"A manager in the minds of doctors" : a comparison of new modes of control in European hospitals

Background: Hospital governance increasingly combines management and professional self-governance. This article maps the new emergent modes of control in a comparative perspective and aims to better understand the relationship between medicine and management as hybrid and context-dependent. Theoretically, we critically review approaches into the managerialism-professionalism relationship; methodologically, we expand cross-country comparison towards the meso-level of organisations; and empirically, the focus is on processes and actors in a range of European hospitals. Methods: The research is explorative and was carried out as part of the FP7 COST action IS0903 Medicine and Management, Working Group 2. Comprising seven European countries, the focus is on doctors and public hospitals. We use a comparative case study design that primarily draws on expert information and document analysis as well as other secondary sources. Results: The findings reveal that managerial control is not simply an external force but increasingly integrated in medical professionalism. These processes of change are relevant in all countries but shaped by organisational settings, and therefore create different patterns of control: (1) ‘integrated’ control with high levels of coordination and coherent patterns for cost and quality controls; (2) ‘partly integrated’ control with diversity of coordination on hospital and department level and between cost and quality controls; and (3) ‘fragmented’ control with limited coordination and gaps between quality control more strongly dominated by medicine, and cost control by management. Conclusions: Our comparison highlights how organisations matter and brings the crucial relevance of ‘coordination’ of medicine and management across the levels (hospital/department) and the substance (cost/quality-safety) of control into perspective. Consequently, coordination may serve as a taxonomy of emergent modes of control, thus bringing new directions for cost-efficient and quality-effective hospital governance into perspective

Konfrontacje i negocjacje : strategie tożsamości we współczesnych praktykach artystycznych

Confrontations and negotiations. Strategies of identity in contemporary artistic practices is a research work aimed at rethinking the anthropology of identity and its imaging in the world of contemporary art. The starting point for this is in the aesthetical and philosophical reflection on history and theory of the functioning of the subject in contemporary culture, and especially contemporary art. Identity and subjectivity are always confronted with what’s public and what’s private. In such understanding they are characterized by ambiguity, common bloodstream and direct connection between the ideas of the Inside and the Outside, the common and archaeological discourse of what got an important development – in wider philosophical perspective – in Michel Foucault’s writings. Equally intriguing complements to this reflection can be found in Jacques Derrida’s notes on the presence/absence of trace and subject, Barthes’ Death of the Author and Gilles Deleuze’s ‘bankruptcy of representation’ and ‘loss of identity’. These humanistic tropes and motives are aided by the ‘theses’ included in over 2000 year-old Buddhist sutras and in scientific discoveries in the area of quantum physics, which unanimously undermine the status of an objective observer and the identity and integrity of our image of the world with the reality. The perspective that emerges from them creates a plane for a subjective, relative or quantum participant of events. Therefore it is a symbolic place, where all the participants of the urban spectacle of contemporaneity meet, including flâneurs (and artists) among others. The work presents the analysis and reinterpretation of artistic strategies occurring in art of the last five decades – in the context of the issues of widely understood identity (of artists, works and the viewer). The work includes the outline and model of modernist and postmodernist understanding of identity which became finally relativized in result of changeable paradigms of knowledge. This has caused the impasse of subjectivity and generally viewed identity. The art of the second half of the twentieth century, as well as the newest works reflect this crack of the classical identity discourse, what reveals among other things through (de)mythologizing the genealogical (and biographical) discourse of the artist. Today the identity of all participants of artistic practices (readings and expressions) has become a space of negotiation and linguistic game, where the subject makes transgression, multiplication or dispersion, and the very identity is a figure of nomadic and rhisomatic character. It is shaped in relation to what’s public and private; therefore the metaphors of ‘flâneur’ and ‘passage’, connoting the dialectics of the Inside and the Outside, seem to be cognitively and aesthetically attractive

Cost Control of Medical Care in Public Hospitals – a Comparative Analysis

Background. Some Polish hospitals are in a good financial position but others are not, eventhough they are of a similar size according to their budgets, the number and structure ofspecialists and type of society they serve. Furthermore, it is difficult to find the factors responsiblefor their different financial standing. To investigate deeper the dissimilarities thatmight exist, the author hypothesizes that one of the most important factors that possiblyinfluences a hospital$s financial performance is its control system.Research aims. In these circumstances the research is aimed at identifying different controlareas and mechanisms which have been used by hospital managers to ensure delivery ofhigh-quality cost-effective patient care and that concurrently balance the hospital budget.Method. During the study the author investigated the operating core of hospitals in order todevelop a deeper understanding of its internal control processes. This qualitative study isbased on several in-depth interviews with general directors of two similar hospitals.Key  findings. The research indicates that hospitals ought to concentrate on four genericareas of control: input control, legitimacy of medical procedures control, revenue control andoverheads control. Thus comparing the studied hospitals according to their activities in thefour control areas it is visible that the hospital which has a good financial situation, takescontrol measures in all four areas, and the top managers are directly involved in supervisingmost of these activities. While the hospital which is facing financial difficulties, is much lessactive in the described areas of control and the director does not participate actively incontrol of the lower levels of his organization nor does he build such extended control mechanismsas the director from the better-off hospital

Shared Decision Making

This chapter is divided into three sections. The first section introduces the concept and models of shared decision-making as a framework of person- centered care. The second section focuses on multicriteria decision-making tech- niques in healthcare settings and literature review about multicriteria decision making analysis methods used in healthcare is presented. The third section introduces the ethical and practical considerations about shared decision-making in person-centered care. In this section, the patient narratives are included, as well as the barriers to implementation

Dynamic analysis of structures with multiple tuned mass dampers

It is the purpose of this paper to analyse the possibility of reducing the vibrations of frame building structures with the help of multiple tuned mass dampers. Structures exposed to strong winds are considered. Excitation forces, which are functions of wind velocity fluctuations, are treated as random forces. The spectral density functions of wind velocity fluctuations are assumed as proposed by Davenport. The correlation theory of random vibration is used and the root mean squares of displacements and accelerations are determined. Several remarks, concerning the effectiveness of multiple tuned or mass dampers, are formulated from the results of calculation. Santrauka Nagrinėjama galimybė sumažinti stipraus vėjo veikiamų rėminių pastatų konstrukcijų svyravimus, taikant masės slopintuvų sistemą. Vibracijas sukeliančios jėgos, priklausančios nuo vėjo greičio svyravimų, laikomos atsitiktiniais dydžiais. Vėjo greičio svyravimo spektro tankio funkcijos nagrinėjamos Davenport metodu. Atlikus atsitiktinių vibracijų regresinę analizę, nustatytos poslinkių ir pagreičių vidutinės kvadratinės paklaidos. Remiantis skaičiavimo rezultatais, padarytos masės slopintuvų efektyvumo išvados. First Published Online: 14 Oct 2010 Reikšminiai žodžiai: svyravimų mažinimas, atsitiktiniai svyravimai, masės slopintuvai

Connect: Katowice

Akademia Sztuk Pięknych w Katowicach/ Academy of Fine Arts Katowice; Chelsea College of Arts, University of Arts London; Housed Collective; Galeria Rondo Sztuki, Ply Gallery; Hornsey Town Hall, London.Arts Council England & British Council funded, British-Polish exchange, collaboration and displays

Testing Cost Containment of Future Healthcare with Maintained or Improved Quality—The COSTCARES Project

Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies

Communication breakdown : dissecting the COM interfaces between the subunits of nonribosomal peptide synthetases

Nonribosomal peptides are a structurally diverse and bioactive class of natural products constructed by multidomain enzymatic assembly lines known as nonribosomal peptide synthetases (NRPSs). While the core catalytic domains and even entire protein subunits of NRPSs have been structurally elucidated, little biophysical work has been reported on the docking domains that promote interactions—and thus transfer of biosynthetic intermediates—between subunits. In the present study, we closely examine the COM domains that mediate COMmunication between donor epimerization (E) and acceptor condensation (C) domains found at the termini of NRPS subunits. Through a combination of X-ray crystallography, circular dichroism spectroscopy, solution- and solid-state NMR spectroscopy, and molecular dynamics (MD) simulations, we provide direct evidence for an intrinsically disordered donor COM region that folds into a dynamic helical motif upon binding to a suitable acceptor. Furthermore, our NMR titration and carbene footprinting experiments illuminate the residues involved at the COM interaction interface, and our MD simulations demonstrate folding consistent with experimental data. Although our results lend credence to the previously proposed helix-hand mode of interaction, they also underscore the importance of viewing COM interfaces as dynamic ensembles rather than single rigid structures and suggest that engineering experiments should account for the interactions which transiently guide folding in addition to those which stabilize the final complex. Through activity assays and affinity measurements, we further substantiate the role of the donor COM region in binding the acceptor C domain and implicate this short motif as readily transposable for noncognate domain crosstalk. Finally, our bioinformatics analyses show that COM domains are widespread in natural product pathways and function at interfaces beyond the canonical type described above, setting a high priority for thorough characterization of these docking domains. Our findings lay the groundwork for future attempts to rationally engineer NRPS domain–domain interactions with the ultimate goal of generating bioactive molecules

Numerical analysis of heat transfer and fluid flow in multilayer deposition of PAW-based wire and arc additive manufacturing

A three-dimensional numerical model has been developed to investigate the fluid flow and heat transfer behaviors in multilayer deposition of plasma arc welding (PAW) based wire and arc additive manufacture (WAAM). The volume of fluid (VOF) and porosity enthalpy methods are employed to track the molten pool free surface and solidification front, respectively. A modified double ellipsoidal heat source model is utilized to ensure constant arc heat input in calculation in the case that molten pool surface dynamically changes. Transient simulations were conducted for the 1st, 2nd and 21st layer depositions. The shape and size of deposited bead and weld pool were predicted and compared with experimental results. The results show that for each layer of deposition the Marangoni force plays the most important role in affecting fluid flow, conduction is the dominant method of heat dissipation compared to convection and radiation to the air. As the layer number increases, the length and width of molten pool and the width of deposited bead increase, whilst the layer height decreases. However these dimensions remain constant when the deposited part is sufficiently high. In high layer deposition, where side support is absent, the depth of the molten pool at the rear part is almost flat in the Y direction. The profile of the deposited bead is mainly determined by static pressure caused by gravity and surface tension pressure, therefore the bead profile is nearly circular. The simulated profiles and size dimensions of deposited bead and molten pool were validated with experimental weld appearance, cross-sectional images and process camera images. The simulated results are in good agreement with experimental results

Feasibility, safety and tolerability of accelerated dobutamine stress echocardiography

A continuous infusion of a single high dose of dobutamine has been, recently, suggested as a simple and effective protocol of stress echocardiography. The present study assesses the feasibility, safety, and tolerability of an accelerated dobutamine stress protocol performed in patients with suspected or known coronary artery disease. Two hundred sixty five consecutive patients underwent accelerated dobutamine stress echocardiography: the dobutamine was administered at a constant dose of 50 μg/kg/min for up to 10 minutes. The mean weight-adjusted cumulative dose of dobutamine used was 330 ± 105.24 μg/kg. Total duration of dobutamine infusion was 6.6 ± 2.1 min. Heart rate rose from 69.9 ± 12.1 to 123.1 ± 22.1 beats/min at peak with a concomitant change in systolic blood pressure (127.6 ± 18.1 vs. 167.6 ± 45.0 mmHg). Dobutamine administration produced a rapid increase in heart rate (9.4 ± 5.9 beats/min2). The side effects were similar to those described with the standard protocol; the most common were frequent premature ventricular complexes (21.5%), frequent premature atrial complexes (1.5%) and non sustained ventricular tachycardia (1.5%); among non cardiac symptoms the most frequent were nausea (3.4%), headache (1.1%) and symptomatic hypotension (1.1%). No major side effects were observed during the test. Our data demonstrate that a continous infusion of a single high dose of dobutamine is a safe and well tolerated method of performing stress echocardiography in patients with suspected or known coronary artery disease. This new protocol requires the administration of lower cumulative dobutamine dose than standard protocol and results in a significant reduction in test time