This thesis evaluates the waste management system in the province of Manitoba, Canada and other jurisdictions to identify best practices for, and barriers and opportunities to, improving its impact on the environment. Multiple methods were used. First, a survey of expert stakeholders in the waste management sector in Manitoba was conducted, which was followed by an expert stakeholder meeting that further refined the results of the survey. Second, waste management systems of Manitoba, Canada, Nova Scotia, Canada, New South Wales, Australia, and Denmark were compared to determine which of the options already in use by other jurisdictions might be useful in Manitoba. Finally, an estimation of the amount of organic waste entering landfills in Manitoba was conducted, along with an estimation of the resulting methane emissions from landfills to determine their greenhouse gas emissions.

This study addressed the use of benefit levers to develop a guide for an operational plan for spread of best practices in the health system of South Africa. Using the best evidence to inform practice is the cornerstone of quality patient care. Besides uptake and implementation, spreading best practices is crucial as this provides more patients with evidence-informed care and to improve practice and health (care) outcomes. However, spread of best practices is not always effectively done. An example includes Kangaroo Mother Care (KMC) as this best practice is translated for practice and implemented on a limited scale; spread to the whole system seems to be problematic. Various factors can be used to facilitate the spread of best practices. Edwards and Grinspun identified four benefit levers which create the tipping point towards successful adoption, implementation and spread of evidence: alignment, permeation plans, leadership for change, and supporting and reinforcing structures. However, little is known about these benefit levers and it remains unclear what the use of benefit levers for system-wide spread would entail, specifically for other contexts as the model (including the benefit levers) has never been operationalised (Edwards & Grinspun, 2011:19). The overall aim of this study entails therefore the development of a guide for an operational plan, formulating the use of benefit levers in the spread of best practices. To achieve this aim the following objectives for this study were set: 1. To explore and describe characteristics of benefit levers to facilitate spread of best practices. 2. To develop a guide for an operational plan to use benefit levers for the spread of best practices. This study was embedded in the postmodern paradigm, whereby the systems theory was used as a theoretical framework. The first objective was achieved by two steps. Firstly, an integrative literature review of concept clarification of the four benefit levers was done. Secondly, semi-structured individual interviews were conducted with key informants from a variety of levels of the health system involved in the spread of KMC in South Africa. Findings were used to achieve objective two. A draft guide for an operational plan was developed, based on the findings of the individual interviews. A logic model was used as format. This guide was refined by experts using the Delphi technique. The Delphi involved two rounds. From the feedback of the first round of the Delphi, a logic model which provides a graphic outlook of the guide, was suggested and refined in the second round, together with the guide. Further, after the Delphi, a template useable for practice was derived from the guide. The guide, logic model and template could help organisations or departments planning to spread best practices in a certain context (e.g. South Africa), to develop an operational plan, where these benefit levers are considered. This is crucial as currently best practices (such as Kangaroo Mother Care) are often not spread on a system-wide basis to improve practice. The guide will therefore be made accessible to health care workers and researchers in South Africa Finally, conclusions were drawn, the research was evaluated, limitations were identified and recommendations were formulated for nursing practice, education and research. Overall, it can be concluded that for effective spread of best practices the benefit levers alignment, permeation plans, leadership for change and supporting and reinforcing structures are required. Further, specifically regarding the objectives and steps of this study the following conclusions can be made: • Literature/studies about leadership for change and supporting and reinforcing structures was found, but regarding alignment and permeation plans, limited rigorous literature was found (Objective 1 – Step 1). • Key informants involved in the spread of a specific best practice (Kangaroo Mother Care) could see the value of benefit levers used for the spread of best practices in the South African health system (Objective 1 – Step 2). • Benefit levers were found useful for development of a guide for an operational plan to spread best practices. This guide will be made accessible to be used by healthcare organisations and departments in South Africa (Objective 2 – Steps 1 and 2). / Thesis (PhD (Nursing))--North-West University, Potchefstroom Campus, 2013

This study addressed the use of benefit levers to develop a guide for an operational plan for spread of best practices in the health system of South Africa. Using the best evidence to inform practice is the cornerstone of quality patient care. Besides uptake and implementation, spreading best practices is crucial as this provides more patients with evidence-informed care and to improve practice and health (care) outcomes. However, spread of best practices is not always effectively done. An example includes Kangaroo Mother Care (KMC) as this best practice is translated for practice and implemented on a limited scale; spread to the whole system seems to be problematic. Various factors can be used to facilitate the spread of best practices. Edwards and Grinspun identified four benefit levers which create the tipping point towards successful adoption, implementation and spread of evidence: alignment, permeation plans, leadership for change, and supporting and reinforcing structures. However, little is known about these benefit levers and it remains unclear what the use of benefit levers for system-wide spread would entail, specifically for other contexts as the model (including the benefit levers) has never been operationalised (Edwards & Grinspun, 2011:19). The overall aim of this study entails therefore the development of a guide for an operational plan, formulating the use of benefit levers in the spread of best practices. To achieve this aim the following objectives for this study were set: 1. To explore and describe characteristics of benefit levers to facilitate spread of best practices. 2. To develop a guide for an operational plan to use benefit levers for the spread of best practices. This study was embedded in the postmodern paradigm, whereby the systems theory was used as a theoretical framework. The first objective was achieved by two steps. Firstly, an integrative literature review of concept clarification of the four benefit levers was done. Secondly, semi-structured individual interviews were conducted with key informants from a variety of levels of the health system involved in the spread of KMC in South Africa. Findings were used to achieve objective two. A draft guide for an operational plan was developed, based on the findings of the individual interviews. A logic model was used as format. This guide was refined by experts using the Delphi technique. The Delphi involved two rounds. From the feedback of the first round of the Delphi, a logic model which provides a graphic outlook of the guide, was suggested and refined in the second round, together with the guide. Further, after the Delphi, a template useable for practice was derived from the guide. The guide, logic model and template could help organisations or departments planning to spread best practices in a certain context (e.g. South Africa), to develop an operational plan, where these benefit levers are considered. This is crucial as currently best practices (such as Kangaroo Mother Care) are often not spread on a system-wide basis to improve practice. The guide will therefore be made accessible to health care workers and researchers in South Africa Finally, conclusions were drawn, the research was evaluated, limitations were identified and recommendations were formulated for nursing practice, education and research. Overall, it can be concluded that for effective spread of best practices the benefit levers alignment, permeation plans, leadership for change and supporting and reinforcing structures are required. Further, specifically regarding the objectives and steps of this study the following conclusions can be made: • Literature/studies about leadership for change and supporting and reinforcing structures was found, but regarding alignment and permeation plans, limited rigorous literature was found (Objective 1 – Step 1). • Key informants involved in the spread of a specific best practice (Kangaroo Mother Care) could see the value of benefit levers used for the spread of best practices in the South African health system (Objective 1 – Step 2). • Benefit levers were found useful for development of a guide for an operational plan to spread best practices. This guide will be made accessible to be used by healthcare organisations and departments in South Africa (Objective 2 – Steps 1 and 2). / Thesis (PhD (Nursing))--North-West University, Potchefstroom Campus, 2013

This thesis evaluates the waste management system in the province of Manitoba, Canada and other jurisdictions to identify best practices for, and barriers and opportunities to, improving its impact on the environment. Multiple methods were used. First, a survey of expert stakeholders in the waste management sector in Manitoba was conducted, which was followed by an expert stakeholder meeting that further refined the results of the survey. Second, waste management systems of Manitoba, Canada, Nova Scotia, Canada, New South Wales, Australia, and Denmark were compared to determine which of the options already in use by other jurisdictions might be useful in Manitoba. Finally, an estimation of the amount of organic waste entering landfills in Manitoba was conducted, along with an estimation of the resulting methane emissions from landfills to determine their greenhouse gas emissions.

Objectives: To determine the level of adoption and which characteristics are most strongly associated with the adoption of a clinical innovation in Mental Health and Addiction Service organizations in Ontario, one year after dissemination. Methods: This cross-sectional study included a voluntary quantitative mail-out survey, using a self administered questionnaire that was sent to 260 mental health and addiction service organizations in Ontario. Linear regression analysis was conducted to identify significant predictors of the overall adoption-decision of the best practice recommendations. Results: Individuals’ tenure within the organization and the provision of screening (organizational variable) was identified to be predictors of adoption for the organization. Conclusions: The results of this study demonstrated the majority of the organizations are on the path towards a finale decision of adopting or rejecting the recommendations. The results also demonstrate the importance of individual characteristics and organizational characteristics in identifying predictors of adoption.

Objectives: To determine the level of adoption and which characteristics are most strongly associated with the adoption of a clinical innovation in Mental Health and Addiction Service organizations in Ontario, one year after dissemination. Methods: This cross-sectional study included a voluntary quantitative mail-out survey, using a self administered questionnaire that was sent to 260 mental health and addiction service organizations in Ontario. Linear regression analysis was conducted to identify significant predictors of the overall adoption-decision of the best practice recommendations. Results: Individuals’ tenure within the organization and the provision of screening (organizational variable) was identified to be predictors of adoption for the organization. Conclusions: The results of this study demonstrated the majority of the organizations are on the path towards a finale decision of adopting or rejecting the recommendations. The results also demonstrate the importance of individual characteristics and organizational characteristics in identifying predictors of adoption.

A gestão por processos de negócio aumenta a qualidade de produtos e serviços e diminui o custo operacional nas organizações. Para realizar gestão por processos é necessário mapear estes processos em modelos de processo de negócio que precisam ter qualidade sintática, semântica e pragmática. A qualidade pragmática, em particular, garante que um modelo é compreensível. Os modelos são criados por analistas de processo, os quais reúnem informações que estão distribuídas pela organização e, a partir do conhecimento dos stakeholders do processo. Esta é uma tarefa complexa, que nem sempre resulta em modelos de processo com boa qualidade pragmática. Processos com baixa qualidade pragmática podem ser de difícil entendimento pelos stakeholders do processo. Para certificar a qualidade pragmática é necessário testar o entendimento do processo com novos usuários. Na maioria das vezes é difícil obter novos usuários para realizar testes. Este trabalho propõe uma abordagem que tem como base uma ontologia para representar modelos de processo e boas práticas de modelagem para auxiliar na identificação de modelos com baixa qualidade pragmática. A abordagem desenvolvida inclui o desenvolvimento de um plug-in para o editor de ontologia Protégé, que a partir de indicadores propostos na literatura automatiza a identificação de problemas na qualidade pragmática da modelagem de processos de negócio. Esta ferramenta pode ser utilizada no contexto acadêmico em cursos de modelagem de processos de negócio, auxiliando alunos no entendimento de boas práticas de modelagem, e no contexto empresarial, para revisar grandes repositórios de processos e selecionar os modelos que possam ter problemas na qualidade pragmática. / Business Process Management (BPM) increases the products and services quality and decreases operational costs in organizations. BPM requires the mapping of such process models that must present synthetic quality, semantic quality and pragmatic quality. Pragmatic quality, in particular, ensures understandability of the model. Models are designed by process analysts, gathering information spread at the organization and the knowledge of stakeholders. The design task is complex and some times does not result in process models with high pragmatic quality. Process model with low pragmatic quality may be difficult to understand by process stakeholders. Pragmatics quality certication tests the understanding of the process with new users. Most of the time it is hard to get new users to run tests. This work proposes an approach based on an ontology to represent process models and modeling practices to identify models with low pragmatic quality. The proposed approach is based on the development of a plug-in for Protégé ontology editor, and uses metrics from the literature to identify pragmatic quality problems in process models. This tool can be aplied in academic context so that students can better understant best practices in business process modeling, and also at business context, to review large process repositories selecting models which may have pragmatic quality problems.

A gestão por processos de negócio aumenta a qualidade de produtos e serviços e diminui o custo operacional nas organizações. Para realizar gestão por processos é necessário mapear estes processos em modelos de processo de negócio que precisam ter qualidade sintática, semântica e pragmática. A qualidade pragmática, em particular, garante que um modelo é compreensível. Os modelos são criados por analistas de processo, os quais reúnem informações que estão distribuídas pela organização e, a partir do conhecimento dos stakeholders do processo. Esta é uma tarefa complexa, que nem sempre resulta em modelos de processo com boa qualidade pragmática. Processos com baixa qualidade pragmática podem ser de difícil entendimento pelos stakeholders do processo. Para certificar a qualidade pragmática é necessário testar o entendimento do processo com novos usuários. Na maioria das vezes é difícil obter novos usuários para realizar testes. Este trabalho propõe uma abordagem que tem como base uma ontologia para representar modelos de processo e boas práticas de modelagem para auxiliar na identificação de modelos com baixa qualidade pragmática. A abordagem desenvolvida inclui o desenvolvimento de um plug-in para o editor de ontologia Protégé, que a partir de indicadores propostos na literatura automatiza a identificação de problemas na qualidade pragmática da modelagem de processos de negócio. Esta ferramenta pode ser utilizada no contexto acadêmico em cursos de modelagem de processos de negócio, auxiliando alunos no entendimento de boas práticas de modelagem, e no contexto empresarial, para revisar grandes repositórios de processos e selecionar os modelos que possam ter problemas na qualidade pragmática. / Business Process Management (BPM) increases the products and services quality and decreases operational costs in organizations. BPM requires the mapping of such process models that must present synthetic quality, semantic quality and pragmatic quality. Pragmatic quality, in particular, ensures understandability of the model. Models are designed by process analysts, gathering information spread at the organization and the knowledge of stakeholders. The design task is complex and some times does not result in process models with high pragmatic quality. Process model with low pragmatic quality may be difficult to understand by process stakeholders. Pragmatics quality certication tests the understanding of the process with new users. Most of the time it is hard to get new users to run tests. This work proposes an approach based on an ontology to represent process models and modeling practices to identify models with low pragmatic quality. The proposed approach is based on the development of a plug-in for Protégé ontology editor, and uses metrics from the literature to identify pragmatic quality problems in process models. This tool can be aplied in academic context so that students can better understant best practices in business process modeling, and also at business context, to review large process repositories selecting models which may have pragmatic quality problems.

Background: Individuals with intellectual and/or developmental disabilities (IDD) are experiencing longer life expectancies with the majority requiring the ongoing support of family caregivers into adulthood. Medicaid is the primary funding source for supports and services for adults with IDD. Growing Medicaid expenditures and goals to improve quality of care are driving more states to move their Medicaid fee-for-service programs into a managed care model. The stated goals of Medicaid managed long-term services and supports (MLTSS) are to improve care coordination and access to care while controlling costs, but the evidence regarding these outcomes is limited and mixed. Given the level of uncertainty about MLTSS for adults with IDD and their family caregivers, best practices recommendations have been produced by the federal government and advocacy agencies to help guide future MLTSS implementation efforts. These best practice recommendations combined with the continued expansion of MLTSS in the states, provided an opportunity to further explore implementation of MLTSS to inform both policy and practice. One state which recently reformed their Medicaid program to MLTSS and which has been referred to as a bellwether state is Kansas. The MLTSS program in Kansas, titled “KanCare”, is the first for adults with IDD to integrate across health, behavioral health, and LTSS while also contracting through three private-for-profit managed care organizations (MCOs). Aims: The objective of this study was to describe the current implementation of MLTSS for adults with IDD and their family caregivers in one state, Kansas. Study aims were as follows: 1) To understand the rationale behind and what actually happened with MLTSS implementation for adults with IDD in Kansas; 2) To understand how service coordination providers and family caregivers perceived care coordination and access to services for adults with IDD in MLTSS; 3) To understand how family caregivers and their roles were recognized in MLTSS for adults with IDD. Methods: A single case embedded design case study approach was used with in-depth semi-structured interviews completed with state/regional level representatives (N=13), MLTSS service coordination providers (N=7), and family caregivers of adults with IDD (N=11). Data collection and analysis were guided by the unified theory of family quality of life (FQOL) and Bronfenbrenner’s ecological model. The framework method was used to structure the data analysis process. Member checking was completed to ensure accuracy of results. Findings: Regarding aim one, respondents identified reducing costs and improving care quality as the rationale behind MLTSS, but these were outcomes not yet realized given the early stages of implementation. At the time of this study, the Managed Care Organizations (MCOs) were continuing to work on expanding provider networks and to provide additional services to address health disparities amongst individuals with IDD. Study participants identified the importance of adequate planning and stakeholder engagement to reduce confusion and fear when transitioning into MLTSS. Addressing aim two, timely and accessible consumer education, clear care coordination processes, and provider network adequacy were identified as important to influence the challenges experienced to date in care coordination and access to services. Regarding aim three, participants acknowledged the important role of family caregivers. At the current stage of the KanCare implementation, participants reported lack of formal processes for family caregiver assessment and a need for more proactive family support services planning. Conclusion: Lessons learned from this implementation experience include the importance of having long planning timelines and including stakeholder feedback into the design of MLTSS programs. Care coordination holds promise to better integrate care, but more research is needed to understand best practices for the provision of care coordination in MLTSS. In order to address access to services, MLTSS programs will need to work and build provider capacity and provider networks. MLTSS programs will also need to formally recognize the role of family caregivers by incorporating the use of family caregiver assessments to proactively plan for support needs.

Recreational organizations that deliver activities to youth within their communities can provide an effective setting for positive youth development (PYD) endeavours due to being fun, engaging, and an environment where skill-building is inherent. However, not all recreational organizations offering PYD aimed programs are successful and many are cancelled after a short amount of time. A framework or guide for (1) promoting PYD through community recreation and (2) evaluating and identifying PYD outcomes does not yet exist. This research seeks to develop a model to inform recreational program design to bring about positive developmental outcomes in youth participants using empirical data collected from three successful organizations. Both one-on-one interviews and a focus group with youth participants and adult staff were utilized following a qualitative multiple case study approach. Data collected was concerned with the positive developmental outcomes experienced by youth participants in the organizations and mechanisms used to realize these outcomes. The key themes, derived through inductive and deductive analyses, are presented as a five-step logic model. These themes help identify the intended results of programs along with the resources and processes needed to achieve these results, thus making this study’s findings easy to integrate into recreational programming. The model’s process factors included a series of inputs (i.e., contextual factors and external assets) and activities (i.e., direct and indirect strategies). Findings identified as intended PYD outcomes included outputs (i.e., objective measurable indicators), short-term outcomes (i.e., life skills), and long-term impacts (i.e., the four Cs including life skill transfer and contribution). This study elaborates on concepts identified in previous research that are conducive to PYD while bringing them together into a framework for designing recreational programs with the goal of promoting positive developmental outcomes in youth. However, further testing through quantitative, longitudinal, and intervention research may be needed.