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The benefits of an early integration of palliative care in patients with cancer were already shown in various studies. Regarding the increase of palliative care it is important to ensure an adequate end of life care (EoL Care). One possibility is the use of clinical quality indicators (cQIs). Therefore the present study sought to explore the applicability of cQIs in the German health care system and in certification programs of the German Cancer Society. Retrospective clinical routine data from patients with recurrent or newly diagnosed lung cancer, gastrointestinal cancer, melanoma or brain tumor treated at the University Hospital Würzburg were used. 331 patients were included in the analysis. 18,1% underwent a tumorspecific therapy in the last 14 days of life and 21.8% had a new tumorspecific therapy in the last 30 days of life. This was most common in patients with lung cancer and newly diagnosed cancer. 56.2% had contact with palliative care services. 17.2% were admitted to an intensive care unit and 3.7% had more than one emergency admission during the last 30 days of life. This was most common in patients with gastrointestinal or lung cancer and in patients with newly diagnosed cancer or tumorspecific therapy. Only 22.4% had a documented formal living will. Due to the variant results shown between the different cancer diagnoses we concluded that it is possible to compare the quality of EoL Care in different samples using cQIs. As shown in various studies the benchmarks defined by C. Earle could not be achieved in all cQIs. Therefore we conclude that the use of cQIs comparing the quality of EoL Care in an international approach is limited. On the other hand it could be stated, that cQIs are valuable tools to assess the quality of EoL Care in individual hospitals to detect gaps in the quality of care and to provide the basis for a quality improvement. Therefore it could be advisable to implement cQIs in certification programs of the German Cancer Society. / Zahlreiche Studien haben in den vergangenen Jahren den Vorteil einer frühen Einbeziehung der Palliativmedizin in die Versorgung von Tumorpatienten nachgewiesen. Aufgrund der Zunahme an palliativmedizinischen Einrichtungen besteht Bedarf, die Qualität der Patientenversorgung zu evaluieren. Hierfür können klinische QI zum Einsatz kommen, anhand derer auch andere Aspekte der Versorgung am Lebensende (z.B. Zeitpunkt der letzten tumorspezifischen Therapie) evaluiert werden können. In der vorliegenden Arbeit sollte geklärt werden, inwieweit sich klinische QI auf das deutsche Gesundheitssystem übertragen lassen und in Kennziffern für Zertifizierungsprogramme der Deutschen Krebsgesellschaft überführbar sind. Hierfür wurden mithilfe des SAP retrospektiv die Daten von Tumorpatienten der Entitäten Lunge, ZNS, Darm und Haut erhoben, die im Jahr 2011 aufgrund der Diagnose einer primären Metastasierung oder aufgrund eines Rezidivs und/oder Metastasen in einer Tumorkonferenz an der Universitätsklinik Würzburg vorgestellt wurden. Von den insgesamt 631 Patienten war eine Auswertung bei 331 möglich. 263 wurden ausgeschlossen – größtenteils, weil sie noch nicht verstorben waren – und bei weiteren 37 Patienten war die Datenlage nicht ausreichend. Im Folgenden sind die wichtigsten Ergebnisse dieser Studie nochmal kurz zusammengefasst. In den letzten 14 Lebenstagen hatten 18,1% eine tumorspezifische Therapie und 8,4% eine Chemotherapie, wobei die Lungenkrebspatienten am häufigsten betroffen waren. Es ergaben sich signifikante Unterschiede zwischen den einzelnen Tumorentitäten. Für die Umstellung bzw. den Start einer neuen tumorspezifischen Therapie in den letzten 30 Lebenstagen ergab sich ein Anteil von 21,8%, wobei 8,4% aller Patienten eine Chemotherapie erhielten und auch hier die Lungenkrebspatienten den größten Anteil ausmachten. Ebenfalls zeigten sich Unterschiede zwischen den Entitäten und zudem zwischen Primär- und Rezidivfällen. Kontakt zur Palliativmedizin bestand bei 56,2% aller Patienten und dies am häufigsten bei den Hirntumorpatienten und Rezidivfällen. Mit 12,9% hatten nur wenige Patienten einen Erstkontakt kürzer 3 Tage vor Tod, was bei Patienten mit tumorspezifischer Therapie signifikant häufiger war. Eine medizinische Akutversorgung hatten 19,9%, wobei 17,2% intensivmedizinisch behandelt wurden und nur 3,7% mehr als eine Notaufnahme hatten. Am häufigsten betroffen waren die Lungen- und Darmkrebspatienten. Ein höheres Risiko bestand zudem für Patienten mit Primärfall und tumorspezifischer Therapie am Lebensende. Eine Patientenverfügung war bei 22,4% dokumentiert, wobei für 12,4% eine Datenerhebung nicht möglich war. Aufgrund der dargelegten Unterschiede zwischen den einzelnen Tumorentitäten und zwischen den Primär- und Rezidivfällen lässt sich festhalten, dass anhand der QI vergleichende Aussagen zur Versorgungsqualität am Lebensende möglich sind. Wie bereits in verschiedenen internationalen Studien gezeigt, ließen sich auch in dieser Arbeit die Sollvorgaben von C. Earle nur für die QI „Therapie in den letzten 14 Lebenstagen“ und „Palliativkontakt“ einhalten. Ein Vergleich der Versorgungsqualität in verschiedenen Krankenhäusern ist daher vermutlich nur bedingt möglich. Die QI sind dagegen gut dafür geeignet, die Versorgungssituation an einzelnen Kliniken darzustellen, um Lücken der Versorgungsqualität aufzudecken und so die Grundlage für eine Qualitätsverbesserung zu schaffen. Daher ist es durchaus empfehlenswert, die QI im Rahmen von Zertifizierungsprogrammen der Deutschen Krebsgesellschaft zu testen. Um eine vollständige und zeitsparende Datenerhebung zu ermöglichen, sollte allerdings die Dokumentation von Patientendaten verbessert werden, so dass auch eine effiziente Umsetzung im klinischen Alltag möglich ist.

Liya Wang

FundaÃÃo de Amparo à Pesquisa do Estado do Cearà / INTRODUÃÃO: A prescriÃÃo mÃdica à o principal determinante do uso de medicamentos e contribui para a efetividade da atenÃÃo à saÃde, agravos relacionados aos medicamentos e para os gastos pÃblicos em saÃde. A avaliaÃÃo da qualidade da prescriÃÃo tem sido compreendida como uma estratÃgia para sua melhoria. OBJETIVO: Desenvolver e testar indicadores de qualidade da prescriÃÃo (IQP) mÃdica em atenÃÃo primÃria de saÃde (APS) no municÃpio de Fortaleza-CE. METODOLOGIA: RevisÃo da literatura em bases de dados indexadas. SeleÃÃo, adaptaÃÃo e listagem dos IQP; convite aos prescritores da APS e distribuiÃÃo de material para leitura crÃtica; oficina de consenso com prescritores pela TÃcnica do Consenso Informal (TCI); aplicaÃÃo dos indicadores pactuados a uma amostra das prescriÃÃes em APS em Fortaleza no perÃodo de janeiro a fevereiro de 2008. Foram identificados na literatura 99 IQP, dos quais 43 foram excluÃdos obedecendo aos critÃrios de inclusÃo e exclusÃo. Os demais foram adaptados à realidade investigada e aos objetivos do estudo obtendo-se 59 indicadores que foram classificados em dois grupos: Indicadores dos processos gerais da prescriÃÃo (10) e Indicadores orientados ao medicamento (49). Um texto explicativo acompanhado da listagem dos IQP foi distribuÃdo aos prescritores com 7 dias de antecedÃncia e trazido para discussÃo em grupo, seguida de plenÃria de consenso, moderada pelas pesquisadoras. RESULTADOS: Participaram do consenso 17 prescritores (9 mulheres), idade mÃdia de 38 anos. Destes, 35,29% graduaram-se entre 1999 e 2007. Seis eram preceptores (3 mestres) e 11 residentes em medicina da famÃlia (6 especialistas). A mÃdia de atuaÃÃo no serviÃo pÃblico era de 10 anos. Durante a plenÃria, o grupo consenso decidiu aceitar todos os IQP prÃ-selecionados e acrescentaram mais seis. Os indicadores dos aspectos gerais da prescriÃÃo foram mais simples de calcular e interpretar, enquanto os indicadores orientados ao medicamento apresentaram maiores dificuldades devido à ausÃncia de requisitos tÃcnicos na prescriÃÃo que dificultaram a aplicaÃÃo. Todavia apÃs aplicaÃÃo dos IQP foi possÃvel conhecer o perfil da prescriÃÃo mÃdica de Fortaleza. Os indicadores foram aplicados a uma amostra das prescriÃÃes (N=624, sendo 30 por unidade de saÃde), envolvendo 1582 itens de medicamentos prescritos e uma mÃdia de 2,52 medicamentos por prescriÃÃo. 87% dos medicamentos prescritos pertenciam a lista padronizada do municÃpio, sendo o paracetamol o mais freqÃente. A prescriÃÃo por denominaÃÃo genÃrica aconteceu em 90,6% dos casos. 2,1% das prescriÃÃes possuÃam injetÃveis ou psicotrÃpicos e 8,3% das prescriÃÃes eram injustificÃveis. Em mÃdia o gasto por prescriÃÃo foi de R$ 2,40. A prevalÃncia dos grupos terapÃuticos analisados foi: 22,8% - anti-hipertensivos, 8,81% - antiagregante plaquetÃrio, 6,57% antidiabÃticos, 8,17% - anti-secretores, 27,08% - analgÃsicos, 22,25% - antibiÃticos. CONCLUSÃO: AtravÃs da TCI foi possÃvel elaborar um sistema de indicadores capazes de avaliar a prescriÃÃo mÃdica em APS. Esses IQP darÃo suporte ao profissional farmacÃutico para realizar avaliaÃÃes periÃdicas e planejarem intervenÃÃes necessÃrias, no sentido de aperfeiÃoar cada vez mais a prescriÃÃo tendo em vista o benefÃcio dos pacientes. / INTRODUCTION: The medical prescription is the main determinant of the use of medicines and contributes to the effectiveness of the health care, offences related to medicines and for the public costs in health. The evaluation of the quality of the prescription has been considered as a strategy to achieve its improvement. OBJECTIVE: Develop and test indicators of quality of the medical prescription (IQP) in primary health care (PHA) in the municipal district of Fortaleza-CE. METHODOLOGY: Revision of the literature in bases of indexed data. Selection, adaptation and listing of IQP; invitation sent to the doctors of PHA and material distribution for critical reading; consensus workshop with doctors using technique of the informal consensus (TIC); application of agreed indicators to a sample of the prescriptions in PAH in Fortaleza in the period of January to February 2008. 99 IQP were identified in the literature, of which 43 were excluded according to the criteria of inclusion and exclusion. The others were adapted to the reality investigated and the objectives of the study resulting in 59 indicators that were classified into two groups: indicators of processes of the general prescription (10) and targeted drug indicators (49). An explanatory text added of a list of IQP was distributed to prescribers 7 days in advance and brought to discussion groups, followed of full consensus, moderated by the researchers. RESULTS: Seventeen prescribers had participated of the consensus (9 women), average age 38 years. Among these, 35.29% graduated between 1999 and 2007. Six of them were preceptors (3 masters) and 11 residents in family medicine (6 experts). The average performance in the public service was 10 years. During the session, the consensus group decided to accept all IQP pre-selected and added six more. The indicators of the general aspects of the prescription was simple to calculate and interpret, while indicators targeted drug showed greater difficulties due to lack of technical requirements in the prescription that hampered the implementation. However after applying the IQP was possible to know the profile of the medical prescription in Fortaleza. The indicators were applied to a sample of prescriptions (N = 624, being 30 per health unit), involving 1,582 items of prescribed drugs and an average of 2.52 drugs per prescription. 87% of prescribed drugs were the standard list of the municipality, the paracetamol as being the most frequent drug. The prescription by generic denomination occurred in 90.6% of cases. 2.1% of prescriptions had injected drugs or psychotropics and 8.3% of prescriptions were unjustifiable. On average the cost per prescription was R $ 2.40. The prevalence of treatment groups was analyzed: 22.8% - antihypertensives, 8.81% - platelet aggregation inhibitor, 6.57% - antidiabetics, 8.17% - antiulcer, 27.08% - analgesics, 22.25 % - antibiotics. CONCLUSION: Through the TCI it was possible to devise a system of indicators able to evaluate the prescription in APS. These IQP will support the professional pharmacist to conduct periodic assessments and to plan necessary interventions, in order to improve prescribe aiming at the benefit of patients.

<p>The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment.</p><p>To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded.</p><p>To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care.</p> / On the day of the public defence of the doctoral thesis the status of the articles III was: Accepted; article IV and V was: Accepted for publishing.

<p>Bakgrund: Schizofreni är en sjukdom som drabbar cirka 1 % av befolkningen, men en evidensbaserad, effektiv behandling med få biverkningar saknas. Denna litteraturstudie syftar till att kartlägga kvalitetsindikatorer som utgör grunden för en god omvårdnad av patienter med schizofreni. Syfte: Att sammanställa och belysa kvalitetsindikatorer som förväntas säkerställa en god kvalitet i omvårdnad och bemötande av patienter med schizofreni. Design: Litteraturstudie Metod: Litteraturstudie av 17 vetenskapliga artiklar, en review-artikel samt fyra debattartiklar om behandling av schizofreni, som analyserats och kvalitetsgranskats för att kunna belysa vilka faktorer som utgör kvalitetsindikatorer vid omvårdnad av patienter med schizofreni. Resultat: Kvalitetsindikatorer vid omvårdnad av patienter med schizofreni är ett holistiskt synsätt där patienten står i centrum och vården ges av välutbildade vårdgivare. Patienten ska erbjudas möjlighet att vara aktiv i sin behandling. Behandlingsmetod ska väljas och/eller kombineras efter patientens individuella behov och önskemål samt syfta till att involvera anhöriga i vårdprocessen. Slutsats: Det finns många omvårdnadsmetoder för schizofreni, vilken som ger bäst effekt varierar då diagnosen är mycket individuell. Det är viktigt att vårdgivare i samråd med patienten anstränger sig för att finna den metod som passar individen bäst.</p> / <p>Background: Schizophrenia is a psychiatric diagnosis which affects about 1 % of the population. However, there is no evidence based effective treatment with limited side-effects available. This literature review seeks to clarify quality indicators which constitute the basis for a good treatment and care for patients with schizophrenia. Aim: To compile and illuminate quality indicators expected to guarantee good quality of the care and treatment received by patients with schizophrenia. Design: Literature study. Methods: For this review 17 scientific articles, one review and four papers on the subject of treatment of schizophrenia were analyzed and quality examined in order to illuminate the factors which constitute the basis of quality indicators for good treatment and care for patients with schizophrenia. Results: Quality indicators in caring for patients with schizophrenia constitute a holistic, patient centered approach. The caregivers are well educated and the patient is encouraged to take an active part in the treatment. The method of treatment should be chosen and/or combined in accordance with the patient’s individual needs and wishes. It also aims to include close relations in the caring process. Conclusion: There are many methods of treatment available for schizophrenia. It is however a very individual diagnosis, and which treatment gives the best effect varies from case to case. It is important that caregivers, while including the patient in the process, strive to find the method most suited to the individual.</p>

The aim of this thesis was to identify important aspects of surgical nursing care, designing strategic and clinical quality indicators in postoperative pain management, investigate content validity, develop and evaluate psychometric properties of an instrument to measure the indicators, test the applicability of the instrument and investigate patient and nurse assessment. To identify the important aspects of nursing care which might impact on quality of care in surgical wards, it was conducted 4 focus group interviews with clinical nurses (n=20). A tentative model with 15 categories in 2 dimensions, elements of performance and prerequisites, emerged from the data analysis. The categories were, e.g. detecting and acting on signs and symptoms, informing and educating, promoting relationships, responsibility and attitudes. The model was used as a foundation for developing indicators in postoperative pain management, one in each category, each supported by a literature review. To assess the content validity of the indicators, a questionnaire was compiled and sent to registered nurses with a special interest in pain (n=210) and to a random sample of clinical nurses working in surgical wards (n=321). The groups assessed the indicators as essential for achieving high quality, realistic to carry out and possible for nurses to influence management. The first group validated 14 of the 15 indicators and the second group validated 12 as “major” factors in terms of being essential to achieve high quality of care. The remaining factors were classified as “supportive”. No indicator was discarded. To measure the indicators, an instrument was developed and psychometric properties were evaluated. The indicators were converted to statements suitable for a patient questionnaire and were scored on a 5-point scale with higher values indicating higher quality of care. Patients (n=198) answered the questionnaire on their second postoperative day. The inter-item and item-total correlation coefficients were in a satisfactory range, and Cronbach’s coefficient alpha (0.84) supported internal consistency reliability. Four sub-scales, entitled communication, action, trust and environment emerged from the factor analysis with a total variance of 61.4%. The total scale correlated (rs=0.53) with the single item pain-relief-satisfaction question. The patients who reported more pain than expected scored lower on the total scale and the patients who received epidural analgesia reported higher scores on the total scale. A nurse questionnaire, similar to the patient questionnaire, was compiled. The responsible nurse at the time (n=63) answered 196 questionnaires paired with the individual patient. The new instrument appeared to be useful in identifying important areas for improvement both from the patients’ and nurses’ perspectives, based on the number of disagreements (1 and 2). Differences were found among departments. The patients’ assessments on the environment sub-scale and the overall satisfaction question were higher than the nurses’ assessments. The findings suggest initial support for the instrument as a means to measure the quality of nursing care in postoperative pain management. Key words: quality indicators; health care, pain; postoperative, focus groups, psychometrics, questionnaires, nursing care. / On the day of the public defence of the doctoral thesis the status of the articles III was: Accepted; article IV and V was: Accepted for publishing.

Bakgrund: Schizofreni är en sjukdom som drabbar cirka 1 % av befolkningen, men en evidensbaserad, effektiv behandling med få biverkningar saknas. Denna litteraturstudie syftar till att kartlägga kvalitetsindikatorer som utgör grunden för en god omvårdnad av patienter med schizofreni. Syfte: Att sammanställa och belysa kvalitetsindikatorer som förväntas säkerställa en god kvalitet i omvårdnad och bemötande av patienter med schizofreni. Design: Litteraturstudie Metod: Litteraturstudie av 17 vetenskapliga artiklar, en review-artikel samt fyra debattartiklar om behandling av schizofreni, som analyserats och kvalitetsgranskats för att kunna belysa vilka faktorer som utgör kvalitetsindikatorer vid omvårdnad av patienter med schizofreni. Resultat: Kvalitetsindikatorer vid omvårdnad av patienter med schizofreni är ett holistiskt synsätt där patienten står i centrum och vården ges av välutbildade vårdgivare. Patienten ska erbjudas möjlighet att vara aktiv i sin behandling. Behandlingsmetod ska väljas och/eller kombineras efter patientens individuella behov och önskemål samt syfta till att involvera anhöriga i vårdprocessen. Slutsats: Det finns många omvårdnadsmetoder för schizofreni, vilken som ger bäst effekt varierar då diagnosen är mycket individuell. Det är viktigt att vårdgivare i samråd med patienten anstränger sig för att finna den metod som passar individen bäst. / Background: Schizophrenia is a psychiatric diagnosis which affects about 1 % of the population. However, there is no evidence based effective treatment with limited side-effects available. This literature review seeks to clarify quality indicators which constitute the basis for a good treatment and care for patients with schizophrenia. Aim: To compile and illuminate quality indicators expected to guarantee good quality of the care and treatment received by patients with schizophrenia. Design: Literature study. Methods: For this review 17 scientific articles, one review and four papers on the subject of treatment of schizophrenia were analyzed and quality examined in order to illuminate the factors which constitute the basis of quality indicators for good treatment and care for patients with schizophrenia. Results: Quality indicators in caring for patients with schizophrenia constitute a holistic, patient centered approach. The caregivers are well educated and the patient is encouraged to take an active part in the treatment. The method of treatment should be chosen and/or combined in accordance with the patient’s individual needs and wishes. It also aims to include close relations in the caring process. Conclusion: There are many methods of treatment available for schizophrenia. It is however a very individual diagnosis, and which treatment gives the best effect varies from case to case. It is important that caregivers, while including the patient in the process, strive to find the method most suited to the individual.

SAMMANFATTNING Syfte  Syftet med uppsatsen är att undersöka om Sveriges ungdomsmottagningar har liknande förutsättningar att arbeta på ett kvalitetssäkert sätt utifrån de styrdokument som ett urval av mottagningar använder. Ungdomsmottagningar drivs utan nationellt uppdrag och av olika uppdragsgivare och utan enhetliga uppdragsbeskrivningar. Detta skulle kunna vara orsaken till de stora skillnader i bland annat kompetens, struktur och tillgänglighet som rapporter pekar på. Detta skulle kunna leda till bristande eller varierande vårdkvalitet. Metod Genom en kvalitativ innehållsanalytisk ansats undersöks om ett strategiskt urval av styrdokument från ungdomsmottagningsverksamheten behandlar de kvalitetsområden som framgår i Socialstyrelsens föreskrift om ”God Vård”. Reslutat De styrdokument som undersökts ger ett samlat intryck av vad en ungdomsmottagning arbetar med. De har alla ett övergripande mål med i stort sett samma betydelse; att främja ungdomars fysiska och psykiska hälsa, stärka deras identitetsutveckling så att de kan hantera sin sexualitet samt att förebygga oönskade graviditeter och sexuellt överförbara infektioner. Detta mål anger ramen för verksamheten. De styrdokument som studerats uppvisar stora skillnader, framför allt i hur utförligt man beskriver sina mål, samt i hur uppföljnings- och kvalitetsförbättringsarbetet beskrivs. De dokument som bäst täcker God vårds kvalitetsmål, är mer generella och lämnar större tolkningsutrymme till bland annat personal och huvudmän. Detta skulle kunna ge stora skillnader i vårdkvalitet, vilket också påvisats i svenska studier och rapporter. Ytterligare forskning om hur personal och huvudmän har uppfattat ungdomsmottagningarnas uppdrag behövs göras för att stärka denna teori. Slutsats Utifrån de undersökta dokumenten kan sägas att alla ungdomsmottagningar inte har fått liknande förutsättningar för att arbeta på ett kvalitetssäkert sätt utifrån vad God Vård anger. De mål som anges i styrdokumenten lämnar oftast för stort tolkningsutrymme. Det gemensamma övergripande målet för ungdomsmottagningarna tycks finnas, men hur man når dit är mer oklart, d.v.s. den gemensamma styrningen saknas. / ABSTRACT Aim The purpose of this paper is to examine whether Swedish “ungdomsmottagningar” (youth center for services and counseling of sexual and reproductive health) have been given similar opportunities to work in a quality safe way from the policy documents that a sample of clinics use. Today all ”ungdomsmottagningar” are providing care without national mandate, by different healthcare providors and without homogenous mission. This could be a reason for the vast differences reported, in for example in competence, structure and access. There is a risk that the result is a lack of quality of care. Method The various policy documents from the youth centers are examined through a qualitative analytical content approach. The quality areas presented in the National Board of Health and Welfare directive on "Good Care" are searched in the documents. Result The policy documents examined give an overall impression of what a youth center is about. They all have one main goal with essentially the same purpose: to strengthen young people's physical and psychological health, strengthen their identity development toward a safe and responsible sexuality. Their mission is also to prevent unwanted pregnancies and sexually transmitted infections. This goal only defines the framework around the “youth centers”. The policy documents studied show major differences, especially in the detailing of described goals as well as in monitoring and improving quality of work. The documents that best matches ”good care” are more general but leave more room for interpretation on numerous factors, including staffing and principals. This could lead to large differences between the youth centers, which also are demonstrated in Swedish studies and reports. Further research on how staff and principals are perceived by the youth centers mission is needed to strengthen this explannation. Conclusion Based on the reviewed documents it can be said that all youth centers have not received similar conditions to work in a quality safe manner from what Good Care indicates. All policy documents indicate, in principle, the same overall objective. The common goal seems to exist but how to reach it, is still uncertain. The common guide is missing.

In the past decade, there has been an enormous growth of distance education courses and programs in higher education. However, the potential of distance education is tempered by one overriding question: How do you ensure that distance education coursework and degrees are of high quality? The purpose of this study is threefold: (1) to identify quality indicators of distance education; (2) to provide implications of the identified quality indicators for health education researchers and practitioners; and, (3) to develop an instrument to assess student opinions of the quality of distance education. Dillman's (2000) steps of pretesting and the instrument development framework in the Standards (1999) were used, and data were collected from students enrolled in four health education on-line courses during the Spring 2006 semester at Texas A&M University. MPlus (Muthen & Muthen, 2002) was used to conduct reliability and validity analyses of the instrument. The results of the study revealed common benchmarks and quality indicators that all parties deem important in designing, implementing and evaluating distance education courses and programs. Additionally, an instrument was produced that resulted in both valid and reliable scores.