Importance of ocean salinity for climate and habitability.

Modeling studies of terrestrial extrasolar planetary climates are now including the effects of ocean circulation due to a recognition of the importance of oceans for climate; indeed, the peak equator-pole ocean heat transport on Earth peaks at almost half that of the atmosphere. However, such studies have made the assumption that fundamental oceanic properties, such as salinity, temperature, and depth, are similar to Earth. This assumption results in Earth-like circulations: a meridional overturning with warm water moving poleward at the surface, being cooled, sinking at high latitudes, and traveling equatorward at depth. Here it is shown that an exoplanetary ocean with a different salinity can circulate in the opposite direction: an equatorward flow of polar water at the surface, sinking in the tropics, and filling the deep ocean with warm water. This alternative flow regime results in a dramatic warming in the polar regions, demonstrated here using both a conceptual model and an ocean general circulation model. These results highlight the importance of ocean salinity for exoplanetary climate and consequent habitability and the need for its consideration in future studies.

Short-circuiting of the overturning circulation in the Antarctic Circumpolar Current.

The oceanic overturning circulation has a central role in the Earth's climate system and in biogeochemical cycling, as it transports heat, carbon and nutrients around the globe and regulates their storage in the deep ocean. Mixing processes in the Antarctic Circumpolar Current are key to this circulation, because they control the rate at which water sinking at high latitudes returns to the surface in the Southern Ocean. Yet estimates of the rates of these processes and of the upwelling that they induce are poorly constrained by observations. Here we take advantage of a natural tracer-release experiment-an injection of mantle helium from hydrothermal vents into the Circumpolar Current near Drake Passage-to measure the rates of mixing and upwelling in the current's intermediate layers over a sector that spans nearly one-tenth of its circumpolar path. Dispersion of the tracer reveals rapid upwelling along density surfaces and intense mixing across density surfaces, both occurring at rates that are an order of magnitude greater than rates implicit in models of the average Southern Ocean overturning. These findings support the view that deep-water pathways along and across density surfaces intensify and intertwine as the Antarctic Circumpolar Current flows over complex ocean-floor topography, giving rise to a short circuit of the overturning circulation in these regions.

Advancing the science of patient safety.

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Marine iodine emissions in a changing world.

Iodine is a critical trace element involved in many diverse and important processes in the Earth system. The importance of iodine for human health has been known for over a century, with low iodine in the diet being linked to goitre, cretinism and neonatal death. Research over the last few decades has shown that iodine has significant impacts on tropospheric photochemistry, ultimately impacting climate by reducing the radiative forcing of ozone (O3) and air quality by reducing extreme O3 concentrations in polluted regions. Iodine is naturally present in the ocean, predominantly as aqueous iodide and iodate. The rapid reaction of sea-surface iodide with O3 is believed to be the largest single source of gaseous iodine to the atmosphere. Due to increased anthropogenic O3, this release of iodine is believed to have increased dramatically over the twentieth century, by as much as a factor of 3. Uncertainties in the marine iodine distribution and global cycle are, however, major constraints in the effective prediction of how the emissions of iodine and its biogeochemical cycle may change in the future or have changed in the past. Here, we present a synthesis of recent results by our team and others which bring a fresh perspective to understanding the global iodine biogeochemical cycle. In particular, we suggest that future climate-induced oceanographic changes could result in a significant change in aqueous iodide concentrations in the surface ocean, with implications for atmospheric air quality and climate.

The role for clinician educators in implementing healthcare improvement.

Clinician educators-who work at the intersection of patient care and resident education-are well positioned to respond to calls for better, safer patient care and resident education. Explicit lessons that address implementing health care improvement and associated residency training came out of the Academic Chronic Care Collaboratives and include the importance of: (1) redesigning the clinical practice as a core component of the residency curriculum; (2) exploiting the efficiencies of the practice team; (3) replacing "faculty development" with "everyone's a learner;" (4) linking faculty across learning communities to build expertise; and (5) using rigorous methodology to design and evaluate interventions for practice redesign. There has been progress in addressing three thorny academic faculty issues-professional satisfaction, promotion and publication. For example, consensus criteria have been proposed for both faculty promotion as well as the institutional settings that nurture academic health care improvement careers, and the SQUIRE Publication Guidelines have been developed as a general framework for scholarly improvement publications. Extensive curricular resources exist for developing the expert faculty cadre. Curricula from representative training programs include quantitative and qualitative research methods, statistical methodologies appropriate for measuring systems change, organizational culture, management, leadership and scholarly writing for the improvement literature. Clinician educators-particularly those in general internal medicine-bear the principal responsibility for both patient care and resident training in academic departments of internal medicine. The intersection of these activities presents a unique opportunity for their playing a central role in implementing health care improvement and associated residency training. However, this role in academic settings will require an unambiguous development strategy both for faculty and their institutions.

Joy and challenges in improving chronic illness care: capturing daily experiences of academic primary care teams.

BACKGROUND: Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education. OBJECTIVE: We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member's experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork. DESIGN: The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members' daily work and subsequent outcomes. PARTICIPANTS: Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff. APPROACH: Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative). KEY RESULTS: At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or "Joy in Work". In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments-"lack of professional satisfaction" and awareness of "system failures". CONCLUSIONS: The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.

Developing measures of educational change for academic health care teams implementing the chronic care model in teaching practices.

BACKGROUND: The Chronic Care Model (CCM) is a multidimensional framework designed to improve care for patients with chronic health conditions. The model strives for productive interactions between informed, activated patients and proactive practice teams, resulting in better clinical outcomes and greater satisfaction. While measures for improving care may be clear, measures of residents' competency to provide chronic care do not exist. This report describes the process used to develop educational measures and results from CCM settings that used them to monitor curricular innovations. SUBJECTS: Twenty-six academic health care teams participating in the national and California Academic Chronic Care Collaboratives. METHOD: Using successive discussion groups and surveys, participants engaged in an iterative process to identify desirable and feasible educational measures for curricula that addressed educational objectives linked to the CCM. The measures were designed to facilitate residency programs' abilities to address new accreditation requirements and tested with teams actively engaged in redesigning educational programs. ANALYSIS: Field notes from each discussion and lists from work groups were synthesized using the CCM framework. Descriptive statistics were used to report survey results and measurement performance. RESULTS: Work groups generated educational objectives and 17 associated measurements. Seventeen (65%) teams provided feasibility and desirability ratings for the 17 measures. Two process measures were selected for use by all teams. Teams reported variable success using the measures. Several teams reported use of additional measures, suggesting more extensive curricular change. CONCLUSION: Using an iterative process in collaboration with program participants, we successfully defined a set of feasible and desirable education measures for academic health care teams using the CCM. These were used variably to measure the results of curricular changes, while simultaneously addressing requirements for residency accreditation.

Assessing Chronic Illness Care Education (ACIC-E): a tool for tracking educational re-design for improving chronic care education.

BACKGROUND: Recent Breakthrough Series Collaboratives have focused on improving chronic illness care, but few have included academic practices, and none have specifically targeted residency education in parallel with improving clinical care. Tools are available for assessing progress with clinical improvements, but no similar instruments have been developed for monitoring educational improvements for chronic care education. AIM: To design a survey to assist teaching practices with identifying curricular gaps in chronic care education and monitor efforts to address those gaps. METHODS: During a national academic chronic care collaborative, we used an iterative method to develop and pilot test a survey instrument modeled after the Assessing Chronic Illness Care (ACIC). We implemented this instrument, the ACIC-Education, in a second collaborative and assessed the relationship of survey results with reported educational measures. PARTICIPANTS: A combined 57 self-selected teams from 37 teaching hospitals enrolled in one of two collaboratives. ANALYSIS: We used descriptive statistics to report mean ACIC-E scores and educational measurement results, and Pearson's test for correlation between the final ACIC-E score and reported educational measures. RESULTS: A total of 29 teams from the national collaborative and 15 teams from the second collaborative in California completed the final ACIC-E. The instrument measured progress on all sub-scales of the Chronic Care Model. Fourteen California teams (70%) reported using two to six education measures (mean 4.3). The relationship between the final survey results and the number of educational measures reported was weak (R(2) = 0.06, p = 0.376), but improved when a single outlier was removed (R(2) = 0.37, p = 0.022). CONCLUSIONS: The ACIC-E instrument proved feasible to complete. Participating teams, on average, recorded modest improvement in all areas measured by the instrument over the duration of the collaboratives. The relationship between the final ACIC-E score and the number of educational measures was weak. Further research on its utility and validity is required.

A multi-institutional quality improvement initiative to transform education for chronic illness care in resident continuity practices.

BACKGROUND: There is a gap between the need for patient-centered, evidence-based primary care for the large burden of chronic illness in the US, and the training of resident physicians to provide that care. OBJECTIVE: To improve training for residents who provide chronic illness care in teaching practice settings. DESIGN: US teaching hospitals were invited to participate in one of two 18-month Breakthrough Series Collaboratives-either a national Collaborative, or a subsequent California Collaborative-to implement the Chronic Care Model (CCM) and related curriculum changes in resident practices. Most practices focused on patients with diabetes mellitus. Educational redesign strategies with related performance measures were developed for curricular innovations anchored in the CCM. In addition, three clinical measures-HbA1c <7%, LDL <100 mg/dL, and blood pressure

Development of the SQUIRE Publication Guidelines: evolution of the SQUIRE project.

These guidelines address the development and testing of interventions to improve the quality and safety of health care.

Mechanisms driving variability in the ocean forcing of Pine Island Glacier.

Pine Island Glacier (PIG) terminates in a rapidly melting ice shelf, and ocean circulation and temperature are implicated in the retreat and growing contribution to sea level rise of PIG and nearby glaciers. However, the variability of the ocean forcing of PIG has been poorly constrained due to a lack of multi-year observations. Here we show, using a unique record close to the Pine Island Ice Shelf (PIIS), that there is considerable oceanic variability at seasonal and interannual timescales, including a pronounced cold period from October 2011 to May 2013. This variability can be largely explained by two processes: cumulative ocean surface heat fluxes and sea ice formation close to PIIS; and interannual reversals in ocean currents and associated heat transport within Pine Island Bay, driven by a combination of local and remote forcing. Local atmospheric forcing therefore plays an important role in driving oceanic variability close to PIIS.

Transform residency training in chronic illness care -- now.

Identification of the drivers of change that hasten improvement of chronic illness care in resident practices serves as an effective strategy for transformative change. The Academic Chronic Care Collaborative (ACCC) is an ongoing network of 48 teams from 22 teaching hospitals and systems that have committed to implementation of the evidence-based Chronic Care Model in their residency practices. The teams track the results of their efforts by monthly reports of both clinical and educational outcomes. The authors' experience with these self-selected teams shows that the two most effective drivers of change have been organization-wide leadership -- from the CEO to the clinical manager -- and the academic culture, e.g., competitiveness, the aspiration for excellence, focus on the research mission, comfort with data, and commitment to the education mission. These ACCC teams and their sponsoring health systems have successfully harnessed these drivers for the implementation of evidence-based chronic illness care in resident practices.

Knowledge for improvement: who will lead the learning?

If we wish to improve the results of a system, what is needed to help health professionals learn about the redesign of that system? To create learning experiences that will attract good health professionals, a special blend of practical insight and critical thinking is required. To enjoy good standing in the academy, these leaders must be able to design, conduct, and disseminate knowledge-building activities subject to peer review. This is the story of the development of the United States Veteran's Health Administration Quality Scholars Program from those who designed and formed it to prepare health professional teachers and academics.

Healthcare improvement is incomplete until it is published: the cystic fibrosis initiative to support scholarly publication.

OBJECTIVE: Preparation of this supplement, Ten years of improvement innovation in cystic fibrosis care, tested a strategy to support writing and scholarly publication by cystic fibrosis (CF) healthcare improvement professionals. INTERVENTION: Critical elements of the writing initiative included: a request for abstracts that was distributed to over 2000 professionals in the Cystic Fibrosis Foundation-supported improvement community to identify promising work; continuous peer review of manuscripts by co-authors and writing tutors; three webinars and a 2-day face-to-face writing retreat that addressed the challenges of successful scholarly healthcare improvement writing and publication; and finally, journal submission and formal external peer review. The SQUIRE Publication Guidelines provided content framework for manuscripts. RESULTS: 47 abstracts were submitted from which reviewers selected nine for participation. The 28 co-authors of these abstracts took part in the writing initiative. Authors' self-assessment showed that half had previously published fewer than five papers, while 80% considered themselves insufficiently prepared to write for the scholarly improvement literature. Eventually all of the nine abstracts led to full manuscripts, which were submitted to the journal for formal peer review. Of these, seven were accepted for publication and are included in this supplement. CONCLUSIONS: A formal initiative to develop and support scholarly writing-while resource-intensive-offers opportunities for wider publication by healthcare improvement professionals.

Ocean processes at the Antarctic continental slope.

The Antarctic continental shelves and slopes occupy relatively small areas, but, nevertheless, are important for global climate, biogeochemical cycling and ecosystem functioning. Processes of water mass transformation through sea ice formation/melting and ocean-atmosphere interaction are key to the formation of deep and bottom waters as well as determining the heat flux beneath ice shelves. Climate models, however, struggle to capture these physical processes and are unable to reproduce water mass properties of the region. Dynamics at the continental slope are key for correctly modelling climate, yet their small spatial scale presents challenges both for ocean modelling and for observational studies. Cross-slope exchange processes are also vital for the flux of nutrients such as iron from the continental shelf into the mixed layer of the Southern Ocean. An iron-cycling model embedded in an eddy-permitting ocean model reveals the importance of sedimentary iron in fertilizing parts of the Southern Ocean. Ocean gliders play a key role in improving our ability to observe and understand these small-scale processes at the continental shelf break. The Gliders: Excellent New Tools for Observing the Ocean (GENTOO) project deployed three Seagliders for up to two months in early 2012 to sample the water to the east of the Antarctic Peninsula in unprecedented temporal and spatial detail. The glider data resolve small-scale exchange processes across the shelf-break front (the Antarctic Slope Front) and the front's biogeochemical signature. GENTOO demonstrated the capability of ocean gliders to play a key role in a future multi-disciplinary Southern Ocean observing system.