A qualitative analysis of leadership styles and the selection of quality improvement in primary care practice

In the Practice Change Model, physicians act as key stakeholders, people who have both an investment in the practice and the capacity to influence how the practice performs. This leadership role is critical to the development and change of the practice. Leadership roles and effectiveness are an important factor in quality improvement in primary care practices.^ The study conducted involved a comparative case study analysis to identify leadership roles and the relationship between leadership roles and the number and type of quality improvement strategies adopted during a Practice Change Model-based intervention study. The research utilized secondary data from four primary care practices with various leadership styles. The practices are located in the San Antonio region and serve a large Hispanic population. The data was collected by two ABC Project Facilitators from each practice during a 12-month period including Key Informant Interviews (all staff members), MAP (Multi-method Assessment Process), and Practice Facilitation field notes. This data was used to evaluate leadership styles, management within the practice, and intervention tools that were implemented. The chief steps will be (1) to analyze if the leader-member relations contribute to the type of quality improvement strategy or strategies selected (2) to investigate if leader-position power contributes to the number of strategies selected and the type of strategy selected (3) and to explore whether the task structure varies across the four primary care practices.^ The research found that involving more members of the clinic staff in decision-making, building bridges between organizational staff and clinical staff, and task structure are all associated with the direct influence on the number and type of quality improvement strategies implemented in primary care practice.^ Although this research only investigated leadership styles of four different practices, it will offer future guidance on how to establish the priorities and implementation of quality improvement strategies that will have the greatest impact on patient care improvement. ^

Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

Mejora del comportamiento térmico de los morteros de cal aditivados y su empleo en la rehabilitación de inmuebles = Improvement of thermal behaviour of additived lime mortars and their use in rehabilitation of buildings

La envolvente de la edificación es la responsable de equilibrar el intercambio energético entre el interior y el exterior, por lo tanto cualquier actuación encaminada a la reducción del consumo energético ha de establecer, como uno de sus objetivos prioritarios, la mejora del comportamiento de la misma. Las edificaciones anteriores a 1940 constituyen la mayor parte de las existentes en áreas rurales y centros urbanos. En ellas, la repercusión de la fachada sobre las transmitancias globales pone de manifiesto la necesidad de intervención. Sin embargo, su elevada inercia térmica y los importantes saltos térmicos característicos de gran parte de España plantean la importancia de que aquélla se efectúe por el exterior. A tal respecto, la falta de disponibilidad de espesor suficiente para implantar sistemas tipo SATE deriva en que, frecuentemente, la única solución viable sea la de aislar por el interior perdiendo con ello la capacidad de acumulación térmica del muro y con el asociado riesgo de condensaciones. La amplia tradición en el empleo de revestimientos, especialmente en base de cal, permiten que éstos sean utilizados no sólo como elemento estético o de protección de la obra de fábrica antigua sino también para la mejora del comportamiento térmico del soporte, si se aprovecha el mecanismo de transmisión térmica por radiación. Éste es el objetivo de la presente Tesis Doctoral en la que se estudia la modificación de las propiedades radiantes de los morteros de revestimiento para la mejora de la eficiencia energética de las construcciones históricas, principalmente las constituidas por muros monolíticos, aunque podría ser de aplicación a otro tipo de construcciones compuestas por diversas capas. Como punto de partida, se estudió y revisó la documentación disponible sobre las investigaciones de las tres áreas científico-tecnológicas que convergen en la Tesis Doctoral: rehabilitación, material y comportamiento térmico, a partir de lo cual se comprobó la inexistencia de estudios similares al objeto de la presente Tesis Doctoral. Complementariamente, se analizaron los revestimientos en lo concerniente a los materiales que los constituyen, la composición de las mezclas y características de cada una de las capas así como al enfoque que, desde el punto de vista térmico, se estimaba más adecuado para la obtención de los objetivos propuestos. Basándonos en dichos análisis, se preseleccionaron ochenta materiales que fueron ensayados en términos de reflectancia y emisividad para elegir cuatro con los que se continuó la investigación. Éstos, junto con la cal elegida para la investigación y el árido marmóreo característico de la última capa de revestimiento, fueron caracterizados térmicamente, de forma pormenorizada, así como química y físicamente. Los fundamentos teóricos y los estudios preliminares desarrollados con distintos materiales, en estado fresco y endurecido, fueron empleados en la dosificación de componentes de las mezclas, en dos proporciones distintas, para el estudio del efecto del agregado. Éstas se ensayaron en estado fresco, para comprobar su adecuación de puesta en obra y prever su VI adherencia al soporte, así como en estado endurecido a 28 y 90 días de curado, para conocer las propiedades que permitieran prever su compatibilidad con aquél y estimar el alcance de la reducción de transferencias térmicas lograda. Además, se estudiaron las características generales de las mezclas que sirvieron para establecer correlaciones entre distintas propiedades y entender los resultados mecánicos, físicos (comportamiento frente al agua) y energéticos. Del estudio conjunto de las distintas propiedades analizadas se propusieron dos mezclas, una blanca y otra coloreada, cuyas características permiten garantizar la compatibilidad con la obra de fábrica antigua, desde el punto de vista físico y mecánico, y preservar la autenticidad de los revestimientos, en cuanto a la técnica de aplicación tradicional en sistemas multicapa. El comportamiento térmico de las mismas, sobre una obra de fábrica de 40 cm de espesor, se estimó, en estado estacionario y pseudo-transitorio, demostrándose reducciones del flujo térmico entre 16-48%, en condiciones de verano, y entre el 6-11%, en invierno, en función de la coloración y de la rugosidad de la superficie, en comparación con el empleo de la mezcla tradicional. Por lo que, se constata la viabilidad de los materiales compuestos propuestos y su adecuación al objetivo de la investigación. VII ABSTRACT The envelope is responsible for balancing the energy exchange between the inside and outside in buildings. For this reason, any action aimed at reducing energy consumption must establish, as one of its key priorities, its improvement. In rural areas and urban centers, most of the constructions were built before 1940. In them, the impact of the façade on the global transmittance highlights the need for intervention. However, its high thermal inertia and fluctuation of temperatures in the majority of Spain bring up that it should be placed outside the insulation. In this regard, the lack of availability of enough thickness to implement systems such as ETICS results in that often the only viable solution is to isolate the interior, losing thereby the wall’s heat storage capacity with the associated risk of condensation. The tradition in the use of renders, especially lime-based, allows us to use them not only as an aesthetic element or to protect the ancient masonry, but also for improved thermal performance of the support by taking advantage of the heat transfer mechanism by radiation. This is the aim of this Doctoral Thesis in which the modification of the radiative properties of lime mortars for renders to improve the energy efficiency of historic buildings, mainly composed of monolithic walls, is studied, although it could be applied to other structures composed of several layers. As a starting point, the available literature in the three scientific-technological areas that converge at the Doctoral Thesis: rehabilitation, material and thermal behaviour, was reviewed, and confirmed the absence of researches similar to this Doctoral Thesis. Additionally, the renders were studied with regard to the materials that constitute them, the composition of the mixtures and the characteristics of each layer, as well as to the approach which, from a thermal point of view, was deemed the most suitable for achieving the objectives sets. Based on thre aforementioned analysis, eighty materials tested in terms of reflectance and emissivity were pre-selected, to choose four with which the research was continued. Common marble sand, used in the last layer of the renders, together with the appointed materials and hydrated lime were characterized thermally, in detail, as well as chemically and physically. The theoretical bases and preliminary studies with different materials, in fresh and hardened state, were used in the dosage of the composition of the mixtures. In order to study their effect they were used in two different proportions, that is, ten mixtures in total. These were tested in their fresh state to evaluate their setting-up suitability and foresee their adhesion to the support, as well as in their hardened state, at 28 and 90 days of curing, to establish the properties which enabled us to anticipate their compatibility with the old masonry walls and estimate the scope of the reduction of heat transfers achieved. In addition, the general characteristics of the mixtures used to establish correlations and to understand the mechanical, physical and energy results were studied. Two mixtures, one white and one colored, were proposed as the result of the different properties analysed, whose characteristics allow the guarantee of mechanical and physical compatibility VIII with the old masonry and preserve the authenticity of the renders. The thermal behavior of both, applied on a masonry wall 40 cm thick, was estimated at a steady and pseudo-transient state, with heat flow reductions between 16-48% during summertime and 6-11% during wintertime, depending on the color and surface roughness, compared to the use of the traditional mixture. So, the viability of the proposed composite materials and their fitness to the aim of the research are established.

On the improvement of urban regeneration processes from more than thirty years of rehabilitation experiences

At this moment of extended economic, social and environmental crisis within which new interventions on the consolidated city are being set out, it is essential to count on the acquired experience in urban rehabilitation processes that were carried out in Spain during the last thirty years. Despite the complexity of this kind of processes and the diversity of the situations and actions that happened, this paper addresses the analysis of common patterns in twenty urban rehabilitation experiences. Different stages of the processes were studied, from the management to the regenerated areas in order to ease the design of new intervention initiatives.

How does family intervention improve the outcome of people with schizophrenia?

Background: There is strong evidence of the efficacy of family psychosocial interventions for schizophrenia, but evidence of the role played by the attitudes of relatives in the therapeutic process is lacking. Method: To study the effect of a family intervention on family attitudes and to analyse their mediating role in the therapeutic process 50 patients with schizophrenia and their key relatives undergoing a trial on the efficacy of a family psychosocial intervention were studied by means of the Affective Style Coding System, the Scale of Empathy, and the Relational Control Coding System. Specific statistical methods were used to determine the nature of the relationship of the relatives’ attitudes to the outcome of family intervention. Results: Family psychosocial intervention was associated with a reduction in relatives’ guilt induction and dominance and an improvement in empathy. Empathy and lack of dominance were identified as independent mediators of the effect of family psychosocial intervention. The change in empathy and dominance during the first 9 months of the intervention predicted the outcome in the following 15 months. Conclusion: Relatives’ empathy and lack of dominance are mediators of the beneficial effect of family psychosocial intervention on patient’s outcome.

Research and intervention : preventing substance abuse in higher education /

"FIRST 94-7001"--P. [4] of cover.

Multisite, quality-improvement collaboration to optimise cardiac care in Queensland public hospitals

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration. Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003. Setting: Nine public hospitals in Queensland. Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF). Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group. Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods. Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF. Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

Are parent-reported outcomes for self-directed or telephone-assisted behavioral family intervention enhanced if parents are observed?

The study examined the effects of conducting observations as part of a broader assessment of families participating in behavior family intervention (BFI). It was designed to investigate whether the observations improve intervention outcomes. Families were randomly assigned to different levels of BFI or a waitlist control condition and subsequently randomly assigned to either observation or no-observation conditions. This study demonstrated significant intervention and observation effects. Mothers in more intensive BFI reported more improvement in their child’s behavior and their own parenting. Observed mothers reported lower intensity of child behavior problems and more effective parenting styles. There was also a trend for less anger among mothers who were observed and evidence of an observation-intervention interaction for parental anger, with observed mothers in more intensive intervention reporting less anger compared to those not observed. Implications for clinical and research intervention contexts are discussed.

The evaluation and development of the lead authority partnership scheme as a central intervention strategy for health and safety enforcement by local authorities

The research comprises a suite of studies that examines and develops the Lead Authority Partnership Scheme (LAPS) as a central intervention strategy for health and safety by local authority (LA) enforcers. Partnership working is a regulatory concept that in recent years has become more popular but there has been little research conducted to investigate, explore and evaluate its practical application. The study reviewed two contrasting approaches to partnership working between LAs and businesses, both of which were intended to secure improvements in the consistency of enforcement by the regulators and in the health and safety management systems of the participating businesses. The first was a well-established and highly prescriptive approach that required a substantial resource commitment on the part of the LA responsible for conducting a safety management review (SMR) of the business. As a result of his evaluation of the existing ‘full SMR’ scheme, the author developed a second, more flexible approach to partnership working. The research framework was based upon a primarily qualitative methodology intended to investigate and explore the impact of the new flexible arrangements for partnership working. The findings from this study of the flexible development of the scheme were compared and contrasted with those from studies of the established ‘full SMR’ scheme. A substantial degree of triangulation was applied in an attempt to strengthen validity and broaden applicability of the research findings. Key informant interviews, participant observation, document/archive reviews, questionnaires and surveys all their particular part to play in the overall study. The findings from this research revealed that LAPS failed to deliver consistency of LA enforcement across multiple-outlet businesses and the LA enforced business sectors. Improvement was however apparent in the safety management systems of the businesses participating in LAPS. Trust between LA inspector and safety professional was key to the success of the partnerships as was the commitment of these key individuals. Competition for precious LA resources, the priority afforded to food safety over health and safety, the perceived high resource demands of LAPS, and the structure and culture of LAs were identified as significant barriers to LA participation. Flexible approaches, whilst addressing the resource issues, introduced some fresh concerns relating to credibility and delivery. Over and above the stated aims of the scheme, LAs and businesses had their own reasons for participation, notably the personal development of individuals and kudos for the organisation. The research has explored the wider implications for partnership working with the overall conclusion it is most appropriately seen as a strategic level element within a broader structured intervention strategy.

The 'Healthy Passport' intervention with older people in an English urban environment:effects of incentives and peer-group organisers in promoting healthy living

This paper reports the evaluation of the effectiveness of incentives (viz. points and prizes) and of peer-group organisers ('older people's champions') in the outcomes of a health-improvement programme for people aged 50 + years in a multi-ethnic district of the West Midlands, England. Health promotion activities Were provided, and adherence, outcome variables and barriers to adherence were assessed over six months, using a `passport' format. Those aged in the fifties and of Asian origin Were under represented, but people of Afro-Caribbean origin were well represented and proportionately most likely to stay in the project. Those of greater age and With more illness were most likely to drop out. There were significant improvements in exercise, diet and the uptake of influenza vaccines and eyesight tests, but slighter improvements in wellbeing. Positive outcomes related to the incentives and to liking the format. The number of reported barriers was associated with lower involvement and lack of change, as was finding activities too difficult, the level of understanding, and transport and mobility problems, but when these were controlled, age did not predict involvement. Enjoying the scheme was related to positive changes, and this was associated with support from the older people's champions.

Developing and evaluating a methodology for business process improvement

Purpose – There appears to be an ever-insatiable demand from markets for organisations to improve their products and services. To meet this, there is a need to provide business process improvement (BPI) methodologies that are holistic, structured and procedural. Therefore, this paper describes research that has formed and tested a generic and practical methodology termed model-based and integrated process improvement (MIPI) to support the implementation of BPI; and to validate its effectiveness in organisations. This methodology has been created as an aid for practitioners within organisations. Design/methodology/approach – The research objectives were achieved by: reviewing and analysing current methodologies, and selecting a few frameworks against key performance indicators. Using a refined Delphi approach and semi-structured interview with the “experts” in the field. Intervention, case study and process research approach to evaluating a methodology. Findings – The BPI methodology was successfully formed and applied by the researcher and directly by the companies involved against the criteria of feasibility, usability and usefulness. Research limitations/implications – The paper has demonstrated a new knowledge on how to systematically assess a BPI methodology in practice. Practical implications – Model-based and integrated process improvement methodology (MIPI) methodology offers the practitioner (experienced and novice) a set of step-by-step aids necessary to make informed, consistent and efficient changes to business processes. Originality/value – The novelty of this research work is the creation of a holistic workbook-based methodology with relevant tools and techniques. It extends the capabilities of existing methodologies.

Multiple component patient safety intervention in English hospitals:controlled evaluation of second phase

Objective: To independently evaluate the impact of the second phase of the Health Foundation's Safer Patients Initiative (SPI2) on a range of patient safety measures. Design: A controlled before and after design. Five substudies: survey of staff attitudes; review of case notes from high risk (respiratory) patients in medical wards; review of case notes from surgical patients; indirect evaluation of hand hygiene by measuring hospital use of handwashing materials; measurement of outcomes (adverse events, mortality among high risk patients admitted to medical wards, patients' satisfaction, mortality in intensive care, rates of hospital acquired infection). Setting: NHS hospitals in England. Participants: Nine hospitals participating in SPI2 and nine matched control hospitals. Intervention The SPI2 intervention was similar to the SPI1, with somewhat modified goals, a slightly longer intervention period, and a smaller budget per hospital. Results: One of the scores (organisational climate) showed a significant (P=0.009) difference in rate of change over time, which favoured the control hospitals, though the difference was only 0.07 points on a five point scale. Results of the explicit case note reviews of high risk medical patients showed that certain practices improved over time in both control and SPI2 hospitals (and none deteriorated), but there were no significant differences between control and SPI2 hospitals. Monitoring of vital signs improved across control and SPI2 sites. This temporal effect was significant for monitoring the respiratory rate at both the six hour (adjusted odds ratio 2.1, 99% confidence interval 1.0 to 4.3; P=0.010) and 12 hour (2.4, 1.1 to 5.0; P=0.002) periods after admission. There was no significant effect of SPI for any of the measures of vital signs. Use of a recommended system for scoring the severity of pneumonia improved from 1.9% (1/52) to 21.4% (12/56) of control and from 2.0% (1/50) to 41.7% (25/60) of SPI2 patients. This temporal change was significant (7.3, 1.4 to 37.7; P=0.002), but the difference in difference was not significant (2.1, 0.4 to 11.1; P=0.236). There were no notable or significant changes in the pattern of prescribing errors, either over time or between control and SPI2 hospitals. Two items of medical history taking (exercise tolerance and occupation) showed significant improvement over time, across both control and SPI2 hospitals, but no additional SPI2 effect. The holistic review showed no significant changes in error rates either over time or between control and SPI2 hospitals. The explicit case note review of perioperative care showed that adherence rates for two of the four perioperative standards targeted by SPI2 were already good at baseline, exceeding 94% for antibiotic prophylaxis and 98% for deep vein thrombosis prophylaxis. Intraoperative monitoring of temperature improved over time in both groups, but this was not significant (1.8, 0.4 to 7.6; P=0.279), and there were no additional effects of SPI2. A dramatic rise in consumption of soap and alcohol hand rub was similar in control and SPI2 hospitals (P=0.760 and P=0.889, respectively), as was the corresponding decrease in rates of Clostridium difficile and meticillin resistant Staphylococcus aureus infection (P=0.652 and P=0.693, respectively). Mortality rates of medical patients included in the case note reviews in control hospitals increased from 17.3% (42/243) to 21.4% (24/112), while in SPI2 hospitals they fell from 10.3% (24/233) to 6.1% (7/114) (P=0.043). Fewer than 8% of deaths were classed as avoidable; changes in proportions could not explain the divergence of overall death rates between control and SPI2 hospitals. There was no significant difference in the rate of change in mortality in intensive care. Patients' satisfaction improved in both control and SPI2 hospitals on all dimensions, but again there were no significant changes between the two groups of hospitals. Conclusions: Many aspects of care are already good or improving across the NHS in England, suggesting considerable improvements in quality across the board. These improvements are probably due to contemporaneous policy activities relating to patient safety, including those with features similar to the SPI, and the emergence of professional consensus on some clinical processes. This phenomenon might have attenuated the incremental effect of the SPI, making it difficult to detect. Alternatively, the full impact of the SPI might be observable only in the longer term. The conclusion of this study could have been different if concurrent controls had not been used.

Large scale organisational intervention to improve patient safety in four UK hospitals:mixed method evaluation

Objectives: To conduct an independent evaluation of the first phase of the Health Foundation's Safer Patients Initiative (SPI), and to identify the net additional effect of SPI and any differences in changes in participating and non-participating NHS hospitals. Design: Mixed method evaluation involving five substudies, before and after design. Setting: NHS hospitals in United Kingdom. Participants: Four hospitals (one in each country in the UK) participating in the first phase of the SPI (SPI1); 18 control hospitals. Intervention: The SPI1 was a compound (multicomponent) organisational intervention delivered over 18 months that focused on improving the reliability of specific frontline care processes in designated clinical specialties and promoting organisational and cultural change. Results: Senior staff members were knowledgeable and enthusiastic about SPI1. There was a small (0.08 points on a 5 point scale) but significant (P<0.01) effect in favour of the SPI1 hospitals in one of 11 dimensions of the staff questionnaire (organisational climate). Qualitative evidence showed only modest penetration of SPI1 at medical ward level. Although SPI1 was designed to engage staff from the bottom up, it did not usually feel like this to those working on the wards, and questions about legitimacy of some aspects of SPI1 were raised. Of the five components to identify patients at risk of deterioration - monitoring of vital signs (14 items); routine tests (three items); evidence based standards specific to certain diseases (three items); prescribing errors (multiple items from the British National Formulary); and medical history taking (11 items) - there was little net difference between control and SPI1 hospitals, except in relation to quality of monitoring of acute medical patients, which improved on average over time across all hospitals. Recording of respiratory rate increased to a greater degree in SPI1 than in control hospitals; in the second six hours after admission recording increased from 40% (93) to 69% (165) in control hospitals and from 37% (141) to 78% (296) in SPI1 hospitals (odds ratio for "difference in difference" 2.1, 99% confidence interval 1.0 to 4.3; P=0.008). Use of a formal scoring system for patients with pneumonia also increased over time (from 2% (102) to 23% (111) in control hospitals and from 2% (170) to 9% (189) in SPI1 hospitals), which favoured controls and was not significant (0.3, 0.02 to 3.4; P=0.173). There were no improvements in the proportion of prescription errors and no effects that could be attributed to SPI1 in non-targeted generic areas (such as enhanced safety culture). On some measures, the lack of effect could be because compliance was already high at baseline (such as use of steroids in over 85% of cases where indicated), but even when there was more room for improvement (such as in quality of medical history taking), there was no significant additional net effect of SPI1. There were no changes over time or between control and SPI1 hospitals in errors or rates of adverse events in patients in medical wards. Mortality increased from 11% (27) to 16% (39) among controls and decreased from17%(63) to13%(49) among SPI1 hospitals, but the risk adjusted difference was not significant (0.5, 0.2 to 1.4; P=0.085). Poor care was a contributing factor in four of the 178 deaths identified by review of case notes. The survey of patients showed no significant differences apart from an increase in perception of cleanliness in favour of SPI1 hospitals. Conclusions The introduction of SPI1 was associated with improvements in one of the types of clinical process studied (monitoring of vital signs) and one measure of staff perceptions of organisational climate. There was no additional effect of SPI1 on other targeted issues nor on other measures of generic organisational strengthening.

The Future of EU Cohesion Policy. Endogenous Development – Added Value of Intervention – Regulatory Frameworks

The successful operation of the regional development – or cohesion – policy of the European Union has a strategic importance from the point of view of the whole integration process. Strengthening economic, social and territorial cohesion and decreasing disparities between member states and regions are not only one of the main priorities of the integration, but at the same time these are justified expectations of the people living in the member states of the union. The cohesion transfers should be spent on those factors which have the biggest contribution to the improvement of development prospects and competitiveness in the given regions. Theories on regional development have controversial conclusions about the long-term formation of development disparities. However, it has become evident that successful development policies are based on endogenous factors, innovation and well-functioning institutions. After examining theoretical considerations and regional disparities the study analyses the impacts of EU regional policy and evaluates the main elements of the proposed regulatory frameworks for the period 2014-2020.