Quality versus variance: a plea for a different focus and terminology

Much has been written about quality assurance in medical practice over the past 15 years. Medicine suddenly found itself trying to design systems that ensured that medicine was being practiced according to standards of quality when it had neither a definition of its product nor defined standards of practice. Consequently, early quality assurance programs focused primarily on documentation of patient care. As the process matured, it evolved to generic screens, with tolerances and outliers. The theory was that the quality of medical care was enhanced by physicians who practiced within often artificially established norms and was diminished by physicians who practiced outside those same norms. It was much like saying that the quality of manufacturing a new car could be improved by reducing all systems down to one of closely standardizing, observing, and documenting how each individual assembly worker put on a lock nut and then holding each worker independently accountable for the final quality of the care. Physicians felt they were being held responsible for conforming to a rigid set of poorly designed and retrospectively applied standards. Moreover, they were held accountable for applying those standards to all practice situations. Understandably, physicians felt at the mercy of nonphysician quality assurance "detectives" in hospitals and became increasingly suspicious of nurses and administrators, who were perceived as abusing the system at the expense of the physicians. Because of these inadequacies of the earlier quality assurance programs, paranoia among physicians about the quality assurance process remains rampant today. The use of blind outcome scores and practice patterns in credentialing and the reporting of these data to databanks have reinforced the paranoia.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Trust-Based Intervention for Complex Developmental Trauma: A Case Study from a Residential Treatment Center

This case study, conducted in a Midwest residential treatment center, reports results from an attachment-based intervention that addressed the needs of a 16-year-old female, Rachel. Rachel had a long and documented history of severe abuse and neglect before her adoption from a Bulgarian orphanage at age 12 and numerous psychiatric hospitalizations in the years subsequent. Upon entering this residential treatment center, Rachel did not respond to traditional residential treatment modalities and was considered one of the most difficult children the facility had ever attempted to help. After the intensive attachment-based intervention for Rachel, her adoptive parents, and facility staff, dramatic increases in pro-social and attachment behaviors were noted, as well as a significant decrease in violent and self-injurious behaviors. The intervention consisted of three phases of differing levels of intensity and was designed to address the attachment system and related sub-systems in order to facilitate the development of healthy attachments.     

Promises They Can Keep: Low‐Income Women’s Attitudes Toward Motherhood,Marriage, and Divorce

Using data on low‐income mothers in Boston, Chicago, and San Antonio, we test three propositions regarding mothers’ attitudes toward childbearing, marriage, and divorce. These are drawn from K. Edin and M. J. Kefalas (2005) but have also arisen in other recent studies. We find strong support for the proposition that childbearing outside of marriage carries little stigma, limited support for the proposition that women prefer to have children well before marrying, and almost no support for the proposition that women hesitate to marry because they fear divorce. We suggest that mothers’ attitudes and preferences in these three domains do not support the long delay between childbearing and marriage that has been noted in the literature.     

A note on the asymptotic and exact Fisher information matrices of a Markov switching VARMA process

Statistical Methods & Applications - We study the asymptotic and exact Fisher information (FI) matrices of Markov switching vector autoregressive moving average (MS VARMA) models. In a related...     

Scotland at the Russian Front in the First World War: Robert Scotland Liddell,War Correspondent and Photographer,Red Cross Worker and Russian Officer

ABSTRACT

It is unlikely that one would encounter the name of Robert Scotland Liddell (1885–1972) in the list of eminent foreign correspondents covering the First World War in Russia for British newspapers and journals, but he deserves to be much better known both for the quality of the reports and photographs he sent from the Russian front for publication in the magazine The Sphere and for the trilogy of books that appeared in 1916–1917. Liddell began as an orderly attached to the Russian Red Cross in Poland in 1916 and after a period spent with Oliver Locker-Lampson’s British Armed Car Division on the Romanian front, he became an officer in a Russian divisional transport unit and narrowly escaped execution by mutinous troops after the October coup before escaping from Russia at the end of 1917. The article, while concentrating on Liddell’s reporting, experiences and exploits in Russia, attempts to survey his career from his early days as a Fleet Street journalist to the post-First World decades, when he wrote books of travel and novels, before sliding into obscurity.     

Ethnicity and Farm Entry Behavior

Abstract The persistence of ethnic traits in both the visible agricultural landscape and the practices of established farmers in the United States has been well documented but not unchallenged. One limitation of most studies is that they have focused on relatively special populations of farmers who could be expected to have unusually strong ethnic identity. It has not been clear that ethnic background could serve as a useful variable in explaining variation in farmers' behavior in the general farm population. The present study examines the role of ethnicity in a large random sample of recent entrants into dairy farming in Wisconsin. In particular, we provide some confirmation that the farm operator's ethnic identity can be linked to differences in entry paths, current farm characteristics, and cultural beliefs in our sample. We also suggest that ethnicity plays a stronger role in affecting the resources and opportunities available to young farmers than the strategic decisions made to employ these assets.