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Summary As a result of research conducted by the CanmetENERGY research center in Varennes (CE-V) on soil temperature profiles, an empirical correlation of the undisturbed ground temperature (UGT) and a new ground temperature model were developed. The correlation permitted the generation of a map of UGT in Canada, published as part of a new online map tool by Natural Resources Canada entitled: ''Map of Clean Energy Resources and Projects in Canada''. This map showcases the potential of shallow geothermal resources in Canada. However, its use is currently limited to the determination of UGT and cannot be extended for projects that require the temperature as a function of time at different depths from the ground surface. To address this gap, CanmetENERGY undertook the development of a graphical interface (GI) of isotherms of the soil temperature as a function of time and depth, leveraging the model previously developed to generate the necessary data. The objective of this paper is to present the methodology used to develop the GI. This GI will provide a useful tool for a great variety of projects requiring soil temperature as function of depth and time.

The tension between the rigour and the relevance of higher education research remains an important and hotly contested topic among scholars, administrators, practitioners and policymakers. This debate is most evident in professional programmes in which scholars are challenged to pursue new knowledge independent of its immediate relevance to practice while simultaneously contributing actionable knowledge to their profession. This two-part study explores whether the resulting pressure has an impact on the scholarly output and recruitment practices of different professional programmes. The results show that the context of the profession has a significant influence on the level of integration between academia and industry.

Knowledge capital accumulations are impacted by a variety of workplace factors, including the human resource management work system and the workgroup culture in which it is embedded. Organizations adopting high-involvement work systems stressing employee participation, empowerment, commitment, and accountability have the potential to produce, and to be a beneficiary of, greater stores of employee intellectual capital. The role of workplace culture in this relationship is potentially salient but its operational characteristics require further elucidation. Using a competing values framework to characterize workplace culture, four culture archetypes can be specified: hierarchical, market, entrepreneurial, and clan. Results from step-wise regression analysis show that the four workplace culture archetypes contribute differentially to intellectual capital stores, yet only the clan and entrepreneurial culture archetypes partially mediates this relationship.

While performance and reward management practices are critical to the realization of organizational vision and goals, their success fundamentally depends on the way they are designed and implemented. This chapter outlines the purposes, attributes and design principles of performance and reward systems. Further, it explores the nature and role of technology in automating these functions. It then considers the critical adoption factors, in terms of people, technology and organization and highlights the critical success factors that influence the effectiveness of e-performance and reward systems.

This study examines whether nursing homes’ (NHs) human resource management (HRM) practices and organizational culture are associated with nursing staff turnover. HRM practices are classified into traditional (employment selection tests, formal performance appraisal systems, and realistic job previews); employee-centered (flexible work hours and job sharing); and high involvement (incentive based/merit pay and self-managing teams). Organizational culture consists of four types: clan culture (friendly working environment); adhocracy culture (dynamic/creative working environment); market culture (results-based organization); and hierarchy culture (formalized/structured work environment). This study used facility survey data from approximately 324 NH administrators (30% response rate) from 2017- 2018, merged with secondary data from LTCFocus, Area Health Resource File, and Medicare Cost Reports. The dependent variables consisted of RN, LPN, and CNA turnover rates (% voluntarily quit), while the independent variables comprised HRM practices and type of organizational culture. Control variables consisted of organizational (ownership, chain affiliation, size, occupancy rate, and payer mix) and county-level factors (Medicare Advantage penetration, income, education, unemployment rate, poverty, and competition). Generalized linear model results show that every unit increase in high-involvement HRM practices is associated with a reduction of 6%, 4%, and 2% in RN, LPN, and CNA turnover rates, respectively. Also compared to hierarchical cultures, nursing homes with a clan culture are associated with a reduction of 62%, 49%, and 33% in RN, LPN, and CNA turnover rates, respectively. HRM practices and organizational cultures that promote employee participation, engagement, and empowerment have the potential to reduce nurse staffing turnover rates among underresourced nursing homes.

Background: The objective of this study is to explore the nature of the association of discrete systems of human resource management practices and the rate of voluntary turnover of registered nurses (RNs) in a large sample of Canadian acute care hospitals and nursing homes. Turnover of nursing staff is a significant issue affecting healthcare cost, quality and access. The rate of annual turnover for registered nurses has been estimated to be about 20 percent in Canada, with a total cost of almost US$27,000 for each RN. Healthcare organizations that employ large numbers of registered nurses are keen to learn more about the role that organizational policies and practices play in reducing voluntary turnover, including the role of management and its deployment of human resources. The relationship of human resource management (HRM) practices and employee turnover has generally been under-investigated. Three HRM systems, composed of bundles of discrete workplace and employment practices, were assembled in order to assess the relationship of HRM practice systems with the rate of voluntary RN turnover, at the establishment level. The three HRM practice systems constructed are: a technical HRM system that focuses on policies and practices that regulate the employee-employer relationship; a quality-of-worklife HRM system that includes a variety of employee- and family-friendly employment practices; a high-involvement HRM system that involve workplace arrangements that increase commitment, engagement and participation of employees. Method and analysis: A questionnaire was sent to the chief nursing officers of 2,208 hospitals and long-term care facilities in every province and territory of Canada, yielding valid responses from 705 establishments. Each of the three HRM practice systems is estimated at each facility and comprises eight (8) discrete employment and workplace practices. Using estimates of voluntary RN turnover as the dependent variable, the analysis featured a step-wise ordinary least squares (OLS) regression model for each practice system. Results: After controlinf for facility characteristics and local labour market conditions, the quality-of-worklife HRM employment system ( p

The intensity of physician workload has been increasing with the well-documented changes in the financing, organization and delivery of care. It is possible that these stressors have reached a point where they pose a serious policy issue for the entire healthcare system through their diminution of physician's ability to effectively interact with patients as they are burned out, stressed and dissatisfied. This policy question is framed in a conceptual model linking workloads with five key outcomes (patient care quality, individual performance, absenteeism, turnover and organizational performance) mediated by physician stress and satisfaction. This model showed a good fit to the data in a structural equation analysis. Ten of the 12 hypothesized pathways between variables were significant and supported the mediating role of stress and satisfaction. These results suggest that workloads, stress and satisfaction have significant and material impacts on patient care quality, individual performance, absenteeism, turnover and organizational performance. Implications of these results and directions for future research are discussed.

PurposeThe objective of the research is to assess the degree of adoption of high‐involvement nursing work practices in long‐term care organizations. It seeks to determine the organizational and workplace factors that are associated with the uptake/adoption of ten selected human resource high‐involvement employee work practices.Design/methodology/approachA survey questionnaire was sent to 300 long‐term care organizations (nursing homes) in western Canada. Results from 125 nursing home establishments (43 percent response rate) are reported herein.FindingsOf the ten high‐involvement nursing work practices examined, employee suggestion and recognition systems are the most widely adopted by homes in the sample, while shared governance and incentive/merit‐base pay are used by a small minority of establishments.Practical implicationsThe uptake of high‐involvement nursing work practices is not adopted in a haphazard fashion. Their uptake is variously associated with a number of establishment and workplace factors, including the presence of a supportive and enabling workplace culture.Originality/valueThe objective of this research is to examine the extent and degree of adoption of high involvement work practices in a sample of long‐term care establishments operating in the four provinces of western Canada.

Emergency departments in most developed countries have been experiencing significant overcrowding under a regime of severe resource constraints. Physicians in emergency departments increasingly find themselves toiling in workplaces that are characterized by diminished availability of, limited access to, and decreased stability of critical resources. Severe resource constraints have the potential to greatly weaken the overall job satisfaction of emergency physicians. This article examines the impact of hospital resource constraints on the job satisfaction of a large sample of emergency physicians in Canada. After controlling for workflow and patient characteristics and for various institutional and physician characteristics, institutional resource constraints are found to be major contributors to emergency physician job dissatisfaction. Resource factors that have the greatest impact on job satisfaction include availability of emergency room physicians, access to hospital technology and emergency beds, and stability of financial (investment) resources.

This article examines the role and job function of quality assurance officers in hospitals in Ontario, Canada. Results from a mail questionnaire suggest that hospital quality assurance professionals in our sample are much more likely to be female, at mid-career, and to have advanced graduate degrees, although most lack professional certification and formal training in quality management. Although the job duties of hospital quality assurance professionals are broad and varied, many report being engaged in traditional quality assurance managerial activities including hospital accreditation efforts, risk management assessment, and patient satisfaction measurement. Coordinating quality assurance activities, performance reporting, and leading the Total Quality Management (TQM)/Continuous Quality Improvement (CQI) initiative remain central functions associated with their work efforts. Nevertheless, limited formal training in the principles and methods of quality management and improvement may be placing significant constraints on their effectiveness. Copyright © 2005 John Wiley & Sons, Ltd.

During the 1990s, many Canadian hospitals introduced quality improvement initiatives while radically reducing their work force. Yet, the incompatible nature of QM and organizational downsizing suggests that the success of one or both change management programs will be sacrificed when done concurrently. Results from a large sample of Canadian hospitals suggest that the implementation of a strong quality improvement initiative can mitigate the negative consequences of severe work force contractions on certain valued organizational performance objectives.

In recent years, hospitals have radically restructured their operations while significantly downsizing their workforces. To date, little is known about the combined effect of these change processes on organizational functioning. There have been few large‐scale studies investigating how hospitals have performed when both organizational restructuring and downsizing are used concurrently. The research reported here sets out to separate and isolate the independent and combined effect of organizational restructuring and downsizing on hospital performance. In particular, it aims to address the following question: Do hospitals which undergo significant organizational restructuring while maintaining their workforce complement perform any better than hospitals that institute significant restructuring while heavily downsizing, and any better than hospitals which heavily downsize but undertake little or no organizational restructuring? Categorical regression analysis results from a sample of 285 Canadian ac...

Planning for health human resources requires us to think about the forces and factors that attract healthcare professionals to their jobs and keep them there. However, the forces for attracting healthcare employees to a job are not the same as those factors that keep them there. Without effective recruitment and retention policies for healthcare professionals, planning initiatives will continue to be ineffective.

Over the past few years many nations have undertaken activities aimed at restructuring and reengineering their health system as a means of achieving greater cost effectiveness and consumer responsiveness. Most efforts at reforming healthcare delivery have been accompanied by the downsizing of healthcare organizations. Organizations that are undergoing decline or significant workforce contractions are widely believed to experience a number of negative or dysfunctional attributes as a consequence of reductions in, or redeployments of, their labor force. For organizations undergoing planned workforce reductions, much speculation has been made in an attempt to identify a set of "best practices" that have the potential to mitigate the dysfunctional consequences associated with large permanent reductions in the workforce. This article explores the relationships among workforce-reduction practices and perceptions of organizational dysfunction in a large sample of Canadian hospitals. Results of the analysis suggest that the application of certain "progressive" workforce-reduction practices preceding, during, and subsequent to the downsizing process may play an important role in mitigating some of these dysfunctional organizational consequences. This research provides some evidence to suggest that how a workforce reduction is carried out may have a greater effect on organizational effectiveness than either the magnitude or severity of the overall workforce reduction.

This essay explores and examines how rankings and league tables have played (and continue to play) a major andconsequential role in how contemporary business schools manage their affairs. It introduces and advances theproposition that rankings promote the short-term manipulation of public reputation (image) projected by businessschools at the expense of the long-term investments in quality improvement. When schools shift scarce resources toactions aimed at enhancing their public image in the short-term, the consequences for the quality of the professionaleducation is significantly compromised in the long-term to the detriment of the constituencies that they serve. Whilethis paper focuses mainly on business schools in the United States and Canada, where this author has experiencedthese consequences first-hand, the effects are similar if perhaps less dramatic, for those professional businessprograms located in higher education institutions operating in the United Kingdom and Europe. While rankingsystems are not going away anytime soon, some potential ways are identified for business schools to escape thedeleterious and perverse effects of being captive players in the deadly rankings game.

Introduction La Haute Autorite de sante (HAS), conjointement a l’avis rendu lors de l’inscription du gefitinib (IRESSA®) au remboursement le 04 novembre 2009, a demande la mise en place d’une etude observationnelle destinee a decrire la population de patients (pts) traites par gefitinib en France et l’impact du traitement sur la morbi-mortalite ( Fig. 1 ). Methodes Etaient eligibles les pts atteints d’un cancer bronchique non a petites cellules (CBNPC) de stades avances, de tous types histologiques, mutes pour l’EGFR ayant debute entre janvier 2011 et mars 2013 un traitement par gefitinib quelle que soit la ligne de traitement. A partir de janvier 2012 ont ete inclus des pts traites par gefitinib soit avant leur entree dans l’etude (pts « prevalents »), soit a l’inclusion dans l’etude (pts « incidents »). Les donnees d’efficacite, de tolerance et de qualite de vie ont ete collectees sur une periode de suivi de 2 ans. Les evaluations tumorales etaient realisees en routine par les investigateurs selon les criteres RECIST 1.1. Resultats Un total de 361 pts ont ete recrutes par 104 centres jusqu’en mars 2013, dont 116 (32 %) pts « incidents ». Les pts etaient majoritairement des femmes (72,6 %), de type caucasien (93,6 %) et d’âge moyen de 69,1 ans (± 11,7). L’anciennete du diagnostic etait en moyenne de 7,2 mois (± 18,6). Au total, 96,3 % des pts avaient un adenocarcinome et 85,9 % une maladie de stade IIIb/IV au diagnostic initial. La recherche de mutation de l’EGFR a ete realisee pour 98,3 % des pts. La duree mediane de suivi etait de 20,8 mois. Le gefitinib a ete prescrit principalement en 1re ligne de traitement (80,3 %). Les evenements indesirables relies au traitement les plus frequemment reportes etaient des affections dermatologiques (24,6 %) et gastro-intestinales (19,6 %). Conclusion L’etude EPIDAURE montre que les donnees d’efficacite (TRO, SSP, SG) du gefitinib en vraie vie chez les CBNPC mutes EGFR sont similaires a celles observees dans les essais cliniques avec le meme profil de tolerance. Un TRO plus eleve et une SSP/SG prolongees chez les pts avec une deletion de l’exon 19 indiquent que les tumeurs avec ce sous-type moleculaire semblent plus sensibles aux ITKs, de maniere concordante avec les resultats observes avec l’afatinib.

Most western industrial nations are experiencing an acute shortage of health human resources that is beyond national remedies. As a consequence, many are actively recruiting nurses from developing countries that are experiencing acute public health challenges and their own dramatic shortages of nursing personnel. This chapter examines the challenges faced by nursing human resource of sub-Saharan Africa (SSA) from the perspective of human capital development theory and neocolonialism. These perspectives are useful prisms for assessing the factors associated with decisions to emigrate and aid in understanding patterns of migration from colonized host to destination countries, as well as explicating the phenomenon of racism reflecting many of the experiences of nurses of color as they practice their profession in western industrial democracies.

In recent years, health care in Canada as elsewhere has witnessed unprecedented restructuring and reorganization. Concurrent with the massive restructuring of health care systems, many health care organizations have dramatically downsized their workforces by shedding jobs and people. It is generally assumed that forced workforce reductions can have significant deleterious consequences on organizations. This study examines the impact of workforce reduction on perceptions of organizational performance in a large sample of Canadian health care organizations.

Organizational scholars and practitioners alike have long recognized the role of corporate culture in shaping the strategic and operational choices that organizations pursue. It is the responsibility of those who plan for change to select approaches that are compatible with the enduring elements of the organization’s dominant culture. A large sample of Canadian hospitals were surveyed to assess how organizational culture impacts the choices that organizations make in managing fiscal cutbacks. Results suggest that approaches and strategies used by Canadian hospitals in managing the change are variably influenced by CEO perceptions of the prevailing corporate culture.

The rigor versus relevance debate has been ongoing in universities for years, but faculty in professional programs are working on the front lines of the debate. The competing pressures of being seen as legitimate academics within the university and contributing to the knowledge, authority, and status of the profession, place faculty in the middle of the academic-practitioner gap. How do these pressures impact the scholarly output and recruitment practices of professional programs? Our exploration is accomplished by first, understanding the relationship between professional programs and universities and the consequent pressures placed on faculty. Second, we explore the knowledge dissemination (KD) methods of business school faculty and compare it to faculty at other professional programs (i.e., law and social work) based on a sample of 1036 faculty. Third, we assess the expectations of faculty teaching in professional programs through a sample of 438 faculty recruitment advertisements. The results show tha...

PurposeThe purpose of this paper is to explore the impact of hospital emergency department culture on the job satisfaction, patient commitment, and extra‐role performance of Canadian emergency physicians. The conceptual model related four cultural archetypes from the competing valued model to the three outcome variables.Design/methodology/approachIn total, 428 Canadian emergency physicians responded to a national survey. The conceptual model was tested via structural equation modeling via LISREL 8.FindingsCulture had a relatively weak impact on the outcomes. Human resources culture related positively to job satisfaction while bureaucratic culture related positively to patient commitment. Patient commitment, but not job satisfaction strongly and positively related to extra‐role behavior. A direct relationship between entrepreneurial culture and extra‐role behavior emerged from an extended analysis.Practical implicationsOrganizational culture seems to have more distal relationships with outcome variables and its influence is likely to be mediated by more proximal workplace variables.Originality/valueOf value by showing that a key modern leadership challenge is to create the kind of work culture that can become a source of competitive advantage through generating particular organizational outcomes valued by stakeholders.

In the past few years, organizations in a variety of industries have been urged to consider adopting human resource management (HRM) practices that can better capture the full of potential of their human capital (Pfeffer, 1994; 1998). Drawn by the promise for enhanced organizational performance, these HRM practices represent novel and progressive ways of deploying human resources. The rationale for their adoption is to improve employee and customer satisfaction, decrease operating expenses and lower costs, while sharpening organizational effectiveness and financial performance. Although not without controversy, there is a large and rapidly expanding body of evidence which shows a strong relationship between the adoption of certain HRM practices and higher levels of organizational performance (Becker and Gerhart, 1996; Boselie, Dietz and Boon, 2005; Bowen and Ostroff, 2004; Colbert, 2004; Delaney and Huselid, 1996; Guest, 1997; Huselid, 1995; Paauwe and Boselie, 2005; Wood, 1999).

Aim To investigate the impact that increasing human capital through staff training makes on the voluntary turnover of registered nurses. Background Healthcare organizations in Canada, the United Kingdom, the United States, and Australia are experiencing turbulent nursing labour markets characterized by extreme staff shortages and high levels of turnover. Organizations that invest in the development of their nursing human resources may be able to mitigate high turnover through the creation of conditions that more effectively develop and utilize their existing human capital. Methods A questionnaire was sent to the chief nursing officers of 2208 hospitals and long-term care facilities in every province and territory of Canada yielding a response rate of 32.3%. The analysis featured a three-step hierarchical regression with two sets of control variables. Results After controlling for establishment demographics and local labour market conditions, perceptions of nursing human capital and the level of staff training provided were modestly associated with lower levels of establishment turnover. Conclusions and implications for Nursing Management The results suggest that healthcare organizations that have made greater investments in their nursing human capital are more likely to demonstrate lower levels of turnover of their registered nursing personnel.

Background Turnover of nursing staff is a significant issue affecting health care cost, quality, and access. In recent years, a worldwide shortage of skilled nurses has resulted in sharply higher vacancy rates for registered nurses in many health care organizations. Much research has focused on the individual, group, and organizational determinants of turnover. Labor market factors have also been suggested as important contributors to turnover and vacancy rates but have received limited attention by scholars. Purpose This study proposes and tests a conceptual model showing the relationships of organization-market fit and three local labor market factors with organizational turnover and vacancy rates. Methods The model is tested using ordinary least squares regression with data collected from 713 Canadian hospitals and nursing homes. Results Results suggest that, although modest in their impact, labor market and the organization-market fit factors do make significant yet differential contributions to turnover and vacancy rates for registered nurses. Implications Knowledge of labor market factors can substantially shape an effective campaign to recruit and retain nurses. This is particularly true for employers who are perceived to be "employers-of-choice."

Aim This study examines the association of high involvement nursing work practices with employer-of-choice (magnet) status in a sample of Canadian nursing homes. Background In response to a severe shortage of registered nursing personnel, it is imperative for health care organizations to more effectively recruit and retain nursing personnel. Some long-term care organizations are developing employee-centred cultures that allow them to effectively enhance nurse and resident satisfaction. At the same time, many nursing homes have adopted progressive nursing workplace practices (high involvement work practices) that emphasize greater employee empowerment, participation and commitment. Method A mail survey was sent to the director of nursing in 300 nursing homes in western Canada. In total, 125 useable questionnaires were returned and constituted the data set for this study. Separate ordinary least squares regressions are performed with magnet strength, nurse satisfaction and resident satisfaction used as dependent variables. Results Nursing homes that demonstrate strong magnet (employer-of-choice) characteristics are more likely to have higher levels of nurse and patient satisfaction, even after controlling for a number of significant factors at the establishment level. Magnet nursing homes are more likely to have progressive participatory decision-making cultures and much more likely to spend considerable resources on job-related training for their nursing staff. The presence of high involvement work practices is not found to be a significant predictor in magnet strength, nurse or resident satisfaction. Conclusion Merely adopting more high involvement nursing work practices may be insufficient for nursing homes, which desire to become ‘employers-of-choice’ in their marketplaces, especially if these practices are adopted without a concomitant investment in nurse training or an enhanced commitment to establishing a more democratic and participatory decision-making style involving all nursing staff.

Many health care workplaces are adopting more cooperative labour‐management relations, spurred in part by sweeping changes in the economic environment that have occurred over the last decade. Labour‐management cooperation is seen as essential if health care organizations are to achieve their valued performance objectives. Joint labour‐management committees (LMCs) have been adopted in many health care workplaces as a means of achieving better industrial relations. Using data from a sample of Canadian union leaders in the health care sector, this paper examines the impact of labour‐management forums and labour climate on employee and organizational outcomes. Research results suggest that labour climate is less important in predicting workplace performance (and change in workplace performance) than is the number of LMCs in operation. However, labour climate is found to be at least as important in predicting union member satisfaction (and change in member satisfaction) as is the wide adoption of LMCs in operation. These findings are consistent with the notion that the greater use of LMCs is associated with augmented workplace performance (and a positive change in workplace performance), notwithstanding the contribution of the labour climate in the workplace.

In recent years, hospitals in Canada as elsewhere have witnessed unprecedented downsizing of their workforces. It is generally assumed that planned workforce reductions can have deleterious consequences on an organization's human resources. Scholars and practitioners alike have identified a number of humane or progressive approaches that are widely considered to be effective for organizations undergoing downsizing. This study examines the impact that workforce reduction approaches have on perceptions of organizational performance in a large sample of Canadian hospitals undergoing workforce reductions.

Management scholars and practitioners alike have become increasingly interested in learning more about the ability of certain 'progressive' or 'high-performance' human resource management (HRM) practices to enhance organizational effectiveness. There is growing evidence to suggest that the contribution of various HRM practices to impact firm performance may be synergistic in effect yet contingent on a number of contextual factors, including workplace climate. A contingency theory perspective suggests that in order to be effective, HMR policies and practices must be consistent with other aspects of the organization, including its environment. This paper reports on empirical findings from research that examines the relationship between HRM practices, workplace climate and perceptions of organizational performance, in a large sample of Canadian nursing homes. Data from 283 nursing homes were collected by means of a mail survey that included questions on HRM practices, programmes, and policies, on human resource aspects of workplace climate, as well as a variety of indicators that include employee, customer/resident and facility measures of organizational performance. Results derived from ordered probit analysis suggest that nursing homes in our sample which had implemented more 'progressive' HRM practices and which reported a workplace climate that strongly values employee participation, empowerment and accountability tended to be perceived to generally perform better on a number of valued organizational outcomes. Nursing homes in our sample that performed best overall were found to be more likely to not only have implemented more of these HRM practices, but also to report having a workplace climate that reflects the seminal value that it places on its human resources. This finding is consistent with the conclusion that simply introducing HRM practices or programmes, in the absence of an appropriately supportive workplace climate, will be insufficient to attain optimal organizational performance.

The use of martingale residuals have been proposed for model checking and also to get a non-parametric estimate of the effect of an explanatory variable. We apply this approach to an epidemiological problem which presents two characteristics: the data are left truncated due to delayed entry in the cohort; the data are grouped into geographical units (parishes). This grouping suggests a natural way of smoothing the graph of residuals which is to compute the sum of the residuals for each parish. It is also natural to present a graph with standardized residuals. We derive the variances of the estimated residuals for left truncated data which allows computing the standardized residuals. This method is applied to the study of dementia in a cohort of old people, and to the possible effect of the concentration of aluminum and silica in drinking water on the risk of developing dementia.

The purpose of this study was to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. The multi-center trial involved 19 wards stratified according to specialty and recruitment for critically ill older patients; 9 wards were randomly selected for nutritional intervention (nutritional intervention group), consisting of the daily distribution of two oral supplements, with each supplement containg 200 kcal, for 15 d. Pressure ulcer incidence was prospectively recorded for grades I (erythema), II (superficial broken skin), and III (subcutaneous lesion) for 15 d. Nutritional intake was monitored by using estimates in units of quarters validated by comparison with weight measurement. There were 672 subjects older than 65 y, and 295 were in the nutritional intervention group versus 377 in the control group. The patients were similar for age, sex ratio, and C-reactive protein. In comparison with the control group, the nutritional intervention group included more patients with stroke, heart failure, and dyspnea and fewer with antecedent falls, delirium, lower limb fractures, and digestive disease. The nutritional intervention group had a lower risk of pressure ulcers according to the Norton score but was less dependent (Kuntzman score) and had a lower serum albumin level. During the trial, energy and protein intakes were higher in the nutritional intervention group (day 2: 1081 +/- 595 kcal versus 957 +/- 530 kcal, P = 0.006; 45.9 +/- 27.8 g protein versus 38.3 +/- 23.8 g protein in the control group, P0.001). At 15 d, the cumulative incidence of pressure ulcers was 40.6% in the nutritional intervention group versus 47.2% in the control group. The proportion of grade I cases relative to the total number of cases was 90%. Multivariate analysis, taking into account all diagnoses, potential risk factors, and the intra-ward correlation, indicated that the independent risk factors of developing a pressure ulcer during this period were: serum albumin level at baseline, for 1 g/L decrease: 1.05 (95% confidence interval: 1.02 to 1.07, P0.001); Kuntzmann score at baseline, for 1-point increase: 1.22 (0.32 to 4.58, P = 0.003); lower limb fracture: 2.68 (1.75 to 4.11, P0.001); Norton score10 versus14: 1.28 (1.01 to 1.62, P = 0.04); and belonging to the control group: 1.57 (1.03 to 2.38, P = 0.04). In conclusion, it was possible to increase the dietary intake of critically ill elderly subjects by systematic use of oral supplements. This intervention was associated with a decreased risk of pressure ulcer incidence.

BACKGROUND: We exemplify the use of a marginal approach with proportional hazards model when failure times are correlated. METHODS: The marginal distribution for each failure time is formulated by the Cox proportional hazards model, while the dependence structure is unspecified. However, a correct variance-covariance estimate of the regression coefficients that takes into account the intra-group correlation is proposed. The program MULCOX2 which implements this statistical methodology is used to assess the effect of a nutritional supplementation intervention on pressure ulcer development on critically ill older patients from a multicentric trial (involving 19 wards). We compare the results obtained with those of the usual Cox regression. RESULTS: The naive approach yields much smaller standard error estimates of the regression parameters than the robust approach. CONCLUSION: In our example, the results obtained with the marginal approach do not modify the conclusions: a nutritional supplementation intervention tends to decrease significantly the formation of pressure ulcers. However in other situations, ignoring the intra-cluster dependence could lead to invalid statistical inference. The variability of the estimated effects by MULCOX2 can be quite sensitive to the number of clusters in the sample and to the clusters size.

Although many organisations have in recent years installed TQ programs, many have been unable to realize significant performance enhancements. Results from a diverse sample of Canadian health care organisations suggest that merely having a TQ program is insufficient for attaining selected performance improvements. Health care organisations which have both a formal TQ program and a deep commitment to quality improvement are perceived to perform better on a number of valued outcomes.

Patients spend a substantial amount of time in clinics waiting for services to be delivered by nursing and other allied health professionals. The degree to which health consumers are satisfied with the care received is strongly related to the quality of the wait experience. Health care organizations that strive to deliver exceptional service must effectively manage their clinic wait. Failure to incorporate consumer-driven features into the design of the wait experience will lead to patient and provider dissatisfaction.