80 questions for UK biological security.

Multiple national and international trends and drivers are radically changing what biological security means for the United Kingdom (UK). New technologies present novel opportunities and challenges, and globalisation has created new pathways and increased the speed, volume and routes by which organisms can spread. The UK Biological Security Strategy (2018) acknowledges the importance of research on biological security in the UK. Given the breadth of potential research, a targeted agenda identifying the questions most critical to effective and coordinated progress in different disciplines of biological security is required. We used expert elicitation to generate 80 policy-relevant research questions considered by participants to have the greatest impact on UK biological security. Drawing on a collaboratively-developed set of 450 questions, proposed by 41 experts from academia, industry and the UK government (consulting 168 additional experts) we subdivided the final 80 questions into six categories: bioengineering; communication and behaviour; disease threats (including pandemics); governance and policy; invasive alien species; and securing biological materials and securing against misuse. Initially, the questions were ranked through a voting process and then reduced and refined to 80 during a one-day workshop with 35 participants from a variety of disciplines. Consistently emerging themes included: the nature of current and potential biological security threats, the efficacy of existing management actions, and the most appropriate future options. The resulting questions offer a research agenda for biological security in the UK that can assist the targeting of research resources and inform the implementation of the UK Biological Security Strategy. These questions include research that could aid with the mitigation of Covid-19, and preparation for the next pandemic. We hope that our structured and rigorous approach to creating a biological security research agenda will be replicated in other countries and regions. The world, not just the UK, is in need of a thoughtful approach to directing biological security research to tackle the emerging issues.

Clinical governance breakdown: Australian cases of wilful blindness and whistleblowing.

BACKGROUND: After their attempts to have patient safety concerns addressed internally were ignored by wilfully blind managers, nurses from Bundaberg Base Hospital and Macarthur Health Service felt compelled to 'blow the whistle'. Wilful blindness is the human desire to prefer ignorance to knowledge; the responsibility to be informed is shirked. OBJECTIVE: To provide an account of instances of wilful blindness identified in two high-profile cases of nurse whistleblowing in Australia. RESEARCH DESIGN: Critical case study methodology using Fay's Critical Social Theory to examine, analyse and interpret existing data generated by the Commissions of Inquiry held into Bundaberg Base Hospital and Macarthur Health Service patient safety breaches. All data was publicly available and assessed according to the requirements of unobtrusive research methods and secondary data analysis. ETHICAL CONSIDERATIONS: Data collection for the case studies relied entirely on publicly available documentary sources recounting and detailing past events. FINDINGS: Data from both cases reveal managers demonstrating wilful blindness towards patient safety concerns. Concerns were unaddressed; nurses, instead, experienced retaliatory responses leading to a 'social crisis' in the organisation and to whistleblowing. CONCLUSION: Managers tasked with clinical governance must be aware of mechanisms with the potential to blind them. The human tendency to favour positive news and avoid conflict is powerful. Understanding wilful blindness can assist managers' awareness of the competing emotions occurring in response to ethical challenges, such as whistleblowing.

An overview of future EU health systems. An insight into governance, primary care, data collection and citizens' participation.

Background: Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities. Methods: This paper originated from a workshop entitled 'Health systems for the future' held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens' participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process. Results: In the parliamentary debate, was discussed the concept that, in the near future, health systems' effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems. Conclusions: Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges.

Enhanced Multi-Service Markets: An Evolution in Military Health System Governance.

Background: The evolution of governance models for the Military Health System's (MHS) large hospitals, called medical treatment facilities (MTFs), has culminated with the effort to implement Enhanced Multi-Service Markets (eMSM). The term eMSM refers to two separate concepts. First, MSM refers to those geographic areas, that is, markets, which have the following characteristics: they have MTFs that are operated by two or more Department of Defense (DoD) Services, that is, Army, Navy, or Air Force; there is a large beneficiary population; there is a substantial amount of direct care (i.e., beneficiaries are treated at MTFs instead of TRICARE's purchased care from civilian providers); and there is a substantial readiness and training platform. Second, the term "enhanced" refers to an increase in management authority over clinical and business operations, readiness, and MTF workload. Methods: A retrospective review was conducted to study the evolution of military and civilian health care delivery models for the purpose of understanding how governance models have changed since the 1980s to design and manage MTFs with overlapping catchments areas. Primary and secondary data sources were analyzed through a comprehensive literature review. Findings: Since the 1980s, the MHS governance models have evolved from testing various managed care models to a regionally focused TRICARE model and culminating with an overlapping catchment area model entitled eMSMs. The eMSM model partially fulfills the original vision because the eMSM leaders have limited budgetary and resource allocation authority. Discussion: The various models sought to improve governance of overlapping catchment areas with the intent to enhance medical readiness, community health, and individual health care while reducing costs. However, the success of the current model, that is, eMSMs, cannot be fully assessed because the eMSM model was not fully implemented as originally envisioned. Instead, the current eMSM model partially implements the eMSM model. As a result, the current eMSMs operate solely through cooperation and collaboration, without directive authority. Nevertheless, there have been some market-specific initiatives. Further analysis is necessary in the event that eMSM market managers are granted governance authority. This authority would include the ability to allocate the overall market's budget, determine common clinical and business functions, optimize the readiness of both the medical and the operational forces assigned to the market, and reallocate resources to optimize MTF workload. The results of this analysis may determine whether the fully implemented eMSMs optimize patient-centric initiatives as well as improve the market's efficiency and effectiveness.

[Governance - Government Action: Strengthening the Public's Health by more Public Accountability for Health - Results of the Working Group 11 of the Forum Future Public Health, Berlin 2016]. / Governance ­ Staatliches Handeln: Stärkung von Public Health durch mehr öffentliche Verantwortung für Gesundheit.

There is a considerable need for action to systematically strengthen public health in Germany by increasing public responsibility for health. A Good Governance approach for health has not yet been developed. The main areas of action would be the establishment of a health impact assessment for proposed legislation, the expansion of public health services and a new role for structural interventions for disease prevention and health promotion. It is also necessary to focus government action on the provision of public health services and - related to that - on strengthening the municipal level as a relevant decision-making structure for health.

Pre-hospital and retrieval medicine: Clinical governance and workforce models.

Pre-hospital and retrieval medicine (PHARM) has developed significantly in the past decade. This perspective article proposes that PHARM should develop with a clear focus on contemporary health governance principles, and that its workforce and models of care adopt modern interdisciplinary approaches. Many of the older systems of managing clinical standards, and outdated cultural approaches to professional 'turf', workforce and scope of practice have little place in high-performance organisations. This paper calls us to attention with a recommendation that best and safest systems of care, structured to optimise patient outcomes and system performance should be our goal.

Bureaucratization and medical professionals' values: A cross-national analysis.

Understanding the impact of the bureaucratization of governance systems on the occupational values of medical professionals is a fundamental concern of the sociological research of healthcare professions. While previous studies have examined the impact of bureaucratized management, organizations, and healthcare fields on medical professionals' values, there is a lack of cross-national research on the normative impact of the bureaucratized systems of national governance. Using the European Social Survey data for 29 countries, this study examines the impact of the bureaucratization of national governance systems on the occupational values of medical professionals. The findings indicate that medical professionals who are employed in countries with the more bureaucratized systems of national governance are less concerned with openness to change values, that emphasize autonomy and creativity, and self-transcendence values, that emphasize common good. The findings also indicate that the negative effect of the bureaucratization of national governance on the openness to change values is stronger for medical professionals in more bureaucratized organizations with more rationalized administration systems.

Measuring progress with clinical governance development in New Zealand: perceptions of senior doctors in 2010 and 2012.

BACKGROUND: Clinical governance has become a core component of health policy and services management in many countries in recent years. Yet tools for measuring its development are limited. We therefore created the Clinical Governance Development Index (CGDI), aimed to measure implementation of expressed government policy in New Zealand. METHODS: We developed a survey which was distributed in 2010 and again in 2012 to senior doctors employed in public hospitals. Responses to six survey items were weighted and combined to form the CGDI. Final scores for each of New Zealand's District Health Boards (DHBs) were calculated to compare performances between them as well as over time between the two surveys. RESULTS: New Zealand's overall performance in developing clinical governance improved between the two studies from 46% in 2010 to 54% in 2012 with marked differences by DHB. Statistically significant shifts in performance were evident on all but one CGDI item. CONCLUSIONS: The CGDI is a simple yet effective method which probes aspects of organisational commitment to clinical governance, respondent participation in organisational design, quality improvement, and teamwork. It could be adapted for use in other health systems.

What does the future hold for advanced nursing?

This third in a three-part series on advanced nursing explores the future demand for a flexible but regulated nursing career framework. Part 1 explored the historical evolution of advanced nursing, while part 2 discussed the development of a governance framework.

Clinical governance benchmarking issues in oncology: aggressiveness of cancer care and consumption of strong opioids. A single-center experience on measurement of quality of care.

AIMS AND BACKGROUND: The aggressiveness of cancer care near the end of life and the consumption of opioids are potential indicators of quality of care in palliative and end-of-life settings. The purpose of this article is to present a retrospective analysis regarding these themes and the adopted procedures to improve quality of care. METHODS: We evaluated all cancer patients treated and deceased during 2008 and considered those who died and received any antiblastic therapy within 14 and 30 days prior to death. Moreover, we evaluated the annual consumption of pure opioids during 2007 and 2008 in our inpatient clinic. We found that 5% and 9% of all treated patients were still receiving antiblastic treatment near the end of life within respectively 14 and 30 days prior to death (respectively 29.6% and 51.5% of deceased patients). All but 2 patients died from progressive disease, one patient died from acute myocardial infarction during chemotherapy, and one of severe sepsis after chemotherapy for non-Hodgkin lymphoma. As regards the annual consumption of strong opioids, there was a 179% increase in the use of morphine-equivalent doses of oral long-acting opioids (+228% for oxycodone) after the introduction of daily pain measurement through a numerical rating scale. CONCLUSIONS: To reduce the administration of chemotherapy near the end of life, we introduced the palliative prognostic score, to be administered to all advanced cancer patients with performance status of at least 2. To evaluate the effectiveness of analgesics and to reduce the cases of undertreatment of cancer pain, we adopted, in addition to the numerical rating scale, Cleeland's Pain Management Index. We are convinced that attempts to improve the quality of care can be achieved by the collaboration of all health professionals, patients and care givers.

Fit for the future--a regional governance structure for a new age.

Australia's health care system is at a crossroads. It is recognised that the fragmentation of health services, largely caused by the split between Commonwealth and state government funding responsibilities, is undermining patient care. The National Health and Hospitals Reform Commission (NHHRC) has advanced two models of health-system governance to redress this situation - neither incorporating the regional approach so prominent in submissions to the NHHRC and included in Option B of the NHHRC interim report. A regional governance framework such as that described in this paper could keep faith with the importance widely given to local engagement during the consultation process; sit neatly within the NHHRC's Healthy Australia Accord option; make regions responsible for funding allocation and service delivery; eliminate major weaknesses in our current system; and provide stability to the system at a time of significant reform.

Changing governance, governing change: medical regulation in Ireland.

The perceived need for the regulation of the medical profession is rooted in the nature and history of medicine. This paper summarizes theories of professional regulation and explores recent developments in medical regulation in Ireland, through description of background theories of professional regulation and analysis of recent developments in Ireland. Medical self-regulation is the subject of ongoing controversy owing to (1) the complex nature of medical practice; (2) informed service users; (3) identification of alleged anti-competitive practices; (4) apparent restrictions on entry to the profession; (5) the public/private mix in Irish healthcare; and (6) high-profile cases that resulted in enquiries into standards of practice. Measures being implemented to address these challenges include reforms in medical education, a new contract of employment for consultants, and enhanced schemes for continuing medical education. Broader societal trends are presenting new challenges that highlight the need for flexible regulatory frameworks in medicine.

Sense-making by clinical and non-clinical executive directors within new governance arrangements.

PURPOSE: The purpose of this paper is to explore the various ways in which clinical executive directors and non-clinical executive directors are interpreting and responding to the extensive reforms and restructuring in the UK health service. DESIGN/METHODOLOGY/APPROACH: The paper draws upon detailed research in two very large teaching hospital organizations in order to understand how actors crucial to the delivery of this vision are responding. Schedule-structured interviews with executive directors were conducted, recorded, transcribed and coded. FINDINGS: The clinical and non-clinical directors of these organizations engaged in a process of active sense-making are found, which is leading to significant changes to the service and also changes to identity. The clinical directors are revealing a willingness to assume accountability for devolved profit centres in their service lines. The non-clinical directors are supportive of this idea in broad terms but are cautious about releasing "too much" central control. RESEARCH LIMITATIONS/IMPLICATIONS: The paper is based on just two case studies and the analyses are made through the perspectives of the executive teams in each case. PRACTICAL IMPLICATIONS: Changes to healthcare environments of this kind are occurring in many countries, but such is the extent and intensity of these changes in the UK that the government's aspiration is high--it sees this set of reforms leading to a peerless world class health service. The way in which the actors make sense of and navigate their way through the cross cutting principles and the layered reforms is a critical issue. ORIGINALITY/VALUE: There have been few systematic studies of the practical reality involved in the enactment of profit centre and service line management initiatives in acute hospital settings and the ways these are understood and negotiated at executive team level.