Increasingly, old people in India are moving into institutional settings. There is a paucity of qualitative research examining the condition of residents in care homes. This thesis addresses this gap through a detailed qualitative study of three such homes in Goa, India. It explores the care processes and practices in the care homes and how far they are attuned to the needs, lives and identities of their residents. An understanding of the experiences of residents as they have been undergoing different stages of entering and settling into a residential care setting has been the main focus of the research, which illuminates the context in which resident experiences were embedded. The thesis explores the process of institutional living: the conditions (losses and changes) that lead older people to enter institutional care; the losses and changes incurred while entering institutional care; the paradox between induced dependencies created by institutional control and structures resulting in passive compliance; and the struggles of the residents to resist these power structures. In documenting life for the resident in the care homes the thesis shows that their subtle daily forms of resistance exist within a framework of power. The final empirical chapter discusses how residents experience different forms of departure, whether as ending this struggle or beginning a new one. Data were collected through a combined ethnographic methodology of participant observation and semi-structured interviews with residents, staff and management over an eight-month period, in addition to a scoping survey of 37 care homes in the State. The study retrospectively examines residents’ experiences during various stages – pre-entry, entry, post-entry and exit – of their residential career, the drivers and constraints during these stages, and the role of staff and management in contributing to these experiences. These are presented as narratives – interleaved stories highlighting (some) important aspects of life in care homes in Goa. I have included the various responses made by residents to the different stages of their residential career – their ambivalences as well as their certainties, their anger as well as their passive acceptance, their dependence as well as their agency – and to interpret residents as sometimes vulnerable, sometimes invincible, and sometimes struggling. In doing so, I have provided insights into the ups and downs of life in care homes in Goa, through exploring paradigms that were crucial to residents’ lives in my study. These insights reveal that the dismantling of residents’ individual autonomy and control occurred prior to their coming into the institution. Once inside the care home, their lives were further altered by rules, routines and practices of staff and management. The resident’s identities thus were increasingly being defined by the institution. The findings further revealed that residents do not always accept passive dependency but instead struggle to carve their own identity within the institutional settings and controls they are subjected to. Finally, my findings reveal how perceptions and preparations for departure from the institution are coping mechanisms used by the residents and the staff alike, as extensions of their struggle for survival, freedom, and control. These findings lead to a greater understanding of how different processes are intertwined in residential careers for residents in care homes in Goa. The findings invite a rethinking of conceptions of autonomy and ageing, passive compliance and agency, and departure and coping, particularly within the context of institutional living in Goa. This study has thus illustrated the mechanisms in place for older people entering, settling and leaving care homes in Goa and demonstrated whether these mechanisms are adequately suited to their needs. The hope is that this understanding will contribute to the development of improved policy and practice that better reflects the needs and wellbeing of older people.

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According to the progressive era and technical development, many industries have already input emerging technology. In the medical industry of Taiwan, most of the hospitals have set up the operating system, data management and case history in electric facilities. It can help to deliver the information more accuracy and convenient. However, there are still many traditional models in medical regulation. The main reason is that the processes of care usually involve face to face communication. Therefore, to insure safety to the patients, human observation and communication are needed in traditional concept. To give an example of inpatient healthcare, patients always need intimate observation and treatment because the function of ward is to keep the patients safe and easy to observe. In recent years, the tradition care models have been challenged by the lack of human resources and the rise of patient safety conscious. In consequence, the service quality of ward has also been focus. According to the official data record in 2007, there were 2 million people affected with Nephrology disease, and this population content 50 thousands patient of long term dialysis. Nephrology disease has become the most popular disease in Taiwan. This thesis is trying to focus on the huge amount of Nephrology patients, and enhance the care process with forward-looking solutions. After inducing traditional problems and collecting emerging technologies, this research is going to produce an emerging health care model on Nephrology inpatients. The conventional process of IO record, medicament allocation, fall injury prevention, nursing record and home care after discharged from hospital would be improved in many technologies, such as lover¡¦s cup, electric scale, barcode, RFID, urgent button, PDA, mobile nursing station, intouch message board and monitoring stool. Not only building the model, the evaluation of time cost, quality and innovative services would also discuss in the research to make the emerging health care model more suitable for clinical demand.

The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization. Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom. After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today. Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care. In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

Patient wait times and care service times are key performance measures for care processes in hospitals. Managing the quality of care delivered by these processes in real-time is challenging. A key challenge is to correlate source medical events to infer the care process states that define patient wait times and care service times. Commercially available complex event processing engines do not have built in support for the concept of care process state. This makes it unnecessarily complex to define and maintain rules for inferring states from source medical events in a care process. Another challenge is how to present the data in a real-time BI dashboard and the underlying data model to use to support this BI dashboard. Data representation architecture can potentially lead to delays in processing and presenting the data in the BI dashboard. In this research, we have investigated the problem of real-time monitoring of care processes, performed a gap analysis of current information system support for it, researched and assessed available technologies, and shown how to most effectively leverage event driven and BI architectures when building information support for real-time monitoring of care processes. We introduce a state monitoring engine for inferring and managing states based on an application model for care process monitoring. A BI architecture is also leveraged for the data model to support the real-time data processing and reporting requirements of the application’s portal. The research is validated with a case study to create a real-time care process monitoring application for an Acute Coronary Syndrome (ACS) clinical pathway in collaboration with IBM and Osler hospital. The research methodology is based on design-oriented research.

Patient wait times and care service times are key performance measures for care processes in hospitals. Managing the quality of care delivered by these processes in real-time is challenging. A key challenge is to correlate source medical events to infer the care process states that define patient wait times and care service times. Commercially available complex event processing engines do not have built in support for the concept of care process state. This makes it unnecessarily complex to define and maintain rules for inferring states from source medical events in a care process. Another challenge is how to present the data in a real-time BI dashboard and the underlying data model to use to support this BI dashboard. Data representation architecture can potentially lead to delays in processing and presenting the data in the BI dashboard. In this research, we have investigated the problem of real-time monitoring of care processes, performed a gap analysis of current information system support for it, researched and assessed available technologies, and shown how to most effectively leverage event driven and BI architectures when building information support for real-time monitoring of care processes. We introduce a state monitoring engine for inferring and managing states based on an application model for care process monitoring. A BI architecture is also leveraged for the data model to support the real-time data processing and reporting requirements of the application’s portal. The research is validated with a case study to create a real-time care process monitoring application for an Acute Coronary Syndrome (ACS) clinical pathway in collaboration with IBM and Osler hospital. The research methodology is based on design-oriented research.

Bakgrund NCP är en systematisk, problemlösande metod med ett unikt standardiserat språk som används av yrkesverksamma dietister för dokumentation. Det bidrar till att dietisten agerar utifrån ett kritiskt tänkande där besluten för att hantera patientens nutritionsproblem sker utifrån kunskap av evidensbaserad erfarenhet. Dietisternas Riksförbund (DRF) uppmanar legitimerade dietister att arbeta enligt NCP. Syfte Studiens syfte var att studera svenska dietisters arbete med att ställa nutritionsdiagnoser enligt NCP. Metod En webbaserad enkät utformades. Yrkesverksamma dietister rekryterades via det sociala mediet Facebook samt via DRF:s hemsida. Insamlad data bearbetades i SPSS Statistics 22, och analyserades med Chi-2-test och Correlate Bivariate Spearman. Signifikansnivån bestämdes till p-värde < 0.05. Resultat 119 dietister deltog i studien varav 103 (87 %) skrev nutritionsdiagnoser. I genomsnitt hade dietisterna arbetat i 2 år (1-3 år) med NCP, och över hälften arbetade inom akutsjukvård. Analysen visade att det fanns ett samband mellan antal år dietisterna arbetat med NCP och hur många nutritionsdiagnoser de skrev (r=-0.197, p=0.046). Ett samband visades även mellan tiden dietisterna arbetat med NCP och tiden det tog att skriva nutritionsdiagnoser (r=-0.226, p=0.022). Av de 103 dietisterna som använde NCP ansåg 60 % att deras kunskap och erfarenhet kunde förbättras, 89 % tyckte att nutritionsdiagnoser var användbara. Engelskan i referensbladen tyckte 48 % till viss del var svårtolkad och (n=13) angav att översättning till svenska kunde underlätta arbetet. Det framgick att mer än hälften (53 %) av dietisterna ibland utformade PES-meningar utan att ha funnit passande tecken/symtom i referensbladet. Slutsats Svenska dietister önskar mer kunskap och utbildning i NCP och översättning av referensbladen till svenska skulle sannolikt kunna öka användandet av nutritionsdiagnoser. En vidare implementering av NCP i Sverige behövs. / Background The Nutrition care process is a systematic, problem-solving approach with a standardized language used by dietitians for documentation. It stimulates dietitians to critically appraise and take evidence-based decisions on a patient's nutritional problems. The Swedish Association of Clinical Dietitians (DRF) appeals qualified dietitians to work according the NCP. Objective The aim was to study Swedish dietitians’ work with nutrition diagnosis according to the NCP. Method(s) A web-based questionnaire was developed. Dietitians was recruited through the social media Facebook and the DRF website. The collected data were processed in SPSS, analyzed by Chi-2-test and Correlate Bivariate Spearman, with significance level at p < 0.05. Results A total of 119 dietitians responded to the questionnaire and 103 (87 %) of the respondents wrote nutrition diagnosis. The respondents had on average worked with the NCP for 2 years (range 1-3 years), and over half worked in hospitals. There was a correlation between years working according to the NCP and the number of written diagnosis (r=-0.197, p=0.046). Also, the time for writing a nutritional diagnosis was reduced as the experience of working with NCP increased (r=-0.226, p=0.022). It was 60 % that thought their knowledge and experience in NCP could be improved, 89 % stated that the NCP was useful. The English in the reference sheets 48 % of the respondents said partly was difficult to understand and (n=13) wanted them to be translated into Swedish. It showed that more than half (53 %) of the dietitians sometimes composed PES-statements without finding the appropriate signs/symptoms in the reference sheet. Conclusion Swedish dietitians consider themselves to be in need of more knowledge and training in the NCP, and translations of the reference sheets would possibly increase the use of nutrition diagnosis. A further implementation of the NCP is needed in Sweden.

The increasing waiting times to access healthcare services are a major concern for pa-tients in hospitals. Due to the unpredictability of health issues, hospitals and clinical ser-vices are provided to patients even without prescheduled medical appointments. Unex-pected and random patient arrivals can result in high waiting times. Waiting occurs most-ly because of insufficient resources available compared to demanding service delivery requirements at a given time. Thus, appropriate management of resource scheduling over time can help reduce patient wait times. So far, simulation has mostly been used as a support for strategic decision making in healthcare environments. We are proposing a complementary approach, namely, real-time simulation, to support operational decision making rather than long-term strategic decision making. Real-time simulation is a technique used to get a timely prediction of the system status in a near future (e.g., a few hours). Hospitals can benefit from the capa-bilities of real-time simulations by predicting upcoming bottleneck occurrences in patient care processes and make effective decisions in the present time to avoid undesirable out-comes in the near future. This research presents real-time simulation capabilities for short-term operational decision making of patient care processes in hospitals and the possible ways to run alter-native scenarios and evaluate their results to come up with the most effective solution considering various factors. This thesis also provides tool support based on a leading simulation environment, namely Arena. The tool-supported methodology is evaluated through a realistic cardiac care process in an Ontario community hospital, with encourag-ing results.

Reporting patient states is considered an important part of care process monitoring in the hospital to efficiently monitor how well the health care system is performing. Monitoring care processes with enough fine-grained detail to precisely track wait states and service states in order to reduce wait times and improve their quality of care are challenging. Business Process Management (BPM) technology is used to bring care processes online, but there is no clear methodology on how to integrate performance management into BPM tools in a systematic matter that is effective, and minimizes complications and development costs. This thesis proposes a BPM methodology for care process monitoring that structures how to integrate performance monitoring into BPM. The major contribution of this thesis includes a generic methodology for care processes monitoring that describes how to structure and instrument a business process model for systematic care process monitoring which includes support for handoff points between organizations where many wait-time bottlenecks occur. It also includes a prototype implementation based on an existing case study based on a real cardiology care process from an Ontario hospital. Our results are evaluated using three different prototypes based on this same care process. The research methodology for the thesis is based on Design-Science research.

The increasing waiting times to access healthcare services are a major concern for pa-tients in hospitals. Due to the unpredictability of health issues, hospitals and clinical ser-vices are provided to patients even without prescheduled medical appointments. Unex-pected and random patient arrivals can result in high waiting times. Waiting occurs most-ly because of insufficient resources available compared to demanding service delivery requirements at a given time. Thus, appropriate management of resource scheduling over time can help reduce patient wait times. So far, simulation has mostly been used as a support for strategic decision making in healthcare environments. We are proposing a complementary approach, namely, real-time simulation, to support operational decision making rather than long-term strategic decision making. Real-time simulation is a technique used to get a timely prediction of the system status in a near future (e.g., a few hours). Hospitals can benefit from the capa-bilities of real-time simulations by predicting upcoming bottleneck occurrences in patient care processes and make effective decisions in the present time to avoid undesirable out-comes in the near future. This research presents real-time simulation capabilities for short-term operational decision making of patient care processes in hospitals and the possible ways to run alter-native scenarios and evaluate their results to come up with the most effective solution considering various factors. This thesis also provides tool support based on a leading simulation environment, namely Arena. The tool-supported methodology is evaluated through a realistic cardiac care process in an Ontario community hospital, with encourag-ing results.