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.

A acupuntura enquanto prática complementar na atenção à saúde do trabalhador / Acupuncture as a complementary therapy in attention to workers' health

Em 2006, foi publicada a Política Nacional de Práticas Integrativas e Complementares que contribuiu fortemente para o crescimento de práticas até então denominadas Alternativas, como homeopatia, acupuntura, fitoterapia e outros, no entanto, no que se refere à saúde do trabalhador, a oferta desses serviços pelo SUS ainda é escassa, principalmente a acupuntura, objeto desse estudo. Diante desse contexto, foi desenvolvido um primeiro artigo que versou sobre os saberes milenares que fundamentam a acupuntura e sua contextualização no mundo ocidental enquanto prática multiprofissional e em seguida foi desenvolvido um segundo artigo onde buscou-se desenvolver uma tecnologia de informação impressa que fornecesse subsídios e/ou conhecimento quanto à prática de acupuntura, enquanto sistema de intervenção terapêutico, aos trabalhadores do HUCAM. Além disso, foi proposto um serviço complementar de assistência de enfermagem tendo como dispositivo a acupuntura na atenção à saúde do trabalhador atendido pelo NASTH. Para confecção da tecnologia de informação impressa foi realizada revisão sistemática da literatura em busca de estudos publicados nos últimos 10 anos, a fim de destacar os seguintes pontos: breve histórico sobre acupuntura; competência legal de profissionais para exercer a acupuntura no Brasil; indicações e contra-indicações da acupuntura; riscos e benefícios da prática de acupuntura; possíveis efeitos adversos da acupuntura; técnicas disponíveis de tratamento na acupuntura. Em seguida, foi realizado um encontro com os profissionais envolvidos com a gestão e/ou assistência no Nucleo de Atenção à Saúde do Trabalhador (NASTH) a fim de apresentar o instrumento desenvolvido por meio de uma exposição dialogada, onde os mesmos responderam a um questionário sobre o instrumento elaborado. Em relação à proposta de um serviço complementar de assistência de enfermagem, tendo como dispositivo de atenção à saúde a acupuntura, foi elaborada uma sistemática de intervenção contemplando todo o fluxo de atendimento, assim como descrição detalhada dos elementos mínimos para a instalação de um consultório de acupuntura. Acreditamos que este estudo irá contribuir para a difusão de uma gama de conhecimentos em acupuntura voltada à saúde do trabalhador; como também a melhoria da qualidade de vida do mesmo. Palavras chaves: Terapia por acupuntura, terapias complementares, saúde do trabalhador, Administração de serviços de saúde.

In 2006, the National Policy of Integrative and Complementary Practices has been published and contributed strongly to the growth of practices until then named "alternatives", for instance: Homeopathy, Acupuncture, Phytotherapy and others. However, when it comes to workers' health, the offer of this service within SUS is still scarce, mainly Acupuncture, the object of this study which was divided into the following two productions presented: As a first desiring production, developed a article to create a printed information technology, commonly known as Manual, to provide scientific background information in relation to the practice of acupuncture, as being a therapeutic interventions system of a university hospital in the state of Espirito Santo. As a second production desiring drew up a proposal for intervention through which lists the subsidies necessary to implement a complementary service of nursing care as having acupuncture device in attention to workers' health. The purpose of this study is to provide a contribution to the spread of acupuncture focused on workers' health.(AU)

Buenas prácticas en gestión sanitaria: el caso Kaiser Permanente / Good practices in health care management: Kaiser Permanente case

Objetivo. Describir y analizar los rasgos generales que caracterizan el modelo de organización y gestión de la institución sanitaria estadounidense Kaiser Permanente. Material y métodos. Estudio realizado a través de una metodología de estudio de caso, elaborado con información recabada de manera directa en una visita de estudio a Kaiser Permanente y complementada con fuentes documentales procedentes de una revisión bibliográfica. Resultados. Kaiser Permanente engloba las funciones de aseguramiento y de provisión de servicios sanitarios para una población superior a 8 millones de personas. Algunos de los resultados que obtiene pueden ser calificados de "excelentes", principalmente en aspectos de integración de la atención, reducción de hospitalizaciones y de estancias innecesarias, y prevención y control de enfermedades crónicas. Estos resultados son atribuibles en gran medida a un modelo de gestión y de organización de servicios caracterizado por su enfoque poblacional, liderazgo clínico y utilización de modelos innovadores de atención. Conclusiones. Kaiser Permanente muestra un elenco de buenas prácticas de gestión, ya sean a nivel macro, como su enfoque de salud poblacional, meso, como su abordaje de atención integrada, y micro, en el que destacan múltiples herramientas innovadoras vinculadas a la gestión de enfermedades. Estas prácticas suponen oportunidades de aprendizaje relevantes para el Sistema Nacional de Salud español. Desde una óptica de teoría organizativa pueden identificarse en el modelo Kaiser Permanente los principales rasgos que caracterizan una "organización que aprende"

Objective. To describe and analyze the main features of the United States Kaiser Permanente organization and management model. Methods. Study performed with a case study method, elaborated with information obtained directly during a study visit to Kaiser Permanente and completed with documents from a review of the literature. Results. Kaiser Permanente is both a health care insurer and provider and covers a population that exceeds eight million affiliates. Kaiser excels in several performance areas, such as integration of care, hospital care minimization, prevention and control of chronic diseases. These results are mainly attributable to a management model characterized by its population focus, clinical leadership, and broad use of innovative care models. Conclusions. Kaiser Permanente has a wide range of good management practices, for instance, macro-level, such as its population health focus, meso-level, such as its integrated care system and micro-level, in which there are many innovative approaches to disease management. These practices offer good learning opportunities for the Spanish National Health system. From an organizational theory perspective, the Kaiser Permanente models shares many of the features of a "Learning Organization"

Implementing performance management in the Irish Health Sector.

To realize the goals of successive health strategies, managers in the Irish Health Sector will have to proactively facilitate optimal employee performance in line with policy objectives. Along with developing employee and teams' capabilities, these managers have begun to implement performance management to achieve the latter. However, there typically are a variety of foundational organizational characteristics required for the successful implementation of performance management. These include providing top-down support for line management buy-in, providing ongoing managerial and performance management training so that trusting relationships and a culture of consensus and cooperation are developed, and appropriately managing expectations. Agreement on employee role definitions and provision of team-based conflict resolution training is also needed to facilitate performance management. There is a need for negotiated performance indicators that are of various types, specific, measurable, and aligned with strategy objectives. Associated reward systems need to be holistic and imaginative, and personal development plans need to have a broader focus than merely improving current job skills and performance. Performance review needs to be ongoing, conducted in a transparent manner, and allocated sufficient discussion time. Managers also need to be mindful of managing overperformance.

Healthcare in Ontario: what has the system learned?

In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos.

Instilling a soul in your organization without losing yours to it.

Health-care professionals are accustomed to struggling with ethical considerations brought about by advances in the medical sciences. How aware are these professionals of the ethical dilemmas created by advances in the management sciences? Deeply embedded in organizational and departmental changes are theories, paradigms, and philosophies that often are understood poorly even by their promoters. Although these system changes can occur at glacial speed, they also can be glacial in their effects on an organization's culture. Are individuals aware that the latest implemented management fad is changing their behaviors? By becoming mindful of the potential ramifications of change, individuals increase their ability to behave in a civil manner--that is, ethically choosing to embrace or resist the change. By acting within their own sphere of influence, civil individuals at all levels of the organization collectively instill a soul in their organization rather than losing their own souls to it. This article is adapted from a commencement speech presented to graduates of an executive health-care administration program. Most of these graduates were a mixture of hospital department heads, middle managers, and a few medical and hospital executives. Each year, I distribute my current version of this teaching note or mini-lecture to students completing my leadership class in hope that it will help them put in perspective the appropriate use of the management sciences they intensely study.

Influences on the implementation of TQM in health care organizations: professional bureaucracies, ownership and complexity.

TQM is introduced into many organisations in an attempt to improve productivity and quality. There are a number of organisational variables that have been recognised as influencing the success of TQM implementation including leadership, teamwork, and suppliers. This paper presents findings of a study of the implementation of TQM in Australian health care organisations. Structural factors were observed to affect the progress of TQM. Professional bureaucracies were less successful than machine bureaucracies. Private organisations were more successful than their public counterparts.

Spirituality and healthcare organizations.

In recent years, the place of spirituality in organizations has become increasingly discussed and advocated. On a personal level, this may involve achieving personal fulfillment or spiritual growth in the workplace. In the broader sense, spirituality is considered by many to be essential in an organization's interactions with employees, customers, and the community. This article describes a possible role for greater spirituality in healthcare organizations, whose cultures in recent decades have largely excluded spirituality or religiousness. This is the consequence of an analytical, scientific perspective on human health; a reductionist paradigm in biomedical research; and the inevitable bureaucratization occurring in large healthcare organizations. However, in recent decades, numerous scientific articles supporting a connection between faith or religiousness and positive health outcomes have been published. Because individuals seek meaning when experiencing severe illnesses, and humans universally respond to compassion and caring, spirituality among healthcare workers and managers appears highly appropriate. The article describes organizational barriers to the greater inclusion of spirituality in healthcare and presents several approaches to developing a more caring organization. These include eliciting extensive input from all staff and clinicians in identifying core or common values, ethics, and a philosophy of caring. Programs should ensure that the views of nonreligious staff and patients are respected and that clear guidelines are established for the extent and nature of affective or spiritual support for patients.