Thesis (MBA)--Stellenbosch University, 2002. / ENGLISH ABSTRACT: Quality assurance has become a prominent and permanent feature of Higher Education in many countries, and South Africa has been no exception in this regard. The pressing need for social and economic development and the competition for scarce resources has spearheaded the demands for accountability in Higher Education and given rise to the promulgation of a series of Acts and regulations aimed at the transformation of the sector. The most important legislation introduced was the SAQA Act No 58 of 1995. It provides the legal framework for the transformation of the entire educational system in South Africa, and in particular for the evaluation of the quality of Education and Training by establishing structures such as National Standards Bodies (NSB's), Standard Generating Bodies (SGB's) and Education and Training Quality Assurance Bodies (ETQA's). A significant development in South African Higher Education was the publishing of the Education White Paper 3 and the promulgation of the South African Higher Education Bill in 1997. One of the outstanding features of this legislation is that the evaluation of the quality of Higher Education is compulsory, and will be done by the Council on Higher Education (CHE), co-ordinated by its permanent committee, the Higher Education Quality Committee (HEQC). There is a concern that rigidly enforced quality assurance systems could have a negative impact on the academic freedom of institutions. The purpose of this study was, therefore, to determine the most likely impact of quality assurance on academic freedom. In order to achieve this objective, quality assurance and academic freedom frameworks were developed respectively, and the interaction of the various elements in this framework explored. In most instances it was found that quality assurance could have a negative impact on academic freedom. One particular aspect that is of serious concern at the tertiary level is the programme-based as opposed to discipline-based approach to qualifications. This poses a serious threat to academic freedom as it effectively diminishes the space within which academic freedom is practised. However, this conclusion is based on a meta-physical study, and needs to be confirmed by appropriate empirical studies. / AFRIKAANSE OPSOMMING: Kwaliteitsversekering is reeds in baie lande 'n vername en blywende kenmerk van Hoër Onderwys, en Suid-Afrika het in hierdie verband nie agtergebly nie. Die dringende behoefte aan sosiale en ekonomiese ontwikkeling en die mededinging om skaars hulpbronne was aan die spits van die eise om aanspreeklikheid in Hoër Onderwys en het aanleiding gegee tot die promulgering van 'n reeks wette en regulasies wat op die transformasie van die sektor gerig is. Die belangrikste wetgewing wat ingevoer is, is die Wet op die Suid-Afrikaanse Kwalifikasieowerheid 58 van 1995. Dit maak voorsiening vir die wetlike raamwerk vir die transformasie van die hele onderwysstelsel in Suid-Afrika, en veral vir die evaluering van die kwaliteit van Onderwys en Opleiding deur strukture soos Nasionale Standaardeliggame (NSL'e), Standaarde-ontwikkelingsliggame (SOL'e ) en Onderwys-en-Opleidingskwaliteitversekeringsliggame (OOKVL's). 'n Betekenisvolle ontwikkeling in Suid-Afrikaanse Hoër Onderwys was die afkondiging van die Onderwys Witskrif 3 en die promulgering van die Wet op Hoër Onderwys in 1997. Een van die besondere kenmerke van hierdie wetgewing is dat die evaluering van die kwaliteit van Hoër Onderwys verpligtend is en deur die Raad vir Hoër Onderwys (RHO) uitgevoer en deur sy permanente komitee, die Hoër Onderwyskwaliteitskomitee (HOKK), gekoordineer word. Daar bestaan kommer dat streng toegepaste kwaliteitsversekeringstelsels 'n negatiewe uitwerking op die akademiese vryheid van instellings kan hê. Die doel van hierdie studie was dus om die waarskynlikste uitwerking van kwaliteitsversekering op akademiese vryheid te bepaal. Ten einde hierdie doelwit te bereik, is kwaliteitsversekerings- en akademiesevryheidsraamwerke onderskeidelik ontwikkel en is die wisselwerking van die onderskeie elemente in hierdie raamwerk verken. Daar is in die meeste gevalle bevind dat kwaliteitsversekering 'n negatiewe uitwerking op akademiese vryheid kan hê. Een besondere aspek wat ernstige kommer op tersiêre vlak wek, is die programgegronde benadering tot kwalifikasies in teenstelling met die dissiplinegegronde benadering daartoe. Dit hou 'n ernstige bedreiging vir akademiese vryheid in aangesien dit die ruimte waarbinne akademiese vryheid beoefen word, effektief inkort. Hierdie gevolgtrekking is egter op 'n metafisiese studie gegrond en moet deur toepaslike empiriese studies bevestig word.

Thesis (MEd (Education Policy Studies))--University of Stellenbosch, 2010. / Bibliography / ENGLISH ABSTRACT: Evaluation is seen as one of the key elements to enhance the teaching skills and subject knowledge of teachers, thereby facilitating effective and quality teaching and learning. One way of ensuring that this becomes a reality at South African schools is the introduction of an evaluation policy, namely the Integrated Quality Management System, as contained in the document Integrated Quality Management System (IQMS), Collective Agreement Number 8 of 2003 of the Education Labour Relations Council. This research was conducted against the backdrop of IQMS implementation in South African schools since 2005, and explored answers to the following questions: How do teachers experience the implementation of the IQMS (a form of evaluation)? To what extent does the IQMS contribute to the support, development and growth of teachers? Has the implementation of the IQMS had any positive impact on the quality of teaching and learning in schools? The data for the research were collected in 39 schools in Paarl and surrounding areas. The findings of the research study are based on a quantitative (questionnaire) investigation in the framework of an interpretive and positivistic paradigm. The results of the research showed that a significant number of teachers experience the goal and implementation of the IQMS as problematic. This leads to the conclusion that the implementation of the policy has not necessarily contributed to a fundamental improvement in the quality of teaching and learning in the participating schools. This conclusion is also based on the lack of meaningful and ongoing support and assistance that respondents receive before and after the evaluation process. The findings of this study correspond with those of international studies on the same topic, and indicate that teachers face universal problems, particularly with regard to the implementation of evaluation policies. This study could contribute to further research on the topic. / AFRIKAANSE OPSOMMING: Evaluering word as een van die kernelemente beskou om onderwysers se onderrigvaardighede en vakkennis te verbeter, en sodoende doeltreffende en goeie onderrig en leer in die hand te werk. Een manier om toe te sien dat dít in Suid- Afrikaanse skole werklikheid word, is die instelling van evalueringsbeleid, oftewel die Geïntegreerde Gehaltebestuurstelsel (GGBS), soos dit in die dokument Integrated Quality Management System (IQMS), Collective Agreement Number 8 of 2003 van die Raad op Arbeidsverhoudinge in die Onderwys vervat word. Hierdie studie is teen die agtergrond van GGBS-inwerkingstelling in Suid-Afrikaanse skole sedert 2005 onderneem, en soek na antwoorde op die volgende vrae: Hoe ervaar onderwysers die inwerkingstelling van die GGBS ( vorm van evaluering)? In watter mate dra die GGBS by tot die ondersteuning, ontwikkeling en groei van onderwysers? Het die inwerkingstelling van die GGBS enige positiewe invloed op die gehalte van onderrig en leer in skole? Die data vir die navorsing is in 39 skole in die Paarl en omgewing ingesamel. Die bevindings van die navorsingstudie is gegrond op kwantitatiewe (vraelys-) ondersoek in vertolkende en positivistiese paradigma. Die navorsingsresultate toon dat beduidende aantal onderwysers die doel en inwerkingstelling van die GGBS as problematies ervaar. Dít lei tot die gevolgtrekking dat die inwerkingstelling van die beleid nie noodwendig tot grondliggende verbetering in die gehalte van onderrig en leer in die deelnemerskole gelei het nie. Dié gevolgtrekking berus ook op die gebrek aan sinvolle en deurlopende ondersteuning en hulp wat die respondente voor en ná die evalueringsproses ontvang. Die bevindings van hierdie studie stem ooreen met dié van internasionale studies oor dieselfde onderwerp, en toon dat onderwysers, bepaald wat die inwerkingstelling van evalueringsbeleid betref, met universele probleme te kampe het. Hierdie studie kan tot verdere navorsing oor die onderwerp bydra.

The Open Source Software Development (OSSD) model has launched products in rapid succession and with high quality, without following traditional quality practices of accepted software development models (Raymond 1999). Some OSSD projects challenge established quality assurance approaches, claiming to be successful through partial contrary techniques of standard software development. However, empirical studies of quality assurance practices for Open Source Software (OSS) are rare (Glass 2001). Therefore, further research is required to evaluate the quality assurance processes and methods within the OSSD model. The aim of this research is to improve the understanding of quality assurance practices under the OSSD model. The OSSD model is characterised by a collaborative, distributed development approach with public communication, free participation, free entry to the project for newcomers and unlimited access to the source code. The research examines applied quality assurance practices from a process view rather than from a product view. The research follows ideographic and nomothetic methodologies and adopts an antipositivist epistemological approach. An empirical research of applied quality assurance practices in OSS projects is conducted through the literature research. The survey research method is used to gain empirical evidence about applied practices. The findings are used to validate the theoretical knowledge and to obtain further expertise about practical approaches. The findings contribute to the development of a quality assurance framework for standard OSSD approaches. The result is an appropriate quality model with metrics that the requirements of the OSSD support. An ideographic approach with case studies is used to extend the body of knowledge and to assess the feasibility and applicability of the quality assurance framework. In conclusion, the study provides further understanding of the applied quality assurance processes under the OSSD model and shows how a quality assurance framework can support the development processes with guidelines and measurements.

published_or_final_version / Business Administration / Master / Master of Business Administration

Résumé Cette thèse est le rassemblement, par blocs homogènes, de notes d’orientation, de présentations orales, de textes variés, rédigés pour des revues scientifiques, comme chapitres de livres, pour des colloques ou des congrès, pour divers décideurs politiques, des années 80 à ce jour. Son but est de montrer leur cohérence avec un fil conducteur commun : le développement d’outils conceptuels et méthodologiques utiles pour la pratique de la médecine générale en particulier, pour le système de dispensation des soins plus globalement. L’impact espéré est une amélioration de la qualité des soins dispensés, à l’échelle individuelle (relation soignant/soigné) ou à l’échelle collective (système de santé). Les différents blocs se succèdent dans l’ordre suivant : q Chapitre 1 : Introduction. Bloc 1 : Concepts philosophiques q Chapitre 2 : La transdisciplinarité. Concept transcendant la multidisciplinarité (simple juxtaposition indépendante de différentes approches disciplinaires), l’interdisciplinarité (pénétration de différentes disciplines pour éclairer plus complètement un même phénomène) pour arriver à une compréhension globale et homogène où chaque discipline utilise des éléments des autres pour pallier ses manques et ses limites. q Chapitre 3 : La plainte, du normal au pathologique. Développements philosophiques et scientifiques, en complémentarité et en prise directe sur la réalité clinique, sur le normal et le pathologique, le moyen et le divergent, etc. q Chapitre 4 : Les quatre formes de la prévention. Prolongation du texte précédent, en définissant les trois formes classiques de la prévention (primaire au stade « normal », secondaire au stade pathologique mais pré-clinique, et tertiaire au stade clinique), et en introduisant le concept nouveau de prévention quaternaire, ou protection de la population et du système de soins de l’angoisse des soignés et des soignants. q Chapitre 5 : Critique et autocritique du principe de classification. Développement sur les nécessités contradictoires de l’homogénéité et de la complétude (donc du respect de toutes les nuances et de toutes les spécificités), et de la réduction et du traitement de l’information (donc de la prise en compte du classement et des catégorisations). Bloc 2 : Concepts politiques q Chapitre 6 : Les problèmes d’environnement en relation avec la santé. Rapport d’une recherche destinée à élaborer un outil opérationnel à l’usage des médecins généralistes, pour les aider à être sensibilisés aux problèmes d’environnement en relation avec la santé, à diagnostiquer les plus fréquents et les plus importants d’entre eux, et à les prendre en charge de manière non spécialisée. q Chapitre 7 : Faim de travail, fin de la santé. A partir de chiffres concrets, démonstration du lien entre morbidité/mortalité et statut socio-économique. Selon les temps et les lieux, les profils épidémiologiques sont différents, mais ce sont toujours les mêmes populations (position socio-économique basse dans la société, stress professionnel lié à la hiérarchie) qu’on retrouve dans le bas des échelles. q Chapitre 8 : L’éducation à la santé à la Maison Médicale de Forest. Rapport de 15 ans d’éducation et de promotion de la santé dans une maison médicale, sous différents angles (clinique, opérationnel, conceptuel, culturel etc). q Chapitres 9, 10, 11 et 12 : Les soins de santé de 1ère ligne ; Synthèse et communication, ou les fonctions de base de la médecine de famille ; Proposition « martyr » pour une restructuration de la 1ère ligne à Bruxelles ; Mise sur pied d’un centre pilote « urgences » ambulatoire. Plusieurs notes d’orientation proposant quelques modèles théoriques de systèmes de dispensation des soins, basés sur certains principes tels division en niveau de soins, filières de soins, intégration de l’ambulatoire et de l’hospitalier, prise en compte des spécificités des grandes métropoles, des problèmes liés à l’accessibilité et aux urgences. q Chapitre 13 : Les systèmes locaux de santé (SyLoS) : un élément de réponse à la crise du secteur de santé en Belgique ? Proposition, mise sur pied et évaluation de petites unités fonctionnelles de proximité, constituées de soignants intra- et extra-hospitaliers, dans un objectif commun d’amélioration de la qualité des soins, en partant de situations réellement vécues et ayant posé problème. q Chapitre 14 : Le financement forfaitaire à la capitation : une alternative au traditionnel payement à l’acte ? Revue de la littérature internationale sur les systèmes de financement des soins dans une vingtaine de pays différents. Démonstration des limites et des perversions du payement à l’acte intégral. Proposition d’un système de financement global mélangeant payement à l’acte, payement par forfait à la capitation, payement à l’objectif, payement structurel, payement par le patient. q Chapitre 15 : Les pratiques solo dispensent-elles des soins de moins bonne qualité ? Critiques et commentaires d’un article du BMJ sur le sujet. Tentative de réponses au départ d’éléments organisationnels, statistiques et épidémiologiques. Bloc 3 : Concepts relatifs à la pratique clinique q Chapitres 16 et 17 : L’assurance de qualité et le médecin de famille ; Les critères de qualité : tout le monde en parle. Synthèse théorique sur l’assurance de qualité en soins primaires. Définition des concepts de base : critères de qualité, standards et objectifs, méthodes, évaluation et indicateurs, limites et problèmes. q Chapitre 18 : Système de santé, système d’information et méthodes d’évaluation. Structuration du dossier médical global du médecin généraliste, positionnement dans les filières cliniques et de dispensation des soins, utilité pour l’auto-évaluation, la formation, la connaissance scientifique, l’assurance de qualité et la décision politique. q Chapitre 19 : La CISP, concepts généraux et développements. Construction de la Classification Internationale des Soins Primaires, version initiale. Nouveaux principes classificatoires développés au départ des limites de la CIM (Classification Internationale des Maladies) de l’OMS, utilisée dans les dossiers hospitaliers. Apports de la nouvelle (2e) version, CISP-2. Extension des classifications vers les thesaurus (LOCAS et TB3), au travers du transcodage CISP/CIM. q Chapitre 20 : L’approche par problèmes et les éléments du SOAP. Description de l’approche par épisodes (en lieu et place de la notion classique de diagnostics) et de l’analyse de la relation soignant/soigné dans ses quatre dimensions (subjectif, objectif, appréciation et planification). q Chapitre 21 : Structuration du dossier médical électronique : concepts et histoire. A partir des notions cliniques de problèmes et de SOAP, élaboration et explicitation d’un nouveau modèle de dossier médical informatisé, constitué de la relation entre 7 éléments structurants (élément de soins, démarche, contact, sous-contact, service, dispensateur, temps). Ce nouveau modèle est la base du label des logiciels médicaux électronique belges. q Chapitre 22 : Casuistique appliquée. Application à vocation pédagogique du précédent modèle, à partir de deux cas cliniques exemplatifs. q Chapitre 23 : Le DUSOI/Wonca, un indice de gravité pour la médecine générale. Outil développé par la Wonca pour évaluer la gravité de l’état de santé d’un patient à un moment donné au cours de son évolution clinique, évaluation à la fois ponctuelle et diachronique. Application pratique à plusieurs situations réelles. q Chapitre 24 : Evaluation de l’état fonctionnel : les cartes COOP/Wonca. Outil également développé par la Wonca pour l’auto-évaluation fonctionnelle des patients. Il s’agit d’un jeu de 6 cartes représentant graphiquement dans un langage universel l’état de santé somatique, mentale et sociale, de manière à la fois ponctuelle et longitudinale, évalué par le patient lui-même. q Chapitre 25 : Valeurs, paradigmes et recherche en médecine générale. Comparaison des concepts fondamentaux de la recherche traditionnelle, de la recherche opérationnelle et de la recherche action. Intérêt relatif de chacun de ces types de recherche pour des questions et des situations spécifiques, de même que pour l’utilisation des méthodes quantitatives ou qualitatives. q Chapitres 26 et 27 : La CISP et le système SOAP, des outils pour bien décider dans l’incertitude (application à la clinique de la céphalée en médecine de famille) ; « Docteur, j’ai mal au genou », le point de vue du généraliste. Applications à la connaissance scientifique et à la pratique clinique des différents concepts développés dans les chapitres précédents à partir de deux situations fréquentes : les céphalées et les douleurs du genou. q Chapitre 28 et 29 : Vous vouliez des statistiques ? Statistiques Maison Médicale Santé Plurielle 2003. Méthode d’analyse des différentes données disponibles dans une maisons médicale, recueillies systématiquement en temps réel pendant l’activité clinique. Démonstration de son intérêt pour l’auto-évaluation de l’institution, son pilotage cohérent, et les rapports avec le politique. Les chiffres sont des chiffres et seulement des chiffres. Ils doivent être compris, contextualisés, critiqués, commentés et rendus utiles dans leur situation locale spécifique, mais aussi comme partie d’un paquet plus global de données épidémiologiques. q Chapitre 30 : Le bilan biologique de base, un examen inutile ? Définition critique « evidence-based medicine » des examens biologiques de routine de dépistage. q Chapitre 31 : Un projet d’assurance de qualité « diabète » à la Maison Médicale Santé Plurielle. Compte-rendu de l’expérience d’un programme d’assurance de qualité multidisciplinaire dans une maison médicale. Définition opérationnelle d’une série d’indicateurs, évaluation de ceux-ci avant et après le programme. Apports et limites de l’expérience. et q Chapitre 32 : Conclusion. Trente et un chapitres, c’est beaucoup. Et en même temps, c’est très peu : la médecine générale se pratique dans un contexte radicalement différent de ce qu’il était il y a moins de 50 ans. Si elle ne redéfinit pas clairement son rôle et ses outils, elle risque donc de se replier dans des positions défensives et passéistes qui, si elles sont nécessaires face à la médicalisation et à la spécialisation croissantes, ne suffisent cependant pas pour expliciter et faire reconnaître sa spécificité. Rappelons que celle-ci réside essentiellement dans la complexité, puisqu’il s’agit d’aborder l’humain à la fois sur le plan individuel, dans une approche bio-médicale et psychodynamique, et sur le plan collectif, en terme de santé publique, et en faisant appel à diverses disciplines telles que la sociologie, l’anthropologie, l’ethnomédecine. Au fil de ma pratique, j’ai ressenti la nécessité de construire, en dehors du champ bio-médical qui reste la référence essentielle au niveau du savoir académique, des outils spécifiques permettant d’augmenter la qualité des soins primaires. Les outils présentés au fil de cette thèse ont été élaborés dans un constant aller-retour entre la théorie et la pratique, et selon un cheminement traversant plusieurs disciplines. Certains de ces outils sont de type conceptuel, comme la transdisciplinarité, la prévention quaternaire, d’autres sont d’ordre méthodologique, la structure du dossier médical, le SyLoS, les classifications et le thésaurus, le carnet de bord. Tous ces outils visent à baliser la démarche du médecin généraliste, à lui donner des repères théoriques et pratiques à même de le guider dans la complexité des situations qu’il rencontre, le but ultime étant de soutenir une pratique de qualité respectant la singularité des histoires, des sujets rencontrés. Ces outils spécifiques ont été testés sur le terrain ; ils sont actuellement utilisés et intégrés par des médecins généralistes et d’autres professionnels des soins de santé primaires. Leur faisabilité et leur utilité pour améliorer la qualité des soins semblent donc démontrées, mais aussi certaines difficultés d’implantation puisqu’ils engagent les soignants dans une démarche réflexive, les amenant à se questionner sur le sens et l’efficacité de leurs pratiques, pour mieux les évaluer. Summary This thesis is the gathering, through homogenous blocks, of orientation’s notes, oral presentations and various texts, written for scientific journals, as book chapters, for colloquiums or conferences, for different political decision-makers, from the 1980s up until today. The goal is to demonstrate their coherence with a common direction: the development of conceptual and methodological tools for the practice of general medicine in particular, for the system of care-giving more globally. The hoped impact is an improvement of care quality, provided at the individual level (relationship care-receiver/care-giver) or at the collective level (health system). The different blocks are organized according to the following order: q Chapter 1 : Introduction. Block 1 : Philosophical concept q Chapter 2: Trandisciplinarity. Concept transcending the multidisciplinarity (simple juxtaposition independent from different disciplinary approaches) and the interdisciplinarity (penetration of different disciplines to more fully enlighten the same phenomenon) to reach a more global and homogenous understanding where disciplines use each others’ elements to overcome their own lacks and limitations. q Chapter 3: The complaint, from normal to pathological. Philosophical and scientific developments, complementing and directly connecting with the clinical reality, the normal and pathological, the average and the diverging, etc. q Chapter 4: The 4 forms of the prevention. Prolongation of the above-mentioned text, by defining the three classical forms of the prevention (primary at the “normal” stage, secondary at the pathological but pre-clinical stage and tertiary at the clinical stage), and by introducing the new concept of quaternary prevention, or protection of the population and the health system from the anguish of the care-receivers and givers. q Chapter 5: Criticism and auto-criticism of the principle of classification: Elaboration on the contradictory necessities of the homogeneity and completeness (thus of the respect of all the differences and specificities), and of the decrease and the treatment of the information (thus of the taking into account of the ranking and the categorizations). Block 2 : Political concepts q Chapter 6: The environmental problems relating to health. Report of a research aiming at elaborating an operational tool for the use of general practitioners, to help them become sensitive to environmental problems relating to health, to diagnose the most frequent and most important among those, and to take them over in a non-specialized manner. q Chapter 7: Hunger of work, end of health. From concrete numbers, demonstration of the link between morbidity/mortality and the socio-economical status. According to the times and locations, the epidemiological profiles are different but the same populations (low socio-economical position in the society, professional stress due to the hierarchy) are always found at the bottom of the ladders. q Chapter 8: Health education at the “Maison Médicale” of Forest. Report of 15 years of health education and promotion in a primary care health centre, from different angles (clinical, operational, conceptual, cultural etc.). q Chapters 9, 10, 11 and 12: First line health care; Synthesis and communication, or the basic functions of family medicine; “Martyr” proposition for the restructuring of the first line in Brussels; Establishment of a pilot ambulatory “emergency” center. Several orientation’s notes offering different theoretical models of care-providing systems, based on certain principles such as division into care levels, care networks, integration of the ambulatory and hospital, taking into account the specificities of large metropolises, of the problems related to the accessibility and to the emergencies. q Chapter 13: Local systems of health: a partial answer to the crisis of the health department in Belgium? Proposal, establishment and evaluation of small functional proximity units, consisting of intra- and extra-hospital care-givers, with the common goal of enhancing the quality of care, originating from real-life situations that have been problematic. q Chapter 14: Fixed financing by capitation: an alternative to the traditional fee for service payment? Review of the international literature about care financing systems in about twenty different countries. Demonstration of the limits and perversions of the integral fee for service payment. Proposal of a global financing system combining fee for service payment, fixed payment by capitation, target payment, structural payment, payment by the patient. q Chapter 15: Do solo practices provide less quality care? Criticisms and commentaries of a BMJ article on the topic. Attempt of an answer based on organizational, statistical and epidemiological elements. Block 3: Concepts related to clinical practice q Chapters 16 and 17: Quality insurance and the family doctor; Quality criteria: everybody speaks about it. Theoretical synthesis on quality insurance in primary care. Definition of the basic concepts: quality criteria, standards and objectives, methods, evaluation and indicators, limits and problems. q Chapter 18: Health system, information system and evaluation methods. Structuring the global medical record of general practitioners, positioning in the clinical and care-providing networks, use for the auto-evaluation, the formation, the scientific knowledge, the quality insurance and the political decision. q Chapter 19: ICPC, general concepts and developments. Construction of the International Classification of Primary Care, initial version. New classifying principles developed out of the limits of the ICD (International Classification of Diseases) of the WHO, used in hospital records. Contributions of the new (2nd) version, ICPC-2. Extension of the classification towards the thesaurus (LOCAS and TB3), through transcoding ICPC/ICD. q Chapter 20: Approach by problems and elements of the SOAP. Description of the approach by episodes (instead of the classical notion of diagnostics) and the analysis of relationship care-receiver/care-giver in the four dimensions (subjective, objective, appreciation and planning). q Chapter 21: Structuring of the electronic medical record: concepts and history. From the clinical notions of problems and SOAP, elaboration and clarification of a new model of computerized medical record, consisting of the relationship between 7 structuring elements (element of care, approach, contact, sub-contact, service, provider, time). This new model is the base for the label of Belgian electronic medical softwares. q Chapter 22: Applied casuistic. Application with pedagogical vocation of the former model, based on two exemplary clinical cases. q Chapter 23: The DUSOI/Wonca, a gravity index for the general practice. Tool developed by the Wonca to evaluate the gravity of a patient’s health status at a given moment in the course of his/her clinical evolution, evaluation both punctual and diachronic. Practical application to several real-life situations. q Chapter 24: Evaluation of the functional state: The COOP/Wonca cards. Tool also developed by the Wonca for the functional auto-evaluation of patients. It consists of a game of 6 cards graphically representing in a universal language the somatic, mental and social health state, both punctually and longitudinally, evaluated by the patient him/herself. q Chapter 25: Values, paradigms and research in general practice. Comparison of the fundamental concepts of the traditional research, the operational research and the action research. Relative interest of each of these research types for specific questions and situations, as well as for the use of quantitative and qualitative methods. q Chapter 26 and 27: The ICPC and the SOAP system, tools to well decide in uncertainty (application to the headache in family medicine); “Doctor, my knee hurts”, the view point of the general practitioner. Applications to the scientific knowledge and to the general practice of the different concepts developed in the previous chapters based on two frequent situations: the cephalalgia and the knee pains. q Chapters 28 and 29: Did you want statistics? Statistics “Maison Médicale Santé Plurielle 2003”. Method of analysis of the various data available in a primary care health centre, systematically collected in real-time during the clinical activity. Demonstration of its interest for the institution’s auto-evaluation, its coherent piloting, and the relationship with the politics. Numbers are numbers and only numbers. They have to be understood, contextualized, criticized, commented and made useful in their specific local situation, but also as part of a more global package of epidemiological data. q Chapter 30: The basic biological assessment, a useful exam? Critical definition evidence-based medicine of the routine screening biological exams. q Chapter 31: A project of “diabetic” quality insurance at the “Maison Médicale Santé Plurielle”. Report of the experience of a multidisciplinary insurance quality program in a primary care health centre. Operational definition of a series of indicators, evaluation of the latter before and after the program. Contributions and limits of the experience. and q Chapter 32 : Conclusion. Thirty-one chapters, it is a lot. And at the same time it is very little: general practice is carried out in a radically different context than it was less than 50 years ago. If it does not clearly redefine its role and tools, there is a risk for it to fall back to defensive and passeist positions which, even though they are necessary facing the increasing medicalization and specialization, are nevertheless not enough to explain its specificity and make it acknowledged. Let us remember that the latter resides essentially in complexity, since it consists of dealing with the human being at the individual level, in a bio-medical and psychodynamic approach, and at the collective level, in terms of public health, and by bringing in various disciplines such as sociology, anthropology, ethno-medicine. In the course of my practice, I felt the need to construct, outside of the bio-medical field which remains the essential reference at the level of the academic knowledge, specific tools allowing to increase the quality of primary care. The tools presented throughout this thesis have been elaborated through a constant back and forth between theory and practice, and according to a path crossing several disciplines. Some of these tools are conceptual, such as the transdisciplinarity and the quaternary prevention, others are methodological, such as the structure of the medical record, the SyloS, the classifications and the thesaurus, the logbook. All these tools are meant to mark out the approach of the general practitioner, to give him some theoretical and practical points of reference able to guide him in the complexity of the situations he encounters, the ultimate goal being to maintain a practice of quality respectful of the singularity of encountered stories and subjects. These specific tools have been tested in the field; they are currently used and integrated by general practitioners and other professionals of primary health care. Their feasibility and use to enhance the quality of care seemed therefore demonstrated, as well as some implantation difficulties, since it engages the care-providers in a reflexive approach, leading them to question the meaning and efficacy of their practices, to better evaluate them.

Bakgrund och problemdiskussion: Den offentliga upphandlingen kan med väl genomtänkta krav på varor och tjänster bli en stark drivkraft och en föregångare för hållbar utveckling. Trots en svag och oklar lagstiftning inom området finns det idag stora möjligheter att ställa krav både på socialt ansvarstagande och miljöhänsyn i samband med offentliga upphandlingar. Syfte: Syftet är att undersöka hur Värnamo kommun gör för att inkludera hållbarhet med inriktning på miljö i sina avtal med utvalda livsmedelsleverantörer. Vidare undersöks hur Värnamo kommun säkerställer att upphandlade varor och tjänster lever upp till avtalad kvalitet samt hur det faktiska tillvägagångssättet stämmer överens med den teori som finns. Metod: Uppsatsen är av kvalitativ art och har utförts genom en fallstudie. Utgångspunkten är ett positivistiskt synsätt och uppsatsen använder sig av ett deduktivt angreppssätt. Slutsats: I Värnamo kommun finns det en tillsatt kompetensgrupp som arbetar enbart med upphandling av livsmedel, denna grupp har kunskap och kännedom om hur marknaden och upphandlingsprocessen ser ut. Vid upphandling läggs i princip allt fokus kring avtalet, både när det gäller vilka krav som ställs och vad som ska följas upp. Trots att det inte är enkelt för offentliga verksamheter att göra inköp och kvalitetssäkringar enligt teorin finns det delar av teorin som redan idag uppfylls och det finns också en bas för vidare utveckling. Kvalitetssäkring sker i störst utsträckning innan avtalet signeras, vilket ur en tidsaspekt är en liten del av processen. Enligt teorin skall kvalitetssäkring ske kontinuerligt flera gånger per år. Det blir tydligt att teorin lämpar sig bättre för privat sektor eftersom det inom den offentliga sektorn finns mindre incitament för att hjälpas åt att utvecklas då nästa upphandling kan innebära att samarbetet ha nått vägs ände. / Background: Public procurement can with well thought through demands on goods and services become a strong driving force for sustainable development. Even with a weak and uncertain legislation within the field there are grand opportunities to demand both social responsibility and environmental accountability in public procurement. Purpose: The purpose of this study is to examine how Värnamo municipality do to include sustainability with focus on the environment in their agreements with chosen grocery suppliers. Further it is investigated how Värnamo municipality make sure their procured goods and services are to terms with agreed standard, and if the actual approach is in line with theory on the subject. Method: The essay is of qualitative nature and has been performed in the way of a case study. The standpoint of the essay is a positivistic point of view and is performed with a deductive approach. Conclusion: In Värnamo municipality there is an appointed group with special competence that is working solely with the procurement of groceries, this group have knowledge about how the market and the procurement process works. In the time of procurement nearly all the focus is in the documented agreements, both regarding demands put and what is to be followed up. Even though it is not simple for a government controlled business to make procurements and quality assurances according to theory there are parts of theory that today are fulfilled and there is a foundation for further development. Quality assurance is by the most part done before the agreement is signed, which compared to the entire process is a small portion. According to theory quality assurance should happen multiple times yearly. It is apparent that theory is better suited for the private sector since in the public sector there are fewer incentives to help the other party improve where the next procurement can mean the cooperation has come to an end.

Ionization chambers (ICs) are the most commonly used detectors for radiation therapy dose measurements. Typical IC measurements use cylindrical ICs in a water phantom and therefore require initial IC alignment to the water surface. This alignment has long been ignored and only recently has a qualitative governing recommendation been made. This thesis describes a reproducible methodology for quantitative ionization chamber water surface alignment. Depth-ionization measurements are taken with twenty-eight IC designs under varying conditions including, but not limited to, changes in scan direction, speed, and resolution, radiation beam type, field size, energy, and electron contamination. Measurements are acquired using standard radiotherapy accelerators in the Virginia Commonwealth University Department of Radiation Oncology and at the National Research Council of Canada, where a customized scanning system capable of better than 0.15 mm IC positioning precision is used. Measurements are also performed with standard commercial scanning equipment on the Accuray CyberKnife, a specialized radiosurgery-class accelerator. An analytical model is developed from basic principles to test the theoretical foundations of IC response near a water surface. The theoretical foundation is further validated via Monte Carlo simulation models that fully account for all details of the ICs used to take measurements. It is determined that the dose gradient as a function of depth is maximized when a given IC reaches the water surface when moving from depth in water. This effect is unchanged under all of the measurement scenarios tested. Measurements taken at 0.1 mm resolution for several seconds per point over several millimeters near the surface will yield a gradient peak that can be used for quantitative alignment. Using developed software, multiple scans at variant resolutions can be stitched into typical clinical scans so as not to significantly affect clinical measurement workflow. The recommended measurement method is developed in a format suitable for inclusion into a clinical protocol for depth-ionization measurement acquisition.

Failed projects are often caused by not detected failures and therefore tests should be performed at some time during the project to avoid those failures. In the agile method Scrum the tests of IT services are executed by the supplier to secure the quality of the services. In theory, no tests are performed by the product owner. This requires big amount of trust to the supplier and a close partnership. In agile methods the time and costs are fixed, and because of this there is also a risk that unfinished products are delivered on deadline. Little research about tests and Scrum can be found, and therefore the aim with this study is to evaluate how and when quality assurance and tests should be treated in the best way by the product owner in Scrum. The study aims to answer the question of which manual test type is relevant to perform by the product owner to ensure the quality of the IT services. The question about how and when the test should be executed should also be answered. The study is based on a case study at the company Standard Solutions Group (SSG) which is a technical consultancy. The methodology in the study involves interviews, observations, a survey, and a literature study. The different methods are used to gather information from different perspectives and should increase reliability. Acceptance tests are selected to be best suitable to be performed by the product owner. To answer the question about how the test should be executed the authors select to develop a checklist. The acceptance tests should be done continuously to create more efficiency, and it also should be easier to correct the errors. / Idag grundas ofta misslyckade projekt på att fel inte uppmärksammas och för att undvika dessa fel bör tester utföras någon gång under arbetet. I den agila metoden Scrum utförs tester på produkten av leverantören, däremot utförs i teorin inga tester från produktägarens sida, som är kunden i Scrum. Detta kräver stor tillit och ett nära samarbete mellan kund och leverantör. Eftersom agila metoder innebär att tiden och kostnaden är fast finns det även en risk att halvfärdiga produkter levereras vid deadline. Då tidigare forskning inte undersökt ämnet är syftet med arbetet att utvärdera hur och när kvalitetssäkring av leveranser på ett lämpligt sätt ska utföras från produktägarens sida i Scrum. Målet är dels att besvara frågan om vilken manuell testtyp som är relevant att utföra från produktägarens sida vid kvalitetssäkring av IT-tjänster. Dessutom ska även frågorna om hur och när det manuella testet bör utföras i Scrum besvaras. Denna studie baseras på en fallstudie som utförs hos Standard Solutions Group (SSG) som är en teknisk konsultverksamhet. Studien genomförs med hjälp aven övergripande metod som följs genom hela arbetet för att komma fram till en lösning. I studien används även andra modeller för att utföra observationer, enkätundersökning, intervjuer och en litteraturstudie. Detta för att få information från flera olika perspektiv vilket ökar studiens tillförlitlighet. Studien resulterar i atttest-typen acceptanstester är ett lämpligt test att utföra frånproduktägarens sida. En checklista utvecklas för att svara på frågan om hur testet ska utföras. För att skapa mer effektivitet så att fel enklare ska kunna åtgärdas utförs acceptanstestester kontinuerligt under arbetets gång.

A qualidade dos exames mamográficos é uma preocupação constante do sistema de saúde mundial que se vê diante do desafio da detecção precoce do câncer de mama. As organizações responsáveis implementaram protocolos internacionais que consistem em testes de aceitação dos equipamentos mamográficos e de tomossíntese da mama, os quais estabelecem um padrão de qualidade nos serviços radiográficos. Porém, essas diretrizes têm como base o uso de objetos simuladores de mamas com espessuras e composições padrões, que muitas vezes não condizem com os perfis populacionais dos centros de diagnóstico. Neste trabalho, foi desenvolvido um sistema automatizado de rastreamento e gerenciamento de dados, que extrai as informações referentes ao processo de aquisição da mamografia digital e armazena-as em um servidor DICOM SCP (Service Class Provider). Após armazenadas, o sistema correlaciona os fatores de exposição das imagens, de forma a avaliar os níveis de referência em dose de radiação fornecidos pelos equipamentos. Como resultados, foi verificado que o perfil mamário dos centros institucionais de diagnóstico estudados não segue os valores de referência apresentados na literatura em termos de espessura e densidade mamária. Enquanto a mama padrão dos testes de garantia de qualidade é composta por 50 mm de espessura e 50% de densidade (50-50), a população estudada apresentou mamas comprimidas com média de 60 mm de espessura, com baixo percentual de tecido fibroglandular (menor que 25%). Portanto, o uso o sistema desenvolvido pode direcionar os testes de conformidade dos equipamentos para perfis mamários específicos. Esse direcionamento pode auxiliar na determinação de doses ótimas de radiação para melhoria da qualidade da imagem, produzindo valores de referência de grande utilidade para a qualidade dos serviços radiográficos. / Image quality assessment in mammography represents one of the greatest challenges that health services face in order to detect breast cancer early. The world health organization recommends quality assurance guidelines, which consist of acceptance tests for digital mammography (DM) and digital breast tomosynthesis (DBT), to standardize the radiological services. However, these guidelines are based on test objects widely used to simulate standard breasts in terms of composition and thickness, which often do not match with the demographic profiles in the breast care centers. In this thesis work, an automated system for tracking and data management was developed to extract the metadata (DICOM header) from the image acquisition process and to store it into a custom DICOM Service Class Provider (SPC). The developed system correlates the exposure factors\' info in order to evaluate the references for patient radiation dose provided by the manufacturers. As result of the data correlations, the reference required by the international guidelines for standard breasts are not a feasible representation for the demographic profile in the breast care center evaluated in terms of breast density and thickness. While the standard for quality assurance testing consists of breasts with 50 mm of thickness and 50% of density, the demographic population presented compressed breast thickness of approximately 60 mm and low fibroglandular tissue (less than 25%). Therefore, using the developed system should guide the quality assurance in digital mammography to specific breast profiles. This guidance may assist in determining optimal radiation doses to improve the image quality, producing useful benchmarks for the quality of radiological services.

No presente trabalho serão apresentadas as diretrizes e os testes necessários para a implantação de um programa de controle de qualidade para o Eclipse 7.3.10 da Varian no Hospital das Clínicas da Faculdade de Medicina da USP, de acordo com a mais recente publicação da AIEA o TRS 430. Os testes recomendados pelo TRS 430 são basicamente divididos em testes de aceitação, comissionamento (testes dosimétricos e não dosimétricos), e testes rotineiros. O documento da AIEA está sendo implementado para o Eclipse no HC para os feixes de fótons de dois aceleradores lineares da Varian, Clinac 600C e Clinac 2100C. Os testes de aceitação verificaram parâmetros de \"hardware\"; integração do sistema \"network\"; transferência de dados, e \"softwares\". Os resultados obtidos mostraram boa concordância com as especificações do fabricante. Para os testes dosimétricos de comissionamento, foram realizadas medidas de dose absoluta para diversos arranjos experimentais. Esses valores foram comparados com os valores de dose gerados pelo SPTC. A grande maioria dos testes apresentou cerca de 90% a 80% dos pontos comparados, dentro dos níveis de tolerância, ou seja, uma boa concordância entre os valores experimentais e os valores gerados pelo SPTC. Somente arranjos de campos assimétricos apresentaram discordâncias grosseiras, mostrando a necessidade de uma investigação mais apurada para esses casos. Os testes de comissionamento não dosimétricos também apresentaram resultados excelentes, com praticamente todas as ferramentas e desempenho geral do sistema de acordo com as recomendações estipuladas no TRS 430. Foram aplicados também critérios de aceitabilidade para a comparação entre os valores de UMs gerados pelo sistema e os valores de UMs calculados manualmente. Os feixes no Eclipse foram caracterizados com dados transferidos do CadPlan e com dados provenientes do recomissionamento dos aceleradores, assim sendo, para esses testes encontrou- se uma diferença de até 3% para campos conformacionados para os dados de feixe provenientes do recomissionamento dos aceleradores, e de até 4% para os dados de feixe transferidos do CadPlan, sendo que o nível de tolerância estabelecido pelo TRS 430 para o arranjo era de 3%. / This work presents the guidelines and necessary tests tom implement a quality assurance program for Eclipse 7.3.10 from Varian at Hospital das Clinicas, Sao Paulo University School of Medicine - Brazil, in accordance with the new IAEA publication TRS 430. The recommended tests for the TRS 430 air mainly classified into acceptance tests, commissioning (dosimetric and non-dosimetric tests), and routine tests. The IAEA document\'s recommendations are being implemented at the hospital for two Varian linear accelerators - Clinac 600C e Clinac 2100C. The acceptance tests verified \'hardware\', integration of network systems, data transfer and \'software\' parameters. The results obtained are in a good agreement with the manufacturer\'s specifications. Measurements of absolute dose in several set-ups were made for the commissioning dosimetric tests. These data were compared to the absolute doses determined by the TPS. The great majority of the tests showed 90% to 80% of the analyzed data in acceptance levels, with a good agreement between the experimental data and the data determined by the TPS. Only settings with asymmetric fields presented significant discords, showing the need for a more detailed inquiry for these settings. The non-dosimetric commissioning tests have also presented excellent results, with virtually all the system tools and general performance in compliance with TRS 430. The acceptance criteria have been applied for a comparison between the values of MUs generated by TPS and the calculated manually ones. The beams have been characterized for Eclipse with data transferred from CadPlan and with data from recommissioning of accelerators, so for these tests it was found a difference of at least 3% for the conformal field shape for the data originated in the beams of recommissioning and at least 4% for the data proceeded from CadPlan. The tolerance level established by TRS 430 for this setting was 3%.