In March of 2010, the 44th President of the United States, Barack Obama, signed into law a health care reform bill that will change the medical and business approach to healthcare that has been witnessed for quite some time. The Patient Protection and Affordable Care Act, aims to eliminate several inefficiencies encountered in our current health care system, as well as extend coverage by providing affordable care for the roughly forty six million Americans currently uninsured. Many of the changes will be implemented over the next several years, but hospitals, businesses, physicians, and insurance companies are no doubt planning ahead for the effects these changes will have on their particular industry. Although there will be many facets of change affecting all of the previously mentioned occupancies, the goal of this paper is to investigate the effect healthcare reform will have on private medical practices in the United States. The following sections will cover ways in which medicine has been practiced in the pre-reform era, historical attempts made to pass health reform legislation, several of the issues our current system faces along with the reform changes implemented to fix them. Then I will investigate the effect these changes will have, if any, and conclude by relating everything back to independent medical practices.

According to the Institute of Medicine (IOM), the U.S. health care delivery system does not provide consistent, high-quality medical care to all people all the time. As a significant component of the health care delivery system, the state of Graduate Medical Education in the United States has prompted much analysis in recent years due to the general view that desired and actual outcomes are increasingly at variance with each other. One area of focus has been the implications of change for provider credentialing and funding of graduate medical education. With this research we test the hypothesis that residents perform valuable work in the teaching hospitals where they undergo training, to inform the issue regarding provider credentialing for residents. We developed a framework to compare second-year residents (PGY2), physician assistants with one year of experience, and nurse practitioners with one year of experience to measurably address the interchangeability of providers. Data was collected by obtaining expert opinions on the proficiency of the three provider options (resident, physician assistant, nurse practitioner) in performing a set of tasks/procedures by surveying the program directors of Internal Medicine residency programs in the United States. The other residency programs at the University of South Floridas College of Medicine were also surveyed to obtain measurable performance on the service providers.Statistical tools were used to analyze the survey responses, aggregate patient data and salary data for each provider. The data analysis and summary indicated that residents displayed higher levels of proficiency than physician assistants and nurse practitioners for the tasks investigated.

Darbo tikslas. Ištirti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų nuomonę apie konfliktų valdymą. Uždaviniai. 1. Įvertinti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų požiūrį į konfliktus darbe ir jų priežastis; 2. Atskleisti vyraujančias konfliktų valdymo strategijas tarp Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų; 3. Įvertinti Lietuvos daugiaprofilinės ligoninės N skyriaus darbuotojų ketinimus gilinti žinias konfliktų valdymo srityje. Tyrimo metodika. Tyrime objektas – darbuotojai, dirbantys Lietuvos daugiaprofilinės ligoninės N klinikoje. Tyrimui atlikti buvo pasirinkta anketinė apklausa. Naudotas T. Killman konflikto būdo instrumentas. Kokybinių požymių tarpusavio priklausomumui vertinti taikytas chi kvadrato (χ2) kriterijus. Priklausomai nuo imčių dydžio, buvo taikytas tikslus Fisher's arba Monte Carlo (mažoms imtims) ir asimptominis χ2 kriterijus. Tyrimo kintamųjų struktūrai tirti panaudotas faktorinės analizės metodas. Rezultatai. Daugiau nei pusė respondentų (67,4 proc.) konfliktus įvertino visiškai neigiamai, visiškai teigiamai konfliktus vertina tik 7,2 proc. darbuotojų. Pseudokonfliktus, kaip dažniausiai vykstančius, įvardino 34,9 proc., tarpasmeninius – 31,0 proc. darbuotojų. Pusė respondentų (50,0 proc.), esant konfliktinei situacijai, naudoja vengimo strategiją, 27 proc. apklaustųjų bando ieškoti kompromiso ir tik 2 proc. bendradarbiauja. Didžioji dalis respondentų 76,9 proc. norėtų gilinti savo žinias šioje srityje... [toliau žr. visą tekstą] / Aim of the study. To reveal employees opinion on conflict management in N division of Lithuania multi-division hospital. Objectives. 1. Rate employees opinion on conflict at the workplace and conflict management in N division in Lithuanian multi-division hospital; 2. Reveal prevailing conflict management strategies among employees; 3. Reveal employees intention to deepen their knowledge of conflict management. Methods. Study object – employees of N division of Lithuanian multi-division hospital. Study questionnaire along with T. Killman conflict mode instrument was used. For qualitative assessment of interdependence of variables the chi-square (χ2) test was used. Depending on the size of the sample, Fisher or Monte Carlo (for small samples) and asymptomatic χ2 criterion were used. Factor analysis was used to investigate the structure of study variables. Results. More than half of the respondents (67.4 %) evaluated conflicts as a completely negative object and only 7.2 % of employees see it as a positive object. Pseudo conflicts, as usually occurring in the workplace, were named by 34.9 %, interpersonal – 31.0 % and structural – 22.9 % of employees. In a conflict situation half of the respondents (50.0 %) are using avoidance strategies, 27 % - are trying to find a compromise and only 2 % of employees cooperate. The majority of the respondents (76.9 %) would like to deepen their knowledge in this area. Most acceptable conflict management knowledge and skill development... [to full text]

Développer des produits mieux acceptés en intégrant les préférences des parties prenantes constitue un principal défi pour les concepteurs et les chefs de projet. Comment évaluer et améliorer l'acceptabilité des utilisateurs est devenu une importante question de recherche. Les approches actuelles laissent cette question pour les dernières étapes du processus de développement de nouveaux produits (NPD), quand un prototype est presque fini et quand c’est trop tard pour apporter des modifications. Pour cela nos travaux se déclinent dans les contributions suivantes : • Principes et démarches de co-conception testés au travers deux études de cas. • Démarche de co-adaptation de l'habitat pour le maintien à domicile. • Démarche d'évaluation du niveau d'acceptabilité d'une solution basée sur les réseaux bayésiens. • Démarche d'amélioration du niveau d'acceptabilité évalué, permettant la recherche et simulation de scénarios d'amélioration, combinant les réseaux bayésiens et un algorithme de recuit simulé. Les modèles et démarches proposés ont été appliqués à des projets de conception dans le domaine de la santé pour lequel nous avons pu identifier des spécificités / Developing products that are better accepted by integrating users’ and stakeholders’ preferences is a major challenge for designers and project managers. How to evaluate and improve users’ acceptability has become an important research question. Current approaches leave the acceptability evaluation question for the last stages of New Product Development process (NPD), when a prototype is almost finished and when it is too late to make changes. For this our work is divided in the following contributions: • The test of the co-design approaches through two case studies. • A co-adaptation approach of the habitat for home-healthcare. • An assessment approach of the acceptability level of a solution based on Bayesian networks. • An improvement approach of the assessed acceptability level, enabling the research and simulation of improvement scenarios, combining Bayesian networks and a simulated annealing algorithm

Model development for incorporating “indigenous” postnatal care into a midwifery healthcare system is of utmost importance in ensuring the provision of culturally congruent care. There has been only limited evidence of the availability of a model which addresses “indigenous” postnatal care practices in midwifery health care systems. As a result, the nurses operate from a modern healthcare point of view only, rather than combining the two worldviews. The main aim of the study was to develop a model for incorporating “indigenous” postnatal care practices into the midwifery health care system in Mopani District, Limpopo Province of South Africa. The study was conducted in three phases. During the first phase the meaning of the concept “incorporation” was analysed. The results guided the researcher during data collection in the second phase, consisting of in-depth individual and focus group interviews to explore the experiences and perceptions of postnatal patients, family members, traditional birth attendants, registered midwives, Midwifery lecturers and the maternal and child healthcare coordinators. The findings confirmed that currently the “indigenous” postnatal care practices are not incorporated in the Midwifery curriculum, books or guidelines for maternity care. As a result there is lack of knowledge amongst midwives regarding the “indigenous” postnatal care practices and it is difficult for them to provide culturally congruent care. Due to inadequate knowledge midwives are displaying negative attitudes towards the family members, traditional birth attendants and patients from diverse cultures. The participants confirmed that there is no teamwork between the registered midwives and the traditional birth attendants (family members). The study findings also confirmed that currently there are no follow-up visits by the midwives for patients during the postnatal period. The midwives are imposing their health beliefs an practices onto the patients on discharge after delivery, without the involvement of the family members or the traditional birth attendants, resulting in sub-standard postnatal care, leading to postnatal complications and an increasing maternal mortality rate. Based on the findings of phases one and two, a model for incorporating “indigenous” postnatal care practices into a midwifery healthcare system was developed and described. The implications for further studies suggested the evaluation and implementation of the model in the healthcare institutions, nursing colleges, clinics and hospitals as an initial step to assist the Department of Health in Limpopo Province in incorporating “indigenous” practices into healthcare systems. / Thesis (PhD)--University of Pretoria, 2012. / Nursing Science / unrestricted

In a democracy, what should a healthcare system do? It is a question of relevance to many disciplines. In this thesis, I examine that question, and add something original to the existing debate by drawing on, and synthesizing, thinking from several disciplines, and especially philosophical ethics, economics and systems theory. Paper 6 in this thesis, entitled “In a democracy, what should a healthcare system do?”, tackles the thesis question directly. The central conclusion of that paper, and of this thesis, is that a healthcare system in a democracy should do as much good as possible, although sometimes some overall good should be sacrificed for the sake of fairness, as John Broome has argued. However, what counts as the good of healthcare, and when good should be traded off for fairness, depend on your weltanschauung (or worldview). Political pluralism is normal, and every democracy has institutions and processes for making policy when people disagree because their worldviews differ. Ultimately, elected policymakers are accountable for making decisions. This analysis is complemented by paper 5, entitled “Accountability for reasonableness – as unfair as QALYs?”. It assesses the vulnerability of three theories of resource allocation to injustice. It concludes that Daniels and Sabins’ accountability for reasonableness approach is vulnerable because it does not require evidence of costs and benefits. Maximising quality-adjusted life years can also lead to large-scale injustice because it is concerned only with health gain, and not with fairness. I conclude that a “good and fairness framework”, which is drawn from the writing of John Broome, is the least vulnerable to large-scale injustice. There are four other papers in this thesis. “What has the state got to do with healthcare?” (paper 3) makes the case for an important assumption underpinning this thesis, namely that the question of what a healthcare system should do is a question of public policy. Paper 1, entitled “It’s time for rational rationing” argues that efficiency gains are not inexhaustible, and to continue with its austerity programme, policymakers should assess whether the NHS in England could do more good with the same money by doing different things. I explore how philosophical ethics can contribute to policy, and the importance of context when writing papers about policy, in: “Should policy ethics come in one of two colours: green or white?” (paper 2) and “How can one be both a philosophical ethicist and a democrat?” (paper 4).These latter two papers, and much of the narrative within this thesis, explain how my thinking has developed during the course of my PhD, and why I have looked within and beyond philosophical ethics for an answer to my central research question.

The goal of this thesis is to characterize healthcare systems in Czech and Slovak Republic. It compares and describes a development of specific metrics and it aims to create a clear picture of efficiency of a healthcare system in each particular country. In the first part the sole proprietors, employed persons, citizens without any taxable income and citizens insured by state are characterized. The focus of this part is also a description of health insurance system. This description aims mainly on contemporary legal situation, system of redistribution and historical development of healthcare systems. In the practical chapter a system of public health insurance from 2006 until 2010 is analyzed together with national insurance revenue, basic demographic and economic facts influencing the system of health insurance. The practical chapter further analyzes health insurance companies. This analysis is based on comparison of insurance companies from the perspective of insurance revenue and healthcare expenditure. The conclusion summarizes all results of analyses and comparisons.

Le point de départ de cette thèse est le constat que dans les systèmes de santé post-soviétiques les paiements informels aux professionnels de santé perdurent bien au-delà de la transition post-socialiste, et ce malgré les vagues de réforme successives du système de santé.Dans le même temps depuis l'indépendance de la République du Tadjikistan, une défiance profonde envers certains professionnels de santé s'est développée et le renoncement aux soins s'est accru, touchant plus particulièrement les populations vulnérables. Quel rôle jouent alors les différentes pratiques de rémunération informelle ? Sont-elles source de défiance ou un moyen de restaurer la confiance ? Les paiements informels sont-ils ajustés au niveau de vie des patients ou source d'inégalités entre patients ?D'après les indicateurs d'équité mobilisés et contrairement aux idées reçues, les paiements informels ne permettent pas de rendre le système progressif et de garantir l'accès à tous. Les populations les plus démunies cumulent plus de renoncement aux soins.Face à ces barrières à l'accès aux soins, différentes stratégies sont mises en place par les ménages : solidarités informelles, endettement, recours à la médecine traditionnelle, mobilisation de son capital social.On étudie alors, plus précisément, dans quelle mesure la migration, phénomène massif au Tadjikistan, fait partie de ces stratégies et dans quelle mesure les remises de fonds permettent aux ménages bénéficiaires d'améliorer leur accès aux soins. / This dissertation begins with the observation that informal payments to healthcare professionals in post-soviet health systems persisted well beyond the post-socialist transition and despite the successive waves of health care reform.During this transition period, since the independence of the Republic of Tajikistan, there has been a deterioration of trust towards certain health professionals which has been associated with increased forgone care, especially among vulnerable populations. What is the role played by the different informal payment practices? Are they a source of mistrust or a means of restoring trust? Are informal payments adjusted to patients' standard of living or a source of inequality between patients?According to the equity indicators mobilized and contrary to popular belief, informal payments do not make the system progressive and do not guarantee that there will be access for all. The poorest are more likely to forgo care.To cope with these barriers in accessing care, different strategies are put in place by households: informal solidarity, indebtedness, reliance on traditional medicine, mobilization of social capital.More specifically, we then study if migration, a relatively important phenomenon in Tajikistan, is part of these strategies and to what extent remittances enable beneficiary households to improve their access to healthcare.

El acceso a un sistema de salud digno constituye uno de los derechos fundamentales de toda persona, en el Perú se han realizado grandes esfuerzos para mejorar la calidad de los sistemas de salud, es un desafío al bicentenario el brindar un aseguramiento de salud de calidad que pueda alcanzar a todos los peruanos. Este objetivo enfrenta grandes desafíos ya que existen deficiencias en los procesos de las instituciones que brindan servicios de salud, siendo la Aseguradora Pública de Salud uno de los principales actores en el aseguramiento de la salud en el Perú. Nuestra investigación se ha centrado en el proceso de Evaluación Automática (EA), que tiene como objetivo evaluar la validez de las atenciones brindadas por las Instituciones Prestadoras de Servicios de Salud (IPRESS) afiliadas a la Aseguradora Pública de Salud. Durante los años 2017 y 2018 se detectó que el 3.82% y 1.85% del total de atenciones presentaban irregularidades. Estudios hechos a nivel mundial muestran que el nivel de irregularidades en entidades similares se encuentra entre el 3% y el 10% por lo que existe la posibilidad de elevar la capacidad de detección de irregularidades en la citada aseguradora. A través de nuestra investigación hemos identificado que mediante el uso de modelos predictivos construidos mediante la analítica de datos en el proceso de Evaluación Automática (EA), específicamente en la etapa llamada Supervisión Médica Electrónica (SME), se puede incrementar el nivel de detección de irregularidades, para ello es necesario aplicar la metodología CRISP-DM y el software WEKA. / Access to a decent health system is one of the fundamental rights of every person, in Peru great efforts have been made to improve the quality of health systems, it is a challenge for the bicentennial to provide quality health assurance that can reach all Peruvians. This objective faces great challenges since there are deficiencies in the processes of the institutions that provide health services, with the Public Health Insurer being one of the main actors in health insurance in Peru. Our research has focused on the Automatic Evaluation (EA) process, which aims to assess the validity of the health care provided by the Health Services Provider Institutions (IPRESS) affiliated with the Public Health Insurer. During the years 2017 and 2018 it was detected that 3.82% and 1.85% of the total health care presented irregularities. Studies done worldwide show that the level of irregularities in similar entities is between 3% and 10%, so there is the possibility of increasing the ability to detect irregularities in the aforementioned insurer. Through our research we have identified that by using predictive models constructed through data analytics in the Automatic Evaluation (EA) process, specifically at the stage called Electronic Medical Supervision (SME), it is posible to increase the level of irregularity detection, for this it is necessary to apply the CRISP-DM methodology and the WEKA software. / Trabajo de investigación

The Swedish healthcare system is strained today, along with a rise in the number of elderly people in the country. Aside from the expected physical ailments facing this group, mental health issues such as depression are also common amongst older adults. It is the researchers’ assumption that these three societal challenges; the healthcare system being strained, the growing elderly population and the health issues present amongst this group, are connected. Virtual Reality (VR) technologies show promising benefits according to the scientific literature and may prove to be a useful tool in combating the listed challenges. However, the researched benefits of this technology can’t be utilized properly if the target group perceives it as negative or cumbersome, which is why it is imperative to explore this group’s attitude towards the usage of VR as a preventative part of their treatment. This paper aims to explore the perceptions of Virtual Reality technologies in treatment of elderly and to focus on their and the caretakers’ attitudes of its usage, in addition to eventual annoyances or limitations with their current applications by answering the research question: how is the usage of VR technologies in care related functions perceived by elderly people and their caretakers? A qualitative study with an inductive approach was performed by using a small-scale survey strategy, with a focus on the perceptions and experiences of people as well as their feelings and emotions, while aiming to describe and understand the lived experiences of the target demographic and their caretakers. Face-to-face interviews with a semi-structured format were employed at two recreational facilities for elders in Sweden, with participants consisting of three elders between the ages of 83 and 91 along with three caretakers, all of whom were female and had used some form of VR technology in the past. The collected interview data was then analyzed by way of thematic analysis, which generated a total of 2 themes, 8 categories and 21 codes. The results show that both elders and their caretakers generally have a positive attitude towards the use of VR, with none of the interviewees seeing any drawbacks towards its usage. All interviewees wished to see VR become a regular part of the offerings at the recreational facilities, with the frequency of use being deemed reasonable at 2 weeks by all elders who took part in the study. The preferred types of VR experiences consisted of either visiting familiar places or emulating activities that the elders were no longer capable of performing. It was concluded that nostalgia played a big part in what experiences the elders enjoyed, and generated positive effects including feelings of relaxation, escaping reality and increased socialization amongst the elders.