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OSH 4308, Advanced Concepts in Environmental Safety Management 1

 

Course Description A comprehensive overview of the occupational safety and health field to include the application of quantitative problem solving related to workplace safety and health. This course is also designed to be helpful for students in preparation for the ASP and CSP exams.

Course Textbook Yates, W. D. (2011). Safety professional’s reference and study guide. Boca Raton, FL: CRC Press.

Course Learning Outcomes Upon completion of this course, students should be able to:

1. Recognize safety, health, and environmental hazards dealing with ergonomic, electrical, natural, biological,

radiological, physical, mechanical, and other relevant sources.

2. Apply appropriate measurement and evaluation techniques to safety, health, and environmental hazards.

3. Explain important laws, codes, and regulations related to occupational safety and health and the environment.

4. Recommend appropriate means for controlling safety, health, and environmental hazards.

5. Perform appropriate calculations in relation to measurement, evaluation, and control of safety, health, and

environmental hazards.

6. Recognize and discuss safety, health, and environmental training and management techniques.

7. Recognize and discuss fundamental business principles, practices, and metrics commonly applied to safety,

health, and environmental practice.

8. Explain scientific facts and concepts important to the occupational safety and health professional.

 

Credits Upon completion of this course, the students will earn three (3) hours of college credit.

Course Structure

1. Unit Learning Outcomes: Each unit contains Learning Outcomes that specify the measurable skills and knowledge students should gain upon completion of the unit.

2. Unit Lesson: Each unit contains a Unit Lesson, which discusses unit material. 3. Reading Assignments: Each unit contains Reading Assignments from one or more chapters from the

textbook. Suggested Readings are provided in Unit I, II, IV, and V Study Guides to aid students in their course of study. The readings themselves are not provided in the course, but students are encouraged to read the resources listed if the opportunity arises as they have valuable information that expands upon the lesson material. Students will not be tested on their knowledge of the Suggested Readings.

4. Learning Activities (Non-Graded): These non-graded Learning Activities are provided in Units I-VIII to aid students in their course of study.

5. Discussion Boards: Discussion Boards are a part of all CSU term courses. Information and specifications regarding these assignments are provided in the Academic Policies listed in the Course Menu bar.

6. Unit Quizzes: This course contains eight Unit Quizzes, one to be completed at the end of each unit. Quizzes are used to give students quick feedback on their understanding of the unit material and are composed of multiple-choice questions.

OSH 4308, Advanced Concepts in Environmental Safety Management Course Syllabus

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 2

7. Unit Assignments: Students are required to submit for grading Unit Assignments in Units II-VIII. Unit VIII contains two Assignments. Specific information and instructions regarding these assignments are provided below. Grading rubrics are included with the Unit II-VIII Assignments. Specific information about accessing these rubrics is provided below.

8. Ask the Professor: This communication forum provides you with an opportunity to ask your professor general or course content related questions.

9. Student Break Room: This communication forum allows for casual conversation with your classmates.

CSU Online Library The Library is available to support your courses and programs. The online library includes: databases, journals, e-books, research guides, and other support services. The eResources are accessible 24/7 and can be accessed through the Online Portal. To access the library, log into myCSU Student Portal and then click on CSU Online Library. The CSU Library offers several reference services. E-mail (library@columbiasouthern.edu) and telephone assistance is available (1.877.268.8046) Monday – Thursday 8 am to 5 pm, and Friday from 8 am to 3 pm. Ask Librarian! is available 24/7: look for the chat box on the online library page. Librarians can help you develop your research plan or to assist you in any way in finding relevant, appropriate and timely information. Reference requests can include customized keyword search strategies, links to articles, database help and other services.

Unit Assignments Overview of the Unit Assignments In this course, you are asked to prepare a Comprehensive Report as the Unit VIII Final Project, which is made up of various scenarios throughout each unit. Units II through VIII each contain a scenario for you to solve and to provide recommendations. By the end of the course, you are asked to collect all of the individual responses from each scenario and to insert them into a Comprehensive Report as the Unit VIII Final Project. Theme and Setting for Unit Assignments You are employed by Be Safe Consulting, Inc. (BSCI), as an entry-level safety consultant. You report directly to Bob Sanders, the supervising Certified Safety Professional (CSP). For the last two months, you have been assigned to conduct a comprehensive safety evaluation for Acme Manufacturing Co. Based on the observations, calculations, and recommendations in Unit II through Unit VIII, prepare a Comprehensive Report to Bob Sanders, who will in turn use this information to prepare a final report to Acme Manufacturing Co. Board of Directors. While the Board of Directors may be looking for detailed business implications, Bob Sanders is looking for a detail of potential employee-hazard exposures and your recommendation rationale (calculations, observations, and/or regulations). Unit II Project Ventilation Report You are employed by Be Safe Consulting, Inc. (BSCI) as an entry-level safety consultant. You report directly to Bob Sanders, the supervising Certified Safety Professional (CSP). BSCI has been contracted by Acme Manufacturing Co. to conduct a study to determine employee exposures to various particulates and gases. In addition, your company has been contracted to determine if the current ventilation systems that are in place are adequate to protect employees from an over exposure to these chemicals. After conducting a field assessment, prepare a written report that Bob Sanders can utilize to prepare a final comprehensive report for the Board of Directors. During your field investigation, you find the following field observations: Welding Room The company has six welding booths, or areas that are partitioned only for the use of welding curtains. The booth is open to mixing in the front and top. The company is worried about the welder’s exposure to iron oxide (PEL 10 mg/m3). For a valid sample, you must have a minimum of six hours of sampling (The remaining two hours of the work day is considered

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 3

to be equal to or less than the sampled exposure. As a result of your air sampling over an eight-hour time period (i.e., the work schedule), you receive the following analytical report:

Name Location Conc. 1 Time 1 Conc. 2 Time 2 Conc. 3 Time 3

Anne Welding

Booth #1 4.3 mg/m3 150 min. 3.7 mg/m3 150 min 2.2

mg/m3 240 min

Frank Worldly

Booth #2 2.1 mg/m3 180 min 2.8 mg/m3 120 min 3.1

mg/m3 240 min

Jim Young Booth #3 1.7 mg/m3 205 min 1.25

mg/m3 125 min

1.03 mg/m3

150 min

Betty Johnson

Booth #4 12.8

mg/m3 165 min

11.2 mg/m3

72 min 9.8

mg/m3 123 min

Jack Jones Booth #5 7.8 mg/m3 190 min 14.2

mg/m3 149 min

8.8 mg/m3

140 min

Joey Apperton

Booth #6 3.9 mg/m3 155 min 4.6 mg/m3 90 min 2.1

mg/m3 46 min

Based on this information, determine the employee’s actual exposure to iron oxide, whether the samples were valid, and if not, why? Show your work either in the report or as an appendix. During further evaluations of the welding booths, you determine that each booth utilizes a local exhaust system to remove the iron oxide and other contaminants prior to mixing with the breathing air. You take the following measurements:

Location Air Velocity

(fpm)

Work distance from exhaust opening (in

inches)

Duct Diameter (in inches)

Flow Rate (cfm)

Booth #1 683 18 8 Unknown

Booth #2 Unknown 16 8 12,375

Booth #3 710 16 12 Unknown

Booth #4 184 26 8 Unknown

Booth #5 Unknown 22 8 9721

Booth #6 Unknown 18 12 11421

After taking the air samples for employee exposures to iron oxide, then measuring and calculating the performance of the local exhaust ventilation (paying particular attention to the specifics), what recommendations would you make to reduce the employee’s overexposure, if any, to the ventilation systems? Hazardous Materials Storage Area As part of your assessment, you have been asked to evaluate and determine if the hazardous materials storage area has adequate ventilation. In addition to the federal requirements, Acme’s insurance carrier requires that they have a minimum of 12 air changes per hour. In your evaluation, you collect the following information:

Area Width (ft.)

Area Length (ft.)

Area Height (ft.)

Ventilation Supply #1

(volume – cfm)

Ventilation Supply #2

(volume – cfm)

22 30 14 874 993

Determine if the current hazardous materials storage area is adequate and meets the requirements of Acme’s insurance carrier. What recommendations would you make to correct the discrepancies, if any?

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 4

Foundry Room Acme has a foundry room, which is nearing the point of being outdated in terms of engineering controls. For example, one employee stands near an operation that has a canopy hood exhaust and routinely puts his face in the flow of the hood, causing him to inhale particulates and gases that are directly being drawn into the hood. Part of your evaluation is to make a recommendation for a new type of exhaust system. Which one would you recommend, and why? Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit III Project Radiation Safety Report The executives at Acme Manufacturing Co. were impressed by your first report, and they have asked you and BSCI to return for more work. BSCI has been contracted by Acme Manufacturing Co. to conduct a study to determine employee exposures to radiation. In addition, your company has been contracted to determine the effectiveness of engineering controls, including shielding. After conducting a field assessment, prepare a written report for Bob Sanders (CSP) to present to the Board of Directors. During your field investigation, you find the following field observations: Test Equipment and Repair Facility The company has an on-site test equipment and repair facility. Much of the test equipment contains a radiation source. Normal practice inside the facility is to limit the time of exposure of employees working on this equipment as a method of control. However, the company is looking at the possibility of installing lead shields or increasing the distance from the source, thus increasing employee time working on equipment. Based on the following information determine the employee’s exposure:

Location Employee Distance (Initial)

Distance (Proposed)

Intensity (Initial)

Intensity at proposed distance

Bench #3 Rita Ray D’Ashun 0.5 ft. 2 ft. 110 mrem/h Unknown

Bench #5 Robert Long 1 ft. 3 ft. 137 mrem/h Unknown

Bench #6 Paul Row 0.75 ft. 1.5 ft. 102 mrem/h Unknown

Based on this information, determine the employee’s actual exposure rate to the radiation source. Show your work (either in the report or as an appendix). The second option under consideration is to install lead shields in order to reduce the employee’s dose rate. Using the information provided in the table above, determine the intensity at the same distances listed above if a 5 cm lead shield was placed between the source and the detector. [µ for lead, (662 keV gamma ray) = 1.23 cm-1] Radar Testing Facility As part of your assessment, you have been asked to evaluate the estimated power density levels for both near and far fields. You have conducted your assessment and measurements with the following data:

Location Diameter

(cm) Antenna Power

(watts)

Power Density (Near Field)

(mW/cm2)

Power Density (Far Field) (mW/cm2)

Radar Unit #1 48 in 50,000

Radar Unit #2 26 110,000

 

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 5

Laser Laboratory Acme Manufacturing is currently considering constructing a laser laboratory, which will contain Class III, IIIA, and IIIB lasers. Identify the safety control measures that the client must consider before proceeding to the design phase of the project. Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit IV Project Hazardous Noises Report After receiving good remarks from your previous work, you hear that Acme Manufacturing Co. has asked you and BSCI to return for some additional work. BSCI has been contracted by Acme Manufacturing Co. to conduct a study to determine employee exposures to noise. In addition, Acme Manufacturing Co. has requested that while on site, you conduct a needs analysis to determine the development of a new safety training program. Explain your methodology and the steps in conducting this needs analysis. After conducting a field assessment, prepare a written report for Bob Sanders (CSP) to present to the Board of Directors. During your field investigation, you find the following field observations: Machine Shop #1 The company has an on-site maintenance and repair facility. Inside Machine Shop #1, there are five employees that operate a variety of machines, ranging from stationary and portable grinders, drill presses, and metal shearers. Based on the information provided in the following table, determine the individual employee’s exposure: (DO NOT COMBINE NOISE LEVELS)

Location Employee Sample

#1 Sample Time #1

Sample #2

Sample Time #2

Sample #3

Sample Time #3

Stationary Grinding Wheel

Robert Jones 82 dBA 90 min 91 dBA 125 min 83 dBA 265 min

Drill Press #4 Clara Tucker 89 dBA 135 min 79 dBA 249 min 81 dBA 96 min

Metal Shear #2 Rick Starnes 75 dBA 283 min 94 dBA 39 min 84 dBA 158 min

Metal Shear #3 Jennie Gump 83 dBA 114 min 73 dBA 239 min 95 dBA 127 min

Bench Press #7 Bernie Edwards 73 dBA 203 min 79 dBA 172 min 83 dBA 105 min

Carpentry Shop #2 Inside Carpentry Shop #2, there are six machines operating almost continuously, including table saws, planers, exhaust systems, jointers, with 10 employees working in this area. To determine whether this table should be designated as a hazardous noise environment, thus requiring employees to be entered into the hearing conservation program, you must calculate combined exposures and treat the entire area as one noise source. The following table indicates the recorded measurements that you collected during your on-site assessment. Does the data from this table indicate a hazardous noise environment, and do you recommend entering employees into a hearing conservation program?

Machine Noise Level (dBA)

Table Saw #3 92 dBA

Jointer #4 87 dBA

Table Saw #5 90 dBA

Exhaust Ventilation System 80 dBA

Planer #2 84 dBA

Drill Press #1 79 dBA

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 6

Electronic Communication Repair Shop Acme Manufacturing is currently considering remodeling this shop in order to install a new noise absorbing wall and floor insulation. They have asked that you review the previous history of noise level exposures in this area and provide your recommendations. However, this data is given in measurements of N/m2, but the Project Engineer is requesting the information in W/m2. Given the following data, convert N/m2 to W/m2 and include it in your report:

Date Location SPL (N/m2)

4/12/10 East Wall 0.0683 N/m2

4/12/10 West Wall 0.0742 N/m2

4/14/10 South Wall 0.0813 N/m2

4/14/10 North Wall 0.0699 N/m2

Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit V Project Thermal Stressors Report Bob Sanders (your supervisor) has another job for you. Acme Manufacturing Co. was impressed by your last report, and they have asked you to return to complete another job. BSCI has been contracted by Acme Manufacturing Co. to conduct a study at one of its facilities to determine employee exposures to various thermal stressors at different times. You are to conduct this study in January and July of 2012. After collecting and recording data from the field assessments, prepare a written report for Bob Sanders (CSP) to present to the Board of Directors. During your field investigations, you find the following field observations: Security Personnel The security personnel, while contracted by Acme, are still employees that need to be monitored. There are three main entries that are staffed with security personnel. These entries have a booth, which is roughly 5’x5’ with no heating or cooling. Each security officer works an eight hour shift, with two separate fifteen minute breaks (one during the first half of the shift, and the second during the second half of the shift) and one 30-minute meal break. The only opportunity to rehydrate is made during the break or meal periods. There are no drinking fountains or coolers in the security booths. Calculate the wind chill factor and wet bulb globe temperature (WBGT) for each location.

January findings

Location Temperature

0F

Wind Velocity (mph)

Wind Chill Factor (Calculated)

North Entrance -3 20

South Entrance -4 26

East Entrance -6 17

 

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 7

July findings

Location Wet Bulb

(0F) Dry Bulb

(0F)

Globe Temp (0F)

Calculated WBGT Index

North Entrance 98 89 92

South Entrance 102 91 94

East Entrance 99 88 87

Based on this information, determine which category each security location is exposed to and make a recommendation as to what changes, if any, you would make. Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit VI Project Hydrostatics and Hydraulics Report BSCI has another job for you at Acme Manufacturing Co., and Bob Sanders (your supervisor) has asked you to complete it. BSCI has been contracted by Acme Manufacturing Co. to collect measurements of various industrial storage facilities and certain aspects of its fire suppression system. After collecting field measurements and calculating values, prepare a written report for Bob Sanders (CSP) to present to the Board of Directors. During your field investigations, you find the following field observations: Piping System Repair A piping system repair must be made to a vertical piping system. The pipe is 60 ft. long prior to its turn to a horizontal direction. There is a repair that must be done at 35 feet above the floor. The pipe is filled with a liquid having the same properties as water. Due to operational considerations, the pipe cannot be drained. The fluid is considered non-hazardous due to its chemical properties. Before the repair can be completed, a decision has to be made about the material to use and the method in which the repair can occur safely. At the location of the pipe repair, what is the pressure of the fluid? (NOTE: the height of the cylinder is the length of the pipe minus the height of the repair from the floor.) Water Storage Tank Some repairs have been made to the existing water storage tank. New valves and piping systems are to be installed in the distribution system. You have been asked to calculate the velocity of the fluid through the bottom drain opening and prior to entry into the distribution system. This velocity will help to determine the specific valve that must be installed prior to the distribution system. The tank at its highest point is 24 feet. Determine the velocity of the fluid at fluid heights of 24 feet, 18 feet, 12 feet, and 6 feet. Fire Suppression System In a horizontally installed piping system, water flows through a 10 inch pipe. The head loss in a 500 foot section is 40 feet. The residual pressure at Point A is 55 psi and the velocity at Point A is 7 ft./s. If the velocity at Point B is 8.5 ft/s, what is the residual pressure at Point B? Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 8

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit VII Project Fire Prevention and Protection Report Acme Manufacturing Co. has another job for BSCI, and Bob Sanders (your supervisor) asks you to complete it. BSCI has been contracted by Acme Manufacturing Co. to conduct a fire protection and prevention inspection. During the inspection, you make several notes, which you use to prepare a written report. Later, Bob Sanders (CSP) intends to utilize your report as he presents the details to the Board of Directors. During your field investigations, you find the following data: Welding Shop In the welding shop, you collect measurements of the floor space which measures 125 ft. x 80 ft. In the center of the room, near a column, you notice that there is one fire extinguisher, which is a 2A10B:C rated extinguisher. Determine if this is an adequate number of extinguishers for this area. Explain. Molding Shop In the molding shop, employees prepare resins to shape the molds used in creating one of the products manufactured by Acme. The area has a strong odor of acetone, which is used significantly in the preparation of the resin molds. In this area, you notice that there is a sprinkler system, and the sprinkler head is green. What is the maximum ceiling temperature for this area? As mentioned, employees in this shop use a significant amount of acetone in the preparation process. Also while conducting the inspection of this shop, you notice an overhead gas space heater with an open flame. What are the UEL/UFL and LEL/LFL of acetone? What actions would you take immediately in this area? Explain. Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work). Unit VIII Project Ergonomics Report Bob Sanders (your supervisor) has another job for you to complete for BSCI. This time, you have been asked to examine the ergonomic details at Acme Manufacturing Co. Specifically, Acme Manufacturing Co. has asked you to conduct an ergonomic evaluation of the packing line. Given the following worksheet (see the link below to download the worksheet), calculate the (1) RWL and (2) the Lifting Index. Using the data and results, provide your written recommendations for corrective action. Click here to download a copy of the job analysis worksheet included with data. Your report should be in APA style and be at least one page in length, double-spaced (not including title, references, and appendix pages). Respond to the details in each section and be sure to include at least each of the following sections in your report for this unit:

 Introduction: Briefly describe why the studies were performed (why you started the study).

 Report details: Briefly discuss the details of the scenario (what you found from the study).

 Conclusions and recommendations: Briefly describe your recommendations based on your findings (what you recommend to resolve any deficiencies).

 Appendix: Provide measurements and calculations (show your work).

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 9

Unit VIII Final Project Comprehensive Report For the Final Project, you are asked to prepare a Comprehensive Report, which is made up of various scenarios from previous units. Units II through VIII each contain a scenario for you to solve and to provide recommendations. For this assignment, you are asked to compile your responses from each scenario and frame them into a Comprehensive Report. The Comprehensive Report requires each of the following:

I. Title page: Use APA style for the title page and all other components of this report (be sure to cite and reference any outside sources).

II. Executive summary: Summarize the entire report by briefly identifying the main points of each individual report. III. Table of contents: Construct a table of contents for your report. IV. Reports: Provide each of the individual reports (with any necessary corrections or improvements). V. Appendix: Include each appendix from the individual reports (with any necessary corrections or improvements).

The purpose of this project and its constituent reports is to provide you with an opportunity to gather data, calculate data, make recommendations, and prepare reports as an advanced safety professional. Once complete, keep your Comprehensive Report as a demonstration of your ability to perform as an advanced safety professional, as well as a representation of your attention to detail. Bosses like that kind of thing, and so do future employers.

APA Guidelines CSU requires that students use APA style for papers and projects. Therefore, the APA rules for formatting, quoting, paraphrasing, citing, and listing of sources are to be followed. Students can find CSU’s Citation Guide in the myCSU Student Portal by clicking on the “Citation Resources” link in the “Learning Resources” area of the myCSU Student Portal. This document includes examples and sample papers and provides information on how to contact the CSU Success Center.

Blackboard Grading Rubrics Assignment Rubrics One or more assignments in this course utilizes a Blackboard Grading Rubric. A rubric is a tool that lists evaluation criteria and can help you organize your efforts to meet the requirements of an assignment. Your professor will use the Blackboard Grading Rubric to assign points and provide feedback for the assignment. You are encouraged to view the assignment rubric before submitting your work. This will allow you to review the evaluation criteria as you prepare your assignments. You may access the rubric in “My Grades” through the “Tools” button in your course menu. Click the “View Rubric” link to see the evaluation criteria for the assignment. Upon receiving your assignment grade, you may view your grade breakdown and feedback in the rubric.

CSU Grading Rubrics for Papers/Projects, Discussion Boards, and Assessments The Learning Resource area of the myCSU Student Portal provides the rubrics, and information on how to use them, for Discussion Boards, written response questions in Unit Assessments, and Research Papers/Projects. The course writing assignments will be graded based on the CSU Grading Rubric for all types of writing assignments, unless otherwise specified within assignment instructions. In addition, all papers will be submitted for electronic evaluation to rule out plagiarism. Course projects will contain project-specific grading criteria defined in the project directions. To view the rubrics, click the Academic Policies link on the Course Menu, or access them through the CSU Grading Rubric link found in the Learning Resources area of the myCSU Student Portal.

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 10

Communication Forums These are non-graded discussion forums that allow you to communicate with your professor and other students. Participation in these discussion forums is encouraged, but not required. You can access these forums with the buttons in the Course Menu. Instructions for subscribing/unsubscribing to these forums are provided below. Click here for instructions on how to subscribe/unsubscribe and post to the Communication Forums. Ask the Professor This communication forum provides you with an opportunity to ask your professor general or course content questions. Questions may focus on Blackboard locations of online course components, textbook or course content elaboration, additional guidance on assessment requirements, or general advice from other students. Questions that are specific in nature, such as inquiries regarding assessment/assignment grades or personal accommodation requests, are NOT to be posted on this forum. If you have questions, comments, or concerns of a non- public nature, please feel free to email your professor. Responses to your post will be addressed or emailed by the professor within 48 hours. Before posting, please ensure that you have read all relevant course documentation, including the syllabus, assessment/assignment instructions, faculty feedback, and other important information. Student Break Room This communication forum allows for casual conversation with your classmates. Communication on this forum should always maintain a standard of appropriateness and respect for your fellow classmates. This forum should NOT be used to share assessment answers.

Grading

Discussion Boards (8 @ 2%) = 16% Unit Projects (7 @ 4%) = 28% Quizzes (8 @ 3%) = 24% Unit VIII Final Project = 32% Total = 100%

 

Course Schedule/Checklist (PLEASE PRINT) The following pages contain a printable Course Schedule to assist you through this course. By following this schedule, you will be assured that you will complete the course within the time allotted.

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 11

OSH 4308, Advanced Concepts in Environmental Safety Management Course Schedule

By following this schedule, you will be assured that you will complete the course within the time allotted. Please keep this schedule for reference as you progress through your course.

 

Unit I Safety Regulations and OSHA Record Keeping

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 2: Regulations and OSHA Record Keeping  Suggested Reading: See Study Guide

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)

Notes/Goals:

 

Unit II Particulates, Gases, and Ventilation

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 4: Particulates and Gases  Chapter 7: Ventilation  Suggested Reading: See Study Guide

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

Unit III Radiation Safety

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 26: Radiation Safety

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 12

OSH 4308, Advanced Concepts in Environmental Safety Management Course Schedule

Unit IV Noise, OSHA’s Hearing Conservation Program, and Training

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 8: Noise and OSHA’s Hearing Conservation Program  Chapter 17: Training  Suggested Reading: See Study Guide

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

Unit V Thermal Stressors and Electrical Safety

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 11: Thermal Stressors  Chapter 14: Electrical Safety  Suggested Reading: See Study Guide

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

Unit VI Hydrostatics and Hydraulics

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 16: Hydrostatics and Hydraulics

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

 

 

OSH 4308, Advanced Concepts in Environmental Safety Management 13

OSH 4308, Advanced Concepts in Environmental Safety Management Course Schedule

Unit VII Fire Protection and Prevention

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 10: Fire Protection and Prevention

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)

Notes/Goals:

 

Unit VIII Ergonomics

Review:  Unit Study Guide  Learning Activities (Non-Graded): See Study Guide

Read:  Chapter 22: Ergonomics

Discuss:

 Discussion Board Response: Submit your response to the Discussion Board question by Saturday, Midnight (Central Time)

 Discussion Board Comment: Comment on another student’s Discussion Board response by Tuesday, Midnight (Central Time)

Submit:  Quiz by Tuesday, Midnight (Central Time)  Project by Tuesday, Midnight (Central Time)  Final Project by Tuesday, Midnight (Central Time)

Notes/Goals:

Health Consumer And Info Sys

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Textbook: Wager, K. A., Lee, F. W., & Glaser, J. P. (2013). Health care information systems: A practical approach for health care management (3rd ed.). San Francisco, CA: Jossey-Bass.

H 483: Please write up 150 to 200 word counts for questions # 1 to 6; (# 7 It’s a table). Your initial response should include detail that combines the textbook – Health Care Information Systems and with your personal experience/ knowledge. Cite/ References work. Do not plagiarize!

1. RMF: The benefits of using information technology are plentiful. For example, the promise of fully realized electronic medical records is having a single record that includes all of a patient’s health information: a record that is up to date, complete, and accurate.

In addition, do you think information technology really improve the security and confidentiality of patient health information? What research have you found that supports your point of view?

 

2. What is the Health Insurance Portability and Accountability Act (HIPAA)? Why is it important to privacy and security?

 

3. When dealing with HIPAA regulations, the use of security measures begins with the healthcare facility.  The organization must follow regulated rules that abides by HIPAA regulations (Wager, 2013).

How do health care organizations enforce the federal rules associated with HIPAA and the Privacy Rule? What are some methods they employ?

 

4. Healthcare organizations can incure fines and penalties for not protecting pateint informaiton (Wager, 2013). Can anyone provide a brief description of the fines and penalties for disclosing patient information without consent? Also, are these fines and penalties described under federal law or state law?

5.  HIPAA protects electronic medical records. However, converting paper-based health care records to electronic records can be extremely challenging (Wager, 2013). What are the major costs associated with converting paper-based health care records to electronic records?

 

6.  Why have health care organizations not used information technology (IT) as much as other industries? What trends suggest this may change in the near future?

7. Complete : Health Care Information Systems Terms below:

· Each definition and description is supported with APA-formatted citations. This means that every box is required to have a citation.

· Cite and reference all information in APA format.

· There must be APA-formatted citations and a final reference page with at least 2 references.

· Each definition and description is supported with APA-formatted citations. This means that every box is required to have a citation.

Health Care Information Systems Terms

 

Define the following terms. Your definitions must be in your own words; do not copy them from the textbook.

 

After you define each term, describe in 40 to 60 words the health care setting in which each term would be applied. Include at least two research sources to support your position—one from the peer-reviewed and the other from the textbooks. Cite your sources in the References section consistent with APA guidelines.

 

Each definition and description is supported with APA-formatted citations. This means that every box is required to have a citation.

 

Term Definition How It Is Used in Health Care
Health Insurance Portability and Accountability Act    
Electronic medical record    
Electronic health record    
Personal health record    
Computerized provider order entry system    
Unique patient identifier    
Protected health information    
Centers for Medicare & Medicaid Services    
Covered entities    
Health information exchange    

 

 

References:

 

———————————————————————————————————————————–

H 490

Textbooks: Berkowitz, E. N. (2011). Essentials of health care marketing (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.

Solomon, M. R. (2013). Consumer behavior: Buying, having, and being (10th ed.). Upper Saddle River, NJ: FT Press/Pearson. 

Thielst, C. B. (2013). Social media in healthcare: Connect, communicate, collaborate (2nd ed.). Chicago, IL: Health Administration Press.

Please write up 150 to 200 word count for questions 8 to 25; # 27 It’s an essay (700 word count),Must choose 2 Health Care Products Advertisements .Your initial response should include detail that combines the textbook – Health Care Information Systems and with your personal experience/ knowledge. Cite/ References work. Do not plagiarize!

8. There are the four Ps in marketing referred to as the marketing mix, and they are the controllable variables that are used to pursue a desired level of sales and which are; production, price, place, and promotion.  There are many variables that go into marketing.  Things such as the needs vs the wants of the customer is one of those important variables.  Most health care organizations have been categorized by a non market driven culture.  The planning process for a non market drive culture such as health care starts with the defining the mission and goals, then moves onto a strategy and formulation, next is the implementation, and then finally the market.  For example, the marketing to get consumers to sign up for insurance under the Affordable Care Act:

Production – HHS developed a site that would house health care insurance information and prices.

Price – This product is free for consumers to use.  I believe all of the marketing inside the site is general and does not sway in any companies favor. Place – The Internet is the location for this product.

Promotion – EVERYWHERE!  The Affordable Care Act was marketed in every avenue; on line, on television, social media and in health care facilities around the United States.

This was a major publicized product and it was done well – minus the website issues of course.

Can anyone give other examples of the 4P’s?

9. Explain the difference between existing customers, target markets, and stakeholders for an acute care community hospital.

10.  What makes a marketing campaign successful? What are some examples of successful, or unsuccessful, marketing campaigns in health care?

11. If you find you cannot afford to go to the doctors because of the cost, what are some other options available to the consumer, besides applying for state or federal programs?

12. What is the difference between a non market based approach vs market based approach?

13.  You can save money by getting generics and has provided a list. But are generics really “the same thing”?  If so, why are the brand name drugs so much more expensive?

14.  If you get a prescription and find it costs too much, what are some of your options so that you can get the drug(s), other than applying for state or federal assistance programs?

15. Active assessment of the consumer’s wants and needs through systematic information gathering prepares the business to offer the right product for their demographic, at the right price. Knowing the specific needs of the region or area and understanding the mentality of the consumer, allows the business to meet needs and stay ahead of the competition.  Give an example of how a business markets based on demographics.

16.  The Meaning of Marketing, discusses the four Ps in successful marketing.  One of the key variables is place.  In this context, place refers to how goods and services are made available to consumers.  I like how the chapter gives the example that as few as 10 years ago, a physician chose his or her office location based on personal convenience.  Today, the focus is on the consumer, and health care organizations are using this line of thinking when planning where they will provide their services.

17. As you read this chapter the one thing that is quite striking is that health care professionals often speak of the fact that what consumers want may not be what they need. A simple statement but so very true.  What about those who are exposed to a vast number of people on a daily basis, but do not get a flu shot?  Another area to look at would be antibiotics.  Consumers get a sniffle, and they want an antibiotic.  They do not need an antibiotic, and in fact, it may end up doing more harm than good as their body gets used to the medication.  Today we know that antibiotics have been over prescribed for years and that is why our bodies do not respond as well as they should when we do take the antibiotics.  A want and a need may be two different things.  What are other examples of wants vs. needs?

18. Consumers want that “quick fix”.  What are other examples of quick fixes for medical issues?

19. What are the advantages and disadvantages in using social media?

20. Describes demographic variables that distinguish one consumer from another.  The demographic categories include age, gender, family structure, social class and income, race and ethnicity, geography, and lifestyles.  In my area, I see how organizations provide different products at their stores depending on geographic data.  For example, a major grocery store chain, with several locations throughout my city, will stock certain food and household items based on geographic market research studies.  I believe in the importance of this demographic variable because it helps supply the needs of a particular consumer.  In fact, all of the demographic variables are important all businesses can meet the needs of their consumers.

21. What constitutes a consumer category?

22. What is the difference between a B2B and a B2C buyer?  What are characteristics of each group of buyers?

23. Do you think the average consumer can easily navigate around this site and the links and understand what they read?

24. What is the purpose of monitoring consumer behavior?  How are consumers monitored in a brick and mortar store and how are they monitored online?

25. Can anyone tell me (in general) the way the HMO, PPO and CDHP work?  There are usually savings accounts that go with them.  They are the health saving account, the health reimbursement account and the flexible spending account.  Which goes with what plan, and how does it work?

26. Write a review (~ 700 words) of the two health care product advertisements in which you do the following:

· Describe the products (PRODUCTS MUST TARGET A SPECIFIC AGE GROUP OR OTHER SPECIFIC GROUP OF CONSUMERS).

· Describe the advertisement for the products.

· Does it target a specific age group? Indicate what information allowed you to make this conclusion.

· Based on the intended age group, is this advertisement effective? Explain.

· Does it target a specific ethnic group? Indicate what information allowed you to make this conclusion.

· Based on the intended ethnic group, is this advertisement effective? Explain.Does this advertisement appeal to you as a consumer? Explain why or why not.

Note: Formatting, citations and references within your assignment must conform to the

·

Adapting Art Activities

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Adapting Art Activities

Read the following scenarios. Decide which (if any) of these situations reflect appropriate art set-up techniques for activities discussed in this unit, and then answer the questions that follow.

Scenario #1
In a preschool class, Dory and Sammy have been building robots in the block area, so the teacher adds boxes, foil, wire, and a bucket of small, old radio parts to the area.

Scenario #2
Now that the weather is nice, a kindergarten teacher places the sand table just outside the door, which is next to the art area. The teacher explains new rules set up to stop the traffic flow going across the art area to and from the sand table.

Scenario #3
After a field trip to a grocery store, first grade teachers add empty food cartons and labels to the pasting and construction area.

Scenario #4
The teacher concludes that the children are not using the clay modeling area enough. She replaces it with another computer station.

•    Identify which of the scenarios reflects appropriate techniques for setting up for art activities. Why?
•    Discuss each which does not reflect appropriate techniques for setting up art activities.
•    Describe how you would change the situation(s) to make it (them) more appropriate

Assignment-Ethics In Health Care Practice

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Plagiarism Free,  Three references, Please read all Attachments, APA Style

 

Need back on Monday November 30, 2015 at 3pm Central time 

 

 

Ethics in Health Care Practice

In 900 words, identify and describe the issues affecting standards of practice related to competency of medical care identified in the Lyckholm and Hackney article

(Ethics in Health Care Practice).

 

 

In addition to summarizing the relevant points of the article, explain the relevance that standards of practice have (or will have) to you as a practitioner.

 

See Attachments Please

Critical Reviews in Oncology/Hematology

Volume 40, Issue 2 , November 2001, Pages 131–138

 

58183||

Ethics of rural health care

Laurie J. Lyckholm  ,  Mary Helen Hackney , ,  Thomas J. Smith

Department of Medicine and the Division of Hematology/Oncology, Massey Cancer Center, Virginia Commonwealth University School of Medicine, 401 College Street, Richmond, VA 23298-0037, USA

 

Accepted 6 February 2001, Available online 25 October 2001

 

doi:10.1016/S1040-8428(01)00139-1

 

Abstract

One quarter of the US population live in areas designated as rural. Delivery of rural health care can be difficult with unique challenges including limited access to specialists such as oncologists. The Rural Cancer Outreach Program is an alliance between an academic medical center and five rural hospitals. Due to the presence of this program, the appropriate use of narcotics for chronic pain has increased, the number of breast conserving surgeries has more than doubled and accrual to clinical trials has gone from zero to nine over the survey period. An increase in adjuvant chemotherapy has been noted. The rural hospitals and the academic center have seen a positive financial impact. The most prominent ethical issues focus on justice, especially access to health care, privacy, confidentiality, medical competency, and the blurring of personal and profession boundaries in small communities. As medical care has become more complex with an increasing number of ethical issues intertwined, the rural hospitals have begun to develop mechanisms to provide help in difficult situations. The academic center has provided expertise and continued education for staff, both individually and within groups, regarding ethical dilemmas.

Keywords

· Care of the poor; Cost analysis; Medically under-served; Rural; Strategic alliances

1. 1.Introduction

2. Program description: The Rural Cancer Outreach Program (RCOP)

3. Program analysis

 

3.1. Impact of the program on the clinical care provided

3.2. Impact of the program on health care professional recruitment and retention

 

4. Economic analysis

5. Other programs

6. Applicability to other settings

7. Ethical issues in rural health care

 

7.1. Justice issues: access to and delivery of health care

7.2. Competency of medical care

7.3. Confidentiality and privacy

7.4. Institutional ethics committees

 

8. Conclusions

9. Reviewers

10 Acknowledgements

11. References

12. Biographies

1. Introduction

One quarter of the US population lives in areas designated as rural, or fewer than 2500 people per town boundary, and frontier, or fewer than 6.6 people per square mile  [1] . The geographical and socioeconomic features of rural America present unique challenges to delivery of health care resources, especially delivery of oncology care.

 

Rural patient health is often poorer than urban or suburban patient health. The long distances make some types of care difficult. There is increasing evidence that high volume produces high quality cancer care  [2]  and  [3]  and many rural hospitals will always have low volume.

 

This article will explore the ethical issues related to rural health care, particularly oncology care. It will describe the rural cancer outreach program of the Massey Cancer Center (MCC) including a clinical and financial analysis of the program; the ethics of the program; applicability to other settings; and what we have learned in 10 years of creating access to care.

2. Program description: The Rural Cancer Outreach Program (RCOP)

The rural cancer outreach started as a ‘strategic alliance’  [4]  between academic centers and rural non-for-profit hospitals. The goal was to establish a model of care that would provide state of the art care in rural areas, increase the access to care, generate services and revenue for both the rural and academic center, train health care professionals  [5] , and serve as a laboratory for intervention. ( Table 1 ).

 

Table 1.

Goals of the rural cancer outreach program

Goal Comment
Establish a model of care for rural Virginia Virginia is typical rural US state
Deliver state of the art care in rural areas See what care could be delivered at the rural site, what should be centralized
Increase access to clinical trials Allow access to new drugs; increase accrual to clinical trials for the academic center
Train health care professionals Help recruit and retain primary care and specialist physicians and nurses for the rural area. Provide a specialty service that makes rural practice more attractive
Link academic and rural hospitals in strategic alliance Make regional policy, not hospital against hospital, to solve problems of indigent care.
Help finances of both hospital partners Help support unprofitable small rural hospitals.
Serve as a entry point for community based interventions in prevention Use the program for tobacco and nutrition interventions if desired by rural community.

Table options

The RCOP has grown from one program in 1988 to five programs operating at five rural hospitals. Briefly, the majority of cancer care is provided at the rural hospital. A team of two–three oncologists and two nurse practitioners or nurse clinical specialists travel to each site weekly. While there, they see new consultations and patients under treatment. They work with primary care doctors at the rural sites who have expressed an interest in care of cancer patients; this typically includes two–three surgeons and two–four primary care internists or family physicians. Nurses from the rural site come to the academic center for specialized cancer nursing, then receive annual updates. Many of the rural nurses have become certified in oncology nursing.

The program is administered by the Massey Cancer Center of the Medical College of Virginia, Virginia Commonwealth University, and each of the rural hospitals. Support for this program comes from the Commonwealth of Virginia.

3. Program analysis

3.1. Impact of the program on the clinical care provided

We have analyzed three important index conditions in our first two rural hospitals  [6] . We chose these conditions because there was documented wide variation in practice, and poor medical outcomes if optimal process was not followed ( Table 2 ). It was difficult to analyze the type of care because the volume of any one condition, e.g. use of adjuvant chemotherapy in Stage I–III breast cancer, was always low and usually less than ten cases per year. However, the importance of high quality care to those individuals is as important as in other settings. There is often reluctance to analyze care patterns if it is likely to show less than optimal care; for instance, a hospital that reports excess mortality from routine myocardial infarction may find that patients avoid that hospital for all cardiac care, especially troublesome for a small hospital that depends on retaining a large percentage of its market for survival. Also, there is often no financing available to support an in depth look at practice patterns and survival or recurrence.

 

 

Table 2.

Index condition Level before RCOP Level after RCOP
Morphine use in chronic pain 0 +500%
Breast conserving therapy <20% 60%
Clinical trial accrual 0 9
Adjuvant therapy for early breast cancer Unknown. Probably high for affluent patients who could travel, low for the poor Offered to all patients regardless of ability to pay

Table options

The use of morphine for cancer pain was studied in one hospital. In the preceding 3 years before RCOP, there had been almost no morphine prescribed; within 2 years the amount of oral and intravenous morphine increased by over 500%. In addition, the use of meperidine declined. Breast conservation, considered the desired treatment for early stage breast cancer, had been rarely used before RCOP. By the 3rd year of operation at our first hospital, over 60% of patients were routinely treated with breast conservation. In addition, before the RCOP, all breast cancer patients were not routinely offered adjuvant treatment, because many could not see an oncologist due to distance or cost. In other studies, the referral of patients to a medical oncologist — rather than treatment by a surgeon alone — was significantly correlated with the likelihood of receiving adjuvant chemotherapy  [7] . Clinical trial accrual to Cancer and Leukemia Group B (CALGB), National Surgical Adjuvant Breast and Bowel Program (NSABP) and other trials increased from essential zero to 9% of eligible patients. This compares favorably with the 2% national average in the US.

3.2. Impact of the program on health care professional recruitment and retention

The RCOP has been successful in helping to recruit and retain good physicians to rural areas. Physicians commonly mention the increased academic linkage and ease of referral to the academic center. These rural doctors have noted that the concentration of complex cancer care in the hands of a few local doctors rather than many has allowed them to increase their expertise. There has also been continued centralization of some complex procedures such as radiation and leukemia treatment that are not feasible to perform at a rural center.

4. Economic analysis

Pre- and post-RCOP financial data were collected on 1745 cancer patients treated at the participating centers, two rural community hospitals, and MCC. The main outcome measures were costs (estimated reimbursement from all sources), revenues, contribution margins, and profit (or loss) of the program.

Key results are shown in  Table 3 , modified from the full report in the Journal of Rural Health  [8] .

 

 

Table 3.

Impact of RCOP on rural and academic programs

  Pre-RCOP a Post-RCOP b Change (%)
Cancer patients from RCOP areas seen at MCC 173 743 330%
All patients from RCOP areas seen at MCC 6958 7572 9%
Estimated receipts, MCC $1 770 256 1 879 542 6.2%
Estimated receipts, RCOP NA $2 314 516 –
Total estimated receipts $1 770 256 $4 194 058 137%
Net annual cost per patient in the system $10 233 $3862 −62%
Inpatient admission, MCC $12 268 $7370 −40%

a

Represents average values of 1988 and 1989 financial data.

b

Represents average values of 1992 and 1993 financial data.

 

The RCOP had a positive financial impact on the rural and academic medical center hospitals. The RCOP was associated with an increased number of referrals of 330% more cancer patients and 9% more other medical/surgical patients. The MCC had increased receipts of 6.2%. The rural hospitals each had over a million dollars in new charges and over $500 000 US new profit each year. In total, the receipts for both centers increased by 137%. Most of this additional income was from ‘ancillary’ services such as increased use of the computerized axial tomography (CAT) or magnetic resonance imaging (MRI) scan, laboratory, and pharmacy. All patients were treated regardless of ability to pay, and the program generated sufficient profit to allow increased indigent care.

The net annual cost per patient fell from $10 233 to $3862 (−62%) associated with more use of outpatient services, more efficient use of resources, and the shift to a less expensive locus of care. The cost for each rural patient admitted to MCV fell by 40%, compared to only an 2% decrease for all other cancer patients consistent with other programs that have increased coordination among providers  [9] .

5. Other programs

Similar results of improved clinical care process, equal or better patient outcomes and cost savings have been reported from the Manitoba Cancer Outreach Program, but final results have not yet been published. The Manitoba Cancer Research and Treatment Program was started in 1984 with similar goals  [10] . It works on a similar model of consultation with the academic center, then all the care is delivered in one of six regional centers. Insurance is not an issue in Manitoba since there is a single universal payer. However, there are limited funds for cancer and dollars that can be saved by off loading to a regional center preserve dollars for research. Distance is even more problematic, with some centers 8 h by train, impassible by cars, and air transport too costly. Key rural primary care doctors and surgeons are identified, and given an initial training program followed by yearly updates. All protocols are specified in a central care plan, and the central hub audits dictations from the rural centers. Similar clinical results have been obtained, with excellent clinical care and less overall cost to the province  [11] . (personal communication, Harvey Schipper 1999)

6. Applicability to other settings

We have not identified other similar programs that have published their clinical and economic results. The closest is the Centre Bernard Lyon that has shown good adoption of clinical practice guidelines and better clinical practice  [12]  and  [13] . This program should be applicable to other centers that serve rural, dispersed populations. The main problems have been sustaining the medical innovation part of the program, and not ‘burning out’ the doctors and nurses who must travel the distance. The continued travel can be a major problem for health professionals.

7. Ethical issues in rural health care

The challenge is to provide high quality, affordable, accessible care for all. In the US, the absence of a single payer system allows exclusion of whole segments of the population. Combined with the dispersed poor population in rural areas, these issues represent significant obstacles to delivery of care. In Virginia, one third of the population is rural and most of these people are medically underserved for both primary and specialty care. The rural population has more federal Medicare and state Medicaid health insurance coverage with a low rate of reimbursement compared to most insurance, so rural hospitals and providers have less income than urban centers. ‘Negative marketing’ or locating services in affluent areas so that the poor do not have access is widespread.

The ethical issues most prominent in rural health care include justice issues, especially those involving access to and delivery of health care, related issues of medical competency, confidentiality and privacy issues, and conflicts of interest related to blurring of personal and professional boundaries. Finally, institutional ethics committees at rural hospitals are evolving, but may not have the necessary elements of expertise that are more accessible in urban centers.

7.1. Justice issues: access to and delivery of health care

The principle of justice calls for equitable distribution of health care resources, meaning that health care is distributed according to need rather than to the ability of a person to obtain it. Challenges to this principle in the rural health care setting include geographical and financial barriers. In some rural communities health care may be hours away. Nonmetro and frontier areas possess far less physician coverage than more urbanized areas even after controlling for population size. For example, in 1988, the ratio of primary care physicians per 100 000 persons for remote rural areas was 38.2; for the more inclusive nonmetro areas it was 51.3. In comparison, metro areas had a ratio of 95.9 [14]  and  [15] .

This problem will be compounded as more independent community hospitals close their doors due to the lack of funding. The poor and elderly without access to transportation may receive little to no health care. The traffic and complexity of urban centers may intimidate those who have always lived in rural areas.

Financial barriers are similar to those experienced by the poor urban population. The community, however, may actually be a positive factor in overcoming these barriers. In a review of these issues, Purtilo and Sorrell remarked that in times of hardship, rural community members often help those of their community who are most financially strapped  [16] . Among those community members are the physicians, who are also ‘expected’ to contribute their services and advocacy for the patient. Physicians are part of the community, and “the high probability that the physician will see a rejected patient at the drug store, Lions Club dinner, or next PTA meeting makes saying ‘no’ practically impossible”  [17] . This situation may create a tremendous conflict of interest between the physicians’ allegiance to their community and their hospital, which may not have the financial resources to provide care for indigent members of the community.

 

Improved access to oncology care is at the heart of our rural cancer outreach program. Oncology care in the rural setting is equivalent, or sometimes better, in terms of convenience, than that in the academic medical center. The most important aspect of the program is improving financial and geographic access to subspecialty care and consultation. Transportation is provided for patients who have daily radiation treatments. Although we cannot impact direct costs of the patients’ oncology care, reducing out-of-pocket spending, which is significant, appears to be of great assistance to many of the patients. Finally, by providing care close to home, we hope to offer comfort and a greater sense of security to patients who are frightened or feel threatened by the diagnosis of cancer and the therapy they must endure.

7.2. Competency of medical care

Several issues surrounding competency of medical care exist in the rural setting, and some are particular to our rural outreach oncology setting. The first concerns competency to provide specialty care. Many rural areas have few primary care providers, and no specialists. There is increasing evidence that high volume produces high quality and many rural hospitals will always have low volume  [3] . Physicians may feel forced to provide care, including procedures which they perform infrequently or are beyond their level of expertise, especially if the closest large medical center is 3–4 h away. Physician assistants, nurse practitioners and other nursing personnel may also provide care beyond their level of expertise, with minimal supervision, to meet the health care needs of the rural population.

One of our primary goals was to surmount this problem by traveling 1–2 h to several rural areas to provide oncology expertise in the form of clinics in which we see new and returning patients on a biweekly basis. During the clinic appointment, the medical and radiation oncologists and nurse practitioners perform ongoing management of established patients, plan diagnostic and therapeutic interventions for new patients, and counsel patients regarding palliative care and end of life issues. We also educate the hospital oncology nursing staff, many of whom have become certified in oncology nursing. These specialized nurses see patients every day and administer chemotherapy and other treatments such as transfusions and intravenous fluids, and perform limited patent assessments thus trouble shooting problems experienced by the oncology patients.

Problems that can occur in this setting include are lack of direct supervision on a daily basis, lack of continuity of care, and problems related to handling and communicating medical information between the outreach sites and the cancer center.

Direct supervision by a specialist is obviously impossible 2 h away. We work closely with the primary care physicians in the community and the patients continue to see them regularly after diagnosis. The community physicians are most often the first to see and evaluate patients having problems, and will then often call one of the oncology physicians to discuss the case. If a patient is having a specific problem that must be handled by a specialist, such as a complicated neutropenic fever, or spinal cord compression, the patient usually must be transported to our medical center. However, the patient may often be stabilized and kept at the rural hospital if the primary care physician has the support of the oncologists and other members of the medical center faculty.

Continuity of care is an important concept in the patient–clinician relationship. Unfortunately, we are not always able to provide direct continuity of care to our oncology patients because of time and schedule constraints. We do the best we can by maintaining a constant pool of physicians and nurses designated for each site, detailed patient summaries and clinic visits, so that the next physician will know what the treatment plan and previous problems are, and frequent use of phone calls to patients we know are having problems.

Handling and communication of patient information involves confidentiality issues described below, and also involves management of large volumes of information from multiple sites, which is extremely challenging. Some information is critical, and elaborate systems are in place to assure that the information is noted and recorded by the site nurses and the cancer center nurse practitioners, and that the oncology physicians are made aware of any critical values, such as abnormal CT scans or blood tests. Ongoing quality assessment is in place to assure impeccable data management, to avoid missing critical information.

7.3. Confidentiality and privacy

The proximity in which patients and health care workers live and work in rural communities makes it much more likely that physicians and other health care workers will know their patients personally and socially, which creates significant challenges to maintaining respect for confidentiality and patient privacy. A 1993 survey of 510 general and family physicians in Kansas revealed that 46% of respondents practicing in a community of less than 5000 were likely to have more than 5% of patients who were family members or friends of the physician or staff, significantly more than the 13% of respondents from communities of more than 20 000. fourteen percent of the physicians in the communities of less than 5000 also reported that in more than 5% of cases medical information is passed through the physician or staff to an outside party who knows the patient in question  [18] .

 

Purtillo and Sorrell describe a patient who is found to have genital herpes during a routine prenatal visit. The patient pleads with the physician not to enter the information in her chart: her sister-in-law is the physician’s receptionist, the county public health clerk to which this transmissible disease should be reported is her cousin; other relatives work at the hospital where she will deliver; “virtually everybody in the situation is either a relative, friend or foe”  [16] .

 

In an instance reported by Roberts et al., a patient drove 6 h to an urban center for help with his substance abuse problems. He told the attending physician that he couldn’t go to his community clinic because his sister worked there, and he was afraid she would tell the whole family. The patient’s subsequent non-compliance with the program was at least partially blamed on the burdensome long distance drive to the urban facility  [17] .

We have had several patients in our rural oncology clinics that have expressed unwillingness to be treated at the facility, because their privacy might be jeopardized. The waiting rooms of these clinics are often crowded with people who are friends, neighbors and relatives. Because it is a specialty clinic only for patients with hematologic or oncologic problems, it is not difficult for one to know another’s general diagnosis. Diagnostic tests are performed, interpreted and transcribed by patients’ relatives and acquaintances. The patients are given chemotherapy in one large room and on any given day, they may find themselves sitting next to a neighbor, the local florist, or a distant cousin. Several of the nurses have found themselves treating old friends, teachers, neighbors and relatives. This may sometimes be a comfort to the patient. but may also be embarrassing or uncomfortable for both the patient and nurse.

In our rural outreach practice, we must exchange information about patients frequently by phone and often by fax and by email over the Internet. None of these communication devices are entirely secure, especially the email system, but they are necessary in communicating important patient information in a timely and efficient manner.

Safeguarding confidentiality in such circumstances is important; the Kansas physicians reported several measures they took to do so, some of which could potentially compromise patient care, the physician’s integrity or even legally endanger the physician, such as in the case of misrepresenting or omitting certain details on insurance forms, and omitting required notification of local public health officials. Other measures taken included speaking with office personnel regarding the importance of confidentiality of a specific patient, omitting or misrepresenting certain details for the official medical record and recording the importance of confidentiality in the chart  [15] .

 

Our outreach site staff are aware of the sensitive nature of our patients’ conditions and maintain a high level of awareness regarding privacy and confidentiality. Simple measures such as keeping telephone conversations and reports out of hearing distance from the waiting room and patient rooms as well as ongoing discussions regarding confidentiality between nursing staff and outreach staff are highly effective. The nursing and secretarial staff maintains a high level of professionalism and respect for patients, and in particular, confidentiality, which sets the tone for the rest of the staff.

7.4. Institutional ethics committees

In response to the mounting complexity and number of clinical ethical issues encountered in healthcare, institutional ethics committees are developing in rural and urban hospitals. Some have the specific goals of developing and overseeing hospital policies, to respond to the requirements of the JCAHO and similar organizations, and others have multiple goals, including the former as well as addressing day-to-day dilemmas that arise in the course of patient care. They are as heterogeneous in their compositions as in their goals and missions, some composed of physicians and administrators, others representatives from multiple divisions of the hospital, such as nursing, pastoral care, and even from the community. Their members have various levels of ethics knowledge and expertise. Some have support from local institutions that have established ethics committees and considerable expertise. Others have members who have taken additional training in bioethics at community or university programs.

The hospital ethics committee can be a tremendous source of knowledge and support for physicians and other health care providers confronted by the dilemmas listed above. It is critical that these committees have the expertise and influence to support and uphold behavior and policy based on ethical principles.

The development of such committees has been described as occurring in three stages: emergence of a local expert, educating the ethics committee and developing a body of knowledge, and expansion of the ethics activity into policy development and consultation[19].

In our rural cancer outreach programs, we have offered the expertise of our established and experienced hospital ethics committee and its members, as well as persuaded them to identify interested individuals for further training by the Richmond Community Bioethics Consortium. We have also given several lectures and held discussions related to ethical issues in the care of oncology patients to the nursing and medical staff. We will continue to support them in any way possible to guarantee ethical treatment of their patients and employees.

8. Conclusions

There are distinct and novel ethical issues in providing rural health care. Two groups have shown that rural cancer outreach (a structured alliance of a cancer center and rural hospitals and providers) works well clinically and economically. In addition, rural cancer outreach is ethical because it is distributive and just.

9. Reviewers

Dr Dieter K. Hossfeld, Universitäts-Krankenhaus Eppendorf, Medizinische Klinik, Abteilung Onkologie und Hämatologie, Martinistrasse 52, D-20246 Hamburg, Germany. Dr Leslie R. Laufman, Hematology/Oncology Consultants, Inc., 8100 Ravines Edge Ct., Columbus, OH, 43235-5436, USA.

Acknowledgements

We gratefully acknowledge grant support from the Jessie Ball duPont Fund, 225 Water Street, Jacksonville, Florida, USA

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Corresponding author. Tel.: +1-804-8280450; fax: +1-804-8288453

Vitae

Laurie Lycholm, M.D., is director of the ethics program for the medical school. She also has active roles as a traveling physician with the Cancer Outreach programand as a member of the Brain Tumor Multidisciplinary Clinic.

Mary Helen Hackney, M.D., is the director of Rural Cancer Outreach Program and travels regularly to rural clinics. She is also part of the Breast Health Center and is involved in patient and physician education about breast cancer.

Tom Smith, M.D., is recognized nationally and internationally for his papers on health services research. He is currently the director of the ASCO curriculum on palliative care and has focused his research on palliative care topics. He is a Project on Death in America Scholar.