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For many small and medium‐sized enterprises (SMEs), quality systems, and ISO 9000 (BS EN, ISO 9000‐1, 1994) in particular, are a fact of life. Quality systems are seen as a necessary qualification for trading in certain markets. This can encourage businesses to think of quality only in terms of the cheapest way to obtain a certificate, thereby failing to appreciate the organisational benefits which could be obtained if more resources were applied to the development of effective quality systems. The use of quality consultants is widespread as a means of implementing ISO 9000. The selection and use of consultants can have a major influence on the commercial impact of quality systems developed through their work. Clients do not always appreciate differences between consultants, who all promise registration. As a consequence, a client often places its trust in the cheapest consultant, the first one to come along, or a friend. This paper, which is based on a survey of SMEs registered to ISO 9000, and will be presented at the Small Business and Enterprise Development Conference, 22nd and 23rd March, 1999, explores clients’ perceptions of value through the development of a model of client‐consultant relationships. It is argued that both clients and consultants need to have awareness of these perceptions at different project stages in order to realise the benefits of consultancy relationships. Clients’ perceptions of value are identified in both the experience of the consultancy relationships as well as the outputs. By viewing client‐consultant relationship development as a process, key activities within a project can be investigated, such as initial contracting and ultimate project outputs. The paper concludes that ISO 9000 can act as a bureaucratic constraint on improvement activities, but can also provide an opportunity to develop structures and processes that help to achieve improvements in a controlled manner. It is argued that the achievement of third‐party registration is largely irrelevant to the effectiveness of a quality system in bringing about improvements, although the prospect of registration is often a necessary driver towards instigating a system. It is shown that quality consultancy relationships are perceived by clients as having widely differing outcomes. These can be both favourable and unfavourable, whilst still meeting the objective of registration.

Small-bore drains (≤ 16 Fr) are used in many centers to manage all pleural effusions. The goal of this study was to determine the proportion of avoidable chest drains and associated complications when a strategy of routine chest drain insertion is in place.

We retrospectively reviewed consecutive pleural procedures performed in the Radiology Department of the McGill University Health Centre over one year (August 2015–July 2016). Drain insertion was the default drainage strategy. An interdisciplinary workgroup established criteria for drain insertion, namely: pneumothorax, pleural infection (confirmed/highly suspected), massive effusion (more than 2/3 of hemithorax with severe dyspnea /hypoxemia), effusions in ventilated patients and hemothorax. Drains inserted without any of these criteria were deemed potentially avoidable.

A total of 288 procedures performed in 205 patients were reviewed: 249 (86.5%) drain insertions and 39 (13.5%) thoracenteses. Out of 249 chest drains, 113 (45.4%) were placed in the absence of drain insertion criteria and were deemed potentially avoidable. Of those, 33.6% were inserted for malignant effusions (without subsequent pleurodesis) and 34.5% for transudative effusions (median drainage duration of 2 and 4 days, respectively). Major complications were seen in 21.5% of all procedures. Pneumothorax requiring intervention (2.1%), bleeding (0.7%) and organ puncture or drain misplacement (2%) only occurred with drain insertion. Narcotics were prescribed more frequently following drain insertion vs. thoracentesis (27.1% vs. 9.1%, p = 0.03).

Routine use of chest drains for pleural effusions leads to avoidable drain insertions in a large proportion of cases and causes unnecessary harms.

This paper presents an overview of the x‐ray guided robotic radiosurgery system that has been developed for the ablation of solid tumors. A robot‐mounted linear accelerator is directed through a sequence of positions and orientations designed to deliver high radiation dosages focused at a specific location. Patient movement during treatment is identified by stereo x‐ray measurements and the robotic system adjusts the linear accelerator prior to the delivery of radiation at each location. The result is accurate delivery without rigid fixation of the tumor relative to the treatment system.

The purpose of this paper is to advance understanding about the facilitation process used in complex implementation projects, by describing the function of novice clinician facilitators, and the barriers and enablers they experience, while implementing a new model of care for managing hospital malnutrition.

Semi-structured interviews were undertaken with local facilitators (n=7) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. Facilitator networks and training supported the clinicians acting as novice facilitators.

Key functions of the facilitator role were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. “Dedicated role, time and support” was identified as a theme encompassing the key barriers and enablers to successful facilitation.

When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. With these structures in place, facilitators can support iterative improvements through building trust and relationships, co-designing strategies with champions and teams and developing internal capacity for change.

This case study extends the knowledge about how facilitation works in action, the barriers faced by clinicians new to working in facilitator roles, and highlights the need for an adapt-to-fit approach for the facilitation process, as well as the innovation itself.

The purpose of this paper is to theoretically propose a complex perspective as the third way to understand disasters which is used to describe the Hiroshima landslide disaster 2014 in Japan. In the first half of the paper the complex perspective is explained in detail with comparison to two conventional perspectives on disasters, i.e. hazard approach and vulnerability approach. According to the complex perspective, deaths in disasters are avoidable. In the second half of the paper, Hiroshima landslide disaster is analyzed in line with the complex perspective. Also, how will Hiroshima not repeat such landslide disaster is suggested.

To develop the case study for Hiroshima, a desk-based literature review, a field site visit and five key informant interviews were conducted by the authors in 2016. The authors’ initial analysis based on newspaper reports indicated a failure in the early warning system, evacuation and severity of the hazard. Based on this, the broader literature on traditional perspectives on risk, vulnerability and complexity were mined to understand and theorize the failure in Hiroshima. Then the interviews were conducted in the city of Hiroshima to analyze the disaster from complex perspective.

The authors demonstrated that the Hiroshima Landslide disaster 2014 and its deaths could be explained by complex perspective. Complex perspective brings us the following suggestions not to repeat landslide disaster in Hiroshima. Political leaders at national and local levels must take up responsibilities to set a “goal” for the disaster management system to “reduce deaths.” Also, governmental and non-governmental organizations should make efforts to engage proactively with community through disaster education or through community awareness program to shift the mind set from hito-goto to jibun-no-koto (their story to our story).

Reducing deaths by disasters is essential for the world thus it is UN’s Sendai Goal One. As most contemporary sciences are based on reductionism, disasters have been described as a combination of the related components such as hazards, vulnerability. Although the great contributions from the reductionism to disaster studies, it has been said that integrated disaster management is needed since the reductionism usually give the partially optimized solution to disaster reduction. This study proposes complex approach to find comparatively total optimized solution to disaster reduction, in particular reducing deaths. Although it is based on merely one case study, this paper describes the possibility of different way to reduce deaths by disasters.

The purpose of this trial was to establish whether a change in the X‐ray referral procedure would reduce the time between presentation and admission for patients who attended a busy Accident and Emergency department with a fractured neck of femur. This group of patients was selected because they are susceptible to decubitus ulcers, the development of which may relate to the time spent on a trolley. Senior nurses in the Accident and Emergency department were educated in patient assessment and management, and knowledge and implementation of ionising radiation regulations. They then referred patients who presented with suspected fractures of the femoral neck to the radiology department within agreed guidelines and without a doctor's examination. Records were kept over a 3‐month trial period. A total of 27 completed cases were recorded and the data included radiological findings, total time from presentation to arrival on the ward or discharge, total time waiting for a porter and being transported, total time spent in the radiology department, and whether the patient reattended for a further X‐ray examination. We concluded that the change in X‐ray referral procedure resulted in an appreciable reduction in the overall time between presentation and admission. However, it was not possible to draw any valid conclusions regarding any reduction in decubitus ulceration as a result of this speedier diagnosis and admission.

The purpose of this paper to synthesise much of the existing research on autistic spectrum disorder (ASD) and offending behaviour.

It considers three key areas, namely, first, a discussion about the nature of ASD and how it might be related to offending behaviour; second, a brief commentary about the prevalence of this population; and, finally, an exploration of the effective management and possible treatment outcomes.

Methodological limitations have resulted in variable findings which has hindered our understanding of this population. Some of the research is based on small, highly specialist samples making prevalence difficult to measure. The link between ASD and offending is still not well understood, and despite advances in staff training, awareness amongst practitioners remains an underdeveloped area, thus yielding variable treatment outcomes.

This review continues to demonstrate the urgent need for robust research in order to better understand the link between ASD and offending behaviour, to provide tailored, needs-led interventions, and reduce the risk of offending amongst this group as a whole.

Claims that people with autism spectrum disorders (ASD) are overrepresented in offending populations and are more likely to commit crimes than others are explored in this review. Evidence to date makes these claims difficult to substantiate, although methodological difficulties make this area particularly challenging. ASD does not appear to account for a large number of crimes in society, though certain characteristics may render those on the spectrum vulnerable to offending. Comorbid psychiatric conditions such as depression and psychosis, when present in a person that additionally has ASD, are important risk factors. Once in the criminal justice system, people with ASD are often misunderstood and open to bullying. Very little is known about what treatment programmes are effective for offenders in this population. This review summarises some of the important studies in this field.

This paper aims to explore consumer experiences of spiritual value and investigates whether it is distinct from ethical value within a large and growing private sector health-care setting. Understanding consumers’ experiences of spiritual value versus ethical value has important implications for corporate social responsibility as increasingly, consumers want their spiritual needs met.

The research adopts an exploratory case study approach using in-depth interviews with 16 consumers who use complementary and alternative medicine health-care services. Drawing on consumer value frameworks, a thematic analysis identified dimensions of spiritual and ethical values co-created during their consumption experiences.

From a consumer’s perspective, spiritual value is distinct from ethical value. The key finding is that participants talked about spiritual value predominantly in reactive terms (apprehending, appreciating, admiring or responding), whereas ethical value was referred to as active (taking action).

This paper enhances the understanding of spiritual value and provides evidence that people want their spiritual needs met in a private health-care context. Furthermore, this study provides insights into the consumption experience of spiritual value that can be considered, with further research, in other health-care and service contexts.

This paper offers a new view on corporate social responsibility by taking a consumer’s perspective, and identifying that consumer experiences of spiritual value are important and distinct from ethical value.