Classificação do nível de complexidade assistencial dos pacientes em hospital oncológico / Clasificación del nivel de complejidad asistencial de los pacientes en un hospital oncológico / Levels of care complexity classification of patients in an oncology hospital

RESUMO Objetivo Classificar o nível de complexidade assistencial requerido da Enfermagem por pacientes oncológicos internados. Método Estudo observacional, seccional, de abordagem quantitativa, realizado diariamente com pacientes oncológicos em unidades de internação de Oncologia Clínica e Cirúrgica de um hospital de referência ao tratamento de câncer durante o período de três meses. A coleta foi realizada por meio da aplicação de um questionário semiestruturado e instrumento de classificação de pacientes de Fugulin et al. (2007). Resultados Foram entrevistados 242 pacientes e realizadas 1309 avaliações com maior quantidade de indivíduos do sexo masculino e que possuíam o Ensino Fundamental incompleto. Houve maior ocorrência de câncer no sistema gastrintestinal e sistema reprodutor feminino, respectivamente, na internação de Oncologia Clínica e Cirúrgica, com maior taxa de ocupação nos meses de junho e de maio, nessa ordem. O comportamento observado foi bastante similar em ambas as internações, correspondendo, respectivamente, a pacientes que se enquadravam nos cuidados mínimos (33,1%; 35,1%) e intermediários (30,2%; 37,5%). Conclusão e implicações para a prática O sistema de classificação de pacientes e dimensionamento em Enfermagem na área oncológica merece maiores discussões e carece de instrumentos validados capazes de representar a real situação do cuidado.

RESUMEN Objetivo Clasificar el nivel de complejidad asistencial requerido en Enfermería por pacientes oncológicos hospitalizados. Método Estudio observacional, seccional, con enfoque cuantitativo, realizado diariamente con pacientes oncológicos en unidades de internación de Oncología Clínica y Quirúrgica de un hospital de referencia para el tratamiento del cáncer durante un período de tres meses. La recolección de datos se realizó mediante la aplicación de un cuestionario semiestructurado y un instrumento de clasificación de pacientes de Fugulin et al. (2007). Resultados Se entrevistaron 242 pacientes y se realizaron 1309 evaluaciones con mayor número de individuos del sexo masculino que tenían la Enseñanza Básica incompleta. Hubo mayor ocurrencia de cáncer en el aparato digestivo y aparato reproductor femenino, respectivamente, en el ingreso de Oncología Clínica y Quirúrgica, con la mayor tasa de ocupación en los meses de junio y mayo, en ese orden. El comportamiento observado fue bastante similar en ambas hospitalizaciones, correspondiendo, respectivamente, a pacientes que se encontraban en cuidados mínimos (33,1%; 35,1%) e intermedios (30,2%; 37,5%). Conclusión e implicaciones para la práctica El sistema de clasificación y dimensionamiento de pacientes en Enfermería en el área de oncología merece mayor discusión y carece de instrumentos validados capaces de representar la situación real del cuidado.

ABSTRACT Objective To classify the level of complexity of care required from Nursing by hospitalized oncology patients. Methods This is an observational, sectional, quantitative study, carried out daily with oncology patients in the Clinical and Surgical Oncology inpatient units of a cancer treatment reference hospital during a three-month period. The collection was carried out through the application of a semi-structured questionnaire and an instrument of patient classification by Fugulin et al. (2007). Results 242 patients were interviewed and 1309 evaluations were performed, with a greater number of males and those with incomplete elementary school education. There was a higher occurrence of cancer in the gastrointestinal system and female reproductive system, respectively, in the admission of Clinical and Surgical Oncology, with higher occupancy rate in the months of June and May, in that order. The behavior observed was quite similar in both admissions, corresponding, respectively, to patients who fell into minimal (33.1%; 35.1%) and intermediate care (30.2%; 37.5%). Conclusion and implications for practice The patient classification and dimensioning system in Nursing in oncology deserves further discussion and lacks validated instruments capable of representing the real situation of care.

A comparative analysis on human resources among the specialized ophthalmic medical institutions in China.

BACKGROUND: This study compares perspectives on specialized ophthalmic medical institutions, identifies the gaps in property and geographic offerings, and explores the ways that ophthalmic medical institutions can better allocate resources. The results of this research will increase patient's access to equitable and high-quality ophthalmic care in China. METHODS: The data for this research was gathered from the Survey of China National Eye Care Capacity and Resource for the year 2015. The paper specified the number, professional level of expertise, and educational background of ophthalmic health personnel. The authors of the paper analyzed and compared the differences in ophthalmic care in public vs. private and urban vs. rural regions in China. Descriptive statistics were used. RESULTS: Of the 395 specialized ophthalmic hospitals surveyed, 332 were private medical institutions (84%), and 63 were public (16%). Of the 26 607 ophthalmic personnel surveyed, working in specialized ophthalmic hospitals, 17 561 were in private hospitals (66%) and 9 046 were in public ones (34%). Furthermore, 22 578 of those personnel worked in urban ophthalmic institutions (85%) and 4 029 worked in rural ones (15%). As for regional differences, 14 090 personnel were located in eastern China (53%), 8 828 in central regions (33%), and 3 689 in the western regions (14%). CONCLUSIONS: Public ophthalmic medical institutions still face challenges in providing equitable and widespread care. The availability of well-staffed health centers varies significantly by region. These variations impact resource allocation and directly lead to inequalities and inaccessibility of health services in certain regions of China.

Quality and safety of the nurse practice environment: Implications for management commitment to a culture of safety.

BACKGROUND: The Philippines experiences several challenges pertaining to the quality of the practice environment (PE) and nursing quality safety (NQS) among nurses. Although there is already considerable empirical data on PE effects on NQS, there is still little overall information on the association between these variables. AIM: This survey study examined the contribution of nurses' perceptions of their PE on their perception of their PE's quality of safety among hospital nurses in the Philippines. This survey was conducted in two government hospitals and two private hospitals in the Philippines. PARTICIPANTS: A total of 374 nurses selected from two selected government hospitals and two private hospitals in the Philippines using a convenience sample technique. METHODS: Data were collected using a self-administered questionnaire focusing on the PE and NQS among nurses. RESULTS: The overall PE mean score of nurses is 3.07 (SD = 0.159) while the overall mean score of their NQS is 3.97 (SD = 0.702). NQS was higher in female nurses compared with male nurses (M = 2404 vs 4.16). Nurses assigned to emergency departments (F = 1.04, [df = 11], and P = .025) presented higher perceived NQS compared with those in other departments. CONCLUSION: Nurses report moderate PE and higher NQS. Sex and emergency room department are significantly associated with NQS. Health care services have an obligation to ensure strong PE, as an important factor in regard to nursing management and affecting the QNS.

[Occupational aspects of emergency medicine practice in Catalonia: the OPENCAT opinion survey]. / Opinión de los profesionales acerca de diversos aspectos laborales de los servicios de urgencias y emergencias de Cataluña: Estudio OPENCAT.

OBJECTIVES: To gather information on the contracting and training of members of the Catalan Society of Emergency Medicine (SoCMUE) who work in emergency medicine and services in Catalonia. To survey their opinions on certain aspects of resource availability and working conditions. MATERIAL AND METHODS: Cross-sectional descriptive study based on a survey sent to SoCMUE members. We studied the opinions of 5 types of respondent: hospital physicians, out-of-hospital physicians, hospital nurses, out-of-hospital nurses, and emergency medical technicians. Responses were grouped to compare the opinions of physicians and nurses and workers in hospital and prehospital settings. RESULTS: We received 616 responses from 1273 members (48.4% response rate). More physicians than nurses come from outside Catalonia and have contracts specifically linked to emergency care; in addition, physicians have done less postgraduate training in emergency medicine. More hospital staff than prehospital staff have permanent contracts linked to the department where they work. More hospital physicians are specialized in internal medicine than in family and community medicine. The opinion that emergency services are inadequately staffed was widespread. Most respondents believed that patient transport is good or adequate. However, respondents working in prehospital services expressed a lower opinion of transport. Great difficulty in combining work with family (life achieving work-life balance) was expressed by 13.5% overall, and more often by hospital staff. Some type of aggression was experienced by 88.2%; 60% reported the event to superiors. Nurses reported aggression more often than physicians. A police report was filed by 10.1%. CONCLUSION: Emergency medicine working conditions can be improved in Catalonia according to members of SoCMUE. Relations between groups of professionals are not optimum in some aspects.

OBJETIVO: Investigar las condiciones contractuales y formativas de los socios de la Societat Catalana de Medicina d'Urgències i Emergéncies (SoCMUE) que trabajan en el ámbito de la Medicina de Urgencias y Emergencias (MUE) en Cataluña, y su percepción acerca de algunos recursos disponibles y aspectos de su práctica laboral. METODO: Estudio descriptivo transversal mediante encuesta enviada a los socios de SoCMUE. Se distinguieron médicos hospitalarios y extrahospitalarios, enfermeros hospitalarios y extrahospitalarios, y técnicos en emergencia sanitaria (TES). Se realizaron agrupaciones de médico/enfermero y hospitalario/extrahospitalario. RESULTADOS: Respondieron 616 de 1.273 socios (48,4%). Respecto a los enfermeros, los médicos tienen mayor porcentaje de profesionales no comunitarios, contratos más vinculados a urgencias/emergencias, y han realizado menos formación de postgrado en MUE. Los profesionales hospitalarios, respecto a los extrahospitalarios, tienen mayor proporción de contratos fijos y vinculados al propio servicio, han realizado menos formación de postgrado, y la proporción de especialistas en medicina interna es mayor y en medicina familiar y comunitaria menor. Existe la percepción generalizada de plantillas insuficientes. La transferencia de pacientes es considerada mayoritariamente buena o correcta, pero es peor percibida por extrahospitalaria. El 13,5% refiere una conciliación familiar imposible, más frecuentemente en el ámbito hospitalario. El 88,2% ha sufrido algún tipo de agresión, el 60% lo comunicó a sus superiores (enfermeros más que médicos) y el 10,1% lo denunció judicialmente. CONCLUSIONES: Para los socios de la SoCMUE, en la práctica de la MUE en Cataluña, existen algunas condiciones laborales mejorables y la relación entre colectivos de profesionales es poco óptima en algunos aspectos.

Organizational Issues, Structure, and Processes of Care in 257 ICUs in Latin America: A Study From the Latin America Intensive Care Network.

OBJECTIVE: Latin America bears an important burden of critical care disease, yet the information about it is scarce. Our objective was to describe structure, organization, processes of care, and research activities in Latin-American ICUs. DESIGN: Web-based survey submitted to ICU directors. SETTINGS: ICUs located in nine Latin-American countries. SUBJECTS: Individual ICUs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred fifty-seven of 498 (52%) of submitted surveys responded: 51% from Brazil, 17% Chile, 13% Argentina, 6% Ecuador, 5% Uruguay, 3% Colombia, and 5% between Mexico, Peru, and Paraguay. Seventy-nine percent of participating hospitals had less than 500 beds; most were public (59%) and academic (66%). ICUs were mainly medical-surgical (75%); number of beds was evenly distributed in the entire cohort; 77% had 24/7 intensivists; 46% had a physician-to-patient ratio between 1:4 and 7; and 69% had a nurse-to-patient ratio of 1 ≥ 2.1. The 24/7 presence of other specialists was deficient. Protocols in use averaged 9 ± 3. Brazil (vs the rest) had larger hospitals and ICUs and more quality, surveillance, and prevention committees, but fewer 24/7 intensivists and poorer nurse-to-patient ratio. Although standard monitoring, laboratory, and imaging practices were almost universal, more complex measurements and treatments and portable equipment were scarce after standard working hours, and in public hospitals. Mortality was 17.8%, without differences between countries. CONCLUSIONS: This multinational study shows major concerns in the delivery of critical care across Latin America, particularly in human resources. Technology was suboptimal, especially in public hospitals. A 24/7 availability of supporting specialists and of key procedures was inadequate. Mortality was high in comparison to high-income countries.

Dimensioning of hospital nursing personnel: study with brazilian official parameters of 2004 and 2017 / Dimensionamiento de personal de enfermería hospitalaria: estudio con parámetros oficiales brasileños de 2004 y 2017 / Dimensionamento de pessoal de enfermagem hospitalar: estudo com parâmetros oficiais brasileiros de 2004 e 2017

Abstract Objective: To investigate the dimensions of the nursing team of a hospital unit according to the official Brazilian parameters of 2004 and 2017 and compare the dimensioned conditions to the actual condition existing. Method: A cross-sectional study with data from patients (n = 325) hospitalized in the Neurology and Orthopedics unit of a university hospital in Paraná, Brazil. Data from the Patient Classification System related to nursing work, as well as sociodemographic and clinical variables of the clientele were compiled. The dimensioning of the nursing staff followed the Federal Nursing Council Resolutions of 2004 and 2017. Results: The profile of the patients showed predominantly men (66.46%) hospitalized for Orthopedics (49.58%). The negative difference of professionals dimensioned compared to the actual condition was more evident for the category of nurses, below both the parameters of 2004 (-8) and 2017 (-11). Conclusions: The number of nursing staff in the unit was insufficient.

Resumen Objetivo: Dimensionar el equipo de enfermería de una unidad hospitalaria según los parámetros oficiales brasileños de 2004 y 2017; comparar los cuadros dimensionados con lo real existente. Método: Estudio transversal, realizado entre junio y septiembre de 2016, en la unidade de Neurología y Ortopedia de un hospital universitario de Paraná, Brasil. Los datos fueron procesados en el Sistema de Clasificación de Pacientes, relativos al equipo de enfermería; y variables sociodemográficas y clínicas de la clientela (n = 325). El cálculo del personal de enfermería respondió a las resoluciones del Consejo Federal de Enfermería 2004 y 2017. Resultados: El perfil de los pacientes eran predominantemente hombres (66,46%) admitidos por Ortopedia (49,58%). La diferencia negativa de profesionales dimensionados en comparación con lo real fue más evidente para la categoría de enfermeros, tanto a los parámetros de 2004 (-8) como los de 2017 (-11). Conclusiones: El cuantitativo de enfermería en la unidad es insuficiente.

Resumo Objetivo: Dimensionar a equipe de enfermagem de uma unidade hospitalar segundo os parâmetros oficiais brasileiros de 2004 e de 2017 e, comparar os quadros dimensionados ao quadro real existente. Método: Estudo transversal realizado entre junho a setembro de 2016 na unidade de Neurologia e Ortopedia de um hospital universitário do Paraná, Brasil. Compilou-se dados do Sistema de Classificação de Pacientes, relativos à equipe de enfermagem; e, variáveis sociodemográficas e clínicas da clientela (n = 325). O dimensionamento de pessoal respondeu às Resoluções do Conselho Federal de Enfermagem nacional de 2004 e 2017. Resultados: O perfil dos pacientes era de homens (66,46%) internados pela Ortopedia (49,58%). A diferença negativa de profissionais dimensionados em comparação ao quadro real foi mais evidente para enfermeiros, tanto aos parâmetros de 2004 (-8) como de 2017 (-11). Houve superávit de técnicos de enfermagem (+6) pelos parâmetros antigos. Conclusões: O quadro de pessoal de enfermagem da unidade é insuficiente.

Differences between nurse- and physician-assessed ICU characteristics using a standardized survey.

OBJECTIVE: Surveys are often used to assess intensive care unit (ICU) organizational characteristics for quality improvement. Typically these surveys target ICU nurse managers and/or physician directors. However, it is unclear whether these providers' assessments differ. We sought to determine whether differences existed in nurse- and physician-assessed ICU characteristics using a standardized survey. DESIGN: We administered a previously developed survey to nurse managers and medical directors in adult ICUs within a single healthcare system in 2013. The survey asked about interprofessional staffing and evidence-based protocols. We examined differences between nurse managers' and medical directors' responses using McNemar's test and assessed concordance using the kappa statistic. SETTING: Twenty-three ICUs in 10 hospitals in Southwestern Pennsylvania. RESULTS: Sixteen (69%) were specialty ICUs. The median number of ICU beds was 34. Concordance was moderate for high- vs. low-intensity physician staffing (κ = 0.60) and almost perfect on questions related to interprofessional staffing (κ = 0.83 nurse practitioners/physician assistants; 1.0 respiratory therapists; 0.83 physical therapists). However, concordance was slight to fair with regard to the presence of these providers on rounds (κ = 0.20-0.21) and poor to slight for protocols for liberation from mechanical ventilation (κ = 0.19), sedation (κ = -0.03) and central line insertion (κ = -0.03). CONCLUSIONS: Despite a standardized survey, we found substantial disagreement on ICU characteristics when assessed by the nurse manager or physician director. This study raises questions about the use of surveys to examine ICU organizational characteristics and suggests that differences in nurse managers' and medical directors' assessments could be helpful in guiding future ICU quality improvement projects.

Examining variations in hospital productivity in the English NHS.

OBJECTIVES: Numerous papers have measured hospital efficiency, mainly using a technique known as data envelopment analysis (DEA). A shortcoming of this technique is that the number of outputs for each hospital generally outstrips the number of hospitals. In this paper, we propose an alternative approach, involving the use of explicit weights to combine diverse outputs into a single index, thereby avoiding the need for DEA. METHODS: Hospital productivity is measured as the ratio of outputs to inputs. Outputs capture quantity and quality of care for hospital patients; inputs include staff, equipment, and capital resources applied to patient care. Ordinary least squares regression is used to analyse why output and productivity varies between hospitals. We assess whether results are sensitive to consideration of quality. RESULTS: Hospital productivity varies substantially across hospitals but is highly correlated year on year. Allowing for quality has little impact on relative productivity. We find that productivity is lower in hospitals with greater financial autonomy, and where a large proportion of income derives from education, research and development, and training activities. Hospitals treating greater proportions of children or elderly patients also tend to be less productive. CONCLUSIONS: We have set out a means of assessing hospital productivity that captures their multiple outputs and inputs. We find substantial variation in productivity among English hospitals, suggesting scope for productivity improvement.

How do strategic decisions and operative practices affect operating room productivity?

Surgical operating rooms are cost-intensive parts of health service production. Managing operating units efficiently is essential when hospitals and healthcare systems aim to maximize health outcomes with limited resources. Previous research about operating room management has focused on studying the effect of management practices and decisions on efficiency by utilizing mainly modeling approach or before-after analysis in single hospital case. The purpose of this research is to analyze the synergic effect of strategic decisions and operative management practices on operating room productivity and to use a multiple case study method enabling statistical hypothesis testing with empirical data. 11 hypotheses that propose connections between the use of strategic and operative practices and productivity were tested in a multi-hospital study that included 26 units. The results indicate that operative practices, such as personnel management, case scheduling and performance measurement, affect productivity more remarkably than do strategic decisions that relate to, e.g., units' size, scope or academic status. Units with different strategic positions should apply different operative practices: Focused hospital units benefit most from sophisticated case scheduling and parallel processing whereas central and ambulatory units should apply flexible working hours, incentives and multi-skilled personnel. Operating units should be more active in applying management practices which are adequate for their strategic orientation.

[From personnel administration to human resource management : demographic risk management in hospitals]. / Von der Personalverwaltung zur Personalentwicklung : "Demographic risk management" in Krankenhäusern.

BACKGROUND: The healthcare market is facing a serious shortage of qualified personnel in 2020. Aging of staff members is one important driver of this human resource deficit but current planning periods of 1-2 years cannot compensate the demographic effects on staff portfolio early enough. Therefore, prospective human resource planning is important to avoid loss of competence. METHODS: The long range development (10 years) of human resources in the hospitals of the City of Cologne was analyzed. The basis for the analysis was a simulation model that included fluctuation of staff, retirement, maternity leave, status of employee illness, partial retirement and fresh engagements per department and profession. The model was matched with the staff requirements for each department. The results showed a capacity analysis which was used to convey strategic measures for staff recruitment and retention. RESULTS: The greatest risk for shortage of qualified staff was found in the fluctuation of doctors and in the aging work force. Without strategic human resource management the hospitals would face a 50% reduction of the work force within 10 years and after 2 years there would be a 25% deficit of anesthesiologists with impact on the function of operation rooms (OR) and intensive care units. Qualification and continuous training of staff members as well as process optimization are the most important spheres of activity for human resource management in order to recruit and retain qualified staff members. CONCLUSION: Prospective human resource planning for the OR and intensive care units can help to detect shortage of staff and loss of competence early enough to apply effective personnel development measures. A growing number of companies have started to plan ahead of the current demand of human resources. Hospitals should follow this example because the competition for qualified staff members is increasing rapidly.

Estado nutricional de trabajadores bajo turnos rotativos o permanentes / Nutritional state of workers under steady or rotating shifts

Restrictions of sleep predispose to experience, in the long-term, excess malnutrition and non-transmissible chronic diseases. The objective of this research has to study the influence of working shifts on nutritional status lipid profile and fasting blood glucose (FBG). Study of a series of cases considered a total of47 recruited workers from which 31 of them had a rotating shift (day and night) and 16 a steady shift (day). The nutritional assessment involved: BMI (Body Mass index), waist and hip circumference, tricipital, bicipital, sub scapular and supra iliac skin folds. Sleep hours were studied with a weekly record, food intake was studied by means of 24-hours dietary recall. It was determined: total cholesterol, c-HDL, c-LDL, blood triglycerides and fasting blood glucose (FBG). The sample was composed by 87 percent women and 13 percent men, average age of 38,7years [19,0] v/s 44,7[25¿2] (p=0,420) in rotating and steady shifts respectively. The rotating shift did not show any significant differences compared to the steady shift in terms of anthropometric parameters except for sub scapular skin fold that was significantly higher (p=0,032) in relation to the macronutrients intake. Lipid profile and glycerin did not show important differences (p=>0,05). The prevalence of the nutritional status was: rotating shift 35,4 percent normal, 45,1 percent overweight and 19,5 percent obese. On the other hand, the steady shift showed: 43,7 percent normal and 56¿ percent overweight. Seniority only in the rotating shift showed a positive correlation of BMI (r=0,436 p<0,005) body fat (r=0,454 p<0,005) total cholesterol (r= 0,¿94 p<0,005) LDL (r=0,484 p<0,005) and glycerin (r=0,405 p<0,005). We concluded that workers of the rotating and steady shift did not show significant differences among variables studied except for the sub scapular skin fold that was significantly higher in the rotating shift, that can be associated to predominantly central fat distribution.

Restricciones del sueño predisponen a padecer, a largo plazo, malnutrición por exceso y enfermedades crónicas no transmisibles. El objetivo fue estudiar la influencia del turno laboral sobre estado nutricional, perfil lipídico y glicemia en ayuno. Estudio exploratorio del tipo de serie de casos, 47 reclutados; 31 turnos rotativos (día y noche), y 16 turno permanente (día). La evaluación nutricional se efectuó mediante el IMC, la circunferencia cintura-cadera y los pliegues tricipital, bícipital, subescapular y suprailiaco. Se estudió las horas sueño mediante un registro semanal, la ingesta dietética por encuesta de recordatorio de 24 horas. Se determinó el colesterol total, c-HDL, c-LDL, triglicéri-dos séricos y glicemia. La muestra estuvo representada en un 87 por ciento mujeres y 13 por ciento por hombres, cuya mediana de edad fue de 38,7 años [19,0] y 44,7[25,2] (p=0,420) en turno rotativo y permanente, respectivamente. El turno rotativo no mostró diferencias significativas respecto al turno permanente en los parámetros antropométricos a excepción, del pliegue subescapular que fue significativamente superior (p=0,032), respecto a ingesta de macronutrientes, perfil lipídico y glicemia tampoco mostró diferencias significativas (p=> 0,05). La prevalencia del estado nutricional en el turno rotativo fue en 35,4 por ciento normal, en 45,1 por ciento sobrepeso y en 19,5 por ciento obesidad, y turno permanente: 43,7 por ciento normal y 56,3 por ciento sobrepeso. La antigüedad laboral sólo en el turno rotativo se correlacionó positivamente con IMC (r=0,436 p<0,005), grasa corporal (r=0,454 p<0,005), el colesterol total (r= 0,394 p<0,005) el LDL (r=0,484 p<0,005) y la glicemia (r=0,405 p<0,005). En conclusión, los funcionarios del turno rotativo y permanente no mostraron diferencias significativas entre las variables estudiadas, a excepción del pliegue subescapular que fue significativamente mayor en el turno rotativo, lo que podría asociarse a la distribución de la...

Discrete event simulation as a tool in optimization of a professional complex adaptive system.

Similar urgent needs for improvement of health care systems exist in the developed and developing world. The culture and the organization of an emergency department in developing countries can best be described as a professional complex adaptive system, where each agent (employee) are ignorant of the behavior of the system as a whole; no one understands the entire system. Each agent's action is based on the state of the system at the moment (i.e. lack of medicine, unavailable laboratory investigation, lack of beds and lack of staff in certain functions). An important question is how one can improve the emergency service within the given constraints. The use of simulation signals is one new approach in studying issues amenable to improvement. Discrete event simulation was used to simulate part of the patient flow in an emergency department. A simple model was built using a prototyping approach. The simulation showed that a minor rotation among the nurses could reduce the mean number of visitors that had to be refereed to alternative flows within the hospital from 87 to 37 on a daily basis with a mean utilization of the staff between 95.8% (the nurses) and 87.4% (the doctors). We conclude that even faced with resource constraints and lack of accessible data discrete event simulation is a tool that can be used successfully to study the consequences of changes in very complex and self organizing professional complex adaptive systems.

Patient journeys: the process of clinical redesign.

*Clinical process redesign is a successful improvement method that has been used to increase access to health services in 60 public hospitals across New South Wales, and at Flinders Medical Centre (FMC) in South Australia. *The method focuses on the patient journey as the primary improvement locus, and uses process mapping to identify the value-adding steps in that journey; it involves redesign teams identifying and eliminating non-value-adding steps to improve flow and reduce delays in access to emergency and elective care. *The method engages clinicians, managers, patients and carers, and delivers real gains in health care delivery. *This article outlines the clinical process redesign programs being used by NSW Health and at FMC.

Retirement benefits as a recruitment tool.

Using data from "Retirement Plan Trends in Today's Healthcare Market-2003," a new report, this gatefold shows how hospitals can use retirement benefits to attract and retain staff, a matter of vital importance as the U.S. work force ages.

Organizational strategy and diversity management: diversity-sensitive orientation as a moderating influence.

Empirical studies on diversity suggest that health care organizations have been slow to embrace diversity management. We propose that sensitivity to diversity, at the corporate level, moderates strategic decision making, which influences human resource management practices such as diversity initiatives. This study of 203 hospitals explored the relationships among organizational strategy, organizational sensitivity to diversity, and diversity management practices.

Indicadores para dimensionamento e remuneração da equipe de clínica médica em pronto-socorro de hospital privado / Indicators for the Design and Financial Compensation of the Clinical Medical Staff in a Private Hospitals Emergency Room

Os serviços de pronto-socorro, na área de clínica médica, apresentam uma demanda com grandes flutuações, o que dificulta o dimensionamento da Equipe Médica. A remuneração da Equipe consome quase todo o faturamento do setor, com risco de inadimplência em meses de baixo movimento. Por meio do estudo retrospectivo de indicadores de atividade nos pronto-socorros dos Hospitais São Camilo de Pompéia, Santana e Ipiranga, determinou-se um fator de cálculo. Denominado Coeficiente de Dimensionamento, ele permite a estimativa do número de médicos necessário para o atendimento adequado a certo volume de pacientes, assim como o cálculo da remuneração destes profissionais por hora trabalhada.