This master´s thesis deals with marketing research of customer satisfaction of Akademie Caffé and subsequent evaluation of this research based on questionnaire as a research instrument. An important part of this work are also suggestions and recommendations that lead to increased satisfaction, thereby increasing sales and gaining a better position in the market.

Sammanfattning Bakgrund: Lymfödem är en kronisk symtomdiagnos som kräver livslång behandling där egenvård är en viktig del. Bristande egenvård leder till försämrat lymfödem och större benägenhet för erysipelasinfektioner. Problemet är att patienterna känner sig osäkra på egenvård av lymfödem och tvivlar på dess effekt. Syfte: Förbättringsarbetets syfte var att skapa förutsättningar och bättre följsamhet till patienters egenvårdsbehandling för att bidra till bibehållet eller förbättrat stadie av lymfödem och uppleva en god hälso-relaterad livskvalitet. Syftet med studien var att beskriva patienters erfarenheter av att leva med lymfödem, erfarenhet av den lymfterapeutiska vårdtjänsten och redogöra för patienters förbättringsförslag för att förbättra egenvård. Metod: Förbättringsarbetet genomförs med inspiration från tjänstedesign och förbättringsmodellerna 5P, Nolans förbättringsmodell och PGSA.Studien utförs med tematisk analys och beskrevs utifrån delar av Kanomodellen av Noriaki Kano; bas-, uttalade- och omedvetna behov. Resultat: Patienter blir säkrare på att göra egenvård om de har en egenvårdsplan och lymfterapeuterna blir tydligare i sin kommunikation med checklistan och i samskapande med patienten. Resultat från studien visar att lymfterapeuterna behöver bättre kommunicera egenvård och anpassa informationen individuellt. Slutsatser: Genom att patienterna delar med sig av sina erfarenheter och förbättringsförslag kan vi skapa ett lärande och öppna upp för mer patientinvolvering i utvecklingsarbetet. / Summary Background: Lymphedema is a chronic diagnosis that requires lifelong treatment where self-care is an important part. Lack of self-care leads to impaired lymphedema and greater tendency for erysipelas infections. The problem is that patients feel insecure about self-care of lymphedema and doubt its effect.  Purpose: The purpose of the improvement work was to create better compliance to the patients self-care treatment. The purpose of the study was to describe patients 'experiences of the lymphatic care service and living with lymphedema and also the patients' improvement suggestions for improving self-care. Method: With inspiration from service design and the improvement models 5P, Nolan's improvement model and PGSA. The study with thematic analysis method was described from parts of the Kano model by Noriaki Kano; basic-, expected- and  unexpected needs. Results: Patients become more confident in self-care if they have a self-care plan and the Lymphatic Therapists become clearer in their communication by a checklist and in collaboration with the patient. Results from the study show that the lymphatic therapists need to better communicate self-care and adapt the information individually.  Conclusions: By sharing patients' experiences and suggestions for improvement, we can create learning and more patient involvement in development work.

No description available.

Världshälsoorganisationen (WHO) klassar barnobesitas (fetma) som en av tjugohundratalet största hälsoutmaningar, där obesitas och dess följdsjukdomar internationellt dödar fler människor än svält. Det nationella kvalitetsregistret BORIS visade att barn med obesitas hade en hög grad av inaktivitet och få barn uppnådde WHO´s rekommendation av fysisk aktivitet. Vilket är en viktig komponent till god fysisk och psykosocial hälsa En barn- och ungdomsmedicinska mottagning i Region Jönköpings län saknade ett strukturerat sätt att tillsammans med barn och familj identifiera förutsättningar och intressen för fysisk aktivitet, som en del i obesitasbehandlingen.  Det övergripande syftet med förbättringsarbetet var öka barn med obesitas fysiska aktivitet genom införande av Fysisk aktivitet på recept (FaR) samt tydliggöra målsättning, frekvens och uppföljning av fysisk aktivitet som en del i obesitasbehandlingen. Förbättringsarbetet utgick från Nolans förbättringsmodell med målsättningen enligt SMART. Resultat och utvärdering visade att FaR var en metod som på ett mer strukturerat sätt definierade målsättning och gav förutsättning till delaktighet i ordinationen av fysisk aktivitet. Ökad vardagsmotion var den vanligaste ordinationen. Efter 12 veckor hade fem av sju barn i ett urval ökat sin fysiska aktivitet. Stor andel föräldrar upplevde att utformningen i FaR hade utgått från barnets förutsättningar och intressen. Syftet med studien av förbättringsarbetet var att beskriva barnsjuksköterskornas erfarenheter av FaR till barn. Datainsamling till studien genomfördes genom fokusgruppsintervju som analyserades med kvalitativ innehållsanalys. Studien visade att FaR upplevdes som ett stöd till barnsjuksköterskorna att initiera, kartlägga förutsättningar och ordinera fysisk aktivitet som en del i obesitasbehandlingen. FaR bidrog till en tyngd i ordinationen, där uppföljningsansvaret inom hälso- och sjukvården förtydligades. Föräldrarnas ansvar och delaktighet beskrevs som viktiga faktorer i barnets förutsättningar att följa ordinationen i FaR. Införandet av FaR har medfört att fysisk aktivitet strukturerat uppmärksammas, definieras och följs upp som en del i barnobesitasbehandlingen på barn- och ungdomsmedicinsk mottagningen. / The World Health organization (WHO) classifies childhood obesity as one of the greatest global health challenges of the 21st century. Internationally, obesity kills more people than starvation.  The Swedish quality register of childhood obesity showed that children with obesity had a high degree of inactivity. Few children reached the recommended level of physical activity, described by WHO. The paediatric and adolescent outpatient medical clinic in Region Jönköping lacked a structured way to identify preconditions and interests for physical activity together with the child and the family in the obesity treatment. The overall purpose of the improvement work was to introduce Physical activity on prescription (FaR) as a part of the treatment of childhood obesity. The improvement work was based on the improvement model and the goal was set in accordance with the SMART model.  Results showed that FaR is a method which in a more structured way defines goals and encourage the children´s participation in physical activity. Increased daily exercise was the most common prescription. Twelve weeks after prescription, five of seven children had increased their physical activity. Most of the parents felt that the prescription was based on the child´s preconditions and interests.  The purpose of the study was to describe the paediatric nurses experiences of FaR. Data collection for the study were collected by a focus group interview and a qualitative content analysis was performed. The results showed that FaR was perceived as a support in the obesity treatment by the paediatric nurses. It initiated physical activity and described the child´s preconditions and interests. The nurses also describe that FaR made the responsibly to follow-up the FaR clearer to them. The parent’s responsibilities and participation was described as an important factor supporting the child follow the prescription.

Philosophiae Doctor - PhD / The value of accountability as a key feature of strengthening health systems and reducing maternal, newborn and child mortality is increasingly emphasised globally, nationally and locally. Frontline health professionals and managers play a crucial role in promoting maternal, newborn and child health (MNCH) services in an equitable and accountable manner. They are at the interface between higher-level health system management and communities, facing demands from both sides and often expected to perform beyond their available means. Although accountability is a central topic in the governance of MNCH literature, it has mostly been approached at global and national levels, with little understanding of how accountability is integrated into the routine functioning of local health systems. This PhD explores the forms and functioning of accountability at the district level focusing on MNCH as a programmatic area with long-established institutional mechanisms (structures and processes) in South Africa (SA). The thesis is presented in the form of four empirical papers (published or submitted), exploring different dimensions of accountability, which are embedded in a series of narrative chapters. In this thesis, accountability is understood as a set of relations between an accountholder and ‘accountor’ (or duty bearer), in which the latter provides information or justification for actions or decisions taken, and faces the resulting consequences of his/her actions (reward or sanction). Accountability mechanisms are the means to regulate accountability relationships and include broad strategies, interventions or instruments. These mechanisms can take various forms including performance, financial and public accountability, and operate both vertically (accountability inside bureaucratic hierarchies, or towards external stakeholders and/or the community), or horizontally (between peers, ‘neighbour’ units, departments or ministries in a national health system). Drawing conceptually on the field of governance and considering the complexity of the accountability phenomenon, I adopted a case study approach to the PhD research, using a combination of policy document review, interviews (with managers, providers, community representatives and members of labour unions) and field observations, conducted iteratively over 16 months. The study was conducted in Gert Sibande District, one of the three South African health districts in Mpumalanga Province, with an in-depth focus on two of the seven sub-districts in the District. The research found that frontline health professionals have a clear understanding and conceptualisation of accountability in the SA health policy context, despite the reported inability to define accountability by health professionals described in the literature. Respondents referred to accountability as responsibility, answerability and virtue, and also argued for strengthening accountability mechanisms as critical to addressing maternal and child mortality. While deeming accountability as important, frontline professionals experienced the existing accountability mechanisms as ‘too much’ and indicated the desire for the streamlining of existing mechanisms. In this regard, the study documented numerous mechanisms at district level, almost all related to performance accountability in MNCH. These included a performance management system, quality assessment and accreditation processes, quarterly reviews, and death surveillance and response processes. The existence of multiple and overlapping accountability mechanisms engenders operational confusion and ‘accountability overload’ for frontline providers, encouraging empty bureaucratic compliance, while critical gaps – notably in community accountability – remain. In practice, at their best, some mechanisms operate following a reciprocal1 pathway of capacity building with resource provision (from management) and expectation for better performance (from providers). There were, however, contextual variations in the implementation and practice of the mechanisms between sub-district settings. The fieldwork observations and interviews were also able to document how formal institutionalised mechanisms are embedded within a complex system of informal accountability relationships and social norms (‘accountability ecosystem’) that enables or constrains the ability of frontline professionals to fulfil their tasks. In addition, using a Social Network Analysis approach, the research identified key actors and their involved network, which form the relational backdrop to the functioning of accountability mechanisms for MNCH. By revealing complex relationships and collaboration patterns among frontline health professionals, the study was able to show the multi-level action and multiple actors required to achieve MNCH goals.

Objective: Project ECHO (Extension for Community Healthcare Outcomes), a telementoring program, utilizes lectures, case-based learning, and an “all teach–all learn” approach to increase primary care provider (PCP) knowledge/confidence in managing chronic health conditions. The American Academy of Pediatrics (AAP) Epilepsy and Comorbidities ECHO incorporated quality improvement (QI) methodology to create meaningful practice change, while increasing PCP knowledge/self-efficacy in epilepsy management using the ECHO model. Methods: Monthly ECHO sessions (May 2018 to December 2018) included lectures, case presentations/discussion, and QI review. Pediatric practices were recruited through the AAP. Practices engaged in ECHO sessions and improvement activities including monthly Plan-Do-Study-Act cycles, team huddles, chart reviews, and QI coaching calls to facilitate practice change. They were provided resource toolkits with documentation templates, safety handouts, and medication side effects sheets. QI measures were selected from the American Academy of Neurology Measurement Set for Epilepsy. The AAP Quality Improvement Data Aggregator was used for data entry, run chart development, and tracking outcomes. Participants completed retrospective surveys to assess changes in knowledge and self-efficacy. Results: Seven practices participated across five states. Average session attendance was 14 health professionals (range = 13-17). A total of 479 chart reviews demonstrated improvement in six of seven measures: health care transition (45.3%, P =.005), safety education (41.6%, P =.036), mental/behavioral health screening (32.2% P =.027), tertiary center referral (26.7%, not significant [n.s.]), antiseizure therapy side effects (23%, n.s.), and documenting seizure frequency (7.1%, n.s.); counseling for women of childbearing age decreased by 7.8%. Significance: This project demonstrated that integrating QI into an ECHO model results in practice change and increases PCP knowledge/confidence/self-efficacy in managing epilepsy.

In recent years, the transplant community has explored and adopted tools for quantifying clinical insight into illness severity and frailty. This dissertation work explores the interplay between objective and subjective assessments of physical health status and the implications for liver transplant candidate and recipient outcomes. The first aim characterizes national epidemiologic trends and the impact of Centers for Medicare and Medicaid quality improvement policies on likelihood of waitlist removal based on the patient being too frail to benefit from liver transplant (“too sick to transplant”). This aim includes more than a decade (2002–2012) of comprehensive national transplant waitlist data (Scientific Registry of Transplant Recipients (SRTR)). The second aim will assess and define objective parameters of liver transplant patient frailty by measuring decline in lean core muscle mass (“sarcopenia”) using abdominal CT scans collected retrospectively at a single U.S. transplant center between 2006 and 2015. The relationship between these objective sarcopenia measures and subjective functional status assessed using the Karnofsky Functional Performance (KPS) scale are described and quantified. The third aim quantifies the extent to which poor functional status (KPS) pre-transplant is associated with worse post-transplant survival and includes national data on liver transplantations conducted between 2005 and 2014 (SRTR). The results of this dissertation will help providers in the assessment of frailty and subsequent risk of adverse outcomes and has implications for strategic clinical management in anticipation of surgery. This research will also to serve to inform national policy on the design of transplant center performance measures.

Background: Time matters in multiple sclerosis (MS). Irreversible neural damage and cell loss occur from disease onset. The MS community has endorsed a management strategy of prompt diagnosis, timely intervention and regular proactive monitoring of treatment effectiveness and disease activity to improve outcomes in people with MS. Objectives: We sought to develop internationally applicable quality standards for timely, brain health–focused MS care. Methods: A panel of MS specialist neurologists participated in an iterative, online, modified Delphi process to define ‘core’, ‘achievable’ and ‘aspirational’ time frames reflecting minimum, good and high care standards, respectively. A multidisciplinary Reviewing Group (MS nurses, people with MS, allied healthcare professionals) provided insights ensuring recommendations reflected perspectives from multiple stakeholders. Results: Twenty-one MS neurologists from 19 countries reached consensus on most core (25/27), achievable (25/27) and aspirational (22/27) time frames at the end of five rounds. Agreed standards cover six aspects of the care pathway: symptom onset, referral and diagnosis, treatment decisions, lifestyle, disease monitoring and managing new symptoms. Conclusion: These quality standards for core, achievable and aspirational care provide MS teams with a three-level framework for service evaluation, benchmarking and improvement. They have the potential to produce a profound change in the care of people with MS.

Das psychologisch-diagnostische Interview gehört zu den diagnostischen Breitbandverfahren, die eine effiziente Sammlung von Informationen zu einer Vielzahl von Themen ermöglichen, die mit Tests, Fragebögen oder einer Verhaltensbeobachtung nicht effizienter erfasst werden können. Trotz der großen Schwankungen in der Datenqualität, die in der Interviewliteratur berichtet werden, erfreut sich das Verfahren in den verschiedenen Anwendungsbereichen der Psychologie großer Beliebtheit. Für die Gewinnung zuverlässiger Daten und somit Urteile sind Objektivität, Zuverlässigkeit sowie Gültigkeit, wie sie es DIN 33430 für psychodiagnostische Instrumente vorschreibt, von großer Bedeutung. Die anforderungsbezogene Gestaltung des Interviews, die Verwendung eines Leitfadens, die Trennung der Informationserhebung von der Auswertung, die Verwendung verhaltensverankerter Auswerteskalen sowie die Formulierung von Interviewfragen stellen nach der aktuellen Interviewliteratur wichtige Ansatzpunkte zur Verbesserung der Datenqualität aus dem Interview dar. In diesem Zusammenhang spielt der Interviewer, der Instrument und Anwender zugleich ist, eine Schlüsselrolle. Ziel der vorliegenden Arbeit war es, Qualitätsstandards in Form von Anforderungen an die Planung, Durchführung sowie Auswertung von psychologisch-diagnostischen Interviews, systematisch zusammengetragen und diese empirisch zu prüfen. Auf diese Weise können die einzelnen Phasen getrennt beurteilt und eine Rückmeldung zu Stärken und Schwächen sowie gezielte Verbesserungsvorschläge zum Interview bzw. zu der Interviewerkompetenz gemacht werden. Eine Analyse der Interviewliteratur machte deutlich, dass das Konzept der Entscheidungsorientierten Gesprächsführung (EOG, Westhoff & Kluck, 2003) eine geeignete Grundlage für die iterative Entwicklung eines Anforderungsprofils für psychologisch-diagnostische Interviews darstellt. Interviewexperten aus deutschen Hochschulen wurden in strukturierten Interviews befragt, wie sie Interviews planen, durchführen und auswerten und wie sie Studierende im Interviewen ausbilden. Der Vergleich der qualitativen Daten aus dieser Studie mit den Regeln der EOG machte deutlich, dass das Regelsystem des EOG weitestgehend vollständig ist (Kici & Westhoff, 2000). Auf dieser Grundlage wurde das „Anforderungsprofil für psychologisch-diagnostische Interviews“ (APDI) bestehend aus drei Teilinstrumenten (Planung, Durchführung und Auswertung) zur Beurteilung eines psychologisch-diagnostischen Interviews entwickelt. Die empirische Prüfung fand mittels eines Prä-Post-Interventionstrainings mit 49 Studierenden der Psychologie im Hauptstudium statt. Von Bedeutung war die Frage, ob mit dem APDI die Stärken und Schwächen eines Interviews identifiziert werden können, um die Interviewerkompetenz konkret zu beschreiben und diesem ggf. eine differenzierte Rückmeldung zu geben. Entsprechend den drei Phasen eines psychologisch-diagnostischen Interviews sind diese Seminare in die Abschnitte Planung, Durchführung sowie Auswertung unterteilt. Den Studierenden wurde jeweils vor und nach dem jeweiligen Ausbildungsabschnitt ein Ausschnitt eines Leitfadens, einer Interviewdurchführung sowie einer Interviewauswertung zur Beurteilung mit dem APDI vorgelegt. Während der Leitfaden und das Interview bezüglich formalem Aufbau, Inhalte und Qualität der Frageformulierungen beurteilt wurden, fand die Beurteilung der Interviewauswertung hinsichtlich formaler und inhaltlicher Anforderungen statt. Die Antworten der Studierenden wurden mit einer Musterlösung verglichen, die mit den Dozenten der EOG Seminare entwickelt worden war und der prozentuale Anteil der Übereinstimmung wurde berechnet. Dieses Übereinstimmungsmaß stellte ein grobes Maß für die Gültigkeit des Verfahrens dar. Die Erkennensleistung der Studierenden bei der Beurteilung des Leitfadens, Interviews und der Interviewauswertung schwankten vor der Ausbildung zwischen 34% und 63% während die Erkennensleistung sich nach der Ausbildung von 58% bis 76% bewegte. Es wurde deutlich, dass zum einen das Instrument dafür geeignet ist, die Qualität von Leitfäden, Interviewdurchführungen sowie Interviewauswertungen zutreffend zu beurteilen und zweitens die praktische Ausbildung in der Regel zu einer Verbesserung der Erkennensleistung der Studierenden führt (Kici & Westhoff, 1999, 2000, 2004). Auf der Grundlage der Erkenntnisse aus der ersten Studie wurde das APDI einer Revision unterzogen. Um die Unabhängigkeit des APDIs vom Thema und der Stichprobe zu untersuchen, wurde die zweite empirische Prüfung des APDI-R im Rahmen der Seminare zur EOG durchgeführt. Die Darbietung des Untersuchungsmaterials sowie die Auswertung erfolgten in Analogie zur ersten Untersuchung. Bei der Beurteilung des Leitfaden und des Interviews als Transkript erzielten die Studierenden vor der praktischen Ausbildung Werte zwischen 0% und 78% und nach der Ausbildung schwankte die Erkennensleistung von 78% bis 100%. Die Erkennensleistung bei der formalen Beurteilung der Interviewauswertung lag bei 87%, während der Wert für die inhaltliche Auswertung bei 66% lag. Die Ergebnisse der empirischen Prüfung des APDI sowie des APDI-Rs aus der Beurteilung durch zwei unabhängige studentische Beurteilungsgruppen eines Leitfadens, eines Interviews sowie einer Interviewauswertung zu jeweils anderen Themen zeigten, dass das Instrument dazu geeignet ist, die Qualität des psychologisch-diagnostischen Interviews und die der Interviewerkompetenz zutreffend zu beurteilen. Das bedeutet, dass mit dem APDI die Stärken und Schwächen eines Leitfadens, Interviews und einer Interviewauswertung beurteilt werden können und die praktische Ausbildung in der Regel dazu führt, dass die Studierenden ihre Kompetenzen im Erkennen von Stärken und Potentialen eines Leitfadens, einer Interviewdurchführung sowie einer Interviewauswertung verbessern können. Geht man davon aus, dass Erkennen eine wichtige Voraussetzung für das tatsächliche Handeln ist, so liefern diese Ergebnisse Hinweise, dass die praktische Ausbildung einen wichtigen Beitrag zur Steigerung der Interviewerkompetenz darstellt.

Healthcare-associated infections (HAIs) are used as a measure for federal value-based payment programs. Using data for 2015, the Centers for Disease Control and Prevention (CDC) developed newer risk adjustment models to calculate the standardized infection ratio (SIR) for various infections occurring in hospitals. New national baselines were set to compare performance among medical facilities and states. Despite adjustments for various facility-level factors that contribute to HAI risk, there are ongoing concerns that SIR calculations do not adequately account for non-hospital risk factors that have been linked to clinical outcomes. This explanatory study evaluates state-level data using simple linear regression to determine relationships between the standardized infection ratio (SIR) for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and several socioeconomic and geographic factors. Bivariate analysis produced significant correlation between SIR and high school education, with states exhibiting lower SIR relative to the percent of adults who completed high school. Higher SIRs were found relative to the percent of state populations subjected to poverty, obesity, and diagnosis of diabetes. Percent of nonprofit hospitals, adults with bachelor’s degrees, and rural residents were not significantly correlated with state measures of MRSA bacteremia. These findings can help guide efforts to reduce HAIs, improve safety of care, and advance population health efforts. The results from this study reinforce the notion that non-hospital factors may have significant effects on the incidence of MRSA bacteremia events occurring in hospitalized patients. Current risk adjustment models that predict MRSA bacteremia events for quality reporting purposes may not adequately account for these risk factors. The present study highlights some ways that hospitals, patients, and policymakers can work together to address social risk factors as a strategy for promoting better and safer care, and healthier communities. This study investigates aspects of the bigger picture of health care quality, performance measurement, and population health. This “feel for the whole” underscores the implications on state performance in infection prevention in the context of socioeconomic and medical vulnerabilities. The study emphasizes the need for greater multidisciplinary collaboration to address community health needs and reduce social and medical disparities.