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The widespread availability of high-fidelity topography combined with advances in geospatial analysis offer the opportunity to reimagine approaches to the difficult problem of predicting sediment delivery from watersheds. Here we present a model that uses high-resolution topography to filter sediment sources to quantify sediment delivery to the watershed outlet. It is a reduced-complexity, top-down model that defines transfer functions-topographic filters-between spatially distributed sediment sources and spatially integrated sediment delivery. The goal of the model is to forecast changes in watershed suspended sediment delivery in response to spatially distributed changes in sediment source magnitude or delivery, whether a result of watershed drivers or intentional management actions. Such an application requires the context of a watershed model that accounts for all sediment sources, enforces sediment mass balance throughout the spatial domain, and accommodates sediment storage and delivery over time. The model is developed for a HUC-8 watershed with a flat upland dominated by corn-soybean agriculture and deeply incised valleys near the watershed outlet with large sediment contributions from near-channel sources. Topofilter computes delivery and storage of field-derived sediment according to its spatial and structural connectivity to the stream channel network; subsequently, delivery of both field- and near-channel-derived sediment along with floodplain storage are computed in the stream channel network to the watershed outlet. The model outputs provide a spatially rich representation of sediment delivery and storage on field and along the stream that is consistent with available independent information on sediment accumulations and fluxes. Rather than a single best-calibrated solution, Topofilter uses the Generalized Likelihood Uncertainty Estimate (GLUE) approach to develop many possible solutions with sediment delivery rates expressed as probability distributions across the watershed. The ensemble of simulation outputs provides a useful basis for estimating uncertainty in sediment delivery and the effectiveness of different landscape management allocation across a watershed.

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Despite decades of policy that strives to reduce nutrient and sediment export from agricultural fields, surface water quality in intensively managed agricultural landscapes remains highly degraded. Recent analyses show that current conservation efforts are not sufficient to reverse widespread water degradation in Midwestern agricultural systems. Intensifying row crop agriculture and increasing climate pressure require a more integrated approach to water quality management that addresses diverse sources of nutrients and sediment and off-field mitigation actions. We used multiobjective optimization analysis and integrated three biophysical models to evaluate the cost-effectiveness of alternative portfolios of watershed management practices at achieving nitrate and suspended sediment reduction goals in an agricultural basin of the Upper Midwestern United States. Integrating watershed-scale models enabled the inclusion of near-channel management alongside more typical field management and thus directly the comparison of cost-effectiveness across portfolios. The optimization analysis revealed that fluvial wetlands (i.e., wide, slow-flowing, vegetated water bodies within the riverine corridor) are the single-most cost-effective management action to reduce both nitrate and sediment loads and will be essential for meeting moderate to aggressive water quality targets. Although highly cost-effective, wetland construction was costly compared to other practices, and it was not selected in portfolios at low investment levels. Wetland performance was sensitive to placement, emphasizing the importance of watershed scale planning to realize potential benefits of wetland restorations. We conclude that extensive interagency cooperation and coordination at a watershed scale is required to achieve substantial, economically viable improvements in water quality under intensive row crop agricultural production.

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Near-channel sediment loading (NCSL) is localized and episodic, making it difficult to accurately quantify its cumulative contribution to watershed sediment loading, let alone predict the effects from changes in river discharge due to climate change or land management practices. We developed a methodological framework, using commonly available stream gaging data, for estimating watershed-scale NCSL, a feature generally absent in most watershed models. The method utilizes a network of paired gages that bracket the incised river corridors of 15 tributaries to the Minnesota River, in which near-channel sources are often the dominant contributors of sediment loading. For each set of paired gages, we calculate NCSL as the difference between the upstream and downstream sediment loading minus the field contribution between the gages. NCSL generally increases with river discharge when it exceeds the observed threshold benchmark in the tributaries of Minnesota River Basin; accordingly, we developed a predictive model for quantifying NCSL using river discharge as the independent variable. This approach provides a predictive basis for evaluating the impacts on near-channel sediment supply from increases in runoff and river discharge. Application of this approach includes evaluation of watershed-scale conservation trade-offs, where benefits of landscape management practices, such as wetlands and reservoirs are measured in terms of reduction in downstream near-channel sediment loading in the incised river corridors.

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INTRODUCTION: Studies exploring the role of patients in interprofessional education (IPE) are found primarily in undergraduate programmes with few reporting on the postgraduate (continuing professional development) setting. This paper describes an interprofessional quality improvement project around the management of back pain in a primary care setting where patients were part of the practice team. METHODS: Patients participated in eight half-day IPE workshops delivered to nine general practice teams in the UK. Educational content included knowledge about quality improvement and evidence-based back pain knowledge, with teamwork, experiential and didactic learning approaches. On-site practice support from a quality improvement facilitator occurred between the workshops to strengthen practice-based learning. Forty-four practice staff and 11 patients attended the workshops and the facilitated project meetings. Evaluation occurred through focus groups with practice teams (including patients) both before and after the workshops. These were recorded, transcribed and analysed by coding and the inductive development of themes. RESULTS: The context of managing back pain was particularly challenging. Focus group participants indicated that patient involvement was highly valued as it gave practitioners a greater understanding of the effects of back pain on their lives whilst permitting patients to hear the experiences of others and to understand their own world better. Listening was important to patients' experiences of healthcare and practitioners' experiences of the workshops. Learning together emerged as particularly important and finally the challenge of finding time to learn together infiltrated the entire endeavour and was a prominent concern. DISCUSSION: Patients sharing their experience of back pain appeared to be a particularly pivotal point in the learning for practice teams. Meaningful engagement with users in IPE was highly valued and provided a catalyst for behavioural change, where professionals relinquished an unhelpful medical model in favour of an integrative biopsychosocial one.

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We used pre- and post-restoration channel surveys of the Donner und Blitzen River, Oregon, to evaluate the effects of grade-control structures on channel morphology and baseflow habitat conditions for native redband trout and other aquatic biota. Six years after installation, we found that the channel had a smaller proportion of riffles and pools and less gravel substrate, combined with an increase in the proportion of flat waters and consolidated clay on the bed surface. Both local scour downstream from weirs and backwater effects upstream from weirs appear to have caused the general flattening and fining of the channel. A direct-step backwater calculation indicates that backwaters extended to the upstream weir at both low and high flows, creating long sections of flat water separated by short, steep drops. Despite backwater effects, a comparison of longitudinal profiles before and six years after weir installation showed bed erosion downstream of nearly all weirs, likely a consequence of the cohesive clay material that dominates the channel bed and banks. A deep inner channel reflects the cohesive nature of the clay and the mechanisms of abrasion, and indicates that sediment load is low relative to the transport capacity of the flow. Unfortunately, weirs were problematic in this system because of the cohesive clay substrate, limited sediment supply, and low channel gradient. Although deeper flows due to backwaters might be more favorable for resident trout, less gravel and fewer riffles are likely to negatively impact trout spawning habitat, macroinvertebrate communities, and biofilm productivity. Our results demonstrate the potential limitations of a single-feature approach to restoration that may be ineffective for a given geomorphic context and may overlook other aspects of the ecosystem. We highlight the need to incorporate geomorphic characteristics of a system into project design and predictions of system response.

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Although sediment is a natural constituent of rivers, excess loading to rivers and streams is a leading cause of impairment and biodiversity loss. Remedial actions require identification of the sources and mechanisms of sediment supply. This task is complicated by the scale and complexity of large watersheds as well as changes in climate and land use that alter the drivers of sediment supply. Previous studies in Lake Pepin, a natural lake on the Mississippi River, indicate that sediment supply to the lake has increased 10-fold over the past 150 years. Herein we combine geochemical fingerprinting and a suite of geomorphic change detection techniques with a sediment mass balance for a tributary watershed to demonstrate that, although the sediment loading remains very large, the dominant source of sediment has shifted from agricultural soil erosion to accelerated erosion of stream banks and bluffs, driven by increased river discharge. Such hydrologic amplification of natural erosion processes calls for a new approach to watershed sediment modeling that explicitly accounts for channel and floodplain dynamics that amplify or dampen landscape processes. Further, this finding illustrates a new challenge in remediating nonpoint sediment pollution and indicates that management efforts must expand from soil erosion to factors contributing to increased water runoff.

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Health care improvement and continuing professional education must be better understood if we are to promote continuous service improvement through interprofessional learning in the workplace. We propose that situating interprofessional working, interprofessional learning, work-based learning, and service improvement within a framework of social learning theory creates a continuum between work-based interprofessional learning and service improvement in which each is integral to the other. This continuum provides a framework for continuing interprofessional development that enables service improvement in the workplace to serve as a vehicle through which individual professionals and teams can continually enhance patient care through working and learning together. The root of this lies in understanding that undertaking improvement and learning about improvement are co-dependent and that health care professionals must recognize their responsibility to improve as well as complete their everyday work. We believe that significant opportunities exist for health care commissioners, service providers, and educational institutions to work together to promote continuing interprofessional development in the workplace to enhance patient outcomes, and we outline some of the opportunities we believe exist.

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The importance of obtaining the opinions of service users has long been recognized and, traditionally, most contact has focused on measuring their satisfaction with the services they receive. However, there is little evidence that this has had much impact on improving care. The Discovery Interview Process, a technique for listening to patients and carers and using their narratives to improve care, is discussed in this article. This approach has been used in the pilot phases of the UK Coronary Heart Disease Collaborative and Critical Care Collaborative. These narratives develop understanding grounded in experience. Those delivering care can interpret the narratives using their own clinical and professional knowledge and experience to create better or new ways of meeting patients' and carers' needs. Using their own expert knowledge they can identify needs within the narratives, including those that patients and carers did not know they had. The principal techniques for gathering these narratives are outlined, and ways of using such data to inform patient-focused service improvements are discussed. Various locally sensitive methods for presenting the narratives to expert interprofessional teams are also described along with emerging experience of this feedback. We consider the Discovery Interview technique for gathering patient and carer narratives to be a potentially powerful method for informing quality improvements, discovering what really matters to patients and their carers. This pragmatic approach could prove manageable within local quality improvement projects.

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There is a need to develop models of practice-based learning that are effective in bringing about improvement in the quality of care that patients receive. This paper describes a facilitated practice-based project where five general practices in Dorset formed interprofessional teams that worked over a six-month period using a continuous quality improvement (CQI) approach to make a change in areas of importance to them. All the teams completed the project and planned and implemented demonstrable changes. Qualitative enquiry showed changes in relationships and teamworking that extended beyond the specific topic of the project with teams reporting an enhanced sense of competence and achievement. The project facilitators were able to develop a model of learning that acknowledges and utilises the depth of experience and understanding within interprofessional practice teams. Protected time and an environment and processes that encourage full partcipation of a wide range of team members is essential.

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