Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

Knight M, Acosta C, Brocklehurst P, Cheshire A, Fitzpatrick K, Hinton L, Jokinen M, Kemp B, Kurinczuk JJ, Lewis G, Lindquist A, Locock L, Nair M, Patel N, Quigley M, Ridge D, Rivero-Arias O, Sellers S, Shah A on behalf of the UKNeS coapplicant group. Background Studies of maternal mortality have been shown to result in important improvements to women’s health. It is now recognised that in countries such as the UK, where maternal deaths are rare, the study of near-miss severe maternal morbidity provides additional information to aid disease prevention, treatment and service provision. Objectives To (1) estimate the incidence of specific near-miss morbidities; (2) assess the contribution of existing risk factors to incidence; (3) describe different interventions and their impact on outcomes and costs; (4) identify any groups in which outcomes differ; (5) investigate factors associated with maternal death; (6) compare an external confidential enquiry or a local review approach for investigating quality of care for affected women; and (7) assess the longer-term impacts. Methods Mixed quantitative and qualitative methods including primary national observational studies, database analyses, surveys and case studies overseen by a user advisory group. Setting Maternity units in all four countries of the UK. Participants Women with near-miss maternal morbidities, their partners and comparison women without severe morbidity. Main outcome measures The incidence, risk factors, management and outcomes of uterine rupture, placenta accreta, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome, severe sepsis, amniotic fluid embolism and pregnancy at advanced maternal age (≥ 48 years at completion of pregnancy); factors associated with progression from severe morbidity to death; associations between severe maternal morbidity and ethnicity and socioeconomic status; lessons for care identified by local and external review; economic evaluation of interventions for management of postpartum haemorrhage (PPH); women’s experiences of near-miss maternal morbidity; long-term outcomes; and models of maternity care commissioned through experience-led and standard approaches. Results Women and their partners reported long-term impacts of near-miss maternal morbidities on their physical and mental health. Older maternal age and caesarean delivery are associated with severe maternal morbidity in both current and future pregnancies. Antibiotic prescription for pregnant or postpartum women with suspected infection does not necessarily prevent progression to severe sepsis, which may be rapidly progressive. Delay in delivery, of up to 48 hours, may be safely undertaken in women with HELLP syndrome in whom there is no fetal compromise. Uterine compression sutures are a cost-effective second-line therapy for PPH. Medical comorbidities are associated with a fivefold increase in the odds of maternal death from direct pregnancy complications. External reviews identified more specific clinical messages for care than local reviews. Experience-led commissioning may be used as a way to commission maternity services. Limitations This programme used observational studies, some with limited sample size, and the possibility of uncontrolled confounding cannot be excluded. Conclusions Implementation of the findings of this research could prevent both future severe pregnancy complications as well as improving the outcome of pregnancy for women. One of the clearest findings relates to the population of women with other medical and mental health problems in pregnancy and their risk of severe morbidity. Further research into models of pre-pregnancy, pregnancy and postnatal care is clearly needed.

A Scalable Design Framework for Variability Management in Large-Scale Software Product Lines

Variability management is one of the major challenges in software product line adoption, since it needs to be efficiently managed at various levels of the software product line development process (e.g., requirement analysis, design, implementation, etc.). One of the main challenges within variability management is the handling and effective visualization of large-scale (industry-size) models, which in many projects, can reach the order of thousands, along with the dependency relationships that exist among them. These have raised many concerns regarding the scalability of current variability management tools and techniques and their lack of industrial adoption. To address the scalability issues, this work employed a combination of quantitative and qualitative research methods to identify the reasons behind the limited scalability of existing variability management tools and techniques. In addition to producing a comprehensive catalogue of existing tools, the outcome form this stage helped understand the major limitations of existing tools. Based on the findings, a novel approach was created for managing variability that employed two main principles for supporting scalability. First, the separation-of-concerns principle was employed by creating multiple views of variability models to alleviate information overload. Second, hyperbolic trees were used to visualise models (compared to Euclidian space trees traditionally used). The result was an approach that can represent models encompassing hundreds of variability points and complex relationships. These concepts were demonstrated by implementing them in an existing variability management tool and using it to model a real-life product line with over a thousand variability points. Finally, in order to assess the work, an evaluation framework was designed based on various established usability assessment best practices and standards. The framework was then used with several case studies to benchmark the performance of this work against other existing tools.

A generic method of engagement to elicit regional coastal management options

Stakeholder engagement is important for successful management of natural resources, both to make effective decisions and to obtain support. However, in the context of coastal management, questions remain unanswered on how to effectively link decisions made at the catchment level with objectives for marine biodiversity and fisheries productivity. Moreover, there is much uncertainty on how to best elicit community input in a rigorous manner that supports management decisions. A decision support process is described that uses the adaptive management loop as its basis to elicit management objectives, priorities and management options using two case studies in the Great Barrier Reef, Australia. The approach described is then generalised for international interest. A hierarchical engagement model of local stakeholders, regional and senior managers is used. The result is a semi-quantitative generic elicitation framework that ultimately provides a prioritised list of management options in the context of clearly articulated management objectives that has widespread application for coastal communities worldwide. The case studies show that demand for local input and regional management is high, but local influences affect the relative success of both engagement processes and uptake by managers. Differences between case study outcomes highlight the importance of discussing objectives prior to suggesting management actions, and avoiding or minimising conflicts at the early stages of the process. Strong contributors to success are a) the provision of local information to the community group, and b) the early inclusion of senior managers and influencers in the group to ensure the intellectual and time investment is not compromised at the final stages of the process. The project has uncovered a conundrum in the significant gap between the way managers perceive their management actions and outcomes, and community's perception of the effectiveness (and wisdom) of these same management actions.

Small-scale fishing in Central American indigenous people: governance, tenure and sustainable management of marine resources

This research develops four case studies on small-scale fisheries in Central America located within indigenous territories. The ngöbe Bugle Conte Burica Territory in the south of Costa Rica, the Garífuna territory in nueva Armenia Honduras, the Rama territory in Nicaragua and the ngöbe Bugle territory in Bocas del Toro, Panamá. This is one of the first studies focusing on indigenous territories, artisanal fisheries and SSF guidelines. The cases are a first approach to discussing and analyzing relevant social and human rights issues related to conservation of marine resources and fisheries management in these territories. The cases discussed between other issues of interest, the relationships between marine protected areas under different governance models and issues related to the strengthening of the small-scale fisheries of these indigenous populations and marine fishing territories. They highlight sustainability, governance, land tenure and access to fishing resources, gender, traditional knowledge importance and new challenges as climate change.

How can science contribute for the sustainable management of natural resource? : Praia da Vitória Bay and Guadiana Estuary, a comparative study

Tese de Doutoramento, Ciências do Ambiente (Ordenamento do Território), 5 de Abril de 2013, Universidade dos Açores.

An ontology for risk management of digital collections

Maintaining accessibility to and understanding of digital information over time is a complex challenge that often requires contributions and interventions from a variety of individuals and organizations. The processes of preservation planning and evaluation are fundamentally implicit and share similar complexity. Both demand comprehensive knowledge and understanding of every aspect of to-be-preserved content and the contexts within which preservation is undertaken. Consequently, means are required for the identification, documentation and association of those properties of data, representation and management mechanisms that in combination lend value, facilitate interaction and influence the preservation process. These properties may be almost limitless in terms of diversity, but are integral to the establishment of classes of risk exposure, and the planning and deployment of appropriate preservation strategies. We explore several research objectives within the course of this thesis. Our main objective is the conception of an ontology for risk management of digital collections. Incorporated within this are our aims to survey the contexts within which preservation has been undertaken successfully, the development of an appropriate methodology for risk management, the evaluation of existing preservation evaluation approaches and metrics, the structuring of best practice knowledge and lastly the demonstration of a range of tools that utilise our findings. We describe a mixed methodology that uses interview and survey, extensive content analysis, practical case study and iterative software and ontology development. We build on a robust foundation, the development of the Digital Repository Audit Method Based on Risk Assessment. We summarise the extent of the challenge facing the digital preservation community (and by extension users and creators of digital materials from many disciplines and operational contexts) and present the case for a comprehensive and extensible knowledge base of best practice. These challenges are manifested in the scale of data growth, the increasing complexity and the increasing onus on communities with no formal training to offer assurances of data management and sustainability. These collectively imply a challenge that demands an intuitive and adaptable means of evaluating digital preservation efforts. The need for individuals and organisations to validate the legitimacy of their own efforts is particularly prioritised. We introduce our approach, based on risk management. Risk is an expression of the likelihood of a negative outcome, and an expression of the impact of such an occurrence. We describe how risk management may be considered synonymous with preservation activity, a persistent effort to negate the dangers posed to information availability, usability and sustainability. Risk can be characterised according to associated goals, activities, responsibilities and policies in terms of both their manifestation and mitigation. They have the capacity to be deconstructed into their atomic units and responsibility for their resolution delegated appropriately. We continue to describe how the manifestation of risks typically spans an entire organisational environment, and as the focus of our analysis risk safeguards against omissions that may occur when pursuing functional, departmental or role-based assessment. We discuss the importance of relating risk-factors, through the risks themselves or associated system elements. To do so will yield the preservation best-practice knowledge base that is conspicuously lacking within the international digital preservation community. We present as research outcomes an encapsulation of preservation practice (and explicitly defined best practice) as a series of case studies, in turn distilled into atomic, related information elements. We conduct our analyses in the formal evaluation of memory institutions in the UK, US and continental Europe. Furthermore we showcase a series of applications that use the fruits of this research as their intellectual foundation. Finally we document our results in a range of technical reports and conference and journal articles. We present evidence of preservation approaches and infrastructures from a series of case studies conducted in a range of international preservation environments. We then aggregate this into a linked data structure entitled PORRO, an ontology relating preservation repository, object and risk characteristics, intended to support preservation decision making and evaluation. The methodology leading to this ontology is outlined, and lessons are exposed by revisiting legacy studies and exposing the resource and associated applications to evaluation by the digital preservation community.

Concepts about risk management in libraries : Notes for characterization

El presente trabajo revisa la bibliografía sobre gestión del riesgo (GRi) que ha aparecido en los últimos tiempos, intentando anclar sus nociones, recomendaciones, pautas y estándares al ámbito de las bibliotecas y centros de documentación e información. Se analiza su utilidad, realizando un balance sobre la bibliografía consultada, proveniente tanto de Argentina como de distintos países. Se concluye sobre la necesidad de aplicar los procesos y los estándares inherentes a la GRi a los de las unidades de información para evitar los peligros o las amenazas en distintos ámbitos tales como el financiero, comunicacional, tecnológico, humano, ambiental, entre otros

Changes in Work from the Global Value Change Perspective The Case of Transformation Economies: Bulgaria and Hungary

The core aim of this paper is to evaluate to what extent were companies able to join to the global value chains (GVCs) through some selected company case studies.

Investigating the Roles and Requirements, Manifestations and Management of Metadata in the Creation of Reliable and Preservation of Authentic Electronic Entities Created by Dynamic, Interactive and Experiential Systems: Report on the Work and Findings of the Interpares 2 Description Cross Domain Group

Metadata that is associated with either an information system or an information object for purposes of description, administration, legal requirements, technical functionality, use and usage, and preservation, plays a critical role in ensuring the creation, management, preservation and use and re-use of trustworthymaterials, including records. Recordkeeping1 metadata, of which one key type is archival description, plays a particularly important role in documenting the reliability and authenticity of records and recordkeeping systemsas well as the various contexts (legal-administrative, provenancial, procedural, documentary, and technical) within which records are created and kept as they move across space and time. In the digital environment, metadata is also the means by which it is possible to identify how record components – those constituent aspects of a digital record that may be managed, stored and used separately by the creator or the preserver – can be reassembled to generate an authentic copy of a record or reformulated per a user’s request as a customized output package.Issues relating to the creation, capture, management and preservation of adequate metadata are, therefore, integral to any research study addressing the reliability and authenticity of digital entities, regardless of the community, sector or institution within which they are being created. The InterPARES 2 Description Cross-Domain Group (DCD) examined the conceptualization, definitions, roles, and current functionality of metadata and archival description in terms of requirements generated by InterPARES 12. Because of the needs to communicate the work of InterPARES in a meaningful way across not only other disciplines, but also different archival traditions; to interface with, evaluate and inform existing standards, practices and other research projects; and to ensure interoperability across the three focus areas of InterPARES2, the Description Cross-Domain also addressed its research goals with reference to wider thinking about and developments in recordkeeping and metadata. InterPARES2 addressed not only records, however, but a range of digital information objects (referred to as “entities” by InterPARES 2, but not to be confused with the term “entities” as used in metadata and database applications) that are the products and by-products of government, scientific and artistic activities that are carried out using dynamic, interactive or experiential digital systems. The nature of these entities was determined through a diplomatic analysis undertaken as part of extensive case studies of digital systems that were conducted by the InterPARES 2 Focus Groups. This diplomatic analysis established whether the entities identified during the case studies were records, non-records that nevertheless raised important concerns relating to reliability and authenticity, or “potential records.” To be determined to be records, the entities had to meet the criteria outlined by archival theory – they had to have a fixed documentary format and stable content. It was not sufficient that they be considered to be or treated as records by the creator. “Potential records” is a new construct that indicates that a digital system has the potential to create records upon demand, but does not actually fix and set aside records in the normal course of business. The work of the Description Cross-Domain Group, therefore, addresses the metadata needs for all three categories of entities.Finally, since “metadata” as a term is used today so ubiquitously and in so many different ways by different communities, that it is in peril of losing any specificity, part of the work of the DCD sought to name and type categories of metadata. It also addressed incentives for creators to generate appropriate metadata, as well as issues associated with the retention, maintenance and eventual disposition of the metadata that aggregates around digital entities over time.

Product/Brand co-creation methodology crossing marketing, design thinking, creativity and management: ideas(r)evolution

This thesis introduce a new innovation methodology called IDEAS(R)EVOLUTION that was developed according to an on-going experimental research project started in 2007. This new approach to innovation has initial based on Design thinking for innovation theory and practice. The concept of design thinking for innovation has received much attention in recent years. This innovation approach has climbed from the design and designers knowledge field towards other knowledge areas, mainly business management and marketing. Human centered approach, radical collaboration, creativity and breakthrough thinking are the main founding principles of Design thinking that were adapted by those knowledge areas due to their assertively and fitness to the business context and market complexity evolution. Also Open innovation, User-centered innovation and later on Living Labs models emerge as answers to the market and consumers pressure and desire for new products, new services or new business models. Innovation became the principal business management focus and strategic orientation. All this changes had an impact also in the marketing theory. It is possible now to have better strategies, communications plans and continuous dialogue systems with the target audience, incorporating their insights and promoting them to the main dissemination ambassadors of our innovations in the market. Drawing upon data from five case studies, the empirical findings in this dissertation suggest that companies need to shift from Design thinking for innovation approach to an holistic, multidimensional and integrated innovation system. The innovation context it is complex, companies need deeper systems then the success formulas that “commercial “Design thinking for innovation “preaches”. They need to learn how to change their organization culture, how to empower their workforce and collaborators, how to incorporate external stakeholders in their innovation processes, hoe to measure and create key performance indicators throughout the innovation process to give them better decision making data, how to integrate meaning and purpose in their innovation philosophy. Finally they need to understand that the strategic innovation effort it is not a “one shot” story it is about creating a continuous flow of interaction and dialogue with their clients within a “value creation chain“ mindset; RESUMO: Metodologia de co-criação de um produto/marca cruzando Marketing, Design Thinking, Criativity and Management - IDEAS(R)EVOLUTION. Esta dissertação apresenta uma nova metodologia de inovação chamada IDEAS(R)EVOLUTION, que foi desenvolvida segundo um projecto de investigação experimental contínuo que teve o seu início em 2007. Esta nova abordagem baseou-se, inicialmente, na teoria e na práctica do Design thinking para a inovação. Actualmente o conceito do Design Thinking para a inovação “saiu” do dominio da area de conhecimento do Design e dos Designers, tendo despertado muito interesse noutras áreas como a Gestão e o Marketing. Uma abordagem centrada na Pessoa, a colaboração radical, a criatividade e o pensamento disruptivo são principios fundadores do movimento do Design thinking que têm sido adaptados por essas novas áreas de conhecimento devido assertividade e adaptabilidade ao contexto dos negócios e à evolução e complexidade do Mercado. Também os modelos de Inovação Aberta, a inovação centrada no utilizador e mais tarde os Living Labs, emergem como possiveis soluções para o Mercado e para a pressão e desejo dos consumidores para novos productos, serviços ou modelos de negócio. A inovação passou a ser o principal foco e orientação estratégica na Gestão. Todas estas mudanças também tiveram impacto na teoria do Marketing. Hoje é possivel criar melhores estratégias, planos de comunicação e sistemas continuos de diálogo com o público alvo, incorporando os seus insights e promovendo os consumidores como embaixadores na disseminação da inovação das empresas no Mercado Os resultados empiricos desta tese, construídos com a informação obtida nos cinco casos realizados, sugerem que as empresas precisam de se re-orientar do paradigma do Design thinking para a inovação, para um sistema de inovação mais holistico, multidimensional e integrado. O contexto da Inovação é complexo, por isso as empresas precisam de sistemas mais profundos e não apenas de “fórmulas comerciais” como o Design thinking para a inovação advoga. As Empresas precisam de aprender como mudar a sua cultura organizacional, como capacitar sua força de trabalho e colaboradores, como incorporar os públicos externos no processo de inovação, como medir o processo de inovação criando indicadores chave de performance e obter dados para um tomada de decisão mais informada, como integrar significado e propósito na sua filosofia de inovação. Por fim, precisam de perceber que uma estratégia de inovação não passa por ter “sucesso uma vez”, mas sim por criar um fluxo contínuo de interação e diálogo com os seus clientes com uma mentalidade de “cadeia de criação de valor”

Management Perspectives on Industrial Heritage: an Exploratory Research

The current research project focuses on the analysis of the critical issues of industrial heritage management in Italy and the preservation of organizational history within the reuse projects of former industrial sites. The organizational and managerial perspective is crucial on two levels. Firstly, it is important in the analysis of the original significance of the site, and in particular its organizational history, and its conservation within the new regeneration strategy. Secondly, it is crucial at the phase of management of reuse projects and its feasibility and sustainability analysis. Based on the analysis of the literature, a unique classification of the reuse strategies that can be implemented in order to regenerate former industrial sites has been formulated. The exploratory research thus adapts a multiple case study design. Eight Italian case studies have been chosen, one for each type of regeneration strategy. Each case study is explored as a stand-alone entity through the analysis of the local differences and idiosyncrasies of the specific context, the factors that stood behind the choice of the reuse strategy and the way the reuse project evolved through the years. Then, the current management of each reuse project is analysed. The narration and musealization of the organizational history is investigated through the spatial dimension, the level of content and the level of expression. Secondly, the case studies are compared through a cross-case analysis from three different perspectives: issues on the phase of preparation and implementation of the reuse projects, critical issues behind the current management of new projects and issues on the ways of preservation and narration of organizational history within the new project. The research shows that all regeneration strategies are affected by the conflict between preservation and change, by the issue of materiality and selectivity.

Proposta educacional on-line sobre úlcera por pressão para alunos e profissionais de enfermagem

OBJETIVOS: Desenvolver uma proposta educacional on-line sobre o tema úlcera por pressão para alunos e profissionais de enfermagem. MÉTODOS: Pesquisa aplicada, de produção tecnológica, composta pelas etapas de concepção/ planejamento e desenvolvimento, caracterizadas por um conjunto de procedimentos, documentação, digitalização de informações e de imagens. Foram utilizados recursos computacionais didáticos interativos como: o Cybertutor e o Homem Virtual. RESULTADOS: Desenvolvimento de uma proposta educacional virtual sobre úlcera por pressão (UP) dividida em módulos de aprendizagem, contendo lista de discussão, estudos de casos e recursos didáticos, tais como fotos e o Homem Virtual. CONCLUSÕES: Utilizou-se de novas tecnologias educacionais, com a finalidade de promover o aprendizado sobre UP a estudantes de graduação de enfermagem e possibilitar a educação continuada de enfermeiros, uma vez que as UP representam um desafio aos profissionais da saúde e aos serviços de saúde.

Controle social e gestão participativa em saúde pública em unidades de saúde do município de Campo Grande, MS, 1994-2002

A participação social no Brasil evoluiu de movimento operário e de sindicatos, culminando na institucionalização através de Conselhos. Na área da saúde, foi legalizada pela Lei 8142/90. O objetivo deste estudo é conhecer a prática do controle social exercida em Conselhos de Unidades e sua influência nas políticas de saúde do município de Campo Grande, MS. Foram feitos cinco estudos de caso, tendo como fonte principal as atas de reuniões e como referencial de análise um documento do Ilpes/Claps (1975). Os Conselhos organizam-se em plenário, com coordenador, secretário, composição hoje paritária, representatividade reduzida e periodicidade mensal. O processo decisório contempla principalmente elementos técnico-administrativos e técnico-operacionais. No período 1998-2002, o controle social fortaleceu-se por encaminhamentos mais concretos, mas a capacidade de deliberação precisa ser fortalecida por uma capacitação que inclua elementos técnicos, políticos e administrativos, representatividade, fortalecimento da cidadania, divulgação intensa das atividades dos Conselhos, inclusive na mídia, maior mobilização social e articulação entre os vários Conselhos e instâncias municipais que fazem interface com o setor de saúde.

Influence of the technological innovation degree on knowledge creation: Evidence from a Brazilian firm

The aim of this paper is to analyze the process of knowledge creation when developing high technology products in projects having various innovation degrees. The main contribution to the literature is the systematization of an approach to analyze knowledge creation during the product innovation process. Three innovation projects developed by a company specialized in industrial automation systems were investigated using case studies. The knowledge creation processes, which took place in these three projects, were analyzed comparatively. As a distinctive result of this paper, the main features of the knowledge creation processes influenced by a degree of technological innovation are identified.

Strategic alignment and performance: Brazilian companies in the medical diagnostics sector

A gap has been identified in the literature on the diagnosis and monitoring of the degree of strategic alignment. The main objective of this article is to diagnose and analyze the strategic alignment profile using the alignment diagnostic profile (ADP) tool, which enables organizations to show visually their degree of strategic alignment. The methodological approach adopted is multiple-case studies, which were conducted at five organizations in the medical diagnostics sector. The results indicate that the ADP enables organizations to understand the steps required to improve their level of alignment and to identify and locate gaps and conflicts.