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2010 Volume 46 Number 1 www.ihf-fih.org
World Hospitals and Health Services The Official Journal of the International Hospital Federation
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M
Y Edittoorial
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MY Opinion matters Health technologies, health systems, and health CY outcomes in the 21st century CMY
K Policy Public-Private Partnerships in the Portuguese health sector
Evidence informed decision-making in healthcare: the case for health technology assessment
“Megatrends” driving healthcare facility design: a look at the major trends that will shape medical Please tick your box and pass this on: facility design ■ CEO Management Cultivating tomorrow’s leaders: comprehensive ■ Medical director development strategies ensure continued ■ Nursing director success ■ Head of radiology Assessment of human resources management practices in Lebanese hospitals ■ Head of physiotherapy ■ Senior pharmacist Clinical care Nutrition and patient safety a report from the ■ Head of IS/IT National Patient Safety Agency (United Kingdom)
■ Laboratory director How research can help control tuberculosis ■ Head of purchasing Promoting quality and patient safety via the new ■ Facility manager integrated hospital accreditation programme 01 contents 46.1:2008 IHF ref 4 20/5/10 09:34 Page 1 01 contents 46.1:2008 IHF ref 4 14/5/10 08:51 Page 1
Contents
Contents volume 46 number 1
02 Editorial Eric de Roodenbeke Editorial Staff Executive Editor: Eric de Roodenbeke, PhD Desk Editor: Opinion matters Sheila Anazonwu, BA(Hons), MSc 04 Health technologies, health systems, and health outcomes in the 21st century Editorial Board Dr Carissa Etienne Dr René Peters Dutch Hospital Association Norberto Larroca Camara Argentina de Empresas de Salud Policy Dr Harry McConnell 06 Public-Private Partnerships in the Portuguese health sector Jorge Simões, Pedro Pita Griffith University School of Medicine (Australia) Barros and Marta Temido Dr Persephone Doupi STAKES
10 Evidence informed decision-making in healthcare: the case for health technology Editorial Office assessment Donald W M Juzwishin PhD Immeuble JB SAY, 13 Chemin du Levant, 01210 Ferney Voltaire, France 13 “Megatrends” driving healthcare facility design: a look at the major trends that will shape Email: [email protected] medical facility design Professor George J Mann, AIA and Dr Kazuhiko Okamoto Internet: www.ihf-fih.org Subscription Office International Hospital Federation Management c/o Fairfax House, 15 Fulwood Place, London WC1V 6AY, UK 18 Cultivating tomorrow’s leaders: comprehensive development strategies ensure continued Telephone: +44 (0) 20 7969 5500; success Jessica D Squazzo Facsimile: +44 (0) 20 7969 5600
ISSN: 0512-3135 23 Assessment of human resources management practices in Lebanese hospitals Fadi El-Jardali, Victoria Tchaghchagian and Diana Jamal Published by Pro-Brook Publishing Limited for the International Hospital Federation
13 Church Street, Clinical care Woodbridge, 29 Nutrition and patient safety a report from the National Patient Safety Agency Suffolk IP12 1DS, UK Telephone: +44 (0) 1394 446006 (United Kingdom) Caroline Lecko Fax: +44 5601 525315 Internet: www.pro-brook.com 33 How research can help control tuberculosis R E Chaisson and M Harrington For advertising enquiries contact Pro-Brook Publishing Limited 41 Promoting quality and patient safety via the new integrated hospital accreditation on +44 (0) 1394 446006 programme Yehuda Dror World Hospitals and Health Services is published quarterly. All subscribers automatically receive a copy of the IHF reference books. The annual subscription to Reference non-members for 2009 costs £175 or US$250. 44 Language abstracts World Hospitals and Health Services is listed in Hospital Literature Index, the single most 47 Governing Council list comprehensive index to English language articles on healthcare policy, planning and administration. The index is produced by the American Hospital 48 Dates for your diary Association in co-operation with the National Library of Medicine. Articles published in World Hospitals and Health Services are selectively indexed in Health Care Literature Information Network.
The International Hospital Federation (IHF) is an independent non-political body whose aims are to improve patient safety and promote health in underserved communities. The opinions expressed in this journal are not necessarily those of the International Hospital Federation or Pro-Brook Publishing Limited.
World Hospitals and Health Services Vol. 46 No. 1 01 02-3 editorial/survey:25 13/5/10 13:58 Page 2
Editorial
Editorial
ERIC DE ROODENBEKE, PHD CHIEF EXECUTIVE OFFICER INTERNATIONAL HOSPITAL FEDERATION
lthough it was expected that 2010 will be the beginning of This edition of World Hospital and Health Services journal the recovery of the crisis, we are not yet there. This is a provides an opportunity to share with our readers some of Aglobal crisis to which countries are responding differently. presentations at our very successful 2009 World Hospital Congress Some continue in their steady grow to becoming the world’s in Rio de Janeiro (Brazil). In the same spirit of the Congress, the leading nations; some are showing resilience to the situation whilst articles cover a large spectrum of subjects but all feature important others are encountering major difficulties. In the main, however, the issues faced by healthcare decision-makers. effect of this crisis has been the introduction of an overarching Safety is a an usual theme for our journal and in addition to an attitude of fear with regards to the unknown future, which has led approach linking better quality to patient safety, an article from the to a marked restraint in risk-taking. Donors as a result have been United Kingdom addresses the importance of nutrition in the unwilling to invest in innovative projects. The IHF, as with many patient safety agenda. Further information on this subject will be other member-based organizations, is affected by such behaviour. soon available on IHF web site reflecting the stream of work in 2009 The launch of new as well as sustaining of on-going activities is on this subject with the support of the infant food manufacturers proving difficult. Crises accelerate the need for re-organisation by association (IFM). Healthcare facilities are made of people and abandoning some activities and putting more effort on others. technology in buildings. For all of theses there is a need for Solidarity can, at the same time, still be present and make a efficiency and appropriateness. The situation of human resources difference in the midst of an economic crisis. The earthquake which (HR) management in Lebanon indicates that there is quite an devastated Haiti has put the population under an unbelievable important scope for improvement there. What is reported for this strain but our Haitian colleagues working in health facilities have country can inspire most of the countries including those in the responded over and above the call of duty, and have been most advanced world. Gains on HR are key for the evolution of supported by health workers from all around the world. As we think healthcare. These gains will be made if there is good utilization of of the people of Haiti and express our compassion to them, we appropriate technology. Health technology assessment should be must also praise the solidarity movement around this disaster. The considered as a routine approach for introducing and reviewing spirit that has mobilized both the population and health workers is technology utilization in facilities. The design of facilities is also a evident. Organizations such as the IHF should not forget that it has critical component of both productivity of HR and effectiveness of a role to play not only in advocating for disaster preparedness but care delivery. It is important to consider all the factors that should also in mobilizing solidarity amongst its own members. be included before designing or refurbishing a facility. The shut down of air space over much of Europe, proved a There is an ongoing debate on the role of private sector in critical moment for all. It has had economic consequences and has delivering care to the population, especially when most of the made life difficult for all those caught in it. Concern over safety, funding is from public money. The article on the Portuguese however, guided the decision and fortunately involved no experience does not provide a solution to this debate but clearly casualties. The number of people grounded at ‘home’ or away from shows that difference in performance is not obvious. ‘home’ exposed the degree to which traveling as part of our daily It is widely recognized that beyond the organizational framework, lives, is taken for granted. Such a phenomenon should also trigger the difference in leadership makes the difference in outcomes. The some thoughts on how much we live in an interrelated world. situation on this front in the USA, the most advanced country is Readers of World Hospitals are among those who consider that very inspiring because it shows how this matter should be taken understanding what is happening in the rest of the world may seriously. It is not an issue of deprived countries with low influence what is delivered at home. capacities, it is a concern related to the health sector which is Although these observations are about three different events their behind the corporate sector. In the IHF we are convinced that there common denominator is that they all made headline news, proving are many opportunities for improvement by considering, in the further that no matter the nature of stress there are always healthcare sector, approaches that have improved performance in resources to respond to priorities. Another lesson learnt, is that it is the corporate sector. Adopting such an approach does not pre- impossible to believe that what is done locally can sustain itself empt the important social role of healthcare delivery and the drive regardless of what is happening in the rest of the world. for responding to populations’ general interest.
02 World Hospitals and Health Services Vol. 46 No. 1 02-3 editorial/survey:25 25/5/10 11:59 Page 3
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World Hospitals and Health Services Vol. 46 No. 1 03 4-5 Health technologies, health systems, and health outcomes in the 21st century:25 13/5/10 13:59 Page 4
Opinion matters
Health technologies, health systems, and health outcomes in the 21st century DR CARISSA ETIENNE ASSISTANT DIRECTOR GENERAL FOR HEALTH SYSTEMS AND SERVICES, WORLD HEALTH ORGANIZATION
ith every year that passes, more new, exciting, and diseases – notably depression and heart disease. HIV/AIDS will potentially life-saving health technologies appear – have dropped from fifth to ninth place in the list of global causes Wranging from advances in new vaccines and better of death. medicines to more appropriate medical devices. At the same time, Second, and closely linked with this, is the fact that populations our ability to store, manage and share information accelerates and all over the world are ageing. High income countries have got used expands. to the fact that people are living longer, and that fewer children are Indeed, as Margaret Chan, Director General of WHO has being born. Low and middle-income countries are going through pointed out: “the world has never possessed such a sophisticated the demographic transition – often at a faster rate and over a arsenal of interventions and technologies for curing disease and shorter period of time. By 2050, it is estimated that one in five prolonging life. Yet the gaps in health outcomes continue to people living in developing countries will be over 60 – a trend that widen… [because] the power of existing interventions is not will be accompanied by increased incidence of cardiovascular matched by the power of health systems to deliver them to those diseases and chronic illnesses. in greatest need, in a comprehensive way, and on an adequate Third, populations are, increasingly, urban. By 2035, it is scale.”1 estimated that more than half the population of low and middle The task today is to harness all these new developments to income countries will be living in urban areas. Urban environments strengthen health systems and services and improve health present their own health challenges, particularly those linked to outcomes – now and in the future. water and sanitation and air pollution, and close physical proximity Five years from the target date for the Millennium Development which can accelerate the spread of communicable diseases. Goals, it is increasingly evident that the world’s ability to improve Meanwhile, those who remain in rural areas find themselves living health outcomes – specifically to improve maternal and child in increasingly isolated, and under-served, communities. As more health and combat AIDS, tuberculosis and malaria – is directly people gravitate to towns and cities, it becomes more difficult to related to the strength of its health systems and the quality of the get health workers to live and work in rural areas, and many services those systems provide. It is no coincidence, for example, hospitals and healthcare facilities in developed countries have that progress on maternal health is slowest in sub-Saharan Africa been closed. and South Asia where years of under-investment have left many Strong health systems have to keep abreast not only of new countries’ health systems and services fragile and ill-equipped. developments like these, but ahead of them, and to ensure that At the same time, health systems all over the world, in rich and they respond to people’s real needs and expectations. poor countries alike, face new challenges on a number of fronts. First and foremost, people need to be able to access medical First, the epidemiological situation is evolving rapidly. In 2004, devices, vaccines, and drugs that work – whoever they are, the leading causes of global disease burden were lower respiratory wherever they live – and be able to afford to use them. infections and diarrhoea. In 20 years’ time, respiratory infections Second, they need to be treated with dignity and respect, and are likely to have been replaced by chronic non-communicable without getting lost between the various parts or levels of the system. They need to be able to consult healthcare workers who are knowledgeable, caring and who listen to them as individuals – and don’t just treat them as cases. As William Osler, one of the The task today is to harness all founders of modern medicine, pointed out: “It is much more these new developments to important to know what sort of patient has a disease than what strengthen health systems and sort of disease a patient has.”2 services and improve health Technology has a part to play in making all this a reality – in rich outcomes – now and in the future and poor countries alike. Simple rapid tests for HIV and TB can and do speed up diagnosis and treatment, lengthening millions of people’s lives.
04 World Hospitals and Health Services Vol. 46 No. 1 4-5 Health technologies, health systems, and health outcomes in the 21st century:25 13/5/10 13:59 Page 5
Opinion matters
Low-tech, low-cost prostheses enable amputees to return to work Greater collaboration between clinical and biomedical engineers, and support their families. Minimally invasive surgery techniques clinicians, managers, and users can greatly improve management simplify procedures and reduce the need for in-patient care and all of health technology. that is associated with this. As a result, costs fall. In 2010, more than 40 countries enter a new phase in their Information and communications technology increase contact national health planning cycles. It will be vital that those involved in between healthworker and patient and among healthworkers. the planning process fully address health technology needs, and Mobile phones, for example, enable health workers to follow up allocate resources for the use, maintenance, and surveillance of with patients and ensure that treatments are being adhered to – an technologies. important issue when dealing with chronic diseases, for example. To conclude, the relationship between technologies and health Phones and email enable specialists in urban settings to provide systems and services is mutually reinforcing. Technologies have real-time technical support to colleagues working hundreds of the potential to greatly strengthen systems and improve services kilometres away in remote, rural areas. Electronic patient records and outcomes so they meet contemporary health needs. But in ensure that accurate records are kept, greatly facilitating life- turn, health systems are vital to obtaining maximum benefit from course approaches to patient management. technologies. But more needs to be done to make the most of such That is why WHO’s medicines and technologies work is technologies. To have real impact on health outcomes, embedded with its efforts to strengthen health workforce and technologies must be available, accessible, affordable, safe, service delivery, and to improve financing and information effective and appropriate for the setting in which they will be used. mechanisms. Our goal is to strengthen health systems and create Twenty-first century technology is itself one means to increase a robust foundation for maximizing health outcomes in this fast- access and availability of services. For example, solar energy changing world. J powers laboratories and keeps medicines cool in places where there is no power grid. Portable ultrasound permits diagnostic References imaging in remote areas. 1. Everybody’s Business - Strengthening Health Systems to Improve Health Outcomes, WHO, But technology is not enough on its own. Technology is only as 2007 effective as the wider health system of which it is part. 2. Osler, W, Aequanimitas, Philadelphia PA, Blakiston, 1904 For a health system to make the most of modern technology, there must be strong leadership on health at national and district level, with a commitment to moving towards universal coverage of patient-centred care. This, in turn, requires a parallel commitment and capacity to establish a robust and well-trained health workforce; strong and equitable financing; well-governed and efficient delivery mechanisms; and reliable information systems – nationwide. To optimize use and maximize the impact of technologies, good management is essential. This includes the establishment of checks and balances to ensure that they are appropriate to the settings in which they will be used. A machine which requires electricity is of limited use if the energy supply is unreliable. Complex equipment loses its value if staff have not been trained to operate it, or if replacement parts are hard to get hold of.
Technologies must also be affordable, providing optimal value for money They must be safe and they must be effective. This requires a good evaluation of the context in which they are to be used, and research into how they have performed in similar contexts elsewhere – something that can itself be greatly facilitated by electronic dissemination of research. That said, there is a need both for more research, greater use of impartial studies, and less reliance on information provided by suppliers. All this means making difficult choices – for example between investing in new state-of-the art equipment for a hospital in the centre of a town and in strengthening blood safety facilities in a health facility out in the suburbs. And it means having proper regulatory systems, procurement procedures and financing mechanisms that are sustainable, inclusive and fair. This may require introducing new regulations, changing the way procurement decisions are made, and adjusting financing mechanisms. It is particularly important to improve coordination.
World Hospitals and Health Services Vol. 46 No. 1 05 6-9 Public-Private Partnerships in the Portuguese Health Sector:25 13/5/10 14:00 Page 6
Policy: Public-Private Partnerships
Public-Private Partnerships in the Portuguese health sector
JORGE SIMÕES MARTA TEMIDO ASSOCIATE PROFESSOR, UNIVERSIDADE DE AVEIRO AND HOSPITAL MANAGER AT CENTRO HOSPITALAR DE COIMBRA, VISITING PROFESSOR AT UNIVERSIDADE CATÓLICA DE EPE LISBOA
PEDRO PITA BARROS PROFESSOR OF ECONOMICS, UNIVERSIDADE NOVA DE LISBOA AND RESEARCH FELLOW AT CEPR (LONDON)
ABSTRACT: In Portugal, the PPP in the healthcare sector appeared only at the dawn of the new century, with the central feature of including clinical activities within its scope. Currently – except for one hospital – the Portuguese PPP experience can only be assessed in terms of conceptual model and tender processes. The analysis showed that, based on arguments associated with non-contractible investment and ex-post renegotiation opportunities, hospitals with higher technological complexity should exclude clinical activities from the PPP contract, and also that, despite the time-consuming process, the PPP can be considered a success in price competition dimension. The analysis also showed that, assessing the performance of the single PPP hospital in Portugal with two comparable units, there is no evidence that the best or worst results are correlated with the legal status and with the established management model.
he origin of Public-Private Partnerships (PPP) in the health position of several agents regarding the role of PPPs in the health sector can be traced back to the beginning of the 1990s in sector results in unnecessary conflict. Thirdly, the scarce Tthe United Kingdom, under the name of PFI – Private experience with PPPs suggests that a demanding technical Finance Initiative. Over the years, PPP have spread out to other assessment is required during the tender process and the countries. The main interest in PPP for the construction of execution phase as well. In particular, frequent renegotiation is hospitals resulted from the presumption that by attracting private expectable due to (natural) contract incompleteness. This is financing to the healthcare sector, hospital infrastructures would especially true under the PPP including clinical activities, where be renewed more quickly and more efficiently than under the technological progress in healthcare is difficult to predict. traditional public sector operation. Moreover, public sector accounts were (are) under close scrutiny in most developed Background countries. The PPP in healthcare started officially with the publication of the Portugal is no stranger to these motivations. The PPP appeared Decree-Law nº 185/2002, of 20th August. This legal document in Portugal only at the dawn of the new century. It has been a slow changes the statutes of the National Health Service to allow PPPs moving process. Currently, we can only describe and assess for construction and management of new healthcare facilities. This based on evidence the process that creates a PPP. legal regime actually precedes a general regime about PPPs in all A major difference of the PPP in Portugal to most of other PPP economic areas, which appears only in 2003 with Decree-Law nº in healthcare is the inclusion of clinical activities within the scope 86/2003, of 26th April (which changes some rulings in the 2002 of the PPP, on top of the infrastructure building and maintenance regime for healthcare). activities. One of the more interesting issues from the Portuguese The Portuguese Government opted, initially, for a new model for experience is to understand the fundamental trade-offs one needs the PPP to build new hospitals. The so-called first wave of PPP to make to assess the specific model for PPP adopted in Portugal. hospitals has the distinctive feature of including both building the The main findings from the analysis of the conceptual model of infrastructure and clinical activities management. This PPP model the Portuguese PPP are the following. Firstly, the administrative differs considerably from the original PFI model from the United delays in the whole process to create a PPP. These delays result Kingdom. Current European experience is diverse in this respect. from both the complex nature of the adopted model and from the We can find other examples of inclusion of clinical activities within lack of technical expertise related to PPP in the public sector. the PPP in Spain and Italy. Other countries have PPPs that include Administrative delays imply high costs for both the public and the only construction and maintenance of infrastructures (France and private parties to the PPP project. Secondly, the strong ideological Germany, for example). In Italy and Spain we can actually find both
06 World Hospitals and Health Services Vol. 46 No. 1 6-9 Public-Private Partnerships in the Portuguese Health Sector:25 13/5/10 14:00 Page 7
Policy: Public-Private Partnerships
Table 1: The competition effect
“Hospital de Cascais” “Hospital de Braga” Initial bid Final bid Initial bid Final bid
Bidder 1 526 M 1125 M Bidder 2 466 M 851 M 843 M Bidder 3 463 M 373 M 1019 M 794 M Bidder 4 429 M 359 M 1139 M Bidder 5 1136 M Bidder 6 1040 M
Source: Vaz (2007)
types of PPP. Based on arguments associated with non-contractible investment International experience suggests that countries with national and ex-post renegotiation opportunities, we can define the health services as the backbone of the health system tend to use following principle. Hospitals with higher technological complexity more intensely PPP. The use of PPPs appears to be a readily and for which technological innovation is more present (and available substitute for public investment. sooner) should have a PPP without clinical activities. On the other The existence of a PPP including clinical activities management hand, hospitals for which being in the technological frontier is not has implications for the specific legal environment generated. A crucial should have a PPP including clinical activities management PPP involving only construction (and maintenance) of hospital as long as the costs of non-contractible investment in the public infrastructure requires a single contract between the two parties, sector are relatively large, and the social benefits from such public and private. The first party pays for the activity developed investment are not sensitive to the level of investment. by the second party. When the PPP model includes clinical Finally, we can address the contract design itself. Távora (2009) activities management, other options can be adopted. The one reports an assessment of properties of the PPP contract for selected in Portugal was to set two different contracts, with construction and management of new hospitals. She concluded different durations for each of the two activities. A contract is set that contract design respects knowledge on best practices in 5 with the entity responsible for building and ensuring maintenance out of 6 areas: performance orientation, risk allocation and risk of the new hospital. Its duration is 30 years. A second contract is sharing, treatment of the different contract phases, system of signed with the entity that will run clinical activities, and this payment and contract duration. Only in renegotiation provisions to contract has duration of 10 years. Activities like cleaning, laundry, accommodate future technological innovations does the contract catering, parking, etc., have been included in the bundle of clinical fall short of being complete. activities management.1 Centro de Medicina de Reabilitação do Sul (CMR Sul) PPP Assessment of the tender process experience A central feature of the PPPs for new hospitals in Portugal is the Currently, in Portugal, the only PPP experience that can be long delay in the setting up every PPP. Such delays create costs, currently assessed in the hospital field is the one in Centro de monetary and time-wise. The delays were recently documented in Medicina de Reabilitação do Sul (CMR Sul). Tribunal de Contas (2009a). Delays are not specific to Portugal, as In 2008/2009 a study was carried out with the purpose of in other countries we find similar evidence, and high costs comparing the performance of this unit with two comparable units: associated with delays.2 To illustrate, no current contract signed Centro de Medicina de Reabilitação da Região Centro (CMRRC) and in operation for a PPP involving a new hospital took less than and Centro de Medicina de Reabilitação do Alcoitão (CMRA). The four years from launch to signature of contract. data in the study included only 2008 as the CMR Sul only started Despite the lengthy, time-consuming, process, the first wave of its activities in April 2007. PPPs can be considered a success in at least one dimension: These three units have the common feature of composing the price competition. The first PPP wave was able to attract a regional vertices of the hospital referencing network of physical reasonable number of candidates, ranging from 4 to 6 participants medicine and rehabilitation. Its main distinctive feature across in each call for proposals for a PPP. The selection process gave them is the different legal status and management models – while high relevance to the price criterion. A public sector comparator the CMR Sul is an establishment operated under the PPP model, was established and prices have to be below such threshold. The the CMRRC is an establishment integrated in the public sector tender is done in two rounds. First, a sealed bid is made by all and the CMRA is a private property establishment of Santa Casa participants. The two lowest bidders are selected for a final offer da Misericórdia de Lisboa. In the comparative analysis, three core stage (remember that the tender is for provision of a service, so areas were considered – structure, processes and results – and the lower the bid the better). After selection of the winner, a final several dimensions were taken into account. Regarding the negotiation takes place, although at this stage the price cannot be structure, we considered the interventional general context for changed. activity, the general characterisation and the legal framework; A third issue is the inclusion of clinical activities in the PPP. regarding the processes, the internal organisation model, the
World Hospitals and Health Services Vol. 46 No. 1 07 6-9 Public-Private Partnerships in the Portuguese Health Sector:25 13/5/10 14:00 Page 8
Policy: Public-Private Partnerships
Table 2: Costs
CMRRC CMRA CMR Sul % human resources expenditure 44% 71% 48% on total expenditure % facilities expenditure 31% 23% 36% on total expenditure % extra work expenditure 12% 4% 12% on total human resources expenditure Operational result € -305.505 € -8.206.257 € -853.992 Liquid result € -233.024 € -8.105.348 € -741.871
Table 3: Effectiveness
CMRRC CMRA CMR Sul % first outpatients appointments 26% 12% 28% on total outpatients appointments Discharged patients to household 100% 75% 93% Transferred patients 0% 4% 3% accomplished activity/contracted activity -7% na 1% discharged patients accomplished activity/contracted activity 31% na 79% outpatients appointments Decubit pad ulcers rate 0.0% na 1.6%
Table 4: Efficiency CMRRC CMRA CMR Sul Average length of stay (days) 84 96 48 Occupancy rate 80% 87% 75% Discharged patients per bed 3.5 3.2 5.7 Discharged patients per FTE physician 18.9 16.1 33.8 Discharged patients per FTE nurse 4.5 3.7 9.3 Outpatients appointments per FTE physician 196.6 425.5 € 236.5 Discharged patient day cost € 247.00 na € 383.00 Treatment cost € 1.23 na € 12.34 Outpatients appointment cost € 128.16 na € 25.00
Table 5: Equity CMRRC CMRA CMR Sul Number of discharged patients 0.1 0.4 0.3 per 1000 inhabitants Number of outpatients appointments 1.8 11.3 2.2 per 1000 inhabitants Number of patients waiting for admission 18 24 0 Number of patients waiting for outpatient appointment 23 na 0 Waiting days for admission 90 196 0 Waiting days for admission to outpatient appointment 45 na 0
Table 6: Quality
CMRRC CMRA CMR Sul % cancelled outpatients appointments na na 0.1 Inpatient mortality rate 0.0% 1.7% 0.3% Number of patients with nosocomial infections na na 11 % employees global retention 77% 90% 82% Average absenteeism work days per accident 0.0 0.4 1.1 % trained employees in BLS na 13% 36% % trained employees in nosocomial na 23% 73% infections control Average days response to complaints na 3 66 Patients satisfaction surveys No Yes Yes Employeessatisfaction surveys No Yes Yes
08 World Hospitals and Health Services Vol. 46 No. 1 6-9 Public-Private Partnerships in the Portuguese Health Sector:25 13/5/10 14:00 Page 9
Policy: Public-Private Partnerships
management tools, the human, financial and material resources, Pedro Pita Barros is Professor of Economics at Universidade Nova the information and communication technologies and the de Lisboa and research fellow at CEPR (London). His research innovation of the offer potential and regarding the results, the includes health expenditure, waiting lists, and bargaining in costs, the effectiveness, the efficiency, the equity and the quality. healthcare. He is editor of the International Journal of Health Care Considering the performance assessment of the centres in Finance and Economics, and associate editor of the Journal of terms of costs, effectiveness, efficiency, equity and quality results, Health Economics, Health Economics and Health Care existing reality is described on Tables 2, 3, 4, 5 and 6. Management Science. More information at: http://ppbarros. It should be stressed that there are limitations to the study that feunl.pt could not be overcome. The specificity of treated pathologies blocked the use of certain measuring instruments usually Marta Temido is a hospital manager at Centro Hospitalar de employed in this type of assessments. The fact that CMR Sul has Coimbra, EPE She has a degree in Hospital Administration (ENSP, only started its activity in April of 2007 reduced the analysis Universidade Nova de Lisboa) and a Master in Healthcare comparability period. The lack of information on some indicators Management and Economics (FEUC, Universidade de Coimbra). interrupted the comparison of all parameters. During last years, she has been working in several hospitals as Despite the precautions listed, some conclusions can be drawn. member of the Direction Board. The results on costs, effectiveness, efficiency and equity of three centres performance are very wide-ranging, with a centre References recording a best execution in a given indicator and then a worse Ahadzi, M. e G. Bowles, 2004, Public-private Partnerships and Contract Negotiations: An functioning in another. In the results of quality, CMR Sul has the empirical study. Construction Management and Economics, 22 (9): 967-978. best mark in selected indicators, which seems a direct Barros, P. P. e X. Martinez-Giralt, 2009, Contractual design and PPPs for hospitals: lessons for the POrtuguese model, European Journal of Health Economics, 10(4): 437 – 453. consequence of the contractual instrument that is behind it. Pollock, A.M., M., Dunningan, D. Gaffney, A. Macfarlane, F.A. Majeed, 1997, What Happens Hence, there is no evidence, from the first year of operation, that, when the Private Sector Plans Hospital Services for the NHS: three case studies under the in most dimensions analyzed, the best or worst results are private finance initiative. British Medical Journal, 314: 1266-1271. Távora, L., 2009, Will PPP for hospitals improve the health of the Portuguese?, Master in correlated with the legal status and with the established Economics, Faculdade de Economia da Universidade Nova de Lisboa, Janeiro de 2009. management model. Tribunal de Contas, 2009, Auditoria ao Programa de Parcerias Público–Privadas na Saúde – primeira vaga de hospitais, Relatório nº 15/2009 AUDIT. Vaz, I., 2007, O contributo dos prestadores privados na eficiência do sector e PPP. Apresentado Conclusions VI Forum Saúde DE, Maio. The PPP healthcare model, launched in 2002, fits in this context and, as happens in other countries, is seen as a mechanism to attract private capital for the construction or renovation of the hospital infrastructures, lightening the public sector accounts and capturing the gains associated with private management. However, except for the CMR Sul case, thus far, the Portuguese PPP experience can only be assessed in terms of tender processes. From our analysis, there is no evidence that a causal link could be established between the best, or worst, rehabilitation centre’s performance indicators and its management model. The main responsible factor for a better positioning of one of the centres in some indicators is related to the contractual instrument that regulates the relationship. Several challenges and questions remain: Whether, or not, the contracting authority has the tools to ensure the effective monitoring of the PPP; whether, or not, the management contract is robust enough to answer any disputes that arise during its execution, mitigating renegotiations and flexible enough to adapt itself to the evolution of a dynamic sector such as healthcare delivery; whether, or not, the strengths and weaknesses of the PPP will be highlighted after a longer period of activity; and finally, whether, or not, the pressure of political cycles will lead to experience’s rejection even before it can be fully evaluated. J
Jorge Simões, PhD in Health Sciences, is Associate Professor at Universidade de Aveiro, Visiting Professor at Universidade Católica de Lisboa, was Adviser to the President of the Portuguese Republic (1996 – 2006) and president of the commission for the financial sustainability of the national health service (2006-2007); now is the coordinator of the new National Health Plan (2011/2016).
World Hospitals and Health Services Vol. 46 No. 1 09 10-12 Evidence Informed Decision Making in Health Care:25 13/5/10 14:02 Page 10
Policy: Health technology assessment
Evidence informed decision-making in healthcare: the case for health technology assessment DONALD W M JUZWISHIN PhD ALBERTA HEALTH SERVICES, ALBERTA, CANADA
ABSTRACT: Delivery of publicly funded healthcare is at the nexus of three conflicting objectives: (1) increasing access to care; (2) improving the quality of care; and (3) sustaining its public financing. This article demonstrates that with tools such as health technology assessment (HTA) evidence informed policy and decision-making (as opposed to following doctrine, habit or expert opinion) access, quality and sustainability do not need to be mutually exclusive. A structure and approach for adopting and advancing HTA in healthcare organizations is provided. Policy recommendations are suggested.
“Most of our so called reasoning consists in finding arguments for and building blocks in order for it to be effective and sustainable. going on believing as we already do.” Below is a diagram illustrating the Canadian Society for JAMES H ROBINSON International Health depiction of the important elements of a strong and viable healthcare system. vidence based medicine (EBM) has been increasing in Three of the core building blocks supporting any societies vision influence in the healthcare practice communities because of of acheving equity and accountablity in its health system is reliance Eits reliance on the scientific method to inform a systematic on evidence based decision-making, data and research. Reliance approach to medical decision-making (Sackett, Rosenberg, & on other means such as expert opinion, habit and doctrine have Gray, 1996). Clinicians and the public are expecting the same resulted in maintaining the status quo which often have been standard of practice from those who make policy and decisions in shown to be clinically and economically ineffective or even harmful healthcare. This movement has come to be known as evidence (Elshaug, Watt, Moss, & Hiller, 2009). based (Muir Gray, 2001) or evidence informed policy-making Experience has taught us is that healthcare systems have (Brehaut & Juzwishin, Bridging the Gap: The Use of Research insatiable appetites and will, if allowed, absorb the lions share of Evidence in Policy Development, 2005). The strength of the any province, state or country fiscal capacity. Experience has also evidence informed movement is that it moves away from basing taught us that improved access and quality of care do not need to decisions on habit, doctrine or expert opinion and moving toward cost more, in fact, they can cost less. a scientific basis. Structured and reproducible tools are employed to assess the quality of evidence, risks, and benefits (clinical and Health technology assessment as an indispensible policy financial) of the interventions being considered. This article will tool explicate how health technology assessment can be an important One tool that has proven to be effective in advancing the policy policy tool to reconcile the challenges of improving access, quality and decision-making environments is health technology and sustainability of healthcare systems. assessment (HTA). Tjam in an article in this journal in 1994 In this paper I will describe and emphasise: described the process of technologies transnational diffusion as the importance of scientific evidence for informing healthcare well as their impact on district health systems particulalry in policy and decision-making; developing countries. Tjam called for the need for assessments how health technology assessment can be an indispensible and quality assurance to more effectively mange the tranfer of tool for policy and decision-making; and technologies (Tjam, 1994). In 1996 the author with co-authors a series of recommendations for advancing health technology (Menon, Juzwishin, Olmstead) published an article describing the assessment. development of hospital based technology assessment programs with an encouragement for hospitals to introduce HTA to bring a Why evidence informed policy making and health rationale to decision-making (Menon, Juzwishin, & Olmstead, technology assessment are necessary ingredients for a high 1996). performing healthcare system? Organziations and agencies that conduct health technology A strong healthcare system is dependent on a number of pillars assessment have emerged around the world in response to the
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Policy: Health technology assessment
Bidder 6 1040 M Figure 1: Canadian Society for International Health (Canadian Society for and their expression need to be mitigated in an InternationalSource: Vaz (2007) Health, 2009) attempt to ensure that the health needs of the population are addressed. The use of health technology assessment can be a powerful leveler Vision: Equity and accountability of influence if the objective of using the best scientific evidence of clinical and cost
Stewardship and leadership “Health in all policies” Social determinants of health frameworks effectiveness is used to adjudicate the issues. Health human Health financing and HTA facilitates a public debate among the facts in resources resource allocation an open forum so that the arguments can be Resource for development (evidence- assessed on their own merits. Being multi- based planning and policy-making) disciplinary HTA also draws on the local contextual
Health information systems conditions exposited through the social sciences, data for decision-making such as economics, ethics, sociology, and Evidence-based decision-making psychology to inform the policy question. This (clinical and community-based) approach permits a discussion of the values
Service delivery- Community interventions associated with the healthcare interventions to be treatment and programmes and health promotion included in the policy analysis being conducted.
Strong and vibrant civil society One approach that has been developed to draw in the qualitative sciences to complement the Transpaent and accountable public/private sector quantitative sciences to inform health policy development is the STEEPLE model (Brehaut & need for objective scientific evidence to inform questions about Juzwishin, Briding the Gap: The Use of Research Evidence in the effectiveness of health technologies which are defined as Policy Development, 2005). The acronym stands for: “prevention and rehabilitation, vaccines, pharmaceuticals and S (social, demographic conditions) devices, medical and surgical procedures, and the sytems within T (technological clinical effectiveness) which health is protected and maintained” (International Network E (economic benefit, effectiveness, utility) of Agencies for Health Technology Assessment). The International E (ethical) Network of Agencies for Health Technology Assessment (INAHTA) P (political/policy) was established in 1993 and currently has 46 member agencies L (legislative) from 24 countries. The Network spans from North and Latin E (environmental) America to Europe, Asia and Australasia (International Network of Agencies for Health Technology Assessment). INAHTA functions There are now many successful applications of HTA around the as a collaborative network on the Internet to support one another globe and these have recently been documented in a recent as well as make available the assessment reports and briefs to any supplemental issue of the field’s peer reviewed journal (Banta & interested party. Jonsson, 2009). Health technology assessment is defined as a multidisciplinary A primary lesson for increasing the likelihood of success for HTA field of policy analysis. It studies the medical, social, ethical, and in policy-making is to ensure that it is integrated into the entire economic implications of development, diffusion, and use of spectrum of healthcare funding and delivery within a jurisdiction. health technology” (International Network of Agencies for Health The Alberta Health Technology Decision Process is one example Technology Assessment). The diagram below illustrates how HTA in Canada where a strong effort has been made to encourage a can be used to inform decisions about making appropriate health policy structure that facilitates the bringing of evidence to choices that result in supporting appropriate interventions which the policy-making table (Borowski, Brehaut, & Hailey, 2007). influence health, reduce costs, improve quality and Figure 2: how HTA can be used to inform decisions about making appropriate sustainablity of the healthcare system. choices that result in supporting appropriate interventions which influence health, A question arises as to why healthcare policy reduce costs, improve quality and sustainablity of the healthcare system
and decisions informed by health technology assessment are better than those informed through doctrine or expert opinion. Research has Health impact Governance demonstrated that rational, open and explicit Reduced cost decision making processes have a greater Improved quality Sustainability likelihood of successfully meeting the needs of its Appropriate Decisions citizens health needs than are the decisions that intervention are made behind closed doors on the basis of opinion and without the need to justify them in the public space (Hanney, Gonzalez-Block, Buxton, & Health technology Kogan, 2003). In the arena of policy debate finding assessment means to neutralize the influence of private interests or narrow interests in favor of the public interest is essential if the needs of citizens are to be addressed. Power structures within society
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In addressing the issues of whether a Table 1: Questions, layers of evidence and forms of evidence to inform policy technology should be utilized in a local setting it is important to ask a series of questions. These Questions Layers of evidence Form of evidence questions serve as a screening or filtering process Does it work is it safe? Technical performance Clinical trials Can it work in our Efficacy and effectiveness Systematic reviews and economic to establish the appropriateness of introducing a setting? effectiveness analysis health technology in a community, hospital or Should we do it here? Appropriateness Fiscal capacity, credentialing province. How should we do it? Implementation Implementation science Did it do what was Post implementation Post implementation evaluation Policy recommendations for adopting and promised? advancing HTA There are several ingredients for advancing the successful utilization of HTA in hospitals, Departments of Health or health evidence appears to be promising but effectiveness is still authorities. A starting point would be comprised of the following: questionable. Declare a public commitment to use HTA to inform Develop a multi-dimensional structure, process, output, governance, policy and resource allocation decisions at the impact and outcomes analytical model to evaluate the macro, mezzo and micro levels. effectiveness of the health technology assessment programme. Identify and describe how HTA integrates and supports the strategic directions, goals and objectives of the organization Concluding remarks and it’s broader societal responsibilities and role. The challenges of maintaining an effective and high performing Develop and implement a screening process for identifying healthcare system are numerous. This article has demonstrated and selecting the HTAs to be undertaken based on the burden the value that health technology assessment can bring to the of illness and health needs of the community. policy- and decision-making in healthcare funding and delivery to Identify the source(s) of health technology assessments that ensure that it is accessible, high quality and sustainable. J will be accessed or the resources to be commissioned in order to answer the policy questions before the organization. Dr Juzwishin is Director Health Technology Assessment and Develop a programme description for HTA which integrates Innovation at Alberta Health Services in Edmonton, Alberta the evidence into the capital and operating budgeting process Canada. He has conducted health technology assessments and in the organization. introduced them to policy- and decision-making settings in Integrate the HTA programme into the organization structure hospitals, Departments of Health and health authorities. He is and processes of the organization from the bedside to the adjunct associate professor at the University of Victoria, University board table. of Calgary and University of Alberta. Identify how the programme delivery of applying HTA to policy and decision making will improve access, quality and References sustainability of healthcare delivery. Banta, D., & Jonsson, E. (2009, July). History of HTA: Introuduction. International Journal of Develop a mechanism to prioritize the requirements for health Technology Assessment in Health Care , pp. 1-6. technology assessments to be undertaken. Borowski, H., Brehaut, J., & Hailey, D. (2007, April). Linking Evidence from Technology Develop and describe an open, transparent and explicit Assessment to Health. International Journal of Technology Assessment in Health Care , pp. 155 - 161. process by which requests for health technology assessments Brehaut, J., & Juzwishin, D. (2005). Bridging the Gap: The Use of Research Evidence in Policy can be requested, undertaken and applied to make decisions. Development. Edmonton: Alberta Heritage Foundation for Medical Research. Develop a mechanism such as the STEEPLE model to Brehaut, J., & Juzwishin, D. (2005, September). Briding the Gap: The Use of Research Evidence in Policy Development. Retrieved January 31, 2010, from Institute of Health customize the appropriateness of the health technology Economics: http://www.ihe.ca/documents/HTA-FR18.pdf assessment to local conditions. Canadian Society for International Health. (2009). Approach to Health System Strengthening. Monitor and report on a regular basis to all stakeholders in the Ottawa. Elshaug, A., Watt, A., Moss, J., & Hiller, J. (2009). Policy Perspectives on the Obsolescence of organization the progress of on HTA projects undertaken. Health Technologies in Canada. Ottawa: Canadian Agency for Drugs and Technology in Develop an explicit program to identify the technologies that Health. should be identified for disinvestment. Hanney, S., Gonzalez-Block, M., Buxton, M., & Kogan, M. (2003). The Utlizisation of Health Research in Policy Making: Concepts, Examples, and Methods of Assessment. Health Develop and organization process to address questions about Research Policy Systems, 1 - 12. the potential introduction of health technologies for which the International Network of Agencies for Health Technology Assessment. (n.d.). About. Retrieved January 31, 2010, from International Network of Agencies for Health Technology Assessment: www.inahta.org Menon, D., Juzwishin, D., & Olmstead, D. (1996). Hoospital - Based Technology Assessment Programs. World Hospitals and Health Services, 2-9. A primary lesson for increasing the Muir Gray, J. (2001). Evidence-based healthcare: How to make health pollicy and management likelihood of success for HTA in decisions. Toronto: Churchill Livingstone. Sackett, D., Rosenberg, W., & Gray, J. (1996). Evidence based medicine: what is it and what it policy-making is to ensure that it is isn’t. British Medical Journal, 71-72. integrated into the entire spectrum Tjam, F. (1994). Technology Assessment and Transfer in District Health Systems. World of health care funding and delivery Hospitals and Health Services, 3-8. within a jurisdiction
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Policy: Healthcare facility design
“Megatrends” driving healthcare facility design: a look at the major trends that will shape medical facility design
PROFESSOR GEORGE J MANN, AIA DR KAZUHIKO OKAMOTO PROFESSOR, THE SKAGGS-SPRAGUE ENDOWED CHAIR OF ASSISTANT PROFESSOR, THE UNIVERSITY OF TOKYO, HEALTH FACILITIES DESIGN, COLLEGE OF ARCHITECTURE, JAPAN AND KAJIMA VISITING SCHOLAR, TEXAS A&M TEXAS A&M UNIVERSITY, USA UNIVERSITY, USA
ABSTRACT: Changes in medical construction and design are accelerating exponentially, and anyone who can anticipate where these changes are going to happen will be at an advantage. Knowing the “Megatrends” defining and driving the future of healthcare delivery and healthcare facility design will help decision makers anticipate the future.
he health facility architect will have to think in the context of tremendously. We are living longer today. “By the year 2050, of the much broader issues than just designing buildings. world’s estimated 9.3 billion people, 16% will be 65 years and T older.” – The Straits Times, June 25 2009, Singapore. An ageing population will force us to rethink how we design Growing population and limited resources regions and cities. In many countries seniors life and The population of Planet Earth will grow from over 6.91 billion independence have been based on the automobile. What people today to 9.39 billion in the year 2050. (Wall St Journal, happens if we can no longer drive? 2008) This expectancy will have profound implications in the planning and design of health facilities, particularly in developing Health education and nutrition areas of the world, where the resources available are so limited. Basic knowledge of personal as well as community health issues and nutrition will be vital to the success of improving longevity and Growing expectations and demands health indicators. At the same time populations will be better informed of what is possible in healthcare, and consequently will demand more, thus Aligning health manpower and resources with health needs placing enormous pressures on governments to see that and health facilities comprehensive health services will be provided for their citizens. There needs to be an aligning of allied health professionals and resources with health needs and facilities. Healthy environments – air and water quality Poor air quality, sanitation, and lack of potable water are basic Anticipating and planning for disasters health environment issues that lead to disease. These issues will The recent earthquake in Haiti points up the need to anticipate and receive dramatically more attention and funding. be prepared for disasters. Pre-positioning food, water, medicine, shelters and hospitals in strategic parts of the world are vital. Disease strategies and public health The underlying assumptions driving medical construction and Surge hospitals design are the prevalent diseases – some of which are genetic, To be prepared for the unexpected, we will develop an alternative some of which are lifestyle-based, and some of which are system of healthcare facilities, ie, surge hospitals. This alternative communicable. network will be available in the event that existing hospitals are Medical facilities design will be based on a disease strategy of overwhelmed in a natural or manmade disaster. Cots, blankets, prevention, early diagnosis and treatment, and rehabilitation of sheets, beds, water, food, and medicine can be pre-positioned illness. Focusing on major diseases will mean more specialized in designated surge hospitals, which can be set up anywhere – facilities like “Centres of Excellence.” from hotels and motels to high schools to convention centers. They would require emergency generators and self-sufficient Demographics communications systems. Basic changes in demographics will impact architecture for health
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Policy: Healthcare facility design
Figure 1: Population chart taken from The Wall Street Journal, 2008
Figure 2: Texas A&M University students Ashely Dias and Alexis Mixon proposed turning the Washington dc convention centre into a “SURGE” The individual and the home as the basic health hospital that could care for 50,000 people in an emergency facility More and more modern technology, coupled with health education, will support the individual’s efforts to remain healthy at home with an array of technology and information, including wearable computers, monitoring, and the ability to test and diagnose disease. A person’s basic health facility will, in fact, become themselves.
Primary care The emphasis will be on community based primary healthcare services in urban and rural clinics. This is the front line in the battle to prevent, diagnosis, and treat disease.
Technology Technology is the real driver in healthcare changes today, from care itself to the affect on buildings. The gap between advancing technology and the ability to integrate technology into the design, construction, and operation of health facilities is widening and is a hot-button topic. Roaring and fundamental changes in technology are affecting: communications; computers; electronic medical records; imaging;
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Figure 3: A traditional Japanese farmhouse is renovated into a group home Building information modeling (BIM) for the elderly “BIM is the process of generating and managing building data during its life cycle. Typically it uses three-dimensional, real-time, dynamic building modeling software to increase productivity in building design and construction. BIM encompasses building geometry, spatial relationships, geographic information, and quantities and properties of building components.” – Wikipedia.
Integrated project delivery “The Construction Industry has suffered from a productivity decline since the 1960’s while all other non-farm industries have seen large boosts in productivity. The problems in contemporary construction include buildings that are behind schedule and over budget as well as adverse relations among the owner, general contractor, and architect. Using ideas developed by Toyota in their Toyota Production System and computer technology advances, the Integrated Project Delivery method is designed to solve these key construction problems. The new focus in IPD is the final telemedicine; value created for the owner, the finished building. Rather than each robotics; participant focusing exclusively on their part of construction nanotechnology. without considering the implications on the whole process, the IPD method brings all participants together early with collaborative Just as the bank building of the future shrank into the ATM and incentives to maximize value for the owner. This collaborative credit cards, technology will open heretofore unimaginable approach allows informed decision making early in the project opportunities and locations for health maintenance. where the most value can be created. The close collaboration eliminates a great deal of waste in the design, and allows data Mixed-use facilities sharing directly between the design and construction team Mixed-use facilities encourage a previously unorthodox mixing of eliminating a large barrier to increased productivity in functions. For example, capitalizing on air rights over malls could construction.” - Wikipedia provide health facilities with easy pedestrian access to shopping below. In urban areas, towers consisting of apartments, Impact on design principles condominiums, independent and assisted living, skilled nursing, Now that we have examined some of the major trends facing and hospital facilities float over commercial shopping malls. healthcare facilities overall, it is time to consider the impact these trends will have on principles of design. Economics and costs Figure 4: Nursing home Freude Hikoshima in Yamaguchi Japan, In free societies we are also free to go broke. designed by APL design workshop, is facing to rich sea and green Healthcare administrators are constantly walking a tightrope. Changing legislation and reimbursement formulas are causing hospital CEOs to trim their staffs and programmes. Health and hospital facilities will have to be lean, efficient, cost-effective, and medically effective. The larger the facility, the more difficult those goals will be to achieve. Designing large hospitals will represent tremendous financial gambles. Costs of construction will soar, as will operating costs. Hospital and healthcare executives are not only concerned with initial construction and project costs, but they are very aware and wary of the much greater costs of operation over the life of the building. Rising energy costs, maintenance, and salaries as well as technology are tremendous factors in operating costs.
Consumer choices As individual choices grow and are encouraged by many insurance programmes, the result has been fierce and healthy competition between hospitals. One result has been a spate of mergers, acquisitions, and closures of health facilities and hospitals.
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Networks Figure 5: Texas A&M University students Jenna Steinbeck and Ramin Health insurance plans and hospitals have been forming Youssefzadeh designed the new National Taiwan University Cancer “networks” of facilities. These often involve a hub of one or more Center large hospitals linked administratively to outlying ambulatory care centres. Networks can consist of as little as two facilities and as many as hundreds. Some networks have already developed international ties such as Johns Hopkins in Istanbul.
Sustainable green buildings Hospitals and medical facilities are tremendous energy guzzlers. In an era of a worldwide movement toward sustainability and LEED certification, health facilities are clearly lagging behind. New design and construction will need to incorporate the latest ideas and technology aimed at sustainability.
Hi-tech, hi-touch With the tremendous emphasis and reliance on technology A/E firms will need to make the health and hospital environment more human, friendly, and home-like, using natural colours, soft lighting, acoustics, texture, carpets, painting, and furniture. The technology needs to be there but tempered by healing, humanized environments and empathetic caregivers. Figure 6: New National Taiwan University Cancer Center project by Transportation and ease of access HKS Inc. Dallas, Texas USA and J.J. Pan and Partners Taipei, Taiwan What good are health facilities if people cannot get to them? New facilities must be located so that they are easily accessible by public transportation (air, bus, train, auto, taxi). Transportation routes will often need to be changed to provide direct and sheltered access to the hospital and/or health facility.
Visibility/wayfinding The way to the health and hospital facility must be simple and direct. The visible design of the building will reinforce branding in the public mind. Clear signage and lighting are basic principles. Once inside the health facility, there must be a clear path to a reception area and clear graphics to help patients find their way to various departments. hotel industry realised years ago that people do not want to share Natural light a room with strangers). Single patient rooms will be designed to Wherever possible, natural light will be brought into the building. It accommodate a second bed that could be used by family is therapeutic and sends a message of hope. members or even by another patient in the event of a disaster or epidemic. Healing gardens Views of and access to outdoor areas and healing gardens are Industrial design vital not only for patients but for staff as well. Products for healthcare, such as beds, headwalls, chairs, wheelchairs, and medical monitoring devices, are just a few of the Retention of staff devices that need to be integrated into medical construction and Pleasant work environments are also vital for staff retention. design. Hospital and medical staff are under constant stress and a total environment that expresses concern for them will result in retaining Collaboration and interdisciplinary efforts staff. In addition to the physical changes brought about in healthcare facilities, there will be changes in the way design and construction Ambulatory care facilities activities are carried out. In order to make progress and create With new medical knowledge and techniques of treating disease, new ways of effectively delivering healthcare, it will become vital to a major trend has developed in walk in-walk out or ambulatory collaborate and work seamlessly across existing disciplines--and care. These facilities may have some short-stay facilities. even create new disciplines that do not now exist. Silo thinking will lead to extinction. Single patient rooms Some A/E firms are developing interdisciplinary teams of One of the biggest trends today is for individual patient rooms (the epidemiologists, public health nurses, physicians, healthcare
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administrators, architects, computer, structural, mechanical, and References electrical engineers, food service consultants, and other relevant experts all working toward a common goal. Mann, G.J.(2006). Megatrends Driving Healthcare Facility Design. Medical Construction and Design, May/June 2006, 22-25 Mann, G.J., (2008). The Evolution of the Architecture for Health Program at Texas A&M International practice opportunities University Since 1966. Urbanism and Architecture, (Harbin, China) 46, 39, 40 Around the world numerous architectural and engineering firms Skaggs, R.L., Sprague, J.G., & Mann, G.J., (2009). The Asian Practice of the Architecture for Health Practice of Texas A&M University - NTUCH - National Taiwan University Cancer are engaged in international practice, and these numbers will likely Hospital, Taipei. Urbanism & Architecture. Harbin China, Vol Con 58 and 41- 45 increase as populations soar and international demand grows. Okamoto, K. et al, (2003). How is hospital architecture forming into? Hospitals, Igaku Shoin The opportunities as well as the pitfalls of international practice are (Tokyo Japan), Vol 62 Issue 2, 156-164 Nagasawa, Y., Itoh, S., Okamoto, K., (2007). Hospital Geography. University of Tokyo Press considerable. Firms must reconfigure themselves to be able to (Tokyo Japan) respond to the needs and demands of international practice.
Demand vs supply of college graduates The demand for graduates majoring in architecture for health is far in excess of the supply. Smart A/E firms are aligning themselves with colleges of architecture, providing real studio projects, giving lectures, offering scholarships and endowments, hiring interns, and maintaining a visible presence in the school. This enables them to identify the top talent. The globalization of the field is also globalizing education. Texas A&M University is collaborating with the University of Tokyo on GUPHA (Global University Programs in Healthcare Architecture), in order to “jump start” architecture for healthcare programs at other schools of architecture around the world, and respond to the growing demands.
Conclusion We are living in an era of unprecedented change. The opportunities, challenges, and pitfalls are enormous and they are moving at light speed. Stepping back, looking at the big picture, and considering all of the above “Megatrends” – (a work in progress) will help individuals and firms successfully manoeuvre the many changes and thrive in the future. J
Professor George J Mann, AIA, is The Skaggs-Sprague Endowed Professor of Health Facilities Design at the College of Architecture, Texas A&M University. He is also the Founder and Chairman of the RPD (Resource Planning & Development) Group, and President of GUPHA (Global University Programs in Healthcare Architecture). He can be reached by phone at 979-845-7856 or by email: [email protected]
Kazuhiko Okamoto, PhD, is Assistant Professor at the Department of Architecture, The University of Tokyo. From 2008 - 2010 he was a Kajima Corporation Visiting Scholar and Visiting Professor at the College of Architecture, Texas A&M University. Dr Okamoto is Vice President of GUPHA (Global University Programmes in Healthcare Architecture). He can be reached by phone at +81-3-5841-6169 and email at [email protected]
World Hospitals and Health Services Vol. 46 No. 1 17 18-22 Cultivating Tomorrow’s Leaders:25 13/5/10 14:07 Page 18
Management: Leadership
Cultivating tomorrow’s leaders: comprehensive development strategies ensure continued success JESSICA D SQUAZZO WRITER, THE DIVISION OF COMMUNICATIONS AND MARKETING, THE AMERICAN COLLEGE OF HEALTHCARE EXECUTIVES IN CHICAGO, ILLINOIS, USA
ABSTRACT: It’s no secret that strong leaders are the backbone of any successful organization. Watch a high- performing healthcare organization in action, and you know a team of talented leaders is at the helm. But successful organizations not only have to have top talent in place — they have to know how to identify high- potential leaders, cultivate them and retain them.
his is not always an easy task, considering the historically Despite these barriers to starting and maintaining leadership dynamic healthcare field. And as healthcare continues to development programmes in healthcare organizations, the need Tgrow in complexity, good leadership will become even more for them remains. “The healthcare industry is on the cusp of some critical as organizations try to keep pace with change and evolve truly revolutionary changes,” says Lee, who is a vice president at into the future. Children’s Medical Center-Dallas and a faculty member of the While the case for fostering future leadership talent in healthcare organization’s leadership academies for directors and managers. is evident, not all organizations have a process in place to do so. “History has shown us, however, that difficult times can create In fact, when it comes to leadership development programmes tremendous opportunities for innovation. The healthcare industry and succession planning, healthcare lags behind other industries. needs a large cadre of qualified and prepared leaders to help Only 21% of freestanding hospitals in the United States have navigate the murky water of our current situation and to help formal processes in place for identifying and developing internal shape the future of our industry.” candidates for senior leadership roles, according to a 2007 American College of Healthcare Executives (ACHE)-commissioned Growing leaders at legacy health study on succession planning by Andrew N Garman, PsyD, and J The processes for developing leaders within an organization vary Larry Tyler, FACHE. A 2008 study of US health systems, prepared in size, scope and quality. Leadership development initiatives can for ACHE by Ann Scheck McAlearney, ScD, of The Ohio State range from formal, structured programmes, including corporate University, revealed that of 104 health system respondents, 52% “universities” complete with in-house training and coursework, to reported having an executive leadership development programme tuition reimbursement for external educational opportunities, or a in place. combination of both in-house and external training. In contrast, 85% of Fortune 500 companies sponsor formal Legacy Health in Portland, Oregon, USA, a nonprofit internal leadership development programs, according to a 2002 organization comprising five full-service hospitals and a children’s study by the American Society of Training & Development cited in hospital, has built its leadership development programme based the book Growing Leaders in Healthcare: Lessons From the on its belief in the benefits of developing internal candidates. The Corporate World (Health Administration Press, 2009) by Brett D programme is a multipronged approach, says Ceva Knight, Lee, PhD, FACHE, and James W Herring, PhD. director of Organizational Development. All programming is In the book, Lee and Herring emphasize that while healthcare produced and offered by the Organizational Development falls short compared to the corporate world in its approach to department with the exception of a contracted arrangement the leadership development, it is not for lack of interest. Many CEOs organization has with an outside vendor to conduct 360-degree recognize the need for and importance of such programmes but evaluations for its managers. cite these two barriers to establishing them: 1) the perception that Legacy’s leadership development process begins with its they are too labour and resource intensive to build; and 2) lack of orientation programming, including a formal leadership class for internal competencies and knowledge required to implement and new leaders entering the health system. In addition, the develop strategies effectively. organization’s new leader transition process, available for staff at
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the manager level and above, is designed to help new team leaders and their staff bridge any gaps that may occur during a One of the things that is really leadership transition. important to us – and I suspect for “It’s a facilitated conversation that we conduct to help that new most organizations – is you can leader and the new team get off on the right foot and start working bring people in and develop them more effectively faster,” says Knight. Legacy also offers two certification programmes. Its Pathways within the existing culture, and that to Leaders certification programme involves 30 hours of way your culture continues coursework. Aspiring leaders, with permission from their supervisors, can attend the programme, through which they get an overview of the leadership aspects at Legacy from a finance, quality and human resources perspective, says Knight. The programme also helps participants define what it means to be a CNO Development Programme. “We work in the programme to leader. fine-tune some of their financial and business skills. The The organization’s Leadership Essentials certification expectation upon completion of the programme is that they are programme includes 80 hours of coursework and is designed for trained to be a CNO.” employees at the supervisor level and above. It is geared toward To date, HCA’s COO programme, which started in 2001, has individuals who are new to Legacy and those who are new to had 119 participants, 65 of whom have been promoted to COO leadership in general. In addition, Legacy offers specialized within HCA facilities and seven who have taken the helm as CEO leadership development for physicians and is expanding its ability at an HCA facility. The CNO programme, which began in 2006, to offer e-learning opportunities. has averaged approximately eight to 10 CNO placements per year Knight says there are many benefits to conducting leadership in various-sized facilities across the health system. development in house. “We know the system, we know the Both programmes have helped HCA prepare for staff retirement people, we know the culture, we know the political environment,” and turnover and are another way to ensure the organization’s she says. “We’re more helpful having that base and that culture is not lost when staff transitions do occur. “One of the foundation.” things that is really important to us – and I suspect for most Legacy President and CEO George Brown, MD, says tying an organizations – is you can bring people in and develop them within organization’s leadership development to its organizational culture the existing culture, and that way your culture continues,” says Lee is essential to the success of that organization. “One of our Nelson, director of Executive Development at HCA. “And those organization’s deepest strengths is our values,” says Brown. things that are important to the organization as a whole get “Legacy is really the coming together of a Lutheran and Episcopal passed on.” organization, and the values of service and integrity, forthrightness, etc., have permeated our organization over the years. The Targeted training at children’s – Dallas consequence of that is that we seek leaders who imbue those Children’s Medical Center – Dallas, a private nonprofit, 483-bed qualities.” system, ensures its three formal leadership academies are tied to the organization’s strategic plan and provides curriculum tailored High sights for hiring at HCA to the level of leadership for which they’re designed. It offers a Nashville, Tennesse, USA, -based HCA is another organization programme for directors and senior directors (including physician focused on developing leaders from within. One way in which it leaders), a programme targeted to managers and an emerging does this is through its COO and CNO Development programmes. leaders programme for new leaders making a transition from peer The COO Development Programme is designed to prepare to supervisor. individuals to become COOs within HCA’s network of 170 Each academy accepts one group of candidates per year, and hospitals and more than 100 outpatient surgery centres. After an that group meets one full day per month for eight months. extensive application process (both external and internal Participants are nominated by their direct supervisors and hand candidates may apply), participants are selected and assigned the selected by the organization’s president and CEO. role of associate administrator within an HCA hospital. Programme “The classes are taught by members of our senior leadership participants are assigned a mentor (usually a CEO), who guides team using a leaders-as-teachers model, allowing for a significant the individual’s development, and participate in projects and amount of interaction between the students and the executive seminars at HCA’s corporate offices. When participants have met staff,” says Lee. Participants complete a 360-degree evaluation all programme requirements and are deemed ready, they move tool based on Children’s leadership competency model. They are into a COO position, with the ultimate goal of eventually becoming required to develop a personal action plan to focus their CEO of an HCA hospital. development activities during their participation in the academy. HCA’s CNO Development Programme is designed for internal The programme culminates in the completion of a formal project applicants only. Nurses in the programme are already within the that is required for graduation. The project must put into practice HCA system and in leadership roles. Participants receive a new process or improve an existing process that serves to recommendations from their supervisors to participate. advance the goals and objectives of the organization, says Lee. “They already have a lot of clinical experience, and senior leadership is already on board before the nurses start the Learning from experience programme,” says Dell Oliver, RN, assistant vice president of the Experts agree that experiential learning is a key component of any Executive Development Programmes at HCA and director of the successful leadership development programme, whether it’s a
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formal programme or less structured. Organizations should Lessons from the corporate world focus on reality rather than role-playing when approaching Compared to other industries, the healthcare field has been much slower to leadership development among their staff members, says adopt formal leadership development strategies. In the book Growing Leaders Carson Dye, FACHE, a partner with Witt/Kieffer and coauthor in Healthcare: Lessons From the Corporate World (Health Administration Press, of the book The Healthcare C-Suite: Leadership Development 2009), authors Brett D. Lee, PhD, FACHE, and James W. Herring, PhD, examine at the Top (Health Administration Press, 2009). why and explore what makes leadership development programmes in some of “The absolute best leadership development is directly tied to the world’s most well-known corporations so successful. specific experiences,” says Dye. “If you asked seasoned One major difference between strategies employed in the healthcare setting leaders, ‘What contributed most to your growth as a leader?’ and those in the corporate world is that in the latter, development strategies I think they would say a specific experience.” are part of a much broader organizational strategy. Because of that, the An ideal leadership development situation should be a budgets for these programmes tend to be much higher. In addition, many of combination of coursework and experiential learning, says these corporations have thousands of employees – even numbering in the Dye. The experiences that offer the most benefit in terms of hundreds of thousands – with many locations throughout the world. learning are specifically those that involve turnaround or fix-it “It is typical for companies from private industry to spend an average of situations, he adds. 2.5% of their annual budgets on leadership development,” says Lee. “They Experiential learning is the focus of the leadership have developed a robust infrastructure to build the leadership talent at all development at Premier Health Partners in Dayton, Ohio, says levels of the organization.” Bill Linesch, vice president of Human Resources and Corporations in other industries use a mix of leadership development Organization Effectiveness. The organization, which includes strategies. Typical methods include instructor-led classroom experiences, four hospitals, does offer core courses and other training Web-based courses and experiential (action learning) activities. For midlevel opportunities that management staff are expected to and frontline managers, classroom training and e-learning methods are most complete, but its experience-based approach to learning prevalent. Experiential techniques are commonly used for senior executives. makes on-the-job training the priority. Development of leaders at large corporations often begins as early as the “We try to reverse the typical development planning that interview process. “Leadership development typically begins with hiring, using focuses on coursework,” says Linesch. “Ten per cent of our behavioral interviewing techniques to test the fit of a new leader to the leadership training is coursework; 20% you learn from a organization’s formal leadership values and competencies,” says Lee. “Formal mentor, boss or your peers; and 70% is on-the-job educational opportunities – both internal and external to the organization – are experiences in which you are put in a challenging situation then offered to leaders at all levels. Corporate universities, which may or may where you don’t know the answer. Those are the kinds of not have partnerships with accredited universities that allow for degree experiences that differentiate people in terms of identifying granting, are common.” their potential.” Science Applications International Corporation (SAIC), a research and At Premier, potential leaders are identified through a talent- engineering firm, created a robust educational infrastructure including a mapping process in which all the organization’s departments corporate university, known as SAIC University. SAIC also now offers an onsite participate. Individuals with high potential are then given MBA programme in partnership with an accredited college. According to Lee opportunities to develop skills in various areas of the and Herring, offerings such as those at SAIC are very common in the corporate organization. This doesn’t necessarily occur in a traditional, world, and those corporations that do not provide such offerings often find vertical pattern but, rather, through cross-moves within the themselves at a significant disadvantage when it comes to recruiting and organization, says Linesch. retaining talented leaders. He cites the example of a vice president of operations at one Another common technique emphasized by successful corporations is of Premier’s hospitals who took a position heading up supply exposing potential leaders to a wide range of business areas. At Dow Chemical, chain for a couple of years at the system level. Linesch high-potential employees are expected to learn a broad range of skills by attributes part of her success – ultimately becoming COO at a working 10 to 15 rotational assignments, of 12 to 18 months each, in rapid Premier hospital – to the experience she gained moving succession. horizontally in the organization, not just vertically. Other successful companies, such as Google Inc., emphasize student “She became the strongest candidate for the COO position internships or fellowship-type programmes as an effective way to identify at the flagship hospital not just because she had operational future talent. Google allows students to apply for internships in key business experience but because she had operated outside the hospital areas. AT&T’s leadership development programme targets recent graduates of she had grown up in,” he says. “We ask our potential leaders MBA programmes and places them in three diverse work assignments during not to just try to convince us they have the skills – we want a period of 24 to 28 months, including supervisory roles. The approach, them to demonstrate it. And you do that often through according to Lee and Herring, helps to create a pipeline of talented leaders. horizontal moves. That’s really the key to it – building a Even in times of economic distress, many corporations are leaving budgets portfolio of the different situations in which you have been able for leadership development programmes intact. “I read a recent Wall Street to demonstrate success.” Journal article that stated that even in the recent economic downturn, nearly Jim Pancoast, FACHE, who was recently named president 90% of Fortune 100 companies made no reduction in their annual leadership and COO of Premier, has personally experienced the value of development budgets,” says Lee. “This type of recognition that effective experiential learning. “Early on in my career with Premier, I was leadership is the only sustainable competitive advantage is crucial for the asked to move out of a traditional finance role and take on ongoing success of corporate leadership development programmes.” leadership positions with our home healthcare company and our physician practice company,” says Pancoast. “The
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experience of running several of our subsidiaries gave me a great business perspective when I moved back into hospital operations. Senior leadership team readiness assessment They just don’t write about that kind of experience in textbooks.” 1. How much time do the CEO and members of the senior leadership Dustin Greene, FACHE, COO of Emory Eastside Medical Center, team spend on the following: an HCA hospital in Snellville, Georgia, USA, found the hands-on Discussing the development of the next generation of senior aspect of HCA’s COO Development Programme invaluable, as it leaders? provided him the experience he needed to successfully move into Participating in key internal leadership training and development a COO role. Greene started the programme in March 2006 and programmes? became a COO two years later. As a participant, he worked Coaching or mentoring emerging leaders or those who report to alongside HCA COOs to learn the role firsthand. them? “In addition to working as a hospital associate administrator, the Working on their own professional and personal development? programme allowed me the opportunity to work with many other Meeting for the purpose of making decisions concerning key developing leaders across the company on various development leadership development tactics, such as moving employees across projects,” says Greene. “One of the projects I was a part of… organizational lines to new assignments? allowed each team to develop a business plan and strategy for a Apprising the board of directors of activities/progress in the area of new facility being contemplated in Northeast Florida. I then had leadership/succession planning? the opportunity to present our business case to several of HCA’s senior executive leaders, which provided great exposure to 2. Can the senior leadership team articulate the principles and philosophy company leadership.” of leadership development in the organization?
Ties to succession planning From: Growing Leaders in Healthcare: Lessons From the Corporate World Organizations with leadership development initiatives in place by Brett D. Lee, PhD, FACHE, and James W. Herring, PhD (Health report far-reaching benefits, including increased employee Administration Press, 2009) retention and satisfaction. “Studies have shown that if an organization focuses on enhancing the skill sets of leaders at all levels, there is a direct tie to retention of frontline staff,” says Children’s Medical Center’s Lee. In order to perform effective “Ultimately, by investing in the development of leaders from within succession planning, there must be the organization, it communicates a strong message that the a pipeline of leaders within an organization is personally vested in the success of its employees, organization who are qualified and and it increases your odds of keeping your best and brightest.” able to fill in when turnover at key At Legacy, employees who have come from other organizations tell Knight they feel supported because of the development positions occurs opportunities the organization has. “They feel that the organization has a wealth of resources that are available to them to help them succeed,” says Knight. Legacy’s Brown says those satisfied employees will add to the ongoing work force shortages and projected retirements of large overall success of the organization going forward. “If you provide numbers of healthcare workers, many in healthcare agree it’s the opportunity and the learning experiences for individuals, then never too early to start planning for staff turnover. they feel that the organization values them and is willing to invest “In order to perform effective succession planning, there must in their future,” he says. “I think then they’re more patient and be a pipeline of leaders within an organization who are qualified willing to work within the organization. In the same vein, those and able to fill in when turnover at key positions occurs,” says Lee. individuals also participate in the development and refinement of “A robust leadership development programme can help to build the organizational culture by looking to their subordinates and that type of leadership bench strength.” developing them for future leadership positions.” And in turn, “An effective succession planning process will Not planning for staff transitions can have a catastrophic effect reinforce, with the individuals being developed, that the on a leadership team or an organization as a whole. In light of organization personally cares about their careers, is providing them the tools and training to be successful and will seriously consider them when a key leadership vacancy occurs,” says Lee.
Building a successful leadership development programme In his book Growing Leaders in Healthcare, Lee emphasizes there If you provide the opportunity isn’t a one-size-fits-all development programme. Instead, there are and the learning experiences for a variety of approaches to fit organizations big and small. individuals, then they feel that “Healthcare organizations do not have to go out tomorrow and the organization values them and start developing internal leadership academies and formal is willing to invest in their future corporate universities to start down the path of providing effective leadership development,” says Lee. “The most important thing is that they make an effort to convey to their existing and emerging
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leaders that the organization personally cares about their careers and is willing to invest in them to help them achieve their goals. This can be as simple as requiring that every leader, or those Beyond setting clear identified as having leadership potential, have a formal expectations for a leader’s professional development plan in place that outlines their career competency requirements and aspirations, current level of competency, identified skill gaps and having a plan in place to provide an action plan to help advance each individual toward his or her leadership training, buy-in from stated career goals.” the organization’s CEO and other One common thread among strong leadership development senior leaders is essential for the programmes is an established list of competencies that define a programme to succeed good leader. “We spent time (about 10 years ago) looking at the competencies for effective leaders at Legacy,” says Knight. “We have captured that in a term called the Preferred Leader Profile. That profile is the foundation of all we do internally.” Leadership competencies are considered distinct from other To help an organization assess if its leadership team is ready to technical skills, says Brown, because while required technical skills invest in a leadership development programme, Lee and Herring may change over time, leadership skills always will be needed. created a Senior Leadership Team Readiness Assessment chart “I think you need to develop technical skills and competencies (see sidebar, “Senior Leadership Team Readiness Assessment”). separate from leadership skills and competencies,” he says. At HCA, senior leadership buy-in is critical because CEOs and “There are probably fields that exist today that may not exist in the other top leaders actively participate in programmes such as the future. But the leadership talents and skills required are perennial COO and CNO Development programmes. Participants in these and will exist into the future regardless of whatever technical programmes receive mentoring from members of the competencies may develop over time.” management teams within HCA’s hospitals. A list of competencies should be designed to fit an Nelson says he can’t overstate the importance of this buy-in. organization’s unique mission and vision. “The starting point for us “You won’t go anywhere if you don’t get buy-in from senior was determining a competency listing for leadership that reflected leadership,” he says. “Within HCA, it starts at chairman of the our organization’s values and cultures,” says Premier’s Linesch. board and goes all the way down to the CEOs, COOs and CNOs He says having a list of competencies also gives the at our facilities. We get tremendous buy-in, and that’s what makes organization an objective language in which to talk about the programme successful.” developing talent. When the organization conducts talent At Premier, the CEOs, COOs and vice presidents are in tune to mapping, it can look at a leader’s distinct skill sets, not just his or leadership development, says Linesch. The organization views its her personality traits. talent as a valuable resource. Beyond setting clear expectations for a leader’s competency “The last bastion of competitive advantage is your people,” says requirements and having a plan in place to provide leadership Linesch. “Everybody can buy the same computer systems and the training, buy-in from the organization’s CEO and other senior same equipment and they can build beautiful places, but the point leaders is essential for the programme to succeed. It can be more of service all comes down to the caliber of your people.” J challenging to achieve this buy-in because the return on investment of a leadership development programme can be much Jessica D Squazzo is a writer with Healthcare Executive. more difficult to quantify than other line items on an organization’s capital budget. “When it comes to development programmes, healthcare leaders need to look beyond the traditional ROI calculations and instead view these activities as an investment in the organization’s future,” says Lee. “Because these programmes require an initial investment of scarce funds that may not show dividends for some time, the senior leadership must fundamentally believe that raising the quality of leaders at all levels of the organization will lead to long-term operational and financial success.” Lee says organizations in other industries have adapted the balanced scorecard approach to measure and track leaders’ operational performance progress. “A healthcare organization may track the graduates of a formal leadership academy on the basis of their employee turnover, employee and patient satisfaction scores, budget performance, and any other key metric that the organization feels is appropriate and that advances their strategic goals,” he says. “These scores can be tracked over time to show individual improvement, or they can be compared at a point in time to a peer group that did not receive the training to see if there is a discernible difference in performance.”
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Assessment of human resources management practices in Lebanese hospitals
FADI EL-JARDALI, VICTORIA TCHAGHCHAGIAN AND DIANA JAMAL HEALTH MANAGEMENT AND POLICY DEPARTMENT, FACULTY OF HEALTH SCIENCES, AMERICAN UNIVERSITY OF BEIRUT, BEIRUT, LEBANON
ABSTRACT: Background: Sound human resources (HR) management practices are essential for retaining effective professionals in hospitals. Given the recruitment and retention reality of health workers in the twenty-first century, the role of HR managers in hospitals and those who combine the role of HR managers with other responsibilities should not be underestimated. The objective of this study is to assess the perception of HR managers about the challenges they face and the current strategies being adopted. The study also aims at assessing enabling factors including role, education, experience and HR training. Methods: A cross-sectional survey design of HR managers (and those who combine their role as HR manager with other duties) in Lebanese hospitals was utilized. The survey included a combination of open- and close-ended questions. Questions included educational background, work experience, and demographics, in addition to questions about perceived challenges and key strategies being used. Quantitative data analysis included uni-variate analysis, whereas thematic analysis was used for open-ended questions. Results: A total of 96 respondents from 61 hospitals responded. Respondents had varying levels of expertise in the realm of HR management. Thematic analysis revealed that challenges varied across respondents and participating hospitals. The most frequently reported challenge was poor employee retention (56.7%), lack of qualified personnel (35.1%), and lack of a system for performance evaluation (28.9%). Some of the strategies used to mitigate the above challenges included offering continuing education and training for employees (19.6%), improving salaries (14.4%), and developing retention strategies (10.3%). Mismatch between reported challenges and strategies were observed. Conclusion: To enable hospitals to deliver good quality, safe healthcare, improving HR management is critical. There is a need for a cadre of competent HR managers who can fully assume these responsibilities and who can continuously improve the status of employees at their organizations. The upcoming accreditation survey of Lebanese hospitals (2010–2011) presents an opportunity to strengthen HR management and enhance competencies of existing HR managers. Recognizing HR challenges and the importance of effective HR strategies should become a priority to policy-makers and top managers alike. Study findings may extend to other countries in the Eastern Mediterranean region.
he 2006 World Health Report1 launched the Health Workforce strong link between the availability of healthcare providers and Decade (2006-2015), with high priority given to retaining high- population health outcomes4. Tquality healthcare workers. The Kampala Declaration (2008) Poor work environments and the absence of sound recruitment stressed the crucial role of retaining an effective, responsive and and retention practices are some of the key health human resources equitably distributed health workforce2. Sound human resources challenges that are facing many Middle Eastern hospitals. These (HR) management practices are a key strategy for retaining effective obstacles have resulted in growing staff shortages, attrition and early health professionals in healthcare organizations (HCOs). Given the retirement, poor staff satisfaction, high turnover, and emigration5. recruitment and retention reality of the health workforce in the Many hospitals suffer from poor managerial and planning capacity twenty-first century, the role of HR managers in healthcare in the area of health human resources, and lack recruitment and organizations (HCOs) and those who combine the role of HR retention strategies. Such strategies are essential in terms of managers with other responsibilities should not be underestimated. planning, job satisfaction, and intent to stay6. Few studies have been One of the biggest challenges for hospitals today is the availability conducted to assess recruitment and retention practices and of a strong, capable, and motivated workforce. Hospitals are strategies in the Eastern Mediterranean Region (EMR). A study “people-driven” and their primary expenses are labour costs. As in targeting nursing directors in Lebanon found that the majority of the many developed and developing countries, many hospitals in sampled hospitals (88.2%) reported facing challenges in retaining Middle Eastern countries have come to realize that the most their nurses due to unsatisfactory salary and benefits (80.8%); important asset to their organization, besides physical capital and unsuitable shifts and working hours (38.4%); presence of better consumables, is their health human resources, without which they opportunities abroad (30.1%) and within the country (30.1%); cannot properly function3. At the system level, evidence indicates a workload (27.4%); and instability of the country (16.4%)6. Many
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hospitals reported engaging in strategies to mitigate the above management (19.4%); improving work environment (14.9%); and challenges such as offering financial rewards and benefits (62.7%); promotion opportunities (11.9%)6. One of the main findings of the implementing a salary scale (47.8%); flexible schedules (31.3%); study was the mismatch between reported challenges and staff development (29.9%); offering praise, incentives and motivation implemented strategies which will probably lead to further (19.4%); improving the relationship between nurses and challenges for Nursing Directors in Lebanese hospitals. There is a need for sound and proven strategies developed by HR TableTable 1: Qualifications1: Qualifications and and descriptiondescription of ofrespondents respondents managers for recruiting and retaining HR in hospitals. Hospitals need effective Human Resources N (%) Management (HRM) to be able to deliver quality and 7 Are you the individual in charge of HR department at your hospital? safe care . No 31 (31.9%) According to evidence in the literature, effective HRM Yes 66 (68.1%) practices lead to better health and well-being of If yes, do you hold another position as well? workers, higher satisfaction, lower absenteeism and No 38 (57.6%) turnover, financial advantages (reduced costs, Yes 28 (42.4%) increased productivity), and better quality of care and patient outcomes. Thus effective HRM strategies Highest level of education practiced by HR managers are becoming critical to the High School 2 (2.1%) 7 BBA/BA/BS 39 (40.2%) success of hospitals . The most prominent challenges BSN 7 (7.2%) to HRM include policies and procedures which hinder BT/TS 12 (12.4%) the process and delay recruitment and retention; very MBA/MA/MS 26 (26.8%) centralized and fragmented HR management systems; MPH 5 (5.2%) lack of incentives; poor utilization of current staff in MD 4 (4.1%) 8 Other 2 (2.0%) addition to absence of proper leadership . In spite of the fact that effective human resources Qualifications in HRM management is essential for the success of No 41 (36.4%) organizations, limited knowledge is available about the Yes 56 (63.6%) challenges and the nature of interventions utilized by human resource managers in hospitals including Currently pursuing education or training related to HRM enabling factors and the competences they have or No 27 (27.8%) require. In addition, limited knowledge is available on Yes 70 (72.2%) the number, qualifications, experience and Interested in pursuing education or training related to HRM competences of existing HR managers in hospitals. No 17 (17.5%) This is known in several East Mediterranean countries, Yes 80 (82.5%) and Lebanon is no exception. To our knowledge, no study has been done in Previously attended workshops on HRM over the past 3 years Lebanon and the region to survey HR managers in No 46 (47.4%) hospitals about their views on current HR challenges, Yes 51 (52.6%) strategies implemented, and enabling factors including How long have you been working in this hospital? role, education, experience and training. < 5 years 10 (10.3%) 5.1 - 10 years 8 (8.2%) Objective 10.1 - 15 years 3 (3.1%) The objective of this study is to assess the HR 15.1 - 20 years 2 (2.1%) challenges and strategies as perceived by HR > 20 years 1 (1%) managers in Lebanese hospitals. Specifically, the study Missing 73 (75.3%) is aimed at assessing the perception of HR managers Mean (Standard Deviation) 7.56 (5.57) about the challenges they face and the current Have you previously worked in the field of HRM? strategies being adopted. The study also aims at No 57 (58.8%) assessing enabling factors including role, education, Yes 40 (41.2%) experience and HR training.
Gender Methods Male 25 (25.8%) A cross-sectional survey design of HR managers (and Female 72 (74.2%) those who combine their role as HR manager with Age other duties) working in all Lebanese hospitals was Below 30 yrs 19 (19.6%) developed. To ensure a balanced design with respect Between 30 and 45 yrs 63 (64.9%) to service and care characteristics, the hospitals were Between 46 and 55 yrs 11 (11.3%) stratified by size (number of beds) into the three Over 55 yrs 4 (4.1%) categories defined by the Lebanese Ministry of Health as follows: small (≤ 100 beds), medium (101-200 beds)
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Table 2: Most commonly reported challenges and strategies function. When contacted, the hospitals were informed about the purpose and significance of the study. Hospitals were assured that N (%) participation was voluntary in addition to the confidentiality and anonymity of their responses. After obtaining informed consent to Challenges participate in the study, the questionnaire was provided to HR Poor employee retention 55 (56.7%) managers. In some instances, hospitals did not have a designated Lack of qualified personnel 34 (35.1%) Lack of a system for performance evaluation 28 (28.9%) HR manager, therefore, two or more employees often combined Challenges in recruitment system 26 (26.8%) their primary role in the hospital (whether clinical or non-clinical) with Financial constraints 24 (24.7%) the HR management function. In these cases, all employees Employee shortages 10 (10.3%) affiliated with the HR department filled the survey. Poor satisfaction 8 (8.3%) All hospitals were sent a fax requesting their participation in the Competition by governmental hospitals 8 (8.3%) study. A total of 72 hospitals expressed their willingness to No strategic planning 6 (6.2%) Limited capacity of HR Department 6 (6.2%) participate and 61 hospitals responded to the survey with a total of 97 respondents. Strategies Offer continuing education and training for employees 19 (19.6%) Data analysis Improve salaries 14 (14.4%) Data was entered and analyzed using the Statistical Package for Develop retention strategies 10 (10.3%) Social Sciences (SPSS) 16.0. The quantitative data analysis Develop incentives 8 (8.3%) included uni-variate and bi-variate analysis. The qualitative data Managerial support 7 (7.2%) Needs assessment of existing challenges 6 (6.2%) analysis comprised thematic analysis of open-ended questions to Develop recruitment strategy 5 (5.2%) derive the main challenges and strategies adopted by hospitals as Develop an HR strategic plan 5 (5.2%) perceived by HR managers. Answers were thematically analyzed Improve overall environment in hospital 5 (5.2%) and coded. Similar codes were grouped under categories and related categories were then gathered under themes. Strategies Have strategies been successful? were compared against reported challenges to assess whether (based on 68 respondents who reported retention strategies) the adopted strategies can serve to mitigate the impact of the Yes 54 (79.4%) reported challenges. Thematic analysis followed both an inductive No 14 (20.6%) and deductive approach whereby some themes were based on a search of the literature (inductive) and others emerged from and large (>200 beds). findings (deductive). The predetermined HR challenges included The survey targeted HR managers (and employees who combine financial constraints, employee shortages and lack of qualified the role of HR manager with other duties) in Lebanese hospitals and personnel, migration, poor job satisfaction, recruitment challenges was designed based on an extensive literature review and (or lack of such a system), and poor employee retention (incentive discussions among the research group. The research team used a programmes). As for proposed strategies, the predetermined combination of openand close-ended questions to allow the HR themes included improving salaries and strengthening incentive managers to better document their viewpoints regarding challenges plans, enhancing managerial support, developing recruitment and and strategies. Questions included educational background, retention strategies, and offering continuing education to staff. qualifications, work experience, gender, and age. Additional challenges and strategies were also derived from the The survey also included questions about perceived challenges deductive approach. Analysis of quantitative data included facing the human resources component at hospitals and key questions on level of education, qualifications in HR management, strategies to mitigate these challenges. These were open-ended experience and training in HR management, and plans for questions so that respondents could freely describe the specific continuing education in the realm of HR management, in addition issues pertaining to each question. to other information about the hospital where respondents were The survey also addressed other issues such as the categories of employed. human resources with whom HR managers were facing the most challenges in retention, frequency of conducting performance Results appraisal, trends in assessment of credentialing for medical and Characteristics of respondents nursing staff, existing continuing education or development When the respondents were asked whether they were in charge of programmes, in addition to the presence of recruitment and the HR function at the hospital, 68% answered positively, and 42% retention strategies being utilized by the hospital. of those held other jobs in the hospital (mainly administrative The questionnaire was originally developed in English and then positions). The majority of respondents (40.2%) held a bachelors translated to Arabic as it is the primary language of most HR degree (Bachelors of Business Administration (BBA), Bachelors of managers in Lebanon. Back translation to English was conducted Arts (BA) or Bachelors of Science (BS), while 26.8% held a masters to validate the Arabic translation. After the questionnaire was degree (Masters of Business Administration (MBA), Masters of Arts finalized, it was pilot tested for both language versions after which (MA) or Masters of Science (MS)), and 12.4% a Masters of Public minor changes were made to the wording of some questions. HR Health (MPH) (See Table 1). A total of 63.6% of respondents managers (and those who combine the role of HR manager with reported holding some qualifications in HRM and 72.2% reported other duties) in all Lebanese hospitals were contacted. Hospitals currently pursuing education or training related to HRM. In addition, were asked to forward the survey to individuals in charge of the HR 82.5% reported being interested in pursuing education or training
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Table No3: HR Management trends in participating hospitals14 (20.6%) personnel (35.1%) ranked second whereby respondents reported that there are few candidates for specific positions in their N (%) hospitals. Moreover, some required specialties are not available in universities and schools (eg Does the hospital conduct performance appraisal for all staff members on regular basis? occupational health and safety officers, quality Yes 75 (77.3%) managers, etc.). This may cripple the hospitals' No 22 (22.7%) ability to provide quality care, as existing staff Does the hospital conduct periodic assessment of credentialing of medical and nursing staff? members cannot assume these roles. The lack Yes 61 (62.9%) of person/job fit may thus impede the No 36 (37.1%) hospitals’ ability to provide certain services or meet national hospital accreditation Does the hospital have continuing education or career development program for employees? requirements in Lebanon. The lack of a system Yes 53 (54.6%) for performance evaluation (28.9%) also No 44 (45.4%) emerged as a major challenge as it has Does the hospital hold regular training sessions for staff? reportedly limited the hospitals' ability to No 14 (14.4%) evaluate the competencies and performance of Yes 83 (85.6%) their staff, especially critical staff members. In the hospital 8 (9.6%) Financial constraints were also reported as a Outside the hospital 0 (0.0%) major challenge by 24.7% of respondents, as Both 74 (89.2%) many staff members may value it more than Missing 1 (1.2%) other forms of incentives. Other less frequently Does the hospital require training on specific skills in HR management? reported challenges included overall employee Yes 55 (56.7%) shortages (10.3%), poor satisfaction (8.3%), No 42 (43.3%) competition with other hospitals (particularly governmental hospitals) (8.3%), and limited Does the hospital have a recruitment and retention strategy? capacity and authority of the HR department Yes 26 (26.8%) (6.2%). The lack of an HR strategic plan also No 71 (73.2%) emerged as a challenge but was only reported by 6.2% of participants (see Table 2). Table 4: Categories of health professionals facing most challenges Respondents were asked to report on some strategies utilized by the hospital to mitigate the impact of the N (%) abovereported challenges. Although many respondents Registered nurse 76 (78.4%) reported HRM challenges, a total of 68 respondents (70.1%) Practical nurse 48 (49.5%) reported strategies to mitigate the effect of these challenges. Administration 32 (33.0%) Thematic analysis (reported in Table 2) revealed that the most Physicians 18 (18.6%) commonly reported strategy by respondents was offering Technician 16 (16.5%) continuing education and training for employees (19.6%). Dieticians 10 (10.3%) Physical, occupational, or speech therapist 5 (5.2%) Hospitals often send some of their employees to workshops or Respiratory therapists 4 (4.1%) short courses to improve their knowledge on certain aspects of Pharmacists 1 (1.0%) their job. Some hospitals also use credits collected from Unit assistant 1 (1.0%) attending such courses when considering promotion Other 18 (18.6%) opportunities. Improving salaries ranked second (14.4%) among reported related to HR management. However, approximately half the strategies, as many hospitals believe that this may be the only way respondents (47.4%) reported not having attended any HRM they can keep their employees. Some hospitals also reported workshops over the past 3 years. developing retention strategies (10.3%) to better retain their The question on years of experience had only a 24.7% response employees; but respondents did not specify exact strategies being rate and thus may not represent the entire sample. Respondents utilized. Other hospitals have started developing incentive plans who answered this question had an average experience of 7.56 (± (8.3%), mainly through material rewards, to encourage staff 5.57) years. It is also worth noting that only 41.2% had previously members to remain employed. Managerial support (7.2%) also worked in the field of HRM. Most respondents were female (74.2%) emerged as an HRM strategy, but was only reported by few and 64.9% were between 30 and 45 years of age. respondents. Other strategies included but were not limited to needs assessment of existing challenges (6.2%), developing HR challenges, strategies and enabling factors recruitment strategies (5.2%), developing an HR strategic plan for Thematic analysis revealed that challenges varied across the hospital (5.2%), and improving overall work environment in the respondents and participating hospitals. The most highly reported hospital (5.2%) (see Table 2). challenge by respondents was poor employee retention at hospitals It is worth noting that 79.4% of respondents reported that the (56.7%), particularly for nurses (see Table 2). Lack of qualified adopted strategies were successful in improving the status of health
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workers in surveyed hospitals. Respondents were asked about results of this study correspond well with those derived from the enabling factors that foster employee retention, such as conducting literature, it should be noted that additional challenges and performance appraisal and evaluation, in addition to staff retention strategies emerged. The additional challenges include: lack of a strategies. When asked about the frequency of conducting strategic HR plan, competition with other hospitals (particularly performance appraisal, 77.3% reported conducting annual governmental hospitals), limited capacity of the HR department, performance appraisal for all of their employees in the hospital (see absenteeism, social constraints, poor communication across Table 3). Although conducting performance appraisals is a departments, hospital location, and lack of trust in hospital requirement of the Lebanese hospital accreditation program, our administration. As for retention strategies, the additional themes that findings imply that not many hospitals recognize its importance for emerged from the results are: needs assessment for existing employee retention yet. The remaining hospitals did not report challenges; improving work environment; communicating specialties conducting performance appraisals. However, respondents needed at universities and schools; cooperating with other indicated that some specific staff members are often appraised as institutions on continuing education for staff members; and cross needed, such as heads of departments, some members of the training to fill vacant positions (for promotion from within hospital). It medical staff, and selected nurses and technicians. is clear that many of these additional challenges and reported Periodic assessment of credentialing for medical and nursing staff strategies are specific to the context of Lebanon. was reported by 62.9% of respondents. Furthermore, 54.6% of As previously stated, many of the reported strategies deployed by hospitals reported having a continuing education or career HR managers did not exactly match the reported challenges. development programmes in their hospitals. However, many of the proposed strategies can remedy to some Most of the HR managers (85.6%) reported that they provided extent the reported challenges. For instance, the most commonly staff with ad-hoc training sessions both in and outside the hospital reported strategy was offering continuing education and training for (89.2%). Moreover, over half the respondents (56.7%) reported a employees (19.6%). Moreover, 54.6% of respondents reported need for training in specific HR skills to help them in their role within offering continuing education sessions to staff while 85.6% offer this department in their hospital (see Table 3). Only 26.8% of training sessions. Offering continuing education and implementing respondents reported that their hospital has a recruitment and professional clinical/career ladders have been cited as effective retention strategy. The low percentage on this question may reflect strategies for improving employee retention9-12 and improving health a lack of awareness about the extent to which recruitment and worker efficiency which is linked to the scaling up of productivity13. retention strategies are effective HR management tools in Lebanese They are forms of non-financial incentive which allow employees the hospitals (see Table 3). opportunity to advance in their careers. Further research is needed Respondents were finally asked to select the top three categories to asses whether continuing education at Lebanese hospitals is of health professionals facing the most challenges at their hospital. strategic and in line with training needs of staff. The majority of respondents reported that the staff categories facing Many respondents revealed that hospitals are engaging in the most challenges were registered nurses (78.4%), practical financial incentives in an effort to retain their staff. Despite the nurses (49.5%), and administrative staff (33.0%) (See Table 4). attractiveness of financial rewards, it has a limited impact if not Respondents also reported that they are facing challenges with combined with improved working conditions, employee motivation additional members of the hospital staff, including: housekeeping and linked to individual performance14. It should be noted that only staff, technicians and casual employees (paid on a daily basis). 14.4% of hospitals are engaging in financial incentives, although 24.7% reported having financial constraints that did not allow them Discussion to compensate their staff as appropriately as desired. It is also The results of this study indicate that HRM in Lebanese hospitals worth noting that some respondents (8.3%) reported that hospitals should be strengthened in order to build capacity to better manage are beginning to develop incentives without specifying whether they and retain health workers. The findings showed that not all hospitals were financial or non-financial. More work is needed to understand clearly delineate the departmental responsibilities for its HRM the types of incentives used by Lebanese hospitals and their level function. This can be demonstrated by the challenges and of success. strategies that emerged from thematic analysis. The most striking Managerial support has been cited as an effective mechanism to observation is the mismatch between challenges and strategies in improve employee motivation, job satisfaction and retention15,16. this study. This finding is similar to an earlier study targeting nursing Managerial support includes but is not limited to coaching and directors6, where retention strategies did not always correspond to mentoring staff, supporting continuing education pursuits, staffing the reported challenges. However, this does not necessarily imply and scheduling, and mediation between staff and administration, that the HR managers are not aware of how to address the among other responsibilities15. Managers also have a leadership challenges they reported. On the contrary, it may reflect the limited role, which is as essential component of employee retention, capacity and authority they have to mitigate challenges that are particularly through encouraging an atmosphere of autonomy and hindering HR development at their institution. This was actually shared governance, in addition to empowerment and group reported as a challenge by some of the respondents. Another cohesion16. Despite the importance of managerial support, only challenge reported by some respondents was the lack of a strategic 7.2% of respondents cited it as a retention strategy at their hospital. plan for HR in hospitals. It is worth noting that Lebanese hospitals Furthermore, a mere 10.3% of respondents reported developing are currently in the process of preparing for a new national retention strategies to counter the HR challenges at their hospitals. accreditation survey, and the development of a HR strategic plan is However, this does not necessarily imply that hospitals do not a requirement in the Lebanese accreditation standards. While many recognize the importance of retention strategies. With regard to themes (related to challenges and strategies) derived from the enabling factors for employee retention, many hospitals reported
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engaging in performance appraisals (77.3%) and assessment of Our study findings may apply to other countries in the Eastern staff credentials (62.9%). Such practices are now required in the Mediterranean Region. Another recent study in nine countries found Lebanese hospital accreditation programme, and all hospitals are that health systems suffer from poor HRM, resulting in absence of required to comply with standards relating to performance effective recruitment and retention strategies, poor HR planning, appraisals and credentialing. However, there is a lack of information lack of proper performance evaluation mechanisms, and absence of on the degree of compliance of hospitals with this standard and the a policy for re-licensing of medical staff5, and other negative types of performance appraisals being used. consequences. HRM challenges in HCOs should be valued by Many respondents reported that the strategies adopted by their policy makers and managers and developing effective HR strategies hospitals were successful in mitigating existing challenges. It is not should become a priority. J clear how success was assessed, particularly in that many of the reported strategies did not fully correspond to the reported Acknowledgements challenges. This may be an indirect outcome of the qualifications of Special thanks to Mr Razmig Markarian for data entry. the respondents and their capacity to fill the position of HR managers. Although some respondents had a masters level degree, Competing interests the majority reported that it was their working experience that The authors declare that they have no competing interests. qualified them to fill this role in their hospital. It is worth noting that many of the respondents had dual roles in the hospital which may Authors’ contributions have affected their perception of the existing challenges and limited FE made substantial contributions to the conception, design, as well their capacity to enforce proper strategies to counter their impact. as analysis and interpretation of results. VT substantially assisted with the literature review, data analysis and write-up of the article. DJ Conclusion made substantial contributions to analysis of data and interpretation With the upcoming accreditation survey of Lebanese hospitals of results. All authors read and approved the final manuscript. (2010-2011), there is an opportunity for hospitals to enhance competencies of existing HR managers, and strengthen the HR Original published in Human Resources for Health 2009, 7:84 management component. There is a need to develop a competency doi:10.1186/1478-4491-7-84 framework for the knowledge, skills, attitudes and behavior required http://www.human-resources-health.com/content/7/1/84 for various HR managers. Thorough assessment of what qualifications and experience HR managers have, including all those References who work in healthcare organizations, is required. In this context, 1. Working Together for Health: The World Health Report 2006 Geneva, Switzerland: World Health there is a need to maintain an adequate number of HR managers in Organization; 2006. 2. healthcare organizations with clearly delineated roles, responsibilities Global Health Workforce Alliance: Health Workers for All and All for Health Workers, The Kampala Declaration and Agenda for Global Action 2008 and competencies. [http://www.who.int/entity/workforcealliance/forum/ 1_agenda4GAction_final.pdf]. One of the major findings of this study was that many 3. Kabene SM, Orchard C, Howard JM, Soriano MA, Leduc R: The importance of human resource respondents combine their duties in the HR department with other management in healthcare: a global context. Human Resources for Health 2006, 4:20. 4. El-Jardali F, Jamal D, Abdallah A, Kassak K: Human Resources for health planning and roles in the hospital. This comes to exemplify the need for a cadre management in the Eastern Mediterranean Region: facts, gaps and forward thinking for of competent and well-trained HR managers who can fully assume Research and Policy. Human Resources for Health 2007, 5:9. 5. these roles in Lebanese hospitals and work to continuously improve El-Jardali F, Makhoul J, Jamal D, Tchaghchaghian V: Identification of Priority Research Questions Related to Health Financing, Human Resources for Health, and the Role of the Non- the status of employees at their hospitals. In this context, middle State Sector in Low and Middle Income Countries of the Middle East and North Africa Region. managers (department heads) can play a vital role in HR Research Report Submitted to Alliance for Health Policy and Systems Research 2008. 6. management and provide supervisory support. These middle El-Jardali F, Merhi M, Jamal D, Dumit N, Mouro G: Assessment of Nurse Retention Challenges and Practices in Lebanese Hospitals: The Perspective of Nursing Directors. Journal of Nursing managers can participate in selection/recruitment processes of HR; Management 2009, 17:453-462. and they can perform supervisory functions related to HR 7. Flynn W, Mathis R, Jackson J: Healthcare Human Resource Management Second edition. performance management and appraisal. With regard to retention Thomson South-Western; 2008. 8. O’Neil M: Human resource leadership: the key to improved results in health. Human Resources strategies, proper assessment of the impact of current retention for Health 2008, 6:10. strategies in Lebanese hospitals is required. Such information will be 9. Gullatte MM, Jirasakhiran EQ: Retention and Recruitment: Reversing the Order. Clinical Journal crucial to improving HRM practices at the hospital level, and also in of Oncology Nursing 2005, 9(5):597-604. 10. Shields MA, Ward M: Improving nurse retention in the National Health Service in England: the providing lessons for peer hospitals, particularly ones that are not impact of job satisfaction on intentions to quit. Journal of Health Economics 2001, 20(5):677- currently implementing any retention initiatives. 701. 11. HRM is a discipline which requires a distinct knowledge base and O’Brien-Pallas L, Duffield C, Hayes L: Do we really understand how to retain nurses? Journal of Nursing Management 2006, 14:262-270. training. It is not common in certain areas in the health sector at the 12. Gould D: Locally targeted initiatives to recruit and retain nurses in England. Journal of Nursing moment to find professional HR managers, as they are usually Management 2006, 14:255-261. 13. promoted from other disciplines. As a result, further education or Dussault G, Fronteira I, Prytherch H, Dal Poz M, Ngoma d, Lunguzi J, Wyss K: Scaling up the stock of health workers: A review International Centre for Human Resources in Nursing, training is generally required in order to have the necessary International Council of Nurses, Florence Nightingale International Foundation; 2009. competencies to perform well. There is a need to expand HR 14. Dussault G, Dubois C: Human resources for health policies: a critical component in health professional knowledge and competencies for the effective policies. Human Resources for Health 2003, 1:1. 15. Anthony MK, Standing TS, Glick J, Duffy M, Paschall F, Sauer MR, Sweeney DK, Modic MB, management of human resources in HCOs. There is also a need to Dumpe ML: Leadership and nurse retention: the pivotal role of nurse managers. Journal of increase the pool of competent HR professionals. A new cadre of Nursing Administration 2005, 35(3):146-155. 16. HR managers will need to be trained and enabled to have real input Force M: The Relationship Between Effective Nurse Managers and Nursing Retention. Journal of Nursing Administration 2005, 35(7-8):336-41. into operational and strategic decisions about HRM.
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Clinical care: Nutrition
Nutrition and patient safety a report from the National Patient Safety Agency (United Kingdom)
CAROLINE LECKO PATIENT SAFETY LEAD, NUTRITION AND PRESSURE ULCERS PATIENT SAFETY DIVISION, NATIONAL PATIENT SAFETY AGENCY (UK)
ABSTRACT: The National Patient Safety Agency (NPSA), established in 2001 as part of the UK National Health Service (NHS), extended it’s portfolio of patient safety programmes to include nutrition in 2006. Since 2006 the focus of the NPSA’s nutrition programme has been to raise awareness of nutrition as a patient safety issue and to encourage healthcare staff to report nutrition related patient safety incidents to the NPSA’s reporting data base, the Reporting and Learning System, to identify key themes and areas for national learning. In the summer of 2009 the NPSA were invited by the International Hospital Federation to join the Improving Infant and Child Food Safety in Health Facilities project as a member of the Advisory Group. This opportunity allowed for the NPSA to share their experience and knowledge of nutrition patient safety themes.
ver the last four years the NPSA has been working to raise Figure 1: Flow diagram demonstrating included and excluded incidents awareness of nutrition as a patient safety issue. To achieve this NHS healthcare workers have been encouraged to O Patient safety incidents reported within the NRLS report a wide range of nutrition related patient safety incidents to during 2006 and 2007 (n=1,612,014 ) the Reporting and Learning System. Incidents captured by nutrition-related keyword search terms in 2006 and 2007 (n=52,675) Table 1: Nutrition-related keywords used by the NPSA
Randomly generated nutrition-related patient safety incidents from 2006 and 2007 supplied to the CNRG NG Tube / NG / NGT / N.G.T. (n=4992) Nas*Gastric Oro*Gastric Duplicate records excluded (n=11) Feeding Tube Feeding Patient safety incidents excluded on the basis of Fed / Feed / Food not having any nutritional involvement (n=3548) Eat / Eaten / Eating Nutrition-related patient safety incidents identified Ate (n=1433) Breakfast Lunch / Brunch Nutrition-related patient safety incidents coded into Dinner categories Supper Meal Snack In order to identify the themes and trends associated with these Nutrition / Nutritional incidents analysis of the data base is undertaken on a regular Starve / Starving / Starvation Nil By Mouth / NBM / N.B.M. / per orem / per orum bases. To date this analysis has been undertaken internally by the Oral Fluids NPSA and also by independent commissioned analysis. Catering Analysis undertaken by a Clinical Nutrition Research Group at Parenteral Kings College London reviewed a random sample of 4992 Drip Weigh / Weight / Weighting nutrition related patient safety incidents reported between 2006 Weighing Scale / Weighing Scales and 2007 using key word search terms. Table 1 shows the Mal-Nourish / Mal-Nourished / Mal-Nourishment keywords used to search the data. BMI / B.M.I. / Body Mass Index From the 4,992 incidents analysed 23% were included as De-hydrate / De-hydrated / De-hydration / De-hydrating nutrition related patient safety incidents. The remaining were excluded on the basis of not having any nutritional involvement or
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Table 2: Nutrition related patient safety themes Ineffective systems around theatre and surgery relating to Theme Number Percent of incident fasting guidelines and reports (n=1433) inadequate communication Provision of nutrition via artificial feeding 321 22.9 between departments. Nil by mouth (NBM) / fasting 323 22.7 Problems relating to ordering, Provision of nutrition via oral feeding 243 17.2 prescription and delivery of Nutritional assessment or support 151 11.0 feed/food/fluids. Discharge related / community assistance 107 7.5 Food hygiene and food safety 79 5.7 Inadequate or incorrect Diabetes and blood sugar levels 64 4.5 patient documentation prior to Consequences of malnutrition 43 3.8 admission, transfer, handover or Fluid management 34 3.3 discharge. Falls/slips/trips (with nutritional involvement) 28 2.0 Lack of equipment and Patient refusal of food / drink 16 1.2 Insufficient information provided 13 0.9 equipment failures. Allergy 9 0.6 Other 2 0.1 In 2009 the NRLS undertook analysis of the RLS to identify Total 1433 103.6* themes in reporting of nutrition * Percentages add up to more than 100% due to the assignment of some incidents to two categories. related incidents from 1 January 2008 to 31 December 2008 using the same search terms as being a duplicated report. Figure 1 shows the number of incidents identified in Table 1. included and excluded in the analysis. All incident reports where the severity of harm was reported as The 1,433 incidents were then further analysed to enable death or severe were extracted plus a sample of incidents themes to be identified. The most commonly reported nutrition reported as moderate, low or no harm. A total of 597 incidents related patient safety incident concerned the provision of nutrition reported as death or severe harm and a sample of 300 incidents via artificial feeding (22.9%) and incidents relating to patients being reported as moderate, low or no harm were analysed. The sample “nil by mouth” (22.7%), followed by provision of nutrition via oral was extracted from a pool of 38,437 incidents meeting the search feeding (17.2%). criteria where the degree of harm was reported as moderate, low Table 2 demonstrates the themes identified. or no harm. Analysis of these incidents also enabled cross-cutting themes to Of the 597 incidents reported as death and severe harm 99 be identified and these included: were actual nutrition related incidents and of the sample 300 Problems relating to poor communication between staff and incidents reported as moderate, low or no harm 50 were actual departments. nutrition related incidents. This represented approximately 20% of Inadequately kept patient documentation regarding fluid and all incidents analysed. food requirements. Figure 2 demonstrates the identified themes for those incidents Inadequate staffing levels to provide sufficient patient care. reported as death or severe harm and figure 3 for incidents Insufficiently trained or skilled staff to provide satisfactory care. reported as moderate, low or no harm. Lack of services around nutrition and nutritional assessment. Some examples of nutrition related patient safety incidents: Failure to follow protocols or guidelines or implement changes Patient admitted with Cervical – spine fracture and Halo jacket in regimens with regards to feeding and fluids. (external fixation) applied on… . Pt found to have developed
Figure 2: Themes reported as death or severe harm Figure 3: Themes reported as moderate, low or no harm
Pressure sores Choking Lack of assessment Artificial nutrition Nil by Mouth – prolonged Nil by Mouth – prolonged period periods of time of time Inappropriate diet Inappropriate diet Dehydration Lack of assessment Artificial Nutrition Nil by Mouth – not observed Naso-gastric tube Choking Transfer of care Catering services Lack of assistance Missed meals Medications Pressure sores Nil by Mouth – not observed Dehydration Allergy Nasogastric tube Catering services Weighing Scales Delay in assessment Delay in treatment Discharge
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Grade III – IV pressure sore on his back (thoracic spine) when available. There were examples of infant formula being prepared the Halo jacket was insitu . Pressure sore found when Pt had using “warm” water obtained from a mineral water container and the Halo jacket removed, Wound Team involved, photos taken. were the main hospital “clean” water supply was obtained from a Pt is malnourished and underweight – prominent pressure central point which was contained in an area with no internal wall. areas as bony prominence are vulnerable to pressure damage. There was some evidence that water supplies were Appropriate dressing done, Dietician involved. Pt advised to microbiologically tested but the frequency of this varied. avoid lying on the affected areas, repose mattress provided The availability, maintenance and monitoring of refrigeration and to continue monitoring. equipment also posed a challenged to the organizations with While …. was eating his tea under supervision , he started to evidence of refrigerators not working but more commonly being choke . Staff tried to dislodge the piece of food without used at temperature higher than the WHO recommendations for success. Cardiopulmonary Resuscitation commenced and a the storage of infant formula and breast milk. Regular monitoring pulse was maintained till the paramedics arrived. …… was and recording of refrigeration temperatures was also an area of then taken to …. where he died. concern for some organisations. A very malnourished complex patient with a high and variable The implications of poorly maintained facilities and equipment ileostomy output for whom we are trying to increase her perhaps had the greatest impact on the healthcare workers ability weight in order to attempt to reverse her ileostomy and to provide safe nutritional care with the design and layout of many improve her quality of life was not weighed in over one week food preparation areas preventing staff from accessing despite daily verbal requests, a written note on the patient handwashing facilities compounded by a limited availability of door and repeated written requests in the nurse notes. Her alcohol hand gel. Some areas had equipment for washing and food record chart was not kept over the weekend either and sterilizing bottles but the equipment was broken and had not been the patient is not able to recount accurately her intake. It is repaired. The preparation areas were generally clean and tidy but very difficult to know how much Total Parenteral Nutrition is again the general maintenance of the areas was limited with floor required in order to meet nutritional requirements if no record is and wall surfaces difficult to clean. kept of oral intake and if no weight is taken to evaluate It was also noticeable that many healthcare workers were not treatment. aware of either international or local guidance or policies. This I was reviewing the patient charts outside her side room when included WHO or local policies for infant food preparation but also the housekeeping staff came round with the beverage trolley of concern was poor compliance with Hazard Analysis Critical and offered the patient a cup of tea. I asked the housekeeper Control Point (HACCP) leading to issues relating to the traceability if they were aware the patient required thickened fluids. They of any potential contamination. knew nothing about this, so I asked if they knew how to thicken the drink and they said no. I therefore advised them Workshop not to give the patient the drink as it was, unthickened. The The workshop was attended by representatives of all of the reason being that the patient has been advised by the Speech hospitals involved in the mission and provided participants with the and Language Therapist to only have syrup thickened fluids as opportunity to identify the key challenges and priories to effect otherwise may be at risk of aspiration pneumonia. behavioural practices and to identify potential solutions for their organisations and decision-makers. The Indonesia experience The workshop all provided an opportunity for the NPSA to share The NPSA were invited to be an Advisory Group member for the their learning of nutrition and patient safety. A brief presentation International Hospital Federation Improving Infant and Child Food was given to delegates which included: Safety in Health Facilities programme as part of this role involved An overview of the NPSA. taking part in field mission trip to Indonesia. During the mission a total of nine hospitals Figure 4: Nutrition related incidents for children from 2006 and 2007 were visited in Jakarta covering a range of both Nutrition related patient safety incidents for children private and public hospitals. The hospital visits Provision of artifical nutrition provided a unique opportunity to gain an insight 30 to the delivery of nutritional services across a Nil by mouth/fasting 25 range of organizations. The issues faced by Provision of oral nutriton healthcare colleagues in Jakarta were complex 20 Nutritonal assessment or involving poor facilities and maintenance support schedules, poor compliance with hand hygiene, 15 Discharge related
a lack of knowledge and training for frontline Number Food hygiene/safety healthcare workers and limitations in resources. 10 The impact of these challenges was reflected in Diabetes 5 the organisations ability to deliver safe nutritional Consequences of malnutriton care across the whole hospital population. 0 Fluid management The specific focus of the mission was on the Under 1 2 -4 safe preparation of infant formula’s and the 28 month - years Patient refusal of nutrition days 1 year organisations ability to ensure safe preparation Age range Allergy was profoundly affected by the water supply
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A background to the nutrition patient safety programme. Feedback of analysis of nutrition related patient safety incidents. A breakdown of nutrition related incidents in children (Figure 4).
It was very clear from the participant’s feedback following the group work sessions that they were all very aware of what the key issues were and whose responsibility it was to take forward the improvements required. The participants were eager for changes to be made quickly with most responding that actions needed to be taken immediately. It was interesting to note that the needs of healthcare staff appear to be similar globally with key needs being identified as being greater access to national guidance/information and increased education and training.
Decision-makers meeting The decision-makers meeting provided opportunity for the IHF team to provide feedback on both the hospital visits and workshop with a key function of acting as a catalyst and facilitator between healthcare workers and decision-makers. It was made clear that the role of IHF team was not to put forward recommendations. However, it became apparent during the meeting that there was an expectation that recommendations would be suggested. The decision-makers meeting did provide opportunity for discussion on the key issues identified by the healthcare workers and there was a general acknowledgement that actions needed to be taken to improve the safety of food preparation but no clearly defined action points were established. J
32 World Hospitals and Health Services Vol. 46 No. 1 33-40 How research can help control TB:25 13/5/10 14:15 Page 33
Clinical care: Tuberculosis
How research can help control tuberculosis
R E CHAISSON M HARRINGTON JOHNS HOPKINS UNIVERSITY CENTER FOR TUBERCULOSIS RESEARCH, TREATMENT ACTION GROUP, NEW YORK, NEW YORK, USA BALTIMORE, MARYLAND, USA
ABSTRACT: Tuberculosis (TB) has played a central role in the history of biomedical science from Koch onwards. Research in the nineteenth and twentieth centuries yielded extremely valuable diagnostic, therapeutic and preventive tools for the control of TB. Following the development of shortcourse chemotherapy in the 1970s and 1980s, research into TB virtually evaporated. Despite the availability of an array of tools, TB control faltered, and the disease remains a major killer. The failure of the fruits of scientifi c research to control TB is a result of the shortcomings of the tools themselves as well the inadequate application of the tools in populations burdened by TB. A changing epidemiologic situation, with escalating rates of human immunodefi ciency virus-related TB and the emergence of multidrug-resistant TB, further threatens global TB control. A robust TB research enterprise will be required to meet the global goals for controlling TB in the twentyfirst century. Basic research is needed to better understand its pathogenesis and immunology, and to identify targets for diagnostics, drugs and vaccines. Research into better biomedical tools to detect, treat and prevent TB is also a major priority, as all of the existing tools have important shortcomings. In addition, research into understanding how to apply both existing and new tools to control TB at the population level is urgently needed. Global funding for TB research, $483 million in 2007, is slowly growing but is far behind need. To meet the ambitious goals of the Global Plan to Stop TB and the Millennium Development Goals, a massive investment in research will be necessary.
uberculosis (TB) has played a central role in the history of the research community grew, despite the continuing toll of TB on biomedical research, and efforts to control the disease have society.2 Minimal interest in TB in industry meant that very few new T benefi ted enormously from scientific discoveries and tools for TB were developed. achievements. Three Nobel Prizes in Physiology or Medicine, to Moreover, the consignment of TB to public health programmes Robert Koch, Niels Finsen and Salman Waksman, have been in some instances led to the perverse attitude that further research awarded for research on TB, and the discoveries of Koch and into the disease was unnecessary and, perhaps, Waksman remain clinically relevant to this day. The spectrum of counterproductive. Most international efforts to address TB control scientific inquiry into TB and the fruits it has borne are truly for much of the 1980s and 1990s focused on improving the quality spectacular. With the cumulative advances of Koch’s discovery of of services delivered by underfunded control programmes and the organism and the development of his postulates, Calmette downplayed the need for new knowledge, tools and approaches and Guérin’s production of the vaccine that bears their name, and to reducing the burden of TB globally.3 While it was very true that the extraordinary progress with drug treatment of the disease, poor performance of programmes was (and remains) a major culminating in short-course chemotherapy in the 1970s and obstacle to the effective control of TB, it was also increasingly 1980s, many felt that science had done all it could do to control evident that the tools available for doing the job were increasingly the disease. Beginning in the late 1960s, research investment in inadequate. As the global epidemiologic situation has changed TB evaporated, victory was declared, and scientists working in the dramatically in the past 20 years, the challenges to contemporary field moved on to other problems.1 It only remained for clinicians control measures have grown. The World Health Organization and public health programmes to use the tools science had so (WHO) set goals for detecting 70% of all sputum smear-positive brilliantly provided for TB to be consigned to history. TB cases and curing 85% of them as an essential process in The neglect of TB research for several decades has had a global control. While great progress has been made towards considerable impact on efforts to control the disease: the lack of achieving these targets, case detection remains unacceptably low academic interest in TB moved the disease out of biomedical in areas such as Africa and Eastern Europe, and even in countries research centers, often meaning that doctors, nurses and health that have achieved the targets, such as Vietnam, incidence rates scientists had little or no training in the disease. Complacency in have not fallen. Reaching the Millennium Development Goals of
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halving the burden of TB disease Table 1: Biomedical tools used to control TB and death by 2015 is therefore Tools Current strategies Limitations Future strategies unlikely. The impact of the human Diagnostics Sputum smear Poor sensitivity ( < 50%) especially in HIV-positive patients Improved yield of sputum smear immunodeficiency virus (HIV) on (e.g., light-emitting diode fl uorescence microscopy) TB has been enormous, with Solid culture systems Slow growth, resulting in long delays in diagnosis and Simpler rapid cultures (Löwenstein-Jensen) detection of drug resistance; need for biosecurity escalating incidence, high mortality Liquid culture systems Expense, need for biosecurity, high contamination rates, Antigen-based detection rates and changes in the clinical diagnostic delays Nucleic acid Sensitivity in smear-negative cases, expense Line-probe assays presentation of the disease that amplifi cation tests Tuberculin skin test Poor specifi city, inability to distinguish latent infection Genotyping make diagnosing, treating and from active disease Interferon-gamma Inability to distinguish latent infection from active disease Third generation nucleic acid preventing TB more difficult. Smear- release assays amplifi cation techniques based case detection, for example, Volatile organic compound detection Treatment First-line drugs Drug resistance, toxicity, duration of treatment, drug Fluoroquinolones misses at least half of all TB cases, (HRZES) interactions, especially with antiretroviral agents Diarylquinolines Second-line drugs Low potency, toxicity and duration of treatment, Nitroimadazopyrans and more so in settings where HIV for MDR-TB extensively drug-resistant TB Diamines is prevalent and among children. Oxazolidinones Preventive H, HR Duration of treatment, toxicity, drug resistance, durability See above First-line drugs must be taken for 6 therapy of protection in HIV-infected patients to 8 months, resulting in non- Vaccines BCG vaccine Lack of protection in adults, lack of standardization Recombinant BCG Subunits adherence and the risk of recurrent Peptides Vectors, e.g., adenovirus disease and selection of resistance. Adjuvants
The emergence of multidrug- TB = tuberculosis; HIV = human immunodefi ciency virus; H = isoniazid; R = rifampicin; Z = pyrazinamide; E = ethambutol; S = streptomycin; resistant (MDR) and, more recently, MDR-TB = multidrug-resistant TB; BCG = bacille Calmette-Guérin. extensively drug-resistant (XDR) TB renders standard approaches to Table 2: Clinical and public health strategies for use of tools to control TB diagnosing and treating TB
ineffective. Notably, most of the 500 Tools Current strategies Limitations Future strategies
000 cases of MDR-TB that occur Diagnostics Passive case fi nding: diagnose Late detection of infectious cases. Active case fi nding each year are not even detected or symptomatic patients who Relies on smear in most settings, with Contact evaluations present to health services sensitivity < 50% Use of new technologies properly treated. Drug-resistant TB Algorithm for smear-negatives Diagnostic delays, poor sensitivity and Joint TB-HIV case fi nding requires new agents for successful specifi city Treatment DOTS with fi rst-line drugs Drug resistance, poor adherence, poor Shortened treatment treatment, given the generally poor program performance Intermittent treatment HE continuation phase (decreasing Unacceptably high failure/relapse rate Avoid drug interactions responses to existing second-line use globally) drugs. The bacille Calmette-Guérin Retreatment with HRZES Amplifi es resistance in many patients Treat based on known susceptibilities Preventive therapy Isoniazid for selected high-risk Inadequate uptake, toxicity, adherence Shorter regimens with new agents (BCG) vaccine has probably patients and fears of resistance (e.g., rifapentine) Continuous or repeated preventive attenuated to impotence in therapy in high HIV settings preventing disease in adults.4 Secondary preventive treatment Community-based preventive Over the past decade there has treatment Mass preventive treatment been a growing appreciation of the Vaccines Vaccinate newborns with BCG No effi cacy in adults Vaccinate neonates importance of research for Vaccinate high-risk adults, e.g., No recent evidence of effi cacy in Booster vaccine for adolescents nursing and medical students newborns strengthening global TB control. Other Antiretrovirals for advanced Many patients have tuberculosis Earlier detection of HIV and earlier HIV disease before HIV therapy can be started initiation of HIV treatment The second Global Plan to Stop TB, Infection control Ignored in most of the world Enhanced infection control published in 2006, makes a strong TB = tuberculosis; HIV = human immunodefi ciency virus; H = isoniazid; R = rifampicin; Z = pyrazinamide; E = ethambutol; S = streptomycin; case for the need for a wide range MDR-TB = multidrug-resistant TB; BCG = bacille Calmette-Guérin. of research, and lays out a budget to support these activities,5 although many feel that even more money is required than is urgent priority for biomedical and public health research. Control proposed in the plan.6 The research agenda for TB control is of TB in the coming decades will surely rest on new discoveries, wideranging and multi-disciplinary. Reducing the burden of TB novel technologies and innovative public health and clinical throughout the world and eventually achieving elimination will approaches to curtailing the spread of infection and the require a combination of effective biomedical tools and public development of disease. A broad portfolio of research initiatives is health strategies. The basic tools used in disease control – essential to ensure future progress, as no one can say with diagnostics, drugs, vaccines – are not magic bullets. To have an certainty which ideas and strategies will be most effective. It is impact at the population level, these tools must be applied using sobering to recall that throughout the global campaign to effective public health strategies that maximize their benefi ts. eradicate smallpox in the 1960s and 1970s, a vigorous research Tables 1 and 2 show the biomedical tools used in controlling TB programme was maintained to ensure that methods that proved and the public health strategies used to apply them to patients ineffective in the field could be replaced with new approaches that and communities. might be more efficacious.7 Only when the disease was actually The tables list the current situation, important limitations and eradicated were the research efforts retired. A similar attitude future directions to improve outcomes. All the tools and strategies toward TB must be maintained as control methods evolve. The currently in use have significant shortcomings. The development recent declaration by over 60 Ministers of Health in Bamako, Mali, of new tools and strategies for delivering them, therefore, is an that at least 2% of national health budgets and 5% of donor
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funding should be earmarked for research, is a reminder of the is available, it is most often done with Löwenstein-Jensen value of research in promoting human health.8 medium, a robust but extremely slow method that results in long delays in case detection. Drug susceptibility testing (DST) is Research needs for new tools generally not available for the vast majority of TB patients, and Basic science where it is performed it is often by the laborious and time- The sequencing of the Mycobacterium tuberculosis genome a consuming proportions method, further contributing to delays in decade ago has released a cornucopia of research on gene providing proper care. expression, drug targets, virulence factors and latency, all of which Research into new tools for TB diagnosis has made are necessary for developing new tools to control TB.9 Advances considerable progress in recent years, and a number of exciting in bacteriology, immunology, genetics, biochemistry and a range of new tools are under study or clinically available.14 Liquid-based other disciplines will continue to foster knowledge that will help culture systems, long known to be both more sensitive and faster develop interventions for disease control. Basic biomedical than solid culture media, have been demonstrated to be feasible research is as important as targeted research, as advances in and effective in resource-poor settings and are now endorsed by seemingly unrelated fi elds can contribute to understanding TB the WHO for routine use in smear-negative, HIV infected biology and control. For example, the development of green individuals with suspected TB.15 Recent efforts to bring liquid fluorescent protein as a tool for studying cell biology, recognized culture to the field have followed two very distinct paths. On the by the 2008 Nobel Prize for Chemistry, has been used by one hand, use of commercial systems, such as Becton researchers to understand M. tuberculosis metabolism and Dickinson’s Mycobacterial Growth Indicator Tubes (MGIT), has survival under stress conditions.10 been demonstrated by a number of groups to be efficient and The polymerase chain reaction, recognized by the 1993 Nobel cost-effective.16 The advantages of commercial diagnostic Prize in Chemistry,11 and other nucleic acid amplifi cation products include reproducibility, standardization of training and techniques not only play a critical role in laboratory research on methods, and management of the supply chain. Limitations to TB, but are central to several new diagnostic tests. Research in these products include costs, including capital expense for both other seemingly remote or unrelated fi elds will certainly influence machines and appropriate buildings for their use, high rates of developments in TB in coming years, as well. contamination and training needs. Others have developed liquid A key biological characteristic of M. tuberculosis is latency, culture methods that are not commercial products, but rather which allows the organism to remain viable for many years without processes that can be adopted in a variety of settings. The most evidence of ongoing replication or damage to the host. notable of these is the microscopic observation drug susceptibility Understanding latency will involve a better grasp of regulatory (MODS) method, a liquid system that is produced locally and has genes, biochemical pathways that sustain viability in the absence shown high sensitivity, specificity and rapidity for both identifi of active replication, and triggers of reactivation.12 A more cation of M. tuberculosis and detection of isoniazid and rifampicin extensive appreciation for the mechanisms of latency could (RMP) resistance.17 Advantages of MODS include low cost, contribute to better diagnostic tools and new drugs for preventive reliance on microscopy skills readily available in many high-burden treatment. Conversely, understanding host factors that are settings, and simplicity. Challenges with MODS include lack of responsible for containing M. tuberculosis infection is important for standardization, variable results with DST, especially for RMP, and vaccine development.13 The majority of individuals infected with M. biosafety concerns.18 tuberculosis never develop clinical illness, but the immune While the use of liquid culture is a major step forward from responses that protect them are not well understood. Elucidating reliance on sputum smears, research is needed to bring faster, the correlates of immunity is an essential step for evaluating new cheaper and simpler tools into clinical practice. Nucleic acid vaccines, and could be used prognostically to distinguish those amplification (NAA) techniques have been used for some time to people who are unlikely to progress from latent infection to detect TB in industrialized countries, but these have been limited disease, and who would therefore not require preventive by expense, technological requirements and moderate to poor treatment. sensitivity in smear-negative patients. Several newer NAA methods are currently under study and could be used in clinical Diagnostics practice in the near future if their initial promise is sustained. A Perhaps the most striking shortcoming of current TB control cartridge-based assay that amplifies specific gene targets to efforts is the inability of clinicians and programmes to accurately detect the presence of both M. tuberculosis and signature diagnose TB in a large proportion of patients, particularly in HIV- mutations associated with drug resistance, with a turnaround time infected individuals and children. Globally, more than half of all TB of several hours, is now in late stages of development.19 Loop- cases are not detected, the result of health care system mediated amplifi cation is an isothermal technique that detects weaknesses and the inadequacy of available technology. DNA using visual inspection of fl uorescence in a closed system.20 If a diagnosis is absent, patients are not treated, transmission Research into these and related techniques is essential before may continue, patients suffer needlessly and many eventually die. they can be introduced in the field, but the prospect of case Reliance on the sputum smear, introduced by Koch more than 125 detection and identification of drug resistance in less than 24 h is years ago, is an unacceptable global standard for case detection. extremely appealing. In addition to its poor sensitivity, sputum microscopy cannot Other genetic diagnostic techniques are also the subject of identify species and offers no information on drug susceptibility, research. The use of solid phase amplifi cation of gene targets for making detection of drug-resistant TB impossible in settings detection of M. tuberculosis sequences and drug resistance where smear is the only tool available for diagnosis. Where culture mutations is the strategy that underlies line-probe assays.21
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Several commercial line-probe assays are already available, and After a hiatus of almost 30 years, the TB drug development their use has been endorsed by the WHO for detection of drug pipeline has of late experienced the beginnings of a renaissance.27 resistance in areas with high rates of MDR- and XDR-TB. Newer Several existing agents in established drug classes are in methodologies for detecting M. tuberculosis can be borrowed advanced clinical trials, and several newer agents are in Phase 1 from other fields, such as sensing volatile organic compounds or and 2 trials. Rifapentine, an RMP analogue that has greater parsing immunologic responses with novel immunoassay potency and a longer half-life, has been shown to be effective in techniques.22,23 shortening the duration of TB treatment in an animal model, and is While all of the new diagnostic modalities described above now under study for treatmentshortening in humans.28 Moxifl would propel TB control forward dramatically, a tool that would oxacin (MXF) is a potent fluoroquinolone that may permit revolutionize the fight against this disease would be a point-of-care treatmentshortening and which should also be very active in MDR- rapid test, such as a dipstick test, that reliably detected active TB.29 Several promising clinical trials have been completed, and a disease and which could be deployed in primary care settings in large study to determine whether treatment can be reduced to 4 high-burden areas. Such a test is currently science fiction, but months when MXF is used is now underway. Gatifloxacin is also most technological breakthroughs begin as science fiction and potent, and studies of this agent are also being conducted.30 only become reality by dint of investment, innovation and New agents with unique mechanisms of action are clearly industriousness. The technology for dipstick tests is widely required for combating MDR- and XDR-TB. Several such agents available and extensively used for diagnosing conditions as varied are currently being evaluated. The adenosine triphosphate as pregnancy and HIV infection, but substantial obstacles to a synthase inhibitor Tibotec Medicinal Compound 207 has been dipstick test for TB must be overcome. For example, detection of shown to have excellent activity against MDR-TB in a small Phase antibodies against M. tuberculosis antigens is a strategy that has 2a trial in South Africa, and a larger trial is ongoing.31 The consistently failed in the past, as humoral immune responses are nitroimidazopyran OPC 67683 is being studied in a multinational neither sensitive nor specific in assessing the presence of disease. trial of patients with MDR-TB,32 while a PA 824, a drug in the same Dipstick detection of M. tuberculosis antigens appears feasible for class, has recently completed its first Phase 1 trial in TB patients.33 patients with disseminated disease, such as those with advanced A new diamine, SQ 107, will enter clinical trials shortly. HIV infection, but serum or urinary antigenemia appears The apparent bounty of new agents in clinical trials obscures a uncommon in the majority of TB patients. Rapid detection of critical problem in TB drug development, however. While a handful antigens in sputum or respiratory secretions is a possible method of new drugs is a huge advance over the situation just a decade for addressing this problem. It is clear, however, that a vigorous ago, the pre-clinical pipeline of anti-tuberculosis drugs is perilously programme of applied research is necessary to bring about this anemic. Substantial investment in basic research to identify new essential revolution in diagnosing TB. targets and pathways is needed, along with screening of compound libraries to identify existing entities with good activity. A Drugs vigorous programme to develop new entities and compounds The current drug armamentarium for TB is remarkable in two must then be followed by the laborious process of studying the respects: first, it is miraculous when one considers that TB was toxicology, pharmacology, formulation and bioavailability issues incurable just 60 years ago; but second, it is absolutely inadequate required to bring a product forward into human clinical trials. This given the current challenges in TB control. The deficiencies of is an expensive and time-consuming process, and many potential current drug therapy for TB include the lack of high-quality drugs are left aside along the way for a variety of reasons. The regimens for drug-resistant disease, the long duration of ‘short- shortage of pre-clinical compounds is thus a serious problem that course’ chemotherapy, the potentially lifethreatening toxicities Table 3: Progress towards global plan to stop TB targets for new tools of first-line agents and serious drug-drug interactions, particularly with RMP. Table 3 Progress towards Global Plan to Stop TB targets for new tools Drug-resistant TB has existed since the dawn of the Tool Global Plan targets Progress to date/comment antibiotic era. The majority of patients treated with Diagnostics By 2006: Rapid culture for case detection and Liquid culture recommended by WHO but not streptomycin in the first Medical Research Council randomized DST in demonstration phase widely used 24 DST still restricted to reference centers trial acquired resistance to that drug, and resistance to By 2010: current first-line drugs is a global crisis.25 Use of second-line Point of care, rapid culture, improved Point of care test unlikely in next 3–5 years microscopy, phage detection and Phage detection technology of limited value drugs has predictably led to the selection of further resistance, simplifi ed nucleic acid amplifi cation Line probe assays proved effective and reliable, tests introduced roll out proceeding slowly and the specter of XDR-TB has emerged in the past several Comment: Progress in diagnostics is impressive; years.26 Development of new drugs that are active against dissemination and uptake are key challenges Drugs By 2006: MDR- and XDR-TB is imperative. In addition, improving the 27 new compounds in the TB 7 drugs in clinical trials (2 old and 5 new classes) pipeline 7–10 entities in preclinical development potency of drug regimens to permit significant shortening of TB By 2010: Comment: Despite real progress, TB drug 1–2 new drugs licensed for TB pipeline is perilously thin treatment would help turn off the spigot of acquired drug indication; treatment shortened to resistance by facilitating treatment supervision and treatment 3–4 months Vaccines By 2006: completion in resource-limited areas. Moreover, development 5 candidates in Phase 1 studies 7 products in Phase 1 or 2 trials By 2010: Comment: Vaccine research is progressing well of new drugs and regimens that are less toxic and that neither 9 vaccines in Phase 2 studies; at least induce nor are affected by P450 cytochromes is important for 2 products in Phase 2b studies (proof of concept); beginning of advancing safety and allowing coadministration of TB and HIV Phase 3 trials drugs in the hundreds of thousands of individuals who require TB = tuberculosis; DST = drug susceptibility testing; WHO = World Health Organization. treatment for both diseases.
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portends a paucity of new agents in the coming decade. A strong inadequate population coverage (e.g., weak health systems), commitment to funding discovery and preclinical development failings in human behaviour (e.g., non-adherence to treatment, activities is therefore essential. resulting in treatment failure and development of resistance) and changing epidemiologic circumstances (e.g., HIV and MDR-TB). Vaccines Research aimed at understanding and overcoming these BCG is one of the most widely used vaccines in the world, but obstacles is imperative for new tools to reduce the burden of there is considerable evidence that it has a minimal impact on TB disease. In the past 4 years, several global expert groups have control. While early trials found high efficacy of BCG in preventing published ambitious research agendas that address specifi c TB and death in children, adolescents and adults, more recent priority focus areas within the overall public health and medical studies fail to find a protective effect, and several suggest a strategies for addressing TB disease in specific populations, harmful effect.34,35 Genetic analysis of BCG strains demonstrates a including among people living with HIV,38 people with drug- large degree of genomic variation in the various extant strains, resistant TB,39– 41 and pediatric TB.42– 45 suggesting that evolution of the parental vaccine strain of Calmette Incorporation of new tools into existing TB control programmes and Guérin has occurred, rendering current preparations less will be both a major challenge and an important opportunity. immunogenic.36 Given that the original BCG strain was not Research into where new tools fit in the diagnostic and treatment archived, it is not possible to begin again with the effective version algorithms will be important to maximize their impact. For of the vaccine. The development of new vaccines is therefore example, should NAA tests replace culture and DST? Should new clearly a priority. An effective preventive TB vaccine would have second-line drugs be added to initial treatment in patients where only a modest immediate effect on TB control, but over a period drug resistance is suspected? Will treatment-shortening regimens of years to decades could result in major reductions in the burden require more or less monitoring of treatment response? of disease as new generations gained protection from the vaccine. Determining the best uses of new tools will require additional A vaccine that protected individuals with latent TB infection as well research beyond proving their effi cacy. Operational research, long as those not yet exposed to the organism would be of recognized as important but almost always underfunded, targets extraordinary value. the processes and procedures of health care delivery in an attempt Unlike developing vaccines for HIV/AIDS (acquired immune-defi to improve performance. There is an extensive agenda of ciency syndrome), making a TB vaccine is known to be feasible operational research priorities that relate to almost every because it has been done before. A key challenge for vaccine component of programme activity. Examples of this include development is understanding the correlates of immunity, as noted improving laboratory processes, increasing the yield of screening above. In addition, the lack of animal models that clearly predict for TB suspects, improving registries and surveillance systems, vaccine efficacy in humans is an important limitation. Nonetheless, reducing barriers to access and addressing infection control in considerable progress is being made in identifying candidate institutional settings, to name a few. vaccines, and a number of clinical trials are planned or underway. More effective use of biomedical tools also can be achieved Approaches being pursued include recombinant BCG with through research aimed at enhancing the impact of clinical and overexpression of antigenic epitopes, other attenuated public health interventions. Beyond operational research, it is mycobacteria (e.g., M. vaccae), subunit vaccines, peptides, essential to evaluate the strategies used to control TB from an adjuvants and novel vectors.37 Early clinical trials focus on safety epidemiological perspective.46 As shown in Table 2, a number of and immunogenicity, although determining the most appropriate our strategies are clearly ineffective at present, and new immune responses is challenging. Clinical trials of vaccine efficacy approaches need to be developed and evaluated to reduce the require extremely large numbers of subjects and many years to burden of disease. complete. So, although it is unlikely that a new vaccine will be In the diagnostics arena, it is essential to move beyond passive available in the coming 5 to 10 years, the impact of an effective case finding at health facilities to find TB cases earlier. Intensified product would be enormous for generations. case finding at the facility level or enhanced case finding in the The Global Plan to Stop TB, as noted earlier, strongly endorsed community are means by which individuals with disease can be the need for research to develop new diagnostics, drugs and detected sooner than by passive case finding.47 Studies of the vaccines for TB control. Table 3 lists the targets for development best ways to effi ciently target those individuals with active TB and of these tools and progress toward these goals to date. It is provide diagnosis and treatment sooner are needed to determine encouraging that so much has been accomplished, particularly the most effective means of reducing transmission in the with respect to diagnostics, but it is also clear that much remains community and limiting unnecessary suffering and death from to be done. undiagnosed disease. As new tools become available it will be imperative to evaluate their impact in community settings, not just Research needs for new public health strategies in clinics and hospitals. A treasure trove of new diagnostics, drugs and vaccines will be of New drugs for TB are the only hope that patients with MDR- and no value if they are improperly or ineffectively deployed to the XDR-TB can be reliably cured. Yet, if they are given without populations affected by TB. An understanding of the assurance of adequate support for adherence, resistance to new epidemiologic basis of TB control is required to ensure that new agents is inevitable. Research into methods to promote adherence tools are utilized to maximize their advantages and to interrupt the through a variety of modalities is necessary to guarantee that all chain of transmission and disease that fuels TB epidemics. The patients are cured and to avoid the emergence of further current tools for TB control have failed for a variety of reasons, resistance. Preventive therapy for TB is woefully under-utilized at including inadequate performance (e.g., sputum smear), present, despite extensive evidence of its effectiveness at both
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individual and population levels. Table 4: Worldwide investment in tuberculosis research in 2007 by funding source (US$; from Mathematical models of TB Treatment Action Group Report)6 control demonstrate that
treatment of latent infection, with 2007 Amount 2007 Amount either drugs or vaccines, will be rank Institution ($USD) rank Institution ($USD) 1 US National Institute of Allergy and Infectious 20 Canadian Institute of Health Research 3 917 387 essential for the elimination of the Diseases, NIH 131 378 370 21 UK Health Protection Agency 3 907 664 48 2 Bill & Melinda Gates Foundation 124 213 521 22 Statens Serum Institute, Copenhagen, disease. Strategies for selecting 3 European Commission Framework 6/7 23 366 617 Denmark 3 611 407 appropriate populations for 4 Otsuka Pharmaceutical Company 20 766 495 23 Germany, Max Planck Institute for Infectious 5 US Centers for Disease Control & Prevention 17 874 795 Biology 2 336 000 preventive treatment, including 6 US other institutes & centers, NIH 17 257 593 24 Company Y 1 770 000 7 Wellcome Trust 15 448 553 25 New Zealand, Health Research Council 1 160 335 but not limited to household 8 UK Medical Research Council 15 021 383 26 South Africa Medical Research Council 1 096 987 9 Netherlands Minisitry of Foreign Affairs 13 735 741 27 Ellison Medical Foundation 1 020 900 contacts and those with HIV 10 Novartis Institute for Tropical Diseases 11 700 000 28 Mexico National Institute of Public Health 814 746 infection, need to be assessed 11 US National Heart, Lung, and Blood Institute, 29 Dafra Pharma International Ltd. 673 770 NIH 11 579 120 30 Swedish International Development and the means of ensuring that 12 Eli Lilly Foundation 10 450 000 Cooperation 572 337 13 US Agency for International Development 10 000 000 31 Denmark Ministry of Foreign Affairs 353 246 treatment is adhered to requires 14 Company X 7 900 000 32 Brazil (amalgamated) 321 481 15 AstraZeneca 7 650 000 33 Anda Biologicals 130 711 additional research. The impact 16 Institut Pasteur 7 468 821 34 Russian TB Institutes 120 316 of mass preventive treatment, as 17 UK Department for International 35 KNCV Tuberculosis Foundation 36 720 Development 6 006 379 36 US Food and Drug Administration 35 000 was done in Alaskan Eskimos in 18 Sequella, Inc 4 735 000 37 Korean Institute of Tuberculosis 30 000 19 Irish Aid 4 050 000 the 1950s and 1960s,49 should Total 482 511 395 be evaluated in other high-risk NIH = US National Institutes of Health. populations – a study of this approach in South African gold miners is currently underway.50 As includes management, hygiene, diagnostics, engineering, new agents that target latent organisms are developed it might be behavioural sciences and physics, to name just a few of the worth considering restricting their use to prophylactic treatment, disciplines that can contribute to this effort. thereby ensuring that resistance will not become a barrier to Other interventions that may play an important role in controlling prevention and that options for those exposed to MDR- or XDR- TB operate at the population level. This includes earlier use of TB are available. Additional strategies for controlling TB are also antiretroviral treatment in people with HIV infection, improved important. Infection control has been completely neglected general and micronutrient nutrition, and the availability of housing throughout the developing world until very recently, for example. with better ventilation and less crowding. While all of these may The importance of institutional transmission of both drug- seem investments that are worthwhile in their own right, research susceptible and drugresistant TB to healthcare workers and other into the relative benefi ts and costs of each will enable policy patients, particularly in settings with a high HIV burden,51 has makers to choose between options for the use of limited resources. become apparent, however, and research into the methods to control this source of infection is now a global priority. The Funding research agenda in infection control is extremely broad, and The research agenda for TB, as outlined above, is large, ambitious
Figure 1: US National Institutes of Health spending on selected infectious diseases, 2005–2008. (From: Estimates of funding for various research, condition, and disease categories [RCDC], http://report.nih.gov/rcdc/categories/). FY = fi nancial year; HIV/AIDS = human immunodeficiency virus/acquired immune-defi ciency syndrome; STDs = sexually transmitted diseases.
3000 Biodefence Hepatitis B 2500 Hepatitis C HIV/AIDS Influenza 2000 Malaria STDs/herpes Smallpox 1500 Tuberculosis $US millions West Nile virus 1000
500
0 FY 2005 FY 2006 FY2007 FY2008
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Even TB treatment research – the most well-funded research Figure 2: Worldwide investment in tuberculosis research in 2007 by category (from Treatment Action Group Report6). category – is, at US$170 million per year, less than half of the US$403 million in estimated direct costs to bring a new drug to market.52* Unspecified US$36,822,851 Conclusion 7.6% Drugs Success at the mid-twentieth century in making TB a curable disease resulted in catastrophic declines in research funding, Operational US$170,154,676 35.3% leaving the world unprepared for the resurgence of TB disease in US$41,925,455 the late century, fueled by the HIV pandemic and by collapsing 8.7% health systems in the former Soviet Union, which created the opportunity for the devastating spread of drug-resistant TB. Now these two forms of TB are converging to form a ‘perfect storm’ Diagnostics which could render TB essentially untreatable without new US$40,585,495 Basic science measures.51 Despite new commitments made by the World Health 8.4% US$121,430,461 Assembly,53 the United Nations General Assembly Special 25.2% Session’s political declaration,54 and world leaders at the launch of the Global Plan to Stop TB 2006–2015,55 new public and private Vaccines investment in TB research continues to lag far behind the needs; US$71,592,456 new philanthropic initiatives such as those supported by the Bill & 14.8% Melinda Gates Foundation, while laudable, will not be able to fill the estimated funding gap of about US$1.5 billion per year. To and urgent. But funding for TB research is anemic, paltry and invest in the basic science, applied research and operational insufficient. Despite the extraordinary global burden of TB in terms studies that are all necessary to develop, validate and refine the of lives lost, disability and healthcare and societal costs, new tools essential to eliminate TB as a public health threat by investment in studying the control of the disease is miniscule. The 2050, governments in industrialized and in high-burden countries, Global Plan to Stop TB 2006–20155 estimates that a minimum of as well as industry and the non-profit and philanthropic sectors, US$9 billion—or US$900 million per year—should be spent on need to increase their funding for TB R&D to at least US$2 billion applied TB research between 2006 and 2015 to develop new per year. drugs, diagnostics and vaccines, and yet current TB research and Control of communicable diseases such as TB is complex and development (R&D) investments total less than half that amount. costly, requiring years of sustained efforts. While much has been Moreover, recognizing that the Global Plan does not even include accomplished in our quest to develop the appropriate tools and budget recommendations for basic science – the foundation of all strategies to contain this disease over the past 60 years, much progress in science – or for operational field studies to validate the more innovation and creativity is needed. Research into better use of new tools and to define the most successful control methods to combat TB must continue until the disease is strategies in standard programme settings, some have eliminated, as was the case for smallpox. To abandon research recommended that TB R&D needs investment of at least US$2 before achieving that goal would be foolhardy and risky. We will billion per year to achieve the goals of developing new tools that know we have performed enough research into controlling TB only can set the stage for TB elimination by 2050.6 According to the when we have controlled it. As the American baseball legend and most complete reported data set on global investments into TB quipster Yogi Berra so famously said, ‘It ain’t over till it’s over.’ J research and development in the years 2005 and 2006 – covering the launch of the Global Plan, in 2007, only US$483 million was spent on all TB R&D, including basic science and operational research, two categories not addressed by the Global Plan (Table 4).6 This represented a 12% increase over the US$429 million reported on TB R&D for 2006, but it still falls far short of the need and targets of the Global Plan. As noted in the Treatment Action Group’s (TAG’s) 2008 report on TB research funding, ‘expenditures are still woefully inadequate by almost five-fold when measured against the Global Plan and TAG’s estimates of annual need in TB research and development. The overall impression is one of inadequacy and failure of political will’.6 The largest single funder of tuberculosis research, the United * The authors focus on new molecular entities and estimate an additional US$399 States National Institutes of Health (NIH), spends just fi ve cents on million per drug in indirect and opportunity costs. For a more recent and balanced TB for each dollar spent on HIV/AIDS research (Figure 1), despite overview of the costs of new drug development, see Congressional Budget Office, the two diseases’ similar global scale, scope and deadliness. ‘Research and development in the pharmaceutical industry’, CBO publication no. Figure 2 shows the TAG’s tally of global TB research investment for 2589, October 2006, at http://www.cbo.gov/ftpdocs/76xx/doc7615/ 10-02-DrugR- D.pdf (accessed 17 December 2008). Conceivably, developing a new TB drug could 2007, highlighting the low levels of funding for basic science, new be cheaper than an average new molecular entity if expedited development and tools (drugs, diagnostics, and vaccines) and operational research. approval procedures were used.
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Extended early bactericidal activity (EBA) of PA-824, 5. World Health Organization. The Global Plan to Stop TB 2006– 2015. WHO Geneva, a novel drug for tuberculosis treatment. Program and abstracts of the 48th Annual Switzerland: WHO, 2009. http://www. stoptb.org/globalplan/ Accessed December 2008. Interscience Conference on Antimicrobial Agents and Chemotherapy/ Infectious Diseases 6. Agarwal N, Syed J, Harrington M. Tuberculosis research and development: a critical analysis Society of America 46th Annual Meeting, 25–28 October 2008, Washington DC, USA. of funding trends, 2005–2007. New York, NY, USA: Treatment Action Group, 2009. www. American Society of Microbiology, 2008. [Abstract B-881a] 34. treatmentactiongroup.org Accessed March 2009. Colditz G A, Brewer T F, Berkey C S, et al. Effi cacy of BCG vaccine in the prevention of 7. Henderson D A. The challenge of eradication: lessons from past eradication campaigns. Int J tuberculosis. Meta-analysis of the published literature. JAMA 1994; 271: 698–702. 35. Tuberc Lung Dis 1998; 2 (Suppl 1): S4–S8. Andersen P, Doherty T M. The success and failure of BCG— implications for a novel 8. Anonymous. The Bamako call to action: research for health. Lancet 2008; 372: 1855. tuberculosis vaccine. Nat Rev Microbiol 2005; 3: 656–662. 36. 9. Cole S T, Brosch R, Parkhill J, et al. Deciphering the biology of Mycobacterium tuberculosis Behr M A, Wilson M A, Gill W P, et al. Comparative genomics of BCG vaccines by whole- from the complete genome sequence. Nature 1998; 393: 537–544. genome DNA microarray. Science 1999; 284: 1520–1523. 37. 10. Valdivia R H, Hromockyj A E, Monack D, Ramakrishnan L, Falkow S. Applications for green fl Skeiky Y A, Sadoff J C. Advances in tuberculosis vaccine strategies. Nat Rev Microbiol 2006; uorescent protein (GFP) in the study of host-pathogen interactions. Gene 1996; 173 (1 Spec 4: 469– 476. 38. No): 47–52. World Health Organization. TB/HIV research priorities in resource-limited settings: report of 11. Saiki R K, Gelfand D H, Stoffel S, et al. Primer-directed enzymatic amplifi cation of DNA with an expert consultation, 14–15 February 2005, Geneva, Switzerland. WHO/HIV/2005. 03, a thermostable DNA polymerase. Science 1988; 239: 487– 491. WHO/HTM/2005.355. Geneva, Switzerland: WHO, 2005. 12. Manabe Y C, Bishai W R. Latent Mycobacterium tuberculosis— persistence, patience, and http://www.who.int/hiv/pub/tb/tb_hiv/en/ Accessed December 2008. 39. winning by waiting. Nat Med 2000; 6: 1327–1329. Fauci A S, NIAID Tuberculosis Working Group. Multi-drugresistant and extensively drug- 13. Ulrichs T, Kaufmann S H. Mycobacterial persistence and immunity. Front Biosci 2002; 7: resistant tuberculosis: The National Institute of Allergy and Infectious Diseases research d458– 469. agenda and recommendations for priority research. J Infect Dis 2008; 197: 1493–1498. 40. 14. Pai M, O’Brien R. New diagnostics for latent and active tuberculosis: state of the art and Cobelens F G J, Heldal E, Kimerling M E, et al. Scaling up programmatic management of future prospects. Semin Respir Crit Care Med 2008; 29: 560–568. drug-resistant tuberculosis: a prioritized research agenda. PloS Med 2008; 5: e150. 41. 15. Getahun H, Harrington M, O’Brien R, Nunn P. Diagnosis of smear-negative pulmonary Mitnick C D, Castro K G, Harrington M, Sacks L V, Burman W. Randomized trials to optimize tuberculosis in people with HIV infection or AIDS in resource-constrained settings: informing treatment of multidrug-resistant tuberculosis. PLoS Med 2007; 4: e292. 42. urgent policy changes. Lancet 2007; 369: 2042–2049. World Health Organization. A research agenda for childhood tuberculosis. Improving the 16. Mueller D H, Mwenge L, Muyoyeta M, et al. Costs and costeffectiveness of tuberculosis management of childhood tuberculosis within national tuberculosis programmes: research cultures using solid and liquid media in a developing country. Int J Tuberc Lung Dis 2008; priorities based on a literature review. WHO HTM/TB/2007.381 WHO/FCH/07.02 Geneva, 12: 1196– 1202. Switzerland, 2007. www.stoptb.org/ 17. Caviedes L, Lee T S, Gilman R H, et al. Rapid, effi cient detection and drug susceptibility researchmovement/assets/documents/ResearchPriorities%20 Final_24.04.07.pdf Accessed testing of Mycobacterium tuberculosis in sputum by microscopic observation of broth December 2008. 43. cultures. J Clin Microbiol 2000; 38: 1203–1208. Donald P R, Maher D, Qazi S. A research agenda to promote the management of childhood 18. Arias M, Mello F C, Pavon A, et al. Clinical evaluation of the microscopic-observation drug- tuberculosis within national tuberculosis programmes. Int J Tuberc Lung Dis 2007; 11: susceptibility assay for detection of tuberculosis. Clin Infect Dis 2007; 44: 674–680. 370–380. 44. 19. Pai M, Kalantri S, Dheda K. New tools and emerging technologies for the diagnosis of Burman W J, Cotton M F, Gibb D M, et al. Ensuring the involvement of children in the tuberculosis: part 2. Active tuberculosis and drug resistance. Expert Rev Mol Diagn 2006; 6: evaluation of new tuberculosis regimens. PloS Med 2008; 5: e176. 45. 423– 432. Hesseling A C, Cotton M F, Marais B J, et al. BCG and HIV reconsidered: moving the research 20. Boehme C C, Nabeta P, Henostroza G, et al. Operational feasibility of using loop-mediated agenda forward. Vaccine 2007; 25: 6565–6568. 46. isothermal amplifi cation for diagnosis of pulmonary tuberculosis in microscopy centers of De Cock K M, Chaisson R E. Will DOTS do it? A reappraisal of tuberculosis control in developing countries. J Clin Microbiol 2007; 45: 1936–1940. countries with high rates of HIV infection. Int J Tuberc Lung Dis 1999; 3: 457– 465. 47. 21. Barnard M, Albert H, Coetzee G, O’Brien R, Bosman M E. Rapid molecular screening for Golub J E, Mohan C I, Comstock G W, Chaisson R E. Active case fi nding of tuberculosis: multidrug-resistant tuberculosis in a high-volume public health laboratory in South Africa. historical perspective and future prospects. Int J Tuberc Lung Dis 2005; 9: 1183–1203. 48. Am J Respir Crit Care Med 2008; 177: 787–792. Dye C, Williams B G. Eliminating human tuberculosis in the twenty-fi rst century. J R Soc 22. Phillips M, Cataneo R N, Condos R, et al. Volatile biomarkers of pulmonary tuberculosis in Interface 2008; 5: 653–662. 49. the breath. Tuberculosis (Edinb) 2007; 87: 44–52. Comstock G W, Ferebee S H, Hammes L M. A controlled trial of community-wide isoniazid 23. Khan I H, Ravindran R, Yee J, et al. Profi ling antibodies to Mycobacterium tuberculosis by prophylaxis in Alaska. Am Rev Respir Dis 1967; 95: 935–943. 50. multiplex microbead suspension arrays for serodiagnosis of tuberculosis. Clin Vaccine Consortium to Respond Effectively to AIDS TB Epidemic. Baltimore, MD, USA: CREATE. Immunol 2008; 15: 433– 438. http://www.tbhiv-create.org/about/ studies/thibela Accessed December 2008. 51. 24. Medical Research Council. Streptomycin treatment of pulmonary tuberculosis. A Medical Gandhi N R, Moll A, Sturm A W, et al. Extensively drugresistant tuberculosis as a cause of Research Council investigation. BMJ 1948; 2: 769–782. death in patients co-infected with tuberculosis and HIV in a rural area of South Africa. 25. Aziz M A, Wright A, Laszlo A, et al. Epidemiology of antituberculosis drug resistance (the Lancet 2006; 368: 1575–1580. 52. Global Project on Antituberculosis Drug Resistance Surveillance): an updated analysis. DiMasi J A, Hansen R W, Grabowski H G. The price of innovation: new estimates of drug Lancet 2006; 368: 2142–2154. development costs. J Health Econ 2003; 22: 151–185. 53. 26. Dorman S E, Chaisson R E. From magic bullets back to the magic mountain: the rise of World Health Organization. Tuberculosis control: progress and long-term planning. 60th extensively drug-resistant tuberculosis. Nat Med 2007; 13: 295–298. World Health Assembly. Resolutions and decisions. Resolution WHA 60.19. Geneva, 27. Spigelman M K. New tuberculosis therapeutics: a growing pipeline. J Infect Dis 2007; 196 Switzerland: WHO, 2007. 54. (Suppl 1): S28–S34. United Nations General Assembly. Declaration of Commitment on HIV/AIDS, 2 June 2006. 28. Rosenthal I M, Zhang M, Williams K N, et al. Daily dosing of rifapentine cures tuberculosis in New York, NY, USA: United Nations, 2006. www.ua2010.org/en/content/download/3487/ three months or less in the murine model. PLoS Med 2007; 4: e344. 36712/fi le/060602DraftPoliticalDeclaration.pdf Accessed December 2008. 55. 29. Conde M B, Efron A, Loredo C, et al. Moxifl oxacin in the initial therapy of tuberculosis: a World Economic Forum. Obasanjo, Brown and Gates call on world leaders to fund new plan randomized, Phase 2 trial. Lancet 2009; 373: 1183–1189. to stop tuberculosis. Press release, 27 January 2006. www.stoptb.org/globalplan/assets/ 30. Rustomjee R, Lienhardt C, Kanyok T, et al. A Phase II study of the sterilising activities of ofl documents/Stop%20TB%20anouncement%20Global%20Plan %20to%20Stop%20TB.pdf oxacin, gatifl oxacin and moxifl oxacin in pulmonary tuberculosis. Int J Tuberc Lung Dis Accessed December 2008. 2008; 12: 128–138.
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Promoting quality and patient safety via the new integrated hospital accreditation programme YEHUDA DROR PRESIDENT AND CEO, DNV HEALTHCARE INC
ABSTRACT: Hospital accreditation should act as a strategic asset hospitals have in promoting quality and patient safety, not just a mere “ticket to trade”. The newly US government-approved DNV NIAHOSM offers healthcare provider organizations a new alternative to hospital accreditation that combines CMS’s Conditions of Participation (CoP) with the proven success of the ISO 9001 quality management standard, to promote sustainable quality and patient safety improvement .
ospital Accreditation is gaining use world wide as a means accreditation standard that is closely following the requirements of to ensure that hospitals meet national or international the CoP and at the same time integrates it with the need to comply Hwidely accepted set of requirements. The European Union with the requirements of the internationally recognized standard has defined it as “Public recognition by a national healthcare for quality management, ISO 9001:20083, hence the acronym of accreditation body of the achievement of accreditation standards the DNV program is NIAHOSM – National Integrated Accreditation by a healthcare organization, demonstrated through an of Healthcare Organizations.4. independent external peer assessment of that organization’s level Given that the DNV Accreditation standard adheres closely with of performance in relation to the standards”1. Accreditation is the CMS Conditions of Participation for Hospitals. DNVHC gaining importance in the rapidly increasing medical tourism accreditation meets and exceeds CoP requirements and sector, as a means to provide a consumer, patients and health integrates the ISO 9001 Quality Management System as a part of insurers alike with acceptable criteria for selecting hospitals to be these requirements. DNVHC surveys are conducted annually; treated. focus on sequence and interactions of processes throughout the A major impetuous to accreditation was the US Governments hospital and do not include a “tipping point” in the process that Center for Medicare and Medicaid (CMS), since it inception in results in varied levels of accreditation of the surveyed 1964 to require hospitals who wish to receive reimbursements for organization. However, for any findings of nonconformity to the CMS-covered patients to comply with the requirements of its requirements the organization is responsible for preparing a Conditions of Participation (CoP)2. One aspect of the CoP was the corrective action plan to address these findings. need of hospitals to be accredited by an accreditation organization The choice of ISO 9001 as the management system model for (AO). hospitals is not accidental. The experience gained by DNV in its On 26 September, 2009, Det Norske Veritas Healthcare, Inc. work as one of the leading certification bodies for ISO9001 (DNVHC) received the US Government Center for Medicare and compliance, and the over 80,000 ISO management Systems Medicaid (CMS) deeming authority. DNVHC is a fully owned Certificates it issues globally, showed that that standard is very subsidiary of Det Norske Veritas (DNV), and international, conducive to the promotion and understanding of continual autonomous foundation established in 1864 in Norway, and improvement while focusing on processes that result in meeting operating in more than 100 countries. DNVHC corporate and exceeding quality objectives sets by the organization that headquarters is in Houston, Texas and the operational office of follows that standard. Moreover, failure to meet these objectives DNV Healthcare Inc. is in Cincinnati, Ohio. DNVHC was the results in a demand to implement a coherent and structures set of hospital accreditation organization to be approved by CMS in the corrective and preventive measures the inevitably leads to last 30 years. Throughout all this time, the predominant AO was enhancement of those processes that result in meeting the the Joint Commission, who after losing its statutory privilege as an organization’s objective and to the removal/change/improvement AO, underwent the same CMS approval process and received it in in those processes that can’t meet the objectives. Since the ISO November 2009. 9001 revision of 2000, followed by the minor changes in 2008, the DNV Healthcare’s Hospital Accreditation Program consists of an standard caters very well to the service industry, and within that,
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to the specific needs of the hospital sector. Analysis, and Improvement. Notably, hospitals can and have Paradoxically, while hospitals increasingly turn to so called achieve the compliance with ISO 9001 faster. “industrial” quality management concepts borrowed from other An organization that selects DNV accreditation would undergo sectors, among them aviation5, methodologies that include Lean the initial steps of application and contracting. Once that is and Six Sigma, by and large they US hospitals shunned ISO 9001 settled, they would face the survey process. on the pretext that ISO 9001 is a “manufacturing” standard. With The survey team consists of three types of surveyors: Clinical, the growing understanding of the congruency of ISO 9001 and for Generalist, and Physical Environment/Life Safety Specialist example Lean6, the experience gained by DNV led to adopting ISO (PE/LSS). The Clinical surveyor must be either a medical doctor 9001 as the management system standard that provides the (MD) or a registered nurse (RN). The Generalist usually comes from “skeletal” strength to the hospitals on which the specific a hospital administrative or managerial background. The PE/LSS requirements stipulated by the NIAHOSM requirement could be would have experience in hospitals’ life safety, medical devices made sustainable. Hence, a hospital that opts to have the DNV management, infection control and/or SHE background. With accreditation, accepts that in three years since the original these qualifications, the candidates must successfully complete accreditation to the criteria of the NIAHOSM, it would be in various types of training including observation surveys and compliance with management system requirements stipulated by completion of 45 hours of CEUs each year. ISO 9001:2008. Considering the strong emphasis that ISO places The training of the surveyors ensures that the qualified personnel on the Leadership’s involvement that is supported by are also competent and proficient in not only the subject matter Management Reviews, Internal Audits and Corrective and they survey but also in the way DNV expects them to conduct Preventive Measures, which are closely echoed by similar such surveys. DNVHC expects each surveyor to attain what is emphasize in the CoP, this integrated approach enabled the known at DNVHC as the three “C’s”, i.e. Currency, Calibration, and accredited hospitals to utilize the accreditation as a vehicle to an Consistency. Therfore, after the candidates undergo rigorous effective, stable and consistent pursuit of a sustainable training in both NIAHOSM and ISO 9001 standards as well as accreditation.7 surveying methodology (PE/LSS undergo additional certificated The NIAHOSM Standard consists of 25 Chapters that are training in NFPA fire code for hospitals), they are subjected to on consistent with those of the CoP: the job monitoring by experienced surveyors. This enables Quality Management System. DNVHC to strive to keep all surveyors current on innovative issues. Governing Body. Survey Team Leader observation as well as client feedback ensure Chief Executive Officer. that surveyors are consistent in applying accreditation standards. Medical Staff. DNVHC, through top management, communicate to surveyors the Nursing Services. desired reaction to this information so that surveyor response Staffing Management. calibrated with the entire survey cadre. Also to attain the goal of Rehabilitation Services. surveyor consistency DNVHC assigns the same surveyors to the Obstetric Services. same hospitals for three years whenever possible. Emergency Department. DNVHC survey activities include observation of services, Outpatient Services. interviews, tracer methodology, and a comprehensive building Dietary Services. tour. The survey team arrives on-site together and all three Patient Rights. disciplines, Clinician, Generalist, and Physical Environment Infection Control. Specialist remain for the entire survey. The size and composition of Medical Records Service. the survey team is determined by several factors including: 1) the Medication Management. size of the surveyed facility including off-site locations, 2) the Surgical Services. complexity of the services offered by the surveyed organization, Anesthesia Services. and 3) the type of survey to be conducted. Some facilities are Laboratory Services. small enough to require just two surveyors. In this case, the team Respiratory Care Services. will consist of a Clinician and Physical Environment specialist who Medical Imaging. can also survey to the Generalist’s discipline. Nuclear Medicine Services. DNVHC surveys are annual. Barring any findings that impede Discharge Planning. patient safety the point of Jeopardy in line with the CMS Utilization Review. requirements, the survey finding fall into three types: Physical Environment. Noteworthy efforts – where hospitals is doing well. Organ, Eye and Tissue Procurement. Opportunities for Improvement (OFI) – issues that do not constitute yet any breach of requirements but have been The first NIAHOSM chapter, Quality Management System observed elsewhere to create an environment where such b stipulates the need to comply, within 3 years with ISO 9001. That reaches may occur. standard is written in a form of eight Clauses to the structure of the Nonconformities where surveyors found issues that are out of ISO 9001 Quality Management System Standards including five compliance with NIAHOSM or ISO Requirements. Nonconformity interactive clauses that are geared to ensure the continual must always show what the breach is and what the supporting improvement. They are clauses number: 4) Quality Management objective evidence that demonstrate such breach is. There System, 5) Management Responsibility, 6) Resource three types of nonconformities: Management, 7) Service Realization and 8) Measurement, – Category One – defined as a systemic absence of breach
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of requirements to manage risk and continually improve but also to enable – Category Two – defined as isolated non-fulfillment of a hospitals receive an objective rating based on it’s “risk maturity standard requirement or inconsistent practice compared to model” to the benefit of the patients and hospitals alike. J requirements. DNVHC does not dictate a “tipping point” beyond which the Yehuda Dror is the President and CEO of DNV Healthcare Inc. The system is non-accredited. The extent of the corrective action or first hospital Accreditation Organization approved by the Centers evidence of them depend of course on the nonconformities’ for Medicare and Medicaid Services (CMS) in the last 30 years. category where the category one would require objective evidence Trained as an engineer (MS from MIT) and business manager of the corrective action initiated prior to accreditation while the (Executive MBA from UH) Yehuda has more than 30 years category two would require a timely and robust corrective action experience in developing and implementing services that safeguard plan whose successful implementation would be verified on the life, property and the environment. next annual survey. References The hospital received a report that includes also an indication 1. EUR/04/5051758, Dec. 2004, Developing Hospital Accreditation in Europe where it is in relation to ISO 9001 (“gap analysis”). The subsequent 2. Code of Federal Regulations, 42 CFR 488 3. ISO 9001:2008, Quality management systems - Requirements, years would see an enhancement of the requirements of ISO 9001 4. National Integrated Accreditation for Healthcare Organizations (NIAHOSM), downloadable such that at the end of the 3-year accreditation cycle, the hospital (free) at www.dnvaccreditation.com would be also considered compliant with ISO 9001:2008. 5. “Why Hospitals Should Fly”, John J. Nance, Published by Second River Healthcare Press 26 Shawnee Way, Suite C | Bozeman, MT 59715 The testimonials that the DNV accreditation receives from its 6. “Lean 9001: Battle for the Arctic Rose” J. Guderian, T. Renaud, Society for Manufacturing accredited hospitals in the US, Brazil and India reveal that the Engineering (SME) Identification Product ID: BK08PUB13, ISBN: 978-0872638570 intent of the accreditation is indeed met. Among such statement, 7. Cherokee Nation official website www.cherokee.com, Jun3 15, 2009 8. http://www.businesswire.com/portal/site/home/permalink/?ndmViewId=news_ one can find the statement of Chad Smith, Principal Chief of the view&newsId=20091217005134&newsLang=en, December 17, 2009 Cherokee Nation. “This [DNVHC] accreditation fits in line with our 9. Requirements Gary Lambert, “Breakthrough in US hospital accreditation looks set to philosophy of “gadugi,” or “working together,” which is what our accelerate ISO 9001 adoption in healthcare”, ISO Management Systems March - April 2009 healthcare system does in assisting our patients”7, and of Patty Scott, vice president of quality, case, risk management and regulatory compliance of IASIS, the First System to Achieve DNV Accreditation at All of Its Hospitals. “DNV accreditation is strategically aligned with our goals for patient safety and medical outcomes. In addition to taking a ‘best practices’ approach to hospital surveys, DNV’s accreditation framework fits well with the Hospital Medical Management and Quality Program (HMMQP) already in place at IASIS hospitals.”8 The benefits expressed in similar testimonials that can be received from the DNV reference hospitals gleaned from the DNV website (www.dnvaccreditation.com) can be summed in the following categories: Approved by CMS and enables us to meet our obligation toward CoP. Enhances our continuous improvement in quality and patient safety. Embraces our ability to utilize our competence to innovate. Drives us to adopt best practices. Demands we discard ineffective practices. Fosters improved communication between hospital and medical staff. Reduces the costly need for implementation and preparation for the programme. Improves understanding of all hospital processes and drives up efficiency. Performed in a collaborative manner that is geared to identify what works best and remove what does not.
The DNVHC accreditation, labeled as a “Breakthrough in US hospital accreditation”9, is making its mark also on international accreditation scene. It has already begun to gain a relatively early but strong following and coupled with the experience that DNV gains from the risk management evaluation of the NHSLA in the United Kingdom is hoping to ensure hospitals learn not only how
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Reference
World Hospitals and Health Services 2010 Volume 46 Number 1 Résumés en Français
PARTENARIATS PUBLICS-PRIVES DANS LE SECTEUR Démographies, • Politiques sanitaires, • Economie, • PRACTICES IN LEBANESE HOSPITALS) DE SANTE PORTUGAIS Education à la santé, • Choix des consommateurs, • Le Contexte : Des pratiques saines de gestion des ressources (PUBLIC-PRIVATE PARTNERSHIPS IN THE PORTUGUESE HEALTH foyer: l’établissement de santé de base, • Soins primaires humaines (RH) sont indispensables pour retenir les SECTOR) et extra-hospitaliers, • Création d’emplois. professionnels compétents dans les hôpitaux. Etant donné Au Portugal, les PPP n’ont fait leur apparition dans le Impact sur la conception les difficultés à recruter et à conserver des travailleurs de secteur de la santé qu’à l’aube du 21 siècle, englobant les • Accès médical et réseaux, • Durabilité, • santé au 21è siècle, il ne faut pas sous-estimer le rôle des activités cliniques dans son rayon d’action. Visibilité/cheminement • Hi - Tech, • Lumière naturelle, • directeurs de RH dans les hôpitaux et ceux qui combinent Actuellement, et à l’exception d’un seul hôpital, Des jardins qui guérissent, • Retenir le personnel, • ce rôle avec d’autres responsabilités. L’objectif de cette l’expérience portugaise des PPP ne peut être évaluée Centres de soins ambulatoires, • Chambres pour patient étude est d’évaluer comment les directeurs de RH qu’en termes de modèle conceptuel et de procédures seul, • Conception industrielle, • Les hôpitaux de crise, • conçoivent les difficultés auxquelles ils sont confrontés et d’appels d’offres. Opportunités de pratique collaborative/interdisciplinaire les stratégies actuelles qu’ils adoptent. L’étude vise aussi L’analyse montre que, d’après les arguments liés aux /internationale, • Education au collège Conclusion à évaluer les facteurs dont ils peuvent tirer parti tels que le opportunités d’investissements non contractuels et aux rôle, l’éducation, l’expérience et la formation aux RH. renégociations ex-post, les hôpitaux complexes de haute CULTIVER LES TALENTS DE NOS FUTURS DIRIGEANTS: Méthodes : On a mené une étude transversale sur des technologie doivent exclure les activités cliniques des DES STRATEGIES COMPLETES DE DEVELOPPEMENT directeurs de RH (et de ceux qui allient ce rôle à d’autres contrats PPP, et que bien que le processus demande POUR ASSURER UN SUCCES DURABLE. tâches) dans des hôpitaux libanais. L’enquête comprenait beaucoup de temps, les PPP peuvent être considérés (CULTIVATING TOMORROW’S LEADERS: COMPREHENSIVE une combinaison de questions ouvertes et de questions à comme un succès sous l’angle de la concurrence des prix. DEVELOPMENT STRATEGIES ENSURE CONTINUED SUCCESS) choix de réponse. Ces questions portaient sur l’éducation L’analyse montre également que si l’on compare les Nul n’ignore qu’une direction énergique est la clef du de base, l’expérience professionnelle et la démographie, performances du seul hôpital en PPP du Portugal avec succès d’une entreprise. Observez les rouages d’un ainsi que des questions sur les difficultés perçues et les deux unités comparables, rien ne prouve que les résultats établissement sanitaire hautement efficace, et vous verrez principales stratégies à employer. L’analyse des données les meilleurs ou les pires soient liés au statut légal et au qu’une équipe de dirigeants talentueux est au gouvernail. quantitatives utilisait l’analyse univariée, alors que l’analyse modèle de gestion établi. Mais les entreprises qui réussissent ne doivent pas se thématique était appliquée pour les questions ouvertes. contenter d’avoir à leur tête des personnes hautement Résultats : Au total 96 interviewés de 61 hôpitaux ont PRISES DE DECISION BASEES SUR PREUVES DANS compétentes—il faut qu’elles sachent les repérer, les répondu. Les répondeurs présentaient divers niveaux de LES SECTEURS DE SANTE: L’INTERET D’UNE cultiver et les retenir. compétence dans le domaine de la gestion des RH. EVALUATION DE LA TECHNOLOGIE SANITAIRE Tâche souvent malaisée, si l’on considère le L’analyse thématique révélait que les difficultés variaient (EVIDENCE INFORMED DECISION MAKING IN HEALTH CARE: THE dynamisme historique du secteur de la santé, dont la selon les répondants et des hôpitaux participants. Les CASE FOR HEALTH TECHNOLOGY ASSESSMENT) complexité croissante impose la nécessité absolue d’une problèmes principaux étaient la mauvaise rétention de Les prestations de soins de santé publique sont au cœur bonne direction alors que les établissements s’efforcent personnel (56,7%), le manque de personnel qualifié d’un conflit entre trois objectifs : (1) l’accès croissant aux d’évoluer et de ne pas se laisser devancer par les (35,1%) et le manque de système d’évaluation des soins, (2) l’amélioration de la qualité des soins et (3) le changements. performances (28,9%). Parmi les stratégies utilisées pour maintien du financement public. Cet article démontre Bien que dans le secteur de la santé, la nécessité de résoudre les problèmes figuraient la possibilité de qu’avec des outils tels que l’évaluation de la technologie cultiver les jeunes talents soit incontournable, les formation continue et de formation des employés (19,6%), de santé (ETS), les politiques et décisions basées sur les établissements ne disposent pas tous de procédures l’amélioration des salaires (14,4%) et le développement de preuves (plutôt que sur des doctrines, des habitudes ou permettant de le faire. Il semble que le domaine de la santé stratégies de rétention (10,3%). On a observé des l’opinion d’experts), l’accès, la qualité et la durabilité ne reste à la traîne derrière les autres industries en matière de anomalies entre les problèmes rapportés et les stratégies doivent pas nécessairement s’exclure mutuellement. programmes de gestion des talents et de plans de appliquées. L’auteur propose une structure et une approche succession. D’après une étude de 2002 par l’American Conclusion: Pour permettre aux hôpitaux d’assurer la permettant d’adopter et de promouvoir l’ETS dans les Society of Training & Development, 85% de 500 sociétés qualité et la sécurité des services de santé, il est crucial établissements de santé. Des recommandations de Fortune sponsorisent des programmes officiels de d’améliorer la gestion des RH. Il est besoin d’un cadre de politique sont proposées. développement internes des cadres supérieurs. Beaucoup directeurs de RH compétents qui puissent pleinement “Une bonne partie de nos soi-disant raisonnements de PDG d’établissements de santé reconnaissent la assumer ces responsabilités et améliorer continuellement consiste à trouver des arguments pour continuer à croire nécessité et l’importance de ces programmes, mais voient le statut des employés de leur entreprise. L’étude ce que nous croyons déjà ” James H. Robinson deux obstacles à leur mise en place : 1) l’idée que leur d’accréditation en cours sur les hôpitaux libanais (2010- implantation demande trop de personnel et trop de 2011) fournit une occasion de renforcer la gestion des RH ressources; et 2) le manque des compétences et savoir- et les compétences des directeurs de RH actuels. La LES “MEGATENDANCES” QUI MENENT LE JEU EN faire internes indispensables à l’implantation et au reconnaissance des problèmes de RH et de l’importance MATIERE DE CONCEPTION DES ETABLISSEMENTS développement efficace des stratégies. Malgré ces de stratégies efficaces de RH doit être une priorité pour les DE SANTE : COUP D’ŒIL SUR LES GRANDES obstacles au démarrage et au fonctionnement de décideurs de politiques et les cadres supérieurs. Les TENDANCES QUI DICTENT LA CONCEPTION DES programmes de formation de cadres dans les conclusions de l’étude peuvent être étendues à d’autres ETABLISSEMENTS MEDICAUX établissements de santé, ils n’en restent pas moins pays de la méditerranée orientale. (“MEGATRENDS” DRIVING HEALTHCARE FACILITY DESIGN: indispensables. A LOOK AT THE MAJOR TRENDS THAT WILL SHAPE MEDICAL NUTRITION ET SECURITE DES PATIENTS : RAPPORT FACILITY DESIGN) EVALUATION DES PRATIQUES DE GESTION DES DE LA NATIONAL PATIENT SAFETY AGENCY (UK) Tendances imposant la conception des établissements de RESSOURCES HUMAINES DANS LES HOPITAUX (NUTRITION AND PATIENT SAFETY: A REPORT FROM THE santé LIBANAIS NATIONAL PATIENT SAFETY AGENCY (UK)) • Stratégies contre les maladies et santé publique, • (ASSESSMENT OF HUMAN RESOURCES MANAGEMENT La National Patient Safety Agency (NPSA), créée en 2001
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dans le cadre du National Health Service (NHS), a élargi dixneuvième et vingtième siècles, la recherche a produit d’importantes limitations. En outre, la recherche s’impose son portefeuille de programmes de sécurité des patients des outils extrêmement valables pour le diagnostic, le d’urgence pour comprendre la façon d’appliquer les outils pour englober la nutrition en 2006. traitement et la prévention dans la lutte contre la TB. A la existants et à venir pour lutter contre la TB au niveau de la Depuis 2006, le programme Nutrition de la NPSA vise suite du développement de la chimiothérapie de courte population. Le fi nancement mondial destiné à la à attirer l’attention sur le facteur nutrition en tant que durée dans les années 1970 et 1980, la recherche en recherche en matière de TB, soit 483 millions de dollars problème de sécurité des patients et d’encourager les matière de TB s’est virtuellement évaporée. En dépit de la US en 2007, augmente progressivement mais reste soignants à rapporter les incidents de sécurité des disponibilité de toute une série d’outils, elle s’est mise à largement inférieur aux besoins. Un investissement massif patients ayant trait à la nutrition à la base de données des hésiter, et la maladie reste un tueur redoutable. L’échec dans la recherche sera nécessaire si l’on veut rencontrer rapports de la NPSA, the Reporting and Learning System, des fruits de la recherche scientifi que dans la lutte les objectifs ambitieux du Plan Mondial Stop TB et les pour repérer les principaux thèmes et les domaines antituberculeuse résume des défaillances des outils eux- Objectifs du millénaire pour le développement. nécessitant une formation au plan national. mêmes tant que de l’application inadéquate de ceux-ci Pendant l’été 2009, la NPSA a été invitée par la dans les populations affectées par la TB. Une situation PROMOUVOIR LA QUALITE ET LA SECURITE DES Fédération Internationale des Hôpitaux à s’affilier au épidémiologique en voie de modifi cation, avec des taux PATIENTS PAR LE NOUVEAU PROGRAMME programme de renforcement de la sécurité des enfants et croissants de TB liées au VIH et avec l’émergence de la TB D’ACCREDITATION HOSPITALIERE INTEGREE nourrissons pour les projets d’établissements de santé en à germes multirésistants, menace davantage la lutte (PROMOTING QUALITY AND PATIENT SAFETY VIA THE NEW tant que membre du groupe consultatif. Cette opportunité antituberculeuse mondiale. Pour arriver aux objectifs INTEGRATED HOSPITAL ACCREDITATION PROGRAM) a permis à la NPSA de partager son expérience et ses mondiaux de lutte antituberculeuse au cours du vingt- et- L’accréditation hospitalière devrait constituer un atout connaissances sur les questions de sécurité nutritionnelle unième siècle, il faudra une hardiesse robuste de stratégique de promotion de la qualité et de la sécurité des des patients. recherche en matière de TB. Une recherche fondamentale patients, et pas un simple “certificat”. Le nouveau DVN est nécessaire pour mieux comprendre la pathogénie et NIAHO est agréé par le gouvernement américain et offre COMMENT LA RECHERCHE PEUT AIDER A LUTTER l’immunologie ainsi que pour identifi er les cibles pour le aux entreprises de soins de santé une nouvelle alternative CONTRE LA TUBERCULOSE diagnostic, les médicaments et les vaccins. La recherche à l’accréditation hospitalière qui allie les Conditions de (HOW RESEARCH CAN HELP CONTROL TUBERCULOSIS) d’outils biomédicaux de meilleure qualité pour la détection, Participation (CoP) du CMS à la norme de gestion de la La tuberculose (TB) a joué un rôle central dans l’histoire de le traitement et la prévention de la TB constitue également qualité ISO 9001, favorisant une amélioration durable de la la science biomédicale depuis Robert Koch. Au une priorité majeure, car tous les outils actuels ont qualité et de la sécurité des patients.
World Hospitals and Health Services 2010 Volume 46 Number 1 Resumen en Espanol
ASOCIACIONES PUBLICO-PRIVADAS EN EL SECTOR La prestación de los servicios de salud con financiamiento sanitaria, • Preferencias del paciente, • El hogar como DE SALUD DE PORTUGAL público se encuentra en la encrucijada de tres objetivos centro básico de salud, • Atención primaria de salud y (PUBLIC-PRIVATE PARTNERSHIPS IN THE PORTUGUESE HEALTH contradictorios; (1) el acceso cada vez mayor a la servicios comunitarios SECTOR) asistencia sanitaria, (2) la mejora de la calidad de los • Creación de empleo En Portugal, las asociaciones público-privadas surgieron cuidados de salud, y (3) la subsistencia del financiamiento Repercusiones del diseño tan sólo a principios de este siglo, con la característica público. Con este artículo se demuestra que con una • Acceso médico y sistemas, • Sostenibilidad central de la inclusión de las actividades clínicas dentro de herramienta como la evaluación de la tecnología sanitaria • Visibilidad/Descubrimiento del medio,• Alta tecnología su ámbito de aplicación (en inglés HTA), los indicios de una política y una toma de • Luz natural, • Jardines curativos, • Retención del Hoy en día, con la excepción de un hospital, la iniciativa decisiones fundamentadas (en contraposición al personal • Cuidados ambulatorios, • Habitación individual, portuguesa, conocida por sus siglas en inglés PPP, sólo seguimiento de una doctrina, costumbre o la opinión de • Diseño industrial, • Hospitales de sobrecarga, • puede evaluarse en términos del modelo conceptual y los expertos) el acceso, la calidad y la subsistencia no tienen Oportunidades de prácticas procesos de licitación. porqué excluirse mutuamente. El informe ofrece una internacionales/colaborativas/ Con el análisis se puso de manifiesto que en base a los estructura y un enfoque encaminados a adoptar y interdisciplinarias argumentos relacionados con la inversión no contráctil y promover la evaluación de la tecnología sanitaria en las • Educación universitaria Conclusión posterior renegociación, los hospitales con una tecnología organizaciones de la salud. También sugiere una serie de más avanzada deberían excluir los procedimientos clínicos recomendaciones de política. CULTIVO DE LOS DIRIGENTES DEL FUTURO: del contrato relativo al programa PPP. También se “La gran mayoría de nuestros razonamientos consiste ESTRATEGIAS GLOBALES DE DESARROLLO, descubrió que a pesar de que se trata de un proceso que en encontrar los argumentos para seguir creyendo en lo GARANTIA DE UN ÉXITO SOSTENIDO requiere mucho tiempo, el programa PPP se puede que venimos creyendo hasta ahora”. James H. Robinson. (CULTIVATING TOMORROW’S LEADERS: COMPREHENSIVE considerar como todo un éxito desde el punto de vista de DEVELOPMENT STRATEGIES ENSURE CONTINUED SUCCESS) la competición de precios. “HIPERTENDENCIAS” EL IMPULSO EN EL DISEÑO Es bien sabido que los dirigentes enérgicos son la piedra El estudio demostró además que al evaluar el ARQUITECTONICO DE LAS INSTALACIONES angular de toda organización con resultados positivos. Si rendimiento del único hospital participante del programa SANITARIAS: UN VISTAZO A LAS TENDENCIAS vemos una organización de asistencia sanitaria con un PPP en Portugal en comparación con otros dos PRINCIPALES QUE DARAN FORMA AL DISEÑO elevado nivel de rendimiento en acción, nos daremos departamentos comparables, no existen pruebas de que ARQUITECTONICO DE LOS ESTABLECIMIENTOS cuenta de que lleva al mando todo un equipo de dirigentes los mejores o peores resultados guarden relación alguna MEDICOS competentes. Bien es verdad que las organizaciones con la situación legal ni con el modelo de gestión habitual. (“MEGATRENDS” DRIVING HEALTHCARE FACILITY DESIGN: prósperas no sólo tienen que contar con personal A LOOK AT THE MAJOR TRENDS THAT WILL SHAPE MEDICAL competente, sino que además necesitan saber distinguir a INDICIOS DE UNA TOMA DE DECISIONES FACILITY DESIGN) los jefes con gran potencial y ser capaces de cultivarlos y FUNDAMENTADA EN LOS SERVICIOS DE SALUD: Las tendencias que impulsan al diseño arquitectónico de conservarlos. EVALUACION DE LA TECNOLOGÍA SANITARIA las instalaciones sanitarias Esto no siempre es fácil de llevar a cabo, teniendo en (EVIDENCE INFORMED DECISION MAKING IN HEALTH CARE: THE • Las estrategias patológicas y la salud pública, • cuenta el carácter dinámico de los servicios de salud, CASE FOR HEALTH TECHNOLOGY ASSESSMENT) Demografía • Política sanitaria, • Economía, • Educación puesto que conforme aumentan las dificultades, más difícil
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se hace contratar personal competente ya que deben descubrió que entre los entrevistados el nivel de DE QUE MANERA PUEDE AYUDAR LA INVESTIGACION intentar mantenerse al corriente de los acontecimientos y conocimientos en la esfera de la dirección en recursos EN LA LUCHA CONTRA LA TUBERCULOSIS evolucionar en el futuro. humanos es muy diverso. En el análisis temático se puso (HOW RESEARCH CAN HELP CONTROL TUBERCULOSIS) Si bien es evidente que hay motivos para fomentar la de manifiesto que los retos eran muy variados en función La tuberculosis (TB) ha representado un papel central en la capacidad de dirección en el sector de la salud en el de los entrevistados y los hospitales participantes. Entre historia de la ciencia biomédica a partir de los trabajos de futuro, no todas las organizaciones cuentan con un las dificultades más frecuentes se encontraban la Koch. La investigación durante los siglos diecinueve y sistema en curso para ponerlo en práctica. El servicio de retención de personal (56.7%), la falta de personal veinte aportó instrumentos diagnósticos, terapéuticos y salud se ha quedado atrás en comparación con otros cualificado (35.1%) y la falta de un sistema para llevar a preventivos extremadamente valiosos en la lucha contra la sectores en lo que respecta a programas de formación de cabo una evaluación del rendimiento en el trabajo (28.9%). enfermedad. Tras la formulación de la quimioterapia breve líderes y planificación de sucesión. Según un estudio Algunas de las estrategias utilizadas para mitigar las en las décadas de 1970 y 1980, la investigación en TB realizado en 2002 por la Sociedad Norteamericana para la dificultades citadas consistían en ofrecer la ampliación de prácticamente desapareció. Pese a la existencia de un Formación y el Desarrollo, el 85 por ciento de las estudios y formación del personal (19.6%), aumentar los conjunto apreciable de instrumentos, el control de la TB se compañías Fortune 500 patrocinan oficialmente sueldos (14.4%) y poner en marcha estrategias ha debilitado y la enfermedad continúa siendo una causa programas internos de formación para el personal de encaminadas a retener al personal (10.3%). En los importante de mortalidad. El fracaso de los frutos de la dirección. Numerosos directores generales reconocen que resultados se observó un desajuste entre el número de investigación científi ca en la lucha contra la TB es estos programas no sólo son necesarios sino también dificultades citadas y las estrategias. consecuencia de defi ciencias propias de los instrumentos, sumamente importantes, aunque citan los dos obstáculos Conclusión: para que los hospitales sean capaces de pero también de una aplicación inadecuada de los mismos siguientes para ponerlos en marcha: 1) en su opinión ofrecer un sistema de prestación de los servicios de salud a las poblaciones agobiadas por la enfermedad. Las requieren un alto coeficiente de recursos, tanto humanos óptimo y unos cuidados sin riesgos, es crucial mejorar la condiciones epidemiológicas cambiantes, con una tasa como económicos para ponerlos en práctica; y 2) falta de dirección de los recursos humanos. Existe la necesidad de progresiva de TB vinculada con la infección por el virus de aptitudes y conocimientos a nivel interno para llevar a cabo crear todo un equipo de directores competentes de la inmunodefi ciencia humana y la aparición de TB y establecer las estrategias pertinentes con eficacia. No recursos humanos capaces de asumir estas multidrogorresistente, amenazan aún más el control obstante, y a pesar de estos obstáculos para poner en responsabilidades completamente y dispuestos a mejorar mundial de la TB. Con el objeto de cumplir la meta mundial marcha y mantener estos programas de formación del constantemente la categoría de los empleados de sus de erradicar la TB en el siglo veintiuno, se precisará una personal de dirección, el caso es que siguen siendo organizaciones. La futura encuesta de acreditación de los iniciativa sólida de investigación en este campo. Se necesarios. hospitales del Líbano (2010-2011) presentará al país la requiere investigación fundamental a fi n de profundizar los oportunidad de reforzar el nivel de dirección de los conocimientos sobre la patogénesis y la respuesta EVALUACION DE LAS PRACTICAS DE DIRECCION DE recursos humanos y aumentar la capacidad del personal inmunológica y con la intención de detectar blancos para LOS RECURSOS HUMANOS EN LOS HOSPITALES disponible en la esfera de la dirección en recursos el diagnóstico, los medicamentos y las vacunas. DEL LIBANO humanos. El reconocer las dificultades en materia de Asimismo, constituye una prioridad importante la (ASSESSMENT OF HUMAN RESOURCES MANAGEMENT recursos humanos y la importancia de adoptar unas investigación sobre instrumentos biomédicos más efi PRACTICES IN LEBANESE HOSPITALS) estrategias eficaces en este sentido, debería convertirse caces para la detección, el tratamiento y la prevención de Antecedentes: unas buenas prácticas de dirección de los en la prioridad de las autoridades responsables de la la TB, pues todos los existentes presentan defi ciencias recursos humanos (en inglés HR) son fundamentales para política y del personal directivo superior. Los resultados de mayores. Además, se precisa en forma urgente la conservar a los profesionales eficaces en los hospitales. esta encuesta podrían ampliarse a otros países del este investigación sobre estrategias de aplicación de los Teniendo en cuenta la realidad de las circunstancias del Mediterráneo. instrumentos actuales y los nuevos, al objeto de luchar respecto a la contratación y la conservación del personal contra la TB a escala de la población. Los fondos de los servicios de salud en el siglo XXI, no debemos LA NUTRICION Y LA SEGURIDAD DEL PACIENTE: mundiales destinados a la investigación en TB, 483 infravalorar el papel que desempeña la dirección de los INFORME DEL ORGANISMO NACIONAL PARA LA millones de dólares en 2007, están aumentando recursos humanos en los hospitales y de aquéllos que SEGURIDAD DEL PACIENTE (RU) lentamente pero son todavía ampliamente insufi cientes además de esa función desempeñan otras (NUTRITION AND PATIENT SAFETY: A REPORT FROM THE frente a las necesidades. Con la fi nalidad de cumplir las responsabilidades. Este estudio tiene por objetivo evaluar NATIONAL PATIENT SAFETY AGENCY (UK)) ambiciosas metas del Plan Mundial para Detener la la opinión del personal encargado de la dirección de los El Organismo nacional para la seguridad del paciente (en Tuberculosis y los Objetivos de Desarrollo del Milenio será recursos humanos con relación a los retos con los que se inglés NPSA), fundado en 2001 como parte integrante del necesaria una inversión masiva en investigación. enfrentan, así como las estrategias que están poniendo en Servicio Nacional de Salud, amplió su lista de programas práctica en la actualidad. Además, este informe se relativos a la seguridad del paciente para incluir la esfera de FOMENTO DE LA CALIDAD Y LA SEGURIDAD DEL propone evaluar los factores de capacitación, tales como la nutrición en 2006. PACIENTE MEDIANTE EL NUEVO PROGRAMA las funciones, la formación, la experiencia y la capacitación Desde 2006 el centro de atención del programa de INTEGRAL DE ACREDITACION HOSPITALARIA en recursos humanos. nutrición del NPSA viene siendo aumentar la toma de (PROMOTING QUALITY AND PATIENT SAFETY VIA THE NEW Métodos: Se llevó a cabo una encuesta transversal conciencia de que la nutrición es un tema estrechamente INTEGRATED HOSPITAL ACCREDITATION PROGRAM) sobre el diseño arquitectónico entre el personal de relacionado con la seguridad del paciente e incitar al La acreditación hospitalaria debería servir como un dirección de los recursos humanos (así como entre personal de la salud a comunicar los incidentes elemento estratégico con el que los hospitales cuentan aquéllos que además de esa función desempeñan otras relacionados con la nutrición a la base de datos del NPSA, para fomentar la calidad y la seguridad del paciente y no responsabilidades) en los hospitales del Líbano. Entre las el Sistema de presentación de informes y aprendizaje, con simplemente como una “oportunidad para comerciar”.El preguntas realizadas, cabe citar los antecedentes el fin de identificar los temas y aspectos principales para el nuevo sistema aprobado por el gobierno de los Estados académicos, la experiencia laboral y la demografía, aprendizaje nacional. Unidos, conocido por sus siglas en inglés DNV NIAHO además de cuestiones relativas a la opinión de los En el verano de 2009 el NPSA recibió una invitación de (Organizaciones sanitarias Nacionales de Acreditación entrevistados respecto a los retos con los que se enfrentan la Federación Internacional de Hospitales para colaborar Integrada), ofrece a las organizaciones proveedoras de y las principales estrategias puestas en práctica. El análisis con el proyecto denominado Mejoremos la seguridad de la asistencia sanitaria una alternativa a la acreditación cuantitativo de los datos comprendía el análisis de una nutrición infantil en los servicios de salud, en calidad de hospitalaria que combine las Condiciones de Participación variable, mientras que para las preguntas de interpretación miembro del órgano consultivo. Esto ofreció al NPSA la (CoP, en inglés) con el éxito comprobado de la gestión de abierta se utilizó un análisis temático. oportunidad de compartir experiencias e intercambiar normas de calidad ISO 9001, promover la calidad Resultados: de los 61 hospitales que participaron en la conocimientos sobre temas relacionados con la seguridad sostenible y mejorar la seguridad del paciente. encuesta, se recibieron 96 respuestas en las que se de la nutrición de los pacientes.
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IHF Governing Council 2009-2011
THE EXECUTIVE COMMITTEE
President President-Designate Immediate Past Presidents Mr GERARD VINCENT Treasurer Dr JOSE CARLOS DE SOUZA Mr THOMAS C DOLAN Dr IBRAHIM A AL Délégué Général Dr LEKE PITAN ABRAHAO CEO ABDULHADI FEDERATION HOSPITALIERE Former Commissioner for President AMERICAN COLLEGE OF Assistant Undersecretary DE FRANCE Health – Lagos State CONFEDERACAO NACIONAL HEALTHCARE EXECUTIVES for Health Insurance Affairs 1 bis Rue Cabanis House G40C, Road 2 DE SAUDE (CNS) One North Franklin Street MINISTRY OF HEALTH 75014 Paris Victoria Garden City, Lagos SRTVIS Quadra 701, Suite 1700 State of Kuwait FRANCE NIGERIA Conjunto E Chicago, Illinois 60606- PO Box 5, PIN Code 13001 Tel: +33 1 44 06 84 42 / 44 Tel: +234 1 775 4544 / Edificio Palacio do Radio 1 3491 KUWAIT Fax: +331 44 06 84 45 +234 803 7787834 / Brasilia DF, CEP 70340-906 UNITED STATES OF Tel: +965 486 3699 E-mail: [email protected] / +44 7785 764 692 BRAZIL AMERICA Fax: +965 486 3524 [email protected] Email: drlekepitan@ Tel: +55 61 3321 0240 Tel: +1 312 424 9365 E-mail: drhadi@ yahoo.com Fax: +55 61 3321 0250 Fax: +1 312 424 0023 moh.gov.kw Email: [email protected] E-mail: [email protected]
Dr JUAN CARLOS LINARES Dr LAWRENCE LAI Dr ERIK KREYBERG NORMANN Mrs ALISON KANTARAMA Representative Senior Advisor Senior Advisor President CAMARA ARGENTINA DE EMPRESAS DE HONG KONG HOSPITAL AUTHORITY The Norwegian Directorate of Health UGANDA NATIONAL ASSOCIATION OF SALUD (CAES) Room 1003, Administration Block Universitetsgata 2 HOSPITAL ADMINISTRATORS (UNAHA) Tucuman 1668, 2 Piso Queen Mary Hospital NO-0130 OSLO, NORWAY Mulago Hospital Buenos Aires C.P. 1050 102 Pokfulam Road Tel: +47 24 163 000; PO Box 7051, Kampala ARGENTINA HONG KONG (SAR) Fax: +47 22 22 66 88 UGANDA Tel: +54 34 88 466 844 / +54 Tel: +852 2255 3253 Email: [email protected] Tel: +256 414 554 748 11 4372 5915 / 5762 Fax: +852 2504 2784 Fax: +256 414 532 591 Fax: +54 11 4372 3229 E-mail: [email protected] Prof CARLOS PEREIRA ALVES Email: [email protected] Email: [email protected] Vice Chair Dr MUKI REKSOPRODJO ASSOCIACAO PORTUGUESA PARA O Mr ABDUL SALAM AL-MADANI Prof HELEN LAPSLEY President Director & CEO DESENVOLVIMENTO HOSPITALAR President Research Professor RUMAH SAKIT METROPOLITAN MEDICAL Av. António Augusto de Aguiar, 32-4º INDEX HOLDING CENTRE OF NATIONAL RESEARCH ON CENTRE (MMCH) 1050-016 Lisboa Dubai Healthcare City DISABILITY & REHABILITATION MEDICINE Jl.H.R.Rasuna Said Kav.C-21 PORTUGAL Block B, Offices 203 – 303 University of Queensland Kuningan Jakarta Selatan 12940 Tel: +351 21 37 83 / 66 P.O.Box 13636, Dubai 3 Keston Avenue INDONESIA Fax: +351 21 37 73 UNITED ARAB EMIRATES Mosman, Sydney NSW 2088 Tel: +6221 72791383, 72791404; Email: [email protected] Tel: +97 14 362 4717 AUSTRALIA Fax: +6221 7252026 Fax: +97 14 362 4718 Tel: +612 99 692 346 Email: [email protected] Dr THABO LEKALAKALA Email: [email protected] Fax: +612 99 684 987 Director - Hospital Management Email: [email protected] Prof SHUZO YAMAMOTO and Planning Prof. STEPHEN BARNETT President DEPARTMENT OF HEALTH Chief Executive Prof GUY DURANT JAPAN HOSPITAL ASSOCIATION Street Hallmark Building NHS CONFEDERATION Administrateur général 13-3 Ichibancho, Chiyodaku, Tokyo 231 Proes Street 29, Bressenden Place CLINIQUES UNIVERSITAIRES SAINT-LUC JAPAN 001 Pretoria London SW1E 5DD Avenue Hippocrate 10 Tel: +813 332 650 077 SOUTH AFRICA UNITED KINGDOM B - 1200 Bruxelles Fax: +813 332 302 898 Tel: +27 12 312 0930 Tel: +44 (0) 20 7074 3281 BELGIUM Email: [email protected] Fax: +27 12 312 3388 Fax: +44 (0) 844 774 4319 Tel: +32 2 764 15 22 Email: [email protected] Email: [email protected] Fax: +32 2 764 15 25 Dr TAI-CHUN YOO Email: [email protected] President Dr DELON WU KOREAN HOSPITAL ASSOCIATION President Dr GEORG BAUM 35-1, Mapo-Dong, Mapo-Gu, Seoul TAIWAN HOSPITAL ASSOCIATION Chief Executive KOREA 25F, No29-5 GERMAN HOSPITAL FEDERATION Tel: +822 718 754 Ext 183 Sec. 2, Jung jeng E. Road Wegelystrasse 3 Fax: +822 718 7522 Danshuei Township, Taipei County 10623 Berlin Email: [email protected] TAIWAN GERMANY Tel: +886 22 808 3300 Tel: +49 30 398 011 001 Fax: +886 22 808 3304 Fax:+4930 398 013 011 Email: [email protected] Email: [email protected]
World Hospitals and Health Services Vol. 46 No. 1 47 47-8 Governing council-diary:25 20/5/10 09:44 Page 48
Reference
Dates for your diary
France 2010 18 - 21 May 1-2 June HOPITAL EXPO IHF Hospital and Healthcare Association Leadership “Porte de Versailles” – Paris, France Summit (By invitation only) http://www.hopitalexpo.com/ Chicago, USA [email protected] United Kingdom 23-25 June - The NHS Confederation 2011 Annual Conference 29-31 March Liverpool, United Kingdom 37th IHF World Hospital Congress* Tel: +44(0) 20 7931 6115 Dubai, Unites Arab Emirates [email protected] [email protected] http://www.nhsconfed.org / http://www.ihf-fih.org http://www.ihfdubai.ae/ http://www.ihf-fih.org
IHF NATIONAL HOSPITAL ASSOCIATION MEMBERS EVENTS DIARY: 2011 Switzerland 2010 November – H+ Les Hôpitaux de Suisse Argentina National Association congress 21 October – Camara Argentina de Empresas de Salud (CAES) Bern, Switzerland International Annual Congress Tel: +41 (0) 31 335 11 33 Health, Crisis and Reform: Equity and Social Exclusion, Hotel [email protected] Sheraton Libertador, Buenos Aires – Argentina, 20 October – Latin www.hplus.ch / http://www.ihf-fih.org American Hospital Federation, Experts meeting: Latin America and Ibero American Countries, Fundacion Docencia e COLLABORATIVE EVENTS: Investigación para la Salud, Buenos Aires – Argentina Tel: + 54 11 4373 2375 / +54 11 4372 5915 2010 [email protected]/[email protected] / 19-21 April [email protected] Geneva Health Forum www.caes.org.ar / http://www.ihf-fih.org Globalization, Crisis, and Health Systems: Confronting Regional Perspectives Australia Geneva, Switzerland 22-24 September [email protected] Australian Healthcare and Hospitals Association http://www.ghf10.org / http://www.ihf-fih.org 2010 Congress Adelaide, South Australia 29-30 June [email protected] Joint ICN/IHF/WMA MDR-TB Training Seminar – www.ahhacongress.com.au / http://www.ihf-fih.org Francophone Africa Health Care Worker Safety in the Context of Drug-resistant TB in Colombia Low and Middle Income Countries 20 – 24 April Cotonou, Republic of Benin 2nd International Health Fair (Meditech 2010) [email protected] 9th National Congress Meeting of Ibero-American Healthcare leaders Association of Colombian Hospital and Clinics in 26-30 July association with Fair and Exhibition Corporation (CORFERIAS) MDR-TB Training Seminar for Hospital Managers Bogota, Colombia Rio de Janeiro, Brazil www.feriameditech.com / www.ihf-fih.org [email protected]
Events marked* are interpreted into English, French and Spanish. All other events will be in English/host country language only. IHF members will automatically receive brochures and registration forms on all the above events approximately 6 months before the start date. IHF members will be entitled to a discount on IHF Congresses, pan-regional conferences and field study courses.
For further details contact the: IHF Project & Event Manager, International Hospital Federation, Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney Voltaire, France; E- Mail: [email protected] Or visit the IHF website: http://www.ihf-fih.org
48 World Hospitals and Health Services Vol. 46 No. 1 Sterile Barrier Systems ensure optimal reliability of use in hospitals and other health care institutions.
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