A simple model to optimize resource allocations when expanding the faculty research base: a case study

Construction of new biomedical research facilities has outpaced the funding sources for faculty to occupy those facilities. This puts a premium on the efficient allocation of central resources for faculty recruitment. The author developed a mathematical model to determine the optimal structure (dollars, space) for allocating resource packages when recruiting new faculty, based on expected financial returns from those faculty. Surprisingly, the optimal strategy was to allocate homogeneous recruitment packages, independent of the recruited faculty member's rank or the individual's expected revenue generation. Optimization results were used to allocate recruitment packages to new department head and center directors in the University of Arizona College of Medicine during the last four years (2005-2008). At any institution that uses this model, appropriate distribution of facilities and administrative revenues at the institution is needed to equitably balance the costs and benefits associated with faculty expansion.

Strengthening the performance and effectiveness of the public health system

Health funders at the national, state, and local levels have made substantial commitments to improve the functionality of the public health system. Using a variety of approaches, they have sought to develop the capabilities, services, and competencies that enhance public health practice. These efforts include developing the operational capacity of public health agencies and raising performance expectations for governmental public health organizations.

A workshop to improve workflow efficiency in emergency medicine

OBJECTIVE

The emergency department (ED) environment requires physicians to focus on workflow efficiency (WFE) and manage ED throughput. We sought to determine whether an interactive workshop could be designed and favourably perceived by emergency physicians and residents as a means to improve their self-assessed WFE skills.

METHODS

The authors designed a 4-station workshop to simulate key components of ED throughput. These included resource management in 1) acute care, 2) minor care, 3) charting and 4) communication skills and patient sign-overs. Anonymous surveys were completed after each workshop using 5-point Likert scales and qualitative responses. Qualitative data encompassed participants' past WFE training experiences and perspectives on the current workshop. Data were analyzed using descriptive statistics. The workshops were administered on 2 separate occasions to different groups of physicians. The first occasion was primarily for residents and the second session was only for practising physicians.

RESULTS

A total of 22 residents and 24 practising physicians participated. Evaluations were completed by 45 of 46 participants. Ratings of "definitely helpful" or "helpful" as noted for each station were received by 37 of 44 respondents for the sign-over and communication station, by 37 of 44 for the minor care station, by 41 of 44 for the acute care station and by 33 of 43 for the effective charting station. Among all participants, 42 of 45 reported that they felt the overall workshop experience was "helpful" or "definitely helpful."

CONCLUSION

ED management "flow skills" are valued yet undertaught. A flow workshop designed to improve self-perceived WFE skills yields positive evaluations. Teaching this competency in a workshop setting is both feasible and appreciated by participants. Similar efforts should be considered for inclusion in both graduate and continuing medical education curricula.

Misfinancing global health: a case for transparency in disbursements and decision making

To address the gap between health investments and financial flows worldwide, we identified the patterns in allocation of funds by the four largest donors--ie, the World Bank, Bill & Melinda Gates Foundation (BMGF), the US Government, and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria--in 2005. We created a disbursement database with information gathered from the annual reports and budgets. Funding per death varied widely according to type of disease--eg, US$1029.10 for HIV/AIDS to $3.21 for non-communicable diseases. The World Bank, US Government, and Global Fund provided more than 98% of their funds to service delivery, whereas BMGF gave most of its funds to research. BMGF grants in 2005 were given largely to private research organisations, universities, and civil societies in rich countries, whereas the US Government and Global Fund primarily disbursed grants to sub-Saharan Africa. Publicly available data for global health disbursements is incomplete and not standardised. Continued attention is needed to develop country ownership, particularly in planning and priority setting.

Knowledge integration: conceptualizing communications in cancer control systems

OBJECTIVE

This paper was prepared by the National Cancer Institute of Canada (NCIC) Working Group on Translational Research and Knowledge Transfer. The goal was to nurture common ground upon which to build a platform for translating what we know about cancer into what we do in practice and policy.

METHODS

Methods included expert panels, literature review, and concept mapping, to develop a framework that built on earlier cancer control conceptualizations of communications that have guided researchers and end users.

RESULTS

The concept of 'knowledge integration' is used to describe the resulting refinement and the nature of evidence necessary for decision-making to at the systems level. Current evidence for knowledge integration in cancer control is presented across the levels of individual, organizational and systems level interventions and across basic, clinical and population science knowledge bases.

CONCLUSION

A systems-oriented approach to integrating evidence into action assists organizations to conduct research and policy and practice.

PRACTICE IMPLICATIONS

Practitioners can use this framework to understand the challenges of implementing and evaluating cancer control strategies.

Health metrics and evaluation: strengthening the science

With the growing importance of health in the global agenda comes the responsibility to develop a scientific foundation of metrics and evaluation. The scope of this emerging field can be viewed in terms of key topics, including health outcomes, other social outcomes related to health systems, health services, resource inputs, evaluations of programmes and systems, and analyses to support policy choice. It can also be defined in terms of key activities that are needed to strengthen the scientific basis of the field: development of new methods, instruments, software, and hardware; setting global norms and standards for data collection; increasing the availability of high-quality primary data; systematic analysis and synthesis of existing datasets; strengthening national capacity to obtain, analyse, and use data; and reporting and disseminating results. We explore in depth topics with major scientific challenges and institutional and cultural barriers that are slowing the development of the field. Cutting across the various topical areas and disciplinary approaches to these problems are some common scientific issues, including limited comparability of measurement, uncorrected known biases in data, no standard approach to missing data, unrealistic uncertainty estimates, and the use of disease models that have not been properly validated. Only through concerted action will it be possible to assure the production, reproduction, and use of knowledge that is crucial to the advancement of global health.

Understanding the relationship between knowledge and African Americans' donation decision-making

OBJECTIVE

To explore the association between different types of knowledge related to donation and transplantation and the expression of donation intentions via one's driver's license, a donor card, or sharing one's wishes with family.

METHODS

Cross-sectional data were gathered via self-administered questionnaire from 425 Black adults, age 18 years and older who were recruited from nine churches in a large metropolitan area in the southeast United States.

RESULTS

Results indicate that knowledge of the allocation system and experiential knowledge of a transplant recipient are associated with donation intentions after controlling for age, gender, and highest level of education. However, the following types of knowledge were unrelated to donation intentions: donation-related statistics (including an understanding of African Americans' overrepresentation among those in need), the donation process, the process for determining medical suitability, and religious institutions' support for donation.

CONCLUSIONS

Findings suggest that the relationship between donation-related knowledge and donation intentions is complex and may depend on the specific type of knowledge being measured.

PRACTICE IMPLICATIONS

Knowledge of the allocation system and experiential knowledge of a recipient may be critical aspects of the donation decision-making process. Research findings suggest the need for an educational approach that seeks to improve the specific types of knowledge that are most strongly associated with donation intentions.

Benchmarking in nursing care by the RAFAELA patient classification system - a possibility for nurse managers

AIM

The aim of the study was to explore the possibilities of benchmarking with the RAFAELA system. In this study, comparisons are made between: (1) costs for one nursing care intensity point; (2) the nursing care intensity per nurse; (3) the relationship between nursing care intensity per nurse and (4) the optimal nursing care intensity.

BACKGROUND

During the period from 1994 to 2000 a new system for patient classification, the RAFAELA system, was developed in Finland.

METHODS

86 wards from 14 different hospitals in Finland took part in the study.

RESULTS

The costs for one nursing care intensity point on the adults' wards were on average 7.80euro. The average workload was 25.2 nursing care intensity points per nurse. The optimal nursing care intensity was exceeded during 49.5% of the days and under during 20% of the days.

CONCLUSIONS

The study shows that benchmarking with the RAFAELA system provides many opportunities for the nurse managers' resource allocation and their personnel administration.

Product line development: a strategy for clinical success in academic centers

OBJECTIVE

Academic medical centers, which have traditionally been relatively inefficient, have increasing difficulty in meeting the missions of patient care, teaching, and research in a progressively competitive medical marketplace. One strategy for improved efficiency in patient care while keeping quality high is utilization of a product line matrix. This study addresses the outcome of utilizing a product line strategy consisting of 3 service lines during the past 5 years at the University of Wisconsin Hospital and Clinics (UWHC).

METHODS

Service lines in heart and vascular surgery, oncology, and pediatrics have been organized since 2001, and report directly to hospital leadership as a product line. Service line leadership consists of a combination of medical leaders plus representatives of hospital administration, and service lines are allowed direct access to resources for program development, marketing, and resource allocation. Measurements of patient numbers, market share, length of stay, net margin, and patient satisfaction have been gathered and compared with the preproduct line era.

RESULTS

In the 3 service lines, UWHC has seen variable but steady growth in patient numbers, enhanced market share, positive net margins, and improved patient satisfaction during the period of measurement. During this same period, the insurance milieu has resulted in consistent downward pressure on reimbursement, which has been offset by improved patient care efficiency as measured by length of stay, enhanced preferred provider status, and gains in market share. Scorecard measures of quality are also being developed and show enhanced teaching and research opportunities for students and trainees as well as improved Press Ganey patient satisfaction scores.

CONCLUSIONS

At UWHC, the development of a product line matrix consisting of 3 service lines has resulted in more patient care efficiency, enhanced patient satisfaction, improved margin for the hospital, and enlargement of teaching and research opportunities. The key to successful implementation of the product line concept is a close working relationship between the hospital administration and service line medical leadership.

[Clinical pathways in rheumatological inpatient treatment - a structured process management]

Clinical pathways for three rheumatological indications have been successfully developed in the rheumatological departments of two hospitals. These diseases were selected because of the number of inpatients seen and/or the costs for diagnostics and therapy. Three quota-concepts, the coordination of treatment processes (quota-concept I), the sequence of implementing services (quota-concept II), and the economical utilization of available resources as well as the transparent definition of therapies (quota-concept III) have been established. These concepts have been tested individually as well as in complex situations.

Lining up your service lines

Steps in implementing a service line approach include: Defining the service line. Allocating service line revenue and expense. Analyzing service line contribution margin and profitability. Determining the value of other factors. Creating standards for investment decisions, benchmarking, and ranking.

Who should be involved in health care decision making? A qualitative study

Most countries appear to believe that their health system is in a state of semi-crisis with expenditures rising rapidly, with the benefits of many services unknown and with pressure from the public to ensure access to a comprehensive range of services. But whose values should inform decision-making in the health area, and should the influence of different groups vary with the level of decision-making? These questions were put to 54 members of the public and health professionals in eight focus groups. Adopting a different perspective from other studies, participants were not asked if particular groups should be involved in decisions but rather through deliberation and discussion nominated their own potential decision makers. This delivered a clear message that participants saw a legitimate role for a broad range of stakeholders in priority-setting decisions so as to incorporate a diversity of expertise and opinion. Companion themes were the acknowledgment that decisions involve ethical judgments and are not purely technical, that the power of special interest groups (such as clinicians) should be kept in check, and that the process by which decisions are reached is important. The results suggest that qualitative methods of investigation have the potential to improve the legitimacy of policy decisions by contributing to a better understanding of the values of the public and health professionals, and by expanding the range of options available for further research.

Ensuring uninterrupted supplies of antiretroviral drugs in resource-poor settings: an example from Malawi

PROBLEM

Drug procurement and distribution practices are weak in many resource-poor countries, and are a major reason for lack of access to medicines. With many countries scaling up antiretroviral therapy (ART), it is vital to avoid interrupted drug supplies, which would lead to drug resistance and treatment failure.

APPROACH

Malawi has adapted a model, based on that adopted by the country's Tuberculosis Control Programme, to allow rational ART drug forecasting.

LOCAL SETTING

The model includes a focus on one standardized first-line ART regimen; a "push system" and "ceilings" for first-line ART drugs for facilities; use of starter pack and continuation pack kits; quarterly monitoring of patient outcomes and ART drug stocks at facility level; provision of a three-month buffer stock of ART drugs at facility level; and use of a procurement and distribution system outside central medical stores.

LESSONS LEARNED

The focus on a single first-line regimen, "ceilings" for first-line ART drugs and quarterly data collections to calculate drug needs (for new and follow-up patients, respectively), as well as the use of an independent procurement facility, allow drug orders to be made 6-9 months ahead. These measures have so far ensured that there have been no ART drug stock-outs in the country.

Malawi's contribution to "3 by 5": achievements and challenges

PROBLEM

Many resource-poor countries have started scaling up antiretroviral therapy (ART). While reports from individual clinics point to successful implementation, there is limited information about progress in government institutions at a national level.

APPROACH

Malawi started national ART scale-up in 2004 using a structured approach. There is a focus on one generic, fixed-dose combination treatment with stavudine, lamivudine and nevirapine. Treatment is delivered free of charge to eligible patients with HIV and there is a standardized system for recruiting patients, monthly follow-up, registration, monitoring and reporting of cases and outcomes. All treatment sites receive quarterly supervision and evaluation.

LOCAL SETTING

In January 2004, there were nine public sector facilities delivering ART to an estimated 4 000 patients. By December 2005, there were 60 public sector facilities providing free ART to 37,840 patients using national standardized systems. Analysis of quarterly cohort treatment outcomes at 12 months showed 80% of patients were alive, 10% dead, 9% lost to follow-up and 1% had stopped treatment.

LESSONS LEARNED

Achievements were the result of clear national ART guidelines, implementing partners working together, an intensive training schedule focused on clinical officers and nurses, a structured system of accrediting facilities for ART delivery, quarterly supervision and monitoring, and no stock-outs of antiretroviral drugs. The main challenges are to increase the numbers of children, pregnant women and patients with tuberculosis being started on ART, and to avert high early mortality and losses to follow-up. The capacity of the health sector to cope with escalating case loads and to scale up prevention alongside treatment will determine the future success of ART delivery in Malawi.

[A survey of neurological medical care resources in grade II suburban and urban hospitals in Beijing]

OBJECTIVE

To survey the current availability of expertise in diagnosis and treatment of neurological diseases in grade II hospitals (primary hospitals) in Beijing.

METHODS

Observation, personal in-depth interview and structured questionnaire methods were conducted to survey the status of neurology health care system.

RESULTS

From June to August 2005, 66 grade II suburban and urban hospitals in Beijing of China were investigated. There were 66 grade II hospitals in Beijing (suburban 34; urban 32). Cerebrovascular disease was the most common disease. Accounting for 84% of the hospitalized cases in inpatients neurology departments. In urban areas, the proportion of grade II and grade III hospitals (referral hospitals) was 58:60, but in suburban and rural areas, the proportion was 48:6. In suburban and rural areas. Only 64.7% of the hospitals could provide urokinase treatment, 26.5% could provide recombinant tissue plasminogen activator (rt-PA) treatment and 58.8% had standardized operation protocol.

CONCLUSIONS

The grade II hospitals in suburban areas have heavy grave responsibility to deal with cerebrovascular disease, but these hospitals are in lack of specialists, diagnostic equipment and stroke treatment protocols and could not satisfy the medical demand. It is suggested that in the grade II hospitals in suburban areas of Beijing, strengthening personnel training, establishing primary stroke center and setting up telestroke emergency care systems are urgently needed.