GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model.

The Multiple Hierarchical Legislatures in a Representative Democracy: Districting for Policy Implementation

We build a multiple hierarchical model of a representative democracy in which, for instance, voters elect county representatives, county representatives elect district representatives, district representatives elect state representatives, and state representatives elect a prime minister. We use our model to show that the policy determined by the final representative can become more extreme as the number of hierarchical levels increases because of increased opportunities for gerrymandering. Thus, a sufficiently large number of voters gives a district maker an advantage, enabling her to implement her favorite policy. We also show that the range of implementable policies increases with the depth of the hierarchical system. Consequently, districting by a candidate in a hierarchical legislative system can be viewed as a type of policy implementation device.

Understanding the dynamics of information technology implementation: The case of clinical information systems

The ultimate intent of this dissertation was to broaden and strengthen our understanding of IT implementation by emphasizing research efforts on the dynamic nature of the implementation process. More specifically, efforts were directed toward opening the "black box" and providing the story that explains how and why contextual conditions and implementation tactics interact to produce project outcomes. In pursuit of this objective, the dissertation was aimed at theory building and adopted a case study methodology combining qualitative and quantitative evidence. Precisely, it examined the implementation process, use and consequences of three clinical information systems at Jackson Memorial Hospital, a large tertiary care teaching hospital.^ As a preliminary step toward the development of a more realistic model of system implementation, the study proposes a new set of research propositions reflecting the dynamic nature of the implementation process.^ Findings clearly reveal that successful implementation projects are likely to be those where key actors envision end goals, anticipate challenges ahead, and recognize the presence of and seize opportunities. It was also found that IT implementation is characterized by the systems theory of equifinality, that is, there are likely several equally effective ways to achieve a given end goal. The selection of a particular implementation strategy appears to be a rational process where actions and decisions are largely influenced by the degree to which key actors recognize the mediating role of each tactic and are motivated to action. The nature of the implementation process is also characterized by the concept of "duality of structure," that is, context and actions mutually influence each other. Another key finding suggests that there is no underlying program that regulates the process of change and moves it form one given point toward a subsequent and already prefigured end. For this reason, the implementation process cannot be thought of as a series of activities performed in a sequential manner such as conceived in stage models. Finally, it was found that IT implementation is punctuated by a certain indeterminacy. Results suggest that only when substantial efforts are focused on what to look for and think about, it is less likely that unfavorable and undesirable consequences will occur. ^

Assessing the effectiveness of five-year mechanical engineering technology programs of junior colleges in Taiwan, R.O.C.: An application of the CIPP evaluation model

The purpose of this study was to evaluate the mechanical engineering technology curriculum effectiveness at the junior college in Taiwan by using the CIPP evaluation model. The study concerned the areas of the curriculum, curriculum materials, individualized instruction, support services, teaching effectiveness, student achievement, and job performance. A descriptive survey method was used with questionnaires for data collection from faculty, students, graduates, and employers.^ All categories of respondents tended to agree that the curriculum provides appropriate occupational knowledge and skills. Students, graduates, and faculty tended to be satisfied with the curriculum; faculty tended to be satisfied with student achievement; graduates tended to be satisfied with their job preparation; and employers were most satisfied with graduates' job performance.^ Conclusions were drawn in the context, input, process, and product of the CIPP model. In Context area: Students were dissatisfied with curriculum flexibility in students characteristics. Graduates were dissatisfied with curriculum design for student's adaptability in new economic and industrial conditions; practicum flexibility in student characteristics; and course overlap. Both students and graduates were dissatisfied with practicum credit hours. Both faculty and students were dissatisfied with the number of required courses.^ In Input area: Students, faculty, and graduates perceived audiovisuals and manipulative aids positively. Faculty and students perceive CAI implementation positively. Students perceived textbooks negatively.^ In Process area: Faculty, students, and graduates perceived all support service negatively. Faculty tended to perceive the ratios of graduates who enter advanced study and related occupation, and who passed the professional skills certification, negatively. Students tended to perceive teaching effectiveness in terms of instructional strategies, the quality of instruction, overall suitability, and receivable, negatively. Graduates also tended to identify the instructional strategies as a negative perception. Faculty and students perceived curriculum objectives and practicum negatively. Both faculty and students felt that instructors should be more interested in making the courses a useful learning experience.^ In Product area: Employers were satisfied with graduates' academic preparation and job performance, adaptability, punctuality, and their ability to communicate, cooperate, and meet organization needs. Graduates were weak in terms of equipment familiarity and supervisory ability.^ In sum, the curriculum of the five-year mechanical engineering technology programs of junior college in Taiwan has served adequately up to this time in preparing a work force to enter industry. It is now time to look toward the future and adapt the curriculum and instruction for the future needs of this high-tech society. ^

Development and implementation of a tool to assess the micro/macro elements in an organization

This study examines the congruency of planning between organizational structure and process, through an evaluation and planning model known as the Micro/Macro Dynamic Planning Grid. The model compares day-to-day planning within an organization to planning imposed by organizational administration and accrediting agencies. A survey instrument was developed to assess the micro and macro sociological analysis elements utilized by an organization.^ The Micro/Macro Dynamic Planning Grid consists of four quadrants. Each quadrant contains characteristics that reflect the interaction between the micro and macro elements of planning, objectives and goals within an organization. The Over Macro/Over Micro, Quadrant 1, contains attributes that reflect a tremendous amount of action and ongoing adjustments, typical of an organization undergoing significant changes in either leadership, program and/or structure. Over Macro/Under Micro, Quadrant 2, reflects planning characteristics found in large, bureaucratic systems with little regard given to the workings of their component parts. Under Macro/Under Micro, Quadrant 3, reflects the uncooperative, uncoordinated organization, one that contains a multiplicity of viewpoints, language, objectives and goals. Under Macro/Under Micro, Quadrant 4 represents the worst case scenario for any organization. The attributes of this quadrant are very reactive, chaotic, non-productive and redundant.^ There were three phases to the study: development of the initial instrument, pilot testing the initial instrument and item revision, and administration and assessment of the refined instrument. The survey instrument was found to be valid and reliable for the purposes and audiences herein described.^ In order to expand the applicability of the instrument to other organizational settings, the survey was administered to three professional colleges within a university.^ The first three specific research questions collectively answered, in the affirmative, the basic research question: Can the Micro/Macro Dynamic Planning Grid be applied to an organization through an organizational development tool? The first specific question: Can an instrument be constructed that applies the Micro/Macro Dynamic Planning Grid? The second specific research question: Is the constructed instrument valid and reliable? The third specific research question: Does an instrument that applies the Micro/Macro Dynamic Planning Grid assess congruency of micro and macro planning, goals and objectives within an organization? The fourth specific research question: What are the differences in the responses based on roles and responsibilities within an organization? involved statistical analysis of the response data and comparisons obtained with the demographic data. (Abstract shortened by UMI.) ^

A qualitative analysis of the lived experience of nursing staff developers in the process of changing to a new educational model

The purpose of this study was to document and critically analyze the lived experience of selected nursing staff developers in the process of moving toward a new model for hospital nursing education. Eleven respondents were drawn from a nation-wide population of about two hundred individuals involved in nursing staff development. These subjects were responsible for the implementation of the Performance Based Development System (PBDS) in their institutions.^ A purposive, criterion-based sampling technique was used with respondents being selected according to size of hospital, primary responsibility for orchestration of the change, influence over budgetary factors and managerial responsibility for PBDS. Data were gathered by the researcher through both in-person and telephone interviews. A semi-structured interview guide, designed by the researcher was used, and respondents were encouraged to amplify on their recollections as desired. Audiotapes were transcribed and resulting computer files were analyzed using the program "Martin". Answers to interview questions were compiled and reported across cases. The data was then reviewed a second time and interpreted for emerging themes and patterns.^ Two types of verification were used in the study. Internal verification was done through interview transcript review and feedback by respondents. External verification was done through review and feedback on data analysis by readers who were experienced in management of staff development departments.^ All respondents were female, so Gilligan's concept of the "ethic of care" was examined as a decision making strategy. Three levels of caring which influenced decision making were found. They were caring: (a) for the organization, (b) for the employee, and (c) for the patient. The four existentials of the lived experience, relationality, corporeality, temporality and spatiality were also examined to reveal the everydayness of making change. ^

An examination of attitude toward change as a predictor of policy/program implementation

Policy/program implementation, e.g., the process of fulfilling policy/program directives, is fundamentally tied to change. Implementation studies have examined the process, identifying many critical organizational variables although individuals perform the activities.^ Many of the studies are predicated on the rational, goal oriented model of organizations and examine implementation, presenting only the goal-oriented view. Organizational change and its resistance, however, are not fully explained by the rational model of organizations. There are other schools of thought providing different views of organizations from which explanation may emerge. Bolman and Deal (1984, 1991a, 1994) provide a different perspective for examining organizations Bolman and Deal argue organizations should be viewed through four different frames or lenses. Framing and reframing organizational action captures the complexity of action and provides better understanding of organizational processes. Understanding of implementation of policies/programs also will benefit from the use of the four-frame approach.^ The goal of this research is to provide a better understanding of the implementation process by examining individual attitudes toward change, the dependent variable of this research, and studying the relationship between the dependent variable and frame. The research was conducted in two phases. In Phase One, a survey was sent to 306 school administrators and teachers in magnet programs in Dade County, Florida. The survey instrument was composed of 55 questions including six from Bolman and Deal's Leadership Orientation Survey (1988) and 38 questions about organizational change. In Phase Two, more in-depth analysis of four school was conducted, to further explore the relationship between frame and attitude toward change.^ The results revealed that frame was a factor in explaining differences in personal Attitude Toward Change and Comfort Level with Change. Individuals using the symbolic frame had more positive attitudes toward change and were also more comfortable with change. The results of Phase Two of the research partially supported this finding in that the most fully implemented program was the product of an administrator who had chosen the symbolic frame. ^

A qualitative case study of teacher perceptions and concerns during the implementation of literacy folders in a select elementary school in Broward County, Florida

Classroom teachers are often required to implement new procedures or practices in response to local or federal education mandates. Attempts to implement innovations, often do not take into account the personal side of change; the perceptions, concerns and needs of those required to implement the innovation. One innovation that was required by the School Board of Broward County, Florida for all elementary classroom teachers was the implementation of Literacy Folders. ^ This study attempted to address the personal side of change by identifying teacher concerns during the implementation of Literacy Folders in a select elementary school in Broward County Florida. The Concerns Based Adoption model (CBAM) for change was used as the conceptual framework for this qualitative case study. ^ Sources of data for this study included participant interviews, observations and analysis of documents. Informal conversations with the participants and unscheduled classroom visits were also sources of data. Seven classroom teachers were interviewed using a predesigned interview guide developed based on the CBAM of change, specifically the Stages of Concern Dimension. Participant responses were coded into two categories, (a) recollections of past perceptions, and (b) present perceptions regarding the innovation. ^ Data analysis resulted in the emergence of one major theme and two subordinate themes. The themes were related to time and purpose of the innovation. The researcher also discovered that the participants exhibited responses typically representative of the CBAM for individuals who are in the process of adjusting to a new innovation. ^ Recommendations based on participant concerns are made for improving the implementation of the innovation. Recommendations for alternatives to the innovation and suggestions regarding areas for further research in the field of educational change are also made. ^

A case study of the Ellison model's use of mentoring as an approach toward inclusive community building

The Ellison Executive Mentoring Inclusive Community Building (ICB) Model is a paradigm for initiating and implementing projects utilizing executives and professionals from a variety of fields and industries, university students, and pre-college students. The model emphasizes adherence to ethical values and promotes inclusiveness in community development. It is a hierarchical model in which actors in each succeeding level of operation serve as mentors to the next. Through a three-step process—content, process, and product—participants must be trained with this mentoring and apprenticeship paradigm in conflict resolution, and they receive sensitivity and diversity training through an interactive and dramatic exposition. ^ The content phase introduces participants to the model's philosophy, ethics, values and methods of operation. The process used to teach and reinforce its precepts is the mentoring and apprenticeship activities and projects in which the participants engage and whose end product demonstrates their knowledge and understanding of the model's concepts. This study sought to ascertain from the participants' perspectives whether the model's mentoring approach is an effective means of fostering inclusiveness, based upon their own experiences in using it. The research utilized a qualitative approach and included data from field observations, individual and group interviews, and written accounts of participants' attitudes. ^ Participants complete ICB projects utilizing The Ellison Model as a method of development and implementation. They generally perceive that the model is a viable tool for dealing with diversity issues whether at work, at school, or at home. The projects are also instructional in that whether participants are mentored or serve as apprentices, they gain useful skills and knowledge about their careers. Since the model is relatively new, there is ample room for research in a variety of areas including organizational studies to determine its effectiveness in combating problems related to various kinds of discrimination. ^

3D TerraFly: Quality of service management for online interactive 3D geographic information system

3D geographic information system (GIS) is data and computation intensive in nature. Internet users are usually equipped with low-end personal computers and network connections of limited bandwidth. Data reduction and performance optimization techniques are of critical importance in quality of service (QoS) management for online 3D GIS. In this research, QoS management issues regarding distributed 3D GIS presentation were studied to develop 3D TerraFly, an interactive 3D GIS that supports high quality online terrain visualization and navigation. ^ To tackle the QoS management challenges, multi-resolution rendering model, adaptive level of detail (LOD) control and mesh simplification algorithms were proposed to effectively reduce the terrain model complexity. The rendering model is adaptively decomposed into sub-regions of up-to-three detail levels according to viewing distance and other dynamic quality measurements. The mesh simplification algorithm was designed as a hybrid algorithm that combines edge straightening and quad-tree compression to reduce the mesh complexity by removing geometrically redundant vertices. The main advantage of this mesh simplification algorithm is that grid mesh can be directly processed in parallel without triangulation overhead. Algorithms facilitating remote accessing and distributed processing of volumetric GIS data, such as data replication, directory service, request scheduling, predictive data retrieving and caching were also proposed. ^ A prototype of the proposed 3D TerraFly implemented in this research demonstrates the effectiveness of our proposed QoS management framework in handling interactive online 3D GIS. The system implementation details and future directions of this research are also addressed in this thesis. ^

An indexing structure and application model for vehicles moving on road networks

Moving objects database systems are the most challenging sub-category among Spatio-Temporal database systems. A database system that updates in real-time the location information of GPS-equipped moving vehicles has to meet even stricter requirements. Currently existing data storage models and indexing mechanisms work well only when the number of moving objects in the system is relatively small. This dissertation research aimed at the real-time tracking and history retrieval of massive numbers of vehicles moving on road networks. A total solution has been provided for the real-time update of the vehicles' location and motion information, range queries on current and history data, and prediction of vehicles' movement in the near future. ^ To achieve these goals, a new approach called Segmented Time Associated to Partitioned Space (STAPS) was first proposed in this dissertation for building and manipulating the indexing structures for moving objects databases. ^ Applying the STAPS approach, an indexing structure of associating a time interval tree to each road segment was developed for real-time database systems of vehicles moving on road networks. The indexing structure uses affordable storage to support real-time data updates and efficient query processing. The data update and query processing performance it provides is consistent without restrictions such as a time window or assuming linear moving trajectories. ^ An application system design based on distributed system architecture with centralized organization was developed to maximally support the proposed data and indexing structures. The suggested system architecture is highly scalable and flexible. Finally, based on a real-world application model of vehicles moving in region-wide, main issues on the implementation of such a system were addressed. ^

System design and resource management in the next-generation integrated WLAN and 3G cellular networks

Next-generation integrated wireless local area network (WLAN) and 3G cellular networks aim to take advantage of the roaming ability in a cellular network and the high data rate services of a WLAN. To ensure successful implementation of an integrated network, many issues must be carefully addressed, including network architecture design, resource management, quality-of-service (QoS), call admission control (CAC) and mobility management. ^ This dissertation focuses on QoS provisioning, CAC, and the network architecture design in the integration of WLANs and cellular networks. First, a new scheduling algorithm and a call admission control mechanism in IEEE 802.11 WLAN are presented to support multimedia services with QoS provisioning. The proposed scheduling algorithms make use of the idle system time to reduce the average packet loss of realtime (RT) services. The admission control mechanism provides long-term transmission quality for both RT and NRT services by ensuring the packet loss ratio for RT services and the throughput for non-real-time (NRT) services. ^ A joint CAC scheme is proposed to efficiently balance traffic load in the integrated environment. A channel searching and replacement algorithm (CSR) is developed to relieve traffic congestion in the cellular network by using idle channels in the WLAN. The CSR is optimized to minimize the system cost in terms of the blocking probability in the interworking environment. Specifically, it is proved that there exists an optimal admission probability for passive handoffs that minimizes the total system cost. Also, a method of searching the probability is designed based on linear-programming techniques. ^ Finally, a new integration architecture, Hybrid Coupling with Radio Access System (HCRAS), is proposed for lowering the average cost of intersystem communication (IC) and the vertical handoff latency. An analytical model is presented to evaluate the system performance of the HCRAS in terms of the intersystem communication cost function and the handoff cost function. Based on this model, an algorithm is designed to determine the optimal route for each intersystem communication. Additionally, a fast handoff algorithm is developed to reduce the vertical handoff latency.^

Seismic performance of hybrid fiber reinforced polymer-concrete pier frame systems

As an alternative to transverse spiral or hoop steel reinforcement, fiber reinforced polymers (FRPs) were introduced to the construction industry in the 1980’s. The concept of concrete-filled FRP tube (CFFT) has raised great interest amongst researchers in the last decade. FRP tube can act as a pour form, protective jacket, and shear and flexural reinforcement for concrete. However, seismic performance of CFFT bridge substructure has not yet been fully investigated. Experimental work in this study included four two-column bent tests, several component tests and coupon tests. Four 1/6-scale bridge pier frames, consisting of a control reinforced concrete frame (RCF), glass FRP-concrete frame (GFF), carbon FRP-concrete frame (CFF), and hybrid glass/carbon FRP-concrete frame (HFF) were tested under reverse cyclic lateral loading with constant axial loads. Specimen GFF did not show any sign of cracking at a drift ratio as high as 15% with considerable loading capacity, whereas Specimen CFF showed that lowest ductility with similar load capacity as in Specimen GFF. FRP-concrete columns and pier cap beams were then cut from the pier frame specimens, and were tested again in three point flexure under monotonic loading with no axial load. The tests indicated that bonding between FRP and concrete and yielding of steel both affect the flexural strength and ductility of the components. The coupon tests were carried out to establish the tensile strength and elastic modulus of each FRP tube and the FRP mold for the pier cap beam in the two principle directions of loading. A nonlinear analytical model was developed to predict the load-deflection responses of the pier frames. The model was validated against test results. Subsequently, a parametric study was conducted with variables such as frame height to span ratio, steel reinforcement ratio, FRP tube thickness, axial force, and compressive strength of concrete. A typical bridge was also simulated under three different ground acceleration records and damping ratios. Based on the analytical damage index, the RCF bridge was most severely damaged, whereas the GFF bridge only suffered minor repairable damages. Damping ratio was shown to have a pronounced effect on FRP-concrete bridges, just the same as in conventional bridges. This research was part of a multi-university project, which is founded by the National Science Foundation (NSF) - Network for Earthquake Engineering Simulation Research (NEESR) program.

Private higher education policy in Ohio, 1980--2006: A case study demonstrating the usefulness of Zumeta's public policy posture model

This study describes the case of private higher education in Ohio between 1980 and 2006 using Zumeta's (1996) model of state policy and private higher education. More specifically, this study used case study methodology and multiple sources to demonstrate the usefulness of Zumeta's model and illustrate its limitations. Ohio served as the subject state and data for 67 private, 4-year, degree-granting, Higher Learning Commission-accredited institutions were collected. Data sources for this study included the National Center for Education Statistics Integrated Postsecondary Data System as well as database information and documents from various state agencies in Ohio, including the Ohio Board of Regents. ^ The findings of this study indicated that the general state context for higher education in Ohio during the study time period was shaped by deteriorating economic factors, stagnating population growth coupled with a rapidly aging society, fluctuating state income and increasing expenditures in areas such as corrections, transportation and social services. However, private higher education experienced consistent enrollment growth, an increase in the number of institutions, widening involvement in state-wide planning for higher education, and greater fiscal support from the state in a variety of forms such as the Ohio Choice Grant. This study also demonstrated that private higher education in Ohio benefited because of its inclusion in state-wide planning and the state's decision to grant state aid directly to students. ^ Taken together, this study supported Zumeta's (1996) classification of Ohio as having a hybrid market-competitive/central-planning policy posture toward private higher education. Furthermore, this study demonstrated that Zumeta's model is a useful tool for both policy makers and researchers for understanding a state's relationship to its private higher education sector. However, this study also demonstrated that Zumeta's model is less useful when applied over an extended time period. Additionally, this study identifies a further limitation of Zumeta's model resulting from his failure to define "state mandate" and the "level of state mandates" that allows for inconsistent analysis of this component. ^

Hybrid approaches to estimating freeway travel times using point traffic detector data

The accurate and reliable estimation of travel time based on point detector data is needed to support Intelligent Transportation System (ITS) applications. It has been found that the quality of travel time estimation is a function of the method used in the estimation and varies for different traffic conditions. In this study, two hybrid on-line travel time estimation models, and their corresponding off-line methods, were developed to achieve better estimation performance under various traffic conditions, including recurrent congestion and incidents. The first model combines the Mid-Point method, which is a speed-based method, with a traffic flow-based method. The second model integrates two speed-based methods: the Mid-Point method and the Minimum Speed method. In both models, the switch between travel time estimation methods is based on the congestion level and queue status automatically identified by clustering analysis. During incident conditions with rapidly changing queue lengths, shock wave analysis-based refinements are applied for on-line estimation to capture the fast queue propagation and recovery. Travel time estimates obtained from existing speed-based methods, traffic flow-based methods, and the models developed were tested using both simulation and real-world data. The results indicate that all tested methods performed at an acceptable level during periods of low congestion. However, their performances vary with an increase in congestion. Comparisons with other estimation methods also show that the developed hybrid models perform well in all cases. Further comparisons between the on-line and off-line travel time estimation methods reveal that off-line methods perform significantly better only during fast-changing congested conditions, such as during incidents. The impacts of major influential factors on the performance of travel time estimation, including data preprocessing procedures, detector errors, detector spacing, frequency of travel time updates to traveler information devices, travel time link length, and posted travel time range, were investigated in this study. The results show that these factors have more significant impacts on the estimation accuracy and reliability under congested conditions than during uncongested conditions. For the incident conditions, the estimation quality improves with the use of a short rolling period for data smoothing, more accurate detector data, and frequent travel time updates.