Macroergonomic analysis and design for improved safety and quality performance.

Macroergonomics, which emerged historically after sociotechnical systems theory, quality management, and ergonomics, is presented as the basis for a needed integrative methodology. A macroergonomics methodology was presented in some detail to demonstrate how aspects of microergonomics, total quality management (TQM), and sociotechnical systems (STS) can be triangulated in a common approach. In the context of this methodology, quality and safety were presented as 2 of several important performance criteria. To demonstrate aspects of the methodology, 2 case studies were summarized with safety and quality performance results where available. The first case manipulated both personnel and technical factors to achieve a "safety culture" at a nuclear site. The concept of safety culture is defined in INSAG-4 (International Atomic Energy Agency, 1991). as "that assembly of characteristics and attitudes in organizations and individuals which establishes that, as an overriding priority, nuclear plant safety issues receive the attention warranted by their significance." The second case described a tire manufacturing intervention to improve quality (as defined by Sink and Tuttle, 1989) through joint consideration of technical and social factors. It was suggested that macroergonomics can yield greater performance than can be achieved through ergonomic intervention alone. Whereas case studies help to make the case, more rigorous formative and summative research is needed to refine and validate the proposed methodology respectively.

Macroergonomic analysis of formalization in a dynamic work system.

Planning systems are widely accepted and used for organizational decision making, but do planning systems actually work? A simulation-based experiment was used to develop a set of indicators to measure and analyze formal and informal planning strategies. Seventy-two subjects participated. Eight planning groups of three members were assigned to a low formalization, high formalization and a control condition. Following planning strategy training, groups performed an organizational decision-making task for four simulated years. While differences in performance were not significant, significant differences in strategy were found and an interesting temporal effect was detected. In a dynamic environment, the groups exhibiting highly formalized strategies migrated in the direction of lower formalization. Results supported are discussed in terms of Mintzberg's [The Rise and Fall of Strategic Planning, 1994, The Free Press, New York] fallacies of planning.

[Simultaneous laparoscopic therapy of cholecysto- and choledocholithiasis. An analysis of results]. / Die einzeitige laparoskopische Therapie der Cholezysto- und Choledocholithiasis. Eine Resultatanalyse.

INTRODUCTION: With the advent of laparoscopic cholecystectomy, ERCP has gained importance in the treatment of choledocholithiasis. Laparoscopic cholecystectomy with intraoperative cholangiography and common bile duct surgery allows diagnosis and treatment of cholecystolithiasis and choledocholithiasis in a single procedure. PATIENTS AND METHODS: Laparoscopic treatment of choledocholithiasis was evaluated in 99 consecutive patients with choledocholithiasis. 28 patients underwent successful preoperative ERCP. Of the patients with intraoperative confirmation of choledocholithiasis, removal was attempted by a transcystic approach in 36 and 23 underwent choledochotomy. 24 patients with a high operative risk underwent postoperative ERCP. RESULTS: The transcystic approach was successful in 72.2%. Choledochotomy was successful in 91.3%, yielding a combined success rate of 80%, 3.4% had local complications and 8.4% had other complications (complication rate 11.8%), 20.3% of the patients underwent ERCP after failed laparoscopic procedures. One patient had a laparoscopic redo. There was no mortality and no conversion to open surgery. CONCLUSION: ERCP and laparoscopic common bile duct surgery are complementary, efficient and safe modalities of treatment for choledocholithiasis. Choice of procedure is influenced by the surgeon's experience and institutional infrastructure, and the individual patient.

Practices of the best companies in the medical industry.

A report containing information about three of the top medical manufacturing companies in the world--Baxter Healthcare Corporation, Johnson & Johnson and Medtronic, Inc. Resources have been gathered and employees in key positions from each company have been interviewed to obtain the most current and accurate information. Interviewees were asked what factors contribute to their company's success. These factors were then explored more explicitly through a variety of publications, and the results are included in this report. In today's competitive market, companies must keep current with the market trends and be flexible and open to changing and/or improving their practices in order to remain successful. It has been found that although the main focuses of each company may be similar, the processes by which they strive to meet their goals are quite unique.

Human resource management in the health-care industry.

It has been said that managing change is a synonym for managing people through change. No other industry has experienced more change in the past ten years than the health-care industry. In order to regulate all this change, managers in health-care organizations must identify new ways to deal with the changes. The issues are as old as time: job satisfaction, cultural conflict, and compensation. This paper addresses each of these key issues with the following examples. A new nursing paradigm that was implemented at a hospital has significantly increased job satisfaction. This paper also takes a look at ways to manage cultural conflict in a diversified workforce. Finally, the results of a team approach to compensation are studied.

Protecting the whistleblower: preventing retaliation following a report of patient abuse in health-care institutions.

Health-care providers throughout the United States face litigation and the threat of litigation on a daily basis due to claims of patient abuse. Hidden within the costs associated with defending patient abuse claims are the wrongful termination filings made by employees who claim they were retaliated against for their whistleblowing activity. The purpose of this paper is to demonstrate why an employer would resort to retaliatory acts in the shadow of a patient abuse filing and to discuss what steps are currently taken to prove and investigate the validity of a retaliation claim. Included within the body of this paper are court decisions on the topics of whistleblowing protection and violation of public policy. These examples are illustrated so that recommendations can be provided that assist the employer in avoiding a wrongful discharge claim and help to conclude that retaliation against the whistleblower is a costly mistake even with the employment at-will principle as a defense.

New developments in a consolidating health care industry.

The current health care industry has recently seen a great deal of consolidation in the form of mergers and acquisitions. These mergers and acquisitions invariably result in a loss of jobs. This paper focuses on two strategies that health care companies use to reduce workforce under these circumstances. Specifically, the paper will focus on the mergers between SmithKline Beckman and Beecham plc in the late 1980s, FHP Health Care and TakeCare Health Plans, and PacifiCare's recent acquisition of FHP Health-care. It will compare and contrast theory, strategy and practices of these six companies as they endeavoured to merge or acquire each other.

Human resource management in the health care industry.

Human resource management practices with special reference to the latest developments of the 1990s such as environmental effects and managing diversity, were investigated. The purpose of the study was to unveil how the health care industry can benefit from these new concepts, as well as to describe how the traditional health care facilities can adapt these new ideas. Specific examples were provided to illustrate this point. In compilation of this report, both primary and secondary research was used. As primary research, many reputable individuals in the health care industry were consulted, and asked to comment on the rough draft of this report. Secondary sources included many journal articles, original researches and books that were written on this technical subject. It can be concluded from this research, that the health care industry should adapt the latest methods to compete and survive, such as use more marketing tools to attract human resource management personnel from other industries, promote diversity at the work place, promote from within the company, and cross-train personnel whenever possible. Health care industry has generally lagged behind other industries in securing high-performance individuals and marketing personnel; however, with the development of health maintenance organizations, this trend is changing.

Practices of excellent companies in the managed health care industry.

The health care profession in the USA has traditionally attracted some of the best talent the country has to offer, with medical practitioners enjoying high incomes due to employer-paid medical indemnity insurance plans. There was no oversight process or quality standards governing the health care delivery process and no motivating factors to contain costs. Prior to the introduction of the Knox-Keene Act in the 1970s requiring employers to offer managed care as an alternative indemnity coverage, the only known managed care company was the Kaiser Permanente Medical Plan. Until just over a decade ago, the concept of managed care was stereotyped as a low quality method of health care delivery. Criticisms from providers themselves suggested managed care systems meant withholding medical care for the sake of profit; "production line" medicine, and compromise in the delivery of quality health care. In order to refute that notion and grow as an industry, managed health care companies were required to take steps to prove their integrity, high quality of care, and cost-effective methods. Today the industry is fast growing, setting management practices that are becoming benchmark standards for other industries too.

Self-expanding metal stents in malignant esophageal obstruction: a comparison between two stent types.

OBJECTIVES: Self-expanding metal stents are a promising alternative in the palliation of malignant esophageal obstruction, but the relative value of different stent types is not well established. METHODS: During a 3-year enrollment period in four different centers, 82 consecutive patients with malignant dysphagia without tumor recurrence after surgery or esophagorespiratory fistulas received either an uncovered Wallstent (44 patients) or a knitted nitinol stent (38 patients). RESULTS: Age (median: 79 yr), sex (F:M = 33:67), dysphagia score (median: 3), Karnofsky score (median: 53), body mass index (median: 19), type of pretreatment, tumor stage, stricture length (median: 5.4 cm), and stricture location were comparable in both stent groups. After stent placement, median dysphagia score improved markedly in both groups by two points. Procedure-related mortality (16 vs 0%; p < 0.01), early complication rate (32 vs 8%; p < 0.01), and severe persistent pain after stent placement (23 vs 0%; p < 0.002) were higher in the Wallstent compared with the knitted nitinol stent group. In contrast, stent dysfunction (7 vs 32%; p < 0.005), reintervention rate (9 vs 34%; p < 0.005), and costs were lower in the Wallstent compared with the nitinol stent group. CONCLUSIONS: In malignant esophageal obstruction, both stents markedly improved dysphagia. Uncovered Wallstents seem to cause more early severe complications than knitted nitinol stents. In contrast, stent dysfunction, reintervention rate, and costs appear to be higher in the nitinol stent group.

Medical rationing as a health strategy.

Notes the problem of rising health care costs in the USA. Considers a highly controversial solution to this problem, which is to consider health care as a scarce resource and to ration access to it. Whether rationing is done by age, ability to pay, or a cost-benefit analysis, the very concept contradicts the US belief in the right to health care. Other industrialized countries currently ration health care through a National Health Insurance Plan. Points out that, in the USA, individual states are beginning to consider health care rationing to combat shrinking budgets and increasing demand for services.

Competition and its implications for managing health care organizations.

Reports that the US health care system has been shifting since the 1960s to a competitive environment with many new and innovative organizational forms. Describes the nature of the competitive environment for health care and some of the basic forms of the new organizational arrangements. Explores some of the implications for managing successful health care organizations by the understanding of interorganizational linkages in the health care industry and a partnership approach to marketing and management.

Practices of excellent companies in the drug industry.

Examines excellence in three major pharmaceutical companies: Merck, Lilly, and Glaxo. Provides an overview of recent trends in the health care industry. Shows that although all three companies are facing tough competition and strict cost-containment pressures, they continue to develop innovative strategies for increasing the quality of their product offering. Analyses Merck's recent acquisition of Medco and its implications; also highlights Merck's "Vital Interests" programme. Discusses Lilly's recent purchase of PCS from McKesson Drug and Lilly's recent efforts to concentrate on its core business. Introduces Helix, Glaxo's new computer network for pharmacists and explains the benefits of this unique service, both to its users and the sponsor.

Prenatal diagnosis of hypospadias.

Despite the fact that hypospadias is one of the most common congenital abnormalities of the genitalia, it is often missed on prenatal sonograms. In this paper, sonographic findings of six fetuses who were prospectively suspected to have hypospadias are presented. Of the six patients, isolated hypospadias was found in three, hypospadias with chordee in two, and isolated chordee in one. Additional malformations were present in four of the six fetuses. Sonographic findings of fetal hypospadias are described, and the embryology, anatomy, and associated abnormalities are discussed.

[15 years of endoscopic therapy in choledocholithiasis]. / 15 Jahre endoskopische Therapie der Choledocholithiasis.

INTRODUCTION: The relevance of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of common bile duct stones has increased since the introduction of laparoscopic cholecystectomy in 1989-1990. METHODS: The number, indications, success and complication rate of ERCP were analyzed retrospectively in 1121 consecutive patients with bile duct stones treated at Berne University Hospital between 1980 and 1994. RESULTS: The number of patients undergoing endoscopic stone extraction increased slowly from 1980 to 1990, but has shown a 4-fold increase in the last 5 years parallel to the introduction of laparoscopic cholecystectomy. Failure to diagnose and remove bile duct stones decreased 5-fold from 23% (14 of 60 patients) in 1986 to 4.4% (10 of 225 patients) in 1994. Major complications occurred in 3.2% (30 of 617 patients) and consisted of acute pancreatitis (1.6%), hemorrhage of the papilla (1%), and cholangitis (0.6%). The severity but not the number of complications has decreased in the last 15 years. CONCLUSION: Gallbladder stones with common bile duct stones are usually treated by endoscopic stone extraction combined with laparoscopic cholecystectomy. Open operation with bile duct exploration is reserved for a small subgroup of patients with specific problems.

Using management information systems to enhance health care quality assurance.

Examines how computers and quality assurance are being used to improve the quality of health care delivery. Traditional quality assurance methods have been limited in their ability to effectively manage the high volume of data generated by the health care process. Computers on the other hand are able to handle large volumes of data as well as monitor patient care activities in both the acute care and ambulatory care settings. Discusses the use of computers to collect and analyse patient data so that changes and problems can be identified. In addition, computer models for reminding physicians to order appropriate preventive health measures for their patients are presented. Concludes that the use of computers to augment quality improvement is essential if the quality of patient care and health promotion are to be improved.

New developments in hospital management.

Changes in the health care environment over the past ten years have prompted changes in the way hospitals are being managed. The rising cost of health care has affected Medicare reimbursement, caused business to be a discerning selector of medical care, and given birth to alternative forms of health care delivery. All these conditions have resulted in decreased revenue and increased competition for hospitals. Focuses on what hospitals have done to adapt to these changing conditions: cost containment, marketing strategies, and human resource management, since these areas have undergone the most meaningful changes.

The monitoring and improvement of productivity in health care.

Considers the monitoring of productivity in the health care environment. Examines especially the development of a labour standard and a volume indicator. Sees the whole as a management tool for controlling staffing requirements and costs. Investigates the question of methods improvement, involving all staff, should the standard fail to be met. Discusses increased training, procedure scheduling, investment in equipment, incentives, reduction of paper work, physician utilization. Cautions that the implementation of change must not be vitiated by internal politics and concludes that that which gets monitored gets controlled.

[Monitoring fetal delivery by oxycardiotocography]. / Fetale Geburtsüberwachung durch Oxykardiotokographie (OCTG).

Oxycardiotocography is a combination of cardiotocography and continuous registration of the foetal arterial oxygen saturation (SaO2). In a few cases, the value of this additional information of foetal SaO2 is demonstrated. During uncomplicated deliveries with normal foetal heart rate patterns, the foetal SaO2 usually ranges between 50% and 70%. Uterine hyperactivity with impaired perfusion of the placenta shows besides a changed heart rate patterns, a significant decrease of the foetal oxygen saturation. Conversely, by supplying oxygen to the mother with a mask, the foetal oxygen saturation can be increased by approx. 10%. In case of a breech presentation and application of the sensor to the buttocks, the measured O2-saturation is approx. 10% to 15% below the values usually obtained from the scalp because the tissue there is supplied with mixed blood after the ductus.

Design and evaluation of an inspection training programme.

As a follow-up to a study of human and machine inspection of precision metal components, a training programme was designed to improve the performance of the inspectors. The methodology for task description, task analysis (including experiments), training programme design and final evaluation are presented as a case study. Improvements due to training were measured both on an individual basis and from plant-wide statistics to show the success of the programme.