BackgroundBeginning in 2012, Lean was introduced to improve health care quality and promote patient-centredness throughout the province of Saskatchewan, Canada with the aim of producing coordinated, system-wide change. Significant investments have been made in training and implementation, although limited evaluation of the outcomes have been reported. In order to better understand the complex influences that make innovations such as Lean “workable” in practice, Normalization Process Theory guided this study. The objectives of the study were to: a) evaluate the implementation processes associated with Lean implementation in the Saskatchewan health care system from the perspectives of health care professionals; and b) identify demographic, training and role variables associated with normalization of Lean.MethodsLicensed health care professionals were invited through their professional associations to complete a cross-sectional, modified, online version of the NoMAD questionnaire in March, 2016. Analysis was based on 1032 completed surveys. Descriptive and univariate analyses were conducted. Multivariate multinomial regressions were used to quantify the associations between five NoMAD items representing the four Normalization Process Theory constructs (coherence, cognitive participation, collective action and reflexive monitoring).ResultsMore than 75% of respondents indicated that neither sufficient training nor resources (collective action) had been made available to them for the implementation of Lean. Compared to other providers, nurses were more likely to report that Lean increased their workload. Significant differences in responses were evident between: leaders vs. direct care providers; nurses vs. other health professionals; and providers who reported increased workload as a result of Lean vs. those who did not. There were no associations between responses to normalization construct proxy items and: completion of introductory Lean training; participation in Lean activities; age group; years of professional experience; or employment status (full-time or part-time). Lean leader training was positively associated with proxy items reflecting coherence, cognitive participation and reflexive monitoring.ConclusionsFrom the perspectives of the cross-section of health care professionals responding to this survey, major gaps remain in embedding Lean into healthcare. Strategies that address the challenges faced by nurses and direct care providers, in particular, are needed if intended goals are to be achieved.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3045-6) contains supplementary material, which is available to authorized users.

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Concerns about the concentrations of chlorofluorocarbons (CFCs) in the atmosphere are based on their effects on the ozone layer by catalytically destroying ozone. The recent steady decline in atmospheric concentration of CFC could be a direct result of the Montréal Protocol's ban on CFC products, in effect since 1989. However, CFCs have long atmospheric residence times because of their low chemical reactivity, and as a consequence have already been distributed globally. To study the spatial effects and extent of the decline, we apply the proposed spatial-longitudinal bent-cable model to CFC data observed over a global detection network. The bent cable is a parametric regression model to study data that exhibits a trend change. It comprises two linear segments to describe the incoming and the outgoing phases, joined by a quadratic bend to model the transition period. For spatial longitudinal data, measurements taken over time are nested within spatially dependent locations. Here, it is useful to extend the existing longitudinal bent-cable regression to handle spatial effects. We do so in a hierarchical Bayesian framework by allowing the error terms to be correlated across space. The methodology is illustrated with applications to CFC-11 and 12 data. Our analysis reveals that: (a) there is a strong spatial relationship among all the monitoring locations across the globe; (b) both CFC-11 and CFC-12 increased significantly before entering into a transition zone; (c) after completing the transition, CFC-11 has been decreasing significantly from the atmosphere, but a slow (insignificant) decrease for CFC-12 is observed; and (d) it may take almost 5 times longer to diminish CFC-12 from the atmosphere compared to CFC-11.

This study found that farm women often report high levels of work, including engagement in the third shift. Women engaged in the third shift are also generally healthier than non-engaged women, consistent with a healthy worker effect.

Hand ventilation during patient transport is superior using the FIR compared to the SIR to achieve target ventilatory goals and avoid unacceptable ventilatory cycles.