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Operating room scheduling. Choosing the best system.

The multiple criteria involved in the hospital OR scheduling problem cannot be ignored. Our goal is to identify the important criteria regarding this problem and determine the degree to which the scheduling approaches in use do or do not support these criteria. This contingency approach to selecting an OR scheduling system should enable hospital administrators to make policy decisions that will most effectively support stated and unstated organizational objectives.

Consumer Behavior↗

Importance of databases for technology assessment.

The data indispensable for carrying out the comprehensive, multi-faceted process of medical technology assessment (MTA) should be collected from a variety of sources. The authors distinguish between type "A" general data, useful for assessment but collected without this specific aim, and type "B" data. Registries of health care procedures or of diseases, as well as clinical data bases are quoted as examples of type "B" data, specifically relating to MTA. Since demographic methods are of importance for the evaluation of long-term effects of medical technologies, examples of sources of type "A" data are presented. Their significance for health policy making is discussed.

Data Collection↗

Nurses speaking up for mothers and children: 25 years of public policy involvement.

Public policy decisions directly affect the health care of women and children and also affect the practice of maternal and child nursing. The past quarter century has seen a shift in nursing involvement in the public policy process. Heightened awareness of the collective power of nurses, greater independence of the nursing profession, the increasing capability for generating research to guide the formulation of public policy, and nurses' better understanding of the political process have all contributed to the increasing influence of our nation's 2.6 million nurses. The passage of several significant pieces of legislation, such as expansions of the Medicaid program for pregnant women and children in the late 1980s, have opened up new opportunities for nurses to further shape the nation's health care agenda for women and children. Nurses can and should become more involved with the policy-making process at local, state, and national levels to assure that decisions are made that benefit this important population group. Leadership in the public policy arena will give nurses the best opportunities for putting forth the agendas that will accomplish these goals.

Female↗

Evidence-based practice as mental health policy: three controversies and a caveat.

Evidence-based practice (EBP) is the subject of vigorous controversy in the field of mental health. In this paper I discuss three distinct but interrelated controversies: how inclusive the mental health evidence base should be; whether mental health practice is a variety of applied science; and when and how the effectiveness goal in mental health is defined. I provide examples of evidence-based policy in mental health. These controversies pertain as well to general medicine. To the extent that they remain unresolved, evidence-based policy making may lead to ineffective and limited care.

Evidence-Based Medicine↗

The Washington scene.

Presentation of an overview of federal policy in health care. The use of omnibus budget bills to "hide" unpopular costs has led to some reductions in health care costs because legislators were less aware of specific details. The Reagan administration has expressed the view that health care, like other economic products, should be subject to competition in the marketplace. It has also promoted a transfer of responsibility for health care from the federal government to the states. Such Federal policy making has stimulated growth of alternative health care systems.

Economic Competition↗

Nutrition communication from theory to practice: some future perspectives.

'Nutrition communication' can be defined as the process by which nutrition knowledge is converted into dietary change. Nutrition communication then includes nutrition education--the process by which people are informed, and sometimes empowered by, nutrition information--but also other actions taken to improve peoples' diets such as restricting misinformation about nutrition or manipulating the composition, availability or price of foods. Dietary goals for populations and food-based dietary guidelines for individuals constitute the starting point for nutrition communication, and if these could be more evidence-based we would be in a much stronger position to develop more effective nutrition communication. A population-based approach to nutrition communication is complementary to an individualistic approach in theory, but in practice they compete for attention in food policy making circles.

Evidence-Based Medicine↗

Ethical and economic issues in the use of zero-emission vehicles as a component of an air-pollution mitigation strategy.

The air pollution generated by motor vehicles and by static sources is, in certain geographic areas, a very serious problem, a problem that exists because of a failure of the marketplace. To address this marketplace failure, the State of California has mandated that by 2003, 10% of the Light-Duty Vehicle Fleet (LDV) be composed of Zero-Emission Vehicles (ZEVs). However, the policy-making process that was utilized to generate the ZEV mandate was problematic and the resulting ZEV mandate is economically unsound. Moreover, an ethical analysis, based primarily upon the work of John Rawls, suggests that implementation of the California ZEV mandate is--in spite of the wide latitude that ought to be given to policy decision makers--unethical. A more ethical and economically efficient approach to the pollution caused by marketplace failure is one that relies on market incentives and thereby achieves the desired improvement in air quality by appealing both to the self-interest of motorists and to those businesses that are directly or indirectly involved with the automobile industry. Such an approach would take better advantage of the creative forces of the market and improvements in technology over time and avoid the infringements on individual liberty and fairness embodied in the ZEV mandate.

Air Pollution↗

Reproductive Health Hazards in the Workplace: Guidelines for Policy Development and Implementation.

To provide occupational health professionals and employers with guidelines for reproductive health policy making, the authors-both of whom are obstetrician-gynecologists and occupational medicine physicians-review the history of and legal basis for U.S. policy on work and reproduction, delineate the goals and important elements of a reproductive health policy (RHP), and emphasize the need to incorporate an RHP into a comprehensive occupational injury and illness prevention program. After suggesting practical ways to achieve the goals of an RHP (maximal health protection, compliance with legal mandates, and reduction of liability), the authors propose a team-based model for RHP implementation with shared responsibility of management and workers in designing, enforcing, and evaluating the policy.

Journal Article↗

Fighting sectional interests in health care.

In the 1970s policy making in The Netherlands took place in sectoral networks, consisting of professional interest groups and like minded civil servants, advisory councils, mp's and departmental ministers. In this article the author examines whether such a sectoral policy network still exists in Dutch health care by comparing past and present data on the background of civil servants, mp's and departmental ministers. Next she describes the political fight against the health care sectoral network, which has gone on for decades. She concludes that the health care sectoral network has been severely weakened, although it remains to be seen whether this will lead to a substantial reduction of health care costs, which was one of the main reasons why politicians fought against sectoral interests in the first place.

Decision Making, Organizational↗

Ways to think about money.

Healthy People 2010, the nation's objectives for achieving a higher level of health, includes Goal 23-16: Increase the proportion of federal, tribal, state, and local public health agencies that gather accurate data on public health expenditures, categorized by essential public health service. Taking time to understand the complexities of accounting for public health expenditures, as well as the reasons for doing so, is an essential precursor to taking the needed steps to include economic information in public health policy making and public health systems research.

Accounting↗

Developing effective systems for delivery of vaccines.

Effective immunization performance depends on the development and continuous improvement of systems and processes in each of the settings in which vaccines are given. This article gives some examples of improved performance and the role of a variety of techniques such as reminders in achieving improved performance. Measurement of performance plays an important, indeed, essential role in quality improvement and has notably been lacking in immunization activities. For future improvement, it will be important to link policy-making with the remaining elements of the quality improvement cycle.

Aged↗

Women's reproductive autonomy: medicalisation and beyond.

Reproductive autonomy is central to women's welfare both because childbearing takes place in women's bodies and because they are generally expected to take primary responsibility for child rearing. In 2005, the factors that influence their autonomy most strongly are poverty and belief systems that devalue such autonomy. Unfortunately, such autonomy is a low priority for most societies, or is anathema to their belief systems altogether. This situation is doubly sad because women's reproductive autonomy is intrinsically valuable for women and also instrumentally valuable for the welfare of humankind. This paper takes for granted the moral and practical necessity of such autonomy and digs deeper into the question of what such a commitment might entail, focusing on the mid-level policy making that, at least in the US and Canada, plays a significant role in shaping women's options. This paper examines a large teaching hospital's policy on reduction of multifetal pregnancies. The policy permits reduction of triplets to twins, but not twins to a singleton. As there is no morally relevant difference between these two types of reduction, it is evident that inappropriate medicalisation can still limit women's autonomy in undesirable ways.

Abortion, Therapeutic↗

Faculty appointment and tenure policies in medical schools: a 1997 status report.

The authors present recent data on changes under way in and the current status of faculty appointment and tenure policies in U.S. medical schools. The data are drawn from a survey conducted by the Association of American Medical Colleges in 1997, to which deans at all 125 U.S. allopathic medical schools responded, supplemented by follow-up telephone and electronic mail inquiries. Faculty evaluation systems and faculty compensation systems top the list of areas in which medical schools are most frequently making policy changes, with approximately half of the schools involved in each area. Changes in evaluation systems reflect an increasing emphasis on post-tenure review. Changes in compensation systems are characterized by the division of pay into separate components, each with its own financial guarantees and with the level of compensation tied specifically to measures of individual and group productivity. Other policy changes include introducing new faculty tracks and career pathways, redefining or clarifying the portion of salary or compensation that is defined by tenure, lengthening the pre-tenure probationary period, and modifying the link between promotion and tenure. Of the 125 medical schools in the United States, only five do not award tenure, while another six effectively limit eligibility for tenure to basic science faculty. These numbers are unchanged from those reported in 1994. Only two schools indicated that eliminating tenure or ceasing to make tenure-eligible appointments was being considered, and neither reported that a policy change was imminent. Current data on the status of tenure guarantees, tenure probationary periods, other tenure eligibility criteria, and special clinical tracks are provided. Nearly three fourths of the medical schools in the United States now have a separate and distinct faculty track for full-time clinical faculty whose primary responsibilities are in patient care and teaching. The vast majority of these tracks do not permit faculty to be tenured, but 71% require evidence of scholarship for promotion. The authors conclude that faculty personnel policies in medical schools are likely to continue to evolve, consistent with a growing insinuation of the corporate culture into academia.

Career Mobility↗

Health care reform in Portugal: an evaluation of the NHS experience.

Since 1979, the Portuguese health care system has been based on a National Health Service structure that is expected to promote equity, efficiency, quality, accountability and the devolution of power. In this article, we analyse the content and impact of policies designed to reform the system between 1979 and 2002. This article differs from previous studies in that it uses a stage-based framework to evaluate the policy-making process and the impact of health care reform throughout different political cycles. We show that the NHS model has never been fully implemented and that many policies have diverted the system from its original objectives. Different governments have endorsed a progressive split between financing and provision and the institution of 'new public management' rules in public providers. We conclude that most policies put forward by Social Democratic governments have aimed at influencing demand, while Socialist governments have targeted the supply side. These policies have led to increases in health expenditure that have been comparatively more cost-shared by the State under Socialist governments. We show some overriding trends, namely as follows: despite huge improvements in health outcomes, the system is nonetheless lasting to meet its goals, particularly in terms of the equity of access and utilisation; accountability problems, inadequacies in the use of operational reforming tools (such as resource allocation mechanisms) and a lack of mechanisms to promote efficient behaviour, are all associated with cost containment problems. Structural reforms have been undertaken since 2002 and these have offered some potential for improving accountability and efficiency. Nonetheless, the success of these reforms calls for certain conditions that do not seem to have been fulfilled.

Financial Management↗

Nutrition and health: patterns and policy perspectives in food-rich countries.

Nutrition and health are becoming legitimate policy issues in food-rich countries. Dietary patterns contribute to a large share of the dominant chronic disease profile in advanced industrial nations, burdening the public purse. Major issues facing governments concern decisions about the appropriate goals, scope, and instruments for effective policy, and the apparatus to promote it. Norway, using a long term, explicit and comprehensive public policy, and the U.S., using a market-oriented strategy, illustrate contrasting policy approaches to the issues. The experience of both have implications for current policy-making in other countries and for the kind of research needed to support it.

Feeding Behavior↗

Imaging technologies. Iconoclasts among the images.

High technology developments in diagnostic imaging raise a number of issues that are disturbing. New developments do not always favor greater diagnostic efficacy since fads, marketing promotion, and entrepreneurs can distort medical goals. New advances disseminate rapidly in affluent societies before formal benefit evaluations are completed. We suggest that digitization of radiography must be critically assessed, and simplicity of equipment design should be promoted. Though medical and economic factors can provide guidelines for policy making, the ultimate priority decisions are political in nature.

Diagnostic Imaging↗

Influencing national policy; public health medicine and coronary heart disease prevention by general practitioners.

BACKGROUND: Public health medicine has a potentially important role to play in influencing national health policy. This study examines the role of public health medicine in the development of the policy on coronary heart disease prevention in general practice, exemplified by the 1990 and 1993 general practitioner (GP) contracts. METHODS: The methods of the study were qualitative. There were two sources of data: interviews with 33 key informants and analysis of documents relating to the policy process. RESULTS: Public health medicine as an organized medical specialty had little involvement with the development of the policy. The reasons for this include a closed policy process which tended to exclude those not from a primary care background, the role of political factors, the predominance of secondary care concerns by public health medicine in the early 1990s, and differences in perspective between primary care and public health medicine. Public health medicine structures did not have systematic links with the policy process. Public health physicians working in research had more influence, but this was also limited by the absence of any systematic scientific advisory links. CONCLUSIONS: To influence national policy it is necessary to have formal and informal systematic links with the policy-making machinery at all levels of the specialty.

Coronary Disease↗