Attending Physician Variability: A Model of Four Supervisory Styles

Purpose: There is wide variability in how attending physician roles on teaching teams, including patient care and trainee learning, are enacted. This study sought to better understand variability by considering how different attendings configured and rationalized direct patient care, trainee oversight, and teaching activities. 

Method: Constructivist grounded theory guided iterative data collection and analyses. Data were interviews with 24 attending physicians from two academic centers in Ontario, Canada, in 2012. During interviews, participants heard a hypothetical presentation and reflected on it as though it were presented to their team during a typical admission case review. 

Results: Four supervisory styles were identified: direct care, empowerment, mixed practice, and minimalist. Driven by concerns for patient safety, direct care involves delegating minimal patient care responsibility to trainees. Focused on supporting trainees’ progressive independence, empowerment uses teaching and oversight strategies to ensure quality of care. In mixed practice, patient care is privileged over teaching and is adjusted on the basis of trainee competence and contextual features such as patient volume. Minimalist style involves a high degree of trust in senior residents, delegating most patient care, and teaching to them. Attendings rarely discussed their styles with the team. 

Conclusions: The model adds to the literature on variability in supervisory practice, showing that the four styles reflect different ways of responding to tensions in the role and context. This model could be refined through observational research exploring the impact of context on style development and enactment. Making supervisory styles explicit could support improvement of team competence.

Heller's myotomy and pneumatic dilatation in the treatment of achalasia: a population-based case–control study assessing long-term quality of life

Long-term health-related quality-of-life (HRQL) outcomes have not been widely reported in the
treatment of achalasia. The aims of this study were to examine long-term disease-specific and general HRQL in
achalasia patients using a population-based case–control method, and to assess HRQL between treatment interventions.
Manometrically diagnosed achalasia cases (n = 120) were identified and matched with controls (n = 115)
using a population-based approach. Participants completed general (SF-12) and disease-specific (Achalasia Severity
Questionnaire [ASQ]) HRQL questionnaires, as appropriate, in a structured interview. Mean composite scores
for SF-12 (Mental Component Summary score [MCS-12] and Physical Component Summary score [PCS-12]) and
ASQ were compared between cases and controls, or between intervention groups, using an independent t-test.
Adjusted mean differences in HRQL scores were evaluated using a linear regression model. Achalasia cases were
treated with a Heller’s myotomy (n = 43), pneumatic dilatation (n = 44), or both modalities (n = 33). The median
time from last treatment to HRQL assessment was 5.7 years (interquartile range 2.4–11.5). Comparing achalasia
patients with controls, PCS-12 was significantly worse (40.9 vs. 44.2, P = 0.01), but MCS-12 was similar. However,
both PCS-12 (39.9 vs. 44.2, P = 0.03) and MCS-12 (46.7 vs. 53.5, P = 0.004) were significantly impaired in those
requiring dual treatment compared with controls. Overall however, there was no difference in adjusted HRQL
between patients treated with Heller’s myotomy, pneumatic dilatation or both treatment modalities. In summary,
despite treatment achalasia patients have significantly worse long-term physical HRQL compared with population
controls. No HRQL differences were observed between the treatment modalities to suggest a benefit of one
treatment over another.

Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients

BACKGROUND:
A cancer diagnosis may lead to significant psychological distress in up to 75% of cases. There is a lack of clarity about the most effective ways to address this psychological distress.
OBJECTIVES:
To assess the effects of psychosocial interventions to improve quality of life (QoL) and general psychological distress in the 12-month phase following an initial cancer diagnosis.
SEARCH METHODS:
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE, EMBASE, and PsycINFO up to January 2011. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. Electronic searches were carried out across all primary sources of peer-reviewed publications using detailed criteria. No language restrictions were imposed.
SELECTION CRITERIA:
Randomised controlled trials of psychosocial interventions involving interpersonal dialogue between a 'trained helper' and individual newly diagnosed cancer patients were selected. Only trials measuring QoL and general psychological distress were included. Trials involving a combination of pharmacological therapy and interpersonal dialogue were excluded, as were trials involving couples, family members or group formats.
DATA COLLECTION AND ANALYSIS:
Trial data were examined and selected by two authors in pairs with mediation from a third author where required. Where possible, outcome data were extracted for combining in a meta-analyses. Continuous outcomes were compared using standardised mean differences and 95% confidence intervals, using a random-effects model. The primary outcome, QoL, was examined in subgroups by outcome measurement, cancer site, theoretical basis for intervention, mode of delivery and discipline of trained helper. The secondary outcome, general psychological distress (including anxiety and depression), was examined according to specified outcome measures.
MAIN RESULTS:
A total of 3309 records were identified, examined and the trials subjected to selection criteria; 30 trials were included in the review. No significant effects were observed for QoL at 6-month follow up (in 9 studies, SMD 0.11; 95% CI -0.00 to 0.22); however, a small improvement in QoL was observed when QoL was measured using cancer-specific measures (in 6 studies, SMD 0.16; 95% CI 0.02 to 0.30). General psychological distress as assessed by 'mood measures' improved also (in 8 studies, SMD - 0.81; 95% CI -1.44 to - 0.18), but no significant effect was observed when measures of depression or anxiety were used to assess distress (in 6 studies, depression SMD 0.12; 95% CI -0.07 to 0.31; in 4 studies, anxiety SMD 0.05; 95% CI -0.13 to 0.22). Psychoeducational and nurse-delivered interventions that were administered face to face and by telephone with breast cancer patients produced small positive significant effects on QoL (in 2 studies, SMD 0.23; 95% CI 0.04 to 0.43).
AUTHORS' CONCLUSIONS:
The significant variation that was observed across participants, mode of delivery, discipline of 'trained helper' and intervention content makes it difficult to arrive at a firm conclusion regarding the effectiveness of psychosocial interventions for cancer patients. It can be tentatively concluded that nurse-delivered interventions comprising information combined with supportive attention may have a beneficial impact on mood in an undifferentiated population of newly diagnosed cancer patients.

On the Ontological Quality and Logical Quality of Conceptual-Modeling Grammars: The Need for a Dual Perspective

A core activity in information systems development involves building a conceptual model of the domain that an information system is intended to support. Such models are created using a conceptual-modeling (CM) grammar. Just as high-quality conceptual models facilitate high-quality systems development, high-quality CM grammars facilitate high-quality conceptual modeling. This paper provides a new perspective on ways to improve the quality of the semantics of CM grammars. For many years, the leading approach to this topic has relied on ontological theory. We show, however, that the ontological approach captures only half the story. It needs to be coupled with a logical approach. We explain how the ontological quality and logical quality of CM grammars interrelate. Furthermore, we outline three contributions that a logical approach can make to evaluating the quality of CM grammars: a means of seeing some familiar conceptual-modeling problems in simpler ways; the illumination of new problems; and the ability to prove the benefit of modifying existing CM grammars in particular ways. We demonstrate these benefits in the context of the Entity-Relationship grammar. More generally, our paper opens up a new area of research with many opportunities for future research and practice.

Exploring the links between urban stucture and air quality

A poluição atmosférica constitui actualmente um grave problema ambiental cujos efeitos se fazem sentir a diversas escalas, desde os efeitos imediatos e de longo termo na saúde humana e nos materiais, até fenómenos regionais, como a acificação, e fenómenos globais que durante este século poderão alterar as condições de vida no globo. Apesar da redução das emissões de poluentes atmosféricos, conseguida através do uso de combustíveis mais limpos e tecnologias mais eficientes, as áreas urbanas continuam a evidenciar sinais de degradação ambiental. Para ser bem sucedida a cidade deve enfrentar as três dimensões da sustentabilidade: social, económica e ambiental. O modo de utilização do solo numa zona urbana é uma característica fundamental da cidade, com influência directa no seu desempenho ambiental e na qualidade de vida que proporciona à população. O presente trabalho explora a ligação entre a estrutura urbana e a qualidade do ar, um dos muitos aspectos do desenvolvimento urbano sustentável. A perspectiva histórica sobre o desenvolvimento urbano, a poluição atmosférica e a sua interligação é abordada, bem como o trabalho de investigação que tem vindo a ser conduzido na área. A aplicação de um sistema de modelação atmosférico a um caso de estudo idealizado demonstra a importância da estrutura espacial da cidade na sustentabilidade urbana, mostrando que cidades compactas com usos do solo misturados promovem uma melhor qualidade do ar quando comparadas com cidades dispersas, com baixa densidade populacional. De modo a explorar a relação entre a estrutura urbana e a qualidade do ar numa zona urbana real, a região urbana do Porto é identificada como um caso de estudo adequado, e o processo de crescimento urbano nas últimas décadas é analisado, assim como os níveis de qualidade do ar da região. De modo a definir a configuração do sistema de modelação mais adequada para a região de estudo, são efectuados diversos testes de sensibilidade com o modelo meteorológico. Relativamente ao modelo de qualidade do ar, é descrito e implementado um conjunto de acções de modo a melhorar o desempenho do modelo para a simulação das concentrações de poluentes na atmosfera urbana, no contexto de alterações do uso do solo. Finalmente, são desenvolvidos e testados, através da aplicação do sistema de modelação, dois cenários alternativos de desenvolvimento urbano para a área de estudo. Estes cenários alternativos implicam diferentes emissões de poluentes e diferentes distribuições espaciais dessas emissões, e como consequência, diferentes níveis de qualidade do ar. O estudo permite concluir que alterações nos padrões de uso do solo em áreas urbanas conduzem a alterações na meteorologia, emissões e qualidade do ar. As áreas urbanas dispersas, quando comparadas com estruturas urbanas compactas são responsáveis por temperaturas mais elevadas, emissões de poluentes para a atmosfera mais elevadas e maiores concentrações de poluentes.

Cumulus momentum fluxes in cloud-resolving model simulations of toga-coare

O objectivo deste trabalho científico é o estudo do transporte vertical de momento linear horizontal (CMT) realizado por sistemas de nuvens de convecção profunda sobre o oceano tropical. Para realizar este estudo, foram utilizadas simulações tridimensionais produzidas por um modelo explícito de nuvens (CRM) para os quatro meses de duração da campanha observacional TOGA COARE que ocorreu sobre as águas quentes do Pacífico ocidental. O estudo foca essencialmente as características estatísticas e à escala da nuvem do CMT durante um episódio de fortes ventos de oeste e durante um período de tempo maior que incluí este evento de convecção profunda. As distribuições verticais e altitude-temporais de campos atmosféricos relacionados com o CMT são avaliadas relativamente aos campos observacionais disponíveis, mostrando um bom acordo com os resultados de estudos anteriores, confirmando assim a boa qualidade das primeiras e fornecendo a confiança necessária para continuar a investigação. A sensibilidade do CMT em relação do domínio espacial do model é analisada, utilizando dois tipos de simulações tridimensionais produzidas por domínios horizontais de diferente dimensão, sugerindo que o CMT não depende da dimensão do domínio espacial horizontal escolhido para simular esta variável. A capacidade da parameterização do comprimento de mistura simular o CMT é testada, destacando as regiões troposféricas onde os fluxos de momento linear horizontal são no sentido do gradiente ou contra o gradiente. Os fluxos no sentido do gradiente apresentam-se relacionados a uma fraca correlação entre os campos atmosféricos que caracterizam esta parameterização, sugerindo que as formulações dos fluxos de massa dentro da nuvem e o fenómeno de arrastamento do ar para dentro da nuvem devem ser revistos. A importância do ar saturado e não saturado para o CMT é estudada com o objectivo de alcançar um melhor entendimento acerca dos mecanismos físicos responsáveis pelo CMT. O ar não saturado e saturado na forma de correntes descendentes contribuem de forma determinante para o CMT e deverão ser considerados em futuras parameterizações do CMT e da convecção em nuvens cumulus. Métodos de agrupamento foram aplicados às contribuições do ar saturado e não saturado, analisando os campos da força de flutuação e da velocidade vertical da partícula de ar, concluindo-se a presença de ondas gravíticas internas como mecanismo responsável pelo ar não saturado. A força do gradiente de pressão dentro da nuvem é também avaliada, utilizando para este efeito a fórmula teórica proposta por Gregory et al. (1997). Uma boa correlação entre esta força e o produto entre efeito de cisalhamento do vento e a perturbação da velocidade vertical é registada, principalmente para as correntes ascendentes dentro da nuvem durante o episódio de convecção profunda. No entanto, o valor ideal para o coeficiente empírico c*, que caracteriza a influência da força do gradiente de pressão dentro da nuvem sobre a variação vertical da velocidade horizontal dentro da nuvem, não é satisfatoriamente alcançado. Bons resultados são alcançados através do teste feito à aproximação do fluxo de massa proposta por Kershaw e Gregory (1997) para o cálculo do CMT total, revelando mais uma vez a importância do ar não saturado para o CMT.

Microbiological quality of bivalves: relevance to food safety

Os moluscos bivalves constituem um recurso haliêutico de elevada importância na economia (inter)nacional pelas suas características organolépticas, valor nutritivo e relevância na gastronomia tradicional. Não obstante, representam um produto alimentar de elevado risco para a saúde pública. A contaminação microbiológica (autóctone e antropogénica), sendo crónica nos bancos de bivalves das zonas estuarino-lagunares, constitui uma das principais preocupações associadas à segurança alimentar. Aquando da filtração inerente aos processos de respiração e alimentação, os bivalves bioacumulam passivamente microrganismos incluindo os patogénicos. A sua colocação no mercado impõe pois, prévia salubrização para níveis microbiológicos compatíveis com a legislação em vigor, salvaguardando a saúde pública. Apesar da monitorização das áreas de apanha e produção, das medidas de prevenção e da depuração, a ocorrência de surtos associados ao consumo de bivalves tem aumentado. Tal deve-se à insuficiente monitorização da contaminação microbiológica dos bivalves, contribuindo para uma gestão ineficaz do produto e consequente sub-valorização. O presente trabalho pretendeu caracterizar o estado de desenvolvimento do sector de exploração de bivalves em Portugal do ponto de vista da segurança alimentar, e analisar os aspectos cruciais da monitorização e da depuração do produto apresentando alternativas abrangentes e aplicáveis ao sector. Assim, desenvolveu-se uma metodologia de base molecular passível de adaptação à monitorização dos bivalves das zonas conquícolas, como alternativa ao método de referência vigente do Número Mais Provável que é baseado apenas na quantificação de Escherichia coli. O mexilhão (Mytilus edulis) da Ria de Aveiro, bivalve de interesse comercial a nível (inter)nacional serviu de modelo para a comparação de protocolos de extração de DNA. Esta metodologia foi desenvolvida de modo a que os métodos de extração de DNA sejam passíveis de aplicação a outras matrizes biológicas ou ambientais. Para além da detecção e quantificação directa de bactérias patogénicas, esta metodologia poderá ser aplicada à monitorização da transferência vertical microbiana nos bancos de bivalves bem como à caracterização da dinâmica espacio-temporal das populações microbianas no ambiente e à monitorização dos processos de depuração. Foi ainda abordado o potencial da aplicação de bacteriófagos ou de enzimas líticas para a optimização dos processos de purificação. O trabalho realizado e as perspectivas futuras propostas pretendem contribuir para a dinamização e requalificação do sector de exploração de bivalves através da melhoria do nível de segurança alimentar dos moluscos bivalves comercializados para alimentação humana, valorizando este recurso.

Regional and urban air quality modelling under a climate change scenario

The better understanding of the interactions between climate change and air quality is an emerging priority for research and policy. Climate change will bring changes in the climate system, which will affect the concentration and dispersion of air pollutants. The main objective of the current study is to assess the impacts of climate change on air quality in 2050 over Portugal and Porto urban area. First, an evaluation and characterization of the air quality over mainland Portugal was performed for the period between 2002 and 2012. The results show that NO2, PM10 and O3 are the critical pollutants in Portugal. Also, the influence of meteorology on O3, NO2 and PM10 levels was investigate in the national main urban areas (Porto and Lisboa) and was verified that O3 has a statistically significant relationship with temperature in most of the components. The results also indicate that emission control strategies are primary regulators for NO2 and PM10 levels. After, understanding the national air quality problems and the influence that meteorology had in the historical air quality levels, the air quality modelling system WRF-CAMx was tested and the required inputs for the simulations were prepared to fulfil the main goal of this work. For the required air quality modelling inputs, an Emission Projections under RCP scenarios (EmiPro-RCP) model was developed to assist the estimation of future emission inventories for GHG and common air pollutants. Also, the current emissions were estimated for Portugal with a higher detailed disaggregation to improve the performance of the air quality simulations. The air quality modelling system WRF/CAMx was tested and evaluated over Portugal and Porto urban area and the results point out that is an adequate tool for the analysis of air quality under climate change. For this purpose, regional simulations of air quality during historical period and future (2045-2050) were conducted with CAMx version 6.0 to evaluate the impacts of simulated future climate and anthropogenic emission projections on air quality over the study area. The climate and the emission projections were produced under the RCP8.5 scenario. The results from the simulations point out, that if the anthropogenic emissions keep the same in 2050, the concentrations of NO2, PM10 and O3 will increase in Portugal. When, besides the climate change effects, is consider the projected anthropogenic emissions the annual mean concentrations of NO2 decrease significantly in Portugal and Porto urban area, and on the contrary the annual mean PM10 concentrations increases in Portugal and decrease in Porto urban area. The O3 results are mainly caused by the reduction of ozone precursors, getting the higher reductions in urban areas and increases in the surrounding areas. All the analysis performed for both simulations for Porto urban area support that, for PM10 and O3, there will be an increase in the occurrence of extreme values, surpassing the annual legislated parameters and having more daily exceedances. This study constitutes an innovative scientific tool to help in future air quality management in order to mitigate future climate change impacts on air quality.

Development of infrared spectroscopy for assessing bacterial quality in foods

Rapid and specific detection of foodborne bacteria that can cause food spoilage or illness associated to its consumption is an increasingly important task in food industry. Bacterial detection, identification, and classification are generally performed using traditional methods based on biochemical or serological tests and the molecular methods based on DNA or RNA fingerprints. However, these methodologies are expensive, time consuming and laborious. Infrared spectroscopy is a reliable, rapid, and economic technique which could be explored as a tool for bacterial analysis in the food industry. In this thesis it was evaluated the potential of IR spectroscopy to study the bacterial quality of foods. In Chapter 2, it was developed a calibration model that successfully allowed to predict the bacterial concentration of naturally contaminated cooked ham samples kept at refrigeration temperature during 8 days. In this part, it was developed the methodology that allowed the best reproducibility of spectra from bacteria colonies with minimal sample preparation, which was used in the subsequent work. Several attempts trying different resolutions and number of scans in the IR were made. A spectral resolution of 4 cm-1, with 32 scans were the settings that allowed the best results. Subsequently, in Chapter 3, it was made an attempt to identify 22 different foodborne bacterial genera/species using IR spectroscopy coupled with multivariate analysis. The principal component analysis, used as an exploratory technique, allowed to form distinct groups, each one corresponding to a different genus, in most of the cases. Then, a hierarchical cluster analysis was performed to further analyse the group formation and the possibility of distinction between species of the same bacterial genus. It was observed that IR spectroscopy not only is suitable to the distinction of the different genera, but also to differentiate species of the same genus, with the simultaneous use of principal component analysis and cluster analysis techniques. The utilization of IR spectroscopy and multivariate statistical analysis were also investigated in Chapter 4, in order to confirm the presence of Listeria monocytogenes and Salmonella spp. isolated from contaminated foods, after growth in selective medium. This would allow to substitute the traditional biochemical and serological methods that are used to confirm these pathogens and that delay the obtainment of the results up to 2 days. The obtained results allowed the distinction of 3 different Listeria species and the distinction of Salmonella spp. from other bacteria that can be mistaken with them. Finally, in chapter 5, high pressure processing, an emerging methodology that permits to produce microbiologically safe foods and extend their shelf-life, was applied to 12 foodborne bacteria to determine their resistance and the effects of pressure in cells. A treatment of 300 MPa, during 15 minutes at room temperature was applied. Gram-negative bacteria were inactivated to undetectable levels and Gram-positive showed different resistances. Bacillus cereus and Staphylococcus aureus decreased only 2 logs and Listeria innocua decreased about 5 logs. IR spectroscopy was performed in bacterial colonies before and after HPP in order to investigate the alterations of the cellular compounds. It was found that high pressure alters bands assigned to some cellular components as proteins, lipids, oligopolysaccharides, phosphate groups from the cell wall and nucleic acids, suggesting disruption of the cell envelopes. In this work, bacterial quantification and classification, as well as assessment of cellular compounds modification with high pressure processing were successfully performed. Taking this into account, it was showed that IR spectroscopy is a very promising technique to analyse bacteria in a simple and inexpensive manner.

Coupling anchovy eggs and hydrodynamic model as an assessement tool for estuarine ecohydrological management

Nitrate and urban waste water directives have raised the need for a better understanding of coastal systems in European Union. The incorrect application of these directives can lead to important ecological or social penalties. In the paper this problem is addressed to Ria Formosa Coastal Lagoon. Ria Formosa hosts a Natural Park, important ports of the southern Portuguese coast and significant bivalve aquaculture activity. Four major urban waste water treatment plants discharging in the lagoon are considered in this study. Its treatment level must be selected, based on detailed information from a monitoring program and on a good knowledge of the processes determining the fate of the material discharged in the lagoon. In this paper the results of a monitoring program and simulations using a coupled hydrodynamic and water quality / ecological model, MOHID, are used to characterise the system and to understand the processes in Ria Formosa. It is shown that the water residence time in most of the lagoon is quite low, of the order of days, but it can be larger in the upper parts of the channels where land generated water is discharged. The main supply of nutrients to the lagoon comes from the open sea rather than from the urban discharges. For this reason the characteristics and behaviour of the general lagoon contrasts with the behaviour of the upper reaches of the channels where the influence of the waste water treatment plants are high. In this system the bottom mineralization was found to be an important mechanism, and the inclusion of that process in the model was essential to obtain good results.

Hydrodynamic model intercomparison for the patos lagoon (Brazil)

An intercomparison study is carried out between two models with different formulations and spatial discretizations in order to overcome the limitations posed by the standard calibration and validation procedures and improve confidence in the hydrodynamic results for the Patos Lagoon. Numerical simulations were carried out applying the TELEMAC and MOHID models, based on the same boundary conditions and identical calibration coefficients so differences in calculated flow conditions result from the formulations and parameterizations of each model. Results from both models are compared with measurements from three stations inside the lagoon. Preliminary results indicate that both models compare well with the measurements and with each other. These results increase the confidence on hydrodynamic results for the Patos Lagoon and provide the first step towards water quality studies for the area.

Simulation of economic benefits achieved by water quality improvement for recreational and professional users, within the SPICOSSA SSA (SPICOSSA System Approach) 11 - Guadiana estuary ecosystem sic

Dissertação de Mestrado, Gestão da Água e da Costa, Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2010

Implementation of a service quality strategy: application to the Algarve hotel industry

Tese dout., Doctor of Philisophy, Sheffield Hallam University, 2001

SWOT analysis of a pediatric rehabilitation programme : a participatory evaluation fostering quality improvement

Purpose. To present the results of a strengths, weaknesses, opportunities and threats (SWOT) analysis used as part of a process aimed at reorganising services provided within a pediatric rehabilitation programme (PRP) in Quebec, Canada and to report the perceptions of the planning committee members regarding the usefulness of the SWOT in this process. Method. Thirty-six service providers working in the PRP completed a SWOT questionnaire and reported what they felt worked and what did not work in the existing model of care. Their responses were used by a planning committee over a 12- month period to assist in the development of a new service delivery model. Committee members shared their thoughts about the usefulness of the SWOT. Results. Current programme strengths included favourable organisational climate and interdisciplinary work whereas weaknesses included lack of psychosocial support to families and long waiting times for children. Opportunities included working with community partners, whereas fear of losing professional autonomy with the new service model was a threat. The SWOT results helped the planning committee redefine the programme goals and make decisions to improve service coordination. SWOT analysis was deemed as a very useful tool to help guide service reorganisation. Conclusions. SWOT analysis appears to be an interesting evaluation tool to promote awareness among service providers regarding the current functioning of a rehabilitation programme. It fosters their active participation in the reorganisation of a new service delivery model for pediatric rehabilitation.

Development, implementation, and evaluation of the Apollo model of pediatric rehabilitation service delivery

This article presents the experience of a rehabilitation program that un- dertook the challenge to reorganize its services to address accessibility issues and im- prove service quality. The context in which the reorganization process occurred, along with the relevant literature justifying the need for a new service delivery model, and an historical perspective on the planning; implementation; and evaluation phases of the process are described. In the planning phase, the constitution of the working committee, the data collected, and the information found in the literature are presented. Apollo, the new service delivery model, is then described along with each of its components (e.g., community, group, and individual interventions). Actions and lessons learnt during the implementation of each component are presented. We hope by sharing our experiences that we can help others make informed decisions about service reorganization to im- prove the quality of services provided to children with disabilities, their families, and their communities.