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對多重利益相關者之意義提升是臨床醫療服務典範轉移的原因—以某區域教學醫院主動脈瘤支架手術迅速普及之經驗為例 / Newly defined meanings to multiple stakeholders are the reasons for paradigm shift in clinical medical service— experience from the rapid adoption of endovascular aortic repair in a regional hospital諶大中, Shen, Ta Chung Unknown Date (has links)
在現代外科實務中,我們今天認為是標準作業程序的手術,追溯到初期可能是激進創新。多年來,外科技術雖然已經有頻繁的修改,但往往是漸進式地。心臟和血管外科領域中的大多數創新並沒有導致日常實踐劇變。然而,在過去的幾年中,在我服務的醫院和全世界,我看到了治療腹主動脈瘤 (AAA) 的典範轉移,亦即主動脈腔內修復 (EVAR)。
相對於傳統開腹手術修復 (OSR),主動脈腔內修復較傳統開腹手術修復有顯著較低的手術死亡率。不過,長遠來說,總死亡率或動脈瘤相關死亡率並無差異;而主動脈腔內修復有較高的植入物相關併發症和必須再次手術的機率,且成本更高。然而,主動脈腔內修復還是成為腹主動脈瘤治療的支柱。這是為什麼?
除了是激進的技術創新,主動脈腔內修復也是技術頓悟。傳統上,醫療服務是典型的技術輔助服務情境,其中包含兩個單獨的、然而是密切相關的溝通系統: 一個是產業與醫師之間,另一個是醫師與病人之間。醫師居於樞紐地位,不僅確保治療之執行,而且還要評估結果。由於現代資訊與通信技術的發達,病人可以方便地搜尋輔助醫療文獻資訊、線上資訊和個人社會網絡的意見。這就像是詮釋者的作用。這詮釋者的解釋對病人、外科醫生、和醫療產業界產生了實質上重大的影響,反之亦然。以前在這服務體系中互相分離的部分現在可以緊密地互相配合了,這與服務導向邏輯中價值共同創造的概念是不謀而合的。
總之,對多重利益相關者之意義提升是臨床醫療服務典範轉移的原因。在醫療行業中引入服務導向邏輯的概念的重要性,不論是在日常實務和創新策略上的意義都是不容忽視的。醫療服務中,多重利益相關者比以前更涉及共同創造價值的過程。未來的創新者除了專注在技術和科技上,更必須考慮該創新對多重利益相關者之意義提升。 / In modern surgical practice, what we consider as standard procedures today may be radical innovations dated back to the early days. Over the years, there has been frequent modification of surgical techniques, often incremental though, and most innovations in the field of cardiac and vascular surgery didn’t result in drastic changes in the daily practice. However, during the past several years, I have been witnessing a paradigm shift in the treatment of abdominal aortic aneurysm (AAA) in my hospital and worldwide towards endovascular aortic repair (EVAR).
In comparison to the traditional open surgical repair (OSR), EVAR was associated with a significantly lower operative mortality than OSR. However, no differences were seen in total mortality or aneurysm-related mortality in the long term, and EVAR was associated with increased rates of graft-related complications and reinterventions and was more costly. Nevertheless, EVAR is becoming the mainstay of AAA treatment. Why is this?
Except for being a radical technology innovation, EVAR is also a technology epiphany. Traditionally, medical service is a typical technology-assisted service encounter, consisting of two separate, however, closely inter-related communication systems: one between the industry and the physician, and the other one between the physician and the patient. The physician is of the pivot role that not only ensures the execution of treatment but also evaluates the results.With modern information and communication technologies, patients caneasily search information from paramedical literatures, online information, and opinions from personal social network. This serves the emerging role of an interpretor. This interpretors’interpretation has substantial influence on patients, surgeons, industry, and payers and vice versa. Previously separated parts in the service system now can be closely inter-related. This is in concordance with the concept of co-creation of value in service-dominant logic.
It is concluded that newly defined meanings to multiple stakeholders are the reasons for paradigm shift in clinical medical service. The importance of introduction of the concept of service-dominant logic into the medical industry, both in daily practice and in innovation strategy can never be over-emphasized. Multiple stakeholders are being involved much more than before in the process of co-creation of value in medical service.Future innovators must concentrate on meanings to multiple stakeholders as well on techniques and technologies.
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A Framework for the Determination of Weak Pareto Frontier Solutions under Probabilistic ConstraintsRan, Hongjun 09 April 2007 (has links)
A framework is proposed that combines separately developed multidisciplinary optimization, multi-objective optimization, and joint probability assessment methods together but in a decoupled way, to solve joint probabilistic constraint, multi-objective, multidisciplinary optimization problems that are representative of realistic conceptual design problems of design alternative generation and selection. The intent here is to find the Weak Pareto Frontier (WPF) solutions that include additional compromised solutions besides the ones identified by a conventional Pareto frontier. This framework starts with constructing fast and accurate surrogate models of different disciplinary analyses. A new hybrid method is formed that consists of the second order Response Surface Methodology (RSM) and the Support Vector Regression (SVR) method. The three parameters needed by SVR to be pre-specified are automatically selected using a modified information criterion based on model fitting error, predicting error, and model complexity information. The model predicting error is estimated inexpensively with a new method called Random Cross Validation. This modified information criterion is also used to select the best surrogate model for a given problem out of the RSM, SVR, and the hybrid methods. A new neighborhood search method based on Monte Carlo simulation is proposed to find valid designs that satisfy the deterministic constraints and are consistent for the coupling variables featured in a multidisciplinary design problem, and at the same time decouple the three loops required by the multidisciplinary, multi-objective, and probabilistic features. Two schemes have been developed. One scheme finds the WPF by finding a large enough number of valid design solutions such that some WPF solutions are included in those valid solutions. Another scheme finds the WPF by directly finding the WPF of each consistent design zone. Then the probabilities of the PCs are estimated, and the WPF and corresponding design solutions are found. Various examples demonstrate the feasibility of this framework.
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Psychotherapeutic effectiveness and social discourse : an ecosystemic explorationCarruthers, Angeline 30 November 2007 (has links)
Extensive questions have been asked regarding the factors that influence psychotherapeutic effectiveness. Past research has addressed the methods, techniques, as well as the client and therapist variables which potentially influence psychotherapeutic effectiveness. The majority of the research indicates that the therapeutic relationship and other contextual variables exert the greatest influence on psychotherapy successes. This implicates the broader social context in psychotherapy processes. Language appears to be one of the primary contextual factors influencing psychotherapeutic processes and is also embedded in social discourse. Society dominant discourses appear to be based on deficit beliefs toward psychotherapy and emotional functioning. The more relevant issue concerning psychotherapeutic effectiveness therefore appears to be society's dominant discourses affecting the profession. Collaborative social discourses embracing psychology are seldom integrated into mainstream public discourse. A post-modern, ecosystemic perspective is applied to these concerns, proposing a collaborative approach to social discourse, psychotherapy and research. This utilizes reflective, multi-dimensional, respectful and nonjudgmental values, reflecting the shift in social paradigms from the Industrial Age to the Knowledge Age. This shift recognizes that cultural, social and language variables appear to have a greater impact on psychotherapeutic effectiveness than most therapeutic techniques or interventions. These discourses are explored and recommendations are made in an attempt to align psychotherapy with a shifting social paradigm. This alignment could enhance psychotherapeutic effectiveness and the general understanding of psychotherapy. / Psychology / D.Litt. et Phil. (Psychology)
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Doelbewuste gebruik van die element van onsekerheid van die terapeut in gesinsterapieVan der Westhuizen, Hedwig Ruth 30 November 2003 (has links)
This is a constructivistic, qualitative single case study of the reflections of a social work post-graduate student in a practical family therapy training situation, to illustrate the integration of person centered and systemic family therapy theory. The element of uncertainty of the therapist, is the focus of this study.
The element of uncertainty, being a part of both the therapist and the therapeutic process, especially if challenged to make paradigm shifts and master new theory and skills, is identified, described, redefined and contructively applied.
The focus is to highlight the use of the reframed element of uncertainty in empowering the therapist in the therapeutic process of family therapy. It is outlined how uncertainty can also be of value to empower the therapist to evolve an own unique therapeutic style. / Social work / M.A. (Geestesgesondheid)
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On the sacramentality of marriage : the divergence of canon law and theology and the inability to maintain the presumption of facere quod facit ecclesiaPothier, Glen Joseph 11 1900 (has links)
The CIC/83, the living law (ius vigens) of the Latin Catholic Church,
contains 110 canons on marriage in cc. 1055 – 1165. [The 1990 Code of Canons of
the Eastern Churches contains a similar section, cc. 776 – 866]. The sacred
canons, in general, are a compilation of theological statements that are
presented in juridical terms. The canons on marriage, like those of the other
sacraments, commence with a theological statement defining the essence of
the sacrament. The first canon, c. 1055, states that (§1) the marriage covenant,
for the baptized, has been raised to the dignity of a sacrament by Christ the
Lord and that (§2) a valid marriage contract cannot exist between baptized
persons without being a sacrament.
A requirement of c. 1099 is that one must not be in error (error iuris)
concerning the unity, indissolubility, or the sacramental dignity of marriage.
Additionally, c. 1101, §2 states that when by a positive act of the will one
excludes marriage itself or an essential element or an essential property, that
marriage is invalid. The expectation of cc. 1099 and 1101, therefore, is that
sacramentality be included at the time of exchange of consent.
From the time of the scholastics, contract and sacrament have been
identified as one for the baptized, hearkening to a time when civil legislation
attempted to subvert the authority and oversight of the Church regarding
(sacramental) marriage.
At the Second Vatican Council, the constitution Gaudium et spes reinterpreted
marriage as a covenantal relationship between man and woman.
A covenant and a contract are not identical terms. More importantly,
marriage was again seen as a covenant, and as a covenant, for the baptized, it
Father Glen J. Pothier
2
is sacramental. Sacrosanctum Concilium, which set forth principles for the
reform of the sacramental and liturgical life of the Latin Church, stated that
sacraments presuppose faith. The International Theological Commission
identified that there are members of the baptized faithful, Catholic or non-
Catholic, who are unbelievers, who may have been baptized as children but
have had no further faith elucidation, or, as members of non-Catholic
ecclesial communities, do not believe in the seven sacraments of the Catholic
Church, or, in particular, that marriage is a sacrament. Such persons would
not, then, understand that sacramentality must be exchanged on the day of
marriage. Rotal jurisprudence has reflected this change.
In addition to the presumption that sacraments require faith, another
presumption exists when the Church expects that the baptized marry
according to the mind of the Church (the mens Ecclesiae), that is, facere quod facit
Ecclesia, ([by] doing what the Church does). But in a society that is weakened by
divorce, secularism, and a lack of understanding of what the Catholic Church
understands by the sacrament of marriage, this presumption needs to be reexamined.
Through research on the historical development of theological and
canonical principles, and by means of independent studies of large groups of
baptized Catholics and non-Catholics, it becomes increasingly clear that the
theologico-juridico principles of c. 1055 and the sacramentality of marriage
must be revisited. / Philosophy, Practical and Systematic Theology / D. Th. (Systematic Theology & Theological Ethics)
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The journey of a trainee therapist : from an intrapsychic to an ecosystemic descriptionAarons, Zahava 11 1900 (has links)
This is a postmodernist dissertation contextualised within the new
epistemology.
The dissertation's descriptive methodology mirrors a personal journey
from intrapsychic to ecosystemic psychology which operates within the
domain of language and narrative discourse. As such it is founded on the
principles of ecosystemic rather than Newtonian thinking.
A conversation between various participants constructs the dissertatioi1
through polyphony and academic dialogue. This is then deconstructed through
the use of metalogue thereby allowing the dissertation to operate
simultaneously on a number of different levels.
As it is a postmodernist text, the structure is in a sense an 'anti-structure'
in that it is indirect while it is still acknowledged as a construction. In this
way it is constructed and deconstructed in terms of its own premises.
Expectations in terms of conventional dissertation formulae are challenged
without negating academic requirements. / Psychology / M.A. (Clinical Psychology)
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Paradigm shift in evangelism : a study of the need for contextualization in the mission of Southern BaptistsJohnson, Ronald Wayne 06 1900 (has links)
This thesis addresses a needed shift of paradigm for mission and
evangelism within the Southern Baptist Convention. The current model
lacks appropriate contextualization in a postmodern world. The proposition of the thesis is that a kingdom model for mission and
evangelism is more appropriate for Southern Baptists' commitment to
mission.
The methodology of this thesis was researching primary and
secondary sources, interviews with persons currently involved within the
mission of Southern Baptists, evaluation of empirical data, and testing
of concepts.
In Chapter One, the validity of this thesis is presented with
the proposition, the limitations, the purpose, the practical nature, and the modus operandi of the thesis stated.
Chapter Two explores the problems of evangelism within the mission of Southern Baptists today. Focus is on empirical statistical evidence and the failure of assumptions, methods, and models currently in practice.
Chapter Three examines the birth of the mission and evangelism
mandate of Southern Baptists and the subsequent development of a
monolithic structure unchanged to the present day.
Chapter Four traces the evolution of evangelistic witness within
the early church and explores the cultural dynamics of the period. / Christian Spirituality, Church History and Missiology / D. Th. (Missiology)
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The paradigmatic shift of service organisations : a proposed marketing model for South African university librariesKunneke, Kathleen Joey 06 1900 (has links)
Rapid changes in the economic and world order have made it imperative for university libraries to make a paradigm shift from prestige collection building to a marketing philosophy as their strategic directive. This philosophy would direct university libraries towards decision making around customers' real needs and preferences, aligning organisational competencies and processes with these needs, resulting in more effective service delivery.
Changes in the world order, economics and marketing as a philosophy are presented on a time line, revealing the influence developments in technology and the Internet have brought about. Various views on the influence of these changes in the world order are presented.
Marketing in service organisations is encapsulated in a service marketing triangle. Competitive advantage for the university library should be achieved if the internal processes of the library are analysed in the context of a value chain. A proposed marketing model has been presented to direct strategic thinking in the university library. / Information Science / M. Inf.
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The Paris Declaration - A Paradigm Shift At All Levels? : Swedish Non-Governmental Organisations' Roles in Development Aid PolicyPalmgren, Anna, Lundberg, Åsa January 2009 (has links)
In order to make development aid more efficient, a large number of donors, including Sweden, signed the so called Paris Declaration in 2005. The Declaration gives the partner countries more responsibility for their own development and aims to make he development aid provided by donor countries more measurable. It has been referred to as a paradigm shift within this policy area due to its far‐reaching goals. The Declaration has consequences for all actors in the development aid community, and this thesis aims at outlining and analyzing the effects of the Declaration on the Swedish non‐governmental organisations which hold a frame agreement with the Swedish International Development Agency (SIDA). As an increasing part of evelopment aid is being channelled through NGOs and they hold an important role in the area, they are interesting subjects of study. The analysis is conducted from a society‐centred governance perspective, which focuses on how different actors in society shape public policy. The perspective hallenges the view on the state as dominating unilaterally and takes into account the diversity of actors involved in policy‐making, such as NGOs. The result of the study is, among other things, that the character of the relationships and interactions between Swedish NGOs and SIDA varies, and can be described as either a more traditional hierarchical model or co‐governing. Furthermore, the Paris Declaration is perceived by the NGOs as being a step in the right direction rather than a paradigm shift at all level. / För att göra utvecklingsbistånd effektivare, undertecknade ett stort antal givare, däribland Sverige, den så kallade Parisdeklarationen 2005. Deklarationen ger samarbetsländerna ett större ansvar för sin egen utveckling och syftar till att göra biståndet från givarländerna mer mätbart. Man har kallat detta ett paradigmskifte inom området på grund av sina långtgående mål. Deklarationen har konsekvenser för alla aktörer inom området utvecklingsbistånd, och denna uppsats syftar till att beskriva och analysera de effekter som deklarationen har på de svenska icke‐statliga organisationer som har ett ramavtal med SIDA. Eftersom en allt större del av utvecklingsbiståndet kanaliseras genom enskilda organisationer och de innehar en viktig roll i området, är de intressanta att studera. Analysen görs utifrån ett samhällsorienterat governance perspektiv som fokuserar på hur olika aktörer i samhället utformar den offentliga politiken. Perspektivet utmaningar uppfattningen om att staten ensidigt dominerar och tar hänsyn till mångfalden av aktörer i det politiska beslutsfattandet, till exempel icke‐statliga organisationer. Resultaten av undersökningen är bland annat att karaktären av de relationer och interaktioner mellan svenska icke‐statliga organisationer och SIDA varierar, och kan beskrivas som traditionellt hierarkisk, eller samarbetsbaserad (co‐governing). Vidare uppfattas Parisdeklarationen av icke‐statliga organisationer som ett steg i rätt riktning, snarare än ett paradigmskifte på alla nivåer.
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Dust of ideas in the wind ou como grão de idéias se propagam: o impacto do ambiente internacional e as pressões internas sobre o padrão na oferta de políticas públicas no Brasil e na Colômbia / Dust of ideas in the wind: or as a grain of ideas spread: the impact of the international environment and domestic pressures on standard in the provision of public politics in Brazil and ColombiaCosta, Saulo Felipe 24 May 2011 (has links)
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Previous issue date: 2011-05-24 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / The research aimed to screen for evidence of the influence of ideals of the
international medium on the pattern of public policies in Brazil and Colombia. Through
an approach that linked the theory of two levels games and policy paradigm
understanding in Kuhn and the mechanism of social learning, it was possible to develop
a proxy for the degree of influence of international pressure for the adoption of a given
policies. We attempted to analyze the influence of the proposed of solution to the state
problems, issued by multilateral agencies, through what became known as the
Washington Consensus. The choice of Brazil was due to an increased availability of
data, while the choice of Colombia is its function in this country experience a long
period of democratic rule, with jarring ideological profile of the Brazilian. For this, the
research has focused on the behavior of public spending in both countries, was also
performed a more specific case study on the deployment of the managerial model of
public administration in Brazil, with the aim of better understanding how this process
occurred import and export of ideas and solutions for different problems. The research
showed that multilateral organizations have greater power to print your ideas in
countries' policies when such changes are first and second order, by type built. In return,
changes in third order are only induced by multilateral bodies, since the ideology of
society plays a more decisive role for the incorporation or not of such ideas
"exogenous . / A pesquisa em tela buscou por evidências da influência de ideais do meio
internacional sobre o padrão de oferta de políticas públicas no Brasil e na Colômbia.
Através de uma abordagem que uniu a teoria dos jogos de dois níveis à compreensão de
mudança de paradigma em Kuhn e ao mecanismo de aprendizagem social (social
learning), foi possível elaborar uma proxy para o grau de influência das pressões
internacionais pela adoção de determinado conjunto de políticas. Buscou-se analisar a
influência das propostas de solução aos problemas estatais, emanadas por agências
multilaterais, através do que ficou conhecido como Consenso de Washington. A escolha
do Brasil se deu devido uma maior disponibilidade de dados, ao passo que a opção pela
Colômbia se deu em função deste país experimentar um longo período democrático,
com perfil ideológico destoante do brasileiro. Para tanto, a pesquisa se debruçou sobre o
comportamento do gasto público em ambos os países, foi executado também um estudo
de caso mais específico sobre a implantação do modelo gerencial de administração
pública no Brasil, com o intuito de melhor compreender como se deu este processo de
importação e exportação de ideais e soluções para os mais diversos problemas. A
pesquisa evidenciou que os organismos multilaterais possuem um maior poder de
imprimir seu ideário nas políticas dos países quando tais mudanças são de primeira e de
segunda ordem, segundo a tipologia construída. Em contra partida, mudanças de terceira
ordem são susceptíveis apenas de indução pelos organismos multilaterais, uma vez que
a ideologia da sociedade desempenha um papel mais determinante para a incorporação
ou não de tal ideário exógeno .
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