[Systemic approach to ecologic safety at objects with radiation jeopardy, involved into localization of low and medium radioactive waste].

The article deals with specifying systemic approach to ecologic safety of objects with radiation jeopardy. The authors presented stages of work and algorithm of decisions on preserving reliability of storage for radiation jeopardy waste. Findings are that providing ecologic safety can cover 3 approaches: complete exemption of radiation jeopardy waste, removal of more dangerous waste from present buildings and increasing reliability of prolonged localization of radiation jeopardy waste at the initial place. The systemic approach presented could be realized at various radiation jeopardy objects.

NRC inspections: risk-informed and performance-based.

In 2002, the U.S. Nuclear Regulatory Commission (NRC) revised its regulations governing the use of byproduct materials for medical purposes (10 CFR Part 35). These changes were the result of a detailed, 4-year examination of the issues surrounding the medical use program of the NRC and are stated in the latest revision to its medical policy statement, published in the Federal Register on August 3, 2000. As part of an overall program for revising its regulatory framework for medical use, the NRC revised its medical policy statement in keeping with the goal of focusing regulation on those medical procedures that pose the highest risk and structuring the regulations to be risk-informed. NRC inspection procedures were also revised to focus on high-risk activities through a performance-based approach, that is, through observations and interviews with licensee personnel performing NRC-regulated tasks. The purpose of this article is to inform the radiation worker (nuclear medicine technologist or authorized user physician) of the revised focus of the medical use program of the NRC and inspection procedures relative to nuclear medicine-licensed activities. After reading this article, the radiation worker should be able to describe the concept of risk-informed, performance-based regulations and inspections, identify areas of high-risk activities in the nuclear medicine laboratory, and describe techniques used by the NRC inspector to determine the licensee's compliance with the regulations.

Where is the pilot? The changing shapes of governance in the European hospital sector.

Hospital governance refers to the complex of checks and balances that determine how decisions are made within the top structures of hospitals. This article explores the essentials of the concept by analysing the root notion of governance and comparing it with applications in other sectors. Recent developments that put pressure on the decision-making system within hospitals are outlined. Examples from the UK, France and the Netherlands are presented. Based on an evaluation of the current state of affairs, a research framework is developed, focusing on the determinants of governance configurations within the national healthcare systems and the wider legal and socio-economic context, as well as on the impact of governance configurations on the efficiency of the governing bodies and overall hospital performance. The article concludes with a preview of the European Hospital Governance Project, which follows the outlines of the described research framework. New techniques of data mining that are used in this project are explained by means of a real data example.

Diagnostic X-ray facilities as per quality control performances in Tanzania.

Without appropriate quality control (QC) and preventative maintenance (PM) measures for X-ray machines in place, the benefits of reduced dose to the patient and early diagnosis will not be realized. Quality control and PM also make it possible to unify X-ray-imaging practices in the country using international image quality guidelines. The impetus for the present work resulted from the concern that with the recent increase in the numbers of X-ray machines in Tanzania, but with limited technical support to maintain and operate them, can increase radiation risk to patients and lower diagnostic accuracy. The aim of this work is to report on the current status of diagnostic X-ray machines in Tanzania in order to produce the data needed to formulate QC and PM policies and strategies. These policies and strategies are needed to ensure that patients receive the lowest possible radiation risk and maximum health benefits from X-ray examinations. Four QC tests were performed on a total of 196 X-ray units. Accurate beam alignment and collimation were tested on 80 (41%) units, the timer accuracy was tested on 120 (61%) units, and a radiation leakage test was performed on 47(24%) units. Preventative maintenance tests were performed on all 196 X-ray units. The results showed that of the units tested for QC, 59% failed the kilovoltage (kVp) test, 57% failed the timer accuracy test, 60% failed the beam alignment test, and 20% failed the radiation leakage test. Only 13% of the units passed the PM test: 53% of the units were defective, and 34% were out of order. As a result of the PM findings, the government has introduced a rehabilitation project to service X-ray units and replace nonoperational X-ray units. The new units have full support service contracts signed by their suppliers. As a result of the QC findings, X-ray maintenance retraining programs have been introduced.

Collaborative strategies for survival.

Pathology and laboratory medicine face major challenges, including multiplying government regulations, increasing competition, decreasing reimbursement, and loss of directorial control. Other industries facing similar threats have found solutions in a variety of collaborative strategies. Several examples of laboratory collaboration and a template for evaluation of potential joint operations are presented. Successful strategies will make it easier to handle meddlesome regulations, increase productivity and decrease costs, allow pathologists to retain control, and make the laboratory more profitable and competitive.

Out of the frying pan: New York City hospitals in an age of deregulation.

For several decades New York City hospitals had been distinguished by their tightly regulated environment, chronically weak finances, high occupancy rates, teaching intensity, dependency on public payers, low managed care penetration, and minimal merger activity. Then in the late 1990s a rapid convergence of forces--the Balanced Budget Act, managed care growth, state deregulation of commercial rates, escalating costs, and plunging hospital occupancy rates--threw the city's hospital industry into turmoil. In this paper we describe this period of turbulent change that has left most of the city's safety-net and small community hospitals near bankruptcy.

Political evolution of federal health care regulation.

Although federal regulation of health care faces cultural obstacles and skepticism among policymakers, it has grown markedly over the past two decades. Beginning in the 1970s with decentralized programs aimed at regulating provider behavior (Health Systems Agencies and certificate of need) and budgets (state rate setting), health care regulation grew more centralized in the 1980s as federal policymakers expanded their influence on behavior (peer review organizations and medical practice guidelines) and budgets (Medicare prospective payment and the resource-based relative value scale). Behavioral regulation has increased the heavy micromanagement that providers face in the United States, while budgetary regulation falls well short of the fiscal macromanagement (global budgets, for example) that other Western nations use. As cost increases intensify, the coalitions that supported limited regulation as a compromise designed to forestall more threatening intrusions may yield to political pressure for firmer central budget controls.

Nursing home regulation: history and expectations.

This article contains a broad overview of the history of Federal regulation of nursing homes from the perspective of an individual involved directly for a number of years in the development and enforcement of Federal regulatory requirements. The article also contains a summary of the major statutory changes in the Omnibus Budget Reconciliation Act of 1987 that affect nursing homes. Finally, the results of these changes are projected in terms of new outcome-oriented requirements and a broad range of new enforcement authorities.

Hospital system management in France and Canada: national pluralism and provincial centralism.

Since the mid-1960s, France and Canada have developed different ways of managing their hospital systems. In Canada, each provincial government has gradually imposed technocratic control with the aim of planning the allocation of health-care resources. In spite of attempts to do the same in France, the hospital system has grown with few restrictions other than those set by the medical profession itself. Consequently, health expenditures have risen at one of the fastest paces in Europe. The provincial monopoly over hospital care in Canada contrasts with the juxtaposition of local 'cartels' throughout France resulting, for the latter, in a much more uncoordinated system. After a description of each country's hospital system and its historical origins, the advantages and disadvantages of each system are assessed so as to understand current public debate in each country.

The effect of airline deregulation on automobile fatalities.

This paper attempts to quantify the effects of airline deregulation in the United States on intercity automobile travel and consequently on the number of highway fatalities. A demand model is constructed for auto travel, which includes variables representing the price and availability of air service. A reduced form model of the airline market is then estimated. Finding that deregulation has decreased airfares and increased flights, it is estimated that auto travel has been reduced by 2.2% per year on average. Given assumptions on the characteristics of drivers switching modes and the types of roads they drove on, the number of automobile fatalities averted since 1978 is estimated to be in the range 200-300 per year.

For-profit hospitals for Europe: the case of Britain and France.

The paper first describes the structural characteristics of the for-profit private sector in Britain and in France. In Britain, the recent growth of the for-profit private hospital's sector, although still a small sector, is related to the growth of private insurance. Cost-containment however coupled to rapid increases in premiums is slowing down the momentum. Moreover, the NHS starts charging private hospitals for such services like blood banks. In France the private sector has always been strong, although living in a highly regulated and dependent symbiosis with the public sector. In a second part, speculations are made on the crucial question whether for-profit hospitals are a legitimate alternative for Europe. In the end, an in-between solution is opted for by which the public sector would sub-contract certain functions like data processing, management and others, from the commercial sector.

Injury, death, and the deregulation fetish: the politics of occupational safety regulation in U.K. manufacturing industries.

The author examines some of the more recent developments in the social and political environments within which the "deregulation fetish" is crucial, but of which it remains only one element. This fetish, as part of a broader assault on the legitimacy of the external regulation of business activity, will not go away; its effects are already being felt in the context of the regulation of occupational safety in the United Kingdom. After outlining recent trends in recorded injuries in U.K. workplaces, with particular reference to manufacturing industries, the author charts the nature and effects of the social and political contexts of the work of U.K. safety regulators in the 1980s. While Thatcher governments withdrew from any direct deregulatory assault on occupational safety, what transpired was a gradual but continual undermining of the ability of these agencies to fulfill their mandated functions. The nature and effects of a new politics of deregulation are examined and this new politics is related to U.K. governmental opposition to European Union influence in domestic social policy, which stands in a symbiotic relationship with the re-emergence of a sustained deregulatory discourse in the United Kingdom.

Healthcare regulation: past, present, and future.

Excessive regulation has created a formidable barrier for physicians to surmount when treating patients. This article examines the increasing intrusion by regulatory agencies--government and private--into the patient-physician relationship. The authors examine the history of healthcare policy leading to today's highly regulated approach to cost-containment. They trace the development of the emphasis on regulatory controls from 1900 to the present. Further, they examine in detail the specific impact of diagnosis-related groups, utilization review firms, and the Clinical Laboratory Improvement Amendments of 1988 on the patient-physician relationship. Diagnosis-related groups set the hospital administration as monitor of the patient-physician relationship. Utilization review firms insert themselves as another gatekeeper in decisions of appropriateness of care. The Clinical Laboratory Improvement Amendments causes laboratories to close, thereby restricting access to care. The reform movement would respect the patient-physician relationship and remove excessive regulation from this confidential interaction. Regulation after reform would react to outcomes rather than controlling the process of healthcare delivery.

Accountability and quality in managed care: implications for health care practitioners.

The development of managed care plans is the most dramatic change in the USA's health care system in recent decades. Despite the widespread growth, society is increasingly concerned with the quality of managed care programs. This article addresses the regulatory pressures that are being placed on managed care organisations and examines what health care practitioners can do to minimize the impact of increased regulation. We look at the major factors that are likely to bring about changes in the health care sector, and predict how these changes will affect the quality of health care that is being delivered in the near future. Addresses how quality can become and remain the primary factor in the delivery of health care services. Finally, concludes that greater involvement by the federal government is necessary to protect consumers' rights, and ensure better quality health care from managed care programs.

An innovative method of government surveillance of services for the aged in Israel.

Explains the conceptual framework behind and the foundation and implementation of the regulation, assessment, follow-up (RAF) method, and continuous improvement of quality of care in the Israeli Government surveillance of long-term care institutions. The RAF method has made crucial changes in the goals, tasks and tools of surveillance and in therapeutic approaches to the elderly. The "maintenance approach" has been replaced by a "rehabilitative approach" bringing about a real improvement in the quality of care in institutions. Presents selected findings from an evaluation of the RAF method's use in the surveillance system operated by the Israeli Service for The Aged of the Ministry of Labor and Social Affairs.

Oversight mechanisms in public managed care programs: from little oversight to negotiations to shared decision-making.

An expanded range of oversight mechanisms is being adopted to hold public human service programs more accountable to funding sources as well as consumers, family members, and providers. Most of these approaches are hierarchical in nature. Some involve negotiated agreements and each is designed to meet certain goals and functions. Each utilizes different forms of decision-making. Stakeholders prefer to be part of a shared decision-making process. Understanding these underlying premises can help to assess the strengths and weaknesses of each method and can suggest how to most effectively utilize combinations of approaches to improve program performance. Whether we will move toward a new paradigm emphasizing participation and collaboration rather than more formal structural approaches is yet undetermined but will greatly affect how programs are monitored and evaluated in the future.

Deregulation of the health care industry: implications of financial change.

DRG-style prospective reimbursement has the potential to act as a destabilizing and deregulating force in the health care industry. The consequences of deregulation are anticipated to include: corporate capture of the delivery system: increased physician investment in the delivery process; shift in governance from the community to the national marketplace; changes in utilization patterns; re-emphasis on market shares; intensification of ambulatory care strategies; changes in the intensity of diagnostic services; new directions in corporate reorganization; and the rise of the chief financial officer.

Will sophisticated MIS lead to increased legislation of medicine?

If the healthcare industry automates clinical practices and links them along critical care pathways, will it be providing Federal regulators with data they may use to legislate how hospital care should be delivered? This article examines the implications of expanded use of increasingly sophisticated information systems in health care.

Competition in health care: strategies from other industries.

Health care managers can learn to adjust to competition by observing companies in other deregulated industries. Six basic strategies will separate the winners from the losers: Increase market share. This strategy requires not only increasing the share of current markets but also introducing new products and services into new markets. Scrutinize operations. Managers must be knowledgeable about strategic planning, adept at product line analysis, and skillful in using management information systems. Prune where necessary. Operations must be periodically reviewed to assess whether programs, products, and services continue to be profitable. Increase productivity. Productivity in this labor-intensive industry is essential. Wages may have to be reduced and staffing levels changed in the future to permit better control of labor costs. Increasing the volume of service, investing in nonclinical technology, and encouraging employee ideas also should be considered in seeking higher productivity. Strengthen the balance sheet. Hospitals should avoid incurring both long- and short-term debt, and they should attempt to accelerate repayment of long-term debt. Not-for-profit hospitals should investigate joint ventures, which spread the financial risk among investors, as means to raise capital to expand their operations. Increase cash. Prudent organizations will establish reserve funds, adopt fund-raising programs, and initiate improved cash collection systems. Health care executives also should reflect on how deregulation may affect their employees, the poor, and access to sophisticated medical procedures. The successful health care organization eventually will position itself in line not only with its markets but also with its mission and values.

Risk management or political micromanagement?

A major healthcare issue of the 1990s is whether providers will create effective risk management programs to cope with government reform mandates or whether an increasingly costly and complex regulatory structure will force them to make changes. Compliance with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards on patient care will become increasingly important to healthcare risk management in the 1990s. The JCAHO standards create a benchmark from which government entities set their present standards and assemble agendas for the future. Another healthcare risk management factor is compliance with the National Practitioner Data Bank. The data bank is intended to protect healthcare consumers from providers who have demonstrated a tendency to commit malpractice. However, the data bank could cause problems for healthcare providers: Inaccurate or misleading data could unfairly haunt them. Healthcare risk managers should be familiar with the prohibitions on patient dumping found in the Consolidated Omnibus Budget Reconciliation Act of 1985. The amendments of the Omnibus Budget Reconciliation Act of 1989 (OBRA '89) do not create strict liability, nor do they impose traditional tort standards that could guide courts in cases that will inevitably result from new rules, creating a "litigation time bomb." And OBRA '90 significantly revises the law. Other risk management issues include the manner in which facilities handle and dispose of medical waste and the manner in which they resolve disputes.