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P03: infrastructures

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OLICOGNOGRAPHY on SOCIAL INFRASTRUCTURES

System

Engineering

Development

Scale

Health

Social

Clinics and Hospitals

Basic Olicognograph: Health Care Facilities

My Kingdom for my life ! Mules for my health ! Wisdom for my Wealth !

Healthcare is considered very specific tradable relations. Plenty of moderns physicians (bad traders but good collectors) as well as good doctors (bad traders & poor collectors) all agree, behaviourilly with economists. But the first physicians prefer fallacy and the seconds prefer not to 'botherboxe' their doctors; afraid by that opening the black box of Panadora could turn, at least, their political coffin. It can be appropriated to call trade of therapeutic relation, at the reverse, the 'basic and least specific of true complex trade relation'.

Clinical processes progresses the most typically by intents and failures in the narrowing margins of flexibility of patients. It grows alike by the inflation of structures and increasing sophistication of means. But good magic for invididual care, as well as ritualized mass of medicine confronting with health, later health progresses much more with safe water, good food, technically targetted large programs of prevention and plenty of modest patients ressources while medicine is often on the margins for some years more, not always quality life adjusted. Which does not contradict that many special prognosis, for some are much better thanks to great Medicine, but confusion is also maintained by plenty. Plenty of struggles for having the power to bias and distort the management of health structures and distort socially good offer of services. Mixing good reasons, bad policies, good practices and intent to disweight issues. Powers mismanagement in health often succeed to prevent prevention, bias health systems toward magical pomposity, stop transversal synergies within structures as well as in common society's public health knowledge. Technocratical oligolocalism and centralism bias where competition could balance, force investments and superior sophistication against cost - effective evidences.

"It is little understood outside the priesthood of national accountants that there is no serious attempt to measure the “real output” of the health-care industry. The techniques used to measure the price and quantity of health care are highly defective, and there 'were' no attempts to account for improvements in the length of life into current measures of living standards. At a common-sense level, the lack of connection comes because “real” medical-care spending in fact measures spending on inputs rather than the results in health outcomes.The current approach is to measure health output primarily by the number of physicians' visits, the number of hospital-days, and similar measures rather than the actual delivery of services or changes in health status". With few changes since that ten years old observation from North.

Assessment Criteria


Cost-benefit Analysis (CBA)

Cost-effectiveness Analysis (CEA)

Cost-utility Analysis (CUA)

Number of Health Outcomes

Multiple outcomes

One outcome

Multiple outcomes

Unit of Health Outcomes

Summary measure in monetary units (eg, US dollars)

Natural units (eg, reduction in number of hot flashes)

Summary measure in quality of life units (eg, quality -adjusted life-years, QALY)

Results

Net benefits1 +

B2 - C1 - C2)

Cost-effectiveness ratio1 - C2) / (E1 - E2)

Cost-utility ratio1 - C2) /

(QALY1 - QALY2)

"4 reasons for this gap in our knowledge seem relevant: 1) No consensus among health specialists on how to conceptualize and measure health status at the individual level. Consequently, validating survey instruments which approximate these measures of health status has progressed slowly. 2) Deep reluctance to summarize the benefits of health in terms of only their productive payoffs, or value as “human capital”, because this appears to deny the “consumption value” of health and the distinctive “capability” aspect of health . 3) Self reported health status involves errors in measurement, even when continuous health indicators of a relatively objective form are analyzed. 4), although healthier people may be more productive, more-productive people may also allocate more resources to creating and maintaining their good health". But as to observe, nevertheless in previous table, some change with QALY and DALY globalization.

Provided the 'basic and least specific of real complex trade relation', requires more explanations, out the reach of this introducing page. See that practically with health infrastructures you will may have: 1) Efficient pograms when health parameters are low, harder to incorporated in healthier environments and often needing periodic renewal (immunization campaigns); 2) Plenty of health engineering investments basic, critical and essential with scare financing or hard to plan time's opportunities; competing with functional needs of existing health infrastructures; 3) Packages of services eventually already financed, well thought but not really appropriated to a local map of opportune health investments, in complex social, disqualifying so health authorities; 4) Many political as well as social pressures for kinds of investments biased toward self-interests (the ones of ill people in leaders' families? or high medical authorities relatives) or social representation carried by modern communication on what to do with health; 5) Control on investments more motivated by distorting budgetary balance rather than by pertinence; 6) Short sighted big investments uncaring the impossibility of posterior functional budgets balance, etc.; 7) Forced returns for amortization of investment, resulting in an unecessary increasing social cost, for the sake of big equipment; 8) Dispersion of ressources with levels of investments not adapted to the place (under or over investment).

"Under a set of hospital behavior assumptions, the structure of costs and production of hospitals may postulates: 1) average cost behavior; 2) cost per unit of output rise or decline as a hospital produces more output; and 3) the level of output at which cost per unit of output is at its lowest level and if the hospitals are producing at this level of output. As costs are affected by the technology of the production process, hospital cost functions affords another angle from which production-related issues can be examined. Postulation of enquiries are critical towards: 1) Optimal size of hospital; 2) Number of beds maintained; 3) Current output levels and hospitals capital equipment; 4) Technical efficiency; 5) Allocative efficiency? (optimal combinations and levels of inputs, given their outputs); 6) Economies of scope. There is even greater variation in the choice of model specification in the cost function literature than in the production function literature. Significant issues raised in cost function literature are: 1) Effects of case-mix on average cost; 2) Short-run average and marginal costs; 3) Economies of scale; 4) Economies of scope; 5) Extent of factor substitution and the existence of complements; and 6) technical and scale efficiency of health care institutions.

Spaces of Health Care

Health care occupancies include: 1) Hospitals. 2) Nursing homes. 3) Limited care facilities. 4) Ambulatory health care centers. Primary health care centers with more simple installation and mobile equipments, may be differenciated according places (urban, rural), extend of services delivered (nurse, with or without physicians, primary care dentist), ambulatory or with few beds, level of primary care (first recourse, reference, second) and/or proportioned to attendance. These should be conceived with communication and transportation (ambulances) for reference. Clinics and hospital are supposed to be third or if with specialities fourth levels. May be with the development of low invasive methods and/or low cost technics installations and equipment could be smaller and more confusing. With target program of clinical care there should be plenty of mobile ressources and a necessary management of logistical movements together with procedures of telemedicine. Large institutions are projecting themselves in more economical ways; day care hospital, and so on. Primary health care systems vary a lot. Www is also changing self-care of persons but good practices of informing attention still behind individual efforts?

"Health Clinics and Hospital infrastructural Components can be: 1) General Design Guidance. 2) Design Procedure, Submittals, and Documentation. 3) Master Planning and Site. 4) Architecture. 5) Structural. 6) Seismic. 7) Energy and Water Conscious Design. 8) Heating, Ventilating, and Air Conditioning. 9) Plumbing and Medical Gases. 10) Electrical. 11) Communications. 12) Accessibility. 13) Fire Protection. 14) Security. 15) Force Protection. 16) Medical and Dental Equipment. 17) Conveyance Systems. 18) Waste Management. 19) Integrated Building Systems. 20) Construction. 21) Signage. 22) Food Service. 23) Acoustics. 24) Individual Room Design Requirements and Conditions. 25) Universal X-Ray Room. 26) Laboratory. 27) Medical Services Facilities: Common Adult (medicine or surgery), Gyneco-Obstetric, Pediatric). 28) Dental Clinics. 29) Maintenance shop buildings. 30) Garages and automotive shelters. 31) Sewage disposal plant structures. 32) Medical helicopter/air evac landing pads. 33) Temple. 34) Guard and sentry boxes. 35) Gate houses. 36) Incinerator buildings. 37) Refrigeration (walk-in) - Deep freeze (walk-in) - Built-in morgue refrigerators. 38) Communications: LAN - Local Area Network. 39)Telephone System, Complete. 40) Intercom systems, Complete. 41) Patient Physiological Monitoring: Conduits, Boxes, Blank Outlets Equipment 42) Staff Radio Paging Systems, Complete: Conduits, Boxes, Wiring, Equipment. 43) Fire Detection and Alarm System, Complete.

Clinics or hospital require spaces and equipment of high and safe technology, coexisting with plenty of more simple equipment and material or inputs needing to be robust, essential (food, drink, furniture and dresses) and easy to maintain. There are also plenty of special places helping functionality. See for: - treatment of sound and noises in and around hospitals - space for pipes of many technical fluids or gas (columns from one plant to another) - Hazard nuisance and risks procedures and architecture considering that some patients cannot move by themselves in case of emergency - Lifts and corridors' dimensions for displacing and receiving beds - Separation of circuits of clean and of dirty so as the second one never cross the first one - Structures ambulance and vehicules movements - Clinics and hospitals are not safe from criminal practices and security is an important issue - Water, gas, steam are under pressures and/or flammable - Electric circuits under strong constraints - Vehicules of many different types and pedestrian coexist everywhere - Some social places are not to miss as atriums/clinic malls/temples - Doors are special - Rooms and storages places differenciate according sterile, semi-steril, for decontamination material - Management of hazard waste - Facility engineer maintenance shops -".

Examples of suggested Research in Health Management of Facilities in Structured Levels are: 1) Individual: - Evidence of project management in projects (objective setting with time scales) - Description of mentorship and supervision structures - Research as part of job description and reviewed in annual appraisal. 2) Teams: - Evidence of project management in projects - A description of mentorship and supervision - Protected time taken. 3) Organisational: - Evidence of information dissemination strategies - Use and availability of protected time - Evidence of back fill availability and use - Research is part of annual appraisal for some jobs - Evidence of help with governance and ethics. 4) Supra-organisational (networks and support units): - The nature of collaborations (co-authorship, order of authorship) - Organize information exchange events. Description of attendance.

Healthy Environment (put its infrastructures first)

"Health Safe Environment: 1) Clean and sufficient drinking water, proper sanitation and drains for waste water, and proper solid waste management are the key health equity interventions in deprived urban areas, and cost-effective solutions exist. 2) Household energy supply is a major environmental health issue because of the harmful effects of biomass and coal smoke. Alternative fuels for cooking and heating need to be made available and electricity for lighting and refrigerators provides great benefits for health. 3) The working environment can be harmful to health of the poor and powerless. Specific interventions exist for all types of industrial activity, including cottage industries. 4) Availability of and access to public transport is a key element in improving transport equity and reducing the negative health impacts of a car society. 5) Providing food for the growing urban populations has its own environmental and health risks. Interventions to create a sustainable food supply based on principles of resource conservation and environmental protection is a key issue for future health equity. 6) Broad environmental health policies, such as those promoted by the Healthy Cities and Municipalities movement, provide excellent frameworks for improving the living environment and health for poor people 7) Global climate change is likely to particularly affect health of poor people in both rural and urban areas. Actions to reduce its severity are therefore actions for health equity. A timely improvement in the living environment for all deprived and disadvantaged people is necessary for health equity and this will require greater transfer of financial and technical resources from the affluent to the less affluent".

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