Sustaining Health Care Practice Change: The Experience of Best Practice Spotlight Organizations Implementing and Sustaining RNAO Best Practice Guidelines

Sustainability of change for improvement initiatives has been widely reported as a global challenge both within and outside health care settings. The purpose of this study was to examine the extent to which factors related to staff training and involvement, staff behaviour, and clinical leaders’ and senior leaders’ engagement and support impact the long term sustainability of practice changes for BPSO health care organizations who have implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines. Semi structured interviews with eleven organizational leaders’ from ten health care organizations were conducted to explore the unique experiences, views and perspectives on factors related to staff, clinical leaders and senior leaders and their involvement and impact on the long term sustainability of clinical practice changes within organizations who had implemented Registered Nursing Association of Ontario’s (RNAO) Best Practice Guidelines (BPGs). The interviews were coded and analyzed using thematic content analysis. Further analysis identified patterns and themes in relation to: 1. The National Health Service (NHS) Sustainability Model which was used as the theoretical framework for this research; and 2. Organizations found to have sustained practice changes longer term verses organizations that did not. Six organizations were found to have sustained practice changes while the remaining four were found to have been unsuccessful in their efforts to sustain the changes. Five major findings in relation to sustainability emerged from this study. First is the importance of early and sustained engagement and frontline staff, managers, and clinical leaders in planning, implementation and ongoing development of BPGs through use of working groups and champions models. Second is the importance of ongoing provision of formal training, tools and resources to all key stakeholders during and after the implementation phase and efforts made to embed changes in current processes whenever possible to ensure sustainability. Third is to ensure staff and management are receptive to the proposed change(s) and/or have been given the necessary background information and rationale so they understand and can support the need for the change. Fourth is the need for early and sustained fiscal and human resources dedicated to supporting BPG implementation and the ongoing use of the BPGs already in place. Fifth is ensuring clinical leaders are trusted, influential, respected and seen as clinical resources by frontline staff. The significance of this study lies in a greater understanding of the influence and impact of factors related to staff on the long term sustainability of implemented practice changes within health care organizations. This study has implications for clinical practice, policy, education and research in relation to sustainability in health care.

Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.

Spatial and Temporal Variation of Microbial Community Structure In Surficial Sediments of Cochin Estuary

This thesis entitled spatial and temporal variarion of microbial community structure in surficial sediments of cochin estuary.In the estuarine and coastal systems, organic matter (OM) is derived not only from autochthonous primary production, but also from allochthonous (terrestrial) organic matter (OM) delivered by river discharge and runoff. A significant portion of the OM sinks through the water column and is ultimately stored in carbon pool in the sediments.Analysis of spatial and temporal variation in benthic microbial community of a tropical estuary was conducted for the first time using non selective measures that affirms that PLFA approach is a sensitive and reliable method in determining microbial community structures of surficial sediments of estuary.The close relationship between the concentrations of the microbial fatty acids and total biomass indicates that bacteria could account for the largest proportion of the biomass in the sediments.This is first study that has documented the changes in microbial community composition linkage to biotic and abiotic variables in benthic estuarine ecosystem. This contemporaneous community will be the backdrop for understanding the response of autochthonous community to increasing anthropogenic stress.

Design and Development of a Frame Based MT System for English-to-ISL

This paper presents the design and development of a frame based approach for speech to sign language machine translation system in the domain of railways and banking. This work aims to utilize the capability of Artificial intelligence for the improvement of physically challenged, deaf-mute people. Our work concentrates on the sign language used by the deaf community of Indian subcontinent which is called Indian Sign Language (ISL). Input to the system is the clerk’s speech and the output of this system is a 3D virtual human character playing the signs for the uttered phrases. The system builds up 3D animation from pre-recorded motion capture data. Our work proposes to build a Malayalam to ISL

Retting Of Coconut Husk - A Unique Case Of Water Pollution On The South West Coast Of India

The extensive backwaters of Kerala are the sites for a flourishing cottage industry - the coir industry. This enterprise almost exclusively located along the 590 km coastal belt of Kerala, provides direct employment to over half a million people in the state and produces nearly 90% of the total coir goods in the world. The shallow bays and lagoons of the 30 backwater systems of the state are traditional areas for the retting of coconut husk for the production of the coir fibre. The paper examines the environmental status of the retting grounds in Kerala, in relation to the biotic communities. The study revealed that retting activity has caused large scale organic pollution along with the mass destruction of the flora and fauna, converting sizeable sections of the backwaters into virtual cesspools of foul smelling stagnant waters. High values of hydrogen sulphide, ammonia, BOD5 associated with anoxic conditions and low community diversity of plankton, benthic fauna, fish, shell fish, wood boring and fouling organisms were the outstanding feature of the retting zones.

Ecology And Seasonal Variation Of Microalgal Community In An Oil Refinery Effluent Holding Pond: Monitoring And Assessment

The microalgal community as primary producers has to play a significant role in the biotic and abitoic interactions of any aquatic ecosystem. Whenever a community is exposed to a pollutant, responses can occur because individuals acclimate to pollutant caused changes and selection can occur favouring resistant genotypes within a population and selection among species can result in changes in community structure. The microalgal community of industrial effluent treatment systems are continuously exposed to pollutants and there is little data available on the structure and seasonal variation of microalgal community of industrial effluent holding ponds, especially of a complex effluent like that of refinery. The aim of the present study was to investigate the annual variation in the ecology, biomass, productivity and community structure of the algal community of a refinery effluent holding pond. The results of the study showed the pond to be a eutrophic system with a resistant microalgal community with distinct seasonal variation in species composition

FEM based Virtual Prototyping and Design of Third Harmonic Excitation System for Low Voltage Brushless Alternators

Salient pole brushless alternators coupled to IC engines are extensively used as stand-by power supply units for meeting in- dustrial power demands. Design of such generators demands high power to weight ratio, high e ciency and low cost per KVA out- put. Moreover, the performance characteristics of such machines like voltage regulation and short circuit ratio (SCR) are critical when these machines are put into parallel operation and alterna- tors for critical applications like defence and aerospace demand very low harmonic content in the output voltage. While designing such alternators, accurate prediction of machine characteristics, including total harmonic distortion (THD) is essential to mini- mize development cost and time. Total harmonic distortion in the output voltage of alternators should be as low as possible especially when powering very sophis- ticated and critical applications. The output voltage waveform of a practical AC generator is replica of the space distribution of the ux density in the air gap and several factors such as shape of the rotor pole face, core saturation, slotting and style of coil disposition make the realization of a sinusoidal air gap ux wave impossible. These ux harmonics introduce undesirable e ects on the alternator performance like high neutral current due to triplen harmonics, voltage distortion, noise, vibration, excessive heating and also extra losses resulting in poor e ciency, which in turn necessitate de-rating of the machine especially when connected to non-linear loads. As an important control unit of brushless alternator, the excitation system and its dynamic performance has a direct impact on alternator's stability and reliability. The thesis explores design and implementation of an excitation i system utilizing third harmonic ux in the air gap of brushless al- ternators, using an additional auxiliary winding, wound for 1=3rd pole pitch, embedded into the stator slots and electrically iso- lated from the main winding. In the third harmonic excitation system, the combined e ect of two auxiliary windings, one with 2=3rd pitch and another third harmonic winding with 1=3rd pitch, are used to ensure good voltage regulation without an electronic automatic voltage regulator (AVR) and also reduces the total harmonic content in the output voltage, cost e ectively. The design of the third harmonic winding by analytic methods demands accurate calculation of third harmonic ux density in the air gap of the machine. However, precise estimation of the amplitude of third harmonic ux in the air gap of a machine by conventional design procedures is di cult due to complex geome- try of the machine and non-linear characteristics of the magnetic materials. As such, prediction of the eld parameters by conven- tional design methods is unreliable and hence virtual prototyping of the machine is done to enable accurate design of the third har- monic excitation system. In the design and development cycle of electrical machines, it is recognized that the use of analytical and experimental methods followed by expensive and in exible prototyping is time consum- ing and no longer cost e ective. Due to advancements in com- putational capabilities over recent years, nite element method (FEM) based virtual prototyping has become an attractive al- ternative to well established semi-analytical and empirical design methods as well as to the still popular trial and error approach followed by the costly and time consuming prototyping. Hence, by virtually prototyping the alternator using FEM, the important performance characteristics of the machine are predicted. Design of third harmonic excitation system is done with the help of results obtained from virtual prototype of the machine. Third harmonic excitation (THE) system is implemented in a 45 KVA ii experimental machine and experiments are conducted to validate the simulation results. Simulation and experimental results show that by utilizing third harmonic ux in the air gap of the ma- chine for excitation purposes during loaded conditions, triplen harmonic content in the output phase voltage is signi cantly re- duced. The prototype machine with third harmonic excitation system designed and developed based on FEM analysis proved to be economical due to its simplicity and has the added advan- tage of reduced harmonics in the output phase voltage.

La relación entre los conceptos de relación estratégica comunitaria de las organizaciones con las comunidades y la responsabilidad social

Para maximizar los beneficios, una compañía fundamenta sus acciones en ciertas estrategias que ayudan a cumplir su objetivo de generar utilidades. Entre las diferentes acciones que una organización puede utilizar, están las de responsabilidad social y las de relaciones estratégicas con la comunidad. Partiendo de la definición de comunidad, pasando por una descripción de responsabilidad social y sus diferentes formas de aplicabilidad dentro de una empresa, hasta la definición de relación estratégica con la comunidad; esta investigación dirige sus esfuerzos a determinar el vínculo que existe entre los conceptos de responsabilidad social y relación estratégica comunitaria. Adicionalmente, se plantea que otras estrategias de relacionamiento con clientes, como el mercadeo relacional o el CRM, las cuales enfocan sus esfuerzos en conocer a cada uno de los clientes de una compañía para plantear una oferta acorde a sus necesidades, no son muy efectivas a la hora de crear un vínculo emocional con la comunidad.

Métodos de análisis de las comunidades de clientes mediante la relación estratégica comunitaria y el marketing.

En este proyecto analizaremos como las organizaciones se relacionan con el medio y marketing. La idea es determinar cuáles son los métodos de análisis de las comunidades de clientes mediante la relación estratégica comunitaria y el marketing. Por medio del mercadeo se puede conocer el entorno y determinar qué métodos de análisis utilizar para conocer a la comunidad de clientes. Las personas de mercadeo se ocupan de todo lo que ocurre en el entorno, de estar al tanto para saber cuándo hay oportunidades que puedan ser provechosas para la organización o por otro lado cuando hay amenazas de las que debe tener cuidado. Dependiendo del entorno, la organización diseña sus actividades de mercadeo enfocadas en satisfacer las necesidades del consumidor. Las actividades del consumidor se conceptualizan en producto, precio, promoción y plaza que se definen y diseñan basados en la comunidad en la que este inmersa la organización. Es importante buscar información confiable sobre el grupo objetivo al cual se le va ofrecer el producto o servicio, ya que toca analizarlos y comprender a estas personas para diseñar una buena oferta que satisfaga sus necesidades y deseos. Esta persona que recibe el producto o servicio por parte de la organización es el cliente. Los clientes son las personas que llegan a una organización en búsqueda de satisfacer necesidades a través de los bienes y servicios que las empresas ofrecen. Es esencial determinar que los clientes viven en comunidad, es decir comparten ideas por la comunicación tan estrecha que tienen y viven en conjunto bajo las mismas costumbres. Debido a estos es que hoy en día, los consumidores se conglomeran en comunidades de clientes, y para saberles llegar a estos clientes, toca analizarlos por medio de diversos métodos. El uso de las estrategias comunitarias es necesario ya que por medio del marketing se analiza el entorno y se buscan los métodos para analizar a la comunidad de clientes, que comparten características y se analizan en conjunto no por individuo. Es necesario identificar los métodos para relacionarse con la comunidad de clientes, para poder acercarnos a estos y conocerlos bien, saber sus necesidades y deseos y ofrecerles productos y servicios de acuerdo a éstos. En la actualidad estos métodos no son muy comunes ni conocidos, es por esto que nuestro propósito es indagar e identificar estos métodos para saber analizar a las comunidades. En este proyecto se utilizara una metodología de estudio tipo teórico-conceptual buscando las fuentes de información necesarias para llevar a cabo nuestra investigación. Se considera trabajar con El Grupo de Investigación en Perdurabilidad Empresarial y se escogió la línea de gerencia ya que permite entrar en la sociedad del conocimiento, siendo capaces de identificar oportunidades gerenciales en el entorno. Es interesante investigar sobre estos métodos, ya que los clientes esperan un servicio excelente, atento y que se preocupe por ellos y sus necesidades.

Development and illustrative outputs of the Community Integrated Assessment System (CIAS), a multi-institutional modular integrated assessment approach for modelling climate change.

This paper describes the development and first results of the “Community Integrated Assessment System” (CIAS), a unique multi-institutional modular and flexible integrated assessment system for modelling climate change. Key to this development is the supporting software infrastructure, SoftIAM. Through it, CIAS is distributed between the community of institutions which has each contributed modules to the CIAS system. At the heart of SoftIAM is the Bespoke Framework Generator (BFG) which enables flexibility in the assembly and composition of individual modules from a pool to form coupled models within CIAS, and flexibility in their deployment onto the available software and hardware resources. Such flexibility greatly enhances modellers’ ability to re-configure the CIAS coupled models to answer different questions, thus tracking evolving policy needs. It also allows rigorous testing of the robustness of IA modelling results to the use of different component modules representing the same processes (for example, the economy). Such processes are often modelled in very different ways, using different paradigms, at the participating institutions. An illustrative application to the study of the relationship between the economy and the earth’s climate system is provided.