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WALKING CITIES: LONDON explores how the temporal and spatial realities experienced through urban walking can act as a method for dialogical and empirical mapping across a range of disciplines. Through bringing together a new interdisciplinary field of artists, writers, architects, musicians, human geographers and philosophers we consider how the city walk informs and triggers new processes of making, thinking, researching, and communicating. In particular, we examine how the city contains narratives, knowledge and contested materialities that are best accessed through the act of walking. Ultimately, Walking Cities: London seeks to understand the wider significance of changing geographies to generate critical questions and creative perspectives for navigating the social and political impact of rapid urban change.

Background Investigation of real incidents has been consistently identified by expert reviews and student surveys as a potentially valuable teaching resource for medical students. The aim of this study was to adapt a published method to measure resident doctors’ reflection on quality improvement and evaluate this as an assessment tool for medical students. Methods The design is a cohort study. Medical students were prepared with a tutorial in team based learning format and an online Managing Incident Review course. The reliability of the modified Mayo Evaluation of Reflection on Improvement tool (mMERIT) was analysed with Generalizability G-theory. Long term sustainability of assessment of incident review with mMERIT was tested over five consecutive years. Results A total of 824 students have completed an incident review using 167 incidents from NHS Tayside’s online reporting system. In order to address the academic practice gap students were supervised by Senior Charge Nurses or Consultants on the wards where the incidents had been reported. Inter-rater reliability was considered sufficiently high to have one assessor for each student report. There was no evidence of a gradient in student marks across the academic year. Marks were significantly higher for students who used Section Questions to structure their reports compared with those who did not. In Year 1 of the study 21 (14%) of 153 mMERIT reports were graded as concern. All 21 of these students achieved the required standard on resubmission. Rates of resubmission were lower (3% to 7%) in subsequent years. Conclusions We have shown that mMERIT has high reliability with one rater. mMERIT can be used by students as part of a suite of feedback to help supplement their self-assessment on their learning needs and develop insightful practice to drive their development of quality, safety and person centred professional practice. Incident review addresses the need for workplace based learning and use of real life examples of mistakes, which has been identified by previous studies of education about patient safety in medical schools.

BACKGROUND Increasing the number of organ donors may enhance organ transplantation, and past health interventions have shown the potential to generate both large-scale and sustainable changes, particularly among minorities. OBJECTIVE This study aimed to propose a conceptual data-driven framework that tracks digital markers of public organ donation awareness using Twitter and delivers an optimized social network intervention (SNI) to targeted audiences using Facebook. METHODS We monitored digital markers of organ donation awareness across the United States over a 1-year period using Twitter and examined their association with organ donation registration. We delivered this SNI on Facebook with and without optimized awareness content (ie, educational content with a weblink to an online donor registration website) to low-income Hispanics in Los Angeles over a 1-month period and measured the daily number of impressions (ie, exposure to information) and clicks (ie, engagement) among the target audience. RESULTS Digital markers of organ donation awareness on Twitter are associated with donation registration (beta=.0032; PP CONCLUSIONS Our framework can provide a real-time characterization of organ donation awareness while effectively delivering tailored interventions to minority communities. It can complement past approaches to create large-scale, sustainable interventions that are capable of raising awareness and effectively mitigate disparities in organ donation.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Risk from sub-optimal medical practice remains a perennial international problem. While regulatory efforts for improvement have been significant, new thinking and innovation is needed. In an ideal world, professional career paths would be enhanced, supported and successfully maintained from medical school to retirement. Regulatory outcomes would be made resilient to public and professional challenge. Professional development, with quality improvement at its heart, would be maximized, and concerns about medical competency would be highlighted and acted upon at an early stage -- before they become “a fitness to practice” matter. At this early stage, referred to in this paper as the “amber zone,” concerns about an individual's ability to practice medicine competently may emerge, but they are not considered of sufficient severity to warrant a referral to a fitness to practice inquiry by medical regulators. The introduction of a concept called Insightful Practice is one attempt to address the unmet challenge of the amber zone. A surrogate measure of professionalism, Insightful Practice is a method that assesses medical professionals' engagement with the system within which they work and with feedback on their performance for any given work role. In addition and crucially, the method considers medical professionals' insight into what they need to change and their plans for improvement. Potential problems are identified early, increasing the likelihood that remediation measures will be successful. An application using Insightful Practice is described here, examples of its use given, and a discussion is provided of the concept's advantages, limitations and potential to help regulatory authorities and other health care agencies address the challenge for regulatory systems to identify and remediate medical professionals who find themselves in an early amber zone of concern. The application described is based on humans' long understood struggle “to see ourselves as others see us,” and is an attempt to support and channel medical professionals' integrity and drive for improvement in order to protect patients. While the Insightful Practice concept is discussed in this paper in the context of the UK's regulatory system, its principles are applicable to other medical regulatory systems around the world.

BackgroundHigh-risk primary care prescribing is common and is known to vary considerably between practices, but the extent to which high-risk prescribing varies among individual general practitioners (GPs) is not known.ObjectivesTo create prescribing safety indicators usable in existing electronic clinical data and to examine (1) variation in high-risk prescribing between patients, GPs and practices including reliability of measurement and (2) changes over time in high-risk prescribing prevalence and variation between practices.DesignDescriptive analysis and multilevel logistic regression modelling of routine data.SettingUK general practice using routine electronic medical record data.Participants(1) For analysis of variation and reliability, 398 GPs and 26,539 patients in 38 Scottish practices. (2) For analysis of change in high-risk prescribing, ≈ 300,000 patients particularly vulnerable to adverse drug effects registered with 190 Scottish practices.Main outcome measuresFor the analysis of variation between practices and between GPs, five indicators of high-risk non-steroidal anti-inflammatory drug (NSAID) prescribing. For the analysis of change in high-risk prescribing, 19 previously validated indicators.ResultsMeasurement of high-risk prescribing at GP level was feasible only for newly initiated drugs and for drugs similar to NSAIDs which are usually initiated by GPs. There was moderate variation between practices in total high-risk NSAID prescribing [intraclass correlation coefficient (ICC) 0.034], but this indicator was highly reliable (> 0.8 for all practices) at distinguishing between practices because of the large number of patients being measured. There was moderate variation in initiation of high-risk NSAID prescribing between practices (ICC 0.055) and larger variation between GPs (ICC 0.166), but measurement did not reliably distinguish between practices and had reliability > 0.7 for only half of the GPs in the study. Between quarter (Q)2 2004 and Q1 2009, the percentage of patients exposed to high-risk prescribing measured by 17 indicators that could be examined over the whole period fell from 8.5% to 5.2%, which was largely driven by reductions in high-risk NSAID and antiplatelet use. Variation between practices increased for five indicators and decreased for five, with no relationship between change in the rate of high-risk prescribing and change in variation between practices.ConclusionsHigh-risk prescribing is common and varies moderately between practices. High-risk prescribing at GP level cannot be easily measured routinely because of the difficulties in accurately identifying which GP actually prescribed the drug and because drug initiation is often a shared responsibility with specialists. For NSAID initiation, there was approximately three times greater variation between GPs than between practices. Most GPs with above average high-risk prescribing worked in practices which were not themselves above average. The observed reductions in high-risk prescribing between 2004 and 2009 were largely driven by falls in NSAID and antiplatelet prescribing, and there was no relationship between change in rate and change in variation between practices. These results are consistent with improvement interventions in all practices being more appropriate than interventions targeted on practices or GPs with higher than average high-risk prescribing. There is a need for research to understand why high-risk prescribing varies and to design and evaluate interventions to reduce it.FundingFunding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.

A drug delivery apparatus for dispensing predetermined volumes of drug, drug solution or other substances into an opening, such as a TMR channel in the human heart, or other laser treated area within the human body, the apparatus consisting of a bifurcated needle with a laser inlet for guiding a laser delivery means, such as an optical fiber or fiber bundle, to adjacent a surface of the human heart or other body structure for creating an opening, such as a TMR channel, or other laser treated area thereon. A drug inlet is for receiving the drug and transmitting the drug to the TMR channel or other laser treated area. Optionally, a piercing tip and/or suction device assists in positioning the apparatus adjacent the tissue to be treated. Drug is dispensed by manually or automatically actuating a piston or syringe element. A method of use is also disclosed.

Background: \ud Increasingly healthcare policies emphasise the importance of person-centred, empathic care. Consequently, healthcare professionals are expected to demonstrate the ‘human’ aspects of care in training and in practice. The Consultation and Relational Empathy (CARE) Measure is a patient-rated measure of the interpersonal skills of healthcare practitioners. It has been widely validated for use by healthcare professionals in both primary and secondary care. This paper reports on the validity and reliability of the CARE Measure with sexual health nurses.\ud \ud Methods: \ud Patient questionnaires were collected for 943 consultations with 20 sexual health nurses. Participating patients self-completed the questionnaire immediately after the encounter with the nurse. The questionnaire included the ten item CARE Measure, the Patient Enablement Index, and overall satisfaction instruments. Construct validity was assessed through Spearman’s correlation and principal component analysis. Internal consistence was assessed through Cronbach’s alpha and the inter-rater reliability through Generalisability Theory. Data were collected in 2013 in Scotland.\ud \ud Results: \ud Female patients completed 68% of the questionnaires. The mean patient age was 28.8 years (standard deviation 9.8 years). Two of the 20 participating nurses withdrew from the study. Most patients (71.7%) regarded the CARE Measure items as very important to their consultation and the number of ‘not applicable’ and missing responses’ were low (2.6% and 0.1% respectively). The participating nurses had high CARE Measure scores; out of a maximum possible score of 50, the overall mean CARE measure score was 47.8 (standard deviation 4.4). The scores were moderately correlated with patient enablement (rho = 0.232, p = 0.001) and overall satisfaction (rho = 0.377, p = 0.001. Cronbach’s alpha showed the measure’s high internal consistency (Cronbach’s alpha coefficient = 0.95), but the inter-rater reliability could not be calculated due to the high achieved CARE Measure scores that varied little between nurses.\ud \ud Conclusions: \ud Within this clinical context the CARE Measure has high perceived relevance and face validity. The findings support construct validity and some evidence of reliability. The high CARE Measure scores may have been due to sample bias. A future study which ensures a representative sample of patients on a larger group of nurses is required to determine whether the measure can discriminate between nurses.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

Objective: To develop a structurally valid and reliable, yet brief measure of patient experience of hospital quality of care, the Care Experience Feedback Improvement Tool (CEFIT). Also, to examine aspects of utility of CEFIT. Background: Measuring quality improvement at the clinical interface has become a necessary component of healthcare measurement and improvement plans, but the effectiveness of measuring such complexity is dependent upon the purpose and utility of the instrument used. Methods: CEFIT was designed from a theoretical model, derived from the literature and a content validity index (CVI) procedure. A telephone population surveyed 802 eligible participants (healthcare experience within the previous 12 months) to complete CEFIT. Internal consistency reliability was tested using Cronbach’s alpha. Principal component analysis was conducted to examine the factor structure and determine structural validity. Quality criteria was applied to judge aspects of utility. Results: CVI found a statistically significant proportion of agreement between patient and practitioner experts for CEFIT construction. 802 eligible participants answered the CEFIT questions. Cronbach’s alpha coefficient for internal consistency indicated high reliability (0.78). Inter-item (question) total correlations (0.28-0.73) were used to establish the final instrument. Principal component analysis identified one factor accounting for 57.3% variance. Quality critique rated CEFIT as fair for content validity, excellent for structural validity, good for cost, poor for acceptability and good for educational impact. Conclusions: CEFIT offers a brief yet structurally sound measure of patient experience of quality of care. The briefness of the five item instrument arguably offers high utility in practice. Further studies are needed to explore the utility of CEFIT to provide a robust basis for feedback to local clinical teams and drive quality improvement in the provision of care experience for patients. Further development of aspects of utility are also required. STRENGTHS AND LIMITATIONS OF THIS STUDY The psychometric findings demonstrate the structural validity and internal consistency of CEFIT to quantify the patient experience of quality of healthcare. While the large sample (n=802) enabled exploration of the CEFIT structure the findings are limited to an Australian community population, with a healthcare experience, as opposed to inpatients. Validity and reliability are not all or nothing approaches. Rather, each study with positive results adds to the psychometric strength of the instrument. Further testing of CEFIT is required to establish the utility of CEFIT to measure patient experience of hospital quality of care for quality improvement at a ward/unit level.

Background Medical revalidation decisions need to be reliable if they are to reassure on the quality and safety of professional practice. This study tested an innovative method in which general practitioners (GPs) were assessed on their reflection and response to a set of externally specified feedback. Setting and participants 60 GPs and 12 GP appraisers in the Tayside region of Scotland, UK. Methods A feedback dataset was specified as (1) GP-specific data collected by GPs themselves (patient and colleague opinion; open book self-evaluated knowledge test; complaints) and (2) Externally collected practice-level data provided to GPs (clinical quality and prescribing safety). GPs' perceptions of whether the feedback covered UK General Medical Council specified attributes of a ‘good doctor’ were examined using a mapping exercise. GPs' professionalism was examined in terms of appraiser assessment of GPs' level of insightful practice , defined as: engagement with, insight into and appropriate action on feedback data. The reliability of assessment of insightful practice and subsequent recommendations on GPs' revalidation by face-to-face and anonymous assessors were investigated using Generalisability G-theory. Main outcome measures Coverage of General Medical Council attributes by specified feedback and reliability of assessor recommendations on doctors' suitability for revalidation. Results Face-to-face assessment proved unreliable. Anonymous global assessment by three appraisers of insightful practice was highly reliable (G=0.85), as were revalidation decisions using four anonymous assessors (G=0.83). Conclusions Unlike face-to-face appraisal, anonymous assessment of insightful practice offers a valid and reliable method to decide GP revalidation. Further validity studies are needed.

Multi-source feedback (MSF) aims to raise self-awareness of performance and encourage improvement. The ECO model (emotions, content, outcome) is a three-step process developed from the counselling literature to facilitate feedback acceptance and use in MSF.The purpose of this study was to explore the acceptability, usefulness and educational impact of the model.This was a qualitative study using interviews to explore general practice (GP) trainer and trainee experiences and perceptions of the ECO facilitation model. Interviews were conducted by telephone, recorded, transcribed and analysed using a thematic framework.About 13 GP trainers and trainees participated in the interviews following their MSF discussions using the ECO model. They agreed that the model was useful, simple to use and engaged trainees in reflection upon their feedback and performance. Exploring emotions and clarifying content appeared integral to accepting and using the feedback. Positive feedback was often surprising. Most trainees reported performance improvements following their MSF-ECO session.The model appeared acceptable and simple to use. Engaging the learner as a partner in the feedback discussion appeared effective. Further research is needed to fully understand the influence of each step in facilitating MSF acceptance and use, and to determine the impact of the ECO model alone upon performance outcomes compared to more traditional provision of MSF feedback.

Calibration among faculty is challenging to achieve and maintain. In this study, calibration refers to the training process by which standardization of chart documentation in a SOAP note format was achieved. In the SOAP format, chart entries by health care providers are written in the following categories: Subjective data, Objective data, Assessment, and Plans. The primary training "effect" or outcome that was measured in this study was the capacity of faculty members to write a SOAP note that adhered to prescribed standards for chart documentation. This study was conducted to assess the short-term effects of training and determine whether faculty members' capacity to write appropriately constructed SOAP notes could be sustained for one year. Eight dental hygiene faculty members at the University of Minnesota participated in a pre-training assessment in which they prepared a SOAP note based on a patient case, completed a training session on writing SOAP notes, and completed a post-training test shortly after training that also consisted of writing a SOAP note based on a patient's case. One year later, a follow-up test, similar to the pre- and post-tests, was conducted. Each component of the SOAP note was compared and scored against a gold standard benchmark score of 29 that represented the number of items that should have been included in an ideal SOAP note in the estimation of the investigators, based on chart documentation guidelines of the University of Minnesota Dental Hygiene Division. The mean score for the pre-test was 18.25 (SD=2.82), which represented 63 percent of the benchmark gold standard score of 29. The post-test mean score immediately after training was 24.63 (SD=2.13; 84.9 percent of the benchmark score), and the one-year follow-up mean score was 22.75 (SD=1.83; 78.4 percent of the gold standard benchmark). From the pre-test to the post-test administered in close approximation to the SOAP note training, faculty members' approximation of the gold standard benchmark increased by 35 percent, or 6.28 points, and from the post-test to the follow-up test one year subsequently, approximation of the benchmark score decreased by approximately 1 percent or 1.88 points. Friedman's test indicated that the differences in mean scores for the pre-test, post-test, and follow-up test were significant. The Sign test was used for post hoc tests; alpha was adjusted using Bonferroni's procedure. Conclusions support a hypothesis that faculty capacity to write a SOAP note that adheres to standards can be increased through training and that the effects can be maintained over a period of approximately one year.

PurposeThe purpose of this paper is to determine the relevance and reliability of the ten‐item Consultation and Relational Empathy (CARE) Measure as a tool for measuring patients' views of anaesthetists during preoperative assessment consultations.Design/methodology/approachSelf‐completed patient questionnaire containing the ten‐item CARE Measure. Consecutive adult patients were asked to complete the ten‐item CARE questionnaire immediately after their pre‐operative assessment consultation with the anaesthetist and return it to a designated local co‐ordinator. Reliability co‐efficient of the overall measure, and relevance of each item to patients' concerns were measured.FindingsUsing the Measure, 31 consultant anaesthetists were assessed by 1,582 patients (559 male, 952 female). The total number of “not applicable” responses was 1,086, (6.8 per cent of the total number of possible “not applicable” responses). The overall number of missing values was 0.6 per cent. The measure effectively discriminated between doctors (reliability co‐efficient of the average score per doctor provided by 40 patients was above 0.8) and had high internal consistency (Cronbach's alpha, 0.93).Originality/valueThe present study presents evidence of a tool which may have utility in anaesthetics and other settings.