Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

High-throughput manufacturing of size-tuned liposomes by a new microfluidics method using enhanced statistical tools for characterization

Microfluidics has recently emerged as a new method of manufacturing liposomes, which allows for reproducible mixing in miliseconds on the nanoliter scale. Here we investigate microfluidics-based manufacturing of liposomes. The aim of these studies was to assess the parameters in a microfluidic process by varying the total flow rate (TFR) and the flow rate ratio (FRR) of the solvent and aqueous phases. Design of experiment and multivariate data analysis were used for increased process understanding and development of predictive and correlative models. High FRR lead to the bottom-up synthesis of liposomes, with a strong correlation with vesicle size, demonstrating the ability to in-process control liposomes size; the resulting liposome size correlated with the FRR in the microfluidics process, with liposomes of 50 nm being reproducibly manufactured. Furthermore, we demonstrate the potential of a high throughput manufacturing of liposomes using microfluidics with a four-fold increase in the volumetric flow rate, maintaining liposome characteristics. The efficacy of these liposomes was demonstrated in transfection studies and was modelled using predictive modeling. Mathematical modelling identified FRR as the key variable in the microfluidic process, with the highest impact on liposome size, polydispersity and transfection efficiency. This study demonstrates microfluidics as a robust and high-throughput method for the scalable and highly reproducible manufacture of size-controlled liposomes. Furthermore, the application of statistically based process control increases understanding and allows for the generation of a design-space for controlled particle characteristics.

Local economic development initiatives and the transition from training and enterprise councils to new institutional structures in England

Current British government economic development policy emphasises regional and sub-regional scale, multi-agent initiatives that form part of national frameworks to encourage a 'bottom up' approach to economic development. An emphasis on local multi-agent initiatives was also the mission of Training and Enterprise Councils (TECs). Using new survey evidence this article tracks the progress of a number of initiatives established under the TECs, using the TEC Discretionary Fund as an example. It assesses the ability of successor bodies to be more effective in promoting local economic development. Survey evidence is used to confirm that many projects previously set up by the TECs continue to operate successfully under new partnership arrangements. However as new structures have developed, and policy has become more centralized, it is less likely that similar local initiatives will be developed in future. There is evidence to suggest that with the end of the TECs a gap has emerged in the institutional infrastructure for local economic development, particularly with regard to workforce development. Much will depend in future on how the Regional Development Agencies deploy their growing power and resources.

An agent approach to improving radio frequency identification enabled Returnable Transport Equipment

Returnable transport equipment (RTE) such as pallets form an integral part of the supply chain and poor management leads to costly losses. Companies often address this matter by outsourcing the management of RTE to logistics service providers (LSPs). LSPs are faced with the task to provide logistical expertise to reduce RTE related waste, whilst differentiating their own services to remain competitive. In the current challenging economic climate, the role of the LSP to deliver innovative ways to achieve competitive advantage has never been so important. It is reported that radio frequency identification (RFID) application to RTE enables LSPs such as DHL to gain competitive advantage and offer clients improvements such as loss reduction, process efficiency improvement and effective security. However, the increased visibility and functionality of RFID enabled RTE requires further investigation in regards to decision‐making. The distributed nature of the RTE network favours a decentralised decision‐making format. Agents are an effective way to represent objects from the bottom‐up, capturing the behaviour and enabling localised decision‐making. Therefore, an agent based system is proposed to represent the RTE network and utilise the visibility and data gathered from RFID tags. Two types of agents are developed in order to represent the trucks and RTE, which have bespoke rules and algorithms in order to facilitate negotiations. The aim is to create schedules, which integrate RTE pick‐ups as the trucks go back to the depot. The findings assert that: - agent based modelling provides an autonomous tool, which is effective in modelling RFID enabled RTE in a decentralised utilising the real‐time data facility. ‐ the RFID enabled RTE model developed enables autonomous agent interaction, which leads to a feasible schedule integrating both forward and reverse flows for each RTE batch. ‐ the RTE agent scheduling algorithm developed promotes the utilisation of RTE by including an automatic return flow for each batch of RTE, whilst considering the fleet costs andutilisation rates. ‐ the research conducted contributes an agent based platform, which LSPs can use in order to assess the most appropriate strategies to implement for RTE network improvement for each of their clients.

Evaluation of vulnerability factors for cyclones : the case of Patuakhali, Bangladesh

Tropical cyclones are considered as the most severe natural disasters in Bangladesh; they cause extensive damage, create losses in the country׳s economy, and affect social settings. The impact of natural disasters has been further intensified due to various vulnerability factors within the Bangladeshi community such as low income; shortages of food; lack of assets such as land and permanent housing; dense population, illiteracy. This study evaluates the vulnerability factors for cyclones in the community based in the Patuakhali region of south western Bangladesh. The bottom-up research approach was adopted for the study, whereby the local community was consulted for their viewpoints by using focus group interviews and semi-structured interviews. Different community groups and social categories including both men and women, from different age groups and livelihoods, participated in the study. The study revealed how the community׳s vulnerability to cyclones has been further aggravated by socio-economic factors such as social status, political influences and economic conditions. The majority of the community in Patuakhali has been “knowingly” vulnerable to cyclone disaster as a result of the lack of alternatives especially in terms of their livelihood patterns. The vulnerability of women, due to their lack of authority, domestic work, and fear of exposure within the society was also highlighted. The study revealed how vulnerability factors are interlinked with each other making them further difficult to manage. This calls for multi-faceted disaster risk reduction strategies that targets vulnerability factors deriving from different origins and root causes.

Evaluation of vulnerability factors for cyclones:the case of Patuakhali, Bangladesh

Tropical cyclones are considered as the most severe natural disasters in Bangladesh; they cause extensive damage, create losses in the country[U+05F3]s economy, and affect social settings. The impact of natural disasters has been further intensified due to various vulnerability factors within the Bangladeshi community such as low income; shortages of food; lack of assets such as land and permanent housing; dense population, illiteracy. This study evaluates the vulnerability factors for cyclones in the community based in the Patuakhali region of south western Bangladesh. The bottom-up research approach was adopted for the study, whereby the local community was consulted for their viewpoints by using focus group interviews and semi-structured interviews. Different community groups and social categories including both men and women, from different age groups and livelihoods, participated in the study. The study revealed how the community[U+05F3]s vulnerability to cyclones has been further aggravated by socio-economic factors such as social status, political influences and economic conditions. The majority of the community in Patuakhali has been "knowingly" vulnerable to cyclone disaster as a result of the lack of alternatives especially in terms of their livelihood patterns. The vulnerability of women, due to their lack of authority, domestic work, and fear of exposure within the society was also highlighted. The study revealed how vulnerability factors are interlinked with each other making them further difficult to manage. This calls for multi-faceted disaster risk reduction strategies that targets vulnerability factors deriving from different origins and root causes. © 2014 Elsevier Ltd.

Partnering with governments and other institutions:driving change in diabetes care

The human and material cost of type 2 diabetes is a cause of increasing concern for health professionals, representative organisations and governments worldwide. The scale of morbidity and mortality has led the United Nations to issue a resolution on diabetes, calling for national policies for prevention, treatment and care. There is clearly an urgent need for a concerted response from all interested parties at the community, national and international level to work towards the goals of the resolution and create effective, sustainable treatment models, care systems and prevention strategies. Action requires both a 'bottom-up' approach of public awareness campaigns and pressure from healthcare professionals, coupled with a 'top-down' drive for change, via partnerships with governments, third sector (non-governmental) organisations and other institutions. In this review, we examine how existing collaborative initiatives serve as examples for those seeking to implement change in health policy and practice in the quest to alleviate the health and economic burden of diabetes. Efforts are underway to provide continuous and comprehensive care models for those who already have type 2 diabetes; in some cases, national plans extend to prevention strategies in attempts to improve overall public health. In the spirit of partnership, collaborations with governments that incorporate sustainability, long-term goals and a holistic approach continue to be a driving force for change. It is now critical to maintain this momentum and use the growing body of compelling evidence to educate, inform and deliver a long-term, lasting impact on patient and public health worldwide. © 2007 The Authors.

A New Class of Processes for Formalizing and Generalizing Individual-Based Models: The Semi-Semi-Markov Processes

2000 Mathematics Subject Classification: 60K15, 60K20, 60G20,60J75, 60J80, 60J85, 60-08, 90B15.

Scalable harmonization of complex networks with local controllers

Computational and communication complexities call for distributed, robust, and adaptive control. This paper proposes a promising way of bottom-up design of distributed control in which simple controllers are responsible for individual nodes. The overall behavior of the network can be achieved by interconnecting such controlled loops in cascade control for example and by enabling the individual nodes to share information about data with their neighbors without aiming at unattainable global solution. The problem is addressed by employing a fully probabilistic design, which can cope with inherent uncertainties, that can be implemented adaptively and which provide a systematic rich way to information sharing. This paper elaborates the overall solution, applies it to linear-Gaussian case, and provides simulation results.

Towards probabilistic synchronization of local controllers

The traditional use of global and centralised control methods, fails for large, complex, noisy and highly connected systems, which typify many real world industrial and commercial systems. This paper provides an efficient bottom up design of distributed control in which many simple components communicate and cooperate to achieve a joint system goal. Each component acts individually so as to maximise personal utility whilst obtaining probabilistic information on the global system merely through local message-passing. This leads to an implied scalable and collective control strategy for complex dynamical systems, without the problems of global centralised control. Robustness is addressed by employing a fully probabilistic design, which can cope with inherent uncertainties, can be implemented adaptively and opens a systematic rich way to information sharing. This paper opens the foreseen direction and inspects the proposed design on a linearised version of coupled map lattice with spatiotemporal chaos. A version close to linear quadratic design gives an initial insight into possible behaviours of such networks.

A megnyilvánult és kinyilvánított időpreferenciák - mennyire vagyunk rövidlátóak?

A társadalmi időpreferenciák vizsgálatához két út áll rendelkezésünkre; a megnyilvánult és a kinyilvánított időpreferenciák vizsgálata. A megnyilvánult preferenciák egyfajta top-down módszertan, vagyis a társadalmi időpreferenciákat makroadatokból számítják ki (pl. megtakarítások, jövedelemrugalmasság, gazdasági növekedés stb.) és vonnak le következtetéseket az emberek preferenciáival kapcsolatosan. Egy másik lehetséges módszer a diszkontráta meghatározásához a kinyilvánított preferenciák megfigyelése, illetve ami azt jelenti, hogy felmérések útján hipotetikus szituációkon át mérjük fel az egyén preferenciáit [Lippai, 2009], vagyis ez esetben egy bottom-up módszertant alkalmazunk.

Designing Lifestyle-specific Food Policies Based on Nutritional Requirements and Ecological Footprints.

Expanded understanding of the trends and determinants of food consumption is needed to reduce the ecological impacts of the contemporary agro-food system while also being attentive to broader issues pertaining to health and the environment. Incorporating these additional aspects and formulating meaningful dietary recommendations is a major challenge. This article seeks to highlight differences in ecological footprint (EF) by activity level for various so-cial groups to meet suggested physiological requirements by nutritionists versus actual food consumption. The study is based on a combination of healthy diet requirements (as expressed by national guidelines) and a survey of a repre-sentative sample of 1,013 Hungarian adults using a bottom-up approach for calculating EFs. Students and women with small children have a higher than average food-related EF due to their higher nutritional needs. At the same time, the elderly are characterized by lower footprints. Perhaps most interesting is our finding that people with seden-tary forms of employment have higher food footprints than those with jobs that require physical labor. We offer rec-ommendations for food-policy planning based on encouraging dietary changes for individuals, differentiated by the nature of their work. The research suggests that dietary policy that improves health often has environmental benefits.

Content and drivers of performance management in agency-type organizations of the hungarian public administration

The improving performance of public administration and the reform of public financing system have been on agenda in Hungary for many years, in accordance with the international trends. However, governments have not expected and supported creating of a performance-oriented public administration in a comprehensive and explicit way. Nevertheless, there are bottom-up initiatives at organizational level, which target performance-oriented organizational function. The research focuses on organizations of central public administration where the successful application of performance management methods is most likely based on the international literature. These are the so called agency-type organizations, which are in Hungary called autonomous state-administration organizations independent of the Government (e.g. Hungarian Competition Authority), government bureaus (e.g. Hungarian Central Statistical Office), and central offices subordinated to the government (either the cabinet or a ministry) (e.g. Hungarian Meteorological Service). The studied agencies are legally independent organizations with managerial autonomy based on public law. The purpose of this study is to get an overview on organizational level performance management tools applied by Hungarian agencies, and to reveal the reasons and drivers of the application of these tools. The empirical research is based on a mixed methods approach which combines both quantitative methods and qualitative procedures. The first – quantitative – phase of the author’s research was content analysis of homepages of the studied organizations. As a results she got information about all agencies and their practice related to some performance management tools. The second – qualitative – phase was based on semi-structured face-to-face interviews with some senior managers of agencies. The author selected the interviewees based on the results of the first phase, the relatively strong performance orientation was an important selection criteria.

Defining the role of floating periphyton mats in shaping food-web dynamics in the Florida Everglades

Expansive periphyton mats are a striking characteristic of the Florida Everglades. Floating periphyton mats are home to a diverse macroinvertebrate community dominated by chironomid and ceratopogonid larvae and amphipods that use the mat as both a food resource and refuge from predation. While this periphyton complex functions as a self-organizing system, it also serves as a base for trophic interactions with larger organisms. The purpose of my research was to quantify variation in the macroinvertebrate community inhabiting floating periphyton mats, describe the role of mats in shaping food-web dynamics, and describe how these trophic interactions change with eutrophication. ^ I characterized the macroinvertebrate community inhabiting periphyton through a wet-season by describing spatial variation on scales from 0.2 m to 3 km. Floating periphyton mats contained a diverse macroinvertebrate community, with greater taxonomic richness and higher densities of many taxa than adjacent microhabitats. Macroinvertebrate density increased through the wet season as periphyton mats developed. While some variation was noted among sites, spatial patterns were not observed on smaller scales. I also sampled ten sites representing gradients of hydroperiod and nutrient (P) levels. The density of macroinvertebrates inhabiting periphyton mats increased with increasing P availability; however, short-hydroperiod P-enriched sites had the highest macroinvertebrate density. This pattern suggests a synergistic interaction of top-down and bottom-up effects. In contrast, macroinvertebrate density was lower in benthic floc, where it was negatively correlated with hydroperiod. ^ I used two types of mesocosms (field cages and tanks) to manipulate large consumers (fish and grass shrimp) with inclusion/exclusion cages over an experimental P gradient. In most cases, periphyton mats served as an effective predation refuge. Macroinvertebrates were consumed more frequently in P-enriched treatments, where mats were also heavily grazed. Macroinvertebrate densities decreased with increasing P in benthic floc, but increased with enrichment in periphyton mats until levels were reached that caused disassociation of the mat. ^ This research documents several indirect trophic interactions that can occur in complex habitats, and emphasizes the need to characterize dynamics of all microhabitats to fully describe the dynamics of an ecosystem. ^

Relative significance of pelagic, benthic and allochthonous organic matter to microbial carbon cycling in a phosphorus-depleted subtropical estuary (Florida Bay)

Heterotrophic bacteria are important decomposers and transformers of primary production and provide an important link between detritus and the aquatic food web. In seagrass ecosystems, much of seagrass primary production is unavailable through direct grazing and must undergo microbial reworking before seagrass production can enter the aquatic food web. The goal of my dissertation research is to understand better the role heterotrophic bacteria play in carbon cycling in seagrass estuaries. My dissertation research focuses on Florida Bay, a seagrass estuary that has experienced recent changes in carbon source availability, which may have altered ecosystem function. My dissertation research investigates the importance of seagrass, algal and/or cyanobacterial, and allochthonous-derived organic matter to heterotrophic bacteria in Florida Bay and helps establish the carbon base of the estuarine food web. ^ A three tiered approach to the study of heterotrophic bacterial carbon cycling and trophic influences in Florida Bay was used: (1) Spatiotemporal observations of environmental parameters (hydrology, nutrients, extracellular enzymes, and microbial abundance, biomass, and production); (2) Microbial grazing experiments under different levels of top-down and bottom-up influence; and (3) Bulk and compound-specific (bacteria-biomarker fatty acid analysis) stable carbon isotope analysis. ^ In Florida Bay, spatiotemporal patterns in microbial extracellular enzyme (also called ectoenzyme) activities indicate that microorganisms hydrolyzed selectively fractions of the estuarine organic matter pool. The microbial community hydrolyzed organic acids, peptides, and phosphate esters and did not use storage and structural carbohydrates. Organic matter use by heterotrophic bacterioplankton in Florida Bay was co-regulated by bottom-up (resource availability) and top-down (grazer mediated) processes. A bacterial carbon budget based on bacterial, epiphytic, and seagrass production indicates that heterotrophic bacterial carbon cycles are supported primarily through epiphytic production with mixing from seagrass production. Stable carbon isotope analysis of bacteria biomarkers and carbon sources in Florida Bay corroborate the results of the bacterial carbon budget. These results support previous studies of aquatic consumers in Florida Bay, indicating that epiphytic/benthic algal and/or cyanobacterial production with mixing from seagrass-derived organic matter is the carbon base of the seagrass estuarine food web. ^