Breast cancer teams:the impact of constitution, new cancer workload and methods of operation on their effectiveness

National guidance and clinical guidelines recommended multidisciplinary teams (MDTs) for cancer services in order to bring specialists in relevant disciplines together, ensure clinical decisions are fully informed, and to coordinate care effectively. However, the effectiveness of cancer teams was not previously evaluated systematically. A random sample of 72 breast cancer teams in England was studied (548 members in six core disciplines), stratified by region and caseload. Information about team constitution, processes, effectiveness, clinical performance, and members' mental well-being was gathered using appropriate instruments. Two input variables, team workload (P=0.009) and the proportion of breast care nurses (P=0.003), positively predicted overall clinical performance in multivariate analysis using a two-stage regression model. There were significant correlations between individual team inputs, team composition variables, and clinical performance. Some disciplines consistently perceived their team's effectiveness differently from the mean. Teams with shared leadership of their clinical decision-making were most effective. The mental well-being of team members appeared significantly better than in previous studies of cancer clinicians, the NHS, and the general population. This study established that team composition, working methods, and workloads are related to measures of effectiveness, including the quality of clinical care. © 2003 Cancer Research UK.

Managing people and performance:An evidence based framework applied to health service organizations

People and their performance are key to an organization's effectiveness. This review describes an evidence-based framework of the links between some key organizational influences and staff performance, health and well-being. This preliminary framework integrates management and psychological approaches, with the aim of assisting future explanation, prediction and organizational change. Health care is taken as the focus of this review, as there are concerns internationally about health care effectiveness. The framework considers empirical evidence for links between the following organizational levels: 1. Context (organizational culture and inter-group relations; resources, including staffing; physical environment) 2. People management (HRM practices and strategies; job design, workload and teamwork; employee involvement and control over work; leadership and support) 3. Psychological consequences for employees (health and stress; satisfaction and commitment; knowledge, skills and motivation) 4. Employee behaviour (absenteeism and turnover; task and contextual performance; errors and near misses) 5. Organizational performance; patient care. This review contributes to an evidence base for policies and practices of people management and performance management. Its usefulness will depend on future empirical research, using appropriate research designs, sufficient study power and measures that are reliable and valid.

Cognition, ocular accommodation, and cardiovascular function in emmetropes and late-onset myopes

PURPOSE. To investigate objectively and noninvasively the role of cognitive demand on autonomic control of systemic cardiovascular and ocular accommodative responses in emmetropes and myopes of late-onset. METHODS. Sixteen subjects (10 men, 6 women) aged between 18 and 34 years (mean ± SD: 22.6 ± 4.4 years), eight emmetropes (EMMs; mean spherical equivalent [MSE] refractive error ± SD: 0.05 ± 0.24 D) and eight with late-onset myopia (LOMs; MSE ± SD: -3.66 ± 2.31 D) participated in the study. Subjects viewed stationary numerical digits monocularly within a Badal optical system (at both 0.0 and -3.0 D) while performing a two-alternative, forced-choice paradigm that matched cognitive loading across subjects. Five individually matched cognitive levels of increasing difficulty were used in random order for each subject. Five 20-second, continuous-objective recordings of the accommodative response measured with an open-view infrared autorefractor were obtained for each cognitive level, whereas simultaneous measurement of heart rate was continuously recorded with a finger-mounted piezoelectric pulse transducer for 5 minutes. Fast Fourier transformation of cardiovascular function allowed the relative power of the autonomic components to be assessed in the frequency domain, whereas heart period gave an indication of the time-domain response. RESULTS. Increasing the cognitive demand led to a significant reduction in the accommodative response in all subjects (0.0 D: by -0.35 ± 0.33 D; -3.0 D: by -0.31 ± 0.40 D, P < 0.001). The greater lag of LOMs compared with EMMs was not significant (P = 0.07) at both distance (0.38 ± 0.35 D) and near (0.14 ± 0.42 D). Mean heart period reduced with increasing levels of workload (P < 0.0005). LOMs exhibited a relative elevation in sympathetic system activity compared to EMMs. Within refractive groups, however, accommodative shifts with increasing cognition correlated with parasympathetic activity (r = 0.99, P < 0.001), more than with sympathetic activity (r = 0.62, P > 0.05). CONCLUSIONS. In an equivalent workload paradigm, increasing cognitive demand caused a reduction in accommodative response that was attributable principally to a concurrent reduction in the relative power of the parasympathetic component of the autonomic nervous system (ANS). The disparity in accommodative response between EMMs and LOMs, however, appears to be augmented by changes in the sympathetic nervous component of the systemic ANS. Copyright © Association for Research in Vision and Ophthalmology.

Using quantitative analysis to implement autonomic IT systems

The software underpinning today’s IT systems needs to adapt dynamically and predictably to rapid changes in system workload, environment and objectives. We describe a software framework that achieves such adaptiveness for IT systems whose components can be modelled as Markov chains. The framework comprises (i) an autonomic architecture that uses Markov-chain quantitative analysis to dynamically adjust the parameters of an IT system in line with its state, environment and objectives; and (ii) a method for developing instances of this architecture for real-world systems. Two case studies are presented that use the framework successfully for the dynamic power management of disk drives, and for the adaptive management of cluster availability within data centres, respectively.

A study of adaptive load balancing algorithms for distributed systems

With the advent of distributed computer systems with a largely transparent user interface, new questions have arisen regarding the management of such an environment by an operating system. One fertile area of research is that of load balancing, which attempts to improve system performance by redistributing the workload submitted to the system by the users. Early work in this field concentrated on static placement of computational objects to improve performance, given prior knowledge of process behaviour. More recently this has evolved into studying dynamic load balancing with process migration, thus allowing the system to adapt to varying loads. In this thesis, we describe a simulated system which facilitates experimentation with various load balancing algorithms. The system runs under UNIX and provides functions for user processes to communicate through software ports; processes reside on simulated homogeneous processors, connected by a user-specified topology, and a mechanism is included to allow migration of a process from one processor to another. We present the results of a study of adaptive load balancing algorithms, conducted using the aforementioned simulated system, under varying conditions; these results show the relative merits of different approaches to the load balancing problem, and we analyse the trade-offs between them. Following from this study, we present further novel modifications to suggested algorithms, and show their effects on system performance.

Individual differences in human-computer interaction

This thesis initially presents an 'assay' of the literature pertaining to individual differences in human-computer interaction. A series of experiments is then reported, designed to investigate the association between a variety of individual characteristics and various computer task and interface factors. Predictor variables included age, computer expertise, and psychometric tests of spatial visualisation, spatial memory, logical reasoning, associative memory, and verbal ability. These were studied in relation to a variety of computer-based tacks, including: (1) word processing and its component elements; (ii) the location of target words within passages of text; (iii) the navigation of networks and menus; (iv) command generation using menus and command line interfaces; (v) the search and selection of icons and text labels; (vi) information retrieval. A measure of self-report workload was also included in several of these experiments. The main experimental findings included: (i) an interaction between spatial ability and the manipulation of semantic but not spatial interface content; (ii) verbal ability being only predictive of certain task components of word processing; (iii) age differences in word processing and information retrieval speed but not accuracy; (iv) evidence of compensatory strategies being employed by older subjects; (v) evidence of performance strategy differences which disadvantaged high spatial subjects in conditions of low spatial information content; (vi) interactive effects of associative memory, expertise and command strategy; (vii) an association between logical reasoning and word processing but not information retrieval; (viii) an interaction between expertise and cognitive demand; and (ix) a stronger association between cognitive ability and novice performance than expert performance.

Behavioural correlates of ocular accomodation and the autonomic nervous system

The binding issue of th is thesis was the examination of workload, induced by relinotopic and spatiotopic stimuli, on both the ocu lomotor and cardiovascular systems together with investigating the covariation between the two systems - the 'eye-heart' link. Further, the influence of refractive error on ocular accommodation and cardiovascular function was assessed. A clinical evaluation was undertaken to assess the newly available open-view infrared Shin-Nippon NVision-K 5001 optometer, its benefit being the capability to measure through pupils = 2.3 mm. Measurements of refractive error taken with the NVision-K were found to be both accurate (Difference in Mean Spherical Equivalent: 0.14 ± 0.35 D; p = 0.67) and repeatable when compared to non-cycloplegic subjective refraction. Due to technical difficulties, however, the NVision-K could not be used for the purpose of the thesis, as such, measures of accommodation were taken using the continuously recording Shin-Nippon SRW-5000 openview infrared optometer, coupled with a piezo-electric finger pulse transducer to measure pulse. Heart rate variability (HRV) was spectrally analysed to determine the systemic sympathetic and parasympathetic components of the autonomic nervous system (ANS). A large sample (n = 60), cross-sectional study showed late-onset myopes (LOMs) display less accurate responses when compared to other refractive groups at high accommodative demand levels (3 .0 0 and 4.0D). Tonic accommodation (TA) was highest in the hypermetropes, fo llowed by emmetropes and early-onset myopes while the LOM subjects demonstrated statistically significant lower levels of TA. The root-meansquare (RMS) value of the accommodative response was shown to amplify with increased levels of accommodative demand. Changes in refractive error only became significant between groups at higher demand levels (3.0 D and 4.0 D) with the LOMs showing the largest magnification in oscilIations. Examination of the stimulus-response cross-over point with the unit ratio line and TA showed a correlation between the two (r = 0.45, p = 0.001), where TA is approximately twice the dioptric value of the stimulus-response cross-over point. Investigation of the relationship between ocular accommodation and systemic ANS function demonstrated covariation between the systems. Subjects with a faster heart rate (lower heart period) tended to have a higher TA value (r = -0.27, p < 0.05). Further, an increase in accommodative demand accompanies a faster heart rate. The influence of refractive error on the cardiovascular response to changes in accommodative demand, however, was equivocal. Examination of the microfluctuations ofacconunodation demonstrated a correlation between the temporal frequency location of the accommodative high Frequency component (HFC) and the arterial pulse frequency. The correlation was present at a range of accommodative demands from 0.0 D to 4.0 D and in all four refractive groups, suggesting that the HFC was augmented by physiological factors. Examination of the effect of visual cognition on ocular accommodation and the ANS confirmed that increasing levels of cognition affect the accommodative mechanism. The accommodative response shifted away from the subject at both near and far. This shift in accommodative response accompanied a decay in the systemic parasympathetic innervation to the heart. Differences between refractive groups also existed with LOMs showing less accurate responses compared to emmetropes. This disparity, however, appeared to be augmented by the systemic sympathetic nervous system. The investigations discussed explored Ihe role of oculomotor and cardiovascular fu nction in workload enviromnents, providing evidence for a behavioural link between the cardiovascular and oculomotor systems.

Dynamic QoS management and optimisation in service-based systems

Service-based systems that are dynamically composed at run time to provide complex, adaptive functionality are currently one of the main development paradigms in software engineering. However, the Quality of Service (QoS) delivered by these systems remains an important concern, and needs to be managed in an equally adaptive and predictable way. To address this need, we introduce a novel, tool-supported framework for the development of adaptive service-based systems called QoSMOS (QoS Management and Optimisation of Service-based systems). QoSMOS can be used to develop service-based systems that achieve their QoS requirements through dynamically adapting to changes in the system state, environment and workload. QoSMOS service-based systems translate high-level QoS requirements specified by their administrators into probabilistic temporal logic formulae, which are then formally and automatically analysed to identify and enforce optimal system configurations. The QoSMOS self-adaptation mechanism can handle reliability- and performance-related QoS requirements, and can be integrated into newly developed solutions or legacy systems. The effectiveness and scalability of the approach are validated using simulations and a set of experiments based on an implementation of an adaptive service-based system for remote medical assistance.

The importance of optical coherence tomography examination of normal fellow eyes in neovascular age-related macular degeneration monitoring clinics

Purpose: To demonstrate the importance of OCT examination of fellow, normal eyes in unilateral nAMD follow up clinics. Methods: The authors present three cases of unilateral nAMD who were undergoing treatment with ranibizumab, in whom OCT evaluation of the previously unaffected, asymptomatic fellow eye allowed early diagnosis, treatment and preservation of vision. Fundus examination had previously failed to demonstrate abnormality. Results: Intravitreal anti-VEGF treatment for nAMD has caused a sharp increase in the number of subjects attending macular clinics, frequently overburdening the system. It may sometimes be tempting for hospitals to reduce the workload by for example, concentrating only on OCT examination of the affected eye in cases of unilateral nAMD. The three reported cases demonstrate that OCT scanning of the fellow, previously unaffected eye is essential in detecting asymptomatic nAMD, which gives a better chance of preservation of vision. Conclusions: Patients with unilateral neovascular AMD undergoing review in macular clinics should always undergo OCT scanning of normal, fellow eyes, as otherwise asymptomatic, “invisible” choroidal neovascular membranes may be missed.

Patients’ and health professionals’ views and experiences of atrial fibrillation and oral-anticoagulant therapy:a qualitative meta-synthesis

Objective - Atrial fibrillation (AF) patients are prescribed oral-anticoagulant (OAC) therapy, often warfarin, to reduce stroke risk. We explored existing qualitative evidence about patients’ and health professionals’ experiences of OAC therapy. Methods - Systematic searches of eight bibliographic databases were conducted. Quality was appraised using the Critical Appraisal Skills Programme tool and data from ten studies were synthesised qualitatively. Results - Four third-order constructs, emerged from the final step in the analysis process: (1) diagnosing AF and the communication of information, (2) deciding on OAC therapy, (3) challenges revolving around patient issues, and (4) healthcare challenges. Synthesis uncovered perspectives that could not be achieved through individual studies. Conclusion - Physicians’ and patients’ experiences present a dichotomy of opinion on decision-making, which requires further exploration and changes in practice. Outcomes of workload pressure on both health professionals and patients should be investigated. The need for on-going support and education to patients and physicians is critical to achieve best practice and treatment adherence. Practice implications - Such research could encourage health professionals to understand and attend better to the needs and concerns of the patient. Additionally these findings can be used to inform researchers and healthcare providers in developing educational interventions with both patients and health professionals.

A simulation study of the shift system at a UK police communications centre

The UK Police Force is required to operate communications centres under increased funding constraints. Staff represent the main cost in operating the facility and the key issue for the efficient deployment of staff, in this case call handler staff, is to try to ensure sufficient staff are available to make a timely response to customer calls when the timing of individual calls is difficult to predict. A discrete-event simulation study is presented of an investigation of a new shift pattern for call handler staff that aims to improve operational efficiency. The communications centre can be considered a specialised case of a call centre but an important issue for Police Force management is the particularly stressful nature of the work staff are involved with when responding to emergency calls. Thus decisions regarding changes to the shift system were made in the context of both attempting to improve efficiency by matching staff supply with customer demand, but also ensuring a reasonable workload pattern for staff over time.

Gesundheitsrisiken bei Unternehmern

An einer Studie zum Zusammenhang zwischen der Gesundheit von Unternehmern, deren Arbeitsmerkmalen und deren Erfolg nahmen 53 klein- und mittelständische Unternehmer teil. Erfasste Arbeitsmerkmale waren: Handlungs-/Entscheidungsspielraum, Arbeitsintensität, Arbeitszeit, Konkurrenzdruck und Prognose über die Auftragsentwicklung. Der Unternehmenserfolg wurde über das Mitarbeiterwachstum, die Möglichkeit des Unternehmers, von seiner Firma abwesend zu sein (Urlaubstage), und dem erlebten Unternehmenserfolg operationalisiert. Gesundheitsindikatoren waren Depression, Angst, vitale Erschöpfung, Schlafstörungen und Bluthochdruck. Im Vergleich zur Gesamtbevölkerung wiesen die Unternehmer in allen untersuchten Gesundheitsvariablen häufiger Beeinträchtigungen auf. Regressionsanalysen ergaben, dass lange Arbeitszeiten und Konkurrenzdruck mit einer verzögerten Rückstellung des systolischen Blutdrucks (SBD) in der Freizeit und Nacht einhergingen. Alle untersuchten Erfolgsmerkmale waren für die Gesundheit prädiktiv. So war Mitarbeiterwachstum negativ mit dem SBD während der Arbeit sowie Schlafstörungen assoziiert. Je mehr Unternehmenserfolg erlebt wurde, desto geringer waren die Werte für vitale Erschöpfung und Depression. Die Urlaubsdauer war negativ mit Angst und vitaler Erschöpfung korreliert. Insgesamt hatte von den Arbeitsmerkmalen nur die Dauer der Arbeitszeit einen Effekt auf die Gesundheit von Unternehmern. Daneben existieren aber offensichtlich weitere Faktoren, die mit der Unternehmergesundheit in Beziehung stehen. Dies sind neben dem Konkurrenzdruck am Markt insbesondere Indikatoren des Unternehmenserfolgs. The relationship between health and workload as well as entrepreneurial success was analyzed in 53 entrepreneurs. Workload data (decision latitude, job demand, working time, competition, market development) were determined by using structured interviews and Karasek's job content questionnaire. Firm success was operationalized by employee growth, the possibility of absence from the company (days of holiday), and perceived success. Health was measured by questionnaires for sleep disturbances, vital exhaustion, depression, and anxiety, and by 24 hour ambulatory blood pressure monitoring. Regression analyses showed that working time and strength of competition within the market were predictive for systolic blood pressure (SBP) during leisure time and night, but not during work. All variables measuring entrepreneurial success were predictive for health. Employee growth was related to decreasing SBP during work and to fewer sleep disturbances. The duration of holidays was negatively related to vital exhaustion and anxiety. Perceived company success was negatively related to depression and vital exhaustion. In conclusion, only the relationship between working time and bad health conformed to findings reported for the relationship between work and health in employees. However, there were additional indicators, especially indicators of competition and entrepreneurial success, that affected the health of entrepreneurs.

A new three phase method (SDP method) for the multi-objective vehicle routing problem with simultaneous delvery and pickup (VRPSDP)

Transportation service operators are witnessing a growing demand for bi-directional movement of goods. Given this, the following thesis considers an extension to the vehicle routing problem (VRP) known as the delivery and pickup transportation problem (DPP), where delivery and pickup demands may occupy the same route. The problem is formulated here as the vehicle routing problem with simultaneous delivery and pickup (VRPSDP), which requires the concurrent service of the demands at the customer location. This formulation provides the greatest opportunity for cost savings for both the service provider and recipient. The aims of this research are to propose a new theoretical design to solve the multi-objective VRPSDP, provide software support for the suggested design and validate the method through a set of experiments. A new real-life based multi-objective VRPSDP is studied here, which requires the minimisation of the often conflicting objectives: operated vehicle fleet size, total routing distance and the maximum variation between route distances (workload variation). The former two objectives are commonly encountered in the domain and the latter is introduced here because it is essential for real-life routing problems. The VRPSDP is defined as a hard combinatorial optimisation problem, therefore an approximation method, Simultaneous Delivery and Pickup method (SDPmethod) is proposed to solve it. The SDPmethod consists of three phases. The first phase constructs a set of diverse partial solutions, where one is expected to form part of the near-optimal solution. The second phase determines assignment possibilities for each sub-problem. The third phase solves the sub-problems using a parallel genetic algorithm. The suggested genetic algorithm is improved by the introduction of a set of tools: genetic operator switching mechanism via diversity thresholds, accuracy analysis tool and a new fitness evaluation mechanism. This three phase method is proposed to address the shortcoming that exists in the domain, where an initial solution is built only then to be completely dismantled and redesigned in the optimisation phase. In addition, a new routing heuristic, RouteAlg, is proposed to solve the VRPSDP sub-problem, the travelling salesman problem with simultaneous delivery and pickup (TSPSDP). The experimental studies are conducted using the well known benchmark Salhi and Nagy (1999) test problems, where the SDPmethod and RouteAlg solutions are compared with the prominent works in the VRPSDP domain. The SDPmethod has demonstrated to be an effective method for solving the multi-objective VRPSDP and the RouteAlg for the TSPSDP.

Senior management leadership, social support, job design and stressor-to-strain relationships in hospital practice

Purpose: The purpose of this paper is to examine the effect of the quality of senior management leadership on social support and job design, whose main effects on strains, and moderating effects on work stressors-to-strains relationships were assessed. Design/methodology/approach: A survey involving distribution of questionnaires was carried out on a random sample of health care employees in acute hospital practice in the UK. The sample comprised 65,142 respondents. The work stressors tested were quantitative overload and hostile environment, whereas strains were measured through job satisfaction and turnover intentions. Structural equation modelling and moderated regression analyses were used in the analysis. Findings: Quality of senior management leadership explained 75 per cent and 94 per cent of the variance of social support and job design respectively, whereas work stressors explained 51 per cent of the variance of strains. Social support and job design predicted job satisfaction and turnover intentions, as well as moderated significantly the relationships between quantitative workload/hostility and job satisfaction/turnover intentions. Research limitations/implications: The findings are useful to management and to health employees working in acute/specialist hospitals. Further research could be done in other counties to take into account cultural differences and variations in health systems. The limitations included self-reported data and percept-percept bias due to same source data collection. Practical implications: The quality of senior management leaders in hospitals has an impact on the social environment, the support given to health employees, their job design, as well as work stressors and strains perceived. Originality/value: The study argues in favour of effective senior management leadership of hospitals, as well as ensuring adequate support structures and job design. The findings may be useful to health policy makers and human resources managers. © Emerald Group Publishing Limited.

The UK MPharm (2) - Do we over assess?

Introduction-The pace of structural change in the UK health economies, the new focus on regulation and the breaking down of professional boundaries means that the Royal Pharmaceutical Society of Great Britain (RPSGB) has to continually review the scope, range and outputs of education provided by schools of pharmacy (SOPs). In SOPs, the focus is on equipping students with the knowledge, skills and attitudes necessary to successfully engage with the pre-registration year. The aim of this study [1] was to map current programmes and undergraduate experiences to inform the RPSGB debate. The specific objectives of this paper are to describe elements of the survey of final year undergraduates, to explore student opinions and experiences of their workload, teaching, learning and assessment. Material and methods-The three main research techniques were: (1) quantitative course document review, (2) qualitative staff interview and (3) quantitative student self completion survey. The questions in the survey were based on findings from exploratory focus group work with BPSA (British Pharmaceutical Students’ Association) members and were designed to ascertain if views expressed in the focus groups on the volume and format of assessments were held by the general student cohort. The student self completion questionnaire consisting of 31 questions, was administered in 2005 to all (n=1847) final year undergraduates, using a pragmatic mixture of methods. The sample was 15 SOPs within the UK (1 SOP opted out). The total response rate was 50.62% (n=935): it varied by SOP from 14.42% to 84.62%. The survey data were analysed (n=741) using SPSS, excluding non-UK students who may have undertaken part of their studies within a non-UK university. Results and discussion • 76% (n=562) respondents considered that the amount of formal assessment was about right, 21% (n=158) thought it was too much. • There was agreement that the MPharm seems to have more assessment than other courses, with 63% (n=463) strongly agreeing or agreeing. • The majority considered the balance between examinations and coursework was about right (67%, n=498), with 27% (n=198) agreeing that the balance was too far weighted towards examinations. • 57% (n=421) agreed that the focus of MPharm assessment was too much towards memorised knowledge, 40% (n=290) that it was about right. • 78% (n= 575) agreed with the statement “Assessments don’t measure the skills for being a pharmacist they just measure your knowledge base”. Only 10% (n=77) disagreed. • Similarly 49% (n=358) disagreed with, and 35% (n=256) were not sure about the statement “I consider that the assessments used in the MPharm course adequately measure the skills necessary to be a pharmacist”. Only 17% (n=124) agreed. Experience from this study shows the difficulty of administering survey instruments through UK Schools of Pharmacy. It is heavily dependent on timing, goodwill and finding the right person. The variability of the response rate between SOPs precluded any detailed analysis by School. Nevertheless, there are some interesting results. Issues raised in the exploratory focus group work about amount of assessment and over reliance on knowledge have been confirmed. There is a real debate to be had about the extent to which the undergraduate course, which must instil scientific knowledge, can provide students with the requisite qualities, skills, attitudes and behaviour that are more easily acquired in the pre-registration year. References [1] Wilson K, Jesson J, Langley C, Clarke L, Hatfield K. MPharm Programmes: Where are we now? Report commissioned by the Pharmacy Practice Research Trust., 2005.