Thesis (Ph. D.)--University of Oregon, 2001. / Typescript. Includes vita and abstract. Includes bibliographical references (leaves 114-117). Also available for download via the World Wide Web; free to University of Oregon users.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 89-98).

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Background: Low performance rate of comprehensive diabetic foot examinations (CDFEs) causing health care disparity. Objective: Increasing performance of CDFEs at Phoenix Indian Medical Center, an Indian Health Service (IHS) facility. Design: Before-after design, convenience sample. Setting: An IHS adult ambulatory care clinic in urban Phoenix, Arizona. Target: Four primary care providers (PCPs).Interventions: Utilizing the PDSA framework, a multidisciplinary group of clinical staff developed a process to increase the performance rate of CDFEs. Brainstorming, use of the Ishikawa diagram, and root cause analysis led to identification of factors contributing to low rates of CDFEs in the clinic. The QI intervention addressed multiple aspects of activities related to the CDFE performance, including pre-visit planning, enhanced communication, making equipment for CDFEs accessible to healthcare providers, and requesting patients to remove shoes and socks. Measurement: Weekly performance rate of CDFEs. Results: The results, analyzed with a run chart, showed an upward trend in performance for some providers. The median aggregate performance rates for pre and post intervention were 82.6% and 80.2%, respectively. Limitations: This study should be replicated over a longer time frame with more participants. Two significant weaknesses were identified in this study. The required provider de-identification prevented provider feedback. The data collection method provided CDFE performance data based on provider empanelment. This method of data collection reflects composite team care rather than specific provider behaviors. Conclusions: This multidisciplinary approach to improving the performance rates of CDFEs showed an upward trend for some providers but was not statistically significant. Post intervention CDFE performance rates were not improved. Significance: This study highlights the role of the doctorally prepared advanced practice nurse (DNP) in designing, facilitating and evaluating a practice change project to address the rate of provider performance of CDFE for their AI/NA patients. An exemplar, this QI intervention can be replicated for quality improvement initiatives targeting improved healthcare outcomes, crucial to the national effort of addressing healthcare disparities.

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Differential item functioning (DIF) can occur across age, gender, ethnic, and/or linguistic groups of examinee populations. Therefore, whenever there is more than one group of examinees involved in a test, a possibility of DIF exists. It is important to detect items with DIF with accurate and powerful statistical methods. While finding a proper DIP method is essential, until now most of the available methods have been dominated by applications to large scale testing contexts. Since the early 1990s, Ramsay has developed a nonparametric item response methodology and computer software, TestGraf (Ramsay, 2000). The nonparametric item response theory (IRT) method requires fewer examinees and items than other item response theory methods and was also designed to detect DIF. However, nonparametric IRT's Type I error rate for DIF detection had not been investigated. The present study investigated the Type I error rate of the nonparametric IRT DIF detection method, when applied to moderate-to-small-scale testing context wherein there were 500 or fewer examinees in a group. In addition, the Mantel-Haenszel (MH) DIF detection method was included. A three-parameter logistic item response model was used to generate data for the two population groups. Each population corresponded to a test of 40 items. Item statistics for the first 34 non-DIF items were randomly chosen from the mathematics test of the 1999 TEVISS (Third International Mathematics and Science Study) for grade eight, whereas item statistics for the last six studied items were adopted from the DIF items used in the study of Muniz, Hambleton, and Xing (2001). These six items were the focus of this study.

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To argue that inferences drawn from a test of writing are valid, empirical evidence must demonstrate that the test adequately represents the construct it is designed to measure (Messick, 1998). The writing component of the Canadian Academic English Language (CAEL) Assessment, was developed in the early 1990's to represent the construct of English in use for academic purposes (EAP). Since that time, EAP approaches have been criticised within the fields of both language testing (Alderson, 1993; Clapham, 2001) and genre and composition studies (Freedman, 1999). Writing is currently viewed as a "site of social and ideological action" (Schryer, 1994), embedded within, and interacting with the disciplinary, historical, political and cultural contexts in which it acts (Freedman and Medway, 1994; Norton, 1995). Informed by cultural-historical Activity Theory (Cole and Engestrom, 1994; Vygotsky, 1989), this research examines the "social actions" which characterise performance on the CAEL writing test in relation to two other tests of English as a Second Language (L2) writing, the personal essay and the timed-impromptu essay. In Study 1, the semiotic potential of each test is defined by analysis of the verbal accounts of 4 raters and 20 test takers. In their accounts, what separates the EAP writing test from the other tests of writing is the academic expertise the EAP test elicits. In Study 2, the scores from n = 375 EAP essays and n = 271 cloze tests are compared in order to examine how much of the variance in each test is accounted for by academic expertise. Taken together, Studies 1 and 2 provide empirical evidence of what performance on the EAP writing test means to those engaged in the activity of testing. Evidence that the EAP writing test represents a construct, which has been reconceptualized to reflect current theories of writing, addresses the criticism of EAP-based tests and provides a model of inter-disciplinary test validation in relation to evolving construct