According to W. Edwards Deming, American companies require nothing less than a transformation of management style and of governmental relations with industry. In Out of the Crisis, originally published in 1982, Deming offers a theory of management based on his famous 14 Points for Management. Management's failure to plan for the future, he claims, brings about loss of market, which brings about loss of jobs. Management must be judged not only by the quarterly dividend, but by innovative plans to stay in business, protect investment, ensure future dividends, and provide more jobs through improved product and service. In simple, direct language, he explains the principles of management transformation and how to apply them.

Out of the Crisis

Biofilms--matrix-enclosed microbial accretions that adhere to biological or non-biological surfaces--represent a significant and incompletely understood mode of growth for bacteria. Biofilm formation appears early in the fossil record (approximately 3.25 billion years ago) and is common throughout a diverse range of organisms in both the Archaea and Bacteria lineages, including the 'living fossils' in the most deeply dividing branches of the phylogenetic tree. It is evident that biofilm formation is an ancient and integral component of the prokaryotic life cycle, and is a key factor for survival in diverse environments. Recent advances show that biofilms are structurally complex, dynamic systems with attributes of both primordial multicellular organisms and multifaceted ecosystems. Biofilm formation represents a protected mode of growth that allows cells to survive in hostile environments and also disperse to colonize new niches. The implications of these survival and propagative mechanisms in the context of both the natural environment and infectious diseases are discussed in this review.

/pdf/bacterial-biofilms-from-the-natural-environment-to-4pdlw3zbzj.pdf

Bacterial biofilms: from the natural environment to infectious diseases.

Part I. Experimental Studies: 2. Experiment in psychology 3. Experiments on perceiving III Experiments on imaging 4-8. Experiments on remembering: (a) The method of description (b) The method of repeated reproduction (c) The method of picture writing (d) The method of serial reproduction (e) The method of serial reproduction picture material 9. Perceiving, recognizing, remembering 10. A theory of remembering 11. Images and their functions 12. Meaning Part II. Remembering as a Study in Social Psychology: 13. Social psychology 14. Social psychology and the matter of recall 15. Social psychology and the manner of recall 16. Conventionalism 17. The notion of a collective unconscious 18. The basis of social recall 19. A summary and some conclusions.

Remembering. A Study in Experimental and Social Psychology, Cambridge (University Press) 1964.

http://diposit.ub.edu/dspace/bitstream/2445/122776/1/gbd2016riskfactorscollaborators2017_3028.pdf

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013

How we raise young children is one of today's most highly personalized and sharply politicized issues, in part because each of us can claim some level of "expertise." The debate has intensified as discoveries about our development-in the womb and in the first months and years-have reached the popular media. How can we use our burgeoning knowledge to assure the well-being of all young children, for their own sake as well as for the sake of our nation? Drawing from new findings, this book presents important conclusions about nature-versus-nurture, the impact of being born into a working family, the effect of politics on programs for children, the costs and benefits of intervention, and other issues. The committee issues a series of challenges to decision makers regarding the quality of child care, issues of racial and ethnic diversity, the integration of children's cognitive and emotional development, and more. Authoritative yet accessible, From Neurons to Neighborhoods presents the evidence about "brain wiring" and how kids learn to speak, think, and regulate their behavior. It examines the effect of the climate-family, child care, community-within which the child grows.

/pdf/from-neurons-to-neighborhoods-the-science-of-early-childhood-3bfl5g72ow.pdf

From Neurons to Neighborhoods: The Science of Early Childhood Development

OBJECTIVES. Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention9s impact on commercially and Medicaid-insured children. METHODS. We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to RESULTS. The data include 223135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to CONCLUSIONS. A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

/pdf/impact-of-a-16-community-trial-to-promote-judicious-1likm221p5.pdf

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts.

Sixteen patients, aged 1 month to 15 years, were studied to determine the clinical course and long-term outcome of empyema in previously healthy children. The pathogens responsible were Haemophilus influenzae type b (seven patients), Staphylococcus aureus (five patients), Streptococcus pneumoniae (three patients), and viridans group Streptococcus (one patient). All patients had loculated fluid showing on chest roentgenographs. Chest tube drainage yielded 20 to 1,495 mL (mean 293 mL) during the first three days, accounting for 83% of total drainage. Chest tubes were removed after three to 17 days (mean ten days). Only slight roentgenographic improvement showed during chest tube drainage. Three patients required an open thoracotomy because of an unsatisfactory clinical response. Hospitalization ranged from eight to 77 days (mean 25 days). All patients had residual pleural thickening shown on chest roentgenographs taken at discharge. Thirteen patients were seen 5 to 140 months (mean 66 months) after discharge. Findings from physical examination were normal in 12 of the 13 patients. Pulmonary function tests in ten of the 13 patients revealed (mean percent predicted +/- 1 SD): vital capacity 92 +/- 12, residual volume 85 +/- 31, total lung capacity 92 +/- 13, peak flow rate 96 +/- 17, forced expiratory volume in 1 second 90 +/- 13, and maximal mid-expiratory flow rate 93 +/- 25. In all but one patient, findings on chest roentgenograms were normal or showed slight pleural thickening. Children with loculated empyema can be treated successfully with antibiotics and chest tube drainage. Few patients require open drainage, and further surgery is rarely required. The long-term outcome is excellent.

Empyema in children: clinical course and long-term follow-up.

Experts in infection control coax, cajole, threaten, and plead, but still their colleagues neglect to wash their hands. Consider, for example, the report by Doebbeling et al. in this issue of the J...

Hand-washing and nosocomial infections.

THE AMERICAN RECOVERY AND REINVESTMENT ACT will provide an unprecedented stimulus for translational and health services research. A $1.1 billion investment in comparative effectiveness research (CER) should produce a torrent of new information about the effectiveness of drugs, technologies, and interventions. For this to result in better, more cost-effective health care, better evidence is needed to address the translational gap between clinical studies and everyday practice. In essence, this is CER for implementation strategies (a type of CER seriously underrepresented in current discourse, but necessary to deliver on the Institute of Medicine’s goals for improved health care quality). Credit is due to the US Department of Health and Human Services for recognizing this need. Evaluation of the implementation and dissemination strategies for mainstream CER is embedded within several programs funded by the American Recovery and Reinvestment Act that share the broad objective of spreading CER findings widely (total funding: $97 million; Karen Migdail, director of media relations, Agency for Healthcare Research and Quality, written communication, November 2010). For this investment to yield a timely return, researchers will need to adopt an array of pragmatic and context-sensitive study designs to determine which strategies are best for implementing evidence-based practices locally and at scale. Traditional CER uses sophisticated data mining of longitudinal administrative databases to evaluate therapeutic and diagnostic interventions. These techniques could revolutionize the speed, population relevance, and context specificity of translational research. However, most databases currently do not include the rich clinical or organizational information needed to take the critical next step of comparing implementation strategies. Expansion of the electronic medical record and improvements in interoperability will help, especially if captured data include key information about organizational structures, clinical processes, risk factors and comorbidities, the true costs of diagnosis and treatment, and important outcomes such as functional status and quality of life. Obtaining and recording this information will require closer collaboration among clinicians, health services researchers, systems improvement experts, and health information technologists. In the meantime, new knowledge of strategies to implement the findings of CER is likely to come mainly from prospective studies. Randomized controlled trials (RCTs) are the criterion standard of clinical research, and designs such as cluster randomization are useful for implementation research in which the unit of analysis is a clinician, microsystem, organization, or community. However, such RCTs tend to be slow, expensive, and insensitive to the heterogeneous contexts in which their output will be deployed. Their restrictive entry criteria limit the rate of recruitment and generalizability of results, and their stringent protocols do not easily accommodate emerging new knowledge about the interventions themselves or changes in the environment in which they are being applied. Given these limitations, it is not surprising that RCTs have been criticized for failing to predict real-world outcomes. The pragmatic clinical trial attempts to address the limitations of conventional RCTs by seeking to reproduce conditions that the intervention will encounter in the real world. The entry criteria of pragmatic clinical trials aim to reflect the full range of patients and clinicians who will be using an intervention. This approach is well suited to research into systems of health care delivery that cannot be separated easily from everyday clinical practice. Pragmatic study designs also can take into account the local adaptations and amendments that often occur when new strategies are introduced. Another flexible approach, the adaptive clinical trial, makes provision for planned, reactive changes as the trial progresses. This is especially important in evaluating the effects of a systems improvement intervention when observations reveal low compliance with care processes that are not the targets of the protocol but are linked to outcomes. In an adaptive trial, such unanticipated problems can be addressed in near real time by protocol adjustment. Bayesian data analysis can enhance efficiency and speed of adaptive

/pdf/the-promise-of-comparative-effectiveness-research-1xulzw57ox.pdf

The Promise of Comparative Effectiveness Research

Objective To describe parent perceptions of their child's hospital discharge and assess the relationship between these perceptions and hospital readmission.

Design A prospective study of parents surveyed with questions adapted from the care transitions measure, an adult survey that assesses components of discharge care. Participant answers, scored on a 5-point Likert scale, were compared between children who did and did not experience a readmission using a Fisher's exact test and logistic regression that accounted for patient characteristics associated with increased readmission risk, including complex chronic condition and assistance with medical technology.

Setting A tertiary-care children's hospital.

Participants: A total of 348 parents surveyed following their child's hospital discharge between March and October 2010.

Intervention None.

Main Outcome Measure Unplanned readmission within 30 days of discharge.

Results There were 28 children (8.1%) who experienced a readmission. Children had a lower readmission rate (4.4 vs. 11.3%, P = 0.004) and lower adjusted readmission likelihood [odds ratio 0.2 (95% confidence interval 0.1, 0.6)] when their parents strongly agreed ( n = 206) with the statement, ‘I felt that my child was healthy enough to leave the hospital’ from the index admission. Parent perceptions relating to care management responsibilities, medications, written discharge plan, warning signs and symptoms to watch for and primary care follow-up were not associated with readmission risk in multivariate analysis.

Conclusions Parent perception of their child's health at discharge was associated with the risk of a subsequent, unplanned readmission. Addressing concerns with this perception prior to hospital discharge may help mitigate readmission risk in children.

Donald A. Goldmann

Papers

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts.

Empyema in children: clinical course and long-term follow-up.

Hand-washing and nosocomial infections.

The Promise of Comparative Effectiveness Research

Hospital readmission and parent perceptions of their child's hospital discharge