Integrating medical specialists and hospitals. The growing relevance of collective organisation of medical specialists for Dutch hospital governance

The policy of the Dutch government (now enshrined in legislation) aims at the integration of medical specialists in hospitals and seeks to end the economic and organisational autonomy of the medical specialist. This article suggests that this policy has also acted as an incentive for medical specialists to develop local strategies that often diverge. Medical specialists are pursuing strategies that aim to strengthen their collective power within the hospital organisation while at the same time consolidating their entrepreneurial status. Medical staff governance has consequently become a key factor in hospital governance.     

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999.

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument 'controlled' by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.     

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in the Netherlands and England, 1970–1999

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the ‘compulsory’ introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument ‘controlled’ by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.     

Care provided by general practitioners to patients with psychotic disorders: a cohort study

Background

There is a decline in the relative numbers of general practitioners in Germany. Earlier research showed that the professional relationship between general practitioners and specialists is overshadowed by conflicts which could influence medical students not to choose a career in general practice. The aim of the study is to analyse potential discrepancies between general practitioners' self-perception of their professional role and their social self-image in relation to medical specialists and to identify potential barriers that might prevent medical students from becoming a general practitioner.

Methods

A qualitative study design consisting of 16 interviews with general practitioners was chosen. Data analysis was carried out using the qualitative content analysis by Philipp Mayring.

Results

There is a discrepancy between general practitioners' professional self-perception and how they perceive they are viewed by specialists. General practitioners communicate a positive self-perception of their professional role. While general practitioners think that specialists in outpatient care have a positive view on general practice, it is assessed to be negative by specialists working in hospitals and as medical teachers.

Conclusion

The negatively influenced social self-image may originate particularly from "badmouthing" general practitioners at universities and in hospitals. "Badmouthing" demonstrates the importance of the consideration of psychological aspects in medical teachers and hospital specialists acting as role models. Negative comments should be considered as an important factor in influencing medical students and trainees' career choices. These aspects should be more integrated in future medical education curricula.     

The hospital medical director: his role and professional qualification in Modena (Italy) health care system

The development of health care system in Italy, from 1968, have changed the hospital medical director function and have put him in conflict with the desired physicians involvement in health care management. In Modena the health care system organisation, the self government and the responsibility decentralisation, promoted the achievement of an organisation model tempering every competence because the success of everyone's task depends on the other one's. Therefore, Italian laws are suitable of getting more efficiency and effectiveness in health care system without new rules, if the clinical governance becomes a way to involve the physicians in management and not an instrument to leave out managers and hospital medical directors.     

大型公立医院运营模式的改革与探索

复旦大学附属华山医院北院在创新体制,建设符合医疗卫生体制改革方向的医院运营模式方面进行了初步的探索,文章从绩效管理、财务管理、后勤管理、药品管理、“点数平衡法”收付费模式、医疗质量与安全管理、人才和学科建设等方面对医院运营改革情况进行了阐述。     

Maritime health in Spain: integrated services are the key

The maritime occupational health services in Spain are overviewed, and their coordination for seafarers and fishermen within the integrated governmental "Maritime Health Programme", which as from 1984 has been supervised by the Labour and Social Affairs Ministry. The institution in charge is the "Instituto Social de la Marina" (ISM) in Madrid (Mariners' Social Institute) established in 1919, which has organised a network of specialised health institutions in ports. They provide medical assistance on board ships and coastal preventive services for maritime workers. There is the Radio Medical Advice Centre in Madrid, local centres in ports, centres abroad, hospital ships and a repatriation centre. All of them are connected in a centralised database net of shared medical records in a confidential computerised system. Another institution is "Sanidad Exterior" which is related to vaccinations and hygienic problems in harbours. There is also a non profit national scientific medical organisation, the Spanish Society of Maritime Medicine (SEMM) established in 1989, and another society of Naval Medicine founded in 1995. There are also groups of specialists in underwater medicine and health problems of divers. A separate article is published on the SEMM and its activities.     

Hospital organisation and structure and its effect on inter-professional behaviour and the delivery of care

Some form of organisation within and between hospitals is necessary to provide effective and integrated care to patients, to ensure that medical, nursing and paramedical services develop efficiently and coherently, and to ensure that needs of the community are met. However research into the design of structures for the provision of hospital services has been remarkably limited considering the transformation of hospital work in recent decades. The absence of clearly articulated models of organisation and lack of consensus on the relevant data make needed comparative studies difficult to mount. Nevertheless systematic empirical and evaluative studies of matters like appropriate limits to authority, working of intraprofessional hierarchies, management of clinical autonomy, and the effects of interprofessional rivalry on patient-care seem both feasible and desirable. Many studies bearing directly on these topics take the form of inquiries mounted within government departments or by professional groups with an interest in the outcome.     

The independent medical specialist and altered legal relations

The relationship between an independent medical specialist and the hospital is governed by the access agreement. On 1 January 2008, the financing of medical specialist care has changed, with dramatic consequences for the legal relationship between independent medical specialists and the hospital. Increased attention to quality control also affects this relationship. The model access agreement needs to be changed on some points as a result of various developments so that the hospital management will have more tools at hand to manage patient care.     

保定市中医医院管理会诊制研究

由卫生管理专家、医疗技术专家组成的管理会诊小组，对保定市各中医院进行了从院外环境到院内各个职能科室的卫生管理会诊，通过会诊发现问题、分析问题和解决问题。该研究的最大特点在于改变了以往的纯理论知识的灌输给管理者带来的管理理论与管理实践的脱节。通过医院管理会诊，使医院管理者针对医院存在的具体问题，运用管理理论进行指导，实现了管理理论指导实践的作用。     

突发公卫事件中医院“四全”系统网格化感染管理探讨及实践

目的 在突发公卫事件背景下，针对既有事件经验模式总结，提升医院感染管理水平以保障医疗安全，恢复日常业务。为医院在应急状态下，筹措全组织、全过程、全流程、全要素的“四全”感染管理机制提供参考。方法 以中国某大型综合医院在突发公共卫生事件中各医疗服务节点的系统性响应行为基础，结合国内外对策研究，归纳“自下而上”与“自上而下”的“四全”网格化系统性管理机制及经验。结果 在“四全”网格化医院感染管理下，门诊业务恢复率达95%，住院率达100%，无院内感染发生。结论 系统性网格化的“四全”院感管理体系在做好疫情防控的同时，保障了医院及时开展日常诊疗服务，为人民群众提供安全有效的医疗服务。     

Therapeutic pluralism? Evidence,power and legitimacy in UK cancer services

The integration of complementary and alternative medicine (CAM) into cancer services is increasingly discussed as a potential part of UK health policy but as yet there has been little sociological research examining this process. This paper examines the results of a study on the provision of CAM to cancer patients in two distinct organisational contexts: the hospice and the hospital. It is based on interviews with medical specialists, nursing staff and CAM therapists. This paper focuses on how integration is managed in each organisation, examining professional boundary disputes and inter-professional dynamics. Discussion focuses on the rhetorical and practical strategies that are employed by a variety of differently positioned interviewees to negotiate the complexities of the interface of CAM and biomedicine. The results show significant differentiation in how differently positioned cancer clinicians view and utilise the biomedical hierarchy of evidence. We argue that the integration of CAM should not be conceptualised as a mere challenge to biomedicine, or, as resulting in a linear process of de-professionalization. Rather, it should be seen as producing a complex array of processes, including strategic adaptation on the part of medical specialists and NHS organisations.     

基于Snell模型和双因素激励理论的公立医院人力资源管理

随着公立医院改革逐步深入,医院传统的人事管理模式弊端凸显.为了探索建立科学高效、分类管理的新型人力资源管理机制,本研究基于人力资本框架模型（Snell模型）.将公立医院人力资源分为核心人才、独特人才、通用人才和辅助人才,结合公立医院人力资源构成,明确这4类人才涵盖范围和特征.然后根据双因素激励理论,结合各类人才特征,制定差异化的管理方式和激励策略,以激发各类人才的工作积极性,提高医院核心竞争力.     

How the organisation of medical work shapes the everyday work experiences underpinning doctor migration trends: The case of Irish-trained emigrant doctors in Australia

Medical migration is a global phenomenon. In Ireland, hospital doctor emigration has increased significantly in recent years, with Australia a destination of choice. With work and employment conditions cited as a driver of these trends, this article explores how health system differences in the organisation of medical work shape the everyday experiences of hospital doctors which underpin migration decisions. Drawing on 51 semi-structured interviews conducted in July-August 2018 with Irish-trained hospital doctors who had emigrated to work in Australia, the findings highlight doctors’ contrasting experiences of medical work in the Irish and Australian health systems. Key system differences in the organisation of medical work manifested at hospital level and related to medical hierarchy; staffing, support and supervision; and governance and task coordination. Findings indicate that retention of hospital doctors is as much about the quality of the work experience, as it is about the quantity and composition of the workforce. At a time of international competition for medical staff, effective policy for the retention of hospital doctors requires an understanding of the organisation of work within health systems. Crucially, this can create working contexts in which doctors flourish or from which they seek an escape.     

The Composition of Rural Hospital Medical Staffs: The Influence of Hospital Neighbors

The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.     

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

PURPOSE

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology.

METHODS

We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach.

RESULTS

The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses.

CONCLUSION

This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients.     

行为医学、医学行为在医院管理中的地位和作用

由于不良行为或不当生活方式而引起的疾病,严重威胁着人类健康,危害社会,影响整个民族素质的严峻事态,是摆在社会学和医学工作者面前不容忽视的新问题。同时也给医院管理者提出了新的课题。医院管理者要适应医学模式的转变,更新服务观念,建立真诚良的医患,护患关系,拓展行为医学工作的范围,加大临床心理学在实践中的应用,使以病人为中心的工作理外新水平。     

Treatment of Pneumonias in a Managed-Care Organisation

Objective: To evaluate a pneumonia disease management programme in a naturalistic setting. Design and Setting: A 300 000 member managed-care organisation introduced an antibacterial treatment guideline designed to change antibacterial prescribing by physicians. A relational database was created to measure changes in healthcare resources, use of antibacterials and health event profiles. One year of data before and after promoting the treatment guideline was compared. Intervention: The primary disease management intervention was the promotion of the guideline through mailings and face-to-face interventions by 2 disease management specialists. Participants: All patients with pneumonia diagnoses on the medical claims database were included in the analysis. Results: The study demonstrated that medical costs increased by 5 to 10% after the treatment guideline was implemented. Health event analysis demonstrated changes in antibacterial prescribing and average cost per antibacterial selected. In both years, the highest success rate was with the amoxicillin group. Although there were fewer patients, doxycycline also had success rates of at least 70%. The econometric model demonstrated that holding other variables constant, including patient age and the presence of any comorbidities, treatment with amoxicillin was associated with a statistically significant reduction in health event costs. Conclusions: The study identified the need for validating treatment guidelines with results from actual practice. The data also demonstrate the use and importance of measuring clinical and economic outcomes from disease management interventions by using databases readily available within most managed-care organisations. In addition, the econometric model was useful in comparing different drug groups with these retrospective data.     

分时段预约挂号的实现与应用

我院依托医院信息化平台,在创新预约挂号模式,预约号源管理,改善预约挂号服务等方面进行了积极的尝试,尤其在预约挂号方式上,实行分时段预约就诊,推行专家门诊和普通门诊全预约诊疗,由患者自主选择就诊时间,最大程度满足广大群众就医需求,缓解门诊供需矛盾,使门诊医疗活动更加文明有序,缓解患者看病难的突出问题.     

关于医院管理学科体系的研究

目的 探讨医院管理学科体系结构,为医学院纱学生课程设置及医院进行管理队伍继续教育提供参考。方法 采用文献复习、重点调研、专家咨询结合的方法实施研究。结果 赞同管理学科为４年制的有２０人,５年制的有２５人;认为管理者的医学学历为大专的１８人,本科的２７人;管理专业课程设置可分为公共基础课,医学基础课、医学临床课、专业基础课、专业课５部分５个阶段进行,并认为管理者的素质与一般医生的要求不同。结论对医院