What is best for Esther? Building improvement coaching capacity with and for users in health and social Care-A case study

While coaching and customer involvement can enhance the improvement of health and social care, many organizations struggle to develop their improvement capability; it is unclear how best to accomplish this. We examined one attempt at training improvement coaches. The program, set in the Esther Network for integrated care in rural Jonkoping County, Sweden, included eight 1-day sessions spanning 7 months in 2011. A senior citizen joined the faculty in all training sessions. Aiming to discern which elements in the program were essential for assuming the role of improvement coach, we used a case-study design with a qualitative approach. Our focus group interviews included 17 informants: 11 coaches, 3 faculty members, and 3 senior citizens. We performed manifest content analysis of the interview data. Creating will, ideas, execution, and sustainability emerged as crucial elements. These elements were promoted by customer focusembodied by the senior citizen trainershared values and a solution-focused approach, by the supportive coach network and by participants' expanded systems understanding. These elements emerged as more important than specific improvement tools and are worth considering also elsewhere when seeking to develop improvement capability in health and social care organizations.

BUILDING EFFICIENT AND COST-EFFECTIVE CLOUD-BASED BIG DATA MANAGEMENT SYSTEMS

In today’s big data world, data is being produced in massive volumes, at great velocity and from a variety of different sources such as mobile devices, sensors, a plethora of small devices hooked to the internet (Internet of Things), social networks, communication networks and many others. Interactive querying and large-scale analytics are being increasingly used to derive value out of this big data. A large portion of this data is being stored and processed in the Cloud due the several advantages provided by the Cloud such as scalability, elasticity, availability, low cost of ownership and the overall economies of scale. There is thus, a growing need for large-scale cloud-based data management systems that can support real-time ingest, storage and processing of large volumes of heterogeneous data. However, in the pay-as-you-go Cloud environment, the cost of analytics can grow linearly with the time and resources required. Reducing the cost of data analytics in the Cloud thus remains a primary challenge. In my dissertation research, I have focused on building efficient and cost-effective cloud-based data management systems for different application domains that are predominant in cloud computing environments. In the first part of my dissertation, I address the problem of reducing the cost of transactional workloads on relational databases to support database-as-a-service in the Cloud. The primary challenges in supporting such workloads include choosing how to partition the data across a large number of machines, minimizing the number of distributed transactions, providing high data availability, and tolerating failures gracefully. I have designed, built and evaluated SWORD, an end-to-end scalable online transaction processing system, that utilizes workload-aware data placement and replication to minimize the number of distributed transactions that incorporates a suite of novel techniques to significantly reduce the overheads incurred both during the initial placement of data, and during query execution at runtime. In the second part of my dissertation, I focus on sampling-based progressive analytics as a means to reduce the cost of data analytics in the relational domain. Sampling has been traditionally used by data scientists to get progressive answers to complex analytical tasks over large volumes of data. Typically, this involves manually extracting samples of increasing data size (progressive samples) for exploratory querying. This provides the data scientists with user control, repeatable semantics, and result provenance. However, such solutions result in tedious workflows that preclude the reuse of work across samples. On the other hand, existing approximate query processing systems report early results, but do not offer the above benefits for complex ad-hoc queries. I propose a new progressive data-parallel computation framework, NOW!, that provides support for progressive analytics over big data. In particular, NOW! enables progressive relational (SQL) query support in the Cloud using unique progress semantics that allow efficient and deterministic query processing over samples providing meaningful early results and provenance to data scientists. NOW! enables the provision of early results using significantly fewer resources thereby enabling a substantial reduction in the cost incurred during such analytics. Finally, I propose NSCALE, a system for efficient and cost-effective complex analytics on large-scale graph-structured data in the Cloud. The system is based on the key observation that a wide range of complex analysis tasks over graph data require processing and reasoning about a large number of multi-hop neighborhoods or subgraphs in the graph; examples include ego network analysis, motif counting in biological networks, finding social circles in social networks, personalized recommendations, link prediction, etc. These tasks are not well served by existing vertex-centric graph processing frameworks whose computation and execution models limit the user program to directly access the state of a single vertex, resulting in high execution overheads. Further, the lack of support for extracting the relevant portions of the graph that are of interest to an analysis task and loading it onto distributed memory leads to poor scalability. NSCALE allows users to write programs at the level of neighborhoods or subgraphs rather than at the level of vertices, and to declaratively specify the subgraphs of interest. It enables the efficient distributed execution of these neighborhood-centric complex analysis tasks over largescale graphs, while minimizing resource consumption and communication cost, thereby substantially reducing the overall cost of graph data analytics in the Cloud. The results of our extensive experimental evaluation of these prototypes with several real-world data sets and applications validate the effectiveness of our techniques which provide orders-of-magnitude reductions in the overheads of distributed data querying and analysis in the Cloud.

Unmet health needs in patients with coronary heart disease: implications and potential for improvement in caring services

BACKGROUND: Improving the quality of health care services requires tailoring facilities to fulfil patients' needs. Satisfying patients' healthcare needs, listening to patients' opinions and building a closer provider-user partnership are central to the NHS. Few published studies have discussed cardiovascular patients' health needs, but they are not comprehensive and fail to explore the contribution of outcome to needs assessment. METHOD: A comprehensive self-administered health needs assessment (HNA) questionnaire was developed for concomitant use with generic (Short Form-12 and EuroQOL) and specific (Seattle Angina Questionnaire) health-related quality of life (HRQL) instruments on 242 patients admitted to the Acute Cardiac Unit, Nottingham. RESULTS: 38% reported difficulty accessing health facilities, 56% due to transport and 32% required a travelling companion. Mean HRQOL scores were lower in those living alone (P < 0.05) or who reported unsatisfactory accommodation. Dissatisfaction with transport affected patients' ease of access to healthcare facilities (P < 0.001). Younger patients (<65 y) were more likely to be socially isolated (P = 0.01). Women and patients with chronic disease were more likely to be concerned about housework (P < 0.05). Over 65 s (p < 0.05) of higher social classes (p < 0.01) and greater physical needs (p < 0.001) had more social needs, correlating moderately (0.32 < r < 0.63) with all HRQL domains except SAQ-AS. Several HRQL components were highly correlated with the HNA physical score (p < 0.001). CONCLUSIONS: Patients wanted more social (suitable accommodation, companionship, social visits) and physical (help aids, access to healthcare services, house work) support. The construct validity and intra-class reliability of the HNA tool were confirmed. Our results indicate a gap between patients' health needs and available services, highlighting potential areas for improvement in the quality of services

Reordenamento viário da Rua da República e acompanhamento da instalação da Biblioteca Ary dos Santos em Sacavém

Relatório de estágio para obtenção do grau de Mestre em Engenharia Civil na Área de Especialização de Edificações

Building capacity in the parliaments of Jordan and Morocco : an institutional approach

This thesis examines the parliaments of Jordan and Morocco within an institutional approach. Previous studies of the Middle East and North Africa [MENA] parliaments tended to identify some trends, but most were concerned with the governments’ behaviour rather than examining the extent to which these institutions were working and what their capacity was. This thesis takes an institutional approach as the context for assessing the role of these parliaments, considering in particular their committees and administrative systems. The study emphasizes capacity building to complement the institutional approach adopted. Taking an institutional approach and considering capacity building in the two parliaments the dynamics of environmental factors, the constraints on committees, and administrative capabilities are examined. With this approach, it is possible to identify factors that shaped the current work of the two parliaments ranging from the environment, regulations, political system, and the economic and social identities that may influence the way these parliaments operate. This approach also reveals some of the strengths and weaknesses of the parliamentary practices and the administrative supporting services undertaken, including an explanation of how these parliaments are operating under their respective governing systems. This research offers an empirical study of the chosen parliaments by acknowledging the current levels of capacity and trying to contextualise their identities and capabilities. The findings demonstrate that the institutional approach and capacity building in the two parliaments is highly influenced by a variety of arrangements of legislatures along with the environmental factors affecting the two parliaments’ way of work. This research contributes to institutional and capacity building studies, particularly on the development of parliamentary institutions in the MENA region. This approach recommends the need to undertake further case studies involving other parliaments in the MENA region particularly those accommodating the political transformation towards a new era of vibrant new democracies, not only by rearranging institutional structures, practices and support, but also through cognitive, discursive, and social participation in the two countries’ most prominent institutions – their parliaments.

Technical Services vs. Public Service

Regarding this issue, it seems appropriate to quote Gorman who says: And it came to pass that when Kutta, assistant God made the first library, she noted that it was good. So he called together all librarians and divided as a shepherd divides the sheep and goats. The first group spoke to him saying: you will dwell in the clarity and serve the readers and their glory will be great. Then he turned to the second group and spoke to him saying: you will dwell in the darkness. Secret must be hidden effort and work. You do not know the reader nor shall you know them. Go away and sort ... and has been up to these days (1979, p. 435).

Espionage against Poland in the Documents and Analyses of the Polish Special Services (1944 - 1989) - as Illustrated by the Intelligence Activities of the USA

The text analyses the intelligence activity against Poland in the period 1944-1989. The paper also contains a case study, i.e. an analysis of the American intelligence service activity held against Poland. While examining the research thesis, the author used the documents and analyses prepared by the Ministry of Internal Affairs. In order to best illustrate the point, the author presented a number of cases of persons who spied for the USA, which was possible thanks to the analysis of the training materials of the Ministry of Internal Affairs directed to the officers of the Security Service and the Citizens’ Militia. The text tackles the following issues: (1) to what extent did the character of the socio-political system influence the number of persons convicted for espionage against Poland in the period under examination?, (2) what was the level of interest of the foreign intelligence services in Poland before the year 1990?, (3) is it possible to indicate the specificity of the U.S. intelligence activity against Poland? 1) The analysis of data indicates that the period 1946-1956 witnessed a great number of convictions for espionage, which is often associated with the peculiar political situation in Poland of that time. Up to 1953, the countries of the Eastern bloc had reproduced the Stalin’s system, which only ceased due to the death of Stalin himself. Since then, the communist systems gradually transformed into the system of nomenklatura. Irrespective of these changes, Poland still witnessed a wave of repressions, which resulted from the threats continuously looming over the communist authorities – combating the anti-communist underground movement, fighting with the Ukrainian Insurgent Army, the Polish government-in-exile, possible revisionism of borders, social discontent related to the socio-political reforms. Hence, a great number of convictions for espionage at that time could be ascribed to purely political sentences. Moreover, equally significant was the fact that the then judicial practice was preoccupied assessing negatively any contacts and relations with foreigners. This excessive number of convictions could ensue from other criminal-law provisions, which applied with respect to the crimes against the State, including espionage. What is also important is the fact that in the Stalin’s period the judiciary personnel acquired their skills and qualifications through intensive courses in law with the predominant spirit of the theory of evidence and law by Andrey Vyshinsky. Additionally, by the decree of 1944 the Penal Code of the Polish Armed Forces was introduced; the code envisaged the increase in the number of offences classified as penalised with death penalty, whereas the high treason was subject to the military jurisdiction (the civilians were prosecuted in military courts till 1955; the espionage, however, still stood under the military jurisdiction). In 1946, there was introduced the Decree on particularly dangerous crimes in the period of the State’s recovery, which was later called a Small Penal Code. 2) The interest that foreign intelligence services expressed in relation to Poland was similar to the one they had in all countries of Eastern and Central Europe. In the case of Poland, it should be noted that foreign intelligence services recruited Polish citizens who had previously stayed abroad and after WWII returned to their home country. The services also gathered information from Poles staying in immigrant camps (e.g. in FRG). The activity of the American intelligence service on the territory of FRG and West Berlin played a key role. The documents of the Ministry of Internal Affairs pointed to the global range of this activity, e.g. through the recruitment of Polish sailors in the ports of the Netherlands, Japan, etc. In line with the development in the 1970s, espionage, which had so far concentrated on the defence and strategic sectors, became focused on science and technology of the People’s Republic of Poland. The acquisition of collaborators in academic circles was much easier, as PRL opened to academic exchange. Due to the system of visas, the process of candidate selection for intelligence services (e.g. the American) began in embassies. In the 1980s, the activity of the foreign intelligence services concentrated on the specific political situation in Poland, i.e. the growing significance of the “Solidarity” social movement. 3) The specificity of the American intelligence activity against Poland was related to the composition of the residency staff, which was the largest in comparison to other Western countries. The wide range of these activities can be proved by the quantitative data of convictions for espionage in the years 1944-1984 (however, one has to bear in mind the factors mentioned earlier in the text, which led to the misinterpretation of these data). Analysing the data and the documents prepared by the Ministry of Internal Affairs, one should treat them with caution, as, frequently, the Polish counter-intelligence service used to classify the ordinary diplomatic practice and any contacts with foreigners as espionage threats. It is clearly visible in the language of the training materials concerned with “secret service methods of the intelligence activity” as well as in the documents on operational activities of the Security Service in relation to foreigners. The level of interest the USA had in Poland was mirrored in the classification of diplomatic posts, according to which Warsaw occupied the second place (the so-called Group “B”) on the three-point scale. The CIA experienced spectacular defeats during their activity in Poland: supporting the Polish underground anti-communist organisation Freedom and Independence and the so-called Munich-Berg episode (both cases took place in the 1950s). The text focuses only on selected issues related to the espionage activities against Poland. Similarly, the analysis of the problem has been based on selected sources, which has limited the research scope - however, it was not the aim of the author to present the espionage activity against Poland in a comprehensive way. In order to assess the real threat posed by the espionage activity, one should analyse the case of persons convicted for espionage in the period 1944-1989, as the available quantitative data, mentioned in the text, cannot constitute an explicit benchmark for the scale of espionage activity. The inaccuracies in the interpretation of data and variables, which can affect the evaluation of this phenomenon, have been pointed out in the text.

The suitability for building of zones liable to flooding or the territorial negotiation of Flood Prevention Plans

International audience

Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

City & Spectacle: A Vision of Lisbon Before the 1755 Great Earthquake

City & Spectacle: a vision of pre-earthquake Lisbon consists of a virtual recrea on of the city of Lis- bon on the eve of the great earthquake of 1 November 1755, giving shape to a laboratory model for research into the city’s history. As its star ng point the project has the virtual recrea on of one the most emblema c of spaces from 18th century Lisbon, the Royal Opera House, which disappeared during the 1755 earthquake. The recrea on of the Opera House was developed in the scope of the commemora- ons of the 250th anniversary of the 1755 catastrophe as an a empt to restore this space of the highest ar s c quality to memory and to return it to the inventory of the Portuguese heritage of architectural history.1 Using Second Life® technology it was possible to put forward a model of both the struc- ture and interiors of the Opera House as well as its anima on combined with a small piece of the opera presented at the inaugura on of the building in April 1755. The public presenta on of this virtual model at the conference 1755: Catástrofe, memória e arte (1755: catastrophe, memory and art), which took place at the Centro de Estudos Compara- stas, Universidade de Lisboa, led to a debate on the study and cri cal analysis of documentary sources and their selec on and applica on on recrea ons using virtual world technology. It also emphasized the need to extend the research on pre-earthquake Lisbon.

[access To Basic Health Services And Associated Factors: A Population-based Study].

This study sought to identify factors involved in access to the services of a basic health unit. It is a cross-sectional, population-based study involving 101 randomly-selected families residing in the area covered by the health unit. An adult resident of each household was interviewed. The response variable was whether or not the resident frequented the health unit if he/she or anyone in the family required assistance to resolve a health issue. The independent variables investigated were service provision aspects, demographic and socio-economic characteristics, individual habits, morbidities and use of the health unit. In addition to descriptive and univariate analysis, logistic regression was applied in the multivariate analysis. The results show that access to the basic health unit is associated with the treatment received previously (OR = 3,224) with accessibility (OR = 0,146) and micro-area of residence (OR = 10,918). These findings suggest that access is related to the impressions created by the care received at the health unit and is based on experiences with the service, but can also be strongly modulated by individual aspects and factors related to the territory.

Programas de educação de jovens e adultos e pesquisa acadêmica: a contribuição dos estudos do letramento

The purpose of this article is to introduce elements that allow building an interface between the academic research and the programs of basic education for youngsters and adults. It discusses contributions to these programs that can be found in the results of qualitative research studies. To this end, results of a five-year long project on teacher education are used, which aim was that of analyzing the interaction between teacher and student in youngster and adult literacy classes. The research project was conducted in natural contexts with the purpose of understanding a given social reality, and not of establishing general laws. Therefore, the credibility of its results was built through the observation of multiple contexts, and the gathering of data was made through various methods, from the perspective of several participants observed during a prolonged period of time. This empirical basis was used to evaluate recommendations contained in the report commissioned by Unesco to the International Literacy Institute for presentation at the World Forum on Education held in 2000 in Dakar. This report proposed that the continuous attendance of students to basic education programs is one of the great challenges of the new millennium. With respect to the problem of adult evasion from courses and programs, the article discusses the motivation and accessibility factors, pointed out in official documents as relevant factors to the success or failure of the programs.

Percepção dos usuários, profissionais de saúde e gestores sobre o modelo de atendimento oftalmológico no Hospital Regional de Divinolândia - São Paulo

Purpose: This study aimed to evaluate the assistance quality through the perception of the users and municipal health managers (mayors, health secretaries and screening team). Methods: A transversal and descriptive study was carried out. Results: The sample was comprised by 359 users and 48 managers. Medical assistance was considered excellent by 79.6% of the users, 93.7% of the managers, 87.5% of the health secretaries and 100% of the screening team. Reception received a great evaluation by 73.8% of the users and 93.8% of the selectors. Conclusion: The assistance model used at the Ophthalmologic Clinic of Divinolândia obtained a high level of satisfaction pleasing both users and managers.

Qualidade de vida na empresa : conceitos e práticas em uso (no segmento do comércio de bens e serviços na cidade de São Paulo)

Universidade Estadual de Campinas . Faculdade de Educação Física

Associativismo, lazer e esporte nos clubes sociais de Campinas

Universidade Estadual de Campinas . Faculdade de Educação Física