[Outsourcing of nursing staff costs in psychiatry? : A secondary data analysis of possible effects on the remuneration system in psychiatry]. / Ausgliederung der Pflegekosten in der Psychiatrie? : Eine Sekundärdatenanalyse möglicher Auswirkungen auf das PEPP-System.

BACKGROUND: Nursing staff were excluded from the German DRG system for somatic hospital treatment and will be funded separately in the future. In psychiatry and psychosomatic medicine, binding personnel requirements have been defined but there has been no regulation of how these personnel requirements are adequately financed. OBJECTIVE: The objective of this study was to analyze the costs of inpatient psychiatry and psychosomatic medicine and to evaluate possible effects of funding nursing staff separately. MATERIAL AND METHODS: This analysis is based on aggregated daily treatment costs of selected hospitals (data year 2018), which annually submit their performance and cost data to the Institute for the Hospital Remuneration System (InEK) for the empirical further development of the remuneration system. RESULTS: Nursing staff represent the largest cost factor in inpatient psychiatry and psychosomatic medicine. Excluding nursing staff drastically reduces the variance of psychiatric DRG renumeration and even exceeds its proportion of the total costs. After outsourcing nursing costs, psychiatric DRGs achieve only a very limited cost separation. CONCLUSION: The binding personnel requirements necessitate adequate financing of nursing staff. This raises the debate about the further development of psychiatric remuneration. The question arises as to whether the effort associated with using the psychiatric DRG system justifies its usefulness as an instrument for budgeting when core functions such as cost separation are only given to a limited extent. Alternative approaches to budgeting should also be examined for putting costs and benefits in a better ratio.

Community Health Centers Could Provide Better Outsourced Primary Care for Veterans.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

Use of a collaborative tool to simplify the outsourcing of preclinical safety studies: an insight into the AstraZeneca-Charles River Laboratories strategic relationship.

In 2012, AstraZeneca entered into a strategic relationship with Charles River Laboratories whereby preclinical safety packages comprising safety pharmacology, toxicology, formulation analysis, in vivo ADME, bioanalysis and pharmacokinetics studies are outsourced. New processes were put in place to ensure seamless workflows with the aim of accelerating the delivery of new medicines to patients. Here, we describe in more detail the AstraZeneca preclinical safety outsourcing model and the way in which a collaborative tool has helped to translate the processes in AstraZeneca and Charles River Laboratories into simpler integrated workflows that are efficient and visible across the two companies.

Successful outsourcing: improving quality of life through integrated support services.

This article examines the way that non-clinical support services are provided in healthcare settings through outsourcing partnerships. The integrated support services model and benefits to patient experience and safety as well as organizational efficiency and effectiveness are explored through an examination of services at a busy urban community hospital.

The nature of outsourced preclinical research--the example of chemical synthesis.

The possibility to buy standardized external services or even new and innovative methods within drug discovery has increased dramatically during the last decades. Service providers are able to provide timely and efficient solutions to any given problem within preclinical research. The outsourcing behavior depends on the specific company type. Generally, the outsourcing level of emerging pharmaceutical and biotechnology companies is much higher than established companies due to low or missing internal resources. Whereas the "make-or-buy" decisions of large and fully integrated pharmaceutical companies are mainly competency driven, those of mid-size and small pharmaceutical, as well as biotech companies show a specific combination of cost/capacity and competency. The three different cooperation models "price competition", "project selection," and "strategic partnership" were identified. For all types of companies, the cooperation model of "strategic partnership" offers access to high-level expertise while reducing fixed costs and complexity. This was shown using chemical synthesis as an example but is also true for other areas of preclinical research.

[Problems in the management of clinical laboratories in Japan].

In Japan, laboratory automation has spread over the last two decades. Laboratory automation has saved time and labor for routine sample tests in clinical laboratories, and contributed to the downsizing of the division. This "contribution" resulted in re-arrangement of the work-force, namely, shrinkage of the blood chemistry division and expansion of the physiological tests and diagnostic imaging division. Some may call this re-arrangement as an adaptation for survival. However, I am concerned that extreme adaptation may cause irreversible shrinkage of clinical laboratories and laboratory medicine itself. In fact, outsourcing of sample tests including microbiological tests has become very popular over the last decade. Since the cost for microbiological tests is suppressed by the national health insurance policy, it is becoming difficult to keep microbiological laboratories in small-scale hospitals. The presence of a microbiological laboratory in a hospital is crucial for prompt and appropriate therapies for infectious diseases, and is essential for advanced infection control activities. The government is pushing forward fixed-term employment in national universities and hospitals, threatening long-term career planning for medical technologists. We have to keep in mind that nurturing medical personnel with special skills and extensive knowledge is mandatory to university hospitals, and laboratory medicine is crucial to the progress of modern medicine.

How do the top 12 pharmaceutical companies operate safety pharmacology?

INTRODUCTION: How does safety pharmacology operate in large pharmaceutical companies today? By understanding our current position, can we prepare safety pharmacology to successfully navigate the complex process of drug discovery and development? METHODS: A short anonymous survey was conducted, by invitation, to safety pharmacology representatives of the top 12 pharmaceutical companies, as defined by 2009 revenue figures. A series of multiple choice questions was designed to explore group size, accountabilities, roles and responsibilities of group members, outsourcing policy and publication record. RESULTS: A 92% response rate was obtained. Six out of 11 companies have 10 to 30 full time equivalents in safety pharmacology, who hold similar roles and responsibilities; although the majority of members are not qualified at PhD level or equivalent. Accountabilities were similar across companies and all groups have accountability for core battery in vivo studies and problem solving activities but differences do exist for example with in vitro safety screening and pharmacodynamic/pharmokinetic modeling (PK/PD). The majority of companies outsource less than 25% of studies, with in vitro profiling being the most commonly outsourced activity. Finally, safety pharmacology groups are publishing 1 to 4 articles each year. CONCLUSION: This short survey has highlighted areas of similarity and differences in the way large pharmaceutical companies operate safety pharmacology.

Integration of a nationally procured electronic health record system into user work practices.

BACKGROUND: Evidence suggests that many small- and medium-scale Electronic Health Record (EHR) implementations encounter problems, these often stemming from users' difficulties in accommodating the new technology into their work practices. There is the possibility that these challenges may be exacerbated in the context of the larger-scale, more standardised, implementation strategies now being pursued as part of major national modernisation initiatives. We sought to understand how England's centrally procured and delivered EHR software was integrated within the work practices of users in selected secondary and specialist care settings. METHODS: We conducted a qualitative longitudinal case study-based investigation drawing on sociotechnical theory in three purposefully selected sites implementing early functionality of a nationally procured EHR system. The complete dataset comprised semi-structured interview data from a total of 66 different participants, 38.5 hours of non-participant observation of use of the software in context, accompanying researcher field notes, and hospital documents (including project initiation and lessons learnt reports). Transcribed data were analysed thematically using a combination of deductive and inductive approaches, and drawing on NVivo8 software to facilitate coding. RESULTS: The nationally led "top-down" implementation and the associated focus on interoperability limited the opportunity to customise software to local needs. Lack of system usability led users to employ a range of workarounds unanticipated by management to compensate for the perceived shortcomings of the system. These had a number of knock-on effects relating to the nature of collaborative work, patterns of communication, the timeliness and availability of records (including paper) and the ability for hospital management to monitor organisational performance. CONCLUSIONS: This work has highlighted the importance of addressing potentially adverse unintended consequences of workarounds associated with the introduction of EHRs. This can be achieved with customisation, which is inevitably somewhat restricted in the context of attempts to implement national solutions. The tensions and potential trade-offs between achieving large-scale interoperability and local requirements is likely to be the subject of continuous debate in England and beyond with no easy answers in sight.

Costs and added value of haemodialysis and peritoneal dialysis outsourcing agreements.

BACKGROUND: Despite the discrepancy in results from Spanish studies on the costs of dialysis, it is assumed that peritoneal dialysis (PD) is more efficient than haemodialysis (HD). OBJECTIVES: To analyse the costs and added value of HD and PD outsourcing agreements in Galicia, the medical transport for HD and the relationship between the cost of the agreement and the cost of consumables used in continuous ambulatory peritoneal dialysis (CAPD) with bicarbonate. METHODS: The cost of the outsourcing agreements and the staff was obtained from official publications. The cost of PD and medical transport were calculated using health service data for one month and extrapolating it to one year. The cost of CAPD consumables was provided by the suppliers. The added value was calculated from the investments generated for each agreement treating 40 patients. RESULTS: Expressed as patient/year, the mean costs for treatment were €21595 and €25664 in HD and PD, respectively. Medical transport varied between €3323 and €6338, while those of the CAPD agreement and consumables were €19268 and €12057, respectively. The added value was greater with the HD agreement, especially considering the jobs created. CONCLUSIONS: One cannot generalise that the cost of PD, which is significantly influenced by prescriptions, is lower than that of HD. It would be appropriate to review the additional cost to consumables in the CAPD agreement. The added value generated by dialysis agreements should be considered in future studies and in health planning. More controlled studies are needed to better understand this issue.

Appendix to dialysis centre guidelines: recommendations for the relationship between outpatient haemodialysis centres and reference hospitals. Opinions from the Outpatient Dialysis Group. Grupo de Trabajo de Hemodiálisis Extrahospitalaria.

INTRODUCTION: The different clinical guidelines backed by the Spanish Society of Nephrology (SEN) attempt to homogenise the monitoring of renal patients. However, this effort to homogenise treatment has been obstructed in the case of renal replacement therapy patients on haemodialysis due to, among other reasons, the existence of several different dialysis providers, with private centres located in many cities, each with their own reference hospitals and different criteria for treatment based on the existing outsourcing services agreements with the public health service, which also differ between regions. A good relationship between a private dialysis centre and its reference hospital would lead to equal treatment for all dialysis patients, at least at that particular town. The SEN, through the efforts of the Grupo de Trabajo de Hemodiálisis Extrahospitalaria (Outpatient Haemodialysis Group), has prioritised a close relationship and good communication between reference hospitals and dialysis centres in order to guarantee proper continuity of the health care given to these patients. STRATEGIES FOR IMPROVEMENT: Conditions for referring patients from one centre to another. A patient that starts a haemodialysis programme should be referred from a reference hospital with a definitive vascular access for optimising treatment, with a full report updated within 24-48 hours before the transferral, including essential information for providing proper nephrological treatment: primary pathology, recent viral serology (including hepatitis B and C virus [HBV and HCV] and human immunodeficiency virus [HIV]), parameters for anaemia and calcium-phosphorus metabolism, and ions, date of the first session of dialysis, and the number and dates of blood transfusions received. Furthermore, patients referred from the dialysis centre to the hospital, whether for programmed visits or emergency hospitalisation, should be accompanied by an updated report indicating the primary diagnoses, recent events, viral serology and laboratory analyses, updated haemodialysis and treatment regimens used, and the reason for transferral to the hospital. A single, digital clinical history that is accessible by both institutions would facilitate this situation, although this option is not completely available to all centres and hospitals. There are also legal issues to resolve in this aspect. Continued care for dialysis patients. Good communication between dialysis centres and hospitals is fundamental for achieving a proper level of care for dialysis patients, and not only with the nephrology department. The interconsultations of dialysis patients at each private centre, as well as the requests for diagnostic tests, should be able to be requested by the centre directly. The results and reports from these interconsultations should also be sent to the centre. It would also be best if the reference hospitals and their private dialysis centres shared common treatment protocols. These protocols should include basic aspects of the treatment of renal patients (anaemia, mineral metabolism, vascular accesses including catheter infections, etc., and laboratory tests), transplant protocols, complementary tests, and other components specific to each area. Not only would this generalise and unify the approach taken with dialysis patients regardless of where they are treated, it would also facilitate access to data on all patients regarding clinical trials and research studies. Access to medication. Dialysis patients require medications that are only given in the hospital setting, which is normally provided by the reference hospital, as per the agreement between institutions. It would also be recommendable that any other medications not included in the agreement (antibiotics, urokinase, nutritional supplements, etc.) be dispensed in a similar manner. Access to kidney transplant. The management of the transplant waiting list, once a patient starts renal replacement therapy, should be controlled from the dialysis centre, as in any other procedure. As such, the nephrologists from each centre should be familiar with the existing protocols and new developments in this context, and should participate in meetings with nephrology and urology departments in each hospital. The transplant protocol at each town/region should be followed for all patients, whether dialysis is undergone in a hospital or private centre. Characteristics of the work at dialysis centres. The doctor attending patients at each dialysis centre must be a specialist in nephrology. This complicated issue must be a requirement for agreements within the regional health system in order to guarantee a proper and equitable treatment of patients that receive dialysis in private centres. Only in the case of an absence of a nephrologist should a general practitioner be used, and this doctor must have adequate training in haemodialysis. This training should also be standardised. Over 75% of nephrologists that work at these centres are alone during the workday, and 40% never see another colleague during the whole shift. The administrators of these centres should seek out protocols that provide professional contact, both with the hospital staff and nephrologists from other centres, which would facilitate an exchange of ideas. Training. The nephrologists at each centre have the right and the obligation to perform research and to continuously expand their training, so as to develop and improve health care provision. Since the majority of patients in haemodialysis programmes are treated in outpatient centres that depend on reference hospitals, we might suggest a minimal rotation of nephrology residents in private outpatient dialysis centres, once accreditation has been given for providing this training.

Foreign medical outsourcing: possibilities, perils and parameters.

Medical outsourcing is the process in which a healthcare provider, spanning the provider continuum from individual physician to a health system, contracts with a third party located either domestically or internationally to provide medical services. The combination of ongoing radiologist shortages and technological developments has set the stage for an increasingly probable reality of foreign medical outsourcing by Canada, specifically where diagnostics is concerned. This article briefly discusses liability and quality-of-care issues that arise within the context of foreign medical outsourcing and recommends stakeholder considerations to help inform future discussion.

Productive reorganization, outsourcing, and work relations in the offshore oil industry in the Campos Basin, Rio de Janeiro.

This article analyzes the relationship between the intensive use of outsourcing and labor organizations on offshore oil platforms in the Campos Basin, Rio de Janeiro, Brazil. The theoretical and methodological framework applied in our research is based on Ergonomics of Activity and the Psychodynamics of Work, from an ergological perspective. In addition to the more general trend of increasing precariousness, we highlight the potential loss of formal and informal knowledge resulting from the fragmentation of work collectives, as we consider the cohesion of these collectives to be a crucial element contributing to reliability in process operations. Increasing precariousness of work contributes to this fragmentation and one of its main causes is the uncontrolled increase in outsourcing of work. This situation has had nefarious consequences for workers' health and safety, suggesting that those who have adopted outsourcing as a labor management tool have failed to consider these harmful consequences as rigorously as necessary.

Outsourcing in private healthcare organisations: a Greek perspective.

PURPOSE: The purpose of this paper is to present a study carried out to investigate the extent of outsourcing, the decision-making process, the impact of outsourcing, and the future trend of outsourcing in private healthcare organisations in Greece. DESIGN/METHODOLOGY/APPROACH: A survey instrument was designed and mailed to a random sample of 100 private healthcare organisations in Greece. A total of 25 usable questionnaires were received, representing a response rate of 25 percent. The survey instrument focused on the extent to which private healthcare organisations outsource services, the decision-making process for choosing an external service provider, the impact of outsourcing, and the future trend of outsourcing. FINDINGS: Private healthcare organisations in Greece outsource a variety of activities. Cost savings, customisation, and customer satisfaction are the main factors affecting the outsourcing decision. The cooperation with a contract service provider has led to an improvement in customer satisfaction and to a cost reduction. Most users are highly satisfied with the performance of these companies and believe that there will be a future increase in the usage of these services. PRACTICAL IMPLICATIONS: The paper provides a framework regarding outsourcing in private healthcare organisations. ORIGINALITY/VALUE: This research fills the gap in the area of outsourcing in private healthcare organisations in Greece.