Résumé : La qualité des services est considérée de plus en plus comme un paramètre essentiel de la conception des services sociosanitaires (MSSS, 2005). Selon les divers modèles théoriques de la qualité des services (Donabedian, 1980; Kroger, 2007; OMS, 2004), la continuité des services en constitue une composante importante, surtout pour une organisation des services qui se veut de plus en plus intégrée. La continuité est abordée ici en s'appuyant sur la définition tridimensionnelle qu'en donnent Reid, Haggerty & McKendry, (2003). Elle est relationnelle, ce qui implique l'existence de rapports significatifs entre professionnels et usagers. Elle est informationnelle, ce qui suppose de rendre accessibles aux professionnels les informations requises pour l'exercice de leurs fonctions. Enfin, il faut ajouter la dimension d'approche, laquelle renvoie à la cohérence des diverses actions accomplies pour le bien-être et au bénéfice de l'usager. Le dossier clinique se présente comme une fenêtre par laquelle les trois objets que sont la qualité des services, l'intégration des services et la continuité des services peuvent se révéler et s'articuler. Pourtant, peu de recherches ont analysé le dossier clinique spécifiquement sous cet angle, privilégiant plutôt les études portant sur sa conformité à certaines normes (audits) ou l'utilisation des dossiers cliniques dans une optique de triangulation des données. La présente étude aborde le dossier clinique en tant qu'observatoire de la continuité. Cette position s'explique par les contextes social et scientifique actuels, qui considèrent la continuité comme une dimension transversale de la qualité (Kroger et al. 2007) et la voient comme à la fois une condition et un effet de l'intégration des services. Notre étude vise à repérer et à catégoriser des indices de continuité des services tels qu'on les retrouve dans des dossiers cliniques d'usagers inscrits en gestion de cas, et ce, dans le but de contribuer à l'accroissement de la qualité dans les services dispensés aux personnes âgées. En identifiant les façons dont les professionnels inscrivent des traces de continuité dans les dossiers cliniques des usagers et en dégageant les composantes de la continuité qui sont présentes dans les rédactions, la pertinence de l'usage des dossiers cliniques dans l'analyse de la continuité est précisée et quelques pistes méthodologiques d'analyse de la continuité des services peuvent être esquissées. Nous avons procédé à l'analyse de 16 dossiers cliniques de personnes âgées de 75 ans et plus, qui vivent dans deux territoires où existent des réseaux intégrés de services et qui sont inscrites en gestion de cas depuis au moins six mois. L'information contenue dans les dossiers cliniques des usagers a été extraite à l'aide d'outils conçus à cette fin spécialement pour notre étude. L'approche qualitative que nous mettons à contribution opère un double mouvement analytique de déduction et d'induction des formes de continuité que l'on retrouve dans les dossiers cliniques. Précisons que cette étude s'inscrit dans le cadre d'une plus grande recherche portant sur la fragilité (IRSC team onfrailty) que dirigent François Béland et André Tourigny. Nos résultats indiquent que les dossiers cliniques se révèlent un excellent observatoire de la continuité, bien que ce soit avec une pertinence variable selon la dimension retenue. Ainsi, le principal obstacle à la continuité informationnelle réside dans la difficulté à maintenir à jour les documents standardisés (OÉMC et PIAS, notamment). De même, la continuité relationnelle a pu être appréhendée en termes de permanence de la présence des intervenants dans le dossier clinique de l'usager, même si la qualité de la relation entre le professionnel et l'usager n'y est pas explicite. Enfin, s'agissant de la continuité d'approche, la fragmentation du dossier clinique et l'absence de description des processus de prise de décision clinique rendent son évaluation plus problématique. Une bonne partie du caractère incomplet du dossier clinique pourrait être facilement comblée, ce qui aurait pour effet de placer les pratiques de rédaction utilisées par les professionnels en phase avec les changements qui surviennent dans la conception de la qualité et dans l'organisation des services||Abstract : The quality of services is more and more often viewed as a parameter which plays a crucial role in the conception of socio-sanitary services. According to the diverse theoretical models that seek to define the concept of quality of care (Donabedian, 1980; Kröger, 2007; OMS, 2004), continuity of services represents an important dimension of the quality of care, specifically for a services organization that sees itself as a structure that is more and more integrated. Our point of view on continuity is based essentially on the tridimensional definition of continuity given by Reid, Haggerty & McKendry, (2002). Firstly, relational continuity implies the existence of significant relationships that take place between professionals and services users. Secondly, informational continuity supposes that the professionals involved have access to the information they need in order to accomplish their tasks. Thirdly, management continuity refers to the coherence between the various actions that are undertaken by diverse professionals for the benefit and well-being of services users. The clinical record can be likened to a window through which three objects, the quality of services, the integration of services, and the continuity of services, can appear and form a structure. However, very few researches tried to understand the clinical record in that specific perspective, preferring to focus their attention on the study of audits and on utilization of clinical records in a perspective of data triangulation. Our study considers the clinical record as an observatory of the continuity. The adoption of this specific point of view is best explained by the existing social context and scientific context, which consider the continuity as a cross-sectional dimension of the quality as well as both a cause and an effect of the services integration. Our study aims to identify and categorize the continuity indicators that appear in the clinical records of the services users that were admitted in case management, with the objective of increasing the quality of services provided to the elderly population. In identifying the different ways by which some professionals leave their marks of continuity in the clinical records and recognizing the elements that define continuity and that those professionals take into account when writing their observation notes, the relevance of using clinical records in order to understand the concept of continuity of services is duly confirmed, and some methodological tracks to enhance the study of the continuity of services can be made. We analysed the clinical records of 16 older people aged 75 and more who are living in a territory where there is an integrated services network and who were admitted in case management since at least six months. Data that were contained in the users' clinical records were extracted using instruments that were specialty created for our study. With its double analytic process of deduction and induction, the qualitative approach we utilize seeks to understand the dimensions of the continuity that are present in the clinical records. Our study is part of a bigger research on frailty, namely the CIHR Team in Frailty and Aging, which is led by François Béland and André Tourigny. Our results show that the clinical records represent a very good observatory of continuity, but with more or less relevance depending of the dimension of the continuity that is involved. Thus, the most important obstacle to informational continuity lies in the fact that it is difficult to keep the standardized documents up to date. Similarly, the relational continuity was evaluated taking into account the permanency of the professionals' presence in the clinical records, but the quality of the relationship between professionals and users is not explicit. Finally, concerning the management continuity, the fragmentation which characterizes the clinical record and the absence of description of the decision-making process render the estimation of management continuity much more hazardous. A good part of the sketchy nature of the clinical record could easily be taken care of and completed, which would have the effect of putting the professionals' recording habits in phase with the changes that take place in the conception of the quality and in the services organization.

Dans ce travail de recherche nous nous intéressons à un objet particulier : la conception de lignées de services complexes. Nous étudions cet objet dans un contexte particulier lui aussi, celui de la Défense en Europe. Chacun de ces termes est porteur d’interrogations : que sont les services dans l’armement ? ; en quoi sont-ils complexes ? ; qu’est-ce qu’une lignée de service ? Ces services se caractérisent principalement par une durée de la relation s’inscrivant dans le temps long, de l’ordre de plusieurs décennies, sans commune mesure avec les services le plus souvent étudiés. La complexité de l’écosystème d’acteurs – mêlant public et privé – ainsi que celle intrinsèque aux produits et systèmes d’armement – systèmes de missiles, avions de combat, sous-marins nucléaires, etc. – contribuent également à l’originalité et la valeur de notre objet d’étude. La lignée, issue du monde de la conception innovante de produits, se caractérise sous deux dimensions en interaction : la succession de projets et l’accumulation des connaissances. Là encore, ces deux dimensions sont souvent absentes de la recherche sur les services. Dans l’optique de conception qui est la nôtre, les premières questions en appellent deux autres : comment représenter de tels services ? ; et comment organiser les fonctions de conception et notamment la création des connaissances nouvelles, innovantes, nécessaires à la co-conception et à la co-production du service par l’ensemble des acteurs ? Nous avons mené cette recherche au plus près du terrain. Intégré durant trois ans au sein d’un grand groupe Européen de défense (au titre d’une convention CIFRE), directement impliqué dans différents projets de conception de services innovants, nous avons été confronté d’un point de vue pratique autant que théorique à ces questions. Les travaux s’articulent autour de ces projets ainsi que d’une étude de cas comparative entre des projets de service de défense en France et au Royaume-Uni. À ce titre, le doctorant a effectué une période de six mois en tant que visiting PhD à l’Université de Cambridge. Quoi qu’ancrée dans un secteur particulier, notre recherche est porteuse d’enseignements à la portée plus générale pour la recherche comme pour les praticiens. À la fois Issu des cas et utilisé comme grille de lecture de ces mêmes cas, l’outil ReADy – pour Référentiel d’Analyse Dynamique de la valeur de service – est le principal apport conceptuel de nos travaux. Par la tension qu’il introduit entre ses deux composantes que sont le concept et le contrat, il contribue à représenter et concevoir la succession des projets de service. Par la notion de communauté d’apprentissage, en lien avec ReADy, nous mettons en lumière les principaux mécanismes de la création des connaissances nécessaires à la mise en place d’une lignée de services complexes. / In this research we look at a singular object: lineages of complex services design. We study this object in a context singular in itself, which is the European Defence Sector. Each of the above terms raises questions: what are services in the defence sector? What makes them complex? What is a service lineage? The services we look at are characterised by the duration of the relationship, to be counted in decades, without measure with the ones most commonly studied. The complexity of the ecosystem of actors – comprising public and private sectors – and that of the underlying products and systems – e.g. missiles systems, fighter aircrafts or nuclear submarines – also contribute to the originality and the value of the object of our research. The concept of lineage, rooted in the innovative design of products, is best described by the interplay between the succession of projects and the accumulation of knowledge. Here again, both dimension are most often overlooked in service research. In our perspective of service design, our first questions call for two others: how to describe such services? and how to organise the design functions in such manner that new knowledge is created and shared to allow co-design and co-production of the service by the whole ecosystem of actors?Our research was conducted in close proximity with the actual field. Fully integrated within the organisation of a major player in the European defence sector (as per a CIFRE convention), the researcher was hands-on with several innovative service design projects and confronted with the above questions on both theoretical and practical perspectives. These projects are at the heart of our research, together with a comparative case study of defence services in France and the United-Kingdom. To that effect, a six month visiting PhD period was conducted in the University of Cambridge.Although being rooted in a singular context, our research bears more general insights for academia and practitioners alike. Coming from the case material and used to shed light on it as well, our ‘Dynamic Analysis of service value Referential ‘, dubbed ReADy, is the main theoretical contribution of our work. By the tension it introduces between its two components – the concept and the contract – it contributes to the description and design of the successions of service projects. With the concept of ‘learning communities’, together with ReADy, we shed light on the main knowledge creation mechanisms at work when implementing a lineage of complex services.

published_or_final_version / Social Work / Master / Master of Social Work

Thesis (Ph.D.)--Bowling Green State University, 2008. / Document formatted into pages; contains xv, 162 p. Includes bibliographical references.

Thesis (M.P.A.)--Kutztown University of Pennsylvania, 1993. / Source: Masters Abstracts International, Volume: 45-06, page: 2951. Abstract precedes thesis as 4 preliminary leaves. Typescript. Includes bibliographical references (leaf 75).

Thesis (M.A. (Health Social Science))--Mahidol University, 1999.

Thesis (M.S.)--University of Michigan, 1985.

Thesis (M.B.A.)--University of Hong Kong, 1998. / Includes bibliographical references (leaf 78-79).

The boom of the internet economy and the smartphone explosion currently experienced in South Africa is making it increasingly more convenient for South African residents to purchase electronically supplied goods and services from suppliers located all across the globe with the mere click of a button. The increasing number of purchases online is making it almost impossible for the South African Revenue Service to collect the Value-Added Tax on specifically electronically supplied services purchased from foreign suppliers. It is further placing South African suppliers of similar goods and services in a disadvantaged position in respect of pricing when compared to foreign suppliers. In the 2013 budget speech, the Minister of Finance indicated that the Value-Added Tax implications of the supply of digitised products by foreign suppliers are an area of concern. By July 2013 proposals were contained in the Draft Taxation Laws Amendment Bill to address this very problem. The aim of this study is to critically evaluate the proposed methods to collect Value-Added Tax on electronically supplied services, as contained in the Draft Taxation Laws Amendment Bill through a detailed literature review and critical evaluation. The literature review focuses on sections 7(1)(c) and 14 of the Value-Added Tax Act, the sections of the Value-Added Tax Act which currently regulates the collection of Value-Added Tax on electronically supplied services, as well as the methods used in the European Union and New Zealand to collect Value-Added Tax and Goods and Services Tax on electronically supplied services. The critical evaluation of the proposals identifies shortcomings and provides recommendations to overcome the shortcomings to ensure that the proposed changes will address the concerns and align South African legislation with global practices. The study concludes that, although the proposed changes to the method to collect Value-Added Tax on electronically supplied services are a step in the right direction, there is still work to be done by legislators on the details of the proposals to ensure successful implementation in a South African environment. / Dissertation (MCom)--University of Pretoria, 2014. / am2014 / Taxation / unrestricted

<p>Inappropriate ambulance use can be defined broadly as the use of emergency medical services (EMS) transport for non-urgent medical conditions, or when the patient does not use alternate transportation available. It drains health system resources, contributes to low morale among paramedics, and can delay care for patients who may be appropriately treated in alternative settings. An increasing number of studies indicate <em>that</em> inappropriate EMS use occurs, but few studies investigate how perspectives of inappropriate use are constructed. This study explores the construct of appropriateness in the context of ambulance use, and examines the implications of varying perspectives on ambulance billing policies.</p> <p>We present a grounded theory on the construct of appropriate ambulance use from interviews with paramedics in Ontario, national media reports and online reader commentary. Findings show that the role of paramedics varies across regions, and includes various types of care (e.g., emergency response, primary care and preventative care), and transportation (e.g., to the emergency department or urgent care clinics). In turn, constructs of appropriateness vary. In ambiguous cases, paramedics use their perception of the patients’ ability or attempts to cope with the medical situation to evaluate the appropriateness of ambulance use. Unexpectedly, the most frustrating cases of inappropriate ambulance use tend to be initiated by organizations, such as long-term care facilities, rather than members of the general public. These findings raise questions about the potential for ambulance user fees conditional on ‘appropriateness’ to improve either the effectiveness or the efficiency of ambulance services.</p> / Doctor of Philosophy (PhD)