With advancements in medical technology, the mechanics of dying and death has changed significantly. Centuries ago, people mostly died of infectious diseases. From the time they were diagnosed, to the time of their death did not take long. Today, public health has improved remarkably. We have a better control over infectious diseases, but we have to deal with cancer and other chronic illnesses. The long period of treatment for such illnesses makes us spend a lot of our time in healthcare facilities such as hospitals, hospices, and care homes. Unfortunately, in many cases, these facilities do not pay much attention to emotional and spiritual needs of their patients and are mostly designed around their own institutional and technological needs. In that regard, these buildings become pretty awful places with no natural light and long corridors. Today, due to the nature of chronic diseases that we mostly deal with, hospice care facilities are becoming more popular. The idea of a hospice is to focus on quality of the place for families and patients who have already spent a lot of their time in a hospital setting. The goal is provide humane care for patients who do not have much time left, to make sure that they live the remainder of their lives as comfortably and as fully as possible. It is important to remember that when such facilities are designed for children, we need to pay extra attention to their unique needs. It is important to provide opportunities for children with terminal illnesses to continue to learn and grow. This thesis is exploration of an architectural setting in which children with a terminal prognosis would spend the last few weeks of their lives. Located in Old Town Alexandria, Virginia, this project takes advantage of the existing nature of the site to create an oasis for families who have gone through an exhausting battle with an untreatable disease. The goal is to shift the focus from curing to healing and to create a nurturing place that helps to bring normalcy back to the lives of patients and their families. / Master of Architecture

No

The best public policy arises out of a need to provide protection to those who cannot protect themselves in the marketplace. This paper suggests that consumers with limited literacy skills are routinely overlooked within the healthcare arena and may be in need of consumer protection policies. Low literacy is generally perceived to be a stigma, and consumers may actively work to hide this fact. Moreover, given they lack literacy skills, low literate consumers employ other coping strategies to get their needs met. Based on the analysis of secondary data, in-depth interviews with adults from literacy educational centers, and observations in pharmacies, I explore the viability of the coping strategies that low literate consumers use when buying and consuming prescription and non-prescription drugs. The results suggest that while some of the strategies are successful, other strategies may lead to harmful consequences. / Master of Science

According to the World Health Organisation (WHO) the goal of universal health coverage is to ensure that all people obtain the necessary health services without being financial limped because of the payable fees. This requires: - A strong, efficient, well-run health system; - A system for financing health services; - Access to essential medicines and technologies; and - A sufficient capacity of well-trained, motivated health workers. In an effort to compliment the abovementioned, the South African government proposed the National Health Insurance System (NHIS) to address the health inequality and to improve access to quality healthcare for its citizens. The National Department of Health (NDOH) has already consulted with several stakeholders since the launch of the NHI Green Paper in August 2011. Already 11 National Health Insurance (NHI) pilot sites have been established in the nine South African provinces to assess the feasibility, acceptability, effectiveness and affordability to engage the private healthcare sector. This study aimed to evaluate the feasibility of the NHI in South Africa as well as the way in which it could be implemented to be more acceptable to all stakeholders involved. A qualitative research approach was followed due to the nature of the study. Furthermore, an exploratory methodology was applied in order to generate hypotheses. The research design for this study included a literature review, participatory data collection, semi-structured interviews and data analysis. The study found that there is a need for NHI in South Africa. However, medical practitioners (also referred to as general practitioners or GPs further in the study) feel uncertain about the implementation progress which is unclear to them. Also evident is the, fear for loss of income should the NHI be implemented and thus the remuneration package remained a main concern for all. / MBA, North-West University, Potchefstroom Campus, 2015

According to the World Health Organisation (WHO) the goal of universal health coverage is to ensure that all people obtain the necessary health services without being financial limped because of the payable fees. This requires: - A strong, efficient, well-run health system; - A system for financing health services; - Access to essential medicines and technologies; and - A sufficient capacity of well-trained, motivated health workers. In an effort to compliment the abovementioned, the South African government proposed the National Health Insurance System (NHIS) to address the health inequality and to improve access to quality healthcare for its citizens. The National Department of Health (NDOH) has already consulted with several stakeholders since the launch of the NHI Green Paper in August 2011. Already 11 National Health Insurance (NHI) pilot sites have been established in the nine South African provinces to assess the feasibility, acceptability, effectiveness and affordability to engage the private healthcare sector. This study aimed to evaluate the feasibility of the NHI in South Africa as well as the way in which it could be implemented to be more acceptable to all stakeholders involved. A qualitative research approach was followed due to the nature of the study. Furthermore, an exploratory methodology was applied in order to generate hypotheses. The research design for this study included a literature review, participatory data collection, semi-structured interviews and data analysis. The study found that there is a need for NHI in South Africa. However, medical practitioners (also referred to as general practitioners or GPs further in the study) feel uncertain about the implementation progress which is unclear to them. Also evident is the, fear for loss of income should the NHI be implemented and thus the remuneration package remained a main concern for all. / MBA, North-West University, Potchefstroom Campus, 2015

Nesta dissertação foi estudada a aplicabilidade de ferramentas e técnicas da qualidade em um hospital filantrópico, através da execução de projetos de melhoria seguindo a abordagem Lean. Objetivou-se verificar a possibilidade destas de ser uma solução para problemas de gestão de recursos enfrentados por hospitais públicos e filantrópicos brasileiros. Foi feita revisão de literatura sobre o assunto e um estudo de caso foi conduzido em uma Santa Casa de Misericórdia no interior do estado de São Paulo, onde foram aplicadas ferramentas lean. Foram relatadas diversas melhorias, dentre elas uma enorme redução de estoque, eliminação de desperdícios como excesso de deslocamento/transporte e fluxo contínuo. Foi possível concluir que o Lean foi efetivo no hospital estudado e que ainda possui grande potencial de exploração no contexto da gestão da qualidade. / In this master thesis presents the study of the applicability of quality tools and techniques in a philanthropic hospital, through the execution of improvement projects following the Lean approach. The objective was to verify the possibility of these as a solution to the problems of resource management, common problem faced by Brazilian public health hospitals. A literature review on the subject and a case study were conducted at a non-profit hospital in the interior of the state of São Paulo, where lean tools were applied. Several improvements have been reported, among them a huge reduction of stock, elimination of wastes such as excess displacement/transport and continuous flow. It was possible to conclude that the Lean was effective in the studied hospital and still has great potential for exploration in the context of quality management.

A Gestão de Riscos Corporativos (ERM), a partir das publicações da ISO 31000 em 2009 e do guia do COSO em 2007, vem sendo aplicada e adaptada às especificidades de múltiplos mercados. O contexto hospitalar, caracterizado pela necessidade de avanços em sistemas e métodos gerenciais que permitam maior acurácia de informações e sustento na orientação à tomada de decisão, passou a, também, interessar-se pelo valor da ERM. Influenciado pelos programas de qualidade e segurança do paciente e de gestão de riscos assistencial, presentes na cultura hospitalar mundial, gestores estratégicos à frente de organizações de saúde começaram a procurar por metodologias que possam ser adaptadas à complexidade de um hospital e apoiem a implementação da ERM. A literatura prévia ao desenvolvimento desta tese não apresenta um modelo que consolida e orienta a operacionalização da ERM em organizações de saúde, mas destaca em múltiplas publicações a necessidade que os hospitais têm de atentar a metodologias que permitam gerir de forma proativa e estratégica seus negócios, que estão expostos a riscos internos e externos. Motivada pela lacuna descrita, esta tese explorou o mercado brasileiro e norte americano através de entrevistas, estudos de caso e survey, e propôs um modelo global de ERM para organizações de saúde: o E2RMhealthcare. Este sugere requisitos para a operacionalização global da ERM e é fragmentado em 4 níveis: risk baseline, education, quantitative e governance que orientam uma implementação gradual, considerando a maturidade de gestão da organização. Formas de como explorar as características do hospital e capital humano para exercer a ERM também foram estudadas, sendo proposto uma relação entre as equipes de avaliação de tecnologias de saúde hospitalar e de ERM no processo de criação de valor da organização através de um mapa de causa e efeito. Como destaque do negócio saúde, essa tese inova propondo o primeiro inventário de riscos corporativos orientado a organizações de saúde que foi validado por gestores de múltiplos países, identificando o risco de ataques cibernéticos como o principal. Por fim, o uso de métodos de análise multicriterial e de custeio por atividade são aplicados como soluções inovadoras para a priorização e avaliação econômica de riscos ao longo dos níveis Baseline e Quantitative do E2RMhealthcare. O avanço do E2RMhealthcare com estas metodologias incorporadas para um software com capacidade de inteligência artificial é deixado como sugestão de trabalhos futuros além da sua real aplicação em múltiplos casos. / Since the ISO 31000 publication in 2009 and the COSO guide in 2007 Enterprise Risk Management (ERM) has been applied and adapted to the specificities of different business markets. The hospital context characterized by the demand for advances in management systems and methods that allow to improve information accuracy and to support the decision-making process, also became interested in the value of ERM. Influenced by quality and patient safety and healthcare risk management programs presents in the global hospital culture, managers at the top of healthcare organizations started to look for methodologies that can be adapted to the hospital management complexity to support the ERM implementation. The literature, prior to the development of this thesis, does not present a model that consolidates a guide to operationalize ERM in healthcare organizations. Although emphasizes, in multiple publications, the urgency for methodologies that enable proactive and strategic management of healthcare businesses, which are exposed to internal and external risks. Motivated by the described gap, this thesis explored the Brazilian and American healthcare market through interviews, case studies and survey, and proposed a global ERM model for healthcare organizations: E2RMhealthcare. It suggests requirements for global operationalization of the ERM and is organized in 4 levels: risk baseline, education, quantitative and governance that guide a gradual implementation, considering the maturity of the organization management. Different manners to explore the features of the hospital and human capital to operate the ERM were also studied, and it was proposed a relation between the hospital healthcare technology assessment teams and the ERM in the value creation process of the organization through a cause and effect map. Focusing on the healthcare business, this thesis innovates by proposing the first enterprise risk inventory aimed at healthcare organizations that was confirmed by risk managers from different countries. Cyber-attack was identified as the main enterprise risk in healhtcare. Finally, the use of multicriterial analysis methods and activity-based costing are applied as innovative solutions for prioritization and economic assessment of risks throughout the Baseline and Quantitative levels of E2RMhealthcare. The progress of E2RMhealthcare with these incorporated methodologies for a software with artificial intelligence capacity is left as a suggestion for future studies, in addition to its actual application in multiple cases.

Syftet med denna kandidatuppsats är att, via kvalitativa intervjuer, identifiera och beskriva ett landstings process för hur patient- och sjukvårdsdata, genom olika typer av dataanalyser, kan generera rättidiga beslut.   I det valda kvalitativa tillvägagångssättet skapades en semi-strukturerad intervjuguide, baserad på en analysmodell. Fem intervjuer med anställda inom fallstudieorganisationen genomfördes. För att underlätta för respondenterna och ge en tydlig helhetssyn på intervjuns innehåll, fick respondenterna innan intervjun se analysmodellen som skapats.   Deskriptiv analys är den vanligaste dataanalysmodellen som används av respondenterna, i form av verksamhets- och produktionsuppföljning. Det framgår även i undersökningen att det är viktigt med ett brett dataunderlag för beslutsfattning och att Landstinget i Värmland överlag är en mycket faktabaserad organisation. Förutsättningarna för att kunna fatta rättidiga beslut, genererade från dataanalyser, anses vara att veta vilka frågeställningar som ska besvaras, att data snabbt finns tillgänglig och att analyser utförs på denna tillgängliga data. Men även om data snabbt finns tillgängligt för beslutsfattarna och analyser gjorts, medför inte det rättidiga beslut. Data ger inte alltid en korrekt eller sann bild, utan behöver först tolkas innan besluten kan fattas. Tolkningar av data kan skilja sig åt vilket medför att ytterligare en person behöver titta på materialet, vilket också medför att besluten skjuts fram. Det anses även saknas ett enhetligt arbetssätt för hur de anställda arbetar i vårdsystemen.   Rättidiga beslut finns på olika nivåer inom landstinget. När det gäller den övergripande nivån är det inte brådskande med beslut, men ju mer operativt personalen arbetar desto viktigare är det med snabba beslut. Detta visar att ”rättidiga beslut” har olika betydelser, beroende på var i verksamheten de anställda befinner sig. Vården är tidspressad och det är inte alltid det finns möjlighet att analysera de data som finns tillräckligt mycket.

Governance of the healthcare systems is one of the most important challenges forWestern countries. Within this, an accurate assessment of the quality is key to policy makers and public managers, in order to guarantee equity, effectiveness and efficiency. In this thesis, we investigate aspects and methods related to healthcare evaluation by focussing on the healthcare system in Lombardy (Italy), where public and private providers compete with each other, patients are free to choose where to be hospitalized, and a pay-for-performance program was recently implemented. The general aim of this thesis is to highlight the role of statistics within a quality evaluation framework, in the form of advancing the statistical methods used to measure quality, of evaluating the effectiveness of implemented policies, and of testing the effect that mechanisms of competition and cooperation can have on the quality of a healthcare system. We firstly advance a new methodological approach for measuring hospital quality, providing a new tool for managers involved in performance evaluations. Multilevel models are typically used in healthcare, in order to account for the hierarchical structure of the data. These models however do not account for unobserved heterogeneity. We therefore propose an extension of the cluster-weighted models to the multilevel framework and focus in particular on the case of a binary dependent variable, which is common in healthcare. The resulting multilevel logistic cluster-weighted model is shown to perform well in a healthcare evaluation context. Secondly, we evaluate the effectiveness of a pay-for-performance program. Differently from the existent literature, in this thesis we evaluate this program on the basis of five health outcomes and across a wide range of medical conditions. Availability of data pre and post-policy in Lombardy allows us to use a difference-in-differences approach. The statistical model includes multiple dependent outcomes, that allow quantifying the joint effect of the program, and random effects, that account for the heterogeneity of the data at the ward and hospital level. The results show that the policy has overall a positive effect on the hospitals' performance. Thirdly, we study the effect of pro-competition reforms on the hospital quality. In Lombardy, competition between hospitals has been mostly driven by the adoption of a quasi-market system. Our results show that no association exists between hospital quality and competition. We speculate that this may be the result of asymmetric information, i.e. the lack of transparent information provided to citizens about the quality of hospitals. This is bound to reduce the impact of pro-competition reforms on quality and can in part explain the conflicting results found in the literature on this subject. Our results should motivate a public disclosure of quality evaluations. Regardless of the specifics of a system, hospitals are altruistic economic agents and they cooperate in order to improve their quality. In this work, we analyse the effect of cooperation on quality, taking the network of patients' transfers between hospitals as a proxy of their level of cooperation. Using the latest network models, we find that cooperation does lead to an increase in quality and should therefore be encouraged by policy makers.

Nesta dissertação foi estudada a aplicabilidade de ferramentas e técnicas da qualidade em um hospital filantrópico, através da execução de projetos de melhoria seguindo a abordagem Lean. Objetivou-se verificar a possibilidade destas de ser uma solução para problemas de gestão de recursos enfrentados por hospitais públicos e filantrópicos brasileiros. Foi feita revisão de literatura sobre o assunto e um estudo de caso foi conduzido em uma Santa Casa de Misericórdia no interior do estado de São Paulo, onde foram aplicadas ferramentas lean. Foram relatadas diversas melhorias, dentre elas uma enorme redução de estoque, eliminação de desperdícios como excesso de deslocamento/transporte e fluxo contínuo. Foi possível concluir que o Lean foi efetivo no hospital estudado e que ainda possui grande potencial de exploração no contexto da gestão da qualidade. / In this master thesis presents the study of the applicability of quality tools and techniques in a philanthropic hospital, through the execution of improvement projects following the Lean approach. The objective was to verify the possibility of these as a solution to the problems of resource management, common problem faced by Brazilian public health hospitals. A literature review on the subject and a case study were conducted at a non-profit hospital in the interior of the state of São Paulo, where lean tools were applied. Several improvements have been reported, among them a huge reduction of stock, elimination of wastes such as excess displacement/transport and continuous flow. It was possible to conclude that the Lean was effective in the studied hospital and still has great potential for exploration in the context of quality management.