Avoidable hospitalizations of hospice patients cost Medicare $3 billion a year. When hospice nurses are able to identify early signs and symptoms of acute illness and provide appropriate interventions to prevent such admissions, 20-60% of the hospitalizations are preventable. The practice problem addressed in this quality improvement doctor of nursing project was the 30% hospital admission rate of hospice patients as evidenced by chart review, admission data, and revocation data. The first purpose of the project was to identify evidence-based nursing care paths in the literature for the top 5 medical diagnoses related to avoidable hospital admissions. The second purpose was to develop an educational curriculum to educate the staff on the care paths with a pretest/posttest to assess knowledge gained from the education. Rosswurm and Larrabee's conceptual model was used to frame the project. Three content experts evaluated the curriculum plan using a 4 item dichotomous rating of 1 (not met) and 2 (met). An average score of 2 revealed that the curriculum content met the course objectives. Content experts validated each of the 16 pretest/posttest items using a Likert scale ranging from 1 (not relevant) to 4 (highly relevant). The content validation index score was .94, indicating that the pretest/posttest reflected the course objectives and content. Recommendations were made for structuring the pretest/posttest. The project promotes social change by assessing, intervening, and treating patients in the outpatient hospice setting to prevent avoidable hospitalizations, thus promoting patient well-being and fiscal responsibility of healthcare dollars.

There has been a long standing discourse around youths involved in crimes in Sweden, which contributions are useful and which ones are not. This study examines how outpatient care organizations work with youths involved in crime and/or substance abuse. Also what strengths and shortcomings do the professionals experience when working with youths involved in crime and/or substance abuse during outpatient care treatment. We examined this by doing a qualitative study, interviewing an outpatient care organization with the target group youths involved in crime and/or substance abuse. Through open interviews the professionals gave insight to how their work is carried out, and what they believe to be it’s strengths and weaknesses. The study brought forward that flexibility, cooperation with other involved organizations and authorities and creating an alliance with the young receiving the care is what makes the outpatient care treatment work. The professionals question socio-economic structures that put youth at risk for this kind of norm-breaking behavior. System Theory is used to make an analysis of the work done by the informants, giving another perspective to how it can be interpreted. This alongside earlier research is the basis of this research paper to help us create a better understanding for how outpatient care organizations work with youths involved in crime and/or substance abuse and what interventions benefit the work and what exacerbate it.

Bakgrund: Psykisk ohälsa ökar i Sverige. Rapporter visar att patienter med psykisk ohälsa utsätts för stigmatiserande attityder och bristande vård. Att belysa omvårdnadspersonals erfarenheter kan leda till en djupare förståelse för vården av patienter med psykisk ohälsa. Syfte: Att belysa omvårdnadspersonals erfarenheter av att vårda patienter med psykisk ohälsa inom öppenvården i Sverige. Metod: Litteraturstudien baserades på åtta kvalitativa artiklar. Sökningar genomfördes i databaserna CINAHL och Pubmed. Analysen baserades på Graneheim och Lundmans (2004) artikel. Resultat: Analysen resulterade i tre huvudteman: "behovet av mer resurser”, “vikten av kompetens” och "en krävande professionell roll". Konklusion: Vården av patienter med psykisk ohälsa är komplex och det finns ett behov av mer resurser i form av tid, utbildning och interprofessionellt samarbete för att göra omvårdnadspersonal mer trygga och mötet mer givande. I dagsläget orsakar dessa möten omvårdnadspersonal stress och känslor av otillräcklighet. / Background: The frequency of mental illness is increasing in Sweden. Reports show that patients with mental illness are exposed to stigmatizing attitudes and lack of care in healthcare. Highlighting the experiences of nursing staff can lead to a deeper understanding of the care of patients with mental illness. Aim: To illuminate nursing staff’s experiences of caring for patients with mental illness in outpatient care in Sweden. Methods: Qualitative literature study based on eight articles. Searches were conducted in Cinahl and Pubmed. The analysis was conducted based on a model by Graneheim and Lundman (2004).   Results: The analysis resulted in three themes; “the need for more resources”, “the importance of competence” and “a demanding professional role”. Conclusion: Caring for patients with mental illness is a complex matter and there is a need for additional resources in the shape of time, education and interprofessional collaboration. This in order to make nursing staff more comfortable and the meetings more rewarding. At present these meetings cause stress and feelings of inadequacy in nursing staff.

Bakgrund: Handledning kan ge sjuksköterskan möjlighet att reflektera, avreagera sig, bearbeta känslor och minska stress och känslor av otillräcklighet. Sjuksköterskor kan få ett ökat självförtroende av handledning och en ökad sammanhållning med varandra men att handledas i grupp kan vara en utmaning då det ställer krav på både öppenhet och engagemang. Syfte: Syftet med föreliggande studie var att beskriva sjuksköterskor upplevelse av grupphandledning inom öppen psykiatrisk beroendevård. Metod: Studien har en kvalitativ design med semistrukturerade intervjuer för datainsamling. Nio sjuksköterskor intervjuades och materialet analyserades med kvalitativ innehållsanalys. Resultat: Studiens resultat presenteras utifrån fyra huvudkategorier; att genom handledning reflektera över sitt omvårdnadsparadigm, att genom handledning skapa ett sjukskötersketeam, att genom handledning förstå vad som förväntas av sjuksköterskan och att genom handledning lära känna sig själv bättre. Huvudkategorierna har sammanlagt nio underkategorier. Diskussion: Studiens resultat diskuteras mot Antonovskys KASAM (begriplighet, hanterbarhet och meningsfullhet) samt annan litteratur och vetenskapliga artiklar. Studiens resultat visade att sjuksköterskorna med hjälp av handledning kan minska risk för utbrändhet och känsla av maktlöshet och frustration, öka tilliten till varandra i arbetsgruppen, öka autonomi och självförtroende och hjälpa sjuksköterskan hantera de känslor som uppstår i mötet med patienten / Background: Supervision can give the nurse the possibility to reflect, let of steam, process emotions and reduce stress and feelings of inadequacy. Nurses can get increased self-confidence and a better coherence with each other but to have group supervision can be a challenge because it demands openness and commitment. Aim: The aim of this study was to describe nurses experience of clinical group-supervision in psychiatric dependency care clinics. Method: The study has a qualitative design with semi-structured interviews for data collection. Nine nurses were interviewed and the material was analyzed with qualitative content analysis. Results: The results of the study is represented in four main categories; to reflect on the caring paradigm through supervision, to create a nursing team through supervision, to understand what is expected from the nurse through supervision and to get to know your self better through supervision. The main categories has all together nine appurtenant subcategorys. Discussions: The result of the study is discussed with Antonovskys KASAM (comprehensebility, manageability and meaningfulness) and other literature and scientific articles. The result of the study showed that the nurses could use the supervision to reduce the risk of burnout and feelings of incapacity and frustration, increase the trust to each other in the working group, increase autonomy and self-confidence and to handle the feelings that arises in the meeting with the patient.

The aim of this thesis is to investigate ways of assessing economic efficiency of outpatient health care providers. It analyzes feasibility of employment of risk-adjustment and profiling in the Czech Republic using administrative data reported to health insurance company in the field of otorhinolaryngology. First, the thesis provides an overview of economic profiling methods. Out of these, indirect standardization of costs with risk-adjustment on patient level was used in the empirical part. Next, methods addressing specific problems of health care data (in particular, skewness, excess of zero values and non-negativity) are explored. Using OLS on logarithms on positive part of the distribution, three representations of costs were estimated, based on selected risk-factors. Several patient factors proved significant in final models (specifically, age, gender, number of hospitalizations, region of residence and chronic conditions asthma, COPD and depression), however, the quality of the model is extremely poor. Reasons for dissatisfactory fit of models are various. We conclude that data-selection process is not appropriate to perform economic comparison. And care of outpatient otorhinolaryngology is extremely specific to be captured by information provided. Still, profiling of providers is performed...

A qualidade da assistência médica e dos serviços de saúde é uma questão que nas últimas décadas passou a ser motivo de crescente interesse tanto nos meios científicos e políticos, como na sociedade como um todo. À medida que foram se tornando conhecidos uma grande quantidade de problemas que afetam a prestação de serviços de saúde, a questão da avaliação da qualidade de cuidados médicos passou a ser não apenas um motivo de interesse, mas também uma prioridade entre os responsáveis pela formulação de políticas sociais e de saúde. Enquanto que em vários países a avaliação da qualidade de serviços vem ocorrendo de forma sistemática, no Brasil isso não tem ocorrido, principalmente no que diz respeito à avaliação qualitativa. O estudo desenvolvido nesta tese se propõe a avaliar qualitativamente um serviço ambulatorial de saúde mental. Os principais objetivos deste trabalho são: 1) avaliar o grau de satisfação dos pacientes com o tratamento recebido no serviço estudado; 2) analisar a interrelação entre o processo de prestação de serviços e os resultados finais do tratamento para se avaliar a qualidade da atenção prestada; e 3) determinar o peso que diferentes fatores, tais como processo de prestação de serviço, características individuais dos pacientes, e fatores relacionados à doença, podem ter na determinação de que o resultado final do tratamento possa ser considerado positivo ou negativo. Foram sujeitos deste estudo os pacientes atendidos no Ambulatório de Saúde Mental da Faculdade de Medicina de Botucatu como \"casos novos\" (1a consulta) de Psiquiatria durante os anos de 1989 e 1990, procedentes de Botucatu e São Manoel e portadores dos diagnósticos da \"CID\"-9 (1975) \"Transtornos neuróticos\", \"Reações de ajustamento\" e diagnósticos do \"Código V\" (V.61, V.62 e V.ll). Os dados sobre o tratamento dos pacientes foram coletados das fichas de agendamento de consultas, dos prontuários médicos e de questionários aplicados aos pacientes em entrevistas domiciliares. Dos 1155 pacientes atendidos como \"casos novos\" foram incluídos nesta pesquisa 289 pacientes. Em função dos pacientes que não puderam responder às entrevistas domiciliares, contamos com um total de 211 pacientes dos quais obtivemos informações tanto dos prontuários médicos, como das entrevistas domiciliares. A análise estatística realizada pode ser dividida em duas fases: 1) onde foram obtidas informações através da distribuição de freqüências e associações entre variáveis, e 2), onde foram utilizados métodos de análise multivariada. Em 66.5 por cento dos casos os pacientes referiram sentir-se \"melhor\" como resultado do tratamento recebido, índice bastante similar ao da percepção do médico de \"melhora com o tratamento\" (65,7 por cento). Em 70,1 por cento dos casos os pacientes referiam estar satisfeitos com o tratamento. Neste estudo, as pessoas relacionadas com o tratamento como o médico e funcionários da recepção foram avaliados positivamente enquanto que alguns fatores organizativos foram avaliados mais negativamente. Como em outros estudos, a satisfação geral esteve altamente associada com a percepção de melhora do paciente. Diferentemente de outros trabalhos, neste, a satisfação também esteve fortemente associada à percepção de melhora por parte do médico. São apresentados e discutidos vários aspectos do processo de assistência que estiveram associados aos resultados finais do tratamento. Analisando-se a interrelação de muitas das variáveis do processo com os resultados obtidos, podemos chegar à algumas conclusões \"aproximadas\" sobre a qualidade do serviço, que poderão servir para que se possam tomar ·decisões pragmáticas sobre a organização do serviço, ainda que em última instância não nos permitam responder de forma precisa à pergunta contida em um de nossos objetivos: \"qual foi o nível de qualidade da assistência prestada?\". Isso porque nos faltam critérios e \"standards\" explícitos aplicáveis a nosso meio. O desenvolvimento desses critérios e padrões explícitos de qualidade deveriam ser um objetivo prioritário de futuras pesquisas na área da avaliação qualitativa em Saúde Mental. Com relação ao \"peso que diferentes fatores podem ter na determinação do resultado final do tratamento\", pode-se dizer que algumas características da doença tiveram pouco peso na determinação dos resultados, enquanto que certas características do paciente como sexo e renda per-cápita estiveram associadas de forma significante com os resultados do tratamento. Comentamos com detalhes esses dados, e salientamos que tais achados são válidos no contexto \"deste\" estudo. Além dessas duas características, também descrevemos outras variáveis ligadas ao processo, que estiveram altamente associadas à determinação dos resultados, através da análise multivariada. A \"satisfação com o tratamento\" foi a variável que mais fortemente esteve associada aos resultados finais. Do referido acima poderíamos concluir que atingimos o objetivo de verificarmos em que extensão, certos fatores podem interferir nos resultados finais. Para finalizar, pudemos avaliar o grau de satisfação dos pacientes com o tratamento recebido. Tal avaliação foi de extrema importância nesta pesquisa, no sentido da complementaridade de informações que possibilitou, ao proporcionar a visão subjetiva do usuário que pôde ser somada aos dados obtidos do prontuário. Levando-se em consideração a situação atual das pesquisas qualitativas em nosso meio, sugere-se os estudos na linha da avaliação da satisfação com a assistência recebida sejam os que se mostrem mais factíveis de serem realizados, e em termos de resultados produzidos, poderiam ser tão bons quanto outros métodos para a avaliação da qualidade de serviços de saúde mental. / The interest in the quality of medical care and health services has been an issue that, in the last decades, has grown not only in the scientific and political arenas, but in the society as a whole. As the problems concerning the quality of health care delivery were known, the issue of their evaluation has been not only an issue of interest, but also a priority among the decision makers in the field of social and health policy. While in several countries the evaluation of health services is being sistematically developed, this has not been so in Brazil, and with special emphasis in qualitative evaluation. The aim of this thesis is to develop a qualitative evaluation of a mental health outpatient service. The main objectives of this dissertation are: 1) to evaluate the patients satisfaction level with the treatment that they received in the service; 2) to analyze the relationship between the health care delivery process and the final treatment outcome in order to evaluate the health care delivery quality; and 3) to determine the weight that several factors, such as the health delivery process, the patients individual characteristics, and factors related to the illness, can have in the final positive or negative treatment outcome. The subjects of this study were the patients treated in the outpatient mental health service of the Botucatu Medical School as \"New Patients\" (1st visit) during the years 1989 and 1990, coming from Botucatu and São Manoel Municipalities, and with the ICD-9 (1975) diagnosis \"neurotic disorders\", \"adjustment reactions\" and some \"V Code\" diagnosis (V.61, V.62, V.ll). The patients\' treatment data were collected from the scheduling records, medical records and home interviews applied to the patients. Among the 1155 patients that were examined as \"new patients\" 289 were included. From these, we obtained data from both, home interviews and the medical record with a final total of 211 patients. The statistical analysis can be divided into two phases: 1) when the information was obtained from the frequency distribution and correlations among variables, and 2) from multivariate analysis techniques. From all the patients, 66.5 per cent of them said to feel \"better\" after receiving treatment, a percentage quite similar to that o f the physician\'s perception of \"improvement with the treatment\" (65.7 per cent). In 70,1 per cent of the cases the patients said to be satisfied with the treatment. In our case, while people related with treatment such as the physicians and the reception employees were positively evaluated, some organizational factors related to the service were evaluated negatively. As in other studies, the overall satisfaction was highly correlated to the patients\' perception of improvement. Contrary to other studies, in this one, satisfaction was also highly correlated to the perception of improvement by the physician. Several aspects of the health delivery process related to treatment outcomes are presented and discussed. Analysing the relationship of several process variables with the outcomes, we obtained some conclusions about the service quality. These conclusions can be used to make decisions about the service organization, although these cannot be used to answer in a strict sense the question: \"what was the quality level of health care achieved?\". This is due to the lack of explicit crieteria and standards that can be used in our cultural context. The development of these explicit crieteria should be a prioritary goal of further research in the area of quality evaluation in mental health care. With regards to the \"weight that different factors can have in the treatment outcome\", while some illnesses\' characteristics had a relatively low weight in the outcome, some patients characteristics such as sex and personal income were highly weighted. These results are extensively presented, and we stress that our conclusions are valid within the context of this study. Besides these two characteristics, we also describe other variables related to the process that we found to be highly related to the outcome using multivariate analysis. The \"treatment satisfaction\" was the most significant variable related to the final outcome. From these results we concluded that the objective of verifying that some factors can interfere in the final results has been achieved. Finally, we were able to fully evaluate the patients\' satisfaction level with the treatment received. Such evaluation was quite important for our research, because the subjective point of view of the patient provided complementary information to the data obtained from medical records. If we take into account the actual state of the art of the research on quality in our country, possibly the studies based on the evaluation of patients\' satisfaction with the treatment received are the most feasible and, in terms of the results obtained, as good as other methods of mental health service quality valuation.

A qualidade da assistência médica e dos serviços de saúde é uma questão que nas últimas décadas passou a ser motivo de crescente interesse tanto nos meios científicos e políticos, como na sociedade como um todo. À medida que foram se tornando conhecidos uma grande quantidade de problemas que afetam a prestação de serviços de saúde, a questão da avaliação da qualidade de cuidados médicos passou a ser não apenas um motivo de interesse, mas também uma prioridade entre os responsáveis pela formulação de políticas sociais e de saúde. Enquanto que em vários países a avaliação da qualidade de serviços vem ocorrendo de forma sistemática, no Brasil isso não tem ocorrido, principalmente no que diz respeito à avaliação qualitativa. O estudo desenvolvido nesta tese se propõe a avaliar qualitativamente um serviço ambulatorial de saúde mental. Os principais objetivos deste trabalho são: 1) avaliar o grau de satisfação dos pacientes com o tratamento recebido no serviço estudado; 2) analisar a interrelação entre o processo de prestação de serviços e os resultados finais do tratamento para se avaliar a qualidade da atenção prestada; e 3) determinar o peso que diferentes fatores, tais como processo de prestação de serviço, características individuais dos pacientes, e fatores relacionados à doença, podem ter na determinação de que o resultado final do tratamento possa ser considerado positivo ou negativo. Foram sujeitos deste estudo os pacientes atendidos no Ambulatório de Saúde Mental da Faculdade de Medicina de Botucatu como \"casos novos\" (1a consulta) de Psiquiatria durante os anos de 1989 e 1990, procedentes de Botucatu e São Manoel e portadores dos diagnósticos da \"CID\"-9 (1975) \"Transtornos neuróticos\", \"Reações de ajustamento\" e diagnósticos do \"Código V\" (V.61, V.62 e V.ll). Os dados sobre o tratamento dos pacientes foram coletados das fichas de agendamento de consultas, dos prontuários médicos e de questionários aplicados aos pacientes em entrevistas domiciliares. Dos 1155 pacientes atendidos como \"casos novos\" foram incluídos nesta pesquisa 289 pacientes. Em função dos pacientes que não puderam responder às entrevistas domiciliares, contamos com um total de 211 pacientes dos quais obtivemos informações tanto dos prontuários médicos, como das entrevistas domiciliares. A análise estatística realizada pode ser dividida em duas fases: 1) onde foram obtidas informações através da distribuição de freqüências e associações entre variáveis, e 2), onde foram utilizados métodos de análise multivariada. Em 66.5 por cento dos casos os pacientes referiram sentir-se \"melhor\" como resultado do tratamento recebido, índice bastante similar ao da percepção do médico de \"melhora com o tratamento\" (65,7 por cento). Em 70,1 por cento dos casos os pacientes referiam estar satisfeitos com o tratamento. Neste estudo, as pessoas relacionadas com o tratamento como o médico e funcionários da recepção foram avaliados positivamente enquanto que alguns fatores organizativos foram avaliados mais negativamente. Como em outros estudos, a satisfação geral esteve altamente associada com a percepção de melhora do paciente. Diferentemente de outros trabalhos, neste, a satisfação também esteve fortemente associada à percepção de melhora por parte do médico. São apresentados e discutidos vários aspectos do processo de assistência que estiveram associados aos resultados finais do tratamento. Analisando-se a interrelação de muitas das variáveis do processo com os resultados obtidos, podemos chegar à algumas conclusões \"aproximadas\" sobre a qualidade do serviço, que poderão servir para que se possam tomar ·decisões pragmáticas sobre a organização do serviço, ainda que em última instância não nos permitam responder de forma precisa à pergunta contida em um de nossos objetivos: \"qual foi o nível de qualidade da assistência prestada?\". Isso porque nos faltam critérios e \"standards\" explícitos aplicáveis a nosso meio. O desenvolvimento desses critérios e padrões explícitos de qualidade deveriam ser um objetivo prioritário de futuras pesquisas na área da avaliação qualitativa em Saúde Mental. Com relação ao \"peso que diferentes fatores podem ter na determinação do resultado final do tratamento\", pode-se dizer que algumas características da doença tiveram pouco peso na determinação dos resultados, enquanto que certas características do paciente como sexo e renda per-cápita estiveram associadas de forma significante com os resultados do tratamento. Comentamos com detalhes esses dados, e salientamos que tais achados são válidos no contexto \"deste\" estudo. Além dessas duas características, também descrevemos outras variáveis ligadas ao processo, que estiveram altamente associadas à determinação dos resultados, através da análise multivariada. A \"satisfação com o tratamento\" foi a variável que mais fortemente esteve associada aos resultados finais. Do referido acima poderíamos concluir que atingimos o objetivo de verificarmos em que extensão, certos fatores podem interferir nos resultados finais. Para finalizar, pudemos avaliar o grau de satisfação dos pacientes com o tratamento recebido. Tal avaliação foi de extrema importância nesta pesquisa, no sentido da complementaridade de informações que possibilitou, ao proporcionar a visão subjetiva do usuário que pôde ser somada aos dados obtidos do prontuário. Levando-se em consideração a situação atual das pesquisas qualitativas em nosso meio, sugere-se os estudos na linha da avaliação da satisfação com a assistência recebida sejam os que se mostrem mais factíveis de serem realizados, e em termos de resultados produzidos, poderiam ser tão bons quanto outros métodos para a avaliação da qualidade de serviços de saúde mental. / The interest in the quality of medical care and health services has been an issue that, in the last decades, has grown not only in the scientific and political arenas, but in the society as a whole. As the problems concerning the quality of health care delivery were known, the issue of their evaluation has been not only an issue of interest, but also a priority among the decision makers in the field of social and health policy. While in several countries the evaluation of health services is being sistematically developed, this has not been so in Brazil, and with special emphasis in qualitative evaluation. The aim of this thesis is to develop a qualitative evaluation of a mental health outpatient service. The main objectives of this dissertation are: 1) to evaluate the patients satisfaction level with the treatment that they received in the service; 2) to analyze the relationship between the health care delivery process and the final treatment outcome in order to evaluate the health care delivery quality; and 3) to determine the weight that several factors, such as the health delivery process, the patients individual characteristics, and factors related to the illness, can have in the final positive or negative treatment outcome. The subjects of this study were the patients treated in the outpatient mental health service of the Botucatu Medical School as \"New Patients\" (1st visit) during the years 1989 and 1990, coming from Botucatu and São Manoel Municipalities, and with the ICD-9 (1975) diagnosis \"neurotic disorders\", \"adjustment reactions\" and some \"V Code\" diagnosis (V.61, V.62, V.ll). The patients\' treatment data were collected from the scheduling records, medical records and home interviews applied to the patients. Among the 1155 patients that were examined as \"new patients\" 289 were included. From these, we obtained data from both, home interviews and the medical record with a final total of 211 patients. The statistical analysis can be divided into two phases: 1) when the information was obtained from the frequency distribution and correlations among variables, and 2) from multivariate analysis techniques. From all the patients, 66.5 per cent of them said to feel \"better\" after receiving treatment, a percentage quite similar to that o f the physician\'s perception of \"improvement with the treatment\" (65.7 per cent). In 70,1 per cent of the cases the patients said to be satisfied with the treatment. In our case, while people related with treatment such as the physicians and the reception employees were positively evaluated, some organizational factors related to the service were evaluated negatively. As in other studies, the overall satisfaction was highly correlated to the patients\' perception of improvement. Contrary to other studies, in this one, satisfaction was also highly correlated to the perception of improvement by the physician. Several aspects of the health delivery process related to treatment outcomes are presented and discussed. Analysing the relationship of several process variables with the outcomes, we obtained some conclusions about the service quality. These conclusions can be used to make decisions about the service organization, although these cannot be used to answer in a strict sense the question: \"what was the quality level of health care achieved?\". This is due to the lack of explicit crieteria and standards that can be used in our cultural context. The development of these explicit crieteria should be a prioritary goal of further research in the area of quality evaluation in mental health care. With regards to the \"weight that different factors can have in the treatment outcome\", while some illnesses\' characteristics had a relatively low weight in the outcome, some patients characteristics such as sex and personal income were highly weighted. These results are extensively presented, and we stress that our conclusions are valid within the context of this study. Besides these two characteristics, we also describe other variables related to the process that we found to be highly related to the outcome using multivariate analysis. The \"treatment satisfaction\" was the most significant variable related to the final outcome. From these results we concluded that the objective of verifying that some factors can interfere in the final results has been achieved. Finally, we were able to fully evaluate the patients\' satisfaction level with the treatment received. Such evaluation was quite important for our research, because the subjective point of view of the patient provided complementary information to the data obtained from medical records. If we take into account the actual state of the art of the research on quality in our country, possibly the studies based on the evaluation of patients\' satisfaction with the treatment received are the most feasible and, in terms of the results obtained, as good as other methods of mental health service quality valuation.

There has been inadequate attention to the aftercare of psychiatric patients, resulting in an increase in readmission rates plus longer hospital stays. There is a gap in the aftercare for psychiatric patients; The purpose of this qualitative retrospective study is to explore what may have contributed to readmission for psychiatric patients. The biopsychosocial model was used as the theoretical framework to support the direction of the research. The health belief model and transtheoretical model of change were used to further support for biopsychosocial model. The research questions were created to determine the influences on readmission, psychological well-being, explore the adaptation to aftercare and narrative of aftercare from the caregiver. This study used a content analysis to identify patterns and themes with a total of 10 participants. The data used had been previously collected by the behavioral transition team at Houston Methodist Hospital which consists of case notes, mental health diagnoses, hospital history and reasons for readmission. The findings include reports of psychiatric patients not adhering to their prescribed medication due to its side effects or cost, caregivers feeling overwhelmed, and the importance of psychoeducation. Once adjustments were made to the dosage or a prescription for less expensive medication, adherence improved, regular attendance to therapy sessions occurred, and the increase in the level of frustration from the caregiver. Psychiatric patients can benefit in post-discharge care if there is more focus on the reasons for hospital readmission by developing a treatment plan for the prevention of a relapse. This study may improve patient vulnerability to mental health issues and to assist psychiatric patients in establishing balance in their lives.

122f. / Submitted by Oliveira Santos Dilzaná (dilznana@yahoo.com.br) on 2013-07-26T12:09:46Z No. of bitstreams: 1 Tese-PDF- LEDA LESSA ANDRADE FILHA.pdf: 763503 bytes, checksum: 30eba612dc181a9c5f83ef8e8fec25c0 (MD5) / Approved for entry into archive by Ana Portela(anapoli@ufba.br) on 2013-07-30T19:43:45Z (GMT) No. of bitstreams: 1 Tese-PDF- LEDA LESSA ANDRADE FILHA.pdf: 763503 bytes, checksum: 30eba612dc181a9c5f83ef8e8fec25c0 (MD5) / Made available in DSpace on 2013-07-30T19:43:45Z (GMT). No. of bitstreams: 1 Tese-PDF- LEDA LESSA ANDRADE FILHA.pdf: 763503 bytes, checksum: 30eba612dc181a9c5f83ef8e8fec25c0 (MD5) Previous issue date: 2013 / Esta tese de doutorado em Psicologia tem como tema a clínica do sujeito no atendimento psicanalítico ambulatorial no Hospital Juliano Moreira (HJM), na cidade de Salvador, Bahia. A questão central da qual o trabalho se ocupa é relativa às especificidades para se exercer, no espaço ambulatorial do referido hospital, uma clínica do sujeito referendada pela psicanálise. O desenvolvimento deste tema dá-se a partir do estudo de três casos atendidos por mim nessa unidade, os quais são abordados tendo como eixo principal a questão do diagnóstico. Esta escolha deve-se ao fato de que, em todos os casos, a dúvida em se estar diante de uma neurose ou de uma psicose em algum momento do tratamento se interpõe, e o modo como este problema é tratado na psicanálise é revelador da clínica do sujeito, clínica que se pauta pela escuta da fala do paciente, por meio da qual o sujeito pode advir. Distinguindo-se da anamnese psiquiátrica, na qual diagnóstico e terapêutica são momentos distintos, a construção do diagnóstico na psicanálise acontece no próprio tratamento, articulando-se o particular da referência diagnóstica com o que é da ordem do sujeito do inconsciente. O interesse pelo tema se justifica por minha trajetória enquanto psicóloga naquela unidade há doze anos, e a pesquisa dá continuidade aos estudos sobre o sujeito na psicanálise iniciados no mestrado cursado na Universidade de Brasília. A sua relevância reside no fato de produzir reflexões que podem se tornar úteis não somente aos profissionais que pautam suas práticas pela psicanálise, mas àqueles envolvidos com o campo da saúde mental, uma vez que o interesse pelo tema do sujeito tem sido revigorado com as mudanças advindas no esteio da Reforma Psiquiátrica, e a ascendência de práticas voltadas para o cuidado e para a tutela. O problema da pesquisa é descrito sob a forma da pergunta: Quais as especificidades para se construir e sustentar, a partir da psicanálise, uma clínica do sujeito no trabalho ambulatorial do HJM?. Estabeleço como objetivo geral examinar o trabalho realizado no ambulatório do HJM, a partir de três casos atendidos neste hospital, buscando caracterizar, com a psicanálise, a clínica do sujeito, tendo como eixo de análise a construção do diagnóstico. Para tanto, apresento uma breve descrição da história da loucura e da psiquiatria no Brasil, e contextualizo o HJM; especifico a concepção psicanalítica de sujeito, e analiso diferentes discursos que atravessam as práticas no hospital (do cuidado e da assistência, médica-psiquiátrica, da atenção psicossocial, psicanalítica); ocupo-me da metapsicologia sobre a psicose em Freud e Lacan; e trabalho os três casos clínicos, mostrando como ocorre a construção do diagnóstico em psicanálise, e, portanto a clínica do sujeito. O método adotado é o estudo de caso psicanalítico, e a teoria psicanalítica é o marco teórico fundamental, em que privilegio a obra de Freud e a de Lacan, através dos textos originais, e dos legados de seus seguidores. The theme of this doctoral thesis in psychology is the clinic of the subject in the psychoanalytic treatment at the outpatient care section of the Hospital Juliano Moreira (HJM), in the city of Salvador, Bahia. The main issue of the work is related to the requirements to carry out, in the outpatient care section of that hospital, a clinic of the subject relied on psychoanalysis. The development of this theme is done from the study of three cases treated by me in that hospital, cases that are addressed having the diagnosis as a central issue. This choice was made due to the fact that, in all cases, the doubt of facing a neurosis or a psychosis was present at some stages of treatment, and the way this issue is addressed in psychoanalysis shows the clinic of the subject. This clinic is characterized by the listening to the patient’s word, through which the subject may come. Distinguished from psychiatric interview, in which diagnosis and treatment are done at different times, the construction of diagnostic in psychoanalysis takes place in the treatment itself, in which the particular of the diagnostic reference is linked to what is related to the subject of the unconscious. The interest on this theme was drawn upon my trajectory as a psychologist in that unit for twelve years, and the research appears to be a continuity of the studies on the theme of the subject in psychoanalysis that took place at the Masters held at Universidade de Brasília. Its relevance lies in the possibility to produce reflections that can become useful not only to professionals who base their practice in psychoanalysis, but also to those involved with the mental health field, since the interest in the topic of the subject has been refreshed as a consequence of the changes due to the Psychiatric Reform, and the growth of practices of care and guardianship. The research problem is described in the form of the question: What are the specifics to build and sustain, based on psychoanalysis, a clinic of the subject in the outpatient care section of the Hospital Juliano Moreira?. The main objective is to examine the work carried out in the outpatient care section, through the analysis of three cases, trying to characterize, with psychoanalysis, the clinic of the subject, and taking the construction of diagnostic as the axis of analysis. For that, I present a brief description of the history of madness and of psychiatry in Brazil, and contextualize the HJM; I specify the psychoanalytic conception of the subject, and analyze different discourses and practices that cross the hospital (care and assistance, psychiatric, psychosocial attention, psychoanalytical); I dedicate my attention to Freud’s and Lacan’s metapsychology of psychosis; and work on the three cases, showing how the making of diagnostic in psychoanalysis is done, and therefore the clinic of subject. The method adopted is the psychoanalytic case study, and psychoanalytic theory is the fundamental theoretical framework. The study is grounded on the work of Freud and Lacan, and on the legacy of their followers. / Salvador

Cette thèse traite des effets des modes de régulation faisant appel à des intermédiaires pour promouvoir des cadres souples d’organisation. Ces effets sont analysés à travers un cas d’intermédiation dans le champ sanitaire français : la participation de l’Agence nationale d’appui à la performance des établissements de santé et médico-sociaux (ANAP) à l’axe virage ambulatoire du Plan triennal 2015-2017 de transformation du système de santé. Ce cas est abordé à travers une approche en régimes de gouvernementalité fondée sur les travaux de Michel Foucault. L’application de cette approche au cours d’une recherche-intervention de trois ans en partenariat avec l’ANAP permet de dévoiler de manière inductive les caractéristiques spécifiques du Plan triennal en tant que régime de régulation, ainsi que le fonctionnement de ce régime à l’échelle nationale, régionale et des établissements de santé. Cette approche amène également à dépasser la seule mesure de l’efficacité de l’intermédiation pour s’intéresser à l’explication de cette efficacité et s’interroger sur son utilité par rapport aux besoins des différentes parties prenantes du système de santé. Dans son ensemble, ce travail doctoral a des implications d’ordre méthodologique, théorique et pratique. Sur le plan méthodologique, il est proposé une démarche d’évaluation des effets des dispositifs de régulation reposant sur le changement organisationnel. Sur le plan théorique, sont identifiés trois effets de l’intermédiation – de capacitation contingente, de conjonction des véridictions et d’apprentissage alèthurgique – qui complètent les modèles existants de cette activité organisationnelle en développement. Enfin, sur le plan pratique, cette thèse suggère qu’un usage constructif de l’appareillage conceptuel foucaldien est possible en sciences de gestion et illustre cet emploi en formulant six préconisations à l’attention des acteurs de la régulation sanitaire en France, ainsi que cinq pistes de recherche pour les chercheurs qui souhaiteraient accompagner ces acteurs à l’avenir. / This dissertation addresses the effects of modes of regulation relying on intermediaries in order to promote soft organizational frameworks. For that purpose, I analyze a case of intermediation taking place in the French healthcare field : the participation of the National Agency for the Performance of Healthcare Facilities (NAPHF) in the outpatient shift programmed by the 2015-2017 Transformation Plan of the healthcare system. My approach, which draws on the work of Michel Foucault, consists in examining the regime of governmentality that has been implemented in that case. Having used that inductive approach during a three-year research intervention in partnership with the NAPHF, I unveil the specific features that have enabled the regulatory regime of the Transformation Plan to operate at the national, regional and intra-hospital levels. Furthermore, that approach leads beyond measuring the efficacy of intermediation to explaining its effectiveness and to questioning its usefulness for answering the needs of the different stakeholders of the healthcare system. As a whole, this doctoral thesis bears methodological, theoretical, and practical implications. On the methodological side, I propose a method for evaluating the effects of regulatory tools aimed at fostering organizational change. On the theoretical side, I supplement existing models for understanding intermediation by identifying three effects of that organizational activity, which is currently expanding. Those effect are namely: contingent capacity-building, conjoined truth-telling, and alethurgic learning. On the practical side, my work suggests that management scholars may use the conceptual apparatus inherited from Michel Foucault in a constructive manner. I illustrate the potential benefits of that constructive stance by providing six recommendations for improving the regulation of the French healthcare system as well as five possible orientations for researchers who are seeking to help the actors of that system in the future.