Evaluating the articulation of programme theory in practice as observed in Quality Improvement initiatives

Background: The Action-Effect Method(AEM) was co-developed by NIHR CLAHRC Northwest London (CLAHRC NWL) researchers and QI practitioners, building on Driver Diagrams(DD). This study aimed to determine AEM effectiveness in terms of technical aspects (how diagrams produced in practice compared with theoretical ideals) and social aspects (how engagement with the method related to social benefits). Methods Diagrams were scored on criteria developed on theoretical ideals of programme theory. 65 programme theory diagrams were reviewed (21 published Driver Diagrams (External DDs), 22 CLAHRC NWL Driver Diagrams (Internal DDs), and 21 CLAHRC NWL Action-Effect Diagrams(AEDs)). Social functions were studied through ethnographic observation of frontline QI teams in AEM sessions facilitated by QI experts. Qualitative analysis used inductive and deductive coding. Results ANOVA indicated the AEM significantly improved the quality of programme theory diagrams over Internal and External DDs on an average of 5 criteria from an 8-point assessment. Articulated aims were more likely to be patient-focused and high-level in AEDs than DDs. The cause/effect relationships from intervention to overall aim also tended to be clearer and were more likely than DDs to contain appropriate measure concepts. Using the AEM also served several social functions such as facilitating dialogue among multidisciplinary teams, and encouraging teams to act scientifically and pragmatically about planning and measuring QI interventions. Implications: The Action-Effect Method developed by CLAHRC NWL resulted in improvements over Driver Diagrams in articulating programme theory, which has wide-ranging benefits to quality improvement, including encouraging broad multi-disciplinary buy-in to clear aims and pre-planning a rigorous evaluation strategy

Applying Quality Improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

© Published by the BMJ Publishing Group Limited.Objectives Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge. Setting An acute 400-bedded teaching hospital in London, UK. Participants The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18â €...months. Interventions Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives. Results Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems. Conclusions New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers

Advanced thermal stability investigations of the Mn–Al-Ga system

A ternary Mn–Al-Ga alloy with the nominal composition Mn55Al38.57Ga6.43 was produced by arc melting. After homogenisation, the alloy consisted of the ε and γ2 phases. Appropriate heat treatments were used to transform each of these into a phase with the L10 structure. These two L10 phases had different compositions, lattice parameters and magnetic properties. In order to test the stability of the L10 phases against decomposition, heat treatments were carried out at 700 ​°C for durations of up to 14 days. The results showed that the decomposition started with formation of the β-Mn phase and subsequent appearance of the γ2 phase. The resulting diffusion gradients resulted in composition changes in the L10 phases and after 7 days, only a single, intermediate composition remained. After 14 days, the decomposition was almost complete. The decomposition of the L10 phases in the ternary Mn–Al-Ga alloy was significantly slower than in binary Mn–Al alloys

A new entropy measure based on the Renyi entropy rate using Gaussian kernels

The concept of entropy rate is well defined in dynamical systems theory but is impossible to apply it directly to finite real world data sets. With this in mind, Pincus developed Approximate Entropy (ApEn), which uses ideas from Eckmann and Ruelle to create a regularity measure based on entropy rate that can be used to determine the influence of chaotic behaviour in a real world signal. However, this measure was found not to be robust and so an improved formulation known as the Sample Entropy (SampEn) was created by Richman and Moorman to address these issues. We have developed a new, related, regularity measure which is not based on the theory provided by Eckmann and Ruelle and proves a more well-behaved measure of complexity than the previous measures whilst still retaining a low computational cost

Barriers to investing in cycling: Stakeholder views from England.

BACKGROUND: Planners and politicians in many countries seek to increase the proportion of trips made by cycling. However, this is often challenging. In England, a national target to double cycling by 2025 is likely to be missed: between 2001 and 2011 the proportion of commutes made by cycling barely grew. One important contributory factor is continued low investment in cycling infrastructure, by comparison to European leaders. METHODS: This paper examines barriers to cycling investment, considering that these need to be better understood to understand failures to increase cycling level. It is based on qualitative data from an online survey of over 400 stakeholders, alongside seven in-depth interviews. RESULTS: Many respondents reported that change continues to be blocked by chronic barriers including a lack of funding and leadership. Participants provided insights into how challenges develop along the life of a scheme. In authorities with little consideration given to cycling provision, media and public opposition were not reported as a major issue. However, where planning and implementation have begun, this can change quickly; although examples were given of schemes successfully proceeding, despite this. The research points to a growing gap between authorities that have overcome key challenges, and those that have not

Differences in both prevalence and titre of specific immunoglobulin E among children with asthma in affluent and poor communities within a large town in Ghana.

Background Reports from several African countries have noted an increasing prevalence of asthma in areas of extensive urbanization. Objective To investigate the relevance of allergen-specific sensitization and body mass index (BMI) to asthma/wheezing and exercise-induced bronchospasm (EIB) among children from affluent and poorer communities within a large town in Ghana. Methods Children with physician-diagnosed asthma and/or current wheezing aged 9-16 years (n=99; cases) from three schools with differing socio-economic backgrounds [urban affluent (UA), urban poor (UP) or suburban/rural (SR)] were recruited from a cross-sectional study (n=1848) in Kumasi, Ghana, and matched according to age, sex and area of residence with non-asthmatic/non-wheezy controls. We assayed sera for IgE antibodies to mite, cat, dog, cockroach, Ascaris and galactose-α-1,3-galactose. Results Children from the UA school had the lowest total serum IgE. However, cases from the UA school had a higher prevalence and mean titre of sIgE to mite (71.4%, 21.2IU/mL) when compared with controls (14.3%, 0.8IU/mL) or cases from UP (30%, 0.8IU/mL) and SR community (47.8%, 1.6IU/mL). While similar findings were observed with EIB in the whole population, among cases there was no difference in IgE antibody prevalence or titre between children with or without EIB. BMI was higher among UA children with and without asthma; in UP and SR communities, children with EIB (n=14) had a significantly higher BMI compared with children with asthma/wheezing without EIB (n=38) (18.2 vs. 16.4, respectively, P<0.01). Conclusions and Clinical Relevance In the relatively affluent school, asthma/wheezing and EIB were associated with high titre IgE antibodies to mite, decreased total IgE, and increased BMI. This contrasted with children in the urban poor school and suggests that changes relevant to a Western model of childhood asthma can occur within a short geographical distance within a large city in Africa. © 2011 Blackwell Publishing Ltd

The effect of Ti or Zr additions on the microstructure and magnetic properties of MnAl-C alloys

As-transformed and hot-deformed samples of MnAl-C alloys with Ti or Zr additions have been produced and characterized using magnetometry, X-ray diffraction, scanning electron microscopy and transmission electron microscopy. Both Ti and Zr additions in MnAl-C alloys form carbide primary phases, TiC and ZrC, which consume the carbon meant to be dissolved in the metastable τ-phase to stabilize it against decomposition. With these two additions, the Curie temperature of τ-phase increases while its stability against decomposition decreases. After hot deformation, the MnAl-C alloys with Ti or Zr additions have lower polarisation and remanence due to the reduced stability of the τ-phase. Adding extra carbon along with Ti to a MnAl-C alloy in order to compensate for the C lost on formation of TiC restored the original stability of the τ-phase. After hot-deformation, this alloy exhibited a lower polarisation and remanence owing to the unexpected formation of the γ2-phase

A mixed-methods study of challenges experienced by clinical teams in measuring improvement

Objective: Measurement is an indispensable element of most quality improvement (QI) projects, but it is undertaken to variable standards. We aimed to characterise challenges faced by clinical teams in undertaking measurement in the context of a safety QI programme that encouraged local selection of measures. Methods: Drawing on an independent evaluation of a multi-site improvement programme (Safer Clinical Systems), we combined a qualitative study of participating teams’ experiences and perceptions of measurement with expert review of measurement plans and analysis of data collected for the programme. Multidisciplinary teams of frontline clinicians at nine UK NHS sites took part across the two phases of the programme between 2011 and 2016. Results: Developing and implementing a measurement plan against which to assess their improvement goals was an arduous task for participating sites. The operational definitions of the measures that they selected were often imprecise or missed important details. Some measures used by the teams were not logically linked to the improvement actions they implemented. Regardless of the specific type of data used (routinely collected or selected ex-novo), the burdensome nature of data collection was underestimated. Problems also emerged in identifying and using suitable analytical approaches. Conclusion: Measurement is a highly technical task requiring a degree of expertise. Simply leveraging individual clinicians’ motivation is unlikely to defeat the persistent difficulties experienced by clinical teams when attempting to measure their improvement efforts. We suggest that more structural initiatives and broader capability-building programmes should be pursued by the professional community. Improving access to, and ability to use repositories of validated measures, and increasing transparency in reporting measurement attempts, is likely to be helpful