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Against statutory duties to introduce quality management systems, the increased importance of this subject has led to numerous activities in various public health institutions. Following the International Standardization Organization (ISO 9001:2000) prerequisites, Frankfurt Goethe University Hospital ENT clinic staff introduced a quality management system. This paper aims to investigate this process.

Designing, planning and implementing the quality management system is described. Under the supervision of an executive quality management board, clinic quality goals were defined. Thereafter, several quality management teams performed an actual state analysis as well as developing and realising improvement proposals. Finally a quality management manual containing binding standards and working instructions concerning all patient care, research and teaching aspects was written.

Successful certification by a neutral body ascertained that the clinic's quality management system conformed to current national and international standards while restructuring and reform improved procedural efficiency.

The paper shows that mplementing the quality management system requires considerable effort but patients as well as staff profit considerably from the innovation. On the whole, the positive impact on structure and workflow in a specialist clinic predominates. Therefore, implementing a quality management system in all the clinic's wards and departments is recommended.

This paper traces the innovative development of the Nottingham Cochlear Implant Programmes. The paediatric programme was the first to be established in the UK in 1989 and remains the largest programme in the UK today, whilst the adult programme developed later, in 1994. The first section of the paper describes trends in service development whilst the second section makes detailed reference to the history of funding arrangements which enabled the programme to become established. The third part of the paper examines the (de)merits of locality purchasing versus centralised purchasing for specialist services, using cochlear implantation as way of illustration. The paper aims to provide an informative history of the development of the service in Nottingham and from this background create debate as to the most appropriate future funding mechanism for cochlear implantation in particular and specialist services in general.

“Support a lawyer. go to med school” The above message on the car bumper stickers of members of the medical profession reflects their reaction to the current escalation of malpractice suits filed by attorneys against doctors and hospitals. The impact of these suits against medical personnel and institutions is not limited to patients, doctors and lawyers; the ripple‐effect reaches the entire community, because the rising incidence of malpractice suits tends to increase the cost of malpractice insurance and ultimately the total cost of health care to all members of society. Malpractice is but a small, though highly visible, part of a broader spectrum of interaction between medicine and law. “The complexities of modern society are causing law and medicine to interface with increasing frequency to the extent that contact with the legal process has become an inescapable aspect of the physician's life.” In recognition of this increasing frequency of contacts between medicine and law, a correspondingly increasing number of medicolegal reference works have been published, as exemplified by the selective list which follows this introduction. These should be of direct interest to doctors and members of allied health professions, to attorneys and paralegals and, indirectly, to all who deal with medical personnel and institutions. Traditionally, attorneys, particularly members of the trial bar, have demonstrated a continuing interest in medical literature. For example, the Merck Manual and Goldstein's Medical Trial Technique are familiar to most trial lawyers. They are expected to be well acquainted with anatomy charts, texts on internal medicine, eye, ear, nose and throat, orthopedics, obstetrics, and pediatrics, to name but a few generic medical works of interest to trial lawyers. It should be noted that the lawyer's interest in medical literature is not necessarily motivated by a desire to harass doctors, nurses and hospitals. Attorneys are bound by their Code of Professional Responsibility to represent their clients competently and zealously. In discharging this ethical obligation, the attorney frequently calls upon a physician to testify as an expert witness concerning the cause of a personal injury or death. Consequently, the attorney should be knowledgeable in medical theory and terminology. Furthermore, in pursuit of interdisciplinary competence, a significant number of individuals in the United States have earned both the medical degree and the law degree and appropriate licenses to practice, e.g., Cyril Wecht, M.D., J.D., Director, Pittsburgh Institute of Legal Medicine, Duquesne Law School, member, Faculty of the Pittsburgh School of Medicine and Dentistry, Coroner, Allegheny County, Pennsylvania.

The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.

A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.

The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.

The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.

The pursuit of cost efficiency in the British National Health Service has resulted in increased emphasis on devolved financial accountability and the introduction of an internal market. With the aid of a case study, this paper examines alternative forms of governance and proposes that aspects of the internal market and functioning within acute hospital units, are suited to network‐style organisation. The implications of hierarchies and networks for the design and use of management accounting information (MAI) are identified. These are used to analyse the case evidence concerning the roles, intended and unintended, of MAI in the context of organisational change and where multiple, and sometimes conflicting, goals and priorities existed. It concludes that a network approach to the design of MAI is more consistent with the desirable culture, at operational level, in acute units. However, this will only be achieved through deliberate intervention by those who design MAI systems and senior managers, who by their attitudes towards the interpretation and response to MAI, shape overall organisational culture.

Air pollution indoors is fast becoming a major concern of those involved in the design and maintenance of modern buildings. But poor air quality is just one of several factors held responsible for causing symptoms of ‘sick building syndrome’, defined by the World Health Organization as irritation of the nose, throat and eyes, together with headaches and feelings of lethargy. Such symptoms can significantly lower the productivity and morale of a building's occupants. It is quite possible that indoor air pollution will become one of the major environmental issues of the next decade.

In a number of recent multi-billion dollar cases brought against cigarette manufacturers, plaintiffs have in part alleged that the cigarette manufacturers (1) conspired not to compete on the basis of health claims or the introduction of potentially safer cigarettes since the 1950s, and (2) engaged in fraudulent advertising by making implied health claims in advertisements selling ‘low tar’/‘light’ cigarettes. In this type of litigation, defendants’ actions could be due to alleged illegal behaviour as asserted by plaintiffs, or be the result of market forces that may have nothing to do with allegedly inappropriate acts. We examine the economic evidence relating to these allegations, taking into account some of the major influences on cigarette company behaviour. In particular, our analyses show that much of the cigarette manufactures’ behaviour can be explained by Federal Trade Commission and related government actions, rather than conspiracy or fraudulent acts. We find the economic evidence is inconsistent with an effective conspiracy to suppress information on either smoking and health or the development and marketing of potentially safer cigarettes. Regarding ‘lower tar’ and ‘light’ cigarettes, the economic evidence indicates that the cigarette manufacturers responded to government and public health initiatives, and that disclosing more information on smoking compensation earlier than the cigarette companies did would not have had any significant impact on smoking behaviour.