System-wide Basis Research Articles

High school change: a reflective essay on three decades of frustration, struggle and progress

PurposeThe purpose of this essay is to honor, position and reflect on key themes related to high school reform within the careerlong scholarship of Karen Seashore Louis. It is presented in relation to my own and others' key studies and book-length arguments regarding educational change, knowledge utilization, professional communities and innovation, over the past 30 years and up to the present time.Design/methodology/approachThe article examines and interprets major works by Karen Seashore Louis and other educational change theorists that address repeated systemic failures, and episodic outlier efforts, at transformational change in high schools.FindingsHigh school change has only failed if it is judged by the overarching criterion of system-wide transformation. Fair assessments of high school change must also examine accumulated incremental innovations. In light of the need for transformational aspirations in schools to mesh with transformational directions in society, the global pandemic and its aftermath may provide five key opportunities for long-awaited transformation.Originality/valueThere are different levels and degrees of innovation. Incremental innovation is as important as wholesale transformation. The growing number of networked outliers of innovation raises questions about the false equation of whole system change with bureaucratic state reform. Although the influential literature on whole system change is rooted in a small number of English-speaking countries, transformational change on a system-wide basis already exists in Northern Europe and parts of the Global South. Last, the pandemic and other major disruptions to the global social order have produced conditions that are highly favorable to transformational change in the future.

Integration of palliative care into the inpatient oncology service.

46 Background: Research has demonstrated that early palliative care involvement for patients with advanced cancer has multiple benefits, including improved symptom control/quality of life and reduced readmission rates. Based on this data, the American Society of Clinical Oncology (ASCO) has developed guidelines for early palliative care consultation. At the University of Vermont Medical Center, historically 40% of such patients were evaluated by palliative care during hospital admission. The purpose of this study was to better integrate palliative care into the oncology inpatient setting through the use of a standardized admission template. Methods: A specific oncology H&P template, with inclusion of a drop down menu of ASCO based criteria for palliative care consultation, was created. Providers were educated on template use, and data then were collected for oncology admissions from 2/1-8/31/2018 regarding template usage, if criteria was met for palliative care consultation, and whether consultation occurred. Additionally, 30 day post discharge ED visits and readmissions were recorded, extending data collection for this purpose to 9/30/2018. Results: There were 372 medical oncology admissions during the studied time period, with 284 individual patients. The template was used for 95 (26%) admissions. 267 of those patients admitted qualified for palliative care consultation and, of those in which the template was used, 72% had palliative care consulted versus 50% without the template (p= 0.0013). There was no statistically significant difference in readmission rates between those with palliative care consultation and without. Conclusions: Early palliative care consultation for patients with advanced malignancy has been shown to have multiple benefits on an individual and system-wide basis. It was shown in this study that, though the created template was used for a minority of admissions, with template use a significantly greater proportion of appropriate patients had palliative care consulted. This suggests that, with more widespread practice, this strategy could further promote inpatient palliative care involvement for appropriate oncology patients.

East Sussex Better Together Alliance - Governance to enable cross sector delivery

Our problem, what we did and how: ESBT is a partnership between two local Clinical Commissioning Groups CCGs, the acute and community NHS Trust, mental health NHS Foundation Trust and the County Council. The partners’ aim is to integrate the whole system to ensure they use their combined £860m annual budget to achieve the best possible services for their local population approximately 370,000 people. To facilitate this in 2017/18 ESBT came up with a transitional governance model within the current UK legislative context, in order to enable the partners work differently together as a whole health and care system to achieve their ESBT objectives. The integration transformation programme of work started in 2013 and the new governing arrangements have been in place since April 2017. Highlights innovation, Impact and outcomes: Tangible outputs of this work to date include for example: A single integrated point of contact hub for all health and care services; A Crisis Response service supporting older people at risk of emergency admission to hospital; Fully staffed and operational integrated locality teams in 6 localities; A welfare benefits Project that has supported over 7,000 people; 183schools with developed whole school health improvement plans; 136 nurseries – 82% total / rising to 93% in areas with highest inequalities have signed up to the nursery transformation programme Healthy Active Little Ones HALO; rocess and outcome measures that indicate the impact that the programme has had to date include: Activity change between 2013/14 and 2016/17 is lower for ESBT and the acute provider, than in STP CCGs and nationally in all points of delivery bar AE Comparators showing CCG activity rates per 100,000 weighted population against the average for England are lower across almost all points of delivery other than bed days; 72% of people seen by the Crisis Response have not been re-admitted to hospital within a month; Improved access to psychological therapies– target 75% actual; Eastbourne Hailsham and Seaford 85.5% / Hastings and Rother 89% Healthy Living PharmacistHLP - 53 pharmacists and 10 pharmacy staff in wider roles attended leadership training in preparation for new ways of working. Conclusions: In order to develop and shape proposals for further strengthening the ESBT Alliance in 2018/19 we have mapped and reviewed the existing governance arrangements of our sovereign commissioning member organisations, as well as the key elements of our new ESBT Alliance governance structure, to further develop our understanding of the following: what is currently delegable to our Alliance and what isn’t; where lay, clinical and elected members’ roles could be used to best effect in assuring plans as we move forward on a system-wide basis in 2018/19; an initial screening exercise of potential equalities and health inequalities impacts, and; the transitional timetable that will be necessary to test system-wide governance and leadership arrangements over the year. The process of developing the new governance model should be transferable to any context.

The Effect of Surgical Site Infection on Cost and Utilization Following Primary Knee Replacement in Nova Scotia 2005-2014

IntroductionSurgical site infection (SSI) following joint replacement results in considerable disease burden. Costs include longer wait times for initial joint replacements which, in Nova Scotia (NS), are the longest in the country. Despite the widespread consequences, costs and utilization following knee replacement have not been comprehensively measured in Canada previously.
 Objectives and ApproachThe objective was to measure costs and health care utilization of SSI following knee replacement through linked administrative data sources. The study cohort was constructed using procedure codes from hospital discharge data. Diagnostic variables were examined to determine the occurrence of infection within one year of discharge. A non-infected control group matched on age, sex and comorbidities was also selected. Costs and utilization from inpatient, day surgery, clinic and physician claims data were totaled over two years following discharge. Resource weights multiplied by standard cost was used to measure hospital costs while outpatient costs were government approved payments to physicians.
 ResultsOver the 2005-2014 period, there were 204 infected cases for an overall 1-year rate of 1.8%. Non-infected controls visited a physician or were admitted to the hospital 21 times in the two year period following surgery compared to infected cases who averaged 40 (p-value
 Conclusion/ImplicationsCosts attributable to infection following primary knee replacement are substantial in NS affecting both inpatient and outpatient services. With an increased focus on program evaluation by policy-makers, infection control administrators should include regular monitoring of the direct and indirect costs of SSI on a system-wide basis using linked administrative data.

Who’ll Stop the Rain – A Utility’s Approach to Minimizing the Impacts of Rain on a System-wide and Proactive Basis

Who’ll Stop the Rain – A Utility’s Approach to Minimizing the Impacts of Rain on a System-wide and Proactive Basis

Putting Person Centred Pathways into Practice

The Advancing Quality Alliance (AQuA) is an NHS membership organisation based in the North West of England. AQuA has extensive experience of supporting and enabling change on a system wide basis over the past six years. In addition, AQuA has supported members to put patients and their families at the heart of the services they commission and provide, by ensuring their views are heard and they are involved in the review, design and improvement of services. In 2016, supported by a grant from the Health Foundation, AQuA undertook a 90-day rapid review into Whole System Flow across care systems. This created a huge amount of energy and interest from our members and so a 12 month discovery programme was developed. As part of this work, we piloted a programme with two localities to test the hypothesis ‘co-designing and commissioning services which are person centred will improve whole system flow, quality and cost’. We developed improvement plan outlines with each locality that were both cognisant of local context and also challenged the teams to consider a strategic ambition for testing coproduction and person centred approaches and improving whole system flow . The presentation will describe the programme of work and the key learning emerging from the pilot sites. We will describe how enabling a person centred approach to service design can deliver improved safety; productivity and experience of care. We will also share the operational, engagement and leadership challenges faced and describe the potential for increased coproduction within health and care services. The presentation will suggest how this approach can be replicated by commissioners, particularly where health and social care systems and their communities are coming together to jointly commission services for a defined population. Targeted population and stakeholders: The presentation will be of interest to NHS and Social Care Leaders and clinicians working in Primary Care, Commissioning, Acute hospitals, Mental Health, Community and Specialist services, patient leaders and involvement groups.

Runtime Optimization of System Utility with Variable Hardware

Increasing hardware variability in newer integrated circuit fabrication technologies has caused corresponding power variations on a large scale. These variations are particularly exaggerated for idle power consumption, motivating the need to mitigate the effects of variability in systems whose operation is dominated by long idle states with periodic active states. In systems where computation is severely limited by anemic energy reserves and where a long overall system lifetime is desired, maximizing the quality of a given application subject to these constraints is both challenging and an important step toward achieving high-quality deployments. This work describes VaRTOS, an architecture and corresponding set of operating system abstractions that provide explicit treatment of both idle and active power variations for tasks running in real-time operating systems. Tasks in VaRTOS express elasticity by exposing individual knobs —shared variables that the operating system can tune to adjust task quality and, correspondingly, task power, maximizing application utility both on a per-task and on a system-wide basis. We provide results regarding online learning of instance-specific sleep power, active power, and task-level power expenditure on simulated hardware with demonstrated effects for several prototypical applications. Our results on networked sensing applications, which are representative of a broader category of applications that VaRTOS targets, show that VaRTOS can reduce variability-induced energy expenditure errors from over 70% in many cases to under 2% in most cases and under 5% in the worst case.

Implementation of Universal Microsatellite Instability and Immunohistochemistry Screening for Diagnosing Lynch Syndrome in a Large Academic Medical Center

In 2009, the Evaluation of Genomic Applications in Practice and Prevention recommended that all colorectal cancers (CRCs) be screened for Lynch syndrome (LS) through microsatellite instability (MSI) or immunohistochemistry (IHC). No studies report how this process is implemented on a health system-wide basis. Since 2004, Cleveland Clinic has screened CRC specimens with MSI/IHC. Between January 2004 and July 2007, MSI/IHC results went only to the colorectal surgeon (approach 1). Between August 2007 and June 2008, colorectal surgeons and a genetic counselor received the MSI/IHC results, and the counselor e-mailed the colorectal surgeon regarding appropriate patients for genetic counseling (GC) referral (approach 2). After July 2008, the colorectal surgeon and counselor received MSI/IHC results, but the counselor contacted the patient to facilitate referral (approach 3). In approaches 2 and 3, patients were presumed to have sporadic CRC if the tumor lacked MLH1 expression and was also BRAF mutated or if the patient was diagnosed at age greater than 72 years and had no cancer family history. Abnormal MSI/IHC results occurred in 178 (16%) of 1,108 patients. In approach 1, 21 (55%) of 38 patients with abnormal MSI/IHC were referred for GC, 12 (32%) of 38 underwent GC, and 10 (26%) of 38 underwent genetic testing (GT). In approach 2, nine (82%) of 11 patients were referred for GC, seven (64%) of 11 underwent GC, and five (45%) of 11 underwent GT. In approach 3, 56 (100%) of 56 patients were referred for GC, 40 (71%) of 56 underwent GC, and 37 (66%) of 56 underwent GT. Time from referral to GC was 10-fold quicker in approach 3 than approach 1. Implementation of universal MSI/IHC with GC/GT, along with effective multidisciplinary communication and plans of responsibility for patient contact, resulted in increased identification of patients with LS.

Accountability by Design: Moving Primary Care Reform Ahead in Alberta

Health-care reform is perennially popular in Alberta, but reality doesn’t match the rhetoric. Government has invested more than $700 million in Primary Care Networks — with little beyond anecdotal evidence of the value achieved with this investment. As the province redirects primary care to Family Care Clinics, the authors assert that simply tinkering with one part of the system is not the answer: health care must change on a system-wide basis. Drawing on the experiences of frontline staff and a rich body of literature, the authors present their vision for integrated team-based primary care, designed to be accountable to meet the needs of populations. This will require governance that makes primary care the hub of the system, and brings together government and health-services leadership to support the integration of primary and specialty care. There are shared accountabilities for achieving primary care that exhibits the attributes of high performing primary care systems, and these exist at multiple levels, from individuals seeking primary care, up to and including government. The authors make these accountabilities explicit, and outline strategies to secure their achievement that include system redesign, service delivery redesign and payment reform. All of this demands whole-system reform focused on primary care, and it won’t be easy. There are plenty of vested interests at stake, and a truly transformative vision requires buy-in at every level. However, Alberta’s rapidly growing and aging population makes it more urgent than ever to realize such a vision. This paper offers guidelines to spark the fresh thinking required.

Methodology to Estimate the Distance Traveled by Trucks on Rural Highway Systems

Truck travel, normally expressed in terms of truck vehicle-distance travel (VDT), is a critical data requirement for the design, construction, operation, and management of rural highway systems. The need to estimate and characterize truck travel on a system-wide basis, yet retain a compatible, site-specific mining capability, challenges the traditional approach of traffic monitoring programs. This paper develops and applies a two-phase methodology to estimate truck VDT on rural highway systems. The first phase, which leverages the approach recommended for developing truck traffic data inputs for mechanistic-empirical pavement design, processes vehicle classification data obtained from continuous, sample, and manual counts into annual average daily truck traffic (AADTT) estimates by vehicle class. The second phase attributes these site-specific AADTT estimates to highway segments comprising a rural highway network. The methodology, which is transferrable across jurisdictions, integrates standard statistical procedures with engineering judgment and trucking industry intelligence by establishing transparent decision algorithms and criteria. Application of the methodology using real data reveals relevant limitations and illustrative results that have application to a wide range of transportation engineering decisions.

PMU-Based Wide-Area Security Assessment: Concept, Method, and Implementation

This paper presents a concept, method, and implementation of utilizing phasor measurement unit (PMU) information to monitor the wide-area security of a power system. The close dependency of major transmission paths requires an approach that takes that interaction into account while establishing operational transfer capability, and evaluates grid reliability and security on a system-wide basis. Thus, the concept of wide-area security region, which considers all essential constraints, including thermal, voltage stability, transient stability, and small signal stability, is proposed. This approach expands the idea of traditional transmission system nomograms to a multidimensional case, involving multiple system limits and parameters such as transmission path constraints, zonal generation or load, etc., considered concurrently. In this paper, the security region boundary is represented using piecewise approximation with the help of linear inequalities (so called hyperplanes) in a multidimensional space, consisting of system parameters that are critical for security analysis. The goal of this approximation is to find a minimum set of hyperplanes that describe the boundary with a given accuracy. Offline computer simulations are conducted to build the security region and the hyperplanes can be applied in real time with phasor information for on-line security assessment. Numerical simulations have been performed for the full size Western Electricity Coordinating Council (WECC) system model, which comprises 15 126 buses and 3034 generators. Simulation results demonstrated the feasibility and effectiveness of this approach, and proved that the proposed approach can significantly enhance the wide-area situation awareness for a bulk power system like WECC.

Metabolic brain networks in translational neurology: Concepts and applications

Over the past 2 decades, functional imaging techniques have become commonplace in the study of brain disease. Nevertheless, very few validated analytical methods have been developed specifically to identify and measure systems-level abnormalities in living patients. Network approaches are particularly relevant for translational research in the neurodegenerative disorders, which often involve stereotyped abnormalities in brain organization. In recent years, spatial covariance mapping, a multivariate analytical tool applied mainly to metabolic images acquired in the resting state, has provided a useful means of objectively assessing brain disorders at the network level. By quantifying network activity in individual subjects on a scan-by-scan basis, this technique makes it possible to objectively assess disease progression and the response to treatment on a system-wide basis. To illustrate the utility of network imaging in neurological research, we review recent applications of this approach in the study of Parkinson disease and related movement disorders. Novel uses of the technique are discussed, including the prediction of cognitive responses to dopaminergic therapy, evaluation of the effects of placebo treatment on network activity, assessment of preclinical disease progression, and the use of automated pattern-based algorithms to enhance diagnostic accuracy.

The impact of non-pharmaceutical interventions for 2009 H1N1 influenza on travel intentions: A model of goal-directed behavior

Theoretically, in the tourism context this study introduced a new concept of non-pharmaceutical intervention (NPI) for influenza, and tested the impact of NPI on the behavioral intention of potential international tourists. This study also extended the model of goal-directed behavior (MGB) by incorporating the new concepts of NPI, and the perception of 2009 H1N1. The model found that desire, perceived behavioral control, frequency of past behavior, and non-pharmaceutical interventions predicted tourists’ intention but perceptions of 2009 H1N1 had nil effect on desire and intention. Personal non-pharmaceutical interventions were theorized as adaptive behavior of tourists intending to travel during a pandemic which should be supported by tourism operators on a system-wide basis. Practically, this study dealt with the issue of influenza 2009 H1N1 with the study findings and implications providing government agencies, tourism marketers, policy-makers, transport systems, and hospitality services with important suggestions for NPI and international tourism during pandemics.

Multi-Island Endemicity: Phylogeography and Conservation of Coelus pacificus (Coleoptera: Tenebrionidae) Darkling Beetles on the California Channel Islands

Abstract The California Channel Islands have been the focus of multiple conservation studies on charismatic vertebrates and plant species, but very few studies have focused on insects. In this study we examined the phylogeography of Coelus pacificus Fall (Coleoptera: Tenebrionidae), a dune-inhabiting darkling beetle, endemic to the islands. Our aim in this study is to decipher the relationships between C. pacificus and the congeneric species Coelus ciliatus Eschscholtz that is distributed on the mainland, to examine the biogeographic relationships of the islands and augment the conservation efforts on the islands with insect data. We sequenced 235 specimens of Coelus for the cytochrome oxidase I mitochondrial gene. We performed phylogenetic analyses to assess the historical relationships of the different species and islands. We also examined the connectedness of the islands by using pairwise φst and hierarchical analysis of molecular variance to test alternate hypotheses of geographical structure, Based on the phylogenetic analyses, C. pacificus is a valid, multi-island endemic species. Haplotypes were grouped into two clades: one clade composed of Santa Cruz, Santa Rosa, San Miguel, and San Nicolas; and the other clade composed of Santa Catalina and San Clemente. The highest haplotypic diversity was observed in San Clemente and San Nicolas islands, but all islands had unique haplotypes. Two haplotypes morphologically indistinguishable from C. pacificus formed a sister clade to C. ciliatus, suggesting either an ancient hybridization event or cryptic speciation. The California Channel Islands should be managed on a system wide basis, at least for some of the organisms or habitats and each island's population requires separate management to protect genetic integrity.

Protocol for a randomised controlled trial of telemonitoring and self-management in the control of hypertension: Telemonitoring and self-management in hypertension. [ISRCTN17585681

BackgroundControlling blood pressure with drugs is a key aspect of cardiovascular disease prevention, but until recently has been the sole preserve of health professionals. Self-management of hypertension is an under researched area in which potential benefits for both patients and professionals are great.Methods and designThe telemonitoring and self-management in hypertension trial (TASMINH2) will be a primary care based randomised controlled trial with embedded economic and qualitative analyses in order to evaluate the costs and effects of increasing patient involvement in blood pressure management, specifically with respect to home monitoring and self titration of antihypertensive medication compared to usual care. Provision of remote monitoring results to participating practices will ensure that practice staff are able to engage with self management and provide assistance where required. 478 patients will be recruited from general practices in the West Midlands, which is sufficient to detect clinically significant differences in systolic blood pressure between self-management and usual care of 5 mmHg with 90% power. Patients will be excluded if they demonstrate an inability to self monitor, their blood pressure is below 140/90 or above 200/100, they are on three or more antihypertensive medications, have a terminal disease or their blood pressure is not managed by their general practitioner.The primary end point is change in mean systolic blood pressure (mmHg) between baseline and each follow up point (6 months and 12 months). Secondary outcomes will include change in mean diastolic blood pressure, costs, adverse events, health behaviours, illness perceptions, beliefs about medication, medication compliance and anxiety. Modelling will evaluate the impact of costs and effects on a system wide basis. The qualitative analysis will draw upon the views of users, informal carers and professionals regarding the acceptability of self-management and prerequisites for future widespread implementation should the trial show this approach to be efficacious.DiscussionThe TASMINH2 trial will provide important new evidence regarding the costs and effects of self monitoring with telemonitoring in a representative primary care hypertensive population.Trial RegistrationISRCTN17585681

Primary producers and nutrient loading in Silver Springs, FL, USA

The characteristics and dynamics of primary producer communities of Silver Springs was examined to compare with that observed by Odum [Odum, H.T., 1957. Trophic structure and productivity of Silver Springs, Florida. Ecol. Monogr. 27, 55–112.] as a means of evaluating the impacts of changes that have occurred over time. The Silver Springs ecosystem is considered an ecosystem at risk, where nitrate levels have more than doubled over the past 50 years. The spatial and temporal abundance and distribution of above-sediment primary producers in Silver Springs, FL, USA, was estimated on a system-wide basis using a GIS platform. The results of study suggest that while the Sagittaria component of Silver Springs has remained relatively stable, epiphyte and benthic algal mat community biomass has expanded, particularly benthic forms, like Lyngbya. However, we argue for caution in weighing the significance of long-term comparisons of system-wide biomass in light of considerable spatial heterogeneity in aquatic primary producer communities.

Requirements for smart materials

Smart materials obtain their unique properties by the deliberate introduction of multi-functionality. This can enable the material, or the structure fromwhich it is made, to diagnose its condition or environment, change shape, self-repair, or other functions as developing technology allows. It is argued that any of these functions are only viable if both the costs and benefits are considered on a system-wide basis. Some of the particular requirements and challenges for a number of example applications are considered and some general requirements suggested. It is concluded that such system-wide approach to optimization is a challenge for both designers and for those developing smart materials but it is necessary if the full advantages of smart materials are to be realized.

Reducing alcohol-related violence and improving community safety: the Alcohol Linking Program

Harm associated with the consumption of alcohol on licensed premises is an issue of increasing community concern. This paper reports on a decade-long research initiative that involved the development and implementation of police systems designed to enhance identification of, and police capacity to respond to, premises suggested to be associated with such harms. The outcomes of the Alcohol Linking Program demonstrate enhanced information regarding the occurrence and characteristics of alcohol-related incidents; there are more than 34,000 such incidents each year in rural and regional NSW. Evaluation of the impact of an educational intervention demonstrated reductions of about 15% in the number of alcohol-related incidents linked with such premises. The Program has subsequently been adopted into routine practice on a system-wide basis by the NSW Police and New Zealand Police. Opportunities exist for public health practitioners to contribute to reducing alcohol-related harm in the community through the development of equivalent surveillance systems in emergency departments, monitoring licencee compliance with the Liquor Act, and through injury prevention, health promotion and drug and alcohol practitioners enhancing the capacity of licencees to serve alcohol responsibly.

Degradomics: Systems biology of the protease web. Pleiotropic roles of MMPs in cancer

The major role of matrix metalloproteinases (MMPs) is for homeostatic regulation of the extracellular environment, not simply to degrade matrix as their name suggests. We designed and printed a dedicated, focused DNA microarray, the CLIP-CHIP, that enables the analysis of every human and murine protease, protease homologue and inhibitor on a system-wide basis in cancer. We have also developed novel proteomic approaches to identify cleaved substrates of proteases in complex milieu. Isotope coded affinity tag (ICAT) and iTRAQ labeling of conditioned medium proteins secreted by MDA-MB-231 breast carcinoma cells and Mmp2 -/- murine fibroblasts transfected with protease (MT1-MMP or active MMP-2) or their inactive mutant forms enabled quantitative proteomics to be performed. Comparison of the relative abundance ratios of identical peptides from the two samples identified proteins in the conditioned medium that may have been degraded (low ratios) and those that were shed from the cell membrane (high ratios). MS/MS was used to sequence and identify the potential substrates. These analyses have revealed a plethora of new bioactive substrates and biological roles for MMPs. Biochemical confirmation of cleavage of the potential substrates was performed and the cleavage sites identified by MALDI-TOF. In these studies we discovered and confirmed that CTGF, galectin-1, death receptor-6, HSP90alpha, procollagen C-proteinase enhancer protein, the chemokine fractalkine, and cystatin C were novel MT1-MMP or MMP-2 substrates. These sophisticated cellular control functions highlight new intervention points in multiple pathways to treat early stage cancer.

Packet sequencing: a deterministic protocol for qos in ip networks

We describe a deterministic protocol for routing delay and loss-sensitive traffic through an IP network. Unlike traditional approaches, the method described here - packet sequencing - does not rely on queue management. Instead, it uses a temporally-based deterministic protocol to coordinate and switch IP packets on a systemwide basis. As a result, end-to-end throughput is guaranteed, without packet loss, loss variance, or accumulated performance impairment; additionally, end-to-end delay is minimized, and jitter is essentially eliminated. We also show that packet sequencing can complement conventional IP networks: sequencing does not negate the use of queue management QoS methods that are the subject of considerable ongoing study. This article describes the fundamental approach, issues associated with scalability, illustrative performance in the context of storage networking, and attributes related to the security and reliability of IP networks.