Healthcare Worker's Satisfaction Assessment for a Healthcare Adverse Event Reporting Framework and the Management Approach for Such Reporting in the Emergency Department of Rural Government Hospitals.

BACKGROUND: The healthcare adverse event (HAE) reporting framework is more than just a tool. It is a crucial pillar in our pursuit of patient safety, quality improvement, trust maintenance, regulatory compliance, and ethical standards in healthcare delivery. AIM: To assess healthcare workers' satisfaction with the HAE reporting framework and the management approach towards such reporting in the emergency department of rural government hospitals by conducting a satisfaction survey. MATERIALS AND METHOD: This prospective observational research was conducted in the Department of Emergency Medicine of the Uttar Pradesh University of Medical Sciences, Saifai, and adjoining district hospitals from November 2023 to January 2024. The study involved 320 healthcare professionals working in the emergency department. The quantitative survey research used a questionnaire and a quality Likert scale response. The data were analyzed on an ordinal measurement scale using nonparametric statistical methods. The sample data were analyzed using frequency tables, percentage pie charts, and comparison bar graphs. In nonparametric statistical tests, the one-sample Wilcoxon signed rank test was used to infer the population's central tendency, and the Kruskal-Wallis test was used to make inferences about the population categories. RESULTS: The satisfaction of healthcare professionals with the HAE reporting framework and the management approach was diverse. When surveyed about the HAE reporting framework in the emergency department, out of the 320 healthcare professionals, 50% (161) expressed dissatisfaction, 47% (149) were satisfied, and 3% (10) did not comment. Paramedics were most dissatisfied (61% of 133). When asked about the management approach while dealing with such reporting, 50% (159) were satisfied, 46% (147) were unsatisfied, and 4% (14) did not comment. On comparing professions, 43% (29) of 33 doctors and 62% (83) of 133 paramedics were unsatisfied, giving a poor response. Additionally, 61% (72) of the 119 nursing staff were satisfied. The non-parametric inferential tests yielded a p-value of less than 0.001 for both questions, indicating a notable difference in the population's response to the HAE reporting framework and management approach. On pairwise comparison, there was a significant difference in perception (p<0.001) between the occupation groups, except for doctors and paramedics (p = 0.638) in the HAE reporting framework. CONCLUSION: By encouraging reporting, standardizing processes, analyzing incidents thoroughly, and using data-driven insights to inform improvement efforts, healthcare organizations can enhance patient safety, improve quality of care, and prevent future adverse events. The management approach to HAE reporting involves fostering a culture of safety and transparency, implementing standardized reporting systems, providing education and training to healthcare staff, establishing feedback mechanisms, conducting robust analysis of reported events, promoting continuous improvement, and ensuring transparency and accountability.

Improving Care Continuity in Oncology Settings: A Lean Management Approach to Minimize Discharges Without Follow-Up Appointments.

OBJECTIVE: This study aimed to reduce the number of patients discharged without scheduled follow-up appointments by implementing lean management principles. METHODS: Conducted at the Sultan Qaboos Comprehensive Cancer Center in Muscat, Oman, the research utilized a one-group pretest-posttest quasi-experimental design to evaluate the impact of lean management interventions on the rate of patient discharges without follow-up appointments. Strategies such as the Kaizen principle, Gemba Walks, cross-functional collaboration, standard work procedures, and waste reduction were employed to enhance operational efficiency. RESULTS: Spanning from Quarter 3 of 2022 to Quarter 2 of 2023, the study demonstrated a significant decrease in the percentage of patients discharged without planned follow-up appointments. The rate dropped from 9% in September 2022 to 0% in March 2023, with statistically significant differences observed (X2= 65.05, p value=<.0001). CONCLUSION: By effectively implementing lean management principles, this research successfully enhanced care continuity for oncology patients after being discharged.

Case report: Intraoperative frozen section analysis of Thyroid paraganglioma.

Paraganglioma (PGL) is a neuroendocrine tumor that arises from the sympathetic or parasympathetic paraganglia. Primary thyroid PGL is extremely rare. PGL may be difficult to diagnose on frozen sections because its histopathological features, such as polygonal tumor cells with eosinophilic cytoplasm arranged irregularly, overlap with those of thyroid follicular adenoma. We present a case of thyroid PGL in a female patient and provide a detailed description of the patient's clinicopathologic characteristics. Cervical computed tomography showed a left thyroid mass with uneven density. Intraoperative frozen section analysis showed an uneven fibrous septa and rich networks of delicate vessels surrounding tumor cell nests. The tumor cells were polygonal or epithelioid with eosinophilic cytoplasm, arranged in a nest, trabecular, or organoid pattern were and diagnosed as thyroid follicular adenoma. However, in postoperative immunohistochemistry, these were diagnosed as thyroid PGL. The postoperative recovery was uneventful. The patient showed no signs of tumor recurrence or metastasis until 16 months of follow-up. Herein, we summarize the characteristic features of thyroid PGL based on frozen section analysis. In the appropriate clinical context, its proper use as diagnostic and differential diagnostic management strategies is recommended.

Understanding How Marine Protected Areas Influence Local Prosperity-A Case Study of Gili Matra, Indonesia.

A Marine Protected Area (MPA) is always expected to create a specified outcome in ecosystem improvement. While they are certain to benefit marine life, MPAs also impact the surrounding communities, as they directly affect the livelihoods of people who rely on marine exploits to make a decent living. In other words, MPAs create new communal dynamics influencing the rate of prosperity in the surrounding communities. Unfortunately, the leverage of MPAs in the coastal communities' social economy is often under-assessed in MPA-related research. The MPA's influence on communal prosperity emphasizes the importance of policy incentives from stakeholders. Therefore, stakeholders' perceptions of MPAs are fundamental in the planning and implementation of MPAs, which could improve the prosperity of the coastal communities. In Gili Matra, Indonesia, where tourism is the MPA's backbone, MPAs are expected to sustain prosperity for future generations. However, some stakeholders with different influential stances to the MPA (Influential Stakeholders (IS) and Non-Influential Stakeholders (NIS)) demand a contradictive approach. This could lead to managerial issues for the MPAs. These issues must be addressed to avoid contradictory objectives that could harm MPA implementation.

Huanglongbing Pandemic: Current Challenges and Emerging Management Strategies.

Huanglongbing (HLB, aka citrus greening), one of the most devastating diseases of citrus, has wreaked havoc on the global citrus industry in recent decades. The culprit behind such a gloomy scenario is the phloem-limited bacteria "Candidatus Liberibacter asiaticus" (CLas), which are transmitted via psyllid. To date, there are no effective long-termcommercialized control measures for HLB, making it increasingly difficult to prevent the disease spread. To combat HLB effectively, introduction of multipronged management strategies towards controlling CLas population within the phloem system is deemed necessary. This article presents a comprehensive review of up-to-date scientific information about HLB, including currently available management practices and unprecedented challenges associated with the disease control. Additionally, a triangular disease management approach has been introduced targeting pathogen, host, and vector. Pathogen-targeting approaches include (i) inhibition of important proteins of CLas, (ii) use of the most efficient antimicrobial or immunity-inducing compounds to suppress the growth of CLas, and (iii) use of tools to suppress or kill the CLas. Approaches for targeting the host include (i) improvement of the host immune system, (ii) effective use of transgenic variety to build the host's resistance against CLas, and (iii) induction of systemic acquired resistance. Strategies for targeting the vector include (i) chemical and biological control and (ii) eradication of HLB-affected trees. Finally, a hypothetical model for integrated disease management has been discussed to mitigate the HLB pandemic.

Reducing Food Waste in Buffet Restaurants: A Corporate Management Approach.

Food waste has become a significant issue in the foodservice industry. However, food waste management in buffet restaurants has rarely been investigated. Considering the popularity of buffet restaurants in Taiwan, this study serves as the first attempt to identify a corporate management approach to food waste reduction in Taiwanese buffet restaurants. The study case comprises two buffet restaurants of a large chain restaurant company in Taiwan. This study uses both individual in-depth interviews and a focus group, comprising 15 managers, chefs, and front-line employees. The results identify various strategies to mitigate food waste in buffet restaurants at different stages of operation: establishing a central kitchen, cooperating with qualified suppliers, accurate forecasting of food demand, aesthetic buffet table design, redesigning the service method, continually monitoring food waste, and proactive communication to customers. The 3R (Reduce-Reuse-Recycle) food waste hierarchy is also developed to encourage buffet restaurant practitioners to design appropriate food waste mitigation programs.

Severe asthma in South Africa: A literature review and management approach for primary care.

Severe asthma in South Africa (SA) is underappreciated, especially in the primary care setting. This study highlights the epidemiological context of severe asthma as a phenotypic variant. Primary care practitioners, as first-contact medical providers, need grounding in the management of severe asthma based on the precision of diagnosis and negotiated along the 10-point strategy. The underdiagnosis and undertreatment of asthma ought to inform educational programmes and research in this country.

Effect of the exercise programme on the quality of life of prostate cancer survivors: A randomized controlled trial.

AIM: The aim of this study was to investigate the effect of the exercise programme on the quality of life of prostate cancer (PCa) survivors. METHODS: A randomized controlled, parallel trial was conducted from April 2017 to January 2018 on 80 PCa survivors. They were randomly assigned to intervention and control groups (n = 40 in each group). The exercise programme was designed based on the self-management approach (SMA). The intervention group participated in a 12-week exercise programme consisting of one session of group exercise and three sessions of individual exercise per week using exercise facilities in the community. Data were collected using the quality of life questionnaires and the follow-up checklist. RESULTS: In the intervention group, statistically significant improvements in physical, role, emotional, social and sexual functions were reported. Also, the patients in this group reported reduced fatigue, insomnia, constipation, diarrhoea, urinary, bowel and hormonal treatment-related symptoms in comparison with before the exercise programme (p < 0.05). CONCLUSIONS: Nurses are suggested to plan for improving the participation of PCa survivors in exercise programmes using exercise facilities in the community in order to reduce the complications of treatment and improve their quality of life.

A critical review on antibiotics and hormones in swine wastewater: Water pollution problems and control approaches.

Swine wastewater (SW) is an important source of antibiotics and hormones (A&H) in the environment due to their large-scale application in swine industry. A&H in SW can be released into the water environment through the direct discharge of SW, effluent from SW treatment plants, and runoff and leaching from farmland polluted by swine wastes. The presence of A&H in the water environment has become an increasing global concern considering their adverse effects to the aquatic organism and human. This review critically discusses: (i) the occurrence of A&H in global water environment and their potential risks to water organisms and human; (ii) the management and technical approaches for reducing the emission of A&H in SW to the water environment. The development of antibiotic alternatives and the enhanced implementation of vaccination and biosecurity are promising management approaches to cut down the consumption of antibiotics during swine production. Through the comparison of different biological treatment technologies for removing A&H in SW, membrane-based bioprocesses have relatively higher and more stable removal efficiencies. Whereas, the combined system of bioprocesses and AOPs is expected to be a promising technology for elimination and mineralization of A&H in swine wastewater. Further study on this system is therefore necessary.

Management of children with congenital nephrotic syndrome: challenging treatment paradigms.

BACKGROUND: Management of children with congenital nephrotic syndrome (CNS) is challenging. Bilateral nephrectomies followed by dialysis and transplantation are practiced in most centres, but conservative treatment may also be effective. METHODS: We conducted a 6-year review across members of the European Society for Paediatric Nephrology Dialysis Working Group to compare management strategies and their outcomes in children with CNS. RESULTS: Eighty children (50% male) across 17 tertiary nephrology units in Europe were included (mutations in NPHS1, n = 55; NPHS2, n = 1; WT1, n = 9; others, n = 15). Excluding patients with mutations in WT1, antiproteinuric treatment was given in 42 (59%) with an increase in S-albumin in 70% by median 6 (interquartile range: 3-8) g/L (P < 0.001). Following unilateral nephrectomy, S-albumin increased by 4 (1-8) g/L (P = 0.03) with a reduction in albumin infusion dose by 5 (2-9) g/kg/week (P = 0.02). Median age at bilateral nephrectomies (n = 29) was 9 (7-16) months. Outcomes were compared between two groups of NPHS1 patients: those who underwent bilateral nephrectomies (n = 25) versus those on conservative management (n = 17). The number of septic or thrombotic episodes and growth were comparable between the groups. The response to antiproteinuric treatment, as well as renal and patient survival, was independent of NPHS1 mutation type. At final follow-up (median age 34 months) 20 (80%) children in the nephrectomy group were transplanted and 1 died. In the conservative group, 9 (53%) remained without dialysis, 4 (24%; P < 0.001) were transplanted and 2 died. CONCLUSION: An individualized, stepwise approach with prolonged conservative management may be a reasonable alternative to early bilateral nephrectomies and dialysis in children with CNS and NPHS1 mutations. Further prospective studies are needed to define indications for unilateral nephrectomy.

Identifying conservation priority areas to inform maritime spatial planning: A new approach.

Accommodating sea uses while protecting the ecosystems is a challenge of the marine planning and management process. The European Directive on Maritime Spatial Planning calls for Maritime Spatial Plans until 2021 developed within an Ecosystem Based Management approach. The main goal of this study is to support the Maritime Spatial Planning process with ecological meaningful information, namely identifying priority areas for conservation that are facing less anthropogenic impacts. We developed a new approach for selection of high priority areas for conservation using Marxan software and Cumulative Impacts decision support tools. We identified four main areas prone to conservation in Portuguese mainland subdivision, namely the areas of Figueira da Foz/Peniche, south Cabo Espichel/Sines, Cabo Sardão/Faro and Lagos/Faro. The outputs from this study show the valuable input when allocating space to activities and uses in the marine realm supporting the planning process in the development of management alternatives. This case study also illustrates how ecological goals can be better included to contribute to the Maritime Planning process in Portugal. Systematic planning can be applied to support the connection between Marine Strategy Framework and Maritime Spatial Planning European Directives. This is highly relevant in the time being for Portugal, as the 2nd cycles of both directives are ongoing.

Understanding institutional stakeholders' perspectives on multidrug-resistant bacterial organism at the end of life: a qualitative study.

BACKGROUND: Information lacks about institutional stakeholders' perspectives on management approaches of multidrug-resistant bacterial organism in end-of-life situations. The term "institutional stakeholder" includes persons in leading positions with responsibility in hospitals' multidrug-resistant bacterial organism management. They have great influence on how strategies on multidrug-resistant bacterial organism management approaches in institutions of the public health system are designed. This study targeted institutional stakeholders' individual perspectives on multidrug-resistant bacterial organism colonization or infection and isolation measures at the end of life. METHODS: Between March and December 2014, institutional stakeholders of two study centers, a German palliative care unit and a geriatric ward, were queried in semistructured interviews. Interviews were audiotaped, transcribed verbatim, and analyzed qualitatively with the aid of the software MAXQDA for qualitative data analysis using principles of Grounded Theory. In addition, two external stakeholders were interviewed to enrich data. RESULTS: Key issues addressed by institutional stakeholders (N=18) were the relevance of multidrug-resistant bacterial organism in palliative and geriatric care, contradictions between hygiene principles and patients' and family caregivers' needs and divergence from standards, frame conditions, and reflections on standardization of multidrug-resistant bacterial organism end-of-life care procedures. Results show that institutional stakeholders face a dilemma between their responsibility in protecting third persons and ensuring patients' quality of life. Until further empirical evidence establishes a clear multidrug-resistant bacterial organism management approach in end-of-life care, stakeholders suggest a case-based approach. CONCLUSION: The institutional stakeholders' perspectives and their suggestion of a case-based approach advance the development process of a patient-, family-, staff-, and institutional-centered approach of how to deal with multidrug-resistant bacterial organism-positive patients in end-of-life care. Institutional stakeholders play an important role in the implementation of recommendations following this approach.

Discussion on Relevant Issues of Medical Institution Preparation Registration Management Approach( Trial) / 中国药房

OBJECTIVE:To provide reference for improving registration regulation of medical institution preparation and pro-moting the development of it. METHODS:According to sorting out and summarizing the Medical Institution Preparation Registra-tion Management Approach(trail)contents,for its shortcomings in terms of medical institution preparation definitions,related im-provement suggestions were put forward. RESULTS & CONCLUSIONS:The Medical Institution Preparation Registration Manage-ment Approach(trail)has promulgated for 12 years from 2005 till now,existing shortcomings were that the definition of medical institution preparations was too wide,requirement on data of application and registration was less rigorous,regulation of clinical re-search was vague,clinical application re-evaluation was inadequate,disapproved case was lacked. In view of the above shortcom-ings,it is suggested to narrow the definition of medical institution preparations,modify the requirement on data of application and registration specify the regulation of clinical research,add monitoring period for the new preparation and update the disapproved case,so as to improve the registration regulation of medical institution preparations and promote the development of preparations in medical institutions.

Do diabetes-specialty clinics differ in management approach and outcome? A cross-sectional assessment of ambulatory type 2 diabetes patients in two teaching hospitals in Nigeria.

OBJECTIVES: To evaluate management approach and outcome in two endocrinologist-managed clinics using data on treatment adherence, diabetes-specific parameters, prescribed medications and self-management practices among ambulatory type 2 diabetes patients. Opinion on cause(s) and perceived fear about diabetes were also explored. DESIGN: A cross-sectional prospective study using semi-structured interview among consented patients for eightweek, and a review of participants' case notes at 3-month post-interactive contact for details of diabetes-specific parameters and antidiabetes medications. SETTINGS: The University College Hospital (UCH) and Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) in southwestern Nigeria. PARTICIPANTS: Adult patients with type 2 diabetes, on therapies for >3-month and who had average fasting blood glucose (FBG)>6.0mmol/L were enrolled. All patients with type 1 diabetes, and type 2 diabetes who decline participation were excluded. Out of 185 participants who were approached, 176(95.1%) consented and completed the study including 113(64.2%) from UCH and 63(35.8%) in OAUTHC. RESULTS: Mean FBG for patients were 9.6mmol/L in UCH and 11.0mmol/L in OAUTHC (p=0.03). Medication adherence among patients was 47(46.5%) in UCH and 31(52.5%) in OAUTHC (p=0.46). Prescribed antidiabetes medications between the clinics significantly differ. Practice of self-monitoring of blood glucose among participants was 26(23.0%) in UCH and 13(20.6%) in OAUTHC (p=0.72). Thirty-two participants (29.4%) in UCH and 33(43.4%) from OAUTHC (p=0.02) mentioned complications as perceived fear about type 2 diabetes. CONCLUSION: There are differences and similarities between the diabetes-specialty clinics with respect to diabetes management and outcome. This underscores the necessity for a protocol-driven treatment approach in ensuring improved diabetes care and outcome. FUNDING: None declared.

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

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

Multidisciplinary management of locally advanced and widely metastatic paraganglioma in a patient with life-threatening compressive symptoms.

BACKGROUND: Patients presenting with locally advanced, metastatic paraganglioma with life-threatening compressive symptoms of critical anatomic structure pose a significant management challenge. METHODS: We present a case of a 15-year-old patient with enlarging right neck mass causing dysphagia and respiratory compromise from near complete obstruction of the oropharynx. RESULTS: Evaluation of the patient's family history led to the identification of a mutation in the succinate dehydrogenase subunit B (SDSD) gene (G725A). Laboratory and imaging workup revealed an 8.8 × 6.6 × 4.1 cm metabolically and biochemically active right neck mass, a tumor in the left para-aortic region, and multiple bony lesions consistent with widely metastatic disease. Multidisciplinary management included preoperative clinical optimization, coil embolization, and palliative resection of the neck mass. CONCLUSION: Although the currently available treatment options for patients with advanced metastatic paraganglioma render no survival benefit, a multidisciplinary management approach aimed at relief of tumor-related symptoms and catecholamine excess should be undertaken.

A New Approach of Measuring Hospital Performance for Lowand Middle-income Countries

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

Self-management and quality of life of patients with chronic obstructive pulmonary disease in community / 中华健康管理学杂志

Objective To evaluate the impacts of self-management on quality of life of patients with chronic obstructive pulmonary disease (COPD) in community. Method A total of 130 patients with COPD from selected 3 neighbourhood residential committees in Longhua community were randomized into intervention group (65 cases) and control group (65 cases). The control group was treated with conventional health education, the intervention group was treated with self-management education program. Both groups were evaluated by the Chinese version of the chronic disease self-management study measures and SF-36 profile before and after the 6 months intervention. Result After 6 months, the scores of the chronic disease self-management study in the control group were holistic health (3.52 ± 0.64), symptom (18.86 ± 3.06), shortness of breath (3.92 ± 1.74), somatic function (8.15 ± 0.51) and impact on life (22.21 ± 7.14), while the scores in the intervention group were holistic health (2.43±0.43), symptom (15.68±3.66), shortness of breath (2.06 ± 1.30), somatic function (5.73 ± 1.08) and impact on life (16.43 ± 5.17) , and the differences were statistically significant (P<0.01). Compared with the control group, the dimensions and total score of quality of life of the intervention group were (52.41±7.90 vs. 71.63±8.11, P<0.01). Conclusion The effective self-management could improve symptoms, the ability of self-management and their quality of life.

El costo en salud y la corresponsabilidad clínica desde un enfoque gerencial / Health cost and clinical co-responsibility from a management approach

El trabajo enfoca el costo en salud, y particularmente su crecimiento, bajo una óptica gerencial, lo que implica destacar aquellos aspectos que se relacionan con los recursos empleados y la efectividad en los resultados para la salud de las personas y las poblaciones. Se presentan cinco posibles causas que pudieran explicar la multicausalidad del crecimiento de los costos en salud. Tres de ellas tienen la particularidad de que no aparecen suficientemente analizadas en estudios sobre el tema de los costos en salud y todas tienen un componente gerencial significativo: la corrupción, la deficiente organización de los servicios y el manejo irresponsable de los recursos por parte de los prestadores. Se amplía el análisis de la última causa mencionada al considerar que tiene mayor interés gerencial, ya que acumula un porcentaje alto de los costos y al mismo tiempo, es un elemento susceptible de modificarse por los gerentes en los niveles de atención primaria y secundaria. Para ampliar las posibilidades del análisis se procede a tratar la causa como problema y a este se le aplica el diagrama de causa-efecto de Ishikawa, que permite revelar las subcausas sobre las cuales los gerentes pudieran enfocar su trabajo para convertir la irresponsabilidad en corresponsabilidad. En la parte final se analizan cada una de las subcausas y se hacen recomendaciones sobre los métodos, habilidades y tecnologías gerenciales útiles para producir el cambio(AU)

This paper focused on health costs, particularly their increase, from a management approach. This implied to underline those aspects associated with the resources used and the effectiveness of results for the health of individuals and populations. Five possible causes that might explain the multi-causality of the health cost increases were presented. Three of them had not been deeply analyzed in the studies on health costs and had a basic management component: corruption, poor organization of service and irresponsible management of resources on the part of providers. The analysis of the last mentioned cause is extensive since it has a greater management interest, accounts for a high percentage of costs and it is at the same time an element that can be changed at the primary and secondary care levels by the managers. In order to extend the analytical possibilities, the cause was seen as a problem to which Ishikawaïs cause/ effect diagram was applied. This allowed disclosing the subcauses upon which the managers might work to turn irresponsibility into co- responsibility. The last part of the paper analyzed each of these subcauses and made recommendations about the useful management methods, abilities and technologies to bring about the desired changes(AU)

El costo en salud y la corresponsabilidad clínica desde un enfoque gerencial / Health cost and clinical co-responsibility from a management approach

El trabajo enfoca el costo en salud, y particularmente su crecimiento, bajo una óptica gerencial, lo que implica destacar aquellos aspectos que se relacionan con los recursos empleados y la efectividad en los resultados para la salud de las personas y las poblaciones. Se presentan cinco posibles causas que pudieran explicar la multicausalidad del crecimiento de los costos en salud. Tres de ellas tienen la particularidad de que no aparecen suficientemente analizadas en estudios sobre el tema de los costos en salud y todas tienen un componente gerencial significativo: la corrupción, la deficiente organización de los servicios y el manejo irresponsable de los recursos por parte de los prestadores. Se amplía el análisis de la última causa mencionada al considerar que tiene mayor interés gerencial, ya que acumula un porcentaje alto de los costos y al mismo tiempo, es un elemento susceptible de modificarse por los gerentes en los niveles de atención primaria y secundaria. Para ampliar las posibilidades del análisis se procede a tratar la causa como problema y a este se le aplica el diagrama de causa-efecto de Ishikawa, que permite revelar las subcausas sobre las cuales los gerentes pudieran enfocar su trabajo para convertir la irresponsabilidad en corresponsabilidad. En la parte final se analizan cada una de las subcausas y se hacen recomendaciones sobre los métodos, habilidades y tecnologías gerenciales útiles para producir el cambio

This paper focused on health costs, particularly their increase, from a management approach. This implied to underline those aspects associated with the resources used and the effectiveness of results for the health of individuals and populations. Five possible causes that might explain the multi-causality of the health cost increases were presented. Three of them had not been deeply analyzed in the studies on health costs and had a basic management component: corruption, poor organization of service and irresponsible management of resources on the part of providers. The analysis of the last mentioned cause is extensive since it has a greater management interest, accounts for a high percentage of costs and it is at the same time an element that can be changed at the primary and secondary care levels by the managers. In order to extend the analytical possibilities, the cause was seen as a problem to which Ishikawaïs cause/ effect diagram was applied. This allowed disclosing the subcauses upon which the managers might work to turn irresponsibility into co- responsibility. The last part of the paper analyzed each of these subcauses and made recommendations about the useful management methods, abilities and technologies to bring about the desired changes