Att lära av sina misstag- en studie kring klagomålsarbete ur ett processförbättringsperspektiv

Misstag är oundvikliga och därför är det viktigt att företaget har system för att hantera klagomål. Dock klagar missnöjda kunder sällan när de upplever problem. Informationen från klagomål är ett sätt för företaget att bli medveten om problem i organisationen. Därför bör företag uppmuntra sina kunder till att klaga. Då en liten del av de missnöjda kunderna klagar behöver företaget arbeta med att själv identifiera brister i organisationen. Syftet med denna uppsats är att analysera betydelsen av lärandeprocessen i tjänsteverksamheters kvalitetsarbete. Detta besvaras genom att undersöka hur hotell arbetar med att lära sig av sina klagomål samt gör förändringar i organisationen. Empirin från hotellbranschen har huvudsakligen insamlats genom intervjuer samt och därmed är uppsatsens metodologiska ansats kvalitativ. Uppsatsen tar sin teoretiska utgångspunkt i tidigare forskning kring service management, klagomålsarbete och processförbättringsarbete. Empirin är baserad på information från chefer och receptionister på fyra svenska hotell. Deras upplevelse av hotellens klagomåls- och processförbättringsarbete utgör grunden till denna uppsats empiriska material. Studien har visat att hotellen inte har någon helhetssyn i sitt klagomålsarbete. De fokuserar huvudsakligen på att hantera klagomål och kompensera missnöjda gäster. Däremot arbetar de inte i någon större utsträckning med att förebygga och avsluta klagomål. Hotellen brister dessutom i sin dokumentering av inkomna klagomål. Detta orsakar bland annat tyst kunskap som i sin tur leder till att hotelledningen inte har rätt informationsunderlag vid beslutsfattande. Den bristande dokumenteringen innebär också att hotellen inte har någon statistik på hur många gäster som klagar. Detta försvårar deras analys av vad klagomålshanteringen kostar och var åtgärder är nödvändiga för att kunna öka lönsamheten

Performance of magnetic resonance imaging-based prostate cancer risk calculators and decision strategies in two large European medical centres

Objectives: To compare the performance of currently available biopsy decision support tools incorporating magnetic resonance imaging (MRI) findings in predicting clinically significant prostate cancer (csPCa). Patients and Methods: We retrospectively included men who underwent prostate MRI and subsequent targeted and/or systematic prostate biopsies in two large European centres. Available decision support tools were identified by a PubMed search. Performance was assessed by calibration, discrimination, decision curve analysis (DCA) and numbers of biopsies avoided vs csPCa cases missed, before and after recalibration, at risk thresholds of 5%–20%. Results: A total of 940 men were included, 507 (54%) had csPCa. The median (interquartile range) age, prostate-specific antigen (PSA) level, and PSA density (PSAD) were 68 (63–72) years, 9 (7–15) ng/mL, and 0.20 (0.13–0.32) ng/mL2, respectively. In all, 18 multivariable risk calculators (MRI-RCs) and dichotomous biopsy decision strategies based on MRI findings and PSAD thresholds were assessed. The Van Leeuwen model and the Rotterdam Prostate Cancer Risk Calculator (RPCRC) had the best discriminative ability (area under the receiver operating characteristic curve 0.86) of the MRI-RCs that could be assessed in the whole cohort. DCA showed the highest clinical utility for the Van Leeuwen model, followed by the RPCRC. At the 10% threshold the Van Leeuwen model would avoid 22% of biopsies, missing 1.8% of csPCa, whilst the RPCRC would avoid 20% of biopsies, missing 2.6% of csPCas. These multivariable models outperformed all dichotomous decision strategies based only on MRI-findings and PSAD. Conclusions: Even in this high-risk cohort, biopsy decision support tools would avoid many prostate biopsies, whilst missing very few csPCa cases. The Van Leeuwen model had the highest clinical utility, followed by the RPCRC. These multivariable MRI-RCs outperformed and should be favoured over decision strategies based only on MRI and PSAD.</p

Современные подходы в диагностике и лечении тромбозов системы нижней полой вены

ТРОМБОЗ ВЕНОЗНЫЙ /ДИАГН /ТЕРПОЛАЯ ВЕНА, НИЖНЯЯТРОМБОЭМБОЛИЯЛЕГОЧНАЯ ЭМБОЛИ

Regional factors as major drivers for microbial community turnover in tropical cascading reservoirs

The turnover of microbial communities across space is dictated by local and regional factors. Locally, selection shapes community assembly through biological interactions between organisms and the environment, while regional factors influence microbial dispersion patterns. Methods used to disentangle the effects of local and regional factors typically do not aim to identify ecological processes underlying the turnover. In this paper, we identified and quantified these processes for three operational microbial subcommunities (cyanobacteria, particle-attached, and free-living bacteria) from a tropical cascade of freshwater reservoirs with decreasing productivity, over two markedly different dry and rainy seasons. We hypothesized that during the dry season communities would mainly be controlled by selection shaped by the higher environmental heterogeneity that results from low hydrological flow and connectivity between reservoirs. We expected highly similar communities shaped by dispersal and a more homogenized environment during the rainy season, enhanced by increased flow rates. Even if metacommunities were largely controlled by regional events in both periods, the selection had more influence on free-living communities during the dry period, possibly related to elevated dissolved organic carbon concentration, while drift as a purely stochastic factor, had more influence on cyanobacterial communities. Each subcommunity had distinct patterns of turnover along the cascade related to diversity (Cyanobacteria), lifestyle and size (Free-living), and spatial dynamics (particle-attached)

Disease-specific outcomes of Radical Prostatectomies in Northern Norway; A case for the impact of perineural infiltration and postoperative PSA-doubling time

Background Prostate cancer is the most common male malignancy and a mayor cause of mortality in the western world. The impact of clinicopathological variables on disease related outcomes have mainly been reported from a few large US series, most of them not reporting on perineural infiltration. We therefore wanted to investigate relevant cancer outcomes in patients undergoing radical prostatectomy in two Norwegian health regions with an emphasis on the impact of perineural infiltration (PNI) and prostate specific antigen- doubling time (PSA-DT). Methods We conducted a retrospective analysis of 535 prostatectomy patients at three hospitals between 1995 and 2005 estimating biochemical failure- (BFFS), clinical failure- (CFFS) and prostate cancer death-free survival (PCDFS) with the Kaplan-Meier method. We investigated clinicopathological factors influencing risk of events using cox proportional hazard regression. Results After a median follow-up of 89 months, 170 patients (32%) experienced biochemical failure (BF), 36 (7%) experienced clinical failure and 15 (3%) had died of prostate cancer. pT-Stage (p = 0.001), preoperative PSA (p = 0.047), Gleason Score (p = 0.032), non-apical positive surgical margins (PSM) (p = 0.003) and apical PSM (p = 0.031) were all independently associated to BFFS. Gleason score (p = 0.019), PNI (p = 0.012) and non-apical PSM (p = 0.002) were all independently associated to CFFS while only PNI (P = 0.047) and subgroups of Gleason score were independently associated to PCDFS. After BF, patients with a shorter PSA-DT had independent and significant worse event-free survivals than patients with PSA-DT > 15 months (PSA-DT = 3-9 months, CFFS HR = 6.44, p < 0.001, PCDFS HR = 13.7, p = 0.020; PSA-DT < 3 months, CFFS HR = 11.2, p < 0.001, PCDFS HR = 27.5, p = 0.006). Conclusions After prostatectomy, CFFS and PCDFS are variable, but both are strongly associated to Gleason score and PNI. In patients with BF, PSA-DT was most strongly associated to CF and PCD. Our study adds weight to the importance of PSA-DT and re-launches PNI as a strong prognosticator for clinically relevant endpoints

PCASTt/SPCG-17-a randomised trial of active surveillance in prostate cancer : rationale and design

Introduction Overtreatment of localised prostate cancer is substantial despite increased use of active surveillance. No randomised trials help define how to monitor patients or when to initiate treatment with curative intent. Methods and analysis A randomised, multicentre, intervention trial designed to evaluate the safety of an MRI-based active surveillance protocol, with standardised triggers for repeated biopsies and radical treatment. The aim is to reduce overtreatment of prostate cancer. 2000 men will be randomly allocated to either surveillance according to current practice or to standardised triggers at centres in Sweden, Norway, Finland and the UK. Men diagnosed in the past 12 months with prostate cancer, 0.2ng/mL/cc, any International Society of Urological Pathology (ISUP) grade 1 are eligible. Men with ISUP grade 2 in Ethics and dissemination Ethical approval was obtained in each participating country. Results for the primary and secondary outcome measures will be submitted for publication in peer-reviewed journals. Trial registration number NCT02914873.Peer reviewe

Niche construction by non-diazotrophs for N2 fixers in the eastern tropical North Atlantic Ocean

Diazotrophic dinitrogen (N2) fixation contributes ~76% to "new" nitrogen inputs to the sunlit open ocean, but environmental factors determining N2 fixation rates are not well constrained. Excess phosphate (phosphate-nitrate/16 > 0) and iron availability control N2 fixation rates in the eastern tropical North Atlantic (ETNA), but it remains an open question how excess phosphate is generated within or supplied to the phosphate-depleted sunlit layer. Our observations in the ETNA region (8°N-15°N, 19°W-23°W) suggest that Prochlorococcus and Synechococcus, the two ubiquitous non-diazotrophic cyanobacteria with cellular N:P ratios higher than the Redfield ratio, create an environment of excess phosphate, which cannot be explained by diapycnal mixing, atmospheric, and riverine inputs. Thus, our results unveil a new biogeochemical niche construction mechanism by non-diazotrophic cyanobacteria for their diazotrophic phylum group members (N2 fixers). Our observations may help to understand the prevalence of diazotrophy in low-phosphate, oligotrophic regions

The connection between IBS and FODMAPs

Sahlgrenska Akademin vid Göteborgs universitet Avdelningen för invärtesmedicin och klinisk nutrition SAMMANFATTNING Titel: Sambandet mellan IBS och FODMAPs En systematisk översiktsartikel Författare: Helena Hautamäki och Rebecka Bertilsson Handledare: Sofia Klingberg Examinator: Frode Slinde Linje: Dietistprogrammet, 180/240 hp Typ av arbete: Examensarbete, 15 hp Datum: 2013-04-10 Bakgrund: IBS (Irritable Bowel Syndrome) är en funktionell mag-tarmsjukdom, som är en vanlig åkomma i den västerländska befolkningen. Symptomen domineras av diarré, uppblåsthet, buksmärta, förstoppning, och gaser. Idag finns inga vetenskapligt baserade kostrekommendationer vid IBS, men nyligen har man identifierat faktorer i kosten som tros kunna trigga igång symptomen. Dessa är kortkedjiga kolhydrater, Fermentable Oligosaccarides Disaccarides, Monosaccarides and Polyols (FODMAPs), som ej absorberas tillräckligt i tarmen. Syfte: Att undersöka om det finns evidens för att en diet låg på FODMAPs kan lindra symptomen hos patienter med IBS. Sökväg: Sökning via databaserna PubMed, Scopus, Summon och Google Scholar. Sökord som användes var ”Irritable bowel syndrome + FODMAPs”, ”Irritable bowel syndrome + diet” och ”FODMAP and diet”. Urvalskriterier: Inklusionskriterier: Patienter diagnosticerade med IBS, ålder 18-69 år. Exklusionskriterier: Mag-tarmkirurgi, övriga magtarmsjukdomar, graviditet. Datainsamling och analys: Fem relevanta artiklar hittades varav två exkluderades då de inte matchade urvalskriterierna. De tre återstående studierna granskades med granskningsmallarna för RCT och kohort från Statens Beredning för medicinsk Utvärdering (SBU). De tre utvalda effektmåtten uppblåsthet, buksmärta och flatulens, evidensgraderades enligt riktinjer från SBU. Resultat: Två RCT-studier visade måttlig evidens för att en kostbehandling låg på FODMAPs ger symptomlindring vid flatulens och uppblåsthet. En kohortstudie visade låg evidens för samma effektmått. Baserat på samtliga studier föreligger det låg evidens för att en kostbehandling låg på FODMAPs ger symptomförbättring vid buksmärta. Slutsats: En kostbehandling låg på FODMAPs är relevant för symptomförbättring vid flatulens och uppblåsthet. Kostbehandlingen bör dock individanpassas. Mer forskning inom detta område behövs.Sahlgrenska Academy at University of Gothenburg Department of Internal Medicine and Clinical Nutrition ABSTRACT Title: The connection between IBS and FODMAPs Author: Helena Hautamäki and Rebecka Bertilsson Supervisor: Sofia Klingberg Examiner: Frode Slinde Programme: Dietician study programme, 180/240 ECTS Type of paper: Examination paper, 15 hp Date: 2013-04-10 Background: IBS (Irritable Bowel Syndrome) is a functional gastrointestinal disorder, and is a common disorder in the western population. The predominant symptoms are diarrhoea, abdominal pain, bloating, constipation, and excessive flatus. Today there are no evidence based recommendations concerning dietary factors for patients diagnosed with IBS, but recently certain factors in the diet that seems to trigger the symptoms have been identified. These factors are short-chain carbohydrates, Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols (FODMAPS), which are not completely absorbed in the lumen. Objective: The purpose of this systematic review article is to examine whether there are any evidence that a diet low in FODMAPs may induce improvement of symptoms in patients diagnosed with IBS. Search strategy: The literature search was performed in the databases PubMed, Scopus, Summon and Google Scholar. The keywords were “Irritable bowel syndrome + FODMAPs”, “Irritable bowel syndrome + diet” and “FODMAP and diet”. Selection criteria: The inclusion criteria were patients diagnosed with IBS between the ages 18 and 69. The exclusion criteria were surgery made in the gastrointestinal tract, other gastrointestinal dysfunctions and pregnancy. Data collection and analysis: Five relevant articles were found whereas two of them didn´t match the chosen selection criteria and were therefore excluded. The remaining articles were examined according to SBU guidelines. The evidence of the three chosen endpoints bloating, abdominal pain and flatulence were then examined according to the SBU guidelines. Main results: According to two RCTs there are moderate evidence that a dietary treatment low in FODMAPs gives symptom improvements in flatulence and bloating. A cohort study shows low evidence for the same endpoints. According to all the examined studies, there is low evidence that a dietary treatment low in FODMAPs improves abdominal pain for patients with IBS. Conclusions: A dietary treatment low in FODMAPs is relevant for symptom improvements of flatulence and bloating. However, the dietary treatment should be individualized, and more research is needed in this area of concern

Sjuksköterskors möjlighet att arbeta efter barnkonventionen

Bakgrund: Vård av barn är komplex och sjuksköterskan behöver kunskap om den specifika vård som krävs i mötet med barn för att säkerställa god kvalitet i vården. Att möta barnet efter ålder och utveckling samt göra barnet delaktigt är en utmaning för sjuksköterskan och ställer krav på vårdandet. Att vårda utifrån barnets perspektiv och utvecklingsstadier ingår i sjuksköterskans vårdande. Vid införandet av barnkonventionen som lag i Sverige 2020 ska barnets rättigheter stärkas och kvaliteten i vården av barn förväntas förbättras. Syftet var att undersöka i vilken utsträckning sjuksköterskor arbetar efter barnkonventionen. Metoden var empirisk kvantitativ och utgick från ett frågeformulär vilket analyserades genom beskrivande statistik. Resultatet belyser svårigheter för sjuksköterskan att se till barnets bästa, göra barnet delaktigt, låta barnet uttrycka sig och möjliggöra barnets utveckling i den utsträckning som krävs för att uppnå barnkonventionen som lag. Slutsats: Det finns begränsningar i sjuksköterskans arbetssituation för att uppnå barnkonventionen som lag. Barns delaktighet i vården är begränsad och det finns brister i sjuksköterskans arbetssituation. Examensarbetet ger en fingervisning på hur sjuksköterskans arbetssituation ser ut idag. Åtgärder behöver sättas in för att vården ska kunna leva upp till barnkonventionens mål, exempelvis genom tydliga riktlinjer och arbetsredskap