Care delivery value chains for ophthalmic clinics in Switzerland

Perceived patient value is often not aligned with the emerging expenses for health care services. In other words, the costs are often supposed as rising faster than the actual value for the patients. This fact is causing major concerns to governments, health plans, and individuals. Attempts to solve the problem have habitually been on the operational effectiveness side: increasing patient volume, minimizing costs, rationing, or closing hospitals, usually resulting in a zero-sum game. Only few approaches come from the strategic positioning side and "competition" among hospitals is still perceived rather as a danger than as a chance to create a positive-sum game and stimulate patient value. In their 2006 book, "Redefining Health Care", the renowned Harvard strategy professor Michael E. Porter and hospital management expert Professor Elizabeth Olmsted Teisberg approach the challenge from the positive-sum perspective: they propose to form Integrated Practice Units (IPUs) and manage hospitals in a modern, patient value oriented way. They argue that creating value-based competition on results should have the same effect on the health care sector like transparency and competition turned other industries with out-dated management models (like recently the inert telecommunication industry) into highly competitive and customer value creating businesses. The objective of this paper is to elaborate Care Delivery Value Chains for Integrated Practice Units in ophthalmic clinics and gather a first feedback from Swiss hospital managers, ophthalmologists, and patients, if such an approach could be a realistic way to improve health care management. First, Porter's definition of competitiveness (distinction between operational effectiveness and strategic positioning) is explained. Then, the Care Delivery Value Chain is introduced as a key element for understanding value-based management, followed by three practice examples for ophthalmic clinics. Finally, recommendations are given how the Care Delivery Value Chain can be managed efficiently and how the obstacles of becoming a patient-oriented organization can be overcome. The conclusion is that increased transparency and value-based competition on results has the potential to change the mindset of hospital managers-which will align patient value with the emerging health care expenses. Early adapters of this management approach will gain a competitive advantage. [Author, p. 6]

Implicit self-theories of shyness : predictors and correlates in preadolescence /

Implicit theories of shyness refer to a beUef that shyness is a fixed trait versus the belief that shyness is changeable and controllable. In this study, I explored the association between overall shyness and children's implicit self-theories of shyness, as well as between implicit self-theories of shyness and children's other shyness-related beliefs (perceptions of others' theories of shyness, shyness as a perceived problem, and ideas about treatment for shyness). Forty-six 10-12- year- old children (M = 10.74, SD = .88) were interviewed individually, filled out a set of questionnaires, and completed a computer-presented task. ' "^ As was expected, in ambiguous social situations, children perceived others' theories of shyness in a way that confirmed their own theories. The hypothesized curvilinear relation between shy and implicit self-theories of shyness was not found; instead, a linear positive relationship between these two variables emerged. Although implicit self-theories of shyness were not effective in predicting either the children's views of shyness as a perceived problem or children's ideas about treatment for shyness, some interesting results were found. Specifically, children's motivation to change their shyness correlated with their views of shyness as a problem for children in general and their perceptions of others' theories of shyness. Specific agents and strategies were regarded by children as having different effectiveness in their potential to change shyness. The theoretical and practical implications of these findings were discussed. Suggestions for future research were provided.

Un modèle systémique d’analyse de changement dans les organisations : le cas de l’analyse de l’implantation du projet PATH de l’OMS Europe en France

Thèse de doctorat effectuée en cotutelle au Département d’administration de la santé Faculté de médecine, Université de Montréal et à l’École doctorale Biologie-Santé Faculté de médecine, Université de Nantes, France

Anticiper l’avenir de la prévention basée sur le risque génétique : analyse qualitative de la perception des participants à l’étude «Dessine-moi un futur!»

En cette ère de «nouvelle santé publique», les professionnels sont exhortés à détourner leur attention de l’individu afin de pouvoir mettre l’accent sur les déterminants sociaux de la santé. Un phénomène contraire s’opère dans le domaine des sciences biomédicales, où un mouvement vers la santé personnalisée permet d’envisager des soins préventifs et curatifs adaptés à chaque individu, en fonction de son profil de risque génétique. Bien qu’elles n’aient que partiellement fait leur entrée dans notre système de santé, ces avancées scientifiques risquent de changer significativement le visage de la prévention, et dans cette foulée, de susciter des débats de société importants. L'étude proposée vise à contribuer à une réflexion sur l'avenir d'une des fonctions essentielles de la santé publique en tentant de mieux comprendre comment le public perçoit la prévention basée sur le risque génétique. Ce projet de recherche qualitative consiste en l'analyse secondaire des échanges ayant eu lieu lors de quatre ateliers délibératifs auxquels ont participé des membres du public d'horizons divers, et durant lesquels ceux-ci ont débattu de la désirabilité d'une technologie préventive fictive, le «rectificateur cardiaque». La théorie de la structuration d'Anthony Giddens est utilisée comme cadre conceptuel guidant l’analyse des échanges. Celle-ci permet d’émettre les trois constats suivants: a- le « rectificateur cardiaque » est loin d’être interprété par tous les participants comme étant une intervention préventive; b- son utilisation est perçue comme étant légitime ou non dépendamment principalement des groupes de personnes qu’elle viserait; c- l’intervention proposée ne se pense pas hors contexte.

The prediction of seasonal and inter-annual climate variations and their impacts on the water resources in the eastern seaboard of Thailand

The research of this thesis dissertation covers developments and applications of short-and long-term climate predictions. The short-term prediction emphasizes monthly and seasonal climate, i.e. forecasting from up to the next month over a season to up to a year or so. The long-term predictions pertain to the analysis of inter-annual- and decadal climate variations over the whole 21st century. These two climate prediction methods are validated and applied in the study area, namely, Khlong Yai (KY) water basin located in the eastern seaboard of Thailand which is a major industrial zone of the country and which has been suffering from severe drought and water shortage in recent years. Since water resources are essential for the further industrial development in this region, a thorough analysis of the potential climate change with its subsequent impact on the water supply in the area is at the heart of this thesis research. The short-term forecast of the next-season climate, such as temperatures and rainfall, offers a potential general guideline for water management and reservoir operation. To that avail, statistical models based on autoregressive techniques, i.e., AR-, ARIMA- and ARIMAex-, which includes additional external regressors, and multiple linear regression- (MLR) models, are developed and applied in the study region. Teleconnections between ocean states and the local climate are investigated and used as extra external predictors in the ARIMAex- and the MLR-model and shown to enhance the accuracy of the short-term predictions significantly. However, as the ocean state – local climate teleconnective relationships provide only a one- to four-month ahead lead time, the ocean state indices can support only a one-season-ahead forecast. Hence, GCM- climate predictors are also suggested as an additional predictor-set for a more reliable and somewhat longer short-term forecast. For the preparation of “pre-warning” information for up-coming possible future climate change with potential adverse hydrological impacts in the study region, the long-term climate prediction methodology is applied. The latter is based on the downscaling of climate predictions from several single- and multi-domain GCMs, using the two well-known downscaling methods SDSM and LARS-WG and a newly developed MLR-downscaling technique that allows the incorporation of a multitude of monthly or daily climate predictors from one- or several (multi-domain) parent GCMs. The numerous downscaling experiments indicate that the MLR- method is more accurate than SDSM and LARS-WG in predicting the recent past 20th-century (1971-2000) long-term monthly climate in the region. The MLR-model is, consequently, then employed to downscale 21st-century GCM- climate predictions under SRES-scenarios A1B, A2 and B1. However, since the hydrological watershed model requires daily-scale climate input data, a new stochastic daily climate generator is developed to rescale monthly observed or predicted climate series to daily series, while adhering to the statistical and geospatial distributional attributes of observed (past) daily climate series in the calibration phase. Employing this daily climate generator, 30 realizations of future daily climate series from downscaled monthly GCM-climate predictor sets are produced and used as input in the SWAT- distributed watershed model, to simulate future streamflow and other hydrological water budget components in the study region in a multi-realization manner. In addition to a general examination of the future changes of the hydrological regime in the KY-basin, potential future changes of the water budgets of three main reservoirs in the basin are analysed, as these are a major source of water supply in the study region. The results of the long-term 21st-century downscaled climate predictions provide evidence that, compared with the past 20th-reference period, the future climate in the study area will be more extreme, particularly, for SRES A1B. Thus, the temperatures will be higher and exhibit larger fluctuations. Although the future intensity of the rainfall is nearly constant, its spatial distribution across the region is partially changing. There is further evidence that the sequential rainfall occurrence will be decreased, so that short periods of high intensities will be followed by longer dry spells. This change in the sequential rainfall pattern will also lead to seasonal reductions of the streamflow and seasonal changes (decreases) of the water storage in the reservoirs. In any case, these predicted future climate changes with their hydrological impacts should encourage water planner and policy makers to develop adaptation strategies to properly handle the future water supply in this area, following the guidelines suggested in this study.

Dinámica del debate sobre el lobby israelí y su influencia en la toma de decisiones en política exterior estadounidense respecto de Israel. 2002-2012

El interés de este estado del arte es establecer la dinámica que ha tenido el debate en torno al lobby israelí y su influencia en las decisiones en política exterior. Ante esto lo que se pretende es determinar cual es la tendencia que se sigue y específicamente cual es el estado del debate hoy en día. Por esto se pretende probar que el lobby israelí como fuerza de influencia, no es la única que busca fijar políticas en los EEUU en materia de política exterior ya que existen otros grupos que así mismo le hacen contrapeso. Para esto se recurrirá a fuentes de diferente tipo, en donde se recolecten los principales exponentes sobre el tema y así analizarlos a mayor profundidad.

Administración en la cadena de suministro y su relación con el desempeño de las PYME del sector agroindustrial

En la actualidad las organizaciones están en búsqueda de una mejora continua, esto lleva a que las empresas hagan una revisión de estrategias que permitan alcanzar una posición de líderes en los diferentes sectores en los que se desempeñan. Una de las estrategias para lograr un alto posicionamiento en las nuevas empresas es la adecuada gestión que hacen de la cadena de suministro. El sector agroindustrial tiene un amplia cadena de suministro desde la obtención de materias primas hasta la llegada al cliente final, por su gran magnitud requiere de una adecuada administración de procesos que permitan ser eficaces y eficientes para alcanzar logros propuestos, aprovechar los recursos limitados con los que cuentan para su cumplimiento y, por último, la capacidad propia para la transformación de sus recursos. Para lograr que las empresas obtengan ventajas competitivas, es necesario que los distintos eslabones de la cadena de suministros cuenten con una capacidad de interacción que les permita, tanto agilizar como asegurar el éxito durante la incorporación de los nuevos productos en el mercado. Por medio de esta investigación se busca esclarecer y analizar la importancia de la administración en la cadena de suministro y la relación con el desempeño, basándose en las Pymes del sector agroindustrial. La intención es evaluar la información de diversos autores quienes han hablado de la relación que existe entre la cadena de suministro y su desempeño, teniendo en cuenta variables como el sector agroindustrial y las Pymes.

Land-atmosphere energy exchange in Arctic tundra and boreal forest: available data and feedbacks to climate

This paper summarizes and analyses available data on the surface energy balance of Arctic tundra and boreal forest. The complex interactions between ecosystems and their surface energy balance are also examined, including climatically induced shifts in ecosystem type that might amplify or reduce the effects of potential climatic change. High latitudes are characterized by large annual changes in solar input. Albedo decreases strongly from winter, when the surface is snow-covered, to summer, especially in nonforested regions such as Arctic tundra and boreal wetlands. Evapotranspiration (QE) of high-latitude ecosystems is less than from a freely evaporating surface and decreases late in the season, when soil moisture declines, indicating stomatal control over QE, particularly in evergreen forests. Evergreen conifer forests have a canopy conductance half that of deciduous forests and consequently lower QE and higher sensible heat flux (QH). There is a broad overlap in energy partitioning between Arctic and boreal ecosystems, although Arctic ecosystems and light taiga generally have higher ground heat flux because there is less leaf and stem area to shade the ground surface, and the thermal gradient from the surface to permafrost is steeper. Permafrost creates a strong heat sink in summer that reduces surface temperature and therefore heat flux to the atmosphere. Loss of permafrost would therefore amplify climatic warming. If warming caused an increase in productivity and leaf area, or fire caused a shift from evergreen to deciduous forest, this would increase QE and reduce QH. Potential future shifts in vegetation would have varying climate feedbacks, with largest effects caused by shifts from boreal conifer to shrubland or deciduous forest (or vice versa) and from Arctic coastal to wet tundra. An increase of logging activity in the boreal forests appears to reduce QE by roughly 50% with little change in QH, while the ground heat flux is strongly enhanced.

The dichotomous structure of the warm conveyor belt

The warm conveyor belt (WCB) of an extratropical cyclone generally splits into two branches. One branch (WCB1) turns anticyclonically into the downstream upper-level tropospheric ridge, while the second branch (WCB2) wraps cyclonically around the cyclone centre. Here, the WCB split in a typical North Atlantic cold-season cyclone is analysed using two numerical models: the Met Office Unified Model and the COSMO model. The WCB flow is defined using off-line trajectory analysis. The two models represent the WCB split consistently. The split occurs early in the evolution of the WCB with WCB1 experiencing maximum ascent at lower latitudes and with higher moisture content than WCB2. WCB1 ascends abruptly along the cold front where the resolved ascent rates are greatest and there is also line convection. In contrast, WCB2 remains at lower levels for longer before undergoing saturated large-scale ascent over the system's warm front. The greater moisture in WCB1 inflow results in greater net potential temperature change from latent heat release, which determines the final isentropic level of each branch. WCB1 also exhibits lower outflow potential vorticity values than WCB2. Complementary diagnostics in the two models are utilised to study the influence of individual diabatic processes on the WCB. Total diabatic heating rates along the WCB branches are comparable in the two models with microphysical processes in the large-scale cloud schemes being the major contributor to this heating. However, the different convective parameterisation schemes used by the models cause significantly different contributions to the total heating. These results have implications for studies on the influence of the WCB outflow in Rossby wave evolution and breaking. Key aspects are the net potential temperature change and the isentropic level of the outflow which together will influence the relative mass going into each WCB branch and the associated negative PV anomalies at the tropopause-level flow.

Progress in observing and modelling the urban boundary layer

The urban boundary layer (UBL) is the part of the atmosphere in which most of the planet’s population now lives, and is one of the most complex and least understood microclimates. Given potential climate change impacts and the requirement to develop cities sustainably, the need for sound modelling and observational tools becomes pressing. This review paper considers progress made in studies of the UBL in terms of a conceptual framework spanning microscale to mesoscale determinants of UBL structure and evolution. Considerable progress in observing and modelling the urban surface energy balance has been made. The urban roughness sub-layer is an important region requiring attention as assumptions about atmospheric turbulence break down in this layer and it may dominate coupling of the surface to the UBL due to its considerable depth. The upper 90% of the UBL (mixed and residual layers) remains under-researched but new remote sensing methods and high resolution modelling tools now permit rapid progress. Surface heterogeneity dominates from neighbourhood to regional scales and should be more strongly considered in future studies. Specific research priorities include humidity within the UBL, high-rise urban canopies and the development of long-term, spatially extensive measurement networks coupled strongly to model development.

The risk of water stress

Water resources are under stress in many regions due to increasing demands and, in places, falling quality. Climate change has the potential to change the risks of water stress.1 The focus in this section is on strategic definitions of water stress, which are based on generalized indicators of the amount of water that is available and the demands on that resource. Operational definitions, on the other hand, are typically based on the reliability of the supply of appropriate quality water and are strongly determined by local conditions.

Mobilidade da força de trabalho: os impactos de intensos deslocamentos geográficos sob a ótica de trabalhadores docentes

O trabalho ocupa um inegável espaço na vida dos indivíduos, sendo este rico de sentido individual e social, é um meio de produção da vida de cada um ao prover subsistência, criar sentidos existenciais ou contribuir na estruturação da identidade e da subjetividade. O cenário atual de adoção e uso das Tecnologias de Informação e Comunicação pelas organizações e pessoas, demonstra um crescimento da incorporação de dispositivos tecnológicos que têm o potencial de alterar as características espaciais e temporais do trabalho, aumentando a mobilidade do trabalhador. Considerando-se o fato de que o indivíduo ao deslocar-se, ao mover-se pelo espaço, anexa ou remodela sua identidade pessoal, profissional, cultural, social ou política a partir da mobilidade, o objetivo final desta pesquisa foi refletir sobre de que maneira os impactos positivos e negativos gerados pela intensa mobilidade geográfica demandados pelo exercício da profissão, são percebidos por trabalhadores docentes de curso de pós-graduação lato sensu em Administração que se deslocam de um território para outro(s), com a finalidade de exercerem suas atividades docentes. Realizou-se para tanto uma revisão bibliográfica acerca de sentido do trabalho, apresentando, a seguir, algumas reflexões sobre as alterações ocorridas nas relações de trabalho em decorrência de mutações no mundo do trabalho, abordando, por fim, o tema Mobilidade da força de trabalho. Após esta etapa, buscou-se compreender, na ótica desses trabalhadores docentes, por meio de entrevistas pessoais analisadas à luz do método de análise de conteúdo, os caminhos percorridos e significados atribuídos por eles a estas vivências, procurando perceber como os trabalhadores docentes em destaque representam o olhar sobre si e sobre os outros, visando demonstrar o significado (positivo e negativo) da mobilidade espacial, as práticas cotidianas e estratégias de sociabilidade e interação com e no local de destino. Pode-se concluir que, apesar de haver alguns fatores que podem tornar os constantes deslocamentos geográficos destes trabalhadores um elemento negativo para eles, uma vez que são fontes de alta demanda física e mental, geradoras de estresse, sobrecarga, tensão emocional, cansaço, ansiedade, desânimo, frustração e descontentamento em relação ao trabalho, levando-os ao afastamento constante do contexto social, podendo resultar em consequências graves para a saúde deste trabalhador. Estes constantes deslocamentos geográficos tornam-se, contudo, um elemento positivo, uma vez que possibilitam o incremento às suas práticas docentes, por meio das vivências enriquecidas pelos contactos estabelecidos, pelas aprendizagens realizadas e pelas capacidades de relacionamento em meios multiculturais adquiridas, tornando-se espaço de autorrealização, inserção e reconhecimento social, prestígio, status e de senso de utilidade.

E-business innovation and customs renovation for secure supply chain management

Includes bibliography

Coeffcients of herdability and relatedness in a forest fragment of Araucaria angustifolia (Bertol.) Kuntze using genetic markers

Methods based on genetic markers to estimate the coefficient of heritability in natural populations are important to understand the effects of natural selection on inheritance of quantitative traits. The objective of this study was to investigate the genetic control of the trait plant height in a fragmented population of Araucaria angustifolia. This study was conducted in a forest fragment of 5.4 ha of area, located in the State of Parana, Brazil. Estimates of heritability were performed using data from genotypes and height of regenerating individuals of the population. Four methods to estimate the relatedness between pairs of individuals (RITLAND, 1996; LYNCH; RITLAND, 1999; QUELLER; GOODNIGHT, 1989; WANG, 2002) for three distances (without criteria, 25 and 50 m) were used. The coefficient of heritability estimated using the estimator of relatedness of Ritland (1996), suggest that the genetic control of the trait height is low in the regeneration, thus the natural selection as well as the artificial selection have a low potential to change the mean of the population. The estimates based on the other methods to calculate the relatedness presented low precision, indication that these methods are not adequate for the data used.

Redes de atenção à saúde para gestantes usuárias de álcool e/ou outras drogas

Pós-graduação em Saúde Coletiva - FMB