Thesis (Ph.D.)--Industrial and Systems Engineering, Georgia Institute of Technology, 2008. / Committee Chair: Vidakovic, Branislav; Committee Co-Chair: Edwards, Paula; Committee Member: Goldsman, David; Committee Member: Griffin, Paul; Committee Member: Lee, Eva

This dissertation seeks to investigate how hospital reimbursement policy affects the quality of care provided to patients when providers compete for healthcare labor that is limited in supply. Cost payment systems fully reimburse a provider’s the total cost of healthcare provided, fixed reimbursements are predetermined at a fixed amount and mixed reimbursements have a cost and fixed component. The first chapter investigates how government reimbursement schemes that induce quality competition among health providers affects the choice of quality of care provided to patients and how these choices depend on the labor supply constraints in the healthcare labor market. We build a theoretical model that explicitly incorporates the healthcare labor supply into a framework of a hospital cournot competition, to show how a hospitals' choice of quality of patient care will be directly influenced when there is a shortage of health personnel in a regulated reimbursement system. We find that multiple equilibria can arise in healthcare markets depending on the consumers’ sensitivity to quality and hospitals’ share of cost when investing in quality. Contrary to existing findings, we are able to show that the effects of reimbursement schemes can vary in different equilibria and in different labor market situations. For instance, in high patient quality sensitivity hospital markets under a high hospital quality equilibrium, we can show that a cost payment scheme decreases a provider’s quality of care while a fixed reimbursement scheme increases quality. More importantly we find that the labor market constraint increases or decreases the effect of the reimbursement system on quality of care. Consequently, the labor constraint changes the quality choice of the provider as compared to the quality level that would have been induced by a particular reimbursement’s policy incentive for quality. In the second chapter, we carry out some of the testable implications of the theoretical finding from the first chapter. This paper investigates how higher Medicare payments brought about by geographical reclassification affects a provider’s quality of care as captured by registered nurses (RN) and licensed practical nurses (LPN) staffing, as well as patient outcomes (mortality, urinary tract infections, pneumonia, peptic ulcer deep vein thrombosis) and length of stay when hospitals compete for nurses. In contrast with past literature, we specifically allow for asymmetry in the hospital’s choice of quality, by permitting coefficients to differ across reclassified hospitals in response to the higher Medicare payments. This asymmetry is based on the relativity of the labor cost faced by the hospital due to competition for nurses in the healthcare labor market. Using Healthcare Cost and Utilization Project (HCUP) and the Center for Medicare and Medicaid (CMS) data from the period 2001 to 2011, we find that hospitals who face relatively higher labor costs will post reclassification increase their RN to LPN staffing ratio as compared to hospitals in their post geographical reclassification areas. A higher RN staffing by these hospitals will result in an improvement of quality of care as the incidence of patient complications due to Pneumonia, Peptic Ulcer and Deep Vein Thrombosis reduces for hospitals that were reclassified after allowing for asymmetry in response to the higher Medicare payment due to differences in labor costs (Pneumonia and Peptic Ulcer complications improve as compared to pre re-class area hospitals and DVT in both pre/post re-class area hospitals). Length of stay also increases for hospitals that faced a higher labor cost while mortality and UTI complications remain unchanged post reclassification. Finally, in the third chapter, we examine how the for profit (FP) or not for profit (NFP) status of hospitals impact the choice of nurse staffing and patient outcomes when there is an increase in provider reimbursement due geographical reclassification. Most of the past studies focus on mortality and length of stay in FPs and NFPs, we extend these studies by investigating the impact of geographical reclassification on patient outcomes that have been established as outcomes sensitive to nursing care. From our regression results, with reference to the ratio of RN to LPN staffing, we find evidence that an increase in Medicare payments will have a greater impact in FPs than in NFPs as compared to their pre re-class geographical area control hospitals. We also find that in hospitals that face a relatively higher labor cost as compared to their controls; (1) There is no difference in the impact of reclassification between FPs and NFPs (2) There is a better response from FPs than NFPs to geographical reclassification when the outcome considered is DVT as evidenced by a decreases in cases of DVT (3) NFPs decrease length of stay whiles FPs increase length of stay as compared to their post re-class geographical area hospitals.

Submitted by admin tede (tede@pucgoias.edu.br) on 2016-11-29T12:10:22Z No. of bitstreams: 1 JOÃO ALCIONE CARDOSO SANTOS.pdf: 2045029 bytes, checksum: 7f9f2c4810fbd94b17606435feab0766 (MD5) / Made available in DSpace on 2016-11-29T12:10:22Z (GMT). No. of bitstreams: 1 JOÃO ALCIONE CARDOSO SANTOS.pdf: 2045029 bytes, checksum: 7f9f2c4810fbd94b17606435feab0766 (MD5) Previous issue date: 2016-09-29 / There are major remaining obstacles to consolidation of programs, policies and actions involving assistance, promotion, monitoring and prevention of work related diseases. Changes are needed in the work process covering the health-work relations in all of its complexity. The creation Integrated Attention to Workers’ Health Subsystem (SIASS) structuring base of the Attention to Health and Safety of Federal Civil Workers Policy (PASS) emerges with the task of ensuring sustainability and effectiveness through work management. This dissertation, Occupational Health in the Federal Public Service: Challenges the policies of health care and work safety at the University Hospital context, aims to analyze the effectiveness of the policies on health and safety in implementation by the Federal Government in the context of the University Hospital at the Federal University of Goias (HC/UFG). We sought to understand and analyze the social, economic, technological organization influencing the process of disease in the workers. To support the debate on the existing conceptual differences of workers’ health; health and work; and genre and work, theoretical references of researchers have been studied. We also sought to further the principles, objectives and guidelines of established public policies of health and safety as reference. This study is presented methodologically as a quantitative and qualitative research. The methodological procedure as the objective of this study was an exploratory research. The research location was chosen mainly because the University Hospital (HC/UFG) has the largest number of absences due to sickness in the Federal University of Goias. A proportional stratified probability sampling of simple random type was performed. The study population consisted of 986 effective workers linked to the Unitary Judicial Regime and 131 workers were selected to participate. As for the data collection, two questionnaires were especially developed with objective and subjective questions. One questionnaire was used for the technical and administrative staff of the University Hospital/ UFG, and the other was applied to the managers at SIASS/ UFG. The review of specialized literature, documental research, and field research, all contributed with the reflection and analysis of data. A discussion was sought out about the perception aspects of technical and administrative staff; managers of SIASS/UFG, as the executing agency of the institution analyze the development and implementation of PASS. Regarding the profile of those involved in the research, there’s a prevalence of women with 79% aged between 41 and 60 years, with 71% prevalence of qualified education, 90% did not undergo periodic examinations, and 56%of respondents with double employment bond. The analysis of data infers that the implementation of Federal Health Care Policy is unsatisfactory relating to Public Workers in the University Hospital/UFG regarding health promotion and work safety, and it has been unable to cope with sickness of the workers. / Persistem grandes obstáculos à consolidação de programas, políticas e ações envolvendo assistência, promoção, vigilância e prevenção dos agravos relacionados ao trabalho. São necessárias mudanças nos processos de trabalho que contemplem as relações saúde-trabalho em toda a sua complexidade. A criação do Subsistema Integrado de Atenção à Saúde do Servidor (SIASS), base estruturante da Política de Atenção à Saúde e Segurança do Trabalho do Servidor Público Federal (PASS), surge com a tarefa de garantir sustentabilidade e efetividade através do gerenciamento de trabalho. A presente dissertação, Saúde do Trabalhador no Serviço Público Federal: desafios para uma política de atenção à saúde e segurança do trabalho no contexto de hospital universitário tem o objetivo de analisar a efetividade da política de atenção à saúde e segurança do trabalho em implementação pelo governo federal no contexto do hospital universitário da Universidade Federal de Goiás (HC/UFG). Buscou-se compreender e analisar os fatores sociais, econômicos, tecnológicos, organizativos que influenciam o processo de adoecimento desses servidores. Para subsidiar o debate sobre as diferenças conceituais existentes sobre a saúde do trabalhador, saúde e trabalho e gênero e trabalho, estudou-se referenciais teóricos de pesquisadores da área. Buscou-se ainda os princípios, objetivos e diretrizes das políticas públicas instituídas de Saúde e Segurança como referência. Este estudo se apresenta metodologicamente como uma pesquisa quanti-qualitativa. O procedimento metodológico quanto ao objetivo nesse estudo foi pesquisa exploratória. A escolha deste local para ser pesquisado ocorreu devido à unidade Hospital das Clínicas/UFG possuir o maior número de afastamentos por adoecimentos no âmbito da Universidade Federal de Goiás. Foi realizada uma amostragem probabilística estratificada proporcional do tipo aleatória simples. A população do estudo foi constituída de 986 servidores do quadro efetivos, vinculados ao Regime Jurídico Único e selecionados 131 servidores participantes. Para o instrumento de coleta de dados utilizou-se dois questionários especificamente desenvolvidos para este estudo, elaborados com questões abertas e fechadas para aplicação de um questionário aos servidores técnico-administrativos do Hospital das Clínicas/UFG e outro questionário específico aplicado aos gestores do SIASS/UFG. A revisão da literatura especializada, a pesquisa bibliográfica, a pesquisa documental e a pesquisa de campo contribuíram na reflexão e na análise dos dados. Procurou-se discutir os aspectos relativos à percepção dos servidores técnico-administrativos da PASS e ainda como os gestores do SIASS/UFG, enquanto órgão executor da instituição, analisam o desenvolvimento/implementação da PASS. O perfil dos pesquisados há predominância de mulheres com 79%, faixa etária entre 41 e 60 anos com 71%, predominância de escolaridade qualificada, 90% não realizaram exames periódicos e duplo vínculo de servidores técnicos 56% dos pesquisados. A analise dos dados permitem inferir que a implementação da Política de Atenção à Saúde do Servidor Público Federal, no contexto do Hospital Universitário/UFG é insatisfatória como instrumento de promoção à saúde e segurança do trabalho e não tem sido capaz de enfrentamento do processo de adoecimento dos servidores.

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The status of women in Bangladesh has long been an issue, with high reports of negative perceptions regarding women’s capabilities. This is reflected in the poor position of women in the labor market, and combined with reports of poor mental health among women in Bangladesh, it raises the question of whether these issues are related. Previous research has found a relationship between perceived gender-based discrimination in the labor market and mental health. Since such research can justify preventative policy measures, we wanted to investigate if the same relationship can be found in a country heavily experiencing these issues, like Bangladesh. Based on the stress process theory and the cognitive appraisal theory, we expected to find a relationship between perceived gender-based discrimination and mental health. We investigated the relationship by analyzing survey data (N = 957) collected from the Sylhet district in Bangladesh through systematic random sampling. We used linear probability models in our main analysis, which indicated that women who experienced higher levels of discrimination were more than 30 percentage points likelier to suffer from poorer mental health than women who experienced lower levels of discrimination. We found the same relationship for all of our discrimination measurements. In addition, having decision-making power in the job role, having more wealth, and living in an urban area decreased the likelihood of suffering from poorer mental health when exposed to discrimination. There was no significant difference between using emotion-focused coping and problem-focused coping. We suggest that policies promoting higher education for women, accessible childcare, and women in high-status jobs could reduce gender-based discrimination in the labor market, improving mental health. / Kvinnors status har länge varit ett problem i Bangladesh där negativa uppfattningar om kvinnors förmågor är utbredda. Det speglas i kvinnors svaga position på arbetsmarknaden vilket, i kombination med rapporter om höga nivåer av mental ohälsa bland kvinnor i Bangladesh, väcker frågan om huruvida de relaterar till varandra. Tidigare forskning visar på ett förhållande mellan uppfattad könsdiskriminering på arbetsmarknaden och mental hälsa. Sådan forskning skulle kunna användas som stöd för motverkande politiska åtgärder. Vi ämnade därför att undersöka om förhållandet även finns i ett land som starkt erfar båda dessa problem, så som Bangladesh. I enlighet med teorierna “stress process theory” och “cognitive appraisal theory” förväntade vi oss ett förhållande mellan uppfattad könsdiskriminering och mental hälsa. Vi undersökte förhållandet genom att analysera enkätdata (N = 957) som samlats från Sylhetdistriktet i Bangladesh med hjälp av systematiskt urval. Vi använde linjära sannolikhetsmodeller i den huvudsakliga analysen. Resultatet visade att kvinnor som upplever högre nivåer av diskriminering hade mer än 30 procentenheter större sannolikhet att lida av sämre psykisk hälsa än kvinnor som upplever lägre nivåer av diskriminering. Vi fann samma förhållande för alla diskrimineringsmått. Utöver det minskade sannolikheten att lida av sämre psykisk hälsa vid exponering av diskriminering med beslutsfattande i sin arbetsroll, högre välstånd och bosättning i stadsområde. Det fanns ingen signifikant skillnad mellan att använda känslofokuserade copingstrategier och problemfokuserade copingstrategier. Vi föreslår att policyer som främjar högre utbildning hos kvinnor, tillgänglig barnomsorg och kvinnor i högstatusyrken kan minska könsbaserad diskriminering på arbetsmarknaden vilket skulle leda till bättre psykisk hälsa.

Made available in DSpace on 2011-05-04T12:36:21Z (GMT). No. of bitstreams: 0 Previous issue date: 2009 / O objeto deste estudo foi o Curso de Formação Profissional de Auxiliar de Enfermagem realizado no município de Natividade, estado do Rio de Janeiro nos anos de 1995 a 1997, pela Escola de Formação Técnica em Saúde Enfª Izabel dos Santos ETIS SESDEC/RJ e teve como objetivo estudar os efeitos ocorridos na prática profissional das egressas da rede de saúde. Na implantação e no desenvolvimento deste curso foi utilizada a proposta do Projeto de Formação em Larga Escala de Pessoal de Nível Médio e Elementar para os Serviços de Saúde, mais conhecido como Projeto Larga Escala PLE, que objetivava a formação profissional de nível médio visando à qualidade da assistência à saúde da população, e que ainda hoje influencia a formação dos trabalhadores da saúde. O Projeto Larga Escala concebia que para transformar a realidade é preciso construir novas práticas de formação e de gestão na saúde, tornando necessário que a educação profissional se fundamente numa concepção que amplie os horizontes de interesses da sociedade, numa visão de mundo que posiciona e compreende o homem como centro das preocupações. Para atingir o objetivo proposto, foi realizada pesquisa em documentos na ETIS-SESDEC/RJ e aplicado um questionário com perguntas abertas e fechadas às egressas do curso. Os dados foram trabalhados dentro de uma abordagem quanti-qualitativa. Os resultados indicaram que: 100 por cento dos respondentes são do sexo feminino, a maioria (38,9 por cento) está na faixa etária entre 41 e 50 anos e 50 por cento são casadas. Quanto à escolaridade, 27,8 por cento possuem 3º grau, 11,1 por cento 3º grau incompleto, 44,4 por cento ensino médio, 11,1 por cento ensino médio incompleto e 5,5 por cento ensino fundamental. Destaca-se que 83,3 por cento das egressas encontram-se desenvolvendo atividades relacionadas à saúde e 16,7 por cento não atuam na saúde. O curso de formação profissional de auxiliar de enfermagem, em conformidade com as egressas, contribuiu para melhorar a prática, além de promover mudanças significativas nos aspectos humanístico, ético e no comprometimento com a sociedade. / The object of this study was the Nursing Assistant Professional Training Course held in the municipality of Natividade, in the State of Rio de Janeiro between the years 1995 and 1997, by the Nurse Izabel dos Santos Health Technical Training School – ETIS – SESDEC/RJ and aimed to study the effects in the professional practice of alumni of the health network. In the implementation and development of this course, the Project Proposal for the Large Scale Training of Mid- and Elementary-Personnel for Health Services, better known as the Large Scale Project – PLE, which sought the training of mid-level professionals aimed at quality health assistance of the population, and still today influences the training of health workers. The Large Scale Project understood that in order to transform reality it is necessary to construct new training practices and health management, thus making professional education necessarily base itself on an idea that broadens the horizons of the interests of society, into a worldview which places and understands humanity at the center of its worries. To meet this proposed objective, an ETIS-SESDEC/RJ documentary study was created and a questionnaire given to the graduate from the course consisting of open and closed responses. The data was elaborated within a quantitative-qualitative prism. The results indicated that: 100% of respondents were female, the majority (38.9%) is in the age group between 41 and 50 years old and 50% are married. As for schooling, 27.8% have a college education, 11.1% did not complete college, 44.4% have a high school education, 11.1 did not complete high school and 5.5% have an elementary education. It should be noted that 83.3% of alumni found them developing health related activities and 16.7% do not work in health. The nursing assistant professional training course, in confirmation with the alumni, contributed toward bettering the practice, in addition to provoking significant changes in the humanistic and ethical aspects and in the commitment to society.