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Feedback loops are a key characteristic of engineering design processes that increase complexity, time to market, and costs. However, some feedback loops, due to design iteration, have a positive impact on design outcomes (i.e., the quality of the final design), so are worth the time and costs incurred. Other loops, resulting from rework, also have a positive impact on the final design but their impact on current projects, in terms of their urgency and so interruption, is high. Thus, overall, and drawing on socio-technical systems literature, some feedback loops are virtuous circles with a positive impact whereas others are vicious circles with a negative impact. In this paper, we report early work exploring these interplays between rework and design iteration through the development of process simulation models.
This chapter seeks to give an overview of the place of Quality Management (QM) in contemporary fertility practice. It provides the reader with an understanding of the terminology used in QM and explores the definition of quality and success in fertility care. An examination of process modelling in the organisation of services is outlined and an analysis in practical terms as to how QM is applied in practice is provided, covering key issues such as document control, organisational structure and the role of the quality manager. Audit as a tool for improving quality is a fundamental tool and its use within a clinical governance framework including risk management/assessment, and other key responsibilities is detailed. Measuring what we do, analysing performance and setting targets to improve should be fundamental to how we approach our work in contemporary clinical practice.
Extremely low birth weight (ELBW) survivors have higher rates of shyness, a risk factor for poorer outcomes across the life span. Due to advances in fetal and neonatal medicine, the first generation of ELBW survivors have survived to adulthood and become parents. However, no studies have investigated the transmission of their stress vulnerability to their offspring. We explored this phenomenon using a population-based cohort of ELBW survivors and normal birth weight (NBW) controls. Using data from three generations, we examined whether the shyness and parenting stress of ELBW and NBW participants (Generation 2) mediated the relation between the parenting style of their parents (Generation 1) and shyness in their offspring (Generation 3), and the extent to which exposure to perinatal adversity (Generation 2) moderated this mediating effect. We found that among ELBW survivors, parenting stress (in Generation 2) mediated the relation between overprotective parenting style in Generation 1 (grandparents) and child shyness in Generation 3. These findings suggest that perinatal adversity and stress may be transmitted to the next generation in humans, as reflected in their perceptions of their children as shy and socially anxious, a personality phenotype that may subsequently place their children at risk of later mental and physical health problems.
Globular clusters (GCs) display anomalous light-elements abundances (HeCNONaMgAl), resembling the yields of hot-hydrogen burning, but there is no consensus yet on the origin of these ubiquitous multiple populations. We present a model in which a super-massive star (SMS, ≳103 M⊙) forms via stellar collisions during GC formation and pollutes the intra-cluster medium. The growth of the SMS finds a balance with the wind mass loss rate, such that the SMS can produce a significant fraction of the total GC mass in processed material, thereby overcoming the so-called mass-budget problem that plagues other models. Because of continuous rejuvenation, the SMS acts as a ‘conveyer-belt’ of hot-hydrogen burning yields with (relatively) low He abundances, in agreement with empirical constraints. Additionally, the amount of processed material per unit of GC mass correlates with GC mass, addressing the specific mass budget problem. We discuss uncertainties and tests of this new self-enrichment scenario.
Objectives: Down syndrome (DS) is a population with known hippocampal impairment, with studies showing that individuals with DS display difficulties in spatial navigation and remembering arbitrary bindings. Recent research has also demonstrated the importance of the hippocampus for novel word-learning. Based on these data, we aimed to determine whether individuals with DS show deficits in learning new labels and if they may benefit from encoding conditions thought to be less reliant on hippocampal function (i.e., through fast mapping). Methods: In the current study, we examined immediate, 5-min, and 1-week delayed word-learning across two learning conditions (e.g., explicit encoding vs. fast mapping). These conditions were examined across groups (twenty-six 3- to 5-year-old typically developing children and twenty-six 11- to 28-year-old individuals with DS with comparable verbal and nonverbal scores on the Kaufman Brief Intelligence Test – second edition) and in reference to sleep quality. Results: Both individuals with and without DS showed retention after a 1-week delay, and the current study found no benefit of the fast mapping condition in either group contrary to our expectations. Eye tracking data showed that preferential eye movements to target words were not present immediately but emerged after 1-week in both groups. Furthermore, sleep measures collected via actigraphy did not relate to retention in either group. Conclusions: This study presents novel data on long-term knowledge retention in reference to sleep patterns in DS and adds to a body of knowledge helping us to understand the processes of word-learning in typical and atypically developing populations. (JINS, 2018, 24, 955–965)
The relationship between depression and sexual behaviour among men who have sex with men (MSM) is poorly understood.
To investigate prevalence and correlates of depressive symptoms (Patient Health Questionnaire-9 score ≥10) and the relationship between depressive symptoms and sexual behaviour among MSM reporting recent sex.
The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) is a cross-sectional study of UK genitourinary medicine clinic attendees without diagnosed HIV (2013–2014).
Among 1340 MSM, depressive symptoms (12.4%) were strongly associated with socioeconomic disadvantage and lower supportive network. Adjusted for key sociodemographic factors, depressive symptoms were associated with measures of condomless sex partners in the past 3 months (≥2 (prevalence ratio (PR) 1.42, 95% CI 1.17–1.74; P=0.001), unknown or HIV-positive status (PR 1.43, 95% CI 1.20–1.71; P<0.001)), sexually transmitted infection (STI) diagnosis (PR 1.46, 95% CI 1.19–1.79; P<0.001) and post-exposure prophylaxis use in the past year (PR 1.83, 95% CI 1.33–2.50; P<0.001).
Management of mental health may play a role in HIV and STI prevention.
Problem Management Plus (PM+) is a brief multicomponent intervention incorporating behavioral strategies delivered by lay health workers. The effectiveness of PM+ has been evaluated in randomized controlled trials in Kenya and Pakistan. When developing interventions for large-scale implementation it is considered essential to evaluate their feasibility and acceptability in addition to their efficacy. This paper discusses a qualitative evaluation of PM+ for women affected by adversity in Kenya.
Qualitative interviews were conducted with 27 key informants from peri-urban Nairobi, Kenya, where PM+ was tested. Interview participants included six women who completed PM+, six community health volunteers (CHVs) who delivered the intervention, seven people with local decision making power, and eight project staff involved in the PM+ trial.
Key informants generally noted positive experiences with PM+. Participants and CHVs reported the positive impact PM+ had made on their lives. Nonetheless, potential structural and psychological barriers to scale up were identified. The sustainability of CHVs as unsalaried, volunteer providers was mentioned by most interviewees as the main barrier to scaling up the intervention.
The findings across diverse stakeholders show that PM+ is largely acceptable in this Kenyan setting. The results indicated that when further implemented, PM+ could be of great value to people in communities exposed to adversities such as interpersonal violence and chronic poverty. Barriers to large-scale implementation were identified, of which the sustainability of the non-specialist health workforce was the most important one.
The end of the last Ice Age in Britain (c. 11500 BP) created major disruption to the biosphere. Open habitats were succeeded by more wooded landscapes, and changes occurred to the fauna following the abrupt disappearance of typical glacial herd species, such as reindeer and horse (Conneller & Higham 2015). Understanding the impact of these changes on humans and how quickly they were able to adapt may soon become clearer, due to recent discoveries in the Colne Valley on the western edge of Greater London, north of the River Thames. An exceptionally well-preserved open-air site was discovered in 2014 as part of a wider project of archaeological investigation and excavation carried out by Wessex Archaeology (2015), on behalf of CEMEX UK. The site, at Kingsmead Quarry in Horton, is unusual because it has good organic preservation and, in addition to worked flint artefacts, it has yielded groups of articulated horse bone. The extreme rarity of such sites of this period in Britain makes this discovery especially significant and re-emphasises the potential importance of the Colne Valley (Lacaille 1963; Lewis 2011; Morgi et al. 2011).
Objectives: This study examined whether children with distinct brain disorders show different profiles of strengths and weaknesses in executive functions, and differ from children without brain disorder. Methods: Participants were children with traumatic brain injury (N=82; 8–13 years of age), arterial ischemic stroke (N=36; 6–16 years of age), and brain tumor (N=74; 9–18 years of age), each with a corresponding matched comparison group consisting of children with orthopedic injury (N=61), asthma (N=15), and classmates without medical illness (N=68), respectively. Shifting, inhibition, and working memory were assessed, respectively, using three Test of Everyday Attention: Children’s Version (TEA-Ch) subtests: Creature Counting, Walk-Don’t-Walk, and Code Transmission. Comparison groups did not differ in TEA-Ch performance and were merged into a single control group. Profile analysis was used to examine group differences in TEA-Ch subtest scaled scores after controlling for maternal education and age. Results: As a whole, children with brain disorder performed more poorly than controls on measures of executive function. Relative to controls, the three brain injury groups showed significantly different profiles of executive functions. Importantly, post hoc tests revealed that performance on TEA-Ch subtests differed among the brain disorder groups. Conclusions: Results suggest that different childhood brain disorders result in distinct patterns of executive function deficits that differ from children without brain disorder. Implications for clinical practice and future research are discussed. (JINS, 2017, 23, 529–538)
We investigated the association between maternal expressed emotion and twin relationship quality, after controlling for a maternal questionnaire measure of the mother–child relationship. This was explored within a community sample of 156 mothers and their two young twin children (Mchild age = 3.69 years; SDchild age = 0.37). Mothers reported on the twin–twin relationship and the mother–child relationship via questionnaire. They were also interviewed about each child using the innovative Preschool Five Minute Speech Sample (Daley et al., 2003), which yields information about relative positive:negative maternal expressed emotion. Mothers who expressed more family-wide positive emotion and less family-wide negative emotion also reported more positivity, but not negativity, within the twin relationship — even when controlling for questionnaire reports of the mother–child relationship. Counter to expectations, discrepancies in mothers’ expressed emotion between their twins also predicted more positive sibling relationships. Our findings corroborate the well established spill-over effect, whereby families are viewed as emotional units of interdependent individuals, none of whom can be understood in isolation from one another. Most importantly, the Preschool Five Minute Speech Sample provides information about mothering that questionnaire reports may not, and thus it is a useful tool in better understanding the twin family system.
As a discipline, design science has traditionally focused on designing products and associated technical processes to improve usability and performance. Although significant progress has been made in these areas, little research has yet examined the role of human behaviour in the design of socio-technical systems (e.g., organizations). Here, we argue that applying organizational psychology as a design science can address this omission and enhance the capability of both disciplines. Specifically, we propose a method to predict malfunctions in socio-technical systems (PreMiSTS), thereby enabling them to be designed out or mitigated. We introduce this method, describe its nine stages, and illustrate its application with reference to two high-profile case studies of such malfunctions: (1) the severe breakdowns in patient care at the UK’s Mid-Staffordshire NHS Foundation Trust hospital in the period 2005–2009, and (2) the fatal Grayrigg rail accident in Cumbria, UK, in 2007. Having first identified the socio-technical and behavioural antecedents of these malfunctions, we then consider how the PreMiSTS method could be used to predict and prevent future malfunctions of this nature. Finally, we evaluate the method, consider its advantages and disadvantages, and suggest where it can be most usefully applied.
New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.
We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.
We included outcomes for 230,099 registered patients, assigned to ranked risk groups.
Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.
Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.
Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.