Although open to debate, it is something of an undisputed fact and has been since the days of Florence Nightingale, that hospital management is frustrated with recurring problems - many of them due to broken processes. Hospitals are places of phenomenal healing and heroic care. However, as with any human-led endeavour, there are problems. (Grunden (2009)) A first time use of the word ‘lean’ generally begs some explaination as it is not a commonly used word. The simplest way to explain the word is by way of the introduction of the concept known as ‘lean management’. Lean management is a methodology which allows hospitals to advance the quality of patient care by reducing errors and waiting times. Lean is a system of reinforcement of hospital business for the long term thereby reducing costs and risk. Kanban (2009) states that lean is a toolset; a management system and a viewpoint that can change the way hospitals are structured and managed. Lean helps managers to comprehend and identify broken systems and to improve these in small parts, while employees aid in finding solutions for broken systems. This proposal analyses the effect lean tools have had within Arwyp Medical Centre in Kempton Park, South Africa.

Although open to debate, it is something of an undisputed fact and has been since the days of Florence Nightingale, that hospital management is frustrated with recurring problems - many of them due to broken processes. Hospitals are places of phenomenal healing and heroic care. However, as with any human-led endeavour, there are problems. (Grunden (2009)). A first time use of the word ‘lean’ generally begs some explaination as it is not a commonly used word. The simplest way to explain the word is by way of the introduction of the concept known as ‘lean management’. Lean management is a methodology which allows hospitals to advance the quality of patient care by reducing errors and waiting times. Lean is a system of reinforcement of hospital business for the long term thereby reducing costs and risk. Kanban (2009) states that lean is a toolset; a management system and a viewpoint that can change the way hospitals are structured and managed. Lean helps managers to comprehend and identify broken systems and to improve these in small parts, while employees aid in finding solutions for broken systems. This proposal analyses the effect lean tools have had within Arwyp Medical Centre in Kempton Park, South Africa.

Background: Current cesarean delivery (CD) rates in many industrialized countries are well above the recommended rates. Objective: The overall goal of this thesis was to identify sources for unnecessary CD. Specific objectives were to: 1) analyze the leading indications for CD and their associations with neonatal outcomes; 2) compare adverse birth outcomes between elective primary cesarean delivery (EPCD) and trial of labor after vaginal birth (TOLAV), and between elective repeat cesarean delivery (ERCD) and trial of labor after cesarean birth (TOLAC); and 3) assess the cost-effectiveness of ERCD and TOLAC. Methods: A retrospective cohort study was conducted. Leading indications for CD were analyzed and risks of neonatal outcomes between “soft” indications and “hard” indications were compared first, using 2006 to 2013 Better Outcomes and Registry Network Ontario data. A pair of analyses: comparing risks of adverse birth outcomes between EPCD and TOLAV and between ERCD and TOLAC, were then conducted using United States 2005 to 2010 birth registration data. Analysis were performed using logistic regression and propensity score matching models. Finally, a cost-effectiveness analysis between ERCD and TOLAC was performed. Results: The single largest contributor for overall CD was ERCD (34.3%) and for primary CD was dystocia (31.9%) in Ontario. Compared with infants of mothers with CD for “hard” indications, the risks of Apgar score <7 at 5 minutes for infants of mothers with CD for non-reassuring-fetal-status was increased, while the risks of Apgar score <7 at 5 minutes and neonatal death for infants of mothers with ERCD and dystocia were decreased. Compared with infants of mothers who underwent TOLAV, infants of mothers who underwent EPCD were more likely to require antibiotics and ventilation support, but less likely to have birth injury. On the other hand, compared with infants of mothers who underwent TOLAC, infants of mothers who underwent ERCD were less likely to require antibiotics and ventilation support. ERCD was similar to the TOLAC birth option in terms of cost effectiveness. Conclusions: Tight up criteria for “soft” indications such as labor dystocia could result in substantial reduction in CD without harming the infants.

The thesis is concentrated on the analysis of the decision - making process. Concretely in the case of building-up of R35 highway. The analysis describes landscape planing process, strategic environmental assessment process, environmental impact assessment process, planing inquiry and buliding control. I'm trying to find optimum alternate of building-up of the highway as a combination of economic,environmental,technological and social point of view.

This dissertation puts in place a risk-cost-benefit analysis for waste management facilities that explicitly recognizes the adversarial relationship that exists in a regulated market economy between the owner-operator of the facility and the government regulatory agency under whose terms the facility must be licensed. The risk-cost-benefit analysis is set up from the perspective of the owner-operator. It can be used directly by the owner-operator to assess alternative design strategies. It can also be used by the regulatory agency to assess alternative regulatory policies, but only in an indirect manner, by examining the response of an owner-operator to the stimuli of various policies. The objective function is written in terms of a discounted stream of benefits, costs, and risks over an engineering time horizon. Benefits are in terms of revenues for services provided; costs are those of construction and operation of the facility. Risk is defined as the expected cost associated with failure, with failure defined as a groundwater contamination event that violates the licensing requirements set forth by the regulatory agency. Failure requires a breach of the containment structure and contaminant migration through the hydrogeological environment to a compliance surface. Reliability theory is used to estimate the probability of breaching and Monte Carlo finite-element simulations are used to simulate advective contaminant transport. The hydraulic conductivity values in the hydrogeological environment are defined stochastically. The probability of failure is reduced by the presence of a monitoring network established by the owner-operator. The level of reduction in the probability of failure can be calculated from the stochastic contaminant transport simulations. While the framework is quite general, the development in this dissertation is specifically suited for a landfill in which the primary design feature is one or more synthetic liners and in which contamination is brought about by the release of a single, nonreactive species in an advective, steady-state, horizontal flow field. The risk cost benefit analysis is applied to 1) an assessment of the relative worth of alternative containment-construction activities, site-investigation activities, and monitoring activities available to the owner-operator, 2) an assessment of alternative policy options available to the regulatory agency, and 3) two case histories. Sensitivity analyses designed to address the first issue show that the allocation of resources by the owner-operator is sensitive to the stochastic parameters that describe the hydraulic conductivity field at a site. For the cases analyzed, the installation of a dense monitoring network is of less value to the owner-operator than a more conservative containment design. Sensitivity analyses designed to address the second issue suggest that from a regulatory perspective, design standards should be more effective than performance standards in reducing risk, and design specifications on the containment structure should be more effective than those on the monitoring network. Performance bonds posted before construction have a greater potential to influence design than prospective penalties to be imposed at the time of failure. Sitting on low-conductivity deposits is a more effective method of risk reduction than any form of regulatory influence. Results of the case histories indicate that the methodology can be successfully applied at field sites, and that the risks associated with groundwater contamination may be small when compared to the owner-operators' benefits and costs. / Science, Faculty of / Earth, Ocean and Atmospheric Sciences, Department of / Graduate

M.Comm. / Chapter 2 Chapter 2 researches the literature with regard to the evolvement of health care delivery in the USA and specifically the effect that the development and implementation has had on managed care. Chapter 3 Chapter 3 briefly describes the process of management and the components of strategic management. It also mentions the evolvement of management style proposed by Hickman. Finally it sets out in a graphical format the categories and "levels" into which health care can be divided and delivered. It is suggested that these are the issues to consider when assessing a medical benefit fund. Chapter 4 Chapter 4 presents the results and the findings of the various components and factors that impacted upon the external and internal analysis of the fund. The framework used to analyse the fund for strategic management are those proposed by De Bruyn, Kruger and McKinsey. Comments are made about the extent to which each component of strategic management is being applied within Steelmed based upon the evidence assimilated from the study. Finally the financial statements and membership numbers are used to evaluate how successful Steelmed has been. Chapter 5 Chapter 5 highlights the changes to take place if fourth wave strategic management is to be implemented and makes recommendations about the need for an on-going study to measure the effect this will have.

Dans un contexte de ressources limitées, les analyses médico-économiques participent à la réflexion sur l'allocation optimale des budgets disponibles et contribuent à l'identification des priorités de santé publique. Parmi elles, les analyses coût-efficacité permettent de comparer l'efficience de différentes alternatives permettant d'aider à faire un choix. Lorsque ces analyses sont appliquées à la vaccination, elles présentent des particularités que nous avons explorées et illustrées à travers trois pathologies infectieuses prises en charge en France.Vaccination post-exposition conditionnelle au diagnostic de l'immunité avec l'exemple du tétanos, compte-tenu de la disponibilité de tests de diagnostic rapide de l'immunité antitétanique. Vaccination post-exposition conditionnelle à la nature de l'exposition avec l'exemple de la rage, compte-tenu d'un faible niveau de risque.accination préventive avant la période à risque de survenue de l'infection avec l'exemple des infections materno-f¿tales à cytomégalovirus (CMV), compte-tenu des résultats d'un nouveau candidat vaccin.Nos résultats montrent que l'efficience de stratégies vaccinales peut être optimisée si une attention particulière est portée à la mise en place d'un moyen de dépistage de l'immunité sensible et peu coûteux et si ces stratégies sont en adéquation avec le niveau du risque infectieux réel. Le coût-efficacité est également maximisé lorsque la stratégie vaccinale tient compte de l'hétérogénéité du risque infectieux au sein de la population cible. Ces résultats pourraient être utilisés par les autorités de santé pour l'évaluation d'interventions vaccinales futures ou actuellement implémentées en France. / In a context of limited resources, health economic analyses contribute to the optimal allocation of available budgets and public health priorities assessment. Among them, cost-effectiveness analyses allow to compare the efficiency of several alternatives in order to make an informed choice. When those analyses are applied to immunization interventions, they present specific characteristics that we explored and illustrated based on three infectious diseases in the French context.1) Post-exposure immunization conditional to immunity screening with the example of tetanus and the quick diagnostic tests available to screen tetanus immunity.2) Post-exposure immunization conditional to the type of exposure with the example of rabies in a low-risk context. 3) Preventive vaccination before the at-risk period of infection through the example cytomegalovirus (CMV) infections during pregnancy, with the available results of a new vaccine candidate.Our results showed that efficiency immunization strategies can be maximized if we emphasize on the implementation of screening methods that are sensitive and inexpensive, and if those strategies are in adequacy with the real risk of infection. Efficiency is also optimized when the immunization strategy takes into account the heterogeneity of the risk of infection in the target population. Those results could be used by health authorities in the evaluation of current or future immunization interventions implemented in France.

Le Staphylocoque aureus (S. aureus) est une bactérie pouvant causer des infections d’origine communautaire ou hospitalière. En plus des personnes pouvant être infectées par S. aureus, de nombreux individus environ 20-25% parmi les adultes en bonne santé, portent ce pathogène sur leurs corps (ils sont dits "colonisés"). Bien qu’asymptomatique et souvent bénigne, la colonisation à S. aureus peut rarement impliquer un risque d’infection secondaire grave mais représente un risque d’être transmise à une tierce personne. A l’hôpital, le risque d’infection et de transmission apparaît comme étant particulièrement haut pour la souche de S. aureus résistante à la méticilline (SARM). La prévention et la lutte contre le SARM est un problème de santé publique important. Les Nation Unis se sont récemment engagés dans cette lutte en créant le"Global Action Plan on Antimicrobial Resistance". Ce travail de thèse traite de trois différentes études dans la cadre de la prévention et du contrôle de ce pathogène. / Staphylococcus aureus is a bacterium that can cause blood infections that can have a community or hospital origin. Among people infected with S.aureus, about 20-25% is healthy adults that carry the pathogen on their bodies, without suffering any symptom (they are said "colonized"). Although asymptomatic and often benign, colonization with S. aureus involves a risk of secondary infection and represents a serious risk of transmission to a third party. In hospitals, the risk of infection and transmission appears to be unusually high for methicillinresistant S. aureus (MRSA) and complications can be very severe. Prevention and the fight against MRSA is a major public health concern. The United Nations recently engaged in this struggle by creating the "Global Action Plan on Antimicrobial Resistance". This work is about three different studies in the prevention and control of this pathogen.

京都大学 / 新制・課程博士 / 博士(社会健康医学) / 甲第23120号 / 社医博第116号 / 新制||社医||11(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 今中 雄一, 教授 中山 健夫, 教授 佐藤 俊哉 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

This paper presents results from cost-analysis research for treating Post-Traumatic Stress Disorder in adults. Data for this research was provided by Cigna, a nation-wide healthcare manager in the United States of America. The sample size was 12,845 adults who were diagnosed with PTSD and received outpatient individual and family psychotherapy from one of the following mental health care providers: Marriage and Family Therapists (MFTs), Master’s Nurses (RNs), Medical Doctors (MDs), Professional Counselors (LPCs), Psychologists (PSYs), and Social Workers (MSWs). Results were compared across treatment modality, across practitioner license type and between practitioner educational levels. The results demonstrated that family therapy was most cost effective and used the fewest sessions, while mixed therapy was least cost effective. Among practitioner licensure types MDs were found to be the most cost effective, while the group of RNs, MSWs and MFTs were least cost effective compared to one another. Also, no significant differences in cost effective treatment outcomes were found between Masters Level and Doctoral Level practitioners.