A Thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy December 2015 Johannesburg. / Introduction There has been little published in South Africa regarding quality improvement in health and in particular the involvement of patients in this intervention. There is evidence globally that both quality improvement efforts and particularly the engagement of the users adds value to health services. Three projects were conceived around this core concept as explained below. 1. Systematic review. Patients’ involvement in improvement initiatives: a qualitative systematic review After a search was done of databases, 5121 papers were found to be potentially relevant. After screening and critical appraisal for eligibility, it was found that 31 articles qualified for analysis. These were then assessed using JBI software and 5 categories and 2 metasynthesised findings were documented. In summary, there were enablers and barriers to involving patients. The five categories which lead to these 2 findings were the following: (1) although patient participation in QI is acknowledged and encouraged by many policies and documents globally, it is difficult to implement; (2) there are differing views between patients and providers as to the process; (3) on the positive side, different levels of involvement of patients in QI were demonstrated; 4) practical, appropriate and innovative results emerged; (5) individual or group support and incremental development through skills and enablement contributed towards success 2. The Integration of Non Communicable Chronic Diseases (NCDs) and HIV/Aids and mental health care through the involvement of chronically ill patients using Empowerment Evaluation (EE). At 9 primary care clinics, the process of EE was followed with chronically ill stable patients and appropriate healthcare workers. This was an additional intervention in an ongoing QI cycle on the integration of all chronic illnesses into one model, based on Lean principles. Steps followed were ‘’taking stock’’ ie assessing patients’ and HCWs’ impressions of the services at the clinic in a measured way, creating a vision and using this as a yardstick for the project and then problems and solutions being co-managed by the collaborative team. A total of 37 interventions were discussed and 23 implemented in the time frame. Innovative solutions were implemented and teams were empowered by the potential they experienced. 3. An exploration of childhood nutrition and wellness in a subdistrict by patient inclusivity in QI using experience based codesign (EBCD) with mothers/caregivers of malnourished children . Following the steps of EBCD, staff and patients exposed to health services regarding ill children, were interviewed, feedback was given of the findings separately and then in a combined meeting and co-design teams were created to work with the prioritised quality improvement interventions. Touch points in the system were examined through emotional mapping, video interviews and observations. Within the 10 month period of the project, 38 interventions were identified and 25 accepted and implemented at different levels. Conclusion The methodologies were chosen to fit with the qualitative aspect of the research. There were concrete appropriate improvement outcomes due to the engagement of service users in both the primary care clinics serving chronically ill patients and the paediatric system in one subdistrict eg the flow of patients improved, logistical improvements like direct admissions for very ill children, school and library opportunities for admitted ill children etc occurred. Subjective gains like the acknowledgement of their power role by patients and a flattening of the healthcare worker hierarchy were also experienced in the research. Other findings were that unexpected roleplayers were identified, the timeframe of such QI cycles needs to be considered especially regarding the resilience of patients and resources were not an importatn limitation. However some modifications would have to be considered to make these research approaches common practice. The particular research methodologies have not been published in a South African context before and have also not been used for paediatric or integrated chronic illness research and therefore contribute both content and process information to health systems research in South Africa. / MT2017

O presente trabalho propõe uma nova metodologia para elaboração do DFMEA (Design Failure Modes and Effects Analysis - Análise dos Efeitos e Modos de Falha do Projeto) utilizando as técnicas da EV (Engenharia do Valor) para determinação das funções do produto. Para isto, o trabalho é estruturado de forma que os conceitos fundamentais do DFMEA e EV sejam vistos individualmente e, em um segundo momento, mostra a intersecção dessas técnicas, surgindo assim a referida metodologia, batizada de DFFMEA (Design Function Failure Modes and Effects Analysis - Análise dos Efeitos e Modos de Falha para a Função do Projeto). A proposta é validada através da aplicação de três estudos de casos, cujo resultado objetivo é a redução do tempo de desenvolvimento do DFMEA e a otimização da mão-de-obra intelectual. Resultados subjetivos também são apresentados, como incentivo à criatividade. O trabalho pretende, igualmente, divulgar as técnicas da metodologia da EV dentro da organização, incentivando o seu uso e possibilitando ganhos financeiros. / Present work proposes a new methodology to do DFMEA (Design Failure Modes and Effects Analysis) using Value Engineering techniques in order to obtain the product functions. For this purpose, the work is structured in such a way that DFMEA and EV basic concepts are examined individually and, in a second moment, it exhibits the intersection of these techniques, when above mentioned methodology named DFFMEA (Design Function Failure Modes and Effects Analysis) appears. The proposal has been validated through the application of three studies of cases, which objective results are the time reduction for development of DFMEA and the optimization of intellectual labor. Subjective results are also brought out, as an incentive to creativity. The work equally intends to spread the EV methodology techniques throughout the organization, stimulating its use and making possible financial profits.

Com a globalização, a competitividade no mercado automotivo tem aumentado cada dia mais, e os produtos automotivos (veículos e componentes) estão sendo freqüentemente desenvolvidos em um determinado país todavia para construção, uso e aplicação em outros países. As condições de aplicação como altitude, condições climáticas, topografia, percepção dos clientes e outras variáveis podem ser diferentes de um mercado para outro e influenciar na confiabilidade dos produtos. Se as condições de aplicação não são consideradas na fase de desenvolvimento do veículo, pode ser que o produto não venha atender a função à qual ele foi projetado durante a sua vida útil, e pode-se também experimentar um nível de falhas excessivo e/ou modos de falhas específicos de determinados mercados, bem como arruinar a imagem da marca. Portanto é necessário predizer a confiabilidade dos produtos que são exportados e a partir dos dados de confiabilidade usá-los em projetos futuros, fazendo com que sejam projetados veículos para atendimento ao mercado global, ou então no mínimo atender aos requisitos ou demanda de qualidade de cada país importador. Portanto o objetivo deste trabalho é desenvolver um modelo para descrever o comportamento de um produto exportado e predizer a sua confiabilidade no campo. O modelo considera a utilização dos dados de falhas de campo no período de garantia, considerando também a existência de veículos que não apresentaram falhas ao final deste período. De posse da estimativa de confiabilidade para o veículo e seus respectivos subsistemas em cada país, propõe-se um modelo para análise de detecção de diferenças entre confiabilidades e a partir do qual se possa concluir as razões pelas quais há diferenças e usar estes dados para uso em projetos futuros. / Since the globalization, the automotive competition is growing every other day, and automotive products (vehicles and components) are often developed in one country though its made, used and applied in other markets. The operating conditions such as height, climate, topography, customer perception and other variables are often different from one market to another and could influence on the products reliability. If the market operating conditions are not considered in the vehicle development phase, the product may not fully perform its intended function over useful life period, and also may experience an excessive level of field complaints and/or failure modes specific to those markets and also damage the image of the brand. Therefore it is necessary to predict the export products reliability and based on the reliability data to use as lessons learned for future projects in order to fulfill the global market requirements or at least fulfill the requirements of quality from each country that imports the vehicles. Therefore the main objective of this study is to develop a model to describe the export product behavior and predict its reliability in the field. The model considers the use of warranty claims and also uses the data regarding the vehicles which did not have any claim under the warranty period. Based on the estimative of reliability for the exported vehicle and also their subsystems, its proposed a model to analyze and detect differences between reliability and so to use such data on future projects.

O projeto, operação e descomissionamento de uma unidade de tratamento e armazenamento de rejeitos requerem que sejam observados os requisitos regulatórios referentes à garantia da qualidade nuclear, conforme o Regulamento CNENNN1.16 \"Garantia da Qualidade para a Segurança de Usinas Nucleoelétricas e Outras Instalações\", da Comissão Nacional de Energia Nuclear (CNEN). Entretanto, embora a aplicação do regulamento seja obrigatória, o documento da CNEN apresenta requisitos para qualquer tipo de instalação nuclear, sendo por isso genérico e pouco detalhado em relação às ações necessárias para garantir que os requisitos mais específicos de uma unidade de tratamento e armazenamento de rejeitos sejam observados. Além disso, não existem comercialmente ferramentas informatizadas já prontas para utilização, mas somente programas para gestão de qualidade que requerem uma adaptação através da inclusão de conjuntos de dados específicos do programa de controle da qualidade de uma instalação de gestão de rejeitos, ou então o desenvolvimento de uma ferramenta personalizada. Desta forma, o objetivo deste trabalho é buscar informações que permitam o desenvolvimento de bases para um sistema informatizado de garantia da qualidade que esteja em conformidade com o regulamento da CNEN NN-1.16, e que possa vir a englobar os procedimentos específicos para uma instalação de tratamento e gestão de rejeitos radioativos. / The design, operation and decommissioning of a radioactive waste treatment and storage unit requires the compliance with the regulatory requirements for nuclear quality assurance, in accordance with the CNEN-NN.1.16 - \"Quality Assurance for the Safety of Nuclear Power Plants and Other Installations\", of the National Nuclear Energy Commission (CNEN). However, although the regulation is mandatory, the CNEN document presents requirements for any type of nuclear facility, therefore it is generic and not detailed in relation to the actions necessary to ensure that the more specific requirements of a radioactive waste treatment and storage unit are met. In addition, there are no commercially available ready-to-use computer tools, but only quality management programs that require adaptation through the inclusion of specific data sets from the quality control program of a radioactive waste management facility, or the development of a customized tool. Therefore, the objective of this work is to gather information that allows the development of bases for a computerized quality assurance system that is in compliance with the CNEN NN-1.16 regulation, and which may include the specific procedures for an facility of treatment and management of radioactive waste.

O interesse mundial relativo à gestão da qualidade tem sido crescente nas últimas décadas. Esse fato está associado às profundas transformações no cenário econômico, político e social, que ocasionaram uma necessidade de reavaliação e questionamento da postura empresarial adotada. A construção civil, em particular, desde o início dos anos 90, tem se mostrada comprometida com o movimento pela qualidade. No Brasil, tal fenômeno também se verifica e, diante da revisão das Normas da série ISO 9000 e da publicação de sua nova versão em dezembro de 2000, identificou-se a necessidade de avaliar o seu potencial impacto na gestão e certificação da qualidade em empresas construtoras. O trabalho traz a discussão das principais modificações propostas pela nova versão da Norma ISO 9000, analisando com mais detalhe a ISO 9001:2000 - Requisitos, que passa a ser a única norma da série utilizada para fins de certificação. Analisam-se os tópicos voltados para o enfoque no processo da organização, necessidade de comprovação da melhoria contínua e obrigatoriedade de se ter o Sistema de Gestão da Qualidade com o foco voltado para a satisfação das exigências e expectativas do cliente.Nos estudos de caso são identificados os desafios que cada uma das empresas tiveram que superar para adaptarem seus Sistemas de Gestão de modo a atender aos novos conceitos da Norma. Conclui-se com a análise dos impactos destas adaptações, tanto no âmbito gerencial da empresa, como também na produção, em seus canteiros de obras. / The worldwide interest related to the quality management has been increasing in the past few decades. This fact is associated with the deep changes in the economic, political and social scenery that has caused a necessity for reevaluation of the adopted entrepreneurial position. The civil construction, in particular, since the beginning of the 90’s, has been engaged to enhance the quality. In Brazil, such phenomenon is also verified. The ISO 9000 standards series revision and the publication of its new version in December 2000, identified the need to evaluate its potential impact on the management and certification of contractor organizations. This paper presents the discussion of the main changes proposed in the new version of ISO 9000 series, mainly analyzing the ISO 9001:2000 - Requirements, which is now the only standard of the series used for certification. The topics focused on the process of the organization, the need of evidence in the continuous improvement and the obligation of having the quality management system focused on the satisfaction of requirements and customers’ expectations are analyzed. The case studies are identified the challenges that each company have to exceed to adapt their Management System in order to meet the new concept of the ISO 9001 Standard. This analysis ends with the evaluation of the impact of this implementation, both in the office and in the production activities, in their building sites.

Os programas de rastreamento mamográfico (PRM) organizados atingem redução de mortalidade por câncer de mama em até 35%, principalmente quando submetidos a controle de qualidade efetivo. O PRM realizado pelo Hospital de Câncer de Barretos (HCB) é oferecido através de Unidades Móveis e Fixa desde 2003, para mulheres entre 40 e 69 anos, pertencentes à V Regional de Saúde do Estado de São Paulo Barretos (DRS). Trata-se de um projeto pioneiro no Brasil que necessita enquadrar-se em critérios de controle de qualidade para que atinja resultados comparáveis aos da literatura. Objetivo: Este estudo visa avaliar os indicadores de qualidade de detecção e tratamento das pacientes portadoras de câncer de mama diagnosticadas pelo PRM-HCB na DRS-V de São Paulo, entre 2003 e 2010. Métodos: Foram revisados os prontuários de todas as pacientes com câncer de mama, detectados pelo PRM-HCB no período. Os indicadores de controle de qualidade incluíram dados de: estadiamento, diagnóstico, tratamento, laudo patológico, intervalos de tempo, e dados descritivos. As pacientes sintomáticas tiveram os indicadores analisados em separado das assintomáticas. As variáveis contínuas e categóricas foram comparadas aos parâmetros estabelecidos pela European Breast Cancer Network (EBCN), utilizando-se o programa SPSS 15. Resultados: Foram incluídas 257 mulheres. Os estádios clínicos 0 e I compreenderam 68,3% (125/183) dentre as assintomáticas e 33,8% (24/71) das sintomáticas, com 3 casos sem informação (nível desejável >70%). O tamanho médio do tumor foi de 1,96cm entre as assintomáticas e de 3,2cm dentre as sintomáticas (p=0,000). A cirurgia foi conservadora em 85,2% das assintomáticas e em 62,5% das sintomáticas. Dentre os 25 indicadores adequadamente avaliados, 18 encontravam-se em níveis desejáveis, sendo 7 deles a respeito da adequação do tratamento cirúrgico. Um dos indicadores de tempo esteve em nível aceitável (tempo entre a indicação de cirurgia e o procedimento cirúrgico médio de 17,9 dias úteis, nível aceitável = 15du), enquanto outros 2 estiveram insuficientes. Os intervalos de tempo para o laudo anátomo-patológico (AP) estiveram em níveis satisfatórios (82,1% dos laudos AP de diagnóstico em 10du ou menos, nível desejável 80%). As principais deficiências relacionadas ao tempo foram da mamografia de rastreamento até a matrícula (média de 32du, nível aceitável = 5du) e da matrícula aos demais exames diagnósticos (média de 27du; nível aceitável = 5du). Conclusões: Os indicadores de estádio dentre as mulheres assintomáticas estiveram em níveis aceitáveis, entretanto, as mulheres sintomáticas apresentaram tumores maiores e em estádios mais avançados. A abordagem multidisciplinar como Unidade de Mama possibilitou atingir níveis adequados e comparáveis aos europeus quanto aos métodos diagnósticos e terapêuticos. Deficiências quanto aos intervalos de tempo e barreiras que dificultam a adesão da população demandam intervenções futuras. A análise de indicadores de qualidade foi factível e permitiu diagnosticar uma adequação parcial dos processos de diagnóstico e tratamento das pacientes com câncer de mama detectado pelo PRM-HCB, segundo os critérios estabelecidos pela EBCN / In order to achieve a reduction of 35% in breast cancer mortality, organized mammographic screening (MMGS) programs demand quality assurance. BCH has been offering MMGS for 40 to 69-year-old women, since 2003, by means of three mobile units and a standardized breast unit, through the public health system. It is a pioneer Brazilian project, in a São Paulo State nonmetropolitan setting, that has to attend quality assurance to achieve results comparable to those presented in the actual literature. Objective: This study aims to analyze the quality performance indicators regarding diagnosis methods and treatment offered to women whose breast cancer was detected by the BCH MMGS program, between 2003 and 2010. Methods: We reviewed the medical records of breast cancer patients whose disease was detected by the BCH MMGS program during the period. Quality indicators included data about: stage, diagnosis, treatment, pathology, time intervals, and descriptive information. Symptomatic women at the moment of the first evaluation had their data evaluated separately from the asymptomatic. The data gathered were analyzed using SPSS 15. The results were compared to the European Breast Cancer Network Guidelines for quality assurance. Results: 257 patients were included in this study. Stages 0 and I corresponded to 68.3% (125/183) of the asymptomatic cases, and 33.8% (24/71) of the symptomatic group (desirable level >70%), with 3 missing cases. The mean tumor size was 1.96cm for the asymptomatic patients, and 3.2cm for the symptomatic (p=0.000). Breast conserving surgery was possible in 85.2% of the asymptomatic patients, and in 62.5% of the symptomatic. Among the 25 quality indicators adequately evaluated, 18 were in desirable levels. Seven of them were related to the surgical approach. One of the time interval indicators was considered acceptable (mean time interval between decision to operate and date of surgery = 17.9 working days, acceptable level = 15wd), but 2 were in insufficient levels. Time intervals for pathology reports were sufficient (82.1% of the diagnostic pathology reports were performed in 10wd or less, desirable level80%). Main deficiencies were related to time interval between the mammogram and the first evaluation (mean=32wd, acceptable level=5wd) and the evaluation and the results of the additional exams (mean=27wd, acceptable level=5wd). Conclusions: Stage quality indicators were adequate for the asymptomatic group. Symptomatic women had larger tumors, with more advanced stages. The multidisciplinary approach was important to achieve acceptable and desirable levels regarding diagnostic methods and treatment. Deficiencies concerning time intervals and possible barriers that represent delays demand a future action plan. The analysis of quality indicators was feasible and allowed to diagnose a partial adjustment in the diagnostic and treatment process of the cancer patients detected by the BCH MMGS based on the EBCN Guidelines criteria

O projeto, operação e descomissionamento de uma unidade de tratamento e armazenamento de rejeitos requerem que sejam observados os requisitos regulatórios referentes à garantia da qualidade nuclear, conforme o Regulamento CNENNN1.16 \"Garantia da Qualidade para a Segurança de Usinas Nucleoelétricas e Outras Instalações\", da Comissão Nacional de Energia Nuclear (CNEN). Entretanto, embora a aplicação do regulamento seja obrigatória, o documento da CNEN apresenta requisitos para qualquer tipo de instalação nuclear, sendo por isso genérico e pouco detalhado em relação às ações necessárias para garantir que os requisitos mais específicos de uma unidade de tratamento e armazenamento de rejeitos sejam observados. Além disso, não existem comercialmente ferramentas informatizadas já prontas para utilização, mas somente programas para gestão de qualidade que requerem uma adaptação através da inclusão de conjuntos de dados específicos do programa de controle da qualidade de uma instalação de gestão de rejeitos, ou então o desenvolvimento de uma ferramenta personalizada. Desta forma, o objetivo deste trabalho é buscar informações que permitam o desenvolvimento de bases para um sistema informatizado de garantia da qualidade que esteja em conformidade com o regulamento da CNEN NN-1.16, e que possa vir a englobar os procedimentos específicos para uma instalação de tratamento e gestão de rejeitos radioativos. / The design, operation and decommissioning of a radioactive waste treatment and storage unit requires the compliance with the regulatory requirements for nuclear quality assurance, in accordance with the CNEN-NN.1.16 - \"Quality Assurance for the Safety of Nuclear Power Plants and Other Installations\", of the National Nuclear Energy Commission (CNEN). However, although the regulation is mandatory, the CNEN document presents requirements for any type of nuclear facility, therefore it is generic and not detailed in relation to the actions necessary to ensure that the more specific requirements of a radioactive waste treatment and storage unit are met. In addition, there are no commercially available ready-to-use computer tools, but only quality management programs that require adaptation through the inclusion of specific data sets from the quality control program of a radioactive waste management facility, or the development of a customized tool. Therefore, the objective of this work is to gather information that allows the development of bases for a computerized quality assurance system that is in compliance with the CNEN NN-1.16 regulation, and which may include the specific procedures for an facility of treatment and management of radioactive waste.

This study discusses the purpose, process and practice of quality assurance in transnational education (TNE) wherein institutions in one country award their degrees to students studying in another. This arrangement raises the issue of how the quality and standards of the degree programmes are assured so that they enable the programmes delivered in one country to be considered as being of a comparable quality and standard to those delivered in another. The study explores how the cross-national implementation of quality assurance is conducted and perceived by those engaged in it and the challenges such activity faces. Using data collected via structured interviews in Sri Lanka and the UK, the study examines the perceptions of participants in TNE collaboration. The analysis is undertaken within a conceptual framework developed from inter-firm relationship and supply chain management theories. The concept of “relational capital”, and its creation through socialisation activity, is proposed as a key factor in understanding TNE. A further body of literature is explored, that of inter-cultural communication and inter-cultural competence. The study contributes to the literature on TNE and internationalisation by identifying a tension between the financial drivers behind TNE and the resource intensive activities required to build relational capital. The findings are developed into a conceptual model for quality assurance in TNE, which can be used in the planning, management and evaluation of TNE and is designed to develop relational capital through the relational and inter-cultural competences of those engaged in such work. Through such a development, it is argued, quality assurance in TNE can move away from a process of enforced compliance with the prevailing quality assurance processes to one driven by a shared quality culture in which capacity building in the partner institutions of TNE can be achieved.

Available empirical data relating to quality generally and the application of quality assurance principles to language education at tertiary-level are scanty. This study explores how higher education institutions in Ghana apply QA mechanisms to enhance the teaching and learning of English for Academic Purposes. It examines how institutional contexts and cultures of the four case study institutions impact their QA processes. First, the rhetorical tensions and the apparent lack of consensus on the definition of the term “quality” are acknowledged alongside the enviable status of English as a “global lingua franca”; the relevance and pervasiveness of the EAP discipline in tertiary educational circles within and without Ghana and the resultant need for quality assurance and enhancement in its teaching and learning. One particular component of quality in higher education: the need for ensuring that programmes and services are fit for the purpose for which they were designed, and that the “clients” (students) are getting value for their money serves as the focus of the empirical research. The QA dimension of the research attempts to answer the question of whether students provide written feedback on their teaching and whether this is acted upon by the case study institutions in order to improve the EAP course. A combination of qualitative, quantitative, mixed-method approaches and documentary research is adopted to provide the framework for exploring QA and quality issues at each of the institutions involved in this study. The study first considers the quality challenges of higher education in Sub-Saharan Africa and Ghana within the context of policy. Subsequently, the unique features of each case study institution are quantified. To enhance the depth of understanding so as to establish each case study institution’s QA mechanisms and processes for enhancing EAP teaching and learning, a comparative/multiple case study approach is adopted. The blend of methods facilitated exploring the issues and the drawing of conclusions as the strengths of each complements the other. The assessment of QA practices used in the teaching and learning of EAP in the case institutions revealed a number of interesting similarities and differences in terms of institutional context, quality culture, quality assurance mechanisms, pedagogy, and curriculum designs. Based on these findings, suggestions for EAP teaching quality enhancement in the case study institutions are subsequently made. Unique practices identified in the institutions are recommended for replication in other tertiary educational institutions. Suggestions for further and future research are also made followed by a brief account of the author’s professional and personal development during the DBA programme.

Internet applications have varied Quality of Service (QoS) Requirements. Traditional applications such as FTP and email are throughput sensitive since their quality is primarily affected by the throughput they receive. There are delay sensitive applications such as streaming audio/video and IP telephony, whose quality is more affected by the delay. The current Internet however does not provide QoS support to the applications and treats the packets from all applications as primarily throughput sensitive. Delay sensitive applications can however sacrifice throughput for delay to obtain better quality. We present a Traffic Sensitive QoS controller (TSQ) which can be used in conjunction with many existing Active Queue Management (AQM) techniques at the router. The applications inform the TSQ enabled router about their delay sensitivity by embedding a delay hint in the packet header. The delay hint is a measure of an application's delay sensitivity. The TSQ router on receiving packets provides a lower queueing delay to packets from delay sensitive applications based on the delay hint. It also increases the drop probability of such applications thus decreasing their throughput and preventing any unfair advantage over throughput sensitive applications. We have also presented the quality metrics of some typical Internet applications in terms of delay and throughput. The applications are free to choose their delay hints based on the quality they receive. We evaluated TSQ in conjunction with the PI-controller AQM over the Network Simulator (NS-2). We have presented our results showing the improvement in QoS of applications due to the presence of TSQ.