公立医院建立健全现代医院管理制度的实践与思考

建立健全现代医院管理制度是深化公立医院改革、推进医院治理体系和治理能力现代化的客观要求。本文阐述了某公立医院按照现代医院管理制度建设的要求,以完善治理体系、加强精准管控、再造服务流程及增强品牌实力为重点,提升医院经济运营效率及品牌影响力,以期对其他医院完善现代医院管理制度提供有益借鉴。     

Performances of sexuality counselling: a framework for provider-client encounters

Objective

Adequately assessing quality of care poses enormous challenges. While conducting fieldwork, we were struck by the need for a framework that encapsulates provider-client encounters. Little evidence exists concerning the most effective training, and management of health staff engaged in sexuality, reproductive health and HIV related health services. This paper proposes a framework for analysing these encounters.

Methods

This paper is based on five studies. Mixed method studies were carried out in Uganda and Kenya. Two additional studies looked into the effect of HIV on health worker performance in Uganda and Zambia. As a result of the findings, a desk review looked into factors affecting provider-client encounters in order to improve the responsiveness of programs.

Results

Positive encounters between provider and client are built on trust and respect, consist of communication, practice and process, and are influenced by space, place and context. Combining these facets allows for a better understanding of their interactions.

Conclusion

A holistic perspective in which the breadth of dynamics and processes are described should be used when assessing the quality of provider-client encounters.

Practice implications

Within training, management and human resource planning, these dynamics need to be utilized to realize the best possible care.     

Obstacles to European research projects with data and tissue: solutions and further challenges

Most European biomedical research projects are about data. Research with tissue is about data as well; data will accompany the tissue, and data will be derived from analysing the tissue. Data can be merged with data from various sources, copied and re-analysed in the context of European projects. Privacy enhancing technologies (PET) should be used for transferring data from participating centres to the level where data are being merged. PET provide coding techniques which allow donors to be anonymised and still uniquely discernable. It is defended that under certain conditions two-way coded data can be considered as anonymous data in the sense of the European Data Protection Directive. Divergent interpretations of this Directive and most of all about the concept of coded-anonymised data is one of the main obstacles to observational research in Europe. The Data Protection Authorities will have to relax the extremely high threshold before data cannot be considered personal data anymore. Arguments are given for such relaxation. Besides the logic and logistics of data transfer in European projects, it is also about trust and a realistic risk assessment. In spite of the massive dataflow in European research projects no breach of confidentiality has ever been reported. The ethical rationale of such projects can be based on the principles of citizenship and solidarity provided that certain safeguards are met by which that research will remain observational.However, if the project does not preclude individual feed-back on the outcomes of research, as in theory would be possible with two-way coded tissue, that tissue cannot be considered anonymous. It is argued that in most tissuebanking projects individual feed-back should be excluded. Tissuebanking for research should not turn into medical screening without applying the established criteria for screening to it. If individual feed-back is not foreseen, two-way tissue should be considered anonymous, under the same conditions as two-way coded data.Good research governance is proposed as the way forward in the longer run. Good research governance is about a fair balance between the interests of all stakeholders. It should make the basic principles transparent on which observational research projects are based in line with European solidarity-based healthcare systems. It should encompass principles on how the general results of research will be disseminated, ‘conflict of interests’ policies, how the issues of intellectual property rights are dealt with, how the confidentiality of personal data of donors is maintained, etc. This should not become an extra bureaucratic layer. A good research governance framework should not establish rules but principles which provide enough flexibility for the specifics of a project, according to the ‘comply or explain’ principle. Such research governance should be developed bottom-up, by researchers together with the most interested stakeholders, patient organisations. Patients as ‘biosocial citizens’ are the natural allies of researchers against the ‘paternalistic attitudes’ of some ethicists and regulators.     

Risky creatures: Institutional species boundary change in biotechnology regulation

Novel biotechnologies present acute difficulties to regulation for the very reason that they traverse the boundaries between existing regulatory authorities, their terms of reference, their disciplinary capabilities, and so on. To this extent, they are hybrid phenomena, difficult to categorise and a source of acute uncertainty. Moreover, most biotechnologies confuse and trouble the distinctions between different species. These species disruptions are particularly evident in transpecies transplantation, an illustrative case that we address in detail throughout this paper. From time to time, questions about the safety of such hybrid risks have inspired the establishment of equally hybrid regulatory agencies. Such 'institutional hybrids' are 'risky creatures' and are therefore important objects of social science critique if we are to understand whether or not they have successfully traversed otherwise dangerous gaps in risk regulation. To illustrate these processes of institutional species boundary change, we draw on two examples in the regulation of xenotransplantation. The first examines the establishment of a specific institutional hybrid body for regulating transpecies transplantation, and especially, the scope and limitations of its hybridity. In this way it becomes possible to see how biotechnology is carved up and distributed between various arms of regulation. Second, we document important changes in the definition of xenotransplantation, illustrating the acute difficulties faced by hybrid regulatory institutions in determining what developments they should and should not be regulating.     

Good medical practice: guidance for occupational physicians

Following a catalogue of serious, highly publicized medical misdemeanours, the General Medical Council (GMC) has introduced plans for a new system of medical licensing in the UK called 'revalidation'. Under this, the onus will fall on individual doctors, including occupational physicians, to demonstrate their continuing fitness to practice. Doctors will need to show that they meet basic minimum standards in terms of the care they provide, their own continuing professional development, and other aspects of professional life like probity and ethical behaviour. As part of the process, the Faculty of Occupational Medicine, Royal College of Physicians, has produced its own guidance on good medical practice for occupational physicians, following an extensive consultation exercise. This paper summarizes the background to the initiative, the development process and the standards that have been recommended to aid professional accountability.     

What can transaction costs tell us about governance in the delivery of large scale HIV prevention programmes in southern India?

This paper aims to understand the transaction costs implications of two different governance modes for large scale contracting of HIV prevention services to non-governmental organisations (NGOs) in 2 states in India as part of the National AIDS Control Programme between 2001 and 2003. Interviews at purposively selected case study NGOs, contracting agencies and key informants as well as document review were used to compile qualitative data and make comparisons between the states on five themes theoretically proposed to shape transaction costs: institutional environment, informational problems, opportunism, scale of activity and asset specificity (the degree to which investments made specifically for the contract have value elsewhere). The State AIDS Control Society (SACS) in state Y used a management agency to manage the NGO contracts whereas the SACS in state X contracted directly with the NGOs. A high level of uncertainty, endemic corruption and weak information systems served to weaken the contractual relationships in both states. The management agency in state Y enabled the development of a strong NGO network, greater transparency and control over corrupt practises than the contract model in state X. State X's contractual process was further weakened by inadequate human resources. The application of the transaction cost framework to contracting out public services to NGOs identified the key costs associated with the governance of HIV prevention services through NGO contracts in India. A more successful form of relational contract evolved within the network of the contract management agency and the NGOs. This led to improved flows of information and perceived quality, and limited corrupt practises. It is unlikely that the SACS on its own, with broader responsibilities and limited autonomy can achieve the same ends. The management agency approach therefore appears to be both transaction cost reducing and better able to cope with the large scale of these contracting programmes.     

From consent to institutions: designing adaptive governance for genomic biobanks

Biobanks are increasingly hailed as powerful tools to advance health research. The social and ethical challenges associated with the implementation and operation of biobanks are equally well-documented. One of the proposed solutions to these challenges involves trading off a reduction in the specificity of informed consent protocols with an increased emphasis on governance. However, little work has gone into formulating what such governance might look like. In this paper, we suggest four general principles that should inform biobank governance and illustrate the enactment of these principles in a proposed governance model for a particular population-scale biobank, the British Columbia (BC) Generations Project. We begin by outlining four principles that we see as necessary for informing sustainable and effective governance of biobanks: (1) recognition of research participants and publics as a collective body, (2) trustworthiness, (3) adaptive management, and (4) fit between the nature of a particular biobank and the specific structural elements of governance adopted. Using the BC Generations Project as a case study, we then offer as a working model for further discussion the outlines of a proposed governance structure enacting these principles. Ultimately, our goal is to design an adaptive governance approach that can protect participant interests as well as promote effective translational health sciences.     

Data governance requirements for distributed clinical research networks: triangulating perspectives of diverse stakeholders

There is currently limited information on best practices for the development of governance requirements for distributed research networks (DRNs), an emerging model that promotes clinical data reuse and improves timeliness of comparative effectiveness research. Much of the existing information is based on a single type of stakeholder such as researchers or administrators. This paper reports on a triangulated approach to developing DRN data governance requirements based on a combination of policy analysis with experts, interviews with institutional leaders, and patient focus groups. This approach is illustrated with an example from the Scalable National Network for Effectiveness Research, which resulted in 91 requirements. These requirements were analyzed against the Fair Information Practice Principles (FIPPs) and Health Insurance Portability and Accountability Act (HIPAA) protected versus non-protected health information. The requirements addressed all FIPPs, showing how a DRN''s technical infrastructure is able to fulfill HIPAA regulations, protect privacy, and provide a trustworthy platform for research.     

Cambios de regulación y de gobierno de la sanidad. Informe SESPAS 2014

The economic and fiscal crisis of 2008 has erupted into the debate on the sustainability of health systems; some countries, such as Spain, have implemented strong policies of fiscal consolidation and austerity. The institutional framework and governance model of the national health system (NHS) after its devolution to regions in 2002 had significant weaknesses, which were not apparent in the rapid growth stage but which have been clearly visible since 2010. In this article, we describe the changes in government regulation from the national and NHS perspective: both general changes (clearly prompted by the economic authorities), and those more specifically addressed to healthcare. The Royal Decree-Law 16/2012 represents the centerpiece of austerity policies in healthcare but also implies a rupture with existing political consensus and a return to social security models. Our characterization of austerity in healthcare explores impacts on savings, services, and on the healthcare model itself, although the available information only allows some indications. The conclusions highlight the need to change the path of linear, rapid and radical budget cuts, providing a time-frame for implementing key reforms in terms of internal sustainability; to do so, it is appropriate to restore political and institutional consensus, to emphasize «clinical management» and divestment of inappropriate services (approach to the medical profession and its role as micro-manager), and to create frameworks of good governance and organizational innovations that support these structural reforms.     

The 2017 reform of the hospital sector in Poland – The challenge of consistent design

Beginning in October 2017 a system of basic hospital service provision, popularly called the ‘hospitals network’ was implemented in Poland. It covered 594 hospitals out of a total number of approx. 920 operating in 2017. The regulation’s official objectives were to: “(1) improve the organization of services delivered by hospitals; (2) improve access to hospital care; (3) optimize the number of specialist wards; (4) improve coordination of in- and out-patient care; (5) facilitate hospital management”. The aim of this paper is to describe the background of the reform planning and its formal objectives, content and implementation process, as well as to assess the preliminary results and discuss the possible limitations and implications. Although the official term ‘hospitals network’ is used to describe the reform, in practice it does not involve an element of cooperation between hospitals. The regulation’s main feature was changing the financing methods for a pre-defined scope of services (from per-case to global budget).The reform was planned and implemented on a rather ad-hoc basis while its major controversy is the lack of quality of care, health outcome and population health need measures in the network inclusion criteria. The assessment of the reform’s impact on service provision requires long-term analysis and access to detailed quantitative data.