Report of the FELASA Working Group on evaluation of quality systems for animal units

This report compares and considers the merits of existing, internationally available quality management systems suitable for implementation in experimental animal facilities. These are: the Good Laboratory Practice Guidelines, ISO 9000:2000 (International Organization for Standardization) and AAALAC International (Association for Assessment and Accreditation of Laboratory Animal Care International). Good laboratory practice (GLP) is a legal requirement for institutions undertaking non-clinical health and environmental studies for the purpose of registering or licensing for use and which have to be 'GLP-compliant'. GLP guidelines are often only relevant for and obtainable by those institutions. ISO is primarily an external business standard, which provides a management tool to master and optimize a business activity; it aims to implement and enhance 'customer satisfaction'. AAALAC is primarily a peer-reviewed system of accreditation which evaluates the organization and procedures in programmes of animal care and use to ensure the appropriate use of animals, safeguard animal well-being (ensuring state-of-the-art housing, management, procedural techniques, etc.) as well as the management of health and safety of staff. Management needs to determine, on the basis of a facility's specific goals, whether benefits would arise from the introduction of a quality system and, if so, which system is most appropriate. The successful introduction of a quality system confers peer-recognition against an independent standard, thereby providing assurance of standards of animal care and use, improving the quality of animal studies, and contributing to the three Rs—reduction, refinement and replacement.

Social regulation of healthcare organizations in the United States: developing a framework for evaluation

Social regulation is ubiquitous in the US healthcare system, and American healthcare organizations claim to be among the most regulated institutions in the world. Yet relatively little is known about the impact of social regulation on these organizations' performance, or about the characteristics or determinants of effective regulatory strategies and approaches. This paper explores the use of social regulation in US healthcare, drawing on the wider literature on regulation in other countries and settings and on the growing body of general regulatory theory. It offers a framework for analysing and comparing regulatory arrangements, presents the findings from an exploratory qualitative study of regulators and regulated organizations, and concludes by developing a framework of the emergent characteristics of effective regulation which might be used in future evaluations of healthcare regulation.

An Assessment Model for Evaluating Outcomes in Federally Qualified Health Centers' Dental Departments: Results of a 5 Year Study

PURPOSE

The purpose of this report was to establish baseline data on 10 oral health performance indicators over 5 fiscal years (2007 to 2008 through 2011 to 2012) for an Iowa health center. The baseline data provides an assessment model and reports outcomes based on the use of the model. Performance indicators show evidence of provider performance, accountability to stakeholders and provide the benchmarks required for dental management to develop future goals to improve oral health outcomes for atrisk populations.

METHODS

Using descriptive statistic, this report extrapolated data from the Iowa Health Center's computer management systems software, HealthPro, and Centricity electronic medical records, and analyzed using IBM® SPSS® 19. This report describes the change in utilization for number and type of visits for uninsured and Medicaid patients over 5 fiscal years (a fiscal year is measured from November 1 through October 31).

RESULTS

The number of patients receiving at least 1 dental visit in a measurement year showed n=81,673 procedures with 21% (17,167) being unduplicated patients. Preventive averaged 46%, restorative 18%, urgent care 22% and other procedures 14%.

CONCLUSION

Federally qualified health centers (FQHCs) with a dental component serve populations with the greatest health disparities. This population includes ethnic and racial minorities, uninsured, underinsured, rural residents, Medicaid and Medicare. Establishing baseline data for FQHCs provides a foundational tool that will allow dental management to analyze successes as well as deficiencies in the goal to provide increased utilization to oral health care for at-risk populations.

An Assessment Model for Evaluating Outcomes in Federally Qualified Health Centers' Dental Departments: Results of a 5 Year Study

PURPOSE

The purpose of this report was to establish baseline data on 10 oral health performance indicators over 5 fiscal years (2007 to 2008 through 2011 to 2012) for an Iowa health center. The baseline data provides an assessment model and reports outcomes based on the use of the model. Performance indicators show evidence of provider performance, accountability to stakeholders and provide the benchmarks required for dental management to develop future goals to improve oral health outcomes for at-risk populations.

METHODS

Using descriptive statistic, this report extrapolated data from the Iowa Health Center's computer management systems software, HealthPro, and Centricity electronic medical records, and analyzed using IBM® SPSS® 19. This report describes the change in utilization for number and type of visits for uninsured and Medicaid patients over 5 fiscal years (a fiscal year is measured from November 1 through October 31).

RESULTS

The number of patients receiving at least 1 dental visit in a measurement year showed n=81,673 procedures with 21% (17,167) being unduplicated patients. Preventive averaged 46%, restorative 18%, urgent care 22% and other procedures 14%.

CONCLUSION

Federally qualified health centers (FQHCs) with a dental component serve populations with the greatest health disparities. This population includes ethnic and racial minorities, uninsured, underinsured, rural residents, Medicaid and Medicare. Establishing baseline data for FQHCs provides a foundational tool that will allow dental management to analyze successes as well as deficiencies in the goal to provide increased utilization to oral health care for at-risk populations.

Examination of the order of incubation for the recovery of bacteria and fungi from pharmaceutical-grade cleanrooms

A study was undertaken to compare microbial recoveries from pharmaceutical-grade cleanrooms using two different incubation regimes and a general-purpose agar (Tryptone Soy Agar). One temperature regime (A) incubated plates first at 30 degrees C to 35 degrees C, followed by 20 degrees C to 25 degrees C; the second temperature regime (B) began the incubation with plates at 20 degrees C to 25 degrees C, followed by 30 degrees C to 35 degrees C. The experimental outcomes demonstrated that there was no significant difference with the total microbial count when measured using a t-test (0.05 significance level; 95% confidence interval). However, with the recovery of fungi, the second incubation regime (B), which began with the lower 20 degrees C to 25 degrees C temperature, produced higher incidents and numbers of fungi. While this finding might provide the basis for adopting one incubation regime over another, a review of the types of cleanrooms recovering fungi suggests that fungal incidents are low, and they are more often confined to specific areas. Thus, as an alternative, incubation regimes could be varied to suit different cleanroom environments or a selective mycological agar adopted for specific areas.

A survey on auditing, quality assurance systems and legal frameworks in five selected slaughterhouses in Bulawayo, south-western Zimbabwe

The purpose of this study was to explore the audits, quality assurance (QA) programmes and legal frameworks used in selected abattoirs in Zimbabwe and slaughterhouse workers' perceptions on their effectiveness. Data on slaughterhouse workers was gathered through a self-completed questionnaire and additional information was obtained from slaughterhouse and government records. External auditing was conducted mainly by the Department of Veterinary Public Health with little contribution from third parties. Internal auditing was restricted to export abattoirs. The checklist used on auditing lacked objective assessment criteria and respondents cited several faults in the current audit system. Most respondents (> 50.0%) knew the purposes and benefits of audit and QA inspections. All export abattoirs had QA programmes such as hazard analysis critical control point and ISO 9001 (a standard used to certify businesses' quality management systems) but their implementation varied from minimal to nil. The main regulatory defect observed was lack of requirements for a QA programme. Audit and quality assurance communications to the selected abattoirs revealed a variety of non-compliances with most respondents revealing that corrective actions to audit (84.3%) and quality assurance (92.3%) shortfalls were not done. A high percentage of respondents indicated that training on quality (76.8%) and regulations (69.8%) was critical. Thus, it is imperative that these abattoirs develop a food safety management system comprising of QA programmes, a microbial assessment scheme, regulatory compliance, standard operating procedures, internal and external auditing and training of workers.

Differences in regulatory frameworks governing genetic laboratories in four countries

The purpose of this article is to determine how the heterogeneity of the different regulatory frameworks governing genetic laboratories in Australia, France, the United Kingdom, and the United States hinder the international availability of genetic tests. We conclude that a better understanding of the various national standards governing genetic laboratories may help health professionals choose laboratories for referral in an evidence based manner in order to protect the patient's best interests.

Transitioning dementia residents from assisted living to memory care units: a pilot study

Our study examined the process of transitioning residents of assisted living facilities (ALFs) who have Alzheimer's disease or a related disorder to memory care units (MCUs). In-depth surveys with 10 ALF administrators in South Carolina were conducted. Grounded theory identified major themes; thematic analysis organized content. Most administrators used a preadmission screening process to assess cognitive status. About half reported that they discussed the possibility of future transfer to another level of care with the family at admission. Most administrators said that their facilities had transfer policies in place; of these, only two-thirds discussed their policies with families on admission. Transfer triggers included leaving the facility without anyone's knowledge, disturbing behaviors, and increased care needs. Challenges included family resistance and greater costs of MCUs. Assisted living facilities that were part of continuing care retirement communities used more multidisciplinary transfer decision-making than free-standing ALFs. Suggested improvements stressed educating families about dementia and MCUs.

[Investigation of the safety of microbial biotechnological products and their hygienic regulation]

Peculiarities of influence of microbial preparations based on microorganisms of different taxonomic groups on the warm-blooded organisms are considered, that is necessary to take into account when developing the strategy of toxico-hygienic studying of these preparations and when substanting hygienic standards in industrial objects and in the environment. The possibility to simplify the methodical scheme of the toxicological estimation and the hygienic regulation of microbial preparations on the basis of soil nitrogen-fixing microorganisms is discussed.

Amendment to the current good manufacturing practice regulations for finished pharmaceuticals. Direct final rule

The Food and Drug Administration (FDA) is amending certain regulations as the first phase of an incremental approach to modifying the current good manufacturing practice (CGMP) regulations for finished pharmaceuticals. We are amending the regulations to modernize or clarify some of the CGMP requirements, as well as harmonize some of the CGMP requirements with those of other foreign regulators and other FDA regulations. These amendments are also consistent with current industry practice. We are taking this action as part of our continuing effort to revise outdated regulations without diminishing public health protection. We are issuing a direct final rule for this action because FDA expects there will be no significant adverse comments on these amendments. Elsewhere in this issue of the Federal Register, we are publishing a companion proposed rule, under our usual notice-and-comment rulemaking procedures, to provide a procedural framework to finalize the rule in the event the agency receives any significant adverse comments and withdraws this direct final rule. The companion proposed rule and direct final rule are substantively identical.

The current status of forensic science laboratory accreditation in Europe

Forensic science is gaining some solid ground in the area of effective crime prevention, especially in the areas where more sophisticated use of available technology is prevalent. All it takes is high-level cooperation among nations that can help them deal with criminality that adopts a cross-border nature more and more. It is apparent that cooperation will not be enough on its own and this development will require a network of qualified forensic laboratories spread over Europe. It is argued in this paper that forensic science laboratories play an important role in the fight against crime. Another, complimentary argument is that forensic science laboratories need to be better involved in the fight against crime. For this to be achieved, a good level of cooperation should be established and maintained. It is also noted that harmonization is required for such cooperation and seeking accreditation according to an internationally acceptable standard, such as ISO/IEC 17025, will eventually bring harmonization as an end result. Because, ISO/IEC 17025 as an international standard, has been a tool that helps forensic science laboratories in the current trend towards accreditation that can be observed not only in Europe, but also in the rest of the world of forensic science. In the introduction part, ISO/IEC 17025 states that "the acceptance of testing and calibration results between countries should be facilitated if laboratories comply with this international standard and if they obtain accreditation from bodies which have entered into mutual recognition agreements with equivalent bodies in other countries using this international standard." Furthermore, it is emphasized that the use of this international standard will assist in the harmonization of standards and procedures. The background of forensic science cooperation in Europe will be explained by using an existing European forensic science network, i.e. ENFSI, in order to understand the current status of forensic science in Europe better. The Council of Europe and the European Union approaches to forensic science will also be discussed by looking at the legal instruments and documents published by these two European organizations. Data collected from 52 European forensic science laboratories will be examined and findings will be evaluated from a quality assurance and accreditation point of view. The need for harmonization and accreditation in forensic science will be emphasized. The steps that should be taken at the European level for increasing and strengthening the role of European forensic science laboratories in the fight against crime will be given as recommendations in the conclusion.

Diagnostic X-ray facilities as per quality control performances in Tanzania

Without appropriate quality control (QC) and preventative maintenance (PM) measures for X-ray machines in place, the benefits of reduced dose to the patient and early diagnosis will not be realized. Quality control and PM also make it possible to unify X-ray-imaging practices in the country using international image quality guidelines. The impetus for the present work resulted from the concern that with the recent increase in the numbers of X-ray machines in Tanzania, but with limited technical support to maintain and operate them, can increase radiation risk to patients and lower diagnostic accuracy. The aim of this work is to report on the current status of diagnostic X-ray machines in Tanzania in order to produce the data needed to formulate QC and PM policies and strategies. These policies and strategies are needed to ensure that patients receive the lowest possible radiation risk and maximum health benefits from X-ray examinations. Four QC tests were performed on a total of 196 X-ray units. Accurate beam alignment and collimation were tested on 80 (41%) units, the timer accuracy was tested on 120 (61%) units, and a radiation leakage test was performed on 47(24%) units. Preventative maintenance tests were performed on all 196 X-ray units. The results showed that of the units tested for QC, 59% failed the kilovoltage (kVp) test, 57% failed the timer accuracy test, 60% failed the beam alignment test, and 20% failed the radiation leakage test. Only 13% of the units passed the PM test: 53% of the units were defective, and 34% were out of order. As a result of the PM findings, the government has introduced a rehabilitation project to service X-ray units and replace nonoperational X-ray units. The new units have full support service contracts signed by their suppliers. As a result of the QC findings, X-ray maintenance retraining programs have been introduced.

Demystifying the Occupational Safety and Health Administration inspection process

Being prepared for an Occupational Safety and Health Administration (OSHA) inspection can save a facility money, as well as potentially protect employees from serious illness or injury. This article explains the OSHA inspection process, types of violations that may be cited and the appeals process for employers and employees. Actual citations given in four recent OSHA health care facility inspections are discussed and general recommendations to prepare for an OSHA site visit are given.

The quality of laboratory testing today: an assessment of sigma metrics for analytic quality using performance data from proficiency testing surveys and the CLIA criteria for acceptable performance

To assess the analytic quality of laboratory testing in the United States, we obtained proficiency testing survey results from several national programs that comply with Clinical Laboratory Improvement Amendments (CLIA) regulations. We studied regulated tests (cholesterol, glucose, calcium, fibrinogen, and prothrombin time) and nonregulated tests (international normalized ratio [INR], glycohemoglobin, and prostate-specific antigen [PSA]). Quality was assessed on the sigma scale with a benchmark for minimum process performance of 3 sigma and a goal for world-class quality of 6 sigma. Based on the CLIA criteria for acceptable performance in proficiency testing (allowable total errors [TEa]), the national quality of cholesterol testing (TEa = 10%) estimated sigma values as 2.9 to 3.0; glucose (TEa = 10%), 2.9 to 3.3; calcium (TEa = 1.0 mg/dL), 2.8 to 3.0; prothrombin time (TEa = 15%), 1.8; INR (TEa = 20%), 2.4 to 3.5; fibrinogen (TEa = 20%), 1.8 to 3.2; glycohemoglobin (TEa = 10%), 1.9 to 2.6; and PSA (TEa = 10%), 1.2 to 1.8. The analytic quality of laboratory tests requires improvement in measurement performance and more intensive quality control monitoring than the CLIA minimum of 2 levels per day.

The quality of laboratory testing today: an assessment of sigma metrics for analytic quality using performance data from proficiency testing surveys and the CLIA criteria for acceptable performance

To assess the analytic quality of laboratory testing in the United States, we obtained proficiency testing survey results from several national programs that comply with Clinical Laboratory Improvement Amendments (CLIA) regulations. We studied regulated tests (cholesterol, glucose, calcium, fibrinogen, and prothrombin time) and nonregulated tests (international normalized ratio [INR], glycohemoglobin, and prostate-specific antigen [PSA]). Quality was assessed on the sigma scale with a benchmark for minimum process performance of 3 sigma and a goal for world-class quality of 6 sigma. Based on the CLIA criteria for acceptable performance in proficiency testing (allowable total errors [TEa]), the national quality of cholesterol testing (TEa = 10%) estimated sigma values as 2.9 to 3.0; glucose (TEa = 10%), 2.9 to 3.3; calcium (TEa = 1.0 mg/dL), 2.8 to 3.0; prothrombin time (TEa = 15%), 1.8; INR (TEa = 20%), 2.4 to 3.5; fibrinogen (TEa = 20%), 1.8 to 3.2; glycohemoglobin (TEa = 10%), 1.9 to 2.6; and PSA (TEa = 10%), 1.2 to 1.8. The analytic quality of laboratory tests requires improvement in measurement performance and more intensive quality control monitoring than the CLIA minimum of 2 levels per day.

WHO Expert Committee on Specifications for Pharmaceutical Preparations

This report presents the recommendations of an international group of experts convened by the World Health Organization to consider matters concerning the quality assurance of pharmaceuticals and specifications for drug substances and dosage forms. Of particular relevance to drug regulatory authorities and pharmaceutical manufacturers, this report discusses the monographs on antiretrovirals proposed for inclusion in The International Pharmacopoeia and specifications for radiopharmaceuticals, quality specifications for antituberculosis drugs and the revision of the monograph on artemisinin derivatives, as well as quality control of reference materials, good manufacturing practices (GMP), inspection, distribution and trade and other aspects of quality assurance of pharmaceuticals, and regulatory issues. The report is complemented by a number of annexes, including an amendment to good manufacturing practices: main principles regarding the requirement for the sampling of starting materials, guidelines on good manufacturing practices regarding water for pharmaceutical use, guidelines on the sampling of pharmaceutical products and related materials and draft guidelines for registration of fixed-dose combination medicinal products.

Voluntary accreditation of cellular therapies: Foundation for the Accreditation of Cellular Therapy (FACT)

Voluntary accreditation of cells, tissues, and cellular and tissue-based products intended for human transplantation is an important mechanism for improving quality in cellular therapy. The Foundation for the Accreditation of Cellular Therapy (FACT) has developed and implemented programs of voluntary inspection and accreditation for hematopoietic cellular therapy, and for cord blood banking. These programs are based on the standards of the clinical and laboratory professionals of the American Society of Blood and Marrow Transplantation (ASBMT), the International Society for Cellular Therapy (ISCT), and NETCORD. FACT has collaborated with European colleagues in the development of the Joint Accreditation Committee in Europe (jACIE). FACT has published standards documents, a guidance manual, accreditation checklists, and inspection documents; and has trained as inspectors over 300 professionals active in the field. All inspectors have a minimum of 5 years' experience in the area they inspect. Since the incorporation of FACT in 1996, 215 hematopoietic progenitor cell facilities have applied for FACT accreditation. Of these facilities, 113 are fully accredited; the others are in the process of document submission or inspection. Significant opportunities and challenges exist for FACT in the future, including keeping standards and guidance materials current and relevant, recruiting and retaining expert inspectors, and establishing collaborations to develop standards and accreditation systems for new cellular products. The continuing dialogue with the Food and Drug Administration (FDA) is also important to ensure that they are aware of the accomplishments of voluntary accreditation, and keep FACT membership alerted to FDA intentions for the future. Other potential avenues of communication and cooperation with FDA and other regulatory agencies are being investigated and evaluated.

Solutions for research chimpanzees

As one of humankind's closest animal relatives, the chimpanzee has proven to be a valuable but controversial research model. The author provides an overview of efforts to improve chimpanzee welfare, and describes a facility dedicated to providing lifelong care for these nonhuman primates following retirement from research.

Needlestick Safety and Prevention Act

The Occupational Safety and Health Administration (OSHA) is now enforcing the new Needlestick Safety and Prevention Act. Updated enforcement procedures [CPL 2-2.69] for the revised Bloodborne Pathogen Standard were distributed to OSHA inspectors in tlate 2001. Facilities that have not implemented safer medical devices with engineered sharp injury protection are at risk for an OSHA citation. Any facility or organization that employs individuals who might reasonably experience occupational exposure to blood or other potentially infectious materials must comply with the regulation, even if the facility has never had a needlestick injury. This article will present the new regulations and discuss who is affected by the regulations.

Suggested Standard Operating Procedures (SOPs) for the preparation of electron microscopy samples for toxicology/pathology studies in a GLP environment

We provide a set of Standard Operating Procedures (SOPs) for preparing samples for electron microscopic evaluation that allow storage of samples in the primary fixative for at least 17 years without noticeable degradation, do not compromise the ability to prepare the same samples for standard light microscopic evaluation, and provide tips for orientation of samples that may be necessary for evaluation. Guidelines for proper sample size, buffer composition, and fluid concentrations during processing are given. The impact of these procedures on specimen quality, ability to produce truly comparable samples for drug development studies, and ways to minimize time spent by technicians preparing these samples during necropsies is evaluated. Although many laboratories routinely employ most of these techniques, this compilation will facilitate the simultaneous light and electron microscopic preparation by the pathologist of comparable specimens that can be stored long-term at 4 degrees C in McDowell's and Trump's 4F:1G fixative (4F:1G).

Managing a low-level mixed waste storage facility: a checklist for compliance to 40 CFR 266

Do you hold radioactive material for storage and decay before disposal? Does your material contain any hazardous chemical as defined by the EPA? You may need to take a closer look at the Final Rule published by the EPA in the May 16, 2001 Federal Register.

Handling, storage, treatment, and disposal of mixed wastes at medical facilities and academic institutions

Mixed waste includes hazardous/ toxic chemicals and radioactive materials mixed together. Most mixed wastes are difficult and costly to work with safely. Meeting the legal and regulatory requirements to generate, use, store, treat, and dispose of mixed waste can also be costly and difficult. The regulations that govern mixed waste, from creation to final disposition, are extensive and complex to implement. Complete and documented compliance with the applicable regulations is essential to demonstrate that personnel and environment safety has been assured. Noncompliance with the multitude of government's requirements for mixed waste can lead to serious repercussions. Noncompliance may cause serious harm to individuals and the environment, fines and penalties against a facility, and/or suspension of a facility's operations. Each facility that generates, uses, or possesses mixed waste must employ adequate expertise to assure full regulatory compliance. This paper introduces the large scope and variety of mixed waste and the current and potential methods to treat and ultimately dispose of, or recycle, mixed waste. Alternatives for regulatory compliance are also discussed and effective means to control mixed waste are presented. The paper is based on my Master's Thesis (Hageman 2001).

Performing laboratory compliance audits

Billions of dollars are paid improperly each year because of laboratory service billing errors that include services not covered, incorrect coding, lack of medical necessity, and unsupported services. An important part of a laboratory compliance program is the compliance audit. This article discusses barriers to a successful audit, audit skills for the laboratory, areas to cover in an audit, and writing the audit report. Intermountain Health Care (IHC) is an integrated health-care system consisting of 20 hospitals in Utah and Idaho, health plans with 450,000 directly covered lives and contracts to third-party insurance companies covering 500,000 additional lives, and 75 other facilities with 400 employed physicians. Approximately 1,000 of IHC's 23,000 employees work in laboratories.

[On the sanitary-hygienic state of the drinking water supply facility and the organization of the sanitary and bacteriological control of the water supply of the population of Grozny in recent years]

Information on the state of water supply in Grozny in the time of peace, during the armed conflict of 1994-1996 and at the period of the antiterrorist operation in the year 2000 is presented. In the year 2000 the centralized water supply of the population proved to be completely paralyzed. The quality of water brought to the city and water from the sources of decentralized water supply considerably deviated from the norm by its bacteriological characteristics. The control of the quality of drinking water supplied to the population was carried out only by the bacteriological laboratory of the specialized antiepidemic brigade.

The external review of quality improvement in health care organizations: a qualitative study

OBJECTIVE

To explore the use of external approaches to quality improvement in health care organizations, through a descriptive evaluation of the process and impact of external reviews of clinical governance arrangements at health care provider organizations in the National Health Service (NHS) in England.

DESIGN

A qualitative study, involving the use of face-to-face and telephone interviews with senior managers and clinicians in health care provider organizations and with members of a regional clinical governance review team.

SETTING

The West Midlands region of England, in which there are 47 NHS trusts (health care provider organizations).

STUDY PARTICIPANTS

A total of 151 senior clinicians and managers at NHS trusts in the West Midlands and 12 members of a specially constituted regional clinical governance review team.

INTERVENTION

Clinical governance review visits which were undertaken by the regional clinical governance review team to all NHS trusts between April 1999 and February 2000. Interviews with senior managers and clinicians took place before and after the review visits had taken place; interviews with members of the clinical governance review team took place when they had undertaken most of their visits.

RESULTS

The prospect of external review produced mixed reactions in health care provider organizations, and preparing for such a review was a substantial and time-consuming task. The review itself was often productive, although differences in attitudes and expectations between health care provider organizations and review team members created tensions, especially when the results of the review were reported back. External reviews rarely generated wholly new knowledge, were more confirmatory than revelatory, and did not usually lead to major changes in policy, strategy or practice.

CONCLUSIONS

External review systems are widely used in health care to promote quality improvement in health care provider organizations, but their effectiveness is little researched and the optimal design of systems of external review is not well understood. More attention to the design and impact of external review would help to maximize its benefits and minimize costs and adverse effects.

Dentistry, amalgam, and pollution prevention

California has issued fish consumption advisories because of mercury in lakes, reservoirs, creeks, rivers, and bays. Mercury in these waterways leads to the formation of methylmercury, which is toxic and bioaccumulative. Dental practices and other health care settings contribute a portion of this mercury. Government agencies are implementing programs to reduce mercury pollution. Dentists can reduce their contributions by implementing best management practices. They may also consider using pretreatment technologies as more information becomes available about their use and effectiveness.

Crafting a new vision for compliance

The healthcare industry has been overwhelmed with year 2000 activities while providers continue to move toward the goal of a computer-based patient medical record. The ultimate goal remains to provide seamless access to critical patient, clinical, administrative, and financial data and support a cohesive approach throughout the continuum of care. Until recently, compliance and standards have not been at the forefront of provider efforts and have even met with resistance. The view of compliance must move up to the next level: an organizational and management tool. This article discusses how providers may begin to develop a compliance model that supports business strategies and functions as well as information management programs.

Health, safety and environmental protection in a biological research laboratory

This manuscript summarizes the mandatory regulations for Health, safety and environmental protection (HSE) at the Novartis Forschungsinstitut-Vienna to ensure the safe and contained biological laboratory work especially with class II agents in the specialized biosafety level 2 (BL2) facilities available at this institute. These regulations apply to work practices conducted within these facilities; to special safe-containment features of these BL2 facilities; to containment and decontamination of biohazardous or potentially biohazardous materials of risk class II; and to the procedures in place to guarantee that these regulations are strictly carried out, and that only individuals with the appropriate training and approval have access to these facilities. The regulations governing BL2 facilities summarized here have been taken directly from CDC and NIH public documents; any special adaptations or additions to these regulations have been stated as such, in order to make these guidelines as transparent and nonredundant as possible.

Industrial responses to constrained OSHA regulation. Occupational Safety and Health Administration

As part of the effort to reduce the size and economic impact of the federal establishment, congressional conservatives are proposing legislation to restrict the regulatory activity of the Occupational Safety and Health Administration (OSHA). These proposals push OSHA toward a purely consultative role, at a corresponding cost in direct regulatory capability. The Clinton administration's reinvention of government initiative is also moving OSHA toward a consultative role based on a strategy of cooperative compliance or industry self-regulation with a strong coercive foundation. Since both camps appear to agree that self-regulation can assure a safe and healthy workplace, the remaining debate concerns the extent to which coercive regulation is still needed. National survey data on the industrial provision of occupational safety and health services in the manufacturing sector were used to measure changes in industrial safety and health activity between 1972-74 and 1981-83. In conjunction with data on OSHA command-and-control regulatory activity from 1972 to 1979, these data permitted an examination of the relationship between command-and-control regulatory activities and changes in industrial behavior that could be regarded as a form of self-regulation. This analysis showed that coercive regulation by OSHA in the 1970s was significantly related to industry self-regulation efforts, although the relationship varied by industrial facility employment size and type of regulatory coercion. These results indicate that coercive regulation should be retained as an industrial incentive in any self-regulation policy paradigm. The results also provide evidence that OSHA regulatory policy should be based on anticipated differences in industrial response to various coercive measures.