A regionalização intramunicipal do Sistema Único de Saúde (SUS): um estudo de caso do município de São Paulo-SP, Brasil

A regionalização tem sido apontada como um dos principais desafios para viabilizar a equidade e a integralidade do SUS. Este artigo tem como objetivo avaliar o processo de implementação de um projeto de organização de regiões de saúde no município de São Paulo. Para tanto, foi realizado um estudo de caso em uma região selecionada desse município, a partir do referencial da análise de implantação, utilizando-se como fonte de dados documentos da gestão e entrevistas semiestruturadas com informantes-chave da gestão municipal 2005-2008. A análise temática evidenciou que o projeto de regionalização idealizado no início da gestão não foi efetivamente implementado. Dentre os fatores que interferiram nesse insucesso, destacam-se: a) a Secretaria Municipal de Saúde (SMS), além de seu caráter centralizador, manteve estruturas político-administrativas independentes para a gestão da atenção básica e da assistência hospitalar; b) a SMS não assumiu a gestão, de fato, de ambulatórios e hospitais estaduais; c) o poder institucional e a resistência dos hospitais em se integrar ao sistema de saúde. Discute-se, ainda, a necessidade de avançar na descentralização intramunicipal do SUS e buscar novas estratégias para a construção de pactos que consigam superar as resistências e articular instituições historicamente consolidadas, visando uma regionalização cooperativa e solidária.

Évaluation d’un programme novateur de réadaptation par les arts de la scène pour des jeunes présentant un trouble psychiatrique stabilisé : le programme Espace de Transition

L’objectif de cette thèse était d’évaluer Espace de Transition (ET), un programme novateur d’intervention par les arts de la scène visant à favoriser la réadaptation psychosociale d’adolescents et de jeunes adultes présentant des troubles mentaux stabilisés et à diminuer la stigmatisation des individus aux prises avec des problèmes de santé mentale. Ce programme a été conçu par une équipe de cliniciens du département de psychiatrie du Centre hospitalier universitaire Ste-Justine, en collaboration avec des artistes professionnels, et est livré depuis le printemps 2009. L’évaluation du programme ET a été conduite de manière indépendante, selon des approches collaborative et naturaliste et en usant de méthodes mixtes. Les données de recherche ont été recueillies avant pendant et après le programme auprès de l’ensemble des participants à deux sessions distinctes (N = 24), de même qu’auprès des deux artistes instructeurs, de la psychoéducatrice responsable du soutien clinique, ainsi que des psychiatres et autres intervenants ayant référé des participants (N=11). Des entrevues semi-structurées individuelles et de groupe, des observations directes et des questionnaires ont servi à recueillir les données nécessaires à l’évaluation. Des analyses quantitatives de variance, ainsi que des analyses qualitatives thématiques ont été réalisées et leurs résultats ont été interprétés de manière intégrée. Le premier chapitre empirique de la thèse relate l’évaluation de la mise en œuvre du programme ET. Cette étude a permis de constater que le programme avait rejoint des participants correspondant de près à la population visée et que ceux-ci présentaient globalement des niveaux élevés d’assiduité, d’engagement et d’appréciation du programme. L’évaluation de la mise en œuvre a en outre permis de conclure que la plupart des composantes du programme identifiées a priori comme ses paramètres essentiels ont été livrées tel que prévu par les concepteurs et que la plupart d’entre elles ont été largement appréciées et jugées pertinentes par les participants et les autres répondants consultés. Le second chapitre empirique consiste en un article portant sur l’évaluation des effets du programme ET relativement à l’atteinte de trois de ses objectifs intermédiaires, soient l’amélioration 1) du fonctionnement global, 2) du confort relationnel et des compétences sociales, ainsi que 3) de la perception de soi des participants présentant des troubles mentaux. Les résultats de cette étude ont révélé des changements significatifs et positifs dans le fonctionnement global des participants suite au programme, tel qu’évalué par les cliniciens référents et partiellement corroboré par les participants eux-mêmes. Des améliorations en ce qui concerne le confort relationnel, les compétences sociales et la perception de soi ont également été objectivées chez une proportion substantielle de participants, bien que celles-ci ne se soient pas traduites en des différences significatives décelées par les analyses quantitatives de groupe. Le troisième et dernier chapitre empirique de la thèse relate une étude exploratoire des mécanismes sous-tendant les effets du programme ET ayant conduit à l’élaboration inductive d’une théorie d’action de ce programme. Cette investigation qualitative a révélé quatre catégories de mécanismes, soient des processus de 1) gain d’expérience et de gratification sociales, 2) de désensibilisation par exposition graduelle, 3) de succès et de valorisation, et 4) de normalisation. Cette étude a également permis de suggérer les caractéristiques et composantes du programme qui favorisent la mise en place ou l’impact de ces mécanismes, tels l’environnement et l’animation non cliniques du programme, la composition hétérogène des groupes de participants, le recours aux arts de la scène, ainsi que la poursuite d’une réalisation collective et son partage avec un public extérieur au programme. Globalement, les études présentées dans la thèse appuient la pertinence et le caractère prometteur du programme ET, tout en suggérant des pistes d’amélioration potentielle pour ses versions ultérieures. Par extension, la thèse soutient l’efficacité potentielle d’interventions réadaptatives mettant en œuvre des composantes apparentées à celles du programme ET pour soutenir le rétablissement des jeunes aux prises avec des troubles mentaux.

Le développement et la mise à l’essai d’une formation sur l’évaluation et la gestion du risque de violence à l’aide de la grille DASAfr. auprès d’intervenants dans le domaine de la psychiatrie légale

Rapport de stage présenté à la Faculté des sciences infirmières en vue de l'obtention du grade de Maître ès sciences (M.Sc.) en sciences infirmières option formation

Development, implementation, and assessment of a distance module in endocrine physiology

Rangel EM, Mendes IA, Carnio EC, Marchi Alves LM, Godoy S, Crispim JA. Development, implementation, and assessment of a distance module in endocrine physiology. Adv Physiol Educ 34: 70-74, 2010; doi: 10.1152/advan.00070.2009.-This study aimed to develop, implement, and assess a distance module in endocrine physiology in TelEduc for undergraduate nursing students from a public university in Brazil, with a sample size of 44 students. Stage 1 consisted of the development of the module, through the process of creating a distance course by means of the Web. Stage 2 was the planning of the module's practical functioning, and stage 3 was the planning of student evaluations. In the experts' assessment, the module complied with pedagogical and technical requirements most of the time. In the practical functioning stage, 10 h were dedicated for on-site activities and 10 h for distance activities. Most students (93.2%) were women between 19 and 23 yr of age (75%). The internet was the most used means to remain updated for 23 students (59.0%), and 30 students (68.2%) accessed it from the teaching institution. A personal computer was used by 23 students (56.1%), and most of them (58.1%) learned to use it alone. Access to a forum was more dispersed (variation coefficient: 86.80%) than access to chat (variation coefficient: 65.14%). Average participation was 30 students in forums and 22 students in the chat. Students' final grades in the module averaged 8.5 (SD: 1.2). TelEduc was shown to be efficient in supporting the teaching- learning process of endocrine physiology.

Implementation of WHO Quality Rights assessment in Kabul Mental Health Hospital

RESUMO: Objetivo Avaliar a qualidade dos serviços de saúde mental e a situação dos direitos humanos no Hospital de Saúde Mental de Kabul (KMHH) e fornecer recomendações para o desenvolvimento de um plano de melhoria, actualização e revisão da Política, Estratégia e Plano Nacionais de Saúde Mental,. Métodos A avaliação foi realizada em Janeiro de 2015 no KMHH e na Burn Ward do Hospital Terciário de Isteqlal por uma equipa multidisciplinar usando Qualidade Direitos Tool Kit da OMS. Antes da avaliação, o protocolo foi aprovado pelo Institutional Review Board e obtido o consentimento informado de cada entrevistado. Realizaram-se entrevistas com 16 utentes do serviço, 17 funcionários do hospital e 7 familiares, além da revisão de documentos e da observação das unidades de internamento do KMHH e das interações interpessoais entre funcionários do hospital e utentes do serviço. A comissão de avaliação reviu também a documentação e observou a Unidade de Queimados do Hospital Terciário de Isteqlal, a fim de avaliar e comparar a paridade entre as duas instalações. Após a avaliação, todos os membros da comissão se reuniram e puseram em conjunto todas as conclusões num relatório final. Resultados Encontrámos algumas lacunas graves no nível de prestação de serviços e no respeito pelos direitos humanos dos utentes dos serviços e dos seus familiares. Uma série de políticas, diretrizes e procedimentos relacionados com os direitos humanos dos pacientes estavam ausentes. O ambiente terapêutico e o padrão de vida eram inadequados, existia má qualidade do atendimento e dos serviços prestados, os utilizadores enfrentavam violações do direito ao exercício da capacidade legal e da liberdade pessoal, eram quimica e fisicamente (uso de correntes) contidos e expostos a abusos verbais, físicos e emocionais, e havia grande ênfase no tratamento institucional. Todos estes aspectos foram considerados como extensa violação dos direitos humanos dos utentes de serviço do KMHH. Conclusão Os serviços disponíveis para utentes dos serviços de saúde mental apresentam alguns problemas devido à desconfiança e falta de consciencialização sobre os direitos das pessoas com doença mental e precisam ser alterados de forma positiva. A Lei de Saúde Mental existente difere muito das recomendações da Convenção sobre os Direitos das Pessoas com Incapacidades (CRPD) e requer revisão e adaptação de acordo com esta Convenção. -------------------------------- ABSTRACT: Objective To assess the quality of mental health services and human rights condition in the Kabul Mental Health Hospital (KMHH) and provide recommendations for development of an improvement plan and to update and revise the National Mental Health Policy, Strategy and Plan. Methods The assessment was conducted in January 2015 in the KMHH and the Burn Ward of Isteqlal Tertiary Hospital by a multidisciplinary team using WHO Quality Rights Tool Kit. Before the assessment, Institutional Review Board approval and informed consent from each interviewee were obtained. Interviews were conducted with 16 service users, 17 hospital staffs and 7 family members in addition to documents review and observation of inpatient units of KMHH plus interpersonal interactions between hospital staff and service users. The assessment committee reviewed the documentation and observed the Burn Ward of Isteqlal Tertiary hospital in order to measure and compare parity between the two facilities. After the assessment, all committee members gathered and synchronized all findings into a final report. Results There were some serious gaps on service provision level and respecting human rights of service users and their family members. A series of policies, guidelines and procedures related to patients’ human rights were absent. Inadequate treatment environment and standard of living, poor quality of care and services, violations of the right to exercise legal capacity and personal liberty, being chemically and physically (e.g. chain) restrained, being exposed to verbal, physical and emotional abuse, and emphasis on institutional treatment were all extensive human rights violation that service users were experiencing in KMHH. Conclusion The available services for mental health service users are questionable due to mistrust and lack of awareness about rights of people with disabilities and need to be positively changed. Existing Mental Health Act has a large number of disparities with the CRPD and requires revision and adaptation in accordance to CRPD.

Implementation of a probabilistic based framework for safety assessment of existing timber elements

The assessment of existing timber structures is often limited to information obtained from non or semi destructive testing, as mechanical testing is in many cases not possible due to its destructive nature. Therefore, the available data provides only an indirect measurement of the reference mechanical properties of timber elements, often obtained through empirical based correlations. Moreover, the data must result from the combination of different tests, as to provide a reliable source of information for a structural analysis. Even if general guidelines are available for each typology of testing, there is still a need for a global methodology allowing to combine information from different sources and infer upon that information in a decision process. In this scope, the present work presents the implementation of a probabilistic based framework for safety assessment of existing timber elements. This methodology combines information gathered in different scales and follows a probabilistic framework allowing for the structural assessment of existing timber elements with possibility of inference and updating of its mechanical properties, through Bayesian methods. The probabilistic based framework is based in four main steps: (i) scale of information; (ii) measurement data; (iii) probability assignment; and (iv) structural analysis. In this work, the proposed methodology is implemented in a case study. Data was obtained through a multi-scale experimental campaign made to old chestnut timber beams accounting correlations of non and semi-destructive tests with mechanical properties. Finally, different inference scenarios are discussed aiming at the characterization of the safety level of the elements.

Health Impact Assessment Reviewing the implementation of HIA recommendations

This tool provides a template to monitor the implementation of the HIA recommendations by identified decision-makers

RQIA Review of the implementation of Promoting Quality Care (PQC) Good Practice Guidance on the Assessment and Management of Risk in Mental Health and Learning Disability Services (PDF1.07MB)

Overview Report October 2012

Embankment Quality and Assessment of Moisture Control Implementation, TR-677, 2016

A specification for contractor moisture quality control (QC) in roadway embankment construction has been in use for approximately 10 years in Iowa on about 190 projects. The use of this QC specification and the development of the soils certification program for the Iowa Department of Transportation (DOT) originated from Iowa Highway Research Board (IHRB) embankment quality research projects. Since this research, the Iowa DOT has applied compaction with moisture control on most embankment work under pavements. This study set out to independently evaluate the actual quality of compaction using the current specifications. Results show that Proctor tests conducted by Iowa State University (ISU) using representative material obtained from each test section where field testing was conducted had optimum moisture contents and maximum dry densities that are different from what was selected by the Iowa DOT for QC/quality assurance (QA) testing. Comparisons between the measured and selected values showed a standard error of 2.9 lb/ft3 for maximum dry density and 2.1% for optimum moisture content. The difference in optimum moisture content was as high as 4% and the difference in maximum dry density was as high as 6.5 lb/ft3 . The difference at most test locations, however, were within the allowable variation suggested in AASHTO T 99 for test results between different laboratories. The ISU testing results showed higher rates of data outside of the target limits specified based on the available contractor QC data for cohesive materials. Also, during construction observations, wet fill materials were often observed. Several test points indicated that materials were placed and accepted at wet of the target moisture contents. The statistical analysis results indicate that the results obtained from this study showed improvements over results from previous embankment quality research projects (TR-401 Phases I through III and TR-492) in terms of the percentage of data that fell within the specification limits. Although there was evidence of improvement, QC/QA results are not consistently meeting the target limits/values. Recommendations are provided in this report for Iowa DOT consideration with three proposed options for improvements to the current specifications. Option 1 provides enhancements to current specifications in terms of material-dependent control limits, training, sampling, and process control. Option 2 addresses development of alternative specifications that incorporate dynamic cone penetrometer or light weight deflectometer testing into QC/QA. Option 3 addresses incorporating calibrated intelligent compaction measurements into QC/QA.

The development, assessment, and implementation of an evaluation of the EMPOWER Program at shelters for abused women /

The development, assessment, and implementation of a program evaluation instrument was carried out to evaluate the impact and efficacy of the EMPOWER Program. This intervention was created to educate residents at a shelter for abused women with an anticipated outcome of prevention. Participants included the staff and residents at 2 shelters in Southern Ontario. Client pre, post and follow-up measures were obtained and analyzed statistically and using keyword content analysis. A single staff measure was obtained and summarized using keyword content analysis. Qualitative results were suggestive of important change in participants. All women in the post and follow-up measures believed their participation in the EMPOWER Program provided them with the knowledge, skills, and confidence to avoid abusive relationships in the fliture. This transformational impact was repeatedly expressed in both resident and staff feedback. Limitations of this research, as well as suggestions for future study were discussed.

A needs assessment of public health professionals: supporting the implementation of Ontario 2010 revised elementary health and physical education curriculum

Based on the Comprehensive School Health framework, Ontario's Foundations for a Healthy School (2009) outlines an integrated approach to school health promotion. In this approach the school, community and partners (including public health) are fully engaged With a common goal of youth health. With the recent introductions of the Ontario Public Health Standards (2009) and the revised elementary health and physical education curriculum (2010), the timing for a greater integration of public health with schools is ideal. A needs assessment was conducted to identify the perceived support required by public health professionals to implement the mandates of both policy documents in Ontario. Data was collected for the needs assessment through facilitated discussions at a provincial roundtable event, regional focus groups and individual interviews with public health professionals representing Ontario's 36 public health units. Findings suggest that public health professionals perceive that they require increased resources, greater communication, a clear vision of public health and a suitable understanding of the professional cultures in which they are surrounded in order to effectively support schools. This study expands upon these four categories and the corresponding seventeen themes that were uncovered during the research process.

An Assessment of the Degree of Implementation of the Lean Aerospace Initiative Principles and Practices within the US Aerospace and Defense Industry

This report is a formal documentation of the results of an assessment of the degree to which Lean Principles and Practices have been implemented in the US Aerospace and Defense Industry. An Industry Association team prepared it for the DCMA-DCAAIndustry Association “Crosstalk” Coalition in response to a “Crosstalk” meeting action request to the industry associations. The motivation of this request was provided by the many potential benefits to system product quality, affordability and industry responsiveness, which a high degree of industry Lean implementation can produce.

Health system context and implementation of evidence-based practices-development and validation of the Context Assessment for Community Health (COACH) tool for low- and middle-income settings

Background: The gap between what is known and what is practiced results in health service users not benefitting from advances in healthcare, and in unnecessary costs. A supportive context is considered a key element for successful implementation of evidence-based practices (EBP). There were no tools available for the systematic mapping of aspects of organizational context influencing the implementation of EBPs in low- and middle-income countries (LMICs). Thus, this project aimed to develop and psychometrically validate a tool for this purpose. Methods: The development of the Context Assessment for Community Health (COACH) tool was premised on the context dimension in the Promoting Action on Research Implementation in Health Services framework, and is a derivative product of the Alberta Context Tool. Its development was undertaken in Bangladesh, Vietnam, Uganda, South Africa and Nicaragua in six phases: (1) defining dimensions and draft tool development, (2) content validity amongst in-country expert panels, (3) content validity amongst international experts, (4) response process validity, (5) translation and (6) evaluation of psychometric properties amongst 690 health workers in the five countries. Results: The tool was validated for use amongst physicians, nurse/midwives and community health workers. The six phases of development resulted in a good fit between the theoretical dimensions of the COACH tool and its psychometric properties. The tool has 49 items measuring eight aspects of context: Resources, Community engagement, Commitment to work, Informal payment, Leadership, Work culture, Monitoring services for action and Sources of knowledge. Conclusions: Aspects of organizational context that were identified as influencing the implementation of EBPs in high-income settings were also found to be relevant in LMICs. However, there were additional aspects of context of relevance in LMICs specifically Resources, Community engagement, Commitment to work and Informal payment. Use of the COACH tool will allow for systematic description of the local healthcare context prior implementing healthcare interventions to allow for tailoring implementation strategies or as part of the evaluation of implementing healthcare interventions and thus allow for deeper insights into the process of implementing EBPs in LMICs.