Capability Traps Impeding Homeless Services: A Community-Based System Dynamics Evaluation

Continuums of Care (CoCs) are the primary coordinating bodies for homeless services in the United States. However, the complexities involved in delivering homeless services across interagency networks challenges coordination and system improvement. CoC governance, planning, and service provision have received little attention in academic literature, and thus, Continuums attempt to manage complex systems with little guidance. This evaluation applied community-based system dynamics with homeless consumers and service providers to (1) identify capability traps that impede services delivery and to (2) engage stakeholders in a structured system improvement process. Results revealed organizational structures for governance and planning that inhibit system outcomes. Insights led to policy and practice recommendations for the homeless system.     

AN EXISTENTIAL PERSPECTIVE ON DIFFERENTIATION/FUSION: THEORETICAL ISSUES AND CLINICAL APPLICATIONS

This paper calls for a recognition of existential issues in family therapy. It begins by noting the importance of "big questions" to families, reviews the roots of existential philosophy and existential therapy, offers an example of the usefulness of connecting existential thought to the family field by discussing differentiation/ fusion from an existential perspective, and offers guidelines for clinical application.     

Evaluating utility conservation programs: The BPA plan

This paper summarizes a detailed plan for evaluation of the residential energy conservation programs offered by the Bonneville Power Administration (BPA). The major purpose of the evaluation is to determine the energy savings attributable to the programs and to identify differences between program participants and nonparticipants. The focus of this paper is on the sampling issues associated with reliable estimates of energy savings. The methodology attempts to correct for the self-selection bias likely to occur in conservation program evaluation by using intentional nonrandom sampling. In addition, the paper suggests a variety of analytical approaches to analyzing the data with respect to energy savings.The proposed design, using four different groups to estimate program effects, is a comprehensive endeavor. This is appropriate for BPA because of the substantial investment it is making in conservation. However, the design is flexible and allows for use offewer groups to reduce evaluation costs.     

Learning from adversity: diary of a medical manager

This article is one physician's account of his experiences in managing a large multispecialty group practice. While he was able to accomplish much in his tenure during the latter half of the 1980s, it was, on balance, a negative experience. He describes both the high and the low points of the period and assesses how both contributed to his eventual downfall. While personal, the account has important implications for others involved in the rapidly changing, personally rewarding, and eminently challenging health car system in which physician executives work.     

The attributable estimand: A new approach to account for intercurrent events

The term “intercurrent events” has recently been used to describe events in clinical trials that may complicate the definition and calculation of the treatment effect estimand. This paper focuses on the use of an attributable estimand to address intercurrent events. Those events that are considered to be adversely related to randomized treatment (eg, discontinuation due to adverse events or lack of efficacy) are considered attributable and handled with a composite estimand strategy, while a hypothetical estimand strategy is used for intercurrent events not considered to be related to randomized treatment (eg, unrelated adverse events). We explore several options for how to implement this approach and compare them to hypothetical “efficacy” and treatment policy estimand strategies through a series of simulation studies whose design is inspired by recent trials in chronic obstructive pulmonary disease (COPD), and we illustrate through an analysis of a recently completed COPD trial.     

Defining and measuring patient satisfaction with medical care

This paper describes the development of Form II of the Patient Satisfaction Questionnaire (PSQ), a self-administered survey instrument designed for use in general population studies. The PSQ contains 55 Likert-type items that measure attitudes toward the more salient characteristics of doctors and medical care services (technical and interpersonal skills of providers, waiting time for appointments, office waits, emergency care, costs of care, insurance coverage, availability of hospitals, and other resources) and satisfaction with care in general. Scales are balanced to control for acquiescent response set. Scoring rules for 18 multi-item subscales and eight global scales were standardized following replication of item analyses in four field tests. Internal-consistency and test-retest estimates indicate satisfactory reliability for studies involving group comparisons. The PSQ well represents the content of characteristics of providers and services described most often in the literature and in response to open-ended questions. Empirical tests of validity have also produced generally favorable results.     

Planning future raw material supply

The emphasis of this article is on the need to pay greater attention to the longer-term. It deals particularly with the potential problems and opportunities surrounding the supply of key raw materials. A key question is the potential availability of certain new materials given what are now effectively uneconomic prices to the producer. The author argues for much closer liaison and involvement of Europe organizations in mining (e.g.) and points to some areas of considerable potential.