Não tem sido frequentes no Brasil estudos de avaliação da qualidade dos serviços de saúde. Tem sido adotado entendimento de qualidade como o grau em que processo de assistência aumenta a probabilidade de resultados favoráveis e diminui a probabilidade de resultados desfavoráveis, dado o estado do conhecimento médico. Indicadores de resultados de efeitos adversos do processo de assistência costumam ser empregados e, entre eles, para aquelas condições e procedimentos onde óbitos ocorrem com frequência, estão as taxas de mortalidade hospitalar. Entre esses procedimentos inclui-se a cirurgia de revascularizaçäo do miocárdio. Apesar de frequentes na literatura, particularmente norte-americana, não há estudos de escala realizados no Brasil. Para estudos deste tipo bases de dados administrativas tem sido empregadas. No Brasil recentemente tem sido exploradas as potencialidades dos bancos de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde do Ministério da Saúde (SIH-SUS) em diversos estudos. Como há registro de óbitos hospitalares no sistema é possível utilizá-lo para a obtenção de dados sobre mortalidade hospitalar. Os bancos de dados do SIH-SUS de 1996 a 1998 foram integrados e as variáveis disponíveis no banco obtido examinadas quanto a possibilidade de inclusão do estudo descritivo de características da cirurgia coronária no país. Foram identificadas aquelas variáveis que poderiam ser utilizadas para proceder algum grau de ajuste de risco para os casos atendidos pelos diferentes hospitais. Para que se obtivesse uma comparação do comportamento do ajuste obtido com essas variáveis com modelos mais completos que incorporassern mais variáveis, inclusive variáveis clínicas, foram estudadas para o mesmo período, as internações realizadas no Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, utilizando dados de banco específico do Serviço de Cirurgia Cardíaca. Além do estudo descritivo foram desenvolvidos para os casos deste hospital modelos de regressão logística incorporando variáveis pré-operatórias e com as variáveis disponíveis no SIH-SUS para avaliar as diferentes capacidades de ajuste de risco. Após a escolha de um modelo de risco com maior capacidade de ajuste, foram calculadas as taxas de mortalidade hospitalar e obtidos os valores de taxas esperadas após o ajuste de risco. Os hospitais forma ordenados de acordo com as razões entre as taxas observadas e esperadas e identificados aqueles hospitais que apresentavam razões estatisticamente significativas superiores e inferiores a média nacional. Estudou-se também o efeito do volume de casos sobre a mortalidade hospitalar. Foram obtidas informações de 41.989 cirurgias codificadas como cirurgia coronária com circulação extracorpórea realizadas em 131 hospitais brasileiros, em 22 unidades da federaçâo. A taxa anual por 100000 habitantes foi de 8,7 para o Brasil, com São Paulo apresentando taxa de 16,6. Para efeitos de comparação a taxa em anos em torno de 1997 foi de 144,5 nos EUA, 54,4 no Canadá, 90,0 na Austrália e 31,5 em Portugal. A taxa de mortalidade no período foi de 7,2 % (EUA, 2,8%; Canadá, 2,5%: França, 3,2%). A maioria de pacientes operados foi do sexo masculino (67,5%) e a idade média foi de 59,9 anos.

Não tem sido frequentes no Brasil estudos de avaliação da qualidade dos serviços de saúde. Tem sido adotado entendimento de qualidade como o grau em que processo de assistência aumenta a probabilidade de resultados favoráveis e diminui a probabilidade de resultados desfavoráveis, dado o estado do conhecimento médico. Indicadores de resultados de efeitos adversos do processo de assistência costumam ser empregados e, entre eles, para aquelas condições e procedimentos onde óbitos ocorrem com frequência, estão as taxas de mortalidade hospitalar. Entre esses procedimentos inclui-se a cirurgia de revascularizaçäo do miocárdio. Apesar de frequentes na literatura, particularmente norte-americana, não há estudos de escala realizados no Brasil. Para estudos deste tipo bases de dados administrativas tem sido empregadas. No Brasil recentemente tem sido exploradas as potencialidades dos bancos de dados do Sistema de Informações Hospitalares do Sistema Único de Saúde do Ministério da Saúde (SIH-SUS) em diversos estudos. Como há registro de óbitos hospitalares no sistema é possível utilizá-lo para a obtenção de dados sobre mortalidade hospitalar. Os bancos de dados do SIH-SUS de 1996 a 1998 foram integrados e as variáveis disponíveis no banco obtido examinadas quanto a possibilidade de inclusão do estudo descritivo de características da cirurgia coronária no país. Foram identificadas aquelas variáveis que poderiam ser utilizadas para proceder algum grau de ajuste de risco para os casos atendidos pelos diferentes hospitais. Para que se obtivesse uma comparação do comportamento do ajuste obtido com essas variáveis com modelos mais completos que incorporassern mais variáveis, inclusive variáveis clínicas, foram estudadas para o mesmo período, as internações realizadas no Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro, utilizando dados de banco específico do Serviço de Cirurgia Cardíaca. Além do estudo descritivo foram desenvolvidos para os casos deste hospital modelos de regressão logística incorporando variáveis pré-operatórias e com as variáveis disponíveis no SIH-SUS para avaliar as diferentes capacidades de ajuste de risco. Após a escolha de um modelo de risco com maior capacidade de ajuste, foram calculadas as taxas de mortalidade hospitalar e obtidos os valores de taxas esperadas após o ajuste de risco. Os hospitais forma ordenados de acordo com as razões entre as taxas observadas e esperadas e identificados aqueles hospitais que apresentavam razões estatisticamente significativas superiores e inferiores a média nacional. Estudou-se também o efeito do volume de casos sobre a mortalidade hospitalar. Foram obtidas informações de 41.989 cirurgias codificadas como cirurgia coronária com circulação extracorpórea realizadas em 131 hospitais brasileiros, em 22 unidades da federaçâo. A taxa anual por 100000 habitantes foi de 8,7 para o Brasil, com São Paulo apresentando taxa de 16,6. Para efeitos de comparação a taxa em anos em torno de 1997 foi de 144,5 nos EUA, 54,4 no Canadá, 90,0 na Austrália e 31,5 em Portugal. A taxa de mortalidade no período foi de 7,2 % (EUA, 2,8%; Canadá, 2,5%: França, 3,2%). A maioria de pacientes operados foi do sexo masculino (67,5%) e a idade média foi de 59,9 anos.

The main intention of this thesis was to monitor the activities of nurses as risk managers in selected healthcare facilities. The first objective was to map the current state of accreditation procedures in the Czech Republic, the number of accredited facilities and the types of accreditation. Another objective was to find out in which healthcare facilities there is a nurse as a risk manager or who has the responsibility of a risk manager in healthcare facilities. The third objective was to explore the activities of nurses - risk managers. To achieve these objectives, the following research questions were set: 1st What is the current state of accreditation procedures in the Czech Republic? 2nd In which accredited facilities there is a nurse - a risk manager? 3rd research question: What are the activities and roles of a nurse - a risk manager? (What activities nurses carry out in the performance of their duties; whether nurses feel a change in the provision of nursing care; which risks and incidents nurses encounter in their facilities and what are their solutions; what is the level of communication between the parties in the risk management process in a given facility; which benefits are seen in risk management). The research was conducted with respondents from those healthcare facilities that were willing to cooperate. The research conducted is a qualitative one. The respondents underwent interviews according to the structure of categorized questions. Subsequently, transcripts of the interviews were made as well as the analysis and categorization of the data was carried out and presented in tables under the framework analysis according to Ritchie and Spencer. The research revealed the answers to the research questions. In no of the facilities that have responded to the questions there is a nurse with the function of a risk manager. Activities within the risk management are taken over by staff at other positions, mostly quality managers, head nurses or auditors. Detailed proportion of these functions is clearly presented in the accompanying graphs. Research question 3 yielded a great number of responses. For example, nurses who have competence in risk management play mainly the roles of communicators, defenders, authors, auditors and mentors. In exercising their functions, they have observed changes, as compared with the past, in the responsibilities of nurses, patient activity, greater transparency, the quality and safety of the care provided. They describe in detail the risks and incidents which they have met at their workplaces, and how they have been solved. The respondents see the advantages of risk management in the fact that it is a good tool for defending not only patients but also nurses themselves; that it is a tool to increase responsibilities and activities of patients and to improve the quality and safety of the care provided. All the responses are clearly presented in tables and confronted with the knowledge derived from professional literature and our own experience. The results of the thesis can be provided to the healthcare facilities where the research has been carried out; it could be provided to competent institutions and also, in the form of an informative brochure, to nurses and other healthcare personnel. We would suggest a higher level of education about risk management potential. Our suggestions also include changes to legislation - powers, the establishment of clear procedures and rules, and the regulation of education in risk management so that implementation of this tool is unified and becomes accessible to all facilities.

This thesis treats the issues regarding the role of healthcare assistants in the nursing process and their mutual cooperation with general nurses. Four goals were set. The first goal was to ascertain in which way the general nurses allow the healthcare assistants to engage in the nursing process. The second goal was to ascertain what are the healthcare assistants? opportunities to participate in the nursing process. The third goal was to determine what problems are seen by managers regarding the integration of the healthcare assistants in the nursing care system. The last, fourth goal, tried to ascertain whether the system of integration of general nurses and healthcare assistants in the nursing team contributes to improvement of the patient?s care. The thesis is divided into two parts: theoretical and practical one. The theoretical part deals with the nursing process as a method of work of a nurse, qualification training of general nurses and healthcare assistants and possibilities of finding vacancies in the nursing practice. The practical part consists of quantitative-qualitative research survey. For the qualitative research a method of individually conducted, pre-prepared interviews with representatives of the above mentioned professions. Four research questions were determined, i.e.: 1. To what extent are the healthcare assistants, general nurses and managers in positions of ward sisters aware of the nursing process? 2. Have the healthcare assistants a possibility to use their knowledge of the nursing process pursuant to Act No. 96/2004 Coll.? 3. Is the cooperation of healthcare assistants and general nurses perceived as a positive element for improvement of nursing care? 4. What experience have managers in the position of ward sisters in integration of healthcare assistants into the nursing team? The surveyed group consisted of six healthcare assistants, six general nurses and eight ward sisters-managers from minor inpatient facilities in the Pilsen region and Cental Bohemian region. Qualitative research was realized through a survey by questionnaire. Students of the last grade of the study field ?Healthcare assistant? and the study programme ?General nurse? were addressed. For the qualitative part of the research survey the following hypotheses were set: 1. Students of the study field ?Healthcare assistant? are oriented in the competences of healthcare assistants and general nurses in accordance with At No. 96/2004 Coll. 2. Students of the study programme ?General nurse? are oriented in the competences of healthcare assistants and general nurses in accordance with At No. 96/2004 Coll. 3. Students of the study field ?Healthcare assistant? perceive the determined competences for individual fields as a tool for quality professional care. 4. Students of the study programme ?General nurse? perceive the determined competences for individual fields as a tool for quality professional care. In total, 200 questionnaires were distributed, and subsequently, 142 of correctly completed questionnaires were evaluated. The output of this thesis is the verification of the present status of the issue in question. The results will be provided to nursing care managers in the researched healthcare facilities where they could help to improve the management of healthcare activities. The results may be also used to prepare informational and educational sessions clarifying the rules of cooperation of healthcare assistants and general nurses. Furthermore, the results could be offered to the Ministry of Health of the Czech Republic, namely to the Working Committee for transformation of non-medical healthcare professions in the Czech Republic the main work objective of which is the amendment of Act No. 96/2004 Coll.

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2018-03-06T18:44:58Z No. of bitstreams: 1 Paulo Silas Ribeiro Nunes.pdf: 2342555 bytes, checksum: 867037189db2739736b4092de22d28be (MD5) / Made available in DSpace on 2018-03-06T18:44:58Z (GMT). No. of bitstreams: 1 Paulo Silas Ribeiro Nunes.pdf: 2342555 bytes, checksum: 867037189db2739736b4092de22d28be (MD5) Previous issue date: 2016 / Mestrado Profissional em Enfermagem Assistencial / O estudo aborda como temática a Segurança do Paciente no contexto específico da Meta 4 – Cirurgia Segura do Ministério da Saúde, cujo enfoque baseia-se em aplicar as metas de segurança e qualidade na gerência de risco dos processos de enfermagem transoperatório em pediatria, aperfeiçoando a dinâmica da assistência à saúde da criança cujo prognóstico é cirúrgico. A pesquisa propõe como objetivo geral, elaborar tecnologias assistenciais em enfermagem para avaliação de risco perioperatório do paciente cirúrgico pediátrico. Como específicos, prima em realizar uma análise da literatura científica sobre os eventos adversos relacionados ao bloco operatório e as principais estratégias para mitigá-los; Identificar o conhecimento dos enfermeiros a respeito da segurança do paciente cirúrgico pediátrico; Discutir os resultados deste processo, frente às recomendações do Programa Nacional de Segurança do Paciente, para a elaboração do produto da pesquisa. O estudo assume um caráter exploratório e descritivo, de natureza qualitativa. As informações foram obtidas através do método de pesquisa de revisão integrativa, e entrevistas com os enfermeiros responsáveis diretos pelo cuidado em um Hospital Público Pediátrico situado na Baixada Fluminense. As mesmas seguiram um roteiro com perguntas semiestruturadas, abertas e fechadas. Os resultados foram analisados e agrupados em categorias temáticas, e sobre tudo, analíticas. A pesquisa foi submetida à apreciação do Comitê de Ética e Pesquisa da Universidade Federal Fluminense/UFF, obtendo aprovação em dezembro de 2014 através do parecer consubstanciado de Nº 895.049. Resultado de Pesquisa: O bloco operatório, quando comparado às demais clínicas de uma unidade de saúde, apresenta alta taxa de incidência e/ou prevalência de erros e/ou acidentes ligados à assistência direta ao paciente. Estes eventos vão, desde a simples perturbação do fluxo operatório, sem consequências reais em potencial para o doente, até às mais graves complicações, com a produção de danos irreversíveis e/ou incapacitantes, ou mesmo, morte prematura, em detrimento de práticas assistenciais em saúde inseguras / The study discusses the Patient Safety theme in the specific context of Goal 4 - Safe Surgery from the Ministry of Health. The approach is based on applying the safety and quality goals in the risk management of the nursing processes in pediatrics, improving dynamics of health care to the child whose prognosis is surgical. The research proposes as a general objective to develop an assistive technology for evaluation of trans-operative risk of pediatric surgical patients. The specifics objectives is to perform an analysis of the scientific literature on adverse events related to the operating room and the main strategies to mitigate them; to identify the knowledge of nurses about the scenario regarding the safety of pediatric surgical patients; To discuss the results of this process, facing the recommendations of the National Program for Patient Safety – PNSP, to the development of the investigational product. The study takes on an exploratory and descriptive feature, of a qualitative nature. The information was obtained integrative review, through interviews with nurses, directly responsible for the care of a Pediatric Public Hospital located in the Baixada Fluminense. The interviews followed a script with open and closed semi-structured questions that were analyzed and grouped into deductive categories and themes. The research was submitted to the Ethics Committee and the Federal Fluminense University (Universidade Federal Fluminense), getting approval in December 2014 through the consolidated report No. 895,049. As expected results: The operating block, when compared to other clinics in a health unit, has a high incidence rate and prevalence of errors and / or accidents related to direct patient care. These events range from the simple disturbance of the operative flow, with no real potential consequences for the patient, to the most serious complications, with the production of irreversible and incapacitating damages, or even premature death, to the detriment of Health hazards

The purpose of this study was to examine Residential Care Aides’ (RCAs) experiences of good quality dementia care provision. Informed by a political economy perspective, I sought to understand how RCAs conceptualize quality dementia care, whether such conceptualizations are reflected in their daily care practice and how the organizational care context impedes or facilitates such care provision. Drawing on a focused ethnographic approach, I utilized in-depth interviews, participant observation and the review of selected documents to contextualize RCAs’ experiences within the organizational care environment. Over a 12-month period, in-depth interviews with 29 staff (21 RCAs, 3 LPNs and 5 managers) and 239 hours of participant observation were conducted in four small-scale dementia units in two nursing homes in British Columbia, Canada. In-depth interviews yielded information-rich data about RCAs’ care experiences and their relationships with residents, while participant observation afforded the opportunity to strategically link RCAs’ actions and interactions with what was said, a feature missing from much of the previous research examining staff perceptions of quality dementia care. A select review of facility documents and provincial licensing regulations provided additional insight regarding the relevance of the larger structural context for RCAs’ care experiences. In general, RCAs conceptualized, and exhibited in their daily physical care provision, quality dementia care as that which focused on tangible care outcomes (i.e., keeping residents clean, comfortable, calm and happy), on their care approach (i.e., delivering care in a compassionate, patient and affectionate manner) and was guided by family ideology (i.e., invoking of family metaphors). Inherent in their care provision was a sense of role tension, as they sought to incorporate social interaction with task completion and their co-workers’ conflicting expectations. Study findings also illustrated how, in the face of continued disempowerment and organizational constraints, RCAs sought to provide quality dementia care by negotiating their peer and supervisory relationships and selectively breaking formal and informal policies/procedures. Salient to RCAs’ experiences of personhood was the limited recognition and appreciation they received from management and the manner in which work-life balance, staffing coverage, human resource management practices and limited information sharing further devalued them and their work. Study findings draw attention to the importance of: acknowledging the role of structural constraints in the pervasiveness of a task-oriented work culture; attending to (and facilitating) staff personhood; facilitating supportive peer and supervisory relationships and; fostering effective management practices as a means of potentially improving care quality. As such, the study sheds important light on what RCAs require within their work environments to help facilitate resident well-being, reinforcing the assertion that residents’ care conditions are inextricably linked to RCAs’ care work conditions. / Graduate / 0351

Abstract The purpose of this study was to develop the patient classification at the Oulu University Hospital, establish the validity and reliability of the patient classification from the perspective of nursing care quality standards. The data were collected at the Oulu University Hospital through the use of content experts judgements (n=36) and by gathering inter-rater classifications (n=8129), by nursing care activity study (n=17599), focus-group interviews (n=8) and through the international literature review. Data were analyzed and described using Excel and SPSS programs and data driven content analysis. The inter-rater reliability was tested using per cent agreement, weighted per cent agreement, Gronbach’s alfa correlation coefficient, Phi correlation coefficient, ICC-(intraclass-coefficient) and Kappa coefficient. Associations between the variables in the amount of time spent with various activities were tested using chi-square test within and between medical and surgical wards. There was notable consensus among the experts showing that the items and categories of Oulu patient classification represented the known content of nursing care at the wards of the Oulu University Hospital. The agreement and the weighted agreement provided evidence of an acceptable level of agreement concerning the intensity of nursing care. Nurses performed inter-rater classifications regularly. The agreement between raters had approved during the study at many wards. However, the agreement between raters had also declined at some wards. The declining trend of inter-rater classifications showed problems in the consistent patient classification. The problems may due to changes of the environment affecting nursing care. Nurses performed most of their time with medication and patient physical nursing care activities. The nursing personnel spent least of their time with emotional support and guidance. The indirect nursing care activities consisted of charting and reporting. The study results indicate that the nurses do not use the patient classification for matching caregiver skills and patients or for anticipating the workload shift-by-shift. There are problems with using Oulu-patient classification for classifying the nursing care provided if the patient classification does not account the patients’ actual individual needs for nursing care. The basic question is does the nursing care provided respond to patients’ actual individual needs. If it does not, the patient classification does not quarantee high quality of nursing care. If it is possible to prove that the nursing care provided respond to patients’ individual needs, the patient classification information can be used in staffing and nursing cost accounting. The information obtained from the study can be used to assure the quality of nursing processes based on individual needs of the patients. / Tiivistelmä Tämän tutkimuksen tehtävänä oli kehittää hoitoisuusluokitus Oulun yliopistolliseen sairaalaan, arvioida hoitoisuusluokituksen luotettavuus hoitoisuuden mittaamiseen ja arvioida hoitoisuusluokitus hoitotyön laatuvaatimusten näkökulmasta. Tutkimusaineistot kerättiin Oulun yliopistollisessa sairaalassa asiantuntija-arvioinneilla (n=36) ja rinnakkainluokituksilla (n=8129), ajanhavainnoinnilla (n=17599), ryhmähaastattelulla (n=8) ja kansainvälisellä kirjallisuuskatsauksella. Aineistojen analyysissa käytettiin Excel- ja SPSS-ohjelmistoja sekä sisällön analyysiä. Luokitusten vastaavuuden testaamisessa käytettiin yksimielisyysindeksiä, painotettua yksimielisyysprosenttia, yksisuuntaista varianssianalyysia (ANOVA), Cronbachin alfaa, Phin korrelaatiota, ICC- (intraclass-coefficient) kerrointa ja Kappa-tunnuslukua. Khiin neliön testiä käytettiin osoittamaan eroja sairaanhoitajien ajankäytössä kirurgisten ja sisätautien osastojen välillä. Oulu-hoitoisuusluokitus kattoi hoitotyön sisällön vuodeosastopotilaan hoidossa yliopistosairaalassa tutkimuksen lähtötilanteessa hyvin ja vastasi näkemystä hoitotyöstä. Rinnakkainluokituksia tehtiin säännöllisesti. Useilla osastoilla luokitusten välinen vastaavuus oli kehittynyt parempaan suuntaan tutkimusaikana. Luokitusten välinen vastaavuus oli toisaalta heikentynyt joillakin osastoilla. Tulosten aleneva trendi monilla osastoilla osoitti ongelmia luokituksen yhtenäisessä käytössä. Ongelmat voivat johtua ainakin osittain muutoksista toimintaympäristössä ja niiden vaikutuksesta hoitotyöhön. Eniten hoitohenkilökunnan aikaa kului lääkehoidon ja fyysisen hoidon toteuttamiseen. Vähiten aikaa käytettiin potilaan psyykkiseen tukemiseen ja potilaan ohjaukseen. Välillisessä hoitotyössä kaikilla osastoilla eniten aikaa käytettiin potilaan hoidon suunnitteluun ja raportointiin. Tulosten perusteella näytti kuitenkin siltä, että luokitusta ei hyödynnetty työvuoroittain päivittäin osaamisen kohdentamisessa tai työkuormituksen ennakoimisessa. Oulu-hoitoisuusluokituksen käyttäminen toteutuneen hoitotyön luokittelussa oli ongelmallista, jos luokitus ei ottanut huomioon potilaan yksilöllisiä hoitotyön tarpeita. Olennainen kysymys on, vastasiko toteutunut hoito potilaiden todellisia yksilöllisiä tarpeita. Jos toteutunut hoito on vastannut potilaiden yksilöllisiä tarpeita, on hoitoisuusluokitustietoja voitu käyttää myös henkilöstösuunnittelussa ja kustannusten selvittämisessä. Tutkimustuloksia voidaan hyödyntää potilaan yksilöllisen ja tarpeenmukaisen hoitotyön kehittämisessä.

Att mäta och dokumentera kliniskt vårdarbetet har inte prioriterats inom röntgenverksamheter. Tillgång till jämförelsedata skulle möjliggöra olika former av standardisering för förbättrad vårdkvalitet och patientsäkerhet. Att SPC- diagram (statistisk process styrning diagram)  inte uppmärksammas får effekt på patientsäkerhetsarbetet. Aktuell studie avser att öka kunskapen om vilka mätverktyg som finns att tillgå, vilka svar de kan ge och deras användbarhet. Syftet var jämföra och analysera olika standardiserade mätverktyg som kan användas inom somatisk slutenvård, för att förbättra vårdkvalitet och patientsäkerhet. Om möjligt, med betoning på röntgenverksamheter. En syntetiserande (integrativ) litteraturöversikt, av typen systematisk litteraturstudie, i avsaknad av metaanalys, valdes. Metoden är kvalitativ med induktiv ansats, mixad med kvantitativ metod. Fjorton olika mätverktyg presenteras i denna studie. Mätverktygen Shewhart- (styr-) diagram, flödesscheman och orsak-och-verkan diagram beskrivs mest frekvent. Alla, i studien medtagna mätverktyg, förbättrar noggrannheten vid beslutsprocesser. Shewhart- (styr-) diagram visar på variation (slöseri) över tid och om en process är stabil eller instabil. Flödesscheman och orsak-och-verkan diagram visar var förbättringsinsatser bör fokuseras i första hand.  Mätverktygen Lean, WMS (workflow management system), RFMEA (radiology failure mode and effect analysis) är unika genom sin mångsidighet. Att använda standardiserade mätverktyg ger tillgång till kvalitativ och betydelsefull information som förbättrar vårdens kvalitet, patienternas säkerhet samt förenklar analysen av data. / Measuring and documenting clinical care work has not been prioritized in radiology operations. Access to comparative data would allow for different forms of standardization for improved quality of care and patient safety. That SPC charts (statistical process control charts) are not noticed affects patient safety work. This study aims to increase knowledge about measurement tools available, what answers they can provide and their usefulness. The purpose was to compare and analyze various standardized measuring tools that can be used in somatic in-patients care, to increase the quality of care and patient safety. If possible, with emphasis on radiology operations. A synthesizing (integrative) literature review, of the type systematic literature review, in absence of meta-analysis, was chosen. Method is qualitative inductive approach, mixed with quantitative method. Fourteen different measuring tools are presented in this study. Shewhart (control) charts, flow charts and cause-and-effect charts are most frequently described. All measurement tools, included in the study, improves the accuracy at decision making processes. Shewhart (control) chart shows variation (waste) over time and whether a process is stable or unstable. Flow charts and cause-and-effect charts show where improvement efforts should be focused primarily. The Lean measurement tools, WMS (workflow management system), RFMEA (radiology failure mode and effect analysis) are unique through their versatility. Using standardized measurement tools provides access to qualitative and meaningful information that improves quality of care, patient safety, and simplifies data analysis.

Magister Public Health - MPH / Namibia has recorded an ascending trend of maternal and neonatal mortality rate from 225 – 449 per 100 000 women from 1992 to 2006, and 38 – 46 per 1000 live births from 2000 to 2006 respectively. Kavango Region in Namibia is one among the top seven regions with high maternal and infant mortality rate. Most pregnant women in peri-urban areas of Rundu District in the Kavango region, where this study was conducted, attend ante-natal care services but do not use public health facilities for delivery. The health records from the public health facilities in Rundu, especially from Nkarapamwe clinic and Rundu Hospital maternity section, reveal that although the pregnant women comply with the required standard policy of a minimum of three visits per pregnancy or more, over 40% of women who attend public ante-natal care clinics do not deliver in the public health facility.The aim of this study was to explore the perceptions of women regarding obstetric care in public health facilities in Kehemu settlement, a peri-urban area of Rundu town. The objectives of the study were to explore the perceptions of women on accessibility and acceptability of maternity services in public health facilities.An explorative qualitative study design using focus group discussion as a data collection method was conducted with three groups of women. A purposeful sampling procedure was used to select participants. Ethical approval was obtained from the High Degree Committee of University of the Western Cape and permission to use data from local facilities was obtained from the Ministry of Health and Social Services. Participants were recruited on their own free will and they signed an agreement on confidentiality. A data reduction process was used for analysis.The study findings indicate that women wish to use public health facilities for deliveries due to perceived benefits, in particular, safety for the mother and the baby and that those services are affordable. However a number of reasons hinder women to access services including the attitudes of health care providers, inability to afford transport at night and cultural influences.The study recommends that delivery services at the local clinic be expanded from eight to twenty-four hours; an information campaign on pregnancy and birth complications as well as the benefits of delivering in a public facility be implemented; refresher training for nurses to improve their caring practices during delivery should be considered and that a similar research be conducted with care providers to ascertain ways to improve maternity services in the public health facility in the area.

En France, les prix des EHPAD sont élevés au regard d’une qualité qui semble insuffisante. Des projets de réformes sont en discussion, mais les pouvoirs publics sont face à un dilemme : toute recherche de réduction des coûts risque de dégrader la qualité plus qu’elle ne l’est déjà et toute amélioration de la qualité serait probablement inflationniste.L’objectif de cette thèse est d’étudier si ce dilemme peut être résolu, en analysant en particulier le rôle de la concurrence, réelle et par comparaison, qui pourrait être introduite dans ce secteur. Par une approche micro-économétrique, nous organisons notre analyse autour de trois questions de recherche : (i) que peut-on attendre des réformes proposées de la tarification et de l’augmentation de la capacité des établissements ? (ii) comment le développement du secteur privé lucratif pourrait permettre de réduire les prix et d’améliorer la qualité ? (iii) existe-t-il des contraintes environnementales responsables de la faible qualité des EHPAD? Nous observons, d’une part, que les projets de réforme permettraient de réduire l’inefficacité et donc éventuellement les prix des EHPAD, mais au détriment de leur qualité. D’autre part, nous constatons que l’essor des EHPAD lucratifs s’accompagne d’une augmentation des tarifs et d’une dégradation de la qualité de la prise en charge, qui pourraient être modérées par une structure de marché plus concurrentielle. Enfin, les EHPAD sont confrontés à des difficultés locales de fidélisation du personnel soignant qui affectent leur qualité et qui ne semblent pas pouvoir être résolues par un ajustement des salaires. Ces résultats peuvent servir de repères à la mise en place d’une politique publique adaptée. / High prices and insufficient quality of care are observed in nursing homes in France. Reforms are currently under discussion, but governments are facing a dilemma : any measure of price cut is likely to affect quality and any improvement in quality would probably be inflationary. This work analyzes if this dilemma can be solved by focusing more particularly on the potential effect of real and yardstick competition that could be introduced in this long term care sector. Using a micro-econometric framework, we organize this analysis into three research issues : (i) What might be expected from the pricing reform and the increase in the number of beds in nursing homes currently proposed ? (ii) How the development of for-profit nursing homes could reduce prices and improve quality ? (iii) Are there local difficulties responsible for the poor quality of nursing homes ? Several implications for public policy may be involved. Using cost frontier estimates, we demonstrate that the reform plans would reduce inefficiency and nursing home prices, but at the expense of their quality. The rise of for-profit nursing homes leads to high prices and a deterioration of the quality of care which could be tempered however by a more competitive market structure. Nursing homes face local difficulties in nursing staff retention, affecting their quality and which do not seem to be solved by adjusting wages.