L’annonce d’un diagnostic de cancer devrait être considérée par les professionnels de la santé, comme un processus constitué de plusieurs étapes que doit traverser la personne atteinte, plutôt que comme un évènement en soi (Tobin & Begley, 2008). Lors de la période entourant l’annonce du diagnostic, la personne peut être confrontée à des difficultés reliées à la navigation dans un système de santé complexe, en plus des sentiments négatifs engendrés par la crainte de la maladie. Pour soutenir les personnes atteintes de cancer, le programme québécois de lutte contre le cancer (PQLCC), a instauré le rôle de l’infirmière pivot en oncologie (IPO) en 2000. À l’heure actuelle, peu d’études, à notre connaissance, se sont attardées au soutien de l’IPO dans cette période. La présente étude avait pour but, d’explorer les perceptions de personnes atteintes de cancer quant au soutien offert par l’IPO, dans la période entourant l’annonce du diagnostic. L’étudiante-chercheuse s’est inspirée du Cadre de soins de soutien de Fitch (1994) pour entreprendre cette étude qualitative descriptive. Des entrevues individuelles auprès de sept personnes atteintes de différents cancers ont été réalisées. L’analyse de données a été effectuée à l’aide de la méthode de Miles et Huberman (2003), par la transcription intégrale des entrevues. Elle a permis d’identifier trois thèmes soit : le soutien formel requis pour faire face au chaos, le soutien informationnel et émotionnel à parfaire et le soutien disponible apportant sécurité et assurance. Les résultats ont mis en évidence les perceptions de personnes atteintes de cancer quant au soutien offert par l’IPO soit la nécessité de rendre accessible les soins et services de l’IPO plus tôt dans la période entourant l’annonce du diagnostic. Les personnes atteintes de cancer ont besoin d’être aidées à faire face aux difficultés rencontrées lors de cette période, notamment à l’incertitude reliée aux résultats d’examens diagnostics, à l’incompréhension des informations reçues et aux sentiments négatifs engendrés par la menace de la maladie. Les résultats évoquent le souhait des participants, à l’effet que, l’offre de soutien de l’IPO, soit axée sur leurs besoins essentiellement dans les domaines informationnel et émotionnel. Ils auraient souhaité pouvoir, partager leur expérience avec l’IPO, mieux comprendre le diagnostic de cancer et savoir davantage à quoi s’attendre lors du début des traitements. Par ailleurs, savoir que le soutien de l’IPO est disponible apporte aux personnes atteintes de cancer une assurance et une confiance en leur capacité à faire face aux traitements et leur apporte un sentiment de sécurité. / The announcement of a diagnosis of cancer should be considered by health professionals, a composed process of several steps that must pass through the person, rather than as an event in itself (Tobin & Begley, 2008). During the period surrounding the announcement of the diagnosis, the person may be faced with difficulties related to navigation in a complex health system, in addition to the negative feelings engendered by the fear of disease. To support people with cancer, the PQLC (French acronym of the Quebec Cancer Control Program) has established the oncology nurse navigator (ONN) role in 2000. At the present time, few studies, to our knowlecdge, are both in support of the ONN in this period. This study was designed, to explore the perceptions of people with cancer as regards the support offered by the ONN, in the period surrounding the announcement of the diagnosis. The student-researcher is inspired by the framework of Fitch supportive care (1994) to undertake this descriptive qualitative study. Individual interviews with seven people with different types of cancer were performed. Data analysis was performed using the method of Miles and Huberman (2003), by the full transcripts of the interviews. It has identified three themes is: formal support required to deal with the chaos, the informational and emotional to perfect and available support bringing security and insurance. The results highlighted the perceptions of people with cancer as regards the support offered by ONN or the need for accessible health care and services of the ONN earlier in the period surrounding the announcement of the diagnosis. People with cancer need to be helped to cope with the difficulties encountered during this period, including uncertainty about the results of diagnostic tests, to the bemusement of the information received and the negative feelings engendered by the threat of the disease. The results suggest the wish of the participants, to the effect that, the offer of support from the ONN, focuses on their needs mainly in both informational and emotional. They would have liked to be able to share their experience with the IPO, better understand the diagnosis of cancer and know more what to expect at the beginning of treatment. On the other hand, know that the support of the ONN is available brings to people with cancer insurance and a confidence in their ability to cope with treatment and brings them a sense of security.

近年來，隨著臺灣醫療產業的重要性漸增及其所面臨的種種挑戰，個別醫院面臨的生存壓力漸增，醫院組織的策略議題也漸受重視，過去文獻多著重於營利組織的策略管理探討，醫院組織雖非以營利為目的，卻仍須重視成本控管與績效表現，以提供更優質的醫療服務，其中，提升資源運用與配置效率是相當重要的課題。 智慧資本導航分析法(ICN)過去多應用於營利企業，本研究目的在於引進ICN分析技術，以量化指標和圖形呈現輔助，分析醫院對於智慧資本資源運用之管理議題。本研究以某個案醫院為例，研究期間歷時10個月，訪談對象為8位來自醫院各部門的高階經營主管，於專業領域的經歷與年資皆相當豐富，各主管針對醫院資源的相對比重及資源間的轉換進行評估，並提出理想狀況的資源轉換關係，作為未來策略發展的參考依據。 研究結果分別回答三大研究議題，就醫院中各項資源的轉換關係來看，「人力資本」主要貢獻於醫師、醫療人員及聲譽形象，且期望於未來投入更多於組織策略與行銷的能力提升和顧客關係的建立；「組織資本」主要貢獻於行政人員、醫師、醫療人員、資訊管理、創新學習、財務管理和流程管理，以吸引人才、提升人力素質和提升組織管理效率為組織創造價值；「關係資本」主要貢獻於強化組織與外部利害關係人之關係。就各項資源間轉換的對稱性而言，各項資本對「關係資本」的投入普遍大於從「關係資本」所獲得的反饋，代表組織未來可思考提升「關係資本」對其他資本的貢獻。此外，傳統資源對智慧資本的貢獻亦大於從智慧資本所獲得的反饋，部分原因可能來自智慧資本的反饋較難具體衡量，而未來仍應以策略目標作為提升智慧資本運用效率的前提。最後，就個案醫院而言，「人力資本」不僅是最重要的資源，同時也是組織價值創造的來源，其中又以醫師、醫療人員和高階管理為主，代表知識與專業是醫院高績效表現最重要的兩項資源。 / This research aims at adopting the intellectual capital perspective and its analytical approach in the managerial practice of a health-care organization. The concept of intellectual capital has been applied to the practice of for-profit organizations. However, health-care organizations, which were regarded as non-for-profit, have not been paied close attention to their resource management. Based on intellectual capital perspective, this research introduces Intellectual Capital Navigator (ICN) approach to evaluate the efficiency of using resources.. This research is conducted by an in-depth study on a hospital, demonstrating the importance of needed resources and analyzing the resource transformation among human capital, organizational capital, relational capital, physical capital and monetary capital. The conclusion of this research found that human capital contributed more to itself and organizational capital. Moreover, it is expected to contribute more to relational capital in the future. When it comes to the symmetry of transformations, ICN analysis shows that each capital contributed to relational capital more than getting from it, and that traditional capital contributed to intellectual capital more than getting from them. This study also found that human capital is the most important value source in the hospital. Therefore, the hospital should pay more managerial attention to the balance and asymmetric transformation among resources to enhance the effectiveness and efficieny of its resource management. The adoption of ICN analytical approach into health-care organization extends the application of intellectual capital management.

Syfte: Att skapa förutsättningar för en förbättrad cancervård, genom att fördjupa kunskapen och förståelsen om behov hos huvud- och halscancerpatienter under cancerprocessen. Därutö- ver önskas ett förbättrat omhändertagande genom att implementera och utvärdera kvalitetshö- jande förbättringsinsatser. Satsningen ska resultera i en trygg och smidig resa genom vården med ett minimum av avbrott mellan olika vårdhändelser. Metod: Patientens vårdkedja studerades med en fallstudie, utifrån en aktionsforskningsansats. Behoven identifierades med patientskuggning, reflektion från observationer och semistruktu- rerade fokusgruppsintervjuer med mikrosystemet, före (referensgrupp) och efter intervention (jämförelsegrupp). Analys genomfördes med kvalitativ innehållsanalys och Kano-modell. Resultat: En fast vårdkontakt var en viktig faktor i vårdkedjan. Den fasta vårdkontakten till- mötesgick behov såsom trygghet och tillgänglighet, vilket medförde en smidigare vårdkedja. Under hela vårdförloppet fanns ett stort behov av stöd, praktiskt liksom psykosocialt, från både profession och närstående. Oberoende av position i vårdkedjan önskades individanpas- sad information och ett gott bemötande. Interventionsgruppen rapporterade bättre tillgänglig- het och stöd i förhållande till jämförelsegruppen, som inte hade tillgång till kontaktsjukskö- terska. Involvering av hela mikrosystemet vid analys med Kano-modell medför att behov och förbättringsmöjligheter identifieras och valideras. Slutsatser: En kontaktsjuksköterska kan utgöra en fast vårdkontakt som tillmötesgår och sä- kerställer cancerpatienters behov. Närstående är en viktig del av mikrosystemet och måste beredas utrymme och resurser. En förbättringsinsats genom implementering av kontaktsjuk- sköterska, utformning av nutritions- och kvalitetsregisterrutiner baserat på patientens behov bidrar till god vård och minskar risken för resursslöseri. Studien har även bidragit med fördju- pad kunskap gällande applicering av Kano-modellen i Hälso- och sjukvårdsmiljö. / Purpose: To create opportunities for an improved cancer care, by providing deeper knowledge and understanding of the needs of head and neck cancer patients during the cancer treatment process. Furthermore, to improve care for these patients by implementing and eval- uating QI efforts. This will result in a safe and smooth journey through the care with a mini- mum of disruption. Method: The cancer treatment process was examined in a case study with an action research approach. Patient needs were identified by patient-shadowing, observational reflections and focus groups-interviews with the microsystem, before (non-intervention group) and after in- tervention (intervention group). The data analysis involved qualitative content analysis in- formed by Kano’s quality model. Results: A contact nurse (CN) was an important factor. The CN provided a sense of security and accessibility, giving patients a smoother trajectory of care. Continual support was needed, regarding both, practical and psychosocial matters, from both professionals and relatives. Re- gardless of position in the continuum of care, individual information and good reception was required. Members of the intervention group reported better accessibility and support com- pared to the non-intervention group members, who were not offered a CN. Conclusion: A CN can provide a continual health care contact; meeting and ensuring that the needs of cancer patients are met. Relatives are an important part of the microsystem and should be given space and resources. An improvement effort by implementing routines for a CN, quality registry and nutrition, based on patient needs will facilitate good care and opti- mise resources. The study has also contributed to deeper knowledge of how to use the Kano model in health care.

Cardiac magnetic resonance (MR) imaging can non-invasively assess heart function. Displacement encoding with stimulated echoes (DENSE) is an advanced cardiac MR imaging technique that measures tissue displacement and can be used to quantify cardiac mechanics (e.g. strain and torsion). When combined with clinical risk factors, cardiac mechanics have been shown to be better predictors of mortality than traditional measures of heart function. End-expiratory breath-holds are typically used to minimize respiratory motion artifacts. Unfortunately, requiring subjects to breath-hold introduces limitations with the duration of image acquisition and quality of data acquired, especially in patients with limited ability to hold their breath. Thus, DENSE acquisitions often require respiratory navigator gating, which works by measuring the diaphragm during normal breathing and only acquiring data when the diaphragm is within a pre-defined acceptance window. Unfortunately, navigator gating results in long scan durations due to inconsistent breathing patterns. Also, the navigator echo can be used in different ways to accept or reject image data, which creates several navigator configuration options. Each respiratory navigator configuration has distinct advantages and disadvantages that directly affect scan duration and image quality, which can affect derived cardiac mechanics. Scan duration and image quality need to be optimized to improve the clinical utility of DENSE. Thus, the goal of this project was to optimize those parameters. To accomplish this goal, we set out to complete 3 aims: 1) understand how respiratory gating affects the reproducibility of measures of cardiac mechanics, 2) determine the optimal respiratory navigator configuration, and 3) reduce scan duration by developing and using an interactive videogame to optimize navigator efficiency. Aim 1 of this project demonstrated that the variability in torsion, but not strain, could be significantly reduced through the use of a respiratory navigator compared to traditional breath-holds. Aim 2 demonstrated that, among the configuration options, the dual-navigator configuration resulted in the best image quality compared to the reference standard (traditional breath-holds), but also resulted in the longest scan duration. In Aim 3, we developed an interactive breathing-controlled videogame and demonstrated that its use during cardiac MR can significantly reduce scan duration compared to traditional free-breathing and also led to a small improvement in signal-to-noise ratio of the acquired images. In summary, respiratory navigator gating with DENSE 1) reduces the variability in measured LV torsion, 2) results in the best image quality with the dual-navigator configuration, and 3) results in significantly shorter scan durations through the use of an interactive videogame. Selecting the optimal navigator configuration and using an interactive videogame can improve the clinical utility of DENSE.

In real world applications such as rescue robots, service robots, mobile mining robots, and mine searching robots, an autonomous mobile robot needs to reach multiple goals with the shortest path while avoiding obstacles. In this thesis, we propose Artificial Immune System (AIS) based algorithms and two hybrids based on AIS associated with the Simulated Annealing (SA) algorithm and Voronoi Diagram (VD) for real-time map building and path planning for multi-goal applications. A global route is initially planned by the Immune System Algorithm (ISA). Then the created path is used to guide the robot to multiple waypoints following the foraging trail. An AIS-based point-to-point navigator is also proposed and tested here, which is used to navigate the robot along a collision-free global route. The proposed hybrid ISA model integrated with SA or VD algorithm aims to generate paths while a mobile robot explores terrain with map building in an unknown environment. We explore the ISA algorithm with simulation and comparison studies to demonstrate the capability of the proposed hybrid model of AIS and SA or AIS and VD algorithms in achieving a global route with minimized overall distance. Simulation and comparison studies validate the efficiency and effectiveness of the proposed hybrid models. They also confirm that concurrent multi-waypoint navigation with obstacle avoidance and mapping of an autonomous robot is successfully performed under unknown environments.

In an era of value based purchasing and healthcare reform, hospitals face the challenge of delivering high quality care in an environment of diminishing resources. This performance improvement project describes the use of master’s prepared nurses on medical surgical units to improve quality and patient satisfaction. The setting was five medical surgical units in a 200+ bed hospital in the southeastern United States. Declining resources necessitated an increase in the nurse to patient ratios on the units (from 5:1 to 6:1). The project involved the modification of the model of care through the change in nurse/patient ratios and the addition of master’s prepared nurses to coordinate and supplement the care of the staff RNs for complex patients. While inconclusive, the literature review confirmed the impact of master’s prepared nurses on quality metrics and did not conclusively confirm that delivering high quality, safe care was not possible with nurse/patient ratios of 1:6. The goal of the project was to determine if the presence of the master’s prepared nurse could mitigate the changes in ratios and produce high quality and satisfaction outcomes. Measures of success were drawn from archived standardized quality measures in the realms of service (HCAHPS questions), patient safety (CABSI, HAPU) and quality outcomes (core measures and 30 day readmissions). The project design was a retrospective, one-group pre-post design looking at two six-month intervals—before and after project implementation. Results demonstrated sustained or improved quality in six of ten measures. Highest positive impact was in readmissions and nurse sensitive indicators. The most negative results were in patient satisfaction. Modifying the model of care is an iterative process requiring continued evaluation and changes to improve outcomes. Results of this project supported the further evaluation of staffing and expansion of the number of master’s prepared nurses on medical surgical units.