Lean machine(s): chasing the contexts

There is a perennial game in health and social care called assessment and evaluation: the game could also be called 'CTC' - 'chasing the context'.

Relativity lies not only in the realm of physics and philosophy.

When I say relativity I am referring of course to the influence and impact of a health and social care situation from the constantly changing perspective of each of several different players:

• the patient;
• carer;
• nurse;
• doctor;
• manager;
• medical ward;
• community mental health team;
• commissioner.

Usually, the context collapses to a specific problem (a situation) and the players set to solve a care problem presented by an individual -

• a client, resident or patient;

and their -

• relatives;
• residential care home manager;
• residential care home staff nurse and team;
• community mental health nurse;
• medical personnel.

Context directs, dictates, and shapes health and social care theory, practice, management and policy.

This relativism can also subvert, sublime, confuse and stymie plans, common sense notions, creativity, innovation and management directives.

Like a tide this relativity picks us up and re-figures, re-paints and shifts the location of everything - including measures and how they are used.

Context is all! - so the saying goes. But context never wholly reveals itself. For that is another situation, another context, another side, another coin.

For context there are key defining parameters (location, diagnoses, risk, need, physical, mental, holistic ...) all of these are couched or spring from time.

So, the game calls for us and the tide teases us to measure and evaluate. This coast is never clear, but how long is it now? Where are the pathways now? Where will they be again?

As we travel (and travail) to and from this context to that - thresholds are also altered: up and down and always around; the way of life and ..... .

Image source:
http://www.esd112.org/edtech/no_limit/rs_archive.cfm

Journal of Evaluation in Clinical Practice

Dear All,

I’m pleased to advise you that the next edition of the forum has been published in the Journal of Evaluation in Clinical Practice. I hope you enjoy the ongoing efforts of all our contributors and will be encouraged to submit your next manuscript to the journal.
With kind regards
Joachim and Carmel
Co-editors

Volume 16 Issue 3 (June 2010)

Editorial

Variability, continuity and trust – towards an understanding of uncertainty in health and health care (p 401-402)
Joachim P. Sturmberg
DOI: 10.1111/j.1365-2753.2010.01458.x

Original Articles

Homeostasis and Gauss statistics: barriers to understanding natural variability (p 403-408)
Bruce J. West
DOI: 10.1111/j.1365-2753.2010.01459.x
Abstract
Music in the Park. An integrating metaphor for the emerging primary (health) care system (p 409-414)
Joachim P. Sturmberg, Carmel M. Martin, Di O'Halloran
DOI: 10.1111/j.1365-2753.2010.01460.x
Abstract
W(h)ither complexity? The emperor's new toolkit? Or elucidating the evolution of health systems knowledge? (p 415-420)
Carmel M. Martin, Margot Félix-Bortolotti
DOI: 10.1111/j.1365-2753.2010.01461.x
Abstract
Power law relationships between health care utilization and symptom assessment among people with panic attacks (p 421-426)
David Katerndahl
DOI: 10.1111/j.1365-2753.2010.01462.x
Abstract
Social factors in clinical complexity: reflections from a paediatric unit (p 427-430)
Shruti Sarkar, Dipankar Sarkar
DOI: 10.1111/j.1365-2753.2010.01463.x
Abstract
How do primary care doctors deal with uncertainty in making diagnostic decisions? : The development of the 'Dealing with Uncertainty Questionnaire' (DUQ) (p 431-437)
Antonius Schneider, Bernd Löwe, Stefan Barie, Stefanie Joos, Peter Engeser, Joachim Szecsenyi
DOI: 10.1111/j.1365-2753.2010.01464.x
Abstract
Joachim P Sturmberg
Prof. of General Practice
PO Box 3010
Wamberal, NSW 2260
Australia
http://monash.academia.edu/JoachimSturmberg
The core value of medical care is the improvement of personal health, the value inherent and constant since the beginnings of medicine, and the achievement of personal health depends on an ongoing personal relationship with the doctor. - The Foundations of Primary Care. Daring to be different.

International Journal of Integrated Care

Dear IJIC reader,

Recently PUBLISHED in the International Journal of Integrated Care

A Research and Theory paper:

An evaluation of SNOMED CT® in the domain of complex chronic conditions,
by Tara Sampalli, Michael Shepherd, Jack Duffy and Roy Fox

… It is the hypothesis of this work that showing the availability of multidisciplinary concepts for one complex condition can generate a similar expectation of available terms for other chronic conditions …

A policy paper:

Integrating care for people with mental illness: the Care Programme Approach in England and its implications for long-term conditions management,
by Nick Goodwin and Simon Lawton-Smith

… the lesson from the CPA experience suggests that there is potential for better care integration to be had in a strategy based on personalised care planning and investment in care co-ordination for people with chronic and sometimes complex needs …

And a book review:

Managing transition. Support for individuals at key point of change, edited
by Alison Petch and reviewed by AnneLoes van Staa

…This book is unique in its broad focus on different transitions in various contexts, and its exploration of the evidence for support given to people who risk getting ‘lost in transition’. This makes this publication highly interesting to readers of the International Journal of Integrated Care …

The IJIC journal is freely available at: http://www.ijic.org/

10th INTERNATIONAL INTEGRATED CARE CONFERENCE

“All together now: Exploring the Many Faces and Facets of Integrated Care”,
Tampere Finland, June 16-18, 2010.

The INIC Conference 2010 will make an effort to look at and evaluate the challenges and status quo of mutual many-faceted collaboration of integrated care from the point of view of benefits to patients, service users and carers. The annual conferences offer an ideal meeting place for the integrated care community to discuss recent developments and future challenges across systems and continents.

On the website you can find more information on the keynote speakers, the pre-conference and site-visits, the program of the conference and the parallel sessions.

Visit the conference website at: http://www.integratedcare.org for more information and registration.

Thanks for the continuing interest in our work.

Erika Manten
Managing editor IJIC
ijic at uu.nl
___________________________________________________
Erika Manten - Managing editor International Journal of Integrated Care,
http://www.ijic.org/ - IJIC Editorial office: Igitur, Utrecht Publishing &
Archiving Services, University Library Utrecht, P.O. Box 80124, 3508 TC
Utrecht, The Netherlands.

h2cm - Being at the center of things [I]

The center of Hodges' model can represent many things:

an epistemological nexus for the transdisciplinary dependencies of our times
multidisciplinary coffee shop
self-care engagement stage
the chaos of all things
holistic harmony
integrated idyll*

More down to Earth and acknowledging this cruciform '+' structure as a mythic device, in addition to searching for the mysteries of the universe at the center we can also place the 'well' person there.

As the previous post on ADLs suggests the 'well' person can function on a basic level and has negotiated the four axes and the four and five fold knowledge domains. They can therefore be considered (sufficiently) wholly integrated. We are all travellers, constantly traversing these domains of experience consciously, unconsciously, expertly or with the awkwardness that denotes the novice.

Conversely and reflecting the model's utility: it is also possible to locate the unwell individual in the center too. In this instance the placement suggests impoverishment of experience, ongoing personal and social stasis and in the case of substance misuse the presence of specific disruptive focus and preoccupations. The person becomes lost to their potential, stuck in a 4:5-fold minima. They continue to travel chronologically, but the journey is spiral, self-iterative and diminishing by return.


However: what you can see you can change, or come to terms with.

*from Greek eidyllion, little picture (h2cm as a snapshot).

Image source: http://www1.lsbu.ac.uk/water/protein2.html

Call for Papers: Special Issue of Nonlinear Dynamics, Psychology, and Life Sciences on Medical Applications of Nonlinear Dynamics

NDPLS is actively searching for manuscripts for a special issue to be entitled, “Medical Applications of Nonlinear Dynamics.” Potential papers could range from the level of individual patients to that of the health care system, and could include such topics as:

• Nonlinear patterns in illness
• Treatment effects and nonlinearity
• Practice change via nonlinear intervention
• Neural networks in clinical decision-making
• Catastrophes in health care utilization
• Nonlinear advice for health care reform
• Modeling ambulatory practice
• Dynamical effects of illness upon the family
• Nonlinear dynamics within the doctor-patient relationship

Contributions may be theoretical or empirical. Theoretical papers should be firmly grounded in the extant literature and culminate in new principles involving nonlinear dynamics that can be tested; manuscripts heavy on conjecture with little reference to evidence are not encouraged. Reviews of the relevant literature on applications of nonlinear dynamics are also welcome, if they synthesize and interpret this material in novel ways. Empirical papers may include experimental observations, simulations, or analyses of real-world data. Articles will be reviewed by two or more experts in the relevant field.

The purview of the journal is critical to the inclusion of articles: Nonlinear Dynamics, Psychology, and Life Sciences publishes papers that augment the fundamental ways we understand, describe, model, and predict nonlinear phenomena in psychology and the life and social sciences. One or more of the following nonlinear concepts must be an explicit part of the exposition: attractors, bifurcations, chaos, fractals, solitons, catastrophes, self-organizing processes, cellular automata, genetic algorithms and related evolutionary processes, neural networks, agent-based models.

The broad mixture of the disciplines represented here indicates that many bodies of knowledge share common principles. By juxtaposing developments in different fields within the life and social sciences, the scientific communities may obtain fresh perspectives on those common principles and their implications. Because the journal is multidisciplinary in scope, each article should make an original contribution to at least one substantive area and, to the extent possible, illuminate issues beyond that area's boundaries.

NDPLS is a refereed journal and is published quarterly by the Society for Chaos Theory in Psychology & Life Sciences. Additional information for the preparation of articles for submission can be found on the journal’s web site: www.societyforchaostheory.org/ndpls/ .

The project is planned on the following schedule (please see link above for full details):

• Abstracts are requested prior to submission in order to assist with the organization of the issue contents, and they are welcome any time before the paper submissions deadline.
  
• Full-text papers need to arrive by December 31, 2009.
• Manuscripts should be prepared in APA style. Key style points and small variations that are specific to the journal can be found in the Instructions for Authors on the journal web site.
  Reviews completed by February 28, or sooner to the extent possible. Revisions and final edits should be received by April 1, 2010.
• Publication in October, 2010.

We look forward to receiving your abstracts and papers. If you have any questions about the project, please do not hesitate to ask one of the editors below.

Sincerely,
Stephen J. Guastello, Ph.D.
Stephen.guastello at marquette.edu
Editor in Chief

David Katerndahl, M.D.
katerndahl at uthscsa.edu
Special Issue Editor

My source:
COMPLEXITY-PRIMARY-CARE at JISCMAIL.AC.UK

Open for applications: USA based Quality Improvement Fellowships

Dear NHS W2tQ readers,

Do you know of a clinically qualified NHS leader with a proven track record in quality improvement?
Do they have the potential to drive change and promote quality at a high level?

The Health Foundation's Quality Improvement Fellowships are now open for applications. Fellows will have an opportunity to spend a year in the USA working with the Institute for Healthcare Improvement (IHI) based in Cambridge, Massachusetts, studying the best international practice in quality improvement.

The fellowship includes:

• participation in the clinical effectiveness programme at the Harvard School of Public Health
• a personalised programme of taught and interactive learning at IHI
• active participation in the leadership teams for key IHI initiatives
• significant involvement in authorship and publication of research and improvement work
• strategic planning sessions to enable effective integration of a fellow's learning to better meet the needs of their home organisation

The Health Foundation will provide fellows with an allowance to support relocation, travel, visa and and USA healthcare costs, as well as replacement staff costs for their employing organisations.

Who can apply?
We are looking for senior NHS leaders who are clinically qualified and have a strong track record of achievement in the field of quality improvement.

Applicants must have the enthusiasm and potential to promote quality improvement nationally and to build organisational capability to drive quality improvement to higher levels of performance.

Please pass this information on to individuals who may be interested in applying.
The deadline for applications is 16 October 2009.

Visit Quality Improvement Fellowships or email awards@health. org.uk to find out more.

My source: Mental Health Informatics - SIG RCPsych via Stephen Thornton, The Health Foundation.

Cash Transactions : Care Continuity

In programming major applications such as finance there is a need to ensure within the transactions and the database operations that mistakes do not occur.

The classic example is a transfer between two accounts:

def transfer(from, to, amount)
  from.debit(amount)
  to.credit(amount)
end

It is vital that the above method (example provided by Tate and Hibbs) does not fail after the debit. In Rails the transaction method help to prevent 'digital accidents' as follows:

def transfer(from, to, amount)
  Account.transaction do
   from.debit(amount)
   to.credit(amount)
  end
end

transaction is itself a method built into Rail's Active Record that helps to maintain the integrity of transactions. Which brings me to 'care'. ...

There are several blog posts here since you reach a stage in your career when the hard fought lessons of yesteryear have to be faced again but this time like after dinner wind.
There are many possible care transactions that arise.

Many have a specific context and frequently these are conjoined:

• timing
• relationships - trust
• responsibility - transfer
• care environment
• record (paper, electronic)
  

As to care transaction consider these:

def transfer(from, to, care_plan)
 Care.transaction do
  from.hospital(care_plan)
  to.community(care_plan)
 end
end

def transfer(from, to, day_care)
 Care.transaction do
  from.home(day_care)
  to.day_center(day_care)
 end
end

Wherever, whenever, whatever and whoever your transactions involve, take care of them and remember in health and social care (esp.) outcomes add up.

Don't forget to look after the however: the information, the knowledge, the promises ....

def transfer(from, to, promise_plan_of_action)
 Care.transaction do
  from.nurse(promise_plan_of_action)
  to.carer(promise_plan_of_action)
 end
end

Reference: Bruce Tate, Curt Hibbs (2006) Ruby on Rails: Up and Running, O'Reilly, p.35.

Blog Action Day 15 October: Poverty - Hodges' model

The table below indicates some of the main concepts and concerns that
surround poverty presented using the four care domains of Hodges' model:

INTERPERSONAL : SCIENCES
SOCIOLOGY : POLITICAL

Well-being, mental health, mood, hope, human spirit. Education - literacies: 3Rs, ICT, social, visual, spiritual, health.... human potential, premature death, personal choices & autonomy. ability to work, philanthropy, disability, gender, LEARNING - UNLEARNING, adversity, personal development, making a difference - Giving. Awareness of poverty. Attitudes, beliefs, sustainability.

Physical health, nutrition, DIAGNOSES: infectious diseases - diarrhoeal illness, malaria, tuberculosis, HIV/AIDS. Infant / maternal mortality. Water. Natural resources, fuel, crops, disasters. Geography, global warming, climate change, gender, age. WHO regional-global reporting, ICD. Complexity. Research: Dimensions of Poverty - "The human development index (HDI) includes income, longevity and education. This paper contends that poverty extends beyond these domains. It explores dimensions of poverty that poor people value, but for which little or no data is available."

Shelter, housing, schools, local environment, social inclusion, work, social mobility, homelessness, stigma (poverty as a disease?), media, major - national & global fund-raising events. Access to information and communications technology. Dependency. Social justice. Social Impact Analysis (PSIA) Religion, humanitarianism, fatalism, leisure. http://www.poverty.com/

HUMAN RIGHTS, LAW, POLICY, U.N., FUNDING, GLOBAL ECONOMICS, MDG 2015. Governance. DEFINITIONS: Relative poverty, absolute poverty, exclusion. effects of globalisation, industrialisation, urbanisation, conflict, refugees, migration, loss of statehood, immigration, professional migration, corruption, economic costs, welfare, benefits, income thresholds, min. wage, inflation, poverty indicators, GDP, major philanthropic programmes, charities, NGOs. social exclusion, unemployment, 'knowledge' economy - learning disability, pension economics, micro lending. International Aid: Official Development Assistance 0.7% national targets.

The POLITICAL links page includes Development, Human Rights, Activism, Policy...

Butterflies make the news go-round

In health, social care and the news media at large there are themes that recur. While every summer has its silly season, there is a strange irregular-regularity in the way the light is re-cast on issues important to us all. It may be triggered due to a tragic incident involving a child, older person, or a whole family. At other times the stimulus for further exposure and prompt for debate is found when different coloured papers have their political say. The political opposition can force or be forced into a reaction.

Chaos is hardly a new kid in town, but there are many groups such as Society for Chaos Theory in Psychology & Life Sciences who are trying to understand and apply this infant science to specific disciplines and even conjoin and create new ones. I mention chaos due the question of migration.

Where do the various items of news head to when they disappear off the media's smörgåsbord?

Maybe they are still there, they just merge into the background noise? This movement is not just a binary, metronomic tick-tock, in and out of the media's eyes. It's more complex than that.

Like the butterflies beloved of chaoticists everywhen, perhaps these issues travel an unpredictable and yet inevitable course through the four fold space of Hodges' model? They travel together and yet in separate lanes, like the horses racing at an amusement arcade. When one reaches the socio-cultural-political boundary, that is when things happen and the volume is ramped up.

Events may frequently have their origin in the intrapersonal domain (it takes a person to find a tango partner), but one way or another - either heading south through the social domain or east and south through the sciences domain - news worthy items will and do repeat themselves.

Original image source: http://10outof10.blogspot.com/2008/04/lorenz-father-of-chaos-theory-died-at.html