Vanguard Project Research Articles

Implementation of Physical Activity in the Curricula of Medical Schools and Healthcare Professions Across Europe: The VANGUARD Project Study Protocol.

The 2018 published World Health Organisation (WHO) Europe physical activity factsheet reports, specify agreed targets for physical activity and articulate the need to improve the education of medical doctors and healthcare practitioners in order to increase physical activity and reduce sedentary time in people at risk and/or living with Noncommunicable Diseases (NCDs). Given the dearth of relevant initiatives and the continuous need to increase physical activity participation towards better health management of NCDs, the aim of this study is to embed physical activity in the undergraduate curricula of future frontline healthcare professionals (medical doctors and allied health professions) in European countries. The Virtual Advice, Nurturing, Guidance on Universal Action, Research and Development for physical activity and sport engagement (VANGUARD) project consists of a collaborative partnership Consortium between six European Universities, WHO Europe and Ministry representatives that has been developed to implement physical activity in the curricula of medical schools and healthcare professions. The methodology of the VANGUARD project is informed by the WHO implementation guidance and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework. Through a carefully planned implementation process and via using established appropriate implementation evaluation tools, the end result of the VANGUARD project will be the a) implementation of a physical activity module in six different European Universities (five medical schools and one physiotherapy department) and b) development of a toolkit/guide, in order to assist other healthcare systems and European Universities to develop relevant grass-root innovations for addressing the decline in physical activity levels.

NIHR Global Health Research Group on Vaccines for vulnerable people in Africa (VAnguard): Concept and Launch event report

Background Vaccination is an important public health intervention, but not everyone benefits equally. Biological, social and structural factors render some communities vulnerable and unable to secure optimal health benefits from vaccination programmes. This drives health inequity and undermines wider vaccine impact by allowing the persistence of non-immune communities as foci for recurrent disease outbreaks. The NIHR Global Health Research Group on Vaccines for vulnerable people in Africa (VAnguard) aims to understand how biological, social, and structural factors interact to impair vaccine impact in vulnerable African communities. Methods The VAnguard project will be implemented through three thematic work packages (1-3) and four cross-cutting work packages (4-7). Work package 1 will investigate the biological drivers and mechanisms of population differences in vaccine responses. Work package 2 will support the understanding of how structural, social and biological determinants of vaccine response interrelate to determine vaccine impact. Work package 3 will synthesise data and lead analyses to develop, model and test community-based integrated strategies to optimise vaccine access, uptake and effectiveness. Work package 4 will plan and implement field investigations (community survey and qualitative studies (with support of work package 2) to explore structural, social & biological determinants impairing vaccine impact. Work package 5 will collaborate with work packages 1-4, to engage communities in designing interventions that aim to directly optimise vaccine impact through a process of co-learning and co-creation between them and the researchers. Work package 6 will build capacity for, and a culture of, consultative, collaborative multidisciplinary vaccine research in East Africa. Work package 7 will support the overall project management and governance. Following the project inception on the 1st of September 2022, project launch was held in November 2022. Conclusion Results from this project will contribute to the development of integrated strategies that will optimise vaccine benefits and drive health equity.

Embedding physical activity into the undergraduate curricula of a Portuguese medical school

Abstract Background One of the strategies endorsed by the World Health Organization and the European Commission to promote physical activity (PA) is to incorporate PA content into the curricula of healthcare professionals. Objectives As part of the VANGUARD project (supported by the European Union Erasmus+ Programme), we aimed to analyse the acceptability of a course on PA and health among undergraduate medical students. The School of Medicine and Biomedical Sciences of the University of Porto (ICBAS) was invited to participate. An online survey was administered in June-July 2022 to solicit the input of the students regarding the importance and the operational procedures of implementing a PA and health course into their curricula. Results A total of 77 students answered the survey (median age of 21.0 years [interquartile range, P25-P75, 20-24], 75.3% female). Students rated the importance of incorporating PA content in their medical degree program with a median (P25-P75) of 5 (4-5) on a scale of 1 to 5. Most students expressed an interest in PA and mental health (88.3%), cancer (75.3%), cardiovascular disease (75.3%), diabetes (68.8%), and pregnancy (68.8%). In terms of the operational aspects, students expressed their preference for a course offered in the second year (33.8%); as part of the epidemiology and public health discipline (27.3%); optional (58.4%); through a hybrid learning system (49.4% [face-to-face activities + online live sessions + online self-paced learning]); taught in Portuguese (66.2%); with face-to-face assessments (55.8%); with continuous evaluation (77.9%); and using quantitative grading (62.3%). Conclusions Medical students showed considerable acknowledgement regarding the importance of incorporating PA and health into their curricula. Additionally, they provided guidance on developing and implementing a course on this topic. A course is going to be offered to the students and proposed to the Council of Portuguese Medical Schools to be scaled up nationally. Key messages • Medical students considered PA and health as a very important topic for curricula. • Medical students have specific preferences for embedding new courses in their curricula.

O.4.4-3 Developing a bespoke undergraduate physical activity course for a Portuguese Medical School - the VANGUARD European Union Erasmus+ project

Abstract Purpose Embedding physical activity in the undergraduate curricula of frontline health professionals is one of the policies recommended by the World Health Organization and the European Commission to promote health-enhancing physical activity (HEPA). The VANGUARD project is supported by the European Union Erasmus+ Programme, and aims to embed physical activity in the undergraduate curricula of healthcare professionals in European countries. Within this project, this work aimed to describe the bespoke development of a physical activity and health course integrated into the undergraduate medical curriculum of a Portuguese Medical School. Project or policy description The School of Medicine and Biomedical Sciences of the University of Porto (ICBAS) was the invited Medical School to implement the VANGUARD project in Portugal - led by the Institute of Public Health of the University of Porto (ISPUP). An auscultation process with the undergraduate medical students was held to evaluate the importance of HEPA in their curriculum and assess the preferred operational characteristics of including a physical activity and health course in the Integrated Master’s degree in Medicine. A course proposal structure was then developed by the VANGUARD project Portuguese team from ISPUP, the Director of the Integrated Master’s degree in Medicine, and the Coordinator of the Medical Education Office of ICBAS, based on the students’ acceptability, the Medical School constraints, and VANGUARD project goals and resources. The course integrates 26 lessons, from physical activity technical terminology, epidemiology and guidelines, going through its relation with noncommunicable diseases (using #MovementForMovement resources), to Portuguese National Health Service brief intervention tools and community-based exercise programs - in a total of 20 hours of contact, including continuous evaluation and final case studies analysis. The course will be offered on an optional basis to 2nd-year medical students, on an online training platform, using a self-paced learning method. After embedding this course in ICBAS, it will be presented to the Council of Portuguese Medical Schools to be scaled up nationally. Conclusions Medical doctors and Medical Schools are key stakeholders in HEPA promotion, especially in the health sector. Successful implementation of HEPA policies requires tailored solutions to organizations and direct involvement of target groups in policy development.

NIHR Global Health Research Group on Vaccines for vulnerable people in Africa (VAnguard): Concept and Launch event report.

Vaccination is an important public health intervention, but not everyone benefits equally. Biological, social and structural factors render some communities vulnerable and unable to secure optimal health benefits from vaccination programmes. This drives health inequity and undermines wider vaccine impact by allowing the persistence of non-immune communities as foci for recurrent disease outbreaks. The NIHR Global Health Research Group on Vaccines for vulnerable people in Africa (VAnguard) aims to understand how biological, social, and structural factors interact to impair vaccine impact in vulnerable African communities. The VAnguard project will be implemented through three thematic work packages (1-3) and four cross-cutting work packages (4-7). Work package 1 will investigate the biological drivers and mechanisms of population differences in vaccine responses. Work package 2 will support the understanding of how structural, social and biological determinants of vaccine response interrelate to determine vaccine impact. Work package 3 will synthesise data and lead analyses to develop, model and test community-based integrated strategies to optimise vaccine access, uptake and effectiveness. Work package 4 will plan and implement field investigations (community survey and qualitative studies (with support of work package 2) to explore structural, social & biological determinants impairing vaccine impact. Work package 5 will collaborate with work packages 1-4, to engage communities in designing interventions that aim to directly optimise vaccine impact through a process of co-learning and co-creation between them and the researchers. Work package 6 will build capacity for, and a culture of, consultative, collaborative multidisciplinary vaccine research in East Africa. Work package 7 will support the overall project management and governance. Following the project inception on the 1 st of September 2022, project launch was held in November 2022. Results from this project will contribute to the development of integrated strategies that will optimise vaccine benefits and drive health equity.

Understanding the Phoenix Phenomenon: Can a Project Be Both a Failure and a Success?

While the concept of project success remains largely open nowadays, we introduce here the Phoenix phenomenon, namely a project being both a success and a failure. Our analysis of an automotive vanguard project exhibits key characteristics of a Phoenix phenomenon: the very innovative and ambitious nature of the project; a project management approach that hybridizes causal innovative project development and effectual approaches; the strategic and operational capacity of the company to recover and valorize after the initial failure; and the learnings from and the achievements of the project in renewed scenarios. We conclude that project evaluation must now combine retrospective and prospective assessments methods to evaluate both achieved outcomes and potentialities of a project.

Ethics of Early Clinical Trials of Bio-Artificial Organs

Regenerative medicine is the new frontier in the field of organ transplantation. Research groups around the world are using regenerative medicine technologies to develop bio-artificial organs for transplantation into human patients. While most of this research is still at the preclinical stage, bio-artificial organ technologies are gearing up for first-in-human clinical trials in the not-too-distant future. What are the ethical conditions under which early-phase clinical research of bio-artificial organs can be conducted safely and responsibly? What lessons can be learned from prior experiences with early-phase clinical trials in adjacent fields of research? This is a Meeting Report of an online international workshop organised in the context of the Horizon 2020-funded VANGUARD project, which is developing a bio-artificial pancreas for the treatment of patients with type 1 diabetes.

Editorial introductions.

Current Opinion in Supportive and Palliative Care was launched in 2007. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The fields of supportive and palliative care are divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Journal's Section Editors for this issue. SECTION EDITORS Anthony H. DickensonAnthony H. DickensonAnthony H. Dickenson, BSc, PhD, FmedSci, FBPharmcolS is Professor of Neuropharmacology in the Department of Neuroscience, Physiology and Pharmacology at University College, London, UK. He gained his PhD at the National Institute for Medical Research, London, UK, and has held posts in Paris, California and Sweden. His research interests are pharmacology of the brain, including the mechanisms of pain and how pain can be controlled in both normal and pathophysiological conditions, and how to translate basic science to the patient. Prof. Dickenson is an Honorary Member of the British Pain Society, was a Member of the Council of the International Association for the Study of Pain for six years and is Section Editor for the journal Pain. He has authored more than 340 refereed publications and has an h index of 90, all due to his motivated and brilliant research team. He is a founding and continuing Member of the Wellcome Trust funded London Pain Consortium. Prof. Dickenson has given plenary lectures at the World Congress on Pain, the American Pain Society, the European Pain Congress, the Canadian Pain Society, the Belgium Pain Society, ASEAPs, the Scandinavian Pain Society, the British Pain Society, the Thailand Pain Society, the Irish Pain Society, the Singapore Pain Society, the Australian Pain Society, the New Zealand Pain Society and many other international and national meetings. He has also spoken at the Royal Institution, to GPs, and to schools on pain. Paul Farquhar-SmithPaul Farquhar-SmithPaul Farquhar-Smith has been a Consultant in pain and anaesthetics for 14 years and is a Fellow of the Faculty of Pain of the Royal College of Anaesthetists. He has a PhD in visceral pain and cannabinoids. He works in chronic cancer pain in close collaboration with supportive and palliative care services. A major interest of his is neuropathic pain in cancer survivors, such as chronic pain after surgery and chemotherapy-induced neuropathic pain (CIPN). He is involved in the London Cancer Vanguard project developing pathways and recommendations for CIPN. He has written in reference textbooks and in the British Pain Society guidelines for cancer pain and has lectured nationally and internationally on these subjects. He is currently co-Chair of the British Pain Society / Association for Palliative Medicine Joint Working Group on Pain in Cancer Patients. Kirsty BannisterKirsty BannisterAssociate Professor Dr Kirsty Bannister leads the Central Modulation of Pain laboratory at King's College London, UK. Her research team bridges the gap between bench and bedside pain research as they conduct exploratory experiments that seek to molecularly, anatomically and/or functionally define descending control pathways in animals and humans. Notably, Kirsty was recently awarded the 2022 Patrick D Wall prize for basic pain research from the International Association for the Study of Pain, and she performs section editor duties for Pain, Pain Reports and British Journal of Pharmacology. Kirsty has led multiple symposia at international meetings including the World Congress on Pain (IASP) and the European Pain Federation (EFIC). She is also part of the Scientific Programme Committee for IASP 2022.

IT Evaluation of Foundation Healthcare Group NHS Vanguard programme: IT simultaneously an enabler and a rate limiting factor

ABSTRACT The goal of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use, and implementation of the IT infrastructure based on qualitative interviews focused mainly on the perspectives of the IT staff and the clinicians’ perspectives. Methods: In total, 24 interview transcripts, along with ‘Acute Care Collaboration’ questionnaire responses, were analyzed using a thematic framework for IT infrastructure, sharing themes across the vascular, pediatric, and cardiovascular strands of the FHG programme. Results: Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project but later appreciated that remote access to most clinical applications including scans between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient traveling time by providing locally based shared care. Conclusion: Lesson learnt is that ensuring patient benefit and priorities is a strong driver to implementation and one needs to identify IT rate-limiting steps at an early stage and on a regular basis and then focus on rapid implementation of solutions. In fact, future work may also assess how the IT infrastructure developed by FHG vanguard project might have helped/boosted the ‘digital health’ practice during the COVID-19 times. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders. After COVID-19, the use of IT is scaled up and now, the challenges in the use of IT are much less compared to the pre-COVID-19 time when this project was evaluated.

Ethics of First-in-Human Transplantation Trials of Bioartificial Organs

"The most effective treatment for type 1 diabetes is transplantation of either a whole pancreas from a deceased donor or islet cells derived from multiple deceased donors. However, transplantation has several limitations, including shortage of post-mortem donors and the need for post-transplant patients to use life-long immunosuppressive medication. In the last decade, the field of regenerative medicine has combined engineering and biological technologies in the attempt to regenerate organs. The European VANGUARD project aims to develop immune-protected bioartificial pancreases for transplantation into non-immunosuppressed type 1 diabetic patients. This project is creating a ‘combination product’ using cells and tissue from a variety of sources, including placentas and deceased donors. The clinical development of this complex product raises ethical questions for first-in-human (FIH) clinical trials. Under what conditions can bio-artificial organs safely are transplanted in humans for the first time? How can patients be selected, recruited and informed responsibly? In this presentation, we investigate the ethical conditions for clinical trials of bio-engineered organs, focusing inter alia on study design, subject selection, risk-benefit assessment, and informed consent. We present the results of a review of the literature on the ethics of clinical trials in regenerative medicine, cell and gene therapy and transplantation, and specify existing ethical guidance in the context of FIH transplantation trials of bioartificial organs. We conclude that this new and innovative area at the intersection of regenerative medicine, cell and gene therapy and transplantation requires adequate consideration of the ethical issues in order to guide responsible research and clinical implementation. "

IT Evaluation of Foundation Healthcare Group Vanguard Project.

The aim of the Foundation Healthcare Group (FHG) Vanguard model was to develop a sustainable local hospital model between two National Health Service (NHS) Trusts (a London Teaching Hospital Trust and a District General Hospital Trust) that makes best use of scarce resources and can be replicated across the NHS, UK. The aim of this study was to evaluate the provision, use and implementation of the IT infrastructure; based on qualitative interviews and focused mainly on the perspectives of the IT staff and the clinicians' perspectives. In total 24 interview transcripts, along with 'Acute Care Collaboration' questionnaire responses, were analysed using a thematic framework for IT infrastructure, sharing themes across the vascular, paediatric and cardiovascular strands of the FHG programme. Findings indicated that Skype for Business had been an innovative and helpful development widely available to be used between the two Trusts. Clinicians initially reported lack of IT support and infrastructure expected at the outset for a national Vanguard project, but later appreciated that remote access to most clinical applications between the two Trusts became operational. The Local Care Record (LCR), an IT project was perceived to have been delivered successfully in South London. Shared technology reduced patient travelling time by providing locally based shared care. Spreading and scaling-up innovations from the Vanguard sites was the aspiration and challenge for system leaders.

Vanguard projects as relay races: A historical case study on the building of Eurocan pulp and paper mill, 1965–1970

Previous research recognises the strategic role of vanguard projects in providing their initiators with avenues for entering new markets or gaining mastery over innovative technologies. This study makes a contribution to this research by focusing on the extent to which vanguard projects are under control and serve the interests of their principal initiators and the other actors involved. Simultaneously, the present study contributes to project management research by applying historical case study methodology on Eurocan, a vanguard project that a major Finnish forest industry firm Enso established in the mid-1960s to the wilderness of British Columbia, Canada. Our historical analysis encourages regarding vanguard projects as relay races in which several actors participate, largely in unanticipated ways. This is especially because the initiation of vanguard projects appears to be characterised by both the heterogeneity of the actors involved, a wide variety of actions taken by these actors to increase their centrality in the project organisation as well as abrupt changes among them and their relative importance over the project lifecycle. Together these characteristics make vanguard projects particularly prone to influence from external actors and events.

Reprint of: From open innovation projects to open innovation project management capabilities: A process-based approach

How do organizations use the experience from projects to build a systematic capability to manage open innovation projects? Drawing upon Project Management and Open Innovation capability-building frameworks, we studied the crusade of an industrial company to create an open innovation capability. In that sense, we applied an Event Structure Analysis (ESA) to evaluate the event network, which evidenced a four-stage process: closed mode, open driver, vanguard project, project-to-organization. Results demonstrate, from causal connections, that the referred capability can be leveraged from the execution of key projects, especially from a vanguard project. Our study contributes to Project Management theory by reveling that previous experiences in both project and organizational levels offer a fertile ground for the emergence of a vanguard project. For the open innovation field, this paper provides a project-oriented approach to the discussion of open innovation's adoption in mature firms.

From open innovation projects to open innovation project management capabilities: A process-based approach

How do organizations use the experience from projects to build a systematic capability to manage open innovation projects? Drawing upon Project Management and Open Innovation capability-building frameworks, we studied the crusade of an industrial company to create an open innovation capability. In that sense, we applied an Event Structure Analysis (ESA) to evaluate the event network, which evidenced a four-stage process: closed mode, open driver, vanguard project, project-to-organization. Results demonstrate, from causal connections, that the referred capability can be leveraged from the execution of key projects, especially from a vanguard project. Our study contributes to Project Management theory by reveling that previous experiences in both project and organizational levels offer a fertile ground for the emergence of a vanguard project. For the open innovation field, this paper provides a project-oriented approach to the discussion of open innovation's adoption in mature firms.

Editorial introductions

Editorial introductions

Editorial introductions

Editorial introductions

NASA in Chile: Technology and Branding of a Satellite-Tracking Station

In 1957 as part of the Minitrack Network, the U.S. Army installed a satellite-tracking station in Peldehue, Chile, intended to track radio signals from what was then the United States’ Vanguard project. With the creation of the National Aeronautics and Space Administration (NASA) in 1958, the station came under its new administration, becoming the subject of a process of rebranding that included the monumental installation of the agency insignia, a rounded slab made in concrete and tiles. By examining this object from a design and archaeological perspective - as it nowadays lays abandoned nearby its original location - this paper attempts to advance our understanding of the Chilean station in terms of its place within a much larger global network by analyzing it within the intersection of design, military economies, technologies, ideologies, and cultural and geospatial considerations.

A4-2: ICD-10 CM Transition across Three Research Centers

Background/AimsThe United State currently uses version nine (ICD-9) for diagnosis and procedure coding. Federal regulations require that the US adopt the next version (ICD-10) by 10/1/2014. The new version expands the number of diagnosis codes from about 13,000 to 68,000, providing more granularity to classify diseases. Challenges in moving to ICD-10 include: (a) the crosswalk between versions is a many-to-many match; (b) the relationship between the old and the new codes will sometimes be complex; and (c) it will encompass system-level changes such as expanded field sizes and support for alphanumeric characters. Our challenge is to implement the transition across three research centers at Kaiser Permanente Northwest, Southeast and Hawaii.MethodsThe three research centers need to account for the new ICD-10 code set and any new data structures introduced by either the EMR or Research Data Warehouse. A smooth transition between coding systems requires working with researchers across the three regions. This includes identifying corresponding ICD-10 codes that correctly identify the research cohort members and remediating the existing programing logic. Kaiser Permanente’s Center for Health Research (CHR) has developed a detailed plan to accomplish these two goals. CHR staff are partnering with the Kaiser Health Plan ICD-10 implementation team in the development of our project plans. The standard source to be used for mapping at the three Kaiser Research centers is the General Equivalence Mappings based Crosswalk Query Tool, which Kaiser is implementing to support transition mapping needs.ResultsThe CHR ICD-10 remediation team has completed the Framing and Planning phases including identifying programs/tables affected, sharing remediation solutions across the Kaiser regional research teams, and meeting with the Health Plan to coordinate efforts. We have developed a project remediation checklist and will report on the development of validation testing plans and the refinement of vanguard project code mappings.ConclusionsIn the transition to ICD-10, it is essential to have a well-formed plan and to identify and include all stakeholders in the process. It is also beneficial to share tools and ideas between research centers to improve the overall methods.

‘Meticulously Crafted Ambiguities’: The Confused Political Vision of Ulster Vanguard

In his insightful ‘intellectual history’ of the modern Irish troubles, Richard Bourke, reflecting upon the fated implosion of William Craig's Vanguard Unionist Party, identified a set of ‘meticulously crafted ambiguities’ (Bourke (2003) Peace in Ireland: The War of Ideas, p. 227 (London: Random House)) as crucial factors in that movement's abortive attempt to capture the political soul of Protestant Ulster. Through a close reading of Vanguard's ideological development, from its origins as a Unionist ‘ginger group’ through to its marginalisation from the authoritative centre of Unionist politics in September 1975, this essay sets out to recover a sense of that internal dissonance which, from the movement's inception in February 1972, threatened to undermine the cohesion of the Vanguard project. Though it was to be Craig's inability to reconcile a majority of his party's elite to the idea of Nationalist participation in government that would prove decisive in precipitating his political downfall, as this article will attempt to demonstrate, a conspicuous failure to address these so-called ‘meticulously crafted ambiguities’ and resolve the numerous internal contradictions of Vanguard's ‘post-Unionist’ ideology tended to underscore the improbability of its acting as a unifying locus for the realignment of populist forces within contemporary Unionism.

Hydropower Project Ventures: Testing International Waters

A vanguard project is an effective mechanism for testing new opportunities to deploy existing technologies into new markets in an effort to realize growth. Typically such endeavors are motivated by organizational needs to generate new knowledge and learning to develop or renew existing capabilities of the firm. In the case of Norwegian independent power producers (IPP), a recent trend to achieve company level growth is by expanding hydropower operations into international markets thus testing theoretical foundations of vanguard projects. Whilst many other European IPPs have internationalized stepwise in a pan-European context, Norwegian IPPs have chosen to pursue non-core European markets for international expansion. This paper serves to underscore the innovative globalization strategy shifts amongst Norwegian IPP by underpinning the challenges and opportunities of these activities in developing and emerging countries. To achieve this research objective triangulation of quantitative and qualitative data is utilized. Primary qualitative data includes exploratory case studies at the firm level, whereas quantitative data includes a national survey amongst Norwegian IPPs. Theoretical considerations lie within how such vanguard projects allow for core business activities to persist by diversifying geographically into dissimilar markets. The result of this research stream identifies the degree to which Norwegian IPP actors are actively developing such vanguard projects in which geographic locales of emerging markets. The mixed method approach results delineate how Norwegian IPPs are internationalizing and what the managerial implications are for entrepreneurs and IPPs alike.