinguishing between symmetric mixed quantum states. It is assumed that the matrix elements of at least one of the symmetric quantum states are all real and nonnegative in the basis of the eigenstates of the symmetry operator.Comment: 10 page

Home-based exercise rehabilitation in addition to specialist heart failure nurse care: design, rationale and recruitment to the Birmingham Rehabilitation Uptake Maximisation study for patients with congestive heart failure (BRUM-CHF): a randomised controlled trial.

Background Exercise has been shown to be beneficial for selected patients with heart failure, but questions remain over its effectiveness, cost-effectiveness and uptake in a real world setting. This paper describes the design, rationale and recruitment for a randomised controlled trial that will explore the effectiveness and uptake of a predominantly home-based exercise rehabilitation programme, as well as its cost-effectiveness and patient acceptability. Methods/design Randomised controlled trial comparing specialist heart failure nurse care plus a nurse-led predominantly home-based exercise intervention against specialist heart failure nurse care alone in a multiethnic city population, served by two NHS Trusts and one primary care setting, in the United Kingdom. 169 English speaking patients with stable heart failure, defined as systolic impairment (ejection fraction ≤ 40%). with one or more hospital admissions with clinical heart failure or New York Heart Association (NYHA) II/III within previous 24-months were recruited. Main outcome measures at 1 year: Minnesota Living with Heart Failure Questionnaire, incremental shuttle walk test, death or admission with heart failure or myocardial infarction, health care utilisation and costs. Interviews with purposive samples of patients to gain qualitative information about acceptability and adherence to exercise, views about their treatment, self-management of their heart failure and reasons why some patients declined to participate. The records of 1639 patients managed by specialist heart failure services were screened, of which 997 (61%) were ineligible, due to ejection fraction>40%, current NYHA IV, no admission or NYHA II or more within the previous 2 years, or serious co-morbidities preventing physical activity. 642 patients were contacted: 289 (45%) declined to participate, 183 (39%) had an exclusion criterion and 169 (26%) agreed to randomisation. Discussion Due to safety considerations for home-exercise less than half of patients treated by specialist heart failure services were eligible for the study. Many patients had co-morbidities preventing exercise and others had concerns about undertaking an exercise programme