Using routine, independent, scientific-data audits as an early-warning for potentially fraudulent toxic-site cleanup: PCE, TCE, and other VOCs at the former Naval-Ordnance Test Station, Pasadena, California.

Two of the most prevalent Superfund-site contaminants are carcinogenic solvents PCE (perchloroethylene) and TCE (trichloroethylene). Because their cleanup is difficult and costly, remediators have repeatedly falsified site-cleanup data, as Tetra Tech apparently did recently in San Francisco. Especially for difficult-to-remediate toxins, this paper hypothesizes that scientific misrepresentations occur in toxic-site assessments, before remediation even begins. To begin to test this hypothesis, the paper (1) defines scientific-data audits (assessing whether published conclusions contradict source data), (2) performs a preliminary scientific-data audit of toxic-site assessments by consultants Ninyo and Moore for developer Trammell Crow. Trammel Crow wants to build 550 apartments on an unremediated Pasadena, California site - once a premier US Navy weapons-testing/development facility. The paper (3) examines four key Ninyo-and-Moore conclusions, that removing only localized metals-hotspots will (3.1) remediate TCE/PCE; (3.2) leave low levels of them; (3.3) clean the northern half of soil, making it usable for grading, and (3.4) ensure site residents have lifetime cancer risks no greater than 1 in 3,000. The paper (4) shows that source data contradict all four conclusions. After summarizing the benefits of routine, independent, scientific-data audits (RISDA), the paper (5) argues that, if these results are generalizable, RISDA might help prevent questionable toxic-site assessments, especially those of expensive-to-remediate toxins like PCE/TCE.

Modelo de evaluación del plan de respuesta frente a la pandemia de COVID-19 en un hospital de tercer nivel / Assessment model for evaluating the preparedness plan for COVID-19 in a tertiary care hospital

ANTECEDENTES Y OBJETIVO: Durante la primera onda epidémica del SARS-CoV-2, los hospitales han soportado una importante presión asistencial. Este escenario de incertidumbre, baja evidencia científica y medios insuficientes ha generado una importante variabilidad de la práctica entre diferentes centros sanitarios. En este contexto, planteamos desarrollar un modelo basado en estándares para la evaluación del sistema de preparación y respuesta frente a la COVID-19 en un hospital terciario. MATERIALES Y MÉTODOS: El estudio se llevó a cabo en el Hospital Universitario Vall d'Hebron de Barcelona en dos fases: 1) desarrollo de modelo de estándares mediante revisión narrativa de la literatura, análisis de planes y protocolos del hospital, método Delphi por profesionales expertos y plan de actualización y 2) validación de aplicabilidad y utilidad del modelo mediante autoevaluación y auditoría. RESULTADOS: El modelo consta de 208 estándares distribuidos en nueve criterios: liderazgo y estrategia; prevención y control de la infección; gestión de profesionales y competencias; áreas públicas comunes; áreas asistenciales; áreas de apoyo asistencial; logística, tecnología y obras; comunicación y atención al paciente; sistemas de información e investigación. La evaluación alcanza un 85,2% de cumplimiento, y se identifican 42 áreas de mejora y 96 buenas prácticas. CONCLUSIONES: La implementación de un modelo basado en estándares es útil para identificar áreas de mejora y buenas prácticas en los planes de preparación y respuesta frente a la COVID-19 en un hospital. En el actual contexto, proponemos la conveniencia de adaptar esta metodología a otros ámbitos de atención sanitaria no hospitalaria o de salud pública

BACKGROUND AND PURPOSE: During the first wave of the epidemic caused by SARS-CoV-2, hospitals have come under significant pressure. This scenario of uncertainty, low scientific evidence, and insufficient resources, has generated significant variability in practice between different health organisations. In this context, it is proposed to develop a standards-based model for the evaluation of the preparedness and response system against COVID-19 in a tertiary hospital. MATERIALS AND METHODS: The study, carried out at the University Hospital of Vall d'Hebron in Barcelona (Spain), was designed in two phases: 1) development of the standards-based model, by means of a narrative review of the literature, analysis of plans and protocols implemented in the hospital, a review process by expert professionals from the centre, and plan of action, and 2) validation of usability and usefulness of the model through self-assessment and hospital audit. RESULTS: The model contains 208 standards distributed into nine criteria: leadership and strategy; prevention and infection control; management of professionals and skills; public areas; healthcare areas; areas of support for diagnosis and treatment; logistics, technology and works; communication and patient care; and information and research systems. The evaluation achieved 85.2% compliance, with 42 areas for improvement and 96 good practices identified. CONCLUSIONS: Implementing a standards-based model is a useful tool to identify areas for improvement and good practices in COVID-19 preparedness and response plans in a hospital. In the current context, it is recommended to repeat this methodology in other non-hospital and public health settings

Resource reduction in pediatric chest pain: Standardized clinical assessment and management plan.

OBJECTIVE: Using a Standardized Clinical Assessment and Management Plan (SCAMP) for pediatric patients presenting to clinic with chest pain, we evaluated the cost impact associated with implementation of the care algorithm. Prior to introduction of the SCAMP, we analyzed charges for 406 patients with chest pain, seen in 2009, and predicted 21% reduction of overall charges had the SCAMP methodology been used. The SCAMP recommended an echocardiogram for history, examination, or ECG findings suggestive of a cardiac etiology for chest pain. DESIGN: Resource utilization was reviewed for 1517 patients (7-21 years) enrolled in the SCAMP from July 2010 to April 2014. RESULTS: Compared to the 2009 historic cohort, patients evaluated by the SCAMP had higher rates of exertional chest pain (45% vs 37%) and positive family history (5% vs 1%). The SCAMP cohort had fewer abnormal physical examination findings (1% vs 6%) and abnormal electrocardiograms (3% vs 5%). Echocardiogram use increased in the SCAMP cohort compared to the 2009 historic cohort (45% vs 41%), whereas all other ancillary testing was reduced: exercise stress testing (4% SCAMP vs 28% historic), Holter (4% vs 7%), event monitors (3% vs 10%), and MRI (1% vs 2%). Total charges were reduced by 22% ($822 625) by use of the Chest Pain SCAMP, despite a higher percentage of patients for whom echocardiogram was recommended compared to the historic cohort. CONCLUSIONS: The Chest Pain SCAMP effectively streamlines cardiac testing and reduces resource utilization. Further reductions can be made by algorithm refinement regarding echocardiograms for exertional symptoms.

Correcting India's Chronic Shortage of Drug Inspectors to Ensure the Production and Distribution of Safe, High-Quality Medicines.

BACKGROUND: Good drug regulation requires an effective system for monitoring and inspection of manufacturing and sales units. In India, despite widespread agreement on this principle, ongoing shortages of drug inspectors have been identified by national committees since 1975. The growth of India's pharmaceutical industry and its large export market makes the problem more acute. METHODS: The focus of this study is a case study of Maharashtra, which has 29% of India's manufacturing units and 38% of its medicines exports. India's regulations were reviewed, comparing international, national and state inspection norms with the actual number of inspectors and inspections. Twenty-six key informant interviews were conducted to ascertain the causes of the shortfall. RESULTS: In 2009-2010, 55% of the sanctioned posts of drug inspectors in Maharashtra were vacant. This resulted in a shortfall of 83%, based on the Mashelkar Committee's recommendations. Less than a quarter of the required inspections of manufacturing and sales units were undertaken. The Indian Drugs and Cosmetics Act and its Rules and Regulations make no provisions for drug inspectors and workforce planning norms, despite the growth and increasing complexity of India's pharmaceutical industry. CONCLUSION: The Maharashtra Food and Drug Administration (FDA) falls short of the Mashelkar Committee's recommended workforce planning norms. Legislation and political and operational support are required to produce needed changes.

Good hygiene practices in hospital nutrition services: the view of internal and external auditors

The objective of this study was to evaluate the hygienic-sanitary conditions of hospital nutrition services according to internal and external auditors, before and after intervention, based on the requirements of Good Hygiene Practices. Fifteen hospital nutrition services were evaluated based on a checklist applied by internal auditors and by an external auditor. The intervention program was prepared and implemented in all the locations over one year, and was composed of four points: 1) training; 2) preparation of the action plan; 3) preparation of the documentation; 4) monthly visits to motivate the food handlers and responsible technicians, accompaniment and assistance in the implementation of Good Hygiene Practices. An improvment in the application of Good Hygiene Practices was observed in the hospital nutrition services after the systematic intervention, in the view of both the internal and external auditors, except the requirement related to operational aspects, which had a low percentage of adequacy, both before and after the intervention Before the intervention, there was a significant difference between the evaluation of the internal auditors and the external auditor, which was not found later. These results suggest that the systematic intervention assisted in the adoption of Good Hygiene Practices by hospital nutrition services, according to both the internal and external auditors, and contributed to increasing the knowledge of the internal auditors.(AU)

A Quantitative Analysis of Cold Water for Human Consumption in Hospitals in Spain.

An estimation of the water used for human consumption in hospitals is essential to determine possible savings and to fix criteria to improve the design of new water consumption models. The present work reports on cold water for human consumption (CWHC) in hospitals in Spain and determines the possible savings. In the period of 2005-2012, 80 Eco-Management and Audit Schemes (EMAS) from 20 hospitals were analysed. The results conclude that the average annual consumption of CWHC is 1.59 m(3)/m(2) (with a standard deviation of 0.48 m(3)/m(2)), 195.85 m(3)/bed (standard deviation 70.07 m(3)/bed), or 53.69 m(3)/worker (standard deviation 16.64 m(3)/worker). The results demonstrate the possibility of saving 5,600,000 m(3) of water per year. Assuming the cost of water as approximately 1.22 €/m(3), annual savings are estimated as 6,832,000 €. Furthermore, 2,912 MWh of energy could be saved, and the emission of 22,400 annual tonnes of CO2 into the atmosphere could be avoided.

Examining Quality Management Audits in Nuclear Medicine Practice as a lifelong learning process: opportunities and challenges to the nuclear medicine professional and beyond.

This essay will explore the critical issues and challenges surrounding lifelong learning for professionals, initially exploring within the profession and organizational context of nuclear medicine practice. It will critically examine how the peer-review process called Quality Management Audits in Nuclear Medicine Practice (QUANUM) of the International Atomic Energy Agency (IAEA) can be considered a lifelong learning opportunity to instill a culture of quality to improve patient care and elevate the status of the nuclear medicine profession and practice within the demands of social changes, policy, and globalization. This will be explored initially by providing contextual background to the identity of the IAEA as an organization responsible for nuclear medicine professionals, followed by the benefits that QUANUM can offer. Further key debates surrounding lifelong learning, such as compulsification of lifelong learning and impact on professional change, will then be weaved through the discussion using theoretical grounding through a qualitative review of the literature. Keeping in mind that there is very limited literature focusing on the implications of QUANUM as a lifelong learning process for nuclear medicine professionals, this essay uses select narratives and observations of QUANUM as a lifelong learning process from an auditor's perspective and will further provide a comparative perspective of QUANUM on the basis of other lifelong learning opportunities such as continuing professional development activities and observe parallelisms on its benefits and challenges that it will offer to other professionals in other medical speciality fields and in the teaching profession.

Seizing opportunities for change at the operational level.

Purpose - This paper presents a method for handling everyday opportunities for improvement, led by floor staff in healthcare institutions. More than 400,000 incidents and accidents were recorded in Quebec healthcare institutions in 2013. The burden of treatment falls on hospital floor staff. The purpose of this paper is to raise the visibility of this problem and support staff better in their efforts to handle opportunities for improvement. Design/methodology/approach - Based on issues identified in the literature, which have been found to exist in various organizations, the method involved reviewing practices in the field, proposing a solution, and testing it to assess its relevance and limitations. The method was tested in partnership with the Centre Hospitalier de l'Université de Montréal, in the internal medicine unit at Hôtel-Dieu campus. The test lasted three months. Indicators from this test have been compared to results in the literature. Findings - The proposed method presents a 68 per cent increase in ideas generated per person and per week compared to the reference study. The mean time for closing actions was about 41 per cent better (lower) than in the reference case. Research limitations/implications - The test lasted 15 weeks; a longer test is needed to collect more data. Practical implications - The first practical implication of this study was the creation of a method allowing employees to seize opportunities for improvement in their daily work. The application of this method revealed: first, the operational nature of the proposal (empowerment of the work team); second, the operationalization of continuous improvement (71 per cent of ideas were finalized while the initiative was monitored); third, the smooth operation of the mechanism for facilitating continuous improvement (organization of weekly meetings and team participation in these meetings in 90 per cent of cases); and fourth, a shared feeling that intra- and inter-team communication had been strengthened. Originality/value - The main value of this paper is that it proposes a simple problem-solving process that gives employees an opportunity to improve their daily work. The originality of this paper resides in comparing results to a standard case and observing an improvement. This paper proposes a new problem-solving structure and tests it scientifically.

Strengthening the U.S. Public Health Service Commissioned Corps: A View From The Assistant Secretary for Health.

OBJECTIVE: To summarize the results of the major management review of the U.S. Public Health Service Commissioned Corps (2009-2010) and note related outcomes. METHOD: Narrative from the U.S. Assistant Secretary for Health, who directed and oversaw the management review. RESULTS: The management review led to 46 recommendations, all of which have since been implemented. The subsequent organizational and operational changes have unified reporting structures, streamlined the administrative Corps organizational structure, and transferred support services to providers with expertise in uniformed services to create a new integrated personnel and payroll system. Related processes have also prompted a systematic billet review as well as establishment of explicit criteria for eligibility to become a Corps officer. Corps leaders report improvements in recruiting talented officers, increased selectivity from the candidate pool, and enhanced matching of incoming officers with agency assignments. Furthermore, Corps activity has grown in both traditional and innovative ways. CONCLUSION: The Corps has enjoyed heightened activity and outcomes in the era of health reform. The management review and its implementation have strengthened the Corps, helping officers to do their job and achieve their mission.

A New Approach of Measuring Hospital Performance for Low- and Middle-income Countries.

Efficiency of the hospitals affects the price of health services. Health care payments have equity implications. Evidence on hospital performance can support to design the policy; however, the recent literature on hospital efficiency produced conflicting results. Consequently, policy decisions are uncertain. Even the most of evidence were produced by using data from high income countries. Conflicting results were produced particularly due to differences in methods of measuring performance. Recently a management approach has been developed to measure the hospital performance. This approach to measure the hospital performance is very useful from policy perspective to improve health system from cost-effective way in low and middle income countries. Measuring hospital performance through management approach has some basic characteristics such as scoring management practices through double blind survey, measuring hospital outputs using various indicators, estimating the relationship between management practices and outputs of the hospitals. This approach has been successfully applied to developed countries; however, some revisions are required without violating the fundamental principle of this approach to replicate in low- and middle-income countries. The process has been clearly defined and applied to Nepal. As the results of this, the approach produced expected results. The paper contributes to improve the approach to measure hospital performance.

Development of certified environmental management in hospital and outpatient haemodialysis units.

INTRODUCTION: The environmental impact of haemodialysis is very high. Institutional activity in this sense is important, even in the production of references. Voluntary environmental management systems (EMS), environmental management and auditing systems (EMAS) and the International Organization for Standardization standards (ISO 14001) are important tools for environmental protection, together with legislation, taxation and tax benefits. OBJECTIVES: To determine the degree of implementation of EMS in hospital units and outpatient haemodialysis in the Spanish National Health System to provide a group of reference centres in environmental management in this healthcare activity. METHODS: Development of a list by autonomous communities showing hospital and outpatient dialysis units using an EMAS and/or ISO 14001 in 2012-2013. The sources of information were the Spanish National Catalogue of Hospitals, Spanish Registry of Healthcare Certification and Accreditation, European and regional EMAS records, world ISO registrations, dialysis centre lists from scientific societies and patients, responses from accredited entities in Spain for environmental certification and the institutional website of each haemodialysis centre identified. RESULTS: Of the 210 hospitals with a dialysis unit, 53 (25%) have the ISO 14001 and 15 of these also have an EMAS). This constitutes 30% of all hospital dialysis chairs in Spain: 1,291 (of 4,298). Only 11 outpatient clinics are recorded, all with the ISO 14001. DISCUSSION: There is no official documentation of the implementation of EMS in dialysis units. Making this list provides an approach to the situation, with special reference to haemodialysis because of its significant environmental impact.

CAFÉ: a multicomponent audit and feedback intervention to improve implementation of healthy food policy in primary school canteens: protocol of a randomised controlled trial.

INTRODUCTION: A number of jurisdictions internationally have policies requiring schools to implement healthy canteens. However, many schools have not implemented such policies. One reason for this is that current support interventions cannot feasibly be delivered to large numbers of schools. A promising solution to support population-wide implementation of healthy canteen practices is audit and feedback. The effectiveness of this strategy has, however, not previously been assessed in school canteens. This study aims to assess the effectiveness and cost-effectiveness of an audit and feedback intervention, delivered by telephone and email, in increasing the number of school canteens that have menus complying with a government healthy-canteen policy. METHODS AND ANALYSIS: Seventy-two schools, across the Hunter New England Local Health District in New South Wales Australia, will be randomised to receive the multicomponent audit and feedback implementation intervention or usual support. The intervention will consist of between two and four canteen menu audits over 12 months. Each menu audit will be followed by two modes of feedback: a written feedback report and a verbal feedback/support via telephone. Primary outcomes, assessed by dieticians blind to group status and as recommended by the Fresh Tastes @ School policy, are: (1) the proportion of schools with a canteen menu containing foods or beverages restricted for sale, and; (2) the proportion of schools that have a menu which contains more than 50% of foods classified as healthy canteen items. Secondary outcomes are: the proportion of menu items in each category ('red', 'amber' and 'green'), canteen profitability and cost-effectiveness. ETHICS AND DISSEMINATION: Ethical approval has been obtained by from the Hunter New England Human Research Ethics Committee and the University of Newcastle Human Research Ethics Committee. The findings will be disseminated in usual forums, including peer-reviewed publication and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12613000543785.

A comprehensive model for executing knowledge management audits in organizations: a systematic review.

A knowledge management audit (KMA) is the first phase in knowledge management implementation. Incomplete or incomprehensive execution of the KMA has caused many knowledge management programs to fail. A study was undertaken to investigate how KMAs are performed systematically in organizations and present a comprehensive model for performing KMAs based on a systematic review. Studies were identified by searching electronic databases such as Emerald, LISA, and the Cochrane library and e-journals such as the Oxford Journal and hand searching of printed journals, theses, and books in the Tehran University of Medical Sciences digital library. The sources used in this study consisted of studies available through the digital library of the Tehran University of Medical Sciences that were published between 2000 and 2013, including both Persian- and English-language sources, as well as articles explaining the steps involved in performing a KMA. A comprehensive model for KMAs is presented in this study. To successfully execute a KMA, it is necessary to perform the appropriate preliminary activities in relation to the knowledge management infrastructure, determine the knowledge management situation, and analyze and use the available data on this situation.

Assessment of new public management in health care: the French case.

The French health care system embraced New Public Management (NPM) selectively, and crafted their own version of NPM using Diagnostic-Related-Group accounting to re-centralize the health care system. Other organizational changes include the adoption of quasi-markets, public private partnerships, and pay-for-performance schemes for General Practitioners. There is little evidence that these improved the performance of the system. Misrepresentation has remained high. With the 2009 Hospital, Patients, Health and Territories Act physician participation in hospital governance receded. Decision-making powers and health units were re-concentrated to instill greater national coherence into the health system.

Development of a community nursing drug chart.

In April 2011, three providers of community services in Brent and Ealing, in London, and Harrow, in Middlesex, integrated with an acute NHS provider, Ealing Hospital. As part of a newly merged integrated care organisation, the community health services pharmacist undertook an extensive review of all medicines management processes and activities to ensure that they were safe. One of the recommendations of the review was to harmonise processes, practices, policies and guidance documents between the three community services providers. This article describes the process of developing a community nursing drug chart, which involved auditing drug administration in community nursing sites across the three boroughs, consulting a focus group of nursing service leads and assessing how the chart compared with national standards. The aim of the article is to share the process and the drug chart with other community service providers.

Internal audits can safeguard hospital revenue.

Hospitals should routinely perform internal audits of all functions affecting billing accuracy to mitigate the effects of payer audits and to protect revenue by improving billing processes. A primary focus for internal audits should be on coding accuracy, because coding errors leading to denials often reflect gaps in coders' knowledge or training. Effective communication between coding and denials management professionals is a critical success factor. Audits should support appeals processes, and audit findings should be used in educational initiatives aimed at improving coding accuracy.