In the early 2010s, competitive market logic was introduced into healthcare systems so as to achieve rapid improvements. This took place as improvement policies began to emphasize the notion of collaboration as a method of ensuring patient safety across organizational boundaries. This thesis addresses how staff, in their practical improvement work, balance economic values, on the one hand, against meaningful solutions for the patient, on the other. The research interest focuses on the particular interpretations about improvements that emerge in negotiations about change. These interpretations are foundational to the learning that simultaneously takes place. The aim of the thesis is to analyse and explain the pedagogical conditions that take place in improvement practices in a healthcare system in the 2010s. The thesis takes its theoretical point of departure in a pedagogical theory that describes how contextual conditions influence learning processes in a specific practice where communication is foundational for learning. The thesis uses critical discourse analysis as a methodological point of departure and builds on a model of improvement work, namely, the clinical microsystem. The first study consists of a literature review of the microsystem framework. Subsequently, three case studies were conducted at Jönköping county council, Sweden. Discussions of improvements at clinical meetings and improvement coaches’ reflections over their pedagogical approaches provide the empirical data for the case studies. The findings show that market logic gives rise to a number of displacement effects with respect to learning processes. Short-term profits are shown to supersede goals of a more profound development of knowledge. The composition of an improvement practice is of critical importance to the nature of the negotiation that takes place, and thus how the practice comes to successfully challenge things that are taken for granted and the power structures that exist within the practice. Improvement coaches themselves become pedagogical prerequisites under the influence of the prevailing conditions, as they promote different learning organizations. This thesis develops the conceptual framework that is instantiated by the clinical microsystem, and it also contributes to the social constructionist field of improvement science by establishing pedagogical and discursive perspectives on improvement and change. / Bridging the Gaps

Development of an automated method for classifying digital images using a combination of image quality modification and Bayesian classification is the subject of this thesis. The specific example is classification of images obtained by monitoring molten plastic in an extruder. These images were to be classified into two groups: the “with particle” (WP) group which showed contaminant particles and the “without particle” (WO) group which did not. Previous work effected the classification using only an adaptive Bayesian model. This work combines adaptive image quality modification with the adaptive Bayesian model. The first objective was to develop an off-line automated method for determining how to modify each individual raw image to obtain the quality required for improved classification results. This was done in a very novel way by defining image quality in terms of probability using a Bayesian classification model. The Nelder Mead Simplex method was then used to optimize the quality. The result was a “Reference Image Database” which was used as a basis for accomplishing the second objective. The second objective was to develop an in-line method for modifying the quality of new images to improve classification over that which could be obtained previously. Case Based Reasoning used the Reference Image Database to locate reference images similar to each new image. The database supplied instructions on how to modify the new image to obtain a better quality image. Experimental verification of the method used a variety of images from the extruder monitor including images purposefully produced to be of wide diversity. Image quality modification was made adaptive by adding new images to the Reference Image Database. When combined with adaptive classification previously employed, error rates decreased from about 10% to less than 1% for most images. For one unusually difficult set of images that exhibited very low local contrast of particles in the image against their background it was necessary to split the Reference Image Database into two parts on the basis of a critical value for local contrast. The end result of this work is a very powerful, flexible and general method for improving classification of digital images that utilizes both image quality modification and classification modeling.

Darbo objektas: orientavimosi sporto varžybų kokybės gerinimas. Darbo tikslas: nustatyti orientavimosi sporto varžybų kokybės spragas. Darbo uždaviniai: 1. Išnagrinėti sporto organizacijos sampratą. 2. Apibrėžti sportinių varžybų organizavimo ypatumus. 3. Atskleisti orientavimosi sporto varžybų organizavimo ir formavimo etapus. 4. Nustatyti orientavimosi sporto varžybų dalyvių masiškumą kintant metams. 5. Atskleisti orientavimosi sporto varžybų organizavimo kokybę. Tyrimo metodai: 1. Mokslinės literatūros analizė; 2. Dokumentų turinio analizė; 3. Anketinė apklausa; 4. Aprašomoji statistika. Rezultatai, išvados, pasiūlymai Šiuolaikinės sporto organizacijos neatsilieka nuo verslo organizacijų, jos sugeba pritaikyti naujausius verslo modelius, technologijas, strateginio valdymo metodus. Gerai organizuotos ir sistemingai vykdomos varžybos turi turėti išliekamąją vertę, bet tik gerai organizuotos varžybos bus naudingos atletams bei teiks malonumą žiūrovams. Orientavimosi sporto varžybų organizavimo ištakos siejamos, nuo turistinių sąskrydžių, kuriuo metu, jų dalyviai, kaip laisvalaikio praleidimo formą įtraukdavo šį sportą. Atlikus tyrimą buvo nustatyta, kad dauguma apklaustųjų yra nusivylę šio sporto organizavimo kokybe. Tačiau paskutiniųjų metų statistiniai duomenys rodo, jog dalyvių masiškumas auga. Atsižvelgus į tyrimo gautus rezultatus galima teigti, jog orientavimosi sporto organizavime yra trūkumu ir juos reiktu gerinti. Tyrimas atskleidžia, kad Lietuvoje trūksta... [toliau žr. visą tekstą] / The object of the work: orienteering race quality improvement The aim of the work: determine the quality of orienteering event quality gaps. The goals of the work: 1. To examine the concept of sports organizations. 2. To define the specific organization of sporting events. 3. To reveal of orienteering events organizing and formation stages. 4. To estimate orienteering sports participants in a competition with the changing years. 5. To reveal of orienteering events organizing quality. Methods of survey: 1. Analysis of scientific literature; 2. Content analysis of documents: 3. Questionnaire; 4. Descriptive statistics. Modern sports organizations keeping pace with business organizations, they are able to adapt the latest business models, technologies and strategic management. Well organized and systematic race has to have lasting value, but only well-organized race will be useful for athletes and provide enjoyment to the audience. Orienteering race organizing origins are going back to the tourist hiking time. In that time participants include this sport as a leisure form. The investigation found out that most of the respondents are disappointed with the quality of organization of sport. But last year, statistics show that the massification of participants grows. Based on the study results suggest that orienteering is a lack of organization and they should be improved. The study reveals that orienteering organized in Lithuania has weaknesses in a high-level competition, which... [to full text]

Bakgrund: Det finns statistik som tyder på att det idag är färre människor i Sverige som tar körkort, vilket tros leda till att användandet av taxiverksamheten och kollektivtrafiken kommer att öka, som ett alternativt färdmedel. Digitalisering har i dagens samhälle blivit en större del av människors liv och det har IT-företaget Uber tagit vara på. De har utvecklat en digital plattform där förare kan få kontakt med kunder via en applikation. Uber har en stor mängd förare runt om i världen som styrs genom minimal realkommunikation. Studien kommer att undersöka hur Uber säkerställer kvaliteten på sina tjänster och det kommer att jämföras med andra svenska taxibolag. Syfte: Syftet med studien är att undersöka hur kvalitetsstyrning av taxitjänsten utförs i ett plattformsföretag som Uber jämfört med kvalitets styrningen av andra taxibolag i Sverige. Metod: Studien utgår ifrån en kvalitativ metod med ett deduktivt synsätt samt ett realistiskt perspektiv. Studien omfattar tre respondenter. Insamlad data bearbetades och analyserades med hjälp av tematisk analys för att sedan tolkas. Slutligen drogs slutsatser från resultatet och analysmaterialet. Resultat: Studien visar på att de olika bolagen tycks definiera kvalitet på liknande sätt. De kvalitetsförväntningar kunderna har och de kvalitetskrav som bolagen identifierat tycks vara genomgående i de olika bolagen. Taxibolagen skiljer sig dock åt i arbetet med hur det kontrollerar att förarna tillgodoser den kvalitet som bolagen definierat som viktig. Studien har ven kunnat urskilja att arbetet med kvalitetsstyrning skiljer sig beroende på taxibolagens storlek och vilken marknad de agerar på. Resultatet tyder på att vägen framåt för att tillfredsställa kundernas förväntningar på taxitjänsten verkar vara att satsa på tekniskinnovation. Slutgiltigt kan konstateras att skillnaden i hur taxibolagen arbetar med kvalitet tycks bero på bolagen storlek, inte beroende av bolagens affärsmodell. / Background: There are statistics that point out the fact that less people in Sweden today gets a drivers license. This is believed to lead to an increase in taxi services and public transport. In todays society technical innovation has become a big part of people’s lives and this is something the IT-company Uber has taken advantage of. They have developed a digital platform were drivers and customers can connect with each other trough an application. Uber has a big number of drivers all over the world that is managed by minimal direct communication. The thesis will analyse how Uber ensure the quality of their services and how that comperes to other Swedish taxi companies quality control. Purpose: The purpose of the thesis is to investigate how a platform company like Uber works with quality management compared to how other Swedish taxi companies insure the quality of the service. Methodology: The thesis is based on a qualitative method with a deductive approach and a realistic perspective. The study includes three respondents. The collected data was processed and analysed using thematic analysis and then it was interpreted. Finally, conclusions were drawn from the results and the analysed material. Result: The thesis shows that the various taxi companies seem to define quality in a similar manner. The customer’s expectations of quality and the different companies quality requirements appear to be consistent throughout all of the companies. However, the taxi companies differ in how they ensure that the drivers meet the quality the companies have defined as important. The study has been able to distinguish that quality control differs depending on the taxi companies size and the market in which they operate. The results also suggests that the way to satisfy customers expectations for taxi service today seem to be working with technological innovation. The thesis also shows that the differences in quality work seem to depend on the size of the company, not the business model.

BACKGROUND: Quality improvement (QI) efforts in which providers from various health facilities, with support from coaches, work together to implement innovations for improving health care are rapidly spreading from high-income settings to resource-poor settings. However, limited research exists regarding the factors which drive teams to succeed or fail, spread, and sustain best practices. The purpose of this study was to understand the factors facilitating or inhibiting the performance of QI teams of maternal and child health (MCH) service delivery in resource-poor settings. METHODS: A qualitative multi-site case study was conducted in northern Ghana to determine the views and beliefs of QI teams, coaches, and beneficiaries of Project Fives Alive (PFA) about the application of QI to MCH service delivery. Using key informant interviews, document review, and group interviews, the study elicited information about: 1) the factors that affect QI team success and failure when implementing QI methods designed to improve MCH service delivery; 2) the interplay of factors that facilitate or inhibit the spread of best practices among QI teams in northern Ghana; and 3) steps being taken by stakeholders to sustain these best practices. Grounded theory processes were used to identify themes from the data. RESULTS: Testing of changes using Plan-Do-Study-Act (PDSA) cycles and adoption of a client-centered model to the delivery of services has helped teams to identify the felt needs of clients, resulting in perceived increased uptake of MCH services. Key contributory factors to successes were: availability and accessibility of midwives, training of QI teams, incentive packages for providers and clients, community support groups, and PFA partners. Key challenges inhibiting success were: staff turnover, inadequate supervision, cultural practices, and inadequate infrastructure. Some of the key factors that shaped successes have dissipated, threatening sustainability of QI efforts two years after PFA ended. CONCLUSION: The presence of a midwife, providing leadership for organizing team members and implementing PDSA cycles, can facilitate success. Project staff support is important, but teams and coaches need space and time to drive the QI process independently and practice QI methods in ways that foster continuity beyond donor support.

This research examined if there is a relationship between engagement in quality improvement (QI) and health information technology (HIT) for local health departments (LHDs) controlling for workforce, finance, population, and governance structure. This was a cross-sectional study that analyzed data obtained from the Core questions and Module 1 in the NACCHO 2010 Profile of LHDs. Descriptive statistics, bivariate analyses, and logistic regression analyses were conducted. Findings suggest that LHD engagement in QI has a relationship with utilization of HIT including electronic health records, practice management systems, and electronic syndromic surveillance systems. This study provides baseline information about the HIT use of LHDs. LHDs and their system partners (hospitals, federally qualified health centers, and primary care providers) that utilize HIT as part of their QI decision making may have an easier time of using data to support evidence-based decision making and implementing the provisions of the Patient Protection and Affordable Care Act of 2010 in order to achieve population health for all.

Catheter-associated urinary tract infections (CAUTI) significantly increases patient morbidity and mortality, length of stay, and organizational cost. In the 2 years prior to project implementation, the incidence of CAUTI increased by 15% in the local acute care, inpatient facility that served as the project site. Nursing leaders at the project site linked the increase in CAUTIs to a nursing knowledge deficit related to CAUTI prevention principles. The clinical question focused on the impact of CAUTI prevention staff training on the incidence of CAUTI, length of stay, and cost to the local acute care organization. After a review and critical appraisal of the literature, using Lewin's theory of planned change and the Iowa Model of Evidence-Based Practice Change, an evidence-based, CAUTI-prevention training program was piloted as a quality improvement initiative. The project purpose was to evaluate that initiative by tracking the incidence of CAUTI for 90 days postintervention. A 1-sample t-test of the mean incidence with a 95% confidence interval revealed no statistically significant (p = .732) decrease in the incidence of CAUTI. Similar initiatives with fewer than 12 months of evaluation data have failed to demonstrate statistically significant findings; therefore, additional data are needed to adequately assess the impact of the project. Recommendations include extending the pilot project and additional training of unlicensed nursing personnel. Proper evaluation of the project may provide support for the implementation of CAUTI-prevention training programs, promoting social change by reducing the rate of infection, improving patient outcomes, and demonstrating financial stewardship of the local acute-care organization.

Healthy People 2020 identified hypertension (HTN) as a controllable risk factor to prevent cardiovascular disease and stroke. Adhering to regular antihypertensive (AHT) medications improves outcomes in patients diagnosed with HTN by controlling blood pressure, reducing hospital visits, and promoting patient wellness. Medication adherence occurs when prescribed medicine regimens are utilized by the patient as directed to manage illness or disease, as evidenced by patients receiving medications at their pharmacy. The practice-focused question for this quality improvement project asked whether implementation of health literacy tools from Million Hearts® HTN Control: Action Steps for Clinicians, increased medication adherence as evidenced by regular medication pickups by adult hypertensive patients. Additionally, this project provided an assessment to identify the patient's current health literacy level using the Newest Vital Sign. The purpose of this quality improvement project was to improve health literacy about AHT medications to increase medication adherence in adults diagnosed with HTN. The logic model allowed for communication of resources, activities, and guidance during project implementation. Data related to medication pickups from adult participants, 1 male and 4 females aged 21-76, were analyzed using descriptive statistics via percent difference pre-post program. Results showed an 80% rate of medication adherence, however increased medication adherence was not achieved. Results also revealed a knowledge deficit in 20% of participants indicating they were unaware they had been prescribed combination AHT medication to control their blood pressure, and not knowing their most recent blood pressure results, or how their specific AHT medication regimen worked at controlling their HTN needs. These findings could lead to exploring additional underlying factors that impede medication adherence such as income, medication cost, insurance cost, and transportation needs. This project supports the need for health literacy to be addressed to improve knowledge and understanding about HTN, and implied the need to address the problem of low health literacy in patients with HTN. Implications for nursing practice include health literacy tools for community-based ambulatory clinics to influence medication adherence and self-care management of adults with HTN. Positive social change was demonstrated by providing health literacy to adult HTN population to improve medication adherence thus reducing health risk.

Patient safety is of particular importance within intensive care units (ICUs), where critically ill, vulnerable patients receive complex multidisciplinary care. Prior research has indicated that improving patient safety and reducing errors within healthcare requires a focus on systems and organisational culture issues. This thesis was concerned with three studies. One focused on assessing the patient safety culture and two on quality improvement initiatives within an intensive care unit (ICU) of a large teaching hospital. The first study involved a survey of ICU consultant, registrar and nursing staff regarding aspects of safety culture. This was conducted using an existing Hospital Survey on Patient Safety Culture. Of the twelve patient safety culture composites assessed, eight had scores lower than 50%, highlighting these as areas for improvement. Overall, while the survey results revealed that teamwork within the ICU was considered a strength, event reporting and patient care handovers and transitions were both considered areas with potential for improvement. The second study focused on the evaluation of a change initiative designed to improve the handover of patient clinical information in the ICU. This study involved a survey and interviews with consultant, registrar and nursing staff before and after the introduction of a Patient Management, Plan and Progress (PMPP) document. Examination of the survey responses involved both quantitative and qualitative analysis; respondent interview transcripts were analysed using thematic analysis. The results of this study revealed resistance to, and criticisms of, the introduction of the PMPP document; the initiative failed and use of the document was discontinued. The second initiative concerned an evaluation of the impact of a hospital-wide document on improving documentation of withdrawal of patient treatment within the ICU. This involved both quantitative and qualitative analysis, with a patient medical record audit of decisions to withdraw patient treatment within the ICU before and after the introduction of an Advance Care Plan (ACP) document. ICU consultant, registrar and nursing staff were interviewed regarding the process of withdrawal of patient treatment within the ICU. Interview transcripts were analysed using a modified grounded theory approach. Results revealed that the attempt to improve the documentation of withdrawal of treatment within the ICU failed, with the ACP document remaining unused in 89% of cases and incomplete in the remaining 11%. Also, documentation of decision-making and of the process within the medical records did not improve. Before-introduction findings revealed that only 26% of medical records met the pre-existing requirements for treatment withdrawal in the ICU, and after-introduction findings revealed that only 19% of medical records audited met the requirements of the ACP document. After-audit findings also revealed significant and inappropriate increases in the involvement of an ICU registrar both as primary and secondary decision-makers. In spite of an increased awareness of ICU staff concerning the importance of improving documentation, the medical record audit revealed less compliance with the standards required for documentation. Possible reasons for the document remaining essentially unused, as revealed from interviews with staff, included: previous criticisms by the coroner when they failed to complete a similar formalised document properly; perceived logistical issues associated with obtaining required staff signatures; disagreement concerning who should be involved in documenting the withdrawal of treatment process; and the existence of an ICU subculture of practice that, in one particular aspect of documentation, was not consistent with established hospital and ICU protocol and documentation requirements. The final chapter of this thesis considered implications of the results of the studies for the planning, development, implementation and evaluation of improvement programs within the ICU setting. The results were considered within the context of organisational change management theory and research, including factors that have been found to be critical in the success or failure of change programs, such as resistance to change, the involvement of key stakeholders in the change process, leadership, communication and organisational culture. It is suggested that management consultants with organisational change expertise in the planning, development, implementation and evaluation of such programs should be involved in future quality improvement initiatives. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297608 / Thesis (Ph.D.) -- University of Adelaide, School of Psychology, 2007

Background: Patients in the emergency department are not always satisfied with the care received and the nursing care in the emergency department is sometimes described as instrumental and non-holistic. Structured quality improvement work and evidence-based practice are needed. Aim: The overall aim was to emphasize general patients in the emergency department to enhance the knowledge on how they perceive the quality of care and how the care could be improved through collaboration with the healthcare professionals. Methods: Four studies, with quantitative and qualitative designs, were conducted in a Swedish emergency department. Two hundred patients answered a questionnaire, after which 22 healthcare professionals comprising five focus groups were interviewed, and finally 200 patients were included in an intervention study. Results: The following five areas for improvement were identified: “information, respect and empathy”, “pain relief”, “nutrition”, “waiting time” and “general atmosphere”. Of these areas, the healthcare professionals prioritized “information, respect and empathy”, “waiting time” and “pain relief” to be highlighted in the quality improvement work. Although goals and suggestions for changes were stated, barriers to quality improvement at different levels in the health care were detected. The results of the intervention study showed that structured nursing assessment of the patients’ abdominal status and nurse-initiated intravenous opioid analgesic could increase frequency of analgesic and reduce time to analgesic in the emergency department. Patients perceived lower pain intensity and improved quality of care in pain management. Conclusions: An uncomplicated nursing intervention, related to pain management, based on the results from a patient questionnaire and interviews with healthcare professionals, can improve the care process and pain management in the emergency department, as well as patients’ perceptions of the quality of care in pain management. To succeed with continuous quality improvement work, barriers to change should be addressed.