Residential care in nursing homes continues to be necessary for those individuals who are no longer able to live safely and comfortably at home. The demographic change with increasing number of persons over 65 years in the next 20 years also means that the percentage of those who will require care in a nursing home some time before the end of their lives will increase. Therefore, anticipating this pressure to expand nursing home availability, it is critical that these services are developed from a profound understanding of what creates the best value. Nursing homes in developed countries have evolved over the past half-century from being places of mainly custodial care to facilities responsible for the management of an ever increasing range of complex nursing and medical conditions. Nursing home residents are frail older adults with complex needs, dependent on advanced nursing care.  Determining what aspect of nursing homes should and can be measured is the current work of many national health care systems. However, uncovering what the nursing home residents perceive as the most important aspects of quality and how they experience living in a nursing home is necessary to develop effective person-centred care.  The overall aim of the present thesis was to contribute to a deeper understanding of quality of care in nursing homes, integrating the professionals’, residents’ and family’s perspectives. The research design is a qualitative approach to explore the concept quality of care and its domains. The thesis comprises a review of internationally used nursing sensitive quality indicators for nursing homes. The indicators are evaluated for their validity as described in the literature. The thesis further describes the residents’ experiences with the interpersonal factors of nursing care quality, as well as the residents’ experiences of living in a nursing home. The thesis also explores the understanding and belief about nursing home quality held by family members of residents. The thesis is based on in-depth interviews of residents in four different nursing homes, and focus group interviews of family members of residents in two different nursing homes. The findings are that quality of care in long-term care in nursing homes encompasses at least four domains: quality of the living conditions, quality of the nursing staff, quality of direct nursing care, and quality of the social environment. Moreover, care quality is influenced by a range of external factors such as the national policy, laws and regulations, management of the organization and the physical building. The local community provides a context in which the nursing home is more or less integrated into. The review of internationally used quality indicators indicate that some factors of care processes and health outcomes for nursing home residents could be measured and give valid and reliable evaluation of the nursing home care quality. In the explorative qualitative study, residents and family placed more emphasis on physical and psychological well-being, interpersonal relationships and the social environment if quality of care is to result. Objective indicators of essential areas of resident-experienced quality need to be developed. This should be done in collaboration with the residents and their next-of-kin, in addition to professional expertise. Methodological and practical implications of the results are discussed. / Sykehjem er en helsetjeneste som vil være nødvendig for eldre som ikke føler seg trygge eller kan få tilstrekkelig behandling, pleie og omsorg i eget hjem. Antall eldre over 65 år er økende i Norge, noe som innebærer et økt press på sykehjem i framtiden. Det er derfor av stor betydning at sykehjemstjenesten utvikles med tanke på å skape best mulig nytteverdi ut fra behov. Sykehjemmene har utviklet seg de siste 50 årene fra hovedsakelig et botilbud til helseinstitusjoner som gir avansert helsehjelp. Sykehjemsbeboere er skrøpelige eldre med komplekse problemstillinger, avhengig av avansert sykepleie. Kvalitetsindikatorer er kvantitative mål som reflekterer en profesjonell standard for pleie og omsorg, og slike mål benyttes i økende grad for å vurdere kvalitet i sykehjem. Imidlertid er det nødvendig å inkludere det som har størst betydning for sykehjemsbeboere i slike mål for å kunne gi god pasientsentrert sykepleie.   Hovedmålsettingen med studien var å bidra til en dypere forståelse av sykehjemskvalitet, ut fra helsepersonellets, beboernes og pårørendes ståsted. Avhandlingen omfatter en oversikt over kvalitetsindikatorer som er i bruk internasjonalt. Videre beskriver avhandlingen beboernes erfaringer med mellommenneskelige faktorer ved sykehjemskvalitet, samt hvordan de erfarer å bo i et sykehjem og opplever kvaliteten på “hjemmet” sitt. I avhandlingen blir også pårørendes forståelse av og meninger om sykehjemskvalitet utforsket. Avhandlingen er basert på dybdeintervju av beboere ved fire ulike sykehjem, og fokusgruppeintervjuer med pårørende ved to av sykehjemmene.   Funnene viser at kvalitet på pleie og omsorg i sykehjem omfatter minst fire hovedområder: Bokvalitet, personellkvalitet, helsetjenestekvalitet og sosial kvalitet. Videre er pleie- og omsorgskvaliteten påvirket av en rekke eksterne faktorer som nasjonale føringer, lovverk, ledelsesstruktur, bygningskonstruksjon og lokale forhold. Den internasjonale oversikten over kvalitetsindikatorer gir indikasjoner på at noen av dem kan brukes som pålitelige og gyldige evalueringer av kvaliteten på pleie og omsorg, samt helserelaterte resultater for beboerne. I den kvalitative intervjuundersøkelsen med beboere og pårørende, ble fysisk og psykisk velvære, mellommenneskelige forhold og det sosiale miljøet tillagt større betydning for kvaliteten. Objektive indikatorer for disse beboererfarte områdene for kvalitet må utvikles. For å sikre at disse er pasientsentrerte, bør utviklingen av kvalitetsindikatorer gjøres i tett samarbeid med sykehjemsbeboerne og pårørende, i tillegg til helsepersonell.

<b>Background. </b> Although antipsychotic medications are primarily intended to treat schizophrenia and psychotic symptoms in adults, they are commonly administered to nursing home residents as pharmacotherapy for "off-label" indications such as disruptive behaviour. However, clinical trials have demonstrated limited efficacy and serious side-effects of antipsychotics among the elderly. As previous studies have reported inappropriate use in several countries, their use in nursing home residents ought to be monitored to detect and reduce inappropriate administration. <br /><br /> <b>Objectives. </b> The aim of this study was a) to determine and compare prevalence rates of antipsychotic use in Ontario and Swiss nursing homes, b) to identify determinants of antipsychotics use in these two countries, by means of a cross-sectional design, and c) to investigate the impact of antipsychotic use on behaviours over time in Ontario and Swiss residents, by means of a longitudinal design. <br /><br /> <b>Methods. </b> This study involved secondary data analysis of 1932 residents from 24 nursing homes in the province of Ontario in Canada and 1536 residents from 4 nursing homes in a German-speaking canton in Switzerland. Residents were assessed with the Minimum Data Set (MDS) tool. Resident characteristics and prevalence rates were compared internationally with the chi-square test. Demographic and clinical determinants of antipsychotic use, as well as behavioural change associated with antipsychotics, were analyzed using logistic regression. <br /><br /> <b>Results. </b> Although Ontario nursing home residents had an overall heavier-care profile than Swiss residents, antipsychotics were administered to 25% of the Ontario residents compared to 29. 5% of the Swiss residents. The adjusted rate among residents without appropriate conditions was also lower in Ontario (14%) than in Switzerland (24. 5%). Apart from schizophrenia, bipolar disorder and cognitive impairment, antipsychotic use was determined by a different range of characteristics in these two countries. Antipsychotic use was not predictive of behavioural improvement. <br /><br /> <b>Conclusion. </b> The high adjusted rates of antipsychotic use in Ontario and Swiss nursing home residents, as well as the presence of "inappropriate indications" and "facility" as determinants of their use, raise concerns about the appropriateness of their administration in both countries. Their lack of effectiveness to improve behaviours also questions their use as long-term treatment for behaviour disturbances. Changes in practice patterns and implementation of policies are warranted to reduce inappropriate prescribing practices to enhance the quality of care provided to residents in nursing homes.

In Taiwan, the nephritis, nephrotic syndrome and chronic renal failure are occupied the eighth of compatriot's ten major causes of the death; Due to medical improvement in recent years, end stage renal disease with long term hemodialysis patients were increasing day by day, the dialysis cost also go up year by year. According to the statesment of Bureau of National Health Insurance, the whole Taiwan dialysis patients were about 50,000 persons, expensed 28,100 million dollars in one year , each dialysis patient expense 600,000 dollars every year on average, it is the first of clinical expenses . In recent years, the dialysis suppliers get involved in the business of the dialysis clinics, they already were not only the large international factory for selling dialysis material, but also get involved in dialysis clinics about dealing , buying and combining resources, so the dialysis clinics form the two kinds of different manageable type :dialysis supplier and independent operator. This research was cross- sectional study and divided dialysis clinics into dialysis supplier and independent operator, the study choose the different kinds of dialysis clinic patients as samples from Kaohsiung and Pingtung area and carry on the interview of questionnaire by the bedside. Through analyzing the patient¡¦s idiosyncrasy, affect patients in choosing health care providers, patient's satisfaction, life quality, life impact after kidney disease and paying medical care quality indicator of dialysis clinics (average serum albumin with the whole people's clinic of health insurance, dialysis efficiency equally to life), probe into the difference between two kinds of different manageable type of dialysis clinics. The descriptive statistical analysis, explored factor analysis, dependent sample analysis of variance, independent sample analysis of variance and Pearson product-moment correlation analysis, etc. method were employed as statistical analysis. The result of study found, the top five expected satisfaction level of hemodialysis patient were avablility to the peritoneum dialysis service, avablility to consultation of kidney transplantation , medicine safe to value , nutritionist for diets consultation , the availability of nephrology specialists , the expected satisfaction level relatively lean to the professional service , but patient satisfaction relatively lean to the hardware service actually. The whole satisfaction of independent operator in the operation service , professional service , extra service , public relations , geographical position are all superior to dialysis suppliers. The dialysis supplier was superior to the independent operator only in the hardware service. Through this research, hope to make the officer in dialysis center, realize the demand of patients,and offer better service as improving direction in medical quality.

Italijos integruoto ugdymo modelis unikalus tuo, kad visiems negalią turintiems moksleiviams suteikia teisę ir galimybes ugdytis visiškos integracijos sąlygomis. Specialiųjų ugdymosi poreikių turinčių moksleivių integracija į bendrojo lavinimo mokyklas šioje šalyje vyksta jau beveik keturiasdešimt metų, todėl remiantis sukaupta patirtimi pastaruoju metu ypatingai susidomėta integruoto ugdymo kokybės problema. Šiame tyrime siekiama įvertinti integruoto ugdymo kokybę empirinio tyrimo pagalba, išskiriant pagrindinius integruoto ugdymo kokybės indikatorius, t.y. tam tikrus reikšmingus integracijos proceso aspektus, kurie padėtų rasti atsakymą į klausimą, ar integruotas ugdymas konkrečiu pasirinktu atveju (t.y. Romos mokyklose) vyksta kokybiškai. Tyrimo objektas. Integruoto ugdymo kokybė Italijos integruoto ugdymo sistemoje. Tyrimo tikslas. Ištirti integruoto ugdymo kokybės indikatorius Romos mokyklose. Tyrimo uždaviniai: 1. Apibūdinti pagrindinius Italijos integruoto ugdymo modelio teisinius, istorinius ir praktinius aspektus. 2. Aktualizuoti integruoto ugdymo kokybės sampratą Italijos integruoto ugdymo modelio kontekste. 3. Remiantis moksline literatūra, teisiniais šaltiniais ir jau atliktais tyrimais išskirti pagrindinius integruoto ugdymo kokybės indikatorius. 4. Įvertinti išskirtus integruoto ugdymo kokybės indikatorius Romos mokyklose. Tyrimo metodai. Mokslinių ir teisinių šaltinių analizė. Empirinis tyrimas: pedagogų anketinė apklausa. Statistinė tyrimo duomenų... [toliau žr. visą tekstą] / The model of integrated education in Italy is unique because it gives to all students with special needs the right to be educated in regular classes of regular schools. In this country the integration of students with special educational needs into regular schools is in process for almost forty years now; therefore having such cumulate experience the problem of the quality of integration is becoming particularly important. Thus this research is aimed at evaluation of the quality of integrated education using empirical analysis: identifying main quality indicators of integrated education intended as significant aspects of integration process which could help answering the question if integrated education model is operating qualitatively in the concrete case of Rome schools. The object of the research. The quality of integrated education in Italy’s integrated education system. The aim of the research. To examine quality indicators of integrated education in Rome schools. The tasks of the research: 1. Define main legal, historical and practical aspects of Italy’s integrated education model. 2. Actualize the conception of integrated education quality in the context of Italy’s integrated education model. 3. Identify main quality indicators of integrated education on the grounds of scientific literature, legal sources and already carried out researches. 4. Evaluate identified quality indicators of integrated education in Rome schools. The methods of the research. The analysis... [to full text]

Floc-pathogen interactions are important determinants of the fate of pathogens in aquatic systems. The dissociation of bacteria from particles due to shear stress can significantly increase the presence of free-floating pathogenic bacteria in the aqueous phase. This has implications for pathogen transport and water quality. This study evaluated the interactions of water-borne pathogens with particles in selected aquatic ecosystems. Three experimental chapters and one concluding chapter is presented. Chapter 3 assesses the strength of the floc-microorganism association under different energy levels in relation to the physico-chemical properties and the bioorganic content of flocs from six different aquatic environments (SB, CSO, RF, AG, ML, MN); Chapter 4 evaluates how energy dissociates bacteria and affects microbial diversity in free-floating and particle-associated fractions in cohesive bed sediments (BedS) and suspended flocs (SusF) of three sites (SB, CSO, RF). Chapter 5 studies the diversity and succession among free-floating and particle-associated bacteria at different energy levels and the abundance of antibiotic resistance genes and Class 1 integrons (intI1) as a result of ecosystem perturbation in the six initial sites. Different strategies, such as standard laboratory analytical methods, as well as techniques based on analytical chemistry, biochemistry and molecular biology were used to accomplish these objectives. The bioorganic and physico-chemical properties of flocs and sediments, and the energy effects these structures are exposed to, play a role in the assessment of pathogen risk in water systems. Molecular approaches showed a significant difference in the composition of free-floating and particle-associated assemblages after simulated flow conditions and detected earlier differences in the dissociation of bacteria, compared to plating techniques. The analysis of integrons provided evidence for horizontal gene transfer events. Free-floating and particle-associated bacterial assemblages are potential genetic reservoirs for antibiotic resistance genes. This research shows that particles act as reservoirs for microorganisms, providing an early warning for potential indicators of human health risk in water systems and could determine the presence of future clinically relevant antibiotic resistance mechanisms and/or pathogenic microbial gene transfer in sediments, demonstrating the need to improve the existing protocols and methodologies that assess water quality. / Natural Sciences and Engineering Research Council of Canada (NSERC)

Made available in DSpace on 2016-06-02T19:35:46Z (GMT). No. of bitstreams: 1 4675.pdf: 5422333 bytes, checksum: 2436f95e521ca0b2dbde8f6089b02697 (MD5) Previous issue date: 2012-09-14 / International Student Assessment) and the results presented by TALIS (Teaching and Learning International Survey), considering the configuration of schools highly evaluated and the practices developed in those institutions. Concerning that matter, two questions were designed as guidelines for the research process: (1) What is the configuration of the schools that performed well in PISA 2009, in São Paulo, according to the TALIS / PISA? (2) What kind of practices are developed in those schools? Considering those questions as a starting point, the procedures of one public and two private schools in the State of Sao Paulo were examined. Those institutions were chosen due to their good scores in PISA 2009. Matching the PISA 2009 modus operandi, the results obtained in reading were selected as the core of our analysis. Three specific objectives were established to shape the procedures followed in this research: (1) analyze the elements that influence the educational performance of students by focusing essentially on the features of their formation, (2) identify the characteristics of teachers and schools by assessing TALIS results, and (3) analyze the opinion of teachers and institution managers on PISA, TALIS and students performance. The current objectives are accomplished by adopting a quantitative-qualitative methodological research approach. The data consist of interviews with the general coordinator of PISA 2009 in Brazil and with directors / coordinators of the selected schools; visits to the focus schools; analysis of a collection of questions from PISA answered by students and directors and analysis of TALIS questionnaires answered by the director and teacher participants. This investigation is justified, therefore, by the potentiality it offers to the understanding of the contributions of PISA and TALIS results to the formulation of public policy and education management in Brazil and its implications for the educational system and schools. It was attainable by analyzing the organization of schools with good performance in PISA in Sao Paulo, considering such aspects as components of quality indicators. Within this context, the results of those large-scale measurement instruments raise important issues, since they acknowledge only a small number of "high quality schools" contrasted with a great number of units, especially public, marked by insufficient and below expectation performance. Further than analyzing the schools based on the results from PISA and TALIS, the outcome of this research invites for reflection on the practices adopted by schools and their relation to the results verified by the focused instruments. / O objetivo desta pesquisa é analisar possíveis justificativas para os resultados verificados no PISA (Program for International Student Assessment) e na pesquisa TALIS (Teaching and Learning International Survey), considerando a configuração de escolas bem avaliadas e as práticas desenvolvidas nessas instituições. Para isso, duas questões foram elaboradas como orientadoras do processo de pesquisa: (1) Como se configuram as escolas que obtiveram bons resultados no PISA 2009, na cidade de São Paulo, segundo dados do TALIS/PISA? (2) Que tipo de práticas elas desenvolvem? Em busca de respostas para tais perguntas, optou-se por obtê-las em três escolas paulistanas, uma pública e duas privadas, escolhidas porque alcançaram boa pontuação no PISA 2009. Selecionou-se como foco avaliar os resultados em leitura, pois, no PISA 2009, esse foi o eixo central. A partir de tais indicações, estabeleceramse três objetivos específicos que encaminharam a organização dos procedimentos adotados na pesquisa: (1) analisar elementos que influem no desempenho educacional dos alunos, abordando essencialmente o tipo de formação que tiveram; (2) caracterizar professores e escolas por meio da pesquisa TALIS e (3) analisar opiniões de professores e gestores das instituições sobre o PISA, TALIS e o desempenho dos alunos. Para alcançar tais metas, adotou-se fundamentação metodológica de base quantitativa-qualitativa. Os procedimentos utilizados para coleta de dados foram: entrevista com a coordenadora geral do PISA 2009 no Brasil; entrevistas com diretores/coordenadores e visitas às escolas foco; análise de questões selecionadas nos questionários do PISA respondidos pelos alunos e pelos diretores dessas escolas; análise dos questionários TALIS respondidos pelos diretores e professores participantes da pesquisa. Esta investigação se justifica, portanto, pela possibilidade de compreender a contribuição dos resultados das pesquisas internacionais PISA e TALIS na formulação de políticas públicas e de gestão educacional no Brasil e sua interferência no sistema educacional e escolas. Para tal, analisa-se a organização das escolas com bom desempenho no PISA na cidade de São Paulo e se considera tais aspectos como componentes dos indicadores de qualidade. Assim, os resultados obtidos por esses instrumentos de medida em larga escala suscitam reflexões importantes, pois demonstram acentuado contraste entre o número de escolas reconhecidas como de alta qualidade e outras unidades, especialmente públicas, marcadas por desempenho insuficiente e aquém do esperado. Mais do que analisar as escolas com base nos resultados do PISA / TALIS, pretende-se provocar uma reflexão fundamentada sobre as práticas adotadas pelas escolas e sua possível relação com os resultados obtidos na avaliação do PISA e na pesquisa TALIS.

Cellular networks are becoming more common, this introduces new challenges in dealing with their error prone nature. To improve end-to-end performance when the first link in the connection is wireless, an adaptive timeout based on network conditions is constructed. Relevant network factors are identified by examining data collected by a device located in a vehicle moving around in southern Sweden. Channel Quality Indicator (CQI) is shown to be the primary predictor of errors in the connection. In our datasets, a CQI index of 2 is a very good predictor of an error prone state. The collected data is split into training and evaluation data, the training data is used to construct a model. An adaptive timeout mechanism which uses this model is proposed, the mechanism is shown to be superior in all tested cases in the dataset compared to the optimal static counterpart. Reducing timeouts allows for applications to make new decisions based on new information faster, increasing responsiveness and user satisfaction.

L'objectif de cette thèse est de souligner l'importance de l'abstraction de la couche physique (PHY abstraction) dans l'évaluation des systèmes LTE (Long Term Evolution). Cette thèse propose une approche pragmatique pour l'utilisation de PHY abstraction dans les simulateurs des systèmes LTE. PHY abstraction est un outil très important pour l'évaluation des systèmes LTE à grande échelle car il est efficace, pratique et à complexité réduite . Dans cette thèse, nous prouvons que, à part son objectif principal et qui consiste à fournir un indicateur instantané de la qualité de liaison pour l'évaluation du système, le PHY abstraction peut aussi: améliorer le feedback de l'indicateur sur la qualité de canal (CQI) en se basant sur les différentes configurations d'antennes, et la prédiction de la performance des réseaux LTE en se basant sur des mesures de canal réelles. Cette thèse est principalement divisée en deux parties: méthodologies et applications. La première partie présente la conception complète et la méthodologie de validation des systèmes de captage PHY pour différentes configurations d'antennes correspondant à des différentes modes de transmissions en LTE. La validation est effectuée en utilisant des simulateurs de niveau de liaison. Nous soulignons aussi les astuces de calibrage nécessaires pour que la production PHY soit précise dans la prédiction de la performance de capacité réalisant turbo-codes. / The main focus of this thesis is to highlight the importance of PHY abstraction for the system level evaluations in the framework of 3GPP Long Term Evolution (LTE) networks. This thesis presents a pragmatic approach towards the use of PHY abstraction in LTE based system level simulators. PHY abstraction is an extremely valuable low complexity tool for efficient and realistic large scale system evaluations. This thesis shows that apart from the primary purpose of PHY abstraction of providing instantaneous link quality indicator for the purpose of system level evaluations, it can be further used for an improved channel quality indicator (CQI) feedback based on the different antenna configurations and for the performance prediction of LTE networks based on the real life channel measurements. This thesis is mainly divided into two parts; methodologies and applications. The first part presents the complete design and validation methodology of PHY abstraction schemes for various antennaconfigurations corresponding to different transmission modes in LTE. The validation is performed using link level simulators and it also highlights the calibration issues necessary for the PHY abstraction to be accurate in predicting the performance of capacity achieving turbo codes.

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13121号 / 論社医博第10号 / 社新制||医||9(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川村 孝, 教授 妹尾 浩, 教授 福原 俊一 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM

The overall aim of this thesis is to define a candidate set of quality indicators that are evidence-based, feasible to implement, and have the potential to improve the quality of care provided for children in UK general practice. The indicators were developed using a three-stage process. First, the areas and aspects of care of highest priority for quality indicator development were identified. This was achieved by seeking the views of primary care clinicians and by undertaking a formal analysis of unplanned hospital admissions for ambulatory care sensitive conditions. Then, the evidence-base to underpin indicator development was identified through an overview of Cochrane systematic reviews of interventions relevant to the primary care of children. A search of SIGN and NICE national guidelines was also conducted to inform the evidence-base. Lastly, an expert panel determined the formulation and selection of indicators by applying the RAND appropriateness methodology. This process created a final set of 26 quality indicators in six priority areas: early recognition of potentially serious illness (n=7); child protection and safeguarding (n=4); mental health (n=4); health promotion (n=1); routinely managed conditions (n=6); and general practice management (n=4). The main strength of these indicators is that they reflect a strong professional consensus on their validity and feasibility. The main weakness is that the indicators are underpinned by evidence mainly derived from expert opinion rather than formal research; the requirement for professional consensus means that they do not challenge existing models of care delivery.