Translational science and the hidden research system in universities and academic hospitals: a case study

Innovation systems (IS) and science policy scholarship predominantly focus on linkages between universities and industry, and the commercial translation of academic discoveries. Overlooked in such analyses are important connections between universities and academic hospitals, and the non-commercial aspects of translational science. The two types of institutions tend to be collapsed into a single entity-'the university'-and relational flows are lost. Yet the distinctions and flows between the two are crucial elements of translational science and the biomedical innovation system. This paper explores what has been called the 'hidden research system' that connects hospitals, universities, and their resources, with the clinical and scientific actors who make the linkages possible. Then, using a novel conceptual model of translational science, we examine the individual interactions and dynamics involved in a particular example of the biomedical innovation system at work: the diagnosis of IRAK-4 deficiency, a rare immunological disorder, and the translational flows that result. Contra to conventional IS analyses, we are able to point to the strong role of public-sector institutions, and the weak role of the private-sector, in the translational processes described here. Our research was conducted within a Canadian network of scientists and clinician-scientists studying the pathogenomics of immunological disorders and innate immunity.     

Trends in specialized surgical procedures at teaching and nonteaching hospitals

Teaching hospitals are the principal site of many specialized surgical procedures. The recipients of these procedures tend to be younger, male, and nonwhite and tend to reside in either the poorest or the most affluent neighborhoods. Although the numbers of these procedures performed at major teaching hospitals increased dramatically between 1989 and 1995, they accounted for only a modest proportion of hospital discharges and patient days. Concentration of specialized surgical procedures in major teaching hospitals will likely continue. This trend has implications not only for these hospitals but for health care purchasers, policymakers, medical educators, and clinical researchers as well.     

A case study: surface contamination of cyclophosphamide due to working practices and cleaning procedures in two Italian hospitals

The efficacy of preventive and organisational measures implemented in Italy to prevent the contamination of cytotoxic drug preparation rooms has been investigated, and oncologic wards of two Italian hospitals were examined. The sampling strategy was based not only on potential sources of contamination but also on responses to detailed questionnaires on workplace practices and work organisation. Wipe samples were taken from different surfaces of preparation rooms, before and after the work shift, over a span of a month. Cyclophosphamide was taken as the marker drug that reflects exposure to cytotoxic drugs, being measurable by GC/MS. In one of the two hospitals (Hospital A), a large amount of cyclophosphamide was found, both before and after shift, on the workbench (median value, 2.55 microg dm(-2), before shift), on the floor between the operator working position and the waste bin (>10 microg dm(-2), after shift), as also on door handles and storage shelves. No quantifiable levels of cytotoxic drug were detected in the second hospital investigated (Hospital B). These results could be attributed to the efficacy of cleaning procedures and working practices. In fact, both hospitals were provided with vertical-laminar airflow hoods and the (male) nurses had attended special training courses; but in Hospital A, cleaning procedures were carried out without substances used specifically for the cleaning of surfaces contaminated by cytotoxic drugs such as sodium hypochlorite. Working practices did not include Luer Lock devices. Cyclophosphamide concentrations found in both hospitals, compared with the quantities of drug handled, gave evidence of the importance of the correct handling of cytotoxic agents as a major tool in reducing contamination levels. The results reveal the insufficiency of the risk management measures which do not take into account working practices that are prevailing, and stress the necessity for periodic environmental monitoring, indispensable for evolving effective procedures to prevent antineoplastic drug exposure.     

Legal review: a case study from California--the sharing of peer review information between hospitals and nonhospital providers

You are the chief executive officer of Friendly Neighbor Medical Center, an acute care hospital. On your desk is a letter from your counterpart at The Behemoth Clinic, a large local medical group that not only is very active in managed care contracting in your service area, but also has an important relationship with your hospital. Behemoth has requested extensive access to Friendly Neighbor's peer review files and patient records in order to investigate the care provided by one of Behemoth's physicians. You happen to be aware that the physician has been the subject lately of peer review scrutiny at your hospital, and you would like to cooperate with Behemoth. Can you do so without jeopardizing the legal confidentiality protections available to your hospital's peer review records, not to mention the peer review process generally?     

Cost containment through pharmaceutical procurement: a Caribbean case study

This article discusses the potential for health sector cost containment in developing countries through improved pharmaceutical procurement. By describing the specific example of the Eastern Caribbean Drug Service (ECDS), which provides a pooled procurement service to nine ministries of health in the small island nations of the Caribbean, it examines the elements of the procurement operation that allowed ECDS to reduce unit costs for pharmaceuticals by over 50 per cent during its first procurement cycle. The analysis of ECDS considers: (1) political will, institutional alliances, and the creation of a public sector monopsony; (2) pooling demand; (3) restricted international tendering and the pharmaceutical industry; (4) estimating demand and supplier guarantees; (5) reducing variety and increasing volume through standardizing pack sizes, dosage forms and strengths; (6) generic bidding and therapeutic alternative bidding; (7) mode of transport from foreign suppliers; (8) financing mechanisms, including choice of currency, foreign exchange, and terms of payment; (9) market conditions and crafting and enforcing supplier contracts; and, (10) the adjudication process, including consideration of suppliers' past performance, precision requirements in the manufacturing process, number of products awarded to suppliers, and issues of judgment. The authors consider the relevance of this agency's experience to other developing countries by providing a blueprint that can be adopted or modified to suit other situations.     

Inpatient nursing case management as a strategy for rural hospitals: a case study.

Increasingly, hospitals are facing the dual challenges of cost containment and a nursing shortage. These challenges are especially problematic for rural hospitals where nursing staff must be recruited and quality standards maintained within the financial limitations of lower DRG reimbursement rates when compared with urban centers. Therefore, it has become necessary for rural administrators to find new approaches to maximizing the utilization of available nursing staff. Experts have proposed that one solution to the nursing shortage is redesigning the work of RNs to more fully utilize the knowledge and skill of nurses. Nursing case management--a system in which the registered nurse (RN) assesses patient needs, develops a plan of care, procures and coordinates needed resources, and provides ongoing evaluation of care--is one strategy for redesigning nursing roles which offers potential financial benefits to hospitals. Through daily coordination and evaluation of patient care activities, nursing case managers can ensure cost effective allocation of organizational resources and facilitate early discharge planning. This article includes a case study of a rural hospital that introduced the nursing case management system, the hospital's steps of planning and implementation, and examples of forms associated with the system.     

Improving the quality of work life in hospitals: a case study

Quality of work life (QWL) programs can improve employee morale and organizational effectiveness. But implementing a successful QWL effort in a healthcare setting is not easy because of the unique administrative structure and inherent complexities of modern hospitals. This article describes a joint union-management quality of work life program that was carried out in a large urban medical center. Despite employee enthusiasm for the program and a major commitment of financial and human resources over its three-and-a-half-year course, the program failed to achieve long-term changes in the hospital. The shortcomings of the QWL program are analyzed and recommendations for future practice are described.     

医院管理模式与信息化—附案例研究

目的　探索在当前宏观经济形势下医院改革和发展的经验。方法　所有数据均来自于 2 0 0 3年 11月对广东省中医院进行的管理诊断调查。调查对象包括行政管理人员和业务管理人员 ,采用描述性统计学方法分析数据。结果　广东省中医院有明确的发展战略 ;管理人员普遍重视信息化建设 ,信息化需求强烈 ;信息化建设水平偏低。结论　医院在战略制定的过程中应该包括合适的信息化规划。     

Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study

The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data.     

Developing a performance-based incentive program for hospitals: a case study from Maine

A health care coalition in Maine has piloted a performance-based incentive payment program that creates a single statewide program, based on common standards. Incentive payments were funded by a hospital's financial guarantee that was matched by employers. A two-step incentive allocation methodology differentiates adequate and superior performance. The incentive model is sufficiently flexible to accommodate different settings and evolving performance standards. This case study provides useful insights to payers and hospitals that are considering similar regional initiatives, emphasizing the collaborative context that underscored this venture.     

Cost efficiency of US hospitals: a stochastic frontier approach

This study examined the impact of managed care and other environmental factors on hospital inefficiency in 1631 US hospitals during the period 1990-1996. A panel, stochastic frontier regression model was used to estimate inefficiency parameters and inefficiency scores. The results suggest that mean estimated inefficiency decreased by about 28% during the study period. Inefficiency was negatively associated with health maintenance organization (HMO) penetration and industry concentration. It was positively related with Medicare share and for-profit ownership status.     

Broadbanding a surgical academic practice salary: a possible score

How can we look at productivity in academic centers when surgeons perform different procedures that pay differently? Another dilemma is how they are compensated for teaching medical students, residents, and other surgeons. We also have to compensate them for the types and difficulty of the procedures. We can view this problem as either "making the pie bigger" or "dividing the pie better. "First, we should focus on how to "divide the pie. "Regardless of the "pie size," the issue of allocation for remuneration purposes is an important issue. "Dividing" the pie is an internal exercise, whereas making the pie "bigger" involves additional internal and external factors. In this paper, we address the issue of dividing the pie in a measurable way. We also address how to score each activity so that bonuses or compensation can be calculated without the "more" productive surgeons effectively subsidizing the "less" productive, a situation that is often detrimental to organizational success. Academic surgeons are very important for teaching new surgeons and medical students; therefore, they should be remunerated adequately. Pay schemes may be developed to improve the retention of highly productive surgeons in the academic environment.     

Introducing healthy catering practice into hospitals: a case study from Wales

This paper describes results from a study examining the introduction of policies to promote healthy catering in 102 hospitals in Wales. Policy development and implementation followed the publication of two major reports in the UK highlighting the relationship between poor nutrition and subsequent high levels of cardiovascular disease and cancer. Changes in hospital catering services were advocated in response to these reports. The study examines the translation of policy intentions into practical action in hospitals. It identifies achievements in implementing changes in catering practice, and promotion of healthier meals for staff, patients and visitors to hospitals. Important organisational problems and external constraints, including cost, are also highlighted. The authors recommend that greater effort is put into the implementation process following policy decisions, including consideration of training needs, the development of effective communication, and establishment of mechanisms for feedback and review.     

Regional differences in the frequency of various common surgical procedures, 1985

The frequency of five common, in-hospital surgical procedures appeared to vary between Dutch provinces in 1985. The degree of variation was largest for (adeno)tonsillectomies (the highest and lowest values differed by a factor of 2.6), and smallest for abdominal hernia operations (difference a factor of 1.1). Appendectomies, cholecystectomies and hysterectomies showed a moderate degree of variation (differences a factor of 1.4-1.6). The possible causes of these differences are not known with certainty, but results from studies in other countries suggest that differences in practice styles may be involved. Information to surgeons and other specialists on interregional variation in surgical procedures could play an important role in the identification of areas where consensus development, or consensus promoting research, is necessary.     

Developing an outcomes report card for hospitals: a case study and implementation guidelines

Except for a few state mandates and dominant business coalitions in selected markets, the provider report card initiative is a voluntary response to a perceived public desire for performance data on healthcare providers. This study uses a detailed investigation of a single "typical" case to collect information about one hospital's decision processes and the operational activities required to develop a report card for communicating clinical outcomes and financial indicators to its external stakeholders. Three research questions are addressed: How did the organization identify who its key stakeholders for outcomes information were? How were the stakeholders' outcomes information needs determined? What were the stakeholders' information needs and preferred reporting formats? The research findings are reported as a case study. A general model for developing and implementing a report card for public dissemination is proposed. Crucial steps include: Hospital leaders should define the intent of the report card and identify key performance domains. Stakeholders' needs, desires, and intended use of the information should be explored when determining the format of the report card. External validation of the information presented should be obtained. The report should be made available through several mediums including direct mailing, print media, and the Internet. Usefulness of the information included in the report card should be continually evaluated. The outcomes report card can be useful to organizations and their stakeholders in many ways. They provide information about clinical outcomes, cost-effectiveness, and organizational performance in an era when healthcare organizations are competing for marketshare and consumers are demanding to be informed about their healthcare providers.     

Cost containment: are hospitals taking a bum rap?

The private market has been distorted by government regulations and programs; more reliance on market incentives rather than on regulation is needed.