Magnet hospital recognition in hospital systems over time

BACKGROUND

Magnet hospitals are recognized for nursing excellence and high-value patient outcomes, yet little is known about which and when hospitals pursue Magnet recognition. Concurrently, hospital systems are becoming a more prominent feature of the U.S. health care landscape.

PURPOSE

The aim of the study was to examine Magnet adoption among hospital systems over time.

APPROACH

Using American Hospital Association surveys (1998-2012), we characterized the proportion of Magnet hospitals belonging to systems. We used hospital level fixed-effects regressions to capture changes in a given system hospital's Magnet status over time in relation to a variety of conditions, including prior Magnet adoption by system affiliates and nonaffiliates in local and geographically distant markets and whether these relationships varied by degree of system centralization.

RESULTS

The proportion of Magnet hospitals belonging to a system is increasing. Prior Magnet adoption by a hospital within the local market was associated with an increased likelihood of a given system hospital becoming Magnet, but the effect was larger if there was prior adoption by affiliates (7.4% higher likelihood) versus nonaffiliates (2.7% higher likelihood). Prior adoption by affiliates and nonaffiliates in geographically distant markets had a lesser effect. Hospitals belonging to centralized systems were more reactive to Magnet adoption of nonaffiliate hospitals as compared with those in decentralized systems.

CONCLUSIONS

Hospital systems take an organizational perspective toward Magnet adoption, whereby more system affiliates achieve Magnet recognition over time.

PRACTICE IMPLICATIONS

The findings are relevant to health care and nursing administrators and policymakers interested in the diffusion of an empirically supported organizational innovation associated with quality outcomes, particularly in a time of increasing hospital consolidation and system expansion. We identify factors associated with Magnet adoption across system hospitals and demonstrate the importance of considering diffusion of organizational innovations in relation to system centralization. We suggest that decentralized system hospitals may be missing potential benefits of such organizational innovations.

Relationship between leadership support and operational excellence in health care sector: A study of Indian health care managers

BACKGROUND AND OBJECTIVE

Leadership communicates purpose and innovative ways to thrive for performance. Leadership support influences and impacts operational excellence in the health sector as a patient-centered operation, with effective management, excellence framework, challenges and constraints, teamwork and value stream mapping. It is hypothesized that: (1) perceived leadership support will positively correlate with perceived operational excellence (Patient-centered Operations, Effective Resource Management, Excellence framework, Eliminating Challenges or Constraints, Team Work, Value Stream Mapping) and (2) the correlation would be highest with Patient-centered Operations. The aim of this study was to examine the relationship between leadership support and operational excellence in the health care sector among a selected group of healthcare managers.

MATERIALS AND METHOD

A correlation study between leadership support and operational excellence was designed for a group of health care managers (n=80) from eight hospitals in Kerala, South India. The selection of executives was from NABH accredited hospitals from districts with a minimum of four NABH accredited hospital. A survey was sent to a selected study sample. The respondents were cooperative and provided responses on perceived leadership support for operational excellence.

RESULTS

Factors of leadership support correlated to operational excellence.

CONCLUSION

In the health care sector, leadership support for patient-centered operations helps achieve operational excellence.

Evaluation of iLead, a generic implementation leadership intervention: mixed-method preintervention-postintervention design

OBJECTIVES

The present study aimed to evaluate the iLead intervention and to investigate whether or not transfer of training can be supported by contextualising the intervention (recruiting all managers from one branch of the organisation while focusing on one implementation case, as well as training senior management).

DESIGN

A pre-evaluation-postevaluation design was applied using mixed methods with process and effect surveys and interviews to measure the effects on three levels.

SETTING

Healthcare managers from Stockholm's regional healthcare organisation were invited to the training.

PARTICIPANTS

52 managers participated in the iLead intervention. Group 1 consisted of 21 managers from different organisations and with different implementation cases. Group 2, representing the contextualised group, consisted of 31 managers from the same organisation, working on the same implementation case, where senior management also received training.

INTERVENTION

iLead is an intervention where healthcare managers are trained in implementation leadership based on the full-range leadership model.

PRIMARY OUTCOME MEASURES

Reactions, knowledge and implementation leadership are measured.

RESULTS

Quantitative and qualitative analyses indicate that iLead was perceived to be of high quality and capable of increasing participants' knowledge. Mixed effects were found regarding changes in behaviours. The contextualisation did not have a boosting effect on behaviour change. Hence, group 2 did not increase its active implementation leadership in comparison with group 1.

CONCLUSIONS

iLead introduces a new approach to how implementation leadership can be trained when knowledge of effective leadership for implementations is combined with findings on the importance of environmental factors for the transfer of training. Even though managers reported general positive effects, transfer was not facilitated through the contextualisation of the intervention. There is a need to further develop approaches to help participants subsequently apply the learnt skills in their work environment.

CQI approaches for evaluating management development programs: A case study with health service managers from geographically remote settings

Health systems are known for being complex. Yet, there is a paucity of evidence about programs that successfully develop competent frontline managers to navigate these complex systems. There is even less evidence about developing frontline managers in areas of contextual complexity such as geographically remote and isolated health services. This study used a customised management development program containing continuous quality improvement (CQI) approaches to determine whether additional levels of evaluation could provide evidence for program impact. Generalisability is limited by the small sample size; however, the findings suggest that continuous improvement approaches, such as action learning workplace-based CQI projects not only provide for real-world application of the manager's learning; they can potentially produce the type of data needed to conduct evaluations for organisational impact and cost-benefits. The case study contributes to the literature in an area where there is a scarcity of empirical research. Further, this study proposes a pragmatic method for using CQI approaches with existing management development programs to generate the type of data needed for multi-level evaluation.

Development and pilot of a multicriteria decision analysis (MCDA) tool for health services administrators

INTRODUCTION

Health administration is complex and serves many masters. Value, quality, infrastructure and reimbursement are just a sample of the competing interests influencing executive decision-making. This creates a need for decision processes that are rational and holistic.

METHODS

We created a multicriteria decision analysis tool to evaluate six fields of healthcare provision: return on investment, capacity, outcomes, safety, training and risk. The tool was designed for prospective use, at the beginning of each funding round for competing projects. Administrators were asked to rank their criteria in order of preference. Each field was assigned a representative weight determined from the rankings. Project data were then entered into the tool for each of the six fields. The score for each field was scaled as a proportion of the highest scoring project, then weighted by preference. We then plotted findings on a cost-effectiveness plane. The project was piloted and developed over successive uses by the hospital's executive board.

RESULTS

Twelve projects competing for funding at the Royal Brisbane and Women's Hospital were scored by the tool. It created a priority ranking for each initiative based on the weights assigned to each field by the executive board. Projects were plotted on a cost-effectiveness plane with score as the x-axis and cost of implementation as the y-axis. Projects to the bottom right were considered dominant over projects above and to the left, indicating that they provided greater benefit at a lower cost. Projects below the x-axis were cost-saving and recommended provided they did not harm patients. All remaining projects above the x-axis were then recommended in order of lowest to highest cost-per-point scored.

CONCLUSION

This tool provides a transparent, objective method of decision analysis using accessible software. It would serve health services delivery organisations that seek to achieve value in healthcare.

Health Information Infrastructure for People with Intellectual and Developmental Disabilities (I/DD) Living in Supported Accommodation: Communication, Co-Ordination and Integration of Health Information

People with intellectual and/or developmental disability (I/DD) commonly have complex health care needs, but little is known about how their health information is managed in supported accommodation, and across health services providers. This study aimed to describe the current health information infrastructure (i.e., how data and information are collected, stored, communicated, and used) for people with I/DD living in supported accommodation in Australia. It involved a scoping review and synthesis of research, policies, and health documents relevant in this setting. Iterative database and hand searches were conducted across peer-reviewed articles internationally in English and grey literature in Australia (New South Wales) up to September 2015. Data were extracted from the selected relevant literature and analyzed for content themes. Expert stakeholders were consulted to verify the authors' interpretations of the information and content categories. The included 286 sources (peer-reviewed n = 27; grey literature n = 259) reflect that the health information for people with I/DD in supported accommodation is poorly communicated, coordinated and integrated across isolated systems. 'Work-as-imagined' as outlined in policies, does not align with 'work-as-done' in reality. This gap threatens the quality of care and safety of people with I/DD in these settings. The effectiveness of the health information infrastructure and services for people with I/DD can be improved by integrating the information sources and placing people with I/DD and their supporters at the centre of the information exchange process.

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

OBJECTIVE

To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services.

DESIGN

Classic e-Delphi survey.

SETTING

National study in Wales.

PARTICIPANTS

Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification.

RESULTS

A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences.

CONCLUSION

Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals.

Health-care quality and information failure: Evidence from Nigeria

Low-quality health services are a problem across low- and middle-income countries. Information failure may contribute, as patients may have insufficient knowledge to discern the quality of health services. That decreases the likelihood that patients will sort into higher quality facilities, increasing demand for better health services. This paper presents results from a health survey in Nigeria to investigate whether patients can evaluate health service quality effectively. Specifically, this paper demonstrates that although more than 90% of patients agree with any positive statement about the quality of their local health services, satisfaction is significantly associated with the diagnostic ability of health workers at the facility. Satisfaction is not associated with more superficial characteristics such as infrastructure quality or prescriptions of medicines. This suggests that patients may have sufficient information to discern some of the most important elements of quality, but that alternative measures are crucial for gauging the overall quality of care.

Preparing Future Healthcare Leaders through Graduate Education: Impact of Program Accreditation on Quality Improvement

Accreditation is used by many health professions to ensure the adequacy of their training programs in preparing future leaders and practitioners. The impact of program accreditation, however, has not historically been the subject of systematic study, meaning the case for program accreditation has been more philosophical than empirical. We hypothesized that a healthcare management program's length of continuous accreditation (accreditation tenure) would be associated with factors related to applicant quality, program selectivity, and starting salaries of students upon graduation. We conducted a retrospective, correlational analysis to investigate the relationship between accreditation tenure and program quality and outcome metrics. The sample included all graduate programs (n=72) that were accredited in the 2013-2014 academic year and had completed a full annual report to the Commission on Accreditation of Healthcare Management Education (CAHME). As hypothesized, we found factors within each of our three areas of interest to be associated with accreditation tenure, providing at least preliminary evidence of an association between program-level accreditation and continuous quality improvement in programmatic outcomes.

[The process of defining the competence profile of the healthcare professions manager in the Veneto Region]

Presented here is the approach used by a multidisciplinary working group fo the drafting of the "core" competence profile of the healthcare professions manager in the Veneto Region. Defining a competence profile allows for specifying a standard for measuring the skills acquired by a professional and the gap level from what is expected by the organization, as well as orienting the preparatory education to carry out the related role.

U.S. healthcare failing in cost, quality, safety; together we can cure what's ailing our system

The American healthcare system is headed toward a cliff, and the fall will be long and painful. Healthcare consumes 18% of our nation's gross domestic product, almost 50% more than the second highest-spending nation. High-deductible health plans are the new norm for one-third of insured patients. Out-of-pocket costs are increasingly unaffordable for many.

[The opinion of personnel of medical organizations concerning effectiveness of systems of quality management and international certification]

The sociological study was carried out concerning effectiveness of systems of quality management. The technique of questionnaire survey was implemented in medical organizations with functioning systems of quality management and internationally certified systems. The evaluation by medical personnel impact of system of quality management on their activities based on results of using the given management sub-system was selected as a study object. At that, opinion ofpersonnel concerning time dynamics of indices of activity was served as a study subject. The involvement of personnel, alterations in activities of organization, remuneration of labor, effectiveness of treatment from point of view of organizations' staff members were considered. The conclusion was made that personnel of considered organizations has favorable opinion concerning effectiveness of the given systems. Among particular characteristics ofmedical care, 67% of respondents marked improvement of organization of functioning and 36% out of them marked significant improvement. The most of respondents (69%) felt positive dynamics of activities. At that, personnel of organizations mark no increasing of income in 68% of all cases and only 24% of respondents indicated salary increasing. Among negative outcomes of implementation of system of quality management, the respondents focused on increasing of workload. This trend was marked by 53% of personnel and 30% out of them indicated significant increasing of workload. The absence of alterations was marked by 38% of respondents and decreasing of workload was confirmed only by 9% of respondents.

Healthcare quality maturity assessment model based on quality drivers

Purpose - Healthcare providers differ in their readiness and maturity levels regarding quality and quality management systems applications. The purpose of this paper is to serve as a useful quantitative quality maturity-level assessment tool for healthcare organizations. Design/methodology/approach - The model proposes five quality maturity levels (chaotic, primitive, structured, mature and proficient) based on six quality drivers: top management, people, operations, culture, quality focus and accreditation. Findings - Healthcare managers can apply the model to identify the status quo, quality shortcomings and evaluating ongoing progress. Practical implications - The model has been incorporated in an interactive Excel worksheet that visually displays the quality maturity-level risk meter. The tool has been applied successfully to local hospitals. Originality/value - The proposed six quality driver scales appear to measure healthcare provider maturity levels on a single quality meter.

Barriers and facilitators to uptake of systematic reviews by policy makers and health care managers: a scoping review

BACKGROUND

We completed a scoping review on the barriers and facilitators to use of systematic reviews by health care managers and policy makers, including consideration of format and content, to develop recommendations for systematic review authors and to inform research efforts to develop and test formats for systematic reviews that may optimise their uptake.

METHODS

We used the Arksey and O'Malley approach for our scoping review. Electronic databases (e.g., MEDLINE, EMBASE, PsycInfo) were searched from inception until September 2014. Any study that identified barriers or facilitators (including format and content features) to uptake of systematic reviews by health care managers and policy makers/analysts was eligible for inclusion. Two reviewers independently screened the literature results and abstracted data from the relevant studies. The identified barriers and facilitators were charted using a barriers and facilitators taxonomy for implementing clinical practice guidelines by clinicians.

RESULTS

We identified useful information for authors of systematic reviews to inform their preparation of reviews including providing one-page summaries with key messages, tailored to the relevant audience. Moreover, partnerships between researchers and policy makers/managers to facilitate the conduct and use of systematic reviews should be considered to enhance relevance of reviews and thereby influence uptake.

CONCLUSIONS

Systematic review authors can consider our results when publishing their systematic reviews. These strategies should be rigorously evaluated to determine impact on use of reviews in decision-making.

Using Event Trees to Inform Quantitative Analysis of Healthcare Services

The paper illustrates how event tree diagrams, used in safety engineering, can be applied to test the design of a healthcare service. Event tree diagrams can be employed to inform quantitative approaches to quality, by providing justification with respect to safety, of operational aspects to be monitored and measured.

Costs and cost-effectiveness of community health workers: evidence from a literature review

OBJECTIVE

This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems.

METHODS

From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings.

RESULTS

Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria.

CONCLUSION

Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.

Strengthening malaria service delivery through supportive supervision and community mobilization in an endemic Indian setting: an evaluation of nested delivery models

BACKGROUND

Malaria continues to be a prominent global public health challenge. This study tested the effectiveness of two service delivery models for reducing the malaria burden, e.g. supportive supervision of community health workers (CHW) and community mobilization in promoting appropriate health-seeking behaviour for febrile illnesses in Odisha, India.

METHODS

The study population comprised 120 villages from two purposively chosen malaria-endemic districts, with 40 villages randomly assigned to each of the two treatment arms, one with both supportive supervision and community mobilization and one with community mobilization alone, as well as an observational control arm. Outcome measures included changes in the utilization of bed nets and timely care-seeking for fever from a trained provider compared to the control group. Analysis was by intention-to-treat.

RESULTS

Significant improvements were observed in the reported utilization of bed nets in both intervention arms (84.5% in arm A and 82.4% in arm B versus 78.6% in the control arm; p < 0.001). While overall rates of treatment-seeking were equal across study arms, treatment-seeking from a CHW was higher in both intervention arms (28%; p = 0.005 and 27.6%; p = 0.007) than in the control arm (19.2%). Fever cases were significantly more likely to visit a CHW and receive a timely diagnosis of fever in the combined interventions arm than in the control arm (82.1% vs. 67.1%; p = 0.025). Care-seeking from trained providers also increased with a substitution away from untrained providers. Further, fever cases from the combined interventions arm (60.6%; p = 0.004) and the community mobilization arm (59.3%; p = 0.012) were more likely to have received treatment from a skilled provider within 24 hours than fever cases from the control arm (50.1%). In particular, women from the combined interventions arm were more likely to have received timely treatment from a skilled provider (61.6% vs. 47.2%; p = 0.028).

CONCLUSION

A community-based intervention combining the supportive supervision of community health workers with intensive community mobilization and can be effective in improving care-seeking and preventive behaviour and may be used to strengthen the national malaria control programme.

[The approach of sciences of complexity in health services administration]

Historically, health services administration has been managed under a Taylorist, Fayolist, humanist and bureaucratic focus approach. However, today dynamic and competitive behaviors that require others approaches in management are developing. Because of the social, scientific and technological changes that are occurring, it is necessary to abandon hierarchical and authoritarian schemes, "up and down" lines, prescriptive rules and order line up must be left behind. Health services administration is an adapted complex system that is not proportional, neither predictable in direction or magnitude. A new proposal is to focus on the sciences of complexity, where the social factors, materials, economics, human and ethics coincide with order and disorder, reason and unreason, and in which we must accept that the phenomenon that emerges creates different organizing different structures from the addition or subtraction of components. There is distance in the process of cause and direct effect. The mirage from the sciences of complexity are trans-disciplinary and we have accepted this in others branches of knowledge, such as quantum physics, non-linear mathematics and cybernetics, so we have to accept the influence of entropy, non-entropy, attractors, the theory of chaos and fractals.

Setting the scene: the challenges of universal health coverage and the contribution of management education

The last decades are being characterized by global trends such as population growth, aging, escalation of non communicable diseases and technological innovation. These unprecedented changes are moving faster than economic growth and threaten universal health coverage. What is at stake nowadays is governments' and healthcare systems' ability to renovate themselves and develop new paradigms aimed at finding innovative solutions to manage the new global forces so to maintain universal access to care in a changing environment. We have to be imaginative because if we keep relying on current paradigms to answer already too far-ahead complex problems, we will fail. And here education has a role to play. Although the recent years have seen a steep increase in the offerings of post-graduate management education programs in health and healthcare, the majority of these programs are still traditionally conceived and designed, aiming to train students to deal with specific, domestic, current problems. With the promise of making students the best specialists on Earth, to get the highest return on his or her investment in education, the performance of these programs is often measured in terms of earnings maximization. Although an indicator of success, this often incentivizes individuals to be context-based, individualistic, short-sighted and self-focused. Education has the greatest potential to foster imagination, to leverage diversity, to exploit team-working and free creative thinking. Education can substantially contribute to anticipate the impact of global forces by but an endeavor is needed to design programs and measures performances differently.

Is management essential to improving the performance and sustainability of health care systems and organizations? A systematic review and a roadmap for future studies

Recent studies have highlighted the importance of management in the health care sector. Positive correlations have been found between clinical and economic performance. Although there is still controversy regarding what kind of management and which managers should lead health care organizations and health systems, we now have interesting evidence to analyze. Starting with a systematic review of the literature, this article presents and discusses the streams of knowledge regarding how management can influence the quality and sustainability of health systems and organizations. Through the analysis of 37 studies, we found that the performance of health care systems and organizations seems to be correlated with management practices, leadership, manager characteristics, and cultural attributes that are associated with managerial values and approaches. There is also evidence that health care organizations run by doctors perform better than others. Finally, we provide a roadmap that indicates how the relationship between the management and performance of health systems and organizations can be further and more effectively investigated.

Perspective: Organizational professionalism: relevant competencies and behaviors

The professionalism behaviors of physicians have been extensively discussed and defined; however, the professionalism behaviors of health care organizations have not been systemically categorized or described. Defining organizational professionalism is important because the behaviors of a health care organization may substantially impact the behaviors of physicians and others within the organization as well as other institutions and the larger community. In this article, the authors discuss the following competencies of organizational professionalism, derived from ethical values: service, respect, fairness, integrity, accountability, mindfulness, and self-motivation. How nonprofit health care organizations can translate these competencies into behaviors is described. For example, incorporating metrics of population health into assessments of corporate success may increase collaboration among regional health care organizations while also benefiting the community. The unique responsibilities of leadership to model these competencies, promote them in the community, and develop relevant organizational strategies are clarified. These obligations elevate the importance of the executive leadership's capacity for self-reflection and the governing boards' responsibility for mapping operational activities to organizational mission. Lastly, the authors consider how medical organizations are currently addressing professionalism challenges. In an environment made turbulent by regulatory change and financial constraints, achieving proficiency in professionalism competencies can assist nonprofit health care organizations to promote population health and the well-being of their workforces.

Independent review of clinical health services for prisoners

PURPOSE

The purpose of this paper is to describe the parameters for the development of performance measurement of the quality of medical care behind bars, drawing from widely-published free-world clinical guidelines and aspects of care that are unique to the criminal justice arena.

DESIGN/METHODOLOGY/APPROACH

One way to help assure that prisoners receive timely and appropriate health care is through independent review of health care services, to identify strengths of programs and opportunities for improvement. This is a quality of medical care assessment. When done in a systematic way, this has the potential to reduce risk of harm and enhance the personal health of the prisoner and improve the public health. Independent external review provides the best opportunity to identify and remedy opportunities for improvement. "External" can mean wholly independent or "corporate," that is, review by agency staff that has no vested interest in the findings at the individual facility. Recently, the methodology for assessment of the quality of medical care in the community has blossomed, yet there is little guidance on how to adapt this methodology to the prison setting.

FINDINGS

This paper introduces a prison-oriented method for assessing clinical performance. To the extent possible, the author cites references to the scientific basis for the recommendations. Where there is no science, the author relies as much as possible on consensus, and in a few cases resorts to "wisdom and experience," as unreliable as this might be. This is a conceptual paper with a viewpoint.

ORIGINALITY/VALUE

The paper provides guidance on reducing risk of harm and promoting improved health and health care for prisoners.

Examining quality and efficiency of the U.S. healthcare system

PURPOSE

The fundamental concern of this research study is to learn the quality and efficiency of U.S. healthcare services. It seeks to examine the impact of quality and efficiency on various stakeholders to achieve the best value for each dollar spent for healthcare. The study aims to offer insights on quality reformation efforts, contemporary healthcare policy and a forthcoming change shaped by the Federal healthcare fiscal policy and to recommend the improvement objective by comparing the U.S. healthcare system with those of other developed nations.

DESIGN/METHODOLOGY/APPROACH

The US healthcare system is examined utilizing various data on recent trends in: spending, budgetary implications, economic indicators, i.e., GDP, inflation, wage and population growth. Process maps, cause and effect diagrams and descriptive data statistics are utilized to understand the various drivers that influence the rising healthcare cost. A proposed cause and effect diagram is presented to offer potential solutions, for significant improvement in U.S. healthcare.

FINDINGS

At present, the US healthcare system is of vital interest to the nation's economy and government policy (spending). The U.S. healthcare system is characterized as the world's most expensive yet least effective compared with other nations. Growing healthcare costs have made millions of citizens vulnerable. Major drivers of the healthcare costs are institutionalized medical practices and reimbursement policies, technology-induced costs and consumer behavior.

PRACTICAL IMPLICATIONS

Reviewing many articles, congressional reports, internet websites and related material, a simplified process map of the US healthcare system is presented. The financial process map is also created to further understand the overall process that connects the stakeholders in the healthcare system. Factors impacting healthcare are presented by a cause and effect diagram to further simplify the complexities of healthcare. This tool can also be used as a guide to improve efficiency by removing the "waste" from the system. Trend analyses are presented that display the crucial relationship between economic growth and healthcare spending.

ORIGINALITY/VALUE

There are many articles and reports published on the US healthcare system. However, very few articles have explored, in a comprehensive manner, the links between the economic indicators and measures of the healthcare system and how to reform this system. As a result of the US healthcare system's complex structure, process map and cause-effect diagrams are utilized to simplify, address and understand. This study linked top-level factors, i.e., the societal, government policies, healthcare system comparison, potential reformation solutions and the enormity of the recent trends by presenting serious issues associated with U.S. healthcare.

Best practices of total quality management implementation in health care settings

Due to the growing prominence of total quality management (TQM) in health care, the present study was conducted to identify the set of TQM practices for its successful implementation in healthcare institutions through a systematic review of literature. A research strategy was performed on the selected papers published between 1995 and 2009. An appropriate database was chosen and 15 peer-reviewed research papers were identified through a screening process and were finally reviewed for this study. Eight supporting TQM practices, such as top-management commitment, teamwork and participation, process management, customer focus and satisfaction, resource management, organization behavior and culture, continuous improvement, and training and education were identified as best practices for TQM implementation in any health care setting. The article concludes with a set of recommendations for the future researchers to discuss, develop, and work upon in order to achieve better precision and generalizations.

[On the interaction between State Forensic Medical Centers of the Russian Ministry of Defense and territorial organs of the Russian Federal Service on Surveillance for Consumer Rights (Roszdravnadzor): topical problems and possibilities for their solution]

The present paper is focused on the consideration of topical problems pertaining to the interaction between state forensic medical centers of the Russian Ministry of Defense (SFMF MD RF) and territorial organs of the Russian Federal Service on Surveillance for Consumer Rights (Roszdravnadzor) in the framework of unscheduled inspections of the organization and conduction of forensic medical expertise. Such inspections not infrequently give rise to conflicts between the administration of SFMF ND RF and commissions of territorial organs of Roszdravnadzor. The principal source of such conflicts is the representatives of Roszdavnadzor frequently fail to observe the requirements envisaged by the normative legal acts of the Russian Federation regulating activities of this state agency and the laws of the Russian Federation governing action management in the field of forensic medical expertise. The main causes behind the conflicts and their consequences are discussed, recommendations are proposed to resolve them.

Health services management in Qatar

AIM

To assess health care delivery system in the State of Qatar and audit it according to the Joint Commission International (JCI) standard.

METHODS

The data for this retrospective descriptive study were taken from the Annual Health Report of the National Health Authority and Hamad Medical Corporation and various additional sources like World Health Organization reports, Annual Report of Saudi Arabia, and Compendium of Health Statistics, UK. Population per physician, per general practitioner, and per hospital bed, and nurses per physician ratio were calculated.

RESULTS

In 2008, the population per physician in Qatar was 444; the population per general practitioner (GP) was 949; the population per hospital bed was 716; and nurses per physician ratio was 2.6. During the last decade, the population of Qatar has more than doubled, which has resulted in a similar increase in the number of health care providers; moreover, many initiatives launched in cooperation with internationally recognized institutions have greatly improved the quality of the health service. The weighted mean number of visits for 100 population was calculated for the UK and Qatar, taking into consideration the difference in age and sex structure. After comparison with the UK data, population/GP ratio for Qatar should be 1193.

CONCLUSION

The Qatar health system has improved in the last decade, but there is still the need for more medical workers in primary health care.

[Application of liquid chromatography in substitution of the radioimmunoassay technique in order to reduce residues generated in health services in research laboratory]

Designing a Health Care Service Waste Management Plan, according to the RDC 306 rules, is a responsibility of all those who produce such waste. Since radioimmunoassay (RIA) is one of the most employed techniques, we studied the impact of replacing this technique by liquid chromatography (HPLC) with regard to the reduction of the radioactive residues routinely produced by the Unifesp steroid laboratory. The residues produced by the determination of serum cortisol and 17 alpha-hydroxyprogesterone were classified, and those belonging to groups B and C were evaluated. We observed that, when RIA is used, chemical residues (group B) and radioactive waste (group C) are produced, whereas HPLC generates only chemical residues. Adequation of these techniques showed to be advantageous, by significantly reducing the time of analysis and mainly by eliminating and/or reducing the generation of radioactive waste, encouraging its application to other methodologies, as well as its adoption by other research units.

Using a Malcolm Baldrige framework to understand high-performing clinical microsystems

BACKGROUND, OBJECTIVES AND METHOD: The Malcolm Baldrige National Quality Award (MBNQA) provides a set of criteria for organisational quality assessment and improvement that has been used by thousands of business, healthcare and educational organisations for more than a decade. The criteria can be used as a tool for self-evaluation, and are widely recognised as a robust framework for design and evaluation of healthcare systems. The clinical microsystem, as an organisational construct, is a systems approach for providing clinical care based on theories from organisational development, leadership and improvement. This study compared the MBNQA criteria for healthcare and the success factors of high-performing clinical microsystems to (1) determine whether microsystem success characteristics cover the same range of issues addressed by the Baldrige criteria and (2) examine whether this comparison might better inform our understanding of either framework.

RESULTS AND CONCLUSIONS

Both Baldrige criteria and microsystem success characteristics cover a wide range of areas crucial to high performance. Those particularly called out by this analysis are organisational leadership, work systems and service processes from a Baldrige standpoint, and leadership, performance results, process improvement, and information and information technology from the microsystem success characteristics view. Although in many cases the relationship between Baldrige criteria and microsystem success characteristics are obvious, in others the analysis points to ways in which the Baldrige criteria might be better understood and worked with by a microsystem through the design of work systems and a deep understanding of processes. Several tools are available for those who wish to engage in self-assessment based on MBNQA criteria and microsystem characteristics.

Assessing goal attainment for quality improvement

Organizations that support persons with intellectual disabilities will likely experience increasing pressure to provide evidence of the benefits of services to participants in programs. In this article we propose a model for assessing goal attainment modified from scales used with other populations that both develops from the person-centered planning process and informs on program and organizational efficacy. Implications for assessing goal attainment and considerations for applying information to improve individual, program and organization quality are presented.

Dismantling institutional racism: theory and action

Despite a strong commitment to promoting social change and liberation, there are few community psychology models for creating systems change to address oppression. Given how embedded racism is in institutions such as healthcare, a significant shift in the system's policies, practices, and procedures is required to address institutional racism and create organizational and institutional change. This paper describes a systemic intervention to address racial inequities in healthcare quality called dismantling racism. The dismantling racism approach assumes healthcare disparities are the result of the intersection of a complex system (healthcare) and a complex problem (racism). Thus, dismantling racism is a systemic and systematic intervention designed to illuminate where and how to intervene in a given healthcare system to address proximal and distal factors associated with healthcare disparities. This paper describes the theory behind dismantling racism, the elements of the intervention strategy, and the strengths and limitations of this systems change approach.