Nesta dissertação foi estudada a aplicabilidade de ferramentas e técnicas da qualidade em um hospital filantrópico, através da execução de projetos de melhoria seguindo a abordagem Lean. Objetivou-se verificar a possibilidade destas de ser uma solução para problemas de gestão de recursos enfrentados por hospitais públicos e filantrópicos brasileiros. Foi feita revisão de literatura sobre o assunto e um estudo de caso foi conduzido em uma Santa Casa de Misericórdia no interior do estado de São Paulo, onde foram aplicadas ferramentas lean. Foram relatadas diversas melhorias, dentre elas uma enorme redução de estoque, eliminação de desperdícios como excesso de deslocamento/transporte e fluxo contínuo. Foi possível concluir que o Lean foi efetivo no hospital estudado e que ainda possui grande potencial de exploração no contexto da gestão da qualidade. / In this master thesis presents the study of the applicability of quality tools and techniques in a philanthropic hospital, through the execution of improvement projects following the Lean approach. The objective was to verify the possibility of these as a solution to the problems of resource management, common problem faced by Brazilian public health hospitals. A literature review on the subject and a case study were conducted at a non-profit hospital in the interior of the state of São Paulo, where lean tools were applied. Several improvements have been reported, among them a huge reduction of stock, elimination of wastes such as excess displacement/transport and continuous flow. It was possible to conclude that the Lean was effective in the studied hospital and still has great potential for exploration in the context of quality management.

This study utilizes a hypercube innovation model to analyze the changes in both healthcare informatics and medical related delivery processes based on the innovations from Tele-health care, E-health care, to M-health care. Further, the critical impacts of the E-health innovations on the stakeholders: healthcare customers, hospitals, healthcare complementary providers, and healthcare regulators are identified. These results indicate that the innovation from Tele-health care to E-health care is architectural for healthcare customers, radical for both hospitals and healthcare complementary providers, and architectural for healthcare regulators. From E-health care to M-health care, innovation is architectural for both healthcare customers and hospitals, racial for healthcare complementary providers, and modular for healthcare regulators. Thereafter, the critical capabilities and suggestions for adopting each innovation are discussed

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Similar to other healthcare systems worldwide, Kuwait faces challenges of increased demand and cost while trying to operate with constrained resources. There are some data suggesting that Lean methodology, first used by Japanese car manufacturer Toyota, could improve system efficiency or flow by waste elimination, may be useful in addressing some of the challenges found in healthcare. Lean has so far not been used in Kuwaiti primary healthcare centres. This thesis explores the case for using Lean in Kuwait by examines issues around diabetes, as Kuwait rank the six highest in the world. In Kuwait, patients with diabetes are mainly managed in primary healthcare centres. The case for using Lean was explored across five interrelated studies which are summarised below: Study 1 involved a review of the literature which found that Lean tools have been used mostly in hospital settings without any rigorous evaluation and with little or no attention paid to primary healthcare or in developing countries. Study 2 was a systematic documentary review of the challenges facing the healthcare system of Kuwait. In Kuwait, expenditure on healthcare services is expected to double within five years. Life expectancy is increasing, while the percentage of the elderly population is growing, leading to increasing demand of services to treat non-communicable disease such as diabetes. Kuwait still sends many of its patients overseas for treatment. Currently, 10 mega projects worth approximately 2 billion Kuwaiti Dinar are being constructed in Kuwait that will result in a doubling of the bed capacity. However, the average occupancy rate between 2006 to 2015 was 63.6%, which is considered low compared to the average occupancy rate in European Union countries. Study 3 sought the views of Kuwaiti healthcare leaders about Lean and challenges facing the healthcare system of Kuwait. The key findings were: (1) Most leaders agreed that the current healthcare system in Kuwait faces difficult challenges and needs to change its management approach; (2) Lean as a management approach is considered a new concept among leaders of Kuwaiti healthcare organisations; (3) They did not have adequate knowledge regarding Lean but were willing to support any future Lean improvement initiatives. Study 4 explored the knowledge of Healthcare Workers regarding Lean within Kuwait’s primary healthcare centres through a cross-sectional survey in four primary healthcare centres. Only 11% of participants were familiar with Lean. None of the participants were involved or had an ongoing Lean initiative or project but 80% of participants were willing to be involved in future Lean initiatives. Study 5 mapped the flow of patients with type 2 diabetes in primary healthcare centres to identify potential waste and make recommendations for improvement. Patients with type 2 diabetes typically visit their General Practitioner at least every two months for a review appointment. When a blood test is required to monitor blood sugar levels, three more visits are required, involving the blood test, collection of test results by the patient and a review of the results with the general practitioner. Four potential improvements were identified: using point of care testing, the posting of laboratory results to general practitioner computer systems, the introduction of guidelines that standardise the practice for the patient’s visit and permitting the general practitioner to prescribe medication that will last four months. The process map of patients with type 2 diabetes has highlighted waste and improvement suggestions that may reduce workload, enhance patient satisfaction, avoid unnecessary visits, enhance the timeliness of laboratory testing, improve communication between and across departments and minimise the use of resources without undermining the quality of care. These suggestions, if implemented on the national level, could bring tremendous benefits but still need to be rigorously evaluated. The thesis concludes by noting that there is considerable potential in adopting Lean to improve the healthcare services in Kuwait, but further work is required to implement the changes and rigorously evaluate them.

In comparison to the European healthcare system, the U.S. healthcare system has lower quality care, higher costs, and covers a smaller percentage of the population. Despite the high costs, the U.S. healthcare system remains dysfunctional. The purpose of this exploratory single case study was to identify the strategies that some healthcare managers in a hospital setting in the midwestern region of the United States use to improve efficiency while decreasing healthcare costs. Complex adaptive systems theory was used to frame this study that included face-to-face interviews with 6 highly experienced healthcare managers. Data were collected from audio recorded interviews and publicly available documents, and the audio recordings were transcribed and analyzed using deductive and open coding techniques to identify themes regarding strategies used by managers to find effective ways for improvement. Three strategies emerged as themes, including improving the accuracy of information and reports, implementing precise and accurate information, and improving quality. The findings of this study may directly benefit healthcare managers and compel positive social change by facilitating successful strategies to improve efficiency and reduce costs. The successful strategies identified in the study might provide a new direction to healthcare managers attempting to adopt new methods. The findings may also contribute to social change by providing solutions that may improve overall organizational performance in a hospital setting.

Healthcare reforms and restructuring have been a global phenomenon since the early 1980s. The major structural reforms in the healthcare system in New South Wales (NSW) including the introduction and implementation of the area health management model (1986), the senior executive service (1989) and performance agreements (1990), heralded a new era in management responsibility and accountability. It is believed that the reforms, the process of the reforms, and the instability brought about by the reforms may have not only resulted in the change of senior healthcare management practices, but also in the change of competencies required for senior healthcare managers in meeting the challenges in the new era. However, limited studies have been conducted which examined how health reforms affected its senior health executive workforce and the above changes. Moreover, no study on senior healthcare managers has focused specifically on NSW after the major reforms were implemented. The purpose of this research was to examine how reforms in the NSW Health public sector affected its senior health executive workforce between 1990 and 1999 in terms of their roles and responsibilities, the competencies required, and the challenges they faced. This study, from a broad perspective, aimed to provide an overview of the NSW reforms, the forces behind the reforms and the effects the reforms may have had on senior health managers as predicted by the national and international literature. This study also explored the changes to the senior health executive workforce in the public sector during the period of rapid change in the 1990s and has provided indications of the managerial educational needs for future senior healthcare managers. Both quantitative and qualitative data have been collected by this study using triangulated methods including scientific document review and analyses, a postal questionnaire survey, and in-depth telephone interviews. The findings from the two quantitative methods informed and guided the development of the open-ended questions and overall focus of the telephone interviews. This study found differences in the characteristics and employment-related aspects between this study and previous studies in the 1980s and 1990s, and identified four major tasks, twelve key roles and seven core competencies required by senior health executives in the NSW Health public sector between 1990 and 1999. The study concludes that the demographic characteristics and the roles and responsibilities of the NSW Health senior executive workforce since the reforms of the 1980s have changed. This study also identified seven major obstacles and difficulties experienced by senior health executives and suggested that during the introduction and implementation of major healthcare reforms in NSW since 1986, barriers created by the ‘system’ prevented the achievement of its full potential benefits. Although this study did not focus on detailed strategies on how to minimise the negative impact of the health reforms on the senior health executives or maximise the chance of success in introducing new changes to the system, some suggestions are proposed. Most significantly, the study has developed a clear analytical framework for understanding the pyramidal relationships between tasks, roles and competencies and has developed and piloted a new competency assessment approach for assessing the core competencies required by senior health managers. These significant findings indicate the need for a replication of the study on an Australia-wide scale in order to extend the generalisability of the results and test the reliability and validity of the new competency assessment approach at various management levels in a range of healthcare sectors. This is the first study acknowledging the impact of the introduction of the area health management model, the senior executive service and performance agreements in the NSW public health system through an original insight into the personal experiences of the senior health executives of the reforms and examination of the major tasks that senior health executives performed and relevant essential competencies required to perform these tasks. The possible solutions identified in this study can guide the development of strategies in providing better support to senior healthcare managers when large-scale organisational changes are proposed in the future.

abstract: ABSTRACT Leadership in Energy and Environmental Design (LEED) is a non-governmental organization of U.S. Green Building Council (USGBC) which promotes a sustainable built environment with its rating systems. One of the building segments which it considers is healthcare, where it is a challenge to identify the most cost-effective variety of complex equipments, to meet the demand for 24/7 health care and diagnosis, and implement various energy efficient strategies in inpatient hospitals. According to their “End Use Monitoring” study, Hospital Energy Alliances (HEA), an initiative of U.S. Department of Energy (DOE), reducing plug load reduces hospital energy consumption. The aim of this thesis is to investigate the extent to which realistic changes to the building envelope, together with HVAC and operation schedules would allow LEED credits to be earned in the DOE–hospital prototype. The scope of this research is to specifically investigate the inpatient block where patient stays longer. However, to obtain LEED credits the percentage cost saving should be considered along with the end use monitoring. Several steps have been taken to identify the optimal set of the end use results by adopting the Whole Building Energy Simulation option of the LEED Energy & Atmosphere (EA) pre– requisite 2: Minimum Energy Performance. The initial step includes evaluating certain LEED criteria consistent with ASHRAE Standard 90.1–2007 with the constraint that hospital prototype is to be upgraded from Standard 2004 to Standard 2007. The simulation method stipulates energy conservation measures as well as utility costing to enhance the LEED credits. A series of simulations with different values of Light Power Density, Sizing Factors, Chiller Coefficient of Performance, Boiler Efficiency, Plug Loads and utility cost were run for a variety of end uses with the extreme climatic condition of Phoenix. These assessments are then compared and used as a framework for a proposed interactive design decision approach. As a result, a total of 19.4% energy savings and 20% utility cost savings were achieved by the building simulation tool, which refer to 5 and 7 LEED credits respectively. The study develops a proper framework for future evaluations intended to achieve more LEED points. / Dissertation/Thesis / M.S. Built Environment 2012

Numerous separate legal norms dealing with the individual spheres of everyday life exist in the Czech Republic at present; some acts mutually overleap and complement one another. Provision of healthcare and healthcare services is regulated by numerous international and national regulations in compliance with adherence to the basic human rights. The healthcare law issues are particularly dealt with by Act No. 372/2011 Col. on healthcare services and the conditions of their prevision, which became effective on 1 April 2012 and substituted Act No. 20/1966 Col. on people health care. Acceptance of the Healthcare Service Act completed the post-revolution changes in healthcare. The Act represents a relatively comprehensive system of rules, among others it regulates the rights and obligations of patients, healthcare providers and healthcare staff in provision of healthcare services. Recodification of the private law was completed in 2012. Act No. 89/2012 Col., the Civil Code was passed within that. It became effective on 1 January. This thesis is divided into five chapters including the conclusion. The first chapter tries to outline the development of the legal norms in healthcare and social sphere in our country. The development of the social-healthcare policy of the state from the late 19th century was later slowed down by the world economy crisis, the Second World War and the consequent normalization. The second chapter gives a brief introduction in the healthcare issues and is divided into several subchapters. It defines the basic terms health and disease. It specifies the individual models of human approach to health, the structure of the Czech healthcare; a part of the chapter deals with the physician-patient relation, particularly with its modification from the paternalistic approach of a physician to a patient to the partnership relation, in which a physician and a patient become equal partners. The third chapter introduces the international and national regulations forming a part of the current healthcare legislation. This legal norm expresses the willingness of the society not only in the Czech Republic to protect the basic values of a human being in healthcare provision. The fourth part of the thesis focuses in detail on selected spheres of provision of healthcare and healthcare services under the effectiveness of Act No. 372/2011 Col. on Healthcare Services and the newly passed Act No. 89/2012 Col., the Civil Code. The new regulation introduces a new type of contractual relation, a contract of healthcare, which should regulate the legal mode of the healthcare provision, including the position of a healthcare provider and a patient in healthcare provision. It also includes a complex regulation of intervention into natural person's integrity and the necessity of his/her agreement with such an intervention. This part of the thesis examines the relation between the Healthcare Service Act and the new Civil Code. The aim of the thesis was to map the previous and the new healthcare legislations and to specify the basic differences in the legal norms, and to assess the consequences of the changes in the regulations for a patient upon comparison of both the legal norms. This thesis is a theoretical one, based on detailed studying and on a content analysis of particularly regulations, specialized literature and further available sources. The conclusion, i.e. the fifth chapter summarizes selected problems of provision of healthcare and healthcare services. The new civil code is based on the requirements of the modern society and provides much higher improvement of patient rights. This levels the legal positions of both the involved subjects, the physician and the patient. Healthcare provision is however primarily regulated by the Act on Healthcare Service Provision and the Conditions of their Provision, namely in more detail than by the new Civil Code, which is in the subsidiarity relation to the special regulation.

abstract: This research is an anthology of a series of papers intended to describe the health state, healthcare experiences, healthcare preventive practice, healthcare barriers, and cardiovascular disease (CVD) risk factors of Asian Americans (AA) residing in Arizona (AZ). Asian Americans are known to be vulnerable populations and there is paucity of data on interventions to reduce CVD risk factors. An extensive literature review showed no available disaggregated health data of AA in AZ. The Neuman Systems Model guided this study. Chapter 1 elucidates the importance of conducting the research. It provides an overview of the literature, theory, and methodology of the study. Chapters 2 and 3 describe the results of a cross-sectional descriptive secondary analysis using the 2013, 2015, and 2017 Behavior Risk Factor Surveillance System (BRFSS) datasets. The outcomes demonstrate the disaggregated epidemiological phenomenon of AA. There were variations in their social determinants of health, healthcare barriers, healthcare preventive practice, CVD risk factors, and healthcare experiences based on perceived racism. It highlighted modifiable and non-modifiable predictors of hypertension (HTN) and diabetes. Chapter 4 is an integrative review of interventions implemented to reduce CVD risks tailored for Filipino Americans. Chapter 5 summarizes the research findings. The results may provide the community of practicing nurses, researchers, and clinicians the evidence to plan, prioritize, and implement comprehensive, theoretically guided, and culturally tailored community-led primary and secondary prevention programs to improve their health outcomes. The data may serve as a tool for stakeholders and policy makers to advocate for public health policies that will elevate population health of AA or communities of color in AZ to be in line with non-Hispanic White counterparts. / Dissertation/Thesis / Doctoral Dissertation Nursing 2020

This study examines major American maternal and children’s healthcare initiatives in the backdrop of international and national crises from 1917 to 1969. During these crises, maternal and child welfare reformers used the rhetoric of citizenship and democracy to garner support for new maternal and child healthcare policies at the national level. While the dissertation focuses on national policies, it also explores how state public health officials from Alabama, Mississippi, and New York implemented these programs and laws locally. The dissertation chapters study regional similarities and differences in maternal and child healthcare by highlighting how economy, culture, and politics influenced how national programs operated in different states. By utilizing White House Conference on Children and Youth Series sources, state public health records, and newspapers, this dissertation argues that by using rhetoric about protecting mothers, children, and American democracy, the Children’s Bureau (CB) members claimed and maintained control of maternal and child health care for over fifty years. CB leaders used World War I draft anxieties as a rallying call to reduce infant mortality and improve children’s health. In the following decades, maternal and children’s healthcare advocates met at the White House Conference on Children and Youth Series to discuss policies and influence legislation relating to maternal and child hygiene. The Sheppard-Towner Program, Title V or the Maternal and Children’s Health Section of the Social Security Act, and the Emergency Maternity and Infancy Care Program reflect policies debated at these White House conferences. By the 1950s, child welfare advocates associated mental health with a child’s overall health and the CB leaders and other child welfare reformers linked happy personalities to winning the Cold War. In the 1960s, the CB members and child welfare advocates’ attention shifted to focusing on low socio-economic mothers and children or children with intellectual disabilities. By 1969, the Children’s Bureau no longer managed national maternal and child healthcare programs and could not “safeguard the health of mothers and children.”