993 resultados para Process indicators
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Introducción: El programa de Fisioterapia de la Universidad del Rosario, en su responsabilidad social de generar un impacto positivo en la comunidad y en su propósito de formar profesionales, cuenta con los Programas Académicos de Campo (PAC) que se consideran una fuerte estrategia de extensión de la Universidad. Los PAC contribuyen a la adquisición de competencias para el desarrollo de procesos de acción-actuación-creación en los estudiantes para que resuelvan problemas en un espacio real de ejercicio profesional. Bajo esta perspectiva los PAC del programa de Fisioterapia muestran su comportamiento a través de la medición de indicadores de proceso y resultados propuestos desde el Programa con el fin de proveer información útil para la reorientación y permanente actualización de los contenidos programáticos en las asignaturas y en los mismos PAC. Materiales y métodos: En el siguiente artículo se presenta un análisis de los indicadores de demanda por género, régimen de Seguridad Social en Salud, procedimiento y morbilidad de los Programas Académicos de Campo Integral Pediátrico, Integral de Adultos y Rehabilitación cardíaca y/o pulmonar, con el fin de establecer las características de la población objeto de la prestación de los servicios y procurar información verificable que dé soporte para la construcción de procesos de cambio dentro de la dinámica de mejoramiento continuo que debe tener cualquier institución. Este seguimiento es útil para la toma de decisiones de planeación académica que contribuye a mejorar los procesos de planeación y a facilitar el cumplimiento de los propósitos de formación para cada práctica, y de esta manera ayuda a ser elemento de análisis para directivas, instructores y estudiantes en la orientación del proceso de gestión académico-administrativo, y a retroalimentar los procesos de planeación y programación académica. Resultados: Los resultados arrojados en el análisis de los datos de la morbilidad en los programas académicos de campo muestran el siguiente comportamiento durante los años 2004, 2005, 2006 y 2007. Conclusiones: En el PAC pediátrico la mayor incidencia es de asma con un 37,2% y la más baja incidencia es para luxación congénita de cadera y enfermedad mental de origen central con un 0,1%. El 58% de los usuarios es de género masculino, y el 81% del total pertenece al régimen contributivo. En la morbilidad del PAC de adultos la mayor incidencia es de EPOC, con un 23,2%, y la menor incidencia es de lumbalgia, con un 2,4%. La mayoría de usuarios atendidos (58%) son hombres, y el 58% de los usuarios pertenece al régimen contributivo. En el PAC de rehabilitación cardíaca y/o pulmonar la mayor incidencia fue de EPOC, con un 40%; seguido de neumonía, con 17%; y con una menor incidencia para asma, con un 2%. El 54% de los usuarios son hombres y el 91% del total pertenece al régimen subsidiado.
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Rationale. The Brisbane Cardiac Consortium, a quality improvement collaboration of clinicians from three hospitals and five divisions of general practice, developed and reported clinical indicators as measures of the quality of care received by patients with acute coronary syndromes or congestive heart failure. Development of indicators. An expert panel derived indicators that measured gaps between evidence and practice. Data collected from hospital records and general practice heart-check forms were used to calculate process and outcome indicators for each condition. Our indicators were reliable (kappa scores 0.7-1.0) and widely accepted by clinicians as having face validity. Independent review of indicator-failed, in-hospital cases revealed that, for 27 of 28 process indicators, clinically legitimate reasons for withholding specific interventions were found in
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With business incubators deemed as a potent infrastructural element for entrepreneurship development, business incubation management practice and performance have received widespread attention. However, despite this surge of interest, scholars have questioned the extent to which business incubation delivers added value. Thus, there is a growing awareness among researchers, practitioners and policy makers of the need for more rigorous evaluation of the business incubation output performance. Aligned to this is an increasing demand for benchmarking business incubation input/process performance and highlighting best practice. This paper offers a business incubation assessment framework, which considers input/process and output performance domains with relevant indicators. This tool adds value on different levels. It has been developed in collaboration with practitioners and industry experts and therefore it would be relevant and useful to business incubation managers. Once a large enough database of completed questionnaires has been populated on an online platform managed by a coordinating mechanism, such as a business incubation membership association, business incubator managers can reflect on their practices by using this assessment framework to learn their relative position vis-à-vis their peers against each domain. This will enable them to align with best practice in this field. Beyond implications for business incubation management practice, this performance assessment framework would also be useful to researchers and policy makers concerned with business incubation management practice and impact. Future large-scale research could test for construct validity and reliability. Also, discriminant analysis could help link input and process indicators with output measures.
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There is a national debate on how universities should respond to sexual assault, specifically the advantages and shortcomings of the campus adjudication Process. One major critique of university adjudication is that it does not provide the necessary due process rights to the accused and is therefore not fundamentally fair. This study seeks to assess this validity of this critique by seeing if sexual misconduct policies lack due process and if so, to what extent. This investigation is a comparative case study of 14 private higher education institutions, belonging to the Ivy Plus Society, analyzing their policy and procedure documents for indicators of due process. Findings show that schools are complying between 45% and 85% of due process indicators with an average of 65%. Colleges do lack due process rights and need to revise their policies and procedures to clearly present these rights. Key recommendations include guaranteeing a hearing procedure with impartial decision-makers and the opportunity to submit evidence and witnesses.
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The Montreal Process indicators are intended to provide a common framework for assessing and reviewing progress toward sustainable forest management. The potential of a combined geometrical-optical/spectral mixture analysis model was assessed for mapping the Montreal Process age class and successional age indicators at a regional scale using Landsat Thematic data. The project location is an area of eucalyptus forest in Emu Creek State Forest, Southeast Queensland, Australia. A quantitative model relating the spectral reflectance of a forest to the illumination geometry, slope, and aspect of the terrain surface and the size, shape, and density, and canopy size. Inversion of this model necessitated the use of spectral mixture analysis to recover subpixel information on the fractional extent of ground scene elements (such as sunlit canopy, shaded canopy, sunlit background, and shaded background). Results obtained fron a sensitivity analysis allowed improved allocation of resources to maximize the predictive accuracy of the model. It was found that modeled estimates of crown cover projection, canopy size, and tree densities had significant agreement with field and air photo-interpreted estimates. However, the accuracy of the successional stage classification was limited. The results obtained highlight the potential for future integration of high and moderate spatial resolution-imaging sensors for monitoring forest structure and condition. (C) Elsevier Science Inc., 2000.
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The collection of spatial information to quantify changes to the state and condition of the environment is a fundamental component of conservation or sustainable utilization of tropical and subtropical forests, Age is an important structural attribute of old-growth forests influencing biological diversity in Australia eucalypt forests. Aerial photograph interpretation has traditionally been used for mapping the age and structure of forest stands. However this method is subjective and is not able to accurately capture fine to landscape scale variation necessary for ecological studies. Identification and mapping of fine to landscape scale vegetative structural attributes will allow the compilation of information associated with Montreal Process indicators lb and ld, which seek to determine linkages between age structure and the diversity and abundance of forest fauna populations. This project integrated measurements of structural attributes derived from a canopy-height elevation model with results from a geometrical-optical/spectral mixture analysis model to map forest age structure at a landscape scale. The availability of multiple-scale data allows the transfer of high-resolution attributes to landscape scale monitoring. Multispectral image data were obtained from a DMSV (Digital Multi-Spectral Video) sensor over St Mary's State Forest in Southeast Queensland, Australia. Local scene variance levels for different forest tapes calculated from the DMSV data were used to optimize the tree density and canopy size output in a geometric-optical model applied to a Landsat Thematic Mapper (TU) data set. Airborne laser scanner data obtained over the project area were used to calibrate a digital filter to extract tree heights from a digital elevation model that was derived from scanned colour stereopairs. The modelled estimates of tree height, crown size, and tree density were used to produce a decision-tree classification of forest successional stage at a landscape scale. The results obtained (72% accuracy), were limited in validation, but demonstrate potential for using the multi-scale methodology to provide spatial information for forestry policy objectives (ie., monitoring forest age structure).
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O trabalho que a seguir se apresenta tem como objectivo descrever a criação de um modelo que sirva de suporte a um sistema de apoio à decisão sobre o risco inerente à execução de projectos na área das Tecnologias de Informação (TI) recorrendo a técnicas de mineração de dados. Durante o ciclo de vida de um projecto, existem inúmeros factores que contribuem para o seu sucesso ou insucesso. A responsabilidade de monitorizar, antever e mitigar esses factores recai sobre o Gestor de Projecto. A gestão de projectos é uma tarefa difícil e dispendiosa, consome muitos recursos, depende de numerosas variáveis e, muitas vezes, até da própria experiência do Gestor de Projecto. Ao ser confrontado com as previsões de duração e de esforço para a execução de uma determinada tarefa, o Gestor de Projecto, exceptuando a sua percepção e intuição pessoal, não tem um modo objectivo de medir a plausibilidade dos valores que lhe são apresentados pelo eventual executor da tarefa. As referidas previsões são fundamentais para a organização, pois sobre elas são tomadas as decisões de planeamento global estratégico corporativo, de execução, de adiamento, de cancelamento, de adjudicação, de renegociação de âmbito, de adjudicação externa, entre outros. Esta propensão para o desvio, quando detectada numa fase inicial, pode ajudar a gerir melhor o risco associado à Gestão de Projectos. O sucesso de cada projecto terminado foi qualificado tendo em conta a ponderação de três factores: o desvio ao orçamentado, o desvio ao planeado e o desvio ao especificado. Analisando os projectos decorridos, e correlacionando alguns dos seus atributos com o seu grau de sucesso o modelo classifica, qualitativamente, um novo projecto quanto ao seu risco. Neste contexto o risco representa o grau de afastamento do projecto ao sucesso. Recorrendo a algoritmos de mineração de dados, tais como, árvores de classificação e redes neuronais, descreve-se o desenvolvimento de um modelo que suporta um sistema de apoio à decisão baseado na classificação de novos projectos. Os modelos são o resultado de um extensivo conjunto de testes de validação onde se procuram e refinam os indicadores que melhor caracterizam os atributos de um projecto e que mais influenciam o risco. Como suporte tecnológico para o desenvolvimento e teste foi utilizada a ferramenta Weka 3. Uma boa utilização do modelo proposto possibilitará a criação de planos de contingência mais detalhados e uma gestão mais próxima para projectos que apresentem uma maior propensão para o risco. Assim, o resultado final pretende constituir mais uma ferramenta à disposição do Gestor de Projecto.
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Os objectivos principais deste estudo são a caracterização de uma das linhas de extrusão existentes na Cabelte, nomeadamente a linha de extrusão de referência EP5, composta por duas extrusoras. Pretende-se fazer a determinação de indicadores energéticos e de processo e a optimização do consumo energético, no que diz respeito à energia consumida e às perdas térmicas relativas a esta linha. Para fazer a monitorização da linha de extrusão EP5 foi colocado no quadro geral dessa linha um equipamento central de medida de forma a ser possível a sua monitorização. No entanto, para a extrusora auxiliar as medições foram efectuadas com uma pinça amperimétrica e um fasímetro. Foram também efectuados ensaios onde foi avaliada a quantidade de material transformada, para isso foi utilizado um equipamento de pesagem, doseador gravimétrico aplicado nas extrusoras. As medições de temperatura para os cálculos das perdas térmicas da extrusora principal e para a caracterização dos materiais plásticos, foram efectuadas utilizando um termómetro digital. Foram efectuados ensaios de débito às extrusoras auxiliar e principal e foi estudada a variação do factor de potência em função da rotação do fuso. Na perspectiva do utilizador final a optimização para a utilização racional de energia está na redução de encargos da factura de energia eléctrica. Essa factura não depende só da quantidade mas também do modo temporal como se utiliza essa energia, principalmente a energia eléctrica, bastante dependente do período em que é consumida. Uma metodologia diferente no planeamento da produção, contemplando o fabrico dos cabos com maior custo específico nas horas de menor custo energético, implicaria uma redução dos custos específicos de 18,7% para o horário de verão e de 20,4% para o horário de inverno. Os materiais de revestimento utilizados (PE e PVC), influenciam directamente os custos energéticos, uma vez que o polietileno (PE) apresenta sempre valores de entalpia superiores (0,317 kWh/kg e 0,281 kWh/kg)) e necessita de temperaturas de trabalho mais elevadas do que o policloreto de vinilo (PVC) (0,141 kWh/kg e 0,124 kWh/kg). O consumo específico tendencialmente diminui à medida que aumenta a rotação do fuso, até se atingir o valor de rotação óptimo, a partir do qual esta tendência se inverte. O cosφ para as duas extrusoras em estudo, aumenta sempre com o aumento de rotação do fuso. Este estudo permitiu avaliar as condições óptimas no processo de revestimento dos cabos, de forma a minimizarmos os consumos energéticos. A redução de toda a espécie de desperdícios (sobre consumos, desperdício em purgas) é uma prioridade de gestão que alia também a eficácia à eficiência, e constitui uma ferramenta fundamental para assegurar o futuro da empresa. O valor médio lido para o factor de potência (0,38) da linha EP5, valor extremamente baixo e que vem associado à energia reactiva, além do factor económico que lhe está inerente, condiciona futuras ampliações. A forma de se corrigir o factor de potência é instalando uma bateria de condensadores de 500 kVAr. Considerando o novo sistema tarifário aplicado à energia reactiva, vamos ter um ganho de 36167,4 Euro/ano e o período de retorno de investimento é de 0,37 ano (4,5 meses). Esta medida implica também uma redução anual na quantidade de CO2 emitida de 6,5%. A quantificação das perdas térmicas é importante, pois só desta forma se podem definir modos de actuação de forma a aumentar a eficiência energética. Se não existir conhecimento profundo dos processos e metodologias correctas, não podem existir soluções eficientes, logo é importante medir antes de avançar com qualquer medida de gestão.
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BACKGROUND: While Switzerland invests a lot of money in its healthcare system, little is known about the quality of care delivered. The objective of this study was to assess the quality of care provided to patients with diabetes in the Canton of Vaud, Switzerland. METHODS: Cross-sectional study of 406 non-institutionalized adults with type 1 or 2 diabetes. Patients' characteristics, diabetes and process of care indicators were collected using a self-administered questionnaire. Process indicators (past 12 months) included HbA1C check among HbA1C-aware patients, eye assessment by ophtalmologist, microalbuminuria check, feet examination, lipid test, blood pressure and weight measurement, influenza immunization, physical activity recommendations, and dietary recommendations. Item-by-item (each process of care indicator: percentage of patients having received it), composite (mean percentage of recommended care: sum of received processes of care / sum of possible recommended care), and all-or-none (percentage of patients receiving all specified recommended care) measures were computed. RESULTS: Mean age was 64.4 years; 59% were men. Type 1 and type 2 diabetes were reported by 18.2% and 68.5% of patients, respectively, but diabetes type remained undetermined for almost 20% of patients. Patients were treated with oral anti-diabetic drugs (50%), insulin (23%) or both (27%). Of 219 HbA1C-aware patients, 98% reported ≥ one HbA1C check during the last year. Also, ≥94% reported ≥ one blood pressure measurement, ≥ one weight measurement or lipid test, and 68%, 64% and 56% had feet examination, microalbuminuria check and eye assessment, respectively. Influenza immunization was reported by 62% of the patients.The percentage of patients receiving all processes of care ranged between 14.2%-16.9%, and 46.6%-50.7%, when considering ten and four indicators, respectively. Ambulatory care utilization showed little use of multidisciplinary care, and low levels of participation in diabetes-education classes. CONCLUSIONS: While routine processes-of-care were performed annually in most patients, diabetes-specific risk screenings, influenza immunization, physical activity and dietary recommendations were less often reported; this was also the case for multidisciplinary care and participation in education classes. There is room for diabetes care improvement in Switzerland. These results should help define priorities and further develop country-specific chronic disease management initiatives for diabetes.
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Objective Evaluating the performance of primary care services for the treatment of tuberculosis according to the assessment referential of health services (structure/process) in Cabedelo, a port city in the state of Paraíba. Method An evaluation quantitative, cross-sectional study, in which were carried out 117 interviews with health professionals using a structured instrument. The analysis was based on the construction of indicators using a standardized value for the reduced variable (z=1). Results The structural indicators showed regular performance for the following variables: professional training, access to record instruments and coordination with other services. The process indicators related to external actions and information about the disease had unsatisfactory performance. The directly observed treatment and the flows of reference/counter-reference had regular performance. Conclusion The focused professional qualification, the fragmentation of practices and the unsystematic home care constitute obstacles for carrying out actions aimed at providing expanded, continuous and resolute care.
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Background: Chronic disease management initiatives emphasize patient-centered care, and quality of life (QoL) is increasingly considered a representative outcome in that context. In this study we evaluated the association between receipt of processes of diabetic care and QoL. Methods: This cross-sectional population-based study (2011) used self-reported data from non-institutionalized, adult diabetics, recruited from randomly selected community pharmacies in Vaud. Outcomes included the physical and mental composites of the SF-36 (PCS, MCS) and the disease-specific Audit of Diabetes-Dependent QoL (ADDQoL). Main exposure variables were receipt of six diabetes processes-of care in the past 12 months. We also evaluated whether the association between care received and QoL was congruent with the chronic care model, when assessed by the Patient Assessment of Chronic Illness Care (PACIC). We used linear regressions to examine the association between process measures and the three composites of health-related QoL. Analyses were adjusted for age, gender, socioeconomic status, living companion, BMI, alcohol, smoking, physical activity, co-morbidities and diabetes mellitus (DM) characteristics (type, insulin use, complications, duration). Results: Mean age of the 519 diabetic patients was 64.4 years (SD 11.3), 60% were male and 73% had a living companion; 87% reported type 2 DM, half of respondents required insulin treatment, 48% had at least one DM complication, and 48% had DM over 10 years. Crude overall mean QoL scores were PCS: 43.4 (SD 10.5), MCS: 47.0 (SD 11.2) and ADDQoL: -1.56 (SD 1.6). In bivariate analyses, patients who received the influenza vaccine versus those who did not, had lower ADDQoL and PCS scores; there were no other indicator differences. In adjusted models including all processes, receipt of influenza vaccine was associated with lower ADDQoL (β= - 0.41, p=.01); there were no other associations between process indicators and QoL composites. There was no process association even when these were reported as combined measures of processes of care. PACIC score was associated only with the MCS (β= 1.57, p=.004). Conclusions: Process indicators for diabetes care did not show an association with QoL. This may represent an effect lag time between time of process received and quality of life; or that treatment may be related with inconvenience and patient worry. Further research is needed to explore these unexpected findings.
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Introduction: Within the framework of the «Programme cantonal Diabète», we aimed at collecting data to 1) describe the population of diabetic patients in the canton of Vaud, and 2) assess the quality of their care. Methods: A cross-sectional study was conducted in the fall of 2011. Out of 140 randomly selected community pharmacies registered in the canton of Vaud, 56 accepted to participate in patients' recruitment. Noninstitutionalized adult diabetic patients (disease duration >12 months) visiting a pharmacy with a prescription for oral anti-diabetic drugs, insulin, glycemic strips or glucose meter were eligible. Patients not residing in the canton of Vaud, not speaking and understanding French well enough, presenting obvious cognitive impairment, and women with gestational diabetes, were excluded. Using a self-administered questionnaire, data was collected on patients' characteristics and diabetes as well as various process (e.g. recommended annual screenings) and outcomes quality of care indicators. Descriptive analyses were performed. Results: A total of 406 patients with diabetes participated. Mean age was 64 years, 41% were women and 63% were married. Patients reported type 1, 2 and other types of diabetes in 13%, 69% and 19%, respectively. They were treated with oral anti-diabetic drugs, insulin or both in 50%, 23% and 27% of the cases. Half of the patients did not report any diabetes-related complication. Glucose self-monitoring was reported by 82% of the patients. Of those who were aware of HbA1C (n = 218), 98% reported at least one HbA1C control during the last 12 months. During that same time frame, 97% and 95% reported at least one blood pressure and weight measure, 94% reported having had a cholesterol check, 74%, 68% and 64% had eyes, feet and urine screening respectively. 62% of the patients had been immunized against influenza. At least 76% of the patients had a minimum of 5 of the 7 described process indicators performed during the last 12 months. Among patients who knew the value (n = 145), mean HbA1C was 7.4 (SD 1.2). Conclusion: This study targeting community-based diabetic patients shows that while routine clinical and laboratory tests were annually performed in the vast majority of patients, feet and urine screening, as well as influenza immunization, were less often reported by patients. The proportion of patients with diabetes having had at least 5 out of the 7 annual screenings performed was nevertheless very high.
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The objective of the pilotage effectiveness study was to come up with a process descrip-tion of the pilotage procedure, to design performance indicators based on this process description, to be used by Finnpilot, and to work out a preliminary plan for the imple-mentation of the indicators within the Finnpilot organisation. The theoretical aspects of pilotage as well as the guidelines and standards used were determined through a literature review. Based on the literature review, a process flow model with the following phases was created: the planning of pilotage, the start of pilo-tage, the act of pilotage, the end of pilotage and the closing of pilotage. The model based on the literature review was tested through interviews and observation of pilotage. At the same time an e-mail survey directed at foreign pilotage organisations, which included a questionnaire concerning their standards and management systems, operations procedures, measurement tools and their attitude to the passage planning, was conducted. The main issues in the observations and interviews were the passage plan and the bridge team co-operation. The phases of the pilotage process model emerged in both the pilotage activities and the interviews whereas bridge team co-operation was relatively marginal. Most of the pilotage organisations, who responded to the query, also use some standard-based management system. All organisations who answered the survey use some sort of a pilotage process model. According to the query, the main measuring tools for pilotage are statistical information concerning pilotage and the organisations, the customer feedback surveys, and financial results. Attitudes to-wards passage planning were mostly positive among the organisations. A workshop with pilotage experts was arranged where the process model constructed on the basis of the literature review was tuned to match practical pilotage. In the workshop it was determined that certain phases and the corresponding tasks, through which pilo-tage can be described as a process, were identifiable in all pilotage. The result of the workshop was a complemented process model, which separates incoming and outgoing traffic, as well as the fairway pilotage and harbour pilotage from each other. Addition-ally indicators divided according to the data gathering method were defined. Data con-cerning safety and traffic flow is gathered in the form of customer feedback. The pilot's own perceptions of the pilotage process are gathered through self-assessment. The measurement data which is connected to the phases of the pilotage process is generated e.g. by gathering statistics of the success of the pilot dispatches, the accuracy of the pi-lotage and the incidents that occurred during the pilotage, near misses, deviations and accidents. The measurement data is collected via the PilotWeb at the closing of the pilo-tage. A separate project and a project group with pilots also participating will be established for the deployment of the performance indicators. The phases of the project are: the definition phase, the implementation phase and the deployment phase. The purpose of the definition phase is to prepare questions for ship commanders concerning the cus-tomer feedback questionnaire and also to work out the self-assessment queries and the queries concerning the process indicators.
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Tutkimuksessa selvitettiin kyselytutkimuksella yritysseurannan nykytilaa Koneyrittäjien liiton jäseninä olevissa metsäkoneyrityksissä ja haastateltiin sekä käytiin keskusteluja metsäkonealan asiantuntijoiden kanssa. Työn tuloksena tehtiin ehdotus metsäkoneyrityksille soveltuvan seurantatyökalun tietosisällöstä ja hahmoteltiin työkalun rakenne. Vain 54 prosentilla yrityksistä oli järjestelmällistä yritystoiminnan seurantaa. Yleisin syy seuraamattomuudelle oli ajan puute. Niissä yrityksissä, joilla oli järjestelmällistä seurantaa, talouden tunnusluvuista aktiivisimmin seurattiin liikevoittoa. Puunkorjuuprosessia kuvaavista tunnusluvuista aktiivisimmin seurattiin puunkorjuun tuottavuutta. Ehdotetussa työkalussa rajauduttiin suorituskyvyn taloudelliseen ja prosessinäkökulmaan. Prosessinäkökulmassa keskityttiin puunkorjuuprosessiin ja tutkittiin, kuinka uuden StanForD2010 –tiedonsiirtostandardin avulla puunkorjuun tunnuslukujen tuottaminen voitaisiin automatisoida. Seurantatyökalun sisällöksi ehdotettiin yhteensä 43 talouden ja puun-korjuuprosessin tunnuslukua. Lisäksi ehdotettiin, että yrityksen suorituskykyä kuvaamaan laskettaisiin yrityskohtaisesti valittavista tunnusluvuista johdettu yksi tunnusluku – kokonaissuorituskykyindeksi. Ehdotettu seurantatyökalu mahdollistaa suorituskyvyn mittaamisen tehostamisen metsäkoneyrityksissä. Työkalusta puuttuvat asiakas- ja henkilöstö- sekä oppimisnäkökulmat, joten jatkossa onkin selvitettävä näiden näkökulmien liittäminen työkaluun.
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Travail dirigé présenté à la Faculté des sciences infirmières en vue de l’obtention du grade de Maître ès sciences (M.Sc.) en sciences infirmières option administration des services infirmiers