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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.

Regionalism implying some form of city-region or metropolitan-level planning and governance has long been promoted for multiple reasons albeit with varied success. Experiencing a resurgence in 1990s, regional coordination and cooperation has proven effective in pursuing economic development and bolstering competitiveness. Unfortunately, other voices, such as those promoting regional scale land use planning and management to cultivate more sustainable urban form and settlement patterns became comparatively crowded out. With climate change-related environmental and ecological pressures mounting, the chapter suggests it is time to frame regions as socio-ecological rather than mere socio-economic spaces, thereby placing greater emphasis on ecosystems and ecological land management and a circular, regenerative economy. Using the city-region of Stuttgart (Germany) as exemplar, our contribution initiates an exploration into whether statutory regional planning in combination with various informal tools and a multi-level governance framework allows actors to begin to embed and implement these emerging ecological sustainability concepts.

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.

Shang and Croson (2009) found that providing information about the donation decisions of others can have a positive impact on individual donations to public radio. In this study, we attempted to replicate their results, but found no evidence that social information affected donation decisions. However, most of our donors were renewing members, a group which Shang and Croson also found was not influenced by social information.

According to the US Census Bureau’s biweekly Household Pulse Survey, the percentage of homeschoolers – children whose parents withdrew them from public or private schools and assumed full control of their education – grew significantly during the pandemic. The percentage of households that homeschooled at least one child increased from 5.4% at the start of the pandemic in the spring of 2020 to 19.5% in May of 2021. While homeschooling has long been associated with conservative, religious White families, the most significant increases during the pandemic have been among families of color and, in particular, Black households. Around 3% of Black students were homeschooled before the pandemic; by October 2020, the number had increased by more than five times – to 16%. What is driving the migration from mainstream education is difficult to parse, due in part to the dearth of research and reporting on homeschooling among families of color – both before the pandemic and as it continues to unfold. Although COVID-19 and concern for children’s health and safety acted as the impetus for many, if not most, families’ decisions, the shift from traditional schooling has also been driven by parents’ concerns about the disparities, inadequacies, and racism that run deep in public education. The nation’s ongoing reckoning with race alongside COVID-19 has acted as a catalyst for some parents of color to remove their children from mainstream education settings entirely. While do not yet know if new adopters of homeschooling will continue the practice post-pandemic or if they may delay their decision to re-enroll their children in brick-and-mortar schools, there are clear implications for students and the school districts they leave behind. This chapter explores the growth of homeschooling among Black families specifically, providing an overview and typologies, pre-pandemic trends and changes during COVID-19, a review of the literature on Black homeschooling, and concluding with implications.

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.