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Introduction: Increased interest in collaborative and inclusive approaches to healthcare improvement makes revisiting Elinor Ostrom’s ‘design principles’ for enabling collective management of common pool resources (CPR) in polycentric systems a timely endeavour. Theory and method: Ostrom proposed a generalisable set of eight core design principles for the efficacy of groups. To consider the utility of Ostrom’s principles for the planning, delivery, and evaluation of future health(care) improvement we retrospectively apply them to a recent co-design project. Results: Three distinct aspects of co-design were identified through consideration of the principles. These related to: (1) understanding and mapping the system (2) upholding democratic values and (3) regulating participation. Within these aspects four of Ostrom’s eight principles were inherently observed. Consideration of the remaining four principles could have enhanced the systemic impact of the co-design process. Discussion: Reconceptualising co-design through the lens of CPR offers new insights into the successful system-wide application of such approaches for the purpose of health(care) improvement. Conclusion: The eight design principles – and the relationships between them – form a heuristic that can support the planning, delivery, and evaluation of future healthcare improvement projects adopting co-design. They may help to address questions of how to scale up and embed such approaches as self-sustaining in wider systems.

Over the past three years, the U.S. Department of Health and Human Services (HHS) has made significant investments in state and local public health in an effort to enhance public health emergency preparedness. The RAND Corporation was contracted to work with the HHS Office of the Assistant Secretary for Public Health Emergency Preparedness (OASPHEP) to develop resources and to prepare analyses to help describe and enhance key aspects of state and local public health emergency preparedness. As part of this contract, RAND was asked to study the response of state and local health departments to recent disease outbreaks -- specifically, Severe Acute Respiratory Syndrome (SARS), monkeypox, West Nile virus, and Hepatitis A -- to address the following questions: (1) How did the public health system in the United States respond to each of these disease outbreaks? What were the roles of federal, state, and local health departments, health care providers, community organizations, and other groups, and how did they interact? (2) In what ways did recent federal investment contribute to public health preparedness? (3) What lessons does the public health response to these outbreaks have for future preparedness, particularly to address the threat of bioterrorism? What improvements are needed to public health infrastructure in the United States and in functional capabilities to address a public health emergency? (4) Was the Centers for Disease Control (CDC) guidance helpful in building capacity for health departments to respond to the outbreaks studied? Are there areas in which guidance is still needed?

There is much the nation must do-and is doing-to guard against and prepare for terrorist attacks. In some possible situations, individuals may have to rely on themselves to protect their own health and safety-perhaps even their own lives. Thus, individual preparedness is an important element of our nation's strategy for homeland security. Many people know how to respond in such disasters as fires and earthquakes, but few would know what to do if someone were to use a chemical, radiological, nuclear, or biological weapon in their vicinity. Although the characteristics of such attacks may vary widely and their likelihood is highly uncertain, they can all create unfamiliar and very dangerous circumstances. Consequently, individuals need an overall strategy they can use to prepare for and respond to such attacks. This guide emerged from a detailed what-if, scenario-driven analysis we conducted to examine four types of terrorist attacks: chemical, radiological, nuclear, and biological. In each case, the response strategy is guided by a fundamental objective, which we refer to as an overarching goal, which in turn depends on taking certain actions. We have distilled our findings into this guide to offer individuals a series of actions they can take to save lives, even in catastrophic situations.

The public health and medical communities have long sought to address the threat of biological, chemical, or other weapons of mass destruction (WMD) and their potential effects on the health and safety of U.S. citizens The United States has made some key advances in the past five years or so toward increasing the capacity of the public health system to conduct disease surveillance, establishing pharmaceutical stockpiles, and improving the training of medical and public health personnel to detect and treat exposed victims. However despite these important strides, another key challenge remains: Are local public health agencies and our nation's hospitals (both public and private) prepared to deal with biological or chemical terrorism? These local health responders represent the front line for ensuring the public's health against such emerging threats, especially in the aftermath of the September 11, 2001, attacks on the World Trade Center and the Pentagon and the anthrax attacks that followed in the fall of 2001. Yet these events have called into question how prepared our public health system and hospitals actually are to respond effectively to such incidents.

The Los Angeles County Board of Supervisors (the Board) adopted the Long-Term Family Self-Sufficiency (LTFSS) Plan on November 16,1999. The LTFSS Plan consists of 46 projects whose goal is to promote self-sufficiency among families that are participating in the California Work Opportunity and Responsibility to Kids Act of 1997 (CalWORKS) program, former CalWORKS families, and other low-income families. The Chief Administrative Office (CAO) is the lead agency responsible for implementing the evaluation of the LTFSS Plan. On December 5, 2000, the Board approved the implementation plan for the evaluation of the LTFSS Plan, LTFSS Project #46. Following an open and competitive bidding process, the Board awarded RAND a contract to conduct a Countywide evaluation of the LTFSS Plan. The LTFSS Plan is explicitly guided by Mark Friedman's Results-Based Decision Making (RBDM) Framework (the RBDM Framework). LTFSS Plan experiences with the RBDM Framework can provide early indications of the utility of the RBDM Framework, the challenges that are likely to be encountered as County departments attempt to apply the RBDM Framework in the County, and approaches to addressing those challenges. This document is intended to extract those lessons learned by providing insights into the use and utility of the RBDM Framework as it has been adopted and adapted by the County. Most of the analysis in this report represents work completed as of the end of October 2001.

The California Work Opportunity and Responsibility to Kids Act of 1997 (CalWORKs) provided Los Angeles County (hereafter, the County) with a large stream of funds. The County Board of Supervisors (hereafter, the Board) instructed the County's New Directions Task Force (NDTF) to develop a Long-Term Family Self-Sufficiency (LTFSS) Plan for CalWORKs recipients and the broader low-income population, with the purpose of selecting projects that would improve the capacity of families to become self-sufficient. Each of the projects was to: (1) have an adequate evaluation design to track achievement of measurable outcomes; (2) not duplicate existing services; (3) be culturally and linguistically sensitive; (4) not supplant existing funding; and (5) address a clearly documented need. To identify those projects and more broadly to guide the LTFSS effort, the NDTF adopted Mark Friedman's Results-Based Decision Making (RBDM) Framework (hereafter, the RBDM Framework). The NDTF effort resulted in the 46 projects known collectively as the LTFSS Plan that was approved by the Board on November 16,1999. The Chief Administrative Office (CAO) is the lead agency responsible for implementing the evaluation of the LTFSS Plan. The evaluation is taking place on two levels: the Countywide level and the individual projects level. The contract to evaluate outcomes at the county level was awarded to RAND by the Board after an open and competitive bidding process. In brief, this evaluation is not on the individual progress of 46 projects, but on the progress the County has made in achieving its goal of long-term family self-sufficiency. The contract stipulated that one deliverable would be an annual Countywide Evaluation Report. This document, which is the first of three such reports draws from three previous RAND reports produced under the contract.

People in the United States have been terrorized on U.S. soil with targeted violence, on various scales and with varying success, for decades.1 Yet, the recent September 2001 attacks and the earlier bombing of Oklahoma City's Alfred P. Murrah Federal Building vividly demonstrate something disturbing and new: Some contemporary terrorists, both home-grown and foreign, are not deterred by-indeed may even be attempting to produce-human casualties on a massive scale. These events are part of a pattern of increasing lethality that started in the 1990s.2 Even more troubling is that, while conventional explosives may continue to be the predominant terrorist weapon, the magnitude of the September 11 attacks coupled with the spread of anthrax-laced letters have led some to conclude that chemical or biological weapons are now more likely than ever to be used.3 Although, strictly speaking, terrorism4 has never been absent from the set of threats facing American citizens, the magnitude and character of recent events have called into question the readiness of the nation's state and local emergency response and health and medical personnel to respond effectively to the next incident, to correctly identify hazards as they occur, and to mitigate damage to persons and property. In particular, response to the anthrax incidents subsequent to September 11 was less than reassuring. While the mode of attack made initial identification and response difficult, authorities also had a hard time organizing, coordinating, and communicating an appropriate response even after anthrax was identified.5 This issue paper has two purposes: (1) to suggest some nationally representative measures of local responder preparedness for chemical and biological terrorism as a baseline for the current debate; and (2) to illustrate the limitations of our measures and describe why quantifying preparedness for terrorism, by any measure, is elusive.

The Centers for Medicare and Medicaid Services (CMS, formerly the Health Care Financing Administration) and the Department of Defense (DoD) have been testing the feasibility of making Medicare-covered health care services available to Medicare-eligible DoD beneficiaries through the TRICARE program (the managed care program of the Military Health Service) and military treatment facilities (MTFs). The vehicle used was the Medicare-DoD Subvention Demonstration, which was established by the Balanced Budget Act of 1997 (BBA). The goal of the demonstration was to implement cost-effective alternatives for care for this dually eligible population while ensuring budget neutrality, that is, neither CMS's nor DoD's total costs increase. The Secretaries of the Department of Health and Human Services and of the Department of Defense executed a Memorandum of Agreement that specified how the subvention demonstration was to be designed and operated. The Memorandum provided for an independent evaluation of the demonstration, which RAND conducted. This report describes the final results of the RAND evaluation.

Violence has long been a major issue for citizens of the United States, who experience homicide and robbery rates that are several times higher than those reported in most other industrialized countries. Between the mid-l980s and mid-1990s this problem became particularly acute for persons under 21, whose homicide arrests doubled and whose violent-crime victimization rate went up by more than 50 percent. At the same time, the analogous numbers for older groups were stable or increasing only slightly. Despite the magnitude of the youth violence problem in this country, little is known about the potential success of various strategies for reducing it. All of the recent reviews that have attempted to identify promising intervention strategies have concluded that the knowledge base is still too thin to provide compelling evidence in support of any single approach, particularly those in which the community or neighborhood is the focus of the intervention, as opposed to interventions which target specific youth. It is now often suggested that youth violence will yield only to a multitude of approaches that can work on several aspects of the problem in unison. The California Wellness Foundation's Violence Prevention Initiative (VPI) represents one such effort. With funding in excess of $35 million for its first five years, the VPI represents an ambitious attempt to combine policy and media advocacy, community action, individual leadership, research, and evaluation in one integrated initiative. The evaluation of the first phase of the VPI was carried out by teams of researchers from RAND and from the Center for Research in Disease Prevention at Stanford University. This report presents findings from an evaluation of the VPI's first five years (1993-1998). It begins with the historical context of the Initiative, the goals and intent of the Initiative, its structure, and the design of the evaluation.

This report provides findings of a study of technology in use or needed by law enforcement agencies at the state and local level, for the purpose of informing federal policymakers as they consider technology-related support for these agencies. In addition, it seeks to characterize the obstacles that exist to technology adoption by law enforcement agencies and characterize the perceived impact of federal assistance programs intended to facilitate the process. The study findings are based on a nationwide Law Enforcement Technology Survey (LETS) and a similar Forensics Technology Survey (FTS) conducted in late spring and early summer 2000, interviews conducted throughout the year, focus groups conducted in autumn 2000, and review of an extensive, largely non-academic literature.

On April 13-14, 1999, the RAND Arroyo Center, Marine Corps Warfighting Lab (MCWL), and J8 Urban Working Group (UWG) Co- hosted a conference on military urban operations in the Joint Military Intelligence College auditorium, Boiling Air Force Base, Washington, D.C. The conference sought to provide a forum for information exchange and debate on the complete range of possible operations in urban areas likely to challenge U.S. national interests in the next generation. Such activities could include: * Operations at the strategic, operational, and tactical levels of war * Domestic and international events * Combat, stability, and support missions * Service, joint, multinational, and interagency concerns Homeland defense and WMD issues., Proceedings of the RAND Arroyo MCWL-J8 UWG Urban Operations Conference, 13-14 Apr 1999.

This literature review, one of eight commissioned by the Special Assistant to the Deputy Secretary of Defense for Gulf War Illnesses, summarizes the existing scientific literature on the health effects of stress that may have affected military personnel who served in Operations Desert Shield and Desert Storm. The eight RAND reviews are intended to complement efforts by the Defense Department and other federal agencies in their attempt to understand the full range of health implications of service in that conflict. Many veterans have reported an array of physical and mental health complaints since the war. Whether veterans are experiencing either higher than expected rates of identifiable illnesses with known etiologies or other illnesses from unidentified origins is not yet clear.