Speech by Mr. Micheál Martin TD – Meeting The Challenges Of Cultural Diversity In The Irish Healthcare Sector

It gives me great pleasure to accept the invitation to address this conference on “Meeting the Challenges of Cultural Diversity in the Irish Healthcare Sector” which is being organised by the Irish Health Services Management Institute in partnership with the National Consultative Committee on Racism and Interculturalism. The conference provides an important opportunity to develop our knowledge and understanding of the issues surrounding cultural diversity in the health sector from the twin perspectives of patients and staff. Cultural diversity has over recent years become an increasingly visible aspect of Irish society bringing with it both opportunities and challenges. It holds out great possibilities for the enrichment of all who live in Ireland but it also challenges us to adapt creatively to the changes required to realise this potential and to ensure that the experience is a positive one for all concerned but particularly for those in the minority ethnic groups. In the last number of years in particular, the focus has tended to be on people coming to this country either as refugees, asylum seekers or economic migrants. Government figures estimate that as many as 340,000 immigrants are expected in the next six years. However ethnic and cultural diversity are not new phenomena in Ireland. Travellers have a long history as an indigenous minority group in Ireland with a strong culture and identity of their own. The changing experience and dynamics of their relationship with the wider society and its institutions over time can, I think, provide some valuable lessons for us as we seek to address the more numerous and complex issues of cultural diversity which have arisen for us in the last decade. Turning more specifically to the health sector which is the focus of this conference, culture and identity have particular relevance to health service policy and provision in that The first requirement is that we in the health service acknowledge cultural diversity and the differences in behaviours and in the less obvious areas of values and beliefs that this often implies. Only by acknowledging these differences in a respectful way and informing ourselves of them can we address them. Our equality legislation – The Employment Equality Act, 1998 and the Equal Status Act, 2000 – prohibits discrimination on nine grounds including race and membership of the Traveller community. The Equal Status Act prohibits discrimination on an individual basis in relation to the nine grounds while for groups it provides for the promotion of equality of opportunity. The Act applies to the provision of services including health services. I will speak first about cultural diversity in relation to the patient. In this respect it is worth mentioning that the recognition of cultural diversity and appropriate responses to it were issues which were strongly emphasised in the public consultation process which we held earlier this year in the context of developing National Anti-Poverty targets for the health sector and also our new national health strategy. Awareness and sensitivity training for staff is a key requirement for adapting to a culturally diverse patient population. The focus of this training should be the development of the knowledge and skills to provide services sensitive to cultural diversity. Such training can often be most effectively delivered in partnership with members of the minority groups themselves. I am aware that the Traveller community, for example, is involved in in-service training for health care workers. I am also aware that the National Consultative Committee on Racism and Interculturalism has been involved in training with the Eastern Regional Health Authority. We need to have more such initiatives. A step beyond the sensitivity training for existing staff is the training of members of the minority communities themselves as workers in our health services. Again the Traveller community has set an example in this area with its Primary Health Care Project for Travellers. The Primary Health Care for Travellers Project was established in 1994 as a joint partnership initiative with the Eastern Health Board and Pavee Point, with ongoing technical assistance being provided from the Department of Community Health and General Practice, Trinity College, Dublin. This project was the first of its kind in the country and has facilitated The project included a training course which concentrated on skills development, capacity building and the empowerment of Travellers. This confidence and skill allowed the Community Health Workers to go out and conduct a baseline survey to identify and articulate Travellers’ health needs. This was the first time that Travellers were involved in this process; in the past their needs were assumed. The results of the survey were fed back to the community and they prioritised their needs and suggested changes to the health services which would facilitate their access and utilisation. Ongoing monitoring and data collection demonstrates a big improvement in levels of satisfaction and uptake and ulitisation of health services by Travellers in the pilot area. This Primary Health Care for Travellers initiative is being replicated in three other areas around the country and funding has been approved for a further 9 new projects. This pilot project was the recipient of a WHO 50th anniversary commemorative award in 1998. The project is developing as a model of good practice which could inspire further initiatives of this type for other minority groups. Access to information has been identified in numerous consultative processes as a key factor in enabling people to take a proactive approach to managing their own health and that of their families and in facilitating their access to health services. Honouring our commitment to equity in these areas requires that information is provided in culturally appropriate formats. The National Health Promotion Strategy 2000-2005, for example, recognises that there exists within our society many groups with different requirements which need to be identified and accommodated when planning and implementing health promotion interventions. These groups include Travellers, refugees and asylum seekers, people with intellectual, physical or sensory disability and the gay and lesbian community. The Strategy acknowledges the challenge involved in being sensitive to the potential differences in patterns of poor health among these different groups. The Strategic aim is to promote the physical, mental and social well-being of individuals from these groups. The objective of the Strategy on these issues are: While our long term aim may be to mainstream responses so that our health services is truly multicultural, we must recognise the need at this point in time for very specific focused responses particularly for groups with poor health status such as Travellers and also for refugees and asylum seekers. In the case of refugees and asylum seekers examples of targeted services are screening for communicable diseases – offered on a voluntary basis – and psychological support services for those who have suffered trauma before coming here. The two approaches of targeting and mainstreaming are not mutually exclusive. A combination of both is required at this point in time but the balance between them must be kept under constant review in the light of changing needs. A major requirement if we are to meet the challenge of cultural diversity is an appropriate data and research base. I think it is important that we build up our information and research data base in partnership with the minority groups themselves. We must establish what the health needs of diverse groups are; we must monitor uptake of services and how well we are responding to needs and we must monitor outcomes and health status. We must also examine the impact of the policies in other sectors on the health of minority groups. The National Health Information Strategy, currently being developed, and the recently published National Strategy for Health Research – Making Knowledge Work for Health provide important frameworks within which we can improve our data and research base. A culturally diverse health sector workforce – challenges and opportunities The Irish health service can benefit greatly from successful international recruitment. There has been a strong non-national representation amongst the medical profession for more than 30 years. More recently there have been significant increases in other categories of health service workers from overseas. The Department recognises the enormous value that overseas recruitment brings over a wide range of services and supports the development of effective and appropriate recruitment strategies in partnership with health service employers. These changes have made cultural diversity an important issue for all health service organisations. Diversity in the workplace is primarily about creating a culture that seeks, respects, values and harnesses difference. This includes all the differences that when added together make each person unique. So instead of the focus being on particular groups, diversity is about all of us. Change is not about helping “them” to join “us” but about critically looking at “us” and rooting out all aspects of our culture that inappropriately exclude people and prevent us from being inclusive in the way we relate to employees, potential employees and clients of the health service. International recruitment benefits consumers, Irish employees and the overseas personnel alike. Regardless of whether they are employed by the health service, members of minority groups will be clients of our service and consequently we need to be flexible in order to accommodate different cultural needs. For staff, we recognise that coming from other cultures can be a difficult transition. Consequently health service employers have made strong efforts to assist them during this period. Many organisations provide induction courses, religious facilities (such as prayer rooms) and help in finding suitable accommodation. The Health Service Employers Agency (HSEA) is developing an equal opportunities/diversity strategy and action plans as well as training programmes to support their implementation, to ensure that all health service employment policies and practices promote the equality/diversity agenda to continue the development of a culturally diverse health service. The management of this new environment is extremely important for the health service as it offers an opportunity to go beyond set legal requirements and to strive for an acceptance and nurturing of cultural differences. Workforce cultural diversity affords us the opportunity to learn from the working practices and perspectives of others by allowing personnel to present their ideas and experience through teamwork, partnership structures and other appropriate fora, leading to further improvement in the services we provide. It is important to ensure that both personnel units and line managers communicate directly with their staff and demonstrate by their actions that they intend to create an inclusive work place which doesn´t demand that minority staff fit. Contented, valued employees who feel that there is a place for them in the organisation will deliver a high quality health service. Your conference here today has two laudable aims – to heighten awareness and assist health care staff to work effectively with their colleagues from different cultural backgrounds and to gain a greater understanding of the diverse needs of patients from minority ethnic backgrounds. There is a synergy in these aims and in the tasks to which they give rise in the management of our health service. The creative adaptations required for one have the potential to feed into the other. I would like to commend both organisations which are hosting this conference for their initiative in making this event happen, particularly at this time – Racism in the Workplace Week. I look forward very much to hearing the outcome of your deliberations. Thank you.

Cardiopulmonary support and extracorporeal membrane oxygenation for cardiac assist.

BACKGROUND: Use of cardiopulmonary bypass for emergency resuscitation is not new. In fact, John Gibbon proposed this concept for the treatment of severe pulmonary embolism in 1937. Significant progress has been made since, and two main concepts for cardiac assist based on cardiopulmonary bypass have emerged: cardiopulmonary support (CPS) and extracorporeal membrane oxygenation (ECMO). The objective of this review is to summarize the state of the art in these two technologies. METHODS: Configuration of CPS is now fairly standard. A mobile cart with relatively large wheels allowing for easy transportation carries a centrifugal pump, a back-up battery with a charger, an oxygen cylinder, and a small heating system. Percutaneous cannulation, pump-driven venous return, rapid availability, and transportability are the main characteristics of a CPS system. Cardiocirculatory arrest is a major predictor of mortality despite the use of CPS. In contrast, CPS appears to be a powerful tool for patients in cardiogenic shock before cardiocirculatory arrest, requiring some type of therapeutic procedures, especially repair of anatomically correctable problems or bridging to other mechanical circulatory support systems such as ventricular assist devices. CPS is in general not suitable for long-term applications because of the small-bore cannulas, resulting in significant pressure gradients and eventually hemolysis. RESULTS: In contrast, ECMO can be designed for longer-term circulatory support. This requires large-bore cannulas and specifically designed oxygenators. The latter are either plasma leakage resistent (true membranes) or relatively thrombo-resistant (heparin coated). Both technologies require oxygenator changeovers although the main reason for this is different (clotting for the former, plasma leakage for the latter). Likewise, the tubing within a roller pump has to be displaced and centrifugal pump heads have to be replaced over time. ECMO is certainly the first choice for a circulatory support system in the neonatal and pediatric age groups, where the other assist systems are too bulky. ECMO is also indicated for patients improving on CPS. Septic conditions are, in general, considered as contraindications for ECMO. CONCLUSIONS: Ease of availability and moderate cost of cardiopulmonary bypass-based cardiac support technologies have to be balanced against the significant immobilization of human resources, which is required to make them successful.

Cairde le Cheile CFI

Potatoes, cabbage, onions, carrots, turnips and a range of herbs are grown for use in the Cairde le Cheile Meals on Wheels service. The core workers in the garden are Rural Social Scheme participants. The gardens are open weekly on Monday and Tuesday and many people visit. Local Agenda 21 Initiative Type Meals on Wheels Location Mayo Target Groups Older people Funding Local Agenda 21 Partner Agencies HSE Mayo County Council The Community Foundation for Ireland

Centre Food Services

The catering section, at present, offers the following: The Resource Centre accommodates classes in Healthy Eating. In the near future we hope to offer Cookery Classes in Healthy Eating, and low income meals: teaching adults and children the importance of a healthy-balanced diet which is within a low income budget; showing them how to cook these meals; supervising groups while they cook a selection of dishes which incorporate the low cost, balanced diet Initiative Type Community Food Centres Meals on Wheels Nutrition Education and Training Programmes Location Dublin 10

WMR navigation using local potential field corridors and narrow local occupancy grid perception

Path planning and control strategies applied to autonomous mobile robots should fulfil safety rules as well as achieve final goals. Trajectory planning applications should be fast and flexible to allow real time implementations as well as environment interactions. The methodology presented uses the on robot information as the meaningful data necessary to plan a narrow passage by using a corridor based on attraction potential fields that approaches the mobile robot to the final desired configuration. It employs local and dense occupancy grid perception to avoid collisions. The key goals of this research project are computational simplicity as well as the possibility of integrating this method with other methods reported by the research community. Another important aspect of this work consist in testing the proposed method by using a mobile robot with a perception system composed of a monocular camera and odometers placed on the two wheels of the differential driven motion system. Hence, visual data are used as a local horizon of perception in which trajectories without collisions are computed by satisfying final goal approaches and safety criteria

Cerebellar cleft: confirmation of the neuroimaging pattern.

We recently described the neuroimaging and clinical findings in 6 children with cerebellar clefts and proposed that they result from disruptive changes following prenatal cerebellar hemorrhage. We now report an additional series of 9 patients analyzing the clinical and neuroimaging findings. The clefts were located in the left cerebellar hemisphere in 5 cases, in the right in 3, and bilaterally in one child who had bilateral cerebellar hemorrhages as a preterm infant at 30 weeks gestation. In one patient born at 24 weeks of gestation a unilateral cerebellar hemorrhage has been found at the age of 4 months. Other findings included disordered alignment of the folia and fissures, an irregular gray/white matter junction, and abnormal arborization of the white matter in all cases. Supratentorial abnormalities were found in 4 cases. All but 2 patients were born at term. We confirm the distinct neuroimaging pattern of cerebellar clefts. Considering the documented fetal cerebellar hemorrhage in our first series, we postulate that cerebellar clefts usually represent residual disruptive changes after a prenatal cerebellar hemorrhage. Exceptionally, as now documented in 2 patients, cerebellar clefts can be found after neonatal cerebellar hemorrhages in preterm infants. The short-term outcome in these children was variable.

Measurement of Pavement Surface Variations, July 1974

The measurement of pavement roughness has been the concern of highway engineers for more than 70 years. This roughness is referred to as "riding quality" by the traveling public. Pavement roughness evaluating devices have attempted to place either a graphical or numerical value on the public's riding comfort or discomfort. Early graphical roughness recorders had many different designs. In 1900 an instrument called the "Viagraph" was developed by an Irish engineer.' The "Viagraph" consisted of a twelve foot board with graphical recorder drawn over the pavement. The "Profilometer" built in Illinois in 1922 was much more impressive. ' The instrument's recorder was mounted on a frame supported by 32 bicycle wheels mounted in tandem. Many other variations of profilometers with recorders were built but most were difficult to handle and could not secure uniformly reproducible results. The Bureau of Public Roads (BPR) Road Roughness Indicator b u i l t in 1941 is the most widely used numerical roughness recorder.' The BPR Road Roughness Indicator consists of a trailer unit with carefully selected springs, means of dampening, and balanced wheel.

Iäkkään rukous

Summary: Prayer of the aged

Iowa DOT Evaluation of the PASCO Road Survey System, HR-539, 1987

The report compares and contrasts the automated PASCO method of pavement evaluation to the manual procedures used by the Iowa Department of Transportation (DOT) to evaluate pavement condition. Iowa DOT's use of IJK and BPR roadmeters and manual crack and patch surveys are compared to PASCO's use of 35-mm photography, artificial lighting and hairline projection, tracking wheels and lasers to measure ride, cracking and patching, rut depths, and roughness. The Iowa DOT method provides a Present Serviceability Index (PSI) value and PASCO provides a Maintenance Control Index (MCI). Seven sections of Interstate Highway, county roads and city streets, and one shoulder section were tested with different speeds of data collection, surface types and textures, and stop and start conditions. High correlation of results between the two methods in the measurement of roughness (0.93 for the tracking wheel and 0.84 for the laser method) were recorded. Rut depth correlations of 0.61 and cracking of 0.32 are attributed to PASCO's more comprehensive measurement techniques. A cost analysis of the data provided by both systems indicates that PASCO is capable of providing a comparable result with improved accuracy at a cost of $125-$150 or less per two-lane mile depending on survey mileage. Improved data collection speed, accuracy, and reliability, and a visible record of pavement condition for comparable costs are available. The PASCO system's ability to provide the data required in the Highway Pavement Distress Identification Manual, the Pavement Condition Rating Guide, and the Strategic Highway Research Program Long Term Pavement Performance (LTPP) Studies, is also outlined in the report.

Outcome of severe unilateral cerebellar hypoplasia.

Aim: Complete or subtotal absence of one cerebellar hemisphere is exceptional; only single cases have been described. We aimed to assess the long-term outcome in children with severe unilateral cerebellar hypoplasia (UCH). Method: As part of a retrospective study we describe neuroimaging features, clinical findings, and cognitive outcomes of seven children with UCH (five males, two females; age at first magnetic resonance imaging [MRI]: median 1y 3mo, range 9d-8y 10mo; age at latest follow-up: median 6y 6mo, range 2y 3mo-14y 11mo). Results: One child had abnormalities on prenatal MRI at 21 weeks' gestation. The left cerebellar hemisphere was affected in five children, and the right hemisphere in two children. The vermis was involved in five children. The volume of the posterior fossa was variable. At the latest follow-up, neurological findings included truncal ataxia and muscular hypotonia in five children, limb ataxia in three patients, and head nodding in two patients. Three children had learning disability*, five had speech and language disorders, and one had a severe behavioural disorder. Interpretation: Severe UCH is a residual change after a disruptive prenatal cerebellar insult, most likely haemorrhagic. The outcome is variable, ranging from almost normal development to marked developmental impairment. Ataxia is a frequent but not a leading sign. It seems that involvement of the cerebellar vermis is often, but not consistently, associated with a poorer cognitive outcome, whereas an intact vermis is associated with normal outcome and no truncal ataxia.

Gefäßchirurgische Ausbildung in endovaskulärer Technik in Lausanne

Between 1995 and 2005, the number of aortic aneurysms treated annually using endovascular techniques (EVAR) increased from 0 to 50, including all aortic stages. Our organization includes a large team of surgeons, a stock of three complete families of endoprostheses (straight, conical and bifurcated), a mobile trolley with accessories (arterial introducer/introducer sheath, guide wire, catheters, balloons, etc.) and an appliance on wheels for intravascular ultrasound examination (IVUS). This appliance, together with a mobile fluoroscopy device (c-arm), allows endovascular aneurysms analysis of every operating room in our institution, usually without angiography or the use of contrast medium. In general, we are therefore not depending on substantial preoperative imaging in order to identify candidates for endovascular aneurysms repair and can treat abdominal and thoracic aortic ruptures without delay. For endovascular aortic aneurysms repair we distinguish between process steps on the one hand (determining indications, imaging of the access vessels, measurement using IVUS and road mapping via fluoroscopy, selection of implant, implant insertion, positioning, setting the implant, determining success, reconstruction of the access vessel and follow-up) and the level of competence on the other (assistant, senior and directing physicians). Our ultrasound supported technique for endovascular aneurysms repair has been successfully brought to other hospitals using an IVUS transporter and telementoring.

Mesurar el temps al Magrib: la determinació de les hores d'oració

The calculation of time prayer is a key element of the Islam. Therefore specialists in this field, the muwaqqits, appeared. In al-Andalus and the Magrib there are a great number of scholars, some of which, like al-Mu"addib and al-Tájúrí are good examples of the literature that they generated.

Nelitietrukin ohjausjärjestelmän suunnittelu QFD-laatutyökalua hyväksikäyttäen

Tämä työ käsittelee tuotekehitysprojektia, jonka tarkoituksena on suunnitella uusi nelitietyöntömastotrukki asiakaslähtöisesti QFD-laatutyökalua hyväksi käyttäen. Työ esittelee QFD-laatutyökalun, sekä varsinkin sen nelivaiheisen ASI:n toimintamallin. Työ antaa myös perusvalmiudet ASI:n toimintamallin käyttöön tuotekehitysprojektissa. Työssä keskitytään tarkastelemaan uuden ohjausjärjestelmän mekaanista kehittelyä. Suunnittelutyössä käytetään hyväksi ASI:n (American Supplier Institute) nelivaiheista QFD-laatutyökalua, joka on autoteollisuuden toimintatapoihin perustuva QFD-tekniikka. QFD tulee sanoista Quality Funcktion Deployment ja vapaasti suomennettuna se merkitsee asiakaslähtöinen tuotesuunnittelu. Nelivaiheinen QFD-malli koostuu seuraavista matriiseista: 1. Tuotteen suunnittelu, 2. osien suunnittelu ja kehittäminen, 3. prosessin suunnittelu sekä 4. tuotannon suunnittelu. Matriisin tulokset muodostavat aina seuraavan matriisin lähtökohdat. Ensimmäisen matriisin lähtökohdat muodostuvat asiakastarvekuvauksesta, joka saadaan haastatteluista, tutkimuksista yms. Tuotekehitysprojektissa kehitetty TEM-monitietrukki, jossa rajattomasti ympäripyöriviä tukipyöriä ohjataan CAN-väylän kautta älykkäällä ohjauslogiikalla, on markkinoilla erittäin kilpailukykyinen sekä ominaisuuksiensa että hintansa puolesta. QFD yhdessä huolellisesti analysoidun asiakastarvekuvauksen kanssa selkeyttää ja priorisoi tuotteen spesifikaation määrittelyä sekä ohjaa tuotteen kehittelyä ja tuotannollistamista. Tuotekehitysprojekti pysyy aikataulussaan ja tuotannollistamisen kynnyksellä tehtävät muutokset vähenevät selkeän jäsentelyn ansiosta.

Vannesahalinjan tuotantokapasiteetin kasvattaminen konstruktiota kehittämällä

Tässä tutkimuksessa selvitetään, mitä muutoksia vannesahalinjan koneisiin tulee tehdä, jotta syöttönopeutta voidaan nostaa. Lisäksi työn perusteella on onnistuttu sahaamaan tuotannossa ohuemmalla terärungolla samalla mittatarkkuudella kuin aikaisemmin paksummalla terärungolla. Työssä on kartoitettu kyseessä olevan vannesahalinjan todennäköisimmät pullonkaulat nopeutta nostettaessa. Lisäksi on tarkasteltu mittauksin eräiden kriittisten koneiden käyttäytymistä sahauksen aikana. Mittausten perusteella on tehty ehdotukset tarvittaville konstruktiomuutoksille, jotta sahaus korotetulla nopeudella onnistuu hyvällä mittatarkkuudella. Tutkimuksen aikana on kehitetty mittausjärjestelmä, jolla vannesahan teräpyörien muoto voidaan mitata ja siirtää tietokoneelle myöhempää tarkastelua ja arkistointia varten.

Satamanosturin dynamiikan reaaliaikasimulointi

Työn tavoitteena oli mallintaa satamanosturin dynamiikkaa mahdollisimman tarkasti kuvaava yksinkertaistettu malli Simulink-ohjelmalla, jonka jälkeen malli käännettiin edelleen reaaliaikasimulaattorille soveltuvaan muotoon. Nosturin malli yksinkertaistettiin käsittämään kolme osaa: Nosturin rungon, nostovaunun ja kontin. Voimista mallinnettiin pyörien kontaktivoimat, köysivoimat sekä siirtovoima. Reaaliaikasimulaattorina käytettiin Opal-RT:n RT-LAB reaaliaikasimulointiohjelmistoa, sekä tavallisia PC-tietokoneita. Simulointiin liitettiin myös 3D-animaatio, jolla nosturin liikkeet saatiin visualisoitua. Animoitava grafiikka luotiin WorldUp-ohjelmistolla ja liitettiin RT-LAB-simulaatioon RT3D-rajapinnan ja WorldUp Player:n avulla. Työn tuloksena saatiin satamanosturin dynaamista käyttäytymistä kuvaava Simulink-malli, jota on mahdollista käyttää reaaliaikaisessa simuloinnissa. Mallia testattiin RT-LAB reaaliaikasimulaattorissa, ja simuloinnista saatuja tuloksia verrattiin Adams:lla simuloituihin tuloksiin. Saatujen tulosten perusteella mallia voidaan pitää onnistuneena. Myös RT-LAB reaaliaikasimulaattori visualisointeineen vaikuttaa toimivalta kokonaisuudelta.