National health insurance: comments on selected issues.

The primary objective of national health insurance is to make sure that good medical care is available to everyone at a price he or she can afford. Any plan when first adopted will have a role for both private and government insurance but, regardless of the mix, the combined system should meet the following goals: (i) to the extent possible the needs of low-income people should be met through plans that cover others; (ii) the part of the plan to be operated by government should be built on the administrative structure of Medicare, but with changes in reimbursement to encourage more efficient delivery of care; (iii) direct capital and manpower controls should be included; and (iv) rather than acting primarily as an insurer protecting people against the cost of medical care, the plan should be an aggressive buyer of health services, defining the product it is willing to buy and the price it is willing to pay.

Nurse autonomy expressed in Portuguese and Brazilian professional legislation: a documentary study (1986-2022) / Autonomía enfermera-enfermero expresada en la legislación profesional portuguesa y brasileña: estudio documental (1986-2022) / Autonomia da enfermeira-enfermeiro expressa na legislação profissional portuguesa e brasileira: estudo documental (1986-2022)

ABSTRACT Objective: To analyze the convergence of nurse's autonomy expressed in Brazilian and Portuguese professional practice legislation. Method: Qualitative, social-historical documentary study on the normalization of Brazilian and Portuguese professional standards for nursing practice, materials socialized in the digital collection of the profession's organizational and disciplinary entities. Qualitative analysis from the perspective of Eliot Freidson's sociology of professions. Results: Ten standards were analyzed, five from each country, which establish legislation for the nurses' professional practice. The following categories emerged: autonomy of knowledge and specific competence of the profession, in the ethical limits of the multi-professional relationship and in the disciplining of training for professional practice. Conclusion: The professional autonomy under analysis implies providing access to services and to multi-professionality for the availability of health to society.

RESUMEN Objetivo: Analizar la convergencia de la autonomía enfermera-enfermero expresada en la legislación de práctica profesional brasileña y portuguesa. Método: Estudio documental cualitativo, sociohistórico, sobre la normalización de los estándares profesionales brasileños y portugueses para la práctica de enfermería, materiales socializados en el acervo digital de las entidades organizativas y disciplinarias de la profesión. Análisis cualitativo desde la perspectiva de la sociología de las profesiones de Eliot Freidson. Resultados: Se analizaron 10 normas, cinco de cada país, que establecen la legislación para el ejercicio profesional de la enfermería. Surgieron las categorías: autonomía del conocimiento y competencia específica de la profesión, en los límites éticos de la relación multiprofesional y en la disciplina de la formación para el ejercicio profesional. Conclusión: La autonomía profesional bajo análisis implica posibilitar acceso a los servicios, multiprofesionalidad para la disponibilidad de la salud a la sociedad.

RESUMO Objetivo: Analisar a convergência da autonomia da enfermeira-enfermeiro expressa na legislação do exercício profissional brasileiro e português. Método: Estudo qualitativo, sócio-histórico documental na normalização de padrões profissionais brasileiro e português do exercício da enfermagem, materiais socializados no acervo digital das entidades organizativas e disciplinares da profissão. Análise qualitativa sob a perspectiva da sociologia das profissões de Eliot Freidson. Resultados: Analisadas 10 normalizações, cinco de cada país, em que estabelecem as legislações para o exercício profissional da enfermeira-enfermeiro. Emergiram as categorias: autonomia de conhecimento e competência específica da profissão, na eticidade dos limites da relação multiprofissional e no disciplinamento da formação ao exercício profissional. Conclusão: A autonomia profissional em análise implica em oportunizar o acesso aos serviços, à multiprofissionalidade para a disponibilidade de saúde à sociedade.

In loco nursing practice inspection costs in a Brazilian setting / Costes de la inspección in loco de la supervisión de la práctica profesional de enfermería en una realidad brasileña / Custos da inspeção in loco da fiscalização do exercício profissional de Enfermagem em uma realidade brasileira

Abstract Objective: To identify the average direct cost related to the direct labor of the inspectors involved in the "in loco inspection" step of the inspection process carried out at the Headquarters of the Regional Nursing Council of São Paulo. Method: Quantitative, exploratory-descriptive research, in the form of a single case study. The non-probabilistic convenience sample consisted of records of initial and return "in loco inspections", carried out by inspectors working at the Headquarters of The Regional Nursing Council of São Paulo, from January 13, 2020 to March 13, 2020. Results: The average direct cost of initial in loco inspection (N = 182) corresponded to BRL 331.67 (SD = 140.32), ranging from BRL 115.80 to BRL 1071.15, and that of return in loco inspection (N = 98) to BRL 256.16 (SD = 130.90), ranging from BRL 77.20 to BRL 694.80. Time and cost variables analysis of initial and return in loco inspections showed an alpha significance level of 0.05, and it was possible to statistically state that the time (p ≤ 0.001) and the cost of initial in loco inspection (p ≤ 0.001) are higher than those for return in loco inspection. Conclusion: the cost of the step of "in loco inspection" will support the Nursing Council in the decision-making process aiming at allocating efficiency of human resources required in the inspection process.

RESUMEN Objetivo: Identificar el coste medio directo relacionado con la labor directa de los inspectores involucrados en la etapa de "inspección in loco" del proceso de inspección realizado en la Unidad Sede del Consejo Regional de Enfermería de São Paulo. Método: Investigación cuantitativa, exploratoria-descriptiva, en forma de estudio de caso único. La muestra de conveniencia no probabilística consistió en registros de "inspecciones in loco", iniciales y de retorno, realizadas por inspectores que trabajan en la Sede, desde el 13/01/2020 al 13/03/2020. Resultados: El coste medio directo de la inspección inicial (N = 182) correspondió a R$ 331,67 (DP = 140,32), con un rango de R$ 115,80 a R$ 1071,15, y el de la inspección de retorno (N = 98) a R$ 256,16 (DP = 130,90), oscilando entre R$ 77,20 y R$ 694,80. El análisis de las variables tiempo y coste de las inspecciones inicial y de retorno indicó un nivel de significancia alfa de 0.05, y fue posible afirmar estadísticamente que el tiempo (p ≤ 0.001) y el costo de la inspección inicial (p ≤ 0,001) son mayores que los de la inspección de retorno. Conclusión: el costo de la etapa de "inspección in loco" subsidiará el Consejo en el proceso de toma de decisiones buscando la eficiencia en la asignación de los recursos humanos requeridos en el proceso de inspección.

RESUMO Objetivo: Identificar o custo direto médio relativo à mão de obra direta dos fiscais envolvidos na etapa "inspeção in loco" do processo de fiscalização realizado na Unidade Sede do Conselho Regional de Enfermagem de São Paulo. Método: Pesquisa quantitativa, exploratório-descritiva, na modalidade de estudo de caso único. A amostra de conveniência, não probabilística, foi constituída por registros de "inspeções in loco", iniciais e de retorno, realizadas por fiscais atuantes na Unidade Sede, no período de 13/01/2020 a 13/03/2020. Resultados: O custo direto médio da inspeção in loco inicial (N = 182) correspondeu a R$ 331,67 (DP = 140,32), variando de R$ 115,80 a R$ 1071,15, e da inspeção in loco de retorno (N = 98) a R$ 256,16 (DP = 130,90), variando entre R$77,20 e R$ 694,80. A análise das variáveis tempo e custo das inspeções in loco iniciais e de retorno evidenciou nível de significância alfa de 0,05, sendo possível afirmar estatisticamente que o tempo (p ≤ 0,001) e o custo da inspeção in loco inicial (p ≤ 0,001) são maiores do que os da inspeção in loco de retorno. Conclusão: o custeio da etapa "inspeção in loco" subsidiará o Conselho no processo decisório visando à eficiência alocativa dos recursos humanos requeridos no processo de fiscalização.

Tipos penais no exercício profissional de enfermagem: abordagem quantitativa / Tipos penales en el ejercicio profesional de enfermería: enfoque cuantitativo / Legal actions in professional nursing practice: a quantitative approach

Resumo Objetivo: Descrever as ocorrências éticas de enfermagem envolvendo tipos penais nos processos éticos (PEs) julgados pelo Conselho Regional de Enfermagem de São Paulo (Coren/SP). Métodos: Estudo descritivo de abordagem quantitativa. A amostra foi constituída por documentos relacionados a 169 profissionais julgados em 2012 e 2013 no Coren-SP por ocorrências envolvendo tipos penais. Resultados: Profissionais de nível médio foram os mais envolvidos (71%), com maior participação de Auxiliares de Enfermagem (46,12%). Detectou-se maior prevalência de iniciantes no exercício profissional. As ocorrências descritas como tipos penais foram: homicídio; lesão corporal; abandono de incapaz; maus tratos; injúria; furto; apropriação indébita; estelionato; vilipêndio a cadáver; estupro; importunação sexual; assédio sexual, falsificação; corrupção; adulteração ou alteração de produto destinado a fins terapêuticos e medicinais; exercício ilegal da medicina; falsificação de documento público; uso de documento falso; falsidade ideológica; peculato; extravio, sonegação ou inutilização de livro ou documento público e; contravenções relativas à organização do trabalho como exercício ilegal de profissão. A maioria das ocorrências foram de natureza procedimental com resultado óbito ou lesão corporal, tendo maior incidência no ato negligente. Quanto às ocorrências de natureza atitudinal, o exercício ilegal de profissão teve maior incidência, seguida de falsificação de documento. Como desfecho dos julgamentos, 63,3% dos profissionais envolvidos foram considerados culpados e a penalidade mais aplicada foi advertência (21,5%). Conclusão: Os resultados do estudo foram de suma importãncia para identificar as ocorrências envolvendo tipos penais e com isso, a necessidade de se aprofundar a discussão sobre os problemas éticos na prática cotidiana do trabalho em enfermagem.

Resumen Objetivo: Describir los casos éticos de enfermería que incluyen tipos penales en procesos éticos (PE) juzgados por el Consejo Regional de Enfermería de São Paulo (Coren/SP). Métodos: Estudio descriptivo con enfoque cuantitativo. La muestra fue formada por documentos relacionados con 169 profesionales juzgados en 2012 y 2013 en el Coren/SP por casos que incluyeron tipos penales. Resultados: Profesionales de nivel intermedio fueron los más involucrados (71 %), con mayor participación de Auxiliares de Enfermería (46,12 %). Se detectó una mayor prevalencia de iniciantes en el ejercicio profesional. Los episodios descriptos como tipos penales fueron: homicidio; lesión corporal; abandono de incapaz; malos tratos; injuria; hurto; apropiación indebida; estafa; profanación de cadáver; violación; hostigamiento sexual; acoso sexual; falsificación; corrupción; adulteración o modificación de producto destinado a fines terapéuticos y medicinales; ejercicio ilegal de la medicina; falsificación de documento público; uso de documento falso; falsedad ideológica; malversación de fondos; pérdida, apropiación o inutilización de libro o documento público, e infracciones relacionadas con la organización del trabajo como ejercicio ilegal de la profesión. La mayoría de los episodios fueron de naturaleza procedimental con resultado de fallecimiento o lesión corporal, con una mayor incidencia en el acto negligente. Con relación a los episodios de naturaleza actitudinal, el ejercicio ilegal de la profesión tuvo una incidencia mayor, seguida por la falsificación de documento. Como resultado de los juzgamientos, el 63,3 % de los profesionales involucrados fueron considerados culpables y la pena más aplicada fue advertencia (21,5 %). Conclusión: Los resultados del estudio fueron de suma importancia para identificar los casos que incluyen tipos penales y, por lo tanto, también lo es la necesidad de profundizar la discusión sobre problemas éticos en la práctica cotidiana del trabajo de enfermería.

Abstract Objective: To describe the ethical violations involving legal actions in ethical lawsuits (ELs) judged by the Regional Nursing Council of São Paulo (Coren/SP). Method: Descriptive study with a quantitative approach. The sample consisted of documents related to 169 professionals tried in 2012 and 2013 at Coren-SP for cases involving legal actions. Results: Professionals with complete high school were more involved in lawsuits (71%), most professionals were Nursing Assistants (46.12%) and early career professionals. The occurrences described as legal actions were: homicide; bodily injury; abandonment of disabled person; maltreatment; defamation; theft; embezzlement; swindling; abuse of corpse; rape; sexual abuse; sexual harassment; forgery; corruption; counterfeiting, contamination, adulteration or alteration of product intended for therapeutic or medicinal purposes; illegal practice of medicine; forgery of public document; use of false document; identity fraud; peculation; loss, fraud or destruction of a public book or document; and misdemeanors related to the organization of work as an illegal exercise of profession. Most of the occurrences had a procedural nature and resulted in death or bodily injury, with a greater incidence of negligent acts. As for the attitudinal occurrences, the illegal exercise of profession had a higher incidence, followed by forgery of documents. As for the outcome of the trials, 63.3% of the professionals involved were found guilty and the most applied penalty was a warning (21.5%). Conclusion: The results of the study were extremely important to identify the occurrences involving legal actions and, consequently, the need to deepen the discussion about ethical issues in the daily nursing practice.

The relationship of community mental health centers to the professional standards review organizations program.

Given the realities of the professional standards review organization (PSRO) program and the necessity for accountability on the part of all health service providers, community mental health centers (CMHCs) should begin now to take an active role in planning their involvement in the PSRO program. The author points out the need for both psychiatrists and nonphysician professionals to become involved. There are many types of mental health services delivered in a given area, and the active involvement of CMHCs can be a major determinant of the shape and direction of this impact.

Development of a pollution prevention and energy efficiency clearinghouse for biomedical research facilities.

This is the report of the National Association of Physicians for the Environment Committee on Development of a Pollution Prevention and Energy Efficiency Clearinghouse for Biomedical Research Facilities from the Leadership Conference on Biomedical Research and the Environment held at the National Institutes of Health in Bethesda, Maryland, on 1--2 November 1999. A major goal of the conference was the establishment of a World Wide Web-based clearinghouse, which would lend tremendous resources to the biomedical research community by providing access to a database of peer-reviewed articles and references dealing with a host of aspects of biomedical research relating to energy efficiency, pollution prevention, and waste reduction. A temporary website has been established with the assistance of the U.S. Environmental Protection Agency (EPA) Regions III and IV, where a pilot site provides access to the EPA's existing databases on these topics. A system of peer review for articles and promising techniques still must be developed, but a glimpse of topics and search engines is available for comment and review on the EPA Region IV-supported website (http://wrrc.p2pays.org/).

Quality-of-care assessment. I. Outpatient management of acute bacterial cystitis as the model.

A study was undertaken to determine whether a process audit of outpatient medical care would correlate significantly with the outcomes of care and thus prove to be a valid method for assessing the quality of medical care in the outpatient setting. Acute bacterial cystitis in women was selected as the model for study. A series of 42 cases was reviewed by retrospective analysis of patient records supplemented by follow-up interviews and collection of a follow-up urine culture from each patient to document the outcome of treatment. No positive association was demonstrated between the processes for satisfactory care selected by the expert criteria committee and the observed outcomes. Reasons for this failure in the present study and for deficiencies of the process audit method in general are discussed.

Effectiveness research and assessment of clinical outcome: a review of Federal Government and medical community involvement.

Because of their concern about the increasing costs of health care, industry and government contractors for health care will attempt to control health-care costs for the foreseeable future. New proposals for cost containment include those that are focused on cost alone--for example, expenditure limits--and those that propose to control costs by limiting medical interventions to those of known efficacy. This latter attempt has come to be known as "effectiveness research." Herein, we briefly review the history of quality assurance and cost-containment efforts in the United States, giving special attention to the current initiative based on effectiveness research. Although the effectiveness research initiative has shortcomings (for example, it will not provide guidance when data are not available), it seems to be superior to the current peer review system because it encourages the development of a knowledge base and deemphasizes punitive measures as a way to ensure quality and control costs. The Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) establishes a federal agency, the Agency for Health Care Policy and Research, within the Public Health Service to focus on effectiveness research.

Benefits of an intensive community surgical audit program.

In addition to educational benefits, an intensive audit program has satisfied Joint Commission on the Accreditation of Hospitals requirements, allowed in-house Professional Standards Review Organization accreditation, increased percentage of surgery performed by qualified surgeons, and led to the establishment of an effective morbidity and mortality conference. Better methods of granting surgical privileges have been developed, and our accumulated statistics have been utilized to assure our local press and public that we are practicing good quality surgery.

Health Care Quality Improvement Program: a new approach.

The Health Care Financing Administration (HCFA) has embarked on a new program to ensure the quality of care provided to Medicare and Medicaid beneficiaries. The approach, entitled the Health Care Quality Improvement Program (HCQIP), focuses on improving the outcomes of care, measuring improvement, and surveying for patient satisfaction. HCQIP, still in its infancy, is undertaken in collaboration with the providers of care. This article describes HCQIP.

Legislative update ... quality of care under the Medicare program.

The following is the text of a statement made by William L. Roper, M.D., Administrator of the Health Care Financing Administration, before the Committee on Finance, U.S. Senate, on June 3, 1986. He discusses concerns about quality of care under the Medicare program and his commitment to ensuring that every Medicare patient receives high quality, medically necessary care. He delineates the mechanisms and activities that the Health Care Financing Administration uses to assure quality, new methods that are being explored, and the research program emphasis on the impact of the prospective payment system on quality as well as possible refinements to the system.

The dynamics of dietetics.

The forces which have and are producing change in dietetics are recapitulated, as are developments in the profession which have evolved since 1972 when the Study Commission on Dietetics made its report. The coordinated undergraduate program in dietetics has gained much ground; in 1972, there were but seven such programs. Today there are forty-three. More than three hundred traineeships are currently preparing over five hundred trainees to take their places in the profession. Another facet of training involves programs for dietetic technicians and dietetic assistants, designed to open up the career ladder concept. Continuing education is of prime importance for those beyond the entry-level of competence. The dietitian's first responsibility is to society, preceding that for the profession-as has been plainly indicated in a number of A.D.A. Position Papers and the emphasis of the Association in its legislative thrust on the value of nutrition education in preventive health care. Concern of the Association about the competency of practicing dietitians has also been reflected in the early appointment of a Committee on Professional Standards Review. The Association, as a member of the National Nutrition Consortium, is an advocate for a "National Nutrition Policy" and must continue to work for recognition that nutritional care is basic to comprehensive health care.

Quality assurance in ambulatory nutritional care. I. Past, present, and future.

Public health nutritionists have begun to coordinate efforts toward development of national standards for ambulatory nutritional care by writing and field testing criteria for selected target populations of pregnant women, infants, and children. These efforts have identified problems related to the "state of the art" in both quality assurance and nutrition science. This article reviews the literature on quality assurance in nutritional care and summarizes the current efforts culminating in publication of a preliminary guide on quality assurance in ambulatory nutrition care by the U.S. Department of Health and Human Services.

A suggested schema for utilization review for a Community Mental Health Center.

Three record-keeping models were examined by an interdisciplinary committee at the Rochester Mental Health Center to see which would best meet the needs for a standardized record format that could be used by an outpatient comprehensive community mental health center. The systems examined were: (1) Model Criteria Set, (2) Problem Oriented Record, and (3) a Combination Diagnosis and Standardized Problem List. A modification of the Combination System used at the Cleveland Metropolitan General Hospital was developed. Using this tool, an audit committee began the process of Utilization Review. It is a suggested schema to other outpatient mental health centers who are in the process of developing a utilization review process.

Setting program standards for New York State's periodic medical review.

This article describes the methodology used to develop program standards for a new periodic medical review/independent professional review (PMR/IPR) in New York State nursing homes. The new program consists of two stages: a first, cursory stage for the purpose of identifying patients to be subjected to a more thorough process review in the second stage. Program standards consist of (1) norms for the percentage of patients failing Stage 1 before a second stage is undertaken in a nursing home and (2) norms for the percentage of patients failing the second stage before the home is subject to corrective action. The actual standards that were developed are also presented.

Quality assurance through external controls.

Concern since the early part of this century for the quality of health care services has led to external controls in the United States that are more extensive, more intrusive, and more complex than they are elsewhere in the world. I suggest that this is the result of the decentralized nature of our health care system and the dominance of the American legal system and its adversarial orientation. This in turn has led to external control processes that focus on quantifiable, but often secondary or tangential, aspects of service that measure what is minimally acceptable rather than what is optimal. Perhaps it would be more fruitful for external control to intervene at a higher level by creating expectations for the process of quality assurance--that is, to create a system of external controls over internal controls. This, in turn, may lead to a quality assurance system focused on the more central, if more subjective, dimensions of health care.

Profits and fiscal pressure in the prospective payment system: their impacts on hospitals.

For hospitals that were under Medicare's Prospective Payment System (PPS) for one and two years in their 1985 fiscal year, this paper examines how variation in the fiscal pressure PPS imposed affected expenditures and other aspects of behavior. The analysis shows that in hospitals' second as well as first year on PPS, hospitals under greater pressure experienced greater behavioral change. However, second year changes were far smaller than changes in the system's first year. Evidence that variation in pressure reflects factors in addition to hospitals' relative efficiency and may undermine rather than promote appropriate cost containment leads the authors to propose modifications in PPS methods.

The challenges and prospects for quality assessment and assurance in ambulatory care.

As hospital cost containment has moved care into ambulatory settings, quality assurance requirements have followed. These requirements should focus on primary care as a means to prevent disease and limit disability while saving hospital costs. Methods for external and internal quality assurance already exist for primary care, although refinement and development of less expensive techniques is needed. Uniform quality assurance requirements that satisfy all external reviewers should be developed and applied evenhandedly to fee-for-service and prepaid providers. A top priority is the development of a uniform computerized data base for primary care encounters.

PSRO: current status of the professional standards review organization program.

Since Public Law 92-603 was enacted in October 1972 considerable progress has been made in the establishment of Professional Standards Review Organizations (PSROs) for the purpose of determining the necessity, appropriateness, and quality of medical care provided beneficiaries of the major programs authorized in the Social Security Act. Sixty-five conditional PSROs are implementing review in acute care hospitals in their geographic area, and 55 planning groups are developing plans to qualify for conditional PSRO designation. The PSRO hospital review system is based on three interrelated review mechanisms. These are concurrent review, which includes admission certification, and continued stay review through discharge; medical care evaluation studies; and analysis of hospital, practitioner, and patient profiles. This article describes the review system in some detail and the potential opportunities the PSRO program offers to occupational therapists.