Academic medical centers: A framework for strategic repositioning

This study sought to understand the elements affecting the success or failure of strategic repositioning efforts by academic medical centers (AMC). The research question was: What specific elements in the process appear to be most important in determining the success or failure of an AMC.s strategic repositioning? Where success is based on the longterm sustainability of the new position.^ "An organization's strategic position is its perceptual location relative to others" (Gershon, 2003). Hence, strategic repositioning represents a shift from one strategic position within an environment to another (H. Mintzberg, 1987a). A deteriorating value proposition coupled with an unsustainable national health care financing system is forcing AMCs to change their strategic position. Where the value proposition is defined as the health outcome per dollar spent. ^ AMCs are of foundational importance to our health care system. They educate our new physicians, generate significant scientific breakthroughs, and care for our most difficult patients. Yet, their strategic, financial and business acumen leaves them particularly vulnerable in a changing environment. ^ After a literature review revealed limited writing on this subject, the research question was addressed using three separate but parallel exploratory case study inquiries of AMCs that recently underwent a strategic repositioning. Participating in the case studies were the Baylor College of Medicine, the University of Texas M. D. Anderson Cancer Center, and the University of Texas Medical Branch.^ Each case study consisted of two major research segments; a thorough documentation review followed by semi-structured interviews of selected members of their governance board, executive and faculty leadership teams. While each case study.s circumstances varied, their response to the research question, as extracted through thematic coding and analysis of the interviews, had a high degree of commonality.^ The results identified managing the strategic risk surrounding the repositioning and leadership accountability as the two foundational elements of success or failure. Metrics and communication were important process elements. They both play a major role in managing the strategic repositioning risk communication loop. Sustainability, the final element, was the outcome sought.^ Factors leading to strategic repositioning included both internal and external pressures and were primarily financial or mission based. Timing was an important consideration as was the selection of the strategic repositioning endpoint.^ In conclusion, a framework for the strategic repositioning of AMCs was offered that integrates the findings of this study; the elements of success, the factors leading to strategic repositioning, and the risk communication loop. ^

Development of a standard sign-out procedure for clinicians in a pediatric intensive care unit

Background: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Sign-out of patient data at the change of clinician shifts is a component of communication that is especially vulnerable to errors. Sign-outs are particularly extensive and complex in intensive care units (ICUs). There is a paucity of validated tools to assess ICU sign-outs. ^ Objective: To design a valid and reliable survey tool to assess the perceptions of Pediatric ICU (PICU) clinicians about sign-out. ^ Design: Cross-sectional, web-based survey ^ Setting: Academic hospital, 31-bed PICU ^ Subjects: Attending faculty, fellows, nurse practitioners and physician assistants. ^ Interventions: A survey was designed with input from a focus group and administered to PICU clinicians. Test-retest reliability, internal consistency and validity of the survey tool were assessed. ^ Measurements and Main Results: Forty-eight PICU clinicians agreed to participate. We had 42(88%) and 40(83%) responses in the test and retest phases. The mean scores for the ten survey items ranged from 2.79 to 3.67 on a five point Likert scale with no significant test-retest difference and a Pearson correlation between pre and post answers of 0.65. The survey item scores showed internal consistency with a Cronbach's Alpha of 0.85. Exploratory factor analysis revealed three constructs: efficacy of sign-out process, recipient satisfaction and content applicability. Seventy eight % clinicians affirmed the need for improvement of the sign-out process and 83% confirmed the need for face- to-face verbal sign-out. A system-based sign-out format was favored by fellows and advanced level practitioners while attendings preferred a problem-based format (p=0.003). ^ Conclusions: We developed a valid and reliable survey to assess clinician perceptions about the ICU sign-out process. These results can be used to design a verbal template to improve and standardize the sign-out process.^

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

From left to right -- Israel's repositioning in the world

第二次大戦時に大量のユダヤ人避難民を受け入れたイスラエルは、1946年の建国時には共産主義的な社会改革思想に基づくキブツ運動などの左翼的思潮を国家建設の支柱にしていたが、その後の政治過程のなかで一貫して右傾化の方向をたどり、現在では国際的にみても最も保守的な軍事主義的思想傾向が国民のあいだで広く共有され、国内のアラブ系住民の経済的従属が永く固定化するに至った。現在のイスラエル国家を思想的にも実体経済的にも支えている基本的な理念は、建国時のそれとは全く対極的な新保守主義とグローバル化された「新自由主義」的な資本主義であり、それは当然ながら国内における安価な労働力としてのアラブ系住民の存在を所与の前提条件として組み込んでいる。これは具体的にどのような経緯によるものであり、またイスラエル国家のどのような性格から導き出されるものなのか。本論稿では政治的シオニズムがイスラエル建国後から現在までにたどってきた思想的な系譜を改めて確認し、現在のイスラエルが国際的に置かれている特異な立場とその背後にある諸要因を説明する。

Analysis of the Fracture of Reinforced Concrete Flat Elements Subjected to Explosions. Experimental Procedure and Numerical Validation

Many of the material models most frequently used for the numerical simulation of the behavior of concrete when subjected to high strain rates have been originally developed for the simulation of ballistic impact. Therefore, they are plasticity-based models in which the compressive behavior is modeled in a complex way, while their tensile failure criterion is of a rather simpler nature. As concrete elements usually fail in tensión when subjected to blast loading, available concrete material models for high strain rates may not represent accurately their real behavior. In this research work an experimental program of reinforced concrete fíat elements subjected to blast load is presented. Altogether four detonation tests are conducted, in which 12 slabs of two different concrete types are subjected to the same blast load. The results of the experimental program are then used for the development and adjustment of numerical tools needed in the modeling of concrete elements subjected to blast.

Simplified Procedure for the Nonlinear Seismic Analysis of Bridges

The severe accidents suffered by bridges during recent earthquake show that more careful analysis are needed to guarantee their behaviour. In particular simplified non-linear analysis could be useful to bridge the gap between theoretical research and practical applications. This paper presents one of those simplified methods that can be applied for first designs or to retrofitting of groups of bridges.

A robust procedure for damage detection from strain measurements based on principal component analysis

FBGs are excellent strain sensors, because of its low size and multiplexing capability. Tens to hundred of sensors may be embedded into a structure, as it has already been demonstrated. Nevertheless, they only afford strain measurements at local points, so unless the damage affects the strain readings in a distinguishable manner, damage will go undetected. This paper show the experimental results obtained on the wing of a UAV, instrumented with 32 FBGs, before and after small damages were introduced. The PCA algorithm was able to distinguish the damage cases, even for small cracks. Principal Component Analysis (PCA) is a technique of multivariable analysis to reduce a complex data set to a lower dimension and reveal some hidden patterns that underlie.

Procedure for verification of sound source coverage over façades according to the International Standard ISO 140-5

This paper presents a new verification procedure for sound source coverage according to ISO 140?5 requirements. The ISO 140?5 standard applies to the measurement of façade insulation and requires a sound source able to achieve a sufficiently uniform sound field in free field conditions on the façade under study. The proposed method involves the electroacoustic characterisation of the sound source in laboratory free field conditions (anechoic room) and the subsequent prediction by computer simulation of the sound free field radiated on a rectangular surface equal in size to the façade being measured. The loudspeaker is characterised in an anechoic room under laboratory controlled conditions, carefully measuring directivity, and then a computer model is designed to calculate the acoustic free field coverage for different loudspeaker positions and façade sizes. For each sound source position, the method provides the maximum direct acoustic level differences on a façade specimen and therefore determines whether the loudspeaker verifies the maximum allowed level difference of 5 dB (or 10 dB for façade dimensions greater than 5 m) required by the ISO standard. Additionally, the maximum horizontal dimension of the façade meeting the standard is calculated and provided for each sound source position, both with the 5 dB and 10 dB criteria. In the last section of the paper, the proposed procedure is compared with another method used by the authors in the past to achieve the same purpose: in situ outdoor measurements attempting to recreate free field conditions. From this comparison, it is concluded that the proposed method is able to reproduce the actual measurements with high accuracy, for example, the ground reflection effect, at least at low frequencies, which is difficult to avoid in the outdoor measurement method, and it is fully eliminated with the proposed method to achieve the free field requisite.

A FEM-BEM coupling procedure through the Steklov-Poincarè operator

Many advantages can be got in combining finite and boundary elements.It is the case, for example, of unbounded field problems where boundary elements can provide the appropriate conditions to represent the infinite domain while finite elements are suitable for more complex properties in the near domain. However, in spite of it, other disadvantages can appear. It would be, for instance, the loss of symmetry in the finite elements stiffness matrix, when the combination is made. On the other hand, in our days, with the strong irruption of the parallel proccessing the techniques of decomposition of domains are getting the interest of numerous scientists. With their application it is possible to separate the resolution of a problem into several subproblems. That would be beneficial in the combinations BEM-FEM as the loss of symmetry would be avoided and every technique would be applicated separately. Evidently for the correct application of these techniques it is necessary to establish the suitable transmission conditions in the interface between BEM domain and FEM domain. In this paper, one parallel method is presented which is based in the interface operator of Steklov Poincarè.

Identification procedure of mealy apples by instrumental means. Extraction of storage features.

Mealiness is a negative attribute of sensory texture that combines the sensation of a disaggregated tissue with the sensation of lack of juiciness. Since January 1996, a wide EC Project entitled : "Mealiness in fruits. Consumers perception and means for detection'" is being carried out. Within it, three sensory panels have been trained at : the Institute of Food Research (IFR, United Kingdom), the Instituto de Agroquímica y Tecnología de los Alimentos (IATA, Spain) and the Institut voor Agrotechnologisch Onderzoek (ATO-DLO, Netherlands) to assess mealiness in apples. In all three cases, mealiness has been described as a multidimensional sensory descriptor capable of gathering the loss of consistency (of crispness and of hardness) and of juiciness. Also within the EC Project several instrumental procedures have been tested for mealiness assessment. In this sense the Physical Properties Laboratory (ETS1A-UPM) has focused its aims in a first stage on performing instrumental tests for assessing some textural descriptors as crispiness, hardness and juiciness. The results obtained within these tests have shown to correlate well with the sensory measurements (Barreiro et Ruiz-Altisent, 1997) in apples, but also have succeed when trying to generate several texture degradation levels on peaches from which mealiness appears to be the last stage (Ortiz et al. 1997).

A procedure for testing padding materials in fruit packing lines.

Padding materials are commonly used in fruit packing lines with the objective of diminishing impact damage in postharvest handling. Two sensors, instrumented sphere IS 100 and impact tester, have been compared to analyze the performance of six different padding materials used in Spanish fruit packing lines. Padding materials tested have been classified according to their capability to decrease impact intensities inflicted to fruit in packing lines. A procedure to test padding materials has been developed for "Golden" apples. Its basis is a logistic regression to predict bruise probability in fruit. The model combines two kinds of parameters: padding material parameters measured with IS, and fruit properties.

A new procedure for race analysis in swimming based on individual distance measurements

biomecanica de la natación